Aortic arch replacement using a four-branched aortic arch graft.

Surgical repair for aortic arch aneurysms is associated with considerable mortality and morbidity. Adequate brain protection is essential. Experience of aortic arch repair in six patients using a four-branched arch graft is described. There were two emergency and three reoperations. One patient had ruptured aneurysm. Hypothermic cardiopulmonary bypass (18-22 degrees C) was employed. A four-branched polymer albumin-coated arch graft was used. The fourth branch of the graft was used for secondary arterial cannulation to ensure continuous brain circulation. One hospital death occurred. No permanent neurological event occurred. The four-branched arch graft facilitates fashioning arch branch anastomoses and provides better brain protection.

Myocardial revascularization and bilateral lung transplantation without cardiopulmonary bypass.

Coronary artery disease is occasionally encountered in lung transplant recipients and is a risk factor for perioperative complications and poor survival. Besides combined heart-lung transplantation, various techniques of myocardial revascularization can be performed before, or at the time of lung transplantation. We report herein a patient with end-stage bronchoemphysema and two-vessel coronary disease who underwent 'off-pump' coronary artery bypass graft immediately followed by bilateral lung transplantation.

Impact of double internal thoracic artery grafts on long-term outcomes in coronary artery bypass grafting.

We performed this study to determine if bilateral internal thoracic artery grafts provide greater benefit than single internal thoracic artery grafts. Six hundred ninety-four consecutive patients who received 2 coronary grafts in a single operation during 1983-1989 were given 10 years of follow-up and then analyzed retrospectively. Group 1 (n=382) received 2 internal thoracic artery grafts, Group 2 (n= 139) received 1 internal thoracic artery graft and 1 saphenous vein graft, and Group 3 (n= 173) received 2 saphenous vein grafts. Patient demographics, preoperative angiographic findings, and operative indications were the same. Hospital mortality rates were 2.6%, 2.2%, and 2.3%, respectively. Hemorrhage, sternal wound infection, mediastinitis, sternal dehiscence, and prolonged ventilatory support showed no group differences. Follow-up over 10 years was complete in 677 survivors. Mortality rates during follow-up were 1.8%, 2.9%, and 4.7%, respectively. Cardiac-related mortality rates were 71%, 75%, and 88%, respectively (Group 1 vs Group 3, P=0.0412). Ten-year survival was better for Group 1 than for Groups 2 and 3 (P=0.0356 and P <0.0001). Cardiac-event-free survival at 10 years was 93% in Group 1, 84% in Group 2, and 74% in Group 3 (all P <0.0001). The use of 2 internal thoracic artery grafts resulted in significantly lower risk of cardiac death and re-intervention, compared with the use of 1 internal thoracic artery, which in turn was superior to the use of vein grafts. Use of double internal thoracic arteries did not increase postoperative complications.

[Closed trauma of the abdominal aorta--current update]. / Traumatismes fermés de l'aorte abdominale--mise au point.

This study constitutes an update on current knowledge in the literature concerning closed traumas of the abdominal aorta. The morbidity of such lesions, in case of initial survival, depends on both rapid diagnosis and prompt treatment of hypovolemia and ischemia. The presence of associated intestinal lesions renders diagnosis difficult, modifies surgical treatment, and aggravates prognosis.

Aortocaval fistula associated with abdominal aortic aneurysm: a diagnostic challenge.

The purpose of this study is to determine the clinical features with the best preoperative diagnostic value for aortocaval fistulas (ACF) associated with abdominal aortic aneurysm (AAA). A review of our experience of seven patients presenting ACF between 1980 and 1994 as well as an extensive study of the literature provide a clearer picture of the signs and symptoms allowing diagnosis of ACF: edema of the lower extremities and signs of venous hypertension are the most predictive findings; continuous abdominal murmur is noted in 66% of cases and is of good diagnostic value.

Multiple-leaflet mitral valve as a rare cause of congenital mitral insufficiency.

A rare case of congenital mitral insufficiency characterized by six well-demarcated leaflets of mitral valve and annular dilatation is reported. At operation, the mitral valve was successfully repaired by resection of the posterior median leaflet with subsequent annular plication, closure of unusual valvular tissue divisions, and ring annuloplasty.

Blunt injury to the ascending aorta: three patterns of presentation.

BACKGROUND: Injury to the ascending aorta is a rare lesion that may present in various forms. A thorough analysis of this lesion is lacking in the literature. This study was undertaken to delineate the prevalence and modes of presentation of injuries to the ascending aorta after blunt trauma and to suggest guidelines for management. METHODS: A retrospective analysis of autopsies performed in our department of forensic medicine on blunt trauma victims from 1984 to 1993 and a literature review of autopsy series were undertaken to delineate the prevalence and relevant characteristics of this injury. A cash report from our institution and a review of the literature were used to provide information regarding clinical presentations of this injury and treatment approaches. RESULTS: Three modes of presentation were encountered. (1) Presentation at autopsy: The prevalence of injury to the ascending aorta after a traffic accident was 2% in our autopsy series. Among 13 patients with this injury 12 had other associated, potentially lethal lesions. A massive hemopericardium was present in two patients only. In autopsy series the incidence of injury to the ascending aorta in patients with an injury to the aorta ranged from 0% to 23%. (2) CLINICAL PRESENTATION: Twenty-one patients were treated surgically and reported in the literature. Fourteen presented with a pseudoaneurysm and seven with a chronic sinus of Valsalva fistula. One patient with a pseudoaneurysm presented with signs of cardiac tamponade and required immediate decompression; the others were hemodynamically stable. Seven patients had a cardiac lesion (valve tear in six and cardiac contusion in one), and three had an arch vessel lesion. Aorta repair was performed under cardiopulmonary bypass in every patient. (3) Incidental presentation: Seven patients with a traumatic tear of the aortic valve presented an incidental lesion of the ascending aorta. It was a subadventitial hematoma in three patients and an intimal and medial tear in four patients. Aortic tears were reinforced by direct suture. CONCLUSIONS: Injury to the ascending aorta after blunt trauma is rare but lethal mostly from associated injuries. Survivors may appear in stable condition and present mostly with pseudoaneurysms of the ascending aorta or sinus of Valsalva fistula. Associated lesions to the heart and arch vessels should be looked for. Repair of the ascending aorta injury is performed under cardiopulmonary bypass.

Traumatic occlusion of the left anterior descending artery and rupture of the aortic isthmus.

A patient with occlusion of the left anterior descending artery and rupture of the aortic isthmus following blunt trauma is reported. Treatment of both lesions through a median sternotomy using cardiopulmonary bypass was accomplished successfully. Special considerations regarding the surgical management of combined cardiac and aortic isthmus lesions in trauma patients are discussed.

[Reconstructive methods of the antero-lateral thoracic wall after extensive surgery of invasive tumors]. / Méthodes de reconstruction de la paroi thoracique antéro-latérale après chirurgie extensive de tumeurs invasives.

Local recurrence after conservative or enlarged surgery for breast carcinoma, or primary chest wall's tumors should first be approached surgically, chimio- and radiotherapy being used only later on. A precise local and general evaluation has to be made first, trying to determine whether there is or not an invasion of bony structures. When they are free of tumor, regional transfer of musculocutaneous flaps can usually cover the defect (latissimus dorsi, 1-2 rectus abdomini, pectoralis major); great omentum is used when this defect is too large. When ribs, sternum or deep structures are invaded, reconstruction uses successively: a mersilene mesh, bone cement, an omental flap covered with mesh skin grafts 2 days later. Surgical management of these difficult situations is most of the time only a palliative measure which gives these patients a better quality of life for the short time they still have got.