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Summary: Mediastinitis are among the most dreadful infectious complications following cardiac surgery. Their prognosis depends essentially on the precociousness of the diagnosis. In most of the cases, the medical treatment associated with an irrigation drainage is sufficient. But in case of severe sternal dehiscence, plastic surgery becomes necessary in order to fill up the loss with a well-vascularized tissue. We report the case of a 78-year-old patient, chronic bronchitic who presented, after a coronary artery bypass, an aseptic sternal dehiscence necessitating an osteosynthesis, then a Klebsiella pneumoniae mediastinitis with an enlarged sternal necrosis which was treated by bone resection and a myoplasty via reversal of the right pectoris major muscle. The postsurgery course was favourable. Now, after one-year remote, cicatrisation is complete and we have not noticed any infectious recurrence. [Copyright &y& Elsevier]

Summary: Postoperative mediastinitis is one of the most worrisome complications after heart surgery. Until now there is no universally accepted strategy in the management of this infectious complication. Recently, various novel techniques like negative pressure therapy and titanium plates sternal reconstruction have allowed a dramatic decrease of mortality and morbidity after mediastinitis. We report the case of a diabetic patient suffering from morbid obesity who developed a severe postoperative mediastinitis after a coronary artery bypass; she was successfully treated by combining negative pressure therapy, titanium plates osteosynthesis and bilateral pectoral muscle flaps. [ABSTRACT FROM AUTHOR]

Abstract: Purpose of the study: Extensive coronary dissection is a rare complication of intraluminal angioplasty. We report a retrospective study of 19 patients who consulted in a general hospital without cardiac surgery. Patients and methods: After consulting our coronarography and angioplasty database, we included the extensive coronary dissections (type D, E and F) in our study. The medical files of the selected patients were analysed. Results: Between January 2003 and March 2010, 19 coronary angioplasty (total: 2542) were complicated with extensive dissections (incidence 0,75%). For 62,3% of the patients, the dissection was related to the guiding catheter. Eleven patients had type A and B1 lesions. The dissections affected the right coronary artery for 16 patients, the left anterior descending coronary artery for two patients and the left main coronary artery for one patient. After angioplasty, a final TIMI flow 3 was obtained for only 11 patients. In nine cases, we observed a limited extension to the aorta that did not need a chirurgical intervention and had no influence on the prognosis. The complications were common, such as death (n =1), coronary bypass (n =2), myocardial infarction (n =8), cardiogenic shock (n =2) and circulatory assistance (n =2). Conclusion: Extensive coronary dissection is a rare complication of angioplasty. The right coronary is the most frequent vessel concerned and an extension to aorta is usual. The treatment is usually based on sealing the entry with a coronary stent. The complications are common and serious and we did not find any predicting factors to extensive coronary dissections that are unpredictable. [Copyright &y& Elsevier]

Abstract: Type II heparin-induced thrombocytopenia (HIT) has a low incidence in cardiac surgery, but its mortality once declared is high. Its clinical recognition can be difficult with these patients who usually have thrombocytopenia in postoperative period and who are predisposed to develop HIT prematurely. Thromboses in this context must be specific, and treatment, which is nowadays well codified, must be begun without waiting for biologic results. Besides, specificity of Elisa''s test is weakened in this population since there is a high rate of serum conversion; yet, its preoperative realization associated with pre-test probability scoring for HIT, can turn out useful. [Copyright &y& Elsevier]

Abstract: Aims: Perioperative management of anticoagulation in patients referred for pacemaker or cardiac defibrillator implantation isn’t consensual. Our objective was to evaluate, in a large cohort, hemorrhagic complications in patients having implantation or replacement of a cardiac pacemaker or defibrillator, and to assess perioperative anticoagulation effect on hemorrhagic risk. Methods and results: A cohort of 461 consecutive patients having implantation or replacement of a cardiac pacemaker or defibrillator has been analyzed. Thirty patients (6,5%) had oral anticoagulants (OAC) switched to heparin/low-molecular-weight heparin, while 76 (16,5%) had their oral anticoagulation disrupted habitually for 48hours. A total of six over 30 (20%) and two over 76 (2.6%) patients in the bridge and OAC, respectively experienced a pocket hematoma (bridge vs. OAC, p <0.05), while ten over 355 (2.8%) had a pocket hematoma in the control group (bridge vs. control p =0.006). Duration of the hospital stay was longer in the bridge group in comparison with OAC and control groups (9 vs. 7 vs. 6 days, respectively, p =0.006). Conclusion: Oral anticoagulation bridging with heparin or low-molecular-weight heparin is associated with a higher risk of pocket hematoma and a longer duration of hospitalization, in comparison with a strategy allowing a temporary disruption of OAC adapted to the thromboembolic risk. [Copyright &y& Elsevier]

Summary: We report on a 12-year-old patient from Congo who presented acute chorea following cardiac surgery for poststreptococcal mitral valvulopathy. She showed severe and asymmetrical chorea, associated with motor impersistence and agitation. Biological investigations disclosed inflammatory signs and brain MRI was normal. Due to the negative results of the biological and morphological investigations, the diagnosis of Sydenham chorea was suspected. High doses of oral steroids resulted in a dramatic improvement of the chorea as well as the behavior disturbance within 1 month. Sydenham chorea is not an unusual complication of rheumatic fever. Usually, patients develop chorea a few weeks after β-hemolytic streptococcal pharyngitis. Details on its pathophysiology remain to be determined. Our case highlights its possible onset in the postoperative period if alternative etiologies of infantile chorea have been excluded. [Copyright &y& Elsevier]

Abstract: Objectives: To study the early and late results of mitral valve replacement (MVR) by Starr-Edwards caged-ball and bileaflet mechanical prosthesis. Material and methods: We retrospectively analyzed 236 MVR performed in 236 patients: 127 by Starr-Edwards prosthesis (group 1) and 109 by bileaflet prosthesis (group 2). Results: During the early period (30 days), the mortality rate was higher in group 1 (6.3 % vs 1.8 %; p =0.0001), while hemorrhagic, thromboembolic and infectious complications were comparable in the two groups. In the late period (>30 days) and with an average follow-up of 11.5±5.7 years, mortality was higher in group 1 (9.4 % vs 4.6 %; p <0.0001). The same was true for thromboembolic complications (20.8 % vs 6.4 %; p <0.0001), hemorrhagic complications (13.4 % vs 7.3 %; p =0.02), infectious complications (3.1 % vs 0.9 %; p =0.02) and cardiac complications that were not due to the prosthesis (32.3 % vs 14.7 %; p =0.02). The hemodynamic profile of the bileaflet prostheses was better than that of the Starr-Edwards prostheses (average functional prosthetic surface area was 2.37±0.44cm2 and average pressure gradient was 5.6±1.1mmHg vs 2.04±0.52cm2 and 7.6±4.9mmHg). Conclusion: Our work confirms the superiority of bileaflet mechanical prostheses, with rates of early and late mortality, thromboembolic and hemorrhagic complications lower than those of the Starr-Edwards prostheses in more than 11 years of follow-up. However, one should not forget that the prevention of infective endocarditis, good observance of oral anticoagulant treatment and early surgery before left ventricular dysfunction occurs remain the best guarantee a good result of the MVR. [Copyright &y& Elsevier]

Abstract: Mitral valvuloplasty which is currently the most popular surgical procedure in MVD may be complicated mostly by restenosis or valvular leakage. Hemolysis occurs less frequently and by far less commonly than in prosthetic valves but deserves to be known. Delay between valvuloplasty and hemolytic anemia occurrence may vary within a wide range (from some weeks to several years as in the case we report here). A careful follow-up of the patients who undergo MV repair will help to identify this complication which is related not to the size of the regurgitation flow but to the velocity of the jet. Surgery is the unique treatment of this kind of anemia. [Copyright &y& Elsevier]

Abstract: Aims. – Conductive disorders following open-heart valvular surgery represent serious complications that may require definitive pacemaker implantation. The natural history of these troubles is not well established thus, controversy persist concerning the timing of pacemaker implantation. In this study we identify the predictive factors of permanent conductive disorders in order to assess the optimal time of pacing. Methods and results. – Two hundred thirty valvular replacements were done between 1993 and 2003. The mean age of our patients was 42±13.4 years. Rheumatic valvulopathies accounted for 76% of cases, with 54% of multiple valvulopathies. Twenty-two patients (9,5%) had an early postoperative conductive disorder, 9 of them (4%) were definitively implanted after a mean delay of 31.8 days. Preoperative bifascicular bloc and early installation of postoperative high-grade conduction disturbances and its persistence for more than 48 hours are significantly associated with permanent postoperative conductive disorders (respectively P =0.04 and=0.03). Aortic valve surgery and infective endocarditis were more frequent in the implanted group but the difference was not significant. Conclusion. – After open-heart valvular surgery; predictive factors of definitive conductive troubles justify an earlier pacemaker implantation. This attitude may accelerate the hospital discharge and decrease the disease cost effectiveness. [Copyright &y& Elsevier]

Abstract: Patients with a cardiac pathology are at high risk of perioperative cardiac complications. Therefore, an evaluation of the cardiac risk before a non-cardiac surgery has to be performed. The importance of the risk depends on the type of surgery, the patient''s clinical symptoms and his adaptation to a physical effort. Exams are chosen according to the pathology, the information searched for and should be non invasive. After the evaluation, a specific preparation of the patient and the institution or an adaptation of cardioprotective medications should be discussed. The cardiologic consultation also allows a better management of antithrombotic or antiplatelet therapy. Preoperative evaluation of the cardiac risk is based on the collaboration between cardiologist and anesthesiologist to select the patients to evaluate, optimize their management, and decrease the risk of complications. [Copyright &y& Elsevier]

Abstract: Although diaphragmatic rupture occurs after violent blunt trauma, its diagnosis is often delayed. The intra-thoracic displacement of abdominal organs through diaphragmatic rupture may lead to early or delayed complications because of compression of heart and lungs or strangulation of the abdominal viscera. A 49-year-old woman was scheduled to undergo elective lumbar disc surgery in prone position. The preoperative chest radiograph revealed an abnormally elevated right hemi diaphragm with loops of colon filling the right costophrenic angle. The CT-scan confirmed right chronic diaphragmatic rupture with colon and liver herniations. Fifteen months previously, this woman had been involved in a traffic accident, with blunt right trauma resulting in right pelvic fractures. Perianaesthetic course increase the pre-existing mechanical risk of complications of chronic diaphragmatic rupture. Primary repair of right chronic diaphragmatic rupture through thoracotomy must be recommended. When another surgery must be done in emergency, the feasibility of regional anaesthesia should be considered. [Copyright &y& Elsevier]

Résumé: La chirurgie cardiaque et la circulation extra-corporelle (CEC) ont fait d’importants progrès au cours des dernières années. Malgré ces efforts des évènements indésirables continuent à survenir au cours des interventions. À partir des études récentes concernant les incidents et accidents en cours de CEC cet article insiste de manière critique sur les éléments importants à respecter lorsque l’on a la responsabilité d’une CEC. Certains faits établis ne reposent que sur des données non supportées par des travaux scientifiques. D’autres n’ont pas prouvé leur bénéfice en termes de morbidité postopératoire. Ce qu’il ne faudrait plus voir concernant la gestion de l’anticoagulation, de l’hématocrite, du débit de pompe et de la température est rappelé. Enfin, il est mis en évidence l’importance du travail d’équipe surtout au niveau de la cohésion et de la communication. [ABSTRACT FROM AUTHOR]

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