Biomedical subjects
A Carpentier
Publications and source records attributed to A Carpentier.
Biatrial transseptal approach in case of difficult exposure to the mitral valve.
The biatrial transseptal approach according to the Dubost technique provides an excellent exposure to the mitral valve. Over a 5-year period (1984 to 1989) we used this approach in 210 patients. We believe that this incision is indicated in the following situations: reoperation on the mitral valve and acute mitral insufficiency with little enlargement of the left atrium.
Inadequate flow of the internal mammary artery: another complication of sternal overretraction.
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Ventricular septal defect associated with aortic valve incompetence: results of two surgical managements.
Aortic valve insufficiency with ventricular septal defect is usually treated by plication of the commissures. However, long-term deterioration is common. We propose a new technique that corrects the aortic annulus dilatation and the leaflet prolapse and reinforces the sinus of Valsalva. Two groups were compared: group I (29 patients) had plication of the prolapsed leaflet(s) and folding of the free edge; group II (26 patients) had triangular resection of the prolapse cusp, annuloplasty, and reinforcement of the aortic wall. The two groups were similar with regarding to preoperative clinical data. There was no perioperative mortality. Primary failure (aortic valve replacement) occurred in 8 patients in group I (28%) and in 2 patients in group II (8%). The rate of secondary failure was 31% in group I and 4% in group II. The actuarial rate of freedom from reoperation at 5 years is 55% in group I and 88% in group II (p less than 0.05). The late mortality was 6.5% in group I and 10.9% in group II (no difference). We conclude that aortic valve insufficiency with ventricular septal defect is a malformation of the aortic leaflets, the annulus, and the sinus of Valsalva, and that the proposed technique offers a better result than the usual methods in terms of residual aortic valve insufficiency.
Operative findings after percutaneous mitral dilation.
Ten patients were operated on within one hour to 3 months after percutaneous mitral dilation. Operative analysis of the lesions demonstrated hemopericardium (n = 3), acute mitral insufficiency (n = 7), left atrial thrombus (n = 2), and atrial septal defect (n = 3). A conservative treatment of the mitral valve lesion was performed in 6 patients. All patients had uneventful postoperative courses. The complications presented in this series were either due to technical error or occurred in patients with relative contraindications to percutaneous mitral dilation (calcified commissures).
Serum lipid abnormalities in heart transplant recipients: predominance of HDL2-like particles in the HDL pattern.
Accelerated coronary atherosclerosis is a major risk limiting long-term survival after heart transplantation and is commonly associated with dyslipoproteinemia even in subjects who were not dyslipoproteinemic before intervention. The purpose of this study was to analyse the abnormalities in the lipid profiles of 2 different groups of heart-transplanted males: 18 subjects with underlying ischemic heart disease (IHD) and 19 subjects with non-obstructive cardiomyopathy of unknown aetiology (CM). Both groups were compared to 33 healthy males. All patients were under immunosuppressive therapy including prednisone, cyclosporin A and azathioprine. A moderate hyperlipidemia was found in all transplant recipients, associated with high HDL-cholesterol concentrations in the CM group (1.80 +/- 0.37 vs. 1.29 +/- 0.23 mmol/l) and normal HDL-cholesterol levels in the IHD group (1.40 +/- 0.23 mmol/l). HDL subfractionation showed a marked increase in HDL2-cholesterol (CM: 1.12 +/- 0.32; IHD: 0.69 +/- 0.28; control: 0.40 +/- 0.17 mmol/l) while HDL3-cholesterol was significantly lower than in the control group. Analysis of HDL particle sizes showed in all transplant subjects an increase of an intermediate size particle HDL2a (diameter 9.0 +/- 0.10 nm) which is a minor form in control subjects. In the CM group, both the common HDL2b (10.2 +/- 0.13 nm) and HDL2a were abundant in 13 of 17 patients. The pattern was more heterogeneous in the IHD group but witnessed to a high frequency of HDL2a particles either alone (5/14) or associated with larger HDL2b (4/14) or with small HDL3 (4/14).(ABSTRACT TRUNCATED AT 250 WORDS)
Effect of systemic hypertension on renal function and left ventricular hypertrophy in heart transplant recipients.
To evaluate the incidence, risk factors and effects of systemic hypertension on renal function and left ventricular hypertrophy after cardiac transplantation, 85 transplant recipients on triple drug, low dosage, immunosuppressive therapy were studied. After a mean follow-up period of 12.5 +/- 8.7 months, a high incidence of hypertension was observed in 57 (67%) of the patients, and 42 (71%) of the 57 had developed new hypertension. None of the pretransplant and posttransplant cardiovascular risk factors were significantly associated with posttransplant hypertension. Faster deterioration of renal function, as assessed by intraindividual variations of serum creatinine values, was demonstrated in hypertensive patients and appeared as an early indicator of cyclosporine nephrotoxicity in patients at risk for hypertension. Serial echocardiographic evaluations demonstrated an early increase in left ventricular mass and fractional shortening in both hypertensive and normotensive heart transplant recipients. Fractional shortening further diminished significantly in normotensive patients but remained elevated in hypertensive patients, demonstrating sustained enhanced contractility in this group. Further studies will help to determine the exact relation between cyclosporine dosages and hypertension and their respective roles in the development of renal insufficiency and left ventricular hypertrophy after cardiac transplantation.
Long-term efficacy of dynamic cardiomyoplasty. Clinical, ultrasonic and haemodynamic evidence in one case.
We report one case of successful cardiomyoplasty in a 21-year-old male and its beneficial effects as assessed by clinical examination, Doppler echocardiography, phonocardiography, haemodynamic and angiographic evaluation at 1 year. Long-term efficacy of this procedure on left ventricular function was confirmed by these techniques.
Heart transplantation for corrected transposition of the great vessels.
Orthotopic heart transplantation was performed in a patient with corrected transposition of the great vessels. Technical modifications were necessary to be able to transplant a normal heart in this patient. The surgical technique is illustrated.
Abdominal aortic aneurysmectomy in renal transplant patients.
Because renal transplantation is allowing an increased number of patients to survive for prolonged periods, abdominal aortic aneurysms can be expected to occur with growing frequency in these patients. Surgical management of such cases involves the provision of allograft protection. To date, the literature contains 15 reports of abdominal aortic aneurysms in renal allograft recipients. We describe a 16th case and discuss the management of these patients.
[Surgery of endomyocardial fibrosis. Apropos of 32 cases].
From 1971 to 1984, 32 patients with endomyocardial fibrosis (EMF) were treated by endocardial resection (decortication) and valve replacement. The population consisted in 20 men and 12 women (age ranged from 8 to 64); 19 patients were european and 13 african. All were symptomatic, 78 p. 100 in stages III or IV of the NYHA. Hypereosinophilia was detected in 21 patients and its cause was determined in 11 cases. Cardiac involvement was biventricular in 22 patients and monoventricular in 10 patients. Six patients died in the immediate postoperative period and 6 late deaths were observed, owing to extracardiac causes in 4. There were no recurrence of EMF. Despite a high mortality rate, the authors suggest that all symptomatic EMF should benefit from endocardial resection.
Absorbable rings for pediatric valvuloplasty. Preliminary study.
Secondary valvular stenosis is a significant risk of annular ring implantation during valvular repair in children. To avoid this problem, we have developed an absorbable prosthetic ring (APR), which induces the generation of a biologic fibroelastic ring with mitotic capability and thereby allows atrioventricular annulus growth with age. Twelve polydioxanone (PDS) biodegradable APRs were surgically implanted in immature goats. To avoid possible embolic complications from ring fragments during the absorption period, APRs were covered with an extensible sewing sheath of high-porosity polyester, allowing contact between the PDS, blood, and endocardium. Four APRs were implanted into the right atrial cavity, four in the tricuspid position, and four in the mitral position. Histological studies at 6 months showed a considerable amount of remaining PDS. At 1 year, only small residual fragments of PDS were present, surrounded by collagen and elastic fibers as well as fibroblasts with mitotic activity. This histological structure represents a new biologic fibroelastic ring, which has originated from PDS rings. Echocardiography at 12 months showed that the elasticity of APRs and fibrotic tissue allows normal systolic and diastolic valve motions. These findings, which demonstrate histological changes in native valve annuli as well as stable and elastic annuloplasty without secondary stenosis in growing animals, call for new studies involving hearts with valvular disease.
[Dynamic cardiomyoplasty. Hemodynamic study of 3 patients].
Dynamic cardiomyoplasty is a surgical operation aimed at compensating for a loss of substance or a severe deficiency of the left ventricular myocardium by implanting around the heart the latissimus dorsi muscle the contraction of which, synchronous with that of the ventricles, acts on the heart in the manner of a massage or milking. The operation, which in its present form is recent, consists of applying Onto the heart, or wrapping that organ with, a skeletal muscle that keeps its neurovascular supply and its high insertion, and of installing the appropriate electrodes and a pacemaker. We report the haemodynamic data collected in 3 patients operated upon for severe cardiac failure 13, 8 and 9 months ago respectively and who are now in NYHA functional stages I and II. During 1/1 stimulation of the latissimus dorsi systolic pressures remain unchanged while diastolic pressures rise; cardiac output increases satisfactorily in two of the patients (cases No. 1 and 3) and is unmodified in the third one (case No. 2). We conclude that cardiomyoplasty seems to give favourable results but its future and indications remain to be determined.
[A new technique of simultaneous revascularization of coronary vessels and lower limbs. 4 cases].
Management of patients with concomitant coronary and aorto-iliac atherosclerosis is controversial. It is universally accepted that coronary artery surgery should precede aorto-iliac reconstruction. The technique described consists of an ascending aorta to bifemoral graft. This technique allows combined surgery of the coronary arteries and to the lower limbs without opening the peritoneum.
[Treatment of type A aortic dissection by exclusive glueing].
From 1984 to 1990, 24 patients suffering from type A aortic dissection were treated by directly suturing the entry orifice of the dissection and glueing (gelatin-resorcin-formaldehyde glue) the dissected aortic tunicae, without any prosthetic replacement. Associated aortic insufficiency in 21 patients was treated by valve replacement (8 patients) or plasty (8 patients). Deep hypothermia with circulatory arrest was required in 13 patients, whose aortic arch was involved by the dissection. All patients survived the operation. All these patients were followed up from 6 to 60 months. All were controlled with Doppler echography. In addition, 21 of them were examined with angiography, 17 with CT and 5 with MRI. 21 patients had an ascending aorta and an apparently normal aortic arch. Limited dissection of the descending aorta, requiring no second surgery, was noted in 2 patients. Persisting dissection of the descending aorta was present in 13 patients. Valve replacement was necessary 18 months later in 1 patient. Heart transplantation was necessary 14 months later in a patient suffering from associated cardiomyopathy. These results demonstrate that aortic glueing is effective and safe in the middle term for the treatment of aortic dissection.
[Mid-term echographic evaluation of systolic function after cardiac transplantation].
The aim of this study was to analyse variations in left ventricular mass (LVM) and systolic function after cardiac transplantation and to evaluate eventual changes induced by the onset of systemic hypertension (HT). In a retrospective study, we selected the echocardiographic examinations of 42 patients performed at the end of the first month (M1), sixth month (M6), and at the end of follow-up (ME) after cardiac transplantation. The patients were divided into two groups (NT: n = 14; HT: n = 28) depending on whether hypertension occurred during follow-up. The average duration of follow-up was 12.8 +/- 6 months; this was comparable in the two groups. Mild left ventricular hypertrophy was observed from the first postoperative examination: M1 = 193 +/- 50 g; M6 = 199 +/- 62 g; ME = 197 +/- 45 g (NS). The hypertrophy was constant with time and related to wall thickening; it was associated with an increased left ventricular fractional shortening (FS) which decreased with time especially in the NT group (average/42 patients: M1 = 0.38 +/- 0.09; M6 = 0.34 +/- 0.08; ME = 0.35 +/- 0.05; p = 0.03 between M1 and ME). The influence of hypertension on the development of LVH and wall thickening was negligible. The role of transplant rejection should be considered: the repetition of episodes of rejection was less marked than the histological severity of rejection. The role of other factors (ischaemia, persistent haemodynamic abnormalities) is a matter of discussion.
[Effect of hypertension on the renal and cardiac functions of patients with heart transplantation].
To evaluate the incidence, risk factors and effects of systemic hypertension on renal function and left ventricular hypertrophy after heart transplantation, 85 recipients under triple drug low low dosage immunosuppressive therapy were studied. After a mean follow-up of 12.5 +/- 8.7 months, high incidence of hypertension was observed in 67% of the patient and 71% had developed de novo hypertension. None of the pre-transplant nor post-transplant cardiovascular risk factors were significantly associated with post-transplant hypertension. Faster deterioration of renal function, as assessed by intraindividual variations of serum creatinine values, was demonstrated in hypertensive patients and appeared as an early indicator of cyclosporine nephrotoxicity in patients at risk for hypertension. [table: see text] Serial (early, intermediate, late) echocardiographic evaluations demonstrated early increase in left ventricular mass and in fractional shortening in both hypertensive and normotensive heart transplant recipients with sustained enhanced contractility in hypertensive patients. [table: see text] Further studies will help to determine the exact relationship between cyclosporine dosages and hypertension, and their respective roles in the development of renal insufficiency and left ventricular hypertrophy after heart transplantation.
Elevation of plasma atrial natriuretic factor after heterotopic cardiac transplantation in rats.
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