[Cardiac transplantation. Evaluation of a consecutive series of 75 grafts]. / Transplantation cardiaque. Bilan d'une série consécutive de 75 greffes.

OBJECTIVES: The global results of various series of heart transplantation (HT) are essential to assess the life expectancy provided by this technique. Due to the increasing graft shortage, it appears essential to very strictly candidates for HT. METHODS: From March 8, 1989 to December 7, 1994, 75 orthotopic Hts were performed in 62 men and 12 women (1 case of retransplantation). The mean age was 47.46 +/- 15.02 years (range: 2.5-66 years). Four patients were younger than 10 years and 22 were older than 60 years. Our series included more cases of ischaemic heart disease (36) than dilated cardiomyopathies (33), with a history of cardiac surgery in almost one quarter (20) of patients with ischaemic heart disease. RESULTS: The immediate postoperative survival rate was 94.7% with 3 deaths attributable to refractory pulmonary hypertension associated with graft failure and one death related to postoperative tamponade. Five other patients died during the following 3 months, increasing the mean global survival to 88%. After a mean follow-up of 2.1 years (maximum 5.8 years), the actuarial 5-year survival rate was 56.8%. Eleven patients died between 4 and 38 months (mean: 18.2 months). Two deaths were due to cancers, 4 were due to septicaemia, another 4 were due to rejection and finally 1 was due to meningeal haemorrhage. The frequency (19) of reoperations for clot removal was due to the large number of patients with a history of previous heart surgery (20). CONCLUSION: Strict recipient selection, possibly based on 123I-MIBG scintigraphy, the use of pulsatile circulatory assistance systems, improved CMV, morphometry and donor-recipient age matching, should optimize the results of a technique, whose efficacy is confirmed in this series.

[Comparative trials of fluid gelatins on hemostasis in heart surgery in adults]. / Essais comparatifs des gélatines fluides sur l'hémostase dans la chirurgie cardiaque de l'adulte.

The purpose of this study was to compare, in adult cardiac surgery, the results of two gelatin substitutes (Plasmion and Haemaccel) especially for haemostasis and coagulation factors. Patients showing before operation any perturbation of blood parameters (anaemia, coagulation troubles) as well as patients suffering from serious complications or deceased in the postoperative period have been excluded. This study was realised with 54 patients randomised in two groups: group P (Plasmion); group H (Haemaccel). Anaesthesia was a diazanalgesia. Hemodilution was used in combination with autologous peroperative blood transfusion and reinfusion of residual blood from ECC after ultrafiltration. The two groups were statistically similar. In average, patients received the same gelatins quantity. The only remarkable findings were: a lesser decrease of platelets number per-ECC: a lesser fibrinogen level in postoperative period with Haemaccel.

[Effectiveness of the Cell Saver and salvage from ultrafiltered extracorporeal circulation in heart surgery]. / Efficacité respective du Cell Saver et de la récupération du circuit de CEC ultrafiltré en chirurgie cardiaque.

The efficiency of two intraoperative techniques of blood saving were compared prospectively. During a period of eight months, in 120 adults patients undergoing heart surgery with a cardiopulmonary bypass (CPB). They all had blood removed before the start of CPB for isovolaemic haemodilution. They were randomly assigned to two groups (n = 60 for each): for group A patients, blood was salvaged during surgery before the start of the CPB, during cardioplegia, and from the CPB circuit at the end of surgery, using a Cell Saver 1V (Haemonetics), and returned to the patient in theatre or in intensive care; in group B patients, blood in the CPB circuit at the end of surgery was ultrafiltered and returned to the patient at the same time as 0.8 mg.kg-1 protamine sulfate. The same anaesthetic protocol was used in all the patients (flunitrazepam, phenoperidine and pancuronium bromide). There was no significant difference between the two groups in the volume of blood removed at the start of surgery (9.12 +/- 2.01 ml.kg-1 (A) vs. 8.85.2.22 ml.kg-1 (B)), in the amounts of replacement fluid (Haemaccel, 4% albumin) given to maintain volaemia, and in postoperative blood loss Red cell count, haemoglobin level and haematocrit were higher in the Cell Saver group at the third postoperative hour and on the first postoperative day, whereas fibrinogen levels and platelet count were higher in the ultrafiltration group at the same times. A mean of 1.02 +/- 1.71 homologous blood units were given to group A and 1.45 +/- 1.71 in group B (not significant).(ABSTRACT TRUNCATED AT 250 WORDS)

[The use of the Haemolite Cell Saver in cardiovascular surgery]. / Utilisation du Cell Saver Haemolite en chirurgie cardio-vasculaire.

In eighteen adult patients scheduled for cardiac and vascular surgery, shed blood was treated with the Haemonetics Cell Saver Haemolite. On average by patient, the autologous blood volume restored was 471.94 +/- 235.7 ml. The haemoglobin level was 16.88 g.dl-1 and haematocrit level was 49.31 +/- 7.2%. Thirteen by eighteen patients did not require any homologous blood transfusion. The Cell Saver Haemolite technique is restricted to moderate and gradual peroperative bleeding. This technique is particularly designed for vascular and pediatric surgery. Postoperative shed blood salvage is a marginal indication.

[Use of an antibioprophylaxis with pefloxacin and fosfomycin in cardiac surgery in patients with beta-lactam hypersensitivity]. / Utilisation d'une antibioprophylaxie par péfloxacine et fosfomycine en chirurgie cardiaque chez des malades allergiques aux bêtalactamines.

An association of pefloxacin plus fosfomycin was used as antibioprophylaxis in beta lactam allergic patients who underwent cardiac surgery with cardiovascular-bypass. Pefloxacin (800 mg), was administered orally, one hour before anesthetic induction and fosfomycin (60 mg/kg) was injected at the time of induction. The whole course of prophylaxis wat 24 hours. Antibiotic concentrations were measured in serum before (P1, P2) during (C1, C2, C3, C4) and after cardiovascular-bypass (P3) and in bone, endocardiac and pleural tissues. The efficacy was evaluated on clinical and biological data. Antibiotic levels of pefloxacin were measured by HPLC and those of fosfomycin by bacteriological method. Antibiotic concentrations are high in blood and tissues, without evidence of cardiovascular-bypass influence. The tissue penetration of both drugs is excellent. Two patients have presented serious post-operative infections. The pharmacokinetic of pefloxacin associated with fosfomycin is appropriate during cardiovascular-bypass and the local antibiotic concentrations are above the MIC of the strains commonly responsible of post operative infections in cardiovascular surgery. The clinical efficacy of this prophylaxis must be studied in a large population of patients.

[Antibiotic prophylaxis using a combination of pefloxacin and fosfomycin in heart surgery with CEC (extracorporeal circulation) in patients allergic to beta-lactams]. / Antibioprophylaxie utilisant l'association péfloxacine-fosfomycine en chirurgie cardiaque avec CEC chez les patients allergiques aux bêta-lactamines.

This study conducted for 15 months, was carried out in 34 patients with beta-lactam allergy scheduled for open heart surgery. In the study, pefloxacin was given orally an hour before the induction of anaesthesia and then as a short infusion following induction. When the bypass was stopped, pefloxacin (400 mg) and fosfomycin (60 mg.kg-1) were given in association by two separate slow intravenous infusions just before sternal closure and repeated in intensive care unit postoperatively. The antibiotic kinetics was observed in blood and cellular concentrations (atria, sternum and mediastinal part of pleura). The antibiotic level analysis showed a good diffusion during the surgical procedure, particularly during the bypass. The pefloxacin given orally was found to achieve satisfactory plasma levels of 5.4 to 6.9 mg.l-1 during sternotomy and always higher than 3 mg.l-1 during bypass. At the sternal closure, the residual plasma level was about 2.8 mg.l-1 before the reinfusion. The kinetic evaluation of fosfomycin has also shown same effective levels. Hence, the clinical potency of these antibiotics was confirmed as predicted by their excellent tissue diffusion. Thus, clinical evaluation was in favour of this antibiotic-association in most cases, except the two following ones. The first case had a lethal bronchiolar and lung reinfection with Pseudomonas aeruginosa and Candida albicans germs which appeared at the 6th postoperative day. The second patient is a case of antibiotic prophylaxis failure. He had developed an acute suppurating mediastinal infection at the seventh postoperative day with a methicillin resistant Staphylococcus aureus which had become pefloxacin fosfomycin resistant. However, the evolution was ultimately good after surgical disinfection of sternotomy and 30 days of drainage and irrigation with antiseptic solution associated with well adapted antibiotic treatment: vancomycin, pristinamycin and rifamycin. In fact, the choice of pefloxacin and fosfomycin for prophylaxis against staphylococcus in cardiac surgery is the right choice for patients having beta-lactam allergy. Their spectral activity and pharmacokinetics give us satisfactory results. But it is not the absolute solution as the bacteria responsible for nosocomial infection (hospital borne infection) may be found resistant to this association.

[Heart surgery in 2 previously pneumonectomized patients]. / Chirurgie cardiaque chez deux patients antérieurement pneumonectomisés.

Two cases of cardiac surgery under cardiopulmonary bypass in previously pneumonectomized patients are reported. In one case a postoperative tension pneumothorax required an emergency drainage. No other complications occurred. The authors describe their technique and underline the value of an adequate pre-operative respiratory preparation and a systematic drainage of the pleural cavity.

[Antibiotic prophylaxis in cardiac surgery: 12-hour cefazolin versus 36-hour cefazolin]. / Antibioprophylaxie en chirurgie cardiaque: céfazoline "12 h" versus céfazoline "36 h".

A prospective randomized study was carried out to assess two protocols of antibiotic prophylaxis in patients undergoing cardiac surgery with cardiopulmonary by-pass. Each patient of the first group received four intravenous injections of 1 g cefazolin over a period of 12 h, whilst in the second group each one received twelve doses over a period of 36 h. Between May 1983 and April 1984, 159 patients scheduled for cardiac surgery entered the study. Those who underwent emergency surgery, or weighed less than 20 kg, or received antibiotics in the week before surgery, or had a previous history of anaphylaxis to cephalosporins were not included in the study. Both groups were similar in their distribution of age, weight, height, sex, past history of infectious disease, surgery and iatrogenic factors. There were no significant differences between the two groups in the number of minor infections and bacterial floral changes. There were no major infections either (septicaemia, mediastinitis, endocarditis). Temperature charts were the same on the first four days. The length of stay at hospital was the same in both groups. Since the efficacy of the two protocols in preventing major infections was the same, the authors recommend the short prophylaxis with cephazolin for cardiac surgery patients.

[Contribution of autologous blood transfusion in cardiac surgery in the adult]. / Apport de l'autotransfusion sanguine en chirurgie cardiaque de l'adulte.

The use of autologous blood transfusion in cardiac surgery is still controversial. This study was prospectively designed to evaluate the haemodynamic and haematological benefits of this method, with special attention to its impact on reducing bank blood requirements. Between November 1983 and October 1984, 160 patients underwent cardiac surgery with extracorporeal circulation and were randomly assigned to two groups: group I (81 patients) was the control group and group II (79 patients) received autologous transfusion following extracorporeal circulation. Blood was withdrawn immediately after the induction of anaesthesia via a jugular catheter and stored in CPD solution at room temperature. The volume of blood removed was replaced with gelatin solutions; after bypass, blood was returned to the patient. There was no difference in systolic, diastolic or mean blood pressures between the two groups. Right atrial pressure and heart rate were not statistically different in both groups. Myocardial perfusion and myocardial oxygen consumption remained unchanged in group II compared with group I. Complete haematological evaluation was carried out before and during bypass, and thereafter daily for the first twelve days of the postoperative period. There was no significative difference between the two groups in platelet counts, fibrinogen levels, prothrombin and partial thromboplastin times. During extracorporeal circulation, mean haematocrit was 22.9 +/- 0.4% in group II and 25.3 +/- 0.5% in group I (p less than 10(-3)). The mean haematocrit time course was similar in both groups during the postoperative period and returned to preoperative value at discharge.(ABSTRACT TRUNCATED AT 250 WORDS)

[Preventive antibiotics in cardiac surgery: cefazolin versus cefamandole]. / Antibioprophylaxie en chirurgie cardiaque: céfazoline versus céfamandole.

A prospective, randomized study was carried out to evaluate two antibiotic prophylactic regimens for patients undergoing cardiac surgery with cardiopulmonary bypass. Each patient of the first group (cefazolin) received four intravenous injections of 1 g cefazolin during 12 hours, patients of second (cefamandole), four doses of 750 mg. 155 patients scheduled for cardiac operation were included in the study. (May 1983 to April 1984). Patients were not admitted to the study in case of emergency, if their weight was less than 20 kg, if they had received antibiotics during the week before surgery or if they had a history of anaphylactic reactions to cephalosporins. There were no differences between the two groups on age, weight, height, sex, previous history of infectious disease, surgery and intensive care. There were no significant differences between the two groups in minor infections. The rate of urinary tract infection by streptococci was significatively higher (p less than 0.02) in the cefamandole group (38.3%) than in the cefazolin group (17.6%). There were no major infections (septicemia, mediastinitis, endocarditis). Patients temperature was the same during the first four postoperative days. Hospital stay was the similar in the two groups. The two antibiotics are similarly effective to prevent major infections in cardiac surgery. However cefazolin was preferred for antibiotic prophylaxis in cardiac surgery because of the higher rate of streptococcal urinary infections in patients given cefamandole.

[Contribution of hemoconcentration in the recovery of residual blood from extracorporeal circulation circuits]. / Apport de l'hémoconcentration dans la récupération du sang résiduel des circuits de CEC.

The effects of recuperation from the remaining pump circuit blood with restitution to the patient after hemoconcentration are studied in 80 patients undergoing cardiopulmonary by-pass. This population is randomized into two groups: group 1 of 41 patients represents the control group and is compared with the group 2 of 39 patients who undergo the post-by-pass hemoconcentration. The volume of restored blood is 669 +/- 14 ml with an hematocrit of 38 +/- 6,6% and the total protein concentration is 81,2 +/- 2 g.l-1. The heparin level is high (4,24 units.ml-i) and the perfusion of the hemoconcentrated blood must be preceded by a slow injection of 0,8 mg.kg-1 of protamine sulfate. The advantages of this method represent a saving of two homologous blood units (p less than or equal to 10(-4] and the post operative urine output is increased by 32% (p less than or equal to 0,05). No complication, particularly infectious, was observed in this study.

[Complications of surgical treatment of interventricular communications in the infant]. / Complications du traitement chirurgical des communications interventriculaires du nourrisson.

Interventricular communication in the infant is presently treated by complete surgery under extracorporeal circulation and hypothermia. Improved techniques in surgery, anesthetics and resuscitation explain a low, acceptable, level of postoperative morbidity; it is estimated by most authors at 3-4% during the first six months of life. Postoperatively, acute pulmonary arterial hypertension is to be feared, resulting in low cardiocirculatory flow from right ventricle failure. In a group of 20 infants who underwent IVC surgery, the authors have observed two cases of this complication, one being lethal. Its treatment is based on the administration of alpha-blocking vasodilating agents, which can be associated or not with exogenous bêta I-adrenergic catecholamines. Results could probably be improved by preventing such acute postoperative pulmonary arterial hypertension.