Left atrium papillary fibroelastomas: a cause of cerebral emboli.

Papillary fibroelastomas are cardiac benign tumours. Among the benign cardiac tumor, papillary fibroelastomas are reported second after myxomas. Most often diagnosed incidentally, papillary fibroelastomas may embolize to cerebral circulation. Valvular locations are predominant; location in left atrium is rare. In this paper, we present a case of papillary fibroelastoma located in left atrium with symptoms of cerebral embolization. Transoesophageal echocardiography diagnosed a mobile mass. The patient was treated with surgical resection without further embolic complication.

An in-use microbiological comparison of two surgical hand disinfection techniques in cardiothoracic surgery: hand rubbing versus hand scrubbing.

Surgical site infection after heart surgery increases morbidity and mortality. The method of presurgical hand disinfection could influence the infection risk. From February to April 2003, we compared the microbiological efficacy of hand-rubbing (R) and hand-scrubbing (S) procedures. The surgical team alternately used hand-scrubbing or hand-rubbing techniques every two weeks. Fingertip impressions were taken before and immediately after hand disinfection, every 2h and at the end of the operation. Acceptability of hand rubbing was assessed by a questionnaire. Mean durations of surgical procedures were 259+/-68 and 244+/-69min for groups S and R respectively (P=0.43). Bacterial counts immediately after hand disinfection were comparable with the two techniques, but significantly lower in group R at the end of surgery. No differences were observed between the percentages of negative samples taken after 2h, 4h and at the end of surgery between the two groups. Bacterial skin flora reduction immediately after hand disinfection, after 2h and 4h of operating time and at the end of surgery was better in group R, but the difference was not statistically significant. Before surgery, the hand-rubbing method with alcohol solution preceded by hand washing with mild neutral soap is as effective as hand scrubbing to reduce bacterial counts on hands. It decreased the bacterial counts both immediately after hand disinfection and at the end of long cardiothoracic surgical procedures. The acceptability of hand rubbing was excellent and it can be considered to be a valid alternative to the conventional hand-scrubbing protocol.

The genome of Salinibacter ruber: convergence and gene exchange among hyperhalophilic bacteria and archaea.

Saturated thalassic brines are among the most physically demanding habitats on Earth: few microbes survive in them. Salinibacter ruber is among these organisms and has been found repeatedly in significant numbers in climax saltern crystallizer communities. The phenotype of this bacterium is remarkably similar to that of the hyperhalophilic Archaea (Haloarchaea). The genome sequence suggests that this resemblance has arisen through convergence at the physiological level (different genes producing similar overall phenotype) and the molecular level (independent mutations yielding similar sequences or structures). Several genes and gene clusters also derive by lateral transfer from (or may have been laterally transferred to) haloarchaea. S. ruber encodes four rhodopsins. One resembles bacterial proteorhodopsins and three are of the haloarchaeal type, previously uncharacterized in a bacterial genome. The impact of these modular adaptive elements on the cell biology and ecology of S. ruber is substantial, affecting salt adaptation, bioenergetics, and photobiology.

[The long term (15 years) evolution after valvular replacement with mechanical prosthesis or bioprosthesis between the age of 60 and 70 years]. / Evolution à long terme (15 ans) après remplacement valvulaire par prothèse mécanique ou bioprothèse entre 60 et 70 ans.

OBJECTIVE: the aim of this study was to document the choice between prosthesis and bioprosthesis in cases of valvular replacement during the seventh decade of life. METHODS: a retrospective and cooperative study linking eleven cardiac surgical teams and five medical cardiology teams combined 497 subjects born between 1915 and 1925 (average age 64.4 years) who underwent aortic (313 cases) or mitral (184 cases) valvular replacement with mechanical prosthesis (259 cases) or bioprosthesis (238 cases). Information was collected at each centre during the year 2000 on the long term evolution (going back 15 years), in particular on the mortality, non-fatal complications linked to the valve, cardiac complications and extra-cardiac events. These results were subjected to statistical analysis. RESULTS: the operative mortality of this group was 4.8%. The 15 year survival was 46% for the aortic mechanical prostheses, 32% for the aortic bioprostheses (p=0.04). 34% for the mitral bioprostheses and 33% for the mitral mechanical prostheses. Events linked to the valve were more frequent for the mitral valvulopathies than for the aortic valves (49% vs 26%, p<0.001). The absence of events linked to the valve at 15 years was 69% for the aortic mechanical prostheses and 68% for the aortic bioprostheses. This was the case in only 57% of mitral mechanical prostheses and 36% of the mitral bioprostheses (p=0.11). Thromboembolic accidents were three times more frequent in the mitrals than in the aortics (11.5 vs 3.8%, p=0.002). Haemorrhage was four times more frequent for the mechanical prostheses than for the bioprostheses (7.7 vs 2%, p=0.01). The risk of degeneration for the aortic bioprostheses was 20% at 15 years, three times less so after 65 years of age (p=0.03). At 48% it was much higher in the mitral valves at 15 years with no significant difference before and after 65 years of age (p=0.3). CONCLUSION: the current life expectancy of subjects in their seventh decade is important. The greatly elevated risk of bioprosthesis degeneration in the mitral position does not allow this alternative to be advocated before 70 years of age. In the aortic position, this risk is elevated before 65 years of age. It is lower after 65 years old. Nevertheless, this means the risk of reoperation in certain octogenarians must be accepted, balanced with the linear risk of haemorrhagic accidents for which a future reduction is expected thanks to milder anticoagulation for aortic mechanical prostheses and anticoagulation autocontrol.

[Medullary extradural hematoma revealing a coarctation of the aorta]. / Hématome extra-dural médullaire révélant une coarctation de l'aorte.

The authors report a spontaneous, unusual complication of coarctation of the aorta. An 11 year old child was admitted for investigation of chest pain. Cardiovascular examination revealed typical clinical signs of coarctation of the aorta. Neurological examination found neck stiffness without headache or deficit. The presumptive diagnosis of dissection of the aorta was infirmed by echocardiography and MRI. The latter investigation, with views of the spinal cord, revealed a compressive medullary extradural haematoma. Antihypertensive therapy and corticosteroids with strict bed rest resulted in complete regression of the haematoma and the coarctation was operated 6 months later. Medullary complications of coarctation of the aorta are usually postoperative. Spontaneous complications are exceedingly rare but very serious: medullary compression by the dilated anterior spinal artery or rupture of an aneurysmal collateral vessel. In this case, magnetic resonance imaging led to diagnosis and effective early treatment of this complication before the patient developed a neurological deficit and the coarctation was treated surgically thereafter.

[Cross-sectional imaging of post endocarditis paravalvular myocardial abscesses of native mitral valves: 4 cases]. / Imagerie en coupes et abcès myocardiques paravalvulaires sur mitrale native au décours d'endocardites infectieuses: 4 cas.

Four cases of submitral myocardial abscess imaged by CT or MRI following endocarditis are described. All cases occurred in fragile patients (diabetes mellitus, dialysis, severe cardiovascular diseases). An iatrogenic source was noted in one patient. Staphylococcus aureus was responsible in 2 patients. If subvalvular aortic abscesses are usually described, submitral myocardial abscesses are infrequent. In addition to transesophageal echocardiography, a technique superior to transthoracic echocardiography, CT and MRI may incidentally suggest the correct diagnosis. Both techniques provide useful morphological evaluation, information that can be used to optimize the timing for surgical repair.

Mitral and mitro-aortic valve replacement with Sorin Bicarbon valves compared with St. Jude Medical valves.

OBJECTIVE: We assessed the clinical results of two bileaflet mechanical valves: the St. Jude Medical (SJM) and the Sorin Bicarbon (Sorin Bicarbon) used either in single mitral valve replacement (MVR) or in double, aortic and mitral, valve replacement (DVR). METHODS: Between September 1990 and November 1995, 217 patients received either a St. Jude Medical (n=134) or a Sorin Bicarbon (n=86): 136 mitral valve replacement with 83 St. Jude Medical and 53 Sorin Bicarbon and 84 double valve replacement with 51 St. Jude Medical and 33 Sorin Bicarbon. There was no difference between both St. Jude Medical and Sorin Bicarbon cohorts in respect of mitral valve physiopathology, etiology of valve disease, associated lesions, echocardiographic and hemodynamic data. The only significant preoperative difference was the age of patients within the double valve replacement group and the size of implanted valves within the mitral valve replacement group. Follow-up was 100% complete with a mean of 39+/-18 months, ranging between 6 and 68 months. The total follow-up was 657 patient-years (pt-y): 396 pt-y in the mitral valve replacement group and 274 pt-y in the double valve replacement group. RESULTS: Hospital mortality (St. Jude Medical: 2.2%; Sorin Bicarbon: 6.9%) and late mortality (St. Jude Medical: 8.4%; Sorin Bicarbon: 6.3%) were not significantly different. Ten deaths were considered valve-related (St. Jude Medical 6, Sorin Bicarbon 4). The estimated 4-yr overall survival, including hospital mortality, was for St. Jude Medical--mitral valve replacement: 89+/-4% and St. Jude Medical--double valve replacement: 93+/-4%, and for Sorin Bicarbon--mitral valve replacement: 87+/-5% and Sorin Bicarbon--double valve replacement: 91+/-5%. The linearized incidence (% per pt-y) of valve-related complications was 6.39 in the St. Jude Medical cohort and 9.2 in the Sorin Bicarbon cohort. The linearized incidence (% pt-y) of the prevalent complication, valve thromboembolism and bleeding, was for St. Jude Medical-mitral valve replacement: 3.41, St. Jude Medical--double valve replacement: 3.16 and for Sorin Bicarbon--mitral valve replacement: 2.17 and Sorin Bicarbon--double valve replacement: 3.67. The differences between each group of an estimated 4-yr freedom from combined thromboembolism and bleeding were not significant (St. Jude Medical--mitral valve replacement: 90+/-4%, St. Jude Medical--double valve replacement: 84+/-6%, and for Sorin Bicarbon--mitral valve replacement: 94+/-3% and Sorin Bicarbon--double valve replacement: 75+/-17%). CONCLUSIONS: In this clinical non-randomized study, there was no evidence of any significant difference between St. Jude Medical and Sorin Bicarbon valves over a 4-yr follow-up.

[Kidney cancers with supra-diaphragmatic invasion. Surgical treatment using extracorporal circulation with heart arrest]. / Cancers du rein avec envahissement cave supra-diaphragmatique. Traitement chirurgical sous circulation extracorporelle à coeur battant.

STUDY AIM: The study aim was to report results of nephrectomy with resection of cavo atrial thrombus in 6 patients with a renal carcinoma and supra-diaphragmatic vena cava extension and to discuss limits of the surgical indications. PATIENTS AND METHOD: Six patients, five adults (mean age: 57 +/- 10 years) and a four-year old girl, were operated on for a renal cell carcinoma with supra-diaphragmatic vena cava extension. The venous extension was detected in all cases by abdominal ultrasonography. The superior extent of the thrombus was effectively visualized by CT scan in three cases, and by ultrasonography and magnetic resonance imaging in all cases. All the patients were operated on, using cardio-pulmonary bypass, without circulatory arrest, four in normothermia, two in moderate hypothermia at 28 degrees C. RESULTS: Hospital mortality was 0%. Average intensive care unit stay was 3.8 days. During the following period, all the patients developed metastatic disease. Mean survival rate of the five adult patients who had loco-regional invasion was 9.4 months (range: 6 to 19). The young girl underwent a wedge excision of two pulmonary metastases one year later and was still alive 7 years later. CONCLUSIONS: With cardio-pulmonary bypass, surgical resection of cavo-atrial thrombi may be performed with a low mortality and morbidity rate but late results were disappointing. Surgery should be limited to patients without loco-regional invasion or distant metastatic disease, and therefore accurate preoperative staging is mandatory.

Flexible posterior mitral annuloplasty: five-year clinical and Doppler echocardiographic results.

BACKGROUND: Stabilization of the posterior annulus seems to be a critical factor to achieve a stable mitral valve repair. To assess the benefit of softer mural annuloplasty, we analyzed results obtained with the flexible linear reducer. METHODS: From 1985 to 1993, 120 patients, with pure mitral regurgitation, mainly degenerative, had a mitral reconstruction. Mean age was 64+/-11 years and 74% of the patients were in New York Heart Association functional class III or IV. RESULTS: Hospital mortality was 3.3%. Mean follow-up was 56+/-24 months. There were 23 late deaths; 10 valve-related including 7 sudden deaths. Two patients (1.7%) required a reoperation. Doppler echocardiographic studies revealed excellent valve function; 5-year freedom from significant regurgitation was 85.8%+/-5.4%. Mean mitral valve area was 2.76+/-0.77 cm2. Although 105 patients were in class I or II, 23 patients were not functionally improved. Previous myocardial infarction and shorter deceleration time of early filling were risk factors for worsening functional disability. CONCLUSIONS: This support provides stable repair with excellent clinical and echographic results. Previous myocardial infarction and noncompliant left ventricle negatively influence outcome.

Doppler echocardiographic study of three different mechanical valves in the aortic position: the use of external nominal diameter indexed to body surface area.

BACKGROUND AND AIMS OF THE STUDY: Previous studies have demonstrated the benefit of indexing body surface area (BSA) with ventriculo-arterial orifice diameters (or calculated effective surface dynamics) and with nominal external diameters of valves in order to study hemodynamic profiles in vivo or determine the clinical influence of this parameter. This study analyzes the relationship between BSA and nominal external diameter of mechanical valves implanted in the aortic position. It also evaluates the potential interest of using these diameters indexed to BSA in an echo-Doppler study of valves. METHODS: During 1994, a prospective echo-Doppler study of three models of mechanical valves in the aortic position was carried out. RESULTS: The echo-Doppler parameters of the aortic St. Jude Medical, Sorin Bicarbon and Dideco Monostrut prostheses have been studied with regard to nominal external diameters and were found identical to published data. There were no significant differences in these parameters between the three valves. In 128 patients, prosthetic external diameters were evenly distributed heterogeneously with regard to BSA. Indexing of nominal external diameter with BSA appeared a more reliable reference to study different echo-Doppler parameters, minimizing the effect of cardiac output. CONCLUSION: The in vivo echo-Doppler determination at rest of valve hemodynamic profiles should be carried out with reference to the nominal external diameter indexed to the BSA.

Successful treatment of tetralogy of Fallot with pulmonary atresia using a pulmonary homograft.

A 13-year-old boy with tetralogy of Fallot and pulmonary atresia after a Waterston and Blalock-Taussig shunt underwent successful repair using a cryopreserved pulmonary homograft as a valved extracardiac conduit. Aortic transection gave a good operative field for pulmonary angioplasty and closure of the Waterston anastomosis. The cryopreserved pulmonary homograft provided excellent handling characteristics. The postoperative course was good, and postoperative echocardiography showed good function of the valved conduit.

Right anterolateral thoracotomy for repair of atrial septal defect.

BACKGROUND: To procure a cosmetic incision in female patients, we performed operation on atrial septal defects through a right anterolateral thoracotomy. METHODS: From 1984 to 1994, 80 female patients with a mean age of 24 +/- 13 years (ranging from 12 to 62 years) underwent right anterolateral thoracotomy for atrial septal defect repairs. Defects repaired included 62 ostium secundum, 12 sinus venosus, 2 low septal defect, and 4 ostium primum. The right iliac external artery was systematically used for arterial cannulation, through a cosmetic incision. Repairs were always performed under fibrillation, except in the 4 ostium primum defects, for which cardioplegia was used. RESULTS: There was no operative or late mortality, and no morbidity directly related to the thoracotomy approach. CONCLUSIONS: The right thoracotomy incision appears to be a safe and effective alternative to median sternotomy for repair of atrial septal defects.

[Congenital pulmonary arteriovenous fistula. Apropos of 2 cases]. / Fistule artério-veineuse pulmonaire congénitale. A propos de deux observations.

The authors discuss echocardiographic diagnosis and endovascular treatment of two different anatomical types of pulmonary arteriovenous fistula. Transoesophageal echocardiography in a cyanotic 3 year old boy revealed a direct right pulmonary artery left atrial fistula, treated by surgical ligation of the anomalous feeding artery. A cerebral abscess in a 22 year old man with hereditary haemorrhagic telangiectasia revealed pulmonary and cerebral arteriovenous malformations, which were both treated successfully by embolization. The value of echography is the demonstration of the right to left shunt at pulmonary level and, in some cases, the direct visualization of the arteriovenous malformation. Embolization should be considered as the therapeutic method of choice in all pulmonary arteriovenous fistula, except for direct pulmonary artery left atrial fistula.

Mitral annuloplasty with a flexible linear reducer.

Although the ideal technique is still controversial, mitral valve reconstruction for mitral insufficiency usually includes an annuloplasty. From August 1985 to June 1993, 126 cases of pure, acquired mitral insufficiency were repaired by means of a posterior annuloplasty. Whatever the etiology, all types of mitral insufficiency allowing a mitral reconstruction were included. The annuloplasty, performed with a flexible linear reducer, was associated with valvular (62%) and subvalvular (11%) repairs. An associated surgical procedure was necessary in 62% of the patients. Operative mortality was 2.4%, and follow-up (mean 29 months) was complete for all survivors. Five-year survival was 90%. Five-year complication-free rate for emboli was 91%. Only one patient at 12 months underwent reoperation to treat recurrent mitral insufficiency. Ninety-seven patients were in New York Heart Association Class I or II. Follow-up echocardiographic studies on 75% of eligible patients showed a free rate for significant regurgitation of 99%. Mean valve area was estimated at 2.88 +/- 0.85 cm2. These findings suggest that the flexible linear reducer seems to be a reliable device and a valid alternative for annuloplasty.

Systemic-pulmonary shunt with a right retroesophageal subclavian artery.

A 19-day-old child suffering from cyanosis due to tetralogy of Fallot was palliated by using his right retroesophageal subclavian artery. It was anastomosed side-to-side onto the ascending aorta and end-to-side onto the right pulmonary artery. The palliation obtained with this systemic-pulmonary shunt was satisfying. The right brachial vascular flow was normal.

[Interruption of the left aortic arch with right descending thoracic aorta disclosed in adulthood]. / Interruption d'un arc aortique gauche avec aorte thoracique descendante droite découverte à l'âge adulte.

Evaluation of hypertension, in a 30 years old man, revealed an interruption of a left aortic arch beyond the origin of the left subclavian artery, associated with a right descending thoracic artery. Surgical restoration of the continuity between the ascending aorta and the low descending aorta was successfully achieved by interposition of a graft. Survival in adulthood without bronchial compression, is explained by the absence of ventricular septal defect and patent ductus arteriosus.

A canine ex vivo shunt for isotopic hemocompatibility evaluation of a NHLBI DTB primary reference material and of a IUPAC reference material.

Factors determining the thrombogenic response to particular artificial surfaces were investigated ex vivo in a canine shunt model. Methods using radioisotopic tracers made it possible to dynamically monitor the deposition of labelled blood cells and proteins on a NHLBI.DTB primary reference material polydimethylsiloxane (PRM.PDMS) and on a IUPAC reference material polyvinyl chloride (IUPAC.PVC). On the one hand, leukocyte affinity tau s(leu) (number of deposited leukocytes mm-2s-1) was not significantly different between IUPAC.PVC (tau s(leu) = 1.2-2.5) and PRM.PDMS (tau s(leu) = 1.5-3.4) and the fibrinogen adsorption rate varied from 33 to 48.10(-5) micrograms mm-2s-1 for both these materials. On the other hand, platelet affinity tau s(plat) (number of deposited platelets mm-2s-1) was significantly different (p < 0.05) for IUPAC.PVC and PRM.PDMS (tau s(plat)PVC = 683 +/- 200 > tau s(plat)PDMS = 327 +/- 80). Scanning electron micrographs of adherent platelets, red cells and leukocytes after blood contact ex vivo were performed after each experiment. This preliminary work contributes not only to quantify the adsorption of different radiotracers, but also to evaluate the superficial distribution of the labelled biological species on the inner surface of the tested biomaterials.