Ventricular patch endocarditis caused by Propionibacterium acnes: advantages of gallium scanning.

Propionibacterium acnes is a weakly pathogenic commensal of the skin. When isolated from blood cultures it is often considered a contaminant. However, P. acnes may be responsible for severe infections and its role in certain cases of infectious endocarditis has now been definitely established.(1) We report a case of endocarditis due to P. acnes stemming from a ventricular patch and revealed by a gallium 67 scan.

[Effect of open heart surgery on intellectual efficiency. Prospective study apropos of 40 cases]. / Retentissement des interventions à coeur ouvert sur l'efficience intellectuelle. Etude prospective à propos de 40 cas.

Neurological accidents following open heart surgery have become exceptionaly rare because of technical advances. However, some minor intellectual problems are quite common (loss of memory, lack of concentration...). The results of previous studies on this subject have been quite contradictory. A prospective study of 40 patients was undertaken to determine the repercussions of open heart surgery with cardiopulmonary bypass on intellectual efficiency. The protocol chosen used Wechsler's intelligence test, the calculation of mental deterioration based on this test and Wechsler's clinical scale of memory. The tests were performed before surgery, in the immediate postoperative period and after six months (30 patients). The purely cardiological side of these cases and social considerations were also taken into account. In the immediate postoperative period, 55% of patients showed signs of intellectual deterioration, with respect to their age. After six months, the overall incidence was 25%. Some patients showed intellectual deterioration before surgery. The influence of the type of surgery is difficult to determine. The cardiopulmonary bypass time was significant. The preoperative intellectual level was also important, as was the return to normal activities after surgery. Finally, age, of course, played an important part. These results cannot be isolated from the study of the psychological reactions of the patients to cardiac surgery and their influence on the outcome and rehabilitation after surgery.

[Myocardial infarct complicated by a posterior aneurysm of the left ventricle. Correction by resection and double coronary bypass. 1-year clinical and angiographic follow-up]. / Infarctus du myocarde compliqué d'un anévrysme postérieur du ventricule gauche. Correction par résection et double pontage coronaire. Contrôles clinique et angiographique à un an

5 months after a posterior infarction, a man of 48 was found to have a posterior aneurysm with right coronary thrombosis and anterior inter-ventricular stenosis. A total treatment approach (resection of the aneurysm + double bypass graft) led to a stable clinical cure, which has been monitored one year later by ventriculography and coronary arteriography. The authors make the comment, however, that in this case surgery was more in the way of a safety measure than a necessity.

[Emergency surgical revascularization in establishing myocardial infarctions. Treatment of subtotal coronary occlusions]. / Revascularisation chirurgicale urgente dans l'infarctus du myocarde en voie de constitution. Traitement des occlusions coronaires subtotales.

The introduction of intracoronary thrombolysis as a treatment for myocardial infarction has led to an increase in the number of very early coronary angiographies carried out in the acute phase of myocardial infarction. These investigations can be performed without excessive risk. In some cases, severe stenosis with significant distal circulatory impairment without evidence of thrombosis is found. In these very early investigations, these findings may represent a "pre-thrombolic" lesion in an evolving myocardial infarction. Six cases of very severe pre-thrombolitic stenosis of the LAD were observed in a series of 67 coronary angiographies performed in the early stages of myocardial infarction. These six cases were selected on strict clinical, ECG and angiographic criteria. One patient was hospitalised with cardiogenic shock. The six patients underwent emergency coronary bypass surgery: average time from admission to coronary angiography was 55 minutes; average time from coronary angiography to surgery was 3 hours. These 6 pre-thrombolic lesions of the LAD were also associated with lesions of the left circumflex and right coronary arteries. There were no operative complications but two patients had stormy immediate postoperative periods. There was no hospital mortality. All patients were reinvestigated at 1 month and all grafts were shown to be patent. The left ventricular ejection fractions improved in 3 cases, remained unchanged in 2 cases, and deteriorated in 1 case (the patient with cardiogenic shock). These results suggest that emergency coronary bypass surgery is a rational treatment of pre-thrombolic coronary stenosis observed at early coronary angiography in patients with evolving myocardial infarction in order to preserve as much myocardial muscle as possible.

[Funnel-chest and cardio-pericardial pathology, apropos of 2 cases treated by pericardioplasty and parietal remodelling]. / Thorax en entonnoir et pathologie cardiopéricardique à propos de deux cas traités par péricardoplastie et remodelage pariétal

Numerous pathogenic hypotheses were put forward to explain the Funnel Chest. It is possible that the origin of this malformation is not related to an involvement of the thoracic wall or the diaphragm, but rather to a negative pressure behind the sternum which is attracted by inspiratory movements, this resulting in, and aggravating the malformation. This negative pressure of the anterior mediastinum would result from an absent cardiac mass which was displaced leftward, favoured by an enlarged and flaccid pericardial sac. Haemodynamic examination of the subjects with a funnel chest has a two-fold interest: it provides the data for a physiopathologic study. Particularly the measurement of the right ventricular pressure which becomes negative on deep inspiration. On the other hand, it makes it possible to demonstrate the presence or the absence of any cardiac lesion combined with the deformity. The angiographic pictures demonstrate the distortion of the right ventricular chamber in particular, and the elongation of the inferior vena cava. Among the various classical treatments, some aim at cosmetic improvement, others at thoracic wall correction. However, the latter do not prevent recurrence in the child, and are too severe a procedure in the adult. This is why a new treatment is put forward, on the basis of the new pathogenic considerations: repositioning of the cardiac mass displaced leftward, after a pericardoplasty, combined with remodelling of the excavated thoracic wall. Thus cardiac reposition into the anterior mediastinum avoids a long-term recurrence of the deformity. In our experience, pericardioplasty combined with thoracic wall remodelling has given good results, both immediate and delayed, in the two cases in which it was performed. A longer series, particularly on the younger child, is necessary to form an opinion on the value of this procedure.

[Medium term results of commissurotomies and mitral plasties in open heart surgery. Apropos of 50 cases]. / Résultats à moyenne échéance des commissurotomies et plasties mitrales à ciel ouvert. A propos de 50 cas

The authors report on 50 cases of mitral commissurotomies in open heart surgery. The operations were performed during a short by-pass with hemodilution. The procedure involved the sub-valvular system in more than half the cases. There was no operative death. 41 patients were seen again regularly. The results were deemed excellent in 24 cases, good in 8, average in 6 and bad in one. On the basis of this experience, the authors think it preferable to perform commissurotomies by sight.

[Preliminary study on the resumption of work after aorto-coronary bypass]. / Etude préliminaire sur la reprise du travail après pontage aorto-coronarien.

A questionnaire was sent 8 months to 3 years after aorto-coronary bypass to 98 patients who, before surgery, had had to abandon their professional activities because of ischaemic heart disease to assess the numbers who had returned to work: thirty six patients (37%) had not returned to work for medical or personal reasons; only one patient had been refused by his employee; sixty two patients (63%) had returned to work, 81% full-time and 19% with a different job. Only 19% had to stop working secondarily for medical reasons. The criteria thought initially to influence the chances of resumption of professional activity were analysed: factors not influencing the return to work were: type of work before operation (judged by the physical activity involved and the statute of salaried or independent worker), the severity of surgery (number of grafts and associated resection of aneurysm), a subjective assessment of physical condition after surgery (91% or patients not returning to work admitted to feeling well); uncontrollable factors influencing the return to work were: age of patient (average 51,7 years for those returning to work, compared to 55,1 years for the others), previous history of myocardial infarction (2,5 times more common in those not returning to work); finally, controllable factors influencing return to work were: the duration of unemployment before surgery (3,3 months for those returning full-time, compared to 16,4 months for those not returning to work); the period between surgery and resumption of activity which averaged 5 months and should not exceed 6 months. Three factors seemed to be particularly important: apart from the shortest possible period of unemployment before surgery, early physical reeducation after surgery based on chest physiotherapy and readaptation to physical activity and a psychological preparation for the return to work which should be started even before surgery.

[Aneurysm of the sinus of Valsalva rupturing into the pulmonary infundibulum. Echographic study]. / Anévrysme du sinus de Valsalva rompu dans l'infundibulum pulmonaire. Etude échographique.

Rupture of a Sinus of Valsalva aneurysm into the pulmonary infundibulum with ventricular septal defect was diagnosed by M mode echocardiography The differential diagnosis was prolapse of an aortic valve cusp associated with ventricular septal defect. The relevant features were the presence of an echo anterior to the anterior aortic wall. This echo was related to the aortic valve as a small posterior movement was recorded at aortic valve closure. Systolic fluttering of the pulmonary valve suggested a degree of subvalvular obstruction. Diastolic fluttering was related to the aortic regurgitation immediately below the pulmonary valve. This case confirms the hypothesis that the anterior echo produced by the aortic valve is in fact the left anterior coronary cusp.

[Coronary endarterectomy associated with by-pass. A series of 111 patients controlled angiographically]. / Endartériectomie coronaire associée au pontage. Une série de 111 patients contrôlés angiographiquement.

Out of 2 638 patients undergoing coronary bypass surgery at the Arnault Tzanck Centre from 1973 to September 1984, 305 (12%) also required coronary endarterectomy. One hundred and eleven of these patients had control angiographies at the Centre and were the object of this study. Endarterectomy was carried out on a totally occluded artery in 38% of cases and was performed out of necessity in the other cases. One hundred and twenty-nine disobliterations were performed in these 111 patients. The average number of bypass grafts per patient was 2.8. The overall hospital mortality was 6% (19 out of 305) which was higher than for bypass surgery alone. The postoperative myocardial infarction rate was 10%. The 117 control angiographies were performed on average during the 8th month after surgery; these controls were routine in 99 cases (84.5%) in Stage I of the NYHA classification and for recurrent angina in 18 cases (15.5%). The endarterectomised vessel was patent in 72% of cases, which was less than the patency rate of the bypass grafts. Considering the indications of necessity, this result is satisfactory and is compared which those of other reported series.

[Technical problems during coronary revascularization in case of massive calcified aorta]. / Problèmes techniques rencontrés au cours des revascularisations coronariennes avec aorte massivement calcifiée.

A massively calcified ascending aorta which may make aortic clamping impossible, is a major obstacle to coronary revascularisation surgery. The aim of this study was to demonstrate that by the use of certain technical modifications, these patients can be treated even in multivessel disease. In the author's experience, two patients with this condition underwent complete revascularisation with a good surgical result controlled by angiography. The sites of arterial cannulation were the aortic arch in one case, the brachiocephalic artery and the common femoral artery in the other case. The ascending aorta was not clamped in either patient or used as the origin of the coronary bypass grafts. Myocardial protection was performed by systemic cooling with ventricular fibrillation without cardioplegia. The feasibility of these methods has led to the suggestion of a classification of the aortic wall according to peroperative palpation. This classification would provide indications for the use of technical modifications not only in extreme cases of aortic calcification but also in patients with severe atherosclerotic changes at high neurological risk; it would not, however, interfere with the classical technique of revascularisation.

[Osler aortic aneurysm in isthmic coarctation. Clinical and angiographic aspects and postoperative results]. / Anévrysme aortique oslérien sur coarctation isthmique. Aspects cliniques, angiographiques et résultats postopératoires.

A case of probable infective aneurysm complicating isthmic coarctation of the aorta, is reported. On radiology, the aneurysmal mass seemed to have developed in less than two years. However, it was not possible to culture the causative organism. The pre- and postoperative angiographical appearance after one-stage radical surgery of the lesion and its complication are described.

[Aortic insufficiency and syphilitic coronary ostial disease. Pre- and postoperative angiographic aspects]. / Insuffisance aortique et coronarite ostiale syphilitique. Aspects angiographiques pré et postopératoires.

The authors report the case of a 50 year old patient with severe aortic incompetence (stage IV on angiography) and syphilitic left coronary ostial disease confirmed by complementary investigations. Management comprised aortic valve replacement and saphenous vein aorto-coronary bypass. The postoperative angiographic appearances showed normal valve function and a permeable aorto-left anterior descending bypass graft. The outcome was also satisfactory from the clinical point of view.

[Coronary circulation in abnormal left coronary artery arizing from the pulmonary artery trunk, before and after correction]. / La circulation coronaire dans les "naissances" anormales de la coronaire gauche à partir du tronc de l'artère pulmonaire, avant et après correction.

Two patients, both of them young girls, aged 14 and 15, had this condition and were studied by haemodynamic methods preoperatively and during the seventh postoperative month. In both cases, the retrograde perfusion of the left coronary vascular tree was shown up well, demonstrating the "coronary steal" and a left-right shunt of 2 volumes. In both cases also, the postoperative coronary arteriogram showed a return of the left coronary circulation to normal, disappearance of the large anastomatic vessels, and above all a return to normal dimensions of the right coronary artery, previously extremely tortuous and dilated. The 30 or so cases of total correction published in the world literature have been reviewed in the light of these two new cases.

[Cardiac surgery in Jehovah's witnesses. Apropos of 47 cases]. / Chirurgie cardiaque chez les témoins de Jéhovah. A propos de 47 observations.

47 cardiac defects in Jehova's witnesses were operated on without using any blood during the operation. In 9 cases the patients were under 15 years of age. 7 cases were of congenital heart defects in which the operation could be carried out with the heart still beating or by a closed heart technique: 4 of these were adults and 3 were children. In 40 cases, extracorporeal circulation was required: 19 valve defects, 8 coronary areterial cases, 10 congenital cardiac lesions, 2 valve defects associated with coronary artery disease, and 1 aneurysm of the thoracic aorta. Of these 40 patients, 4 died. The details and limits of this total haemodilution are analysed, as are the causes of failure and complications. This technique does not worsen the postoperative prognosis appreciably, but limits the scope of the surgery, and cannot be applied to a child of less than 10 kg.

[Transluminal coronary angioplasty. Experience apropos of 155 procedures]. / L'angioplastie coronaire transluminale. Expérience à propos de 155 procédures.

The authors report their experience of transluminal coronary angioplasty (TCA) from February 1980 to November 1983. 140 patients underwent TCA and 155 procedures were performed. The mean age was 55 years (range 33 to 74 years). Clinically, the patients presented with Stage I angina in 26 cases (18 p. 100), Stage II in 18 cases (13 p. 100), Stage III in 24 cases (17 p. 100) and Stage IV in 72 cases (52 p. 100), according to the NYHA Classification. 23 patients (16.5 p. 100) underwent combined thrombolysis - TCA. The coronary artery disease was limited to a single vessel in 135 cases (96 p. 100) and involved 2 vessels in 5 cases (4 p. 100). The overall results showed a 71 p. 100 primary success rate. There were no fatalities. The incidence of myocardial infarction was 3 p. 100 (5 patients) and emergency coronary bypass surgery was necessary in 16 patients (10 p. 100). The results in two groups of patients were compared: Group A: 69 patients treated with a conventional balloon catheter. Group B: 86 patients treated with a balloon catheter with a guide wire. The coronary stenosis was catheterised in 73 p. 100 of patients in Group A, and 90 p. 100 of patients in Group B (p less than 0.01). The primary success rate was 56 p. 100 in Group A and 83 p. 100 in Group B. The use of this new material improves the primary success rate and also makes more distal, anatomically atypical lesions, accessible.

[Postoperative acute aortic dissection. Apropos of two cases]. / Dissection aortique aiguë post-opératoire. A propos de deux cas.

Aortic dissection after cardiac surgery is a rare complication. The prognosis is often poor: 33-78% of mortality. The study of two cases out of 2100 patients operated upon during the last three years, and the review of the literature, allows to recall the mechanism, the anatomic origin and the different surgical techniques. Early diagnosis is essential. Some preventive techniques may reduce the incidence of the iatrogenic dissections.

[Intra-aortic balloon counterpulsation. Percutaneous insertion at surgical units. Apropos of 170 cases]. / Contre-pulsion par ballon intra-aortique. Insertion par voie percutanée en milieu chirurgical. A propos de 170 cas.

From 1st January 1985 to 31st December 1987, an intra-aortic balloon counterpulsation device (IABCP) was inserted in 170 patients: 166 balloons were inserted percutaneously and 4 surgically after failure of the percutaneous route. The indications for insertion of IABCP are classified into 3 categories. Category 1 (N = 28) consists of non-operated patients, category 2 (N = 60) consists of patients in whom IABCP balloons were inserted by necessity before, during of after a surgical operation under cardiopulmonary bypass (CPB) and category 1 (N = 82) consists of patients in whom the IABCP balloons were inserted prophylactically prior to an operation under CPB in patients at high risk. Sixteen patients with a percutaneous IABCP balloon developed a major complication related to the balloon (9.6 +/- 2.3%). The early mortality for the entire population was 49.4 +/- 3.8% (84/170). The mortality was 89 +/- 6% (25/28), 65 +/- 6% (39/60) and 24 +/- 5% (20/80) respectively in categories 1, 2 and 3. In category 3, 56 IABCP balloons (68.3%) were retrospectively considered to be necessary (group A). Nineteen patients in group A died (34 +/- 6%). The mortality observed in the 30 patients in category 2 in whom an IABCP balloon was required during the intra- or post-operative period (group B) was 76.6 +/- 7.7% (23/30). It was significantly higher than that observed in group A (p less than 0.001). However, the retrospective nature of this study prevented any formal conclusions concerning the benefit provided by prophylactic IABCP.

[Protection and reperfusion of the myocardium by cardioplegia with blood enriched in aspartate and glutamate. Technique and initial results. Report of 60 cases]. / Protection et reperfusion du myocarde par cardioplégie au sang enrichie en aspartate et glutamate. Technique et résultats préliminaires. A propos de soixante patients.

From 1st November 1987 to 30th September 1988, 27 patients with recent myocardial infarction and 33 patients at high risk of postoperative circulatory failure were operated according to the same protocol. In each case, myocardial protection, at the time of aortic clamping, consisted of an intra-coronary injection of a cardioplegic solution of blood enriched with aspartate and glutamate, administered in 3 phases (normothermic induction, hypothermic induction, normothermic reperfusion) according to the protocol described by Buckberg et al. The operative mortality was 11.6% (7/60) and 46.6% (28/60) of patients did not develop any postoperative complications. It is difficult to draw any conclusions concerning the superiority of the method on the basis of a non-comparative clinical study, but its simple application and its safety appear to be clearly demonstrated.