Biomedical subjects
Publications and source records attributed to F Wellens.
We report a 57-year-old patient who developed a significant stenosis in a proximal anastomosis after CABG. Reconstruction was carried out with the left internal mammary artery which provided the global myocardial perfusion with an excellent longterm functional result.
After combined left ventricular aneurysmectomy and myocardial revascularization, four patients developed infection at the cardiac suture line. The infected cardiac suture line causes a variety of complications including cardiocutaneous fistula, erosion of pulmonary tissue, or pseudoaneurysm. The diagnosis is made by sinogram and left ventricular angiography, which is mandatory in all patients with suspected infection to guide the surgical approach. Once the diagnosis is made, aggressive and prompt surgical treatment is necessary to remove all infected material. A left anterolateral thoracotomy in the fifth or sixth intercostal space is the preferred approach. In the presence of a pseudoaneurysm, femoro-femoral bypass is required to reopen the left ventricle without cross-clamping the aorta. The septic material is removed, left ventricular wall and pericardial fibrous scar are closed, and extensive antibiotic treatment administered. All four patients survived and are free of complications two to three and a half years postoperatively.
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An alternative route, using the oblique pericardial sinus, is described for single and sequential vein grafts of the lateral aspect of the heart. This technique prevents kinking of the graft, reduces the need for excess vein length, and is an elegant way of protecting the graft in case a resternotomy is necessary. When the route was used in 63 patients, no technique-related morbidity or mortality was encountered.
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ALVT is a rare congenital lesion. The paravalvular tunnel causes a clinical picture of aortic regurgitation. An aortic regurgitant murmur is present since birth. The clinical diagnosis, often overlooked, is best confirmed by angiocardiography in the lateral view. Although 80% of reported cases present with congestive heart failure before age 1, our two cases were asymptomatic at age 13 and 8 respectively. Both were operated on the basis of progressive left ventricular (L.V.) overload and dilatation. Diagnosis was made at operation in case 1 and suspected by the surgeon in case 2. Case 1 necessitated implantation of a bioprosthetic valve and replacement of the prosthesis 3 years later for primary tissue failure. Case 2 could be handled more conservatively with obturation of the aortic orifice of the tunnel. The natural evolution of the lesion involves progressive aortic valve regurgitation both by annuloectasia and retraction of the valve cusps. The diagnosis of ALVT should be considered in any infant or child with an aortic regurgitation murmur. Surgical treatment should be undertaken before alteration of the valve and the aim should be preservation of native valve function.
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Cyclosporine nephrotoxicity after heart transplantation can lead to acute renal failure requiring haemodialysis. In four long-term heart-transplant survivors, cyclosporine nephropathy was characterised by extensive fibrosis, with uraemia, hypertension and/or anaemia. In contrast, the long-term survivor of heart-lung transplantation who had received her graft for accelerated respiratory failure, did not develop chronic renal disease. Thus, chronically reduced renal perfusion before heart transplantation may play a critical role in the development of chronic cyclosporine nephropathy.
Combined heart-lung transplantation with cyclosporine is reported in a 26-year-old patient who presented with end-stage pulmonary lymphangioleiomyomatosis. The operation was successful and the patient's rehabilitation excellent over the first 7 postoperative months. She then developed obliterative bronchiolitis of unknown origin. To our knowledge, this is the first published report of an out-hospital survival after heart-lung transplantation for terminal nonvascular lung disease.
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This morphologic study (X-ray examination of gross specimens, histologic study and histochemical staining) compares two groups of explanted left-sided bioprosthetic valves: group I, 6 valves with normal cusp function and group II, 10 valves with significant dysfunction. Implantation periods ranged from 26 to 79 months. A computerized descriptive statistical method (principal component analysis) is used to analyze the qualitative results. Although qualitatively identical alterations are observed in both groups, the findings in the deep layers of the cusps of severe collagen breakdown, intensive fibrin penetration and various degrees of calcification are restricted to group II. Other findings of interest in both groups include amyloid deposits (four cases) and layering of fusiform host cells on the cusp surface (three cases). The computerized study shows that individuals of one clinical group are morphologically different from those of the other. Mechanical stress may contribute to surface alterations early after implantation, while further collagen breakdown and macrophagic activity result in deep penetration of plasma components and fibrin. Subsequent calcification is likely to be dystrophic rather than metabolic. Colonization of the cuspal surface by endothelial cells after long-term implantation of bioprosthetic valves expresses a new type of relation between host and bioprosthesis.
Congo red staining with microscopic examination under polarized light was performed in 30 porcine bioprosthetic cardiac valves and one autologous fascia lata valve explanted from 31 patients in order to detect the presence of amyloid. Microdeposits of amyloid were present in the sewing ring of the fascia lata valve and in 10 porcine bioprostheses, and this finding was confirmed by transmission electron microscopy in 3 porcine bioprostheses. All amyloid-laden porcine valves had been implanted for at least 33 months before removal, and all except two showed dysfunction and/or severe degeneration of cuspal tissue. Statistical analyses failed to establish any correlation between the presence of amyloid and patient-related factors. In a majority of porcine bioprostheses amyloid was permanganate-sensitive and tryptophan-positive. The pathogenesis of this new form of heart valve amyloidosis might consist in penetration of human macrophages in deteriorated bioprosthetic cusps and their interaction with blood-borne amyloid precursors.
A case of Aspergillus fumigatus osteochondritis after median sternotomy for open heart surgery is presented. To the best of our knowledge, it is the second well documented case that has been reported in the literature. Successful healing was obtained with combined operative treatment (consisting of a large resection of the 8th, 9th and 10th right costal cartilages and surrounding soft tissues), and systemic drug therapy with Amphotericin B. Repeated serologic studies and bone scans were used for both the diagnosis and monitoring of the evolution of the infection; these 2 tools are recommended in cases of mycotic infections in that area.
UNLABELLED: Right thoracotomy is an alternative to mid-sternotomy for left atrium access. The Port-Access approach is an option that reduces the skin incision and obviates rib spreading. PATIENTS AND METHODS: From February 1997 until November 1999, 121 patients underwent mitral valve surgery through a right antero-lateral thoracotomy using the Heartport cardiopulmonary bypass (CPB) system. Mean age was 60 years (31-84). Most patients had normal ejection fractions and were in NYHA Class II or III. Seventy-five patients had valve repair (62%) and 46 (38%) had valve replacement. Pathologies were myxoid (n = 80), rheumatic (n = 30), chronic endocarditis (n = 5), annular dilatation (n = 3), sclerotic (n = 1), ingrowing myxoma (n = 1), and one closure of a paravalvular leak. RESULTS: Two patients had conversion to sternotomy for aortic dissection (one died) with the Endo-Aortic Clamp, and two others for peripheral vascular problems. One patient died at postoperative day 1 after reoperation for failed repair, another with double valve surgery on postoperative day 4 after two revisions for bleeding. Twelve underwent revision for bleeding (10%). Three had prolonged ICU stay for respiratory insufficiency. Two late valve replacements for endocarditis occurred. Echographic control revealed residual insufficiencies (grade 1-2) in two valvular repairs. There were neither paravalvular leaks nor myocardial infarcts. There were no cerebrovascular accidents due to embolic phenomena. Mean ICU and hospital stay were 2.1 and 8.7 days, with a major difference between the first 30 patients and those who followed. CONCLUSION: Port-Access mitral valve surgery can be a valid alternative to conventional sternotomy and seems to be an important improvement in minimally invasive cardiac surgery.
From September 1988 until March 1990, 22 orthotopic heart transplantations (HTX) were performed in 20 patients (18 male and 2 female). Median age was 56.5 years (23-66). The indication for HTX was an end-stage ischemic disease in 7 pts. a dilated cardiomyopathy in 13 pts, and a retransplantation in 2 pts. The mean waiting time was 58 days. Immunosuppressive therapy included OKT3, prednisone and azathioprine. Cyclosporine was introduced at day 10. Donor hearts were obtained from our institution in 5 cases, from other hospitals in Belgium in 9 cases, and from other European countries in 8 cases. The mean ischemic time was 129 +/- 28 min. No patient died in the operating room. During the first postoperative month, weekly endomyocardial biopsies were performed to detect early rejection. Five patients died in the early postoperative period, mainly from rejection. After a mean hospital stay of 23 days, 15 patients (75%) were discharged. During the late follow-up, 3 patients died: 1 from chronic mediasdinitis, 1 from hypoglycemia, and 1 from cardiac arrest following non-compliance with the medical treatment. In conclusion, early acute rejection after HTX still remains a major cause of death.
Chronic left ventricular aneurysm and ischemic mitral valve incompetence have been treated during the last 2 years with more physiologic techniques. Left ventricular reconstruction with the endoaneurysmorrhaphy technique was carried out in 20 patients. Sixteen patients had additional procedures. Early mortality was 5% and functional results are encouraging with 18 patients in NYHA class I of II. Mitral valve repair was carried out in combination with myocardial revascularization in 15 patients. All patients had a Carpentier Edwards annuloplasty ring implanted. Nine patients needed additional reconstructive procedures. There were no early or late deaths neither reoperations. Late functional results are good with all patients in NYHA, class I or II. Three patients present a mild mitral regurgitation on echo. This physiologic approach to restore volume, size and shape of the left ventricle and the mitral valve can be combined with CABG without additional operative risk and excellent results up to 2 years.
The initial experience in 18 patients undergoing coronary artery bypass surgery with the right gastroepiploic artery (RGEA) between April 1988 and August 1989 is reported. The indication for RGEA-use included the aim to obtain complete arterial revascularization in 15 patients and absence of suitable veins in 3 patients. Twelve patients had at least one previous CABG-operation. The average number of distal arterial anastomoses per patient was 2.5. The RGEA was connected to the right coronary artery (RCA) or its terminal branches in 13 patients, to the circumflex (CX) in 2 and sequentially to RCA and CX in 3 patients. In combination to the RGEA, 8 patients received bilateral internal mammary grafts and 6 patients received a single IMA-graft. There was one hospital death and there were no major early or late complications related to the RGEA-use. Postoperative angiographic controls in 16 patients revealed only one early RGEA-graft occlusion due to inadequate diameter and low run-off. There was one demonstrated late occlusion. These early results suggest that the RGEA can be used as an in situ graft to the posterior coronary vessels. Indications can be extended in function of the longterm patency and functional results.
Paradoxical embolism, due to passage of emboli through an intracardiac defect is now recognised as a cause of acute arterial embolisation. We present the case of a patient in whom unexplained arterial embolisation was diagnosed before further investigation, including contrast echocardiography, revealed a patent foramen ovale associated with pulmonary embolisation and deep venous thrombosis. This report illustrates the often confusing clinical picture that can accompany this syndrome. Early diagnosis and successful management depends on early clinical recognition and appropriate diagnostic procedures.