What is the place of pulmonary embolectomy today?

From 1.1970 to 31.12.1989, 134 patients with pulmonary embolism were treated by pulmonary embolectomy (74 women and 60 men) of mean age 55 years (23-78 years); 93 (69%) of these patients developed embolism during the postoperative period following surgery for another condition. In 12 cases the embolectomy was performed without circulatory assistance by a modified Trendelenburg operation after an average delay time of 2 hours. In 122 cases, extracorporeal circulation (ECC) was used, preceded in 64 cases, by a femoral-femoral bypass (the average delay interval of operation being 16.9 hours). At operation, 23 patients were in complete circulatory failure needing external cardiac massage, 34 were in cardiogenic shock with systolic arterial pressures (SAP) less than 60 mmHg, 42 maintained their arterial pressure between 60 and 100 mmHg, and only 35 were seen with SAP higher than 100 mmHg under vasopressive drugs. No haemodynamic and angiographic investigations could be undertaken in 31 patients because of their dramatic clinical state. In the other 103 patients who had invasive angiographic investigations performed the pulmonary bed was obstructed from 65% to 90% (mean 79.4%) according to Miller's index. The mean arterial pulmonary pressure was 51.2 mmHg. The survival rate at the 30th postoperative day showed 113 patients were alive (84.3%) with 7 among the 12 operated by the Trendelenburg's modified method and 106 among the 122 operated under ECC. The main causes of the 21 deaths were: peroperative 8, neurological 4, cardiac 4, respiratory 1, recurrent embolism 1, acute thrombosis of the IVC 1. Our results of pulmonary embolectomy can be compared favorably to those obtained by thrombolysis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of the cost-efficacy ratio of Pall BB 22 15 filters for the bacterial protection of anesthesia circuits]. / Evaluation du rapport coût-efficacité des filtres Pall BB 22 15 dans la protection bactérienne des circuits d'anesthésie.

The aim of this study is to assess wether the use of the bacteriological filter Pall BB 22 15 placed on the Y piece of the anesthesia equipment decreases contamination and furthermore to evaluate the cost of this practice versus changing anesthetic circuits after every patient. Randomized trials are conducted with three "Engström" machines in three cardiac surgery operating rooms. The Y pieces were examined with qualitative and quantitative bacteriological analysis. Use filters is less expensive than changing circuit for each patient for a comparable efficacy.

[Bronchospasm during extracorporeal circulation]. / Bronchospasme en cours de circulation extracorporelle.

Six cases of bronchospasm are reported, which occurred at the end of cardiopulmonary bypass (CPB). One patient developed this condition twice within one year. This was a rare occurrence (6 cases for 3714 CPB). Symptoms were the same every time: increased inflation pressures, impossible deflation, and low left atrial pressures. Adrenaline given by way of the bypass was the quickest and most effective treatment. The favourable outcome in all 5 patients was due to the continuing of circulatory assistance by the CPB. Although the prevention of anaphylactoid accidents in atopic patients has been well documented, the cause of the bronchospasm in our patients has not been recognized, and it may well not have been due to a particular drug.

[Surgical correction of interventricular communication with pulmonary stenosis in a hemophiliac]. / Correction chirurgicale d'une communication interventriculaire avec sténose pulmonaire chez un hémophile.

Open heart surgery was performed in a 5 year-old boy with severe hemophilia A and large ventricular septal defect with pulmonary stenosis. High doses of Factor VIIIC superconcentrates delivered as small transfusion volumes allowed the use of extracorporeal circulation with heparin. Transfusions began 5 hours before surgery and were stopped 21 days later. No adverse reaction was observed. Thus major surgery is possible in severe hemophiliacs provided strict rules for replacement therapy are followed.

Intrapericardial teratoma in a newborn infant: use of fetal echocardiography.

The case of an infant with intrapericardial benign teratoma, which was suspected in utero after fetal echocardiography, is reported. This new approach permitted very early diagnosis and surgical treatment before cardipulmonary distress appeared. The tumor was excised completely, and the patient was asymptomatic three months postoperatively.

[Aortic and mitral monovalvular replacements. Comparison of the ball prosthesis of Starr-Edwards (1260-6120) and the tilting disc prosthesis of Bjork-Shiley. Series of 390 patients]. / Remplacements monovalvulaires aortiques et mitraux. Comparaison des prothèses à bille de Starr-Edwards (1260-6120) et à disque basculant de Björk-Shiley. Une série de 390 patients.

The evaluation of short and long term replacement by the Björk-Shiley tilting disc prosthesis (BS) and by the Starr-Edwards ball and cage prosthesis (SE) was carried out on a series of 390 consecutive patients. In mitral replacement, operative mortality rate (SE 5.9 P. 100 - BS 4.8 P. 100), 5 year actuarial survival (SE 79.8 P. 100 +/- 3.8 P. 100 - BS 86.3 P. 100 +/- 9 p. 100) incidence of thromboembolic complications and valvular thrombosis (SE 1.6 P. 100 - BS 1.3 P. 100) as well as the degree of post-operative improvement were virtually identical in both types of prosthesis. Likewise, in aortic valve replacement, operative mortality rate (SE 4 p. 100 - BS 3.2 p. 100), 5 year survival (SE 82 +/- 7.8 P. 100 - BS 86 +/- 3.3 p. 100) incidence of thromboembolic complications (SE 2.2 p. 100 - BS 1.8 p. 100) and the degree of post-operative improvement were not statistically different. However, the incidence of sudden death was statistically smaller with a BS prosthesis than with a SE prosthesis (respectively 1.6 p. 100 and 6.9 p. 100).

[Problems encountered by the anesthetist-intensive care specialist during aorto-coronary bypass surgery]. / Problèmes posés a l'anesthésiste-réanimateur par la chirurgie du pontage aorto-coronaire.

The authors studied a series of 288 patients undergoing surgery for aorto-coronary bypass. The anaesthetic protocol and operative protocol are described and particular emphasis is placed upon the aortic clamp time. Mortality and peri-operative complications are then analysed. The treatment of such complications is based essentially upon vasodilators and where necessary intra-aortic counter-pressure balloon device to provide circulatory assistance.

[Surgical treatment of massive pulmonary embolism. (Reported of 45 successful embolectomies inclusive 10 with Trendelenburg's technic) (author's transl)]. / Chirurgische Behandlung der massiven Lungenembolie. Bericht über 45 erfolgreiche Operationen, hiervon 10 Eingriffe nach Trendelenburg.

45 pulmonary embolectomies have been carried out successfully, 10 by Trendelenburg's procedure, 35 with extracorporeal circulation. The latter method gives satisfactory results (34 survivals out of 36 attempts since 1970) and appears to be the procedure of choice. Any pulmonary trauma should be avoided at operation; embolectomy is done by intra-vascular suction. The hemodynamic status was always abnormal: 5 initial cardiac arrests, 20 cases of severe shock (9 demonstrating cardiac arrest on the operating table) and 11 cases with less severe shock. In 9 cases cyanosis, respiratory distress and signs of acute cor pulmonale were the clinical features of the massive embolus. In 9 patients the operation was performed after an unsuccessful trial of thrombolysis. Preoperative pulmonary angiography could be performed in 30 cases and always showed extensive pulmonary vascular obstruction of 60 to 95 per cent. These data are important for diagnosis and for assessment of the prognosis. Despite of present medical treatment with fibrinolytics, surgery is still advisable in the treatment of massive pulmonary embolism. The indications are moribund patients, those in whom thrombolysis is contraindicated or unsuccessful and those with massive pulmonary obstruction (greater than 60 per cent). In this latter subset thrombolytic therapy carries a high level of mortality.

[Traumatic rupture of the descending aorta. A report of 21 operated cases (author's transl)]. / Die traumatischen Rupturen des Isthmus der Aorta anhand von 21 operierten Fällen.

From 1965 to December 1976, 21 traumatic ruptures of the descending thoracic aorta have been operated; the last 13 cases have been managed in 1975 and 1976. The lesions consisted in 15 recent ruptures (R.R.) and 6 chronic aneurysma (C.A.). Associated injuries were the rule and 6 patients underwent exploratory laparotomy prior to thoracotomy. Surgical repair was consistently due by use of an extracorporeal by-pass (20 times), and resulted in 12 end-to-end aortic sutures (11 R.R., 1 C.A.) and in 9 reconstruction by means of a tubular dacron graft (5 C.A., and 4 R.R.). 4 patients died. 16 of the 17 survivals are healthy and active. Paraplegia developed in one patient.

[Massive pulmonary embolism Apropos of 26 embolectomies with definitive survival, 10 of them by Trendelenburg's operation]. / L'embolie pulmonaire massive. A propos de 26 embolectomies avec survie définitive, dont 10 par opération de Trendelenburg.

The authors report 26 pulmonary embolectomies carried out successfully, 10 of them having been Trendelenberg procedures and 16 having been carried out under extracorporeal circulation. The latter method gives better results, and appears to be the procedure of choice. The haemodynamics before operation were always abnormal, and there were 4 cardiac arrests, 11 cases of severe shock, and 6 cases with less severe hypotension. In the other cases, cyanosis, respiratory distress and signs of acute cor pulmonale were the clinical features of the massive embolus. It was possible to carry out arteriography in 14 cases, and this showed extensive pulmonary vascular obstruction in between 70 and 90%. In 4 cases this procedure was followed by an exacerbation, and extremely urgent treatment became neccessary. This examination is important for diagnosis and for assessment of the prognosis. It seems clear to the authors that surgery has a certain place, alongside medical fibrinolysis of a severe prognosis. It seems clear to the authors that surgery has a certain place, alongside medical fibrinolysis of a severe pulmonary embolus. The essential indications for surgery are moribund patients, those in whom fibrinolysis is contraindicated or unsuccessful, and those with massive obstruction of the pulmonary arterial tree.

[Study of recovery and the post-anaesthetic period (author's transl)]. / Etude du réveil et de la phase post-anesthésie.

The authors compare recovery and the post-anaesthetic period in 45 patients anaesthetised with a combination of either pentothal, nitrous oxide, fluothane and dolosal (group 1, 24 subjects), or of pentothal, nitrous oxide and phenoperidine (group 2, 21 subjects). The quality of recovery was judged at the end of anaesthesia by determining of occurrence of the first response to 3 types of stimulation (calling the name, noise and pain) and the density of these responses during each minute. During the post-anaesthetic period the respective percentages of wakefulness and sleep were calculated. In this way the authors demonstrate a significant (P less than 0.01) shortening in recovery time for group 2, reactivity to own name occurring first in both groups, and a very significant (P less than 0.001) increase in the percentage of physiological sleep in subjects of group 2 during the post-anaesthetic stage.

[Post-traumatic interventricular communication. Closure under extracorporeal circulation].

Report of one case of acquired traumatic interventricular septal defect due to a stab injury of the right ventricle by a knife. The highly-placed penetrating injury involved the muscular septum and very probably resulted in a right bundle-branch block of the His system. Surgical operation performed in view of a starting clinical intolerance with moderately increased right cardiac pressures, was done under ECC with easy suture of the septal wound. The post-operative course was normal and a quick clinical cure was noted, which persisted for 8 months after surgery. The interest of this case, in addition to the very severe condition of the patient who had sustained 11 stab-knife wounds, lies in the high localization of the septal wound, which explains the involvement of the intracardiac conduction pathways.