[Anesthesia for minimally invasive cardiac procedure]. / Anesthésie pour interventions cardiaques minimalement invasives.

The objectives are to present the different minimally invasive cardiac surgery techniques to repair the mitral valve, TAVI and MitraClip, as well as the implications for the anaesthetist. Evaluate retrospectively the anaesthesist methods, change in monitoring and how the patients are selected. The mitral valve repair by minithoracotomy and video-surgery requires selective left intubation and monitoring by TEE. The TAVI methods seem to be working best under local anaesthesia and sedation for haemodynamic and neurologic monitoring. The MitraClip surgery requires an extensive monitoring during and after surgery. In conclusion, the care of patients that are candidates for a TAVI requires the same level of expertise as anaesthesiology in cardiac surgery. The number of procedures performed under sedation will increase. These patients require multidisciplinary care (surgeons, cardiologists, sonographers and anaesthesiologists) due to comorbidities, and the possible haemodynamic, neurologic and vascular complications. These patients have an Euroscore greater than 20% and a STS score greater than 10%. In our experience, 80% of the cases are done femorally, 17% of the cases are done through the subsclavian artery (Corevalve(®)). 80% of the patients have surgery with a local anaesthesia and sedation. 20% of the patients get surgery with general anaesthesia. For the Edwards-Sapien(®) valve, when the femoral approach is impossible, the patient can get surgery with general anaesthesia using the transapical access.

Choice of echocardiography method for postoperative evaluation of mitral valve replacement with a mechanical prosthesis.

OBJECT: The French Cardiology Society (SFC) systematically recommends (Class I) transesophageal echocardiography (TEE) after any mitral valve replacement with a mechanical prosthesis (MMVR). Taking into account the increasing workload of echocardiography laboratories, our attitude was to propose that only post-operative transthoracic echocardiography (TTE) is performed. The purpose of this study was to evaluate the possible risks of this simplified procedure. METHODS: We performed a precise analysis of one full year of practice of MMVR with exhaustive follow-up for the first 2 years concentrating on thromboembolic complications. RESULTS: From January to December 2003, 84 MMVRs (46 after rheumatic fever, 22 degenerative disease, 11 infective endocarditis (IE) and 5 ischemia) were conducted in 45 women and 39 men of average age 61 years. Early mortality (<30 days) concerned 5 patients (5.9%). A control TTE to determine normal prosthetic function was performed 7+/-2 days after surgery and this revealed 2 cases of nonobstructive thrombosis which were treated medically, 3 cases of paraprosthetic regurgitation, and 1 vegetation due to underlying IE. Actuarial survival was 90.5% at 1 year and 83.3% at 2 years. After a mean follow-up of 179.3 patient-years, 5 patients were reoperated (5.9%): 1 for IE, 1 for paravalvular regurgitation, 1 for mitral valve insufficiency with haemolysis, and 2 for obstructive prosthetic valve thromboses. In addition there were 2 cases of prosthetic valve thrombosis, 8 ischemic strokes (2 ministrokes, 6 sequelar strokes), and 1 peripheral embolism. The global thromboembolic complication rate was therefore 6.1 per 100 patient-years (n=11). There were 4 hemorrhagic events, i.e. a rate of 2.2 events per 100 patient-years. 63% of the 1193 INR conducted were within the target range (3-4.5), 26% were below 3 and 11% were greater than 4.5. 35% of patients with thromboembolic complications had an INR<3. CONCLUSION: Morbidity and mortality during the first 2 years after MMVR were relatively high but equivalent to the values of comparable series in the literature. These complications would not have been reduced by a more precise screening based on early TEE. Despite the increasingly litigious nature of the doctor-patient relationship, it would probably be excessive to oppose that this guideline was not followed in a dispute; in particular as it is difficult to apply this measure as echocardiography departments are overworked.

[Replacement of the ascending aorta with conservation of the aortic valve. Results of 50 cases using the Tirone David procedure]. / Remplacement de l'aorte ascendante avec conservation valvulaire aortique.

Aortic valve sparing operations are now widely accepted for ascending aortic aneurysm surgery. We herein report our experience of the Tirone David procedure in larger indications. From January 1997 to August 2003, 50 Tirone David procedure have been performed on 36 male and 14 female (mean age: 60 +/- 15). Five patients presented a Marfan disease and 4 acute dissections. Grade III or IV aortic insufficiency was frequent (40%). Aortic diameter was not particularly dilated, ranging from 44 to 78 mm (mean: 57 +/- 10 mm). Mean ejection fraction: 57 +/- 10%. Mean left ventricular end diastolic diameter =63 +/- 7 mm. An associated mitral valve repair and 1 coronary bypass were necessary. Mean cross clamp and bypass times =94 min and 122 +/- 28 min respectively. There was one in-hospital mortality. Secondary mortality affected 2 patients (non-cardiac deaths), for a cumulative follow-up of 946 months. During follow-up continence control was always excellent, only 1 bicuspid valve had an aortic insufficiency >grade II. Tirone David procedure gave satisfactory results as regards both aortic ectasia and aortic regurgitation control. We consider it feasible even in case of aortic dissection but caution is required when facing bicuspid aortic valves.

Predictive factors for usefulness of fiberoptic pulmonary artery catheter for continuous oxygen saturation in mixed venous blood monitoring in cardiac surgery.

The main goal of this prospective study was to identify among cardiac surgery patients, usually monitored through a standard pulmonary artery catheter (PAC), those in whom a fiberoptic catheter oximeter to measure oxygen saturation in mixed venous blood (SVO2 PAC) would be most useful. Data from 286 patients who underwent coronary artery bypass graft (50%) or valvular surgery were recorded, including ASA physical status, New York Heart Association (NYHA) classification, and Parsonnet score (PS). Hemodynamic events and SVO2 changes were collected intra- and postoperatively until weaning from mechanical ventilation. The anesthesiologist in charge graded the usefulness of SVO2 PAC, and another anesthesiologist carried out a blindly controlled overall evaluation. Usefulness was defined as the presence of a change in therapeutic maneuver triggered solely by continuous SVO2 data that would not have occurred based on other routine parameters. SVO2 was also considered useful if earlier recognition of significant adverse events occurred. SVO2 PAC was useful in 57% of the patients. Independent predictive factors (multivariate analysis) for the perioperative usefulness of SVO2 in the whole population consisted of ASA class > or = 4 (P < 10(-5); relative risk [RR] 1.78, 1.51-2.07), mitral surgery (P < 10(-4); RR 1.72, 1.4-2.02), and NYHA score > or = 3 (P < 0.01; RR 1.66, 1.35-2.05). Independent predictive factors for the perioperative usefulness of SVO2 in the coronary artery bypass graft population were NYHA score > or = 3 (P < 10(-5); RR 1.90, 1.42-2.55) and ASA class > or = 4 (P < 0.01; RR 1.99, 1.51-2.63). The presence of three stenosed coronary arteries showed borderline significance (P < 0.06). Independent predictive factors for perioperative usefulness of SVO2 in the valvular population were mitral pathology (P < 10(-5)) and ASA class > or = 4 (P < 0.01). The receiver operator characteristic curve assessed the predictivity of the PS. SVO2 PAC was more useful in the group of patients with the greatest severity of illness (PS in useful group 17.0 +/- 10.3; in nonuseful group 8.7 +/- 6.6; P < 10(-4)). Intensive care unit duration and hospital stay in the useful group was prolonged compared with the nonuseful group. Similarly, morbidity was frequent in the useful group, although it was not always significantly different from the nonuseful group according to the type of complications. Mortality was comparable in the groups despite their different degree of illness and was reduced when taking into account the predictive and observed mortality provided by the PS. This study defined independent preoperative factors associated with SVO2 PAC monitoring and proposed a cutoff point above which SVO2 may be useful.

[Use of propofol in anesthesia in cardiac surgery. Preliminary results]. / Utilisation du propofol pour l'anesthésie en chirurgie cardiaque. Résultats préliminaires.

Nine patients, all NYHA class III and IV, who were to undergo surgery with cardiopulmonary bypass, were divided into two groups. All nine were premedicated with 2 mg flunitrazepam orally 90 min before surgery. Group A consisted in five men, mean age 53 years (extremes: 43 and 73), with no significant difference in weight and body surface area, who were to undergo aortic valve replacement (2), mitral valve replacement (2), and aortic and mitral valve replacement (1). They were given 1.5 mg X kg-1 propofol as a bolus at induction, followed by an infusion of 50 micrograms X kg-1 X min-1 propofol. Group B consisted in four patients, two men and two women, mean age 60 years (extremes: 49 and 76), with no significant difference in weight and body surface area, who were to undergo aortic valve replacement (3) and corrective surgery for left ventricular aneurysm (1). They were given 2 mg X kg-1 propofol as a bolus at induction, followed by an infusion of 100 micrograms X kg-1 X min-1 propofol. All the patients were intubated after 0.1 mg X kg-1 pancuronium; they were given 10 micrograms X kg-1 before intubation and 10 micrograms X kg-1 before skin incision. Repeat doses of fentanyl and pancuronium were given as required. The haemodynamic parameters studied were: heart rate, systolic, diastolic and mean blood pressures, central venous pressure, mean pulmonary pressure, wedge pressure, and cardiac output measured by thermodilution. The following indices were calculated: cardiac index, systolic index, right and left systolic work indices, and pulmonary and systemic vascular resistances.(ABSTRACT TRUNCATED AT 250 WORDS)