Bernard Kreitmann

Association of mild hyperhomocysteinemia with cardiac graft vascular disease

In non-transplant patients mild hyperhomocysteinemia is an independent risk factor for vascular disease. The aim of this study was to determine whether hyperhomocysteinemia is associated with graft vascular disease. Fasting total plasma homocysteine was assessed in 18 patients with graft vasculopathy and 18 transplanted patients without graft vasculopathy matched for age, sex and the time since transplant. All were on cyclosporin. Graft vasculopathy was defined at coronary angiography as stenoses > or = 25%, or aneurysms. We found that hyperhomocysteinemia ( > or = 15 micromol/l) is common among transplanted heart recipients and significantly more frequent in the patients with graft vasculopathy (17/18 versus 11/18). Accordingly, the mean homocysteinemia was significantly higher in the group with graft vasculopathy (23.6+/-7.8 versus 16.9+/-7.1 micromol/l, P=0.01). The elevation of homocysteine plasma levels in the heart transplant recipients has probably multiple causes. The main cause seems to be renal failure. Additional causes could be azathioprine treatment or genetic polymorphisms. These results suggest that besides the immunological factors, homocysteine can play an additional role in the pathogenesis of graft vascular disease.

Postoperative extracorporeal life support in pediatric cardiac surgery: recent results.

We retrospectively reviewed the files of 19 extracorporeal life support (ECLS) applications performed after cardiac surgery in 15 patients from January 2002 to December 2004. We placed 16 arteriovenous ECLS applications with oxygenator, 2 venovenous ECLS applications with oxygenator, and 1 biventricular ECLS application without oxygenator (graft dysfunction after heart transplant). Mean age was 4.9 ± 7 years (median 5.9 months, range 11 days to 21 years). All patients underwent surgery for congenital heart disease, except for one patient who had a heart transplant. Indications were hemodynamic failure in 12 cases, respiratory failure in 5 cases, and mixed failure in 2 cases. Four patients were undergoing cardiopulmonary resuscitation during ECLS placement (no deaths). Mean delay between surgery and ECLS placement was 3.2 ± 3.4 days (median 2 days). Mean ECLS duration was 3.4 ± 5.8 days (mean 6 days, range 3–16 days). Three patients had further surgery for residual lesions. Thirteen patients (86.7%) survived to ECLS weaning; 12 patients survived to hospital discharge (80%). No survivor presented obvious neurologic damage. Specific morbidity included re-entry for bleeding, multiple transfusions, and mediastinitis. These results support early placement of ECLS in children whenever a severe postoperative hemodynamic or respiratory failure, refractory to medical treatment, is present.

Lung infections in pediatric lung transplantation: experience in 49 cases

OBJECTIVES Pulmonary infections, and particularly cytomegalovirus (CMV) infections, are a major cause of morbidity after lung transplantation. We report here our results in 49 pediatric lung transplantations. METHODS Between may 1988 and 1997, we have done 49 lung transplantations in 42 children (en bloc double lung transplantation (DLT):10, HLTx:7, sequential bilateral sequential-lung transplantation (BSLT):31, single-lung transplantation (SLT): 1). In seven, it was a retransplantation. Among these, 34 were cystic fibrosis (CF) patients, all with multiresistant organisms (Pseudomonas aeruginosa, Burkholderia cepacia, Achromobacter xylososydans, Staphylococcus aureus). All patients were treated with multiantibiotic prophylaxy adapted to the preoperative cultures. Donor-recipient CMV matching was possible in only 31 cases. CMV prophylaxy and immunosuppression protocols have evolved with time, with a current protocol of IV Gancyclovir prophylaxy for 3 months and triple drug immunosuppression without post-operative rabbit anti-thymocyte globulin (RATG) induction. There was no perioperative mortality in the primary transplantations and three early deaths in the whole group (6.1%). RESULTS Only five patients had no pulmonary infection. The patients presented 3.2 infection episodes per year, 75% localized on the lungs, 41% during the first 3 months. Among the 13 deaths in the 1st year, 10 were directly related to infection, 60% due to CMV. After the 1st year, in all patients dying of pulmonary dysfunction or obliterative bronchiolitis (OB), bacterial infections were associated. There was no serious fungal infection. Actuarial survival at 3 months, 1, 3, 5 years were 85, 65.7, 47.5 and 28.5%, respectively. There was a significant difference in 3 year survival between patients receiving CMV negative organs (40%) and CMV positive organs (17%). CONCLUSION In our experience, as in others, pulmonary infection risk is important in lung transplantation. Bacterial infections were mainly an aggravating factor of secondary pulmonary dysfunction or OB, and were not the primary cause of death. CMV infections have been very severe and lead us, despite the scarcity of donors, to avoid positive donors in negative recipients, this leads to disastrous mid-term results in our experience, despite prophylaxis.

Delayed sternal closure: a life-saving measure in neonatal open heart surgery; could it be predictable

OBJECTIVES The tight syndrome after open-heart procedures in neonates renders delayed sternal closure (DSC) a life-saving measure. The goal of this study is to analyze the risk factors that may predict the need for DSC. METHODS Between January 1991 and December 2000, 312 consecutive open-heart procedures in neonates (180 males, 132 females) were studied retrospectively. Median age was 11.9 days (range 1-30 days) and weight 3.63 kg (range 1.8-4.2 kg). The major pathologies were transposition of the great arteries (153), interruption of the aortic arch (IAA) (33), total anomalous pulmonary venous drainage (TAPVD) (24) and single ventricle (19). Two hundred and twenty-eight patients had profound hypothermia with circulatory arrest and 74 normothermic cardiopulmonary bypass (CPB), 195 had crystalloid cardioplegia and 111 blood cardioplegia. Median CBP time was 146 min (range 37-284 min) and aortic clamping 67.6 min (range 0-164 min). Two hundred and fifty-five patients had a continuous ultrafiltration and 57 had a modified ultrafiltration. The criteria for DSC were hemodynamic instability, deterioration of the central venous saturation, metabolic status and/or high ventilatory pressures. RESULTS One hundred and nineteen patients had DSC (38.12%). Median CBP time was 145 min (range 37-284 min) and aortic clamping time 67.6 min (range 0-164 min). Twenty-one patients (6.7%) needed reopening in the intensive care unit (ICU) during the first 24 h. Among the studied factors, the age below 7 days (P=0.014), the diagnosis of IAA and TAPVD (P<0.05), CBP duration over 185 min (P=0.048), clamping time over 98 min (P=0.039) and central venous saturation below 51% P=0.024) were statistically significant risk factors. All the patients who had more than 106 min of clamping, more than 196 min of cardiopulmonary bypass or less than 47% of central venous saturation were either left opened or reopened in the ICU. CONCLUSIONS Many of the factors thought to be associated with the need for delaying the sternal closure had no statistical significance as risk factors. On the other hand, the diagnosis of IAA or TAPVD, an age less than 7 days, aortic clamping more than 98 min, CPB time more than 185 min and a post-bypass central venous saturation less than 51% were statistically significant risk factors that could be used in predicting the need for delaying the sternal closure.

Double-lung transplantation in children: A report of 20 cases

In the last 3 1/2 years, we have performed 20 double-lung transplantations in children between 7 and 16 years old (mean age, 13 years). One patient had primitive bronchiolitis obliterans and the other 19, cystic fibrosis. Eight patients were operated on in an emergency situation, 7 of them requiring ventilator support before transplantation. The procedures were en bloc double-lung transplantation in the first 11 patients with separate bronchial anastomoses in 10, and sequential bilateral lung transplantation in the later 9 patients. There were no operative deaths. Two patients died in the hospital on postoperative days 37 and 73, and there were four late deaths, which were due to infection, rejection, and bronchiolitis obliterans. The acceptable incidence of airway complications, the improvement in lung function of survivors, and the acceptable midterm survival make double-lung transplantation an acceptable alternative to heart-lung transplantation in children. However, in very small children, heart-lung transplantation may be preferable because of the size of the airway anastomoses at risk.

Absence of rapid deployment extracorporeal membrane oxygenation (ECMO) team does not preclude resuscitation ecmo in pediatric cardiac patients with good results.

We evaluated the results of using extracorporeal membrane oxygenation (ECMO) as resuscitation for cardiac patients undergoing cardiopulmonary resuscitation (CPR) in our setting where neither perfusionists nor surgeons are always on site, and no circuit may be ready. Between 2003 and 2006, we used ECMO for all cardiac patients who underwent cardiac arrest in the pediatric intensive care unit (PICU) or Cath Laboratory. We reviewed retrospectively 14 consecutive files (15 episodes). Mean CPR time before ECMO institution was 44 minutes (10–110 minutes). The surgeons, perfusionist, and scrub nurse, not on site for three of these patients, had to be called in simultaneously with institution of CPR. Two died on ECMO, the third one was successfully transplanted after 5 days. Globally, 10 patients could be weaned (66%). Eight patients (57%) survived to hospital discharge, seven without obvious neurological damage. One patient was bridged to a left ventricular assist device (LVAD) and was eventually successfully transplanted. He had an ischemic brain lesion with good recuperation and no sequel. We obtained good results with resuscitation ECMO in our setting where a permanently on-site rapid deployment ECMO team is not present at all times.

Isolated cleft of the mitral valve: distinctive features and surgical management.

BACKGROUND Controversy remains as to whether isolated cleft of the mitral valve and cleft of the atrioventricular septal defect are different entities. Our objectives were to provide a precise description of isolated cleft of the mitral valve and to clarify its surgical management and outcome. METHODS Patients with surgical repair of isolated cleft of the mitral valve were included. RESULTS Ten patients (9 female) underwent repair at a mean age of 12.1 +/- 10.5 years and mean weight of 32.1 +/- 17.8 kg. Preoperative echocardiography showed mild or less than mild mitral regurgitation in 6 cases and moderate to severe regurgitation in 4. Intraoperative examination confirmed in all cases a cleft dividing the anterior leaflet of an otherwise normal mitral valve. Attachment of the cleft to the ventricular septum by accessory chordae was found in 3 cases whereas preoperative echocardiography found such attachments in 5. Direct suture of the cleft was performed in 9 cases, associated with repair of tricuspid valve straddling (n = 1), subaortic stenosis (n = 1), and ventricular septal defect (n = 1). One patient with thickened clefts edges required an Alfieri-type repair. After a mean follow-up of 4.9 years (range, 1.3 to 11.9), all patients are asymptomatic without significant mitral regurgitation. CONCLUSIONS Echocardiographic description of isolated cleft of the mitral valve is not always as accurate as intraoperative analysis. This is a distinct morphologic entity from the cleft of the left-sided valve of atrioventricular septal defect, and seems associated with a strong female predominance, with various cardiac and extracardiac features. Surgical repair is successful with excellent midterm results.

Systemic embolism: a serious complication after cardiac transplantation avoidable by bicaval technique

OBJECTIVE Systemic embolism is a serious complication after classical orthotopic transplantation, presumably originating from enlarged left atrium. We specifically studied this problem after classical and modified bicaval transplantation. METHODS Between December 1985 and March 1999 we consecutively performed 72 classical and 106 modified heart transplantation. Modification included bicaval anastomosis and recipient left atrium maximal reduction. Mean age was 47 years. All the patients received an antiplatelet therapy and were routinely followed. When clinical signs of systemic embolism were present, a neurological evaluation and transesophageal echocardiography were done. Sixty matched patients (30 of each group) had comparative transesophageal echocardiography study, at least 6 months after transplantation. RESULTS Perioperative mortality was 17.4%. Mean follow-up was 6.8 2+/47 years. All patients were in sinus rhythm. Among 147 survivors, 11 patients who underwent classical transplantation had a systemic embolism, 1 month to 12 years after transplantation, 15.3%, (11/72). Two limb ischemia and one mesenteric ischemia (needing surgery), seven strokes (one death, two permanent neurological deficit). There was no systemic embolism in the modified technique group (P=0.013). Left atrial comparative transesophageal echocardiography study showed a larger left atrial surface in classical transplantation. 33+/-4 cm(2) versus 20+/-3 cm(2) in a modified technique, P=0.01. Spontaneous echo contrast was present in 56% of classical technique group associated with atrial thrombosis in nine patients, there were no atrial thrombosis in modified technique group and spontaneous echocontrast was present in 0.5% (P=<0.001). CONCLUSION The occurrence of systemic embolism, left atrial spontaneous echocontrast and thrombosis when using classical technique, and the absence of these complications with the bicaval technique justified the use of this method. Our experience with atrial thrombosis and spontaneous echocontrast rises the question of anticoagulation in classical transplantation.

Correction of cardiac defects through a right thoracotomy in children.

Median sternotomy is the conventional approach for correction of cardiac defects, but it is invasive and often yields poor cosmetic results. For this reason, a right anterolateral thoracotomy is used in selected cases. The aesthetic result is preferable and acceptable to many patients. 3 However, the indications have been limited. 4 We present our technique and results of correction of cardiac defects through a right lateral thoracotomy in 351 patients, emphasizing that left-sided cardiac anomalies are not contraindications for this approach. Patients and results. From October 1994 to July 1997, 351 patients underwent heart operations through a right thoracotomy (male 183, female 168). The mean age was 3.35 6 1.56 years (range 5 months to 8 years). The mean weight was 13.78 6 3.67 kg (6 to 26 kg). The mean cardiothoracic ratio was 0.58 6 0.01 (range 0.43 to 0.73). All patients had a definite diagnosis made by physical examination, chest radiography, and echocardiography. The types of cardiac anomalies and the procedures are listed in Table I. The patient is placed in the lateral decubitus position with the right side elevated 60 to 80 degrees. A skin incision about 6 to 8 cm in length is made obliquely between the anterior and posterior axillary folds. The upper border is the third intercostal space and the lower border is the sixth. A flap of breast tissue and pectoralis muscle is dissected from the underlying chest wall and retracted cephalad, so that the chest cavity can be entered through the fourth or third intercostal space. The pericardium is opened longitudinally 1 to 2 cm anterior to the phrenic nerve. After placement of two concentric purse-string sutures on the ascending aorta, it is cannulated with a 12F to 18F right-angled cannula. The superior vena cava is cannulated through the right atrial appendage and the inferior vena cava cannula is inserted through a stab wound at the cavoatrial junction. Cardiopulmonary bypass is established and core cooling is begun. When the body temperature reaches 24° to 32° C, the aorta is crossclamped and cold crystalloid cardioplegic solution is infused into the ascending aorta. Acceptable exposure of the intracardiac anatomy can be obtained with a standard oblique right atriotomy or a vertical right ventriculotomy incision, and the heart anomalies can be corrected in almost the same manner as with a median sternotomy. With Fallot’s tetralogy and right ventricular outflow tract obstruction, two traction sutures are placed in the infundibulum in an area free of major coronary arteries, and two small cat’s-paw retractors are placed on each side of the ventriculotomy so as to get good exposure of the right ventricular outflow tract and pulmonary artery (Fig. 1). After closure of the ventricular septal defect with a Dacron patch and excision of the heavy muscle bundles, the autologous pericardium or the homograft artery with a single cusp is used in widening the right ventricular outflow tract and/or the main pulmonary artery. The aortic clamp is slowly released and intracardiac air evacuated with an aortic needle vent connected to suction. Cardiopulmonary bypass is gradually discontinued and the chest is then closed in a routine fashion. The mean aortic crossclamp time was 31.83 6 20.26 minutes (range 6 to 140 minutes). The average duration of postoperative mechanical ventilation was 18.62 6 23.23 hours (range 2 to 140.72 hours). The mean thoracic and pleuropericardial drainage was 105.87 6 81.21 ml (range 15 to 753 ml). The mean postoperative hospital stay was 7.09 6 0.71 days (range 7 to 17 days). There were no early or late deaths. Complications were seen in 14 patients and included temporary neurologic deficits in one, a residual shunt through a ventricular septal defect in one, delayed cardiac tamponade in one, atelectasis in eight, and paresis of the right hemidiaphragm in three. Discussion. The right thoracotomy is an alternative to median sternotomy with more acceptable cosmetic results in the repair of some congenital heart defects. However, some anomalies are not suitable for correction by this approach. 4 Contraindications include pulmonary stenosis, severe pulmonary hypertension, age less than 2 years, patent ductus arteriosus, and left superior vena cava. In our practice, more types of congenital heart lesions could be corrected through this approach in children. The reasons for expanding the indications are that the thoracic cavity is smaller and the elasticity of the ribs is greater in the child than in the adult. The heart could easily be retracted posteriorly, providing better visualization, especially of the pulmonary artery and right ventricular outflow tract. However, this series includes no cases of left pulmonary artery stenosis. It is necessary to perform cardiac catheterization and correct the anomalies through a From the Department of Cardiovascular Surgery, Fu Wai Cardiovascular Institute and Cardiovascular Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.

Complete Atrioventricular Canal Repair Under 1 Year: Rastelli One-Patch Procedure Yields Excellent Long-Term Results

BACKGROUND Considering more recently proposed techniques, we have evaluated our midterm and long-term results of Rastelli one-patch repair in complete atrioventricular canal. METHODS Between 1984 and 2005, 107 patients with a complete atrioventricular canal underwent a Rastelli one-patch procedure. Two groups were identified: 1984 to 1995 and 1995 to 2005 (respectively, 56 and 51 patients). Mean age at surgery was 5.3 +/- 3.4 months; mean weight was 5.5 +/- 3 kg; trisomy 21 was present in 81 patients; complete atrioventricular canal type A was found in 67 patients, type C in 40 patients. There were 12 cases of potentially parachute mitral valve and 14 associated anomalies treated simultaneously (pulmonary obstruction 11, coarctation 3). The coronary sinus was always left on the right side. After functional and anatomic evaluation, the cleft was closed completely in 8 and partially in 29, and was left intact in 70 cases. RESULTS Early survival was 86% +/- 3%. Five patients underwent early reoperation for residual ventricular septal defect (n = 2) and mitral valve repair (n = 3). Nine patients underwent late reoperations with successful repair: subaortic stenosis (n = 4) and mitral valve repair (n = 5). Late survival at 10 and 15 years was 84% +/- 3%. Freedom from reoperation for mitral regurgitation was 94% +/- 3% at 10 years, and 91% +/- 3% at 15 and 20 years. At last follow-up 30 patients had mild and 3 had moderate mitral regurgitation. CONCLUSIONS Rastelli single-patch repair in complete atrioventricular canal is a safe and reproducible technique. Among survivors, freedom from late reoperation for mitral regurgitation is very satisfactory. A properly taught, learned, and transmitted Rastelli one-patch technique compares very well with any other proposed technique.