Jean-Marc Frapier

Malignant ventricular arrhythmias revealing anomalous origin of the left coronary artery from the pulmonary artery in two adults.

We report two cases of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA), revealed by malignant ventricular arrhythmias in adult patients. A two coronary system was re-established in both patients, and cryotherapy was performed on one of the patients who, in addition, presented ventricular aneurysm triggering ventricular tachycardia.

Reconstructive surgery of postinfarction left ventricular aneurysms: techniques and unsolved problems

The progress in the surgical treatment of postinfarction left ventricular (LV) aneurysm surgery has reduced the operative mortality considerably, while the selection of the optimal LV repair technique remains unclear. Any of the surgical techniques presented in this review has its own advantages and disadvantages. The main goal of this study was to perform a selective literature review of LV aneurysm repair techniques, the most widespread being the linear repair and patch ventriculoplasty.

Fibrin sealant improves surgical results of type A acute aortic dissections

From January 1984 to July 1990, 63 patients were operated on for type A acute aortic dissection. Forty-two patients (aged 22 to 80 years) had isolated replacement of the ascending aorta with the following techniques: group 1 (n = 10) had replacement of the ascending aorta with an intraluminal sutureless graft, group 2 (n = 14) had a Dacron prosthesis sutured to the aorta, and in group 3 (n = 18) the proximal and distal aortic stumps were glued together and reinforced at the suture sites with fibrin sealant before implantation of the Dacron prosthesis. There were no significant differences between the three groups with respect to age, sex, or preoperative clinical and anatomical data. Three (30%) intraoperative deaths occurred in group 1, 4 (29%) in group 2, and none in group 3. Cross-clamp and extracorporeal circulation time were significantly lower in group 1 when compared with groups 2 and 3. Perioperative blood loss during the first 24 hours was significantly lower in group 3 (372 +/- 155 mL) when compared with group 1 (755 +/- 210 mL; p less than 0.05) or group 2 (1,055 +/- 370 mL; p less than 0.01). Total hospital mortality was 7 (70%) in group 1, 6 (43%) in group 2, and 1 (5.5%) in group 3. All patients were reviewed: one late death occurred in group 2 and none in the other groups. All survivors were in good clinical condition. In conclusion, intraluminal sutureless grafts allowed shorter cross-clamp and extracorporeal circulation time but did not improve surgical results for treatment of type A acute aortic dissections.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term outcomes after cryoablation for ventricular tachycardia during surgical treatment of anterior ventricular aneurysms

Intraoperative map‐guided procedures have been widely advocated as the best surgical strategy for the treatment of ventricular tachycardia (VT), though favorable results have been reported with subendocardial resection without mapping. This study examined the very long‐term results of encircling cryoablation without mapping during surgery for anterior left ventricular aneurysm complicated by VT. Between 1985 and 2003, this procedure was performed in 52 patients, 7 of whom (13.7%) were operated within 1 month of anterior myocardial infarction. Their mean age was 64.4 ± 8.3 years and mean left ventricular ejection fraction was 31.7%± 9.5%. The overall hospital mortality was 1.9%. At 14 years, 86% of patients (95% CI: 75.4–96.6) were free from VT or sudden death. An implantable defibrillator was implanted in five patients (9.6%) during follow‐up. The 14‐year overall survival was 51.4% (95% CI: 33.8–72.4), and two patients (3.8%) underwent cardiac transplantation during follow‐up. The main cause of late death was congestive heart failure in eight patients (40.0%). Favorable long‐term results can be achieved with encircling cryoablation without mapping in patients undergoing surgery for anterior left ventricular aneurysm complicated by VT.

Postoperative exercise tolerance after aortic valve replacement by small-size prosthesis: functional consequence of small-size aortic prosthesis.

OBJECTIVES The objective of this study was to determine whether a small-size valve prosthesis contributes to exercise intolerance, as assessed by VO2 measurement during an exhaustive cycle ergometer exercise. BACKGROUND The determinants of exercise capacity after mechanical aortic replacement are not well known. The selection of small valve sizes has, however, been described as an independent predictor of exercise intolerance as assessed by exercise duration. Maximal oxygen uptake (VO2max) is a good index of exercise tolerance. METHODS Fourteen patients were eligible, with a mean age of 62 +/- 6 years. Before surgery, the mean left ventricular ejection fraction (LVEF) was 73 +/- 8%. Two valve types with small diameter (19 to 21 mm) were used: Medtronic Hall and St Jude Medical. A healthy sedentary control group (n = 14) paired for age, weight and size was constituted. After one year of follow-up, cardiorespiratory tests were performed. In addition, the gradients through the prostheses were determined by continuous pulse Doppler at rest and immediately after the cardiorespiratory test. RESULTS The exercise tolerance was not significantly different between the control group and patient group: VO2 peak (21.7 vs. 20.4 ml/kg/min; p = 0.42), workloads (115 vs. 93 W; p = 0.13) and ventilatory parameters were similar. The mean and peak gradients at rest and during exercise were not correlated with VO2max. CONCLUSIONS Valve replacement by small aortic prosthesis does not seem to be a factor of exercise intolerance as assessed by VO2max in patients without LVEF dysfunction before surgery.

Pacemaker surgical site infection caused by Mycobacterium goodii.

We describe what we believe to be the first documented case of Mycobacterium goodii infection in Europe. It is also the second documented report of a pacemaker pocket surgical site infection caused by M. goodii. Although rarely involved in such infections, rapidly growing mycobacteria should be recognized during conventional bacteriological investigations and further identified by molecular tools to provide adequate therapy. In the present case, antimicrobial therapy with doxycycline without removal of the pacemaker was successful.

Dynamics of the surgical microbiota along the cardiothoracic surgery pathway

Human skin associated microbiota are increasingly described by culture-independent methods that showed an unexpected diversity with variation correlated with several pathologies. A role of microbiota disequilibrium in infection occurrence is hypothesized, particularly in surgical site infections. We study the diversities of operative site microbiota and its dynamics during surgical pathway of patients undergoing coronary-artery by-pass graft (CABG). Pre-, per-, and post-operative samples were collected from 25 patients: skin before the surgery, superficially and deeply during the intervention, and healing tissues. Bacterial diversity was assessed by DNA fingerprint using 16S rRNA gene PCR and Temporal Temperature Gel Electrophoresis (TTGE). The diversity of Operational Taxonomic Units (OTUs) at the surgical site was analyzed according to the stage of surgery. From all patients and samples, we identified 147 different OTUs belonging to the 6 phyla Firmicutes, Actinobacteria, Proteobacteria, Bacteroidetes, Cyanobacteria, and Fusobacteria. High variations were observed among patients but common themes can be observed. The Firmicutes dominated quantitatively but were largely encompassed by the Proteobacteria regarding the OTUs diversity. The genera Propionibacterium and Staphylococcus predominated on the preoperative skin, whereas very diverse Proteobacteria appeared selected in peri-operative samples. The resilience in scar skin was partial with depletion in Actinobacteria and Firmicutes and increase of Gram-negative bacteria. Finally, the thoracic operative site presents an unexpected bacterial diversity, which is partially common to skin microbiota but presents particular dynamics. We described a complex bacterial community that gathers pathobionts and bacteria deemed to be environmental, opportunistic pathogens and non-pathogenic bacteria. These data stress to consider surgical microbiota as a “pathobiome” rather than a reservoir of individual potential pathogens.

Right coronary cusp perforation after mitral valve replacement

Secondary to leaflet injury, which is a well-known technical mistake, aortic regurgitation can occur during mitral valve replacement or repair. In most cases, the left or the non-coronary cusps are affected. For the first time, we report the case of a patient who had severe aortic regurgitation due to right coronary cusp perforation after mitral valve replacement. This complication was not identified until reoperation. Had transoesophageal echocardiography (TOE) been used during the first procedure, a delayed reoperation could have been avoided. During mitral surgery, every aortic cusp is at risk and peroperative TOE should be a mandatory procedure.

Percutaneous Atrioseptostomy for Right Heart Failure After Left Pneumonectomy

We present a case of right heart failure after left pneumonectomy as a result of an isolated, contralateral partial anomalous pulmonary venous return. We successfully treated this with percutaneous atrioseptostomy. For unstable patients with postoperative acute heart failure from an undetected partial anomalous pulmonary venous return, this minimally invasive procedure represents a useful primary option while allowing secondary conventional surgery if required.

Supravalvular aortic stenosis of the diffuse type: 29 years follow-up after aortic endarterectomy and symmetric enlargement of the ascending aorta and of the three coronary sinuses.

Supravalvular aortic stenosis is a rare congenital anomaly characterized by variable amounts of left ventricular outflow tract obstruction distal to the aortic valve. Macroscopically, it is categorized into three morphologic subtypes: membranous, hourglass, and diffuse. The diffuse type is the most rare, and its surgical repair is the most challenging due to variable length of ascending aorta hypoplasia. Surgical treatment options of supravalvular aortic stenosis are well established for the membranous and hourglass type, whereas they are challenging and less well defined for the diffuse type. We present a case of long-term follow-up (29 years) after a very complex surgical repair of supravalvular aortic stenosis of the diffuse type, with focus on technical aspects. To our knowledge, the present case represents one of the longest follow-up routines in the English language literature of surgical treatment of supravalvular aortic stenosis.