Supravalvular aortic stenosis of the diffuse type: 29 years follow-up after aortic endarterectomy and symmetric enlargement of the ascending aorta and of the three coronary sinuses.

Supravalvular aortic stenosis is a rare congenital anomaly characterized by variable amounts of left ventricular outflow tract obstruction distal to the aortic valve. Macroscopically, it is categorized into three morphologic subtypes: membranous, hourglass, and diffuse. The diffuse type is the most rare, and its surgical repair is the most challenging due to variable length of ascending aorta hypoplasia. Surgical treatment options of supravalvular aortic stenosis are well established for the membranous and hourglass type, whereas they are challenging and less well defined for the diffuse type. We present a case of long-term follow-up (29 years) after a very complex surgical repair of supravalvular aortic stenosis of the diffuse type, with focus on technical aspects. To our knowledge, the present case represents one of the longest follow-up routines in the English language literature of surgical treatment of supravalvular aortic stenosis.

Reconstructive surgery of postinfarction left ventricular aneurysms: techniques and unsolved problems.

The progress in the surgical treatment of postinfarction left ventricular (LV) aneurysm surgery has reduced the operative mortality considerably, while the selection of the optimal LV repair technique remains unclear. Any of the surgical techniques presented in this review has its own advantages and disadvantages. The main goal of this study was to perform a selective literature review of LV aneurysm repair techniques, the most widespread being the linear repair and patch ventriculoplasty.

Cardiac lymphoma following mitral valve replacement.

A primary cardiac lymphoma was encountered in a patient with prosthetic mitral valve dysfunction. Although rare, this tumor could be related to the presence of prosthetic material and specifically that of Dacron. Primary cardiac tumors have to be considered in the differential diagnosis of prosthetic valve dysfunction.

Long-term outcomes after cryoablation for ventricular tachycardia during surgical treatment of anterior ventricular aneurysms.

Intraoperative map-guided procedures have been widely advocated as the best surgical strategy for the treatment of ventricular tachycardia (VT), though favorable results have been reported with subendocardial resection without mapping. This study examined the very long-term results of encircling cryoablation without mapping during surgery for anterior left ventricular aneurysm complicated by VT. Between 1985 and 2003, this procedure was performed in 52 patients, 7 of whom (13.7%) were operated within 1 month of anterior myocardial infarction. Their mean age was 64.4 +/- 8.3 years and mean left ventricular ejection fraction was 31.7%+/- 9.5%. The overall hospital mortality was 1.9%. At 14 years, 86% of patients (95% CI: 75.4-96.6) were free from VT or sudden death. An implantable defibrillator was implanted in five patients (9.6%) during follow-up. The 14-year overall survival was 51.4% (95% CI: 33.8-72.4), and two patients (3.8%) underwent cardiac transplantation during follow-up. The main cause of late death was congestive heart failure in eight patients (40.0%). Favorable long-term results can be achieved with encircling cryoablation without mapping in patients undergoing surgery for anterior left ventricular aneurysm complicated by VT.

Pericardial exploration by pericardioscopy during a surgical sub xyphoid approach.

This clinical feasibility study was planned to evaluate pericardioscopy as a means of control of the pericardial cavity during drainage for pericardial effusion by a surgical sub xyphoid approach. Seventeen patients who underwent an operation for surgical drainage of the pericardium (11 medical and 6 postoperative pericardial effusions) benefited from a pericardial exploration with a mediastinoscope or rigid thoracoscope (Karl Storz, Germany). In 7 of the 11 medical cases, a severe inflammation of the pericardium associated with false membranes was visualized; in 3 cases, the pericardium was considered as normal; and in 1 case, pericardial metastases were visualized. In the 6 postoperative cases, clots were visualized with a venous bypass graft and the pulmonary cannula of a right ventricular assist device (Thoratec, USA) was also perfectly controlled. The cause of bleeding was reported in one case and suspected in another, but required total sternotomy for repair in both cases. No mortality or morbidity was reported to be directly due to the technique. The peroperative assessment of pericardial cavity is possible by use of pericardioscopy with a satisfactory resolution, but visualization of the left lateral part of the heart remains difficult. The possibility exists to partially remove clots and false membranes, obtain various samples, and control the position of the drains. Improvement in the optic device with the possibility of a flexible device that has a tip protector for optimal visualization, may improve both the technique and results.

Increased early postoperative morbidity with off-pump coronary artery bypass grafting surgery in patients with diabetes.

BACKGROUND: Patients with diabetes constitute a high-risk population for myocardial revascularization due to extensive coronary disease. OBJECTIVE: To compare the early postoperative outcomes of patients with diabetes undergoing off-pump or on-pump coronary artery bypass surgery. METHODS AND RESULTS: Over a four-year period (1995 to 1998), 885 diabetics were operated for primary isolated coronary bypass; 156 patients had off-pump and 729 had on-pump coronary artery bypass surgery. Patients in the off-pump group were significantly older, had a higher incidence of hypertension and renal failure, and received fewer distal anastomoses (2.7 versus 2.9, P=0.004). Postoperative myocardial infarction, reintubation and postoperative use of intra-aortic balloon pump occurred significantly more frequently in the off-pump group (10.3% versus 5.5%, P=0.04; 8.3% versus 3.6%, P=0.03; 7.7% versus 1.5%, P=0.0001, respectively). Multivariate analysis revealed that type of surgery was an independent predictor of these complications, which occurred 1.9, 2.7 and 7.9 times more often, respectively, in the off-pump group. The 30-day mortality rate was not significantly different between the groups. CONCLUSIONS: Off-pump coronary artery bypass surgery is associated with an increased early postoperative morbidity in patients with diabetes and, thus, should be used with caution.

Off-Pump Coronary Artery Bypass Grafts Assessment by Multislice Computed Tomography.

Abstract Background: Selective coronary angiography is the standard but invasive procedure for postoperative assessment of coronary artery bypass graft patency. The aim of this prospective study is to evaluate the multislice computed tomography (CT) as a means of postoperative patency assessment and anastomotic site control of arterial and venous coronary bypass grafts performed with off-pump coronary artery bypass techniques. Methods: Over a 6-month period, 20 patients underwent isolated coronary artery bypass (beating heart technique) and benefited, 7 days later, from a patency and anastomotic site control by multidetector angio multislice CT with cardiac gating. Results: Whole internal thoracic artery bypasses and venous grafts were visualized perfectly on their entire length, including the anastomotic site, and 3-dimensional reconstruction was possible. The relationship between cardiac cavities and the bypasses were well visualized, allowing quantification of bypass stenosis ensured by software analysis. Conclusions: Postoperative control of coronary bypasses is possible by multislice CT with a very satisfactory resolution, thus making it possible to check the patency of coronary bypasses and the quality of anastomosis with a noninvasive method. Three-dimensional reconstructions are very useful in the event of redo surgery.

Experimental model for comparative evaluation of pharmacologically induced vasodilation of arterial wall mechanical properties.

Arterial wall compliance (C) and distensibility coefficient (DC) are key factors of pathologic physiology, especially in arteries less than 2 mm in diameter. The aim of this study was to design an experimental model allowing comparative measurement of C and DC during pharmacologically induced vasodilation on small-diameter arteries. Both femoral arteries were exposed in eight New Zealand White rabbits. Diameter (d) and systolic/diastolic diameter changes (deltad) were measured simultaneously, and C and DC were calculated before and after topical application of 1 mL of 4% papaverine on the right side and topical application of 1 mL of 1% lidocaine on the left side. Diameter measurements were performed by echo tracking with 20-MHz implanted microprobes. After papaverine and lidocaine application, respectively, d increased from 1.36 mm to 2.23 mm (P < 0.0001) and from 1.45 mm to 2.4 mm (P < 0.0001), deltad increased from 0.0568 mm to 0.0571 mm (P = 0.34) and from 0.064 mm to 0.077 mm (P < 0.01), C increased from 5.7 x 10(-3) mm/mm Hg to 6 x 10(-3) mm/mm Hg (P < 0.02) and from 6.23 x 10(-3) mm/mm Hg to 8.49 x 10(-3) mm/mm Hg (P < 0.01), and DC decreased from 4.22 x 10(-3) mm Hg(-1) to 2.61 x 10(-3) mm Hg(-1) (P < 0.0004) and from 4.36 x 10(-3) mm/mm Hg to 3.46 x 10(-3) mm/mm Hg (P < 0.005). Papaverine- and lidocaine-induced changes were significantly different for deltad, C, and DC (P < 0.01). These results suggest that, unlike that with papaverine, lidocaine-induced vasodilation leads the artery up to the nonlinear part of its pressure/diameter relationship, with decreased distensibility contrasting with increased diameter and compliance. Our experimental model may be useful to compare the effects of different vasoactive drugs at different concentrations on the mechanical properties of the arterial wall.

Influence of intracoronary shunt size on coronary endothelial function during off-pump coronary artery bypass.

OBJECTIVE: The insertion of intracoronary shunts during off-pump coronary artery bypass surgery may induce severe endothelial dysfunction in the target arteries. The purpose of this study was to determine the role of the ratio of the shunt diameter to the target artery diameter in the development of endothelial dysfunction and to develop guidelines for selecting the most appropriate shunt size. METHODS: Nine swine (25 +/- 4 kg) were used for this study. Three ClearView shunts 3 mm, 2 mm, and 1.25 mm in diameter were inserted proximally to distally via 3 arteriotomies into the right coronary artery to obtain oversizing with the 3-mm shunt, undersizing with the 1.25-mm shunt, and a satisfying congruence with the 2-mm shunt. The shunts were left in place for 15 minutes, and the levels of bleeding were quantified. Coronary rings upstream and downstream from the arteriotomies were then harvested and placed in organ chambers to study endothelium-dependent relaxations to serotonin and bradykinin. Noninstrumented coronary arteries served as controls. RESULTS: A decrease of endothelium-dependent relaxation occurred with the 3-mm shunts (P <.005), which were associated with an adequate hemostasis. A decrease of endotheliumdependent relaxation occurred with the 2-mm shunts (P <.05), which were associated with intermittent bleeding, and no significant decrease of endothelium-dependent relaxation occurred with 1.25-mm shunts (P >.05), which were associated with continuous bleeding. CONCLUSIONS: Intracoronary shunts are associated with different disadvantages, depending on the mismatch to the target coronary artery, and whatever their size, shunts are not the ideal device for safely obtaining a satisfactory hemostasis. These results support our clinical attitude of the selective use of intracoronary shunts.

Interrupted coalescent nitinol clip versus continuous suture coronary anastomosis: a comparative endothelial function study.

BACKGROUND: A new penetrating stapled anastomotic system using nitinol microclips (Coalescent Surgical U-Clip) has been developed to facilitate the construction of compliant interrupted sutures for minimally invasive and robotic surgery as well as for conventional procedures. The purpose of this study was to determine the effect of nitinol U-Clips used for coronary anastomosis in the development of endothelial dysfunction, compared with conventional running sutures. METHODS: In a porcine model, both internal thoracic arteries were harvested, and the heart was removed. In a Krebs solution, 2 anastomoses were realized ex vivo between internal thoracic arteries and the left anterior descending artery. One was carried out with 12 Coalescent microclips, and the other used conventional running 7-0 polypropylene suture material (Prolene). Coronary rings on the anastomotic sites were then placed in organ chambers filled with oxygenated Krebs solution. Vascular reactivity studies were performed in standard organ chamber experiments. After the contraction of the coronary arteries in response to prostaglandin F2alpha, the endothelium-dependent relaxation response to bradykinin was studied. The other coronary arteries served as controls. RESULTS: There was no statistically significant difference among the groups (P >.05) in the amplitude of the contraction response to KCl and prostaglandin F2alpha. There were no statistically significant differences in endothelium-dependent relaxation response to bradykinin between the nitinol microclip group and controls, between the suture group and controls, and between the nitinol microclip and suture groups. CONCLUSIONS: Coalescent nitinol U-Clips used as anastomotic devices do not induce an endothelial dysfunction and allow a compliant anastomosis under satisfactory conditions.

Surgical radiofrequency ablation induces coronary endothelial dysfunction in porcine coronary arteries.

OBJECTIVES: Surgical radiofrequency ablation is increasingly used during open heart surgery for the treatment of chronic atrial fibrillation. The purpose of this study was to determine the effects of application of radiofrequency on coronary endothelial function and structure and establish the relationship between coronary lesions and distance of radiofrequency application. METHODS: Six Landrace swine (25.9+/-2.0 kg) were included in the study. With the heart kept beating, three epicardial radiofrequency lesions (20 W, 20 s duration, 60 degrees C) 2 cm in length each, were created 1, 5 and 10 mm away from the left anterior descending and the right coronary arteries. The circumflex artery served as control. Coronary rings were placed in organ chambers. After contraction to KCl and prostaglandin F2alpha, endothelium-dependent relaxations to bradykinin were studied. Gomori trichrome and hematoxylin-eosin safran staining were used for histological evaluation. RESULTS: Exposure to radiofrequency 1 mm from the coronary arteries caused a significant decrease in endothelium-independent contractions to KCl and endothelium-dependent relaxations to bradykinin compared to controls (P<0.05). No significant decrease of endothelium-dependent relaxations occurred for rings exposed to radiofrequency at a distance of 5 and 10 mm, compared to controls. Histological examination showed endothelial disruption and medial smooth muscle cells at different stages of necrosis up to 5 mm from the radiofrequency application site. CONCLUSIONS: Radiofrequency may induce coronary endothelial functional and morphological damages when applied less than 5 mm from the artery. Caution must be exerted during left atrial radiofrequency application due to the proximity of the circumflex artery.

Depression and anxiety and outcomes of coronary artery bypass surgery.

Psychological and psychiatric disorders independently increase the risk of cardiovascular disease and worsen the prognosis in patients with established cardiovascular lesions. The objective of this literature review is to discuss recent data concerning the relationships between depression and anxiety and the outcomes of coronary artery bypass grafting. Pathophysiological hypotheses are put forward to explain observed links. We suggest recommendations aimed at improving the psychological evaluation and management of heart surgery candidates, as well as postbypass patients, in the hope of improving quality of life and cardiovascular outcomes in these patients.

The Monoshunt: a new intracoronary shunt design to avoid distal endothelial dysfunction during off-pump coronary artery bypass (OPCAB).

Insertion of intracoronary shunts during off-pump coronary artery bypass surgery can induce a severe endothelial dysfunction. The purpose of this study was to propose a new intracoronary shunt design called Monoshunt, to avoid distal endothelial damage of the target artery in a porcine model. The use of the Monoshunt avoids distal endothelial denudation and allows distal coronary perfusion.

A new technique for the treatment of delayed sternotomy healing: the vacuum therapy.

BACKGROUND: The treatment of nonhealing and infected sternotomies after cardiac surgery is a challenging task, with its increased rates of mortality, morbidity, and costs. Local vacuum therapy (V.A.C. system) allows treatment of local infections, thanks to continuous aspiration and the sealed dressing that stimulates granulation tissue formation. The purpose of this clinical investigation was to evaluate vacuum therapy in cardiac surgery for achieving healing of delayed sternotomy closure after cardiac surgery. MATERIALS AND METHODS: From January 1998 to December 2002, 7 patients who underwent coronary artery bypass surgery under cardiopulmonary bypass by median sternotomy approaches presented a nonhealing infected sternal surgical wound that was treated with local vacuum therapy. Aspiration maintained between -125 mm Hg and -200 mm Hg was carried out on the entire surface of the wound with a sponge connected hermetically to an aspiration system. The treatment was associated with antibiotic therapy adapted to the results of bacteriological studies of the aspirates. RESULTS: All patients with delayed sternotomy closure healed in approximately 8 weeks (2-12 weeks) with the exception of one patient who died of multiorgan failure after a satisfactory muscular pectoral flap. Treatment was possible with vacuum therapy alone (n = 2), with vacuum therapy in association by second intention with a skin graft (n = 1), or both with a muscular pectoral flap (n = 4). Sternal stability appears to be an important factor for achieving satisfactory and complete healing. CONCLUSIONS: This new therapy offers an alternative to the classic treatment of infected sternotomies in cardiac surgery, especially in preparing rewiring and muscular flaps for complicated cases with sternal instability or alone. The treatment must be instituted early to be more effective.