M. Hurni

Systematic surgical closure of patent foramen ovale in selected patients with cerebrovascular events due to paradoxical embolism. Early results of a preliminary study.

OBJECTIVEnTo define therapeutic strategy for management of patients with ischemic stroke due to a high probability of paradoxical embolism through a Patent Foramen Ovale (PFO).nnnMETHODSnSince 1988 all consecutive patients with cerebrovascular events and PFO from the Stroke Registry of our population-based primary-care center are prospectively studied and followed. Since 1992, among 118 patients with cryptogenic embolic brain infarct or transient ischemic attack (TIA) and PFO, 32 consecutive patients younger than 60 years who presented at least two of the following criteria were admitted for surgery: history of Valsalva strain before stroke (11); multiple clinical events (13); multiple infarcts on brain Magnetic Resonance Imaging (MRI) (15); atrial septal aneurysm (ASA) (16); large right-to-left shunt (> 50 microbubbles) (12).nnnRESULTSnOperative time 135 +/- 33. CPB time 34 +/- 14. Aortic crossclamping time 16 +/- 6. Post-operative bleeding 485 +/- 170 ml. No homologous blood transfusion required. No neurological, cardiac or renal complications. All patients were followed-up corresponding to a cumulative time of 601 patient-months. This revealed no recurrent vascular events nor silent new brain lesions on brain MRI. Systematic simultaneous contrast Trans Esophageal Echocardiography (TEE)-Trans Cranial Doppler showed a small residual interatrial shunt in two patients.nnnCONCLUSIONnSurgical closure of a patent foramen ovale can be accomplished with very low morbidity and reduce efficiently the risk of stroke recurrence. It seems to be the option of choice in selected patients with a higher (> 1.5%/year) risk of stroke recurrence.

Impact of a remote pump head on neonatal priming volumes

Reduction of priming volumes of the cardiopulmonary bypass (CPB) circuit in neonatal cardiac surgery to decrease haemodilution and blood transfusion requirements can be achieved with the use of neonatal low prime oxygenators and smaller diameter tubing. We have further reduced our prime volume with the use of a custom-designed arm allowing for remote positioning of a double-headed roller pump. This arm enables the double pump to be placed alongside the main heart-lung machine close to the operating table, and to position the pump inlet and outlet tubing immediately at the reservoir outlet and oxygenator inlet, respectively, therefore reducing tubing lengths. Priming volumes of four cases using this configuration were compared to four cases using our standard neonatal bypass setup. Results showed a 29% decrease in priming volume and a 58% reduction in blood utilization during CPB. This reduction in priming volume is clinically significant as it lowers the ratio of priming volume to patient blood volume and reduces homologous blood requirements.

Persistent Left Superior Vena Cava in Cardiac Congenital Surgery

Persistent left superior vena cava (LSVC) is a relatively frequent finding in congenital cardiac malformation. The scope of the study was to analyze the timing of diagnosis of persistent LSVC, the timing of diagnosis of associated anomalies of the coronary sinus, and the global impact on morbidity and mortality of persistent LSVC in children with congenital heart disease after cardiac surgery. Retrospective analysis of a cohort of children after cardiac surgery on bypass for congenital heart disease. Three hundred seventy-one patients were included in the study, and their median age was 2.75xa0years (IQR 0.65–6.63). Forty-seven children had persistent LSVC (12.7xa0%), and persistent LSVC was identified on echocardiography before surgery in 39 patients (83xa0%). In three patients (6.4xa0%) with persistent LSVC, significant inflow obstruction of the left ventricle developed after surgery leading to low output syndrome or secondary pulmonary hypertension. In eight patients (17xa0%), persistent LSVC was associated with a partially or completely unroofed coronary sinus and in two cases (4xa0%) with coronary sinus ostial atresia. Duration of mechanical ventilation was significantly shorter in the control group (1.2 vs. 3.0xa0days, pxa0=xa00.04), whereas length of stay in intensive care did not differ. Mortality was also significantly lower in the control group (2.5 vs. 10.6xa0%, pxa0=xa00.004). The results of study show that persistent LSVC in association with congenital cardiac malformation increases the risk of mortality in children with cardiac surgery on cardiopulmonary bypass. Recognition of a persistent LSVC and its associated anomalies is mandatory to avoid complications during or after cardiac surgery.

Multivalvular Surgery for Infective Endocarditis

The short and the long-term results of our experience with 25 consecutive patients who underwent multivalvular surgery for infective endocarditis are analysed. Preoperatively, 20/25 (80%) patients were in New York Heart Association (NYHA) stage III or IV, and 2/25 (8%) patients were in cardiogenic shock. All the diseased valves were replaced with mechanical bileaflet prosthesis except seven mitral valves and one tricuspid valve, which could be repaired. Major postoperative complications occurred in 3/25 (12%) patients: a fatal cerebral haemorrhage, a reversible cerebellar syndrome and an intractable heart failure, which required transplantation. During a mean follow-up of 4.7 years (range 6 months to 16.8 years), 7/25 (28%) patients suffered from valve-related complications: five bleedings (one died), one embolic event and one prosthetic valve thrombosis. The actuarial freedom of valve-related event at 10 years was 61.8 +/- 12.4%. There was no prosthetic endocarditis. At follow-up, 20/21 (95%) survivors were in NYHA stage I or II. Long-term outcome in our patient population operated on for multivalvular endocarditis, is satisfactory with no recurrent infection and excellent functional results.

MR and CT imaging of pulmonary valved conduits in children and adolescents: normal appearance and complications

BackgroundThe Contegra® is a conduit made from the bovine jugular vein and then interposed between the right ventricle and the pulmonary artery. It is used for cardiac malformations in the reconstruction of right ventricular outflow tract.ObjectiveTo describe both normal and pathological appearances of the Contegra® in radiological imaging, to describe imaging of complications and to define the role of CT and MRI in postoperative follow-up.Materials and methodsForty-three examinations of 24 patients (17 boys and 7 girls; mean age: 10.8xa0years old) with Contegra® conduits were reviewed. Anatomical description and measurements of the conduits were performed. Pathological items examined included stenosis, dilatation, plicature or twist, thrombus or vegetations, calcifications and valvular regurgitation. Findings were correlated to the echographic gradient through the conduit when available.ResultsCT and MR work-up showed Contegra® stenosis (nu2009=u200912), dilatation (nu2009=u20099) and plicature or twist (nu2009=u20097). CT displayed thrombus or vegetations in the Contegra® in three clinically infected patients. Calcifications of the conduit were present at CT in 12 patients and valvular regurgitation in three patients. The comparison between CT and/or MR results showed a good correlation between the echographic gradient and the presence of stenosis in the Contegra®.ConclusionCT and MR bring additional information about permeability and postoperative anatomy especially when echocardiography is inconclusive. Both techniques depict the normal appearance of the conduit, and allow comparison and precise evaluation of changes in the postoperative follow-up.

Complication of carotid stenting: incomplete misdeployment of the stent in the femoral artery

OBJECTIVESnThe presence of intravascular foreign bodies is underreported in the literature and is more commonly encountered in clinical practice. We report on a case where an attempt to position a carotid stent resulted in misdeployment of the stent in the femoral artery and its surgical removal.nnnMETHODSnA 63-year-old patient admitted to hospital for cerebral stroke underwent thrombolysis for occlusive dissection of right carotid artery and was transferred to our hospital for additional thrombo-aspiration and carotid stenting.nnnRESULTSnThe carotid stent was misdeployed incompletely in the femoral artery and had to be removed surgically.nnnCONCLUSIONSnAppropriate knowledge of intravascular migration and deployment failure management should be considered as important as the optimal device deployment.

CV8 Xenogreffe jugulaire bovine en position pulmonaire : imagerie en TDM multi-coupe

Objectifs Rapporter les aspects en TDM multi-coupe synchronisee a l’ECG (TDM-MC) de la xenogreffe jugulaire bovine (Contegra) implantee en position valvulaire pulmonaire. Materiels et methodes Cinquante-six patients (âge = 16±15 ans) ont beneficie de l’implantation d’un conduit Contegra dans notre institution pour diverses indications : remplacement valvulaire pulmonaire, atresie pulmonaire, tetralogie de Fallot, double ventricule droit, regurgitation valvulaire pulmonaire, truncus arteriosus, Taussig-Bing ou double discordance. Le diametre du conduit etait de 14 a 22 mm. Quatorze patients (25 %) ont beneficie d’un suivi post-operatoire par TDM-MC apres injection de produit de contraste. Resultats La duree moyenne du suivi etait de 29 mois (1-52 mois). Trois patients avaient des complications mecaniques directement liees au montage du conduit (kinking-twist) : deux patients traites par chirurgie et un par voie endovasculaire. Une stenose moderee asymptomatique est detectee. Les calcifications sont observees dans un cas. Aucune dilatation anevrysmale n’est observee. Conclusion La TDM-MC procure des images de haute qualite pour evaluer les complications morphologiques des conduits Contegra. Cette technique peut etre utilisee comme alternative a l’angiographie conventionnelle et l’IRM dans l’evaluation et le suivi post-operatoire de la chirurgie arterielle pulmonaire.