[Value of continuous venous blood oxygen measurement during external circulatory assistance]. / Intérêt de la mesure en continu de la SvO2 pendant une assistance circulatoire externe.

A case is reported of a 40 year-old man, on the waiting-list for heart transplantation, who developed terminal heart failure. Using an Opticath catheter and a radial artery catheter, SV(-)O2 was monitored continuously, and cardiac output, pulmonary arterial and wedged pressures, and right atrial pressure were repeatedly measured. Despite appropriate treatment (adrenaline, dobutamine, glyceryl trinitrate), the patient remained in anuria and cardiogenic shock. External circulatory support (ECS) (BVS 5000 Abiomed) was therefore used as a bridge to cardiac transplantation. The resultant increase in systemic blood flow led to an early and fast rise in SV(-)O2, from 40% to 73%, with a decrease in the oxygen extraction ratio (ERO2) from 50 to 30%. Serum lactate concentrations returned to normal within the first six hours of ECS (less than 120 mg.l-1). During the first 24 h of ECS, SV(-)O2 decreased and ERO2 rose significantly on two occasions: during an episode of shivering, and another of restlessness during nursing. An attempt at weaning the patient from the ventilator at the 39th h also led to a sudden decrease in SV(-)O2, with a rise in ERO2. The Opticath catheter was finally removed after 150 h of ECS because of a decrease in reflected light intensity.

[Emergency coronary surgery after transluminal coronary angioplasty]. / Chirurgie coronarienne en urgence au décours d'une angioplastie transluminale coronarienne.

Twenty-five patients underwent emergency coronary arterial bypass surgery immediately after attempted percutaneous transluminal coronary angioplasty (PTCA). The average time between the onset of PTCA complication and revascularization was 90 min (30-120 min). The surgical indications, the anaesthesia and the perioperative intensive care were analysed. No acute complication was observed during the anaesthesia. Peroperative findings defined two groups: the first "organic" (coronary arterial dissection and/or occlusive coronary thrombi; n = 15), the second "functional" (coronary arterial spasm; n = 10). The rate of perioperative myocardial infarction was significantly higher in the "organic" group. In this group, at the end of the cardiopulmonary bypass, a higher number of patients required circulatory assistance and/or an antiarrhythmic agent, as well inotropic drugs.

[Surgery of the left coronary trunk by the transpulmonary approach. 10 cases]. / Chirurgie du tronc coronaire gauche par voie transpulmonaire. Dix observations.

The most common lesions of the left main coronary artery are atheromatous lesions (1% of all "coronary patients") but traumatic lesions may occur during coronary arteriography or percutaneous coronary angioplasty. To these must be added severe infectious lesions of the aortic annulus in acute endocarditis affecting the valve or a valvular prosthesis. The 10 cases reported here (4 atheromatous, 1 traumatic and 5 infectious lesions) were treated by transpulmonary repair surgery of the left main vessel. The operations performed were endarterectomy alone (2 cases) or associated with venous graft (2 cases), resection and venous graft (1 case) and suprasigmoidal prosthetic reimplantation (5 cases). There were two early post-operative deaths (one due to major hypocoagulation with secondary hypoxia and one from irreversible cardiogenic shock); another patient died of a ruptured intracerebral mycotic aneurysm 2 months after the operation. The 7 remaining patients have been asymptomatic for 1 year, and angiographies performed on 4 occasions since surgery have given "satisfactory results". The transpulmonary route gives direct access to the left main coronary artery and facilitates a reconstructive surgery adapted to the lesions encountered.