Jean Bachet

Antegrade cerebral perfusion with cold blood: a 13-year experience

BACKGROUND In 1986 we introduced the technique of antegrade selective perfusion of the brain with cold blood during surgery of the aortic arch. METHODS Between January 1984 and March 1998, 171 patients (118 males and 53 females) aged 25 to 83 years (mean 56.5 +/- 17), underwent replacement of the transverse aortic arch with the aid of cold blood antegrade selective perfusion. One hundred twenty two patients (71.3%) with chronic lesions were operated on electively; 49 patients (28.6%) were operated on urgently for acute aortic dissection (42 patients) or for a ruptured chronic aneurysm (7 patients). Fifty-one patients (29.8%) had previously undergone a surgical procedure on the thoracic aorta. Mean duration of cardiopulmonary bypass was 121 minutes (range: 65-248); mean duration of cerebral perfusion was 60 minutes (range: 15-90), and mean duration of systemic circulatory arrest circuit was 32 minutes (range: 10-57). The electroencephalogram, routinely recorded, showed disappearance of electrical activity in a mean of 9 minutes (range: 3-16) initial return of electrical activity after a mean of 12 minutes (range: 1-35) and normalization in a mean time of 66 minutes. RESULTS All patients but 7 (4%) showed signs of normal awakening within 8 hours postoperatively. Six patients (3.5%) had fatal neurologic complications, and 16 patients (9.3%) had a non-fatal neurologic complications. Twenty-nine patients (16.9%) died during the postoperative hospital course. There was a significant difference between patients aged less than 60 years (9%) and patients older than 60 years (mortality rate 26.4%, p < 0.02). There was also a significant difference between patients undergoing an isolated replacement of the arch, and those in whom the replacement was extended to the descending aorta in whom mortality was 36.4% (chi2, p < 0.02). Lesion and gender had no significant influence on the outcome of the patients, nor had the duration of cardiopulmonary bypass, circulatory arrest, and cerebral perfusion. In particular, no correlation could be established between the duration of cerebral perfusion and the occurrence of neurologic complications. CONCLUSION The clinical results obtained throughout this experience have demonstrated that selective antegrade cerebral perfusion with cold blood provides excellent protection during surgery of the transverse aortic arch. In addition, it avoids the use of deep hypothermia and prolonged cardiopulmonary bypass and does not limit the time allowed to perform the aortic repair. In our opinion it is the technique of choice, especially in frail patients or those requiring a long and difficult procedure.

Myocardial viability assessment in ischemic cardiomyopathy: Benefits of coronary revascularization

Patients with ischemic heart disease, congestive heart failure, and low ejection fraction are usually referred for orthotopic heart transplantation. Based on results of myocardial viability assessment, we have prospectively used either coronary artery bypass grafting or orthotopic heart transplantation. From January 1990 to June 1992, among 50 patients initially referred for heart transplantation, 46 showing myocardial viability underwent bypass grafting. Forty-five of these 46 patients were men, and the mean age was 58 +/- 12 years (range, 40 to 70 years). Congestive heart failure was present in all patients, and dyspnea was the main symptom in 80% (37/46). Patients were selected according to three criteria. (1) Myocardial viability was primarily assessed by thallium scintigraphy for up to 24 hours (28/46 patients). When results were negative, patients underwent positron emission tomography (20/46 patients). (2) Regional left ventricular function was assessed using gated blood pool single-photon emission computed tomography combined with (3) full hemodynamic evaluation. Results were as follows: end-diastolic volume, 129 +/- 35 mL/m2; ejection fraction, 0.23 +/- 0.06; cardiac index, 2.4 +/- 0.62 L.min-1.m-2; mean pulmonary artery pressure, 26 +/- 0.90 mm Hg; and mean pulmonary capillary wedge pressure, 16 +/- 1.10 mm Hg. Operative mortality was 2.17% (1/46). During follow-up (mean duration, 18 months), there were three late cardiac-related deaths (arrhythmias) and two noncardiac-related deaths. The 40 long-term survivors are in New York Heart Association class II. Angiography (15 patients) or gated blood pool single photon emission tomography (32) showed improvement in mean ejection fraction to 0.39 +/- 0.13 (range, 0.22 to 0.46).(ABSTRACT TRUNCATED AT 250 WORDS)

Surgery for acute type A aortic dissection: the Hopital Foch experience (1977–1998)

BACKGROUND In 1977, we proposed the use of gelatin-resorcinol-formol (GRF) biological glue during surgery for acute type A aortic dissection. METHODS From January 1977 to March 1998, 204 patients (146 men and 58 women) aged from 15 to 79 years (mean 54 +/- 11) underwent emergency operation for type A aortic dissection in our institution. One hundred sixty-five patients (84%) were operated on within 48 h after the onset of symptoms. Twenty-eight patients (13.7%) had Marfans syndrome. In 43 patients (23%), the aortic valve was replaced either independently (6, 3%) or by means of a composite graft (37, 18.1%). Because of the location of the intimal tear, aortic replacement included the transverse arch in 60 patients (29.4%). RESULTS Hospital mortality was 21% (39 patients): 25% in patients with arch replacement and 19.4% in patients without arch replacement (ns). One hundred sixty-one patients were discharged and followed from 2 months to 21 years postoperatively (mean 85 +/- 66 months). During this interval, 25 patients (15.5%) required reoperation for a total of 33 reoperations. Seven patients (28%) died at reoperation. Upon univariate analysis, presence of Marfans syndrome (p < 0.05) and absence of arch replacement (p < 0.02) were risk factors for reoperation. Emergency operation (p < 0.01) and thoracoabdominal replacement (p < 0.04) were risk factors for death at reoperation. The actuarial freedom from reoperation (Kaplan-Meier, confidence interval 95%) is 96.1% (90.9%-98.2%) at 1 year, 87.6% (79.8%-92.7%) at 5 years, 80.9% (70.8%-88.1%) at 10 years, and 66.4% (51.1%-78.9%) at 15 years. A total of 39 patients (24.3%) died during follow-up. The presence of Marfans syndrome (p < 0.01), reoperation (p < 0.02), stroke (p < 0.05), and cardiac failure (p < 0.05) were risk factors for late mortality. The actuarial late survival including hospital mortality is 71.5% (64.3%-77.8%) at 1 year, 66% (58.3%-73%) at 5 years, 56.4% (47.7%-64.7%) at 10 years, and 46.3% (36.4%-56.5%) at 15 years. CONCLUSIONS The GRF glue has proven extremely useful during emergency initial surgery for acute type A dissection, making the procedure much easier and safer. As a result of this operative improvement, the use of the GRF glue seems to have had a beneficial influence on late results, but these also depend upon the patients basic condition.

Four-year clinical experience with the gelatin-resorcine-formol biological glue in acute aortic dissection.

Because of the extreme severity of spontaneous evolution of acute dissection involving the ascending aorta, there is no controversy about the necessity of urgent surgical treatment (1–6). However, hospital mortality rate remains high in most reported experiences (1, 4, 6–9).

Assessment of systematic use of intraoperative transesophageal echocardiography during cardiac surgery in adults: A prospective study of 203 patients

OBJECTIVE To determine the usefulness of systematic intraoperative transesophageal echocardiography in a cardiac surgical unit. DESIGN Open prospective observational survey. SETTING University Hospital. PARTICIPANTS Consecutive adult patients (n = 203) undergoing elective or urgent cardiac operations. MEASUREMENTS AND MAIN RESULTS Pre-cardiopulmonary bypass imaging yielded unsuspected findings in 26 patients (12.8%) and changed the planned surgery in 22 patients (10.8%). Transesophageal echocardiography modified the diagnosis in eight patients (17%) operated on for mitral valvulopathy, in seven patients (15.5%) with aortic valvular disease, in four patients (4.6%) with coronary artery disease, in five patients operated on for thoracic aorta diseases regardless of their localization (18.5%), and in two miscellaneous cases. On the basis of the data obtained from the transesophageal echocardiography carried out at the end of cardiopulmonary bypass, an immediate reintervention was required in five cases (2.5%). CONCLUSIONS It is concluded that systematic intraoperative transesophageal echocardiography significantly affected decision making in this cardiac surgical unit. Its routine use in all cardiac surgical patients is recommended.

Protection of the spinal cord during surgery of thoraco-abdominal aortic aneurysms

OBJECTIVE To assess the risk of ischemic cord injury, we have retrospectively studied the 115 patients who underwent a replacement of the thoracic descending or thoraco-abdominal aorta between January 1980 and December 1994. METHODS In 72 patients the aortic lesion was located above the diaphragm. The aortic replacement was performed with the aid of extracorporeal circulation in all but 2 patients (97.2%). Only two cases of postoperative paraplegia were observed (2.7%). In 43 patients (10 females and 33 males aged from 26 to 69 years), the occurrence of postoperative paraplegia was considered as a major risk, because of the extension of the aortic lesions (Crawford types I, II and III). Twenty-six patients (60.4%) suffered from chronic dissection and 17 patients had atheromatous aneurysms. Sixteen patients (37.2%) had Marfan syndrome. Twelve patients (27.9%) had already undergone aortic replacement. A preoperative study of the spinal cord vascularization was carried out in 36 patients (83.6%) and the Adamkiewicz artery was visualized in 28 patients (77.8%). In 17 patients (39.5%, group I), the surgical procedure was performed without the aid of extracorporeal circulation. In the remaining 26 patients (60.5%, group II), the surgical procedure was carried out with the aid of cardiopulmonary bypass and profound hypothermic circulatory arrest. Sequential unclamping of the aorta was used in all patients. The cord vascularization was surgically restored in 32 patients (74.4%). When the Adamkiewicz artery was identified, the critical intercostal artery was reimplanted together with the two pairs of adjacent intercostal arteries (25 patients). When the origin of the Adamkiewicz artery remained unknown, the two or three most important patent pairs of intercostal arteries were reimplanted (7 patients). In 8 patients (18.6%) there were no patent intercostal arteries. RESULTS Hospital mortality accounted for 37.2% (16 patients, including 5 patients with paraplegia). On univariate analysis, extension of the aortic lesions, emergency and redo surgery were the only significant risk factors of mortality (P = 0.05). Cord ischemia was observed in 9 patients (21%): permanent paraplegia in 7 patients (16.2%) and transient medullar disturbance in 2 patients (4.6%). The occurrence of paraplegia was reduced, though not significantly, in group II (16%) vs group I (29%) and in patients with preoperative assessment of the cord vascularization (18% vs 38%). CONCLUSIONS In our experience: 1) The risk of paraplegia is related to the extension and the type of the aortic lesions. 2) The preoperative study of the medullar vascularization and the use of extracorporeal circulation with deep hypothermia and sequential aortic unclamping, reduce the risk of severe cord ischemia, and 3) Occurrence of postoperative paraplegia depends on several factors and cannot be totally prevented by the surgical technique.

Aortocoronary Bypass with Homologous Saphenous Vein: Long-Term Results

Between February 1973, and February, 1979, 27 homologous saphenous veins were used in 20 patients (mean age, 54 years). Seven fresh grafts were used less than 24 hours after severance. They were kept at a temperature of 4 degrees C in saline solution containing penicillin. Twenty cryopreserved grafts were used within a period of eight days to 2 months from severance. They were preserved in glycerol at a temperature of -40 degrees C. One patient (5%) died postoperatively. A perioperative myocardial infarction developed in 3 patients (15%). Average follow-up is 27 months. No late mortality was registered. Fifteen patients are free from symptoms, and 3 patients have residual angina with exercise. Control angiograms were made in 13 patients 1 to 68 months after operation; 17 homografts were seen. Early occlusion of 1 graft and late occlusion of 8 grafts were registered. The poor late patency rate does not seem to be related to either histocompatibility or technical conditions. Conversely, microscopic examination of several cryopreserved grafts showed that the mode of preservation resulted in deterioration of intimal and medial tissues of the vein. Therefore, it appears to us that the use of homologous saphenous veins should be avoided for coronary bypass.

What is the Best Method for Brain Protection in Surgery of the Aortic Arch? Selective Antegrade Cerebral Perfusion

Despite considerable progress in the operative management of lesions involving the transverse aortic arch, replacement of this portion of the vessel remains a surgical challenge and is still associated with mortality and morbidity. This situation is due not only to the technical difficulties of the procedure but, often, to the unsatisfactory preservation of the integrity of the central nervous system during the period of arch exclusion. The techniques of cerebral protection during surgery of the aortic arch can be divided into those aimed at suppressing the metabolic demand of the central nervous system and those aimed at maintaining the metabolic supply during the time of exclusion of the cerebral vessels. Whichever technique is used, it must maintain the normal metabolism of the central nervous system or, at least, allow restoration of the physiologic conditions of its function. In this regard, selective antegrade cerebral perfusion has demonstrated experimentally and clinically its superiority over the other proposed protective techniques.

THE USE OF BIOLOGICAL GLUE IN AORTIC SURGERY

The biologic sealants presently available on the market that are used in cardiovascular surgery and particularly during surgery of the aorta are described in this article. Two of these biological sealants, the gelatin-resorcinol-formaldehyde (GRF) glue and two-component fibrin sealant have been in use for two decades. Their respective properties are described beneficial in modifying the natural history of the disease. Certain pharmacological agents that result in improved aortic function have been identified.

Repeated surgery for recurrent dissection of the aorta

Emergency surgery of acute dissection of the ascending aorta is generally a palliative procedure aimed at preventing the vessel from rupturing into the pericardium. Evolving dissecting aneurysm or recurrence of the dissection process is, therefore, a common complication and may lead to reoperation or death. Between January 1970 and December 1988, 133 patients were operated upon for acute dissection of the ascending aorta. During the same period, 22 patients underwent 26 reoperations for recurrent or evolving dissection. Eleven (50%) patients had Marfans syndrome. Thirteen patients had been operated upon previously in our institution and 8 had been operated upon elsewhere. In 10 patients, the intimal tear had not been resected during the first operation. Operative procedures varied according to the pathoanatomical features and consisted generally of an extended resection of the aortic arch. Eight reoperations were performed as emergencies and 18 were performed electively. Hospital mortality rate was 18% (4/22). Late follow-up ranged from 3 to 153 months (mean: 55 months) for a cumulative follow-up of 998 months. Late mortality was 27% (5/18) for a linearized rate of 6% pt/yr. The actuarial risk of reoperations is 13.7% +/- 7% and 21% +/- 11% at 5 and 10 years, respectively. Marfans syndrome and persistence of the primary intimal tear are considered the main risk factors of reoperation, while emergency and thoraco-abdominal replacement are the main risk factors at reoperation.