Nicolas Paul Henri Murith

Stratified Gray-Scale Median Analysis and Color Mapping of the Carotid Plaque Correlation With Endarterectomy Specimen Histology of 28 Patients

Background and Purpose— To determine whether a stratified gray-scale median (GSM) analysis of the carotid plaque combined with color mapping could predict plaque histology better than an overall GSM measurement. Methods— Thirty-one carotid plaques derived from 28 patients undergoing carotid endarterectomy were investigated by ultrasound. GSMs of the whole plaque were used as measurement of echogenicity. A profile of the regional GSM as a function of distance from the plaque surface could be generated. Plaque pixels were further mapped into 3 different colors depending on their GSM value. Results— Plaques with large calcifications presented the highest GSM values, and those with large hemorrhagic areas or with a predominant necrotic core exhibited the lowest. Fibrous plaques had intermediate GSM values. A necrotic core located in a juxtalumenal position was associated with significantly lower GSM values (P=0.009) and with a predominant red color (GSM <50) at the surface (P=0.0019). With respect to the thickness of the fibrous cap and the position of the necrotic core, the sensitivity and specificity of the predominant red color of the whole plaque was respectively 45% and 67% and 53% and 75%; considering the predominant red color of the surface, the sensitivity and specificity increased to 73% and 67% and 84% and 75%, respectively. Conclusions— The stratified GSM measurement combined with color mapping showed a good correlation with the different histopathological components and further allowed identification with good accuracy of determinants of plaque instability. This approach should be investigated in a prospective, natural history study.

Aortic valve repair by cusp extension with the use of fresh autologous pericardium in children with rheumatic aortic insufficiency

OBJECTIVES Our goal was to evaluate the midterm results of aortic valve repair by a more sophisticated tailoring of cusp extension-taking into account the dimensions of the native aortic cusps-with the use of fresh autologous pericardium. PATIENTS AND METHODS Forty-one children who had severe rheumatic aortic insufficiency (mean age 11.5 +/- 2.7 years) underwent aortic valve repair by means of this cusp extension technique over a 5-year period. Twenty-four of them underwent concomitant mitral valve repair for associated rheumatic mitral valve disease. All children were then followed up by transthoracic echocardiography before discharge, at 3 and 6 months after the operation, and at yearly intervals thereafter. RESULTS Follow-up was complete in all patients and ranged from 3 months to 5 years (median 3 years). No operative and no early postoperative deaths occurred. Only 1 patient died, 9 months after the operation, of septicemia and multiple organ failure. Actuarial survival was 97% at 1 year and has remained unchanged at 3 years. On discharge, the degree of aortic insufficiency was grade 0 for 27 children and grade I for 14. Exacerbation of aortic insufficiency from grade I to grade II was observed in only 1 patient, and none of the children required reoperation for aortic insufficiency during the follow-up period. Mean peak systolic aortic valve gradients at discharge were lower than preoperative values (P =.04), and no significant increase in the peak systolic transvalvular gradient was detected thereafter during the follow-up period. Mean left ventricular dimensions were significantly reduced at discharge when compared with preoperative values (P <.0001). CONCLUSIONS Functional results of aortic valve repair with cusp extension using fresh pericardium have been satisfactory at medium term, particularly in children with a small aortic anulus at the time of initial repair, because the expansion potential of fresh autologous pericardium is equivalent to that of the growing sinotubular junction and aortic anulus diameters.

Anterior mitral leaflet prolapse as a primary cause of pure rheumatic mitral insufficiency

BACKGROUND This study was designed to revise the mechanisms and repair techniques of anterior mitral leaflet prolapse observed during the correction of pure rheumatic mitral regurgitation in children. METHODS From March 1993 to May 1998, 36 children suffering from pure rheumatic mitral regurgitation due to anterior leaflet prolapse underwent mitral valve repair. The mean age was 12.5 years (range, 6 to 16 years). Anterior leaflet prolapse was due to chordal elongation in 25 patients (group A), chordal rupture in 6 patients (group B), and retraction of anterior secondary chordae tendineae, creating a V-shaped deformity in the middle of the anterior leaflet, thus moving the free edge of the anterior leaflet away from the coaptation plane, in 5 patients (group C). Chordal shortening, transposition, and resection of anterior secondary chordae tendineae were used to correct anterior leaflet prolapse according to the predominantly responsible mechanism. RESULTS All patients were available for clinical follow-up, which ranged from 6 months to 5 years (mean follow-up, 3 years). Echocardiographic studies were obtained until the 3rd postoperative month, and all patients showed significant improvement in their left ventricular and atrial dimensions. There was one late death related to endocarditis. Two patients in group C who had mitral valve repair underwent mitral valve replacement on the 19th and 24th postoperative months, respectively, because of failure of mitral valve repair. CONCLUSIONS Mitral valve repair for pure mitral regurgitation due to rheumatic anterior leaflet prolapse can be performed safely for all types of mechanisms. Although the techniques we used provide stable short-term results in each of these groups, midterm results are better in groups A and B, where tissue thickening is less important, recurrences of rheumatic carditis are lower, and the interval between the first rheumatic attack and the surgical procedure is shorter than in group C.

Cardiovascular response to acute normovolaemic haemodilution in patients with severe aortic stenosis: assessment with transoesophageal echocardiography

Using multiplane transoesophageal echocardiography (TOE), we investigated the haemodynamic response to acute normovolaemic haemodilution (ANH) in anaesthetised patients with critical aortic stenosis. Twenty‐eight patients were randomly assigned to ANH or control groups. In the control group, haemodynamic data remained unchanged over a 20‐min period. In the ANH group, haemoglobin levels decreased from a mean (SD) of 134 (7) to 91 (9) g.l−1 (p < 0.001) whereas stroke volume, central venous pressure and left ventricular (LV) end‐diastolic area all increased significantly (mean (SD) +15 (6) ml; +2.0 (1.1) mmHg; +2.1 (0.8) cm2, respectively). During ANH, the accelerated blood flow through the stenotic valve caused an increased loss (SD) in LV stroke work: from 24 (8)% to 30 (10)%), (p < 0.01). Hence, lowering viscosity with ANH resulted in improved venous return, higher cardiac preload and increased stroke volume. However, this adaptive haemodynamic response was limited by less efficient LV stroke work due to dissipation of fluid kinetic energy.

No-Patch Technique for Complete Atrioventricular Canal Repair

Although no-patch repair was the first surgical treatment for complete atrioventricular canal, patch repairs are currently more widely used. We assessed the safety of forgoing a patch during the correction of complete atrioventricular canal in 8 consecutive patients. The complete atrioventricular canal was repaired using sutures placed on the right of the ventricular septal defect crest, passed through the bridging leaflet, and to the facing part of the ostium primum defect. There were no early deaths; all patients were in sinus rhythm without left ventricular outflow tract obstruction. This no-patch technique produces results comparable with the modified single-patch repair, while reducing ischemic time.

Diagnosis of and treatment for symptomatic carotid stenosis: an updated review

Carotid stenoses of ≥50% account for about 15–20% of strokes. Their degree may be moderate (50–69%) or severe (70–99%). Current diagnostic methods include ultrasound, MR‐ or CT‐angiography. Stenosis severity, irregular plaque surface, and presence of microembolic signals detected by transcranial Doppler predict the early recurrence risk, which may be as high as 20%. Initial therapy comprises antiplatelets and statins. Benefit of revascularization is greater in men, in older patients, and in severe stenosis; patients with moderate stenoses may also profit particularly if the plaque has an irregular aspect. An intervention should be performed within <2 weeks. In large randomized studies comparing endarterectomy and stenting, endovascular therapy was associated with a higher risk of periprocedural stroke, yet in some studies, with a lower risk of myocardial infarction and of cranial neuropathy. These trials support endarterectomy as the first choice treatment. Risk factors for each of the two therapies have been indentified: coronary artery disease, neck radiation, contralateral laryngeal nerve palsy for endarterectomy, and, elderly patients (>70 years), arch vessel tortuosity and plaques with low echogenicity on ultrasound for carotid stenting. Lastly, in direct comparisons, a contralateral occlusion increases the risk of periprocedural complications in both types of treatment.

Impact of anesthesia technique on the incidence of major complications after open aortic abdominal surgery: a cohort study

STUDY OBJECTIVE To determine the risk factors of perioperative complications and the impact of intrathecal morphine (ITM) in major vascular surgery. DESIGN Retrospective analysis of a prospective cohort. SETTINGS Operating room, intensive care unit, and Postanesthesia Care Unit of a university hospital. MEASUREMENTS Data from 595 consecutive patients who underwent open abdominal aortic surgery between January 1997 and December 2011 were reviewed. Data were stratified into three groups based on the analgesia technique delivered: systemic analgesia (Goup SA), thoracic epidural analgesia (Group TEA), and intrathecal morphine (Group ITM). Preoperative patient characteristics, perioperative anesthetic and medical interventions, and major nonsurgical complications were recorded. MAIN RESULTS Patients managed with ITM (n=248) and those given thoracic epidural analgesia (n=70) required lower doses of intravenous (IV) sufentanil intraoperatively and were extubated sooner than those who received systemic analgesia (n=270). Total inhospital mortality was 2.9%, and 24.4% of patients experienced at least one major complication during their hospital stay. Intrathecal morphine was associated with a lower risk of postoperative morbidity (OR 0.51, 95% CI 0.28 - 0.89), particularly pulmonary complications (OR 0.54, 95% CI 0.31 - 0.93) and renal dysfunction (OR 0.52, 95% CI 0.29 - 0.97). Other predictors of nonsurgical complications were ASA physical status 3 and 4 (OR 1.94, 95% CI 1.07 - 3.52), preoperative renal dysfunction (OR 1.61, 95% CI 1.01 - 2.58), prolonged surgical time (OR 1.78, 95% CI 1.16 - 2.78), and the need for blood transfusion (OR 1.77, 95% CI 1.05 - 2.99). CONCLUSIONS This single-center study showed a decreased risk of major nonsurgical complications in patients who received neuraxial analgesia after abdominal aortic surgery.

Isolated Bilateral Profunda Femoris Artery Aneurysm

BACKGROUND Isolated bilateral profunda femoris artery aneurysm (PFAA) is a very rare entity. Most of the cases are unilateral and occur with synchronous aneurysms elsewhere. Symptoms range from none to limb ischemia or hemorrhage because of rupture. METHODS We present a rare case of PFAA. In contrast to the general rule, the patient had a bilateral PFAA which was isolated to the deep femoral artery. The aneurysm was discovered after signs of acute limb ischemia caused by distal embolization. The patient was treated surgically with open aneurysmectomy and ligation of a branch of the deep femoral artery. CONCLUSION PFAA are asymptomatic most of the time. Surgical repair is always recommended to prevent such life-threatening complications. Different treatment modalities are offered, including endovascular options. The presence of a PFAA should prompt screening for concomitant aneurysms.

Lung transplantation: how to perform the venous anastomosis when clamping is too distal

During lung transplantation, the venous anastomosis is performed between the atrial cuffs of the donor and the receiver. In certain rare circumstances, however, the surgeon may find two veins and no possibility to reposition the clamp more proximally. A simple technique can be used in this case: both veins are reunited and the venous anastomosis carried out as usual between two large lumens.

Leaflet's free edge suspension for correction of aortic insufficiency associated with ventricular septal defect

Aortic valve regurgitation in association with ventricular septal defect results from the mechanical effect of the ventricular septal defect, which primarily affects the free edge. The elongated free edge can be repaired by plicating it using several techniques designed to restore a normal geometry to the prolapsing aortic leaflet. We describe 4 cases in which aortic insufficiency was treated by a technique of plication that allows suspension of the free edge along a pericardial strip applied from one commissure to the other.