Detection of pathological aortic tissues by infrared multispectral imaging and chemometrics.

Processing of multispectral images is becoming an important issue, especially in terms of data mining for disease diagnosis. We report here an original image analysis procedure developed in order to compare 42 infrared multispectral images acquired on human ascending aortic healthy and pathological tissues. Each image contained about 2500 infrared absorption spectra, each composed of 1641 variables (wavenumbers). To process this large data set, we have restricted the spectral window used to the 1800-950 cm(-1) spectral range and selected 100 spectra from the aortic media, which is the most altered part of the aortic tissue in aneurysms. Prior to this selection, a spectral quality test was performed to eliminate 'bad' spectra. Our data set was first subjected to a discriminant analysis, which allowed separation of aortic tissues in two groups corresponding respectively to normal and aneurysmal states. Then a K-means analysis, based on 20 groups, allowed reconstruction of infrared images using false-colours and discriminated between pathological and healthy tissues. These results demonstrate the usefulness of such data processing methods for the analysis and comparison of a set of spectral images.

In-vitro analysis of normal and aneurismal human ascending aortic tissues using FT-IR microspectroscopy.

FTIR microspectroscopy has shown to be a proven tool in the investigation of many tissue types. We have used this spectroscopic approach to analyse structural differences between normal and aneurismal aortic tissues and also aortas from patients with congenital anomalies like aortic bicuspid valves. Spectral analysis showed important variations in amide I and II regions, related to changes in alpha-helix and beta-sheet secondary structure of proteins that seem to be correlated to structural modifications of collagen and elastin. These proteins are the major constituents of the aortic wall associated to smooth muscular cells. The amide regions have thus been identified as a marker of structural modifications related to these proteins whose modifications can be associated to a given aortic pathological situation. Both univariate (total absorbance image and band ratio) and multivariate (principal components analysis) analyses of the spectral information contained in the infrared images have been performed. Differences between tissues have been identified by these two approaches and allowed to separate each group of aortic tissues. However, with univariate band ratio analysis, the pathological group was found to be composed of samples from aneurismal aortas associated or not with an aortic bicuspid valve. In contrast, PCA was able to separate these two types of aortic pathologies. For other groups, PCA and band ratio analysis can differentiate between normal, aneurismal, and none dilated aortas from patients with a bicuspid aortic valve.

[Endovascular treatment of aortic isthmus ruptures: medium term results]. / Traitement endovasculaire des ruptures de l'isthme aortique: résultats à moyen terme.

UNLABELLED: Despite an improvement in the surgical management of aortic isthmus ruptures, the observed morbidity and mortality rates remain high. The use of aortic endoprostheses could improve these results, but there are not yet many medium term studies on ruptures of the isthmus. Between January 2000 and December 2005, we treated endovascularly 9 patients (7 males and 2 females) presenting with a rupture of the aortic isthmus, acute in 8 of them and chronic in one case. The average age was 46 years. All of the patients presented with significant traumatic co-morbidity. Ten endoprostheses were used in these 9 patients, and no immediate conversion was necessary. Complete excision of the lesions lasted on average 112 +/- 27 min and there were no per-operative deaths. Hospital mortality was 22% (2 patients: multiple organ failure on day 3, and a CVA on day 10). The mean length of hospital stay was 16 +/- 20 days. The mean follow up of the 7 surviving patients was 38 +/- 17 months. No complications relating to the endoprostheses were reported. In all of the patients an almost complete disappearance of lesions on CT scan was noted: by 6 months for the acute ruptures and at 1 year for the chronic rupture. CONCLUSION: the medium term results of endovascular treatment of isthmus ruptures are good.

[Infectious endocarditis in cerebral death: implications for explantation of tissues and organs]. / Endocardite infectieuse chez les patients en état de mort cérébrale: implications pour le prélèvement de tissus et d'organes.

Allograft valve replacement is the preferred treatment for infectious endocarditis With severe annular destruction. Explantation of the valve in patients with cerebral death requires preliminary cardiac investigations and strict surgical procedures. The authors report two cases of right atrial endocarditis discovered at the time of explantation of the valvular allografts. In view of the infectious nature of the lesions, no tissues were resected. In both cases, transthoracic echocardiography had not diagnosed these lesions. The sensitivity of transoesophageal echocardiography in the diagnosis of these lesions should lead to systematic referral for this investigation. The infectious nature of these endocarditic lesions should raise suspicion about the presence of a central venous catheter. In addition, careful inspection of the chambers, septa and cardiac valves should be performed at surgery. The detection of potentially infectious endocarditic lesions should, in accordance with present recommendations, lead to renouncing the explantation of valvular allografts.

[Primary cardiac lymphoma: diagnosis and treatment. Report of 6 cases and review of the literature]. / L ymphome cardiaque primitif: démarche diagnostique et thérapeutique. A propos de 6 cas et revue de la littérature.

Primary cardiac lymphoma (PCL) is the rarest primary cardiac tumour and carries a poor prognosis. Early diagnosis, often difficult, to introduce appropriate treatment as soon as possible, seems to have a positive impact on prognosis. The authors report their experience of 6 patients with PCL. None of the patients had immune depression. The presentations were tamponade (N= 2), right heart failure (N= 1), general ill health (N= 3). A PCL was suspected on echocardiography and thoracic CT scan showing tumour invading the right heart chambers in all cases. The diagnosis of PCL was confirmed by surgical biopsy in 5 patients and by endomyocardial biopsy in 1 patient. A diffuse large cell type B lymphoma was found in 5 patients and an anaplastic lymphoma in 1 patient. One patient died of right heart failure 4 days after diagnosis and before starting chemotherapy. All the other patients received chemotherapy. Two patients died during their first course. The other three patients had several courses of chemotherapy: there are two survivors 17, 5 months later and one patient died 62 months after diagnosis. The diagnosis of PCL should be suspected in patients with a cardiac tumour associated or not with pericardial effusion. Early, appropriate chemotherapy seems to have a positive impact on the prognosis, justifying aggressive approaches to obtain a rapid histological diagnosis.

[Chronic dissection of the aorta after coronary bypass surgery]. / Dissection aortique chronique après pontages coronaires. Une stratégie chirurgicale difficile.

Dissection of the aorta is a potential complication of all forms of cardiac surgery. It occurs after a variable interval. When observed in the long term, surgery may be complex with greater technical difficulties resulting in increased postoperative morbidity and mortality compared with other types of dissection. These difficulties are all the more marked when the initial surgery is coronary bypass grafting and when the grafts, especially internal mammary artery grafts, remain patent. A surgical strategy has to be elaborated to prevent certain per- and postoperative complications. The authors report the case of a patient who developed a chronic dissection of the aorta 9 months after coronary bypass surgery with patent internal mammary artery grafts. In this situation, a strategy associating anterograde cerebral perfusion before the sternotomy and endovascular control of the internal mammary grafts was proposed.

Anatomic, clinical, and therapeutic features of acute cardiac rupture. Successful surgical management fourteen hours after myocardial infarction.

A 62-year-old man sustained an acute myocardial infarction complicated on the thirteen hour by left ventricular rupture and acute periocardial tamponade. Echocardiography confirmed the suspicion of intrapericardial fluid, and immediate pericardiocentesis improved the hemodynamic state for a period sufficient to permit preparation for operation. Resection of ruptured and necrotic anteroapical left ventricular myocardium with primary reconstruction was successfully accomplished with the aid of temporary extracorporeal circulation. The patient has remained well for 1 year after the operation. Anatomic, clinical, and therapeutic features of acute cardiac rupture are discussed.

Fistula between a saphenous vein graft aneurysm and the pulmonary artery trunk.

We report the case of a 52-year-old man who was admitted for atypical thoracic pain 18 years after a saphenous vein bypass graft of the left anterior descending coronary artery. Investigations demonstrated an aneurysm of the middle portion of the vein graft with a fistulous communication to the pulmonary artery trunk. The aneurysm was excised surgically, and the fistula was closed with an autogenous pericardial patch.

[Right juxtaposition of the atria. Apropos of one case without associated trunco-conal abnormalities]. / Juxtaposition droite des auricules. A propos d'une observation sans anomalie tronco-conale associée

A child of 7 had coarctation of the aorta and an atrial septal defect. In the course of surgery to close the septal defect, she was found to have a right-sided juxtaposition of the appendages. This is a very rare abnormality, with no symptoms of its own, but usually associated with severe cardiac malformations especially of the truncus and conus. This case report is most unusual because of the right-sided disposition of the appendages and the absence of any serious associated cardiac lesion.

[Fibroelastoma of the tricuspid valve presenting with syncope]. / Fibroélastome de la valve tricuspide révélé par des syncopes.

Cardiac fibroelastomas are rare benign tumours. Initially observed as a chance finding at autopsy or during cardiac surgery, the diagnosis has become more common since the introduction of echocardiography. These tumours are usually asymptomatic. When the left heart valves are involved, embolic complications may be threatening. When the right heart valves are affected they are usually asymptomatic. The authors report the case of a fibroelastoma of the tricuspid valve responsible for several syncopal attacks. The tumour was excised with preservation of the native valve. There has been no recurrence of syncope since surgery. The authors believe this to be the second reported case of fibroelastoma of the tricuspid valve presenting with syncope.

[Abnormal communications in acute bacterial endocarditis of the aortic valve]. / Communications anormales au cours des endocardites bactériennes aiguës de la valve aortique.

Abnormal communications acquired during acute aortic valve bacterial endocarditis are rare but serious complications. Seven cases are reported; between the left ventricle and right atrium (3 cases), the left and right ventricles (2 cases), the aorta and right atrium (I case) and the aorta and left atrium (I case). The usual causal organisms is a staphylococcus (4 out of 7). The diagnosis is suspected on the development of atrio-ventricular block, a parasystolic murmur and sudden severe cardiac failure, but can only be confirmed by catheterisation and angiocardiography (impractical in our patients because of their poor condition). Echocardiography is of great diagnostic value. Surgical cure involves a double approach aortotomy and opening the other chamber involved), with extensive excision of the infected tissues, closure of the perforation, reconstruction of the aortic ring and implantation of an aortic valve prosthesis. The extent of the anatomical lesions affects the choice of the mode of reparation. There was no operative mortality in our series but two patients have persistent diastolic murmurs due to perivalvular leaks. In one case, recurrent infection led to the implantation of an apico-aortic tube with a fatal outcome.

[Double aortic arch with coarctation. Apropos of a case]. / Coarctation sur double arc aortique. A propos d'une observation.

One case of double aortic arch with coarctation is reported. Anatomically, partial atresia of the anterior arch presented as a Kommerel's diverticulum; the coarctation was situated on the dominant posterior arch just proximal to the origin of the subclavian artery. This malformation had been diagnosed clinically during childhood. The operative indications were increasingly severe hypertension with associated left ventricular hypertrophy, and dramatic epistaxis from a nasal angioma which necessitated repeated arterial embolisation. The surgical treatment comprised the insertion of a prosthetic tube from the brachiocephalic trunk, proximal to the coarctation, to the descending thoracic aorta distal to the coarctation. The immediate operative result was excellent with return of normal peripheral pulses and blood pressure. The diagnostic difficulties of this malformation and its associations with other vascular malformations are emphasised. The surgical indications are discussed and the different techniques reviewed:--resection and end-to-end anastomosis,--tubular prosthesis,--associated procedures for double aortic arch. The choice of technique depends on the age of the patient, the anatomical conditions (double arch, coarctation, collateral circulation), and the quality of the aortic wall (atheroma).

[Mitral valve insufficiency due to ballooning. A surgical series of 70 cases]. / Insuffisance mitrale par ballonisation. A propos d'une série chirurgicale de 70 observations.

The authors report 70 cases of mitral regurgitation due to ballooning. For the surgeon this is the most frequent cause of degenerative mitral regurgitation in patients around 60-years-old. The aetiology still remains unknown. There are two opposing theories--the congenital and the acquired. The appearances at operation are characteristic--a localised or diffuse ballooning of one or both cusps with elongation of the chordae attached to the ballooned portion. Two histological features are noted--myxomatous degeneration of the cusp and the absence of any inflammatory process. Ballooning may be asymptomatic and bening for a long time before evolving progressively or suddenly into important mitral regurgitation. The pre-operative diagnosis is aided by left ventricular angiography and echocardiography. Surgical treatment, guided by the findings at operation, usually involves mitral valve replacement or, less frequently, mitral valve repair.

[Coronary endarterectomy associated with coronary artery bypass in severe coronary artery disease. 50 cases]. / L'endartériectomie coronaire associée au pontage dans les lésions coronariennes sévères. A propos de 50 observations.

The surgical indications of coronary endarterectomy were defined from a study of 50 cases in which endarterectomy was associated with aorto-coronary bypass surgery. This total represented 6 p. 100 of all the aorto-coronary bypass operations performed in the same period. Coronary endarterectomy was performed "on principal" for the right coronary artery, and "of necessity" for the left anterior descending artery. The special techniques of endarterectomy on the left anterior descending artery are described. Endarterectomy does not increase the operative risk and enables revascularisation of vessels unsuitable for bypass surgery. 85 p. 100 patients are asymptomatic with an average follow up period of 2 years after endarterectomy and aorto-coronary bypass graft of the right coronary artery.

[Massive pulmonary embolism Apropos of 26 embolectomies with definitive survival, 10 of them by Trendelenburg's operation]. / L'embolie pulmonaire massive. A propos de 26 embolectomies avec survie définitive, dont 10 par opération de Trendelenburg.

The authors report 26 pulmonary embolectomies carried out successfully, 10 of them having been Trendelenberg procedures and 16 having been carried out under extracorporeal circulation. The latter method gives better results, and appears to be the procedure of choice. The haemodynamics before operation were always abnormal, and there were 4 cardiac arrests, 11 cases of severe shock, and 6 cases with less severe hypotension. In the other cases, cyanosis, respiratory distress and signs of acute cor pulmonale were the clinical features of the massive embolus. It was possible to carry out arteriography in 14 cases, and this showed extensive pulmonary vascular obstruction in between 70 and 90%. In 4 cases this procedure was followed by an exacerbation, and extremely urgent treatment became neccessary. This examination is important for diagnosis and for assessment of the prognosis. It seems clear to the authors that surgery has a certain place, alongside medical fibrinolysis of a severe prognosis. It seems clear to the authors that surgery has a certain place, alongside medical fibrinolysis of a severe pulmonary embolus. The essential indications for surgery are moribund patients, those in whom fibrinolysis is contraindicated or unsuccessful, and those with massive obstruction of the pulmonary arterial tree.

[Myxomas of the right atrium. Apropos of 3 cases. Review of the literature]. / Les myxomes de l'oreillette droite. A propos de 3 observations. Revue de la littérature.

The authors report 3 cases of right atrial myxoma and review 88 other cases in the literature managed by surgery. The first personal case, in a 74 year old patient, illustrate the dramatic consequences of tumour engagement in the tricuspid orifice, in this instance cardiac arrest during catheterisation justifying emergency surgery. The second case exemplifies the diagnostic value of echocardiography: the correction of an erroneous diagnosis of pericarditis. The third case shows that some forms may be totally asymptomatic, the tumor being diagnosed on clinical examination and confirmed by echocardiography. In their review of the literature, the low overall incidence of primary cardiac tumours, of which myxoma is the most common, is emphasised. A right atrial localisation is found in only 25% cases. 88 surgical reports have been published since Bahnam's original attempt at surgical cure under cardiopulmonary bypass. Myxoma may occur at any age but it usually presents between the ages of 30 and 60. Some familial forms have been reported. The presenting symptoms are protean but usually point to an obstacle in the right heart chambers. They may be summarized as follows: 1. Isolated right ventricular failure without left heart disease may be observed in large tumours (reported in 50% of cases). 2. Simulating pericarditis (25% of cases) with a low grade pyrexia (25% of cases). 3. Paroxysmas of cardio respiratory distress of variable severity (a few cases). Clinical examination, chest x-ray and ECG are not diagnostic but do show non-specific changes which are of value in drawing attention to the heart and leading to echocardiography. This confirms the diagnosis by showing abnormal mobile echos in the right atrium prolapsing into the right ventricle in diastole. Angiography serves only to confirm these appearances. Surgery is the treatment of choice, and preferably with the shortest possible delay. It offers definitive cure at a minimal risk to the patient.

[Postoperative hemopericardium compressing the left atrium. Apropos of a case]. / Hémopéricarde postopératoire comprimant l'oreillete gauche. A propos d'un cas.

We report a case of tamponade due to an effusion of blood which had occurred two weeks after an aorto-coronary bypass and was unusually located behind the left atrium. The effusion, with severe clinical symptoms, was diagnosed by echocardiography and computerized tomography of the chest. These examinations provided an accurate anatomical diagnosis on which the approach route of the emergency operation was based.

[Recurrent mobile thrombus of the ascending aorta diagnosed by transesophageal echocardiography]. / Thrombus mobile récidivant de l'aorte ascendante diagnostiqué par échocardiographie transoesophagienne.

The authors report the case of a 32 year old woman with no risk factors for thromboembolism apart from a raised Lipoprotein (a) level, in whom a mobile thrombus of the ascending aorta was diagnosed only by transoesophageal echocardiography after multiple episodes of systemic embolism. After surgical excision the thrombus recurred and death ensued on the 17th postoperative day after multiple visceral embolism despite adequate anticoagulant therapy. This is a rare condition, the outcome of which seems often to be fatal, due to early recurrence irrespective of the treatment (anticoagulant or platelet antiaggregant therapy). This case illustrates the value of systematic transoesophageal echocardiography for the investigation of cerebral or peripheral ischaemic episodes without carotid artery disease and raises the problem of the best way of treating this pathology.

[Value of transesophageal echography in the diagnosis of posterior ventricular septal rupture during the acute phase of myocardial infarction. Apropos of 2 cases]. / Intérêt de l'échographie transoesophagienne dans le diagnostic de rupture du septum interventriculaire postérieur au stade aigu de l'infarctus du myocarde. A propos de 2 observations.

The authors report two cases of posterior ventricular septal defects complicating acute myocardial infarction diagnosed by transesophageal echocardiography. Transesophageal echocardiography was well tolerated confirmed the diagnosis, and enabled accurate evaluation of the shunt in the transgastric view. The anatomical results guided the surgical approach and correlated well with the operative findings.

[Malignant histiocytofibroma of the heart simulating myxoma of the left atrium]. / Histiocytofibrome malin du coeur simulant un myxome de l'oreillette gauche.

The authors report a case of malignant fibrous histiocytoma of the left atrium which was excised but rapidly recurred in a 47-year-old woman. Clinical examination, echocardiography and the absence of biochemical abnormalities were in favour of the diagnosis of left atrial myxoma. This report illustrates the clinical similarity between myxoma and sarcoma of the left atrium. Very careful anatomopathological examination of multiple sections of the tumour are necessary to distinguish it from benign tumours, especially myxomas.