Biomedical subjects
Publications and source records attributed to C Cabrol.
Hemostasis is a usual problem in surgical heart and lung recipient removal. Since April 1990, we have been using as surgical technique an "en bloc" removal of heart and lungs in order to reduce postoperative bleeding and cardiopulmonary bypass duration.
The purpose of this study was to bring up-to-date the immediate risks and long-term benefits of coronary surgery in elderly people. The results obtained in a series of 475 patients in their seventies suffering from coronary disease who underwent myocardial revascularization alone or combined with heart valve replacement at the La Pitié Hospital, Paris, between 1984 and 1989 were analyzed. Coronary disease was associated with heart valve disease in two-thirds of the cases. The mean number of bypasses was 2.3 per patient. Aortic valve replacement was performed in 119 cases and mitral valve replacement in 12 cases. The operative mortality rate was 10.8 percent in patients with stable angina who underwent elective surgery. The factors which increased the mortality rate were: age (19.6 percent over 75 versus 13 percent under 75, P = 0.05); sex (23.5 percent in women versus 13.2 percent in men, P = 0.01) and emergency (25.8 percent, P = 0.02). No significant difference in mortality was noted between patients who had and those who did not have aortic valve replacement (15.8 versus 10.8 percent, P = 0.14). Fifteen patients (3.1 percent) developed perioperative myocardial infarction. During the follow-up, period myocardial infarction occurred in 7 patients. Out of 29 late deaths, 8 were of cardiac origin (infarction in 5, terminal heart failure in 3). The survival rate at 4 years was 76 percent. Among the patients who could be followed up, 80 percent are now asymptomatic, 15 percent are in stage I or II and 5 percent in stage III or IV of the Canadian Cardiovascular Society classification. Thus, despite a non negligible operative risk the functional improvement and survival rates obtained justify an increase in the indications for myocardial revascularization in elderly patients.
Graft coronary disease is a frequent and devastating complication with rapid development after heart transplantation. Until now, non-invasive and invasive methods have proved to be insensitive in the prediction and detection of the early stages of this disease. Conventional arteriography is considered as the only reliable means of diagnosis, but it remains insensitive in the accurate evaluation of the severity of graft coronary lesions (obliterative, diffuse and distal lesions). Precise quantitation of coronary lumen changes may be a sensitive method for the accurate evaluation of graft coronary disease and help in the understanding of the natural course of development of this disease. The pathogenesis of the disease is still unclear. It is possible that graft coronary disease is a consequence of non-treated low-grade cellular rejections. In most cases, retransplantation must be considered as the unique solution.
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Lesions of the thoracic aorta create problems related to their site and relations with the main aortic branches. The aim of surgery must be to treat the lesion while ensuring perfusion of the tissues excluded by clamping during the operation. Anatomic study of the aortic lesions is based on imaging. Angiography is still often the basic examination though it shows only the lumen and course of the aorta. However, CT and MRI visualise the aortic wall and especially the relations of the aorta to the mediastinal structures. A comparison of anatomic and imaging studies was made on 10 fresh subjects coming from the anatomy department of the Saints-Pères and from the school of surgery of Fer à Moulin. Sections were made every 3 to 5 mm in 3 planes (sagittal, coronal and axial) after CT localisation of the plane of section. This anatomic study was correlated with CT and MR images made on healthy volunteers. The choice of surgical management of a lesion of the thoracic aorta is based on preoperative anatomic assessment by imaging applied not only to the aorta but also to its branches and the territory supplied.
We describe the technique of blood cardioplegia delivery as we routinely use it in clinical heart transplantation. This technique needs a specific circuit. Perfusion of a first dose of blood cardioplegia is immediately started on the arrival of the graft in the operating room. Cardiac reperfusion of a half-dose of blood solution without potassium is performed each 20 minutes. Myocardial warm reperfusion is started at the end of the aortic suture. This technique of blood cardioplegia and warm reperfusion during heart transplantation provided an improvement in heart preservation when compared with standard crystalloid solution.
Clinical application of heart transplantation goes beyond 25 years experience. The main indications for cardiac transplantation remain idiopathic cardiomyopathies and ischemic diseases. To obtain a suitable donor has become progressively more difficult due to the increase of transplants performed and the shortage of donors. Advances in the detection of early rejection, improved organ preservation procedures, and the introduction of new immunosuppressive therapy protocols have produced dramatic results in heart transplantation. Late graft atherosclerosis remains a serious threat despite retransplantation and, in some cases, mechanical cardiac support.
After 22 years of clinical application in our unit, heart transplantation is now an accepted therapeutic method. Its indications are well established, its surgical technique and post-operative control and treatment well defined, mostly due to better diagnosis of the rejection episodes with the aid of echocardiography and endomyocardial biopsy and the use of cyclosporin. The results are remarkable with a survival rate of 70% at 5 years, and a full rehabilitation into family, social and often professional life for almost all the survivors. Its use has dramatically changed the prognosis of patients with irreversible cardiac failure but underlines the lack of a sufficient number of donors' hearts. The heart-lung transplantation, making use of the progress of heart transplantation, has been used successfully since 1982 and for the first time in Europe by our group. Improvement in the selection of recipients, lung preservation, surgical technique and post-operative management have brought a new and real hope to patients not only irreversible cardiopulmonary lesions but also terminal pulmonary disease.
BACKGROUND: Because mechanical circulatory assist as a bridge to heart transplantation places a further strain on current donor shortage as well as on medical cost containment, safe and effective use of the device is essential. METHODS AND RESULTS: To predict survival before undertaking staged heart transplantation with the Jarvik-7 artificial heart, our 58 attempts were reviewed retrospectively. Scores of 1-4 were given for six preoperative factors based on results obtained by univariate and multivariate analyses between survivors and nonsurvivors of staged heart transplantation: transplant rejection (scored 4: S4) or postoperative heart failure (S3) as the indication, recipient height < 175 cm (S3), body surface area < 1.8 m2 (S3), hyperbilirubinemia > 24 microM/l (S2), weight < 60 kg (S2), and age > 40 years (S1). Of 14 survivors, 13 had a total score < 4 (sensitivity, 93%), with an average score of 1.6 in contrast to 5.5 for 44 nonsurvivors (p < 0.001). Among 26 patients scored < 4, 21 had heart transplantation, of whom 13 left the hospital. Of 32 patients scored > or = 4, only four could be discharged after transplantation (specificity, 70%). CONCLUSIONS: Multiple preoperative factors successfully predicted transplantability and survival in staged heart transplantation. The results underscore the importance of preoperative condition and patient selection to achieve successful and effective use of Jarvik-7 as a bridge to heart transplantation.
Between 1987 and 1992, thirty-seven heart-lung transplant recipients had a postmortem examination at the Pitié-Salpêtrière Teaching Hospital in Paris, France. Except for three patients who survived 2 months, 4 months and 16 months after transplantation, respectively, most patients died in the early postoperative period (mean survival time = 34.6 days). Autopsy disclosed minor acute heart rejection in four patients and minor acute lung rejection in three patients. Five patients had obliterating bronchiolitis that was the cause of death in two cases. Main causes of death included perioperative pleural bleeding, respiratory infection with or without septicemia, diffuse alveolar lesions (adult respiratory distress syndrome and/or pulmonary edema undergoing organization) and multiple organ failure. Hemodynamic and respiratory complications responsible for multiple organ failure in the perioperative period, as well as pre-existing morbid conditions such as cirrhosis of the liver induced by heart failure, may have a major bearing on the outcome of heart-lung transplantations.
The results of coronary artery surgery in young adults have not been extensively studied. We analysed the results of 221 patients under 40 years of age operated between 1979 and 1989 at the Pitié-Salpêtrière Hospital. The patients were 200 men and 21 women with an average age of 36.2 years. The most common cardiovascular risk factors were smoking (69.6%) and hyperlipidaemia (52%). One hundred and eighteen patients (53.4%) had previous myocardial infarction (MI). Triple vessel disease was present in 129 cases, double vessel disease in 59 cases and single vessel disease in 33 cases. Twenty three patients had significant left main coronary disease. The number of bypass grafts per patient averaged 2.3. The operative mortality was 2.07% (6 cases), death being due to myocardial infarction in 4 cases. Perioperative myocardial infarction was diagnosed in 12 cases (5.05%). One hundred and ninety nine patients were followed up for an average of 7.4 years. Seven of the 17 late fatalities were of cardiac origin. The actuarial 9 year survival rate was 84%. Five patients were reoperated after an average of 6.4 years. Eighty five per cent of patients were asymptomatic at the last follow-up examination. In conclusion, the symptoms of coronary artery disease in young adults can be effectively treated with a low operative risk by myocardial revascularisation surgery. Long-term follow-up remains essential to define the outcome in these patients. Systematic use of internal mammary artery bypass grafting should improve these results in the future.
Organ transplantation more than a scientific fact is now a social fact. Since the first organ transplantations in France, forty years ago, medicine demonstrated its ability to perform the operation and to obtain (what was more difficult) the tolerance of the graft but medicine so far remains unable to give the material: organs. These organs are given by the donor's relatives when the kidney is concerned and when it is a donation from a living person. But such donation remain strictly limited in our country (less then 5% of the kidney transplantations) due to the risk of moral pressure and commercialization. More often and for the other organs (liver, heart, lung) a the donation is obtained after death, a special and dramatic death: the brain death. The nowadays spectacular results of organ transplantation 70 to 80% survival rate at 10 years with a complete rehabilitation gave a considerable increase on the demand. Unfortunately organ transplantation is the victim of its success, the number of donor's organ being insufficient to satisfy the needs. So in December 1990, 6,055 patients were on the waiting list and only 3,772 (56%) were transplanted. In December 1991, 6,334 patients were on the waiting list and may be only 4,000 could be transplanted. So the difference between the needs and the possibilities is increasing each year with for consequences, the death of 10% of the waiting patients and, for those who could be transplanted, a considerable increase in the waiting period responsible for slow deterioration of their status and less chances of success. The reason of the lack of organs is not due to the lack of brain deaths which are unfortunately too numerous, but to the impossibilities of organ retrieval due to: too advanced age or the presence of a transmissible disease of the donor, lack of medical means in some intensive care units, and family refusal. This refusal is easily understood and due to the very peculiar conditions in which the donation is required: the unexpected death of a loved parent and such a death with some life appearance. To avoid the increasing number of such refusal two actions are possible. One is the modification of the law. The French law is the Caillavet law which requires for organ retrieval, the written permission of the parents for a minor, or for an adult the absence of refusal expressed during his or her life.(ABSTRACT TRUNCATED AT 400 WORDS)
To assess the relative contribution of native and donor hearts to total circulatory performance after heterotopic transplantation, we used cardiac catheterization to examine 10 patients. Left and right ventricular filling pressures significantly decreased by 41% and 36%, respectively, cardiac index increased by 25%, and pulmonary arteriolar resistance was reduced by 61%. Patients were subdivided into two groups according to the presence of one (group I) or two (group II) peaks on the aortic pressure curve. In group I, the donor left ventricle assumed total left ventricular work and 80% of right ventricular work. Because the native left ventricle could not generate enough pressure to open the aortic valve, its entire stroke volume was ejected into the common left atrium. In addition, in all four patients a native aortic regurgitation occurred in diastole and systole. In contrast, in group II, native left ventricular systolic pressure always exceeded aortic diastolic pressure. The donor left ventricle contributed 68% to systemic blood flow and the donor right ventricle 51% to pulmonary blood flow. Mild native aortic regurgitation was demonstrated in two patients only. Native left ventricular function deteriorated postoperatively in all patients (ejection fraction decreased from 0.22 +/- 0.09 to 0.14 +/- 0.08), but this deterioration was more marked in group I. Postoperative depression of native left ventricular function could not be ascribed to progression of coronary artery disease but was mainly due to reduced preload (competitive filling) and increased afterload. Thus in group I patients with more severe preoperative left ventricular dysfunction, the donor heart behaved like a total biventricular assist device. In contrast, in group II patients the donor heart acted like a partial biventricular assist device.
After a long history of recurrent chronic pulmonary infections in a 25-year-old woman with Kartagener's syndrome, a heart-lung transplantation was performed. A modified surgical procedure was needed to perform transplantation because of the presence of a situs inversus, which is usually associated with bronchiectasis and sinusitis in this congenital syndrome. A large single atrium was created with both the right and left recipient atria used to facilitate anastomosis with the donor's right atrium. The patient was discharged after resolution of early ventilatory complications and is in good condition 8 months after transplantation.
Twenty-seven cases of chronic constrictive pericarditis seen between 1975 and 1990 in an internal medicine department were analyzed retrospectively. The chronic pericarditis was consecutive to one (n = 5) or several (n = 7) episodes of acute pericarditis. Echography demonstrated the presence of pericardial effusion in 74 percent of the cases, pericardial thickening in 41 percent and/or compression of right heart cavities in 55 percent. Computerized tomography of the chest, performed in 16 cases, showed pericardial effusion in 63 percent of the cases, pericardial thickening in 37 percent and lymph node enlargement in 19 percent. Magnetic resonance imaging of the chest was carried out in 2 patients but showed no abnormality. All 11 patients who underwent cardiac catheterization were found to be adiastolic. The cause of constrictive pericarditis, elicited in 13 patients was neoplasia in 4, sequelae of radiotherapy in 2, injuries in 2, mediastinal and retroperitoneal fibrosis in 2, myocardial infarction in 1, purulent pericarditis in 1 and bacteriologically proven tuberculosis in 1. Medical treatment with corticosteroids (n = 16) and/or antituberculous therapy (n = 15) was successful in 2 patients; 25 patients had to undergo surgery 7 +/- 11 months after constriction was diagnosed. Pericardial drainage (through a pericardiopleural window in 4 cases) proved to be sufficient in 10/15 patients but failed in 5. Pericardectomy was performed initially in 3 cases and after failure of medical treatment and/or drainage in 11 cases. The 4 patients with neoplastic constrictive pericarditis died 10 months on average after the diagnosis, but the remaining 23 patients were alive after à 9 to 48 months (mean: 19 +/- 15) follow-up. These results suggest that the data provided by echocardiography and computerized tomography of the chest usually point to the relevant therapeutic measures without a need for invasive haemodynamic exploration. Idiopathic constrictive pericarditis now accounts for 50 percent of the cases; tuberculosis has become exceptional, but the other, previously exceptional causes (neoplasia, heart surgery, radiotherapy, connective tissue diseases) are more frequent. Corticosteroids should be used in chronic constrictive pericarditis occurring after cardiac surgery or in the course of a connective tissue disease, but they are effective only in highly inflammatory forms of the disease. Modern treatment relies on early surgery, since functional results and patient's survival are closely related to the date of pericardectomy which must be carried out before very important myocardial repercussions develop.
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Despite the major improvement in immunosuppressive therapy, noninvasive detection of heart graft rejection remains a challenge. As lipoproteins are involved in several immunomodulation mechanisms, we studied their proton NMR spectra in plasma from patients after heart transplantation. NMR data were compared to clinical and functional evaluation of rejection process. The total linewidth (TLW) of methyl and methylene peaks, mainly arising from lipoproteins, were significantly lower for patients without a rejection process than for patients before surgery and patients with evidences of a rejection process. When TLW values are referred to TLW on the 8th day for each patient, the sensitivity and the specificity of the test are increased, with resulting positive and negative predictive values of 90 and 91%, respectively. The results obtained on more than 400 samples from 46 patients justify the use of proton NMR spectroscopy as a clinical tool.
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