Biomedical subjects
Publications and source records attributed to R Limet.
The risk for aortic dissection or further dilation of the ascending aorta exists after aortic valve replacement. We present a case of acute aortic dissection following replacement of the aortic valve. The management and treatment of dilated ascending aorta associated with aortic valve disease are reviewed and discussed.
Orthotopic heart transplantation (OHT) is a major surgical intervention inducing distress and anxiety. Psychological problems after OHT have been described in many studies. Little is known, however, about the relationship between the psychological state of the patient and time after surgery. The present study involved 41 consecutive OHT patients that underwent transplantation from January 1991 to December 1992, with a retrospective review of pretransplant psychiatric evaluations to define a Diagnostic and Statistical Manual of Mental Disorders, 3rd edn., revised (DSM III-R) Axis I diagnosis. Patients completed the Beck Depression Inventory (BDI-13), Spielberger's State Trait-Anxiety Inventory (STAI-Y), and the General Health Questionnaire (GHQ-28) between 1 and 41 months after transplantation. For comparison, 29 presumably healthy volunteers were given the same questionnaires. The study confirms the occurrence of abnormal psychological scores in the OHT group as compared to the reference population. Psychological scores, however, do not appear to be related to the time they were recorded after surgery.
Chronic rupture of abdominal aortic aneurysm (AAA) resulting in unusual clinical manifestations can occur if the resistance of structures surrounding the aorta is sufficient to contain hemorrhage. In this report, we describe five cases of chronic ruptured AAA in which the presenting feature was crural neuropathy. All patients were male with a mean age of 74 +/- 1.8 years. At the time of presentation, crural neuropathy had been ongoing for 3 to 9 weeks. In three cases, AAA was not initially suspected because an inadequate clinical examination was performed (not in the vascular surgery department) and because of the small diameter of the aorta in relation to the patient's morphology. Two patients had one episode of hypotension that was wrongly attributed to vagal attack. Abdominal CT scanning was always diagnostic of chronic rupture. In two cases, rupture was associated with erosion of the body of one or more vertebrae and laboratory evidence of inflammation, i.e., increase in sedimentation rate and fibrinogen level. The mean diameter of the AAA was 7.1 +/- 0.9 cm (range 5-10 cm). All patients underwent midline laparotomy, which was performed under emergency conditions in two cases, under semi-emergency conditions in one case, and electively in two cases. Perforation was consistently located on the posterolateral wall of the aorta and varied from 1 to 3 cm in length. Repair was performed using an aortobifemoral prosthesis in four cases, and a straight tube in one case. The patient who underwent emergency surgery died 4 days after the procedure. The remaining four patients recovered uneventfully and were discharged after 10 days. In the elderly, ruptured AAA should be included in the differential diagnosis of crural neuropathy. An episode of hypotension, regardless of its duration, in an elderly patient should be given serious consideration as a possible sign of ruptured AAA with ongoing retroperitoneal hemorrhage.
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BACKGROUND: Orthotopic heart transplantation (OHT) is a major surgical intervention inducing distress and anxiety. Psychiatric evaluation of organ transplant candidates is now routinely proposed. This study purposed to assess the psychological evolution in patients having received psychological and/or psychiatric assistance before and during 1-6 postoperative months. METHODS: Twenty-two consecutive transplant candidates were psychically evaluated as part of the preoperative protocol. In the waiting period, 1 and 6 months after OHT, they were asked to fill out the following questionnaires: the General Health Questionnaire, the Spielberger's State-Trait Anxiety Inventory, the Beck Depression Inventory, the Perceived Social Support Scale, the Toronto Alexithymia Scale and the Personal Reaction Inventory. RESULTS: A DSM-IV Axis I diagnosis was found in nine patients (41%); four patients (18%) presented with an Axis II diagnosis. One month after OHT, scores of depression, anxiety and general health significantly improved, while scores of social support, alexithymia and social desirability did not differ. In the sixth postoperative month, all psychological scores remained stable. CONCLUSIONS: A high prevalence of preoperative psychopathology was reported in 22 candidates who received OHT. Surgical intervention obviously improved the quality of life after cardiac transplantation. If the impact of psychological and/or psychiatric aid remains difficult to appraise, these results emphasize the positive impact of surgery on psychological status and the appropriateness of the psychosomatician's social support intervention on patients facing the transplant process.
AIMS: Because the elderly are increasingly referred for operation, we reviewed the results of cardiac surgery in patients of 80 years or older. METHODS AND RESULTS: Records of 182 consecutive octogenarians who had had cardiac operations between 1992 and 1998 were reviewed. Follow-up was 100% complete. Seventy patients had coronary grafting (CABG), 70 aortic valve replacement, 30 aortic valve replacement+CABG, and 12 mitral valve repair/replacement. Rates of hospital death, stroke, and prolonged stay (>14 days) were as follows: CABG: 7 (10%), 2 (2.8%) and 41 (58%); aortic valve replacement: 6 (8.5%), 2 (2.8%) and 32 (45.7%); aortic valve replacement+CABG: 8 (26.5%), 1 (3.8%) and 14 (46.6%); mitral valve repair/replacement: 3 (25%), 1 (8.3%) and 5 (41.6%). Multivariate predictors (P<0.05) of hospital death were New York Heart Association functional class, urgent procedure, prolonged cardiopulmonary bypass time, and, after aortic valve replacement, previous percutaneous aortic valvuloplasty. Ascending aortic atheromatous disease was predictive of stroke, while pre-operative myocardial infarction was predictive of prolonged hospital stay. Actuarial 5-year survival was as follows: CABG, 65.8+/-8.8%; aortic valve replacement, 63.6+/-7.1%; aortic valve replacement+CABG, 62.4+/-6.8%; mitral valve repair/replacement, 57.1+/-5.6%; and total, 63.0+/-5.6%. Multivariate predictors of late death were pre-operative myocardial infarction, and urgent procedure. Ninety percent of long-term survivors were in New York Heart Association class I or II, and 87% believed having a heart operation after age 80 years was a good choice. CONCLUSION: Cardiac operations are successful in most octogenarians with increased hospital mortality, and longer hospital stay. Long-term survival and quality of life are good.
We report the case of a patient who developed an evolutive chronic aortic dissection after ascending aorta replacement for acute type A aortic dissection. Owing to the development of severe aortic regurgitation, aortic root pseudoaneurysm and aneurysmal dilatation of the arch and descending aorta, reoperation was adviced. Reoperation included Cabrol modification of the Bentall operation and aortic arch replacement with elephant trunk performed under deep hypothermic circulatory arrest. The incidence of late aneurysmal formation in type 1 aortic dissection has been reported to be 30%. Close postoperative follow-up of the aortic diameter is necessary to detect a critical dilatation and to permit elective reoperation.
A case of complete arterial revascularization using both mammary arteries and the left radial artery is reported. The operation was done on the beating heart with the adjunct of a Y graft owing to a severely calcified ascending aorta. This observation is the occasion to review the basic principles of beating heart surgery.
The observation of four clinical cases of Shone's complex, two of them presenting first with predominant coarctation of the aorta, prompted us to review the pertinent literature. Patients with multiobstructive lesions of the left heart, including Shone's complex, represent a surgical challenge where the adequate management of mitral valve anomalies, subaortic stenosis, and coarctation constitutes the key prognostic factor for satisfactory mid-term outcome.
The treatment of venous ulcers is a challenge even in this era of modern medicine. The role of incompetent perforating veins in the pathophysiology of venous ulcers has been well documented. Open surgical interruption of incompetent perforating veins (Linton's procedure) may be complicated by important wound healing problems, and has never gained widespread acceptance as a first choice treatment. Recently, an endoscopic technique of subfascial interruption of perforating veins has been developed. This new procedure, with smaller scars and faster recovery, gives promising midterm results. The authors summarize their initial experience with subfascial endoscopic perforating surgery (SEPS) during the last three years (25 cases). They obtained ulcer healing in all cases. At 16 month follow-up, 88% of patients remain ulcer free. Three patients developed a new minor ulceration in the era of lipodermatosclerosis. This less invasive technique is a promising tool in the management of patients with venous ulcer disease.
Infrainguinal arterial occlusive disease is very common at the age of 60 years or older. It remains often asymptomatic. In one third of cases, it results in claudication. Claudication is a benign symptom that rarely necessitates surgery or endovascular intervention. Physical training and control of risk factors are sufficient in most cases to improve the walking performance. Nowadays, the authors do no longer perform femoropopliteal bypass grafting as a first choice treatment for intermittent claudication. Conservative treatment has gained widespread acceptance for infrainguinal atherosclerosis with moderate ischemia. What is the fate of the claudicant? How effective is exercise therapy? Should we broaden the indications for percutaneous angioplasty? What is the place of femoropopliteal bypass graft for claudication? The authors investigate these different questions by means of an extensive review of recent literature. Based on this review and on international consensus documents, they justify their conservative approach to claudication secondary to occlusive disease of the superficial femoral artery.
The mechanisms of cellular lesions induced by lung ischemia and reperfusion are not fully understood and, in particular, the consequences of pulmonary ischemia and reperfusion injury on mitochondrial function have not been previously investigated. Therefore, we studied the respiratory function of isolated pulmonary mitochondria in a swine model of lung ischemia and reperfusion. We demonstrated that prolonged hypothermic (4 degrees C) ischemia induces significant lesions of the mitochondrial respiratory chain, particularly if ischemia is followed by normothermic reperfusion. These results should be integrated in the cellular alterations induced by the ischemia-reperfusion injury. In another swine model mimicking controlled non-heart beating donors, we demonstrated that thirty minutes of cardiac arrest do not promote significant alteration of the mitochondrial respiratory function. In contrast, forty-five minutes of cardiac arrest, induced significant mitochondrial lesions. This pulmonary tolerance to normothermic cardiac arrest might be explained by the presence of air in the lung airways, allowing some aerobic metabolism after circulatory arrest. These results suggested that lung grafts might be harvested from non-heart beating donors after thirty minutes of cardiac arrest, significantly increasing the pulmonary graft pool.
Antioxidant status and titers of autoantibodies against oxidized low-density lipoproteins (ox-LDL-Ab) were investigated in top soccer (S; n = 21, age 24.6 +/- 4.3 years) and basketball (B; n 3,000 mIU/ml) in ox-LDL-Ab were found in half the players (12S and 4B) with a maximum reaching 6000 mIU/ml (normal range: 200-600 mIU/ml), showing an in vivo LDL oxidation. There was no correlation between ox-LDL-Ab titers and chlolesterol, LDL cholesterol, or antioxidant levels. Nevertheless, plasma vitamin C concentration was lower in athletes having high levels of ox-LDL-Ab when compared with those with normal levels (8.49 +/- 3.14 mirogram/ml vs. 10.39 +/- 2.55 microgram/ml), but this difference was not statistically significant. In conclusion, our data suggest that potential atherogenic and cardiovascular risks as reflected by high titers in ox-LDL-Ab may exist in some top athletes despite a nonaltered antioxidant status.
The objective of this study was to evaluate the effectiveness of cryopreserved arterial homografts for management of prosthetic graft infection. Between October 1992 and July 1998, 90 patients (84 men) with a mean age of 64 years from six different hospitals were treated for prosthesis infection by in situ replacement using a cryopreserved arterial homograft (CAH). In 43 patients (47%), the primary procedure had been performed at a nonparticipating center. Prosthetic graft infection occurred early (i.e., within 1 month after the primary procedure) in 15 cases and late in 75 cases. In the late group, the mean interval between the primary procedure and CAH replacement was 34 months (range, 3 to 330 months). In 41 patients, infection was located in the aortic region, including 17 presenting with enteroprosthetic fistula (EPF). In 49 patients, infection was confined to the femoral, popliteal, or subclavian region. Bacteriologic cultures were positive for one or more germs in 75 patients and negative in 15. The surgical procedure consisted of complete or partial removal of the infected prosthetic graft, debridement, and in situ reconstruction using one or more CAH. Our results showed that management of prosthetic graft infection, a grave complication, using a CAH is a promising technique, especially for patients in stable condition prior to reconstruction.
BACKGROUND: Cardiopulmonary bypass (CPB) initiates a whole-body inflammatory response where complement and neutrophil activation and cytokine release play an important role. This prospective trial examined the effects of both heparin-coated circuits and aprotinin on the inflammatory processes during CPB, with respect to cytokine release and neutrophil activation. METHODS: Two hundred patients undergoing cardiac surgery were randomized in four groups of 50 patients each: heparin-coated circuit with aprotinin (HCO-A) or without aprotinin (HCO) administration, and uncoated circuit with aprotinin (C-A) or without aprotinin administration (C). In groups receiving aprotinin, a high-dose regimen was given. In all groups, high initial doses of heparin were used (3 mg/kg intravenously). Tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6) and IL-8, and myeloperoxidase and elastase levels were measured in plasma samples taken before, during, and after CPB. RESULTS: In all groups, the TNF-alpha, IL-6, and IL-8 levels reached a maximum after protamine administration. After 24 hours, they remained significantly elevated (IL-6 and IL-8) or returned to baseline values (TNF-alpha). A similar pattern was observed with myeloperoxidase and elastase levels. No significant intergroup differences were observed. CONCLUSIONS: CPB is associated with cytokine release and neutrophil activation, which are not attenuated by the use of heparin-coated circuits or by the administration of aprotinin. Aprotinin and heparin-coated circuits do not show additive effects.
BACKGROUND: Platelet count and function are particularly damaged by cardiopulmonary bypass (CPB). This study evaluated the effects of a novel CPB circuit in terms of platelet count and activation, and postoperative need for blood products. METHODS: One hundred patients undergoing coronary grafting were randomized in two groups: control group (n = 50) and test group (n = 50, surface modifying additives circuit, SMA group). Blood samples were taken before, during, and after CPB. Postoperative blood loss, number of transfused blood products, and postoperative variables were recorded. RESULTS: The platelet count decreased less in the SMA group compared to the control group (end of CPB: respectively, 165 +/- 9 x 10(3)/mm3 vs 137 +/- 8 x 10(3)/mm3; p < 0.01). This was paralleled by a reduction in beta-thromboglobulin plasma levels in the SMA group. There was a trend to decreased blood loss in the SMA group, but the difference was significant only in patients taking aspirin preoperatively (p < 0.05). In the SMA group nearly 50% less fresh frozen plasma and platelet units were administered (p < 0.01). No operative deaths were observed. CONCLUSIONS: The use of circuits with surface additives is clinically safe, preserves platelet levels, and attenuates platelet activation. This may lead to a reduced need for blood products.
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