Robert Soyer

Coarctation of the aorta in adults: surgical results and long-term follow-up

BACKGROUNDnThe aim of this retrospective study was to determine the impact of coarctation surgical repair on arterial blood pressure in adults more than 20 years of age.nnnMETHODSnThirty-five adults (23 men), mean age 28.1 +/- 5.7 years (range, 21 to 52 years), underwent coarctation surgical repair between 1977 and 1997. All patients had preoperative hypertension. Mean systolic blood pressure was 178 +/- 37 mm Hg (range, 110 to 230 mm Hg). Thirty-three patients were taking at least one hypertension medication at the time of operation. All patients had preoperative catheterization and angiography (mean gradient across the coarctation was 62 +/- 27 mm Hg [range, 32 to 130 mm Hg]). Operative technique was resection and end-to-end anastomosis for 30 patients, resection with Dacron (C. R. Bard, Haverhill, MA) graft for 4 patients, and a prosthetic bypass graft for 1 patient. There were no hospital deaths and no late morbidity.nnnRESULTSnAll patients were reviewed. Follow-up was 165 +/- 56 months (range, 25 to 240 months). Of the 35 patients with preoperative hypertension, 23 were normotensive (systolic blood pressure < or = 140 mm Hg, diastolic blood pressure < or = 90 mm Hg) with no medication. Twelve patients were receiving medication: 6 required single-drug therapy and 6 patients required two drugs. Exercise testing was performed at an average of 6 +/- 4 months after repair and revealed hypertensive response to exercise in 8 of the 23 patients who were normotensive at rest and without medication. There were no recoarctation or repeat operations. Six aortic valve diseases were observed: three aortic incompetences (two bicuspid valves) treated by two valve replacements and one Bentall procedure, and three aortic stenoses (two valve replacements). No patient had evidence of a cerebrovascular accident.nnnCONCLUSIONSnSurgical repair of coarctation in adults has proved to be an effective procedure and significantly reduces arterial hypertension. However, long-term surveillance is mandatory and should include exercise testing to identify patients with potential hypertension.

A new treatment for severe pulmonary embolism: percutaneous rheolytic thrombectomy.

BACKGROUNDnThe rheolytic thrombectomy catheter has been specially designed to remove intravascular thrombus from coronary and peripheral arteries. It demonstrates a practical application of Bernoullis principle relating to a low-pressure zone in the region of a high-velocity jet. In this device, this effect is created by direct high-pressure saline jets located at the tip. Thrombus is drawn into this region and, because of the large pressure difference, undergoes mechanical thrombolysis due to the powerful mixing forces. The resulting microparticles are aspirated through the same catheter and removed from the body.nnnMETHODS AND RESULTSnWe report the use of this device in two patients presenting with severe pulmonary embolism and contraindications to thrombolytic therapy. The two procedures were successfully performed with an excellent immediate angiographic result at the site of the rheolytic thrombectomy. In both cases, the clinical improvement was maintained at follow-up with the same good angiographic result and a decrease to a normal level of the systolic pulmonary pressure.nnnCONCLUSIONSnThis preliminary results suggest that this easy technical method may be useful in the treatment of life-threatening pulmonary embolism in patients with absolute contraindications to thrombolytic therapy. A larger cohort of patients is necessary to determine whether this treatment should be proposed as an alternative to the use of fibrinolytics in selected patients.

Dobutamine stress echocardiography in orthotopic heart transplant recipients

Abstract Objectives. This study sought to determine whether dobutamine stress echocardiography could accurately identify coronary artery disease after heart transplantation. Background. After heart transplantation, coronary artery disease is related to either diffuse concentric intimal thickening or focal stenosis and may be underdiagnosed by coronary angiography. Methods. We enrolled 41 patients, a mean (±SD) of 40 ± 20 months after heart transplantation, at the time of their routine control coronary angiogram. Three patients were excluded because of poor echogenicity on the angiogram and one because of ventricular premature beats. Standard echocardiographic views were acquired at baseline and at incremental dobutamine infusion levels (from 5 to a maximal dose of 40 μg/kg body weight per min at 3-min intervals). Regional wall motion score was calculated from a 16-segment model, and each segment was graded from 1 (normal) to 4 (dyskinesia). Coronary angiography was performed 24 h after dobutamine stress echocardiography, and angiograms were analyzed in blinded manner. Results. Twenty-three (62%) of 37 patients had normal coronary angiographic findings. Dobutamine stress echocardiography showed abnormalities in only 2 of 23 patients. Fourteen patients (38%) had abnormal angiographic findings, seven of whom had stenoses >50%. Dobutamine stress echocardiography correctly identified the corresponding hypoperfused segments in these seven patients. More of interest were the other seven patients, of whom three had angiographic nonsignificant stenoses ( Conclusions. Dobutamine stress echocardiography is a useful technique for the diagnosis of coronary artery disease after heart transplantation. These preliminary results indicate that dobutamine stress echocardiography may have a predictive value for further ischemic events in heart transplant recipients.

Surgical treatment of infected composite graft after replacement of ascending aorta.

Infection of a composite graft is a serious complication. However, reports of such cases are rare even in large series. We report our experience with 4 patients in whom infection of a composite graft developed with pseudoaneurysm formation. Two of the patients had Marfans syndrome and were treated by Bentall procedure and 2 were treated by Cabrol technique for non-Marfan cystic medial necrosis. Staphylococcus epidermidis was detected in 2 patients and Enterococcus in 1. Reoperation was carried out between 1 and 32 months after the first intervention. One patient died of cerebral embolism and 3 remained free of infection 11 to 82 months later. These cases and guidelines for managing abdominal and peripheral vascular prosthetic infection indicate the need for prompt reintervention when infection is suspected from chronic sepsis, septicemia, positive blood cultures, fistula, anastomotic leak, hemolysis, embolism, graft deformity, or false aneurysm. When the organism is isolated, appropriate antibiotic therapy should be administered. All prosthetic material should be removed and all adjacent infected or necrotic tissue excised. Local antiseptic irrigation may be helpful. Dead space around the prosthesis should be filled with well-vascularized transposed pedicled flaps. Antibiotic therapy should be intravenously administered for at least 6 weeks.

Pseudomonas aeruginosa coronary stent infection

Stent infection is a rare complication of coronary angioplasty. We report a case of a coronary stent bacterial infection due to Pseudomonas aeruginosa, shortly after implantation of the stent in the left circumflex artery, which presented as an acute pericarditis. Surgical treatment consisted of stent removal and partial excision of the circumflex artery without coronary artery bypass grafting.

Hemodynamic and angiographic evaluation of aortic regurgitation 8 and 27 months after aortic valve replacement.

Eighteen patients with chronic aortic insufficiency were evaluated hemodynamically and angiographically 8 months after aortic valve replacement. Both the pulmonary artery diastolic pressure and the left ventricular end-diastolic volume decreased significantly (p < 0.001), but the mean ejection fraction and the cardiac output remained identically lowered, though some individual cases showed improvement. The relative reduction in end-diastolic volume correlated only with the preoperative ejection (p < 0.05) and regurgitation fractions (p < 0.02).In the 10 patients whose left ventricular volume remained high or ejection fraction low, a second evaluation was performed 27 months after surgery. The left ventricular end-diastolic volume was significantly lowered (from 151 to 120 mI/m2, p < 0.05) back to normal in five cases. The systolic and diastolic ventricular shape returned to normal. Cardiac index and ejection fraction were unchanged.These results show a marked improvement a few months after aortic valve replacement, with a further improvement several months later, as shown mainly by the decrease of left ventricular end-diastolic volume and the return to normal of left ventricular cavity shape. However, in most cases, the ejection fraction remained at its preoperative value, suggesting that surgery should be performed early, before myocardial deterioration appears.

Standard Orthotopic Heart Transplantation Versus Total Orthotopic Heart Transplantation A Transesophageal Echocardiography Study of the Incidence of Left Atrial Thrombosis

BACKGROUNDnAfter standard orthotopic heart transplantation (Sd HT), the enlarged resultant atria may promote atrial thrombosis. The purpose of this study was to compare the incidence of spontaneous echo contrast and left atrial thrombosis after Sd HT and total orthotopic (Tot HT) heart transplantation.nnnMETHODS AND RESULTSnTransesophageal echocardiography (TEE) was performed in 75 patients with Sd HT and in 20 patients with Tot HT. Despite the use of antiplatelet therapy, an acute arterial embolism occurred in 11 (15%) of the 75 patients with Sd HT but in none of the 20 Tot HT patients. All patients were in sinus rhythm. Left ventricular ejection fraction was similar in Sd HT and Tot HT patients. Left atrial diameter was smaller in Tot HT patients than in Sd HT patients (41 +/- 4 versus 58 +/- 6 mm, P < .001). In Sd HT patients, spontaneous echo contrast was present in 43 patients (57%) and was associated with left atrial thrombus in 20 patients (on the left atrial appendage in 12 patients, on the posterior wall in 6, and on the suture in 2). No thrombus was detected by transthoracic echocardiography; all thrombi were detected by TEE. On the other hand, no left atrial thrombus was observed in Tot HT patients, and only 1 patient had spontaneous echo contrast. Of the 11 Sd HT patients who experienced an arterial embolism, 5 had both spontaneous echo contrast and left atrial thrombus and 5 had only spontaneous echo contrast.nnnCONCLUSIONSnThis study demonstrates a high rate of left atrial thrombus after Sd HT and emphasizes the role of TEE in the follow-up of these patients. The therapeutic implications are the need for a preventive anticoagulant therapy in the high-risk population receiving Sd HT diagnosed with TEE and the consideration of Tot HT as a better surgical approach as far as thrombotic complications are concerned.

Intraoperative Coronary Angioscopy— Technique and Results: A Study of 38 Patients

Abstract Over a period of 11 months, 38 patients submitted to coronary artery revascularization underwent intraoperative angioscopy of the coronary arteries and internal thoracic arteries. Fifty‐nine lesions were observed, but only 31 stenoses responsible for coronary insufficiency were observed (33%). Forty‐four distal anastomoses were explored (47%) but ten of these explorations were incomplete. None revealed technical failure of the anastomosis. Thirteen harvested left internal mammary arteries were explored. One of the explorations led to rejection of the graft due to an intimal fracture. Some tiny intimal flaps were observed in our experience, as in others. Although the iatrogenic origin of these lesions in relation to the introduction of the angioscope is obvious, it does not seem to influence the outcome of the operation. In our opinion, two main fields appear to be developing in coronary angioscopy: preoperative assessment of the quality of internal thoracic artery grafts, and control of distal graft anastomoses. The flexibility of the angioscopes and of the leading catheters must be improved to minimize the risk of arterial wall traumatic lesions. (J Card Surg 1993; 8:483–487)