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Biomedical subjects

D Guilmet

Publications and source records attributed to D Guilmet.

At least 19 recordsLinked to original sources
PubMed1992

[Etomidate modifies hemodynamic response to fentanyl in patients with impaired left ventricular function].

The haemodynamic effects and the side-effects of anaesthesia using high doses of fentanyl were compared in two groups of 12 patients each. All the patients had poor left ventricular function and were scheduled for elective coronary artery bypass graft surgery or valvular replacement. Patients were randomly assigned to either group. In group EF, patients were given 5 micrograms.kg-1 of fentanyl, followed by 0.3 mg.kg-1 of etomidate. Once they had lost consciousness, they were given 15 mg of pancuronium and 25 micrograms.kg-1 of fentanyl over a 5 min period. Patients in group F received the full 30 micrograms.kg-1 dose of fentanyl over a 5 min period, followed by 15 mg of pancuronium. The patients were intubated 2 min after the end of the fentanyl infusion. They were mechanically ventilated with 100% oxygen. Anaesthesia was maintained with a continuous infusion of fentanyl (total dose 100 micrograms.kg-1). The usual haemodynamic parameters were monitored and calculated, as well as pain during injection of the drugs, myoclonia, chest wall rigidity and the time to loss of consciousness. The two groups were comparable with respect to age, weight, height and surgery. One third of the patients in group EF complained of pain during etomidate injection. The time required to loose consciousness was shorter in group EF (55 +/- 16 sec) than in group F (177 +/- 56 sec) (p < 0.001). The cardiac index decrease in group EF (2.0 +/- 0.4 l.min-1.m-2 vs. 1.9 +/- 0.4 l.min-1.m-2) (p < 0.05), respectively between the time just before tracheal intubation (T1), and 10 min after tracheal intubation (T3).(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthesia, Intravenous↗
PubMed1991

Cold cerebroplegia. A new technique of cerebral protection during operations on the transverse aortic arch.

Profound hypothermia associated with circulatory arrest is the commonest method of cerebral protection during operations on the aortic arch. This technique allows a limited time to perform the aortic repair, however. It also necessitates prolonged cardiopulmonary bypass to rewarm the patient. This may be the cause of coagulation disorders or infection. Selective perfusion of the carotid arteries can also be used. When the perfusion is derived from the main arterial line, however, the repair of the aorta requires that the vessel be crossclamped, and cannot be performed in an "open, bloodless" manner. To avoid the disadvantages of both techniques, we have developed a new technique of cerebral protection. After a regular cardiopulmonary bypass has been established, the carotid arteries are cannulated and perfused with blood cooled at 6 degrees to 12 degrees C, through a separate heat exchanger, while the core temperature is maintained at moderate hypothermia (25 degrees to 28 degrees C, rectal). To perform the "open" distal repair, the cardiopulmonary bypass is discontinued while the carotid perfusion is maintained (250 to 350 ml/min). When the distal repair is completed, cardiopulmonary bypass is resumed and the carotid perfusion is discontinued. Between 1984 and June 1989, 54 patients (mean age 55 years) were operated on with this method (45 elective operations, 9 emergency procedures). Mean duration of cardiopulmonary bypass was 121 minutes (65 to 248), and mean duration of circulatory arrest was 22 minutes (10 to 51). The electroencephalogram, routinely recorded, showed return of the cerebral activity after a mean time of 12 minutes and normal activity after a mean time of 66 minutes. There was no intraoperative death. Hospital mortality rate was 13% (7/54). One death was related to neurologic disorders. All patients but one awakened normally within 8 hours after operation. Two patients (4.3%) experienced a transient neurologic episode (lateral hemianopia) 9 and 11 days postoperatively. There was no hemorrhagic complication (24-hour average blood loss: 840 +/- 540 ml). In our experience the technique of "cold cerebroplegia" has been demonstrated to provide excellent cerebral protection. It requires no prolonged cardiopulmonary bypass and does not limit the time necessary to perform the aortic repair. It may be considered as a safe alternative to profound hypothermia associated with circulatory arrest.

Adult↗
PubMed1990

Repeated surgery for recurrent dissection of the aorta.

Emergency surgery of acute dissection of the ascending aorta is generally a palliative procedure aimed at preventing the vessel from rupturing into the pericardium. Evolving dissecting aneurysm or recurrence of the dissection process is, therefore, a common complication and may lead to reoperation or death. Between January 1970 and December 1988, 133 patients were operated upon for acute dissection of the ascending aorta. During the same period, 22 patients underwent 26 reoperations for recurrent or evolving dissection. Eleven (50%) patients had Marfan's syndrome. Thirteen patients had been operated upon previously in our institution and 8 had been operated upon elsewhere. In 10 patients, the intimal tear had not been resected during the first operation. Operative procedures varied according to the pathoanatomical features and consisted generally of an extended resection of the aortic arch. Eight reoperations were performed as emergencies and 18 were performed electively. Hospital mortality rate was 18% (4/22). Late follow-up ranged from 3 to 153 months (mean: 55 months) for a cumulative follow-up of 998 months. Late mortality was 27% (5/18) for a linearized rate of 6% pt/yr. The actuarial risk of reoperations is 13.7% +/- 7% and 21% +/- 11% at 5 and 10 years, respectively. Marfan's syndrome and persistence of the primary intimal tear are considered the main risk factors of reoperation, while emergency and thoraco-abdominal replacement are the main risk factors at reoperation.

Adult↗
PubMed1989

[Surgical treatment of chronic pulmonary embolism using thromboembolectomy under extracorporeal circulation and deep hypothermia--a new approach route. 3 cases].

The authors, who have successfully performed thrombectomy of the pulmonary artery under extracorporeal circulation and deep hypothermia in three patients, wish to draw attention to the principal factors of success. The decision to operate, as accepted by most surgeons, rests on the patient's functional status (stage III or IV) and on the presence of a systolic pulmonary arterial pressure exceeding 50 mmHg. Deep hypothermia combined with circulatory arrest seems to be the best method, as it improves visual control, thereby avoiding damage to the endothelium or fracture of the distal thrombi during thrombectomy. Finally, a new approach route (severing of the superior pulmonary vein, opening of the pulmonary artery and use of Volmar-Sisteron strippers) makes it possible to remove the entire thrombus, thus obtaining an almost normal pressure in the pulmonary artery. In all three patients, the complications that are mostly due to intrabronchial haemorrhage by disruption of the endothelium, fracture of the distal thrombus or pulmonary artery contusion were avoided.

Adult↗
PubMed1989

The Omni design: evolution of a valve.

The Lillehei-Kaster prosthesis has been the subject of an engineering evolution to close the gap between engineering expectations and clinical performance. Advanced engineering development in response to users has narrowed this gap with the Omni design (Omniscience titanium and omnicarbon Pyrolite cages). Our studies on mitral Omniscience valves demonstrated that because anatomic and surgical variations, the anterior orientation was more forgiving than the posterior orientation, resulting in lower thrombotic complications (0.5% versus 3.3% patient-year). A subsequent thicker cuff was used to reduce the probability of anatomic interference and incomplete opening after cardiac recovery. Such findings were also incorporated in the Omnicarbon design. Five European centers implanted 354 patients (198 atrial valve replacement, 115 mitral valve replacement, and 41 double valve replacement with Omniscience valves between August 1984 and January 1986. No restrictive patient selection criteria were used. As of June 1987, 96% of the patients at risk were accounted for. Average follow-up was 1.7 +/- 0.4 years (range, 0.3 to 2.8 years), with a total follow-up of 555 years. There were no cases of structural failure or clinically significant hemolysis. Ninety-one percent of the patients improved one or more functional classes. Actuarial analysis of survival probability at 3 years is 92.5% for atrial valve replacement, 97.9% for mitral valve replacement, and 93.6% overall. There were no late deaths from valve thrombosis or thromboembolism. The actuarial freedom from all thromboembolic events (valve thrombosis, thromboembolism, and transient ischemia) is 97.8% at 2 1/2 years. Through close rapport between user surgeons and designers, the evolution of a valve with improved performance becomes a reality.

Actuarial Analysis↗
PubMed1988

Surgery of aortic stenosis and lesions of the ascending aorta.

Between 1978 and 1986, 442 aortic valvular replacements were performed for chronic calcified aortic stenosis. In 11 patients (2.5%, seven men and four women) replacement of the ascending aorta was associated with the valvular replacement, because of: seven supra-coronary aneurysms, two aneurysms involving the Valsalva sinuses, and two acute dissections of the ascending aorta. The repair of the ascending aorta consisted in inserting: one patch on one Valsalva sinus, seven supra coronary Dacron prostheses, three valved conduits (according to the Bentall technique). One patient died postoperatively (9%).

Adult↗
PubMed1988

[Multiple proximal coronaro-pulmonary fistulae. Review of the literature apropos of a new case].

The authors report a new case of multiple proximal coronaro-pulmonary fistula between right coronary arteries, anterior interventricular artery and the trunk of the pulmonary artery, in a 64 year-old female patient with chest pain and a continuous murmur located in the third left intercostal space. The coronary steal is demonstrated by a myocardial scintigraphy during stress with return to normal after surgical ligation. A review of the literature enabled to find 33 cases of this major congenital anomaly of the coronary arteries, defined as an abnormal communication between at least two main coronary vessels and the trunk of the pulmonary artery. This results in a left-right shunt, usually minor without any repercussions on the right cavities and pulmonary pressures. The entire clinical, electrocardiographic, radiological, sonographic, scintigraphic, haemodynamic and angiographic picture is reported for these 33 cases. A physiopathological discussion is proposed. The course of this disease is usually favorable (only one case of myocardial infarction was published, without cardiac failure. Osler's endocarditis or sudden death); this seems to authorize simple monitoring as a logical therapeutic approach except when a myocardial ischemia secondary to coronary steal is demonstrated, imposing a surgical correction.

Arterio-Arterial Fistula↗
PubMed1988

[Congenital diverticulum of the right ventricle apropos of a case complicated by pulmonary endocarditis].

Congenital diverticulum of the right ventricle is an extremely rare abnormality, usually discovered by chance during evaluation of a more complex cardiac malformation. We report a case of isolated diverticulum of the right ventricle in a 14-year old boy who also had pulmonary valve endocarditis secondary to acute osteomyelitis. Owing to the evolutive risks inherent in the diverticulum and to the persistence of highly mobile pulmonary valve vegetations 5 years after the initial infectious episode, surgical treatment of the lesions had to be performed. The diagnostic, evolutive and therapeutic problems raised by right ventricular diverticula are discussed.

Child↗
PubMed1988

[Replacement of the ascending aorta with reimplantation of coronary vessels. Apropos of 81 cases].

Between 1973 and 1985, 81 patients underwent Bentall's operation. 90 p. 100 of the patients had cystic medionecrosis, but only 24 showed signs of Marfan's syndrome. It must be noted that 12 patients were reoperation cases, 18 were operated upon in an emergency for tamponade (stage V) on acute dissection, and 7 had lesions that involved the aortic arch. The operative procedure was that described by Bentall; Cabrol's modification was used in only 26 patients. The most recent improvements concerned myocardial and (in case of aortic involvement) cerebral protection with an autonomous perfusion of blood at very low temperature. Mortality was low in patients with annulo-aortic ectasia (1 death in 53 cases; 1.8 p. 100) and rose to 34.5 p. 100 (33.3 p. 100 in reoperation cases) in patients with chronic dissection. Evaluation of mortality by stage showed virtually no risk in stages I and II, whereas 4 of the 9 stage IV patients died within the first post-operative month. Late mortality with a mean follow-up of 4 years was 14.2 p. 100; 2 of the 10 deaths were accidental, and 4 of the remaining 8 deaths were due to the anticoagulant therapy (death was precipitated in 2 cases by the presence of a cerebral aneurysm). No case of systemic embolism was observed, and the authors raise the question of whether long-term anticoagulant therapy should be abandoned. None of the patients who underwent Bentall's operation were reoperated upon, whereas 7 out of the 23 patients who had had supracoronary aortic replacement before 1976 had been reoperated upon within a few years.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1988

Replacement of the transverse aortic arch during emergency operations for type A acute aortic dissection. Report of 26 cases.

In type A aortic dissection, the intimal disruption is located on or extends to the transverse arch in about 20% of patients. Replacement of the arch may then be necessary to avoid leaving an unresected, acutely dissected aorta and to prevent bleeding, progression of aneurysm, rupture, and ultimately reoperation or death. From 1970 to September 1987, 119 patients were operated on for type A acute dissection. Starting in January 1977, gelatin-resorcin-formaldehyde biologic glue was used in 91 patients to reinforce the dissected tissues at the suture sites. Among these 119 patients, 26 (ages 32 to 76 years) underwent replacement of the transverse aortic arch in addition to replacement of the ascending aorta. In 20 patients cerebral protection was achieved by profound hypothermia (16 degrees to 20 degrees C) associated with circulatory arrest (15 to 40 minutes, mean 27 minutes) during the distal anastomosis. In six patients the carotid arteries were selectively perfused with cold blood (6 degrees C) during moderate core hypothermia (28 degrees C) while cardiopulmonary bypass was discontinued (19 to 34 minutes, mean 25 minutes) to allow the prosthesis to be sutured without the distal aorta being cross-clamped. Moderate hypothermia avoided the long rewarming time necessitated by profound hypothermia. The hospital mortality rate was 34% (9/26). Two of the 20 patients subjected to profound hypothermia and circulatory arrest died during the operation and seven patients died of postoperative complications. No deaths or major complication were observed in the other six patients. Follow-up of the 17 survivors ranges from 3 to 90 months (mean 39). One patient died 6 months after the operation of cerebral hemorrhage. One patient is disabled by neurologic sequelae. Fifteen patients are in good clinical condition (New York Heart Association class I or II). Postoperative aortograms in 12 patients, and computed tomographic scans in all, have shown a stable repair of the transverse arch in all survivors but a persisting dissection of the descending aorta in 11 (70%). Growing experience and improving results in emergency operations for type A aortic dissection have led us to extend the replacement of the aorta to the transverse arch whenever necessary. The gelatin-resorcin-formaldehyde glue has proved to be an efficient adjunct. The best cerebral protection was obtained in our experience by carotid perfusion with cold blood during circulatory arrest at moderate core hypothermia.

Acute Disease↗
PubMed1987

[Emergency surgical repair of acute aortic arch dissection. Apropos of 14 cases].

Among 70 patients operated upon for acute dissection of the ascending aorta between 1977 and 1984, 14 (age range 40-72 years) benefited from emergency aortic arch repair motivated by the presence in, or extension to, this segment of the portal of entry, or by lesions of the supra-aortic main vessels. The operation was performed under cardiopulmonary bypass in all cases. Cerebral protection was ensured in 9 patients by deep hypothermia alone or with circulatory arrest for a mean period of 5 minutes (7 cases), and in 5 patients by continuous brain perfusion (carotid blood flow 4 ml/kg/min; perfusion pressure 70 mmHg). Repair consisted of ascending aorta replacement combined with gluing of the arch whenever possible, or bevelled resection in the concavity of the arch, or complete aortic arch replacement with reimplantation of the cervico-cerebral vessels when necessary. In every case the gelatin-resorcin-formalin glue was used to reinforce the aortic wall or the areas with sutures. Operative mortality was nil. Hospital mortality was 28.5%. In patients operated upon under deep hypothermia alone or associated with circulatory arrest the main complications were neurological (4 cases) and respiratory (3 cases) disorders; these were responsible for the death of 3 patients. A fourth patient died of mediastinitis. No neurological or respiratory complication occurred in patients who had brain perfusion. The mean follow-up period was 37 months (range 7-84 months). Late mortality was nil. All but one patient (sequelae of paraplegia) are in excellent clinical condition. Post-operative angiography alone or combined with computerized tomography showed satisfactory blood distribution in all cases and no aneurysm formation on the dissected aorta despite a persistent false lumen.

Acute Disease↗
PubMed1987

[Clinical experience with the Saint Jude prosthesis. Results over a period of 7 years].

Between January, 1979 and December, 1985, 193 Saint Jude medical valves (SJM) were implanted in 165 patients (74 male, 91 female) aged from 14 to 78 years (mean age: 49 years). 101 patients underwent aortic valve replacement, 36 had mitral valve replacement and 21 had multiple valve replacement. Fitting with an SJM prosthesis was a primary emergency operation for 15 patients (9%) and a reoperation for 49 patients (31%). A concomitant surgical procedure was carried out in 39 patients (24%). The overall peri-operative mortality rate was 9% (15 patients), this figure falling to 5% (6/112 patients) when emergency surgery and reoperations are excluded. No patient was lost sight of. Mean follow-up was 37 +/- 3 months (range: 4 to 84 months), for a total duration of 413 years/patient. Five patients died of heart disease during the follow-up period, representing a mortality rate of 1.2% per year/patient. The actual survival rate was calculated as 90% at 1 year and 83% at 7 years. During that period 7 thromboembolic accidents occurred among 5 patients (actual rate: 1.7 accident per 100 years/patient). Two mechanical valve desinsertions requiring reoperation were recorded. Altogether, the actuarial rate of patients without any post-operative complication was 88% at 1 year and 65% at 7 years. Functional improvement was dramatic since 94% of survivors are now in class I or II, whilst 67% of patients were in class III or IV prior to surgery. It may be concluded that the mid-term

Actuarial Analysis↗
PubMed1986

[Aneurysm of the aortic arch. Surgical therapy. 60 cases].

Sixty patients with aortic arch aneurysm have been operated upon at the Foch Medico-Surgical Centre between 1964 and 1984. This period can be subdivided into: January, 1964 to December, 1975 (24 cases) and January, 1976 to April, 1984 (36 cases). The technique used (closure by patch or segmental replacement prosthesis) depended on the type of lesion encountered. In most cases, the cardiopulmonary bypass was between the femoral artery and the right atrium. After experimenting with different methods, we now protect the brain by selective cold blood carotid perfusion, using independent circuit and heat-exchanger. Operative mortality was 12% in series I (1964-1975) and 0% in series II (1975-1984) patients. Hospital mortality was 25% in series I and 13% in series II patients. The improvements obtained during the last few years, using cold blood carotid perfusion and circulatory arrest in the lower half of the body, have made it possible to perform open distal anastomoses. This method ensures excellent brain protection and short cardiopulmonary bypass period.

Adult↗
PubMed1986

[Acute dissection of the aorta in 1986. Proposal for a new anatomopathological classification].

Acute dissection of the aorta is a rare disease which, when left untreated, has a disastrous prognosis. Two aetiological factors are essential: acquired or congenital fragility of the aortic elastic tissue, and arterial hypertension. The condition must be diagnosed as early as possible to avoid a fatal outcome: it is a surgical emergency. The clinical diagnosis rests on a history of migrating pain and on the presence of signs of ischaemia in a vascular territory. It is confirmed by complementary investigations, chiefly angiography. Acute dissection of the ascending aorta is treated by surgery: the ascending segment is resected, the distal cylindres are recoupled to close the portal of entry, and the aortic regurgitation is treated by valvuloplasty or aortic valve replacement. The introduction of the GRF biological glue has considerably improved the per-operative prognosis and lowered the hospital mortality to 10%. Long-term post-operative follow-up of the patient is crucial, since iterative dissection and formation of aneurysms are not exceptional, especially in patients with Marfan's syndrome.

Acute Disease↗
PubMed1986

[A new technic of cerebral protection. Surgery of the aortic arch].

A new technique of cerebral protection during surgery of the aortic arch is described. It is based on electric perfusion of the carotid arteries with low temperature (6 degrees-10 degrees) blood. This requires the adjunction on the cardiopulmonary bypass of an independent heat-exchanger. The first results obtained in 6 patients showed perfect protection of the brain throughout the surgical procedure, with early recovery from anaesthesia and complete absence of neurological sequelae. There were no deaths.

Aorta, Thoracic↗