Update on GPIIb/IIIa antagonists

in Expert Opinion on Therapeutic Patents (2003), 13

Physiologie du Système nerveux

Learning material (2003)

Cardiac Surgery in Octogenarians; Peri-Operative Outcome and Long-Term Results

in European Heart Journal (2001), 22(14), 1235-43

AIMS: Because the elderly are increasingly referred for operation, we reviewed the results of cardiac surgery in patients of 80 years or older. METHODS AND RESULTS: Records of 182 consecutive ... [more ▼]

AIMS: Because the elderly are increasingly referred for operation, we reviewed the results of cardiac surgery in patients of 80 years or older. METHODS AND RESULTS: Records of 182 consecutive octogenarians who had had cardiac operations between 1992 and 1998 were reviewed. Follow-up was 100% complete. Seventy patients had coronary grafting (CABG), 70 aortic valve replacement, 30 aortic valve replacement+CABG, and 12 mitral valve repair/replacement. Rates of hospital death, stroke, and prolonged stay (>14 days) were as follows: CABG: 7 (10%), 2 (2.8%) and 41 (58%); aortic valve replacement: 6 (8.5%), 2 (2.8%) and 32 (45.7%); aortic valve replacement+CABG: 8 (26.5%), 1 (3.8%) and 14 (46.6%); mitral valve repair/replacement: 3 (25%), 1 (8.3%) and 5 (41.6%). Multivariate predictors (P<0.05) of hospital death were New York Heart Association functional class, urgent procedure, prolonged cardiopulmonary bypass time, and, after aortic valve replacement, previous percutaneous aortic valvuloplasty. Ascending aortic atheromatous disease was predictive of stroke, while pre-operative myocardial infarction was predictive of prolonged hospital stay. Actuarial 5-year survival was as follows: CABG, 65.8+/-8.8%; aortic valve replacement, 63.6+/-7.1%; aortic valve replacement+CABG, 62.4+/-6.8%; mitral valve repair/replacement, 57.1+/-5.6%; and total, 63.0+/-5.6%. Multivariate predictors of late death were pre-operative myocardial infarction, and urgent procedure. Ninety percent of long-term survivors were in New York Heart Association class I or II, and 87% believed having a heart operation after age 80 years was a good choice. CONCLUSION: Cardiac operations are successful in most octogenarians with increased hospital mortality, and longer hospital stay. Long-term survival and quality of life are good. [less ▲]

Evolution of ventriculo-arterial coupling during acute myocardial ischemia

in European Heart Journal (2001), 22

Hemodiafiltration does not improve pulmonary hemodynamics in a porcine model of endotoxin shock

in Intensive Care Medicine (2001), 27(2), 181

Nicardipine Protocol for Cabg Using the Radial Artery Clinical and Angiographic Data

in Acta Chirurgica Belgica (2001), 101(4, Jul-Aug), 185-9

The routine use of arterial grafts in coronary surgery is facilitated by peroperative adjunction of antispasmodic drug to reduce the event of spasm. Diltiazem has been favoured in most clinical studies ... [more ▼]

The routine use of arterial grafts in coronary surgery is facilitated by peroperative adjunction of antispasmodic drug to reduce the event of spasm. Diltiazem has been favoured in most clinical studies devoted to the radial artery graft. The aim of this study was to assess the efficacy of a spasm preventing protocol associating hydrostatic dilation of the graft with a diluted solution of papaverine and nicardipine infusion, starting preoperatively and continued postoperatively in i.v. and per os forms. Between September 1996 and March 1997, a consecutive series of 50 patients underwent myocardial revascularization using the radial artery. The radial artery was prepared by hydrostatic dilation with papaverine (1%) and nicardipine was administrated at 0.25 microgram/kg/min and titrated according to the arterial systemic pressure. Operative mortality was 4% (sepsis). There was no evidence of perioperative MI nor hypoperfusion syndrome. Mean CKMB level at 18 hours was 36 micrograms/l. No ischaemic anomalies of the ECG were detected. Angiography performed in the last 20 patients showed a 98% (51/52) permeability rate for all graft; 19/20 radial grafts (95%) were patent. One radial graft presented a 50% stenosis at the proximal anastomosis, and another a moderate spasm (40%) in the middle part of the conduit. This study confirms that the radial artery conduit can be used with satisfactory results for routine coronary artery bypass. The use of nicardipine allows the control the vasoreactivity of the radial graft without totally obviating at least angiographic spasm. This drug is easy to titrate, and well tolerated in association to beta-blockers in the routine perioperative management of the coronary patients. [less ▲]

Early Stage Results after Oesophageal Resection for Malignancy - Colon Interposition Vs. Gastric Pull-Up

in European Journal of Cardio - Thoracic Surgery (2000), 18(3), 293-300

OBJECTIVE: The aims of our study were to determine if using the colon as a digestive transplant after oesophagectomy for cancer was associated with increased postoperative complications, and to assess the ... [more ▼]

OBJECTIVE: The aims of our study were to determine if using the colon as a digestive transplant after oesophagectomy for cancer was associated with increased postoperative complications, and to assess the impact of preoperative radiochemotherapy on postoperative hospital outcome. METHODS: From January 1990 to December 1998, 130 patients underwent oesophageal resection for malignancy. There were 103 males and 27 females (age: 61.3+/-11.5 years). Indications were squamous cell carcinoma in 69 patients and adenocarcinoma in 61. Preoperatively 30 patients (eight in stage IIB, 18 in stage III, and four in stage IV) received radiochemotherapy. There were 84 subtotal oesophagectomies, with anastomosis in the neck in 44 patients and at the thoracic inlet in 40, and 46 distal oesophageal resections. Digestive continuity was restored with the stomach in 92 patients (age: 63.4+/-10.2 years) and the colon in 38 (age: 52.3+/-12.8 years). With the exception of age (P<0.0001), there was no significant preoperative difference between gastric and colonic groups. RESULTS: Hospital mortality was 8.5% (11 patients), decreasing from 18.5% (before 1993) to 3.8% (since 1993). One patient (2.5%) died in the colonic graft group and ten (11%) in the gastric pull-up group (P=0.17). Postoperative complications occurred in 40 patients (31%), respectively, in ten (26%) and 30 (33%) patients after colonic and gastric transplants (P=0.48), and were pulmonary insufficiency or infection in 29 patients, anastomotic fistula in six, myocardial infarction in five, recurrent nerve palsy in four, renal insufficiency in three, and cerebrovascular accident in one. All fistulas occurred in the gastric pull-up group. The incidence of postoperative pulmonary complications was 70% (21/30 patients) in the subgroup who received preoperative radiochemotherapy, as compared to 11% (5/44 patients) in the subgroup of comparable staging, but without preoperative treatment (P<0.001). CONCLUSIONS: Colonic grafts are not associated with increased postoperative mortality or complications. Our results suggest that preoperative neoadjuvant treatment significantly increases postoperative pulmonary complications. [less ▲]

Increased Aortic Compliance Maintains Left Ventricular Performance at Lower Energetic Cost

in European Journal of Cardio - Thoracic Surgery (2000), 17(3), 272-8

OBJECTIVE: The aim of this study was to investigate left ventricular contractility and energetic cost of cardiac ejection under conditions of acute increase in aortic compliance. METHODS: In six ... [more ▼]

OBJECTIVE: The aim of this study was to investigate left ventricular contractility and energetic cost of cardiac ejection under conditions of acute increase in aortic compliance. METHODS: In six anaesthetized pigs, ascending aortic compliance was increased by adding a volume chamber in parallel to the ascending aorta. Systemic vascular parameters, including characteristic impedance, peripheral resistance, total vascular compliance, and inertance, were estimated with a four-element windkessel model. Arterial elastance was derived from these parameters. Left ventricular systolic function was assessed by end-systolic pressure-volume relationship (end-systolic elastance), and stroke work. Pressure-volume area was used as a measure of myocardial oxygen consumption. Heart rate remained constant during the experimentation. RESULTS: Adding the aortic volume chamber significantly increased vascular compliance from 0. 95+/-0.08 to 1.17+/-0.06 ml/mmHg (P<0.01), while inductance, characteristic impedance, peripheral resistance, and arterial elastance remained statistically at basal values, respectively 0. 0020+/-0.0003 mmHg.s(2)/ml, 0.105+/-0.009 mmHg.s/ml, 1.27+/-0.12 mmHg.s/ml, and 2.43+/-0.21 mmHg/ml. During the same interval, stroke work and pressure-volume area decreased respectively from 2700+/-242 to 2256+/-75 mmHg.ml (P<0.01), and from 3806+/-427 to 3179+/-167 mmHg.ml (P<0.01). Stroke work and pressure-volume area decreased at matched end-diastolic volumes. In contrast, end-systolic elastance, ejection fraction, and stroke volume remained statistically unchanged, respectively at 2.29+/-0.14 mmHg/ml, 48.1+/-2.1 %, and 32. 4+/-1.7 ml. CONCLUSIONS: These data suggest that, when facing an increased aortic compliance, the left ventricle displays unchanged contractility, but the energetic cost of cardiac ejection is significantly decreased. These data may be of clinical importance when choosing an artificial prosthesis for ascending aortic replacement. [less ▲]

Aortic Valve Replacement in the Octogenarians: Perioperative Outcome and Clinical Follow-Up

in European Journal of Cardio - Thoracic Surgery (1999), 16(1), 68-73

OBJECTIVES: To determine long-term results of aortic valve replacement (AVR) in patients 80 years old or older, and assess the factors influencing perioperative outcome. METHODS: Data were reviewed on 83 ... [more ▼]

OBJECTIVES: To determine long-term results of aortic valve replacement (AVR) in patients 80 years old or older, and assess the factors influencing perioperative outcome. METHODS: Data were reviewed on 83 consecutive octogenarians, undergoing aortic valve replacement between 1992 and 1997. There were 66 women and 17 men (mean age: 82.8 years). Fifty-seven patients (69%) were in New York Heart Association (NYHA) class III-IV and six had previous myocardial infarction. Three patients had previous percutaneous aortic valvuloplasty. There were 19 urgent procedures (23%). Coronary artery bypass grafting (CABG) was performed on 21 patients (25%). Possible influence of preoperative and operative variables on early and late mortality was performed with univariate and multivariate statistical analysis, and survival was estimated with the Kaplan-Meier method. RESULTS: Operative mortality was 13% (9% for AVR, 24% for AVR-CABG). Postoperative complications were respiratory failure in 19 patients, atrial fibrillation in 19, hemodialysis in four, myocardial infarction in four and stroke in two patients. Five patients required pacemaker insertion for permanent atrioventricular block. Median hospital stay and intensive care unit stay were 19.8 +/- 12.2 days and 7.9 +/- 3.4 days, respectively. Multivariate predictors of hospital death (P < 0.05) were percutaneous aortic valvuloplasty, NYHA class IV, and urgent procedure. Mean follow-up was 26.5 months. Survival at 1, 2, and 5 years was 98.5 +/- 1.4% (63 patients at risk), 93.4 +/- 3.2% (47 patients at risk), and 78.2 +/- 6.9% (six patients at risk), respectively. Preoperative myocardial infarction and urgent procedure were independent predictors of late death. At most recent follow-up, 91% were angina free and 81% were in class I-II. CONCLUSIONS: Aortic valve replacement in octogenarians can be performed with acceptable mortality. These results stress the importance of early operation on elderly patients with aortic valve disease. Both long-term survival and functional recovery are excellent. [less ▲]

Atheroemboles et chirurgie cardiaque: importance de la mise au point préopératoire

in Revue Médicale de Liège (1999), 54(1), 43-8

OBJECTIVE: Atheroembolization is a recognized complication of cardiac surgical procedures, and has been implicated in postoperative stroke, renal failure, multiorgan failure, and death. Preoperative ... [more ▼]

OBJECTIVE: Atheroembolization is a recognized complication of cardiac surgical procedures, and has been implicated in postoperative stroke, renal failure, multiorgan failure, and death. Preoperative identification of patients at risk for developing atheroemboli is essential. The aim of this study was to determine preoperative risk factors for atheroemboli and to assess the postoperative course of the patients who developed atheroembolic syndrome. METHODS: A retrospective record review was conducted. From 1/1990 to 12/1994, 5.486 patients underwent coronary artery bypass grafting (CABG), valve operations, or other cardiac surgical procedures at the Massachusetts General Hospital. Among this population, 107 patients (1.9%) developed atheroembolic syndrome. There were compared to a concurrent population of 925 patients operated during the same period. RESULTS: Patients who developed atheroemboli were older, with an increased incidence (p < 0.01) of hypertension, cerebrovascular disease, and aortoiliac disease. Many had a complicated course after catheterization, with renal insufficiency (35%) and evidence of peripheral emboli (12%). Average Intensive Care Unit stay, hospital stay, and hospital cost of these patients were 16.8 days, 48.4 days and 88,000 respectively, compared to 1.5 days, 9.6 days and 23,000 for the concurrent population. Of these 107 patients only two were discharged home, the others either died (48 patients, or 25% of all cardiac surgical deaths during this period), or rehabilitation or chronic hospital facilities. Twenty-seven autopsies were performed and invariably showed a diffusely diseased aorta, with calcification, mural thrombus, and ulceration. CONCLUSIONS: Atheroembolization during cardiac surgical procedures has profound medical and economic consequences. Because of the diffuse nature of aortic disease, measures approaching the disease as a local process are likely to be unsuccessful. Appropriate evaluation would ideally identify patients with extensive aortic atheromatous disease, prior to rather than during surgery. [less ▲]