Coronary heart disease:

 

When coronary artery disease affects the entire coronary network with dangerous lesions that cannot be corrected by dilatation and stenting, bypass surgery is indicated. Surgical revascularisation is carried out on each of the affected arteries-involving 3-5 bypasses, in most cases. Ideally, the bypasses are created using thoracic arteries (internal mammaries) which yield better outcomes than ones based on the saphenous vein (taken from the leg). These techniques for multiple coronary repair using exclusively arterial tissue have been extensively worked on at the CCML for the last twenty years, and are now systematically used for all patients because of the superiority of their outcomes over those of alternative approaches.

 

Coronary bypass surgery can be combined with other procedures such as valve replacement.

 

Valvular heart disease:

 

Aortic valve stenosis is the most common valvular heart disease and it is corrected by replacement of the defective valve with an implant, either a so-called "mechanical" artificial valve or a tissue valve. The choice will depend on the patient’s age and history as well as his or her preference (after discussion of the pros and cons for each type of prosthesis). In some elderly patients in whom surgery would be unacceptably risky, percutaneous implantation may be undertaken but this technique is too recent to be proposed on a routine basis.

 

Aortic insufficiency and regurgitation are also usually corrected by valve replacement.

 

Mitral insufficiency or leakage is the second-most common form of valvular heart disease. Almost all cases are treated by valve repair and the implantation of an annulus (annuloplasty).

 

Mitral stenosis has become rare in France but is treated by percutaneous or surgical commissurotomy, or valve replacement. Tricuspid problems (which are rarely seen in isolation) are usually addressed by reconstructive surgery.

 

Severe valvular damages, as can be caused by infectious endocarditis, are treated by complete ablation of all intracardiac infectious foci. This may necessitate complex heart reconstruction procedures to recreate a valvular opening in a solid support and prevent recurrence.

 

Aortic disease:

 

Large aneurysms and severe dilatations of the aorta which may rupture require surgical correction to replace the affected segment with a tube made of Dacron. The complexity of the procedure will depend on the location and extent of the lesion. When the aneurysm begins at the origin of the vessel (the ascending aorta), it involves the aortic valve and the nascent coronary arteries; replacement of the ascending aorta necessarily means reimplantation of both coronary arteries and the aortic valve. If the aortic valve is undamaged, it can be kept and reinserted into the tube (the David operation) but otherwise (if it is stenosed or calcified), it has to be replaced (the Bentall operation).

 

Replcement of the right aortic arch necessitates reimplantation of the vessels supplying the cerebrum. Continuous infusion of the arteries with monitoring of flow rate and pressure enhances the safety of this operation and protects the patient’s brain. Depending on their localisation and extent, aneurysms in the descending thoracic and thoraco-abdominal aorta can be treated by either aortic replacement (open surgery) or by stenting (deployed inside the vessel via the femoral artery).

 

The Department is open for emergencies round-the-clock, notably for aortic dissections which represent a veritable emergency because of the risk of fissuration of the aorta and its branches. Rapid diagnosis and treatment is essential before the vessel ruptures and death.

 

Cardiac muscle disease:

 

Primary cardiomyopathy and the complications of myocardial infarction (destruction of cardiac muscle tissue) can lead to irreversible heart failure, even with optimum medical treatment. A full work-up is important before heart transplantation or assisted circulation (artificial heart) is considered.

 

Other diseases:

 

Cardiac tumours (myxoma, fibroelastoma, etc.) are treated by resection with extracorporeal circulation. The CCML has longstanding experience with this type of disease and also pericarditis (infectious or induced by radiotherapy administered to treat Hodgkin’s disease or cancer).

 

Combined operations:

 

Arrhythmia with concomitant valve or coronary heart disease can be treated in a single operation by ablation of the arrythmogenic foci.

 

Valve surgery is often combined with coronary bypass surgery because these two pathologies tend to be intercurrent.

 

In collaboration with the Thoracic Surgery Department, heart disease associated with lung cancer can be treated at the same time by two different teams working in parallel.