Biomedical subjects
Publications and source records attributed to A Thevenet.
C. Walton Lillehei (1918-1999) from the Surgery Department of the University of Minnesota in Minneapolis (MN, USA), was the precursor of open heart surgery. He successively introduced heart-lung machine, intracardiac repairs, pacemaker, and mechanical cardiac valves.
In a prospective study, 292 consecutive patients received 336 Omnicarbon cardiac valves from September 1984 through September 1992 at the Montpellier University Hospital. There were 153 aortic (52%), 95 mitral (33%) and 44 double (15%) mitral and aortic replacements. Mean age was 58 years; 57% were male. Total follow up was 1,383 patient-years, with a maximum of nine and a mean of 4.87 years. Early mortality was 2.75% overall. Late mortality occurred at a rate of 1.9%/patient-year. Nine-year probability of freedom from mortality (including early mortality) was 85.0% +/- 2.6% overall. There were no cases of structural failure. Thromboembolic events occurred in nine patients, producing a linearized rate of 0.7%/patient-year. Hemorrhage associated with anticoagulant therapy occurred at a rate of 0.8%/patient-year. Therefore, the combined rate of thromboembolic/hemorrhagic events was 1.5%/patient-year. Cumulative overall freedom from thromboembolism and hemorrhage was 91.5% +/- 1.9% at nine years; it was 86.2% +/- 4.3% after mitral and 95.1% +/- 2.0% after aortic valve replacement. Hemolytic anemia was not observed. Endocarditis occurred eight times (0.6%/patient-year), and there were seven cases of perivalvular lead (0.5%/patient-year). At the end of the follow up, 86% of the patients were in NYHA class I. It is concluded that clinical results over a nine-year period are excellent with the Omnicarbon prosthesis.
False aneurysm of the ascending aorta is a rare and life-threatening complication of open heart surgery, usually occurring late after operation. Echocardiography, especially transesophageal echocardiography, is a non-invasive method of examination which can be very helpful in its diagnosis. Deep hypothermia and circulatory arrest allow a bloodless field during surgery and provide an adequate patient protection. Infection is a very well known predisposing factor, but cystic medial necrosis of the aortic wall also seems to play a role in this complication. We report three cases, two of them had cystic medial necrosis and the presence of infection could be proved in none.
Kawasaki disease (KD) is an acute illness encountered in infancy and childhood. Cardiovascular complications of this syndrome are recognized as being part of the adult coronary artery disease population. Reported herein is the surgical treatment of multiple coronary artery aneurysms, severe stenotic lesions and thrombotic involvement of the coronary arterial tree that could be ascribed to childhood KD in two adult patients with no risk factors for atherosclerotic heart disease. Surgical management of such patients reveals safe and provides satisfactory quality of life.
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Dilated hypokinetic cardiomyopathy in an acromegalic patient is an uncommon event. Specific hormonal therapy with octreotide (a somatostatin analogue) is now recognized as able to improve cardiac failure. A case of worsening of cardiac function under such a therapy is described in this report. Octreotide was finally discontinued and a cardiac transplantation performed. Soon after surgery, treatment with octreotide was started again and no other adverse reaction was noticed. Furthermore, no deleterious or synergistic interaction between the somatostatin analogue and cyclosporine A was detected. A pharmacological hypothesis is given to explain the inability of octreotide to counteract cardiac failure. The patient died 6 months after surgery probably because of an acute episode of arrhythmia.
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Following cardiac transplantation bacterial mediastinitis is a severe early complication. Between March 1986 and September 1993, cardiac transplant operations were performed in 101 patients, of whom six developed purulent mediastinitis. Treatment consisted of surgical débridement, closed local irrigation, drainage and systemic antibiotics. No patient died as a result of bacterial mediastinitis. Low cardiac output and requirements for resternotomy for bleeding and prolonged artificial ventilation were significantly higher in the group with sternal infection. In contrast, since January 1991 the dose of corticosteroid was decreased from 5 mg/kg per day to 1.5 mg/kg per day beginning on the first day after operation. A total of 51 heart transplant operations have been subsequently performed without sign of mediastinal infection.
Fifty-eight patients underwent 72 operations for symptomatic fibromuscular dysplasia (FMD) between 1970 and 1986. There were 35 females and 23 males aged between 36 and 76 years (average 56). Among the 72 operated on lesions (11 bilateral) FMD stenotic lesions (string of beads, tubular, focal) were isolated (32) or associated with elongation (tortuosity, coiling, kink) in 24 cases, FDM aneurysms (7), and dissecting pseudoaneurysms (9). The surgical techniques included graduated or balloon intra-luminal dilatation either isolated (29) or associated with resection-anastomosis (35), saphenous graft (4) and reconstructive aneurysmorrhaphy (4). Bifurcation endarterectomy was combined in 14 patients. There was no hospital death. There were 2 neurologic deficits after operation (1 transient) and 12 transient nervous disorders due to dissection near the base of the skull required in one third of the cases. The follow-up period extends from 6 to 22 years. Five patients were lost to follow-up. Out of the 53 remaining patients, 44 (83%) are living and asymptomatic. Nine patients died: 4 from myocardial infarction, 3 from cancer, 2 from neurologic disease. Three late successful reoperations were observed: 1 aneurysm formation following graduated dilatation, 2 anastomotic stenosis. Surgical intraluminal dilatation either isolated or combined with reconstructive techniques is a safe and durable operation relieving symptoms. The benefits of repair are long lasting and should be offered to patients with symptomatic FMD carotid lesions. The medical management of asymptomatic cases allows to study the natural history of the disease whose causes are not so far fully known.
Comprehensive 2 D/Doppler examination of 98 patients (mean age 56), implanted between September 1984 and February 1991, with normally functioning aortic (n = 49) and mitral (n = 49) Omnicarbon valves (OC) were analyzed in order to characterize the normal hemodynamic profiles of the OC valves. The mean time from implantation was 36.4 months (range 6 to 78). The following parameters were assessed (average of 5 measurements): peak transvalvular velocity (peak V), peak instantaneous gradient (peak G), mean transvalvular gradient (mean G), effective aortic valve area (ef Va), modified aortic valve area (m Va), aortic permeability index (PI), mitral valve area (Mit Va). Doppler data were correlated to prosthetic sizes (ranging from 21-29 mm for aortic OC and from 23-31 mm for mitral OC). The study establishes normal Doppler hemodynamics for each size (especially in aortic position) of OC valves and shows excellent performance. Significant correlations between peak G, mean G, Pl, and prosthetic aortic valve size (AS) were moderate. By contrast there were strong relationships between AS and ef Va (r = 0.56, p < 0.001) or mVa (r = 0.55, p < 0.001). These data should be helpful to identify OC prosthetic dysfunction.
Fibromuscular disease is rarely observed in the external iliac artery. During the last 15 years, eight symptomatic cases were encountered in six women and two men whose ages ranged from 29 to 63 years (mean: 47 years). Clinical onset was always recent, either progressive with claudication (three cases) or sudden with abdominal and pelvic pain and acute ischemia due to dissection (five cases). Diagnosis was established by arteriograms showing either a typical appearance of fibromuscular hyperplasia or a segmental dissection or occlusion. Two patients had associated fibromuscular disease of the renal arteries. One of these patients had dysplastic aneurysm of the thyrocervical trunk. Histopathological findings were typical of medial fibromuscular hyperplasia in the seven cases examined. Even though transluminal dilatation is presently simple, adequate, and durable for the management of non-complicated forms, all of our cases were treated surgically either because they were observed before transluminal dilatation was readily available or because of associated dissection. Results of surgery were satisfactory in all cases except one with a mean follow-up of 12.6 years. One patient was reoperated upon 13 years later.
Infection with toxoplasma gondii is a serious complication in the immunocompromised heart transplant recipient. We reported a case of toxoplasmosis in a seronegative heart transplant recipient detected on endomyocardial biopsy. This patient was treated with oral pyrimethamine and sulphadiazine. Because primary toxoplasmosis occurred in seronegative patients receiving hearts from sero-positive donors, it is necessary to screen both recipients and donors for T. gondii. Prophylaxis with pyrimethamine in sero-negative patients transplanted with a heart from sero-positive donors confers considerable benefit.
After cardiac transplantation bacterial mediastinitis is a severe early complication. Between 1986 and 1990, we performed 49 cardiac transplantations. Six patients developed purulent mediastinitis. Treatment consisted in surgical debridement, local irrigation, drainage and systemic antibiotics. No patient died of this bacterial mediastinitis. Low cardiac output, re-sternotomy for bleeding, prolonged artificial ventilation were significantly higher in the group with sternal infection. Closed tube irrigation is a simple and efficient treatment of mediastinitis.
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An infected prosthetic aortic graft is usually treated by ablation of the graft associated with extraanatomic bypass. In spite of this aggressive attitude, mortality and morbidity remain high, especially due to secondary rupture of the aortic stump. We report the case of a patient who incurred periprosthetic purulent collection four weeks after insertion of an inlay aortobiiliac prosthetic graft for aneurysm, who was treated by debridement, irrigation, and omental transposition. Recovery has been maintained for four years. Conservative treatment of infection can control infection and obviate the need of complex resection and revascularization procedures.
Between 1960 and 1989, 609 patients were operated on for abdominal aortic aneurysms. They were 38 females and 571 males from 45 to 87 years old (mean 69). The series has been divided into three consecutive periods: From 1960 to 1973, 135 patients (30 ruptures); from 1974 to 1981, 176 patients (55 ruptures) and from 1982 to 1989, 298 patients (49 ruptures). Perioperative mortality for elective surgery was 8.5% during the first period and 3.2% during the last one. For ruptured aneurysms mortality decreased from 66% to 34%. In the same way, the incidence of rupture decreased from 31.2% to 16.4%. Progresses making possible improvements of the results are related to an early detection with ultrasounds and CT scan, a more precise evaluation of associated pathologies, simplification of surgical techniques, evolution of anesthesia and supportive measures (monitoring, autologous transfusion). On the other hand, rupture is still lethal due to delay in diagnosis and surgery, site of the rupture and multiorgans consequences of hemorrhagic shock. It is only by an echographic screening of people at risk (age, cardiovascular diseases) that frequency can be reduced.