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G El Khoury

Publications and source records attributed to G El Khoury.

15 recordsLinked to original sources
PubMed2002

Surgical repair for degenerative and rheumatic mitral valve disease. Operative and mid-term results.

BACKGROUND: Non randomized studies suggest that mitral valve repair for rheumatic disease is technically more difficult than repair for degenerative disease, and that operative and late results are worse. New surgical techniques have been developed in our and other institutes during the last 5 years, and this moved us to review the experience with these two pathologies and to compare the operative and mid-term RESULTS METHODS: From March 1996 to September 1997, 66 patients underwent primary mitral valve repair for treatment of degenerative or rheumatic disease. Fifty-two patients (79%) were in the former group (group A) and 14 in the latter (group B). Surgery was performed by 2 experienced cardiac surgeons. A new technique to calculate the exact artificial chordae length was introduced. In 2 cases, tricuspid autografts were transposed to mitral position and reinforced with artificial chordae. Patients were followed both clinically and echocardiographically. The follow-up data were collected in a 1-month period (May 2000). The average clinical follow-up was 3.1+/-0.9 years (range 1.7 to 4.2 years) while the average echocardiographic follow-up was 2.7+/-0.7 years (range 9 months to 4 years). All values were expressed by means of the average and standard deviation. chi(2) and Student's "t"-test were used to analyze the significance between variables. The Kaplan-Meyer method was used for actuarial statistics. RESULTS: There were no operative deaths in either group. In group A, 1 patient underwent a second surgical repair 1 week later, successfully. In group B no patients underwent reoperation within 30 days or during the initial hospitalization. At follow-up of group A there were the following events: deaths from cancer (n=2), endocarditis (n=1), aortic dissection (n=1). At follow-up of group B there were mitral valve replacement (1 year after first operation, n=1), Ross procedure (n=1), ischemic heart failure (n=1). Among the remaining 62 patients followed, 32 were in NYHA class I, 15 in class II, 3 in class III, and none in class IV, in group A. In group B, 7 patients were in class I, 4 in class II, 1 in class III and none in class IV (p=ns). In group A mitral regurgitation was absent in 23 patients, mild in 21, moderate in 6, while in group B it was absent in 4, mild in 6, and moderate in 2 (p=ns). In both groups there were no cases of severe insufficiency. The mean gradient was 1.1+/-1.7 mmHg in group A (median=0), and 2.4+/-3.1 mmHg in group B (median=0), (p=ns). No case of systolic anterior movement was seen at mid-term. The event free-survival rate was 92.8% in group A and 92.3% in B. CONCLUSIONS: Perfecting and innovation of surgical techniques make possible nowadays to reach good and equivalent operative and mid-term results in both pathologies.

Case-Control Studies↗
PubMed2001

Complementary saphenous grafting: long-term follow-up.

OBJECTIVE: Recently we reviewed the 10-year clinical and angiographic outcomes of sequential internal thoracic artery grafting. Most of the patients also received complementary saphenous grafts, and their overall long-term patency rates were surprisingly high. Therefore, we decided to analyze these results in more detail. METHODS: The first consecutive 500 patients having received at least one sequential internal thoracic artery graft between October 1985 and August 1991 were restudied retrospectively. The saphenous grafts were only used to achieve complete revascularization in addition to complex arterial grafting on less significant or remote coronary vessels. A total of 161 patients consented to a late angiographic restudy at a mean postoperative interval of 7.5 years (1-12.2 years). RESULTS: At 5 and 10 years postoperatively, freedom from angina was 96% and 82%, and freedom from any cardiac event was 92.8% and 69%, respectively. Only 15 (3.1%) patients needed additional revascularization (0.3% per patient-year): 4 coronary artery bypass grafting (0.8%) and 11 percutaneous transluminal coronary angioplasty (2.3%). The overall patency and intactness rates of saphenous anastomoses were 72.5% and 60.2%, respectively. There was a significant difference between the patency and intactness of sequential versus single anastomoses: 76% versus 60% and 64.5% versus 44.4%, respectively. There was no significant difference in either patency or intactness between right internal thoracic and sequential saphenous grafts anastomosed to the right coronary artery: 83.4% versus 75.2% and 77.8% versus 62.4%, respectively. The same was true for the anastomoses to the "remote area" (distal circumflex, distal right coronary artery). CONCLUSIONS: Complementary sequential saphenous grafting still deserves consideration in some patients below 70 years of age, particularly for those with disease in the "remote area": the distal circumflex and right coronary branches.

Adult↗
PubMed2000

Long-term clinical and angiographic follow-up of sequential internal thoracic artery grafting.

OBJECTIVE: Sequential internal thoracic artery (ITA) grafting allows a more complete arterial revascularization of the myocardium. We wanted to verify whether the excellent clinical and angiographic short term results reported by us before where maintained over 10 years and more. METHODS: the first consecutive 500 patients having received at least one sequential ITA graft between October 1985 and August 1991 were reviewed. Age averaged 61 years. Fifty-three patients had a left ventricular ejection fraction less than 40%, 117 were not elective, 35 (7%) were reoperations, 56 (11%) had diabetes. In total 2156 anastomoses were constructed (4.3/patient), among them 1367 arterial anastomoses (2.7/patient) and 1150 sequential ITA anastomoses (2.3/patient). The clinical follow-up was 97.4% complete and averaged 9.6 (range 8.6-13.6) years. One hundred and sixty-one patients consented to a late angiographic restudy after a mean interval of 7.4 (range 1-12.2) years. RESULTS: At 5 and 10 years, 89 and 72% of the patients were still alive. At 10 years 82% are still asymptomatic and 71% free of any type of ischaemia. Only four patients (0.8%) needed a repeat surgical revascularization, and 11 (2.3%) a percutaneous coronary angioplasty. At 5 and 10 years, 92.8 and 69% of the patients remained free of any cardiac event. Overall, 95.5% of the arterial anastomoses were patent and 96.1% of the sequential ITA were patent. There was a significant difference between the patency rate of pedicled ITA and free ITA anastomoses: 96.3 vs. 86.5% (P=0.02). There was no difference in patency between left ITA and right ITA anastomoses for the LAD and Cx areas. Sequential ITA anastomoses showed excellent patency rates to all coronary vessels but the very distal circumflex and the distal branches of right coronary artery (85%). There was no significant difference between the patency of the proximal and the distal sequential ITA anastomoses. The sequential anastomoses constructed in the length tend to remain more patent than the diamond-shaped ones: 97.2 vs. 91.5% (P=0.004). CONCLUSIONS: Sequential ITA grafting optimizes arterial revascularization. The long-term patency is excellent, is identical to that of single ITA grafting, and appears not much different from postoperative patency. The need for repeat surgical and interventional revascularization has been extremely low: 3.1% over the whole follow-up.

Adult↗
PubMed2000

Surgical repair of the prolapsing anterior leaflet in degenerative mitral valve disease.

BACKGROUND AND AIM OF THE STUDY: Repair of the prolapsing anterior leaflet (AML) in degenerative mitral valve disease is more demanding than that of the posterior leaflet. We reviewed our experience in the past eight years, to examine the safety, efficacy and stability of various repair artifices. METHODS: Between January 1989 and December 1997, 102 patients (mean age 64 years; range: 26-86 years) with mitral regurgitation (MR) due to prolapse of the anterior or both mitral leaflets underwent mitral valve repair. Sixty-six patients were in NYHA class > or =III, and 94 had MR grade >II. Acute endocarditis was present in 12 patients and Barlow disease in 16. Surgical techniques consisted of chordal shortening (n = 36), chordal transposition (n = 16), papillary muscle shortening or plication (n = 10), flip-over (n = 20) and artificial chordae implantation (n = 20). RESULTS: There was no early mortality; one patient required early mitral valve replacement (MVR) for late-appearing systolic anterior motion, and one patient benefited from a successful re-repair on day 8 for partial posterior leaflet desinsertion. Mean follow up was 30 months (range: 3-92 months); there were four late deaths (two valve-related cerebrovascular accidents); two patients required re-repair (one after three months for prosthetic ring thrombosis, and one after 10 months for rupture of shortened chordae (corrected by flip-over)). Five patients had MVR between four and 32 months later: one for mitral stenosis due to posterior leaflet calcification, and four for recurrent MR due to the rupture of shortened chordae (n = 3) or plicated papillary muscle (n = 1). One patient suffered bacterial endocarditis which was treated medically. Of the 92 remaining patients with valve repair, 81 are currently asymptomatic, five are in NYHA class II and four in class III. Transesophageal echocardiographic restudy (n = 76) at a mean of 30 months after surgery revealed no MR in 68 patients, and MR of grade <II in three. CONCLUSIONS: AML prolapse repair is safe, durable, and therefore can be attempted even in mildly symptomatic patients. However, chordal shortening should be substituted by implantation of artificial chordae or by the flip-over technique.

Aged↗
PubMed1999

The effect of chronic mechanical circulatory support on neuroendocrine activation in patients with end-stage heart failure.

OBJECTIVE: To evaluate if the improvement of patients supported with a Novacor was associated with a normalization in neuroendocrine activity. METHODS: Six patients had a Novacor implanted for end-stage heart failure. Four patients were transplanted after a mean of 4.5 months (range 3-6). One patient was weaned after 5 months and one died of a cerebral haemorrhage 5 weeks after implantation. Analysis of neuroendocrine activity was made prior to implantation and after 14, 30, 60 and 90 days. Levels of aldosterone, renin, cortisol, testosterone and T3 were measured using radio-immunoassays. Twenty-four hour urinary collections were made for assessment of adrenaline and noradrenaline excretion. RESULTS: Renin activity fell to normal after 14 days (16 +/- 3.0 ng/ml per h to 4.28 +/- 2.1 ng/ml per h, P < 0.05) and was maintained at 90 days. A similar picture was seen with aldosterone (1.5 +/- 0.4 nM to 0.12 +/- 0.07 nM, P < 0.05). Norepinephrine (67.46 +/- 14.1 microg/24 h) and epinephrine 12.9 +/- 2.5 microg/24 h) fell to normal physiological levels during the same time period. Cortisol levels were above normal pre-implantation but fell by day 30 (665.25 +/- 80.0 nM to 461.8 +/- 43.0 nM, P < 0.01). T3 and testosterone were lower than normal pre-implantation (T3 50 +/- 9.5 ng/dl vs. 90-200 ng/dl, testosterone 6.83 +/- 1.7 nM vs. 13-35 nM). T3 normalized after 90 days (81 +/- 11.7 ng/dl) and testosterone after 60 days (16.3 +/- 1.7 nM). CONCLUSION: Neuroendocrine function is abnormal in patients with cardiac failure who require circulatory support. The Novacor improved this, but metabolic recovery was delayed. The positive effect on the neuroendocrine axis, in the absence of activation of other endocrine systems, suggests that prolonged support may be well tolerated.

Adult↗
PubMed1998

Resection of a chest chondrosarcoma invading the spine and the aorta.

A 34-year-old man presented with a large chondrosarcoma of the chest invading six ribs and the vertebral bodies of five adjacent thoracic vertebrae. En bloc resection of the tumor with six ribs, the anterior part of five vertebral bodies, and the thoracic aorta was performed through a thoracotomy and a paravertebral incision.

Adult↗
PubMed1998

Use of the right gastroepiploic artery as a coronary artery bypass graft in 307 patients.

From October 1988 to October 1995 the right gastroepiploic artery was used as a conduit for coronary surgery in 307 patients. Their average age was 56.5 years (range 25-75) and 274 patients (89%) were male. Twenty-six cases (8.5%) were re-operations and 58 patients (19%) were operated upon on an urgent or semi-urgent basis. Target coronary vessels were the right coronary artery and its branches in 280 cases (91.4%), the circumflex artery in 25 cases (8%) and the left anterior descending artery in two cases. The right gastroepiploic artery was used as an in situ graft in 303 cases (98.7%) and as a free graft in 4 (1.3%). A total of 291 patients (94.8%) also received at least one mammary artery graft: both mammary arteries were used in 167 patients (54.4%). An average of 3.6 distal anastomoses were made per patient, three of them with arterial grafts. Eleven (3.2%) right gastroepiploic artery grafts were doubled with saphenous vein intraoperatively because of persistent myocardial ischemia. In-hospital mortality was 1.6% (five patients). Perioperative myocardial infarction occurred in twelve patients (3.9%). Follow-up now averages 26 months (range 6-88). There have been five late deaths (1.6%). A total of 265 (89.2%) patients are angina free. Of the total, 145 patients have been investigated with a maximal-stress test coupled with scintigraphy: residual myocardial ischemia was found in 10 patients, right gastroepiploic artery was related in three. Ninety-six patients have undergone angiographic restudy at a mean of 12 months (range 8-88) postoperatively. Patency of the right gastroepiploic artery grafts was 91.8%. This study confirms that the right gastroepiploic artery can be used as a conduit for coronary artery bypass surgery with minimal mortality or morbidity. Mid-term patency rates and clinical outcome are encouraging.

Adult↗
PubMed1998

Radical debridement and omental transposition for post sternotomy mediastinitis.

OBJECTIVE: Reported mortality for postoperative mediastinitis treated by debridement alone can reach 40%. The authors' experience with radical debridement and omental transposition is reviewed. METHODS: Between May 1990 and August 1996, 14 patients with untractable mediastinitis had a transfer of the greater omentum: 11 after coronary artery bypass grafting (CABG) (6 bilateral internal thoracic arteries ITA grafts), one after a heart transplant, one after an aortic valve replacement and CABG, and one after a repair of the aortic isthmus related to a motor vehicle accident. The mean age was 63 +/- 8 years. Infection was proven in all patients by cultures of intraoperative specimens. Two patients had such a large sternal defect that no primary closure could be attempted. The remaining 12 patients had a mean of 1.4 +/- 0.7 previous debridement. Five patients had a total sternectomy. After radical debridement, the omentum was transferred over the entirety of the wound and covered with a meshed thin skin graft. All patients had a minimum of 4 weeks of i.v. antibiotic therapy. RESULTS: There was no operative death. Apart from one focal necrosis and one traumatic dehiscence of the omentum, there was no hospital complication. Sepsis was controlled in all patients. The median hospital stay was 31 days (range 20-154 days). At a median follow-up of 20 months (range: 6-44 months), there were two late deaths: one sudden and unexpected death and one after a re-do CABG. The remaining patients had resumed their previous activities. One patient had developed an incisional hernia and another underwent further surgery for cosmetic reasons. CONCLUSION: Radical debridement and omental transposition may achieve a cure for postoperative mediastinitis with good mid-term results.

Aged↗
PubMed1998

Cardiac troponin I as an early marker of myocardial damage after coronary bypass surgery.

STUDY OBJECTIVE: To evaluate the performance of cardiac specific markers, cardiac troponin I (cTnI) and CK-MB by mass assay (CK-MB mass), for the early diagnosis of myocardial ischemia and/or infarction after coronary bypass surgery. METHODS: Prospective clinical, electrocardiograpic and biologic follow-up of 117 patients undergoing isolated coronary surgery with the use of intermittent anterograde normothermic blood cardioplegia. Blood samples for biochemical analysis were drawn before surgery (T0) and at 2 (T1), 6 (T2), 10 (T3) and 20 h (T4) after aortic cross-clamp release. Without knowledge of the biochemical data, patients were classified according to the electrocardiographic evolution into two groups: group 1, uneventful recovery and group 2, evidence of ischemia/infarction based on continuous ST-T segment monitoring and 12-lead ECG. RESULTS: No patients had abnormal markers at T0. At T1, although both markers were elevated, no difference was noted between the two groups. At T2, 6 h after surgery, cTnI and CK-MB mass levels were significantly higher in group 2 than in group 1 (median = 17 microg/l, Interquartile Range (IR): 14.7-27.3 vs. 3.1 microg/l, IR 1.9-5.3 for cTnI and median 42.5 microg/l, IR: 27.1-95.7 vs. 13.6 microg/l, IR: 9.5-18.5 for CK-MB mass). A receiver operating characteristic (ROC) curve analysis shows that a cTnI value of 13.1 microg/ml has 100% specificity and 90% sensitivity to separate both groups, whereas a value of 33.2 microg/ml for CK-MB mass has a specificity of 100% and a sensitivity of 73%. At T3 and T4, the same difference was noted between the groups. cTnI values in all six patients with a Q-wave infarction were > or = 20 ng/ml, whereas only one of five patients with prolonged ischemia had cTnI level > 20 ng/ml. CONCLUSION: As soon as 6 h postoperatively, cTnI and CK-MB by mass assay were able to separate those patients with an uneventful recovery from those with significant ischemia. This is particularly useful in frequent cases when the ECG is difficult to interpret.

Biomarkers↗
PubMed1997

Popliteal-to-distal bypass grafts for limb salvage.

From July 1989 to July 1994, a total of 44 popliteal-to-distal artery bypasses were performed in 36 patients (29 men and seven women, mean age 62 +/- 10 years). These procedures accounted for 8.8% of all infrainguinal revascularizations performed during that period. Risk factors included diabetes in 33 patients (92%), smoking in 18 (50%), and coronary artery disease in 15 (42%). Prior to revascularization all patients were at risk of limb loss. Tissue necrosis was present in 31 cases (71%), ulceration in eight cases (18%), and rest pain in five cases (11%). Patency of the femoral and popliteal arteries was confirmed prior to surgery in all cases. Intraoperative percutaneous angioplasty of the superficial femoral artery was performed in three cases. Proximal anastomosis was made to the distal popliteal artery in all cases. A total of 52 distal anastomoses (eight sequential bypasses) were made on the following arteries: posterior tibial artery in 13 cases, anterior tibial artery in eight cases, peroneal artery in six cases, plantar artery in two cases, and dorsalis pedis artery in 21 cases. The greater saphenous vein was used as graft material in 42 cases (95%) and the lesser saphenous vein in two cases (5%). No patient died during hospitalization. Early bypass occlusion occurred in three cases (6.8%) and led to amputation in all cases. Secondary patency and limb salvage rates at 3 years calculated using the actuarial method were 74% and 82% respectively. Bypass thrombosis due to superficial femoral artery deterioration was not observed in any case. The present study indicates that popliteal-to-distal artery bypass is a simple, durable, and low-risk method of lower limb revascularization. Medium-term results are promising and support routine use of popliteal-to-distal artery bypass for limb salvage in patients without significant stenosis of the superficial femoral artery.

Aged↗
PubMed1997

Aortic allograft and pulmonary autograft for aortic valve replacement: mid-term results.

Between April 1990 and August 1996, 138 patients (median age 42 years, range 10 days to 66 years) underwent aortic valve or root replacement with allografts (n = 70) or autografts (n = 68). Aortic stenosis was the main indication (80 patients, 58%) followed by aortic incompetence (31 patients, 22%). Twenty-five patients had endocarditis (18%) and two patients had truncus repair (2%). Some 140 allograft valves were inserted (70 pulmonary, 70 aortic). Most of the valves were conditioned and cryopreserved by the European Homograft Bank, Brussels, Belgium. Subcoronary implantation was performed in 46 patients, intraluminal cylinder in 29 and root replacement in 63. Peroperative transoesophageal echocardiography was routinely used. Three patients required valves replacement by mechanical valves at the time of surgery due to technical failure. Seven patients (5%) died early, while 131 were followed up from 1 to 76 months (mean 32 months). There were two late deaths. All survivors are in NYHA class I and currently free of any medication. There have been no thromboembolic events. Three patients developed endocarditis (2%). Transthoracic echocardiography was performed routinely in all patients; an initial study showed grade 1 aortic incompetence in nine patients and grade 2 in two. Late studies up to 6 years after surgery showed progression of aortic incompetence in 18 of 43 survivors with subcoronary implantation and in four of 75 survivors who underwent other techniques (P < 0.002). In congenital patients with preoperative aortic incompetence, the left ventricular function has been prospectively analysed by echocardiography. Risk factors have been identified as dilated ventricles with spherical shapes, thin wall and reduced velocities by measuring ejection fraction and velocity of shortening of myocardial fibres. Allograft and autograft replacement of the aortic valve can be performed with excellent results. Considering the risk of degeneration of allografts, and the growth potential of the pulmonary autograft, this should be regarded as the optimal method of treatment for diseased aortic valves in neonates, children and young adults.

Adult↗
PubMed1997

Is mechanical circulatory support helpful before cardiac retransplantation?

Ventricular assist devices are widely used as a bridge for cardiac transplantation patients. The purpose of the present study was to evaluate retrospectively, whether the use of ventricular assist devices could increase survival after early or late retransplantation. Over the past 10 years, 219 patients were transplanted in the authors' centre. Eight of 11 retransplanted patients required preoperative insertion of a ventricular assist device. Five assist systems were implanted in the early period after transplantation ( < 30 days) and three later after transplantation ( > 30 days). After early retransplantation, two patients survived and three died. All three late retransplantations were successful and all patients are still alive with a mean (s.d.) follow-up of 25(22) months. Ventricular assist devices are helpful for late retransplantation but do not improve poor survival after early retransplantation. Such devices should not be set up for early retransplantation.

Adult↗
PubMed1997

Surgical angioplasty of the left main coronary artery.

OBJECTIVE: The conventional surgical treatment of isolated critical stenosis of the left main coronary artery (LMCA) leads to the definitive occlusion of LMCA, restores only a retrograde perfusion to a rather extensive myocardial area and consumes bypass material. Direct surgical angioplasty avoids these inconveniences. METHODS: Between June 1985 and August 1996, 49 surgical angioplasties have been performed in 47 patients. LMCA was approached posteriorly in the first 11 procedures, and an anterior approach was preferred in the last 38 because of better exposure. The onlay patch consisted of saphenous vein in 37 cases; pericardium was used in 12 cases, and only for ostial stenosis. RESULTS: No technical failure occurred in the last 28 cases. 44 procedures, (90%), succeeded, but 1 patient (2.3%) died later of a massive air embolism, and 2 patients needed conventional CABG after 3 and 5 months, respectively. The 35 survivors still benefiting from a successful LMCA angioplasty on the long term are free of ischemia after a mean follow-up of 75 months (2-136). Angiographic restudy was obtained in 30 patients (70%) at an average of 38 months and revealed an excellent result in 26 (87%). In 10 patients, a late angiographic restudy at an average of 71 months (32-119) still revealed a perfect result. CONCLUSION: Provided that well-defined contra-indications (involvement of the distal bifurcation, heavy calcification) are respected, LMCA surgical angioplasty deserves a place in the array of surgical strategies.

Angioplasty↗
PubMed1996

Free internal mammary artery graft in myocardial revascularization.

Between August 1986 and March 1993, 124 patients (102 men; mean age of 59 years) underwent myocardial revascularization with the use of at least one free internal mammary artery (FIMA). This group represents 4.5% of the 2725 coronary bypasses performed during the same period. Seventy-six patients (61%) had suffered from at least one previous myocardial infarction. Forty-five patients (36%) had unstable angina; three-vessel disease was found in 100 cases (80.5%) and a left ventricular ejection fraction lower than 0.4 in 22 (17.7%). There were 18 (14.5%) redo procedures and 90 (72.5%) bilateral internal mammary artery (IMA) grafts. The reasons for using a FIMA were: too short an internal mammary artery pedicle in 83 patients, IMA injury at harvesting in 30 patients and post-bypass ischaemia in areas grafted with pedicled IMA (PIMA) in 11 patients. Cardiopulmonary bypass, moderate hypothermia (30 degrees C) and crystalloid anterograde and retrograde cardioplegia were used in all cases. Sixty-seven FIMA grafts were anastomosed directly to the ascending aorta; 57 were sutured via a saphenous hood using a running suture of polypropylene 7/0 and three were anastomosed end-to-end to a PIMA graft. FIMA grafts were directed to the left anterior descending (34%), the circumflex (37%) and the right coronary artery (29%). In total, 179 anastomoses were constructed using 127 FIMA, 136 using PIMA and 158 using saphenous veins (3.8 anastomoses per patient). Hospital mortality and postoperative myocardial infarction rates were 5.6% (seven patients) and 3.2% (four patients), respectively. Cardiac-related mortality was 3.2% (four patients); three of these four patients had been operated on for evolving infarction and one underwent a redo procedure. Four of the 117 survivors died later on; in two, it was cardiac-related and a result of global heart failure at 9 and 12 months. Of the 113 remaining patients, 106 are symptom free after a mean follow-up of 28.2 (range 3-84) months. Fifty-nine patients (50.4%) were restudied by angiography at a mean interval of 15 months. Patency rates of FIMA anastomosed either directly to the aorta or via a saphenous hood were 82.8 or 89.7%, respectively. Patency rates of FIMA directed to the left anterior descending, the circumflex and the right coronary artery were 85.7, 88 and 83.3%, respectively. Global FIMA patency was 86.4%, while global PIMA patency was 100%. The FIMA mid-term patency rates compare unfavourably with those of PIMA: FIMA should therefore be restricted to the cases where PIMA or other pedicled arterial grafts are unavailable.

Aged↗