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Biomedical subjects

P Berdat

Publications and source records attributed to P Berdat.

15 recordsLinked to original sources
PubMed2004

Impaired poststenotic aortic pulsatility after hemodynamically ideal coarctation repair in children.

Using echocardiographic quantification of aortic pulsatility distal to the site of the surgical anastomosis, we evaluated whether the preoperatively impaired poststenotic aortic pulsatility returned to normal after repair of coarctation with a hemodynamically ideal result. Patients who underwent repair of aortic coarctation without residual obstruction were compared to a matched group of normal children. A standardized M-mode echocardiographic evaluation of the aorta at the diaphragmatic level was performed for all patients. Measurements consisted of maximum and minimum aortic diameters, time intervals, and a calculated pulsatility index. Compared to normal children (n = 19), 20 children with operated coarctation and with a hemodynamically ideal result showed a significantly smaller increase in aortic diameter in systole (mean of 29 +/- 7% in patients versus 37 +/- 7% in normals; p < 0.01). In contrast to patients with coarctation in whom the maximum aortic distension is reached much later during the cardiac cycle, hemodynamically normalized, operated patients in our study had no such delay (maximum aortic pulsation at 28% of cardiac cycle time compared to 27% in normals; p = not significant). The pulsatility index of the poststenotic aorta was clearly lower in operated children (mean, 130 +/- 50%/sec) compared to a normal mean value of 202 +/- 33%/sec but was still significantly higher than that in patients with unoperated coarctation, who showed a low mean value of 51 +/- 24%/sec (p < 0.01). After correction of aortic coarctation with a hemodynamically ideal result, the pulsatility of the poststenotic aorta, severely impaired prior to repair, did not return to normal during the observation period in the patients studied.

Aorta, Thoracic↗
PubMed2002

Radical sternectomy and primary musculocutaneous flap reconstruction to control sternal osteitis.

OBJECTIVE: Sternal osteitis after median sternotomy is associated with considerable morbidity and mortality. The use of muscle and omentum flaps has been proved as valid adjunct to combat these severe infections. In this study we present our experience with a more radical approach. METHODS: Sternectomy consisted of the resection of the entire sternum, including the costochondral arches and the sternoclavicular joints, and was followed by the repair of the defect with musculocutaneous flaps without any restabilization of the thoracic wall. Thirteen patients received a vertical rectus abdominis musculocutaneous flap, 14 patients received a pedicled latissimus dorsi musculocutaneous flap, and 12 patients received a free latissimus dorsi musculocutaneous flap (total of 40 flaps in 39 patients of 66 patients who required surgical revision for sternal osteitis of 6078 total patients with sternotomies). RESULTS: Two patients died within 30 days after the operation (early mortality of 5.1%); however, they did not die of sternal infection, which was cured without any recurrence in all cases. Seventeen patients (44%) required secondary, mostly minor operations for local complications. Despite some paradoxic chest movements, the patient satisfaction rating was unanimously high at the long-term follow-up (0.4 to 8.5 years, median 2.3 years). The short- and long-term complication rates were similar in the three groups. CONCLUSION: We conclude that radical sternectomy and immediate musculocutaneous flap repair provided definitive control of sternal infection in even the most severe cases, thus reducing infection-related mortality. The trade-off was a substantial rate of local complications; however, these did not cause any relevant morbidity.

Aged↗
PubMed2001

Budd--Chiari syndrome and heparin-induced thrombocytopenia.

We report on a patient suffering from Budd--Chiari disease who developed heparin-induced thrombocytopenia preoperatively. Dorsocranial liver resection and hepatoatrial anastomosis were performed with the extracorporeal circulation and perioperative anticoagulation was achieved with r-hirudin. Surprisingly, thrombus formation was observed in the venous reservoir although ACT was 590 s and aPTT 55 s. An additional bolus of hirudin and rinsing the reservoir allowed unproblematic discontinuation of the cardiopulmonary bypass.

Adult↗
PubMed2001

Dilation of the ascending aorta in childhood: 4 cases without obvious predisposing disease.

Dilation of the ascending aorta is rare in childhood. When seen, it is usually associated with some form of connective tissue disease or predisposing cardiac malformations, especially an aortic valve with two leaflets. We describe four children in whom significant dilation of the ascending aorta was encountered as an incidental finding. No patient had any sign of an associated connective tissue disease, nor did we detect any predisposing cardiac anomalies. One patient had undergone surgical ligation of the arterial duct in infancy, whilst another had undergone repair of aortic coarctation, also in infancy. A third child has had repair of an atrioventricular septal defect with exclusively atrial shunting, whereas the fourth patient had a structurally normal heart. The aortic valve had three leaflets, and was functionally normal in all. The dilation of the ascending aorta was progressive in all patients, and finally surgical treatment was recommended, relying on the guidelines established for the management of patients affected with the Marfan syndrome.

Aorta↗
PubMed2001

[New approaches in cardiac surgery for the therapy of congenital heart disease].

Recent developments in the field of pediatric cardiac surgery and pediatric cardiology have led to significant changes in the surgical approach to the various cardiac malformations. There is a clear trend towards surgical treatment at a younger age of the patient, towards complete correction of malformations instead of staged procedures with initial palliation and delayed correction. Perioperative cardioprotection has improved significantly as has postoperative management in specialized pediatric cardiac intensive care units. As a result of this, mortality and morbidity of pediatric cardiac surgery have been in steady decline, although complexity of cardiac surgery in even smaller children has increased. Preoperative diagnostic work-up of the cardiac malformation can nowadays be achieved in an always increasing number of patients without invasive cardiac catheterization and based exclusively on ultrasound findings alone. A new element comes from the possibilities of therapeutic cardiac catheterization, which now allows for a combined therapeutic approach using therapeutic catheter procedures either to perform preparatory interventions prior to surgery or to treat surgical complications in the postoperative course. Refinements in the use of surgical implants have led to new possibilities of correction of complex malformations early in life, especially with regard to the use of biological prosthesis for valvar or outflow tract replacement.

Age Factors↗
PubMed2001

[Challenging perioperative anticoagulation in a patient with Budd-Chiari syndrome and heparin-induced thrombocytopenia].

We report on a patient suffering from Budd-Chiari disease who developed heparin-induced thrombocytopenia preoperatively. Dorsocranial liver resection and hepatoatrial anastomosis were performed with the extracorporeal circulation and perioperative anticoagulation was achieved with r-hirudin. Surprisingly, thrombus formation was observed in the venous reservoir although intraoperative anticoagulation values were within the targeted level. An additional bolus of hirudin and rinsing the reservoir allowed unproblematic discontinuation of the cardiopulmonary bypass.

Adult↗
PubMed2001

The reversed and bidirectional elephant trunk technique in the treatment of complex aortic aneurysms.

BACKGROUND: The elephant trunk technique with a free-floating vascular prosthesis was originally developed to facilitate a subsequent operation on the downstream aorta. We present here our experience with further developments of this technique, which we call the reversed elephant trunk and bidirectional elephant trunk. METHODS: Between January 1, 1995, and December 31, 2000, 505 adult and adolescent patients underwent operations of the thoracic aorta. A reversed elephant trunk procedure in 13 patients and a bidirectional elephant trunk procedure in 4 patients was performed to facilitate either subsequent proximal or proximal and distal aortic replacement. Nine patients underwent subsequent aortic arch replacement with the reversed prosthetic portion after a mean interval of 8 +/- 5.5 months, and 2 patients received distal extension by use of the distal portion of the free-floating graft. RESULTS: There was no hospital mortality (30 days) in this small group of patients, and no patient had aortic rupture, malperfusion caused by the technique itself, or thromboembolic complications during the waiting interval between the first and the second operations. Five patients are still being observed until the contiguous aortic size is large enough to require an operation, and one 74-year-old patient declined a second-stage operation. CONCLUSION: The reversed and bidirectional elephant trunk techniques are interesting options that may be suitable for patients having complex abnormalities of the thoracic aorta and thoracoabdominal aorta when the proximal portion of the descending aorta has to be replaced before the aortic arch with or without the ascending aorta or the distal descending aorta with or without the thoracoabdominal aorta.

Adolescent↗
PubMed2000

Pediatric cardiac surgery after exclusively echocardiography-based diagnostic work-up.

This study was performed to evaluate the accuracy of exclusively non-invasive preoperative diagnostic work-up based on echocardiography and to assess the safety of cardiac surgery using this diagnostic approach in children with heart disease. During a 3. 5-year period, accuracy of preoperative (invasive and non-invasive) diagnostic work-up was prospectively tested by comparison with the intraoperative findings obtained by surgical inspection and transoesophageal echocardiography. Included were all consecutive 358 children undergoing cardiac surgery (except pulmonary artery bandings and ductus ligations) during the study period at our institution. Of the patients, 44% were operated on in infancy, 84% of procedures were on cardiopulmonary bypass. Echocardiography as the only preoperative imaging modality was used in 231 patients (65%), in the other children, a diagnostic catheter was done. Diagnostic errors occurred in 3.9% (n=5) of patients after diagnostic catheter and in 6.9% (n=16) of patients with echocardiography only. Major diagnostic errors (resulting in prolongation of cardiac bypass time) were observed at equal frequency in both groups (1.7% or four children in the echo-only group and 1.6% or two patients in the catheter group). In no case was the outcome affected by the previously unrecognized findings. It was shown that diagnostic cardiac catheterization could be avoided in a majority of pediatric patients prior to surgical palliation or correction of cardiac defects, without increasing the risk of complications or the overall outcome.

Adolescent↗
PubMed2000

Cardiovascular interventions during oncologic surgery: technical principles and mid-term survival.

BACKGROUND: While the veins are primarily affected by compressing or invasive tumors, the arteries usually undergo only a less pronounced stenosis, due to the higher internal pressure. However, some tumors infiltrate the arterial adventitia which should be resected or might be injured in cases where radical surgery is attempted. PATIENTS AND METHODS: We report some technical principles utilized in various vascular localizations and mid-term survival observed in a group of 35 patients in whom a vascular reconstruction was performed during the surgical treatment of a malignant tumor. The following vessels were involved: carotid artery (n = 5), superior vena cava (n = 9), aortic arch (n = 1), subclavian artery (n = 1), right atrium +/- inferior vena cava (n = 6), abdominal aorta (n = 3) and finally iliac artery and/or vein (n = 10). The following surgical techniques were employed: extra-anatomic bypass (n = 3), in situ reconstruction (n = 23) using either prosthetic graft or saphenous vein interposition, patch angioplasty with autologous vein or xenopericardium and ligature of the involved artery or vein (n = 4). In 5 patients suffering from hypernephroma with a tumor thrombus, cardiopulmonary bypass was used to allow radical intracardiac excision. RESULTS: There was no intraoperative mortality despite the fact that a majority of these vascular procedures was performed after incidental and unexpected finding during surgery. Two patients died before hospital discharge (one from pneumonia, the second one from sepsis). Mid-term survival was satisfactory with 45% of the patients still alive after a mean follow-up of 4.5 years--all tumor types confounded. CONCLUSIONS: This series demonstrates that an aggressive approach might be justified in appropriate patients who otherwise might not be considered as operative candidates.

Adult↗
PubMed1999

Intra- and postoperative quality control in minimally invasive direct coronary artery bypass (MIDCAB) surgery.

The introduction of new techniques allowing direct coronary artery revascularisation without sternotomy and extracorporeal circulation--called Minimally (or less) Invasive Direct Coronary Artery Bypass grafting (MIDCAB)--has opened up interesting perspectives for the treatment of patients with limited coronary artery disease. However, like any newer surgical technique, this approach to myocardial revascularisation requires a critical appreciation of the results which may be obtained; when introducing the MIDCAB technique in our institution we developed a quality control protocol based on intraoperative as well as early and late postoperative parameters. This protocol is designed to detect every significant adverse event, exercise capacity and quality of life of our patients. Moreover, several invasive parameters have to be recorded in the protocol, such as intraoperative flow in the internal mammary artery conduit, the angiographic verification of anastomotic patency at one-year follow-up and determination of coronary flow reserve. The results of the first 5 patients observed up to one year postoperatively are presented: all anastomoses were patent and the flow within the internal mammary artery was 69 +/- 40 ml/min at one-year follow-up angiography; this compares very favourably with the flow measured at the end of the operation, which was 31 +/- 8 ml/min. This demonstrates very clearly that internal mammary artery flow is recruitable and usually significantly increases within the first months postoperatively. Coronary flow reserve was 3.4 +/- 1.1 (normal value > 2.5). The results obtained in this pilot study, which was designed to establish a quality control protocol, are very satisfactory and confirm previous experience that this technique may be offered to selected patients with appropriate coronary anatomy.

Coronary Artery Bypass↗
PubMed1999

Different techniques of distal aortic repair in acute type A dissection: impact on late aortic morphology and reoperation.

OBJECTIVE: To compare three different techniques of distal aortic repair in acute type A (de Bakey type I) aortic dissection and to evaluate their impact on the late morphology of the aortic arch and descending aorta and on the incidence of reoperation. METHODS: From 65 patients operated on due to an acute type A aortic dissection between 1989 and 1993, 54 long-term survivors underwent clinical and radiologic follow-up examination after a mean postoperative interval of 62+/-16 months. The surgical techniques of distal aortic reconstruction included closed repair using Teflon felt reinforcement under moderate hypothermic cardiopulmonary bypass (n = 20) and open repair in deep hypothermic circulatory arrest using either Teflon felt reinforcement (n = 16) or gelatin-resorcin-formaldehyde (GRF) glue (n = 18) to readapt the dissected aortic layers. In all patients, MR imaging was performed on a 1.5-T whole body imaging system for the evaluation of the morphology and function of the heart, aorta and supraaortic branches. RESULTS: Overall hospital mortality following surgical repair of type A aortic dissection was 15.4% during this time period. The highest rate of persistent false lumen perfusion (17/20, 85%) and presence of an intimal flap in the aortic arch (13/20, 65%) was observed in patients following closed repair of acute ascending aortic dissection, whereas the lowest rate of such findings was demonstrated in patients who had undergone open distal aortic repair using biological glue (false lumen perfusion 10/18, 55% and intimal flap in the arch 2/18, 11%). Redo-surgery was significantly reduced in the open repair group using GRF glue (1/18, 5.5%) as compared with the Teflon felt repair group (3/16, 18%) and the closed repair group (6/20, 30%). CONCLUSIONS: In patients with acute type A dissection, open distal aortic repair using GRF-glue favourably influences both (1) the severity of late morphologic alterations in the downstream aorta and (2) the incidence of reoperation.

Aortic Dissection↗
PubMed1999

Surgery of the complete atrioventricular canal: relationship between age at operation, mitral regurgitation, size of the ventricular septum defect, additional malformations and early postoperative outcome.

The perioperative risk after repair of the complete atrioventricular canal is reported to be low provided there is a balanced relationship of both ventricles, and elevated pulmonary vascular resistance has been demonstrated to be reversible. However, some pre- and perioperative conditions may adversely affect early postoperative outcome. A consecutive series of 42 patients (mean age 8.5 months, 34/42, 81%, with trisomy 21) operated between 1994 and 1998 was analyzed prospectively for pre- and perioperative risk factors. Echocardiography alone was performed in 35 patients whereas cardiac catheterization was performed in 7 patients aged more than 18 months to confirm operability. Additional malformations were found in 20 patients. Early mortality was 2.3% (1/42), and postoperatively a low cardiac output was observed in 25 patients (59%); NO inhalation was used in 12 patients. Only the size of the ventricular septal defect (> than the diameter of the aortic annulus) could be identified as a predictor of adverse postoperative outcome in multivariate analysis. The presence of associated intracardiac malformations showed a trend to increased perioperative risk in multivariate analysis. Early results after repair of the complete atrioventricular canal are excellent. Survival, postoperative morbidity and normalization of pulmonary artery pressure can be related to the size of the ventricular septal defect. Continuous monitoring of the pulmonary artery pressure (with consequent NO application when indicated) is probably responsible for the low perioperative risk encountered in this series, despite the high incidence of postoperative pulmonary artery hypertension.

Administration, Inhalation↗
PubMed1999

Perioperative bleeding and thromboembolic risk during non-cardiac surgery in patients with mechanical prosthetic heart valves: an institutional review.

BACKGROUND AND AIMS OF THE STUDY: The study aim was to determine the risk of thromboembolic and bleeding complications in patients with mechanical heart valve prostheses who underwent non-cardiac surgery under different regimens of perioperative anticoagulation. Data were analyzed on the basis of surgery type and underlying disease. METHODS: A series of 235 patients (mean age 63 +/- 4.5 years) with one or two mechanical heart valves underwent subsequent non-cardiac surgery comprising abdominal, vascular and thoracic, orthopedic, urologic, neurosurgery, ENT, plastic and reconstructive, and gynecologic operations. Mean interval between heart valve replacement and non-cardiac surgery was 3.9 +/- 3.3 years. Perioperative oral anticoagulation was managed by discontinuation of oral anticoagulation and intravenous heparin administration; or by discontinuation and early postoperative re-institution of oral anticoagulation without intravenous heparin; or by no withdrawal of oral anticoagulation. Patients with bioprostheses were excluded. RESULTS: Overall hospital mortality during non-cardiac surgery was 2.9%. Thromboembolic events included cerebral embolism with transient deficit (n = 3), residual defect (n = 1) and irreversible defect (n = 1), as well as peripheral embolism (n = 11). Hemorrhagic complications included wound hematoma (n = 10) and increased postoperative bleeding (n = 8) with re-exploration in five patients. Thromboembolic complications occurred most often in patients with prosthetic mitral valve and atrial fibrillation; the lowest risk was in patients with sinus rhythm after aortic valve replacement. Most complications occurred after discharge and in patients with surgery for malignancy, within 10 days of instituting oral anticoagulation, and despite a therapeutic INR value. CONCLUSIONS: Minor surgical procedures can be performed safely without discontinuing anticoagulation. When major non-cardiac surgery is planned, discontinuing oral anticoagulation and starting perioperative intravenous heparin minimizes bleeding and thromboembolic risks. Thromboembolic complications may occur within one month of surgery, despite adequate oral anticoagulation, though permanent morbidity is low.

Anticoagulants↗
PubMed1998

[Conventional heart surgery with the fast-track-method: experiences from a pilot study].

Early release after cardiac surgery can be promoted by implementation of a standard protocol for accelerated perioperative and early postoperative care, with optimal education and support of the patient playing a key role. We report on our preliminary experience with 100 selected patients who underwent a "fast track" protocol following coronary artery bypass (n = 61), valve replacement or reconstruction (n = 34) or closure of an atrial septal defect (n = 5) between 1996 and 1998. Surgery was performed through a midline sternotomy using normothermic or mild hypothermic cardiopulmonary bypass. Patients undergoing cardiac surgery with less invasive techniques were excluded from this study. The following criteria had to be fulfilled for early hospital discharge: sinus rhythm, temperature below 37.5 degrees C, stable haematocrit around 0.30, uncomplicated wound healing and complete mobilisation including stair exercises. Mean duration of the operation was 137 +/- 24 minutes and mean intubation time was 4.5 +/- 3 hours. Mean duration of hospitalisation from the day of the operation was 4.9 +/- 2.1 days. There was no early or late mortality in this group of patients and only 2 patients had to be re-admitted on postoperative day 10 and 14 because of atrial fibrillation in one and a wound healing problem in the other. Accelerated recovery and early hospital discharge is highly attractive in selected patients; in helps to promote early cardiac rehabilitation and the costs of the procedure can be substantially reduced. According to our experience and the most recent literature, this approach does not expose patients to higher mortality or morbidity. In addition, fast-tracked patients have shown a higher level of satisfaction. Under optimal cooperation between surgery, anaesthesiology and intensive care unit, the fast-track protocol can be applied in approximately 30% of overall adult cardiac surgery patients.

Adult↗