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A Rama

Publications and source records attributed to A Rama.

15 recordsLinked to original sources
PubMed2005

[Pseudo-aneurysms of the ascending aorta in patients previously operated for acute aortic dissection].

Pseudo-aneurysms of the ascending aorta are a rare but serious complication of surgery for acute dissection of the aorta. The diagnostic methods and surgical technique have changed in recent years. The authors report their experience over a period of 20 years. From January 1981 to December 2001, 21 patients underwent reoperation for pseudo-aneurysms of the ascending aorta. The average age was 54.2 +/- 3 years. Diagnosis is no longer based on aortography but on transthoracic or oesophageal multiplane echocardiography, thoracic spiral computed tomography or magnetic resonance imaging. Four patients presented with a recent history of severe pulmonary oedema. The risk associated with reopening the sternum is avoided by current operative techniques. The authors have chosen anterograde perfusion of the cervical arteries by direct canulation for cerebral protection. The operative mortality at one month is high (30%). All patients who had pulmonary oedema or cardiogenic shock in the immediate preoperative period died. There were no neurological complications. Twelve patients survived and one has to undergo a further operation for recurrence of the pseudo-aneurysm. The authors conclude that patients operated for dissection of the aorta must be followed up. It is important to resect as much as possible of the pathological aorta during the initial operation to avoid the risk of pseudo-aneurysm formation, at least in the proximal segment of the ascending aorta.

Aortic Dissection↗
PubMed2005

[Post-myocardial infarction cardiogenic shock and circulatory assistance].

Post-myocardial infarction cardiogenic shock still carries a very poor prognosis despite the rapid recourse to effective methods of myocardial revascularisation. Circulatory assistance devices allow restoration of adequate haemodynamics with limitation of myocardial work. In the most severe cases, implantation of intra-thoracic devices is associated with a 70% survival rate in the latest series, providing they are used early. However, in many cases, the essential problem is to stabilise the patient's haemodynamic status, sometimes even before myocardial revascularisation. In these situations, implantation of a peripheral femoro-femoral extra corporeal circulation (ECMO: extra corporeal membrane oxygenation) re-establishes an appropriate cardiac output andprovides time to transfer the patient, to perform coronary revascularisation or to assess neurological status, before deciding on the indications for more complicated assist systems. This "bridge to bridge" concept avoids the risk of implanting complicated assist devices in cerebrally dead patients or in those with multi-organ failure beyond treatment. Conversely, it gives some patients with apparent contraindications to complicated assist systems or who are unable to benefit from these systems for geographical reasons, a chance to survive. In early cardiogenic shock, the ECMO which has a low rate of complications, could safely promote myocardial recovery.

Assisted Circulation↗
PubMed2003

Bridge to transplantation with the Jarvik-7 (CardioWest) total artificial heart: a single-center 15-year experience.

BACKGROUND: At our institution, the total artificial heart (TAH) Jarvik-7 (CardioWest) has been used since 1986 as a bridge to transplantation for the most severely ill patients with terminal congestive heart failure. METHODS: Between 1986 and 2001, 127 patients (108 males, mean age 38 +/- 13) were bridged to transplantation with the Jarvik-7 TAH. All were in terminal biventricular failure despite high-dose inotropic support. Nine patients had a body surface area (BSA) of <1.6 m(2). In Group I patients (78%), the etiology of cardiac failure was dilated cardiomyopathy, either idiopathic (n = 60) or ischemic (n = 38). The other 29 patients (Group II) had disease of miscellaneous origin. We analyzed our experience with regard to 3 time periods: 1986 to 1992 (n = 63); 1993 to 1997 (n = 36); and 1998 to 2001 (n = 33). RESULTS: Although Group II patients represented 30% of indications before 1992, they comprised only 15% during the 2 subsequent periods. Duration of support for transplant patients increased dramatically after 1997, reaching 2 months for the most recent period (5 to 271 days). In Group I, the percentage of transplanted patients increased from 43% before 1993 to 55% between 1993 and 1997, and reached 74% thereafter. The major cause of death was multiorgan failure (67%). The clinical thromboembolic event rate was particularly low with no instance of cerebrovascular accident and 2 transient ischemic attacks. Total bleeding complication rate was 26%, including 2 deaths related to intractable hemorrhage and 2 others related to atrial tamponade. The cumulative experience was 3,606 total implant days with only 1 instance of mechanical dysfunction. CONCLUSIONS: TAH is a safe and efficient bridge for patients with terminal congestive heart failure awaiting cardiac transplantation.

Adolescent↗
PubMed2003

[Valvular replacement with the Bicarbon mechanical valve. Results after 7 years in 104 patients].

OBJECTIVE: Study of the medium term results of aortic and mitral valve replacement with the Bicarbon' prosthesis. METHOD: From 1990 to 1996, 109 valves were implanted (70 in aortic position, 31 in mitral position and 4 double replacements). The average age was 61 years and 75% were male. According to the NYHA, 59% of patients were stage III or IV. The average pre-operative ejection fraction was 59.6%. There was re-intervention in 21.1% of patients and 35.3% had an associated procedure during the intervention. RESULTS: The average follow up was 5.4 +/- 1.98 years in 98 patients (that is 522 patient years). One patient died post-operatively and 19 died later. The overall survival at 7 years was 69.4 +/- 6.3%. Complications, expressed in patient years, were 1.15% for thrombo-embolic complications, 2.1% for haemorrhagic complications. 0.38% for endocarditis, 1.72% for non-infectious peri-prosthetic leaks, and 0.76% for re-interventions. At 7 years, the absence of thrombo-embolic, haemorrhagic, endocarditis, and re-intervention complications was 91.8 +/- 4.2%, 85.3 +/- 4.8%, 95.8 +/- 3.2%, 93.8 +/- 3.5% respectively. According to the NYHA, 95% of patients were in stage 1 or II (p < 0.001). CONCLUSION: Valvular replacement in the aortic or mitral position with the Bicarbon' valve is satisfactory as much in terms of survival as of clinical complications.

Aortic Valve↗
PubMed2003

Cardiac surgery in patients receiving long term hemodialysis. Short and long term results.

AIM: Cardiac surgery carries a high risk in hemodialysis patients and has been questioned for its results; the purpose of this study is to focus on the short and long term results in our institution. METHODS: We retrospectively analyzed the data from 124 hemodialysis patients who underwent cardiac surgery in our unit between January 1980 and December 1998; 14.5% were diabetic; 46% had isolated coronary artery disease (group 1); 29.8% had valvular disease alone (group 2); 14.5% valve and coronary disease (group 3) and 9.6% miscellaneous disease at highest risk (group 4). We analyzed the relationship between several variables (age, sex, hypertension, diabetes, previous myocardial infarction, type of disease, preoperative ejection fraction) and operative mortality (30 days) and late survival. RESULTS: The overall operative mortality was 16.9%. The only risk factor was the type of cardiac disease: operative mortality was higher in groups 3 and 4 combined than in groups 1 and 2 combined (30% versus 12.7%, p=0.07). Ninety-nine patients were followed until January 2002. Late survival rate was 46.6+/-5% at 6 years for all patients, it was significantly better in groups 1 and 2 combined than in groups 3 and 4 combined. The only risk factor for late mortality was arterial hypertension. Fifty-seven patients are still alive, 46 in groups 1 and 2, 11 in groups 3 and 4. Progression of coronary lesions occurred in 6 patients and valvular lesions in 3 patients. The remainder are doing well. CONCLUSION: Cardiac surgery seems to be justified by the severity of the lesions. Its actual results can perhaps, be improved by earlier detection of cardiac disease and better prevention of myocardial hypertrophy and cardiac calcifications.

Age Factors↗
PubMed2002

[Fulminating myocarditis: myocardial recovery after circulatory assistance].

The clinical expression of acute myocarditis is variable from paucisymptomatic to fulminating forms which are usually lethal within days. The latter presentation takes the form of very acute cardiac failure. During this phase, the severity of myocardial dysfunction may be such that death ensues. However, if the patient survives, paradoxically, these forms have a better long-term prognosis with complete recovery of myocardial function being possible after the acute phase. The authors report a typical case of fulminating myocarditis with electromechanical dissociation, which recovered completely after a period of circulatory assistance. This case illustrates the rapidity of deterioration of the haemodynamic status and the importance of organ dysfunction despite early management. In a review of the literature, the authors found about 150 reported cases of acute myocarditis treated with circulatory assistance. In the best series, about half the patients were weaned off the circulatory assistance without having to undergo cardiac transplantation. However, the potential recovery of myocardial function is difficult to predict.

Adult↗
PubMed2001

A simple method for heart stabilization during off-pump multi-vessel coronary artery bypass grafting: surgical technique and short term results.

Minimally invasive cardiac surgery regroups several technical options including small incision, video-assisted surgery and beating heart surgery but mechanical stabilization for off-pump multi-vessel coronary artery bypass grafting (CABG), remains a problem. We developed a simple method of stabilization with a fenestrated polytetrafluroethylene patch. Four sutures were passed deeply into the myocardium surrounding the anastomotic site. The sutures were then passed through the patch. Gentle traction on tied sutures, allowed immobilization and exposure in the selected area. This method which was carried in 95 patients, provides good stabilization for performing off-pump multi-vessel CABG in all cardiac territories.

Aged↗
PubMed2001

Expanded polytetrafluoroethylene membranes to wrap surfaces of circulatory support devices in patients undergoing bridge to heart transplantation.

OBJECTIVE: Because of a lack of donor hearts, an increasing number of patients with heart failure must now undergo bridge to cardiac transplantation with a mechanical circulatory support device. Moreover, support periods have become longer. As a result, pericardial adhesions may develop while the support device is implanted, increasing the risk of injury at resternotomy and bleeding after transplantation. Use of expanded polytetrafluoroethylene (ePTFE) pericardial substitutes (membranes) may prevent such adhesions. PATIENTS AND METHODS: From January 1997 to December 1999, ePTFE membranes were used in 23 patients to wrap portions of an implanted left ventricular assist device (LVAD) or total artificial heart (TAH). Any complications during mechanical support or at cardiac transplantation were recorded. Six ePTFE membranes removed at transplantation were studied histologically. RESULTS AND CONCLUSIONS: At resternotomy for transplantation, the plane of dissection between tissues, ePTFE membranes, and surfaces of the mechanical support device were easily discerned. No adhesions were observed between tissues and membranes. There were no injuries during resternotomy and no patient had to undergo reoperation because of bleeding. One patient given a TAH had an infection during circulatory support that was controlled by antibiotic therapy. In another patient, clots developed between the device and an ePTFE membrane; these were removed successfully. Histologic studies of removed ePTFE membranes showed no infiltration of the membranes interstices by collagen or cellular components. Use of ePTFE membranes in patients undergoing bridge to transplantation with either an LVAD or a TAH limited adhesions between tissues and device surfaces without increasing the risk of infection.

Adolescent↗
PubMed1997

Active native valve endocarditis: determinants of operative death and late mortality.

BACKGROUND: In this report, we reviewed 247 patients who underwent operation by our team for active native valve endocarditis between January 1979 and December 1993. METHODS: There were 201 male and 46 female patients (mean age, 45.4 +/- 6 years). The aortic valve was involved in 163 cases, the mitral valve in 36 cases, both mitral and aortic valves in 44 cases, and the tricuspid valve alone in 4 cases. The most common microorganisms were streptococci. Univariate Pearson (chi2 test) and multivariate (stepwise logistic regression [BMDPLR]) analyses were used to identify significant predictors of operative mortality, reoperation, and recurrent endocarditis. Cox proportional hazards regression model was used to study late survival. RESULTS: Operative mortality was 7.6% (n = 19). Increased age, cardiogenic shock at the time of operation, insidious illness, and greater thoracic ratio (>0.5) were the predominant risk factors; the length of antibiotic therapy appeared to have no influence. Two hundred thirteen patients were followed up. Median follow-up time was 6 years (range, 2 to 19 years). Overall survival rate (operative mortality excluded) was 71.3% +/- 3.8% at 9 years. Increased age, preoperative neurologic complications, cardiogenic shock at the time of operation, shorter duration of the illness, insidious illness before the operation, and mitral valve endocarditis were the predominant risk factors for late mortality. The probability of freedom from reoperation (operative mortality included) was 73.3% +/- 4.2% at 8 years; risk factors were younger age and aortic valve endocarditis. The rate of prosthetic valve endocarditis was 7%. No significant risk factor was found. CONCLUSIONS: Increased age, insidious illness, and hemodynamic failure are the main risk factors for operative mortality. Long-term survival is good except for patients with preoperative neurologic complications and mitral valve endocarditis.

Adult↗
PubMed1997

[Video-assisted coronary artery bypass].

The benefits of the internal mammary artery (IMA), as a graft, particularly for the left anterior descending (LAD) coronary artery disease, have been demonstrated. Coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) is now an accepted technique of myocardial revascularization. Thoracoscopy and a minimal thoracotomy have been applied to cardiac surgery, however its use has not been well defined; in our approach, we harvested the left IMA thoracoscopically. Following this the left IMA-LAD coronary artery anastomosis was fashioned, by means of a left small anterior thoracotomy on the beating heart without CPB. A double lumen endotracheal tube was used so the lung could be collapsed. Three left lateral chest ports of 1 cm were made, and the thoracoscope was placed through the initial port, permitting inspection of the thorax. The other ports were used for IMA dissection, using endoscopic instruments (electrocautery, grasping, forceps,...), the side branches were controlled by either cautery or endoscopic clips. When it was possible, the anterior port was extended doing a small left anterior thoracotomy, the pericardium was exposed, the IMA was divided and exteriorized through the thoracotomy. After coronary artery control, the bypass graft was carried out on the beating heart without CPB, in 26 patients. From september 1995 to july 1996, we have operated on 30 patients using this technique. We believe that with increasing operator experience, this minimally invasive approach will have a major impact on the management of the coronary artery disease patients, with a faster recovery, shorter hospitalization, and certainly less cost.

Adult↗
PubMed1997

[Should aortic atheromatous plaques be excised?].

Aortic atheromatous plaque is common condition which has no clinical or therapeutical consequences in the majority of cases. Nevertheless, in some cases, clinical symptoms or potential complications may lead to discussion of the therapeutic indications. The usual diagnostic methods are pre- or peroperative transoesophageal echocardiography. CT scan, magnetic resonance imaging and, rarely, arteriography. These investigations are also valuable in assessing the composition of the plaque and evaluating the risk of thrombosis and therefore of systemic embolism. The surgical indications are discussed in three situations. When the atheroma is large, exuberant and stenotic. This is often the case in the abdominal aorta, much less commonly so in the descending thoracic aorta. Secondly, when the atheroma has been complicated by embolism: this applies to all segments of the aorta. Finally, when there is a potential embolic risk, especially neurological, during open heart surgery; this is usually the case in the ascending aorta. The surgical technique in the first two indications is either excision of the atheromatous plaque or of a segment of the aorta with restoration of continuity by a Dacron patch or tube. In the third indication, two attitudes are possible: either not to manipulate the ascending aorta by changing the site of arterial cannulation, not clamping the aorta, and using pediculated arterial grafts to suppress the aortic implantation of the graft, or, conversely, replacing a fragment of the aorta carrying the atheromatous plaque and reestablishing continuity by a Dacron patch or tube, where a saphenous vein graft may be implanted. In conclusion, excision of atheromatous plaque is always possible but rarely justified. It is essentially a palliative procedure.

Angiography↗
PubMed1996

[Long term results of the surgical treatment of obstructive hypertrophic cardiomyopathies].

Between January 1973 and December 1993, 66 patients underwent surgery in our department for hypertrophic obstructive cardiomyopathy; mean basal outflow gradient was 48.4 +/- 36 mmHg, 20 patients had mitral valve lesions. Thirty six patients underwent myotomy-myomectomy alone, 13 mitral valve replacement alone, and 17 both myotomy-myomectomy and mitral valve replacement. The 30-day mortality rate was 7.5% for all patients; predominant risk factors were gender (female), greater cardiothoracic ratio, preoperative episodes of atrial fibrillation and lack of syncope. Overall survival rate (operative mortality included) was 65.3 +/- 8.6% at 13 years. Predominant risk factors for late mortality were the same than above, plus mitral valve replacement; so mitral valve repair, whenever feasible should be undertaken. Forty nine patients are still followed up: 46 are asymptomatic; Doppler mean basal outflow gradient was reduced to 10 +/- 1.4 mmHg. In conclusion, surgery relieves symptoms and outflow obstruction, and allows mitral valve reconstruction.

Actuarial Analysis↗
PubMed1994

Chronic disease of the ascending aorta. Surgical treatment and long-term results.

Between January 1979 and December 1991, we operated on 339 patients for chronic disease of the ascending aorta. The operation was elective in all. Endocarditis and its sequelae have been excluded. Thirty-one patients had a previous operation on the ascending aorta or the aortic valve; 268 patients had aneurysms of the ascending aorta without dissection; 72 had chronic aortic dissections, of whom 33 had a preexistent aneurysm. The patients included 272 men and 67 women. Mean age was 53.58 +/- 7 years. Eight percent of the patients had clinical stigmata of Marfan's disease. A tubular graft replacement was used in 7 patients, a tubular graft and valve replacement in 72 patients, and a composite valve graft replacement with reattachment of the coronary arteries using a 8 mm Dacron graft was performed in 260 patients. Concomitant procedures were used in 74 patients: coronary artery bypass grafts in 25, mitral valve replacement in 9, and aortic arch reconstruction in 40. The 30-day mortality rate was 7.6% (n = 26). For the whole group, multivariate analysis using stepwise logistic regression showed that operative risk factors were concomitant coronary artery bypass grafting, age (increased), aortic valve regurgitation, and previous cardiac surgery. Follow-up was conducted in 303 patients, and risk factors for late mortality were studied. Long-term survival was 59.6% +/- 3.7% at 9 years. It was 67% +/- 3.5% at 9 years for patients without aortic arch reconstruction and 56% +/- 4.5% for patients with aortic arch reconstruction (p = 0.0018). Reoperation was needed in 14 patients. Actuarial freedom from reoperation was 90% +/- 0.2% at 9 years for all the patients. Only one patient with composite valve graft replacement and reattachment of the coronary arteries had required reoperation for problems related to this procedure. This technique is used routinely by our team, especially in patients with large chronic aneurysms, dissected or not, and in those who had previous operations. The long-term results are good.

Aortic Dissection↗
PubMedDate not supplied

Peripheral extracorporeal membrane oxygenation (ECMO) in patients with posttransplant cardiac graft failure.

INTRODUCTION: We sought to report the usefulness of extracorporeal membrane oxygenation (ECMO) in heart transplant patients. PATIENTS: Between March 2002 and August 2004, 14 heart transplant patients (11 men and three women, 36 +/- 15 years old, range = 12 to 50) with primary graft failure underwent peripheral ECMO implantation. Three patients had pulmonary hypertension and three had been transplanted with hearts from marginal donors. At the time of implantation, all were in severe cardiogenic shock despite maximal inotropic support. In six patients, the ECMO was implanted in the operating room since cardiopulmonary bypass could not be weaned. In the eight remaining patients, ECMO was implanted in the intensive care unit, during the first 48 hours in seven cases. In one patient, implantation was performed during external resuscitation. In all cases, femoral vessels were canulated using the Seldinger technique after anterior wall exposure. Distal arterial perfusion of the lower limb was systematically used. RESULTS: Pump outflow was high enough in all the cases (mean: 2.6 +/- 0.2 L/min/m(2)). Three patients died on circulatory support. One patient was implanted with a total artificial heart after a few hours and another one underwent unsuccessful emergent retransplantation. Nine patients were weaned from ECMO after a mean duration of 5 +/- 2.5 days. Among them, one died of infection at 10 days after weaning and seven others were discharged to rehabilitation centers. CONCLUSION: Fast operating room or bedside implantation of a peripheral ECMO allows the physician to stabilize the hemodynamic status of patients with cardiac graft failure, potentially leading toward myocardial recovery.

Adolescent↗