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Post-sternotomy mediastinitis, a nosocomial infection mostly caused by staphylococci, can be life-threatening. A case of mediastinitis due to Finegoldia magna after a coronary artery bypass graft surgery was reviewed. Although this bacterium is difficult to be isolated from routine blood cultures, a F. magna bacteriemia associated with mediastinitis was diagnosed., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Atrial arrhythmias (AAs) occur frequently after cardiac surgery. However, most authors do not differentiate postoperative atrial fibrillation (AF) from atrial flutter (AFL). Our study sought to investigate the incidence and predictors of AFL following non-congenital cardiac surgery, and the long-term outcome of this arrhythmia., Methods and Results: We conducted an observational, retrospective, single-centre study. Among 821 patients in sinus rhythm (SR) before non-congenital cardiac surgery, AFL occurred in 42 patients (5.1%) and AF in 77 (9.4%). Independent predictors of AAs were older age (odds ratio (OR): 1.06, 95% confidence interval (CI): 1.01-1.11, p = 0.02), low postoperative hemoglobin level (OR: 0.43, CI: 0.29-0.63, p < 0.0001) and long cross-clamp time (OR: 1.02, CI: 1.002-1.037, p = 0.03). Compared to AF patients, those with AFL were younger (67 ± 10 versus 72 ± 8 years, p = 0.005) and less likely to have valve surgery (57% versus 76%, p = 0.03). After conversion to SR, of 41/42 patients with AFL, 5 (12%) developed AFL and 5 (12%) had AF within a mean follow-up of 9.6 ± 8.4 months: only 32% of patients were on long-term antiarrhythmic therapy and 5% had radiofrequency ablation of AFL in the early postoperative period., Conclusion: AFL following non-congenital cardiac surgery is not frequent. Compared to patients in AF, those with AFL are younger and less likely to have valve surgery. After conversion of AFL to SR, recurrence rate of AAs is relatively low. Therefore, AFL occurring in this setting does not require systematic catheter ablation in the postoperative period., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: Either percutaneous coronary intervention (PCI) or coronary artery bypass grafting can be chosen for the treatment of multiple-vessel coronary artery disease. We report the results of a hybrid procedure performed on the same day, combining PCI of the right coronary artery and internal mammary artery bypass grafting of the left coronary artery, for the treatment of diffuse extensive lesions., Methods and Results: Since January 2000, 70 patients (53 male, mean age 68.5 +/- 10 years) underwent this hybrid revascularization combining primary right coronary artery PCI and, within the next 16 h, left coronary artery grafting with left and/or right internal mammary artery. Thirty-one patients (98%) were treated on the same day. At a mean follow-up of 33 months (range: 2-70 months), 68 patients (97%) were asymptomatic at the time of writing. Three adverse events were reported: 2 were PCI-related, due to failure to take ticlopidine, and 1 was surgery-related, resulting in the patient's death during hospitalization., Conclusion: These preliminary results for a same-day combined procedure in patients with diffuse multivessel coronary artery disease are encouraging. This strategy optimizes revascularization when patients are unstable or present very severe coronary lesions, which requiring rapid treatment and are not ideally suitable for PCI management alone., ((c) 2007 S. Karger AG, Basel.)

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.

The authors carried out a retrospective study of short and long-term mortality after aortic valve replacement and assessed the quality of life by the IRIS scale in patients over 75 years of age operated for severe aortic stenosis at the University Hospital of Brest between June 1990 and March 1995. The hospital files of 110 consecutive patients (71 women, 39 men; average age 78 +/- 2 years, range 75-85 years) were studied. The pre- per- and postoperative data was studied. Each survivor was contacted by telephone during the year 2000 and a health and IRIS quality of life questionnaire was sent to them. Precise information about patients who had died was obtained from the family and/or medical practitioner. In the preoperative period, 30.9% of patients had left ventricular failure. The average aortic valve surface area was 0.53 +/- 0.12 cm2. Of the patients who underwent coronary angiography (60%), one third had significant coronary lesions. Coronary artery bypass surgery was associated with aortic valve replacement in 10% of cases. Biological prostheses were used in 108 patients. The operative mortality was 8.2%. One year, 5 year and 10 year survival rates were 89.9%, 75.5% and 33.3% respectively. Of the survivors, 16.7% were in institutional care and 83.3% lived at home. A total of 77.8% were readmitted to hospital, about half of them for cardiac problems. Cardiac treatment was prescribed for 97% of patients. The quality of life questionnaire was completed by 35 patients: the quality of life was better than average in nearly 83% of these patients. Aortic valve replacement for aortic stenosis in patients over 75 years of age improves life expectancy which is almost the same as that of the normal population of the same age, and improves the quality of life by restoring functional autonomy, enabling the majority of them to live in their own houses most of the time.

Retrograde cardioplegia is still controversial due to the heterogeneous left ventricular flow distribution particularly in the posterior wall. The purpose of this study was to compare retrograde flow distribution delivered through the coronary sinus with two types of cannula. Fifty two patients were prospectively randomized to receive cold blood retrograde cardioplegia with manual inflating long balloon prototype cannula (group I, 26 patients) or with manual inflating short balloon cannula (group II, 26 patients). Left ventricular distribution of the cardioplegic solution was assessed by monitoring the left ventricular wall temperatures (anterior and posterior). The cardioplegic retrograde infusion was stopped as the anterior wall temperature reached 15 degrees C. In group I, 91% of the patients had identical cooling in the anterior and posterior wall of the left ventricle, versus 19% in group II (p < 0.05). The mean temperature difference between anterior and posterior wall was 0.5 degrees C (standard deviation = 1.7) in group I versus 8 degrees C (standard deviation = 4.1) in group II (alpha < 0.05). The cannula with the long balloon allows a better left ventricular distribution of the cardioplegia flow than the short one because it occludes the interventricularis posterior vein in the coronary sinus.

We have designed a mechanical device for left ventricular apex cannulation (SCAV). It will be used to implant a ventricular connection for a skeletal muscle ventricle placed in apicoaortic configuration without cardio-pulmonary bypass. The aim of this study was to assess the tightness of the ventricular connection at 48 hours. We used a left ventricular assist device (Biomedicus centrifugal pump) placed between the apex of the left ventricle and the descending thoracic aorta on 10 female sheep. The ventricular connection between the apex of the left ventricle and the Biomedicus was carried out with the SCAV and without cardio-pulmonary bypass. The intra-operative mortality was 10% (1 sheep) due to ventricular fibrillation. Three sheep died early in the run of the ventricular assistance due to technical assistance problems not related to the SCAV. The full ventricular assistance could be managed in 6 sheep through 32 h 30 (range from 15 to 46 h). No death occurred in these 9 sheep due to cardiac hemorrage or tamponade. The average apical bleeding in the pericardial drain was 157 ml (range from 20 to 270 ml). The tightness of the ventricular connection was proved by this study. The SCAV may be suitable for apical implantation of a skeletal muscle ventricle in sheep.

A technique of coronary surgical angioplasty is described. At the level of the stenosis the arteriotomy of the coronary artery is closed with the internal thoracic artery giving an enlargement patch effect. The major surface of the atherome plaque is excluded from the lumen of the anastomosis and put outside the suture line. The origins of the collateral arteries are kept in the vascular lumel. So the new remodeled coronary artery is formed with a small gutter of native coronary artery and the whole surface of the internal thoracic artery wall. In some cases it is useful to associate a limited endarterectomy to the angioplasty. Sixty-six surgical angioplasties have been done in extensive coronary disease. Operative mortality was 5.4% and myocardial infarction 5.4%.

Stab wounds of the heart are frequent: one case every two and a half months in our service. In our series of 9 cases, only three were alive at arrival to the emergency ward, but in all of these three, treatment was simple requiring only simple wound suture without extra-corporeal circulation. Based on our experience and the data in the literature, we propose cooperation between three teams for managing these patients: anaesthesists, echocardiographists and cardiothoracic surgeons. The patients are admitted directly to the cardiothoracic operating theatre where the echocardiographist and the surgery team take charge. The surgical procedure depends on the general situation and especially on whether or not the echocardiologist can confirm haemopericardium immediately. Every patient with possible wound to the heart or major vessels should be managed directly by the cardiothoracic surgery team before of formal diagnosis has been established.

The one year results of three techniques of bypass grafting of the artery of the left border of the heart were compared in a retrospective study in 120 patients all undergoing left anterior descending bypass grafting with an internal mammary artery. Group I comprised 38 consecutive patients: the left border artery was bypassed with a venous graft. Group II comprised 49 consecutive patients who had the left border artery bypassed by an internal mammary artery in situ. Group III comprised 33 consecutive patients who had the left border artery bypassed by an internal mammary graft issuing from a Y-shaped construction (right internal mammary artery as a free graft reimplanted into the left internal mammary artery). The operative mortality, morbidity and functional results were comparable in the three groups. The rate of angiographic success of the left border artery graft at one year was: 65.7% in group I, 89.5% in group II and 87.8% in group III. The one year patency of internal mammary artery grafting of the artery of the left border was higher than that of venous grafts (p < 0.05).

Retrograde cardioplegia is still debated due to heterogeneous left ventricular flow distribution. The purpose of this study was to compare retrograde flow distribution delivered through the coronary sinus with two patterns of cannula. Fifty four patients were prospectively randomized to receive cold crystalloid retrograde coronary sinus cardioplegia with lither a manual inflating balloon cannula (group I, 24 patients) or a self-inflating balloon cannula (group II, 30 patients). Left ventricular distribution of the cardioplegic solution was assessed by monitoring the left ventricular wall temperatures (anterior and posterior). The cardioplegic retrograde infusion was stopped as the anterior wall temperature reached 12 degrees C. In group II, 70.8% of patients had an identical cooling in the anterior and posterior wall of the left ventricle, versus 40.9% in group I (p < 0.05). The mean temperature difference between anterior and posterior wall was 2.9 degrees C (standard deviation: 2.9 degrees C) in group II versus 5.7 degrees C (standard deviation: 4.3 degrees C) for group I (< 0.05). The retroplegia cannula with the self-inflating balloon allows a better distribution of the cardioplegia flow than the manually inflating balloon. We think that this is due to the shape of the self-inflating balloon which more closely fits the morphology of the coronary sinus.

A technique of coronary surgical angioplasty is described. The long arteriotomy of the coronary artery over the stenosis is closed with the Internal Thoracic Artery (ITA) giving an enlargement patch effect. The majority of the atheromatous plaque is excluded from the lumen of the anastomosis and placed outside the suture line. The origin of the collateral arteries is preserved in the vascular lumen. The remodeled coronary artery is composed of a small gutter of native coronary artery and the whole surface of the ITA wall. In some cases, it is useful to associate a limited endarterectomy with the angioplasty. 66 surgical angioplasties have been performed in extensive coronary disease. Operative mortality was 5.4% with a myocardial infarction rate of 5.4%.

We report two cases of right lumbar common iliac arteriovenous injury after an operation on the L4-L5 disk. One case was an arteriovenous fistula disclosed 5 years after the operation and in the other case, a postoperative acute haemorrhage. A retrospective study is carried out in the literature aiming at establishing the frequency of vascular injury in lumbar disk surgery, their nosologic definition, and the provided treatment. One hundred and twenty two observations were taken into account. The frequency cannot be determined. 78 of these observations (63.9%) reported an arteriovenous fistula between two elements of the aortic-cava intersection, with acute revelation (6.4%), sub-acute (19%) or late as a right cardiac failure (64%). Thirty one cases of acute haemorrhages through isolated arterial wound (25.4%), 3 cases of arterial or venous thrombosis (2.5%) and 10 cases of false aneurysms (8.2%) were found. The treatment was always surgical, sometimes in high emergency. In the case of haemorrhage the death rate was 21% and in the event of fistula 1.3%. Morbidity was 11.5%, mostly due to a post-phlebitic syndrome. These results reduce the mildness reputation of lumbar disk surgery all the more as recording of the complications is under estimated and most of them are found far from the initial act.

Background: Cystic adenomatoid malformation of the lung can be seen by ultrasonography during pregnancy. Surgical excision of the affected lobe is indicated during the first days of life., Cases Report: Four neonates were admitted to an intensive care unit from March 1988 to February 1992, due to cystic adenomatoid malformation of the lung, that had been diagnosed by ultrasonography at 19, 22, 34 and 37 weeks of gestational age, respectively. These malformations were not associated with other abnormalities and were type I (three cases) and II (one case) according to Stocker's classification. Only one patient became symptomatic, requiring intubation by 72 hours of age. Surgical excision of the affected lobe was performed in three patients at 4 hours, 2 and 7 days of life, respectively, with a normal long-term survival. A segmental resection was performed at 5 days of life in the remaining symptomatic patient but persistence of cystic lesions required lobectomy at 10 months., Conclusions: Early perinatal management of cystic adenomatoid malformations of the lung is necessary as surgical excision is indicated as soon as possible, even in asymptomatic patients.

Between January 1981 and June 1992, 382 patients, operated by the same surgical team, underwent aortic valve replacement for pure severe aortic stenosis. This population was divided into 2 groups according to whether or not surgery was complicated by the development of a conduction defect (atrioventricular and/or intraventricular block), necessitating permanent cardiac pacing. The aim of this study was to analyse not only the incidence and predictive factors but also the long-term prognosis of the paced patients (Group II: 22 patients) in comparison with the control group (Group I: 360 patients). The results showed: the incidence of permanent cardiac pacing after this type of surgery remains low (5.7%); the predictive factors of atrioventricular block requiring permanent pacing were: pre-existing conduction defect (p < 0.02), decreased ejection fraction (p < 0.05), calcification extending to the subaortic interventricular septum (p < 0.0001); the long-term prognosis of the patients was good with 5 and 10 year actuarial survival rates of 95.4% and 68.9% respectively, identical to those of the control group.

One hundred and twenty-one consecutive patients (104 men, 17 women; mean age 56 +/- 7.8 years) underwent sequential mammary artery grafting for anterior (left anterior descending or diagonal arteries) wall revascularisation. There was one death (0.8%) and five myocardial infarctions (4.2%) including two anterior infarcts during the first 30 postoperative days. All survivors were reviewed at one year. Of these 120 patients, 77 (64%) accepted control coronary angiography on average 456 +/- 143 days after surgery. One internal mammary artery anastomosed to 2 diagonal arteries was occluded. All the other latero-lateral anastomoses were patent. There was, however, one 60% stenosis. Three termino-lateral anastomoses on the left anterior descending artery were occluded and 2 others stenosed (40% and 60% luminal narrowing, respectively). Four internal mammary arteries were narrowed 2 because of stenosis and 2 because of the small calibre of the receiving artery. The patency rate considering the total number of anastomoses was therefore 96.8%. These results show that sequential internal mammary artery grafting for myocardial revascularisation does not increase the number of perioperative complications and is associated with a low rate of occlusion on the left anterior descending artery at one year. This surgical technique may therefore be used routinely.

Aneurysmal arteriovenous fistulae (AVF) for haemodialysis often need surgical closure. We present a technique which consists of inserting the AVF into a constrictive perivenous mesh tube, thereby bringing the caliber of the AVF down to its normal size and restoring the normal shape of the forearm. Nine patients underwent AVF constriction without postoperative events. All AVFs were patent at 4 months. This technique also has the advantage of saving veins which, of course, is worthwhile in patients under haemodialysis.

The distal latero-circumflex arteries and the posterior descending artery are located so far from the mammary arteries that they cannot be revascularized by the conventional procedure. Reimplantation of the right internal mammary artery (RIMA) used as a free graft into the left internal mammary artery (LIMA) in situ doubles the length of the RIMA, thus enabling the distal coronary arteries (lower lateral or posterior interventricular arteries) to be bypassed. The Y-shaped reimplantation anastomosis technique is described, and the immediate results obtained in 25 patients are reported. Seven angiographic controls were performed after 6 months to 1 year, and 6 anastomoses were perfectly patent. One RIMA is occluded (major competitive flow).

From 1985 to november 1989, 270 patients underwent sequential anastomosis with left internal mammary artery (LIMA) on left descending artery (LDA) and diagnonal artery (DA). The first 120 cases have 100% one year follow-up. The perioperative status was: angina stage III or IV: 59%; myocardial infarction (MI): 45%, stenosis of 3 vessels: 52.5%; stenosis of main coronary artery: 10.8%. 2.25 anastomoses were performed per patient. Side-to-side anastomosis (kissing) were not diamond anastomoses but axial and longitudinal. The use of fibrin gllude provides regular curves of the graft between anastomosis. Mortality was 0.8%, morbidity was: MI: 4.2% (2 small infarcts in anterior vessels, 3 others in non-grafted vessels); mediastinitis: 1%; severe bleeding (reoperation): 1%. At one year 93% of patients are free from angina and 71 patients underwent angiographic assessment (145 LIMA anastomosis). Results are as follow: side-to-side anastomosis patency: 98.5%; distal anastomosis obliteration: 3%; LDA anastomosis patency: 95.7% overall sequential anastomosis patency: 97.6%. These results have led our cardiologist in Brest to naturally prefer a surgical approach than percutaneous angioplasty when LDA and DA are involved.

Distal latero-circumflex arteries (DLCA) and posterior descending artery (PDA) are anatomically too far and cannot be revascularized with internal mammary artery (IMA) by a conventional procedure. The reimplantation of the right IMA into the left IMA in situ increases (2 times) the length of right IMA graft available. Fifty-five patients underwent this technique. Their preoperative status was: 22 males, 3 females; mean age: 57 years, 38% myocardial infarction (MI). Coronary angiography showed: stenosis of the left main coronary artery: 3; stenosis of 3 vessels: 15; 2 vessels: 10; 2.3 anastomoses by patient were performed with Y right and left IMA procedure: 24 LDA, 8 diagonals, 25 DLCA and 1 PDA anastomosis. No deaths were observed in this short series. Morbidity was: 1 MI, 2 sternal sepsis, 1 bilateral phrenic paralysis (all were cured without sequelae). To date (March 90) 15 patients have been followed for 3 to 12 months, 12 are angina-free, 3 are significantly improved, 11 have a negative exercise test. Thallium test is normal in the revascularized area in 14 patients. Seven angiographies have been performed (6 months to 1 year) and all Y right IMA are patent.

From April, 1989 to January, 1990, we have been "inducing bronchial fistulae" in dogs by performing 10 lobectomies, 5 middle and 5 caudal, in both the right and the left lung. The bronchial stump was not sutured but closed by a "Tissucol-vicryl mesk" implant, which can be adapted to the size of the stump and is fully absorbed in the long term and replaced by a natural fibrous plug. The results seem to be fairly satisfactory: no dog died; all stumps--followed up a D10, D12... up to the 11th month--were obturated without complications, at least in these animals whose bronchi were normal and not infected. Bronchial fistulae still are a serious complication of lung resections, and while the smaller fistulae (2-3 mm) can be managed with biological glue delivered by simple endoscopy, severe fistulae--especially after pneumonectomy, above all in the right lung--often demand difficult, high-risk surgery. This points out to the interest of this small experimental series. Two conditions are essential to successfully implement this alternative procedure: 1) perfect sterilization of the excision pocket; a window is often required, which in addition has the advantage of facilitating the insertion and observation of the implant; 2) a high concentration of aprotinin (10,000 units) delaying the dissolution of the glue plug, thus allowing it to be integrated by the natural healing process.

Distal latero-circumflex arteries (DLCA) and posterior descending artery (PDA) are anatomically too far and cannot be revascularized with internal mammary artery (IMA) by a conventional procedure. The reimplantation of the right IMA into the left IMA in situ increases (2 times) the length of right IMA graft available. Fifty-five patients underwent this technique. Their preoperative status was: 22 males, 3 females; mean age: 57 years, 38% myocardial infarction (MI). Coronary angiography showed: stenosis of the left main coronary artery: 3; stenosis of 3 vessels: 15; 2 vessels: 10; 2.3 anastomoses by patient were performed with Y right and left IMA procedure: 24 LDA, 8 diagonals, 25 DLCA and 1 PDA anastomosis. No deaths were observed in this short series. Morbidity was: 1 MI, 2 sternal sepsis, 1 bilateral phrenic paralysis (all were cured without sequelae). To date (March 90) 15 patients have been followed for 3 to 12 months, 12 are angina-free, 3 are significantly improved, 11 have a negative exercise test. Thallium test is normal in the revascularized area in 14 patients. Seven angiographies have been performed (6 months to 1 year) and all Y right IMA are patent.

The authors report a case of internal mammary artery graft anastomosed to the left anterior descending coronary artery (LADC) which was found to be non functional in the early post-operative period (one month) but second catheterization at one year revealed the graft to be patent with thrombosis of the LADC. This case shows the flow adjustment possibilities of internal mammary artery graft.

Biotransformation of caffeine and theophylline and the effect of two well-known inducers of P-450 isozymes, namely phenobarbital (PB) and methylcholanthrene (3-MC) were studied in cultured hepatocytes from six human adult donors. Hepatocytes co-cultured with rat liver epithelial cells maintained a higher metabolic capacity than pure cultures. PB treatment of cultured hepatocytes for 3 days slightly increased the rate of caffeine metabolism 1.4 +/- 0.5-fold (N = 6) vs controls, and theophylline metabolism 1.2 +/- 0.4-fold (N = 6), whereas 3-MC treatment increased metabolism markedly 5.8 +/- 2.3- and 3.3 +/- 1.1-fold (N = 6) vs controls for caffeine and theophylline, respectively. Paraxanthine and theophylline formations from caffeine were the most induced by 3-MC. Their increase was significantly correlated (rs = 0.89, P less than 0.007) but not with TB formation, suggesting that at least two isozymes of the P-450IA family are involved in the first demethylations of caffeine. In addition, the N-1 demethylation of theophylline (mean increase of 554% vs controls) was not correlated with the N-1 demethylation of caffeine (mean to increase 247% vs controls) for the same donor after 3-MC treatment, suggesting that these two demethylations are mediated by a different P-450.

Post-mortem anatomical study on the "Tentorial sinus", in 23 skulls, using a retrograde veinous injection of a mixture of Rhodopas and lead tetroxide. Present in more than half the cases, this sinus actually constitutes a true sinus, principally draining the superior and inferior hemispheric veins of the cerebellum, traversing the posterior section of the tentorium cerebelli and opening into the lateral or straight sinus.

In this series of 184 patients (pts), 312 internal mammary arteries were used to graft 430 coronary arteries. Two mammary arteries were used in 104 pts and sequential anastomoses were performed in 118 pts. The operative mortality was 1.6% and the peri-operative myocardial infarction was 4.1%. 9% of patients had post-operative complications: 1% of bilateral phrenic paralysis, 2.1% of post-operative hemorrhage leading to reoperation, 1.6% of sternal infection, 0.5% of true mediastinal infection, 1.6% of sternal dehiscence and 2.7% of reversible psychiatric illness. A 3 month follow-up was available in 160 pts. 95% of patients became angina free, the thallium scan shown a normal uptake of thallium at maximal stress in the myocardial grafted area in 92% of the patients.