Short acting intravenous beta-blocker as a first line of treatment for atrial fibrillation after cardiac surgery: a prospective observational study.

Post-operative atrial fibrillation (POAF) defined as a new-onset of atrial fibrillation (AF) following surgery occurs frequently after cardiac surgery. For non-symptomatic patients, rate control strategy seems to be as effective as rhythm control one in surgical patients. Landiolol is a new highly cardio-selective beta-blocker agent with interesting pharmacological properties that may have some interest in this clinical situation. This is a prospective, monocentric, observational study. All consecutive adult patients (age >18 years old) admitted in the intensive care unit following cardiac surgery with a diagnosed episode of AF were eligible. Success of landiolol administration was defined by a definitive rate control from the beginning of infusion to the 72th h. We also evaluated rhythm control following landiolol infusion. Safety analysis was focused on haemodynamic, renal and respiratory side effects. From 1 January 2020 to 30 June 2021, we included 54 consecutive patients. A sustainable rate control was obtained for 49 patients (90.7%). Median time until a sustainable rate control was 4 h (1, 22). Median infusion rate of landiolol needed for a sustainable rate control was 10 µg/kg/min (6, 19). Following landiolol infusion, median time until pharmacological cardioversion was 24 h. During landiolol infusion, maintenance of mean arterial pressure target requires a concomitant very low dose of norepinephrine. We did not find any other side effects. Low dose of landiolol used for POAF treatment was effective and safe for a rapid and sustainable rate and rhythm control after cardiac surgery.

[Pericardial foreign body: an unusual cause of chest pain in children]. / Corps étranger péricardique: une cause inhabituelle de douleur thoracique chez l'enfant.

Penetrating thoracic trauma by a needle or pin is rarely described in children. Localization of the needle may sometimes be difficult. The needle can migrate from the entrance site into many organs with time and cause little initial morbidity. We describe the case of a 14-year-old male patient with a sewing needle accidentally inserted through the chest wall. The foreign body had migrated spontaneously to the pericardium. A computed tomography scan of the chest is needed to determine the location of the needle and show any complications. Pericardium foreign bodies are dangerous and need electrocardiography and cardiac ultrasound before treatment. Removal of the needle by thoracotomy or thoracoscopy is indicated.

[Evaluation of the renal function in cardiac surgery with CPB: role of the cystatin C and the calculated creatinine clearance]. / Evaluation de la fonction rénale périopératoire en chirurgie cardiaque: rôle de la cystatine C et de clairance de la créatinine calculée.

OBJECTIVES: The evaluation of the renal function in cardiac surgery is difficult. The gold standard remains the creatinine clearance in clinical practice. Cystatin C was recently proposed in order to evaluate the renal function. The aim of our study was to evaluate the cystatin C in cardiac surgery with CPB. PATIENTS AND METHODS: After informed consent and ethical committee agreement, 60 patients operated in cardiac surgery with CPB were prospectively included. Cystatin C,measured and calculated (Cockcroft and MDRD methods) creatinine were compared with the Student t-test and with the Bland and Altman method. p<0,05 was considered as a significant threshold. RESULTS: The reproducibility of the calculated creatinine clearance was better when the urinary collecting time was below 400 minutes. The estimation of the creatinine clearance by the Cockcroft and MDRD methods is better when the clearance is low. A significant correlation between the creatinine clearance and the cystatin C does exist, but the correlation coefficient was low. In case of acute renal dysfunction, the increase of the creatinine occurred earlier than the increase of the cystatin C. CONCLUSION: In cardiac surgery with CPB, the evaluation of the renal function was not improved by the cystatin C.

[Metabolic acidosis after cardiac surgery with cardiopulmonary bypass revisited with the use of the Stewart acid-base approach]. / Evaluation de la théorie de Stewart lors de l'acidose métabolique survenant après chirurgie cardiaque sous circulation extracorporelle.

INTRODUCTION: According to the Stewart approach of acid-base regulation, chloride from either volume replacement or cardiopulmonary bypass (CPB) priming solution may induce metabolic acidosis. The alternative hypothesis stands in volume dilution with solutions free of bicarbonate. OBJECTIVES: Evaluate the acid-base status of patients undergoing cardiac surgery with CPB priming containing chloride and bicarbonate. MATERIAL AND METHODS: Prospective study. METHODS: Twenty-eight patients were prospectively included. Priming of CPB contained 47.4 mmol/l of bicarbonate and 97.7 mmol/l of chloride. Arterial blood samples were taken at 3 timings: prior (T1) and after (T2) CPB, and on arrival in the ICU (T3). Following measurements were performed: Na(+), K(+), Cl(-), Mg(++), Ca(++), phosphates, albumin, lactate and arterial blood gases. RESULTS: After CPB respiratory acidosis was observed. There was a significant increase of chloride with a decrease in apparent strong ion difference (SIDa). At the same time bicarbonate and base excess (BE) remained constant. A significant but weak correlation between BE and SIDa existed (r(2) = 0.06, p=0.024). On the contrary, no correlation was found between variations of BE and SIDa. However, the correlation was stronger between values and variations of bicarbonate and BE (respectively r(2)=0.605, p<0.0001 and r(2)=0.495, p<0.0001). CONCLUSION: No metabolic acidosis occurred after cardiac surgery when CPB was primed with bicarbonate. Therefore, it appears that chloride administration is not the main mechanism being involved in the acid-base regulation. This reinforces the hypothesis that metabolic acidosis during CPB may mainly be due to dilution of bicarbonate.

Cardiac output measurements in off-pump coronary surgery: comparison between NICO and the Swan-Ganz catheter.

BACKGROUND: The aim of this prospective study was to compare continuous cardiac output measurements of the non-invasive cardiac output system (NICO) with the pulmonary artery catheter during off-pump coronary bypass surgery. METHODS: Twenty-two patients enrolled for off-pump coronary surgery received both a pulmonary artery catheter and a non-invasive cardiac output system for measurement of cardiac output. Data were compared by the Bland-Altman method to calculate the degree of agreement and to analyse if a significant difference existed between the two methods of cardiac output measurements. RESULTS: Perioperatively, the non-invasive cardiac output underestimated cardiac output, but postoperatively overestimated it. The limits of agreement were larger during surgery compared to the postoperative period (-3.1; +2.5 vs. -1.4; +2.2 L min(-1)). Perioperatively, cardiac output measured with the pulmonary artery catheter varied from 0.5 to 7.5 L min(-1) (mean 3.6 L min(-1)) and with the non-invasive cardiac output from 0.5 to 8.4 L min(-1) (mean 3.9 L min(-1)). Postoperatively, these were 2.5-7.7 L min(-1) (mean 4.5 L min(-1)) and 2.3-8.4 L min(-1) (mean 4.9 L min(-1)), respectively. CONCLUSION: During off-pump cardiac surgery, the non-invasive cardiac output reliably measures cardiac output and does it more rapidly than a pulmonary artery catheter and may be more useful in order to detect rapid haemodynamic changes.

[Right atrial rupture after abdominal blunt trauma]. / Rupture de l'auricule droite après traumatisme fermé abdominal.

If the cardiac injuries are frequent after closed chest traumatism, the cardiac injuries after abdominal closed traumatism are unusual but serious. We report the case of a right auricular rupture associated with a liver injury after a closed abdominal traumatism. The diagnosis was suspected on the TDM and confirmed by echocardiography. An emergency sternotomy was performed due to sudden haemodynamic instability. The initial clinical signs are often misleading. However the diagnosis must be made quickly and the treatment begun without delay.

[Evaluation of postoperative mortality and quality of life of patients over 75 years of age after valve replacement for aortic stenosis. Report of 110 cases]. / Evaluation de la mortalité et de la qualité de vie postopératoire des sujets de plus de 75 ans après remplacement valvulaire pour rétrécissement aortique. A propos de 110 cas.

The authors carried out a retrospective study of short and long-term mortality after aortic valve replacement and assessed the quality of life by the IRIS scale in patients over 75 years of age operated for severe aortic stenosis at the University Hospital of Brest between June 1990 and March 1995. The hospital files of 110 consecutive patients (71 women, 39 men; average age 78 +/- 2 years, range 75-85 years) were studied. The pre- per- and postoperative data was studied. Each survivor was contacted by telephone during the year 2000 and a health and IRIS quality of life questionnaire was sent to them. Precise information about patients who had died was obtained from the family and/or medical practitioner. In the preoperative period, 30.9% of patients had left ventricular failure. The average aortic valve surface area was 0.53 +/- 0.12 cm2. Of the patients who underwent coronary angiography (60%), one third had significant coronary lesions. Coronary artery bypass surgery was associated with aortic valve replacement in 10% of cases. Biological prostheses were used in 108 patients. The operative mortality was 8.2%. One year, 5 year and 10 year survival rates were 89.9%, 75.5% and 33.3% respectively. Of the survivors, 16.7% were in institutional care and 83.3% lived at home. A total of 77.8% were readmitted to hospital, about half of them for cardiac problems. Cardiac treatment was prescribed for 97% of patients. The quality of life questionnaire was completed by 35 patients: the quality of life was better than average in nearly 83% of these patients. Aortic valve replacement for aortic stenosis in patients over 75 years of age improves life expectancy which is almost the same as that of the normal population of the same age, and improves the quality of life by restoring functional autonomy, enabling the majority of them to live in their own houses most of the time.

Coronary artery reconstruction for extensive coronary disease: 108 patients and two year follow-up.

BACKGROUND: Surgical coronary artery reconstruction for diffuse coronary disease is described and assessed. METHODS: A long arteriotomy, internal thoracic artery graft, and exclusion of atheromatous plaques from the coronary lumen are the bases of the technique. One hundred eighteen reconstructions were performed in 108 patients with a mean age of 59 years. Stable angina was present in 62% of patients and unstable angina in 22%. Sixteen percent had had a recent myocardial infarction. The reconstructions involved 94 left anterior descending coronary arteries, 17 marginal, 5 diagonal, and 2 right coronary arteries. RESULTS: The perioperative mortality rate was 3.7% (4 patients). The rate of perioperative myocardial infarction was 6.3%. Mean follow-up was 29 months (standard deviation, 10 months). Two patients were lost to follow-up. Ninety patients were free from angina and cardiac-related events. Five patients sustained a myocardial infarction, 3 were in congestive heart failure, 3 had class II angina, and 1 died of stroke. Seventy-four of the surgical coronary artery reconstructions have been angiographically evaluated (29 months): 94.6% of the internal thoracic artery grafts were completely patent, and 70 of the reconstructions were patent without restenosis. String signs and occlusions were present in two internal thoracic arteries each. CONCLUSIONS: This technique allows revascularization of severely and diffusely diseased coronary arteries with encouraging results.

Surgical angioplasty with exclusion of atheromatous plaques in case of diffuse disease of the left anterior descending artery: 2 years' follow-up.

OBJECTIVE: A new surgical technique of coronary artery angioplasty for diffuse and extensive lesions of the left anterior descending artery (LAD) is evaluated in this study. METHOD: Ninety-four coronary artery reconstructions (CAR) using a new technique of angioplasty of the LAD were performed: mean age of patients was 59+/-8 years, there were 21 patients with unstable angina, and 21 with recent myocardial infarction (MI). SURGICAL TECHNIQUE: Diseased LAD is bypassed with the internal thoracic artery graft (ITA). The anastomosis is made downstream from the significant proximal lesion of the LAD. A long arteriotomy (from 2 to 12 cm) is performed along the LAD up to the healthy arterial wall, followed by coverage with the onlay graft of ITA in such a fashion as to exclude the plaques from the LAD lumen. The wall of the new reconstructed LAD consisted of 75% of ITA and 25% of native LAD. The remaining part of the native LAD forms a posterior gutter giving the origins of septal and diagonal branches. RESULTS: aortic cross-clamping time was 116 min, operative mortality rate was 3.2% (three patients), peri-operative infarction rate 6.6% (six patients). The follow-up was 29 months (SD=10). Of the 91 survivors, two were lost for follow-up and one died of non-cardiac causes. Of the 88 patients clinically evaluated, 81 were free from angina and other cardiac events, two had new myocardial infarction in a non-grafted area, two were in congestive heart failure, and three in angina class II. Sixty patients underwent angiography. There were 57 perfect-patency CAR (95%), two ITA string sign (competitive flow), two ITA occlusions (2.5%) and no re-stenosis. CONCLUSIONS: CAR allows revascularisation of diffusely diseased LAD with acceptable operative mortality and morbidity, 2 years' good clinical results and graft patency. In this series, exclusion of plaques prevented plaque complications.

[Failure of internal thoracic-coronary artery bypass graft. What are the reasons?]. / Echec des pontages coronaires avec l'artère thoracique interne. Quelles en sont les causes?

The aim of this study was to identify the causes of failure of coronary bypass grafting with the internal thoracic artery. A total of 512 internal thoracic artery grafts in 302 patients were reviewed. Control coronary angiography was performed after an average of 17.3 months (sigma = 4.1 months). Were considered as failures: 11 (2%) occluded grafts and 19 (4%) non-functional (narrowed internal thoracic artery) grafts. The appearances of the anastomosis, presence or absence of stenosis, origin of flow at the anastomosis and distal run-off of the grafted coronary artery, were analysed. Of the 19 non-functional grafts, there were no stenosis of the anastomosis of the narrowed internal thoracic arteries; in 14 cases, competitive flow was observed (2 internal thoracic artery steal syndromes by non-obstructed proximal collateral branches, 8 initially overestimated coronary stenoses, 4 secondary regressions of coronary stenosis); there was poor distal run-off of the grafted artery in 4 cases and significant coronary stenosis distal to the graft in one case. This study shows that, of the 30 failures of internal thoracic artery grafting, at least 2/3 were "avoidable" by a more accurate evaluation of the coronary stenosis on the preoperative coronary angiography and by better surgical technique.

[Failure of coronary artery bypass with the internal thoracic artery. Does extended use of the internal thoracic artery affect the patency of the coronary artery?]. / Echec des pontages coronaires avec l'artère thoracique interne: l'utilisation extensive de l'artère thoracique interne a-t-elle des conséquences sur la perméabilité des pontages coronaires?

OBJECTIVE: The aim of this study was to precise the circumstances of the failure of coronary artery bypass graft by internal thoracic artery (ITA). METHODS: It was a retrospective study which compared angiographic results between several techniques of ITA graft; 512 coronary artery bypass graft have been realized on 302 patients: 115 single left ITA grafts, 78 sequential left ITA grafts, 48 bilateral pedicled ITA grafts, 61 bilateral ITA Y grafts. The mean interval between operation and reangiography was 17.3 months (s = 4.1 months). Graft failures were occluded and non functioning ITA grafts (threadlike ITA). RESULTS: There were 11 occluded grafts (2%) and 19 non functionning grafts (4%). There was no difference of failure rate between the 4 techniques of ITA grafts (p > 0.05). The failure rate for right ITA grafts 13% was higher than for the left ITA grafts 4% (p < 0.001). The failure rate for obtuse marginal branch grafts 13% was higher than for left anterior descending artery grafts 3% (p < 0.001). CONCLUSION: The extended use of ITA doesn't increase the risk of graft failure rate. The patency of obtuse marginal branch ITA graft is less than the patency of left anterior descending artery or diagonal branch ITA grafts.

Postinfarction atrioventricular septal rupture.

Postinfarction communication between a left ventricular aneurysm and the right atrium is a rare acquired disease. We report a case of a 72-year-old man who recently had dyspnea on minimal exertion and was found to have left ventricle-to-right atrial shunt by two-dimensional transthoracic echocardiography. This diagnosis was confirmed with transesophageal echocardiography, cardiac catheterization, and angiography. The patient underwent successful repair but died of multisystem failure. This case shows the importance of transthoracic echocardiography for the adequate diagnosis and management of such cases.

Retrograde cold blood cardioplegia. Obliteration of the posterior interventricular vein in the coronary sinus improves cooling of the left ventricle posterior wall.

The study hypothesis was that obliteration of the posterior interventricular vein in the coronary sinus avoids the back leak of cardioplegia to the right atrium and forces cardioplegia towards the posterior wall of the left ventricle and interventricular septum. A new retrograde cardioplegia cannula with a long balloon (3 cm) was designed which obstructs the posterior interventricular vein in the coronary sinus. The hypothesis was tested by a prospective randomized study in 52 consecutive patients who underwent coronary or aortic valve surgery. In group I (n = 26), the cannula prototype was used, while a standard cannula (balloon length 8 mm) was used in group II (n = 26). The cardioplegic solution was cold blood (14 degrees C). The posterior wall temperature was recorded when the anterior wall temperature reached 15 degrees C. In group I, 91% of patients had the same temperature in the anterior and posterior walls of the left ventricle versus 19% in group II (P < 0.05). The mean of the difference of left ventricular temperatures between anterior and posterior walls was 0.5 degrees C (sigma = 1.7) in group I versus 8 degrees C (sigma= 4.1 ) in group II (alpha < 0.05). In group I, 9.5% of patients had a posterior wall temperature > 20 degrees C versus 81% in group II (P < 0.05). Cooling of the posterior wall of the left ventricle is better in group I than in group II. As cooling and cardioplegia flow are closely linked, obliteration of the posterior interventricular vein in the coronary sinus improves left ventricular distribution of the cardiplegia.

[Left ventricular distribution of retrograde cardioplegia. Should the interventricular posterior vein be occluded in the coronary sinus?]. / Distribution ventriculaire gauche de la cardioplégie rétrograde. Faut-il obturer la veine interventriculaire postérieure dans le sinus coronaire?

Retrograde cardioplegia is still controversial due to the heterogeneous left ventricular flow distribution particularly in the posterior wall. The purpose of this study was to compare retrograde flow distribution delivered through the coronary sinus with two types of cannula. Fifty two patients were prospectively randomized to receive cold blood retrograde cardioplegia with manual inflating long balloon prototype cannula (group I, 26 patients) or with manual inflating short balloon cannula (group II, 26 patients). Left ventricular distribution of the cardioplegic solution was assessed by monitoring the left ventricular wall temperatures (anterior and posterior). The cardioplegic retrograde infusion was stopped as the anterior wall temperature reached 15 degrees C. In group I, 91% of the patients had identical cooling in the anterior and posterior wall of the left ventricle, versus 19% in group II (p < 0.05). The mean temperature difference between anterior and posterior wall was 0.5 degrees C (standard deviation = 1.7) in group I versus 8 degrees C (standard deviation = 4.1) in group II (alpha < 0.05). The cannula with the long balloon allows a better left ventricular distribution of the cardioplegia flow than the short one because it occludes the interventricularis posterior vein in the coronary sinus.

[Mechanical system of left ventricle cannulation: control of tightness by experimental left ventricular assistance]. / Système mécanique de canulation ventriculaire apicale: contrôle de l'étanchéité par assistance ventriculaire gauche expérimentale.

We have designed a mechanical device for left ventricular apex cannulation (SCAV). It will be used to implant a ventricular connection for a skeletal muscle ventricle placed in apicoaortic configuration without cardio-pulmonary bypass. The aim of this study was to assess the tightness of the ventricular connection at 48 hours. We used a left ventricular assist device (Biomedicus centrifugal pump) placed between the apex of the left ventricle and the descending thoracic aorta on 10 female sheep. The ventricular connection between the apex of the left ventricle and the Biomedicus was carried out with the SCAV and without cardio-pulmonary bypass. The intra-operative mortality was 10% (1 sheep) due to ventricular fibrillation. Three sheep died early in the run of the ventricular assistance due to technical assistance problems not related to the SCAV. The full ventricular assistance could be managed in 6 sheep through 32 h 30 (range from 15 to 46 h). No death occurred in these 9 sheep due to cardiac hemorrage or tamponade. The average apical bleeding in the pericardial drain was 157 ml (range from 20 to 270 ml). The tightness of the ventricular connection was proved by this study. The SCAV may be suitable for apical implantation of a skeletal muscle ventricle in sheep.

[Angioplasty and coronary restoration using the internal mammary artery]. / Angioplastie et remodelage coronaire avec l'artère mammaire interne.

A technique of coronary surgical angioplasty is described. At the level of the stenosis the arteriotomy of the coronary artery is closed with the internal thoracic artery giving an enlargement patch effect. The major surface of the atherome plaque is excluded from the lumen of the anastomosis and put outside the suture line. The origins of the collateral arteries are kept in the vascular lumel. So the new remodeled coronary artery is formed with a small gutter of native coronary artery and the whole surface of the internal thoracic artery wall. In some cases it is useful to associate a limited endarterectomy to the angioplasty. Sixty-six surgical angioplasties have been done in extensive coronary disease. Operative mortality was 5.4% and myocardial infarction 5.4%.

Reimplantation of the right internal thoracic artery as a free graft into the left in situ internal thoracic artery (Y procedure). One-year angiographic results.

Reimplantation of the right internal thoracic artery, as a free graft, into the left in situ internal thoracic artery (Y procedure) has enabled us to bypass more distant marginal vessels, which was not possible by the bilateral technique alone. This prospective study was aimed at evaluating the clinical state of the patients and the degree of patency of grafts within 16 months of follow-up. All 80 patients who underwent the Y procedure between January 1988 and January 1992 were included. This group represented 10% of the 840 patients having coronary bypass during the same period. A total of 202 coronary anastomoses were performed in this series. Early postoperative (30 days) complications included three deaths (3.75%), eight myocardial infarctions (10%), one case of phrenic nerve paralysis (1.25%), two cases of respiratory failure (2.5%), and six wound infections (7.5%). At 3 months' follow-up, 96% of patients were free of symptoms. During the follow-up period, four patients died of noncardiac causes (lung, pancreatic, and brain cancer and rupture of an abdominal aortic aneurysm). At 1 year, 71 patients were free of symptoms (97%). Sixty-one patients underwent coronary angiography between 12 and 24 months. Six patients with peripheral arterial disease were not suitable for coronary angiography, and six refused to be tested. These 12 patients had normal thallium test results in the bypassed area (stress or dipyridamole test). The patency rate of the left internal thoracic artery was 98.3% (n = 60), occlusion rate 1.6% (n = 1), and incidence of threadlike arteries 4.9% (n = 3). Thus the rate of perfect patency was 93.4%. The patency rate of the right internal thoracic artery as a free graft was 93.4% (n = 57), occlusion rate 6.5% (n = 4), and the incidence of threadlike arteries 8% (n = 5). Thus the rate of perfect patency was 85.2%. A total of 169 anastomoses were studied. The rate of patency of the anastomoses to the left anterior descending coronary artery was 96% (n = 58) and the occlusion rate, 4% (n = 2). The patency rate of sequential anastomoses (side to side) to diagonal arteries was 100% (n = 16). Patency rate of anastomoses to obtuse marginal arteries was 95% (n = 58) and the rate of occlusion, 4.9% (n = 3). The patency rate of anastomoses to the posterior descending artery or distal branches of the right coronary artery was 80% (n = 4/5).(ABSTRACT TRUNCATED AT 400 WORDS)

[Hospital procedures and surgical management of patients with stab wounds to the heart]. / Prise en charge hospitalière et conduite chirurgicale dans les plaies du coeur par arme blanche.

Stab wounds of the heart are frequent: one case every two and a half months in our service. In our series of 9 cases, only three were alive at arrival to the emergency ward, but in all of these three, treatment was simple requiring only simple wound suture without extra-corporeal circulation. Based on our experience and the data in the literature, we propose cooperation between three teams for managing these patients: anaesthesists, echocardiographists and cardiothoracic surgeons. The patients are admitted directly to the cardiothoracic operating theatre where the echocardiographist and the surgery team take charge. The surgical procedure depends on the general situation and especially on whether or not the echocardiologist can confirm haemopericardium immediately. Every patient with possible wound to the heart or major vessels should be managed directly by the cardiothoracic surgery team before of formal diagnosis has been established.

[Patency of left border artery bypass after 1 year; comparison of three techniques]. / Perméabilité à 1 an des pontages de l'artère marginale gauche; comparaison de trois techniques.

The one year results of three techniques of bypass grafting of the artery of the left border of the heart were compared in a retrospective study in 120 patients all undergoing left anterior descending bypass grafting with an internal mammary artery. Group I comprised 38 consecutive patients: the left border artery was bypassed with a venous graft. Group II comprised 49 consecutive patients who had the left border artery bypassed by an internal mammary artery in situ. Group III comprised 33 consecutive patients who had the left border artery bypassed by an internal mammary graft issuing from a Y-shaped construction (right internal mammary artery as a free graft reimplanted into the left internal mammary artery). The operative mortality, morbidity and functional results were comparable in the three groups. The rate of angiographic success of the left border artery graft at one year was: 65.7% in group I, 89.5% in group II and 87.8% in group III. The one year patency of internal mammary artery grafting of the artery of the left border was higher than that of venous grafts (p < 0.05).