[Late complications of a pseudo aneurysm of the left ventricle: thrombus infection and purulent pericarditis]. / Complications tardives d'un faux anévrisme du ventricule gauche: infection du thrombus et péricardite purulente.

Pseudoaneurysm is a rare complication of left ventricle myocardial infarction. Rupture with tamponade and sudden death is the usual outcome. Surgical intervention remains the treatment of choice. Long term survival cases without surgery are rare. Infection of the thrombus is also a possible event. We report the case of a patient with postinfarction left ventricular pseudoaneurysm complicated by infection of the thrombus and purulent pericarditis involving a peptostreptococcus. Infection must be considered a potential complication of left ventricular pseudoaneurysms.

[Prognosis scores to help revascularization for ischemic heart failure]. / Scores pronostiques pour la revascularisation des myocardiopathies ischémiques.

AIMS: Patients suffering from coronary heart disease with ventricular systolic dysfunction present a bad prognosis and should be potentially revascularized. Up to now, surgery appeared to be the most feasible revascularization technique for such patients. Aims of this study were to assess the influence of different treatments (surgery, angioplasty or exclusively medical treatment) on clinical outcome and to establish a prognostic score practitioners to select the most appropriate therapy adapted to their patient profiles. METHOD: From 1995 to 2000, 492 patients were included in this cohort: 365 in the angioplasty group, 96 in the surgical group and 31 in the medical group. Kaplan Meier curves were made with a multivariate analysis to determine the significant predictive factors of mortality and major adverse cardiac events. RESULTS: After a mean follow-up of 32 +/- 19 months, there was no statistical difference in mortality rate between the groups. However, the survival rate without MACE is higher in the surgical group, intermediate in the angioplasty group and lower in the medical group. Using the significant predictive factors of MACE in multivariate analysis, a prognostic score has been established in order to discriminate three categories of severity. For each category, angioplasty was compared with surgery in terms of the event-free-survival rate. For the two extreme categories (severe and non-severe), both treatments were equal. For the intermediate category, surgery obtained greater results. CONCLUSION: This prognostic score could help physicians in choosing the appropriate revascularization technique to treat patients with severe ischemic heart failure.

Simultaneous orthotopic transplantation of carotid and aorta in the rat by the sleeve technique.

Graft vascular disease (GVD) remains the major limitation to long-term survival after solid organ transplantation. Aortic or carotid allografts in rats have been shown to be useful models because similar changes to those observed in man develop within weeks. Both immunological and non-immunological factors influence the process of GVD and a method that could permit rapid multiple arterial allotransplantation in the rat would be of great value. We performed simultaneous orthotopic aortic and carotid allotransplantations in 25 rats. The vessels were anastomosed using a sleeve technique. No immunosuppression was given. The animals were killed at 15, 30, or 60 days and histological analyses of the grafts were performed. The overall survival rate was 80% and the incidence of technical failure was very low. The histopathological aspect revealed typical progressive GVD. In conclusion, we have developed a new model of simultaneous aortic and carotid transplantation in rats. This model, which incorporates a modification of the sleeve anastomosis, is rapid and yields an easy tool to investigate immunological and non-immunological processes driving GVD.

Pseudoaneurysm and aortobronchial fistula after surgical bypass for aortic coarctation: management with endovascular stent-graft.

PURPOSE: To report the endovascular repair of an aortobronchial fistula at the distal anastomosis of a complex thoracic graft. CASE REPORT: A 61-year-old man operated 18 years prior for aortic coarctation presented with hemoptysis. An aortobronchial fistula was suspected, but spiral computed tomography and angiography showed only a small pseudoaneurysm at the distal anastomosis without revealing the fistulous tract. A Talent stent-graft was successfully deployed through a femoral access, but the large delivery system injured the external iliac artery, producing a retroperitoneal hemorrhage. Prompt balloon occlusion of the aorta and subsequent bypass graft repair of the arterial injury prevented serious sequelae. The patient recovered without further complications. Follow-up imaging to 2 years has documented exclusion of the pseudoaneurysm with no hemoptysis or signs of new false aneurysm formation. CONCLUSIONS: Endovascular exclusion of anastomotic pseudoaneurysms even in complicated cases can be an efficient treatment option, but the procedure must be carefully planned and executed in order to achieve good results.

[Atrial flutter: a possible early sign of acute rejection in heart transplantation. A case report]. / Le flutter atrial: un témoin précoce possible du rejet aigu chez le transplanté cardiaque. A propos d'une observation.

The authors report the case of a cardiac transplant patient with a recurrence of atrial flutter two months after electrical cardioversion and despite long-term preventive treatment with amiodarone. Early investigation for signs of rejection with 4 endomyocardial biopsies was negative. Aggravation of the haemodynamic status due to flutter with a rapid ventricular response led to an attempted radio-frequency ablation. Endocavitary mapping confirmed persistence of sinus activity in the native atrium and the presence of a circuit of type I isthmic flutter (anticlockwise circuit) in the donor atrium. Ablation by radio-frequency in the same procedure was successful. A fifth myocardial biopsy the same day finally confirmed stage 3A acute rejection. No signs of recurrent rejection or arrhythmia have been observed after 24 months' follow-up in this patient. This preliminary experience confirms the need to look for graft rejection by repeated myocardial biopsies in cardiac transplant, patients with atrial flutter and the efficacy of radio-frequency ablation in cases of resistance to conventional therapy.

Aortoduodenal fistula after endovascular stent-graft of an abdominal aortic aneurysm.

Despite satisfying short- and middle-term effectiveness and feasibility, endovascular stent-grafting for abdominal aortic aneurysm is still under evaluation. We report a case of an aortoduodenal fistula after the use of this technique. Enlargement of the upper aneurysmal neck was followed by caudal migration of the major portion of the stent-graft, which resulted in kinking of the device in the aneurysmal sac. Ulcerations were found on adjacent portions of both the aneurysmal sac and the adjacent duodenum. Only the textile portion of the prosthetic contralateral limb separated the aortic lumen from the corresponding duodenal lumen. Early detection of complications after stent-grafting is essential to allow successful treatment, either surgical or endoluminal.

Endovascular retrieval of two migrated venous stents by means of balloon catheters.

The usefulness of vascular stenting was demonstrated in both arterial and venous applications to restore patency and improve suboptimal results after percutaneous transluminal angioplasty. Dislodgment of venous stents with an embolization into the right cavities or the pulmonary artery, however, is one of the most feared complications of this procedure. Percutaneous removal of these migrated stents is an appealing method of replacing more invasive operative intervention with cardiopulmonary bypass, which may be very hazardous in these often severely ill patients. We describe the cases of two patients with stents that migrated into the right ventricle and the pulmonary artery. In one patient, we were able to successfully remove these stents by using an angioplasty balloon with an operative extraction from the iliac vein, thereby obviating the need for a major operative procedure.

[Heart valve diseases specific in rheumatoid polyarthritis. Apropos of 2 cases]. / Les cardiopathies valvulaires spécifiques dans la polyarthrite rhumatoïde. A propos de deux observations.

Rheumatoid nodules represent a rare cardiac valvular involvement in rheumatoid arthritis. Patients are usually asymptomatic. We report two cases of such involvement: one presented as a tumour implanted on the mitral valve, with systemic embolisation; the other presented as aortic regurgitation with acute heart failure. Surgical treatment was performed in both cases. Histological examination revealed typical rheumatoid nodules. The authors discuss valvular involvement in rheumatoid arthritis.

A rare case of embolizing cardiac tumor: rheumatoid nodule of the mitral valve.

We report the case of a 65-year-old woman with rheumatoid arthritis who was admitted with a stroke. Echocardiographic examination revealed a multilobule, highly mobile tumor on the posterior leaflet of the mitral valve. Surgical exploration showed a tumor infiltrating the valve, the annulus, and the adjacent left ventricular wall, which required complete valve resection. Histologic study demonstrated typical characteristics of a rheumatoid nodule.

[Long-term results of the surgical treatment of acute type A thoracic aortic dissection]. / Résultats à distance du traitement chirurgical des dissections aiguës de l'aorte thoracique de type A.

Out of a population of 110 patients operated as an emergency for acute Stanford type A dissection of the thoracic aorta between 1985 and 1994, there were 84 survivors. Seventy-nine were assessed after a mean follow-up period of 47.3 months. The corrected 1 year, 5 year and 10 year survival rates were 69 +/- 5.1%, 53.1 +/- 6% and 42.1 +/- 7.1% respectively. There were 19 deaths during the study period: in two thirds of cases death was due to cardiovascular complications related to the aortic pathology or hypertension. There were 13 reoperations in 12 patients for complications on the initial site of repair or for progression of the pathological process. The average time to reoperation was 21.5 months with an operative mortality of 3 patients (25%). Predictive factors of reoperation were young age (52 +/- 4.4 years vs 60.1 +/- 1.4 years; p = 0.037), the persistence of a patent false lumen (p = 0.033) and the initial surgical techniques as the incidence of reoperation seemed to be higher after treatment with biological glue alone or resuspension of the aortic valve compared with replacement of the ascending aorta or Bentall's procedure (p = 0.08). The incidence of reoperation also varies with time as it was 1.8 +/- 0.7% at 1 year, 18.5 +/- 6.5% at 5 years and 26% +/- 7.8 at 10 years. In spite of improvements in surgical technique and postoperative care, acute type A dissection of the aorta carries a poor prognosis in both the short and the long-term with a notable number of cardiac or other complications related to repair of the initial aorta. Analysis of these and other reported results suggest that initial surgery should be as complete as possible with extension to the aortic arch when involved: this more aggressive attitude should improve the long-term results by reducing the risk of reoperation responsible for a high mortality rate.

[Closure of sternotomy with Cotrel staplers]. / Fermeture des sternotomies à l'aide des agrafes de Cotrel.

The authors describe a new method for the closure of median sternotomies based on immediate compression with two or three Cotrel-Dubousset (CD) staples. This method was effective in a series of 100 patients. It was the curative treatment of septic sternal pseudarthrosis, and has been extended to high risk patients (age, severe sternal osteoporosis, obesity, diabetes, chronic respiratory insufficiency) or when surgery requires resection of the internal mammary arteries (IMA).

Evolution of untreated mild rejection in heart transplant recipients.

To elucidate whether mild rejection requires treatment, we retrospectively examined the spontaneous natural history of this histologic feature without an increase of immunosuppression. During a 4-year period, 55 heart transplantations were performed in 54 patients on whom 958 endomyocardial biopsies were performed. Among these biopsies, 162 specimens showed features of mild rejection. We studied the results of subsequent biopsies performed 7 to 10 days later, without any change in immunosuppression. These revealed regression of lesions to minimal rejection in 51 cases (31%), the same histologic feature in 82 cases (51%), or progression to moderate or severe rejection in 29 cases (18%). In 82% of these cases, therefore, no aggravation of histologic feature was observed. We separated the cases in which current-study biopsies showed mild rejection into three groups according to the result of the most recent biopsy, that is, minimal, mild, or moderate-severe rejection. The percentage of good outcome was not modified by the nature of the previous biopsy specimen: 84%, if minimal rejection was preceding the study biopsy; 82%, in the cases of mild rejection; and 77%, for moderate or severe rejection. We did not find significant differences in this evolution between patients with fewer or more than two moderate or severe acute rejections in the first 4-month period after heart transplantation (respectively, 15% or 24% progression to moderate or severe acute rejection after nontreated mild rejection).(ABSTRACT TRUNCATED AT 250 WORDS)

[Primary mediastinal myxoid liposarcoma. Apropos of a case]. / Liposarcome myxoïde médiastinal primitif. A propos d'un cas.

Liposarcoma is an uncommon mediastinal tumor provides limited CT histologic date. The prognosis depends on the histological grade and surgical possibilities. The authors report a case of mediastinal liposarcoma and discuss the correlation between imaging findings, outcome and histological status.

[The surgical approach to adrenal pheochromocytoma. A plea for lumbotomy]. / Voie d'abord chirurgicale du phéochromocytome surrénalien. Plaidoyer pour la lombotomie.

The authors compare two successive series of surgically treated phaeochromocytomas. The first series consisted of 18 patients treated by laparotomy. During the immediate postoperative course, one patient died, 10 patients developed complications and 11 patients required blood transfusion. One patient died later from a recurrence. In the following series, 17 patients were operated by lumbotomy, which was bilateral in three cases. The mortality was nul, two patients developed complications and three patients required transfusion. Although successive series must be compared very cautiously, lumbotomy is justified by the surgical simplicity and the decreased morbidity. It is only possible as a result of the progress in medical imaging, particularly computed tomography, meta-iodobenzylguanidine isotope scans and magnetic resonance imaging.

Abdominal aortic aneurysmectomy in octogenarian patients.

The authors report 56 patients. 80 years of age or older who had an abdominal aortic aneurysm (AAA): twenty seven were operated upon as emergencies, 7 with intra-peritoneal (Group I) and 20 with retro-peritoneal rupture (Group II). Twenty nine underwent elective surgery (Group III). Renal pulmonary and cardiac disease are frequent in octogenarian patients. The surgical repair consisted of 40 knitted bifurcated grafts and 16 aorto-aortic woven grafts. The overall in-hospital mortality rate is high (28.5%: 16 patients) essentially in "emergency" surgery: 71% for the seven Group I patients and 45% for the twenty Group II patients. The in-hospital mortality rate of 6.9% for the Group III of "elective" procedure is higher than the mortality rate of patients of all ages operated on for asymptomatic AAA in our institution which is 4.3%. Once a patient has been operated on successfully his life expectancy tends to parallel that of a normal population for his age group. These results can be improved with preventive measures such as elective surgery for asymptomatic AAA with a diameter of 6 cm or more. Operative contraindications are severe congestive heart failure, advanced pulmonary disease or neoplastic disease. The age "per se" is not a contraindication to aneurysmectomy. Physiologic rather than chronologic age should determine the selection for AAA in the over-80 age group. CT scans and MR are safe fast and non-invasive preoperative examinations for AAA.

[Cardiac tumor mass. Diagnostic and therapeutic approach. Apropos of 46 cases]. / Masse tumorale cardiaque. Approche diagnostique et thérapeutique. A propos de quarante-six cas.

The authors analyse a series of 46 operated intracardiac tumours (0.4% of all cases of cardiac surgery). The predominant symptoms were episodes of heart failure and pseudo-valvular disease. Peripheral emboli and pericardiac syndromes with tamponade occurred more rarely and constituted surgical emergencies. Non-invasive investigations, dominated by echocardiography, allow early diagnosis. The majority of tumours were situated in the left atrium and consisted, histologically, of myxomas, the surgical treatment of which consists of wide excision of the pedicle. Malignant tumours (17.7%) were dominated by cardiac sarcomas. When possible, extensive resection of these tumours may improve the chances of medium-term and long-term survival. The operative mortality was 8.8%. The delayed mortality was due to malignant tumours (17.3%). Myxomas must be followed in the long-term by systematic echocardiography. The authors observed 11% of recurrences occurring after a interval of 12 to 144 months (3 cases).

Cardiovascular surgery and heparin induced thrombocytopenia.

The Authors report a series of 21 cases of heparin induced thrombocytopenia (HIT) observed in a Department of Cardiovascular Surgery. The indication for heparin treatment was a cardiac procedure in 12 cases, peripheral arterial reconstructive surgery in 3 cases and in 6 cases a prevention of embolism. Two routes were used for heparin administration: subcutaneous and intravenous injections. The diagnosis was biological on low platelet counts (p.c.) in 4 cases, in 7 cases a deep venous thrombophlebitis and in 9 cases an acute arterial ischemia complicated the heparin treatment. From the 7th to 15th day after heparin treatment the p.c. had risen to the average value of 46,857/mm3. The diagnosis was clinical in 3 cases, biological with a positive aggregation test in the presence of heparin in 11 cases out of 14 biological tests performed and pathological with observation of white clots in 11 cases. The related mortality rate to HIT was 28.5% of the cases (6 cases). HIT is a rare but severe complication often associated with thrombo-embolic complications. The routine check of p.c. before and after the first week of heparin treatment is reasonable. The negative aggregation test in the presence of heparin does not permit to confirm this diagnosis. The drop in the p.c. between the 6th to 10th day after heparin treatment required an immediate arrest of this type of anticoagulation and replacement with Coumadin. The low molecular weight Heparin may induce cross matching reactions with heparin and therefore is not used as treatment for HIT. In emergency, cardiac surgery with the use of the extra-corporeal circulation device can be performed with success with heparin (2 cases).

[Lateralization of renin secretion in renovascular hypertension with bilateral arterial stenosis]. / Latéralisation de la sécrétion de rénine dans l'hypertension réno-vasculaire avec sténose artérielle bilatérale.

A retrospective analysis of peripheral and renal vein plasma renin activity has been performed in 9 patients with bilateral renal artery stenosis (3 fibromuscular dysplasia and 7 atherosclerosis). In all cases angiography showed a reduction of the arterial diameter of more than 70 p. 100. The renal artery was occluded in 3 cases. All patients received a constant sodium diet (100 mEq/day). Peripheral PRA values were classified as normal or low in 6 cases (less than 2.8 ng/ml/h) and high in one case (greater than 2.8 ng/ml/h): this values concerned 2 cases with renal artery occlusion and 1 case with a narrowing of 90 p. 100. Renal venous renin ratio of 1.5 or more has been found in 8 cases. In one case, the stenosis was quite symmetrical (70 p. 100) and the ratio less than 1.5. The secretion index has been calculated as the ratio between the venoarterial difference of both affected and unaffected side over the arterial value of PRA (V-A/A). On the more stenosed side, was found a V-A/A ratio of 0.5 or more. This ratio is particularly high in case of artery thrombosis, but there is no correlation between the ratio and the degree of stenosis. On the contralateral side, where the lesions were less important, the V-A/A ratio was low, ranging from 0 to 0.2; this estimation of renin secretion was found despite a significant stenosis on the angiography. 7 patients underwent PTA or surgery. 2 kidneys with arterial thrombosis were nephrectomized. In 5 cases the surgical treatment is performed on the 2 sides during the same procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Disobliteration of coronary arteries by the laser. Peroperative experience]. / Désobstruction des artères coronaires par faisceau laser. Expérience per-opératoire.

The authors report their experience of coronary artery disobliteration by laser in 10 patients. This was a preliminary study to assess the effects of an Argon laser on atheromatous coronary stenosis in vivo. This technique was used during coronary bypass surgery. Two series of patients were treated: an initial group of 5 patients who underwent laser therapy associated with coronary bypass surgery; a second group undergoing laser therapy alone without distal bypass grafting. The results were assessed by immediate angiography in the first series and by the passage of calibrated probes in both series. Secondary control angiography after 3 weeks was carried out in all patients. The immediate results showed a constant improvement (less than 25%) in the degree of stenosis. However, secondary angiography showed secondary occlusion in 88% of cases. These preliminary results show: the immediate efficacy of Argon laser in reducing the size of atheromatous plaques, the innocuity of the method as there were no postoperative deaths, a high incidence of secondary failure which could be related to the type of indication (competitive flow in the first group and poor distal run off in the second group of patients) or to the type of laser used. The authors consider this to be a promising technique but a lot of clinical and experimental work remains to be done before it can be adopted for routine use.