Surgical treatment of subvalvular aortic stenosis. Long-term results.

From 1966 till May 1988, 53 patients underwent surgery for fixed subaortic stenosis. Subvalvular obstruction was isolated in 27 patients (Group I) and associated with aortic valve lesions in 26 (Group II). A membranous stricture was documented in 5 patients and a fibromuscular ring in 48. Excision of the ring and myectomy were performed in all patients, and an associated aortic valve replacement or reconstruction in 7 and 4 patients respectively. There were no hospital deaths. Follow-up evaluation in 50 patients ranged from 6 months to 22 years. Eight patients had to be reoperated upon (1 from group I, 7 from group II): aorto-ventriculoplasty was performed in 3, aortic valve replacement with redo myectomy in 3 and mitro-aortic valve replacement in 2. One of them had 2 reoperations. Functional status at the time of the last outpatient visit was most satisfactory. Continued evaluation remains necessary as obstruction may reappear despite the absence of symptoms.

Sequential mammary grafting. Clinical, functional, and angiographic assessment 6 months postoperatively in 231 consecutive patients.

Between September 1985 and November 1987, 246 sequential mammary grafts were performed in 231 consecutive patients. Seventy-eight percent had triple vessel disease, and 33% required an urgent procedure. The length of the internal mammary artery pedicle was the only limitation to its use. No account was taken of the free cut-end flow of the internal mammary artery. There were 14 bilateral sequential mammary grafts and 15 free sequential mammary grafts. Of the 531 sequential mammary anastomoses, 482 were built with the left internal mammary artery; 113 (21%) were diamond-shaped anastomoses. The right internal mammary artery was brought through the transverse sinus in 44 cases, 10 times for sequential grafting of circumflex branches. Taking into account the adjunctive venous anastomoses and the single internal mammary artery anastomoses, there were 4.5 distal anastomoses per patient, 2.8 being mammary anastomoses and 2.3 being sequential mammary anastomoses. The hospital mortality rate was 2.6%. The prevalence of perioperative myocardial infarction was 5.2%. Follow-up was complete and averaged 15.4 months. Six patients (2.7%) still had angina pectoris. One hundred fifty-seven (71%) patients were recatheterized 6 months after the operation, and 95% of the sequential mammary anastomoses were still patent. The patency rate of the diamond-shaped mammary anastomoses was 94.5% and that of the anastomoses corresponding to the right internal mammary arteries brought through the transverse sinus was 94.3%. The gratifying functional results (maximal stress test combined with exercise thallium scintigraphy) obtained at an average of 6 months postoperatively illustrated the surprising physiologic adaptability of the internal mammary artery. As the attrition rate of the mammary artery grafts beyond 6 months postoperatively is thought to be minimal, gratifying long-term results with widespread use of sequential mammary grafts can be anticipated.

Heart-transplant and mono-amine oxidase inhibitors.

A case of anesthesia for a heart-transplant operation on a patient on mono-amine oxidase inhibitors (M.A.O.I.) is reported. This 63-year-old farmer was in end-stage cardiac failure due to familial cardiomyopathy. For 24 hours before surgery, he was on a dobutamine infusion (3 mcg/kg/min). He had been taking nialamide (100 mg/day) for 8 years for reactional depression and had not stopped it, despite advice. Anesthesia was induced with etomidate and succinylcholine, and maintained with fentanyl (25 mcg/kg/min) and pancuronium. Cardio-vascular stability was maintained during induction and first stage of surgery, up to cardectomy. Graft ischemia was 188 minutes. Successful defibrillation occurred after verapamil 3 mg. Weaning from C.P.B. was easy with dopamine (5 mcg/kg/min) and isoprenaline (0.01 mcg/kg/min). Post-operatively, on day 1, hypertension appeared and needed a nitroprusside infusion. On day 3, the patient needed another anesthetic for removal of pericardial clots, without problems. He remained very confused and disorientated during all his stay in hospital, but improved greatly with a neuroleptic. He left the hospital on day 28 in a good shape, with an anxiolytic, captopril and immunosuppressors. One month later, he was back on nialamide. The pharmacology of the M.A.O.I. is reviewed and their interactions with anesthesia are discussed as well as the use of inotropes. In this case, the denervated heart-graft, free from M.A.O. inhibition, behaved normally when transplanted in a chronically M.A.O.I. treated recipient.

[Congenital heart diseases and obstructive pulmonary vascular diseases in Down's syndrome. Apropos of 142 children with trisomy 21]. / Cardiopathies congénitales et maladie vasculaire obstructive pulmonaire dans le syndrome de Down.

Trisomy 21 accounts for 3 p. 100 of reasons for admission to the Paediatric Cardiology unit of the St Luc University Clinics, Brussels. In a series of 142 cardiac children with trisomy 21 evaluated by catheterization between 1969 and 1987, 54 p. 100 of the cardiac malformations observed consisted of persistent common atrioventricular canal (complete in 45 p. 100 of the cases). The other heart diseases were ventricular septal defect (23 p. 100), atrial septal defect of the ostium secundum type (10 p. 100) and tetralogy of Fallot (9 p. 100). In 40 p. 100 of the patients other cardiovascular abnormalities were associated with these predominant intracardiac shunts. These findings were in agreement with those usually reported in the literature. At the time of investigation (mean age 24 months), pulmonary vascular resistance had already reached a pathological level in 88 p. 100 of the cases. Oxygen tests only slightly improved these results, which suggested that the conditions were favourable to the early development of a pulmonary obstructive vascular disease in Down's syndrome, thus darkening the prognosis of congenital heart disease in mongoloid children. In this series to overall mortality rate of corrective surgery was 23 p. 100. The risk was maximum in infants aged less than 3 months with severe and rapidly symptomatic lesions. The outcome in patients successfully operated upon was satisfactory, with benign residual lesions.(ABSTRACT TRUNCATED AT 250 WORDS)

Should amiodarone be discontinued before cardiac surgery?

Between October 1985 and October 1986, 37 patients, chronically treated with amiodarone, underwent general anesthesia for cardiac, thoracic or vascular surgery. Among them, the 8 non-cardiac surgery patients showed neither intra-, nor postoperative complications. The 29 cardiac surgery patients, had various complications ranging from dysrhythmias (52%), sometimes necessitating a pacemaker (24%), to marked and even fatal vasoplegia. We describe the only fatal case and compare our complication rate with that described in the available literature. Most complications could be symptomatically treated. In addition, amiodarone has a very long elimination half-life: therefore withdrawal before surgery implies delaying operations by several weeks, and puts patients at increased risk of malignant dysrhythmias. However, fatal vasoplegia does occur, and its real incidence should be assessed by a broader survey.

Long-term follow-up of the Senning operation for transposition of the great arteries in children under 3 months of age.

Twenty-six patients aged 6 days to 3 months (mean 57 days) underwent a Senning procedure for transposition of the great arteries. Twenty-two had intact ventricular septum and four had a small ventricular septal defect. They were followed up for 1 month to 8 years (mean 4 years). There were no late deaths. At late examination, 25 patients were asymptomatic and there was no clinical or echographic evidence of caval or pulmonary venous obstruction. Growth was normal in all but two patients. Neurologic assessment was abnormal in eight patients. The electrocardiogram showed sinus rhythm in 22 patients and asymptomatic arrhythmias in four. Twenty-three patients underwent cardiac catheterization and angiographic studies 2 to 72 months postoperatively (mean 15 months), which demonstrated effective left and right atrial contraction. An atrial shunt was noted in one patient and a ventricular shunt in one. Two infants (8%) had a residual left ventricular outflow tract obstruction (gradients of 26 and 37 mm Hg). Two had mild superior vena caval obstruction (gradients of 4 and 5 mm Hg). We conclude that the Senning procedure can be performed in early infancy with good results and a low incidence of late complications.

A safe alternative to awake intubation in neonates.

The authors present a retrospective study on the safety of their induction technique of anaesthesia in infants less than 30 days old. The records of 197 consecutive cases are reviewed, 47 of which concern major cardiac surgery. All the details of the technique are given: inhalation of halothane in O2 following a vagolytic premedication, spray of lidocaine 2 mg/kg on the vocal cords, orotracheal intubation to check adequacy of foreseen tube size, followed by definitive nasal intubation with the tube passed over a siliconed suction catheter. The results are discussed. The use of combined general and topical anaesthesia makes endotracheal intubation of the neonate nice and easy, atraumatic, well suited for training and more humane. Awake intubation should only be used as a resuscitative measure.

[Coarctation of the aortic isthmus in the adult]. / La coarctation de l'isthme aortique chez l'adulte.

Forty four patients over the age of eighteen operated upon for coarctation of the aorta from 1962 to 1983 at our institution were followed for one to 21 years (mean 13 years 3 months). Hypertension was found in 86% of the patients and 82% were preoperatively symptomatic. There were three late deaths. During the follow-up period, drug resistant hypertension persists in 31% of the patients at rest and/or exertion and 18% have functional symptoms. These data emphasize the importance of early diagnosis and treatment for patients with coarctation of the aorta.

Clinical use of continuous monitoring of mixed venous oxygen saturation during and after cardiovascular surgery.

This paper presents the authors' initial experience with a new technique for continuous monitoring of the mixed venous oxygen saturation (SvO2) during and after open heart Surgery. The method uses reflectometric measurements of SvO2 via a fiberoptic pulmonary artery catheter with the capability for thermodilution cardiac output estimates. Changes in SvO2 reflect changes in one or more of the three interacting factors of the Fick equation: arterial oxygen content, cardiac output, and total body oxygen utilization. Intra-and postoperative examples illustrate these various situations. The very short response time of the System allows for early diagnostic and therapeutic decisions.

[Results of the intracardiac repair of tetralogy of Fallot and interventricular communication before the age of 2 years]. / Résultats de la réparation intracardiaque des tétralogies de Fallot et des communications interventriculaires avant l'âge de 2 ans.

The post-operative review of 81 patients operated for a large interventricular communication before the age of two years reveals excellent results: the mean age at operation was 7 months, extracorporeal circulation was performed in 25 patients for a mean duration of 77 minutes and profound hypothermia to 18 degrees C was induced in 56 patients. The atrial approach was used in 30% of cases. The mean follow-up period is 26 months. There was one case of complete bundle branch block, which was subsequently fitted with a pacemaker, 7 cases of bifascicular branch block and a right bundle branch block in the majority of cases. The pulmonary vascular resistance was virtually normal (a mean of 3.2 U.m-2 prior to the operation and a mean of 1.9 U.m-2 after the operation). The left ventricular volume, which was markedly increased in all patients preoperatively, returned to normal with maintenance of a normal ejection fraction. The neuro-psychomotor behaviour was abnormal in 13 of the 63 patients tested. These abnormalities are not related to the correction procedure, but to pre-existing pathology (small birth weight). 52 patients from a series of 63 cases operated for tetralogy of Fallot before the age of 2 years (median age 12 months) were also reviewed. Extracorporeal circulation lasting a mean of 115 minutes was performed in 31 patients, cardiac arrest under profound hypothermia was induced in the other cases, for a mean duration of 61 minutes. The mean follow-up period was 29 months.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiac valvular surgery after 65 years of age]. / La chirurgie valvulaire cardiaque après 65 ans.

252 symptomatic patients aged 65-79 underwent surgery between 1970 and 1982 for heart valve lesions. Hospital mortality was 11.8%. Analysis of the short and long term results justifies cardiac surgery in elderly patients with valve disease.

Clinical use and bacteriological studies of catheter contamination sleeves.

A system combining a valved introducer sheath and a plastic protective sleeve enabling repositioning of pulmonary artery catheters was tested in 73 cardiac surgical patients. It was used for a mean time of 70.3 h and allowed for improved hemodynamic monitoring. A 12 percent incidence of valve contamination was found and makes the safety of the device questionable.

Idiopathic hypertrophic subaortic stenosis: long-term surgical results.

The results of surgery in 21 patients with I.H.S.S. are reported. Dyspnea, angina pectoris and syncope were the most common symptoms in decreasing frequency. Before the operation, 5 patients were in New York Heart Association's functional class II, 10 in class III and 6 in class IV. The mean resting peak systolic pressure gradient was 66 mm Hg in 20 patients and mean left ventricular end-diastolic pressure was 14 mm Hg in 19 patients. The ventriculoseptomyectomy accomplished through a transaortic approach is the procedure of choice. The operative mortality rate was 14% (3 of 21 patients). There were 2 late deaths from congestive heart failure. Any sudden death did not occur. The remaining 16 patients have been followed up for a mean of 75 months (range 12 months to 11 years), 11 patients are in functional class I, 4 in class II and 1 in class III. Complete left-bundle-branch block occurred in 3 patients. Our study with a long post-operative follow-up period, documents that surgery results in good to excellent alleviation of symptoms in survivors. The elevated pre-operative left ventricular end-diastolic pressure has a significantly poor prognosis. We currently recommend surgery for the symptomatic patients who have not responded to medical therapy, not late in the symptomatic course of the disease.

Revascularization of the superior mesenteric artery.

From 1965 to 1973, 7 patients with severe chronic mesenteric vascular insufficiency have been successfully operated upon. Abdominal pain, weight loss and epigastric murmur were the most significant symptoms and signs in these diffusely atheromatous patients. Aortography with exposure in the lateral projection was essential for diagnosis and operative planning. Although two and often all three main splanchnic arteries were involved, revasculariztion of only the superior mesenteric artery restored normal hemodynamics. There was no operative mortality. Weight gain was dramatic and post-prandial pain disappeared in all patients. One patient diedone year and one half after the operation from an acute cerebro-vascular accidnet. Our surgical experience in this field, although small, is very gratifying and rewarding.