Embolic thrombus on mitral anulus calcification.

Embolic thrombus on mitral anulus calcification (MAC) was demonstrated in an 83-year-old woman with retinal embolism. Mitral anulus calcification has been associated with a significant increase of stroke in elderly people. Atrial fibrillation and calcific emboli have been reported, and embolic thrombus by MAC may be another potential cause.

Thrombosis of the abdominal aorta. A rare complication of the intraaortic balloon pumping device.

We describe a patient who died due to thrombosis of the abdominal aorta and its branches after placement of an intraaortic balloon pumping device. This rare complication, which occurred despite careful insertion technique, underscores the need to select balloon size as a function of the individual patient's morphology.

[Myxoma of the mitral valve; apropos of 2 surgically treated cases. Review of the literature]. / Myxome de la valve mitrale; á propos de deux cas opérés. Revue de la littérature.

The authors report two cases of anterior mitral valve myxoma. This is an exceedingly rare localisation and these cases add to the other 8 previously reported cases. Intracardiac tumours and valvular endocarditis may be detected non-invasively by echocardiography but the precise diagnosis may be extremely difficult: mitral valve myxoma is an exceptionally rare condition. Treatment was surgical in both reported cases.

[Tricuspid endocarditis with right-left shunt in the atrium]. / Endocardite tricuspidienne avec shunt droite-gauche à l'étage auriculaire.

A case of tricuspid regurgitation due to endocarditis causing a right-to-left shunt through a patent foramen ovale is reported. Tricuspid valve endocarditis occurred after septic abortion and caused valvular regurgitation with dyspnea and cyanosis. The diagnosis was made by echocardiography and the finding of peripheral arterial desaturation, and it was confirmed at surgery. The physiopathology of these right-to-left shunts is the same as that already described during traumatic tricuspid regurgitation: reopening of the foramen ovale by the right atrial dilatation and ventricularisation of right atrial pressures. The presence of a shunt is an indication for surgery.

[Indications and results of surgery in native valve infectious endocarditis. Apropos of 104 surgically-treated cases]. / Indications et résultats de la chirurgie dans l'endocardite infectieuse sur valve native. A propos de 104 cas opérés.

From 1972 to 1984, 104 cases of aortic valve infectious endocarditis were treated surgically. The average age of the patients was 40 years and the majority were men (69/104). Forty patients had no previous cardiac disease; 44 patients had documented valvular heart disease, which was unlikely in the remaining 20 patients. There were 16 mitral valve, 55 aortic valve, 1 tricuspid, 30 mitro-aortic, 1 mitro-tricuspid and 1 mitro-aorto-tricuspid valve infections. Aerococcus viridans was isolated in only 4 out of 71 positive cultures: the prevalence of the infecting organisms was otherwise normal (30 staphylococcus, 30 streptococcus, 7 rare organisms). Forty one patients were operated because of haemodynamic deterioration, 13 for resistant infection and 13 for an association of both indications; 37 patients were operated for embolism or threatening vegetations. Eight patients were in functional Class I, 26 in Class II, 52 in Class III and 17 in Class IV. The patients were divided into 4 groups according to the degree of surgical emergency (26 extremely urgent, 26 semi urgent, 32 controlled endocarditis and 20 chronic endocarditis). The actuarial survival rate was 70% at 5 years. Poor prognostic factors were the presence of previous valve disease, the isolation of a staphylococcus and an aortic valve localisation. The degree of emergency and the precise surgical indication did not seem to be important. Most patients at long term were in functional Classes I or II. There was no preferential indication for bioprosthetic or mechanical valve replacement in endocarditis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Results of cardiac surgery in patients over 70 years of age. Apropos of a retrospective study of 170 patients]. / Résultats de la chirurgie cardiaque chez les patients âgés de plus de 70 ans. A propos d'une étude rétrospective concernant 170 patients.

The ever increasing age of the general population and the frequency of coronary and aortic lesions in patients aged 70 or older make cardiac surgery in the elderly a topic of current interest. In a retrospective study of 170 cases the overall mortality rate was 14 p. 100 (4.7 p. 100 in 1986). During the past two years (1985 and 1986), the mortality rates in patients with coronary disease who underwent elective surgery were 10 p. 100 and 4 p. 100 respectively. Emergency surgery (left coronary trunk and unstable angina excluded) and associated operations on the heart made the prognosis worse with overall mortality rates of 13 p. 100 and 15 p. 100 respectively (9 p. 100 in 1985, 10 p. 100 in 1986). In aortic valve surgery, hospital mortality rates were 28 p. 100 in 1985 and 6 p. 100 in 1986. Post-operative morbidity was high (52 p. 100 of patients) and consisted mostly of respiratory and neurological complications (14.7 p. 100 and 9.4 p. 100 respectively of all patients). Only 4 p. 100 of the patients developed peri-operative myocardial infarction. Functional results were satisfactory in both coronary disease and heart valve disease patients. The survival rate at 4 years was 74.5 +/- 10 p. 100 globally and 87.3 +/- 9 p. 100 in coronary patients operated upon electively. Thus, the considerable advances in surgical techniques and post-operative intensive care achieved during the last few years have significantly improved the results obtained in this population.(ABSTRACT TRUNCATED AT 250 WORDS)

[Symptomatology of hydatid cyst of the heart. Study of a continuous series of 13 cases and value of x-ray computed tomography]. / Séméiologie du kyste hydatique du coeur. Etude d'une série continue de 13 cas et intérêt du scanner.

Thirteen consecutive cases of cardiac hydatic cyst were studied. The cysts were usually multiple, predominantly left ventricular. There were two cases of rupture of left ventricular cysts with systemic embolism, and three ruptures of right ventricular cysts causing pulmonary embolism. The average age of the patients was 31 years: 12 patients lived in regions where hydatid disease was endemic. Other localisations of hydatic disease were found in 7 cases. Two patients were completely asymptomatic. Three patients presented with a tumoral syndrome. The presentation was atypical simulating coronary artery disease in 2 cases, valvular heart disease in 2 cases, pericarditis in 2 cases and bronchopneumonia in 3 cases. The electrocardiogramme showed sinus rhythm in all cases and changes of subepicardial ischaemia in 8 cases and acute cor pulmonale in 3 cases. Chest X-ray showed a localised deformation of the cardiac silhouette in 5 cases and calcification in 4 cases. Direct angiocardiographic signs were present in 2 out of 8 cases; usually there was an indirect image of endocavitary filling defect. The tumour was demonstrated by 2D echocardiography in the three most recent cases. The value of CAT was assessed in the last 2 cases: it was absolutely diagnostic in 1 case of septal localisation. The results were poor in the second case due to the presence of mitral calcification. Twelve patients underwent surgery; there were 3 deaths due to rupture and 1 death before surgery. The clinical presentation of cardiac hydatid disease is very variable and the diagnosis is difficult.(ABSTRACT TRUNCATED AT 250 WORDS)

[False subaortic aneurysm after surgery of calcified aortic stenosis. Apropos of a case treated successfully]. / Faux anévrysme sous-aortique après chirurgie d'un rétrécissement aortique calcifié.

The authors report a case of false aneurysm of the posterior subaortic region of the left ventricle after a technically difficult surgical decalcification in a case of aortic stenosis. At reoperation, the surgeon used the femoral artery and both vena cavae for canulation. A direct approach of this "vascular" tumour, which was exterior to the great vessels, confirmed the diagnosis and enabled the localisation of the internal orifice inside the left ventricle. This was closed simply by suturing. No previous cases of this kind were found in the literature. This report underlines the necessity of taking the greatest care when decalcifying this region in order to avoid this type of serious complication.

[Septal rupture repaired in the acute stage of myocardial infarction. Clinical, hemodynamic and angio-coronarography findings in the evaluation of surgical risk]. / Ruptures septales opérées à la phase aiguë de l'infarctus du myocarde. Evaluation du risque opératoire par les données cliniques, hémodynamiques et angio-coronarographiques.

Between 1977 and 1987, 27 consecutive patients (16 men, 11 women, mean age 66 years, range 54 to 75 years) with ventricular septal rupture complicating acute myocardial infarction underwent surgical repair. The purpose of this retrospective study was to analyse the post-operative mortality factors from clinical, haemodynamic and operative data in all patients and also from coronary angiographic data in 23/27 patients whose haemodynamic status allowed this type of exploration. Seventeen patients (63 p. 100) died during the first post-operative month, 10 survived and were discharged. Factors that influenced the prognosis were: (1) inferiorly-located necrosis associated with a 75 p. 100 mortality rate (9 out of 12 patients), as opposed to 53 p. 100 (8 out of 15 patients) with anterior necrosis; (2) right ventricular dysfunction, observed in 83 p. 100 of patients with inferior necrosis and 53 p. 100 with anterior necrosis, which was responsible for 7 out of 9 deaths in the inferior necrosis subgroup and contributed to 3 out of 8 deaths in the anterior necrosis subgroup; this established a cause-effect relationship between right ventricular function and the overmortality of patients with inferior necrosis; (3) independently of the haemodynamic status, two- and three-vessel lesions (56 p. 100 of all lesions) which had an 84 p. 100 mortality rate as opposed to 40 p. 100 with one-vessel lesions; (4) the presence of a state of shock which was associated with a 78 p. 100 mortality rate as opposed to 55 p. 100 in patients without shock. We conclude that when permitted by the patient's haemodynamic status coronary angiography should be part of the pre-operative evaluation to assess the operative risk and guide the surgical procedure.

[Hemopericardium after coronary recanalization with streptokinase in the acute phase of myocardial infarction. Drainage and early aortocoronary bypass on the 4th day]. / Hémopéricarde de postrecanalisation coronarienne par streptokinase en phase aiguë d'infarctus du myocarde. Drainage et pontage aorto-coronaire précoce au 4e jour.

A case of hemopericardium after coronary recanalisation with streptokinase during the acute phase of myocardial infarction is reported, emphasising the value of routine daily echocardiography in all cases of intracoronary thrombolysis. The patient was a 48 year old man with a primary antero-lateral infarct in whom coronary angiography was performed at the 4th hour, showing total proximal obstruction of the left anterior descending artery. The streptokinase protocol of intracoronary thrombolysis was performed, resulting in recanalisation of the left anterior descending artery at the 30th minute. Improved left ventricular function and persistance of coronary patency were confirmed 14 hours after recanalisation. In the following days the patient showed signs of right ventricular failure with successive echocardiogrammes demonstrating an increasing pericardial effusion. On the 4th day, 600 ml of blood were drained surgically and aorto-coronary bypass carried out on the left anterior descending artery. This procedure maintained coronary patency and the improvement in left ventricular function. Several studies have shown that the hemorrhage of reperfusion only occurs in the zones of necrosis, and thrombolytics, especially streptokinase, may aggravate this condition.

[Relations between the site of significant monotruncular coronary stenosis and left ventricular function. Therapeutic implications]. / Relations entre le siège d'une sténose coronarienne monotronculaire significative et la fonction ventriculaire gauche. Implications thérapeutiques.

The indications of coronary bypass surgery in single vessel disease remain controversial. Therefore, we carried out a retrospective study of the coronary angiogrammes and left ventriculography of 93 patients with single vessel disease (greater than 70 p. 100 stenosis) involving the left anterior descending (LAD) or dominant right coronary arteries (RCA) to evaluate the quantity of myocardium at risk. Five angio-hemodynamic parameters were compared: the ejection fraction (EF), the ratio of end systolic left ventricular pressure to volume (LVESP/LVESV), the velocity of circumferential fibre shortening (VCF), end diastolic volume (EDV) and end systolic volume (ESV). Six subgroups were defined: 28 proximal LAD stenosis (16 without and 12 with myocardial infarction (MI], 37 mid LAD stenosis (20 without and 17 with MI), and 28 RCA stenosis (8 without and 20 with MI). In all, there were 44 single vessel stenoses without MI and 49 with previous necrosis. Left ventricular function was normal in the absence of MI but deteriorated progressively in cases with MI and LAD disease. In cases of proximal LAD stenosis without and with MI, the hemodynamics showed: EF (p. 100) = 67,12 +/- 2,07 leads to 43,83 +/- 4,7 (p less than 0,001); LVESP/LVESV = 3,24 +/- 0,34 leads to 1,92 +/- 0,50 (p less than 0,05); VCF (s-1) = 1,28 +/- 0,05 leads to 0,74 +/- 0,06 (p less than 0,001); in cases of mid LAD stenosis without and with MI: EF = 69,1 +/- 2,08 leads to 45,11 +/- 3,42 (p less than 0,001); LVESP/LVESV = 3,64 +/- 0,39 leads to 1,46 +/- 0,12 (p less than 0,001); VCF = 1,32 +/- 0,008 leads to 0,74 +/- 0,06 (p less than 0,001). In contrast the change in LV function was minimal in patients with necrosis and RCA stenosis: EF = 70,37 +/- 3,85 leads to 56,4 +/- 3,19 (p less than 0,05); LVESP/LVESV = 5,20 +/- 1,83 leads to 2,56 +/- 0,36 (p less than 0,05); VCF less than 1,42 +/- 0,17 leads to 1,03 +/- 0,08 (p less than 0,05).(ABSTRACT TRUNCATED AT 400 WORDS)

[Inidications for multivalve prostheses]. / Les indications des prothèses pluri-valvulaires

The authors consider that the indications for surgery should take into account three unknowns: the natural history of the valvulopathies, our incomplete state of knowledge about the outcome in operated cases, and surgical progress, which may transform the whole subject in a short time. They emphasize the seriousness of the disorders in which mitral incompetence is associated with aortic stenosis and/or incompetence; such cases justify earlier surgery. By contrast, some cases of aortic incompetence, when associated with a predominant mitral valve lesion, may not constitute an indication for valve replacement. Tricuspid annuloplasty is a noteworthy advance which provides a simple answer to some of the problems.

[Successful cardiac transplantation after 38 days of circulatory assistance with a heterotopic artificial heart]. / Succès d'une transplantation cardiaque après 38 jours d'assistance circulatoire par coeur artificiel en position hétérotopique.

The survival of a patient with irreversible cardiac failure on the cardiac transplantation waiting list was assured for 38 days by circulatory assistance with heterotopic Pierce Donachy prosthetic ventricles and followed by successful cardiac transplantation. This method of circulatory assistance is relatively simple to install from the technical point of view and provides a satisfactory haemodynamic result whilst waiting for a compatible donor organ. Several complications, some of them serious, were observed. Some were related to the patient's poor preoperative condition: acute renal failure, disorders of coagulation. These regressed slowly when the patient's haemodynamic status improved. On the other hand, septic problems and local haemorrhage were inherent to this technique. These are the commonest complications reported by other authors. Although the mortality rate during the period of circulatory assistance may appear to be high, this technique remains a valuable method of survival for selected patients and does not affect the chances of success of ulterior cardiac transplantation.

[Giant leiomyoma of the inferior vena cava]. / Léiomyome géant de la veine cave inférieure.

The authors report an uncommon case of giant leiomyoma of the inferior vena cava with intracardiac extension and arising from the external iliac vena. This case report illustrates the diagnostical problems usually encountered with this type of tumour. Indeed, despite ultrasound and transverse CT scan, the diagnosis was only assessed by histopathological analysis following a successful surgical removal of the leiomyoma. Only 7 cases of leiomyoma of the inferior vena cava are already reported in the literature. Relationship with intravenous leiomyomatosis of the uterus is also discussed.

[Cardiac hydatidosis. Review of recent literature and report of 15 cases]. / L'hydatidose cardiaque. Revue de la littérature récente à propos d'une expérience de quinze cas.

In the context of a personal series of fifteen cases of hydatid cyst of the heart, the authors present a computerized review of the last one hundred cases published in the literature. The modern features of the disease are discussed together with its severity (mortality of 23.47% in 98 recent cases). Despite the considerable contribution of ultrasonography, computed tomography and magnetic resonance imaging, a certain number of pejorative criteria appear to persist:delayed diagnosis, diagnostic error, acute pulmonary oedema and incomplete surgical cure.

[Unstable angina and single vessel stenosis of the anterior interventricular artery. Evaluation of the threatened myocardium. Therapeutic implications]. / Angor instable et sténose monotronculaire de l'artère interventriculaire antérieure. Appréciation du myocarde menacé. Implications thérapeutiques.

The authors report a special cases of precise evaluation of threatened myocardium during coronaro-ventriculography. Two elements provided this evaluation: 1) spasm in the tight stenosis of the middle part of the anterior interventricular artery with immediate left ventricular dyskinesia (EF: 37%, EDP/EVD: 1.74; EDV: 98 cc/m2). 2) Complete instantaneous recovery after injection of 2 mg of trinitrine into the left ventricle (EF: 69%, EDP/EVD: 4.33; EDV: 28 cc/m2). This loss, in the order of 50%, in the left ventricular function led us to perform an angioplasty (ACT) with success. A further clinical and angiographic stenosis, three months later, in this 72 years old patient with arteritis, led us to perform an aorto-coronary graft, rather than another ACT.

[Coronary occlusion immediately following a successful coronary angioplasty. Treatment by repeat angioplasty]. / Occlusion coronarienne au décours immédiat d'un succès d'angioplastie coronarienne. Traitement par nouvelle angioplastie.

The authors report the case of a 52 year old patient with a significant stenosis of the medial portion of the left anterior descending artery (LAD) with excellent left ventricular function. Transluminal coronary angioplasty (TCA) was indicated following a positive exercise stress test. This was initially performed successfully. Fifteen minutes after the end of the procedure, a total obstruction occurred at the site of dilatation immediately eliciting significant precordial chest pain and massive elevation of the ST segment. Isosorbide dinitrate (ISDN) at a dose of 2 mg was injected into the artery 3 times without success as was an attempt to pass through the obstruction with a guide wire. Another TCA was then attempted without administration of the thrombolytic agent. The dilating catheter passed easily by the obstruction permitting several dilatations which restored rapid coronary artery flow, relieved completely the chest pain, and normalized electrocardiographic abnormalities. This procedure represents a new therapeutic approach to obstruction, an often unpredictable and serious complication of coronary angioplasty in the absence of collateral circulation, thereby preventing the development of a myocardial infarction and an emergency aortocoronary bypass operation.

[Disobstruction of the inferior vena cava under extracorporeal circulation]. / Désobstruction cave inférieure sous circulation extra-corporelle.

An original technique used to remove obstructions of the inferior vena cava under cardiopulmonary bypass is described. This technique is indicated in pulmonary embolectomy or to dispose of a vena cava clot prolapsed into the right cardiac cavities. Through a rigid and blunt thoracic drain introduced via the right atrium, a Fogarthy venous catheter is pushed into the inferior vena cava, thus avoiding the risks of accidental passage into the supra-hepatic or renal veins and blockage in a thebesian valve. The catheter is inflated, then removed together with the drain, thereby freeing the caval lumen. The technique is reliable and reproducible, and it has proved very effective.

[Suspension of the heart during aortocoronary bypass. A simplified technic]. / Suspension du coeur au cours des pontages aorto-coronariens. Une technique simplifiée.

A technique for suspending the heart, thereby facilitating exposure of the coronary arteries, is described. In this perfectly simple and safe technique, the heart is suspended by a gauze compress passed behind the inferior vena cava and forming a sling.

[Peculiar indications and results of the use of a blood cell saver apparatus in cardiac surgery]. / Indications particulières et résultats de l'apport d'un appareil récupérateur de sang (ARS) en chirurgie cardiaque.

Results are reported of the use of autotransfusion by means of the blood cell saver in a group of patients at high risk for hemorrhage in Heart Surgery Department. Methods employed are described, and results are discussed: these were encouraging both from the clinical and biological viewpoints. The cost benefits of this procedure are emphasized and technical perspectives outlined with respect to recovery of plasma and platelets.