[Development of indications in surgery of coronary revascularization. Current role of mammary-coronary anastomoses]. / Evolution des indications opératoires en chirurgie de revascularisation coronarienne. Place actuelle des anastomoses mammaro-coronariennes.

At a time when the cardio-surgical community has become aware that arterial revascularizations are superior to venous bypasses, GRUNTZIG (24) initiated the now well-known, and highly successful techniques of endoluminal angioplasty (P.T.C.A.) thus leading many teams to explore non-surgical revascularizations. These fast changing events somewhat overshadowed the interest placed in arterial anastomoses in general, and in particular, in mammary-coronary anastomoses. We believe that in 1993, many centres have not used this technique to its fullest and propose to the Académie de Chirurgie a programme of operative indications reinstating mammary-coronary anastomosis to its proper place in the treatment of coronary artery disease.

[Continuous venovenous hemofiltration after cardiac surgery. A retrospective study in 16 patients with multiple organ failure]. / Hémofiltration continue veinoveineuse après chirurgie cardiaque. Etude rétrospective chez seize patients en défaillance multiviscérale.

As intermittent haemodialysis in critically ill patients is often associated with circulatory instability and hypotension, pumped continuous veno-venous haemofiltration (CVVH) has been proposed as an alternative. This technique was used postoperatively in 16 cardiac surgery patients with cardiogenic shock (cardiac index < 2.2 l.min-1.m-2), anuria and multiple organ failure. A mean haemofiltration rate of 0.5 to 1 l.h-1 was used. Average length of treatment was 57 +/- 38 h. Two patients were improved and weaned from CVVH after 96 and 144 h respectively. The other fourteen died. A mean 200 +/- 50 ml of liquid were removed every hour. The technique was well tolerated by the cardiovascular system. The systolic arterial pressure, heart rate and cardiac index remained unchanged. Body weight had decreased by 3 +/- 1 kg after 48 h of use. Similarly, serum creatinine concentration was lowered from 337 +/- 32 mmol.l-1 to 252 +/- 27 mmol.l-1 (p < 0.001). At that time, urea and creatinine clearances were 18 +/- 2 ml.min-1, and 15 +/- 1 ml.min-1 respectively. After 24 h of CVVH, both serum sodium and potassium concentrations had been decreased, from 148 +/- 3 mmol.l-1 to 142 +/- 2 mmol.l-1 (p < 0.001), and from 5.7 +/- 0.3 to 4.2 +/- 0.15 mmol.l-1 (p < 0.001) respectively. In addition, pH increased significantly from 7.13 +/- 0.1 to 7.30 +/- 0.04 (p < 0.001). These results were comparable with these of other authors regarding safety and efficiency of CVVH. The low patient survival rate (12.5%) was due to the severity of cardiac impairment.(ABSTRACT TRUNCATED AT 250 WORDS)

Penetration of ciprofloxacin into heart valves, myocardium, mediastinal fat, and sternal bone marrow in humans.

The penetration of ciprofloxacin into heart tissue (valve and myocardium), mediastinal fat, and sternal bone marrow was the object of a prospective nonrandomized study involving 36 patients undergoing mitral and/or aortic valve replacement. Patients were divided into two groups of 18. Group 1 patients were administered a single 400-mg intravenous dose of ciprofloxacin over a 1-h period. Group 2 patients received a 750-mg dose of ciprofloxacin orally every 12 h over the 48-h period preceding surgery. In this group, the last dose of ciprofloxacin consisted of an intravenous infusion of 400 mg. Concentrations of ciprofloxacin in plasma and tissue were assayed by high-performance liquid chromatography. Peak and trough levels in plasma were, respectively, 6.19 +/- 1.73 and 0.54 +/- 0.25 micrograms/ml in group 1 patients and 11.59 +/- 3.95 and 0.89 +/- 0.57 micrograms/ml in group 2 patients. Levels of ciprofloxacin in plasma remained significantly higher in group 2 than in group 1 until 12 h postinfusion (P less than 0.05). Concentrations of ciprofloxacin in heart valves and myocardia rose rapidly by 1 h postinfusion and remained greater than the MICs for usually susceptible pathogens for at least 5 h. Peak concentrations in myocardia were achieved by hour 1 and were 31.6 +/- 25.0 micrograms/g for group 1 and 21.8 +/- 13.0 micrograms/g for group 2. Peak concentrations in heart valves, achieved between hours 1 and 3, were 5.8 +/- 3.2 and 8.3 +/- 3.1 micrograms/g for groups 1 and 2, respectively. In both groups, peak concentrations in mediastinal fat were lower and achieved later. These were 3.1 +/- 3.8 micrograms/g in group 1 and 2.0 +/- 1.8 micrograms/gram in group 2 and were achieved between hours 3 and 5 and hours 1 and 3, respectively. In conclusion, the good diffusion of ciprofloxacin into heart tissue warrants its use for the treatment of bacterial endocarditis. On the other hand, low and delayed concentrations in mediastinal fat could limit its value as an antibiotic prophylactic agent in a cardiovascular surgical setting when administered immediately (less than 3 h) before surgery.

[Value of continuous venous blood oxygen measurement during external circulatory assistance]. / Intérêt de la mesure en continu de la SvO2 pendant une assistance circulatoire externe.

A case is reported of a 40 year-old man, on the waiting-list for heart transplantation, who developed terminal heart failure. Using an Opticath catheter and a radial artery catheter, SV(-)O2 was monitored continuously, and cardiac output, pulmonary arterial and wedged pressures, and right atrial pressure were repeatedly measured. Despite appropriate treatment (adrenaline, dobutamine, glyceryl trinitrate), the patient remained in anuria and cardiogenic shock. External circulatory support (ECS) (BVS 5000 Abiomed) was therefore used as a bridge to cardiac transplantation. The resultant increase in systemic blood flow led to an early and fast rise in SV(-)O2, from 40% to 73%, with a decrease in the oxygen extraction ratio (ERO2) from 50 to 30%. Serum lactate concentrations returned to normal within the first six hours of ECS (less than 120 mg.l-1). During the first 24 h of ECS, SV(-)O2 decreased and ERO2 rose significantly on two occasions: during an episode of shivering, and another of restlessness during nursing. An attempt at weaning the patient from the ventilator at the 39th h also led to a sudden decrease in SV(-)O2, with a rise in ERO2. The Opticath catheter was finally removed after 150 h of ECS because of a decrease in reflected light intensity.

[Plasma and tissue concentrations of cefamandole during cardiac surgery]. / Concentrations sériques et tissulaires du céfamandole pendant la chirurgie cardiaque.

This study aimed to determine plasma (CPC) and tissue concentrations of cefamandole during cardiac surgery, so as to compare them with the minimal inhibitory concentration (MIC) for staphylococci (0.25 - 1 microgram.ml-1 for S. aureus; 2 micrograms.ml-1 for S. epidermidis). Cefamandole was given prophylactically to 8 consecutive patients as a single intravenous dose of 60 mg.kg-1. Tissue concentrations were measured in presternal subcutaneous loose tissue and sternal marrow. Average CPC was 233.75 +/- 58 micrograms.ml-1, 15 min after drug administration, 187 +/- 6.4 micrograms.ml-1 at the time of sternotomy, 57.9 +/- 36.5 micrograms.ml-1 10 min after the start of bypass and 36.4 +/- 18.4 micrograms.ml-1 at its end, and 15.5 +/- 5.9 micrograms.ml-1 at the end of the procedure. Sternal subcutaneous tissue and marrow concentrations were respectively 24.4 +/- 13.3 micrograms.g-1 and 31 +/- 5.6 micrograms.g-1 at the time of sternotomy, and 9.4 +/- 5.5 micrograms.g-1 and 9.2 +/- 3.5 micrograms.g-1 at the end of the procedure. Giving a high dose of cefamandole preoperatively appeared to have an effective prophylactic antibiotic action, as the plasma and tissue concentrations were always higher than the MIC for staphylococci.

Endarterectomy of the left main coronary artery stenosis by a 'transpulmonary artery approach'.

For better visualization of the left main coronary artery, a new technique involving transection of the main pulmonary artery is described. With this new method it was possible to perform endarterectomy of the left main coronary artery in 35 patients from February 1981 to July 1987. The endarterectomy incision was closed with a pericardial or venous patch. We had no mortality, and 91% are free from angina at a mean follow-up of 31 months. Angiographic evaluation was performed in 19 patients revealing good patency of the left main artery. This procedure is safe, and we recommend it in isolated left main coronary artery stenosis without distal involvement and with good left ventricular function.

Cardiorespiratory function and pathological findings in heart-lung block reimplanted after hypothermic preservation.

A good result from the heart-lung transplantation depends on the quality of the preservation of cardiopulmonary transplants. To determine the functional and pathological status of the heart-lung block after preservation for several hours, we performed 10 heterologous heart-lung transplantations in Beagle dogs (weight 13.5 kg) under extracorporeal circulation. Weight and length compatibility between donor and receiver was ensured. Measurements of hemodynamics, lung mechanics and blood gases were performed in the donor and in the receiver before the transplantation, and in the receiver after heart-lung reimplantation. Histological studies were carried out by biopsy on the heart and on the lung of the donor before removal, at the beginning of the preservation at low temperature, after 3 h of ischemia in cold, and every hour after recirculation in the heart-lung block. Myocardial preservation was conducted with cold cardioplegia at 4 degrees C (Ringer lactate solution with high potassium). Lung preservation was achieved by injecting a Euro-Collins solution at 4 degrees C, with addition of dog plasma, into the pulmonary artery; during the whole ischemic phase, the lung parenchyma was maintained at 0 degrees C, and inflated at a 10 cm H2O pressure. After transplantation, we observed that cardiac output was low in all cases, with normal or subnormal pulmonary arterial pressure. Dynamic lung compliance was very low immediately after transplantation, and increased when restarting the circulation, but deteriorated again after several hours. At the same time alveolo-arterial O2 pressure difference and arterio-alveolar CO2 pressure difference progressively increased, due to the extensive gas exchange impairment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Emergency coronary surgery after transluminal coronary angioplasty]. / Chirurgie coronarienne en urgence au décours d'une angioplastie transluminale coronarienne.

Twenty-five patients underwent emergency coronary arterial bypass surgery immediately after attempted percutaneous transluminal coronary angioplasty (PTCA). The average time between the onset of PTCA complication and revascularization was 90 min (30-120 min). The surgical indications, the anaesthesia and the perioperative intensive care were analysed. No acute complication was observed during the anaesthesia. Peroperative findings defined two groups: the first "organic" (coronary arterial dissection and/or occlusive coronary thrombi; n = 15), the second "functional" (coronary arterial spasm; n = 10). The rate of perioperative myocardial infarction was significantly higher in the "organic" group. In this group, at the end of the cardiopulmonary bypass, a higher number of patients required circulatory assistance and/or an antiarrhythmic agent, as well inotropic drugs.

[Surgery of the left coronary trunk by the transpulmonary approach. 10 cases]. / Chirurgie du tronc coronaire gauche par voie transpulmonaire. Dix observations.

The most common lesions of the left main coronary artery are atheromatous lesions (1% of all "coronary patients") but traumatic lesions may occur during coronary arteriography or percutaneous coronary angioplasty. To these must be added severe infectious lesions of the aortic annulus in acute endocarditis affecting the valve or a valvular prosthesis. The 10 cases reported here (4 atheromatous, 1 traumatic and 5 infectious lesions) were treated by transpulmonary repair surgery of the left main vessel. The operations performed were endarterectomy alone (2 cases) or associated with venous graft (2 cases), resection and venous graft (1 case) and suprasigmoidal prosthetic reimplantation (5 cases). There were two early post-operative deaths (one due to major hypocoagulation with secondary hypoxia and one from irreversible cardiogenic shock); another patient died of a ruptured intracerebral mycotic aneurysm 2 months after the operation. The 7 remaining patients have been asymptomatic for 1 year, and angiographies performed on 4 occasions since surgery have given "satisfactory results". The transpulmonary route gives direct access to the left main coronary artery and facilitates a reconstructive surgery adapted to the lesions encountered.

[Early coronary spasm after myocardial revascularization surgery]. / Spasme coronaire précoce après chirurgie de revascularisation du myocarde.

Six cases of early post-operative coronary artery spasm were observed in a series of 460 consecutive patients who underwent myocardial revascularization. This is a rare accident, only quite recently described. The spasm involves the coronary arterial network or the graft and is reflected in an elevated ST segment accompanied by collapse and ventricular dysrhythmia. The condition may be lethal or may result in myocardial infarction. Treatment consists of calcium inhibitors. The cause of the spasm is unknown, but it seems to be encouraged by trauma of the coronary arteries during surgery and by metabolic changes (production of thromboxane A2) induced by the cardio-pulmonary bypass. This particular spasm must be watched by heart surgeons and their team in order to avoid some deaths and peroperative necroses, as it appears that we are only confronted with its more severe forms.