[Paediatric cardiac surgery and autoevaluation: risk score, complexity score and graphic analysis]. / Chirurgie cardiaque pédiatrique et auto-évaluation: score de risque, score de complexité et analyses graphiques.

The creation of a paediatric surgical unit requires autoevaluation in order to: assess the quality of the results with respect to recognised international standards, answer the family's questions about the results obtained and adhere to criteria of accreditation Between January 2003 and December 2004, 201 consecutive patients, children (N= 164) or operated for adult congenital heart disease (N= 37) were treated. No patient was excluded. The RACHS-1 risk score, the ARISTOTLE scores of complexity and performance and the CUSUM and VLAD graphic analyses were applied to the study of hospital mortality. An original "variable performance-adjusted display" (VPAD) graphic analysis was performed to show up any possible variations of performance. Paediatric hospital survival was 97.56% (95% CI: 93.9 - 99.1). The paediatric complexity and performance scores were 6.79 +/- 0.22 and 6.62 respectively. In the absence of statistical significance in this field of autoevaluation, graphic analyses indicated the performance of our unit with no "learning" curves. Graphic scores and analyses allow assessment of the function of a paediatric cardiac surgical unit and the variations of complexity with respect to time, before the appearance of statistical significance. The ARISTOTLE complexity and performance scores and their adaptation in VPAD seem to be more reliable and discriminating than the RACHS-1 score.

[Late presentation of type A aortic arch blockage with a large type I aortopulmonary window]. / Présentation tardive d'une interruption de l'arche aortique de type A avec large fenêtre aorto-pulmonaire de type I.

We report the case of a 39 day old infant, hospitalised for congenital cardiopathy associated with type A blockage of the aortic arch with a large type I aortopulmonary window. The infant was in cardiogenic shock with pulmonary systemic hypertension and a tightly stenosed arterial canal (< 2 mm). With no possibility of re-opening the arterial canal under PGE1 at this stage, complete repair was performed as an emergency. After section of the aortopulmonary window, it was closed on the pulmonary side with a patch of autologous pericardium. Repair of the aortic arch was performed without prosthetic material, under selective cerebral perfusion to protect the brain parenchyma, after mobilisation of the descending thoracic aorta, which was anastomosed directly with the distal part of the window and aortic arch. Recovery was uncomplicated, with no residual lesion at 6 month post-operative follow up. The late clinical presentation of this patient shows the effect of medical management without prior catheterisation, with operative techniques minimising peri-operative tissular ischaemia and conserving aortic and pulmonary growth potential.

Recombinant hirudin anticoagulation for aortic valve replacement in heparin-induced thrombocytopenia.

PURPOSE: To report the case of a patient with HIT that received a prolonged infusion of r-hirudin (lepirudin; Refludan; Hoechst, France) before, during and after cardiopulmonary bypass (CPB) for aortic surgery. Although administration of r-hirudin for CPB anticoagulation has previously been reported, many questions persist concerning the best therapeutic regimen for CPB anticoagulation as well as the time of onset and the doses for postoperative anticoagulation. CLINICAL FEATURES: A 65-yr-old man was admitted for surgery of aortic stenosis after an episode of acute pulmonary edema complicated by deep venous thrombosis in the context of documented HIT. The patient received r-hirudin for 13 dy before surgery at doses (0.4 mg x kg(-1) bolus followed by 0.15 mg x kg(-1) x hr(-1) continuous infusion) that maintained activated partial thromboplastin time (aPTT) ratios between 2 and 2.5. Anticoagulation for CPB was performed with r-hirudin given as 0.1 mg x kg(-1) i.v. bolus and 0.2 mg kg(-1) in the CPB priming volume. Anticoagulation during CPB was monitored with the whole blood activated coagulation time and ecarin clotting time (ECT) performed in the operating room with values corresponding to r-hirudin concentrations >5 microg x ml(-1) during CPB. Anticoagulation during CPB was uneventful. Two bleeding episodes, related to the r-hirudin regimen and necessitating allogeneic blood transfusion, occurred after surgery. CONCLUSION: This case report confirms previous experience of the use of r-hirudin for anticoagulation during CPB and provides additional information in the context of prolonged r-hirudin infusion before and after CPB.

[Advanced cardiac failure. New surgical approaches]. / L'insuffisance cardiaque avancée. Approches chirurgicales actuelles.

THERAPEUTIC OPTIONS: Prognosis of advanced heart failure is ominous since survival rate is less than 65% one year after an acute and severe cardiac episode. Medical therapy has proven to be efficient in reducing fatal complications and in delaying critical evolution. Depending on the etiology and the myocardial status, new surgical approaches can also be proposed for repair or substitution. SURGICAL REPAIR: The beneficial effect of myocardial revascularization on severe ischemic cardiomyopathy, the relevance of mitral valve repair in dilated cardiomyopathy, and the advantage of ventricular remodeling in patients with major ventricular dyskinesia has been clearly demonstrated. All these surgical techniques improve ventricular function and enhance survival rate by about 70% after three years. SUBSTITUTION PROCEDURES: The best therapeutic option to recover heart function for normal life and reduced mortality remains, when possible, cardiac transplantation. Ventricular cardiac assist devices are planned as a temporary option to bridge the waiting period to transplantation or for myocardial recovery but can also be proposed as a chronic implantation in an outpatient care scheme. Cardiomyoplasty for therapeutic management of advanced cardiac failure is still a controversial surgical approach. Other clinical strategies such as transmyocardial laser revascularization, myocardial angiogenesis and myocardial cell therapy are being investigated or developed. ADAPTED TREATMENT: Optimal management of each patient with advanced heart failure requires an adequate treatment selected among a wide range of medical and/or surgical strategies.

Treatment of end-stage renal failure after heart transplantation.

BACKGROUND: Five to 10% of heart-transplant recipients develop end-stage renal failure (ESRF). Little is known about the outcome of these patients under renal replacement therapy. METHODS: We conducted a retrospective study in 16 men (mean age 52.8+/-7.4 years at heart transplantation) who developed ESRF 5.3+/-2.1 years later. Results. Haemodialysis (HD) was the first-line treatment (mean Kt/V 1.35+/-0.4). Vascular access was unsuccessful in six patients (37.5%) due to peripheral arteriopathy and they were treated with tunnelled catheters for an average 15 months without bacterial infection. Mean weight was 68.4+/-10 kg at onset of HD and 61.7+/-9 kg one month later. Despite this reduction in extracellular overload, one antihypertensive drug was required in 75% of patients and two drugs in 12.5%. One patient tolerated automated peritoneal dialysis (PD) for 16 months (weekly Kt/V 2.1) despite persistent anuria. Renal transplantation (RT) was contraindicated in eight patients because of aortoiliac arteriopathy (n=5), poor general status (n=2), or ischaemic heart disease (n=1). RT was performed in eight patients with no acute episode of heart or renal graft rejection. There were no serious infectious complications. Three months after RT, mean serum creatinine was 115 micromol/l. One patient developed post-transplant lymphoproliferative disorder 3.5 months after RT and was successfully treated with transplant nephrectomy. Sudden death occurred in two patients 18 and 33 months after RT. Overall patient survival was 100, 78, and 59%, 1, 2 and 3 years after HD onset respectively. Using a time-dependent variable, the Cox model analysis demonstrated that heart-transplant recipients with ESRF have a relative risk of death 3.2 times higher than those without ESRF (95% CI = 1.3-7.8). CONCLUSIONS: HD, PD, and RT can be useful for the treatment of ESRF after heart transplantation. After initiating HD, patient survival is nearly the same as that reported in patients in Europe undergoing HD for other causes. But ESRF seems to reduce life expectancy in heart-transplant recipients.

[Practical use of cefepime in an University hospital. Retrospective study of 35 cases]. / Utilisation pratique du céfépime dans un CHU. Etude rétrospective de 35 cas.

The authors report a retrospective study of 35 patients treated with cefepime (Axepim). This patients were either hospitalized in a medical or in a surgical ICU or were febrile neutropenic patients. The non neutropenic group was put on cefepime for nosocomial pneumonia or miscellaneous sepsis. When recovered, Enterobacteriaceae were the most frequent pathogens. Clinical cure rate for the patients treated with cefepime was 83%. Cefepime is a safe and effective empirical treatment for serious infections and nosocomial infections in particular.

[Primary liposarcoma of the left ventricle. Apropos of a case and review of the literature]. / Liposarcome primitif du ventricule gauche. A propos d'un cas et revue de la littérature.

Primary malignant myocardial tumours are rare and essentially sarcomas. The authors report a case of primary left ventricular liposarcoma which is the 18th reported case. The presenting signs were of cardiac failure. Metastases are common by the time of diagnosis. Surgical ablation, though rarely complete because of its myocardial localisation, is justified for precise histological diagnosis. The prognosis of these lesions is poor. Complementary treatment is rarely used. However, it should be proposed as surgery alone has been shown to have limited curative applications.

Inhaled nitric oxide as an adjunct to pulmonary thromboendarterectomy.

In chronic pulmonary vascular thrombotic disease, pulmonary thromboendarterectomy has proved to be effective in reducing pulmonary hypertension and improving gas exchange. However, persistent pulmonary hypertension and unrelenting reperfusion edema are the main causes of death. We report a case of pulmonary thromboendarterectomy followed by an immediate unfavorable postoperative course with acute and persistent pulmonary hypertension, gas exchange impairment, and heart dysfunction. In this particular case, inhaled nitric oxide was successfully administered.

An unusual case of hip septic arthritis due to Bacteroides fragilis in an alcoholic patient.

We describe a 53-year-old alcoholic man who presented with hip septic arthritis due to Bacteroides fragilis. This arthritis involved a severe destruction of the femoral head, which was completely devitalized. Recovery was achieved after 4 months of antimicrobial therapy with imipenem/cilastatin plus metronidazole, surgical debridement of the necrotic tissues and four sessions of hyperbaric oxygen.

Estimation of myocardial interstitial norepinephrine release after brain death using cardiac microdialysis.

Brain death is a pathophysiological condition associated with major hemodynamic changes, temporary myocardial ischemia, and histological damage of the heart. These modifications could be related to a major local release of norepinephrine from myocardial sympathetic nerve endings leading to norepinephrine cardiotoxicity. This study was designed to evaluate the utility of cardiac microdialysis to measure interstitial myocardial norepinephrine release resulting from brain death. The dialysis probe consisted in a 10 x 0.20-mm dialysis fiber with a 18,000 mol wt cutoff. Dialysis probes were implanted into the right and left ventricular walls of the beating heart in anesthetized pigs and perfused with Ringer solution at 2 microliters/min. Dialysate norepinephrine concentration was measured using HPLC with electrochemical detection. The relative recovery rate of norepinephrine in vivo was 34 +/- 4%. Interstitial fluid concentrations were obtained using the following formula: [C]interstitium = [C]dialysate/Recovery in vivo. After brain death, a transient increase in interstitial norepinephrine concentration was observed (from 0.74 +/- 0.20 to 4.50 +/- 0.60 ng/ml and 0.76 +/- 0.20 to 6.2 +/- 0.9 ng/ml in left and right ventricle, respectively, P < 0.01) which far exceeded plasma level increase (from 0.50 +/- 0.10 ng/ml to 0.91 +/- 0.20 ng/ml, P < 0.05). This increase in myocardial norepinephrine was, moreover, biphasic, with a second peak occurring 40 min after brain death. The present study confirms the onset of a dramatic increase in cardiac norepinephrine release from myocardial nerve endings following brain death, and demonstrate the utility of the new cardiac microdialysis technique to assess changes in interstitial fluid content.

Endocrine response to plasma volume expansion during the early postoperative period in heart transplant recipients.

The purpose of this study was to investigate the changes in endocrine control of blood pressure and electrolyte homeostasis during the early postoperative period after heart transplantation. Dynamic testing using volume-expansion to increase cardiac filling pressures was performed to determine changes in alpha atrial natriuretic peptide, renin, aldosterone, and vasopressin secretion in response to a physiologic stimulus. Volume expansion was performed on five heart transplant patients each day from postoperative day 1 to postoperative day 5. Alpha atrial natriuretic peptide, renin, aldosterone, and vasopressin plasma levels were assessed by radioimmunoassay before and during the 6 hours after the beginning of infusion. No significant changes in the secretion of any of the various hormones studied were found after volume expansion. Moreover, we found that heart transplant recipients were unable to increase water and sodium renal excretion after volume expansion. The physiologic decrease in vasopressin release after volume expansion appears to be altered by graft denervation. Furthermore, persistently elevated alpha atrial natriuretic peptide plasma levels at rest despite improved patient hemodynamic status and the absence of enhanced hormone secretion after a physiologic stimulus are in favor of an intrinsic hypersecretion of this hormone. Moreover, the absence of an appropriate renal response could be a major consequence of both the lack of further increased alpha atrial natriuretic peptide secretion and the heart denervation resulting from transplantation. This blunted renal response should be taken into account when managing patients in the early period after transplantation.

Malignant lymphoma in the donor heart after heart transplantation.

A case of post-transplant lymphoproliferative disease (PTLD) with donor heart involvement is reported. The 49-year-old patient presented with heart failure initially ascribed to acute graft rejection. The treatment with high doses of immunosuppressive agents was unsuccessful and the outcome rapidly fatal. This case suggests that cardiac failure occurring after high doses of immunosuppressive therapy could be a sign of early PTLD in heart transplant recipients.

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

Ofloxacin penetration into heart tissue (valve and myocardium), mediastinal fat, and sternal bone marrow was the object of a prospective nonrandomized study. Thirty-six patients undergoing mitral and/or aortic valve replacement were included. Patients were divided into two groups of 18 patients each. Group 1 patients were administered a single 400-mg intravenous dose of ofloxacin over a 30-min period upon anesthesia (n = 6) or at 1 h (n = 6) or 6 h (n = 6) prior to surgery. Group 2 patients received a 200-mg oral dose of ofloxacin every 12 h during the 48 h preceding surgery. In this group, the final dose of ofloxacin was administered 3 h (n = 9) or 8 h (n = 9) before anesthesia. Plasma and tissue ofloxacin concentrations were assayed by high-pressure liquid chromatography. In group 1 patients, the peak level in plasma was 15.9 +/- 2.5 micrograms/ml. Peak ofloxacin levels in tissue were reached by hour 1 and were 8.89 +/- 2.16 micrograms/g in myocardium and 5 +/- 0.75 micrograms/g in heart valves. A significant decrease in ofloxacin levels in heart valve tissue and sternal bone marrow was observed after hour 3. Nevertheless, ofloxacin myocardial, heart valve, and sternal bone marrow levels remained higher than the MICs for the usually susceptible pathogens for at least 3 h. In group 2 patients, myocardial levels were long lasting (6.46 +/- 1.92 micrograms/g [4 to 8 h] and 5.92 +/- 0.95 micrograms/g [8 to 12 h]) and remained higher than those observed in the other tissues over the entire study period. A progressive but insignificant decrease in ofloxacin heart valve levels was observed (from 2.46 +/- 0.40 micrograms/g [4 to 8 h] to 1.57 +/- 0.22 micrograms/g [8 to 12 h]). In both groups, concentration in mediastinal fat were lower and tended to decrease with time. These were 1.83 +/- 0.61 micrograms/g with the first hour and 0.85 +/- 0.43 micrograms/g between hours 8 and 12 in group 1 and 1.74 +/- 0.52 micrograms/g between hours 4 and 8 and 0.67 +/- 0.11 micrograms/g between hours 8 and 12 in group 2. In conclusion, satisfactory diffusion of ofloxacin into heart tissue seems to favor use of the drug in the treatment of bacterial endocarditis due to susceptible pathogens. Furthermore, the progressively decreasing concentrations observed in heart valve and sternal bone marrow and the poor levels achieved in mediastinal fat suggest the need for renewing injection 3 h following initial infusion if the drug is used as an antibiotic prophylactic agent during cardiovascular surgery.

Effects of diclofenac on ceftriaxone pharmacokinetics in humans.

The effects of diclofenac, a nonsteroidal antiinflammatory drug, on the biliary and urinary excretion of ceftriaxone were evaluated in subjects with a T drain in the common bile duct. The kinetic study was carried out on the sixth postoperative day of treatment with ceftriaxone alone (2 g intravenously; group 1) or ceftriaxone combined with diclofenac (50 mg every 12 h orally from postoperative days 3 to 6; group 2). A significant increase in the elimination half-life of ceftriaxone was observed in group 2 patients. Diclofenac caused a significant rise in ceftriaxone biliary excretion. This increase was not sufficient to balance the significant deficit of urinary excretion of ceftriaxone.

[Antibioprophylaxis in pulmonary surgery: a randomized trial with cefamandole versus placebo]. / Antibioprophylaxie en chirurgie pulmonaire: étude randomisée céfamandole versus placebo.

A prospective double-blind study was designed to assess the efficacy of antibiotic prophylaxis in lung surgery. It included 114 patients undergoing lung surgery for primary or secondary malignant tumours randomly assigned to two groups. Group A patients (n = 59) were given cefamandole intravenously every four hours, three times, starting from induction of anaesthesia. The dose was determined according to the patient's weight: 1.5 g for patients weighing less than 60 kg, 2.5 g for those weighing between 60 and 80 kg, and 3 g for those above 80 kg. Group B patients (n = 55) were given a placebo at the same times. Nineteen other patients were excluded because either the tumour was found to be infected, or the patient had to be mechanically ventilated postoperatively, or an exploratory thoracotomy only was carried out, or they were allergic to beta-lactam antibiotics. The efficacy of antibiotic prophylaxis was assessed by recording the incidence of postoperative infections, the length of the patient's stay in hospital, and the need to use an antibiotic treatment. Patients, their sputum and wound were examined every day, and their temperature recorded. The white blood cell count and chest X-ray was carried out every day for the first week. All the drain and catheter tips were cultured, as well as sputum and blood (every three days). In case of infection, samples were obtained and cultured. Both groups of patients were similar with regard to age, risk factors (smoking habit, diabetes mellitus), and type of surgery (segmentectomy, lobectomy, pneumonectomy). There were 9 postoperative infections in group A, and 22 in group B (p = 0.003).(ABSTRACT TRUNCATED AT 250 WORDS)