[Computer assisted open heart surgery. First case operated on with success]. / Chirurgie à coeur ouvert assistée par ordinateur. Premier cas opéré avec succès.

The recent development of less invasive intracardiac surgery using small incisions and videoscopic techniques allowed an evaluation of the advantages and limitations of this new approach. Among the limitations was the increased difficulty of the surgical technique when using long instruments through small incisions and ports. We investigated whether computer assisted surgical instruments might bring a solution to this problem. Among the existing systems, we selected the Intuitive System because of two original features. It provides a stable, magnified, three dimensional view of the operating field at a console where the surgeon is seated to operate, and it uses computer assisted instruments having the same dexterity and range of motion as the hand. After 10 months of active work to adapt this system to intracardiac surgery, the first open heart operation using computer assisted instruments was carried out on a 52-year-old woman presenting an aneurysm and a large defect of the atrial septum. The patient was extubated 8 h after the operation, returned to her room 16 h later and was discharged from the hospital 8 d post-operatively with normal heart function and no residual shunt. This preliminary experience showed that computer assisted cardiac surgery is feasible and may open new and promising directions in open heart surgery.

Dynamic cardiomyoplasty at seven years.

Since January 1985, the date of the first dynamic cardiomyoplasty, until April 1992, 52 patients with end-stage heart disease were operated on in our institution. Mean preoperative New York Heart Association functional class was 3.3 and ventricular ejection fraction 16% +/- 3%. Associated procedures in 23 patients comprised ventricular aneurysm resection (10), valve surgery (9), coronary artery bypass (8), and tumor resection (3). Thirty-eight patients had a ventricular reinforcement, 13 a ventricular substitution, and 1 an atrial reinforcement using the left latissimus dorsi muscle. Preassist mortality rate before full latissimus dorsi muscle stimulation was 7 of 13 patients (54%) in the 1985 to 1987 period and 5 of 39 (12%) in the 1988 to 1992 period. The causes of death were heart failure (4), multiorgan failure (4), septicemia (2), ventricular fibrillation (1), and sudden death (1). Multivariate analysis of factors influencing hospital mortality showed that age, cardiac suture technique, associated surgical procedures, biventricular heart failure, and hemodynamic instability plus inotropic drug support were predictors of unfavorable outcome. All patients were followed up for from 2 months to 7 years (mean 21 months). Postassist mortality rate was 8 of 40 (20%). Causes of death included heart failure (5), ventricular fibrillation (1), myocardial infarction (1), and gastric bleeding (1). Preoperative risk factors influencing long-term mortality were permanent New York Heart Association functional class IV, biventricular heart failure, atrial fibrillation, cardiothoracic ratio greater than 60%, and ejection fraction less than 15%. Actuarial survival at 7 years was 70.4% (preassist mortality excluded). Surviving patients were in a mean New York Heart Association functional class of 1.8 (preoperatively 3.3, p < 0.05). The average ejection fractions (rest/stress) were 25%/28% at 1 year, 26%/30% at 2 years, and 23%/28% at 3 years. Average cardiothoracic ratios were 57% +/- 3% at 1 year, 56% +/- 2% at 2 years, and 57% +/- 2.5% at 3 years. Catheterization obtained in 20 patients showed no significant changes at rest in capillary wedge pressure, pulmonary artery pressure, and diastolic left ventricular pressure when compared with preoperative pressures. Average ejection fractions increased from 24% to 30.6%. Maximal oxygen consumption increased from 12.8 +/- 3.5 to 18.6 +/- 4 ml/min per kilogram. The number of rehospitalizations resulting from congestive heart failure was reduced to 0.4 hospitalizations per patient per year (preoperatively 2.4, p < 0.05). In 62% of the patients, pharmacologic therapy was diminished after the operation. Three patients required orthotopic heart transplantation 6 months, 4 years, and 5 years after cardiomyoplasty.

[Use of a synthetic prostacyclin in extracorporeal circulation]. / Utilisation d'une prostacycline de synthèse en circulation extracorporelle.

Using a prostacyclin in conjunction with standard heparin might limit the occurrence of post-extracorporeal circulation (ECC) thrombopathy and reduce the risk of haemorrhage inherent in this technique. For this reason, we studied the effect of the prostacyclin analogue Iloprost (ZK 36 374), a drug which is active in man when given orally with a biological half-life of 30 min, and devised a double-blind randomized trial to evaluate the potential benefit of Iloprost versus placebo in 2 groups of 15 patients (A: placebo, B: Iloprost). An infusion of the drug in incremental doses (up to 12 ng kg-1 min-1) was begun before starting the ECC and was stopped at the end of the cardiopulmonary bypass, at the time of protamine injection. Significant arterial hypotension was observed during ECC in two patients of the Iloprost group. Comparison between Iloprost and placebo groups showed that the mean number of platelets was not significantly higher in the Iloprost group 20 min after the ECC and during the early post-operative recovery period. Platelet aggregability was higher after surgery in the Iloprost group than in the placebo group. There was no significant difference in post-bypass bleeding between the two groups. Thus, Iloprost does not reduce the fall in circulating platelets observed during cardiopulmonary bypass, but it might help in preserving the platelet function. However, the potential usefulness of the drug is limited by adverse haemodynamic reactions.

[Calcified aortic stenosis and coronary disease. Apropos of 115 surgically-treated cases]. / Rétrécissement aortique calcifié et coronaropathie. A propos de 115 opérés.

The authors studied 115 surgical cases of calcific aortic stenosis (AS) with coronary angiography. Between 1970 and 1981, 56 of these patients also had one or more aortocoronary bypass grafts (ACBG) (Group I). The other 59 cases, recruited from 1978 to 1981, comprise the control group who underwent isolated aortic valve replacement either with a normal coronary angiogram (Group II: 50 cases) or with such extensive coronary artery disease that ACBG was impossible (Group III: 9 cases). 93% of patients in Group I had preoperative angina compared to 80% in Group II and 78% in Group III. The incidence of previous myocardial infarction was 19%, 4% and 44% respectively. The number of main coronary arterial lesions per patient was 2 in Group I and 1.8 in Group III. In Group I, aortic valve replacement (AVR) was associated with a single aorto-coronary bypass in 70% of cases, a double bypass in 27% and a triple bypass in 3% of cases. The revascularisation ratio was 1.3 bypass per patient. The number of "complete" revascularisations rose from 56% (1970-1976) to 73% from 1977 to 1981. Overall hospital mortality per group (less than 1 month) was 16%, 4% and 0% respectively. The mortality rate in Group I fell from 31% (1970-1976) to 10% from 1977 to 1981. The perioperative rate of myocardial infarction in each group was 9%, 0% and 11% respectively. This figure fell considerably in Group I from 12.5% (1970-1976) to 7.5% from 1977 to 1981.(ABSTRACT TRUNCATED AT 250 WORDS)

[Nitroglycerin and anaesthesia in phaeochromocytoma (author's transl)]. / Utilisation de la nitroglycérine au cours de la chirurgie du phéochromocytome.

Six patients who have undergone surgery for phaeochromacytoma have been separated in 2 groups. In group I (n = 3) a nitroglycerin infusion of 7.8 microgram . kg-1 . mn-1 has been used before the removal of the tumor and no vasodilator drug was infused in group II. During the dissection, mean arterial pressure was significantly lower in group I (129 +/- 12 mm Hg) than in group II (172 +/- 17 mm Hg) (p < 0.05). After removal of the tumor the decrease in mean arterial pressure was lower in group I than in group II. In group I the maximal rise in mean arterial pressure (73 +/- 18 mm Hg) was significantly reduced compared to group II (134 +/- 20 mm Hg). These results show that nitroglycerin is an interesting substance to decrease the variations of arterial blood pressure and this effect is important to prevent cardiac complications during and after surgery.

[Nitroglycerin and amyl nitrite action on common bile duct during operation for vesicular lithiasis (author's transl)]. / Effects des dérivés nitrés sur le tonus des voies biliaires au cours de la chirurgie de la lithiase vésiculaire.

Eight patients undergoing cholecystectomy received a single injection of nitroglycerin (0,9 mg) and 8 received amyl nitrite, during a cholangio-kinesimetry. The maximum fall in common bile duct pressure was similar in both group; 3.2 +/- 0.3 torr after nitroglycerin (NTG),3.8 +/- 0.6 torr after amyl nitrite (AN). NTG caused a more persistent lowering of pressure than AN; 614 +/- 42 seconds/343 +/- 27 seconds (p < 0.001). This study showed that it is possible to produce a relaxation of biliary tract muscle fibres with an injection of nitroglycerin and then replace amyl nitrite during anesthesia.

[Anesthesia for aorto-coronary bypass]. / Anesthésie des pontages aorto-coronaires.

The authors have analysed a series of 357 patients undergoing aortocoronary bypass. The onset of complications was studied in relation to the past history, the anaesthetic protocol, the period of extra-corporeal circulation and the type of myocardial protection. Complications consisted of acute hypertensive episodes, arrhythmias, peroperative myocardial ischemia and myocardial infarction. The degree of beta-blocker therapy and above all its continuation up to the time of operation would seem to be an important factor in effective myocardial protection.

[Prinzmetal's angina during myocardial revascularisation. Cardiovascular complications in 71 patients (author's transl)]. / L'angor de Prinzmetal au cours de la chirurgie du pontage aorto-coronaire. Comportement cardio-circulatoire de 71 malades.

71 patients undergo myocardial revascularisation for Prinzmetal's angina; among them, 50 p. cent are operated upon in emergency according to three ways of anaesthesia: neuroleptanalgesia, analgesic anaesthesia, combined anaesthesia. The authors lay stress on the importance of per- and post-operative complications: electrocardiographic ischemia in 22 p. cent of the cases, severe ventricular excitability perturbations were observed in 21 p. cent, myocardial necrosis in 14 p. cent, cardiovascular collapse in 21 p. cent and hypertensions in 22 p cent. These complications are often associated. In the discussion, the authors underline anesthetic induction as a cause of Prinzmetal's angina in 50 p. cent of the cases. They put the accent on the severity of peroperative crisis followed in 50 p. cent of the cases by serious ventricular excitability perturbations. In 25 p. cent of the cases myocardial necrosis is a complication of the spasm of a coronary artery. In this field, posterior necrosis are more frequent and correspond to the spasm of the right coronary artery. All the patients of this series, except one, develop necrosis in the spastic area (by-passed or not). Per-operative hypertension has no incidence on the occurrence of post-operative complications. Lastly, continuous per-operative infusions of nitroglycerine has been performed in several patients in order to reduce morbidity of this type of surgery.