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The objectives are to present the different minimally invasive cardiac surgery techniques to repair the mitral valve, TAVI and MitraClip, as well as the implications for the anaesthetist. Evaluate retrospectively the anaesthesist methods, change in monitoring and how the patients are selected. The mitral valve repair by minithoracotomy and video-surgery requires selective left intubation and monitoring by TEE. The TAVI methods seem to be working best under local anaesthesia and sedation for haemodynamic and neurologic monitoring. The MitraClip surgery requires an extensive monitoring during and after surgery. In conclusion, the care of patients that are candidates for a TAVI requires the same level of expertise as anaesthesiology in cardiac surgery. The number of procedures performed under sedation will increase. These patients require multidisciplinary care (surgeons, cardiologists, sonographers and anaesthesiologists) due to comorbidities, and the possible haemodynamic, neurologic and vascular complications. These patients have an Euroscore greater than 20% and a STS score greater than 10%. In our experience, 80% of the cases are done femorally, 17% of the cases are done through the subsclavian artery (Corevalve(®)). 80% of the patients have surgery with a local anaesthesia and sedation. 20% of the patients get surgery with general anaesthesia. For the Edwards-Sapien(®) valve, when the femoral approach is impossible, the patient can get surgery with general anaesthesia using the transapical access.

SummaryObjectThe French Cardiology Society (SFC) systematically recommends (Class I) transesophageal echocardiography (TEE) after any mitral valve replacement with a mechanical prosthesis (MMVR). Taking into account the increasing workload of echocardiography laboratories, our attitude was to propose that only post-operative transthoracic echocardiography (TTE) is performed. The purpose of this study was to evaluate the possible risks of this simplified procedure.MethodsWe performed a precise analysis of one full year of practice of MMVR with exhaustive follow-up for the first 2 years concentrating on thromboembolic complications.ResultsFrom January to December 2003, 84MMVRs (46 after rheumatic fever, 22 degenerative disease, 11 infective endocarditis (IE) and 5 ischemia) were conducted in 45 women and 39 men of average age 61 years. Early mortality (< 30 days) concerned 5 patients (5.9%). A control TTE to determine normal prosthetic function was performed 7±2 days after surgery and this revealed 2 cases of nonobstructive thrombosis which were treated medically, 3 cases of paraprosthetic regurgitation, and 1 vegetation due to underlying IE. Actuarial survival was 90.5% at 1 year and 83.3% at 2 years. After a mean follow-up of 179.3 patient-years, 5 patients were reoperated (5.9%): 1 for IE, 1 for paravalvular regurgitation, 1 for mitral valve insufficiency with haemolysis, and 2 for obstructive prosthetic valve thromboses. In addition there were 2 cases of prosthetic valve thrombosis, 8 ischemic strokes (2 ministrokes, 6 sequelar strokes), and 1 peripheral embolism. The global thromboembolic complication rate was therefore 6.1 per 100 patient-years (n=11). There were 4 hemorrhagic events, i.e. a rate of 2.2 events per 100 patient-years. 63% of the 1193 INR conducted were within the target range (3-4.5), 26% were below 3 and 11% were greater than 4.5. 35 % of patients with thromboembolic complications had an INR < 3.ConclusionMorbidity and mortality during the first 2 years after MMVR were relatively high but equivalent to the values of comparable series in the literature. These complications would not have been reduced by a more precise screening based on early TEE. Despite the increasingly litigious nature of the doctor-patient relationship, it would probably be excessive to oppose that this guideline was not followed in a dispute; in particular as it is difficult to apply this measure as echocardiography departments are overworked.

This study investigated patients undergoing elective cardiac surgery to evaluate the effects of cardiopulmonary bypass (CPB) on the spontaneous variability of mean arterial pressure (MAP) and heart rate (HR). Forty-one adult patients receiving different cardiovascular system drugs were included in the study. Patients were divided into three groups: no preoperative pharmacological cardiovascular treatment (n = 12), beta-blocker (BB) (n = 13), and angiotensin-converting enzyme inhibition (ACEI) (n = 16). MAP was recorded before anaesthesia until the end of surgery. MAP and HR variability was analysed in very low- (VLF), low- (LF) and high-frequency bands. The LF spectral component of MAP was observed to decrease in patients under ACEI (-92%) or BB (-87%) following induction of anaesthesia. In addition, during CPB, VLF power decreased in BB group (-67%), and LF power decreased in ACEI group (-77%). Concerning HR, VLF spectral power decreased following anaesthesia in BB group (-74%). In addition, after CPB, VLF power reached lower value in ACEI group than in BB group (P < 0.05). LF spectral power of HR showed a large decrease after CPB in ACEI group (-89%). This study showed that MAP variability did not change during CPB in patients with no preoperative pharmacological cardiovascular treatment, suggesting an unaltered vascular control of MAP. Moreover, the change in LF spectral power of MAP in ACEI and BB groups, suggests that both the renin-angiotensin and sympathetic systems participate to the genesis of LF variability of MAP.

Background: Transcatheter Aortic Valve Implantation (TAVI) is a therapeutic option for patients presenting with severe aortic stenosis and in whom surgery is contraindicated. Pre-procedural Pulmonary Hypertension (PH) has been shown to be a factor of poor prognosis in surgical and TAVI studies. Aims: We sought to evaluate the clinical impact and prognostic implications of the presence of post-TAVI PH. Methods: The outcome of post-TAVI Pulmonary Artery Systolic Pressure (PASP) was studied in 58 high-risk patients with severe symptomatic aortic stenosis, by assessing clinical presentation and prognosis and determining predictive factors. Results: Post-TAVI PH (PASP>40 mmHg) affected 43% of patients at 6 months. Despite excellent aortic results in both groups, patients with post-TAVI PH were more symptomatic, with were severer according to the New York Heart Association classification (class III or IV), higher cardiovascular mortality and more frequent readmission for cardiac failure. On univariate analysis, factors for elevated PASP were: female sex, history ofmyocardial infarction, pacemaker implantation and permanent pacing, atrial fibrillation, and degree of mitral regurgitation. On multivariate analysis, only atrial fibrillation remained an independent factor for post-TAVI PH. Conclusion: PH is frequently present after TAVI and allows identification of a subgroup of patients with poorer clinical presentation and cardiovascular prognosis. Further studies and especially complementary myocardial investigation seem necessary.

The main goal of this prospective study was to identify among cardiac surgery patients, usually monitored through a standard pulmonary artery catheter (PAC), those in whom a fiberoptic catheter oximeter to measure oxygen saturation in mixed venous blood (SVO2 PAC) would be most useful. Data from 286 patients who underwent coronary artery bypass graft (50%) or valvular surgery were recorded, including ASA physical status, New York Heart Association (NYHA) classification, and Parsonnet score (PS). Hemodynamic events and SVO2 changes were collected intra- and postoperatively until weaning from mechanical ventilation. The anesthesiologist in charge graded the usefulness of SVO2 PAC, and another anesthesiologist carried out a blindly controlled overall evaluation. Usefulness was defined as the presence of a change in therapeutic maneuver triggered solely by continuous SVO2 data that would not have occurred based on other routine parameters. SVO2 was also considered useful if earlier recognition of significant adverse events occurred. SVO2 PAC was useful in 57% of the patients. Independent predictive factors (multivariate analysis) for the perioperative usefulness of SVO2 in the whole population consisted of ASA classor = 4 (P10(-5); relative risk [RR] 1.78, 1.51-2.07), mitral surgery (P10(-4); RR 1.72, 1.4-2.02), and NYHA scoreor = 3 (P0.01; RR 1.66, 1.35-2.05). Independent predictive factors for the perioperative usefulness of SVO2 in the coronary artery bypass graft population were NYHA scoreor = 3 (P10(-5); RR 1.90, 1.42-2.55) and ASA classor = 4 (P0.01; RR 1.99, 1.51-2.63). The presence of three stenosed coronary arteries showed borderline significance (P0.06). Independent predictive factors for perioperative usefulness of SVO2 in the valvular population were mitral pathology (P10(-5)) and ASA classor = 4 (P0.01). The receiver operator characteristic curve assessed the predictivity of the PS. SVO2 PAC was more useful in the group of patients with the greatest severity of illness (PS in useful group 17.0 +/- 10.3; in nonuseful group 8.7 +/- 6.6; P10(-4)). Intensive care unit duration and hospital stay in the useful group was prolonged compared with the nonuseful group. Similarly, morbidity was frequent in the useful group, although it was not always significantly different from the nonuseful group according to the type of complications. Mortality was comparable in the groups despite their different degree of illness and was reduced when taking into account the predictive and observed mortality provided by the PS. This study defined independent preoperative factors associated with SVO2 PAC monitoring and proposed a cutoff point above which SVO2 may be useful.

The objectives are to present the different minimally invasive cardiac surgery techniques to repair the mitral valve, TAVI and MitraClip, as well as the implications for the anaesthetist. Evaluate retrospectively the anaesthesist methods, change in monitoring and how the patients are selected. The mitral valve repair by minithoracotomy and video-surgery requires selective left intubation and monitoring by TEE. The TAVI methods seem to be working best under local anaesthesia and sedation for haemodynamic and neurologic monitoring. The MitraClip surgery requires an extensive monitoring during and after surgery. In conclusion, the care of patients that are candidates for a TAVI requires the same level of expertise as anaesthesiology in cardiac surgery. The number of procedures performed under sedation will increase. These patients require multidisciplinary care (surgeons, cardiologists, sonographers and anaesthesiologists) due to comorbidities, and the possible haemodynamic, neurologic and vascular complications. These patients have an Euroscore greater than 20% and a STS score greater than 10%. In our experience, 80% of the cases are done femorally, 17% of the cases are done through the subsclavian artery (Corevalve(®)). 80% of the patients have surgery with a local anaesthesia and sedation. 20% of the patients get surgery with general anaesthesia. For the Edwards-Sapien(®) valve, when the femoral approach is impossible, the patient can get surgery with general anaesthesia using the transapical access.

Aortic valve sparing operations are now widely accepted for ascending aortic aneurysm surgery. We herein report our experience of the Tirone David procedure in larger indications. From January 1997 to August 2003, 50 Tirone David procedure have been performed on 36 male and 14 female (mean age: 60 +/- 15). Five patients presented a Marfan disease and 4 acute dissections. Grade III or IV aortic insufficiency was frequent (40%). Aortic diameter was not particularly dilated, ranging from 44 to 78 mm (mean: 57 +/- 10 mm). Mean ejection fraction: 57 +/- 10%. Mean left ventricular end diastolic diameter =63 +/- 7 mm. An associated mitral valve repair and 1 coronary bypass were necessary. Mean cross clamp and bypass times =94 min and 122 +/- 28 min respectively. There was one in-hospital mortality. Secondary mortality affected 2 patients (non-cardiac deaths), for a cumulative follow-up of 946 months. During follow-up continence control was always excellent, only 1 bicuspid valve had an aortic insufficiencygrade II. Tirone David procedure gave satisfactory results as regards both aortic ectasia and aortic regurgitation control. We consider it feasible even in case of aortic dissection but caution is required when facing bicuspid aortic valves.

The instant centre frequency (ICF) of RR interval has been proposed as a global index to analyse the sympathovagal interaction in the heart. The aim of this study was to assess the ICF during anaesthesia to test if it can reliably capture the neural control of the cardiovascular system. Twenty-four ASA II or III patients scheduled for cardiac surgery were included in the study. They were allocated in two groups: control, no treatment (group 1, n = 12), and beta-adrenergic blockade by atenolol (group 2, n = 12). Spectra of pulse interval series were computed with a time-frequency method and they were divided into: very low frequency (VLF, 0.000-0.040 Hz), low frequency (LF, 0.050-0.150 Hz) and high frequency (HF, 0.160-0.500 Hz). Normalized power was obtained by dividing the cumulative power within each frequency band (LF or HF) by the sum of LF and HF; the ratio of LF/HF was also calculated. Instant centre frequency is a time-varying parameter that the evolution along time of the gravity centrum of a local spectrum. All spectral indexes were recorded at the following time points: before induction, after induction and before intubation, during intubation, and after intubation. The atenolol group had lower normalized LF and the LF/HF ratio (P < 0.05) higher HF before induction; and lower LF/HF ratio after induction and before intubation (P < 0.05). The ICF was higher in atenolol group at all times. The ICF shifted towards HF frequency after induction and before intubation and shifted towards LF during intubation in both groups. The autonomic nervous system control on the heart through the interaction of sympathetic and parasympathetic reflex mechanisms could be studied by the ICF. The ICF may assess the autonomic cardiac modulation and may provide useful information for anaesthetic management.

Resume Une insuffisance renale postoperatoire moderee est frequemment notee apres transplantation cardiaque sous cyclosporine, aggravee par la mauvaise tolerance du ventricule droit a la charge hydrosodee et a l'hypertension arterielle pulmonaire residuelle. Le recours systematique aux diuretiques de l'anse (bumetamide/furosemide) est propose. L'etude chez 30 transplantes cardiaques randomises en 2 groupes, trouve un rapport d'equipotence de 50 apres administration intraveineuse continue et une baisse plus rapide de creatininemie sous bumetamide (16 μmol.l−1) sans autre variation significative. L'introduction de la cyclosporine parait sure avec ce protocole, la fraction excretee sodee restant a 2,1 % (0,9/9) pour des apports et des pertes sodes comparables.

Resume Une serie de neuf patients, classes au stade III ou IV de la NYHA, operes sous circulation extracorporelle, apres une premedication de 2 mg per os de flunitrazepam 1 h 30 min avant l'intervention, a ete divisee en deux groupes. Le groupe A, compose de cinq patients hommes, d'âge moyen 53 ans (extremes 43 et 73), sans difference significative de poids et de surface corporelle, comprend deux remplacements valvulaires aortiques, deux remplacements mitraux et un double remplacement. Ce groupe recoit du propofol en intraveineuse directe a la dose de 1,5 mg · kg −1 a l'induction et l'anesthesie est maintenue par une perfusion de propofol a 50 μg · kg −1 · min −1 . Le groupe B, constitue de quatre patients (2 hommes, 2 femmes), d'âge moyen 60 ans (extremes 49 et 76), sans difference significative de poids et de surface corporelle, comprend trois remplacements valvulaires aortiques et une cure d'anevrysme du ventricule gauche. Ce groupe recoit du propofol en intraveineuse directe a la dose de 2 mg · kg −1 a l'induction et l'entretien est assure par une perfusion de propofol a 100 μg · kg −1 · min −1 . Les patients des deux groupes sont intubes sous pancuronium 0,1 mg · kg −1 et recoivent 10 μg · kg −1 de fentanyl avant l'intubation et 10 μg · kg −1 avant l'incision, fentanyl et pancuronium etant ensuite reinjectes a la demande. L'etude hemodynamique comporte la mesure de la frequence cardiaque, des pressions arterielles systolique, diastolique et moyenne, de la pression veineuse centrale, de la pression pulmonaire moyenne, de la pression capillaire et du debit cardiaque par thermodilution. Sont obtenus par calcul l'index cardiaque, l'index systolique, l'index de travail systolique droit et gauche, les resistances vasculaires systemiques et pulmonaires. Les donnees hemodynamiques sont recueillies avant induction (controle), 1 a 3 min apres induction, 1 a 3 min apres intubation, avant sternotomie et 5 min apres sternotomie. Les donnees sont comparees a chaque temps de mesure entre les deux groupes. Les resultats suggerent que le propofol, s'il induit une baisse moderee de la pression arterielle a l'induction, liee a une baisse des resistances peripheriques systemiques, n'a que peu d'action sur le debit cardiaque et ne modifie pas les indices de travail. Par ailleurs, l'usage du propofol gomme dans une large mesure les a-coups tensionnels a l'intubation et dans une moindre mesure au moment de la sternotomie.

Nine patients, all NYHA class III and IV, who were to undergo surgery with cardiopulmonary bypass, were divided into two groups. All nine were premedicated with 2 mg flunitrazepam orally 90 min before surgery. Group A consisted in five men, mean age 53 years (extremes: 43 and 73), with no significant difference in weight and body surface area, who were to undergo aortic valve replacement (2), mitral valve replacement (2), and aortic and mitral valve replacement (1). They were given 1.5 mg X kg-1 propofol as a bolus at induction, followed by an infusion of 50 micrograms X kg-1 X min-1 propofol. Group B consisted in four patients, two men and two women, mean age 60 years (extremes: 49 and 76), with no significant difference in weight and body surface area, who were to undergo aortic valve replacement (3) and corrective surgery for left ventricular aneurysm (1). They were given 2 mg X kg-1 propofol as a bolus at induction, followed by an infusion of 100 micrograms X kg-1 X min-1 propofol. All the patients were intubated after 0.1 mg X kg-1 pancuronium; they were given 10 micrograms X kg-1 before intubation and 10 micrograms X kg-1 before skin incision. Repeat doses of fentanyl and pancuronium were given as required. The haemodynamic parameters studied were: heart rate, systolic, diastolic and mean blood pressures, central venous pressure, mean pulmonary pressure, wedge pressure, and cardiac output measured by thermodilution. The following indices were calculated: cardiac index, systolic index, right and left systolic work indices, and pulmonary and systemic vascular resistances.(ABSTRACT TRUNCATED AT 250 WORDS)