[Surgical treatment of infective endocarditis: Surgical indications, complications, intrahospital and long-term mortality]. / Endocardites infectieuses opérées : indications chirurgicales, complications, mortalité intrahospitalière et à long terme.

BACKGROUND: In addition to medical treatment, half of the patients with infective endocarditis (IE) receive surgical treatment. Despite clear recommendations on the indications and the operating delays, the decision remains difficult and must take into consideration several factors. METHODS: A retrospective study was performed at Foch Hospital. All patients operated for IE between 2005 and 2018 were included. Patient characteristics, indications and operating delays, as well as intrahospital mortality, were noted. Patient follow-up was provided by phone calls. RESULTS: Fifty-two patients were operated on for IE between 2005 and 2018. The most frequent surgical indications were the presence of a massive symptomatic regurgitation, an uncontrolled infection and large vegetations with embolism. The average operative delay was 13.2 days with 56.5% of patients operated within the first 10 days. The most common postoperative complications were acute kidney injury (AKI) in 57.7% of cases, with 9.6% of dialysis, shock in 50% of cases, rhythm disorders in 40.4% of cases, infectious complications in 19.2% of cases, conductive disorders in 25% of cases, of which 17.3% require a definitive pacemaker implementation. The intrahospital mortality was 7.7% and the average length of hospital stay was 35 days. Survival at one year and 5 years was 95% and 85%, respectively. CONCLUSION: The indications and the operating delays were conformed to international recommendations. Intrahospital and long-term mortality rate was low.

[Combined heart and kidney transplantation in Fabry's disease: Long-term outcomes in two patients]. / Transplantation combinée cœur­rein au cours de la maladie de Fabry : suivi à long terme de deux patients.

INTRODUCTION: Fabry disease is a lysosomal storage disorder linked to an alpha-galactosidase A deficiency that can lead to heart and kidney failure. There is little data about the prognosis of patients who undergo a combined heart and kidney transplantation. CASE REPORTS: Two brothers who were diagnosed with Fabry disease after the age of 30 years underwent a combined heart and kidney transplantation at respectively 49 and 42 years of age because of a severe hypertrophic cardiomyopathy with end stage renal failure. They are alive respectively 4 and 9 years after the transplantation. No recurrence of the disease in the transplanted organs has been found. CONCLUSION: Combined heart and kidney transplantation in Fabry disease is an efficient therapy for the cardiomyopathy and kidney failure. Its prognosis can be good when the patients are carefully selected. However, an early diagnosis is critical in order to avoid a procedure associated with a high perioperative mortality.

Fatal pneumoperitoneum caused by nasopharyngeal oxygen delivery after transoesophageal echocardiography for cardiac surgery.

We report a case of fatal post-operative pneumoperitoneum in a patient who had undergone urgent mitral valve surgery. In the absence of a proven cause of the pneumoperitoneum (refusal by the family of an autopsy), we can only propose a hypothesis for its origin. The most probable one is that forceful or sustained retrograde flexion of the transoesophageal echocardiographic probe created a lower oesophagus or gastric rupture and that oxygen flow administered by the nasal cannula went straight to the abdominal cavity, leading to tension pneumoperitoneum.

Combined heart and kidney transplantation in a patient with Fabry disease in the enzyme replacement therapy era.

Fabry disease (FD) is an X-linked genetic disease, resulting from the deficiency of alpha-galactosidase A, a lysosomal enzyme responsible for the cleavage of glycosphingolipids. In absence of enzyme replacement therapy (ERT), globotriaosylceramide (Gb3) accumulates in tissue, leading to progressive organ damage with severe renal, cardiac and central nervous system complications. We herein describe the first case of successful combined and simultaneous heart and kidney transplantation in a young male patient with FD complicated by end-stage renal disease and severe heart failure not responding to late-onset ERT. Combined heart and kidney transplantation can be recommended for Fabry patients with end-stage renal disease and overt hypertrophic cardiomyopathy, severe ischemic or valvular heart disease.

[Long term results for the ATS valve, the first open pivot valve: 182 cases]. / Résultats a long terme de la valve ATS, premiere valve a pivot ouvert: 182 observations.

Between May 1995 and May 2004, 197 ATS valves were implanted in 182 patients: 120 males and 62 females with an average age of 58 +/- 13 years. 149 cases were for aortic valvular replacement and 48 cases were for the mitral valve. Fifteen patients had a double mitral and aortic replacement. Twelve tricuspid procedures were necessary, 17 patients underwent coronary revascularisation and 58 underwent an aortic procedure (Bentall, aortic sub-coronary, aortic cross). The in-hospital mortality (31 days) was 1.6%. The long term mortality at up to 9 years included 23 deaths. No death was attributed to the ATS valve. Nine thrombo-embolic events occurred, but six were minor. One mitral valve thrombosis was due to the voluntary cessation of anticoagulants and another was linked to a reduction in anticoagulant treatment. There were ten haemorrhagic events. They were all linked with an organic visceral lesion. Only one death was recorded. All patients received standard anticoagulant treatment with a target INR between 2.5 and 4. 155 patients were asked about the problem of valve noise. 139 (89.6%) stated that they did not notice any noise from their valves in everyday life. Conclusions The ATS valvular prosthesis is currently the only open pivot valve, fundamentally differentiating it from other valves with 2 leaflets. As a result of this, it has a very low rate of thrombo-embolic complications and a reduction in anticoagulant treatment could therefore be envisaged (Westaby, Van Nooten, Stefanidis). The haemodynamic characteristics are excellent and the ease of rotation of the leaflets allows optimal orientation. Finally, thanks to its structural characteristics, there is less leaflet closure noise and it is less perceptible than with other prostheses. It therefore offers an excellent quality of life.

Repair of anterior leaflet prolapse by papillary muscle repositioning: a new surgical option.

BACKGROUND: Although mitral valve repair is considered the gold standard for treating mitral regurgitation, anterior leaflet prolapse may still remain a challenging problem. This challenge is even greater for posterior commissural prolapse. We have used papillary muscle repositioning to treat anterior leaflet prolapse and suggest it as an alternative technique for all other methods previously described. METHODS: From 1989 to 1999 we performed 253 mitral valve repairs, among which 132 involved anterior leaflet prolapse. In this population there were two groups: group I (n = 92) treated with papillary muscle repositioning and group II (n = 40) treated with chordal shortening. There was no statistical difference between the two groups concerning age, functional class, and left ventricular function. Etiology was similar in both groups, a degenerative process being predominant. At echocardiography, regurgitation was graded 3.4/4 in both groups. There was no statistical difference concerning preoperative ejection fraction, end-systolic and end-diastolic left ventricular diameter. RESULTS: There were one in-hospital death in group I and two deaths in group II not related to mitral valve repair. Mean follow up is 36.4 +/- 29.2 months in group I and 70.5 +/- 9.5 months in group II. No patient was lost to follow-up. Mean regurgitation at follow-up was 0.75 +/- 0.67 in group I and 0.8 +/- 0.8 in group II (p = not significant). There was no statistical difference between the two groups concerning postoperative ejection fraction, end-systolic and end-diastolic left ventricular diameter. There was no late cardiac death in either group and there were no thromboembolic events. Actuarial survival rate is 98.9% and 96.3% in group I and 92.5% and 88.1% in group II at 3 and 8 years, respectively. CONCLUSIONS: Therefore, we conclude that papillary muscle repositioning is a safe technique that provides excellent results at mid-term follow-up and facilitates treatment of anterior leaflet prolapse.

Long term results of mitral valve repair: posterior papillary muscle repositioning versus chordal shortening.

OBJECTIVE: Mitral valve repair is considered as the gold standard to treat mitral regurgitation. However anterior leaflet prolapse in the posterior paramedial and paracommissural area remains a challenging problem. Indeed several elongated chordae may arise from a single posterior papillary muscle head which does not allow safe separate chordal shortening (CS). We therefore suggest use of papillary muscle repositioning in such cases. METHODS: In a cohort of 180 mitral valve repair performed between 1989 and May 1998, we have retrospectively studied 100 consecutive patients who underwent anterior leaflet repair in the posterior paramedial and paracommissural area. Group I (n = 60) had posterior papillary muscle repositioning (PPMR) and group II (n = 40) had CS. There was no statistical difference between the two groups concerning age, functional class and left ventricular function. Etiology was similar in both groups, degenerative process being predominant. At echocardiogram, regurgitation was graded 3.4/4 in both groups. There was no statistical difference concerning preoperative ejection fraction, end systolic and end diastolic left ventricular diameter. RESULTS: There were no in-hospital deaths in group I and two deaths in group II not related to mitral valve repair. Mean follow up is 26.4 +/- 24.2 months in group I and 46.1 +/- 28.8 months in group II. No patient was lost to follow up. Severe mitral regurgitation was not observed. Mean regurgitation at follow up was 0.8 +/- 0.7 in group I and 0.8 +/- 0.8 in group II (P = n.s.); there was no statistical difference between the two groups concerning postoperative ejection fraction, end systolic and end diastolic left ventricular diameter. There was no late cardiac death in either group and there were no thromboembolic events. Actuarial survival rate is 100% and 94.4% in group I and 92% and 84.4% in group II at 2 and 6 years, respectively. CONCLUSION: This experience shows that PPMR provides as good longterm results as CS to repair anterior leaflet prolapse in posterior paramedial and paracommissural area with lesser morbidity and mortality.

[A prospective comparative study of coronary angiography and endocoronary ultrasonography in the detection of coronary lesions after cardiac transplantation]. / Etude prospective comparée de la coronarographie et de l'échographie endocoronaire dans la détection des lésions coronaires après transplantation cardiaque.

Coronary angiography is the reference method for the detection of coronary disease of the cardiac grafts which threatens the long-term prognosis of cardiac transplantation. The primary results of treatment for slowing, stabilising or even improving coronary transplant disease are encouraging and make necessary the development and evaluation of reliable diagnostic methods. The authors undertook a prospective study of 48 asymptomatic patients with normal graft wall motion between January 1995 and March 1997 to compare the results of coronary angiography and endocoronary ultrasonography. The patients had been transplanted in the 10 years preceding the study. The results of the two methods were concordant in 33 cases (69%) (NS), for the confirmation (9 cases) or the information of coronary transplant disease (24 cases). The results were contradictory in 15 cases (31%): in 12 cases, endocoronary ultrasonography showed signs of coronary disease whereas the coronary angiography was estimated to be normal: in the remaining 3 cases, coronary angiography was abnormal but no signs of coronary disease were found on endocoronary ultrasonography. The specificity of coronary angiographic detection was 89% and therefore very satisfactory, but its sensitivity (43%) was poor. In addition, endocoronary ultrasonography allows analysis of the extension of coronary lesions to unstenosed segments, the quantification of intimal thickening. Therefore, endocoronary ultrasonography should become the reference investigation for coronary disease of cardiac transplants.

[Giant cell myocarditis. Report of a case]. / Myocardite à cellules géantes. A propos d'un cas.

The authors report a case of giant cell myocarditis leading to rapidly progressive cardiac failure despite immuno-suppressor treatment in a 20 year old woman. The cardiac failure was successfully managed by implantation of a left ventricular assist device and then cardiac transplantation. The problems encountered underline the importance of accurate diagnosis by endomyocardial biopsy before undertaking treatment and the difficulties in the choice of appropriate method of assistance in this indication. Giant cell myocarditis is a rare cause of cardiac failure and should be considered in the differential diagnosis in view of its clinical features and risk of progression. The literature and the therapeutic implications are discussed.

[Left ventricular reduction (Batista's technique). A new surgical option in dilated cardiomyopathy]. / Réduction ventriculaire gauche (Batista). Une nouvelle option chirurgicale pour les cardiomyopathies dilatées.

Cardiac transplantation remains the standard treatment for severe cardiomyopathy resistant to medical therapy. However, new techniques may help to put this off. Two patients with dilated cardiomyopathy were treated surgically since October 1996, one aged 48 and the other 52. They were in NYHA Class IV and one was dependent on inotropic drugs. Both had relative or absolute contra-indications to transplantation. The left ventricular end diastolic dimensions were over 70 mm with mild mitral regurgitation and fractional shortening of less than 12%. Coronary angiography was normal. They were operated in October 1996 and January 1997. The procedure consisted of correction of mitral regurgitation (annuloplasty) and of reduction of left ventricular volume by a triangular resection from the apese to the base of the heart. At histological examination, the resected myocardium measured 11 to 13 cm long and 5 to 7 cm at its base. The two patients were discharged from hospital after 45 and 30 days. There were no clinical signs of cardiac failure. Follow-up investigations showed a marked decrease in ventricular volumes, the end diastolic dimensions changing from 70 to 52 mm in the first, and from 76 to 54 mm in the second patient. The corresponding values of fractional shortening increased from 11 to 20% and from 6 to 17%. Left ventricular volumes decreased from 328 mL (end diastole) and 259 mL (end systole) to 140 mL and 74 mL in the first case, and from 300 mL (end diastole) and 280 mL (end systole) to 122 mL and 83 mL respectively in the second case. The ejection fraction increased from 20 to 40% and from 10 to 32%. These preliminary results show that the theoretical advantages of this surgical technique correspond to a practical reality. Larger series of patients are required to determine the optimal indications.

[Emergency cardiac transplantation]. / Transplantation cardiaque en urgence.

Emergency cardiac transplantation is a controversial subject in the present context of a lack of donor organs. There are few reports in the literature, which the authors review to suggest a practical approach which is clearly not consensual. The results in the literature report an extramortality of 10 to 30% if the indication of transplantation is that of an emergency. The poor results of emergency transplantation in the present day context of lack of donor organs have led the authors to abandon this indication. They only transplant patients in a stable condition without failure of organs other than the heart.

[Surgery FOR annulo-dystrophic disease of the ascending aorta. Apropos of 203 cases]. / Chirurgie de la maladie annulo-dystrophique de l'aorte ascendante. A propos de 203 patients.

From April 73 to June 94, 203 patients (167 men, 36 women) aged from 10 to 74 years (mean 44.8 +/- 15) underwent ascending aortic replacement with a composite graft for: dystrophic aneurysm (AN) (130 cases, 64.5%), chronic dissection (CD) (35 cases, 17.2%), type A acute dissection (AD) (38 cases, 19%). Forty-six patients (22.6%) suffered from Marfan syndrome (24 AN, 13 AD, 9 CD). Thirty patients (14.7%) had undergone a previous cardiac or aortic operation. The ascending aortic replacement was extended to the transverse arch in 28 patients (14%). A mechanical valve was used in 193 cases (95%). The technique of coronary reattachment has varied with time and according to the aortic lesions. The classic "Bentall" technique was used in 87 patients (43%), the "button" technique in 74 (36%), the "Cabrol" technique in 26 (13%) and a "mixed" technique in 16 cases (8%). The hospital mortality rate was 7.3% (15/203) (AN: 2.3%, CD: 11.4%, AD: 21%). The only predictors of hospital death were emergency AD (p < 0.03) and arch replacement (p < 0.02). Mean follow-up was 46 +/- 10 months (2-246). The overall long-term survival rate was (Kaplan Meier) 89 +/- 6% at 1 year, 77.9% at 5 years, 67.7 +/- 12% at 10 years and 61.3% +/- 15% at 12 years. The 10 years survival rate is significantly higher in patients with AN (77.8 +/- 11%) than in those with AD (61.6 +/- 17%) (Log.rank: p < 0.01). The late survival rate is also significantly higher after the "button" or Bentall reimplantation that after the "Cabrol" or "mixed" methods (90 +/- 5% in the "button" group and 88.7 +/- 6%, 83.8 +/- 9% and 76.6 +/- 12% in the "Bentall" group vs 80 +/- 18%, 63 +/- 21% and 58 +/- 35% in the "Cabrol" group at 1, 5 and 8 years, respectively). In conclusion, ascending aortic replacement with a composite graft is a safe procedure especially when performed electively in patients with dystrophic aneurysm or Marfan syndrome. The technique of coronary reimplantation has a significant on the long-term results.

Protection of the spinal cord during surgery of thoraco-abdominal aortic aneurysms.

OBJECTIVE: To assess the risk of ischemic cord injury, we have retrospectively studied the 115 patients who underwent a replacement of the thoracic descending or thoraco-abdominal aorta between January 1980 and December 1994. METHODS: In 72 patients the aortic lesion was located above the diaphragm. The aortic replacement was performed with the aid of extracorporeal circulation in all but 2 patients (97.2%). Only two cases of postoperative paraplegia were observed (2.7%). In 43 patients (10 females and 33 males aged from 26 to 69 years), the occurrence of postoperative paraplegia was considered as a major risk, because of the extension of the aortic lesions (Crawford types I, II and III). Twenty-six patients (60.4%) suffered from chronic dissection and 17 patients had atheromatous aneurysms. Sixteen patients (37.2%) had Marfan syndrome. Twelve patients (27.9%) had already undergone aortic replacement. A preoperative study of the spinal cord vascularization was carried out in 36 patients (83.6%) and the Adamkiewicz artery was visualized in 28 patients (77.8%). In 17 patients (39.5%, group I), the surgical procedure was performed without the aid of extracorporeal circulation. In the remaining 26 patients (60.5%, group II), the surgical procedure was carried out with the aid of cardiopulmonary bypass and profound hypothermic circulatory arrest. Sequential unclamping of the aorta was used in all patients. The cord vascularization was surgically restored in 32 patients (74.4%). When the Adamkiewicz artery was identified, the critical intercostal artery was reimplanted together with the two pairs of adjacent intercostal arteries (25 patients). When the origin of the Adamkiewicz artery remained unknown, the two or three most important patent pairs of intercostal arteries were reimplanted (7 patients). In 8 patients (18.6%) there were no patent intercostal arteries. RESULTS: Hospital mortality accounted for 37.2% (16 patients, including 5 patients with paraplegia). On univariate analysis, extension of the aortic lesions, emergency and redo surgery were the only significant risk factors of mortality (P = 0.05). Cord ischemia was observed in 9 patients (21%): permanent paraplegia in 7 patients (16.2%) and transient medullar disturbance in 2 patients (4.6%). The occurrence of paraplegia was reduced, though not significantly, in group II (16%) vs group I (29%) and in patients with preoperative assessment of the cord vascularization (18% vs 38%). CONCLUSIONS: In our experience: 1) The risk of paraplegia is related to the extension and the type of the aortic lesions. 2) The preoperative study of the medullar vascularization and the use of extracorporeal circulation with deep hypothermia and sequential aortic unclamping, reduce the risk of severe cord ischemia, and 3) Occurrence of postoperative paraplegia depends on several factors and cannot be totally prevented by the surgical technique.

[Long-term results of cardiac transplantation]. / Résultats à distance de la transplantation cardiaque.

Between 1982 and 1992, 73 patients who had undergone cardiac transplantation and survived the hospital period, were followed up. The actuarial survival was 86%, 65% and 40% at 1, 5 and 7 years. The main causes of the 14 secondary deaths were infection (4), acute rejection (3) and cancer (3). Survival was complicated by acute rejection (1.07 episodes/patient), infection (0.7 episode/patient), cancer, hypertension and renal failure, graft dysfunction and other more secondary side effects. After analysing all the complications, the authors evaluated the quality of long-term survival after cardiac transplantation which allowed one patient out of two to return to normal living but with the threat of secondary graft dysfunction.

Myocardial viability assessment in ischemic cardiomyopathy: benefits of coronary revascularization.

Patients with ischemic heart disease, congestive heart failure, and low ejection fraction are usually referred for orthotopic heart transplantation. Based on results of myocardial viability assessment, we have prospectively used either coronary artery bypass grafting or orthotopic heart transplantation. From January 1990 to June 1992, among 50 patients initially referred for heart transplantation, 46 showing myocardial viability underwent bypass grafting. Forty-five of these 46 patients were men, and the mean age was 58 +/- 12 years (range, 40 to 70 years). Congestive heart failure was present in all patients, and dyspnea was the main symptom in 80% (37/46). Patients were selected according to three criteria. (1) Myocardial viability was primarily assessed by thallium scintigraphy for up to 24 hours (28/46 patients). When results were negative, patients underwent positron emission tomography (20/46 patients). (2) Regional left ventricular function was assessed using gated blood pool single-photon emission computed tomography combined with (3) full hemodynamic evaluation. Results were as follows: end-diastolic volume, 129 +/- 35 mL/m2; ejection fraction, 0.23 +/- 0.06; cardiac index, 2.4 +/- 0.62 L.min-1.m-2; mean pulmonary artery pressure, 26 +/- 0.90 mm Hg; and mean pulmonary capillary wedge pressure, 16 +/- 1.10 mm Hg. Operative mortality was 2.17% (1/46). During follow-up (mean duration, 18 months), there were three late cardiac-related deaths (arrhythmias) and two noncardiac-related deaths. The 40 long-term survivors are in New York Heart Association class II. Angiography (15 patients) or gated blood pool single photon emission tomography (32) showed improvement in mean ejection fraction to 0.39 +/- 0.13 (range, 0.22 to 0.46).(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary surgery can be an alternative to heart transplantation in selected patients with end-stage ischemic heart disease.

Patients with ischemic heart disease (IHD) low ejection fraction (EF), and congestive heart failure (CHF), are usually referred for orthotopic heart transplantation (OHT). This study reports our experience with coronary artery bypass grafting (CABG) in patients initially referred for OHT, and suggests guidelines to facilitate the choice of procedure (OHT or CABG). Between January 1990 and December 1991, 32 patients with IHD, proposed for OHT, underwent CABG 31/32 patients were male, the mean age was 58 +/- 12 years (40 to 70). Congestive heart failure was present in all patients and was the main symptom. The mean EF was 23 (14 to 31%), mean cardiac index (CI) 2.4 l/min per m2 (1.6 to 3.1 l/min per m2), mean pulmonary artery mean pressure (MPAP) 26 (20 to 37 mmHg) and mean pulmonary wedge pressure 16 (12 to 22 mmHg). Every patients underwent a myocardial viability study by thallium scintigraphy (n = 32) and/or by positron emission tomography (n = 10). The perioperative mortality was 9.3% (3/32). All long-term survivors (n = 27) are in NYHA Class II with a complete follow-up (mean 18 +/- 6 months). Ejection fraction control either by angiography (n = 15) or by single photon emission computed tomography (n = 12) showed an increase of up to 38% (22%-46%). Three determinant factors influenced the choice of CABG. 1) CI > 21/min per m2, 2) MPAP < 35 mmHg. 3) Detection of myocardial viability.(ABSTRACT TRUNCATED AT 250 WORDS)

Penetration of vancomycin in uninfected sternal bone.

Concentrations of vancomycin in sternal bones of 10 patients undergoing cardiac surgery were studied at steady state, 48 h after starting intravenous prophylaxis. A sample of sternal bone was taken before (group I) or after (group II) cardiopulmonary bypass. The mean vancomycin concentrations in sternal bones were not significantly different between the groups and were 9.3 +/- 3.0 micrograms/g. The concentrations of vancomycin in sternal bones were always above the MICs for staphylococci, streptococci, and enterococci.

Surgery of type A acute aortic dissection with Gelatine-Resorcine-Formol biological glue: a twelve-year experience.

Gelatine-Resorcine-Formol Glue has been proposed to reinforce the tissues during surgery of type A acute aortic dissection. From January 1977 to December 1988, 105 patients were operated on in emergency. The ascending aorta was replaced in all patients and the aortic stumps were reinforced with the GRF glue before suturing a Dacron prosthesis. In 29 patients the repair extended to the aortic arch. In these cases, the distal repair was carried out under circulatory arrest and profound hypothermia (21 patients) or carotid perfusion (8 patients). The aortic valve was replaced in 20 patients (20%). Four patients died during surgery and 20 patients died during the postoperative course for an overall hospital mortality rate of 23%. Average follow-up is 51 months (range: 3 to 130 m). Three patients were lost to follow-up. Seven patients died 3 months to 10 years postoperatively. Eleven patients had to be reoperated upon for AVR (3 patients), CABG (1 patient) and recurring or evolving dissecting aneurysm (8 patients). The reoperations resulted in 2 deaths. The remaining 69 patients are in good or fair clinical condition. Postoperative angiograms, CT scans or NMR, have shown a satisfactory repair in all documented patients but a persisting dissection beyond the prosthesis in 75% of them. The GRF glue allows easier and safer repair of type A acute dissection. It has permitted the extension of the repair to the aortic arch whenever necessary.

[Surgical treatment of chronic pulmonary embolism using thromboembolectomy under extracorporeal circulation and deep hypothermia--a new approach route. 3 cases]. / Traitement chirurgical des embolies pulmonaires chroniques par thrombo-embolectomie sous circulation extracorporelle et hypothermie profonde--nouvelle voie d'abord. Trois observations.

The authors, who have successfully performed thrombectomy of the pulmonary artery under extracorporeal circulation and deep hypothermia in three patients, wish to draw attention to the principal factors of success. The decision to operate, as accepted by most surgeons, rests on the patient's functional status (stage III or IV) and on the presence of a systolic pulmonary arterial pressure exceeding 50 mmHg. Deep hypothermia combined with circulatory arrest seems to be the best method, as it improves visual control, thereby avoiding damage to the endothelium or fracture of the distal thrombi during thrombectomy. Finally, a new approach route (severing of the superior pulmonary vein, opening of the pulmonary artery and use of Volmar-Sisteron strippers) makes it possible to remove the entire thrombus, thus obtaining an almost normal pressure in the pulmonary artery. In all three patients, the complications that are mostly due to intrabronchial haemorrhage by disruption of the endothelium, fracture of the distal thrombus or pulmonary artery contusion were avoided.

Replacement of the transverse aortic arch during emergency operations for type A acute aortic dissection. Report of 26 cases.

In type A aortic dissection, the intimal disruption is located on or extends to the transverse arch in about 20% of patients. Replacement of the arch may then be necessary to avoid leaving an unresected, acutely dissected aorta and to prevent bleeding, progression of aneurysm, rupture, and ultimately reoperation or death. From 1970 to September 1987, 119 patients were operated on for type A acute dissection. Starting in January 1977, gelatin-resorcin-formaldehyde biologic glue was used in 91 patients to reinforce the dissected tissues at the suture sites. Among these 119 patients, 26 (ages 32 to 76 years) underwent replacement of the transverse aortic arch in addition to replacement of the ascending aorta. In 20 patients cerebral protection was achieved by profound hypothermia (16 degrees to 20 degrees C) associated with circulatory arrest (15 to 40 minutes, mean 27 minutes) during the distal anastomosis. In six patients the carotid arteries were selectively perfused with cold blood (6 degrees C) during moderate core hypothermia (28 degrees C) while cardiopulmonary bypass was discontinued (19 to 34 minutes, mean 25 minutes) to allow the prosthesis to be sutured without the distal aorta being cross-clamped. Moderate hypothermia avoided the long rewarming time necessitated by profound hypothermia. The hospital mortality rate was 34% (9/26). Two of the 20 patients subjected to profound hypothermia and circulatory arrest died during the operation and seven patients died of postoperative complications. No deaths or major complication were observed in the other six patients. Follow-up of the 17 survivors ranges from 3 to 90 months (mean 39). One patient died 6 months after the operation of cerebral hemorrhage. One patient is disabled by neurologic sequelae. Fifteen patients are in good clinical condition (New York Heart Association class I or II). Postoperative aortograms in 12 patients, and computed tomographic scans in all, have shown a stable repair of the transverse arch in all survivors but a persisting dissection of the descending aorta in 11 (70%). Growing experience and improving results in emergency operations for type A aortic dissection have led us to extend the replacement of the aorta to the transverse arch whenever necessary. The gelatin-resorcin-formaldehyde glue has proved to be an efficient adjunct. The best cerebral protection was obtained in our experience by carotid perfusion with cold blood during circulatory arrest at moderate core hypothermia.