[Acute aortic dissection in Horton disease].
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Acute Disease↗
Biomedical subjects
P A Chaptal
Publications and source records attributed to P A Chaptal.
Use of active shunt for surgical repair of intrapericardial inferior vena caval injury.
We report a case of intrapericardial inferior vena caval disruption due to goring by a bull, and we describe the surgical repair of this uncommon penetrating cardiac injury. Review of the literature indicates that, as with other penetrating cardiac injuries, this rare lesion requires aggressive treatment involving an emergency thoracotomy. The use of an atrial caval active shunt was necessary for successful surgical management, and therefore we conclude that surgical treatment of this lesion is comparable with surgical repair of hepatic veins and retrohepatic vena caval injuries incurred during blunt vascular trauma or penetrating abdominal injuries.
Adult↗
Aortic valve repair with fibrin glue for type A acute aortic dissection.
Repair of the acute aortic insufficiency associated with type A aortic dissection is now preferred to valve replacement. This is generally achieved by resuspending the aortic valve using different types of suturing techniques, with sutures usually passing through the aortic wall, which causes bleeding at the suture sites. We suggest, instead, simply injecting fibrin glue between the two dissected layers of the aortic annulus, which achieves resuspension of the aortic valve and reinforces the proximal stump without the need for any sutures. To evaluate the efficacy of this simple technique, the cases of 15 consecutive patients who underwent operative intervention for the treatment of the type A aortic dissection associated with acute aortic insufficiency between January 1989 and July 1993 were reviewed. The mean patient age was 63 +/- 11.2 years (range, 43 to 74 years). All had massive 3+ or 4+ aortic insufficiency, documented pre-operatively by transesophageal echocardiography. None had any history of aortic regurgitation. In all patients, the aortic repair was done in conjunction with a supracoronary replacement of the ascending aorta with a collagen-impregnated graft attached using a running suture, after reinforcement of the dissected tissues with glue. There was one non-valve-related early death (6.7%) and no late mortality. At a mean follow-up of 2.3 years, all patients were in New York Heart Association functional class I and had a mean aortic insufficiency grade of 0.3 (range, 0 to 1+). Follow-up computed tomography in all patients showed closure of the dissecting process on the proximal ascending aorta.(ABSTRACT TRUNCATED AT 250 WORDS)
Acute Disease↗
Repair of the aortic arch with fibrin glue in type A aortic dissection.
Location of the intimal tear in the aortic arch in type A aortic dissection is for many authors an indication for replacement of the aortic arch, but this operation has a high in-hospital mortality rate: 20% to 40%. Instead, we suggest repairing the aortic arch by injecting fibrin glue, which contains a human sealer protein concentrate, between the two dissected layers under circulatory arrest while replacing the ascending aorta. To evaluate this technique, we reviewed 45 successive patients operated on for type A acute aortic dissection between January 1989 and July 1993, of which 6 had the intimal tear located on or extending into the aortic arch. Mean age was 71 +/- 4.2 years (range 68 to 74). After proximal supracoronary anastomosis with a collagen-impregnated graft, aortic arch repair was achieved by injecting fibrin glue between the two layers, using circulatory arrest at a mean temperature of 22 degrees C, with a mean duration of 24 minutes. This obliterated the dissection in the arch and also the intimal flap. The distal part of the graft was then anastomosed to the proximal portion of the aortic arch at the origin of the innominate artery under circulatory arrest. There were no early or late deaths. All patients were asymptomatic at a mean follow-up of 2.6 years. Follow-up angioscan showed obliteration of the dissection in the aortic arch in all patients; there were two patients with dilatation of the distal aortic arch of 40 and 45 mm.(ABSTRACT TRUNCATED AT 250 WORDS)
Acute Disease↗
[Value of the superior trans-septal approach in mitral valve replacements].
Mitral valve exposure is widely improved by the superior-transseptal approach (STS). The diffusion of this technique has been restricted because of the possibility of detrimental effects of sino-atrial arrhythmias, especially in patients in sinus rhythm preoperatively. Between April 1991 and December 1992, we performed mitral valve replacement (MVR) on 55 patients by an STS approach. The mean age was 57.7 +/- 11.3 years (38-75 years). 21 were reoperations and 1 patient had been operated twice. The procedure consisted in 10 MVR with a bioprosthetic valve and 45 with a mechanical valve. Associated procedures were 5 tricuspid annuloplasties, 13 aortic valve replacements, 1 tricuspid valve replacement, 4 CABG, and 1 aneurysm resection. Overall hospital mortality was 9.1 +/- 3.8% (5/55). Mortality for isolated MVR was 6.2 +/- 4.2% (2/32). 51% (28/55) were in sinus rhythm (SR) preoperatively, 43% (12/28) of them had never presented atrial fibrillation. Postoperatively among those 28 patients in SR, 20 remained in SR, 7 were in atrial fibrillation, and 1 in atrial flutter. 3.6% (2/55) needed transient electrosystolic pacing for very slow atrial fibrillation 20% (11/55) have presented a transient sino-atrial dysfunction; None of these rhythmic events had any adverse effect. Finally, the very good visibility and accessibility are the major advantages of this approach, especially in mitro-tricuspid combined procedures, in small left atrium and repeat surgery. As sino-atrial arrhythmias are transient, we think this approach can be routinely employed in MVR.
Adult↗
Static morphometric bases for CT identification and evaluation of the outflow chamber of the left ventricle. Preliminary study in formalin-fixed heart.
A static morphometric study of the outflow chamber of the left ventricle (OCLV) was investigated in a series of 10 formalin-fixed hearts. A spatial reconstruction of the shape and the volume of the OCLV was carried out by means of a Somaton Plus TR4 Tomodensitometer (Siemens). The technic allows evaluation of the surface of the aortic and the mitral orifices and visualization of the three-dimensional OCLV and LV morphology, as well as calculation of their volumes. The limits of the technic in the dynamic study of the OCLV are presented.
Adult↗
Hemodynamic effect of calcium channel blockade during anesthesia for coronary artery surgery.
Because the choice of anesthetic technique does not influence the incidence of perioperative myocardial ischemia, reduction of ischemic risk may require specific antianginal therapy. Calcium entry blockers are effective drugs in antianginal therapy. Diltiazem reduces myocardial oxygen demand through decreases in heart rate, inotropy, and systolic function, while increasing myocardial oxygen delivery through coronary vasodilation. These potentially beneficial effects of diltiazem were evaluated in 15 of 29 patients (diltiazem v placebo, double-blind study) scheduled for coronary artery bypass graft surgery. Continuous infusion of diltiazem (0.15 mg/kg bolus followed by 2 micrograms/kg/min), during anesthesia and surgery before cardiopulmonary bypass, significantly reduced the major MVO2 determinants during anesthesia with moderate doses of fentanyl and a benzodiazepine (midazolam in 8 of 14 control patients and 9 of 15 treated patients, or flunitrazepam in the others). Heart rate, mean arterial pressure, and inotropy were decreased during the most stressful events of surgery when plasma diltiazem concentrations were in the therapeutic range (greater than 96 ng/mL). The number of patients with perioperative ischemia was 2 of 15 in the treated group and 4 of 14 in the control group. Provided that diltiazem plasma concentrations are sufficient, it can contribute to lowering the ischemic burden during anesthesia for coronary artery surgery.
Anesthesia, Intravenous↗
Myocardial depressant effect of nitrous oxide after coronary artery bypass graft surgery.
We have studied the cardiovascular effects of nitrous oxide after cardiac ischaemia-reperfusion injury caused by aortic cross-clamping and unclamping during coronary artery bypass grafting (CABG). At the time of chest closure, 20 patients were allocated randomly to receive oxygen and air (FIO2 = 0.5) or 50% nitrous oxide in oxygen in addition to anaesthesia with fentanyl. Nitrous oxide significantly decreased mean arterial pressure (P less than 0.01) and cardiac index (P less than 0.05), which suggests that nitrous oxide with fentanyl may significantly depress left ventricular performance after CABG. Although ischaemia-reperfusion cardiac injury did not appear to increase the myocardial depressant effect of nitrous oxide, the use of nitrous oxide is not recommended immediately after CABG.
Aged↗
Hemodynamic effects of anesthesia in patients chronically treated with angiotensin-converting enzyme inhibitors.
Angiotensin-converting enzyme inhibitors (ACEIs) are increasingly used in the treatment of cardiovascular disease, but recent reports have warned of some hemodynamic risk (hypotension and bradycardia) when associated with anesthesia. To assess the hemodynamic effects of induction of anesthesia in patients chronically treated with ACEIs, 16 hypertensive patients scheduled for coronary artery bypass graft surgery (n = 12) or vascular surgery (n = 4) were studied. Eight of them were chronically treated (for at least 1 mo) with ACEIs (ACEI group), and the remaining eight (control group) were treated with other classes of antihypertensive drugs. Induction of anesthesia, which consisted of flunitrazepam (0.03 mg/kg), fentanyl (0.006 mg/kg), and pancuronium (0.1 mg/kg) IV, was followed by a significant decrease in mean arterial blood pressure from baseline in both groups (by 16.8% in controls [P = 0.001] and 33.5% in ACEI-treated patients [P = 0.001] [P = 0.041 between groups]). In control patients, mean arterial blood pressure decrease was only associated with a significant decrease in cardiac index (-18%, P = 0.014). In ACEI-treated patients, the arterial blood pressure decreases were associated with consistent reductions in pulmonary capillary wedge pressure (-26.4%; P = 0.035) and cardiac index (-23.9%; P = 0.001). Systemic vascular resistance index and heart rate were moderately changed (-14.2% and -4.5%, respectively). Rapid restoration of arterial blood pressure was obtained in all ACEI-treated patients, mainly with the intravenous administration of 0.4 to 0.7 L of lactated Ringer's solution. Phenylephrine (0.38 +/- 0.9 mg) was, however, required in four patients when mean arterial blood pressure was less than 60 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Fibrin sealant for early repair of acquired ventricular septal defect.
The trend toward early operation for acquired ventricular septal defects exposes the patient to major perioperative bleeding and residual shunt because of the fragility of the recently necrosed myocardium. To reduce these complications we have used a fibrin sealant to reinforce the cardiac tissues in addition to the usual closure of the defect with a Dacron patch through a left ventricular septum around the defect, area. During cardiac arrest fibrin sealant is applied on the ventricular septum around the defect, between the septum and the patch, and on the edges of the ventriculotomy. This technique was used in three patients (mean age 68.2 years) operated on for an acquired ventricular septal defect within 4 days of the infarction and within 24 hours of the occurrence of the defect. Low postoperative bleeding, absence of recurrent shunt, and good ventricular function indicated satisfactory surgical result in all three patients. We suggest that the use of fibrin sealant during operations for acquired ventricular septal defects, by reinforcing the necrotic and fragile tissues, may reduce perioperative bleeding and assure a more solid implantation of the patch.
Adult↗
Interleukin 6 production by cardiac myxomas may explain constitutional symptoms.
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Heart Atria↗
Fibrin sealant improves surgical results of type A acute aortic dissections.
From January 1984 to July 1990, 63 patients were operated on for type A acute aortic dissection. Forty-two patients (aged 22 to 80 years) had isolated replacement of the ascending aorta with the following techniques: group 1 (n = 10) had replacement of the ascending aorta with an intraluminal sutureless graft, group 2 (n = 14) had a Dacron prosthesis sutured to the aorta, and in group 3 (n = 18) the proximal and distal aortic stumps were glued together and reinforced at the suture sites with fibrin sealant before implantation of the Dacron prosthesis. There were no significant differences between the three groups with respect to age, sex, or preoperative clinical and anatomical data. Three (30%) intraoperative deaths occurred in group 1, 4 (29%) in group 2, and none in group 3. Cross-clamp and extracorporeal circulation time were significantly lower in group 1 when compared with groups 2 and 3. Perioperative blood loss during the first 24 hours was significantly lower in group 3 (372 +/- 155 mL) when compared with group 1 (755 +/- 210 mL; p less than 0.05) or group 2 (1,055 +/- 370 mL; p less than 0.01). Total hospital mortality was 7 (70%) in group 1, 6 (43%) in group 2, and 1 (5.5%) in group 3. All patients were reviewed: one late death occurred in group 2 and none in the other groups. All survivors were in good clinical condition. In conclusion, intraluminal sutureless grafts allowed shorter cross-clamp and extracorporeal circulation time but did not improve surgical results for treatment of type A acute aortic dissections.(ABSTRACT TRUNCATED AT 250 WORDS)
Acute Disease↗
Properties and Modulation of Ca channels in adult human atrial cells.
Ca-channel currents have been investigated in single cells isolated from adult human atrium using the whole-cell patch clamp technique. Ca-channel currents are activated at voltage positive to -40 mV, peak between -10 and 0 mV and inactivate with a slow decay when Ba2+ ions (5 mM) are used as charges carrier. These properties correspond to those of the high voltage activated, DHP-sensitive, (L-type) Ca channel. No low voltage activated (T-type) currents have been evidenced. The present work also provides the first report about the modulation of Ca channels in adult human atrial cells by beta-adrenergic agonists and dihydropyridines (agonists and antagonists). Electrophysiological and pharmacological properties of these Ca channels are qualitatively similar to those of the L-type Ca currents recorded from cardiac animal cells. However, at a physiological calcium concentration (2 mM), basal Ca currents are often very small or even absent but are revealed following the addition of the dihydropyridine (DHP) agonist Bay K 8644. Whether the decrease of the basal Ca current amplitude may be related to the chronic pretreatment of the patients by Ca channel blockers or to the pathology is discussed.
3-Pyridinecarboxylic acid, 1,4-dihydro-2,6-dimethy↗
[Vascular effects of adenosine-triphosphate].
This study assessed the effects of adenosine triphosphate (ATP) on systemic vascular resistances during the hypothermic cardiopulmonary bypass phase of cardiac surgery. Twenty patients scheduled for cardiac surgery were randomly divided into an ATP group (n = 10), and a placebo group (n = 10). Anaesthesia was similar for all the patients (diazepam, fentanyl and pancuronium). During the heart arrest phase, and as soon as the arterial pressure, the level in the venous return reservoir, and the pump flow rate had all been in steady state for 5 min, ATP or placebo was injected into the venous line of the oxygenator. Injection speed was doubled every three minutes, twice. The following ATP doses were administered: 0.012, 0.025 and 0.05 mg.kg-1.min-1. The level in the venous return reservoir was kept constant. Mean arterial pressure (MAP) and pump flow rate (DP) were assessed every half minute. Systemic vascular resistances were calculated with the relationship MAP/DP. Changes in vascular capacitance were directly proportional to changes in DP as the heart had been excluded, and all the blood returned to the pump, the blood volume being kept constant. MAP and DP remained unchanged in the placebo group. In the opposite ATP induced a dose-related systemic vasodilation: MAP decreased from 82.8 +/- 12.5 mmHg (control) to 66.0 +/- 14.8 mmHg, 59.8 +/- 10.6 mmHg, and 49.0 +/- 4.7 mmHg with 0.012, 0.025 and 0.05 mg.kg-1.min-1 ATP respectively. The MAP returned to preinfusion control levels when the ATP infusion was discontinued (90.0 +/- 17.8 mmHg). The DP, and therefore venous return, did not change, neither during ATP infusion, nor after its discontinuation.(ABSTRACT TRUNCATED AT 250 WORDS)
Adenosine Triphosphate↗
[Aneurysm of the aorto-coronary venous bypass. Apropos of a case disclosed by a pre-sternal mass and a review of the literature].
A 61 year old man was admitted with a pulsatile pre-sternal swelling ten years after saphenous vein coronary-artery bypass grafting. The precise diagnosis of this vascular tumor was not established despite various investigations. At reoperation, an aneurysm of the saphenous vein graft, eroding the sternum, was found. This rare complication of saphenous vein coronary artery bypass grafting is described and a review of the literature is presented. Reoperation is mandatory for this uncommon alteration of the saphenous vein graft.
Aneurysm↗
[Coronary revascularization by long endarterectomy and reconstruction].
Endarterectomy and reconstruction of the coronary arteries is a technique for patients with diffuse coronary disease and in whom coronary bypass grafting is contraindicated. In a serie of 418 patients undergoing coronary bypass between May 1988 and April 1990, 55 had endarterectomy and reconstruction of a coronary artery. The mean age was 62.2 years (44-80 years). Twenty-five patients had class III (NYHA) angina and 30 had class IV angina. On the coronary angiogram, 10 patients had double-vessel disease and 45 had triple vessel disease. Endarterectomy and reconstruction were performed on one coronary artery in 53 patients and on two coronary arteries in 2 patients. At mean of 2.6 grafts per patient were performed. Four patients died during the perioperative period. Ten had a perioperative myocardial infarction. No other complications were noted. No residual postoperative angina was present. Five patients had a follow-up angiogram during the first postoperative month. All grafts were patent and correctly revascularised the endarterectomised artery and branches. These satisfactory preliminary results suggest that endarterectomy and reconstruction of the coronary arteries is a reliable and reproducible technique for coronary grafting. It is indicated in patients with diffuse atheromatous coronary disease who were previously not considered for surgery.
Adult↗
[Aneurysm of a saphenous vein aortocoronary graft. Apropos of a case presenting with a presternal mass and review of the literature].
A 61 year old man was admitted with a pulsatile pre-sternal swelling ten years after saphenous vein coronary-artery bypass grafting. The precise diagnosis of this vascular tumor was not established despite various investigations. At reoperation, an aneurysm of the saphenous vein graft, eroding the sternum, was found. This rare complication of saphenous vein coronary artery bypass grafting is described and a review of the literature is presented. Reoperation is mandatory for this uncommon alteration of the saphenous vein graft.
Aneurysm↗
Constitutive production of interleukin-6 and immunologic features in cardiac myxomas.
The constitutive production of interleukin-6 (IL-6), a potent hepatocyte-stimulating factor and B cell-differentiating factor, was demonstrated in 3 patients with cardiac myxomas. Tumor cells from the only patient who presented with immunologic features produced 14-23-fold higher levels of IL-6 than those from the 2 patients who lacked such features. A significant serum IL-6 level (56 pg/ml), greater than that observed in patients with active rheumatoid arthritis, was also observed only in this patient, with a subsequent return to an undetectable level after surgical removal of the tumor. This was associated with a regression of the immunologic features. This same patient was observed to have an IL-6-dependent, proliferative polyclonal plasmacytosis of the bone marrow. These observations demonstrate that an overproduction of IL-6 by cardiac myxoma cells, in association with a systemic passage of this IL-6, may be responsible for the immunologic features similar to those observed in true autoimmune diseases such as rheumatoid arthritis.
Acute-Phase Proteins↗