[In coronary surgery can both internal mammary arteries be used systematically? Apropos of 560 patients]. / En chirurgie coronaire l'utilisation des deux artères mammaires internes peut-elle être systématique? A propos de 560 patients.

The grafts commonly used in coronary bypass surgery are the left internal mammary artery and the saphenous veins of the legs: the use of both internal mammary arteries, with potential long-term benefits, is only justified if the operative risk is not increased. Since 1987, the authors use both internal mammary arteries systematically in patients under 70 years of age and in good general condition. The retrospective analysis of 560 patients having undergone this surgery from 1987 to 1994 was undertaken to determine if this surgical option is justified without increased operative risk. The dissection of the mammary arteries is performed in a special manner by skeletonization technique. The total hospital complication rate was 12% with 9 deaths in the first 30 postoperative days (1.6%). Mediastinitis was observed in 6 patients (1.1%) Early angiographic controls showed a patent mammary graft rate of 98%. The use of both internal mammary arteries does not therefore increase postoperative morbidity or mortality. It may be proposed systematically in patients in good general condition and may provide long-term benefits in graft patency rates.

Bilateral skeletonized mammary artery grafting: experience with 560 consecutive patients.

OBJECTIVE: To test the hypothesis that the skeletonized technique of harvesting the internal thoracic artery improves the surgical results of bilateral internal thoracic artery grafting, we reviewed our 7-year experience with this technique. METHODS: Between July 1987 and December 1994, 560 patients received bilateral internal thoracic artery grafts and 236 additional grafts (average 2.6 +/- 0.6 anastomoses per patient). There were 515 men (92%) and the average age was 56.9 +/- 8.8 years. There were 63 diabetic patients (11.3%). During harvesting, the internal thoracic arteries were always totally skeletonized from the surrounding tissues without the use of electrocautery. RESULTS: Postoperative complications included reoperation for bleeding, 17 patients (3%), phrenic nerve paresis, 17 patients (3%), acute respiratory distress syndrome, 9 patients (1.6%), digestive complications, 8 patients (1.4%), neurologic complications, 6 patients (1.1%), and sternal complications, 6 patients (1.1%). No wound complications were observed in diabetic patients. The hospital mortality rate was 1.6% (9 patients, 2 cardiac causes). The early patency of internal thoracic artery grafts was 97.9%. Follow-up averages 29 +/- 20 months. There were 14 late deaths (4 cardiac causes). Angina recurred in 51 patients and the maximal stress test was abnormal in 47 patients. CONCLUSION: Bilateral internal thoracic artery grafting with skeletonized harvesting carried low post-operative mortality and morbidity and therefore it could be applied routinely without the fear of increased complication rate.

[False aneurysm of the left ventricle and coronary aneurysms in Behçet disease]. / Faux anévrisme du ventricule gauche et anévrismes coronaires au cours d'une maladie de Behçet.

A false left ventricular aneurysm and coronary artery aneurysm were discovered in a 29 year old patient with Behçet's syndrome. The operation under cardiopulmonary bypass consisted of closing the neck of the false aneurysm by an endo-aneurysmal approach with a Gore-Tex patch. The coronary artery aneurysms were respected. There were no postoperative complications. Cardiac involvement is rare in Behçet's syndrome (6%). The originality of this case is the association of two aneurysmal pathologies: the coronary and ventricular aneurysms due to the angiitis and the myocardial fragility induced by ischaemia.

[Coronary artery bypass with 2 internal mammary arteries. Early clinical and angiographic results in 100 patients]. / Pontages coronaries avec les 2 artères mammaires internes. Résultats cliniques et angiographiques précoces chez 100 malades.

One hundred patients underwent coronary revascularisation with both internal mammary arteries between 1987 and 1990. The average age of the patients was 55 years. The left internal mammary was used in 97 of the 100 cases as a pediculated graft to revascularise the left anterior descending (66 cases), left lateral (27 cases) or a bissecting artery (4 cases). The right internal mammary was used as a pediculated graft in 51 cases and as a free graft to revascularise a left lateral (51 cases), left anterior descending (29 cases) or right coronary artery (20 cases). There was one death in the first 30 postoperative days. Morbidity was low with no cases of sternal infection. The average postoperative bleeding was 633 +/- 550 ml per patient. The incidence of phrenic nerve paralysis decreased from 36% in the first 50 patients to 6% in the second 50 patients. Angiography at the 10th postoperative day showed 4 occlusions out of 132 internal mammary arteries opacified (97% patency). Ninety four patients are asymptomatic and have negative exercise stress tests. Mortality and morbidity of coronary surgery using the two internal mammary arteries are therefore the same as those of conventional coronary surgery using saphenous veinar only one internal mammary artery, providing that it is reserved for patients in good general condition, under 65 years of age, without obesity or diabetes. This technique of coronary artery revascularization should provide better long-term results because of the high patency rate of the grafts.

[Value of coronary reperfusion in cases of very low cardiac output following coronary artery bypass grafts]. / Intérêt de la reperfusion coronaire dans les bas débits cardiaques graves après pontage coronaire.

From January 1986 to December 1988, 244 patients had a coronary artery revascularization at St Joseph Hospital. Four patients (1.8%) died in post operative time (less than 30 days). None died directly from cardiogenic shock. Five patients had a severe low cardiac output (2 h to 48 h post-op) and needed cardiac resuscitation. These patients were immediately taken to the operating room. The coronary bypasses were explored (2 technical errors corrected), the metabolic disorders were treated and a coronary reperfusion was done with the Buckberg's technique. All the patients could be weaned from cardiopulmonary bypass, two with intra aortic balloon pumping. One patient died of digestive complication the 10th postoperative day. The four other patients survived and are in good clinical condition. The severe low cardiac output after coronary revascularization can be reversible with resuscitation in operating room, short assistance, and coronary reperfusion.

[Peroperative autologous transfusion in cardiac surgery. Course, medical and economic evaluation. Prospects]. / Transfusion autologue per-opératoire en chirurgie cardiaque. Evolution, bilan médical et économique. Perspectives.

The authors report their experience since 1979 in the utilization of a system for blood salvaging in cardiac surgery. An initial comparative study showed that the patient group in which blood salvaging was used, received only 0.8 unit of red cells per patient and per hospitalisation and 50% of patients required no transfusion. In the patients receiving ATS, postoperative bleeding was significantly decreased. To confirm the advantages of the technique, a group of 200 patients was studied, consisting of 28 children and 172 adults. Hemodilution was difficult to perform in children weighing less than 15 kg. Nevertheless, ATS allowed for a significant reduction in the number of red cell units transfused. In the adult group, homologous blood consumption was 0.3 unit per patient and per hospitalization. 83% of the patients received no red cells, and 93% had no need for FFP. This reduction in homologous blood transfusion ensures a reduction in the transfusional risk. An improvement in these results will be obtained by a better organization of preoperative ATS and of the retrieval of postoperative blood.

[Immediate hypertensive flare-up after coronary bypass. A predictable complication]. / Poussée hypertensive immédiate après pontage coronaire. Une complication prévisible.

An immediate post-operative rise in blood-pressure occurred in 44% of 191 patients undergoing coronary bypass. In a retrospective study of the patients' records, the authors have endeavoured to determine which of the 23 parameters characteristic of each patient was predictive of post-bypass hypertension. Using a Bayesian discriminant analysis method, they found that the only variables predictive of hypertension in 86% of the cases were an history of myocardial infarction and the urinary sodium/ potassium ratio. When combined, an urinary Na/K ratio below 1 and the absence of previous infarction constitute a good index of possible post-operative rise in blood pressure.

[Measurement of CK-BB isoenzyme after cardiac surgery (author's transl)]. / La créatine kinase après chirurgie cardiaque. Dosage de la fraction BB.

We measured the BB isoenzyme of creatine kinase in the serum of 135 patients following cardiac surgery with cardiopulmonary bypass: 64 infants, 48 children and 23 adults, 56 of them have had, at least, one positive result. The duration of anaesthesia do not have any influence; we have found the same proportion of positive results in the two groups with anaesthesia less or more than 8 hours. Severity and complexity of the surgical procedure induce the CK-BB increase. In many cases, a high serum concentration of CK-BB is not related to clinical cerebral damage. Under this circumstances, it is possible that the rise in CK-BB concentration is not specific of central nervous system lesion.

[Accidents and complications during aorto-coronary bypass surgery. 100 cases]. / Incidents et accidents au cours de l'anesthésie pour pontage aorto-coronaire. A propos de 100 cas.

Using a series of 100 patients undergoing aorto-coronary bypass surgery in the department of Professor MATHEY at Laennec Hospital, the authors analyse the incidence of accidents and complications during the per- and postoperative phases. Acute hypertensive crises accounted for the most common complication, occurring in 49 per cent of cases. The authors attribute these hypertensive crises to inadequate neuroplegia in the anaesthetic protocol. Other complications are analysed in relation to the type of myocardial protection.

[Risk factors in coronary artery bypass surgery. 55 observations]. / Les facteurs de risque du pontage aorto-coronaire. A propos de 55 observations.

The incidence of complications after aorto-coronary bypass surgery were studied in a series of 55 patients in relation to the duration of extra-corporeal circulation and the value of myocardial protection. The length of the period of extra-corporeal circulation played a significant role in the onset of complications whilst there was no significant difference between the group of patients operated upon under hypothermia and those in normothermia.

[Prevention of complications following aorto-coronary bypass surgery. Proposed solutions]. / Prévention des complications du pontage aorto-coronaire. Solutions proposées.

In the light of per- and post-operative complications seen in the past, the most suitable anaesthetic protocol for aorto-coronary bypass surgery would appear to be neuroleptanalgesia. This anaesthetic technique appears to decrease the incidence of per- and postoperative hypertensive crises. In addition, the use of cardioplegia also made it possible to decrease the incidence of postoperative complications in a recent group of 39 patients.