Carrel T

The internal mammary artery malperfusion syndrome: incidence, treatment and angiographic verification.

Internal mammary artery (IMA) malperfusion syndrome is caused by an acute imbalance between myocardial demand and nutritional support through the mammary artery. In a consecutive series of 2326 isolated myocardial revascularizations-with at least one IMA to the left anterior descending branch (LAD) in 91.3% (2125/2326)-we identified 45 patients (1.9%) with a perioperative course suggesting IMA malperfusion syndrome. Additional saphenous vein graft to the distal segment of the LAD was performed during normothermic ventricular fibrillation in all patients. Hospital mortality was 4.4% (2/45), intra-aortic balloon pumping was required in 15.5% (7/45) and anterior myocardial infarction occurred in 28.8% (13/45). Coronary angiography was performed in all survivors between 3 and 24 months postoperatively. Wide patent IMA graft and patent saphenous vein graft were observed in 56% (24/43), narrowed but patent IMA graft and patent vein graft in 35% (15/43), while patent vein graft and not visualized IMA in 7% (3/43); in one patient with severely diseased peripheral LAD, no flow could be demonstrated in the IMA graft or in the additional vein graft (1/43, 2.4%). No major differences were found between early and late coronary angiography in these patients. Additional vein graft to distal LAD is the treatment of choice in acute IMA malperfusion syndrome. Despite patent vein graft with superior blood flow, early and late postoperative IMA flow to LAD is maintained in the majority of patients.

Modified operation technique for orthotopic heart transplantation.

Atrioventricular (AV) valve dysfunction with tricuspid regurgitation is a common finding after orthotopic heart transplantation (HTx). In 20 patients the heart transplantation was performed with bicaval anastomoses and the results were compared to the precedent 20 patients operated with the standard technique. The right atrium of the recipient was completely removed and the caval anastomoses were performed on the beating heart during reperfusion. Using an interrupted suture line, no stenoses at the venous anastomoses were seen as known from the early implantation technique in heart-lung transplantation. Due to a more stable sinus rhythm only 15% of the patients in the bicaval group needed prolonged pacing (> 30 min) versus 55% (P < 0.01) in the group with standard operation. One to 3 months after surgery the transthoracic echocardiographic evaluation of the AV valve function showed tricuspid valve regurgitation (TVR) in 20% of the patients with bicaval anastomoses versus 75% with a right atrial anastomosis (P < 0.001). Tricuspid valve regurgitation during the first 2 weeks (in 31% of recipients with bicaval and in 70% with atrial anastomoses) improved in all recipients with bicaval anastomoses and in 14% of the recipients with atrial anastomosis. The modification of the operation technique did not result in significantly longer bypass time (75 +/- 14 versus 68 +/- 14 min) and ischemia time (44 +/- 12 versus 41 +/- 9 min with local organ procurement and 111 +/- 24 versus 101 +/- 19 min with distant organ procurement). The AV valve function and the postoperative rhythm after orthotopic HTx can be improved by implanting the heart with bicaval anastomoses.

Reoperation after mitral valve reconstruction : early and late results

Between 1968 and 1990, 68 patients (33 male, 35 female) with a mean age of 47 years were subjected to reoperation (62 valve replacements, 6 reconstructions) after primary mitral valve reconstruction (mean interval = 81 months). The indication for reoperation was residual valve insufficiency in 51, and stenosis in 17 patients. The average preoperative New York Heart Association (NYHA) class was 3.0. The average follow-up was 63 months. The operative mortality was 8.8% (8 out of 68 patients). The actuarial late survival was 90% after 5, and 73% after 8 years. After a second mitral valve reconstruction 66% (four out of six patients) died (one early, three late). The incidence of second reoperations was 4.4% (3 out of 68 patients), and of thromboembolic complications 11.8% (8 out of 68 patients). The mean NHYHA class improved significantly. The actuarial freedom from second reoperations was 98% and 90%, and from thromboembolic complications 91% and 82% after 5 and 10 years, respectively. Endocarditis did not occur, whereas two patients on Coumadin anticoagulation had non-fatal gastrointestinal bleeding. Late survival was less favorable (P < 0.05) in patients operated on before 1980, in a higher preoperative NYHA class, after a second valve reconstruction, and if pulmonary hypertension or atrial fibrillation was present. Significant independent risk factors were older age and earlier reoperation, pulmonary hypertension or higher NYHA class postoperatively. For the last to years it has been possible to perform reoperations after mitral valve reconstructions with good early and excellent late results. The mortality and complication rates were similar to those for primary mitral valve reconstructions.(ABSTRACT TRUNCATED AT 250 WORDS)

Early and late results after correction for double-outlet right ventricle: uni- and multivariate analysis of risk factors.

Between April 68 and May 91, 59 patients underwent total correction for double-outlet right ventricle. The mean age was 59.2 +/- 7.8 months. The hospital mortality rate was 27%; it was 41% before 1980 and 13% thereafter. Low cardiac output failure was the leading cause of early death. Myocardial protection without cardioplegia and long cardiopulmonary bypass time were significant predictors of hospital mortality in univariate as well as in multivariate analysis. The late death rate was 7%. The actuarial survival rate was 67% (CL 55-80%) after 10 and 20 years. The reoperation rate was 42%, a loose VSD patch constituted the main indication (23%). The actuarial freedom from reoperation rate was 51% (CL 33%-69%) after 10 years and 31% (12%-50%) after 20 years. The mean follow-up time was 8.4 +/- 0.9 years (2 to 20 years). Seventy-five percent of all postoperative survivors are in NYHA functional class I and left ventricular ejection fraction is normal in 82%.

Pericarditis constrictiva after aortic valve replacement simulating tricuspid stenosis

Pericarditis constrictiva after cardiac surgery is rare and may occasionally lead to congestive heart failure. The case of a 29-year-old patient is described who presented with pericarditis constrictiva after aortic valve replacement with localized tamponade, causing functional tricuspid stenosis. Pericardiectomy as the treatment of choice was curative.