Biomedical subjects
Publications and source records attributed to J Ninet.
A 16-month-old boy who had a heart-lung transplantation is doing well 16 months postoperatively. The HLT can be a successful treatment for very young patients. Most of the postoperative management can be assessed with noninvasive techniques. Normally, the allograph grows with the recipient.
Accelerated atherosclerosis of cardiac grafts is one of the factors limiting long-term survival after cardiac transplantation. The authors report the case of a patient who had a cardiac arrest associated with severe atherosclerosis 18 months after transplantation. The severity of the coronary lesions was underestimated by coronary angiography. An ergometrine test induced coronary spasm, a phenomenon which has only rarely been observed in transplanted hearts. The patient died one month later despite calcium inhibitor therapy. Autopsy revealed very severe triple vessel disease. This case illustrates the possible rapid evolution of coronary artery disease in cardiac transplant recipients, the difficulty in evaluating the severity of the lesions by coronary angiography and the additional possibility of observing coronary spasm in these cases.
The poor results of palliative surgery in the hypoplastic left heart syndrome has led Bailey to propose neonatal cardiac transplantation for this condition. The authors report the case of a neonate who underwent transplantation 2 days after birth for hypoplastic left heart with mitro-aortic atresia, diagnosed in utero. The child was prescribed triple immunosuppressive therapy (steroids, azathioprine, ciclosporine) and is now 24 months old. An episode of acute rejection during the first month was treated with a short intensive course of intravenous steroids. At the fourth month, the child underwent aortic angioplasty for an isthmic stenosis. Growth is retarded (- 2SD) and he has mild renal failure but psychomotor development has been normal. The number of neonatal cardiac transplantations remains limited by parental refusal and the lack of donor organs. Despite encouraging medium term results, questions remain as to the long-term viability of the graft and the patient's renal function.
The local microcirculatory effect of percutaneous nitrate derivatives was evaluated by determining flux by laser Doppler in 10 controls. The application of Lenitral cream under the recording probe produced a rapid (within a mean of 6.7 min) elevation in the flux, reaching a maximum in 20 min and returning to baseline values in 55 minutes. This vasodilatory effect was maximal in the richly vascularized zones, but remained limited to the site of application of the nitrate derivatives, being undetectable even at a short distance from the application zone.
A case of hemophilus influenzae type B pericarditis in a 2-yr-old infant is reported. The authors emphasize the interest of cardiac ultrasound and pulse Doppler for diagnosis, the evaluation of hemodynamic consequences and follow-up.
Retrospective studies have been conducted in Lyon (33 patients) and Montreal (24 patients) in order to compare the results of transventricular valvotomy (TVV, 20 cases) and aortic valvotomy with cardiopulmonary bypass (CPB, 37 cases) in neonatal critical aortic stenosis. Clinical, echocardiographic, catheterization and operative data were analyzed in order to determine prognostic factors. Mortality rate was 59%: 30/34 perioperative deaths in the first month, and 4 late deaths after a reintervention for severe residual obstruction. Long term follow up was available for 23 patients (41%) for a 2 to 16 year period (mean 7.5). Five patients (7%) required a reintervention six years after the initial operation. Two of them required valve replacement. Eighteen patients (31%) surviving the initial operation, displayed a satisfactory result, being free of symptoms, endocarditis, reoperation and sudden death. Factors that influenced the outcome included severe heart failure, a left ventricular end-diastolic diameter below 14 mm, an aortic valve annulus below 8 mm, and a poor shortening fraction. Factors that did not influence the prognosis were age, pulmonary hypertension, and the anatomic type of the valve. Trans-aortic valvotomy with CPB was associated with a smaller operative mortality and a better long term result than TVV.
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The purpose of this study was to test the efficacy of traditional Chinese acupuncture in the treatment of scapulohumeral pain during the early stage following heart surgery, by puncture of points not related anatomically or metamerically with the scapulohumeral joint and without any needle stimulation. Reduction of pain and angular gain were almost immediate, durable, measurable and reproducible, which could be explained by possible effects of acupuncture on articular sympathetic mechanoreceptors, then suppressing reflex muscular contractions due to intraoperative postural constraints.
A retrospective study of 150 children under 3 months of age who underwent repair of coarctation of the aorta in the same center (between 1972 and 1987) was undertaken to assess the problems posed by surgery without cardiac catheterisation or angiography. The patients were divided into two groups: Group A, comprising 104 children operated after invasive investigations, and Group B, comprising 46 children operated on Doppler echocardiographic data alone. The two populations were comparable and "hypoplastic aortic arch" type coarctation was present in over 60% of cases. However, there were more ventricular septal defects in Group B (67.5%) than in Group A (49%). There were no significant diagnostic errors in Group B (one case of interrupted aortic arch diagnosed at surgery). The 1 month survival was the same in the two groups (82%). The indications of pulmonary artery banding were less frequent in Group B although there were more ventricular septal defects in these patients. These results confirm the value of Doppler echocardiography in the context of urgent surgery of congenital heart disease.
Ninety-three cardiac transplantations were carried out in 91 patients (2 retransplantations) between March 1st 1987 and November 1st 1989, in 84 adults and 7 children under 15 years of age. The indications were dilated cardiomyopathy (48%), ischemic cardiomyopathy (35%), decompensated valvular heart disease (11%), congenital heart disease (3%) and two cases of Uhl's anomaly. Twelve patients underwent transplantation after external circulatory assistance (13%), 11 patients after inscription on the list of extreme emergencies, and 68 on an elective basis (74%). The postoperative immunosuppressive protocol was triple therapy: Ciclosporine, Azathioprine and Prednisone. Three of the children died. The early adult mortality was 9 cases (10.7%). It was 8% in patients operated electively. Major infectious complications occurred in 10 patients (11%). Rejection was looked for by systematic endomyocardial biopsy and echocardiography. Three hundred and forty-nine biopsies were made. Thirty-five patients (44%) had no problems of rejection. Seventy-nine patients have now been followed up for an average of 19 months. There were 7 late deaths. Seventy seven per cent of the survivors are asymptomatic. Acute rejection and transplant dysfunction were the two main causes of early mortality after cardiac transplantation. Although the long-term prognosis is uncertain, the medium-term results are very encouraging.
The authors report two cases of anomalous origin of the left coronary artery from the pulmonary artery in the adult. The two patients were pauci-symptomatic and were successfully operated, the one by reimplantation of the left coronary artery in the aorta and the other by an internal mammary artery left anterior descending artery bypass. Resting and stress myocardial scintigraphy and radionuclide ventriculography were performed before and after surgery in both cases. An analysis of segmental wall motion was possible in one patient. Before surgery, there was hypo-fixation of the tracer during the stress test and an alteration of left ventricular function. Postoperative isotopic investigations confirmed the efficacy of surgery the absence of regional ischemia and the normalisation of the ventricular contraction. These results argue in favour of a surgical reconstruction of a two coronary system, given the spontaneous risk of sudden death in this condition.
Twenty-four patients with a Saint-Jude Medical tricuspid valve prosthesis, aged 5 to 77 years, were studied. The etiology of the tricuspid lesion was rhumatic in 17 cases, infectious in 4 cases, and congenital in the other 3. Fourteen patient (58%) had undergone previous valve surgery, 7 of whom had undergone tricuspid valve replacement (TVR) by a bioprosthesis. Three patients were operated on for the third time. The TVR was isolated (4 cases) or associated with aortic valve replacement (3 cases), mitral valve replacement (8 cases), double aortic and mitral valve replacement (7 cases), repair of a ventricular septal defect (VSD) (1 case) and radical treatment of a Wolff-Parkinson-White syndrome (WPW) in 1 case. There were 3 early deaths (12.5%). Eighteen of the 21 survivors were followed up clinically, biologically (detection of hemolysis) and by Doppler echocardiography for an average period of 45 months (range 10 to 96 months). The clinical benefit was clear cut. No embolic complications were observed and there were no cases of hemolysis. The mean resting tricuspid pressure gradient was 3.57 +/- 2.36 mmHg. The Saint-Jude Medical prosthesis would therefore seem to be a good alternative to other mechanical valve prosthesis in the tricuspid position and without the risk of valve degeneration associated with bioprosthesis.
Fifty infants with isolated total anomalous pulmonary venous connection (TAPVC) were operated between 1/01/73 and 31/12/87. The average weight at surgery, which was performed under hypothermia with circulatory arrest in 92 per cent of cases, was 4.5 Kg. The preoperative pulmonary to systemic pressure ratios (PAP/PS) enabled identification of two groups of patients: Group I: TAPVC without severe pulmonary hypertension (PAP/PS less than 0.85) (n = 35), and Group II: TAPVC with severe pulmonary hypertension (PAP/PS greater than 0.55) (n = 15). The hospital mortality was 22 per cent (8 cases) in Group I compared with 73 per cent (11 cases) in Group II (p less than 0.05). Patients in Group II were younger (64 days compared with 137 days, p less than 0.02), lighter (p less than 0.05) and had preoperative mean pulmonary artery systolic pressures of 83 mmHg (p greater than 0.001). Three patients in Group I required early reoperation for stenosis of the pulmonary veins at the site of repair resulting in pulmonary hypertension, and all died. The global survival was 28 patients with an average follow-up of 7 years (range 1 to 15 years). Six of these patients were reoperated (2 phrenoplications, 4 atrial shunts). All survivors are asymptomatic and have no conduction defects. Control echocardiography in 15 of the 28 survivors was judged to be normal. These results show that obstructive forms of TAPVC (Group II) carry a very poor prognosis: immediate results in this group could only be improved by earlier surgery. The clinical long-term results in those who survive surgery are very satisfactory.
Between 1973 and 1989, 81 consecutive patients aged 2 to 42 years old, with ventriculo-pulmonary discontinuity, were treated by implantation of prosthetic conduits. The initial pathology was Tetralogy of Fallot (33%), complete transposition of the great arteries (20%), truncus arteriosus (17%), double outlet right ventricle (17%) and atrioventricular discordance with L malposition of the great arteries (10%). The overall early mortality was 22% (18 cases) and 14% (5 cases) in the 36 patients operated after 1982. Sixty three patients were followed up for 3 months to 16 years; there were 8 late deaths which occurred spontaneously or at reoperation. Postoperative catheterisation was carried out in 33 cases; the average ventriculopulmonary systolic pressure gradient was 40 +/- 26 mmHg. Six patients were reoperated to change the conduit, on average 6 years +/- 23 months after the first operation. Five other patients underwent endoluminal dilatation of a stenosed conduit which delayed reoperation to change the conduit in 3 cases. Prosthetic conduits have been extensively used in patients with ventriculo-pulmonary discontinuity because they are readily available. However, because of progressive degradation of the prostheses between the 5th and 10th postoperative years, other therapeutic solutions should be considered, i.e. endoventricular repair when possible and, in other cases, the use of aortic homografts.
Seven children or adolescents aged 8 to 20 years (average 13.5 years) underwent implantation of an apico-aortic conduit from 1980 to June 1989. Eleven previous operations under cardiopulmonary bypass had been performed. The indications were recurrence of muscular subaortic stenosis and/or congenital valvular stenosis in 3 cases, and stenotic, previously implanted aortic valve prosthesis of small calibre in 4 cases. The preoperative left ventricular-aortic systolic pressure gradient was between 70 and 130 mmHg. The first two patients had a bioprosthetic valvulation and the 5 succeeding patients a St Jude Medical mechanical prosthesis. The early and late mortality was nil. The average follow-up period is 5, 6 years at present (range 6 months to 9 years). One patient had to undergo repeat valve replacement after 5 years for degenerescence of the porcine bioprosthesis implanted in the conduit. No other complications related to the conduit or valve were observed. At the endpoint of the study all patients were asymptomatic without treatment. Control echocardiographic data showed normalisation of the indices of left ventricular function. Apico-aortic conduits would seem to be a safe and effective technique for the treatment of recurrent severe obstruction of the left ventricular outflow tract.
Twenty-five patients aged 31 to 74 years (average 50 years) operated for type A aortic dissection (type I: 19 cases, type II: 6 cases) were included in this study. Surgical repair only concerned lesions of the ascending aorta. The hospital mortality was 20 per cent (5 cases), and usually secondary to extension of the dissection. With the exception of 2 late deaths, all patients were followed up for an average of 3.5 years. A late assessment including nuclear magnetic resonance imaging of the thoracic aorta was obtained in 17 of the 18 survivors. These investigations confirmed the good result of repair of the ascending aorta, the uselessness of systematic aortic valve replacement and the palliative nature of repair of type I dissection as 80 per cent of patients had a persistent patent false lumen in the distal aorta.
Eleven patients aged 7 to 58 years were placed on assisted circulation with Pierce (2 cases) or Abiomed (9 cases) external prosthetic ventricles as a bridge to cardiac transplantation. The indications were terminal cardiac failure following cardiomyopathy (7 cases), decompensated ischemic heart disease (3 cases) and subacute post-transplantation rejection (1 case). The duration of the assisted circulation ranged from 24 hours to 11 days. All patients were transplanted but 3 died after transplantation (27%). The circulatory assistance was satisfactory in all patients as shown by the regression of clinical signs of low cardiac output and the normalisation of diuresis. The complications observed during assisted circulation and after cardiac transplantation were: haemorrhage (36%), infection (27%) and thromboembolism (9%). These preliminary results with a 72% post-transplantation survival rate, show that both systems are effective "bridges to cardiac transplantation". The Abiomen device is excellent value for money and relatively simple to install and represents a good compromise between the sophisticated techniques of circulatory assistance and the problems of the cost of health care.
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