Jean-Claude Schoevaerdts

Intraoperative electromagnetic flowmeter measurements in coronary artery bypass grafts

This study attempts to relate flow findings in internal mammary (IMA) and saphenous vein coronary artery bypass grafts to postoperative outcome. From 262 patients undergoing coronary artery bypass grafting, 601 electromagnetic flow measurements were obtained in IMA and saphenous vein grafts, and free graft flow was measured in 227 IMAs prior to grafting. Retrograde flushing of the IMA with diluted papaverine hydrochloride resulted in a marked increase in IMA free flow (124 +/- 4 mL/min versus 66 +/- 5 mL/min; p < 0.001). However, IMA free flow did not correlate with electromagnetic flow measurements after grafting to the left anterior descending coronary artery. The use of IMAs with free flows lower than 50 mL/min did not affect clinical outcome. Flow measured in saphenous vein grafts (66 +/- 9 mL/min) with an electromagnetic flowmeter was significantly greater (p < 0.001) than that in the IMA grafted on the left anterior descending coronary artery (36 +/- 3 mL/min) under comparable hemodynamic conditions. For the purpose of data analysis, patients were separated into three groups based on increasing incidence of complications: levels 0, 1, and 2. Patients with an uneventful outcome had a mean graft flow at chest closure of 51 +/- 3 mL/min versus 51 +/- 4 mL/min for patients in complication level 1 and 45 +/- 11 mL/min for patients in complication level 2 (p = not significant). Free flow measured in a vasodilated IMA was a poor predictor of flow into a grafted IMA and did not affect clinical outcome. We were unable to validate any flow limit to use of the IMA.(ABSTRACT TRUNCATED AT 250 WORDS)

Pseudoaneurysm of the internal carotid artery : Treatment with a covered stent

Dissection of the cervical segment of the internal carotid artery may occur spontaneously or after trauma. We report the management of a 53-year-old right-handed man with progressive dizziness and neck pain 6 weeks after a motor vehicle collision. The clinical and neurologic examinations were normal. The CT scan led to the diagnosis of a pseudoaneurysm of the right internal carotid artery near the skull base. We successfully treated this post-traumatic lesion with a covered stent. The patient underwent the endovascular procedure under general anesthesia and transcranial Doppler monitoring. No neurologic event was observed. Obliteration of the pseudoaneurysm with preservation of the carotid artery was achieved. The patient was discharged from the hospital 72 hr later with no complications. Clinical and imaging follow-up at 6 months was unremarkable.

Coronary artery bypass grafting with the inferior epigastric artery. Midterm clinical and angiographic results.

Between December 1988 and September 1993, 157 patients (141 men, 16 women, average age 60.2 years, range 37 to 78 years) underwent a complete myocardial revascularization with 157 inferior epigastric artery grafts and 285 internal mammary artery grafts (281 in situ, 4 free grafts). A total of 543 distal arterial anastomoses (average 3.4, range two to five per patient) were constructed, 376 with the internal mammary artery and 167 with the inferior epigastric artery. The inferior epigastric artery grafts were anastomosed to two left anterior descending, 5 diagonal, 34 circumflex, and 126 right coronary arteries. The indications for the use of the inferior epigastric artery were the unavailability of conventional conduits in 56 patients and a favorable anatomy or a young age in 101 selected patients. The clinical follow-up averages 31.8 months (range 6 to 62 months). Four patients died early, and there were three perioperative nonfatal myocardial infarctions. Eight patients required early reoperation for thoracic bleeding (2) or drainage of an abdominal parietal collection (6). There were four late deaths (2 sudden deaths, 2 noncardiac causes) and one nonfatal myocardial infarction. Angina recurred in nine patients, of whom one required reoperation and three underwent successful percutaneous balloon angioplasty of a native coronary artery (2) or an old saphenous vein graft (1). An early recatheterization was obtained before discharge (average 11 days) in 135 patients: 132 of 135 inferior epigastric artery grafts were patent. Seventy-seven patients underwent a second angiographic restudy 6 to 43 months after the operation. Forty-four of the 48 inferior epigastric artery grafts restudied within the first postoperative year (average 8.5 months) were patent, but eight showed a diffuse narrowing. Twenty-eight of the 29 inferior epigastric artery grafts examined angiographically between 13 and 43 months (average 25 months) were open, and among those 29, 25 were widely patent, perfectly matching the receiving coronary artery. Most of the occluded or narrowed inferior epigastric artery grafts were grafted onto coronary arteries with mild stenosis at restudy. Five patients underwent a third angiographic reexamination up to 60 months after the operation (average 39 months). All five inferior epigastric artery grafts were widely patent. The early attrition rate of the inferior epigastric artery, as for any free arterial graft, is probably the result of both the loss of a true pedicle and the need for constructing an additional proximal anastomosis. The fact that the patency rate of the inferior epigastric artery graft seems to remain stable beyond 1 year could suggest a good durability in the future.

Improved Patient Survival With Concomitant Cox Maze III Procedure Compared With Heart Surgery Alone.

BACKGROUND The benefit of the Cox Maze procedure combined with heart surgery was evaluated at long-term follow-up. METHODS The outcome for 37 patients who underwent a Cox Maze III procedure combined with heart surgery (Maze group) was compared with that of 66 patients who had heart surgery alone (control group). All patients were in persistent atrial fibrillation preoperatively. The two groups had similar preoperative characteristics and were operated upon during the same era (1996 to 2004). RESULTS Five-year survival, including hospital deaths, was 89% +/- 5% in the Maze group and 60% +/- 7% in the control group (log rank p = 0.008). Causes of death were predominantly related to heart failure (1 of 37 in the Maze group and 12 of 66 in the control group; p = 0.02) and to sudden death (0 of 37 in the Maze group and 9 of 66 in the control group; p = 0.02). After correction for preoperative variables, Cox regression analysis showed that the Maze procedure improved survival independently (p = 0.019). In a subgroup of patients with left atrial diameter of more than 60 mm preoperatively, the 5-year survival estimate was 92% +/- 6% in the Maze group versus 59% +/- 9% in the control group (log rank p = 0.012). The 5-year estimate of conversion to sinus rhythm was 91% +/- 7% in the Maze group and 33% +/- 7% in the control group (log rank p < 0.001). CONCLUSIONS The restoration of sinus rhythm by a Maze procedure combined with heart surgery markedly improved long-term survival in this series.

Intraoperative assessment of coronary artery bypass grafts using a pulsed Doppler flowmeter.

A pulsed Doppler flowmeter was used in a series of 352 consecutive patients undergoing isolated coronary artery bypass grafting. Doppler flow measurements were available on 909 single terminolateral bypass grafts (327 internal mammary arteries and 582 saphenous veins) and 58 sequential bypass grafts anastomosed to combinations of arteries. Flow (mL/min) categorized as a function of the recipient artery was distributed as follows: left anterior descending coronary artery, 69.9 +/- 2.5; right coronary artery, 68.0 +/- 5.0; diagonals, 61.0 +/- 4.1; obtuse marginals, 55.9 +/- 2.2; and posterior descending coronary artery, 53.3 +/- 3.0 (p < 0.001). Graft outflow obstruction resulting from torsion of the graft pedicle or anastomotic stricture was identified in 7 patients (2%). After graft revision, flow increased from 9 +/- 4 mL/min to 69 +/- 13 mL/min (p = 0.023), and velocity rose from 4.6 +/- 1.1 cm/s to 18.1 +/- 2.4 cm/s (p = 0.009). In conclusion, the system was adequate for operative use and allowed identification and correction of technical errors.

Aortic valve replacement with allograft/autograft: subcoronary versus intraluminal cylinder or root

From April 1990 to May 1994, 89 patients (median age, 42 years; range, 10 days to 66 years) underwent aortic valve or root replacement with allografts or autografts. Thirteen patients were less than 18 years old at the time of operation. Indication for aortic valve replacement was aortic stenosis (50 patients, 56%), small stenotic prosthesis (2 patients, 2%), aortic valve endocarditis (19 patients, 21%), isolated aortic regurgitation (17 patients, 19%), and type II truncus arteriosus (1 patient, 1%). The subcoronary implantation was used in 45 patients (group A), and implantation of an intraluminal cylinder (16 patients) or complete root replacement (28 patients) was performed in the remaining 44 patients (group B). The Ross procedure was performed in 22 patients. Intraoperative transesophageal echocardiography was used routinely. Five patients died in the early postoperative period (6%), 2 in group A and 3 in group B. Three other patients required immediate replacement of a failing graft by a mechanical prosthesis (1 in group A and 2 in group B). There has been no late death. All survivors remained in New York Heart Association functional class I and were free of thromboembolic complications. Endocarditis occurred in 2 patients, 1 year after operation. Both were successfully treated medically. Echocardiographic studies were obtained serially in every patient. Four patients, 2 in group A and 2 in group B underwent reoperation because of mild-to-moderate aortic regurgitation (rate of reoperation, 5%). Two valves were repaired and two were replaced by an allograft.(ABSTRACT TRUNCATED AT 250 WORDS)

Revascularization of the circumflex artery with the pedicled right internal thoracic artery: Clinical functional and angiographic midterm results☆☆☆★★★♢♢♢♦

Retroaortic crossing of the pedicled right internal thoracic artery for revascularization of the circumflex artery used in combination with a pedicled left internal thoracic artery anastomosed to the left anterior descending artery and its branches is an attractive technique to achieve an extensive arterial revascularization of the left ventricle. However, there is a suspicion that pulling the right internal thoracic artery through the transverse sinus could compromise its blood flow capacity and patency. Between January 1990 and July 1994 this technique was applied in 256 patients (202 men, 54 women; average age 62 years, range 31 to 80 years). Sixty-one patients had two-vessel disease and 195 had three-vessel disease. Seventeen patients were undergoing a reoperation. Twenty-two had a left ventricular ejection fraction of 40% or less. Thirty had diabetes. Twenty-eight had morbid obesity. The right internal thoracic artery was directed to the circumflex artery (259 anastomoses) through the transverse sinus and the left internal thoracic artery was anastomosed to the left anterior descending artery and its branches (375 anastomoses) in all patients. The 195 patients with three-vessel disease received additional coronary artery bypass grafts to the right coronary artery (93 saphenous vein grafts, 89 free inferior epigastric artery grafts, 12 pedicled right gastroepiploic artery grafts). In total, the 256 patients received 833 distal anastomoses (average 3.2, maximum 5 per patient) and 634 distal anastomoses were internal thoracic artery anastomoses (average 2.4, maximum 4 per patient). Three patients died early and eight had a nonfatal myocardial infarction. Seven patients needed postoperative intraaortic balloon pump support. Six patients underwent early reoperation because of excessive bleeding. Sternal dehiscence occurred in four patients. One of these four patients died of the complication 10 months after the operation. No patient was lost to follow-up (average 33 months). During follow-up, two sudden deaths and six noncardiac deaths occurred. Two patients had a nonfatal myocardial infarction and 12 had recurrence of angina. There were no late reoperations. One patient underwent a successful percutaneous balloon angioplasty of a native left anterior descending artery. Seventy-four patients, enrolled in prospective angiographic studies, underwent a postoperative recatheterization (average 13.2 months, range 6 to 58 months). Seventy-three of the 74 right internal thoracic artery grafts were patent. In comparison, 74 of 74 of the left internal thoracic artery grafts (106/107 anastomoses) were patent. Maximal stress thallium-201 scintigraphy results, obtained in 25 of those patients, did not reveal ischemia in the area of the circumflex artery.(ABSTRACT TRUNCATED AT 400 WORDS)

External iliac artery endofibrosis: a new possible predisposing factor

External iliac artery endofibrosis (EIAE) is an uncommon disease that affects a large number of athletes. The pathogenesis of EIAE is unclear. We offer an additional possible cause, with a direct relationship between EIAE and psoas muscle hypertrophy.

Operation for unstable angina pectoris : factors influencing adverse in-hospital outcome

Coronary artery bypass grafting for the treatment of unstable angina is still associated with increased operative risk and postoperative morbidity. The impact of the extended use of arterial grafts on early results is incompletely defined. In a 7-year period (1986 to 1993), 474 patients (average age, 65 years; range, 34 to 85 years) underwent coronary artery bypass grafting for the treatment of unstable angina. Sixty-eight patients were operated on emergently and 406 urgently. They received an average of 3.0 distal anastomoses (range, 1 to 6). Seventy-nine patients had exclusively venous grafts, 316 had one internal thoracic artery graft, 79 had bilateral internal thoracic artery grafts, and 20 had inferior epigastric artery grafts. Sequential internal thoracic artery grafting was performed in 70 patients. Redo operations were performed in 26 patients. Thirty-four patients (7.2%) experienced a new myocardial infarction. Eighty-nine patients (18.8%) had an intraaortic balloon pump inserted preoperatively, intraoperatively, or postoperatively. Eight patients (1.7%) died intraoperatively and 24 patients (5.1%) died postoperatively. Seventy-seven patients (16.2%) had an adverse outcome, as shown by the need for an intraaortic balloon pump (intraoperatively or postoperatively) or hospital death, or by both. Forty variables were examined by multivariate analysis for their influence on the occurrence of an adverse outcome. Aortic cross-clamp time (p = 0.0004), transfer from the intensive care unit (p = 0.0023), female sex (p = 0.0023), operation performed in early years (p = 0.0041), left ventricular aneurysm (p = 0.0068), the number of diseased coronary vessels (p = 0.0312), and reoperation (p = 0.0318) were all found to be significant independent predictors of increased risk.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulsed Doppler intraoperative flow assessment and midterm coronary graft patency.

BACKGROUND This study was designed to assess the value of hemodynamic measurements taken intraoperatively in predicting midterm patency of coronary bypass grafts. METHODS A pulsed Doppler flowmeter was routinely used during operation to determine the hemodynamic parameters of coronary bypass grafts. During a 7-year period, 85 patients underwent angiographic evaluation. As a result, a thorough hemodynamic assessment of 214 grafts (89 arterial and 125 venous) at initial operation was available for analysis. RESULTS The overall patency rate was 88.3%. The mean flow measured intraoperatively in 168 intact grafts was 60+/-3 mL/min (range, 9 to 230 mL/min), and the resistance was 1.8+/-0.1 peripheral resistance units (range, 0.3 to 9.0 peripheral resistance units). The mean flow was 36+/-5 mL/min (range, 2 to 107 mL/min), and the resistance was 5.9+/-2.0 peripheral resistance units (range, 0.6 to 46.0 peripheral resistance units) in 25 grafts found occluded at angiographic evaluation. Multivariate analysis identified three independent variables associated with a reduced patency rate: increased resistance as measured in the graft (p = 0.012), increasing interval of control angiography (p = 0.006), and preoperative cardiogenic shock (p = 0.040). CONCLUSIONS The prognosis for midterm patency of aortocoronary bypass grafts depends on the intraoperative hemodynamic status.