Assessing cardiovascular risk factors after coronary artery bypass surgery: value of an aggressive strategy including systematic follow-up.

INTRODUCTION: Coronary revascularization surgery is a palliative treatment modality which should not preclude efforts to treat atherosclerosis. AIM: To assess ongoing cardiovascular risk factors after coronary artery bypass surgery and develop a strategy to attenuate such factors. METHODS: 108 patients requiring a coronary artery bypass were included: 2 died soon after surgery and 6 were excluded for personal reasons. 100 patients were re-admitted into hospital 7 months after surgery for risk factor assessment. Eight months later, they were re-contacted by telephone (systematic follow-up) for a re-assessment. RESULTS: The population consisted of 77 men with an average age of 64+/-11 years. Prior to the operation, the known risk factors were: smoking 34%; HBP 61%; cholesterol 47%; diabetes 30%; obesity 25%. During their hospital stay six months after the procedure: 91% of the patients had at least one lipid metabolism abnormality. New-onset diabetes was diagnosed in 5%. Blood pressure was uncontrolled in 18% and 10% were still smoking. Patients tended to be putting on weight and 55% engaged in little or no physical activity. Systematic follow-up: lipid metabolism had normalized in 70% of the patients. Blood glucose levels were significantly lower. Blood pressure was uncontrolled in 9% and 4% were still smoking. Their weight had stabilized and 65% were engaging in moderate-to-strenuous physical activity. CONCLUSION: Inadequate attention is paid to risk factors after coronary artery bypass surgery. A short hospital stay including a cardiovascular evaluation and education about risk factors has a positive impact on the management of atherosclerosis in the medium term.

Extracorporeal circulation as an additional method for cerebral protection in simultaneous carotid endarterectomy and coronary artery surgical revascularization.

Surgical management of patients with concomitant carotid and coronary artery stenosis remains controversial. Our policy was always to perform at the same time carotid endarterectomy (CE) and coronary artery bypass grafting (CABG), but it was also considered that extracorporeal circulation (ECC), because of full heparinization, hemodilution, pulsatile flow, and hypothermia could provide better cerebral protection during CE. Retrospective data of 124 patients undergoing simultaneous CE and CABGs between January 1994 and December 2001 were reviewed. CE was performed prior to ECC in 65 patients (Group 1-mean age: 70.4 years; sex ratio: 49 male/16 female) and under ECC, prior to CABGs in 59 patients (Group 2-mean age: 69.9 years; sex ratio: 46 male/13 female). Overall hospital mortality was 7.3% (9/124): cardiac-related in 5 patients, or due to septicemia (1 patient), or ARD syndrome (1 patient), or stroke in two others. Univariate analysis demonstrated overweight, unstable angina, and emergency to be significant risk factors. Bilateral carotid stenosis was a significant risk factor of neurologic event when CE was performed prior to ECC (p < 0.05). In Group 1, mortality was 9.2% (6/65), and the incidence of neurologic events was 10.7% (7/65), and was responsible for two of the early deaths in patients with bilateral carotid stenosis. In Group 2, mortality was 5.1% (3/59) but never related to CE, while the neurologic morbidity was 1.7% (1 transient ischemic attack). It is concluded that (1) hospital mortality in patients undergoing simultaneous CE and CABGs was mainly cardiac-related. (2) The combined approach of both localizations appears to be mandatory, when carotid stenosis, even asymptomatic, was hemodynamically significant, or with ulcerative lesions likely to be responsible for embolism. (3) CE, first performed under ECC, appears to be a safe procedure, combining, in terms of cerebral protection, the benefits previously called up. This approach is all the more interesting when carotid stenosis is bilateral; hypothermia < or = 28 degrees C during the carotid clamping time is obviously the optimal method for cerebral protection when ipsilateral or contralateral supply is reduced, or even absent.

[Diagnostic and therapeutic value of lymphography in persistent postoperative chylothorax]. / Intérêt diagnostique et thérapeutique de la lymphographie dans un chylothorax postopératoire persistant.

Chylothorax is a rare but generally severe complication of surgery of congenital heart disease. The authors report the clinical history of a young boy with complex congenital heart disease operated on several occasions and who developed severe and recurrent unilateral chylothorac after a bicavo-bipulmonary derivation. Conservative treatment followed by continuous somatostatin infusion was ineffective. Diagnostic Lipiodol lymphography was required before the chylothorax was cured. The authors describe management of this difficult case and discuss the therapeutic possibilities with reference to a brief review of the literature.

Surgery of chronic traumatic aneurysm of the aortic isthmus: benefit of direct suture.

OBJECTIVE: Retrospective evaluation of long term results after direct suture repair of chronic traumatic aneurysm of the aortic isthmus. METHODS: From March 1979 to June 1998, a total of 19 patients with chronic traumatic aneurysm of the aortic isthmus were operated on, among whom 12 (63%) underwent direct suture. These 12 patients (age ranging from 19 to 68 years; mean 34.2 years) constitute the subject of this study. All but one suffered traffic accidents. Mean delay between trauma and surgery was 4 years (range 3 months to 12 years). All patients underwent a left posterolateral thoracotomy through the fourth intercostal space. Extracorporeal circulation for spinal cord protection was installed in six patients (five ilio-iliac shunts, one atrio-iliac shunt). Aortic rupture was partial in five and circumferential in seven patients. The mean clamping time was 25 min. The absence of loss of aortic substance and a careful mobilization of the aorta made the repair by direct suture easier; this technique could thus be achieved in 63.2% of all 19 patients operated on of chronic traumatic aneurysm within the same period. RESULTS: There was no in-hospital death and no postoperative paraplegia. With a median follow-up of 15 years 3 months (ranging from 22 to 10 years), there were no late complications. Chest X-ray was normal in all patients; eight of them underwent a control angiography between 18 and 72 postoperative months; all these angiographies but one (20% stenosis without gradient) demonstrated a normal appearance of aortic isthmus. CONCLUSION: Direct suture for repair of chronic traumatic thoracic aneurysm is a safe procedure: long-term outcome was excellent and the complications observed with prosthetic grafts or with aortic endoprosthetic stent-grafts were avoided.

[Placement of an implantable defibrillator via the endocavitary route in a patient presenting with a univentricular heart and a Glenn anastomosis]. / Pose d'un défibrillateur implantable par voie endocavitaire chez une patiente présentant un coeur univentriculaire et une anastomose de Glenn.

We report the observation of a female 45 year old patient presenting with a post-surgery complex congenital cardiopathy, associated with serious ventricular rhythm disorders necessitating the placement of an implantable defibrillator. The palliative surgery performed (cavo-pulmonary Glenn anastomosis) does not allow the usual access to the right ventricle via the superior vena cava. The different possibilities for defibrillator implantation are discussed. These include associating a surgical approach to introduce the bipolar probe with subcutaneous tunnelling to connect the probe to the box.

Surgical repair of an aneurysm of the innominate artery with fistulization into the trachea.

This report describes a 43-year-old patient presenting with an aneurysm located at the junction between the innominate artery and aorta, with spontaneous fistulization into the trachea. Emergency treatment of this unusually located lesion was undertaken to prevent intratracheal rupture. After ligation of the innominate artery, right common carotid artery, and right subclavian artery due to the risk of infection, the tracheal fistula was treated by direct closure and exclusion using an autologous pericardial flap. The procedure was performed under extracorporeal circulation and circulatory arrest with profound hypothermia.

The short- and mid-term results of bidirectional cavopulmonary shunt with additional source of pulmonary blood flow as definitive palliation for the functional single ventricular heart.

OBJECTIVE: The purpose of this study was to demonstrate the early and late outcomes of bidirectional cavopulmonary shunt (BCPS) as a definitive procedure for the functional single ventricular heart. METHOD: From September 1991 to December 1997, 34 patients underwent a BCPS procedure without a routine conversion to Fontan circulation. The additional source of pulmonary blood flow was left in all patients. Conversion was performed only when it was required for excessive cyanosis. RESULTS: The hospital mortality rate was 8.8% (3/34, 95% confidence limit; 1.9-23%) and the 5-year survival rate was 75% for a mean follow-up period of 33+/-22 months. Seven patients underwent a conversion procedure for remnant or recurrent cyanosis and deterioration of exercise tolerance. Four of these patients died after conversion to Fontan circulation. Twenty-five long-term survivors with BCPSs maintained an arterial oxygen saturation of 84+/-6.1%, and 52% of them had a normal exercise tolerance or mild limitation. No patients developed severe late complications other than recurrent cyanosis. CONCLUSION: Due to the high mortality after conversion to Fontan circulation in patients whose conditions had deteriorated, we could not demonstrate the clear superiority of long-term BCPS over the construction of Fontan circulation for management of the functional single ventricular heart. If deteriorated conditions were successfully managed in the late period, the outcome of long-term BCPS would have been better.

Early and long-term (one-year) effects of the association of aspirin and oral anticoagulant on thrombi and morbidity after replacement of the mitral valve with the St. Jude medical prosthesis: a clinical and transesophageal echocardiographic study.

OBJECTIVES: The aim of the study was to test the value of low dose aspirin associated with standard oral anticoagulants (OAC) after mechanical mitral valve replacement (MMRV) to reduce strands, thrombi and thromboembolic events. BACKGROUND: Strands and thrombi are thought to increase the risk of embolic events after MMVR, particularly in the immediate postoperative period. METHODS: Two hundred twenty-nine patients were prospectively recruited: 109 patients (group A+) were randomly assigned to aspirin (200 mg per day) with OAC and 120 patients (group A-) to OAC alone (international normalized ratio 2.5 to 3.5). All patients were subjected to multiplane transesophageal echocardiography at nine days and five months and were followed up for one year. RESULTS: At nine days and five months, there was a high and comparable incidence of strands in the two groups (group A+: 44%, 58%; group A-: 49%, 63%). However, the incidence of nonobstructive periprosthetic valve thrombi was significantly lower in group A+ at 9 days: 5% versus 13%, p = 0.03. Total thromboembolic events were reduced in group A+ (9% vs. 25%, p = 0.004) although there was an increased incidence of gastrointestinal hemorrhage (7% vs. 0%). Overall mortality was 9% in group A+ and 4% in group A-. Valve-related events were similar in both groups. Early thrombi, but not strands, were associated with higher morbidity, especially thromboembolic events (30% vs. 13%, p = 0.003). CONCLUSIONS: One year after MMVR, the association of aspirin with OAC reduced thrombi and thromboembolic events, but not morbidity, due to an increase in hemorrhagic complications.

Surgical treatment of an endovascular metastatic melanoma of the superior vena cava.

A 42-year-old woman, who had undergone excision of a melanoma of her right forearm 3 years before (Breslow's index 4.4 mm), was admitted to hospital for the evaluation of an superior vena cava syndrome. The thoracic CT scan and the phlebography showed obstruction of the superior vena cava by an endovascular tumor. Abdominal, pelvis and cranial CT scans did not reveal any other metastatic localization. Surgery with extracorporeal circulation was performed. The mass was resected and histopathologic examination confirmed the endovascular metastatic melanoma. There was no heart metastasis. The patient was then given a polychemotherapy. She was still alive after 18 months of follow-up after the initial metastasis. To our knowledge, no similar case has previously been reported and surgical treatment, as for isolated heart metastatic melanoma, may be considered for vascular metastasis, as in our case.

Early and long term results of coronary artery bypass grafts in patients with dialysis dependent renal failure.

OBJECTIVE: Coronary artery disease is the main cause of mortality and morbidity in patients on renal therapy replacement. The aim of this study was to define peri-operative risk and long term results of coronary artery bypass grafts (CABG) in dialysis patients. METHODS: this retrospective study included 82 patients in chronic dialysis who underwent CABG between 1978 and 1997. The mean age was 61+/-10 years (range 28-81 years), 84% of the patients were male and the average duration of dialysis was 57 months (range 1-148 months). Combined procedures were carotid endarterectomy in one case, left ventricular aneurysm resection in one and valvular replacement in 10 (nine aortic and one mitral replacements). The operation was elective in 42 patients (51 %) and urgent in the others. Previous myocardial infarction was found in 37 patients (45%) and left ventricular ejection fraction (LVEF) at less than 45% in 15 patients (18%); 23 patients (28%) were in NYHA class III or IV and regarding angina functional status, 77% in CCS class 3 or 4. Follow-up was complete. Statistical analysis included 30 and pre and peri-operative data. Statistical analysis used Chi-square analysis or Fisher's exact test, and the Mann-Whitney test when appropriate. The estimated probability of survival, including postoperative mortality, was calculated by the method of Kaplan-Meyer, and the Log-Rank test used to compare the results. RESULTS: the hospital mortality was 14.6 % (n = 12). Ischemic time and ECC time were significantly lengthened in dead patients (P = 0.01). Moreover, use of internal mammary artery was directly related to lower hospital mortality (P = 0.02). For previous myocardial infarction, LVEF at less than 45%, diabetes and combined procedure, a P-value of < or = 0.1 was calculated. The follow-up ranged from 1 to 140 months (mean 36 months). There were 39 late deaths. The survival rates (included hospital mortality) were 71+/-5%, 56+/-6% and 39+/-6% at 1, 3 and 5 years, respectively. All surviving patients improved their functional status and had symptomatic relief. Statistical analysis showed significant difference in favor of long term survival for patients younger than 60 years, LVEF > 45% and NYHA class I or II. CONCLUSION: these data confirm that CABG in patients with renal replacement therapy is associated with an high operative and long term mortality. However it allows an improvement of functional status, and so, let possible duration of dialysis. It may be expected that more active prevention and detection of coronary disease might improve these results.

[Surgical evaluation of transthoracic tridimensional echocardiography in the anatomic study of atrial septal defect]. / Validation chirurgicale de l'échocardiographie tridimensionnelle transthoracique pour l'évaluation anatomique des communications interauriculaires.

The closure of atrial septal defects by interventional catheterisation requires an accurate assessment of their morphology and anatomical relationships. This study evaluated transthoracic three-dimensional echocardiography for the selection of atrial septal defects accessible to an occlusive prosthesis. The transthoracic three-dimensional echocardiographic measurements of 17 patients (4 to 55 years) with ostium secundum atrial septal defects were compared with those of the surgeon in a prospective study. The maximal diameters of the defect, the height of the interatrial septum, the distances to the superior vena cava (postero-superior border) and inferior vena cava (postero-inferior border), to the coronary sinus and the tricuspid valve were measured as a reconstruction of the interatrial septum seen from the right atrium. The aortic border was measured from a three-dimensional view from the left atrium. Thirteen of the 17 investigations (76%) were exploitable. The diameters of the defect varied during the cardiac cycle (p = 0.0002). Ther correlations between the surgical and echocardiographic measurements varied from 0.82 for the maximal diameter to 0.6 for the postero-inferior limits. Three-dimensional echocardiography is capable of detecting all the contra-indications of an occlusive prosthesis: 2 inadequate postero-inferior and 1 inadequate aortic borders, 9 maximal diameters which were too large, 3 insufficiently high atrial septa, 1 double atrial septal defect. The coronary sinus was only visualised in 1 case. Transthoracic three-dimensional echocardiography is a non-invasive technique capable of improving the selection of atrial septal defects for interventional closure. The transoesophageal approach should be reserved for candidates selected by the transthoracic investigation for the detection of small structures (coronary sinus) and when the transthoracic window is poor.

[Congenital left ventricular aneurysms and diverticula. Two case reports]. / Anévrysmes et diverticules congénitaux du ventricule gauche. A propos de deux observations.

The authors report the cases of two young adults (25 and 27 years) presenting with congenital left ventricular aneurysm or diverticulum with healthy coronary arteries. This saccular evagination of the ventricular wall is rare. The authors describe a classification distinguishing muscular (contractile) diverticula, composed of the three cardiac tunics, fibrous diverticula and finally aneurysms with a dyskinetic wall. Although the limits of this classification are sometimes poorly defined, it presents a prognostic value, because it appears logical to propose nonsurgical management in the context of muscular diverticula and it seems legitimate to operate on fibrous diverticula and aneurysms due to the risks of rupture, extension, thrombosis or arrhythmia.

Moderately hypothermic cardiopulmonary bypass and selective cerebral perfusion in ascending aorta and aortic arch surgery. Preliminary experience in twenty-two patients.

Deep hypothermic cardiocirculatory arrest is the commonest method of brain protection during transverse aortic arch surgery. Its principle drawbacks consist in the limited safe ischemic period and in the coagulative, renal and pulmonary complications related to low body temperatures and prolonged cardiopulmonary bypass time. Different selective cerebral perfusion techniques have recently raised the interest of some surgical teams in an effort to obviate these problems. The authors' initial experiences with 22 patients, ranging in age from 19 to 78 years (mean, 55 +/- 15 years), who underwent ascending aorta and/or aortic arch replacement using selective cerebral perfusion and moderately hypothermic cardiopulmonary bypass are reported here. Acute aortic dissection and atherosclerotic aneurysm were the commonest lesions observed: ascending aorta associated with partial or complete arch replacement was the most widely performed procedure. With regard to the perfusion technique, after regular cardiopulmonary bypass had been established through the iliac vessels, selective cerebral perfusion was started after aortic arch vessels cannulation (innominate artery, bilateral common carotid artery, innominate artery and left common carotid artery, or right common carotid artery) using a single roller pump separately from the systemic circulation, and brain perfusion was achieved by blood cooled at 30 degrees C, at a flow rate that ranged from 300 ml/min to 1500 ml/min, at a perfusion pressure of approximately 65 mmHg, with the patient maintained at moderate hypothermia (30 degrees C rectal). To perform distal aortic repair, if transverse aortic arch or proximal descending aorta cross-clamping was not feasible, cardiopulmonary bypass flow was lowered to 300-350 ml/min and an open anastomosis was performed, while independently assuring cerebral perfusion (six patients). There were three hospital deaths (mortality rate of 13.6%; s.d. 6.0-25.5%; 70% confidence limit), but none because of cerebral accident. No paraplegia occurred. One patient suffered from right hemiparesis, neither renal nor pulmonary complications were observed. Two chest reexplorations were necessary for bleeding, which were partially related to hemocoagulative disorders. In our experience, the technique of moderately hypothermic cardiopulmonary bypass and selective cerebral perfusion in aortic surgery has provided good results with regard to cerebral protection and organ function preservation. Therefore, allowing a prolonged distal aortic reconstruction period, it may be considered as a safe alternative to profound hypothermia associated with cardiocirculatory arrest in aortic arch surgery.

[Study of the cardiorespiratory response and chronotropic function after correction of tetralogy of Fallot. Important role of residual pulmonary regurgitation]. / Etude de la réponse cardiorespiratoire et de la fonction chronotrope après correction d'une tétralogie de Fallot. Rôle prépondérant de la régurgitation pulmonaire résiduelle.

Effort tolerance is reduced after correction of Tetralogy of Fallot. This prospective study investigated the cardiorespiratory response and the chronotropic function (mean follow-up 11.1 years) of 70 patients (43 boys and 27 girls) with an average age of 14.9 +/- 7.2 years (group 1) compared with 65 normal, sedentary subjects paired red for age and gender (group 2). All underwent exercise testing (Bruce protocol) with measurement of respiratory gases. Quantification of pulmonary regurgitation was performed by Doppler echocardiography. The chronotropic response to exercise was assessed by calculating the mean of slopes established by chronotropic metabolic relationship of Wilkoff. The cardiorespiratory response to exercise was abnormal in group 1: the duration of exercise (11.3 vs 13.6 min; p = 0.005), peak VO2 (35.5 vs 46 ml/min/kg; p < 0.001) and anareobic threshold (8.3 vs 9.2 min; p = 0.001) were decreased. Maximal heart rate (172 vs 190bpm; p < 0.001) and the mean of the metabolic-chronotropic slopes (0.68 vs 0.83; p < 0.001) were decreased in the patient group, showing abnormal chronotropic response to exercise. The latter seemed to be related to the severity of pulmonary regurgitation. The duration of exercise (10.6 vs 11.5 min; p = 0.001), peak VO2 (33 vs 37 ml/min/kg; p < 0.001), maximal heart rate (161 vs 177 bpm; p = 0.002) and the mean of the slopes of the metabolic-chronotropic relationship (0.59 vs 0.72; p < 0.001) were decreased in patients with moderate to severe pulmonary regurgitation. This study shows that significant pulmonary regurgitation is responsible for a poor cardiorespiratory response to exercise and for an abnormal chronotropic response which seems to be multifactorial but probably related to an adaptation favouring left ventricular filling during exercise.

[Double stenosing valve disease after mediastinal radiotherapy: a case report of a 31 year-old man]. / Double valvulopathie sténosante post-radiothérapie médiastinale. A propos d'un cas, chez un homme de 31 ans.

Cardiac complications of radiotherapy for cancer, especially lymphoma and breast cancer, are well documented. The three tunics of the heart can be affected. However, valvular disease is rare and, when present, is usually regurgitant. Stenosis is very rare. The authors report the case of a 31 year old man who developed double mitro-aortic valvular stenosis 20 years after mediastinal radiotherapy associated with aortic regurgitation, right coronary stenosis and inflammatory epicardo-pericarditis with effusion. Surgery was undertaken and associated double aortic and mitral valve replacement and right coronary by pass grafting.

Is the Parsonnet's score a good predictive score of mortality in adult cardiac surgery: assessment by a French multicentre study.

OBJECTIVE: Parsonnet proposed a preoperative score ("initial Parsonnet's score", which predicts the hospital mortality of adult cardiac surgery. This score was then modified by including several risk factors used in the 'SUMMIT' system ("modified Parsonnet's score", 44 variables). We wanted to assess the predictive value of these two scores in a French surgical population. METHODS: From December 1992 to April 1993, in France, we organised a prospective multicentre study on adult cardiac surgery mortality and morbidity. Data on 6649 patients were included. We analysed statistically the predictive value of each risk factor and of the two scores on mortality and morbidity at one month. RESULTS: Only 6 of the 15 variables of the initial Parsonnet's score and 19 of the 44 variables of the modified Parsonnet's score significantly influence hospital mortality. Both scores are able to predict hospital mortality and severe morbidity, but the modified Parsonnet's score has the best predictive value (initial Parsonnet's score: odds ratio by point of score = 1.01, area under the roc curve = 0.64; modified Parsonnet's score: odds ratio by point of score = 1.05, area under the roc curve = 0.70). CONCLUSIONS: This study shows that the Parsonnet's scores are predictive, but that these scores remain imperfect: many risk factors are non significant, the initial Parsonnet's score has a moderate predictive value, and the modified Parsonnet's score is too complex (44 variables). Thus, we have built a new score for cardiac surgery in French adults.

[Chronic dissection of the thoracic aorta. Diagnosis, management and prognosis]. / Dissection chronique de l'aorte thoracique. Diagnostic, prise en charge, pronostic.

Dissection of the thoracic aorta becomes chronic after the 14th day following the first signs of dissection. It may be "primary", that is to say diagnosed at the chronic stage, the acute stage having passed undiagnosed, or "secondary" because the dissection diagnosed in the acute period was treated medically or surgically. Its outcome depends on the evolution of the false lumen which may thrombose or remain patent and stable or increase in size and progress to a false aneurysm. Management consists in following up the outcome of the false lumen by successive examination every 6 to 9 months: in general, CT scan or magnetic resonance imaging are used for this follow-up; transoesophageal echocardiography is another possibility but, when repeated, is not always accepted by the patients. Antihypertensive therapy is essential as it improves long-term survival in all cases. Surgery is justified but the operative risk is high should an acute complication occur with an immediate threat to life. This indication should be maintained in symptomatic patients (signs of compression of a false aneurysm, painful reactivation) after thorough preoperative preparations, given the poor prognosis of the natural history of chronic dissection of the thoracic aorta irrespective of its site. In asymptomatic patients with aortic diameters of more than 60 mm in the first segments of the aorta (ascending or transverse aorta), surgery provides better long-term survival rates than medical management. In disease of the descending thoracic aorta, no difference in survival is observed between medical or surgical treatment: the surgical indication should be more conservative, especially because of the high incidence of neurological complications (paraparesis-paraplegia) in the absence of peroperative medullary protection, which is always reproducible, effective and validated.

Intermediate-term results after en bloc double-lung transplantation with bronchial arterial revascularization. Bordeaux Lung and Heart-Lung Transplant Group.

OBJECTIVE: Between May 1990 and January 1994, 18 patients underwent en bloc double-lung transplantation with tracheal anastomosis and bronchial arterial revascularization. Because at that time it was already suggested that chronic ischemia could be a contributing factor in occurrence of obliterative bronchiolitis, the purpose of this study was to evaluate, with a follow-up ranging from 22 to 69 months, the midterm effects of bronchial arterial revascularization on development of obliterative bronchiolitis. RESULTS: Results were assessed according to tracheal healing, functional results, rejection, infection, and incidence of obliterative bronchiolitis. There were no intraoperative deaths or reexplorations for bleeding related to bronchial arterial revascularization, but there were three hospital deaths and five late deaths, two of them related to obliterative bronchiolitis. According to the criteria previously defined, tracheal healing was assessed as grade I, IIa, or IIb in 17 patients and grade IIIa in only one patient. Early angiography (postoperative days 20 to 40) demonstrated a patent graft in 11 of the 14 patients in whom follow-up information was obtained. Ten patients are currently alive with a 43-month mean follow-up. Among the 15 patients surviving more than 1 year, functional results have been excellent except in five in whom obliterative bronchiolitis has developed and who had an early or late graft thrombosis. Furthermore, those patients had a significantly higher incidence of late acute rejection (p < 0.02), cytomegalovirus disease (p < 0.006), and bronchitis episodes (p < 0.0008) than patients free from obliterative bronchiolitis. CONCLUSION: We conclude that besides its immediate beneficial effect on tracheal healing, long-lasting revascularization was, at least in this small series, associated with an absence of obliterative bronchiolitis, thus suggesting but not yet proving the possible role of chronic ischemia in this multifactorial disease.

[Cerebral protection by selective cerebral perfusion during surgery on the aortic arch]. / Protection cérébrale par perfusion cérébrale sélective dans la chirurgie de la crosse aortique.

The aim of this study was to evaluate the technique of cerebral protection by selective cerebral perfusion with moderate hypothermia during surgery of the transverse aortic arch. Twenty-three patients were operated for partial or total replacement of the transverse aortic arch between January 1987 and December 1993 by the technique of selective cerebral perfusion by bilateral carotid cannulation. There were 12 cases of aneurysm of the ascending aorta and/or transverse aortic arch, one aneurysm of the innominate artery and 10 Stanford type A aortic dissections. The selective cerebral flow rate was 1-1.5 l/min; the perfusion pressure 60-80 mmHg and the temperature of cerebral perfusion 25-28 degrees C. The perioperative mortality was 13%; the causes of death were not neurological (3 haemorrhages). The neurological morbidity was 10% (one brachial monoparesis and one bulbar tetraparesis). This is therefore a useful technique of cerebral protection which avoids the complications of deep hypothermia with circulatory arrest and does not limit the time of aortic repair.

Review of the long-term course of 52 patients with pulmonary atresia and ventricular septal defect. Anatomical and surgical considerations.

This study reviews the long-term course of 52 patients with pulmonary atresia and ventricular septal defect seen in a single institution and followed for a mean period of 8.6 years (range 2 days to 20 years). Before the first operation, pulmonary blood supply was provided by ductus arteriosus supplying confluent pulmonary arteries in 26 patients (50%, group I), and was partially or entirely dependent on systemic collateral arteries in the other 26 patients (group II). The angiographic mean ratio of diameters of the right and left pulmonary artery/descending aorta (McGoon ratio) was significantly lower in group II than in group I, 0.76 +/- 0.42 vs 1.04 +/- 0.17 (P = 0.006). Severe arborization defects (with fewer than 10 pulmonary vascular segments connected to central pulmonary arteries) were present only in group II patients (eight patients: 15%), six of whom had congenital absence of the central pulmonary arteries. Corrective surgery was performed in 23 patients (44%, 14 in group I, nine in group II). All but one, who died later, had a McGoon ratio > or = 1 (mean 1.19 +/- 0.18) at time of repair. There was one hospital death (4%) and two late deaths (9%). All but one of the surviving corrected patients were in functional class I or II. Conduit replacement reoperation was performed in three patients (14%), 6, 10 and 13 years, respectively, after repair. At the end of the study, among the 37 patients (71%) who were alive (17 in group I, 20 in group II), 20 (39%) were corrected (12 in group I, eight in group II), four await corrective surgery, and six (11.5%) are estimated inoperable (all in group II) because of very hypoplastic or absent pulmonary arteries. This study confirms the estimated rate in the published literature of long-term survival in patients with pulmonary atresia and ventricular septal defect, and the good results of corrective surgery whenever the size and distribution of pulmonary arteries are satisfactory. The problem of very hypoplastic pulmonary arteries and severe arborization defects remains contentious.