[Aortic failure neglected in surgery of mitral or mitro-tricuspid valve diseases]. / Insuffisances aortiques negligees au cours de la chirurgie des valvulopathies mitrales ou mitro-tricuspidiennes.

The objective of this study was to determine the outcome of neglected minimal or moderate aortic regurgitation during mitral or mitro-tricuspid valve surgery. 42 patients were included in this survey between 1985 and 2002. There were 17 men and 25 women aged 9-54 years (mean age: 22 +/- 10 years). Etiology was dominated by acute rheumatic fever (91%). Associated lesions were observed: mitral valve incompetence 11 cases, mitral valve stenosis 9 cases, mitral valve incompetence plus mitral valve stenosis in 8 pateints and mitro-tricuspid valve disease in 14 others. All the patients were symptomatic (NYHA class II 79%, NYHA class III or IV 20%). 90% of patients had a radiological cardiomegaly: mean cardio-thoracic was 0.62. At electrocardiogram, 79% of patients were in sinus rhythm and 57% presented a left ventricular hypertrophy. Minimal or moderate aortic regurgitation has been confirmed by echocardiography and angiocardiography in all patients. Surgical treatment was a mitral valve replacement (n = 35.83%), a mitral valvuloplasty (n = 5.12%), a mitral valve replacement and a tricuspid valve annuloplasty according to DE VEGA technique (n = 2.5%). The operative mortality was 4.7% (2 deaths) due to an acute cardiac failure (1 case) and prosthetic valve endocarditis (1 case). 19 patients have been followed up from a mean 1 month to13 years (mean follow-up: 5 years). The follow-up has been marked by a regression or a stability of the neglected aortic incompetence , a regression of the mean cardio-thoracic ratio from 0.62 preoperatively to 0.56 postoperatively, an improvement of the functional status (84% of cases). We conclude that the neglected aortic incompetence during mitral or mitro-tricuspid valve surgery do not tend to aggravate during follow-up.

[Surgical management of lungs destroyed by tuberculosis]. / Résultats chirurgicaux des poumons détruits post-tuberculeux.

OBJECTIVE: The purpose of this work was to report our experience with surgical management of lungs destroyed by tuberculosis and to analyze our results. MATERIAL AND METHODS: We reviewed the cases of 45 patients who underwent surgery between January 1978 and December 2004 after medical treatment for pulmonary tuberculosis considered successful. The series included 31 men and 14 women, mean age 31 years (range: 7-55 yr). Indications for surgery were chronic bronchorrhea (91.1%) and hemoptoic sputum associated with bronchorrhea (8.9%). Lung function tests were preformed in 42 patients and noted a restrictive syndrome with shunt in all: mean FEV1 was 1 890 ml. All patients were given a preoperative medical regimen for at least four weeks. Pneumectomy (17 right and 28 left) was performed; all bronchial sutures were made manually and protected. Operative bleeding was a constant feature and blood transfusion was needed (mean 1,500 cc). RESULTS: Operative mortality was 4.4% from hemorrhagic and infectious causes. Complications were non-fatal (16.3%) and marked by bleeding (0.9%) empyema with bronchopleural fistulae (8.9%). Mean postoperative hospital stay was 13 days without empyema and 150 days with empyema. Long-term outcome was satisfactory after a mean 7.5 years follow-up (range: 4 months - 20 years). CONCLUSION: Indications are patient comfort and necessity. Morbidity and mortality are acceptable with adequate preoperative preparation.

Surgical treatment of patent ductus arteriosus (PDA). Analysis of 145 cases operated on in Abidjan (Cote D'Ivoire).

This retrospective study aims to analyse our surgical procedures and our results after surgery of patent ductus arteriosus (P.D.A.) in children. Since 1978 to 1992 we have reported Abidjan Cardiology Institute 145 children operated cases. The average age was 4.7 years, the average weight 16 kg. There was female predominance with a sex ratio of 2.3/1. All patent ductus arteriosus had been confirmed by two dimensional echocardiography (2D echocardiography) and cardiac catheterization. Type 11a of NADAS' Classification was the most frequent (50%). Double or triple ligation supported on teflon felt was the most frequent technique used (86 times ie 59.3%). This technique gave good results in view of the absence of hospital mortality, only 4 cases of ductus "recanalization" supervened, a low rate of ductus arteriosus recurrence patency at long follow up of all patients from one to 10 years (mean 5 years). Double or triple ligation on teflon felt according to Wright procedure seems to be a securising technique alternative in our countries.

Usefulness of non-invasive indices in the monitoring of heart-transplanted pediatric patients.

Seven patients underwent cardiac transplantation at Ste-Justine Hospital between June 1984 and October 1988 (age 3-16 years). Indices derived from M-mode echocardiography--left ventricular mass (LVM), isovolumetric relaxation time (IRT), shortening fraction (SF), velocity of circumferential fiber shortening (VCF), ejection fraction (EF), LV pre-ejection period/ejection time (PEP/ET), isometric contraction time (ICT)--and electrocardiography--summation of potentials (Sum Pot)--were used as non-invasive markers of rejection (367 studies), while rejection status was monitored by serial endomyocardial biopsy (55 biopsies). Spontaneous variation of such indices, as defined by the 90% distribution interval of their variation when biopsy was unchanged, was found to be important: -20% to +28% for IRT, -30% to +28% for LVM, -30% to 32% for Sum Pot, -32% to 42% for PEP/ET, etc. Using limits of spontaneous variation such as thresholds, none of the studied indices could consistently predict the 2 biopsy-documented episodes of rejection or the 7 episodes of improvement. Among all the studied indices, IRT was the most promising, correctly predicting 1 of the episodes of rejection and almost predicting the 2nd. Remeasurement of all M-mode tracings by an unique observer, following strict rules to maximize reproducibility, did not decrease the spontaneous variation of these indices, nor did it improve their performance as predictors of changes in the rejection status. These results warrant the continuing search for other non-invasive methods for accurate monitoring of the rejection status.

[The Fontan operation in tricuspid atresia. Effect of age, shunt and type of atrial pulmonary connection in tricuspid atresia]. / L'opération de Fontan dans l'atrésie tricuspidienne. Influence de l'âge, des shunts et du type de dérivation auriculo-pulmonaire dans l'atrésie tricuspidienne.

Between 1977 and 1988, 20 patients underwent the Fontan operation. Their age ranged from 4 to 24 years (mean 11 years). The basic disease was tricuspid atresia with ventriculo arterial concordance and right ventricular hypoplasia. Pulmonary stenosis was present in 16 patients. Twenty-eight palliative procedures had been performed previously in the group of patients presenting some forms of pulmonary stenosis. In 2 cases a non-valved conduit has been used for correction, in a third case a valve conduit was utilised, and in a fourth case a right atrioventricular connection was carried out. In the remaining 16 patients, a wide posterior connection between the right atrium and the pulmonary arteries was performed. There were 2 early deaths (10%), and 2 late deaths (10%). After a follow-up ranging from 6 months to 11 years, all survivors are in a satisfying functional condition. We think that a wide unrestricting atriopulmonary anastomosis is mainly responsible for those good functional results. Age at operation has not influenced the results. Previous and long standing shunts may be responsible for immediate and late postoperate cardiac failure. Consequently, we now prefer an earlier corrective procedure, particularly when the patient has a patent systemic pulmonary shunt.

[Open-heart valvular surgery in children. Apropos of 127 cases]. / La chirurgie valvulaire à coeur ouvert chez l'enfant. A propos de 127 cas.

In view of the frequency and the severity of rheumatic heart disease (RHD) and of endomyocardial fibrosis (EMF) in the african child, the indication of a valvular surgical procedure is frequent in Abidjan. Between 1978 and 1983, 127 open-heart procedures have been performed in 113 patients. The ages ranged from 2 to 15 years, with a mean of 11 years. There were 67 RHD, 37 EMF, 9 bacterial endocarditis. The status of the patients was severe, there was a cardiomegaly (mean CTR of 0.70). 3 patients were in atrial fibrillation. The patients underwent 97 valve replacements (70 mitral, 18 tricuspid, 9 aortic) essentially by a bioprosthesis (n : 87). A mitral valvuloplasty was done in 27 cases. Associate procedures have been employed including : 35 endocardectomies, 11 aortic valvuloplasties, 6 tricuspid annuloplasties. 12 patients have been reoperated for bacterial endocarditis of a mitral prosthesis (n : 4), calcification of a mitral bioprosthesis (n : 5), failure of mitral valvuloplasty (n : 3). There were 13 deaths (10.2 p. 100 mostly in EMF surgery : 7 deaths (5.5 p. 100). No patient with a bioprosthesis received anticoagulants post-operatively. All surviving patients have been improved, with a mean post-operative follow-up of 32 months. There were 11 late deaths (8.6 p. 100). The authors discuss several points including : severity of children valvular diseases in tropical areas; necessity to use the bioprosthesis in this area of the world; increasing tendency to conservative surgery in the mitral and also the aortic position.