How to replace an extracorporeal life support without interruption of the cardiopulmonary assistance.

The extracorporeal life support (ECLS) allows a maximum of a few weeks of cardio-respiratory assistance. Using standard ECLS, the circuit must be replaced after a few days or sometimes more frequently, in case of dysfunction. Classically, the replacement needs the interruption of the support inducing a temporarily hemodynamic instability. We report a simple technique, allowing this replacement without interruption of the assistance, based on the implantation of a new circuit in parallel. We describe the original modification, the complete procedure and our results. This method has been used in 34 ECLS replacements in 14 patients without any incident or thrombo-embolic events. This simple technique is safe, reliable, and avoids the hemodynamic instability induced by classical replacements.

Paracorporeal pulsatile biventricular assist device versus extracorporal membrane oxygenation-extracorporal life support in adult fulminant myocarditis.

OBJECTIVE: Biventricular assist device support with a paracorporeal pulsatile device is known to be an efficient bridge to recovery for patients with fulminant myocarditis-related cardiogenic shock. Whether these patients can be as efficiently supported with femorofemoral extracorporeal membrane oxygenation remains unclear. METHODS: From 2001 to 2006, 11 patients were referred to our cardiac surgery department for fulminant myocarditis-related cardiogenic shock. The first 5 patients (mean age, 32 +/- 2 years) were supported with a biventricular assist device (Thoratec, Pleasanton, Calif; group I), whereas the remaining patients (40 +/- 4 years) were supported with femorofemoral extracorporeal membrane oxygenation (group II). Preimplantation probability of death was calculated by using the APACHE II score, which was 11 +/- 9 in group I versus 24 +/- 18 in group II. RESULTS: One patient in each group died while receiving support. In group I the death occurred after 18 days of support in a patient who had 45 minutes of external resuscitation before biventricular assist device implantation. In group II a patient who remained unstable during extracorporeal membrane oxygenation was switched to a biventricular assist device 13 days later and eventually died of tamponade after 45 days. All other patients were weaned from the device after a mean duration of support of 21 +/- 5 days in group I versus 13 +/- 4 days in group II. At hospital discharge, the mean ejection fraction was 45% +/- 5% in both groups, and at 6 months' follow-up, it was 65% and 75%, respectively, in groups I and II. CONCLUSION: In our experience extracorporeal membrane oxygenation is as efficient as use of a biventricular assist device as a bridge to recovery for patients with fulminant myocarditis-related cardiogenic shock and facilitates renal and hepatic recovery on support.

Management of brachial artery aneurisms in infants.

Brachial artery aneurisms in children under 1 year of age are very rare. The main risk is distal ischaemic complication. We report four infants suffering from brachial artery aneurism of unknown origin. In all cases we used Doppler ultrasonography to validate the clinical diagnosis. Pre-operative vascular check-up was negative for other aneurismal location. Surgical excision with direct end-to-end anastomosis was possible in one patient; the others required interposition of an autologous venous graft. At discharge, patients were given oral aspirin for a few weeks. Histological examination revealed one pseudoaneurism and three true aneurisms. There were no complications either postoperatively or at 18 months follow-up. Arterial ligation might be indicated in only two situations: aneurism distal to profunda brachii artery, or chronic wall thrombus completely occluding (but distal perfusion through a neovascularization must be assessed first on angiography). Surgical excision with arterial reconstruction is the standard treatment. Endovascular treatment is not suitable because such a procedure in an infant would generate excessive radiation exposure, and a risk of stent migration with limb growth. In the case of an initial isolated and idiopathic presentation, or of false aneurism, clinical follow-up at 1 year is sufficient. In the case of secondary lesion, multiple initial presentation or relapse, life-long follow-up with repeated corporal imaging should be performed.

Endovascular treatment of an acute subdiaphragmatic aortic rupture.

We report the case of a 23-year-old man presenting an acute rupture of the subdiaphragmatic aorta in front of a T12 vertebral fracture after a road accident. Because of the location of this lesion, the operative risk and a cardiac instability, we opted for an endovascular treatment with a new and original approach in covering a small part of the aorta using commercial devices. We also describe the probable mechanism of this uncommon aortic rupture. The surgical outcome was uneventful and the 3 month computed tomographic scan confirmed the complete exclusion of the aortic disruption.

Intra-esophageal rupture of a bronchogenic cyst.

Bronchogenic cysts usually are an asymptomatic disease and present as an incidental finding in the chest X-rays. They require a complete and early surgical excision to prevent complications and recurrences. We report a rare case of a voluminous symptomatic para-esophageal bronchogenic cyst complicated by an esophageal fistula. The initial video-assisted thoracoscopic surgery excision of the cyst was converted in open thoracotomy to suture the esophagus and interpose omentum. Previously, only four cases of para-esophageal bronchogenic cysts with esophageal communication have been reported.