Ventricular septal defect after acute myocardial infarction: Early repair.

Thirty-eight patients have been operated upon early after acute myocardial infarction with rupture of the ventricular septum. Preoperative management included bedside hemodynamic evaluation, mechanical left heart support, and pharmacologic agents. The results of the surgical repair reflected both the effectiveness and the duration of preoperative treatment. Operation was performed in 14 patients with refractory cardiogenic shock, 10 of whom died (71%). Hemodynamic and clinical stability was achieved in 24 patients. Early operation (average 46 hours of medical management) in 17 patients permitted accurate repair, even with friable tissues; four of these patients died (23%). Delayed operation (average 12 days of monoperative treatment) was performed in seven patients and resulted in a higher mortality rate, three patients dying (43%). The location of the ventricular septal defect (VSD) also influenced the operative risks, the prognosis for posterior defects being worse than that for anterior defects. Optimal myocardial preservation during the entire procedure is of crucial importance to the success of the operation.

Surgical management of acute dissections involving the ascending aorta. Early and late results in 38 patients.

Thirty-eight patients (32 men and six women, mean age 48.1 years) were operated upon for acute dissection involving the ascending aorta. The surgical procedure included multiple peripheral arterial cannulations, resection of the initial intimal tear if found (35 cases), and obliteration of the false channel by double cuffing with Teflon of the two layers of the dissecting process proximally and distally. When present (29 cases), aortic regurgitation was usually (21 cases) managed by conservative remodeling of the aortic anulus; 34 prosthetic replacements of the ascending aorta and four replacements of the arch were achieved. The operative mortality was 7.9% (3138) and the overall hospital mortality was 23.7% (9138). Nonfatal complications occurred in 11 patients (29%). There were three late deaths (10.3%). Mean follow-up was 3.4 years (2 months to 8 years, 8 months). Twenty-three (88.5%) of the 26 patients were asymptomatic. Contrast tomodensitometry was performed in 14 patients; in type II (two patients), the aorta was normal; in type I (12 patients), residual abnormalities were noted: patency of the false channel (10 cases), aneurysmal dilatation (seven cases), and reduction of the true lumen by the false channel (four cases). These results emphasize the need for scrupulous long-term follow-up in surgically treated aortic dissections.

[Echocardiography in the evaluation of constrictive pericarditis. 25 cases]. / L'échocardiographie dans le bilan des péricardites constritives. A propos de 25 cas.

Twenty five patients with constrictive pericarditis underwent cross-sectional and M-mode echocardiography before pericardectomy. The numerical data were compared with those in thirty healthy subjects. The various parameters noted regarding the left cavities were as follows: --The presence of a pericardial detachment which may sometimes be quite large (more than 10 mm in 6 cases); the degree of parallelism of the pericardial membranes in systole, which is all the less maintained as the detachment is severe. --The increase in size of the right ventricle and decrease of the left, with p less than 0.001 in both cases. --The absence of posterior motion of the left side of the septum in systole in 22 cases, followed by a sudden posterior displacement during the rapid filling stage, after which there is virtually no motion until the end of diastole. --The presence at the level of the posterior wall of a so-called slow filling slope, which is smaller (1.9 +/- 1.5 mm/s) than in the normal subject (p less than 0.001). --A change in left ventricular endocavitary diameter variations, which results from the two previous findings. The tracings thus show the compliance disorder with a very steep rapid filling slope and a plateau during the slow filling stage. --Finally the changes in mitral kinetics involving an earlier (p less than 0.001) and lower (p less than 0.001) F point than in the control series and on the other hand an larger E wave, sometimes forming a summation with A wave in sinus rhythm and a false A wave in atrial fibrillation. We think this type of motion is due to the disturbances in the two mechanisms (recirculation, breaking of a jet) which in physiological conditions seem to combine to chose the mitral valve at point F and account for the valve position in mid-diastole.

[Aortocoronary bypass permeability explored by tomodensitometry. Preliminary study]. / Perméabilité des pontages aorto-coronaires explorés par tomodensitométrie. Etude préliminaire.

The patency of 24 aorto-coronary grafts was studied by tomodensitometry. --16 out of the 18 bypasses examined within the two weeks following surgery were seen. --4 older bypasses were not visible, either by scanner or by angiography and were therefore occluded: two more, performed more than a year previously, were patent on tomodensitometric examination. The interpretation of the results, discussed taking into account the small number of angiographic check ups does not permit any formal conclusion as to the validity of the procedure. The results of this technique seem satisfactory and quite comparable with other non invasive methods used in the study of aorto-coronary grafts.

[Technical development in aortocoronary bypass: multiple outlet saphenous vein graft]. / Evolution technique dans le pontage aorto-coronaire : le greffon saphène à issues multiples.

The technique of multiple outlet saphenous vein grafting with one or several alternating lateral anastamoses was used in 43 patients over a one year period; over half the patients had triple vessel disease, one third had double vessel disease; a total of 128 coronary arteries were revascularised 2.9 arteries per patient, with 60 side to side anastamoses, 1.4 per patient. The technique of this type of bypass necessitates paying particular attention to avoid kinking or twisting of the graft. The blood flow through multiple outlet graft is on average significantly greater than in the classical types of graft, and is one of the main points in favour of this technique and in keeping the graft permeable in the long term. The short term results of this technique are good with a hospital mortality of 4.6% and a peri-operational infarction rate of 6.9%, figures which are comparable with the results of classical bypass grafting techniques in multivessel coronary artery disease.

[Pathological data of 92 rheumatic mitral valve after surgical ablation : comparison with pre-operative echocardiography results]. / Données morphométriques recueillies sur 92 valvulites mitrales rhumatismales après exérèse chirurgicale : les corrélations avec les données échocardiographiques pré-opératoires.

The echocardiographic information obtained pre-operatively with an electronic linear scanning system (Multiscan) was compared with the results of pathological examination of the excised mitral valve in 92 patients, and showed a close correlation. The way in which the pathological changes influence the various parameters usually used to distinguish this type of rheumatic valvular disease is demonstrated. Two-dimensional imagery provides precise information : this is shown by comparison of the still frames of the videoscopic recording and the photographs of the corresponding pathological specimens. Valve thickness, length and thickness of the chordae, calcification, mitral valve surface and commissural separation are well shown, especially at the anterior leaflet. Study of transverse incidences seems the most reliable method of estimating mitral valve area. Systolic separation of mitral valve echos, according to the usual criteria, is a good sign of associated mitral incompetence and was found in 83% of cases of mixed mitral valve disease. The mean values of anterior mitral leaflet excursion, diastolic slope and opening speeds were compared in three groups of mitral stanosis with preferential antatomical features and a control group of pure mitral stenosis with supple valves. No individual parameter was found to be specific for a particular antatomical feature, showing multiple correlations to be indispensable. The difficulty of diagnosis by isolated traditional echocardiography is confirmed and the association of two dimensional imagery would seem essential not only in making the diagnosis but also in the pre operative work up.

[Dwarfism and constrictive pericarditis. Apropos of a case of so-called Mulibrey dwarfism with hypereosinophilia]. / Nanisme et péricardite constrictive. A propos d'un cas de nanisme dit "Mulibrey" avec hyperéosinophilie.

A child of 10 was admitted to a cardiology unit with adiastole. The marked degree of dwarfism and anatomical features were characteristic of the so-called 'Mulibrey' dwarfism. Surgical intervention confirmed the constrictive pericarditis which is normally found in this condition. Unfortunately, the adiastole persisted which, taking into account the marked eosinophilia, made an associated endomyocardial fibrosis seem likely. The distinctive features of constrictive pericarditis and of the constrictive type of cardiomyopathy are recalled.

[Aortopulmonary fistula with interventricular defect and pulmonary valve stenosis in a 15-year-old girl. Surgical correction]. / Fistule aorto-pulmonaire avec communication interventriculaire et rétrécissement orificiel pulmonaire chez une jeune fille de 15 ans. Correction chirurgicale

A young girl of 15 with an aorto-pulmonary fistula was treated surgically, with a successful outcome. The clinical diagnosis could only be established at right-sided catheterisation, and especially at retrograde per-arterial aortography. The small size of the fistula explains the low level of the pulmonary arterial hypertension, and the way in which the condition was well-tolerated for some time. The association of this lesion with ventricular septal defect and pulmonary stenosis is extremely rare.

[Aortic insufficiency caused by incomplete rupture of the ascending aorta. Conservative surgical treatment]. / Un cas d'insuffisance aortique par rupture incomplète de l'aorte sus-sigmoïdienne. Traitement chirurgical conservateur.

Commissural disorganisation secondary to incomplete rupture of the ascending aorta was found at surgery for massive aortic incompetence in a young man with previous hypertension. The lesions were repared by a conservative procedure with an excellent result 3 years after surgery. Incomplete spontaneous rupture of the ascending aorta occurs in the same terrain as dissection of the aorta (hypertension, aortic media necrosis) of which it represents a minor form. It may remain asymptomatic but it is usually complicated either by secondary intrapericardial rupture, by aortic aneurysm or by aortic incompetence due to valvular prolapse. When valvular prolapse is associated with another lesion which aggravates the regurgitation (aortic valve disease, aortic ring dilatation) aortic valve replacement should be performed with a prosthesis; on the other hand, when commissural disorganisation giving rise to valvular prolapse is the cause, a conservative procedure may be envisaged.

[Intermdeiate forms of atrioventricular defects. Reflections apropos of 50 consecutively operated cases]. / Le canal atrio-ventriculaire dans ses formes partielles. Réflexions à propos de 50 cas opérés consécutivement.

Fifty cases of intermediate forms of atrioventricular defect were treated surgically. The operation was performed in the traditional manner in all cases. One post-operative death and three cases of severe mitral incompetence leading to reoperation were observed. The authors emphasise that it is essential to look for and excise the chordae and abnormal fibrous bands, that it is generally unnecessary to touch the tricuspid valve and that there is a danger of obstructing the aortic canal if the correction of the asymmetry of some mitral clefts is attempted. Analysis of the results leads them to tend to respect the cleft mitral valve when the regurgitation is minimal and to suture it all along its length when the regurgitation is severe. Mitral annuloplasty may be a useful complementary procedure and a left atrial approach may be proposed with this in mind in certain cases. Conduction defects remain a serious problem in this type of surgery; not so much complete heart block, which is exceptional, but trifascicular block, often present preoperatively, whose prognostic is, to say the least, uncertain.

[Interruption of the aortic arch and an aorto-pulmonary fistula. Simultaneous correction of lesions in a 5 1/2 month old infant]. / Interruption de l'arche aortique et fistule aorto-pulmonaire. Cure simultanée des lésions chez un enfant de 5 mois et demi.

Aortic arch hypoplasia is rare but carries a poor prognosis. It is usually associated with a left to right shunt at ventricular level. The association of an aorto-pulmonary fistula is exceptional. A case of a 5 1/2 month old infant treated successfully by simultaneous correction is reported with a review of the physiopathological changes. Pulmonary hypertension and aortic perfusion depend on the calibre of the ductus arteriosus and its evolution. The therapeutic problems which result are the suppression or palliation of pulmonary hypertension and resaturisation of distal aortic vascularisation. Surgery is the only hope of cure, and current techniques are reviewed: two stage procedures with revascularisation of the distal aorta and pulmonary artery banding, or simultaneous correction of aortic continuity with suppression of the left to right shunt under cardiopulmonary bypass. The technical conditions are analysed: perfusion of the different aortic segments, methods of reestablishing aortic continuity. Good results are as yet rare, and are obtained after complete correction under cardiopulmonary bypass.

[The "small aortic ring." Hope for a surgical solution]. / Le "petit anneau aortique": un espoir de solution chirurgicale.

The "small aortic ring" was until recently an unresolved problem for surgeons operating on the aortic valves. It used to contraindicate valve replacement in the child, and sometimes led to the insertion of too small a valve in the adult. Some hope of a solution has appeared in the form of three new techniques: enlargement of the aortic ring over the mitral valve, aorto-ventriculoplasty, and apico-aortic shunt. Two adults have had the ring enlarged above the mitral valve with good results in both cases. Five children have had an aorto-ventriculoplasty with good results in two cases, post-operative atrio-ventricular block in one, and two deaths, one early and the other late. These deaths appear to be more closely related to the severity of the initial lesion and to the degree of decompensation of the myocardium than to the operation itself. There are advantages and problems with this technique. An attempt has been made to systematise indications for treatment as a function of the lesions and the state of the patient.

[Resections of the left ventricle in the surgical treatment of parietal sequelae of myocardial infarct]. / Les résections due ventricule gauche dans le traitement chircurgical des séquelles pariétales de l'infarctus du myocarde.

Resection of left ventricular tissue seems to be playing an increasing part in the treatment of the sequelae of myocardial infarction. In a total of 700 patients who underwent surgery for some aspect of coronary atherosclerosis, 40 underwent resection of left ventricular tissue. In the majority of cases, diagnosis rested on left ventricular cine-angiography and in 3 cases this had to be carried out as an urgent procedure with circulatory assistance using diastolic counter-pressure (DCP) from an intra-aortic balloon. A selective contrast technique for the two coronary arteries was used whenever possible. The surgical anatomy of the lesions indicates a difference between a localised dyskinesia and diffuse dyskinesia, the latter having a severe effect on left ventricular function. In a group of localised dyskinesias, the territory supplied by the anterior descending artery was by far the most frequently affected. Resection of left ventricular tissue was associated with a myocardial bypass revascularisation procedure in 9 cases, valve repair in 7 cases, and closure of a septal perforation in 3 cases. The total inpatient mortality rate is still quite high (23.1%) because of the severity and widespread nature of the coronary disease. However, the mid-and long-term results are good, the criteria being functional improvement and the actuarial 4-year survival rate.