Search

The initial development of cardiac surgery at Erasme Hospital was closely related to the achievements in thoracic organ transplantation, with numerous synergies between other clinical and research units of the Faculty of Medicine. New advances in biology and biotechnology have met the challenges of modern cardiology, in the fields of advanced heart failure, refractory angina, rhythm disturbances or minimally invasive surgery. Fundamental aspects of clinical practice have been the subject of laboratory investigations, resulting in fruitful interactions and promising scientific outlooks.

Conversion (C) from ministernotomy (M.S.) to full sternotomy was necessary in 5% of the cases in a series of 100 patients consecutively operated for Aortic Valve Replacement (A.V.R.) Analysis of the demographics and surgical techniques indicate older age, aortic fragility, diffuse coronary disease, chronic renal failure and left vent insertion as contributing factors. Despite increased operative blood losses, extra-corporeal circulation (E.C.C.) times, intensive care unit (I.C.U.) stay and hospital stay, no mortality was observed in the conversion group, as compared to 4.2% mortality in the total ministernotomy (MS) population. Preoperative patients selection, avoidance of technical pitfalls, and knowledge of alternative surgical measures are suggested to further decrease the incidence of conversions.

Surgery for cardiac valvular pathology is one of the great success of the 20th century. Until recently the surgical techniques were centered on median sternotomy and cardiopulmonary bypass with aortic and atrial cannulation. The changes in cardiac surgical technique for minimally invasive valve surgery include: a different and smaller incision to minimize trauma to the body, a new technique of connecting the patient to the cardiopulmonary bypass, a different technique for myocardial perfusion and aortic occlusion.

Reconstructive surgery of the mitral valve has been an alternative to mitral valve replacement in patients with mitral regurgitation. In order to evaluate the early results of mitral valve reconstruction, 38 consecutive cases were analyzed.Between January 1985 and May 1993, 38 patients with mitral valve incompetence were treated with a system of reconstructive techniques. Nineteen (52%) of the patients were in NYHA functional class II and seventeen (45%) in class III or IV preoperatively. The cause of the mitral disease was degenerative in 25 (66%), rheumatic in 6 (15%) and ischaemic in 5 (13%) patients. Isolated mitral valve repair was performed in 25 patients (66%); the remainder underwent associated procedures that included a myocardial revascularization in 9 patients (23.6%). Thirty-eight patients (100%) underwent a ring annuloplasty. Resection of the posterior leaflet was performed in 24 patients (63%).There was one operative death (2.6%) and two late deaths (5.3%). Postoperatively, four patients sustained embolic events (incidence 10.5%). Six patients (15.8%) were precociously reoperated within the following month; two patients required valve replacement, one had mediastinitis and three other ones needed a pericardial drainage. Patients routinely received acenocoumarol anticoagulation for two months. Mean follow-up was 33 months (range 6 to 104) and one patient was lost to follow-up. Two years actuarial survival was 91.4%. There were no thromboembolic complications in the follow-up period. No patient was reoperated for valvular insufficiency beyond this time limit. One patient had late endocarditis and has been reoperated for mitral replacement (2.6%). After surgery, 34 survivors (89.5%) were in the NYHA functional class I or II.These results demonstrate that mitral valvuloplasty is associated with lower operative mortality rates. Preservation of the mitral valve mechanism raised the performance of the left ventricle after reconstructive surgery. The incidence of reoperation and thromboembolism was low.

Between March 1982 and March 1991, 225 heart transplantations (HTx) have been performed in 220 patients suffering end stage cardiac disease. Thirteen percent were females and 87% were males. Age range was from 5 to 68 years. The underlying cardiac disease was ischemic cardiopathy in 51.5%, congestive dilated cardiomyopathy in 42%, valvular cardiomyopathy in 3.5%, toxic myocarditis (post-adriamycin) in 1.5% and chronic rejection in 2.5% (retransplantation). Selection of the recipients was done following the currently well established criteria also taking into account the absolute major contraindications for HTx. Due to the still increasing demand of donor organs, currently donor age has been extended up to 50 years for male and 55 years for female donors. One quarter of the grafts were harvested on site in our institution, two other quarters were harvested somewhere else in Belgium and the last quarter provided by other countries cooperating with Eurotransplant. All patients have undergone orthotopic cardiac transplantation using the standard Lower and Shumway technique. Immunosuppression protocols have changed four times throughout the years. Nevertheless all were based on the use of Ciclosporine variously combined with other current immunosuppressive drugs. Rejection monitoring relied on routine endocardiac biopsy and was diagnosed according to the Billingham criteria. The in-hospital mortality is currently 11%. Infection, early right heart graft failure and acute rejection were the leading causes of death. The major causes of early morbidity were several curable infections, reversible rejection episodes, transient acute renal failure and controllable arterial hypertension. Among the survivors followed for at least one month up to nine years, half of late mortality was caused by chronic rejection followed by infection, sudden death, metabolic disorders, stroke and malignancy. Late morbidity involves cases of mild coronary graft diseases, biological renal insufficiency, some degree of arterial hypertension, dislipidemia. Current actuarial survival rate is 87% at one year, 76% at 5 years up to 9 years. Our experience confirms that HTx represents today and effective therapy for selected patients suffering end stage cardiac disease.

Brucella endocarditis, although a rare complication of brucellosis, is the main cause of death related to this disease. This report describes a case of aortic endocarditis due to Brucella abortus in an elderly farmer with known aortic stenosis. Urgent valve replacement was performed because of progressive heart failure despite appropriate antimicrobial treatment. The infection was cured with trimethoprim-sulfamethoxazole and rifampin given for 3 months after surgery. A review of the literature reports on the 38 other cases of cured brucella endocarditis made clear the need for combined antimicrobial treatment and surgical valve replacement.

The authors present a series of 15 cases of traumatic disruption of the aortic isthmus. There were 9 cases of acute rupture and 6 of chronic rupture. All the patients have been operated on. Different technics was used to protect the viscera during aortic cross-clamping, partial E.C.C. in 9 cases, clamp-repair technic in 4 cases and a GOTT shunt in 2 cases. 4 patients died in the first thirty days (3 acute and 1 chronic). 2 cases of paraplegia was observed. All the patients have been reviewed after a mean follow-up of 36 months and remain well but one who is still paraplegic. Surgical repair is mandatory in acute and aortic disruption with a great attention to the associated injuries.

To date, 12 cases of primary leiomyosarcomas of the pulmonary artery have been described in the literature. In only 3 instances was a surgical treatment attempted. We describe a patient with pulmonary artery leiomyosarcoma presenting in obstructive shock. Surgical excision under extracorporeal circulation allowed temporary relief, but the patient died in septic shock on the 10th postoperative day. Relevant clinical and pathological data are briefly reviewed.

The value of continuous wave doppler with spectral analysis for the evaluation of aortic stenosis in adults being controverted, we analyzed prospectively the results obtained in 30 consecutive elderly patients (mean age 63 years) investigated by invasive and non-invasive methods. In 24 patients who underwent both ultrasonic and catheter examinations, the correlation between mean gradients measured by catheterization and calculated separately by doppler was 0.80. For a semi-quantitative evaluation of the aortic valve area, we suggest to use an additional severity index R calculated from doppler data (R = mean gradient/maximal instantaneous gradient) which correlated well (r = -0.68) with the aortic valve area. In our experience, this index makes it possible to separate patients with a less than 0.75 cm2 aortic valve area, as calculated from Gorlin's formula (R greater than 0.65) from patients with a more than 0.75 cm2 aortic valve area (R less than 0.65), irrespective of the associated cardiac index. It is concluded that the doppler ultrasound method provides a highly satisfactory evaluation of transaortic gradient, as well as a semi-quantitative evaluation of the stenotic aortic ostium in the majority of elderly patients with aortic stenosis.

In a 18 year-old woman, an isolated benign hemangioma of the right atrium led to cardiac tamponade and acute renal failure. After 8 days of anuria, the tumor was excised and replaced by a pericardial patch. The persistence of severe renal shutdown necessitated further hemodialysis during 22 days postoperatively. The patient was discharged on the 45th day in good hemodynamic and renal condition. Thirteen cases of benign hemangioma of the heart have been reported in the literature: 12 were found at autopsy; only 4 were complicated by hemopericardium but none of these survived.

Cardio-respiratory stress tests of 14 patients, performed one month and one year after orthotopic heart transplant, are compared in order to demonstrate the functional and metabolic improvements of their adaptation to stress. At maximal stress, we note a 33 p. cent increase of the oxygen consumption (p 0.001), an 11 p. cent increase of the heart rate (p 0.025) and an 18 p. cent increase of the systolic arterial pressure (p 0.005). Respiratory quotients and respiratory equivalent for oxygen are significantly lower (p 0.008) while there was no significant variation of ventilation/minute, respiratory rate, and the normal capacity. At the sub-maximal level, the only significant differences observed are the decrease of the respiratory quotient (p 0.01), the ventilation/minute (p 0.025), the respiratory equivalent for oxygen (p 0.005) and the respiratory rate (p 0.03). The improvement of the physical condition observed in heart transplants seems related to a better peripheral adaptation to stress (lower respiratory quotients, reflection of the decreased demand on anaerobic metabolism) permitting a lesser demand on the ventilatory response to stress.

Massive pulmonary embolism (more than 50% of the pulmonic arterial bed obstructed) has a high mortality. If the accident is not immediately fatal and if the patient is in an adequate hospital environment, the diagnosis has to be confirmed by pulmonary scan and arteriography. Immediate institution of an intensive medical support against shock combined with the induction of thrombolysis prove effective in a majority of cases. The few patients who do not favorably respond to this medical therapy must without delay undergo embolectomy under extracorporeal circulation. The risk is mainly dependent on the hemodynamic state of the patient at the moment of operation. However conditions related to time and place for optimal surgery may restrict the number of favourable results.

Operative and late results in a series of patients operated on the tricuspid valve (replacement or annuloplasty) at the moment of surgery upon mitral and aortic valves are reported. Functional tricuspid insufficiency carries a greater risk than organic tricuspid disease. Considering the duration of the underlying mitral disease, four grades are set up for the mitro-tricuspid patient allowing for prognosis and indication of the type of surgery to be done on the tricuspid valve.