-
[show abstract]
[hide abstract]
ABSTRACT: Background: Off-pump coronary artery bypass surgery should have a significantly lower risk of postoperated bleeding than on-pump surgery. However, the use of a cell saver has been considered necessary, with significant additional cost incurred. Can we consider performing off-pump coronary artery bypass surgery without a cell saver? Patients and methods: A prospective observational study was performed in 68 consecutive patients operated on for 2- or 3-vessel coronary lesions by the off-pump technique. Results: The mean number of distal anastomoses was 2.7 ± 0.7. Both internal thoracic arteries were used in 45 patients, and sequential revascularization was performed in 27, with 140 (77.8%) arterial grafts. Cell savers were used in 21 (30.9%) patients. In these 21 patients, the mean volume retransfused after treatment was 315 ± 177 mL. Postoperatively, 11 (16.2%) patients were transfused with packed red blood cells, with a mean volume of 636 ± 234 mL per patient. The 2 factors identified as associated with a higher risk of autotransfusion were female sex and a lower preoperative hemoglobin. Conclusions: The use of a cell saver in off-pump surgery is useless in most cases. Careful surgical hemostasis is essential to limit hypovolemia.
Asian cardiovascular & thoracic annals 10/2012; 20(5):539-43.
-
[show abstract]
[hide abstract]
ABSTRACT: We evaluate the clinical results of the Carpentier-Edwards supraannular (CE SAV) aortic bioprosthesis at long-term follow-up (over 25 years).
Between 1983 and 1994, 1,002 CE SAV prostheses were implanted. Data were prospectively collected, retrospectively analyzed, and stratified by age groups at the time of surgery (group 1, ≤60 years; group 2, 61 to 70 years; group 3, >70 years), using both the actuarial and the "actual" (cumulative risk) methods.
The operative mortality was 11.3% (valve-related in 2 cases). Follow-up included 8,164.09 patient-years (average 13.7 ± 6.6 years, up to 26.9 years). Overall survival at 25 years was significantly higher in group 1 (p < 0.001). Freedom from structural valve deterioration (SVD) at 15 years was 85.9% (actuarial) and 94.8% (actual). Freedom from reoperation for SVD was 91.8% (actuarial) and 97% (actual). There were no significant differences in valve-related endpoints among group 2 and group 3. Death was valve-related in 11.3%. Younger age at surgery was associated with higher incidence but not earlier presentation of SVD. Freedom from any valve-related complication at 15 years was 23.6%, 66%, and 68% in groups 1, 2, and 3 (actuarial), and 38.9%, 76.1%, and 81.2%, respectively (actual) (p = 0.6 among groups 2 and 3).
The CE SAV bioprosthesis provides similar outcomes (SVD and reoperation) in patients aged 61 to 70 years and older individuals. Use of a bioprosthesis is justified in patients older than 60 years. Younger patients may be rightfully informed over the expected durability of the prosthesis.
The Annals of thoracic surgery 07/2012; 94(4):1191-7. · 3.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: With progressive occlusion of a coronary main artery, some anastomotic vessels are recruited in order to supply blood to the ischemic region. This collateral circulation is an important factor in the preservation of the myocardium until reperfusion of the area at risk. An accurate estimation of collateral flow is crucial in surgical bypass planning as it alters the blood flow distribution in the coronary network and can influence the outcome of a given treatment for a given patient. The evaluation of collateral flow is frequently achieved using an index based on pressure measurements. It is named Collateral Flow Index (CFI) and defined as: (P(w)-P(v))/(P(ao)-P(v)), where P(w) is the pressure distal to the thrombosis, P(ao) the aortic pressure and P(v) the central venous pressure. We propose here another index, that is more sensitive to the P(w) value and could thus describe the role of collateral flow with more precision. We illustrate this idea using some clinical pressure measurements in patients with severe coronary disease (stenoses on the left branches and total occlusion of the right coronary artery).
Medical Hypotheses 05/2012; 79(2):261-3. · 1.39 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: In this work, patients with severe coronary disease and chronic occlusion of the right coronary artery (RCA) are studied. In this clinical situation, the collateral circulation is an important factor in the preservation of the myocardium until reperfusion of the area at risk. An accurate estimation of collateral flow is crucial in surgical bypass planning as it can influence the outcome of a given treatment for a given patient. The evaluation of collateral flow is frequently achieved using an index (CFI, Collateral Flow Index) based on pressure measurements. Using a model of the coronary circulation based on hydraulic/electric analogy, we demonstrate, through theoretical simulations, that a wide range of fractional collateral flow values can be obtained for any given distal pressure difference depending on the values of the capillary and collateral resistances.
Medical Engineering & Physics 05/2012; · 1.62 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Aortic stenosis is of concern in the elderly. Although aortic valve replacement provides good long-term survival with functional improvement, many elderly patients are still not referred for surgery because of their age. Percutaneous aortic valve implantation offers an alternative to open-heart surgery. Concerns about the management of aortic valve stenosis in the elderly will be reviewed.
We retrospectively analyzed 1,193 consecutive aortic valve replacements, performed in octogenarians since January 2000. A total of 657 patients (55%) had at least one associated comorbidity (eg, respiratory failure) and 381 (32%) associated coronary lesions. Valve replacement was the only procedure in 883 patients (74%), and was associated with coronary revascularization in 262 cases, or with another cardiac procedure in 48 patients.
Overall operative mortality was 6.9% (83 of 1,193 patients); 5.5% for single replacement and 11.5% if associated with coronary artery bypass surgery. Univariate and multivariate analyses identified 11 operative risk factors related to general status, cardiologic condition, and the procedure itself: older age (p<0.015); respiratory failure (p<0.03); aortic regurgitation (p<0.001); emergency surgery (p<0.0029); New York Heart Association class IV (p<0.0007); right heart failure (p<0.03); atrial fibrillation (p<0.04); impaired ejection fraction (p<0.001); coronary disease (p<0.01); redo surgery (p<0.02); associated coronary revascularization (p<0.008).
Today, valve replacement has acceptable low hospital mortality, even in the elderly. Thus, older patients should not be denied surgery due to their advanced age alone. Conventional surgery remains the gold standard treatment for aortic stenosis; the decision should be made on an individual basis. If several risk factors suggest very high-risk surgery, then percutaneous valve implantation should be considered instead.
The Annals of thoracic surgery 01/2012; 93(1):70-7; discussion 77-8. · 3.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: In this work, we propose a model of the coronary circulation based on hydraulic/electric analogy. This model aims to provide quantitative estimations of the distribution of flows and pressures across the coro-nary network for patients with stenoses of the left main coronary artery (LMCA), left anterior de-scending artery (LAD) and left circumflex branch (LCx), and chronic occlusion of the right coronary artery (RCA), undergoing off-pump coronary sur-gery. The results of the simulations are presented for 10 patients with various stenoses grades and collat-eral supply. For each patient, the four revasculariza-tion situations (no graft operating, pathological situa-tion (0G); right graft only (1G), left grafts only (2G), complete revascularization (3G)) are considered. It is shown that: 1) the complete revascularization is fully justified for these patients because neither the right graft alone, nor the left grafts alone can ensure a suf-ficient perfusion improvement for the heart; 2) the capillary and collateral resistances (and the propor-tion between them) have a major impact on the flows and pressures everywhere in the network; 3) in the presence of the left grafts, the flows in the native stenosed arteries become low and this could promote the development of the native disease in these branches.
Journal of biomedical science and engineering 01/2011; 4:34-45.
-
[show abstract]
[hide abstract]
ABSTRACT: Preoperative measurements of collateral blood flow in patients with triple vessel disease and chronic occlusions of the right coronary artery do not, currently, ascertain the need to revascularise an occluded right coronary artery. We performed direct measurements of flow across left coronary bypass grafts to determine their contributions to collateral blood flow.
Collateral blood flow was scored preoperatively according to Rentrop in 13 patients with triple vessel disease and chronic occlusions of the right coronary artery who underwent complete, off-pump, surgical revascularisation. The transit-time flow through the left coronary grafts was measured before and after unclamping of the right coronary artery bypass graft.
Unclamping of the right coronary artery bypass graft was associated with a 5.9+/-6.9ml/min (mean+/-SD) decrease in flow across the left circumflex territory (P=0.009), which was proportional to the preoperative Rentrop score (P=0.007). No significant change was observed in flow across the graft to the left anterior descending artery.
Grafts to the left circumflex system are the only grafts that supply a significant, albeit modest amount of collateral blood flow to chronically occluded right coronary artery. These observations confirm that (1) most collateral flow after revascularisation is supplied by the native network, and (2) revascularisation of an occluded right coronary artery is fully justified.
European Journal of Cardio-Thoracic Surgery 02/2007; 31(1):49-54. · 2.55 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: We report the initial experience of two cardiovascular surgery centers in the treatment of descending thoracic aorta lesions with covered stent grafts in high-surgical risk patients. From April 1999 to November 2004, 54 patients, mean age 64 years (range 16-83), were treated by stent graft for a lesion of the descending aorta (degenerative aneurysms n = 22, aortic dissections n = 12, chronic post traumatic aneurysms n = 5, anastomotic false aneurysms n = 2, penetrating ulcers n = 4, intramural hematomas n = 5, traumatic rupture n = 4), with 42.6% treated on an emergency basis. Three devices were used: Talent (n = 49), Excluder (n = 4), and Zenith (n = 1). In three patients, combined surgery of the proximal aorta was performed. Prior bypass of the left supra-aortic arteries was performed in four patients. The follow-up was clinical and radiological (plain chest film and computed tomographic scan) at 1, 3, 6, 12, 18, and 24 months and yearly thereafter. The stent graft was successfully deployed in all cases. Two early deaths related to the stent graft (one migration and aortic rupture and one stroke) and one related to adult respiratory distress syndrome occurred. Morbidity was 16.6% (iliac access damage n = 4, groin reintervention n = 3, transient ischemic attack n = 1, tamponade n = 1). The follow-up was 100% complete (mean 22.8 months, range 3-51). Fifteen primary endoleaks (type I n = 6, type II n = 8, type III n = 1) and one secondary endoleak were reported. They were treated by additional stent graft (n = 7) and elective surgical conversion (n = 1). Six endoleaks resolved spontaneously at 6 months, and two are being monitored. Twelve endoleaks (75%) occurred in patients treated for degenerative aneurysms. Freedom from secondary reintervention was 81.3% at 3 years. Two transient paraparesias were observed at 3 and 18 months. Of the 13 deaths observed during the follow-up, only one was related to the stent graft. Actuarial survival at 12 and 24 months was 90.0% and 75.4%, respectively. Mortality results are encouraging in this specific cohort of high-surgical risk patients. A new kind of morbidity is observed, related to endoleaks, whose necessary management could hinder the durability of the technique.
Annals of Vascular Surgery 12/2006; 20(6):714-22. · 1.03 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The increasing incidence of cardiovascular disease with age, coupled to a constant extension of life expectancy in industrialized countries, is leading to an ever-increasing number of elderly patients being referred for aortic valve replacement (AVR). In light of advances in surgical technology and cardiac protection, the operative mortality and risk factors have been updated in order to specify surgical indications.
Between January 2000 and December 2004, a total of 442 patients (203 males, 239 females) aged > or =80 years (mean age 82.7 +/- 2.3 years) underwent AVR at the authors' institution. Surgery was either isolated (n = 344) or associated with coronary revascularization (n = 86), mitral valvuloplasty (n = 5) or aortic surgery (n = 7). Seventeen patients had undergone previous cardiac surgery. The EuroScore was calculated for each patient.
Overall operative mortality was 7.5% (n = 33). Independent predictive factors of mortality were: aortic insufficiency (30%, p <0.004), NYHA class IV (20.5%, p < 0.001), left and right heart failure (11.5% and 19.4%, p <0.02), chronic renal insufficiency (18.5%, p <0.04), emergency (37.5%, p <0.001, OR = 4.7), left ventricular ejection fraction (21.1%, p <0.004, OR = 0.9), and redo surgery (35.3%, p <0.001, OR = 6). Mortality was also increased in case of associated coronary revascularization (11.6%), mitral or tricuspid surgery (20%) and ascending aorta procedure (25%).
Patient functional improvement achieved after valve replacement at the cost of a rather low operative mortality justifies considering octogenarians for surgery. However, decisions should be taken on an individual basis. An earlier referral to surgery before the onset of altered cardiac function could lead to further reductions in hospital mortality.
The Journal of heart valve disease 10/2006; 15(5):630-7; discussion 637. · 0.81 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The study aim was to examine, retrospectively, the risk of accelerated progression of aortic stenosis (AS) and outcome after aortic valve replacement (AVR) in patients who had undergone previous coronary artery bypass graft (CABG) surgery.
Between 1994 and 2004, 81 patients with mild-to-moderate AS at the time of CABG underwent subsequent AVR. The mean EuroScore was 10.8 +/- 1.8. The population was divided into three subgroups according to the time interval between AVR and CABG: group A, < 5 years (n = 23); group B, 5-10 years (n = 34); and group C, > 10 years (n = 24).
Mean age at the time of CABG was 70 +/- 5, 64 +/- 6 and 58 +/- 5 years in groups A, B, and C, respectively. The peak transvalvular gradient was < or = 30 mmHg in 65 patients (80.2%), and 30-50 mmHg in 16 (19.7%). Operative mortality after AVR was 16% in the overall population (30%, 11.7%, and 8.6% in groups A, B, and C, respectively). The mean time interval between CABG and AVR was 8.9 +/- 5.2 years. By multivariate analysis, a peak transvalvular gradient > or = 30 mmHg (p = 0.003), moderate calcifications with moderately-to-severely limited valve motion (p = 0.05), and left ventricular hypertrophy (LVH) (p = 0.005) were independent predictors of AVR within five years of CABG surgery. Systemic vascular atherosclerotic disease was a predictor of rapid disease progression by univariate analysis, and a predictor of operative mortality by multivariate analysis.
Because of the high mortality associated with repeat operations within five years, AVR should be considered at the time of CABG in patients aged < or = 75 years, with a peak transvalvular gradient > 30 mmHg, moderately prominent calcifications with moderately to severely limited valve motion, and LVH.
The Journal of heart valve disease 07/2006; 15(4):474-8. · 0.81 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The aim of this study was the determination of the pressure-derived collateral fractional flow reserve (FFR(coll)) in patients with three vessel disease and chronic occlusion of the right coronary artery undergoing surgical complete revascularization with the off-pump technique. The angiograms of eight patients were preoperatively analysed to quantify collaterality. FFR(coll) was determined before any revascularization (FFR(coll) 0), and after revascularization of the left coronary arteries, (FFR(coll) 1). FFR(coll) 0 was compared to the Rentrop grade, to the left ventricular ejection fraction (LVEF), and to FFR(coll) 1. No correlation was demonstrated between preoperative Rentrop grade and FFR(coll) 0. There was a linear statistically significant correlation between FFR(coll) 0 and LVEF (P;ie0.001). No significant variation of the FFR(coll) index was observed after performing left coronary artery bypass grafts. Collaterality observed on the coronary angiogram cannot be used as an estimation of the functional collaterality, which can be better appreciated with the LVEF. The absence of variation of FFRcoll before and after left coronary artery revascularization suggests that grafting of the occluded right coronary artery remains justified.
Interactive cardiovascular and thoracic surgery 03/2005; 4(1):23-6.
-
[show abstract]
[hide abstract]
ABSTRACT: To assess the relationship between the base deficit value in the immediate postoperative period of coronary surgery for cardiopulmonary bypass and the length of stay in the ICU.
Prospective descriptive study in the department of anesthesia and cardiovascular surgery of a university hospital.
185 consecutive patients.
Coronary artery bypass graft with cardiopulmonary by pass.
Thirty variables were determined during the pre-, intra-, and postoperative periods; a statistical univariate analysis was performed differentiating patients whose length of stay in the ICU was 2 days or less and those whose stay was more than 2 days. Secondly, a logistic regression model was performed on the variables shown to have a statistically significant difference in univariate analysis, with determination of the odd ratio. Fourteen variables had a statistically significant difference in univariate analysis and three of them highlighted by the logistic regression model: administration of catecholamines, base deficit value in the 1st h postoperatively, and age with odd ratios, respectively, of 3.15, 1.51, and 1.07).
The value of base deficit measured during the 1st h after coronary surgery for cardiopulmonary bypass is correlated with the length of stay in ICU.
Intensive Care Medicine 03/2003; 29(2):257-61. · 5.40 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Heart failure is one of the leading causes of hospitalization and death. The aim of this study was to evaluate long term outcomes after cardiac transplantation.
A retrospective review of 222 consecutive cardiac allograft recipients who underwent 233 transplantations between 1986 to 2000 was undertaken. Cardiomyopathy (123) and ischemic heart disease (87) were the most common indications. Mean age was 51 years +/- 11, and male gender was predominant (184).
33 patients (14.8%) died in the post operative period, mainly from graft failure (24 pts). During the follow-up period (total 1157 pt/yrs, mean 6.2 +/- 5 yrs, max 16 yrs), 60 late deaths occurred from cancer (21), graft failure (13), infection (13), and miscellaneous (13). Retransplantations were performed in 11 patients. The actuarial survival of the entire cohort was 75%, 66% and 50% at 1, 5, and 10 years respectively.
Cardiac transplantation gives satisfactory long term results for patients with end-stage heart failure, providing good exercise tolerance and survival for 10 years or more in a large number of patients. Improvement in immunosuppression therapy is responsible for decrease in acute rejection rate. Reduction in HLA mismatch should allow for better immunomodulation and decreased incidence of cardiac allograft vasculopathy and malignancies.
Bulletin de l'Académie nationale de médecine 02/2003; 187(2):325-40; discussion 340-3. · 0.25 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The Medtronic Intact porcine bioprosthesis is a second-generation porcine bioprosthesis. This study was designed to evaluate results with this valve implanted in the aortic position at 13 years, notably with regard to the risk of structural valve deterioration (SVD).
A total of 188 patients (mean age 72.0+/-8.2 years; range: 28-89 years), who underwent aortic valve replacement between June 1987 and December 1990, was reviewed.
Operative mortality was 9.0% (n = 17). Mean follow up per patient was 7.2+/-4.2 years (maximum 13.6 years); total follow up was 1,408.4 years. Linearized late mortality rate was 6.8%/patient-year (pt-yr) (n = 96), and the overall survival at 13 years 31.5+/-4.3%. SVD occurred in eight patients (linearized rate 0.57%/pt-yr), and freedom from SVD at 10 and 13 years was respectively 95.8+/-1.9% and 91.0+/-3.3% actuarial, and 97.3+/-1.2% and 95.5+/-1.6% actual. The mean time to onset of SVD was 7.8+/-2.8 years, and was independent of patient age at the time of implantation. Freedom from SVD at 10 and 13 years by age groups was: age < or =60 years, 76.6+/-14.8% and 60.9+/-18.0% actuarial, and 80.0+/-12.6% and 68.6+/-15.1% actual (linearized rate 3.3%/pt-yr); age 61-70 years, 96.3+/-2.6% and 92.4+/-4.5% actuarial, and 96.6+/-2.4% and 94.8+/-2.9% actual (linearized rate 0.37%/pt-yr); and age >70 years, 98.3 1.7% and 95.8+/-3.0% actuarial, and 99.2+/-0.8% and 98.3+/-1.2% actual (linearized rate 0.26%/pt-yr) (p <0.007).
When implanted in the aortic position, the Medtronic Intact porcine bioprosthesis provides a low rate of SVD at 13 years. The prosthesis can be used in the aortic position in subjects aged over 60 years with a low rate of deterioration, similar to that with other second-generation bioprostheses.
The Journal of heart valve disease 07/2002; 11(4):537-41; discussion 541-2. · 0.81 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To report our experience with surgery of thoracic aortic rupture due to blunt trauma.
Between October 1976 and October 1999, 50 patients suffering from acute rupture of the thoracic aorta due to blunt trauma were operated on. On admission, 22 patients (44%) presented with hypovolemic shock and all but five (90%) sustained major associated injuries. Thirty-one patients (62%) underwent immediate operation for aortic repair, whereas the procedure was delayed from 6 to 60 days in ten patients because of late diagnosis or coexisting life-threatening lesions thought to largely worsen the operative risk. In 48 patients, the aortic repair was carried out with the aid of cardiopulmonary bypass (CPB) in order to maintain the distal perfusion and to prevent spinal cord injury. An inert 'Gott' shunt and the 'clamp-and-sew' technique were used in one patient each.
The hospital mortality amounts to 18% (nine patients). Four patients (8%) died intraoperatively and five patients (10%) died in the postoperative course. In five patients (10%) death was caused by cerebral or pulmonary hemorrhage, possibly worsened by systemic heparinization during CPB. One case of postoperative paraplegia (2%) was observed in a patient operated on with the aid of CPB. There was neither aortic rupture nor sudden death in the group of patients in whom the surgical procedure was delayed.
The immediate outcome of patients suffering from acute traumatic aortic rupture strongly depends on the associated injuries. In some cases, the emergency aortic repair must be favorably delayed because of the necessity of life-sustaining measures and management of major coexisting injuries, which could be worsened by the use of CPB. Conversely, the risk of paraplegia is significantly reduced by the use of CPB and distal perfusion during the time of aortic cross-clamping.
European Journal of Cardio-Thoracic Surgery 03/2002; 21(2):282-7. · 2.55 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Cardiac disease in the elderly represents a major burden on public healthcare. Their frequences is linked to ageing process of general population and prevalence of cardiovascular diseases in older ages. Two diseases are of primary importance in elderly: Aortic valve stenosis is the most common. Valve replacement is the procedure of choice in the majority of patients. In coronary artery disease, although drug eluting stents have improved the results of percutaneous coronary intervention, coronary artery bypass grafts have still has an important place in the treatment of severe lesions: multivessel disease, left main and diabetes. Our report is a retrospective review of 8871 patients aged 70 years or more operated on between 1974 and 2004.
Bulletin de l'Académie nationale de médecine 190(4-5):855-71; discussion 871-6. · 0.25 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome occurring predominantly in young women without any cardiovascular risk factors, especially during the peripartum and early postpartum period. Here, we report a case of a 28-year-old pregnant woman who was found to have an isolated distal SCAD of the left anterior descending artery (LAD). Coronary angiography was complicated by extensive LAD and circumflex arteries dissection, requiring an emergency coronary artery bypass grafting associated with ventricular assist device implantation and underlying the extreme fragility of coronary arteries in pregnant women.
Cardiovascular revascularization medicine: including molecular interventions 11(3):182-5.
-
[show abstract]
[hide abstract]
ABSTRACT: Background. With increased life expectancy, valve operations are more and more common in elderly patients. The choice of valve substitute—mechanical valve or bioprosthesis—remains debated.Methods. Two groups of patients of the same age (69, 70, and 71 years) with isolated aortic valve replacement (mechanical 240, bioprostheses 289) were compared for mortality, morbidity, and valve-related complications.Results. No significant difference was found in survival, valve-related mortality, valve endocarditis, and thromboembolism. Mechanical valve had more bleeding events; bioprostheses had more structural deterioration, reoperation, and valve-related morbidity and mortality.Conclusions. To avoid reoperations in octogenarians, the 10-year durability of current bioprostheses should be matched with the life expectancy of the particular patient. Bioprostheses should be used after 74 years in men and 78 years in women.
The Annals of Thoracic Surgery.
