Hypopharynx perforation by a transesophageal echocardiography probe.
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Aged↗
Biomedical subjects
T Carrel
Publications and source records attributed to T Carrel.
Pseudoaneurysm following aortic homograft: clinical implications?
OBJECTIVE: To determine the prevalence of pseudoaneurysm formation after aortic (left ventricular outflow tract) homograft implantation and to evaluate predisposing factors. METHODS: Echocardiographic data were analysed in 30 patients for evidence of pseudoaneurysm formation after homograft implantation. Pseudoaneurysm was characterised as a perfused echo-free space between the homograft and the native aortic wall communicating with the left ventricular outflow tract. Clinical data were analysed for potential predisposing factors for pseudoaneurysm formation. RESULTS: Pseudoaneurysms were found in 22 of 30 patients. Mean age, length of follow up after surgery, aortic systolic pressure gradient (15 (SD 12) v 10 (4) mm Hg), aortic root diameter, and size of the homografts were comparable in patients with and without pseudoaneurysm. preoperative infection, operating techniques, and whether first or reoperation did not affect pseudoaneurysm formation. However, pseudoaneurysms were often localised at the site of an abscess or a paravalvular leak after eradicated prosthetic valve endocarditis. CONCLUSIONS: (1) Doppler echocardiography demonstrates that pseudoaneurysm formation is common after aortic homograft implantation. (2) A prospective study is needed to clarify the prognostic importance of pseudoaneurysms. (3) The high incidence of pseudoaneurysm formation may lead to an improvement of surgical technique (application of fibrin glue).
Adult↗
[Palliative treatment of tetralogy of Fallot using a PTFE (polytetrafluoroethylene) vascular graft].
The application of a PTFE (polytetrafluorethylene) vascular graft for palliative surgical treatment in a case of tetralogy of Fallot in a dog is described. The surgical procedure took place after an attempt to perform a Blalock anastomosis failed. The surgical technique, the postoperative care and the outcome are presented. The technique and its indications are discussed.
Animals↗
[When should the family physician contact the cardiological transplantation team?].
End stage heart failure has a poor prognosis and may be treated by cardiac transplantation, which offers these seriously sick patients a good chance of survival with an usually outstanding quality of life as compared to the preoperative state. The indication for heart transplant depends on hemodynamic and symptomatic evaluation as well as functional values. Spiro-ergometric assessment of peak oxygen consumption is used by an increasing number of cardiac transplant centres in order to achieve helpful data considering the ideal timing of transplantation. Correct assessment of the measured peak oxygen uptake is only suitable after the onset of tailored treatment of chronic heart failure; moreover, thinking about timing of heart transplantation, it is requested to be well informed on the spontaneous course of the underlying disease. Availability of appropriate organs depends on logistic factors, especially ABO blood group matching. In summary, these data may provide enough information whether and when patients should be scheduled for cardiac transplant. Ambulatory chronic heart failure clinics which are part of cardiac transplant programs are specialized institutions for the investigation of the underlying cardiac disease and for the institution of an appropriate therapy as well as for continuous observation of these patients. These chronic heart failure clinics are working very closely together with general practitioners and specialists involved in the treatment of these patients.
Cardiology↗
Prediction of early cardiac morbidity and mortality following aorto-iliac reconstruction: comparison between clinical scoring systems, echocardiography and dipyridamole-thallium scanning.
Preoperative cardiac assessment may be difficult in patients with aorto-iliac and/or peripheral vascular disease because of severe physical limitation due to the disease itself, advanced age, locomotor problems or because of beta-blocker usage. 216 patients with aorto-iliac occlusive disease were studied; several cardiac risk scoring systems were determined for each patient. Preoperative echocardiography was performed in 182 patients and thallium-scanning in 63 patients. The results from the preoperative risk factor evaluations, echocardiographies and thallium examinations were correlated individually with the postoperative observed cardiac complications. Overall mortality was 2.8% (4 patients died from myocardial infarction). A total of 13 major postoperative cardiac events (10 myocardial infarctions and 3 life-threatening arrhythmias) were registered. No statistical correlation could be identified between the patient's clinical examination nor the scoring system and the occurrence of postoperative cardiac complications. 12 events occurred out of 13 patients who were shown to have a reversible defect on the preoperative thallium scan. These patients also presented hypokinesia or akinesia on the preoperative echocardiography. Thallium imaging and echocardiography represent a valid preoperative test to evaluate the risk of cardiac morbidity and mortality in vascular patients. Coronary angiography is recommended in patients suffering from progressive and/or unstable angina.
Aged↗
[Extra-anatomic thoraco-bifemoral bypass: an excellent alternative to in-situ reconstruction for repeat revascularization of the lower limbs].
Severe late complications after reconstruction of the abdominal aorta are unusual; when they occur, they demand a different strategy to treat the patient with success and to achieve a durably favourable long term outcome. These complications include prosthetic infection, enteric erosion and graft thrombosis. Treatment by resection of the infected graft and extra-anatomic reconstruction with axillary-femoral or axillary-popliteal bypass leaves the patient with an unreliable arterial inflow for the lower extremities. In patients who survived graft removal and extra-anatomic bypass, a source of major arterial inflow should be at least considered in order to secure a permanent repair. The descending thoracic aorta has been described as an ideal inflow source for definitive intracavitary conversion of extra-anatomic subcutaneous bypass and as a valid alternative to avoid dense adhesions in the abdomen or retroperitoneum. We present our experience with 8 patients in whom the aorta had been previously oversewn below the renal arteries (resection of infected graft [n = 4], repair of aorto-enteric fistula [n = 3]) or avoided because of dense adhesions after radiotherapy (n = 1). Temporary extra-anatomic reconstruction consists of an axillo-femoral (-popliteal) bypass on the right side with femoro-femoral cross-over graft. This method avoids surgery in the left thoraco-abdominal region, thus facilitating the definitive repair. Proper preoperative radiographic evaluation with inflow and outflow details is essential before conversion into thoraco-bifemoral bypass. Posterolateral thoracotomy is performed and the chest entered in the 7th interspace. The thoracic aorta is clamped tangentially and a bifurcated graft is anastomosed to the aorta. The bypass is passed through a retroperitoneal tunnel and anastomosed end-to-end with the distal portion of the previously inserted grafts; this technique avoids a second dissection of the vessel itself.(ABSTRACT TRUNCATED AT 250 WORDS)
Aorta, Abdominal↗
[Dynamic obstruction of the left ventricular outflow tract: surgical problems].
Dynamic subaortic obstruction caused by septal hypertrophy may worsen the hemodynamics in some patients after heart surgery. Resection of the hypertrophied septum allows normal left ventricular function. We describe two patients with subaortic stenosis and a complicated postoperative course following heart surgery and additional resection of the subaortic muscular stenosis. One patient was reoperated because of residual obstruction of the left ventricular outflow tract; the postoperative course was uneventful thereafter. The second patient died after the primary surgery because of low output syndrome and sepsis. The postoperative management of this group of patients is difficult, demanding frequent assessment of the patient's hemodynamic condition and echocardiographic surveillance.
Aged↗
[Ectopic ossification as a cause of vague abdominal pain following heart surgery: a case report].
Vague abdominal pain after cardiac surgery was caused by ectopic ossification in the distal part of sternotomy. The rarity of this complication (one case seen in recent years, operation volume: 1200 cases/year) prompted us to review the literature, where only 6 cases are described. Diagnostic problems and therapy are discussed.
Abdominal Pain↗
[Cardiovascular interventions in elderly patients].
From January 1981 to December 1990, 204 patients between 70 and 81 years of age underwent aortocoronary bypass-surgery, and 20 patients age 80 years or older underwent valvular surgery. The operative mortality rate (30-day mortality) of aortocoronary bypass-surgery was 6.8%; actuarial survival rate at 1 and 5 years was 92% and 86%, respectively. The operative mortality rate of valvular surgery was 15%; actuarial survival rate at 1 and 5 years was 78.5% and 67%, respectively. The mean follow-up was 25 months. Most patients undergoing myocardial revascularization (71%) and all the patients undergoing valvular surgery were preoperatively in New York Heart Association (NYHA) functional class III or IV, at the end of the follow-up in NYHA functional class I or II (95%). A rapid rise in the number of heart operations in the elderly is evident. It is associated with increased but acceptable operative risk. Longterm results and postoperative improvement of functional status are satisfactory.
Age Factors↗
[Problems and results of coronary reoperation].
Reoperative coronary bypass surgery has been encountered with increasing frequency over the last few years. It is associated with several major problems: difficulties with myocardial protection secondary to progression of arterial disease and occluded saphenous vein grafts, left ventricular dysfunction, and concomitant medical and vascular disease. We present our experience with 194 consecutive patients operated on between 1980 and 1992. They represent 4.0% of the overall number of isolated coronary revascularizations performed during the same period. There were 178 men and 16 women, mean age 58.6 +/- 7.4 years. The interval between primary coronary bypass grafting operation and redo-operation extended from 4 to 12 years, mean 8.2 years. At reoperation, 91.7% (178/194) of the patients received at least one arterial conduit, whereas revascularization with arterial conduits only was performed in 16 patients. Perioperative mortality amounted to 4.6% and was significantly higher than mortality of primary isolated coronary operations (1.6%) during the same period; the following significant morbidity was encountered: perioperative myocardial infarction (8.2%), postoperative low output requiring intraaortic counterpulsation (8.7%), postoperative bleeding (8.2%) and infectious complications (9.2%). First postoperative follow-up showed a significant improvement of symptomatology with a decrease of 1.5 point in NYHA functional class. Mid term survival is promising with a 5-year survival rate of 88.5%. Improved myocardial preservation and a trend towards complete revascularization should become routine and will probably reduce perioperative mortality and morbidity.
Adult↗
Aortic homograft and mitral valve repair in a patient with Werner's syndrome.
We report the case of a 66-year-old man suffering from Werner's syndrome (adult progeria); he presented with several cardiac disorders, including coronary artery disease, aortic stenosis, and mitral regurgitation, mainly due to calcific deposits in the mitral annulus and the aortic cusps. Treatment consisted of mitral repair, homograft replacement of the aortic valve, and coronary artery bypass grafting. Avoidance of prosthetic material because of chronic infectious skin ulcers constituted the main goal of the operation.
Aged↗
Should cardiac transplantation for congenital heart disease be delayed until adult age?
The number of pediatric heart transplantations for complex congenital heart disease has increased over the last years, but little experience has been reported in adolescent and adult populations. Between 1987 and 1992, 14 patients (mean age 33.2 years, range 14 to 51 years) were transplanted in our institution because of structural congenital heart disease (n = 9) or other rare disorders of the endomyocardial morphogenesis (n = 5). The main diagnosis included transposition of the great arteries, congenitally corrected transposition of the great vessels, left superior vena cava, tricuspid atresia with right ventricular hypoplasia, double outlet right ventricle with transposition, left ventricular sinusoidal malformation and right ventricular dysplasia. In several cases there were additional intracardiac malformations, including ventricular septum defect, atrial septum defect as well as different forms of pulmonary stenosis. Seven patients had undergone one or more palliative repairs that consisted of modified Blalock-Taussig shunts, Glenn's cavopulmonary anastomosis, Waterstone shunt, Blalock-Hanlon atrioseptectomy and Brock pulmonary valvotomy. Two patients had undergone Senning procedure for transposition of the great arteries. The donor cardiectomy was modified in order to include complete inflow and outflow tissue in the explant and transplantation could be performed without prosthetic material in all patients; deep hypothermic cardiac arrest was never necessary in this series. There was no early or late mortality after a mean follow-up of 37 months (range 4 to 74 months); postoperative echocardiography and cardiac catheterization demonstrated perfect anatomical and functional results in all patients. Adolescent and adult patients with complex congenital cardiac diseases can be transplanted with a very low perioperative risk, even after several prior operative procedures.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Early and late results after correction for double-outlet right ventricle: uni- and multivariate analysis of risk factors.
Between April 68 and May 91, 59 patients underwent total correction for double-outlet right ventricle. The mean age was 59.2 +/- 7.8 months. The hospital mortality rate was 27%; it was 41% before 1980 and 13% thereafter. Low cardiac output failure was the leading cause of early death. Myocardial protection without cardioplegia and long cardiopulmonary bypass time were significant predictors of hospital mortality in univariate as well as in multivariate analysis. The late death rate was 7%. The actuarial survival rate was 67% (CL 55-80%) after 10 and 20 years. The reoperation rate was 42%, a loose VSD patch constituted the main indication (23%). The actuarial freedom from reoperation rate was 51% (CL 33%-69%) after 10 years and 31% (12%-50%) after 20 years. The mean follow-up time was 8.4 +/- 0.9 years (2 to 20 years). Seventy-five percent of all postoperative survivors are in NYHA functional class I and left ventricular ejection fraction is normal in 82%.
Adolescent↗
Treatment of internal mammary artery malperfusion syndrome by additional venous graft: early postoperative angiographic results.
BACKGROUND: Internal mammary artery malperfusion syndrome is caused by an acute imbalance between myocardial demand and nutritional support through the mammary artery. METHODS: We performed early angiography in 11 consecutive patients in whom the perioperative course suggested mammary artery malperfusion. All patients received an additional saphenous vein graft distally to the mammary artery anastomosis. RESULTS: Postoperative angiography revealed patent mammary artery and vein graft in 10 patients (three with a markedly reduced caliber of the arterial graft). CONCLUSION: Additional vein graft is the treatment of choice in mammary artery malperfusion syndrome; it does not lead to occlusion of the internal mammary artery.
Coronary Angiography↗
[Descending thoracic aorta: an excellent inflow source for recurrent revascularization of the lower limbs].
Although severe complications after anatomic reconstruction of the abdominal aorta are unusual, when they occur, a different strategy is required to treat the patient with success and a distinct operation is generally required for a durable favourable long term outcome. Late complications after abdominal aortic grafting include prosthetic infection, enteric erosion and graft thrombosis. Treatment by resection of the infected graft and extra-anatomic reconstruction with axillary-femoral or axillary-popliteal bypass leaves the patient with an unreliable arterial inflow for his lower extremities; in those patients who survive graft removal and extra-anatomic bypass, an alternative source of major arterial inflow should at least be discussed to effect a permanent repair. The descending thoracic aorta has been described as an ideal inflow source for definitive intracavitary conversion of extra-anatomic subcutaneous bypasses and as an occasional alternative to avoid a densely scarred abdomen or retroperitoneum. Our experience with 8 patients includes 7 in whom the aorta had been overseen below the renal arteries in a previous operation [after removal of infected graft (n = 4) and after repair of aorto-enteric fistula (n = 3)]. Our technique of primary extra-anatomic reconstruction consists of a right-sided axillo-femoral (-popliteal) bypass with femoro-femoral crossing graft. This method avoids tunneling an extra-anatomic graft in the left thoraco-abdominal region, thus facilitating the definitive repair. Preoperative radiographic evaluation of inflow and outflow details is essential in these complex cases.(ABSTRACT TRUNCATED AT 250 WORDS)
Aorta, Thoracic↗
[Type B aortic dissections: surgical technique and results].
Between 1978 and 1992, 70 patients were operated for type B aortic dissection (tear in the descending aorta without involvement of the ascending aorta). 15/70 (21%) patients had an acute dissection (onset of symptoms < 24 h), 19/70 (27%) a subacute dissection (onset of symptoms < 14 days), and 36/70 (51) a chronic dissection (onset of symptoms > 14 days). The indications for surgery in cases of acute dissection were: hematothorax, oliguria, leg ischemia and persistent pain. Persistent hypertension was an additional indication in cases of subacute dissection. In large majority (93%) of chronic dissections the indication for surgery was enlarged aortic diameter. In 86% (60/70) graft replacement of the aorta was performed, in 6% (4/70) extra-anatomic bypass, in 3% (2/70) fenestration, in 3% (2/70) thrombendarterectomy, in 3% (2/70). The overall mortality was 17% (12/70); 27% of acute dissection, 26% for subacute dissection, and 8% for chronic dissection. The morbidity for acute dissection was 73%, of subacute dissection 43%, and of chronic dissection 12%. The most frequent complications were: leg ischemia (8 patients), renal failure (4 patients), paraparesis (4 patients) and sepsis (2 patients). No paraparesis was encountered in surgery of the chronic dissection. Conservative treatment was tried in all acute B-dissections, with surgical therapy being reserved for complications of the dissection, such as rupture, such as rupture, risk of rupture (hematothorax, large aortic diameter resp. expansion, persistent hypertension, persistent pain) or ischemia of distal vascular beds. Long-term survival for chronic type B dissections is good. Strong control of risk factors (hypertension) is essential.
Adult↗
Echo-free perfused spaces: a current postoperative finding after homograft replacement of the aortic valve.
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Adult↗