Etienne Tatou

Surgical outcome of traumatic rupture of the thoracic aorta

BACKGROUND The aim of this study was to point out the results of different techniques of spinal cord protection in surgically-treated patients with traumatic thoracic aorta (TTA). METHODS A multicentric study was carried out involving 182 patients with TTA. Four patients died before surgery. Two patients were operated on without any investigation and 2 had no aortic tear at thoracotomy. The remaining 174 patients had aortic isthmus disruption and were included in the study. The mean age was 32.3+/-14.29 years with 126 men (72.4%) and 48 women (27.6%). Road accidents were causal in 163 patients (93.66%); polytraumatism was frequent. A standard chest roentgenogram led to a diagnosis which was confirmed with aortography in 94.8% of cases. Surgical repair of visceral lesions was performed in 52 patients (29.9%) for traumatic spleen, liver, diaphragm, mesentery, and gut. These operations were done before or after aortic operation in 21.3% and 8.6% of cases, respectively. Thirty-three patients (19%) died and 9 (5.2%) had paraplegia. Sixty-nine patients had clamp and sew technique (group 1). Ninety-three patients had different types of extracorporeal circulation (group 2), and 12 patients had Gott shunt (group 3). No difference appeared between the 3 groups according to mortality and paraplegia. But the sex ratio, age, visceral lesions, craniocerebral lesions, the type of aortic repair, and cross-clamp time were discriminative. RESULTS The univariate analysis point out age, cross-clamp time, hemothorax, and anatomical type of aortic injury as the risk factors of death. This was confirmed by a multivariable test which retained age, cross-clamp time, and hemothorax as risk factors. When not diagnosed in time, TTA is serious and has a bad prognosis. In spite of a high mortality and morbidity, the surgical management has improved. Immediate operation and medullar protection are the stumbling block in this operation. CONCLUSIONS Operation can be delayed in some cases, but one must take care of hemodynamic instability. This calls for a repair of the serious associated lesions first, or of a quick performing of a thoracotomy for ruptured aorta. The question remains, is it better to protect the spinal cord with the lower aortic perfusion and avoid the simple cross-clamp? Clinical studies give few answers to this question, and the best answer has not yet been given, as we lack prospective studies in this field.

Fracture-embolization of duromedics valve prosthesis and microscopic uncommon lesions

We report a sudden leaflet fracture of a Duromedics mitral valve 6 years after implantation. The patient had cardiogenic shock and complained of asthenia, orthopnea, and tachycardia. Transesophageal echocardiography showed the lack of one leaflet of the prosthesis and regurgitation. An emergency mitral replacement was successfully performed. Angiographic computed tomography scan localized the sequestrum that embolized the common iliac arteries. Examination of the deficient prosthesis showed multiple lesions and, in particular, a subsurface lesion that may be characteristic of carbon pyrolytic valves.

Mycotic Aneurysm of Both Internal Iliac Arteries due to Candida albicans

We report the case of a 21-year-old man, with a Candida-related endocarditis causing multiple emboli and bilateral false aneurysms of the internal iliac arteries. As the distal runoff vasculatures of both internal iliac arteries were occluded, these arteries required ligation. Although there were few consequences with the procedure, multiple emboli and recurrence of endocarditis after cardiac surgery led to the patients death.

Long term aortic stenosis on magnetic resonance imaging after direct repair for acute traumatic rupture of the thoracic aorta.

Thirty two patients underwent aortic repair for acute traumatic rupture of isthmus in our institution between 1978 and 1998. Twenty seven direct sutures were performed and ®ve vascular prostheses were implanted. Medullar protection was: cardiopulmonary bypass (5/32), Gotts shunt (4/32), left atria-femoral artery circulatory assistance (3/32), and 20 simple clamps. Hospital mortality was 9.38% (three patients). No paraplegia was observed, but there were four cases of regressive spinal cord injury (12%). Follow-up was 24/27 survivors (two subsequent deaths) with a mean time of follow-up of 9 ^ 4:8 years. The clinical aortic status was excellent in all the patients. Two-thirds of these patients have been checked by MRI; aortic reconstitution revealed: a normal thoracic aorta in 14 patients (Fig. 1), a stenosis on the direct suture line in three European Journal of Cardio-thoracic Surgery 19 (2001) 82±83