[Angioplasty or surgery in the patient with multivessel disease]. / Angioplastie ou chirurgie chez le patient pluritronculaire.

The aims of myocardial revascularisation are to treat angina, reduce ischaemia and improve life expectancy. Patients with multivessel disease have a poor prognosis, especially when the lesions are proximal, when the preseptal left anterior descending artery is involved and when left ventricular dysfunction is present. In this particular group of patients, coronary bypass surgery has been shown to improve 10 year survival. Coronary angioplasty has been compared with surgical treatment in many clinical trials. The medium-term survival is the same in both groups, but with a higher number of repeat procedures except in diabetic patients in whom mortality is higher after angioplasty. The use of coronary stents should reduce the number of post-angioplasty procedures. Constant technical improvements, the introduction of surgery without cardiopulmonary bypass, combined revascularisation procedures, new antiplatelet drugs, the absence of long-term comparative results, all this results in a personalized choice of revascularisation procedure based on the overall clinical and angiography features of each particular case.

A 8-year follow-up of the Edwards-Duromedics bileaflet prosthesis.

Following reports of leaflet escapes, distribution of the Edwards-Duromedics prosthesis (ED), introduced in 1982, was suspended from 1988 to 1990. From our experience of 257 patients operated on between March, 1983, and April, 1988, it appeared to us that, among the five key factors identified by extensive studies, surgical mishandling, specially in mitral position, could have been the main contributing factor. These 257 patients, mean age 57 years (range 2 to 75 years), underwent 138 aortic (AVR), 86 mitral (MVR), and 33 double valve (DVR) replacements. Hospital mortality was 2.3% (6 patients): 1.4% for AVR, 3.5% for MVR, and 3% for DVR, none of them being directly valve-related. But there were 3 early replacements of a mitral ED for intra or postoperative impingement of one leaflet. Follow-up has been 93%, with a total of 1.155 patient-years. Among the 20 late deaths (8%), 4 (20%) were considered as valve-related; there was one MV thrombosis and 7 non-fatal systemic emboli, the total incidence of thromboembolism being 0.7% patient-year. No structural failure or leaflet escape was observed in this series. At 8 years, actuarial survival, hospital mortality excluded, was 85.5% for AVR, 95% for MVR, and 89% for DVR. The ED prosthesis is, from a hydrodynamic point of view, an advance in terms of both mechanical and bileaflet valve: the valve design accounts for its low thrombogenicity. But its persistent drawback remains the prohibitive vertical exposure of leaflets in mitral position, that can be responsible for immediate or delayed leaflet entrapment, or for incautious handling for rotating the mechanism, leading to extensive fissuration of pyrolitic carbon and delayed rupture. (ABSTRACT TRUNCATED AT 250 WORDS)

Modifications of platelet shape change and ATP release during cardiopulmonary bypass.

Platelet activation is accompanied by characteristic morphological changes: smooth-disc platelets become more spherical in shape and develop psudopods. The purpose of this study is to investigate whether platelets change after extracorporeal bypass. Twenty-two patients undergoing cardiopulmonary bypass (CPB) were studied prior to anesthesia and immediately after the operation. Platelets activated by different agonists were monitored simultaneously for morphological changes, ATP release and aggregation. While shape change measured before surgery was large, it was significantly reduced after bypass surgery (p < 0.01); morphological changes were quicker postoperatively. Several other parameters also changed: the time lapse between administration of the agonist and the start of ATP secretion decrease significantly (p < 0.01). After activation with high concentrations of ADP, ATP release was significantly increased (p < 0.01). On the other hand, less ATP was released after platelet activation with collagen and arachidonic acid, suggesting a change in platelet adhesion or a downregulation of endoperoxide synthesis. In our study, the importance of preactivation change in shape, estimated quantitatively by percent loss in ability of changing shape, can be compared using various agonists, with proportional defects in release and aggregation. These data provide evidence for different intrinsic levels in platelet defects after CPB.

Should we avoid ostial implantations of Wiktor stents?

Complications arising during stent implantations in coronary arteries have been reduced by technological progress and the accumulated experience of interventional cardiologists. Retrospective and prospective randomized studies with several types of stents are currently available and show improved short and mid-term results. Wiktor stent provides increased flexibility for ease of implantation particularly in curved lesions. However, the flexibility of the Wiktor stent is also associated with low resistance in the longitudinal axis. We report four cases (in 4 out of 6 ostial lesions treated and 4 out of 43 Wiktor stents implanted during a 9-month period) in which stents have become unraveled during procedures on ostial lesions (2 saphenous venous grafts and 2 native coronary arteries). Death occurred in one case and one patient was treated by emergency coronary bypass surgery. In three cases the distal extremity of the guiding catheter stretched the stent meshes during the final control angiograms, and in one case the stent was stretched during withdrawal of the deflated balloon into the guiding catheter. We believe that it is preferable to avoid using this stent in ostial lesions.

[Perioperative ischemia in coronary surgery caused by coronary spasm of an angiographically normal coronary artery]. / Ischémie périopératoire en chirurgie coronaire par spasme coronaire sur artère radiologiquement normale.

Spasm of healthy native coronary arteries is rare but a serious cause of perioperative ischaemia after coronary bypass surgery. The authors report five characteristic cases. In each case, the spasm presented with giant ST elevation and haemodynamic changes. In one case, further coronary bypass surgery was required. In three cases, symptomatic treatment of the hypotension associated with diltiazem completely cured the problem. One case was complicated by a small myocardial infarction. There were no fatalities. Previously reported cases often describe very heavy therapeutic protocols, justified by the high risks of this condition. Due to the fact that it is not possible to identify a target-population, simple prophylactic treatment with diltiazem seems to be justified in patients undergoing coronary artery bypass surgery.

[Early results of coronary surgery in patients between 71 and 80 years of age]. / Résultats immédiats de la chirurgie coronarienne entre 71 et 80 ans.

One hundred consecutive patients aged 71 to 80 without other cardiac pathology underwent coronary bypass surgery by the same surgical team between January 1986 and May 1989. These patients were recruited from a group of 687 patients undergoing coronary bypass surgery in the same period. The indication was always based on the severity of clinical symptoms resistant to medical therapy. Recent unstable angina despite triple therapy was a particularly common indication in this group of patients (61%). Preoperative coronary angiography showed a high incidence of triple vessel (62 cases) and left main stem disease (23 cases). Double vessel (12 cases) and single vessel disease (3 cases) were less common. Preoperative myocardial infarction was observed in 35% of cases; the site was nearly always on the inferior wall. In all, 230 bypasses were performed including 23 internal mammary artery bypasses (average 2.3 bypasses per patient). Six patients developed perioperative myocardial infarction confirmed by ECG and a rise in cardiac enzymes in 4 cases and by a rise in the cardiac enzymes alone in 2 cases. The mortality was low in this group of patients (3%). This was due to strict selection of patients in this age group and also to the improvement in the techniques of myocardial protection, anaesthesia and intensive care. Our results justify the operative indications in this group of patients in whom medical therapy has failed.

[Use of a thin wall Impra prosthesis for a vascular approach in chronic hemodialysis. Short- and middle-term evaluation. Apropos of 66 cases]. / L'utilisation des prothèses Impra à paroi fine dans l'abord vasculaire en hémodialyse chronique. Evaluation à court et à moyen terme. A propos de 66 observations.

The authors report their experience of thin wall PTFE IMPRA prostheses in providing vascular access for chronic haemodialysis. Sixty-six prostheses were inserted between 14/10/1983 and 31/10/1986, with review of all patients at 31/6/1987. Twenty-three per cent of patients died during the study period. Patency analysed by the actuarial method was 49.07 +/- 15.7% at 2 years. There was no evidence of any significant difference between use of the forearm and of the arm. The main cause of failure was early (responsible for the loss of 9.2% of prostheses) or secondary (after the first month) thrombosis. A total of 30.3% of prostheses were lost by thrombosis by the end of 2 years, the principal cause being anastomotic or post-anastomotic venous stenosis. The use of thin walls in no way modified the incidence of this complication. The authors suggest its preventive protection by routine ansography. False aneurysms occurred beyond 18 months of dialysis requiring removal of the prosthesis in 3 cases. Thinning of the wall is one of the probable factors involved in this complications, justifying the abandonment of this type of prosthesis in this indication despite technical advantages at implantation and during use.

Anomalous origin of the right pulmonary artery from the ascending aorta: successful surgical repair.

A case of isolated anomalous origin of the right pulmonary artery from the ascending aorta with severe pulmonary hypertension is reported. Surgical repair was achieved by anastomosis of the anomalous vessel to the pulmonary artery trunk using a continuous absorbable suture. Special emphasis is laid on the favorable postoperative evolution of the pulmonary hypertensive disease following the successful repair. The poor natural history of this uncommon congenital defect if untreated makes early corrective surgery imperative.