Jean-Michel Grinda

Long-Term Results of Mitral Valve Repair in Active Endocarditis

Background—Several investigators have reported the feasibility of mitral valve repair in active endocarditis, but the long-term results are still unknown. Methods and Results—We reviewed 37 consecutive patients who underwent mitral valve repair with the Carpentier technique for active endocarditis in our center between 1989 and 1994. This repair involved prosthetic annuloplasty in 31 patients (84%), valve resection in 31 (84%), chordal shortening or transposition in 19 (51%), pericardial patch in 16 (43%), and direct suture of leaflet perforation in 4 (11%). Associated procedures were primarily aortic valve repair or replacement in 11 (30%) and tricuspid repair in 2 (6%). Early complications included 1 operative death (3%; 95% CI, 0 to 15.5) and 1 reoperation for pericardial patch dehiscence. Recurrence of endocarditis was observed in 1 patient (3%; 95% CI, 0 to 16). The 10-year survival rate and freedom from mitral valve reoperation were 80% (95% CI, 66 to 94) and 91% (95% CI, 81 to 100), respectively. At 10 years, most patients (96%) were in good functional status (NYHA class I to II) with no or trivial mitral regurgitation (92%) on echocardiography. Conclusions—Mitral valve repair using Carpentier’s techniques in patients with active endocarditis offers very good long-term results with a low rate of recurrence or reoperation.

Right Anterolateral Thoracotomy for Repair of Atrial Septal Defect

BACKGROUND To procure a cosmetic incision in female patients, we performed operation on atrial septal defects through a right anterolateral thoracotomy. METHODS From 1984 to 1994, 80 female patients with a mean age of 24 +/- 13 years (ranging from 12 to 62 years) underwent right anterolateral thoracotomy for atrial septal defect repairs. Defects repaired included 62 ostium secundum, 12 sinus venosus, 2 low septal defect, and 4 ostium primum. The right iliac external artery was systematically used for arterial cannulation, through a cosmetic incision. Repairs were always performed under fibrillation, except in the 4 ostium primum defects, for which cardioplegia was used. RESULTS There was no operative or late mortality, and no morbidity directly related to the thoracotomy approach. CONCLUSIONS The right thoracotomy incision appears to be a safe and effective alternative to median sternotomy for repair of atrial septal defects.

Bypass graft for complex forms of isthmic aortic coarctation in adults

BACKGROUND Bypass grafting for complex forms of coarctation has been poorly documented as an alternative to decrease the high complication rate associated with anatomic repair. METHODS Between mid-1980 and the end of 1994, 16 patients underwent bypass grafting for complex forms of isthmic aortic coarctation. Age ranged from 11 to 49 years (mean age, 28.4 +/- 13 years). Indications were atypical anatomic forms of coarctation (n = 12) and reoperation after multiple or complicated previous coarctation repair (n = 4). Lateroisthmic bypass grafts were performed in 14 patients and ascending aorta-descending aorta bypass grafts in 2. RESULTS There was no hospital mortality. Morbidity consisted of postoperative paradoxical hypertension in 3 patients. There were no spinal cord complications. One death 10 years postoperatively was unrelated to the surgical technique. One patient successfully underwent ascending aorta-descending aorta bypass grafting for a false aneurysm 10 years after lateroisthmic grafting. All patients were asymptomatic and all grafts, patent after a mean follow-up of 5.7 +/- 4 years. CONCLUSIONS On the basis of these results, bypass grafting appears to be a safe alternative in this select group of patients. The lateroisthmic bypass graft is the procedure of first choice, and the ascending aorta-descending aorta bypass graft should be reserved for failure of previous lateroisthmic bypass grafting.

Bridge to transplantation with the DeBakey VAD® axial pump: a single center report

AIMS To report our experience with a left ventricular assist device axial pump as a bridge to transplantation: the DeBakey Ventricular Assist Device (VAD). METHODS From February 1999 to February 2002, nine patients (among which eight males), with a mean age of 47 years, all in NYHA functional class IV, were proposed for a bridge to transplantation with the DeBakey VAD. Five patients had primary dilated cardiomyopathy, four had ischemic cardiomyopathy. All the patients had inotropic support prior to the intervention (dobutamine with a mean dose of 12 mcg/kg per min), six had an intra-aortic counterpulsation, four presented ventricular rhythm disorders. Interventions were performed through sternotomy alone (no need for an abdominal pocket) under extra-corporeal circulation on beating heart (except in one patient suffering from an apical thrombosis for which cardioplegic arrest was performed) as followed: implantation of the apical inflow cannula, tunneling of the percutaneous cable, implantation of the outflow graft under aortic side clamping, starting of the DeBakey VAD during CPB weaning-off. RESULTS Mean support duration was 81+/-62 days (16-224 days). Eight reoperations were required (three for bleeding or cardiac tamponade, one for haemoperitoneum, one for aortic bifurcation thrombectomy, one for right ventricular assist device implantation, two for iterative replacements of the DeBakey VAD). A significant hemolysis was observed in two patients. No device infection or dysfunction were observed. Secondary recovery of a pulsed flow was observed either clinically or by Echo-Doppler in six patients. Five patients were transplanted, four died prior to transplantation (three from multi-organ failure on post-operative day 35, 16 and 50, respectively, and the last patient was found disconnected at day 109). CONCLUSIONS The DeBakey VAD is at the origin of renewed interest for continuous flow assist devices. Still under evaluation, the advantages of miniaturization and facility of implantation of this new device seem to be promising.

Mechanical ventricular assistance in heart failure: pathology of the cardiac apex removed during device implantation

BACKGROUND Ventricular assistance device (VAD) implantation provides large ventricular core biopsies available for pathological assessment. We present here the pathological data from 60 apex removed during a 7-year-period in a single institution. RESULTS The most frequent specific lesions were ischemic myocardial damage. Nonspecific pathological features were quite as frequently observed and correspond either to dilated cardiomyopathies, chronic ischemic cardiopathies, or miscellaneous conditions. Myocarditis represented 10 out of the 60 cases. The pathological data changed the clinical diagnosis in four cases: 1 case of juvenile hemochromatosis featuring as myocarditis and three cases of myocarditis featuring as dilated cardiomyopathies. CONCLUSION Apex pathological analysis provides definite diagnosis and contributes to determine the cases which the cardiac disease have a possibility to recover under VAD.

Obstructive right ventricular cardiac fibroma in an adult

This study reports the case of a large intramural right ventricular cardiac fibroma, causing a right medio-ventricular stenosis and full loss of consciousness in a 31-year-old female patient, which was successfully treated by enucleation.

Valved conduit bypass for extensively calcified tricuspid valve stenosis

A case of calcified tricuspid valve stenosis resulting from a complication of ventriculoatrial shunt implantation is presented. Tricuspid valve repair or replacement was not possible because of the prohibitive risk of damaging the right atrioventricular junction and conductive pathways. This rare lesion was treated successfully by insertion of an external right atrial-right ventricular valved conduit. The role of echocardiography in the detection of such a lesion is emphasized and the etiologic and therapeutic aspects are discussed.

Intermittent cyanosis: unusual diagnosis of an ascending aortic aneurysm

The authors report here an unusual case of an ascending aorta aneurysm diagnosed in the event of a check-up for a dyspnea with cyanosis. The right atrium compression by the aneurysm initiated a right-to-left shunt through a patent foramen ovale.

Aortic insufficiency associated with complex cardiac anomalies

The purpose of this study was to determine the cause, onset, clinical outcome and treatment of aortic insufficiency developing during treatment of complex cardiac anomalies. Aortic insufficiency associated with ventricular septal defect is a well-recognized entity. Very few studies, in contrast, have addressed the development of aortic insufficiency in the presence of more complex cardiac anomalies. Ten patients were selected from two clinical centers. All patients were diagnosed with a major cardiac anomaly requiring surgical treatment. Each patient developed aortic insufficiency requiring a surgical treatment of the valve after correction or palliation of their cardiac defect. There were six males, and mean age for the series was 17 years (range 5.5 to 33 years). All patients were initially operated for repair (eight patients) or palliation (two patients) of their congenital anomaly. Five patients had tetralogy of Fallot, one had tetralogy associated with pulmonary atresia, and two patients had double outlet right ventricle, and two had complete transposition. The degree of aortic insufficiency, the amount of pulmonary stenosis present before the original procedure and the diameter of the aortic root measured before the aortic surgical procedure on the valve were assessed by angiography and echocardiography. The mean time between the last surgical procedure and the appearance of aortic regurgitation was three years, with a mean time between the last intervention and the aortic procedure of 7.3 years. The etiology of the insufficiency was explained by prolapse of an aortic leaflet in three patients. Four patients had annular dilation with central regurgitation, two patients had traumatic perforation of a leaflet, one patient had lesions consistent with endocarditis. Eight patients had dilation of the aortic root. Surgical procedures included five replacements of the aortic valve, three aortic valvoplasties, one aortic valvar replacement associated with a Glenn shunt, and one Bentall procedure. One patient died two months following an aortic valvar replacement. All patients were assessed by transthoracic echocardiography before discharged. The two main causes of aortic regurgitation, leaflet prolapse and annular dilation are age-related complications. Most patients had dilation of the aortic root from longstanding increases in aortic flow. Early repair of congenital anomalies may decrease these complications.