P. Ruchat

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.

Primary isolated aortic valve surgery in octogenarians

OBJECTIVESnWe reviewed our surgery registry, to identify predictive risk factors for operative results, and to analyse the long-term survival outcome in octogenarians operated for primary isolated aortic valve replacement (AVR).nnnMETHODSnA total of 124 consecutive octogenarians underwent open AVR from January 1990 to December 2005. Combined procedures and redo surgery were excluded. Selected variables were studied as risk factors for hospital mortality and early neurological events. A follow-up (FU; mean FU time: 77 months) was obtained (90% complete), and Kaplan-Meier plots were used to determine survival rates.nnnRESULTSnThe mean age was 82+/-2.2 (range: 80-90 years; 63% females). Of the group, four patients (3%) required urgent procedures, 10 (8%) had a previous myocardial infarction, six (5%) had a previous coronary angioplasty and stenting, 13 patients (10%) suffered from angina and 59 (48%) were in the New York Heart Association (NYHA) class III-IV. We identified 114 (92%) degenerative stenosis, six (5%) post-rheumatic stenosis and four (3%) active endocarditis. The predicted mortality calculated by logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 12.6+/-5.7%, and the observed hospital mortality was 5.6%. Causes of death included severe cardiac failure (four patients), multi-organ failure (two) and sepsis (one). Complications were transitory neurological events in three patients (2%), short-term haemodialysis in three (2%), atrial fibrillation in 60 (48%) and six patients were re-operated for bleeding. Atrio-ventricular block, myocardial infarction or permanent stroke was not detected. The age at surgery and the postoperative renal failure were predictors for hospital mortality (p value <0.05), whereas we did not find predictors for neurological events. The mean FU time was 77 months (6.5 years) and the mean age of surviving patients was 87+/-4 years (81-95 years). The actuarial survival estimates at 5 and 10 years were 88% and 50%, respectively.nnnCONCLUSIONSnOur experience shows good short-term results after primary isolated standard AVR in patients more than 80 years of age. The FU suggests that aortic valve surgery in octogenarians guarantees satisfactory long-term survival rates and a good quality of life, free from cardiac re-operations. In the era of catheter-based aortic valve implantation, open-heart surgery for AVR remains the standard of care for healthy octogenarians.

Animal model to compare the effects of suture technique on cross-sectional compliance on end-to-side anastomoses

OBJECTIVEnAn animal model has been developed to compare the effects of suture technique on the luminal dimensions and compliance of end-to-side vascular anastomoses.nnnMETHODSnCarotid and internal mammalian arteries (IMAs) were exposed in three pigs (90 kg). IMAs were sectioned distally to perform end-to-side anastomoses on carotid arteries. One anastomosis was performed with 7/0 polypropylene running suture. The other was performed with the automated suture delivery device (Perclose/Abbott Labs Inc.) that makes a 7/0 polypropylene interrupted suture. Four piezoelectric crystals were sutured on toe, heel and both lateral sides of each anastomosis to measure anastomotic axes. Anastomotic cross-sectional area (CSAA) was calculated with: CSAA = pi x mM/4 where m and M are the minor and major axes of the elliptical anastomosis. Cross-sectional anastomotic compliance (CSAC) was calculated as CSAC=Delta CSAA/Delta P where Delta P is the mean pulse pressure and Delta CSAA is the mean CSAA during cardiac cycle.nnnRESULTSnWe collected a total of 1200000 pressure-length data per animal. For running suture we had a mean systolic CSAA of 26.94+/-0.4 mm(2) and a mean CSAA in diastole of 26.30+/-0.5 mm(2) (mean Delta CSAA was 0.64 mm(2)). CSAC for running suture was 4.5 x 10(-6)m(2)/kPa. For interrupted suture we had a mean CSAA in systole of 21.98+/-0.2 mm(2) and a mean CSAA in diastole of 17.38+/-0.3 mm(2) (mean Delta CSAA was 4.6+/-0.1 mm(2)). CSAC for interrupted suture was 11 x 10(-6) m(2)/kPa.nnnCONCLUSIONSnThis model, even with some limitations, can be a reliable source of information improving the outcome of vascular anastomoses. The study demonstrates that suture technique has a substantial effect on cross-sectional anastomotic compliance of end-to-side anastomoses. Interrupted suture may maximise the anastomotic lumen and provides a considerably higher CSAC than continuous suture, that reduces flow turbulence, shear stress and intimal hyperplasia. The Heartflo anastomosis device is a reliable instrument that facilitates performance of interrupted suture anastomoses.

Active cooling during open repair of thoraco-abdominal aortic aneurysms improves outcome.

OBJECTIVEnEvaluate impact of active cooling with partial cardiopulmonary bypass (CPB) and low systemic heparinization during open repair of thoracoabdoninal aortic aneurysms.nnnMETHODSnProspective analysis of 100 consecutive patients undergoing surgical repair of thoracoabdominal aortic aneurysms. Partial CPB and normothermic (36 degrees C) or hypothermic (29 degrees C) perfusion was selected in accordance to the surgeons preference. In the hypothermic group, aortic cross clamp was applied when the target temperature of the venous blood was achieved and rewarming was started after declamping.nnnRESULTSn52/100 patients (62.2+/-10.9 years) received normothermic and 48/100 patients hypothermic perfusion (63.8+/-10.6 years: NS). Emergent procedures accounted for 18/52 (35%) with normothermia vs. 21/48 (44%: NS) with hypothermia. The number of aortic segments (eight = maximum including arch and bifurcation) replaced was 3.9+/-1.5 with normothermia vs. 4.1+/-1.5 with hypothermia (NS); Crawford type II aneurysms accounted for 21/52 patients (40%) for normothermia vs. 20/48 (42%:NS) for hypothermia. Total clamp time was 38+/-21 min with normothermia vs. 47+/-28 min with hypothermia (P=0.05). Pump time was 55+/-28 min with normothermia vs. 84+/-34 min with hypothermia (P=0.001). Mortality at 30 days was 8/52 patients (15%) with normothermia vs. 2/48 (4%) with hypothermia (P=0.06; odds ratio = 4.1). Parapareses/plegias occurred in 4/52 patients (8%) with normothermia vs. 4/48 (8%) with hypothermia (NS). Revisions for bleeding were required in 4/52 patients (8%) with normothermia vs. 2/48 patients (4%) with hypothermia (P=0.38). Revisions for distal vascular problems were necessary in 5/52 patients (10%) with normothermia vs. 2/48 (4%) with hypothermia (P=0.25). Freedom from death, paraplegia, and surgical revision was 89.9% with normothermia vs. 94.8% with hypothermia (P=0.04; odds ratio 2.0).nnnCONCLUSIONSnActive cooling during repair of thoracoabdominal aortic aneurysms allows for longer cross-clamp times, more complex repairs and improves outcome.

Surgical Procedure in Immunoglobulin G4–Related Ascending Aortitis?

Immunoglobulin G4 (IgG4)-related fibroinflammatory systemic disease accounts for 7% of all noninfectious aneurysms of the thoracic aorta. A patient was admitted with a symptomatic ascending aortic aneurysm and thickened aortic wall (outer/inner diameter 55/45 mm), which was replaced. Probes revealed IgG4-related aortitis associated with a primary tuberculosis infection. Corticosteroid and antituberculosis therapies were used, and the patients clinical evolution was favorable. The optimal treatment strategy of IgG4-related aortitis, a new entity, remains vague. Inner aortic diameter alone does not justify aortic replacement, but wall thickening may mimic intramural hematoma. In this particular case of IgG4-related aortitis, immunosuppressive treatment alone, as an alternative to a surgical procedure, may be debatable.

A cardiopulmonary bypass score system to assess quality of perfusion performance

During cardiopulmonary bypass, the perfusionist maintains physiological parameters laid down in protocols; this is his or her performance capability. In order to assess his or her performance we need to be able to analyse these physiological parameters objectively. We defined six parameters, pH, BE, PaCO2, PaO2, ACT and oesophageal temperature and gave them ideal values of 7.40 ± 0.05, 0.0 ± 2.5 mmol/l, 39.0 ± 3.0 mmHg, 150 ± 50 mmHg, 540 ± 60 s and 37.2 ± 0.2°C, respectively. We established ranges and a score system: ± one standard deviation of the mean for a score of zero; between ± one and two standard deviations for a score of one; and greater than ± two standard deviations for a score of two. We captured and analysed the most outlying value, with respect to known normal values, for each parameter recorded on the pump sheet. This was performed for 100 consecutive patients. Mean ± standard deviation (medians) values for pH, BE, PaCO2, PaO2, ACT and oesophageal temperature were 7.41 ± 0.07 (7.41), -1.85 ± 2.37 mmol/l (-1.85 mmol/l), 34.6 ± 5.42 mmHg (34.0 mmHg), 320 ± 96.2 mmHg (317 mmHg), 558 ± 164 s (503 s) and 37.3 ± 0.5°C(37.4°C), respectively. We then analysed what percentage of our 100 patients fell within each score range for each of the six parameters. This is an efficient means in analysing whether the perfusionist abides by the protocols, what quality is supplied to the patient, does he or she react when he or she is faced with parameters that are out of range and finally advocating in-line blood gas monitoring. This is another step towards our goal of total quality management.

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.

Caught in the act

A 59-year-old woman presented with acute pulmonary embolism. A routine echocardiography showed pulmonary hypertension, right ventricular dysfunction and a mass floating in the left atrium (Fig. 1). Numerous clots could also be removed from the left pulmonary artery (Fig. 2). An inferior vena cava filter was inserted post-operatively and the patient recovered uneventfully. At the 6 months follow-up visit, she was asymptomatic. European Journal of Cardio-thoracic Surgery 14 (1998) 516

Localized Amyloid Light-Chain Amyloidosis and Extramedullary Plasmacytoma of the Mitral Valve

An unusual case of localized amyloid light-chain (AL) amyloidosis and extramedullary plasmacytoma of the mitral valve is described. The worsening of a mitral regurgitation led to investigations and surgery. The valve presented marked distortion and thickening by type AL amyloid associated with a monotypic CD138+ immunoglobulin lambda plasma cell proliferation. Systemic staging showed a normal bone marrow and no evidence of amyloid deposition in other localizations. The patients outcome after mitral valve replacement was excellent. To our knowledge, this is the first description of a localized AL amyloidosis as well as of a primary extramedullary plasmacytoma of the mitral valve.

Gefäßchirurgische Ausbildung in endovaskulärer Technik in Lausanne

ZusammenfassungZwischen 1995 und 2005 wuchs die Anzahl der jährlich von uns mit endovaskulären Techniken versorgten Aortenaneurysmen (EVAR) von 0 auf 50, und dies auf allen Stufen der Aorta. Zu unserer Organisation gehören ein breites Team von Chirurgen, ein Lager mit 3xa0kompletten Familien von Endoprothesen (gerade Endoprothesen, konische Endoprothesen, und Bifurkationen), ein mobiler Wagen mit Zubehör (Einführungsbestecke, Führungsdrähte, Katheter, Ballone etc.) und ein Apparat auf Rädern für die intravaskuläre Ultraschalluntersuchung (IVUS). Letzterer erlaubt es zusammen mit einer mobilen Durchleuchtungsanlage (C-Bogen), in jedem Operationssaal unserer Institution endovaskulär Aneurysmen zu analysieren, und dies in der Regel ohne Angiographie bzw. Kontrastmittel. Deshalb sind wir nicht mehr auf eine ausgiebige bildgebende präoperative Abklärung potenzieller Kandidaten für eine endovaskuläre Sanierung von Aneurysmen angewiesen und können rupturierte Aneurysmen der Bauchaorta oder der thorakalen Aorta ohne Verzug behandeln. Bei der endovaskulären Sanierung von Aortenaneurysmen unterscheiden wir zwischen Prozessschritten (Indikationsstellung, Darstellung der Zugangsgefäße, Ausmessen mittels IVUS und Roadmapping mittels Durchleuchtung, Implantatwahl, Implantatinsertion, Positionierung, Implantatabwurf, Erfolgsbeurteilung, Rekonstruktion der Zugangsgefäße und Nachkontrolle) und Kompetenzstufen (Assistent, Oberarzt, Leitender Arzt). Unsere ultraschallgestützte Technik zur endovaskulären Sanierung von Aneurysmen wurde mittels IVUS-Transporter und Telementoring erfolgreich auch anderen Institutionen zur Verfügung gestellt.AbstractBetween 1995 and 2005, the number of aortic aneurysms treated annually using endovascular techniques (EVAR) increased from 0 to 50, including all aortic stages. Our organization includes a large team of surgeons, a stock of three complete families of endoprostheses (straight, conical and bifurcated), a mobile trolley with accessories (arterial introducer/introducer sheath, guide wire, catheters, balloons, etc.) and an appliance on wheels for intravascular ultrasound examination (IVUS). This appliance, together with a mobile fluoroscopy device (c-arm), allows endovascular aneurysms analysis of every operating room in our institution, usually without angiography or the use of contrast medium. In general, we are therefore not depending on substantial preoperative imaging in order to identify candidates for endovascular aneurysms repair and can treat abdominal and thoracic aortic ruptures without delay. For endovascular aortic aneurysms repair we distinguish between process steps on the one hand (determining indications, imaging of the access vessels, measurement using IVUS and road mapping via fluoroscopy, selection of implant, implant insertion, positioning, setting the implant, determining success, reconstruction of the access vessel and follow-up) and the level of competence on the other (assistant, senior and directing physicians). Our ultrasound supported technique for endovascular aneurysms repair has been successfully brought to other hospitals using an IVUS transporter and telementoring.