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Biomedical subjects

J Rubay

Publications and source records attributed to J Rubay.

At least 19 recordsLinked to original sources
PubMed2000

Surgical repair of the prolapsing anterior leaflet in degenerative mitral valve disease.

BACKGROUND AND AIM OF THE STUDY: Repair of the prolapsing anterior leaflet (AML) in degenerative mitral valve disease is more demanding than that of the posterior leaflet. We reviewed our experience in the past eight years, to examine the safety, efficacy and stability of various repair artifices. METHODS: Between January 1989 and December 1997, 102 patients (mean age 64 years; range: 26-86 years) with mitral regurgitation (MR) due to prolapse of the anterior or both mitral leaflets underwent mitral valve repair. Sixty-six patients were in NYHA class > or =III, and 94 had MR grade >II. Acute endocarditis was present in 12 patients and Barlow disease in 16. Surgical techniques consisted of chordal shortening (n = 36), chordal transposition (n = 16), papillary muscle shortening or plication (n = 10), flip-over (n = 20) and artificial chordae implantation (n = 20). RESULTS: There was no early mortality; one patient required early mitral valve replacement (MVR) for late-appearing systolic anterior motion, and one patient benefited from a successful re-repair on day 8 for partial posterior leaflet desinsertion. Mean follow up was 30 months (range: 3-92 months); there were four late deaths (two valve-related cerebrovascular accidents); two patients required re-repair (one after three months for prosthetic ring thrombosis, and one after 10 months for rupture of shortened chordae (corrected by flip-over)). Five patients had MVR between four and 32 months later: one for mitral stenosis due to posterior leaflet calcification, and four for recurrent MR due to the rupture of shortened chordae (n = 3) or plicated papillary muscle (n = 1). One patient suffered bacterial endocarditis which was treated medically. Of the 92 remaining patients with valve repair, 81 are currently asymptomatic, five are in NYHA class II and four in class III. Transesophageal echocardiographic restudy (n = 76) at a mean of 30 months after surgery revealed no MR in 68 patients, and MR of grade <II in three. CONCLUSIONS: AML prolapse repair is safe, durable, and therefore can be attempted even in mildly symptomatic patients. However, chordal shortening should be substituted by implantation of artificial chordae or by the flip-over technique.

Aged↗
PubMed1998

Long-term survival after aortic valve replacement for native active infective endocarditis.

BACKGROUND: The objective of this study was to analyse the impact of acute surgery for native aortic valve endocarditis and its influence on the long-term prognosis after surgery. METHODS: A total of 161 patients underwent aortic valve replacement for native active aortic valve endocarditis (NAAVE) during a 29-year period, from 1967 to 1995 (age range: 10 to 72 years; mean 48 +/- 12). The main indication for surgery was progressive congestive heart failure (76%). Other indications were untreatable sepsis (27%), peripheral or central emboli (12%) and, from 1978, echocardiographic evidence of friable, pedunculated vegetations (3%). Streptococcal and staphylococcal infections predominated. Concomitant procedures were performed in 27% of the patients, including mitral and tricuspid valve surgery and coronary bypass procedures. RESULTS: Operative mortality was 8% in the majority of cases caused by heart failure or multi-organ failure. Multivariate logistic regression analysis identified NYHA class IV to be an independent predictor for postoperative death. Long-term survival for discharged patients was 75% at 10 years and 58% at 15 years, with a mortality rate of 3.6%/patient/year. Cox regression analysis identified the year of operation, trivalvular endocarditis and staphylococcal infection as independent predictors of survival. At 10 and 15 years after aortic valve replacement, 91% and 84% of the patients, respectively, were free of recurrent endocarditis. The presence of an abscess cavity at first operation was found to be predictive of recurrent endocarditis. CONCLUSIONS: Valve replacement for NAAVE offers a good chance for a cure and satisfactory long-term survival. Improvements in pre- and per-operative management of the very ill patient, and the use of allograft valves are likely to further improve long-term results. Finally, the presence of staphylococcal endocarditis requires long-term postoperative antibiotic therapy.

Adolescent↗
PubMed1998

Late homograft valve insertion after transannular patch repair of tetralogy of Fallot.

BACKGROUND AND AIMS OF THE STUDY: Transannular patch repair of tetralogy of Fallot leads to pulmonary insufficiency and progressive right ventricular dilatation responsible for a decreased exercise capacity. We studied the impact of late homograft insertion on the regression of the right ventricular volumes in symptomatic patients. METHODS: Between July 1992 and August 1996, 15 consecutive patients (age range: 4 to 24 years) were operated on at a median of 13 years (range: 3 to 20 years) after transannular patch repair of tetralogy of Fallot. All patients complained of exertional dyspnea and fatigue. Syncopes were reported in six patients and four patients had sustained episodes of ventricular tachycardia. Fourteen had pulmonary regurgitation grade 3 or 4 and one had an associated stenosis and insufficiency. All patients had a dilated right ventricle. At reoperation, no patients presented with major aneurysm. The patch was resected and the right ventricular outflow tract reconstructed with a cryopreserved pulmonary homograft. Right ventricular volumes were studied before the procedures and at the last follow up consultation. RESULTS: There was no operative death. One patient who had a concomitant patch repair of a hypoplastic left pulmonary artery needed extracorporeal circulatory support for eight days. After a median follow up of 25 months (range: 3 to 54 months) all patients but one are in NYHA class I. There were no late deaths. The mean end-diastolic diameter of the right ventricle decreased from 36 +/- 9 mm before surgery to 31 +/- 6 mm (not significant). The mean ratio between the end-diastolic diameter of the right and left ventricles decreased from 0.94 +/- 0.3 to 0.74 +/- 0.2 (p < 0.01). CONCLUSION: An increasing number of patients who had transannular patch repair for tetralogy of Fallot will require reoperation for symptomatic long-term pulmonary regurgitation. Homograft reconstruction of the right ventricular outflow tract of these patients induces regression of their right ventricular dilatation and leads to their functional recovery.

Adolescent↗
PubMed1997

The usefulness of the spinal and subcortical components of the posterior tibial nerve SEPs for spinal cord monitoring during aortic coarctation repair.

This study examines how the recording of the lumbar and subcortical components of the posterior tibial nerve (PTN) SEPs may usefully replace that of cortical components in situations in which these components cannot be reliably obtained (infants, high concentrations of halogenated gasses). Lumbar, brain-stem, and cortical PTN SEPs were intraoperatively monitored in 7 patients undergoing repair of aortic coarctation under variable isoflurane concentration (up to 1.2%). Four patients were less than 1 year old. Two distinct activities were evidenced at the lumbar level in all of the patients: the dorsal root component (DRC) and the dorsal horn negativity (DHN). The equivalent of the adult P30 (lemniscal positivity; LP) was also present in all of the patients, whatever their age or the concentration of isoflurane. By contrast, the parietal activities were absent intraoperatively in the youngest patients. Spinal-cord ischemia consecutive to aortic cross-clamping gave rise to early DHN changes and later alterations of the LP in the two patients in which it occurred, while the DRC and the peripheral nerve activities remained unchanged. This elective sensitivity of the DHN is likely due to it being dependent on the gray matter of the spinal cord, the basal metabolism of which is greater than that of the white matter and to the situation of the DHN generator in a watershed zone of the spinal cord. This study emphasizes the interest of PTN SEPs for spinal-cord monitoring in vascular surgery and the importance of combining the recording of parietal activities with that of the lumbar spinal components.

Adult↗
PubMed1997

Is mechanical circulatory support helpful before cardiac retransplantation?

Ventricular assist devices are widely used as a bridge for cardiac transplantation patients. The purpose of the present study was to evaluate retrospectively, whether the use of ventricular assist devices could increase survival after early or late retransplantation. Over the past 10 years, 219 patients were transplanted in the authors' centre. Eight of 11 retransplanted patients required preoperative insertion of a ventricular assist device. Five assist systems were implanted in the early period after transplantation ( < 30 days) and three later after transplantation ( > 30 days). After early retransplantation, two patients survived and three died. All three late retransplantations were successful and all patients are still alive with a mean (s.d.) follow-up of 25(22) months. Ventricular assist devices are helpful for late retransplantation but do not improve poor survival after early retransplantation. Such devices should not be set up for early retransplantation.

Adult↗
PubMed1996

Free internal mammary artery graft in myocardial revascularization.

Between August 1986 and March 1993, 124 patients (102 men; mean age of 59 years) underwent myocardial revascularization with the use of at least one free internal mammary artery (FIMA). This group represents 4.5% of the 2725 coronary bypasses performed during the same period. Seventy-six patients (61%) had suffered from at least one previous myocardial infarction. Forty-five patients (36%) had unstable angina; three-vessel disease was found in 100 cases (80.5%) and a left ventricular ejection fraction lower than 0.4 in 22 (17.7%). There were 18 (14.5%) redo procedures and 90 (72.5%) bilateral internal mammary artery (IMA) grafts. The reasons for using a FIMA were: too short an internal mammary artery pedicle in 83 patients, IMA injury at harvesting in 30 patients and post-bypass ischaemia in areas grafted with pedicled IMA (PIMA) in 11 patients. Cardiopulmonary bypass, moderate hypothermia (30 degrees C) and crystalloid anterograde and retrograde cardioplegia were used in all cases. Sixty-seven FIMA grafts were anastomosed directly to the ascending aorta; 57 were sutured via a saphenous hood using a running suture of polypropylene 7/0 and three were anastomosed end-to-end to a PIMA graft. FIMA grafts were directed to the left anterior descending (34%), the circumflex (37%) and the right coronary artery (29%). In total, 179 anastomoses were constructed using 127 FIMA, 136 using PIMA and 158 using saphenous veins (3.8 anastomoses per patient). Hospital mortality and postoperative myocardial infarction rates were 5.6% (seven patients) and 3.2% (four patients), respectively. Cardiac-related mortality was 3.2% (four patients); three of these four patients had been operated on for evolving infarction and one underwent a redo procedure. Four of the 117 survivors died later on; in two, it was cardiac-related and a result of global heart failure at 9 and 12 months. Of the 113 remaining patients, 106 are symptom free after a mean follow-up of 28.2 (range 3-84) months. Fifty-nine patients (50.4%) were restudied by angiography at a mean interval of 15 months. Patency rates of FIMA anastomosed either directly to the aorta or via a saphenous hood were 82.8 or 89.7%, respectively. Patency rates of FIMA directed to the left anterior descending, the circumflex and the right coronary artery were 85.7, 88 and 83.3%, respectively. Global FIMA patency was 86.4%, while global PIMA patency was 100%. The FIMA mid-term patency rates compare unfavourably with those of PIMA: FIMA should therefore be restricted to the cases where PIMA or other pedicled arterial grafts are unavailable.

Aged↗
PubMed1996

Multilevel somatosensory evoked potentials (SEPs) for spinal cord monitoring in descending thoracic and thoraco-abdominal aortic surgery.

The usefulness of somatosensory evoked potential (SEP) monitoring as a means of preventing paraplegia in descending aorta surgery was evaluated in 47 consecutive cases operated on for isthmic (14 cases), thoracic (22 cases), or thoraco-abdominal (11 cases) repair. An aortic dissection was found in 11 cases (acute in 6). Somatosensory evoked potentials were obtained by unilateral left and right posterior tibial nerve (PTN) stimulation at the ankle and recordings were performed on four channels: peripheral nerve, lumbar spinal, brain-stem, and cortical recordings. Our experience led to the following current strategy: the establishment of atrio(aorto)-femoral(aortic) bypass (29 cases), proximal and distal aortic cross-clamping, aortic repair with reimplantation of the culprit artery(ies) as indicated by SEP alterations. Five types of SEP alterations were defined on the basis of the neural level involved: type I (27.7% of cases) = distal spinal ischemia due to proximal aortic cross-clamping in the absence of bypass; type II (21.3%) = PTN ischemia due to left common femoral artery cross-clamping; type III (12.8%) = segmental spinal ischemia due to the exclusion of critical feeding arteries; type IV (4.3%) = ischemia in the left carotid artery territory; type V (4.3%) = global brain hypoperfusion due to systemic hypotension. Forty-five patients survived the operation and could be tested for neurological dysfunction. Three patients presented a postoperative spinal cord deficit, but this deficit was already present preoperatively in one case, so that the actual incidence of a new paraplegia in our series was 2/45 cases (4.4%). One of the two cases was clearly a delayed paraplegia with SEP alterations appearing several hours after the operation. Somatosensory evoked potentials were evaluated on the basis of their sensitivity, specificity, and impact on the surgical strategy. Regarding SEP sensitivity, we did not encounter any unexpected immediate paraplegia, but the critical factor appeared to be the duration of SEP absence due to spinal cord ischemia, which, according to the literature, should never exceed 30 min; after a longer absence, SEP return does not guarantee neurological recovery. Somatosensory evoked potential specificity was also 100%, but only 58% of the abnormalities found were actually consequent to spinal cord ischemia, the rest of the abnormalities being consequent to peripheral nerve or brain ischemia. Finally, SEP monitoring had a significant impact on surgical strategy in 19% of the cases. It is concluded that distal aortic perfusion and multilevel SEP monitoring play a significant role in preventing paraplegia in descending aorta surgery.

Adolescent↗
PubMed1995

Early balloon dilatation of the pulmonary valve in infants with tetralogy of Fallot. Risks and benefits.

BACKGROUND: Balloon dilatation, an established treatment for pulmonary valve stenosis, remains a controversial procedure in tetralogy of Fallot. METHODS AND RESULTS: Balloon dilatation of the pulmonary valve was performed in 19 infants with tetralogy of Fallot. Its effects on the severity of cyanosis, the growth of the pulmonary valve and pulmonary arteries, and the need for transannular patching were evaluated. Clinical, echographic, angiographic, hemodynamic, and operative data were analyzed. The procedure was safe in all, without significant complications. After balloon dilatation, systemic oxygen saturation increased from a mean value of 79% to 90%. This increase proved to be short-lasting in 4 patients, who required surgery before the age of 6 months. Balloon dilatation increased pulmonary annulus size in each case, from a mean value of 4.9 to 6.9 mm (P < .001). This gain in size remained stable over time, with a mean Z score of -4.8 SD before dilatation, -3.1 SD immediately after the procedure, and -2.7 SD at preoperative catheterization (P < .001). Pulmonary artery dimensions remained unchanged immediately after balloon dilatation but increased at follow-up from a Z score mean value of -2.5 to -0.06 SD and from -2.2 to 0.04 SD for right and left pulmonary arteries, respectively (P < .001). At the time of corrective surgery, the pulmonary annulus was considered large enough to avoid a transannular patch in 69% of the infants. This represented a 30% to 40% reduction in the need for a transannular patch compared with the incidence of transannular patch expected before balloon dilatation. CONCLUSIONS: Pulmonary valve dilatation in infants with tetralogy of Fallot is a relatively safe procedure and appears to produce adequate palliation in most patients. It allowed the growth of the pulmonary annulus and of the pulmonary arteries, resulting in a mean gain of 2 SD for those structures.

Cardiac Catheterization↗
PubMed1995

[Cardiovascular evaluation in athletic children].

Although rare, sports related sudden cardiac deaths in children and adolescents justify the search for risk factors in any child or adolescent who wishes to practice sports. Each time that history and careful clinical cardiovascular examination point to a possible cardiovascular abnormality, an electrocardiogram and an echocardiography must be performed. Exercise testing is useful to appreciate the cardiovascular tolerance, either in normal subjects or in subjects with a cardiovascular abnormality; its interpretation requires good knowledge and understanding of hemodynamic responses to exercise. Indications, risks and procedures of exercise testing are discussed with reference to exercise physiology.

Cardiovascular Diseases↗
PubMed1995

Surgical treatment for acute native aortic valvular infective endocarditis: long-term follow-up.

During the period 1970-1993, 116 patients (63 men, 53 women) with native aortic valvular infective endocarditis were treated surgically. The mean age was 37 years. The main causative organisms were streptococci and staphylococci. Indication for surgery was cardiac failure (70 cases), uncontrolled sepsis (30), peripheral emboli (11) and overwhelming destruction of the aortic valve (five). Hospital and late mortality rates were 8% and 11% respectively. Patients who died in hospital and those who presented a paravalvular leakage had a ring abscess associated with aortic wall destruction. Among 34 patients screened for cerebral septic emboli the condition was confirmed in 15, of whom six were symptom-free. Thus, it is believed that in the presence of root abscess, surgery should be undertaken promptly, regardless of the cardiac status. It is confirmed that cerebral septic emboli should be systematically screened for in the presence of any infective endocarditis.

Acute Disease↗
PubMed1994

Isolation of the left coronary artery ostium by an aortic cusp attachment: a rare cause of myocardial ischemia.

A 34-year-old woman experienced a 3-month history of recurrent chest pain on exertion. Extensive investigation, including coronary angiography, revealed severe aortic incompetence with suspicion of single-vessel coronary disease. At operation the aortic valve was tricuspid but the left coronary cusp was adherent to the aortic wall, resulting in isolation of the left coronary artery with only a tiny communication with the aortic lumen. The three cusps were excised. An aortic valve replacement was performed with an aortic homograft. The postoperative course was uneventful and myocardial ischemia was totally relieved.

Adult↗
PubMed1994

The use of somatosensory evoked potentials to determine the optimal degree of hypothermia during circulatory arrest.

We sequentially recorded subcortical (P14) and cortical (N20) somatosensory evoked potentials (SEPs) in 32 patients undergoing deep hypothermic circulatory arrest (CA). Under normal hemodynamic conditions, hypothermia initially produced N20 disappearance at a mean nasopharyngeal temperature of 20.4 +/- 2.6 degrees C (range 14.5 to 26.1 degrees C) and P14 disappearance at a mean of 16.9 +/- 2.0 degrees C (range 12.4 to 20.2 degrees C). On rewarming, P14 reappeared at mean temperature of 19.3 +/- 4.0 degrees C (range 13.5 to 29.2 degrees C) and N20 at a mean of 21.1 +/- 4.1 degrees C (range 14.3 to 29.6 degrees C). The delay of SEP reappearance after restoration of blood flow correlated significantly with CA duration (r = 0.74 for P14, and r = 0.62 for N20; p < 0.01). Neurological recovery was uneventful in 23 patients; 5 patients presented with neurological sequelae (minor or transient in 4; no recovery from anesthesia and death after 48 hours in 1), and 4 patients died during operation. Twenty-three of 24 surviving patients in whom P14 disappearance was the criterion that hypothermia was deep enough to perform CA (duration: 17 to 94 min) had a normal neurological outcome. By contrast, all surviving patients in whom cortical SEPs disappeared at higher temperatures presented neurological sequelae. In conclusion, the neurophysiological monitoring of brain stem activity, as specifically provided by SEPs, enables determination of the optimal temperature for CA, and demonstrates superiority of SEP monitoring over the use of EEG.

Adult↗
PubMed1993

Bilateral mammary grafting. Clinical, functional and angiographic assessment in 400 consecutive patients.

Between October 1985 and September 1991, 400 patients benefited from bilateral internal mammary artery (BIMA) grafting. Of these, 354 (88.5%) were male and the average age was 57.4 years. There were 132 (33%) urgent procedures, 55 in diabetic patients (14%) and 15 in end-stage renal failures (4%). An average of 3.9 distal anastomoses (AN) per patient was undertaken, 2.8 using arterial grafts. Two hundred sixty-nine patients (67.2%) received exclusively arterial grafts. Right internal mammary artery (RIMA) grafts were predominantly directed to the left coronary system (348 AN = 78%) and particularly to the circumflex (CX) area. Postoperative myocardial infarction was diagnosed in 16 patients (4%). Reoperation was required for early myocardial ischemia in 12 patients (3%) and for excessive bleeding in 23 patients (5.8%). Sternal complications occurred in 18 patients (4.1%), 5 in diabetic patients (9%) and 3 in renal patients (20%). The hospital mortality was 2% (8 patients, 3 cardiac causes). Follow-up averages 37.7 months. Late mortality was 3% (12 patients, 4 cardiac causes). Angina recurred in 12 patients (3.1%). The maximal stress test at a mean interval of 9 months was abnormal in 7.4% (21 patients). One hundred eighty-one patients (47%) consented to an angiographic restudy at an average of 13 months postoperatively. Pedicled RIMA patency rates equal those of pedicled LIMA (95.1 vs 96.7, NS) and the grafted vessel does not alter the patency rates of IMA AN. A pedicled IMA graft is preferable to a free IMA graft (96.1 vs 79.6, P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Cardiac myxoma.

Thirty-five patients (10 men and 25 women) with a preoperative diagnosis of cardiac myxoma have undergone cardiac surgery since 1964 at the University of Louvain. The mean age of the patients was 49 (range 20-75) years. The most commonly encountered symptoms were: dyspnoea 49%; thoracic pain 26%; cough and peripheral embolism 17% each; stroke and preoperative atrial fibrillation 14% each; flutter 11%; expectoration, acute pulmonary oedema, syncope and transient ischaemic attack 6% each; and pulmonary embolism 3%. The different locations were: left atrium 66%; right atrium 26%; both atria 3%; right ventricle 3%: and retrohepatic vena cavae 3%. Septal implantation was found in 66%. Histological examination confirmed 28 myxomas but three 'tumours' were thrombi, two haemangiomas, one rhabdomyosarcoma and one liposarcoma. The follow-up has now reached 2829 months with an average of 81 months per patient (range 0-342 months). Three patients died early (9%) and there were four late deaths (11%). No cases were familial. Surgical resection is the correct treatment for cardiac myxomas and gives good long-term results.

Adult↗
PubMed1989

Ventricular paired pacing to control intractable junctional tachycardia following open heart surgery in a child.

A 5-month-old girl presented postoperatively with an atrioventricular (A-V) junctional tachycardia at a rate of 245/min following surgical repair of tetralogy of Fallot. The systolic blood pressure dropped to 60 mmHg with this rapid heart rate, and the infant became shocked. Drugs and overdrive pacing were ineffective in suppressing the A-V junctional tachycardia and in improving cardiac output. Ventricular paired pacing was used successfully to halve the mechanically effective ventricular rate and to restore cardiac output. When ventricular paired pacing was stopped after 12 h, the spontaneous rhythm was an atrial rhythm with 1-1 A-V conduction. The patient was discharged in sinus rhythm on the 5th postoperative day.

Cardiac Output, Low↗
PubMed1988

Anatomic repair of anomalies of ventriculo-arterial connection (REV). Results of a new technique in cases associated with pulmonary outflow tract obstruction.

From November 1980 to November 1986, 63 patients aged 4 months to 13 years (mean 3.4 years) underwent repair of anomalies of ventriculo-arterial connection with ventricular septal defect and pulmonary outflow tract obstruction, using a technique (REV) first described by us in 1982. The selection of patients was based on preoperative criteria, namely the measurement of the distance between the tricuspid and the semilunar valves. These measurements enabled us to select from patients with an abnormal ventriculo-arterial connection, those in whom the anomaly could be repaired by intra-ventricular partition alone. In the remaining cases, REV was indicated in the presence of pulmonary stenosis. The principles of the technique are: (1) resection of the infundibular septum creating a large, direct and subarterial communication between the left ventricle and the aorta; (2) construction of a straight left ventricle to aorta tunnel by intraventricular partition; (3) direct anastomosis of the pulmonary trunk to the right ventricle. There were 12 hospital deaths (19%). The mean follow-up was 32 months. One patient died suddenly 1 year after repair. Six patients required reoperation. All survivors are in NYHA class I, except for 3 patients who are in class II. No stenosis of the left ventricular outflow tract was found but 5 patients had a significant pressure gradient at the pulmonary outflow tract level. Our present experience suggests that in properly selected patients, REV allows anatomic repair in a wide variety of anomalies of the ventriculo-arterial connection associated with VSD and pulmonary outflow tract obstruction with an acceptable rate of mortality and morbidity.

Abnormalities, Multiple↗
PubMed1988

To switch or not to switch? The Senning alternative.

We analyzed the fate of 100 consecutive patients with simple arterial transposition who were admitted within the first 2 weeks of life to the Hospital for Sick Children during the period 1978-1986. In contrast to current practice, these patients were managed with the objective of performing a Senning operation as the definitive procedure. Five of these 100 patients died on the first day of life of sequelae of perinatal hypoxia, four died within the first month of life (often of complications of catheterization and septostomy), and three died later than the first month but before definitive operation (12% preoperative mortality). There were four operative deaths, and two late deaths have occurred to date. Actuarial survival was 84% at 5 years and 81% at 9 years. The postoperative attrition rate was 0.4 deaths per 100 patient-years. Actuarial survival of all patients treated for simple arterial transposition seems to be the best index for comparing arterial switch with interatrial repair protocols, because each protocol is associated with different patterns of preoperative, perioperative, and postoperative mortality.

Actuarial Analysis↗