Spatial inhomogeneity of refractory periods, as measured during clinical electrophysiological studies, is a known predisposing factor of arrhythmia. We studied effective refractory periods (ERP) and action potential duration (ADP90) on isolated human atrium. Twelve samples of right atrium obtained during cardiac surgery from patients with (n = 6) and without (n = 6) atrial fibrillation (AF) were studied by microelectrode technique. For each preparation, ERP were measured at basic cycle lengths (BCL) of 1,600, 1,200, 800, and 400 msec in five different cells located around (0.8 mm) the stimulating electrode. Dispersion of ERP was significantly greater in the AF group (96.7 +/- 9 versus 70.9 +/- 9 msec, p = 0.01). In the non-AF group, we observed a positive linear correlation between ERP and BCL (r = 0.86) ADP90 and BCL (r = 0.93). On the contrary, in the AF group this correlation was absent between ERP and BCL (r = 0.28), poor between ADP90 and BCL (r = 0.62). These results suggest that nonhomogeneous recovery of excitability (dispersion and poor adaptation) may be an important factor of arrhythmia. This inhomogeneity is present at the cellular level as well as in the entire heart.

Action Potentials↗

PubMed1986

[Compressive hemopericardium of the right atrium after cardiac surgery].

Between June 1983 and September 1984, 3 patients operated for mitral valve disease presented with acute right heart failure due to right atrial compression. Emergency echocardiography did not show pericardial separation around the ventricles but in the apical 4 chamber view severe right atrial compression by an extracardiac mass was observed. Emergency surgery was performed in all three cases to evacuate a localised haemopericardium despite the absence of pericardial fusion. These cases of acute right ventricular failure underline the importance of multiplying the number of echocardiographic views in order to detect localised pericardial effusion. The diagnosis should be made as soon as possible as clinical deterioration may be rapid despite effusions of small volume. The main differential diagnoses are right atrial thrombosis and acute postoperative pulmonary embolism. In these cases of localised tamponade, the clinical signs are the result of vena caval compression or extrinsic compression of the tricuspid orifice. The preferential localisation of the haemopericardium around the right atrium is difficult to explain. It is probably related to the low pressures in this region. The echocardiographic appearances of this condition have been established allowing reliable diagnosis.

Adolescent↗

PubMed1986

[Intraoperative evaluation of mitral valve reconstruction using two-dimensional contrast echocardiography].

20 patients who underwent reconstructive surgery for mitral regurgitation were peroperatively investigated by contrasted bidimensional echocardiography using intraventricular injection of 20 ml of physiologic saline. Before the valvuloplasty, the peroperative quantitation of mitral leakage was in all cases closely correlated with the data obtained preoperatively. After the mitral reparation, three groups of patients could be observed: group I (12 cases): absent or minimal regurgitation (0-+); group II (5 cases): moderate mitral regurgitation (++); group III (3 cases): marked regurgitation ( - +) necessitating an immediate ECC. In two cases it was possible to improve successfully the valvular function, in the third case valvular replacement was necessary. The correlation between the data of peroperative contrasted echography at one hand and the clinical examination and the postoperative paraclinical investigations on the other hand was excellent in all cases. Thus the contrasted bidimensional peroperative echocardiography represents a reliable method for predicting the immediate results of mitral reconstructive surgery.

Adolescent↗

PubMed1986

[Sequential internal mammary artery bypass for multiple coronary stenoses].

Long-term studies (10 years) show a 50 per cent patency rate of saphenous vein autograft and 95 per cent patency rate of internal mammary artery coronary bypass grafts. In some situations (after saphenous vein stripping, varicose and fibrotic veins) it is not possible to use venous grafts and the internal mammary artery has to be used. However, the internal mammary artery is usually only used for revascularisation of the left anterior descending artery. Sequential internal mammary artery bypass is a technique which can be used for revascularizing the left anterior descending artery. Seven men aged 44 to 68 years (average 55 years) were operated between November 1983 and February 1985. These patients had clinically stable (4 cases) or instable (3 cases) angina. Two patients had previously undergone bilateral saphenous vein stripping and one patient a terminal anastomosis on the left anterior descending and a latero-lateral anastomosis on the diagonal artery. Three patients had an associated venous bypass graft and one patient also underwent aortic valve replacement. There were no cases of postoperative myocardial infarction. Five control angiographies were carried out during the first postoperative month. In 4 patients the internal mammary graft ant the latero-lateral and termino-lateral anastomoses were patent. In the other case, the latero-lateral anastomosis and the diagonal artery was occluded but the internal mammary graft and the termino-lateral anastomosis on the left anterior descending artery were patent. The average follow-up period is now 18 months: there have been no recurrences of chest pain or any ECG changes. These results show that internal mammary artery bypass grafting is a delicate procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1986

Long-term results of valve repair in children with acquired mitral valve incompetence.

From March 1969 to March 1984, 89 children aged 2 to 12 years (mean 8.3 +/- 2.5) with acquired mitral valve incompetence underwent mitral repair using Carpentier's techniques. There were 84 cases of rheumatic valve disease, four cases of endocarditis, and one case of Barlow's syndrome. Valve dysfunction was classified into three types: type I (normal leaflet motion), five patients; type II (prolapsed leaflet), 74 patients; and type III (restricted leaflet motion), 10 patients. Cumulative follow-up was 546 patient/years. At 10 years, 90% of the patients were still alive, with an incidence of valve-related death of 5.5%; 98% of the patients were free of thromboembolism, 78% were free of reoperation, and 69% of the patients were free of any complications related to valve repair. We conclude that whenever feasible (92% of the cases in our experience), mitral valve repair using valvuloplasty techniques is the preferred procedure in the surgical treatment of acquired mitral valve incompetence in children.

Child↗

PubMed1985

[Reoperation after saphenous aortocoronary bypass].

The results of a consecutive series of 24 patients reoperated for coronary bypass grafting between May 1977 and February 1983 are reported. The overall incidence of reoperation was 1.4 p. 100 (24 out of 1 716 cases); the incidence is tending to increase (2.3 p. 100 in 1982). Preoperative assessment revealed the persistence of cardiovascular risk factors: 75 p. 100 of patients had continued to smoke; 61 p. 100 had persistent hyperlipidaemia. The usual presenting syndrome was recurrence of chest pain (21 out of 24 cases) leading to control coronary arteriography on the results of which the surgical indication was based. The average time between the two operations was 38.7 months. The patients were classified into two groups; early reoperation (6 cases) for a technical problem or incomplete revascularisation, and late reoperation (8 cases) for disease of the graft and atherosclerosis. Progression of coronary atherosclerosis was the major long-term cause of occlusion of the saphenous graft (10-14 cases). The arteries most commonly bypassed at reoperation were the left anterior descending and right coronary arteries (12 times each). Reoperation comprised single bypass (13 cases), double bypass (10 cases) and triple bypass (1 case) with an average of 1.5 grafts per patient. The most commonly used vein was the internal saphenous vein (32 out of 36 grafts). Myocardial protection was insured by cardioplegia (13 cases) and intermittent clamping (10 cases) after cooling (general hypothermia at 22 degrees C). Global reoperative mortality (4 p. 100) was higher than for elective primary coronary surgery (2.3 p. 100). The incidence of perioperative infarction was 8 p. 100.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary Artery Bypass↗

PubMed1985

[Direct atriopulmonary anastomosis (modified Fontan) for single ventricle and its equivalents].

The modified Fontan procedure is being used in an increasing number of complex cyanotic cardiac lesions with pulmonary stenosis. Seven patients aged 11 to 24 years (average 17.5 years) underwent surgery by a technique derived from the Fontan procedure: direct atriopulmonary anastomosis without a tube or valve. The tricuspid valve when patent was closed with a patch. The diagnoses were: single ventricule (4 cases), Taussig-Bing anomaly (2 cases) and tricuspid atresia (1 case). All patients had associated pulmonary stenosis with low pulmonary vascular resistances. The great vessels were in L-malposition in 3 cases. The hospital mortality was nil. Transient atrial fibrillation was observed in 2 cases and was well tolerated clinically. The follow-up period ranges from 2 months to 4 years (average 2.3 years). All patients are acyanotic with no signs of right-sided failure and in sinus rhythm. Control cardiac catheterisation and angiography were performed in 6 cases and showed good function of the anastomosis and a mean atrial pressure of 14 mmHg. Direct atriopulmonary anastomosis offers a very acceptable surgical solution to certain forms of single ventricle or equivalent with low pulmonary pressures. The short and medium term results seem to be better than those of intraventricular repair.

Adolescent↗

PubMed1985

[Reoperation on valve bioprostheses. Apropos of 64 cases].

Sixty-four patients with one or more bioprostheses were reoperated between 1970 and 1982. Reoperation was performed for degenerative lesions in cases (48%), for aseptic periprosthetic leaks in 18 cases (28%), for infectious lesions in 13 cases (21%) and for thrombosis in 2 cases (3%). Degenerative and infectious lesions were commoner in aortic bioprostheses whilst periprosthetic leaks were commoner in mitral bioprostheses. The average interval between operations was 38 months. This was shorter in patients reoperated for mechanical problems (6 months) than those with infections (28 months) or degenerative (5 years) complications. At reoperation 14 prostheses were reinserted and 50 were replaced. The global hospital mortality was 21% (14 deaths). The mortality was related to the surgical indication: mechanical lesions (11%), degenerative lesions (16%), infectious endocarditis (38%), thrombosis (100%). The mortality rate also varied with time (36% during the period 1970-1978 and 18% during the period 1979-1982). This improvement was related to two factors: the use of cardioplegic solutions for myocardial protection and earlier recognition of surgical indications before the onset of irreversible haemodynamic complications. When choosing a valvular prosthesis, the mortality of reoperation for degenerative changes is the only disadvantage of the bioprosthesis which is silent, rarely complicated by thromboembolism and which does not require anticoagulant therapy for life. The mortality has decreased with time and will continue to fall if the indications for reoperation are based on stethacoustic, electrical, radiological and echocardiographic criteria of valvular dysfunction and not on the presence of overt cardiac failure as is still often the case.

Adolescent↗

PubMed1985

Comparative evaluation of aortic valve replacement with Starr, Björk, and porcine valve prostheses.

Three groups of 100 consecutive patients with aortic valve disease who were operated on between 1974 and 1978 underwent long-term evaluation. There were 100 aortic valve replacements with porcine bioprosthetic valves (group I), 100 with Starr valves (group II), and 100 with Björk valves (group III). There were no significant differences in the preoperative clinical conditions of the patients in the three groups. Cumulative follow-up was 1688 patient-years. Incidence of valve-related death at 8 years was 4 +/- 2.3% in group I, 13 +/- 3.6% in group II, and 13 +/- 3.8% in group III (p less than .05). At 8 years 95 +/- 2.8% of the patients in group I were free of thromboembolism, compared with 81 +/- 4.8% of those in group II and 84 +/- 4.2% of those in group III (p less than .002). The actuarial risk of a reoperation at 8 years was 16 +/- 6% in group I, 5 +/- 2% in group II, and 2 +/- 1.6% in group III (p less than .025 group I vs group III). At 8 years 98 +/- 1.2% of the patients in group I were free of anticoagulant-related complications, compared with 88 +/- 3.8% of those in group II and 86 +/- 3.9% of those in group III (p less than .005). We conclude that at 8 years porcine bioprosthetic valves performed better than mechanical valves, taking into consideration thromboembolism, anticoagulant-related hemorrhage, and valve-related death.

Actuarial Analysis↗

PubMed1985

[Reoperation for aortic coarctation. Comparison of the direct approach and aorto-aortic shunt].

Explore the source record for details and available documents.

Adolescent↗

PubMed1984

[Acute thrombosis of the superior vena cava after cardiac surgery].

One case of acute superior vena cava syndrome occurring twelve days after open-heart surgery was reported. The severity of the accompanying clinical signs led to the carrying out of an urgent superior vena cavogram. It revealed a superior vena caval obstruction by a thrombus which extended into the azygos vein; extrinsic compression was therefore ruled out. The thrombosis seemed to be due to direct trauma by the catheter or to the infusion of irritating solutions. Emergency thrombectomy was successfully carried out.

Acute Disease↗

PubMed1984

[Mitral insufficiency complicating idiopathic subvalvular aneurysm of the left ventricle. Apropos of 5 surgical cases].

The surgical team of Pr Ch. Dubost operated 5 cases of idiopathic subvalvular left ventricular aneurysm with associated mitral incompetence over a 6 year period (from 1976 to 1981). These 5 cases closely resemble Abraham's et al's classical description of "annular subvalvular left ventricular aneurysms". They occur in black Africans, often young adults (mean age of our five cases 31,8 years) in the absence of coronary artery disease. The common feature is the peculiar anatomical localisation of the aneurysm on the posterior or lateral wall of the left ventricle, which explains the common finding of mitral regurgitation. They are often calcified and thrombosed, the thrombosis tending to extend into the left heart chambers. This was the case in 3 of the reported cases. Mitral regurgitation was controlled in one case by closure of a fistula into the left atrium with a very good result, and in 2 cases by simple section-suture of the neck of the aneurysm with good results and a small residual mitral leak. In a fourth case (Case n degree 1) the mitral valve was normal, regurgitation being the result of an extensive thrombosis. The valve was replaced but, in the light of the following cases, it is possible that the valve might have been unnecessarily sacrificed. Despite their sometime vast size and the association with mitral regurgitation, these subvalvular idiopathic left ventricular aneurysms are reasonable surgical indications for the following three reasons: the neck is often narrow, enabling closure under satisfactory surgical conditions; the structure of the valve is normal which, in the majority of cases, means that it can be respected at surgery; the absence of coronary artery disease.

Adult↗

PubMed1984

[Exudative enteropathy and residual tricuspid insufficiency following repair of tetralogy of Fallot. Regression following tricuspid valvuloplasty].

Chronic right ventricular failure was observed in a young female operated at 25 years of age for Fallot's tetralogy despite surgical refixation of the patch closing the ventricular septal defect which had previously worked loose. The signs of right ventricular failure were due to severe tricuspid incompetence, confirmed at catheterisation and selective right ventricular angiography. They were associated with major hypoproteinaemia which was not due to urinary loss nor hepatic dysfunction, but which was attributed to an exudative enteropathy. The correction of the valvular defect by valvuloplasty was followed by rapid correction of the biological abnormality. The authors review the relationship between serum proteins and cardiac disease, discuss those cardiac affections with known associations with exudative enteropathy, and also the possibilities of reversing the biological abnormality after surgical cure of the causal cardiac lesion.

Adult↗