Enhancement of non-coronary collateral blood flow from the internal thoracic arteries: the theoretical and practical basis of an alternative method of myocardial blood supply.

Non-coronary collateral blood flow arrives to the heart from mediastinal, bronchial, and pericardial channels. These enter the heart through the pericardial reflections surrounding the pulmonary and systemic veins, as well as from the vasa vasorum of the aorta and the pulmonary artery leading to and from the myocardium. Before the advent of cardiopulmonary bypass surgery, surgical bilateral ligature of the internal thoracic arteries (ITAs) was performed in patients with ischemic heart disease to increase the perfusion pressure within the channels leading to the heart. Nowadays, the occurrence of natural collaterals between coronary and extracardiac arteries including the ITAs, the potential hemodynamic effects of ITA ligation, the potential of ITAs for developing important collateral branches, and the current availability of angiogenic growth factors could pave the way for the development of a new field in cardiovascular research aimed at developing an alternative strategy of myocardial blood supply by means of the surgical and biological enhancement of non-coronary collateral circulation.

Recurrence of postoperative aortic fistulas: is there an ideal method of prevention? A case report.

There are very few cases in English literature of recurrent postoperative aortic fistulas (RPAFs). These are neo-communications between the aortic bloodstream and the lumen of contiguous organs which occur after unpredictable periods from surgical treatment of a previous fistula. The supradiaphragmatic aorta may fistulize into the airways, pulmonary circulation, oesophagus, and cardiac chambers; the infradiaphragmatic aorta into the intestine, stomach, and vena cava. According to the etiology, aortic fistulas are categorized as postoperative (or secondary) and spontaneous (or primary), and RPAF may be considered a subgroup of secondary fistulas. They may recur even more times in the same patient, hence the role of prevention is of the utmost importance. The simultaneous respect of different surgical principles is crucial to make the risk of recurrence less likely. Surgical treatment represents a real challenge due to the emergency conditions and redo nature of operations. Mortality rate is very high. In this article, we describe a case of recurrent aorto-duodenal communication, we discuss the principles of prevention both for the supra and infradiaphragmatic aorta, we introduce some modifications to the classic categorization and we present the first RPAF literature review.

[Surgery of ventricular tachycardia in post-infarction left ventricular aneurysm]. / Chirurgie des tachycardies ventriculaires sur anévrismes ventriculaires gauches post-infarctus.

The treatment of post-infarction ventricular tachycardias with antiarrhythmic drug therapy, implantable automatic defibrillators, radiofrequency ablation, also includes different surgical procedures such as endocardial resection of the infarct scar, encircling endocardial ventriculotomy and endocardial cryoablation or thermoexclusion by laser. These procedures may be extensive or limited, guided or not by preoperative mapping. The aim of this review of the literature is to update our knowledge of these different surgical techniques and to define their indications.

Internal thoracic arterial grafts evaluation by multislice CT scan: a preliminary study.

BACKGROUND AND AIM: The internal thoracic artery (ITA) has a better long-term patency than saphenous veins, and anastomosis between ITA and the left anterior descending artery (LAD) represents the "gold-standard" of surgical myocardial revascularization. The aim of this study is to evaluate the multidetector multislice CT Scan (MCTS) as a means of postoperative evaluation of ITA coronary artery bypass grafts. METHODS: Twenty-eight patients having been operated on for coronary artery bypass with ITA during a 6-months period, benefited, 7 days after surgery, from a patency and anastomotic site control of ITA with a MCTS associated with cardiac gating (Light Speed, General Electric, USA). RESULTS: Internal thoracic artery bypasses are visualized perfectly on all their courses, with possibility of 3D reconstructions, showing the relationship between cardiac cavities and the arterial bypasses. The anastomotic site on the LAD was, in selected cases, perfectly visualized. Sequential bypasses with left ITA are well visualized as well as T or Y right-to-left ITA grafts. However, surgical clips create some image artefacts. CONCLUSIONS: The postoperative control of ITAs are possible by MCTS with a satisfactory resolution. This makes it possible to check the patency of ITAs, their course on the heart surface, and the location and quality of anastomosis with a noninvasive reproductive method.

Inhaled prostacyclin reduces cardiopulmonary bypass-induced pulmonary endothelial dysfunction via increased cyclic adenosine monophosphate levels.

OBJECTIVE: Cardiopulmonary bypass triggers a systemic inflammatory response that alters pulmonary endothelial function, which can contribute to pulmonary hypertension. This study was designed to demonstrate that inhaled prostacyclin, a selective pulmonary vasodilator prostaglandin, prevents pulmonary arterial endothelial dysfunction induced by cardiopulmonary bypass. METHODS: Three groups of Landrace swine were compared: control without cardiopulmonary bypass (control group); 90 minutes of normothermic cardiopulmonary bypass (bypass group); 90 minutes of cardiopulmonary bypass and treated with prostacyclin during cardiopulmonary bypass (continuous nebulization with continuous positive airway pressure until the end of the cardiopulmonary bypass; prostacyclin group). After 60 minutes of reperfusion, swine were put to death and pulmonary arteries harvested. After contraction to phenylephrine, endothelium-dependent relaxation to bradykinin and acetylcholine was studied in standard organ chamber experiments. The pulmonary artery intravascular cyclic adenosine monophosphate content was compared between the 3 groups (post-cardiopulmonary bypass). RESULTS: There was a statistically significant improvement of the endothelium-dependent relaxation to bradykinin in the prostacyclin group when compared with the bypass group (P <.05). There was no statistically significant difference for endothelium-dependent relaxation to acetylcholine (P >.05) between the prostacyclin and the bypass groups. There was a statistically significant decrease in the cyclic adenosine monophosphate content and a statistically significant increase of the mean pulmonary artery pressure in the bypass group only (P <.05). CONCLUSION: Prophylactic use of inhaled prostacyclin has a favorable impact on the pulmonary endothelial dysfunction induced by cardiopulmonary bypass associated with preservation of pulmonary intravascular cyclic adenosine monophosphate content and the pulmonary vascular tone.

Topical negative pressure therapy. A very useful new method to treat severe infected vascular approaches in the groin.

AIM: The treatment of infected vascular surgery sites is challenging. Negative pressure applied uniformly to the entire wound surface has been shown to allow granulation tissue formation and to promote healing of acute and chronic wounds. METHODS: We used the Vacuum-Assisted Closure (VAC, Kinetic Concepts Incorporated, San Antonio, Texas, USA) system in 4 patients with severe groin wound infection after emergency surgery on the femoral artery. RESULTS: In all 4 patients, general health improved and the wound changed rapidly from a large infected cavity to a minor lesion readily covered using a simple surgical technique. CONCLUSION: This study establishes VAC as a very valuable tool for managing severe complications of groin vascular surgery sites even in patients with obesity and/or diabetes mellitus.

Simple surgical technique to prevent direct secondary aortoenteric fistulas.

To prevent direct secondary aortoenteric fistulas, a devastating complication of abdominal aortic surgery, we describe here a rapid, very easy to perform and no cost operating technique. A part about 4 cm long of the vascular prosthesis was cut to obtain a partial tailored ring which was passed through the prosthesis. After the anastomosis was realized, the tailored ring was hitched up to totally cover proximal anastomosis and prevent direct contact between aorto-prosthetic anastomosis and the bowel.

Aspergillus flavus mitral valve endocarditis after lung abscess.

A 16-year-old male with bone marrow failure due to chemotherapy for recurrent acute lymphoblastic leukemia developed an abscess in the lower lobe of the left lung draining through a bronchogastric fistula, as well as mitral valve endocarditis with large vegetations. After a course of antifungal therapy, the left lobe was removed and the fistula closed. The mitral valve was then replaced, after a failed attempt at valve repair, by a mechanical, double-leaflet prosthesis. Microscopy of the lung and heart specimens disclosed hyphae. Cultures of both specimens on Sabouraud's medium recovered a fungus, which was identified by culturing on Czapek's medium as Aspergillus flavus. Despite further antifungal therapy, fatal embolism developed. The emboli contained the same A. flavus as the valve and lung specimens. This case confirms the grim prognosis of primary Aspergillus endocarditis in immunocompromised patients, and suggests that delayed surgical treatment and the presence of another focus of Aspergillus infection may increase the risk of death.

Vertebral artery surgery with cardiopulmonary bypass and deep hypothermia.

Deep hypothermia was proposed to prevent neuronal ischemia and stroke during surgical procedures on arteries that supply the brain, especially with extended occlusive lesions on both internal carotid arteries. The interest of this therapeutic option is still under discussion, even in the case of combined cardiac and cerebrovascular surgery. We report the case of a 53-year-old male who was admitted to our institution for symptomatic vertebrobasilar insufficiency. Angiography showed a thrombosis of both internal carotid arteries, stenosis of both external carotid arteries, and a tight proximal stenosis of a dominant right vertebral artery. Endarterectomy and angioplasty of the origin of the right external carotid artery was done first to increase the blood supply to the brain via collateral arteries connecting the extra- and intracranial networks. Six weeks after this, a right-sided vertebral-to-carotid artery anastomosis was performed during cardiopulmonary bypass (CPB)-induced deep hypothermia for optimal neuronal protection, with good results. However, early thrombosis of the right vertebral artery requiring reintervention in normothermia, without any stroke, indicate that deep hypothermia was unnecessary in this case, probably because of the previous natural and surgical development of collateral circulation. However, there was no means of predicting this in a reliable manner before the procedure and deep hypothermia appeared a safe technique for neuronal protection without any specific postoperative complications.