Biomedical subjects
Publications and source records attributed to J A Barra.
Intracardiac ectopic thyroid tissue was removed in a 51 years old woman, after echography has discovered a tumor in the right ventricle. There was a normal thyroid gland in the neck and thyroid function tests were normal. Intra-cardiac ectopic thyroid tissue is very rare; it is due to an abnormality of embryological development, when thyroid anlage is in close contact with the embryonic heart.
The marked decrease in neuropsychiatric morbidity (NPM) following coronary artery bypass (CAB) over a period of four years led us to carry out a retrospective study in order to identify the cause. Two hundred fifty-eight consecutive CAB procedures were performed between 1983 and 1986. For 133 patients (group A), the CAB procedure was performed with left ventricular vent (LVV) and for 125 patients (group B) without LVV. In group A, 93 patients (group A1) had cardiopulmonary bypass (CPB) with a bubble oxygenator and 40 patients (group A2) had CPB with a membrane oxygenator. In group B, 30 patients (group B1) had CPB with a membrane oxygenator without filter in the arterial line and 95 patients (group B2) had CPB with a membrane oxygenator and filter in the arterial line. The reduction in NPM arose from the removal of the LVV, as the incidence of NMP was in group A 24.6% versus 12.3% in group B (p < 0.05). The substitution of the bubble oxygenator by a membrane oxygenator does not alter the incidence of NPM: 23.3% in group A1 versus 27.5% in group A2 (p > 0.05) nor did incorporation of a filter in the arterial line: 10% in group B1 versus 13.1% in group B2 (p > 0.05). Introduction of air in the left ventricle via an LVV catheter opening and coronary arteriotomy therefore causes gaseous microembolic events responsible for NPM following CAB.
Aneurysmal arteriovenous fistulae (AVF) for haemodialysis often need surgical closure. We present a technique which consists of inserting the AVF into a constrictive perivenous mesh tube, thereby bringing the caliber of the AVF down to its normal size and restoring the normal shape of the forearm. Nine patients underwent AVF constriction without postoperative events. All AVFs were patent at 4 months. This technique also has the advantage of saving veins which, of course, is worthwhile in patients under haemodialysis.
The distal latero-circumflex arteries and the posterior descending artery are located so far from the mammary arteries that they cannot be revascularized by the conventional procedure. Reimplantation of the right internal mammary artery (RIMA) used as a free graft into the left internal mammary artery (LIMA) in situ doubles the length of the RIMA, thus enabling the distal coronary arteries (lower lateral or posterior interventricular arteries) to be bypassed. The Y-shaped reimplantation anastomosis technique is described, and the immediate results obtained in 25 patients are reported. Seven angiographic controls were performed after 6 months to 1 year, and 6 anastomoses were perfectly patent. One RIMA is occluded (major competitive flow).
Distal latero-circumflex arteries (DLCA) and posterior descending artery (PDA) are anatomically too far and cannot be revascularized with internal mammary artery (IMA) by a conventional procedure. The reimplantation of the right IMA into the left IMA in situ increases (2 times) the length of right IMA graft available. Fifty-five patients underwent this technique. Their preoperative status was: 22 males, 3 females; mean age: 57 years, 38% myocardial infarction (MI). Coronary angiography showed: stenosis of the left main coronary artery: 3; stenosis of 3 vessels: 15; 2 vessels: 10; 2.3 anastomoses by patient were performed with Y right and left IMA procedure: 24 LDA, 8 diagonals, 25 DLCA and 1 PDA anastomosis. No deaths were observed in this short series. Morbidity was: 1 MI, 2 sternal sepsis, 1 bilateral phrenic paralysis (all were cured without sequelae). To date (March 90) 15 patients have been followed for 3 to 12 months, 12 are angina-free, 3 are significantly improved, 11 have a negative exercise test. Thallium test is normal in the revascularized area in 14 patients. Seven angiographies have been performed (6 months to 1 year) and all Y right IMA are patent.
Distal latero-circumflex arteries (DLCA) and posterior descending artery (PDA) are anatomically too far and cannot be revascularized with internal mammary artery (IMA) by a conventional procedure. The reimplantation of the right IMA into the left IMA in situ increases (2 times) the length of right IMA graft available. Fifty-five patients underwent this technique. Their preoperative status was: 22 males, 3 females; mean age: 57 years, 38% myocardial infarction (MI). Coronary angiography showed: stenosis of the left main coronary artery: 3; stenosis of 3 vessels: 15; 2 vessels: 10; 2.3 anastomoses by patient were performed with Y right and left IMA procedure: 24 LDA, 8 diagonals, 25 DLCA and 1 PDA anastomosis. No deaths were observed in this short series. Morbidity was: 1 MI, 2 sternal sepsis, 1 bilateral phrenic paralysis (all were cured without sequelae). To date (March 90) 15 patients have been followed for 3 to 12 months, 12 are angina-free, 3 are significantly improved, 11 have a negative exercise test. Thallium test is normal in the revascularized area in 14 patients. Seven angiographies have been performed (6 months to 1 year) and all Y right IMA are patent.
From 1985 to november 1989, 270 patients underwent sequential anastomosis with left internal mammary artery (LIMA) on left descending artery (LDA) and diagnonal artery (DA). The first 120 cases have 100% one year follow-up. The perioperative status was: angina stage III or IV: 59%; myocardial infarction (MI): 45%, stenosis of 3 vessels: 52.5%; stenosis of main coronary artery: 10.8%. 2.25 anastomoses were performed per patient. Side-to-side anastomosis (kissing) were not diamond anastomoses but axial and longitudinal. The use of fibrin gllude provides regular curves of the graft between anastomosis. Mortality was 0.8%, morbidity was: MI: 4.2% (2 small infarcts in anterior vessels, 3 others in non-grafted vessels); mediastinitis: 1%; severe bleeding (reoperation): 1%. At one year 93% of patients are free from angina and 71 patients underwent angiographic assessment (145 LIMA anastomosis). Results are as follow: side-to-side anastomosis patency: 98.5%; distal anastomosis obliteration: 3%; LDA anastomosis patency: 95.7% overall sequential anastomosis patency: 97.6%. These results have led our cardiologist in Brest to naturally prefer a surgical approach than percutaneous angioplasty when LDA and DA are involved.
One hundred and twenty-one consecutive patients (104 men, 17 women; mean age 56 +/- 7.8 years) underwent sequential mammary artery grafting for anterior (left anterior descending or diagonal arteries) wall revascularisation. There was one death (0.8%) and five myocardial infarctions (4.2%) including two anterior infarcts during the first 30 postoperative days. All survivors were reviewed at one year. Of these 120 patients, 77 (64%) accepted control coronary angiography on average 456 +/- 143 days after surgery. One internal mammary artery anastomosed to 2 diagonal arteries was occluded. All the other latero-lateral anastomoses were patent. There was, however, one 60% stenosis. Three termino-lateral anastomoses on the left anterior descending artery were occluded and 2 others stenosed (40% and 60% luminal narrowing, respectively). Four internal mammary arteries were narrowed 2 because of stenosis and 2 because of the small calibre of the receiving artery. The patency rate considering the total number of anastomoses was therefore 96.8%. These results show that sequential internal mammary artery grafting for myocardial revascularisation does not increase the number of perioperative complications and is associated with a low rate of occlusion on the left anterior descending artery at one year. This surgical technique may therefore be used routinely.
The Medtronic Intact is a recently commercialized porcine bioprosthesis. Its function and ultrasonic characteristics have not been widely studied. The authors performed a prospective Doppler echocardiographic study of 38 patients with Intact bioprosthesis (n. 19:1, n. 21:10, n. 23:9, n. 25:14, n. 27:3, n. 29:1) implanted in the aortic position and without clinical signs of dysfunction over a period of 8 +/- 5 months after surgery. The following parameters were measured: maximum and mean velocities, maximum and mean transprosthetic pressure gradients, permeability index (PI) or the ratio of subaortic to transprosthetic velocities, and the effective prosthetic surface area (S) calculated using the continuity equation. The PI and S were calculated by two methods, the first using the ratio of maximum velocities (PI1 and S1) and the second using the ratio of the velocity-time integrals (PI2 and S2). The global results were: Vmax 2.65 +/- 0.4 m/s range 1.9 to 3.7 m/s), maximum pressure gradient 29 +/- 9 mmHg (range 15-55 mmHg), mean pressure gradient 16.8 +/- 5.6 mmHg (range 9-32 mmHg), PI1 37.8 +/- 4.5 p. 100 (range 26-48%), PI2 39.1 +/- 5.5 p. 100, S1 1.25 +/- 0.19 cm2 (range 0.96-1.7 cm2) and S2 1.29 cm2 +/- 0.17 cm2. Minimal central prosthetic valve regurgitation was observed in 2 cases (5%). No correlations were found between the size of the prosthesis and blood flow velocities, pressure gradients or permeability indices. On the other hand, a correlation was observed between S and the size of the prosthesis (r = 0.88, p less than 1.10(-6) (S1); r = 0.80, p less than 1.10(-6) (S2)).(ABSTRACT TRUNCATED AT 250 WORDS)
The authors report a case of internal mammary artery graft anastomosed to the left anterior descending coronary artery (LADC) which was found to be non functional in the early post-operative period (one month) but second catheterization at one year revealed the graft to be patent with thrombosis of the LADC. This case shows the flow adjustment possibilities of internal mammary artery graft.
We report the case of a 73-year-old woman successfully treated for a subacute rupture of the ventricular free wall which occurred on the fourth day after a postero-lateral myocardial infarction. Angiography performed prior to surgical repair revealed the presence of normal coronary arteries. The pathogenetic mechanism of such a happening remains uncertain, but the role of abrupt recanalization must be considered.
In this series of 184 patients (pts), 312 internal mammary arteries were used to graft 430 coronary arteries. Two mammary arteries were used in 104 pts and sequential anastomoses were performed in 118 pts. The operative mortality was 1.6% and the peri-operative myocardial infarction was 4.1%. 9% of patients had post-operative complications: 1% of bilateral phrenic paralysis, 2.1% of post-operative hemorrhage leading to reoperation, 1.6% of sternal infection, 0.5% of true mediastinal infection, 1.6% of sternal dehiscence and 2.7% of reversible psychiatric illness. A 3 month follow-up was available in 160 pts. 95% of patients became angina free, the thallium scan shown a normal uptake of thallium at maximal stress in the myocardial grafted area in 92% of the patients.
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Analysis of the first 50 clinical cases confirmed conclusions of experimental studies in large animals with respect to the use of absorbable synthetic clips formed of lactomer and polydioxanone. The advantages of clips when compared with ligatures include rapidity and simplicity of use and ease of insertion, even in regions difficult to approach surgically with the fingers. The advantages of clips of the absorbable synthetic type over conventional metallic material are: safety and reliability due to their locking system and the conservation of sufficient residual resistance, improved behavior in biologic media, radio-transparency and total inertia in magnetic fields compatible with postoperative radiation and modern medical imaging procedures (CT scan, IRM), and finally progressive resorption predictable by simple hydrolysis and then total disappearance after 6 to 7 months. With staplers of the TA and GIA type these clips make sutures and ligatures during lung resection surgery entirely automatic.
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Saphenous veins undergo dramatic morphologic changes when used as coronary bypass grafts, and careful preparation of the graft alone is inadequate in preventing these changes. In this study, the use of a constrictive mesh for vein graft was evaluated. Fourteen sheep were subjected to a 5 cm resection of the carotid artery. Six sheep (Group A) received a jugular vein interposition graft, and the other eight sheep (Group B) received a jugular vein graft on which the constrictive mesh had been applied. The diameter of grafts in Group A was 14 +/- 1 mm compared with 7 +/- 0.5 mm for Group B (p = 0.05). The animals were put to death 4 months later. Scanning electron microscopy showed a disruption of the endothelial lining in Group A and a normal endothelium in Group B. Microscopy showed a statistical difference between Groups A and B regarding regularity and thickness of the intimal hyperplasia. Group B showed a moderate and regular intimal thickening and increased vasa vasorum. This indicates that distention and subsequent damage of the vein graft may be minimized by use of a constrictive mesh. Saphenous grafts surrounded by this constrictive mesh were inserted in four patients. Vein diameters were, respectively, 5, 4.3, 3.5, and 3.5 mm before meshing. After insertion in the mesh, vein diameters were 4.3, 3.5, 2.8, and 2.5 mm, respectively. Angiography performed 2 months later showed patent grafts of regular caliber.
Patients with angiographic non-surgical triple vessel coronary artery disease are usually considered to have a poor prognosis. We studied the evolution of 110 consecutive patients (mean age of 54.8 years) who underwent coronary angiography between April 1979 and March 1983 and followed up for an average of 24 months after the investigation. There were 10 deaths during the study period, all of "cardiac" causes (5 sudden deaths, 1 cardiac failure and 4 myocardial infarctions). Ninety nine of the 100 survivors at the time the study was closed had a medical treatment (nitrate derivatives, beta-blockers, calcium antagonists, usually associated). The actuarial survival was 94 +/- 2.2% at one year, 87.3 +/- 3.5% at 4 years. The quality of life expressed in terms of angina and breathlessness was good on the whole, as only 16 and 10 patients respectively had Grade III angina and dyspnea at the end of the study. Lack of resources and a follow-up period which was too short to assess the mortality rate meant that we were unable to analyse the factors which influenced the prognosis in this group of patients. These results support those of recent studies showing a mortality rate of patients with angiographic non-surgical triple vessel coronary artery disease that does not exceed 3 to 4% per year; these results seem to have improved over the last twenty years.
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