Heart transplantation in 1992: the La Pitié experience.
Explore the source record for details and available documents.
Contraindications↗
Biomedical subjects
P Nataf
Publications and source records attributed to P Nataf.
[Fractures of the distal end of the radius in adults. Mechanism, diagnosis, treatment].
Explore the source record for details and available documents.
Adult↗
["Monobloc" resection in heart and lung transplantation. Technique and advantages of a new procedure].
Hemostasis is a usual problem in surgical heart and lung recipient removal. Since April 1990, we have been using as surgical technique an "en bloc" removal of heart and lungs in order to reduce postoperative bleeding and cardiopulmonary bypass duration.
Heart-Lung Transplantation↗
[Results of myocardial revascularization in patients aged 70 years and over].
The purpose of this study was to bring up-to-date the immediate risks and long-term benefits of coronary surgery in elderly people. The results obtained in a series of 475 patients in their seventies suffering from coronary disease who underwent myocardial revascularization alone or combined with heart valve replacement at the La Pitié Hospital, Paris, between 1984 and 1989 were analyzed. Coronary disease was associated with heart valve disease in two-thirds of the cases. The mean number of bypasses was 2.3 per patient. Aortic valve replacement was performed in 119 cases and mitral valve replacement in 12 cases. The operative mortality rate was 10.8 percent in patients with stable angina who underwent elective surgery. The factors which increased the mortality rate were: age (19.6 percent over 75 versus 13 percent under 75, P = 0.05); sex (23.5 percent in women versus 13.2 percent in men, P = 0.01) and emergency (25.8 percent, P = 0.02). No significant difference in mortality was noted between patients who had and those who did not have aortic valve replacement (15.8 versus 10.8 percent, P = 0.14). Fifteen patients (3.1 percent) developed perioperative myocardial infarction. During the follow-up, period myocardial infarction occurred in 7 patients. Out of 29 late deaths, 8 were of cardiac origin (infarction in 5, terminal heart failure in 3). The survival rate at 4 years was 76 percent. Among the patients who could be followed up, 80 percent are now asymptomatic, 15 percent are in stage I or II and 5 percent in stage III or IV of the Canadian Cardiovascular Society classification. Thus, despite a non negligible operative risk the functional improvement and survival rates obtained justify an increase in the indications for myocardial revascularization in elderly patients.
Actuarial Analysis↗
Myocardial protection by blood cardioplegia and warm reperfusion in heart transplantation.
We describe the technique of blood cardioplegia delivery as we routinely use it in clinical heart transplantation. This technique needs a specific circuit. Perfusion of a first dose of blood cardioplegia is immediately started on the arrival of the graft in the operating room. Cardiac reperfusion of a half-dose of blood solution without potassium is performed each 20 minutes. Myocardial warm reperfusion is started at the end of the aortic suture. This technique of blood cardioplegia and warm reperfusion during heart transplantation provided an improvement in heart preservation when compared with standard crystalloid solution.
Blood↗
Heart transplantation: update.
Clinical application of heart transplantation goes beyond 25 years experience. The main indications for cardiac transplantation remain idiopathic cardiomyopathies and ischemic diseases. To obtain a suitable donor has become progressively more difficult due to the increase of transplants performed and the shortage of donors. Advances in the detection of early rejection, improved organ preservation procedures, and the introduction of new immunosuppressive therapy protocols have produced dramatic results in heart transplantation. Late graft atherosclerosis remains a serious threat despite retransplantation and, in some cases, mechanical cardiac support.
Adolescent↗
[Infectious complications of heart-lung transplantation].
This study describes the infectious complications in 68 heart-lung transplant patients. We focused interest on early post-transplant infections so called nosocomial pulmonary infections, their exacerbating cofactors their clinical expression, and elements of diagnosis and treatment. Furthermore we describe the principal infections seen during long-term followup, which are opportunist infections caused most often by immunosuppression: Cytomegalovirus infections have a high incidence with serious clinical consequences in heart-lung transplant patients. As well as pneumocystis carinii infections and fungal infections, such as aspergillosis.
Adolescent↗
[Immediate and long-term results of coronary surgery under age 40].
The results of coronary artery surgery in young adults have not been extensively studied. We analysed the results of 221 patients under 40 years of age operated between 1979 and 1989 at the Pitié-Salpêtrière Hospital. The patients were 200 men and 21 women with an average age of 36.2 years. The most common cardiovascular risk factors were smoking (69.6%) and hyperlipidaemia (52%). One hundred and eighteen patients (53.4%) had previous myocardial infarction (MI). Triple vessel disease was present in 129 cases, double vessel disease in 59 cases and single vessel disease in 33 cases. Twenty three patients had significant left main coronary disease. The number of bypass grafts per patient averaged 2.3. The operative mortality was 2.07% (6 cases), death being due to myocardial infarction in 4 cases. Perioperative myocardial infarction was diagnosed in 12 cases (5.05%). One hundred and ninety nine patients were followed up for an average of 7.4 years. Seven of the 17 late fatalities were of cardiac origin. The actuarial 9 year survival rate was 84%. Five patients were reoperated after an average of 6.4 years. Eighty five per cent of patients were asymptomatic at the last follow-up examination. In conclusion, the symptoms of coronary artery disease in young adults can be effectively treated with a low operative risk by myocardial revascularisation surgery. Long-term follow-up remains essential to define the outcome in these patients. Systematic use of internal mammary artery bypass grafting should improve these results in the future.
Adult↗
[Lung resection for cancer in coronary patients. Immediate and medium-term results. Retrospective study in a series of 51 patients].
Patients with both resectable lung cancer and coronary artery disease require preoperative cardiac evaluation in order to determine and prevent the surgical risk and to discuss the desirability of preventive myocardial revascularization. The results of thoracic surgery in coronary disease patients have been studied in a series of 51 patients operated upon for lung cancer at the Marie Lannelongue hospital, Paris, between 1985 and 1988. Thirty-two patients underwent non invasive exploration prior to surgery (exertion ECG in 22, myocardial radioisotope scanning in 10); 35 patients had coronary arteriography at the last moment, and 9 asymptomatic patients with an old history of myocardial infarction had no specific exploration. Forty-nine patients had lung surgery alone, preceded in 5 cases by percutaneous coronary angioplasty; one patient had pulmonary surgery and coronary surgery simultaneously, and another patient had coronary surgery first, later followed by lung surgery. No perioperative death was due to cardiovascular causes. A 75-year old male patient died of respiratory failure 30 days after lobectomy. The postoperative period was totally uneventful in 39 patients. No perioperative myocardial infarction was recorded; 4 patients experienced an episode of thoracic pain with ECG signs of myocardial infarction but no rise in serum enzyme concentrations. One patient had a cerebral vascular accident responsible for hemiplegia. Two late sudden deaths, probably of cardiac origin, occurred 4 and 11 months respectively after surgery. The actuarial survival rate at 3 months was 48 percent. In all survivors, the coronary symptoms were controlled by medical treatment. It seems, therefore, that perioperative complications in this type of patient can be avoided by preoperative evaluation of the coronary disease and by preventive myocardial revascularization in case of critical coronary stenosis.
Adenocarcinoma↗
[Surgical strategy in polyarterial disease. Value and results of combined surgery].
Patients with coronary disease associated with carotid artery stenosis and/or abdominal aortic aneurysm often raise problems of operative strategy; in particular, the order in which these lesions must be treated is a frequent source of controversy. We report the results of sequential or simultaneous combined surgery for multiple arterial lesions. Between 1979 and 1988, 65 patients with such lesions underwent either cerebral revascularization simultaneously with coronary bypass (n = 48) or repair of infrarenal aortic aneurysm a few weeks after myocardial revascularization (n = 17). After simultaneous surgery on the carotid and coronary arteries, the postoperative mortality rate was 4.2 per cent (2 patients). Myocardial infarction occurred in 3 cases (6.2 per cent). No neurological disorder consecutive to carotid endarterectomy was observed. Late postoperative mortality involved 5 patients; in 2 of these the cause of death was non-cardiovascular. No other late complication due to coronary or carotid artery disease was noted. The 5-year survival rate, operative mortality included, was 74.8 +/- 8.6 per cent. After coronary bypass followed by abdominal aortic aneurysm repair, there was no operative death, and no perioperative complication due to coronary disease was observed. Late mortality involved 2 patients. One patient underwent bilateral femoro-popliteal bypass 4 years after repair of an aortic aneurysm. Percutaneous angioplasty for proximal stenosis of a venous coronary graft implanted 8 years previously was performed in one patient with primary success. All other patients are now asymptomatic as regards both coronary and peripheral arteries. The 7-year survival rate is 85.7 +/- 9.4 per cent. The absence of neurological disorders after simultaneous myocardial and cerebral revascularization, and the absence of cardiac complications after aortic aneurysm repair preceded by coronary bypass enable us to recommend systematic combined or sequential vascular surgery. The long-term survival rate obtained in this series supports this recommendation.
Aged↗
[Cardiac surgery in patients over 80 years of age. Experience of a series of 51 patients].
Between January 1980 and June 1988, 51 patients over 80 years of age underwent open heart surgery at the La Pitié hospital (26 women and 25 men; average age 82 +/- 2 years, range 80-90 years). The cardiac pathology was calcific aortic stenosis (AS) in 40 cases, associated with coronary artery disease in 7 cases, mitral valve prolapse in 3 cases, coronary artery disease alone in 6 cases [complicated by a post-infarction ventricular septal defect (VSD) in one patient] or associated with aortic regurgitation in 1 case, and degeneration of an aortic bioprosthetic valve in 1 case. Forty patients (78%) were in Stage III or IV or the NYHA Classification. There was no other major pathology associated with the cardiac disease. Aortic valve replacement (AVR) was carried out in 42 patients, with a bioprosthetic valve in 38 patients. This procedure was associated with coronary bypass surgery in 7 cases and carotid artery surgery in 1 case. A mitral bioprosthesis was implanted in 2 patients and mitral valvuloplasty was carried out in 1 patient. An isolated myocardial revascularisation procedure was performed in 5 cases; the VSD was closed in 1 case. The hospital mortality was 17.6 per cent (9 patients). All deaths were of cardiac origin. Eleven patients had no postoperative complications at all. The 3 year survival rate of those who survived surgery was 71 per cent. Of the current 31 survivors, 29 are in Stage I or II of the NYHA Classification. These results suggest that surgery can be offered to octogenarians with invalidating cardiac disease alone carrying a poor short term prognosis.
Actuarial Analysis↗
[Value and results of coronary surgery before the repair of abdominal aortic aneurysm].
Seventeen polyarteriosclerotic patients underwent coronary bypass surgery before repair of an abdominal aortic aneurysm between December 1979 and November 1988 in the Cardiovascular Surgical Department of the Pitié Hospital. Sixteen patients had triple vessel disease and 1 patient had single vessel disease but with mitro-aortic valvular disease. The abdominal aortic aneurysm was asymptomatic in 9 cases. The diameter of the aneurysm was over 5 cm in all patients. The average time between the two operations was 6.3 +/- 5.4 months. One myocardial infarction was observed following the coronary bypass surgery. There were no complications related to the coronary artery disease or operative deaths after repair of the abdominal aortic aneurysm. Two late deaths occurred, one due to an aortoduodenal fistula and the other to extra cardiovascular causes. One patient underwent femoro-popliteal bypass surgery 4 years after repair of the aortic aneurysm. One patient had successful percutaneous transluminal angioplasty of an aorto-coronary venous bypass graft 8 years after its implantation. All the other patients are asymptomatic from the coronary and peripheral arterial points of view. The 7 year survival was 85.7 +/- 9.4 per cent. These results seem to justify immediate and late preventive myocardial revascularisation in patients with coronary artery disease requiring surgery prior to repair of an abdominal aortic aneurysm.
Aged↗
Long-term evaluation of a new selectively biodegradable vascular graft coated with polyethylene oxide-polylactic acid for right ventricular conduit. An experimental study.
Low-porosity woven Dacron grafts have been used extensively as an extracardiac conduit in the surgical treatment of congenital and acquired heart diseases involving total heparinization. Caution is still warranted in their use, however, because of long-term complications, including calcification and development of obstructive fibrous peel. In contrast, high-porosity grafts offer much better tissue anchorage and healing but cannot be used under heparinization. We have developed a compound vascular prosthesis in which a knitted Dacron graft is coated with a polymeric biodegradable sealant. Polyethylene oxide-polylactic acid-segmented copolymers comprised the degradable component of the graft. In vitro studies showed that the coated prosthesis exhibited a highly flexible elastomer-like mechanical response. The prostheses were completely watertight, and significant degradation started after 1 week, with absorption completed after 3 weeks. Seven woven and six knitted polyethylene oxide-polylactic acid-coated Dacron grafts used as extracordiac conduits (16 mm), connecting the right ventricle and the pulmonary artery were implanted in dogs. The dogs were killed after 12 to 18 months, and the results are reported. Scanning electron microscopy examination showed peel detachment and nonhomogenous intimal surface with fenestrations in the woven graft group, but complete healing and incorporation of the pseudointima with homogenous, thin lining of the luminal surface in the polyethylene oxide-polylactic acid-coated group. Histologic studies indicated much superior healing and anchorage of the periprosthetic tissue and the pseudointima in the polyethylene oxide-polylactic acid-coated grafts. The biodegradable polymer was fully degraded and exhibited a complete incorporation of the compound vascular prosthesis. This study indicates the superior healing properties of these selectively biodegradable grafts, which might increase long-term patency and decrease complications of right ventricular conduits.
Animals↗
[Results of simultaneous myocardial and cerebral revascularization surgery].
Out of 3,678 patients who underwent aorto-coronary bypass between May, 1979 and October, 1987 at the La Pitié Hospital, Paris, 48 had simultaneous myocardial and cerebral revascularization. Operative mortality rate was 4.2 p. 100. Peri-operative myocardial infarction occurred in 3 cases (6.2 p. 100). No neurological complication was observed. The survival rate at 5 years (operative mortality included) was 74.8 +/- 8.66 p. 100. These results obtained in patients with multiple arterial disease are in agreement with those found in the literature. The lack of neurological complications is in favour of a systematic combined surgical treatment of severe carotid and coronary lesions.
Aged↗
[Cardiomyoplasty. Experimental bases, operative technic, indications].
Dynamic cardiomyoplasty aims at restoring ventricular contractility by means of a skeletal muscle sutured around the heart. It consists of transferring a latissimus dorsi muscle flap onto the heart through a window created in the thoracic wall by partial resection of the second rib. The skeletal muscle may be used to reinforce the ventricular systole in ischemic or dilated cardiomyopathy, or to replace the myocardium after resection of a large aneurysm or an extensive tumour. The electronic pacing material includes an implantable cardiomyostimulator, muscle stimulating electrodes and R wave detecting electrodes. Muscular pacing begins 2 weeks after the operation, this being the time required for adhesions to be formed between the heart and the muscle. A progressive and sequential electrostimulation procedure results in the transformation of glycolytic muscle fibres that are fatigue-sensitive into fatigue-resistant oxidative fibres. The purpose of this biomechanical cardiac assistance system, where cardiac surgery is combined with plastic surgery and biomedical engineering, is to prolong life and improve its quality in patients with severe heart failure.
Assisted Circulation↗
[Delayed autotransfusion associated with the cell-saver method in cardiovascular surgery. Values, methods, initial results].
The aim of deferred autotransfusion associated with the Cell-Saver system, i.e. the recovery of intraoperative blood loss, is to avoid using external homologous blood products. Transfusion-transmitted diseases and immunisation problems can be avoided: normovolumic haemodilution is an advantage in patients with coronary artery disease and economies can be made in the use of homologous blood. This technique has been in use in Professor Cabrol's department since 1987 with the help of the Blood Transfusion Centre of the Pitié Hospital. The contraindications are unstable angina, severe cardiac failure and anaemia of less than 11 g Hb at the first consultation. A review of the first 65 patients included in the protocol showed that deferred autotransfusion was well tolerated in all cases and that only 10 per cent of patients required transfusion with homologous blood. Autotransfusion associated with the Cell-Saver system is therefore a good method which should be extended to the largest possible number of patients referred for elective cardiac surgery.
Adult↗
[Systematic peroperative use of an autotransfusion system in heart surgery. A prospective and comparative study in 283 patients].
A series of 283 patients undergoing cardiac bypass surgery was studied to determine whether intraoperative autotransfusion, haemodilution, and a change in transfusion techniques of the same surgical team could reduce homologous blood requirements. The Cell-Save Haemonetics* system was used systematically in 167 consecutive patients (Group I). This group of autotransfused patients was analysed prospectively and compared with a control group (Group II) of 116 patients operated one year before and analysed retrospectively. During the whole hospitalisation, homologous blood products were required in 40.7% of patients in Group I compared with 73.3% of patients in Group II (p less than 0.0001). The average requirements of packed cells per patient were 2.7 +/- 1.3 in Group I compared with 4.1 +/- 2.5 in Group II (p less than 0.0001). The haematocrit on discharge from the department was 29.9 +/- 4% in Group I compared with 32 +/- 4.5% in Group II (p less than 0.0001). The average volume of blood recovered by the system and then autotransfused was 620.8 +/- 242.6 ml. There was no significant difference in postoperative bleeding in the first 24 hours between the two groups. This study confirms that peroperative autotransfusion during cardiac surgery and the acceptance of a clinically well tolerated normovolumic anaemia are associated with a significant reduction in homologous blood consumption.
Adult↗
[Epithelioid hemangioendothelioma of the azygos vein].
The authors report a case of epithelioid hemangioendothelioma of the azygos vein diagnosed during the investigation of a superior vena cava syndrome. Venography and thoracic CT and nuclear magnetic resonance scans showed an endovenous tumour with spinal and lymph node invasion. Cavographic-controlled biopsies allowed histological identification of the tumour. Palliative therapy consisted in tumour ablation and superior vena cava bypass. Epithelioid hemangioendothelioma is a rare vascular tumour characterised by the presence of epithelioid endothelial cells. It is slowly progressive and its potential malignancy justifies surgical excision whenever possible.
Azygos Vein↗