[From Hippocrates to Harvey: twenty centuries of research on circulation]. / D'Hippocrate à Harvey: vingt siècles d'histoire de la circulation.

The concept of blood circulation was difficult to emerge. By assessing the non-religious cause of any disease, Hippocrates allowed future studies and observations to elucidate the concept of blood circulation. Alexandria's school erroneously described the roles of respiration and air transfer up to the viscera. "Arteries are filled with air". Galen demonstrated the absence of air in arteries, but sticked to the opinion of two forms of blood: "spirituous" from the left and "trivial" from the right. The Galenic system implied the presence of anatomic communications between the trivial (right) and spirituous (left) hearts. Genuine Galen's works were lost for the two thirds, but one third was transmitted to the Middle Age and Renaissance by hispano-arabic physicians. Moreover, one of them criticized the Galenic views about transfer of blood from the right to the left via intracardiac holes. The presence of these Galenic cardiac holes could not be visualized by Vesalius, while Servet stressed the crucial role of the lung for the right-left transfer. It was Harvey's achievement to make the synthesis of the real nature of blood continuously circulating from right to left and from left to right via the lungs thanks to the propelling function of the cardiac muscle and without any action of arteries.

[Cardiac metastasis from malignant melanoma]. / Métastase cardiaque d'un mélanome.

The authors describe a case of cardiac metastasis associated with a malignant melanoma, which was removed in its totality. Malignant melanoma is a tumour which metastases frequently at the cardiac level. The mechanism of implantation and the symptomatology of this metastatic localisation are discussed.

Bilateral humeral artery aneurysm as a cause of digital ischaemia.

Bilateral humeral artery aneurysm is a very rare condition. Simultaneous bilateral complication of these aneurysms makes it even more unusual. We present a case of a 44-year-old man with bilateral digital ischaemia as a complication of a bilateral humeral artery aneurysm. Anamnestic, clinical and per-operative findings led to several hypotheses. A venous bypass graft was done to exclude both aneurysms and to arrest the embolisation into the digital arteries.

Extended transsternal thymectomy for myasthenia gravis: a report of 19 consecutive cases.

BACKGROUND: Thymectomy is considered as an effective therapeutic option for patients with myasthenia gravis (MG). This study reports the experience of our centre's investigation into the efficacy and the safety of the procedure and the influence of different pre-operative factors on the surgical outcome. METHODS: A retrospective chart review/interview was made of 19 consecutive patients who underwent extended transsternal thymectomy for MG from 1992 to 2003. The severity of the disease was determined according to the Osserman Classification. Efficacy was measured by determining the change in clinical status, the rate of remission during follow-up, and the reduction in medication requirements after thymectomy. Complete remission (CR) was defined as asymptomatic off medication for 6 months. The CR rate was calculated using the Kaplan-Meyer method. RESULTS: The mean age of the patients at surgery was 34 years (range, 9-63) and 78.9% were female. Mean length of follow up was 86 months (range, 24-163). The overall complication rate was 10.6% (1 episode of atrial fibrillation and a left recurrent laryngeal nerve palsy that resolved after the first postoperative month). There was no operative mortality. The mean hospital stay was 9.4 days (range, 5-23). The crude CR rate was 32% (n = 6). The Kaplan-Meier estimate of CR was 42% at 6 years. Age, gender, duration of symptoms, thymic histology, Osserman stage and the presence of thymoma were not identified as prognostic variables. The average daily dose of Medrol and Mestinon decreased significantly between the pre-operative period and the last follow-up (Medrol, p = 0.0081; Mestinon, p = 0.0013). CONCLUSIONS: Transsternal thymectomy for MG is safe and effective. It benefits patients with MG at all stages. Patients with thymoma are not associated with poorer remission rates. Complete responses are durable, as the CR rate remains stable over time.

Open surgery for abdominal aortic aneurysm or aorto-iliac occlusive disease--clinical and ultrasonographic long-term results.

OBJECTIVE: To determine postoperative and long-term outcome and assess the relevance of abdominal ultrasound (US) after surgery for abdominal aortic aneurysm (AAA) or aortoiliac occlusive disease (AIOD). METHODS: Records of 1704 consecutive patients having graft implantation from 1988 to 2000, either for AAA (n = 1144) or for AIOD (n = 560), were reviewed. In 2006, follow-up was 9180 patients-years for the AAA group and 5450 patients-years for the AIOD group. Among 1006 alive patients, 377 were invited randomly for US and clinical examination. RESULTS: Hospital death occurred in 99 patients (8.6%) of the AAA group (53% in ruptured and 2% in elective AAA), and in 18 patients of the AIOD group (3.2%). There were 581 late deaths, including eight due to prosthesis infection, one to pseudo-aneurysm rupture, and one to graft thrombosis (0.6% graft-related mortality). Prosthesis thrombosis occurred in 32 patients (26 in AIOD group, p < 0.001), and graft infection in 26 (17 in AAA group, p < 0.01). Pseudoaneurysms developed in 90 patients (68 in AIOD group, p < 0.001), including eight at the proximal aortic, one at the distal aortic, two at the iliac and 79 at the femoral anastomosis. In the AAA group only, surgery was required for a new thoraco-abdominal and pararenal aneurysm in eight and four patients, respectively, while US evidenced a 26-35 and a 36-50 mm supraanastomotic aortic dilatation in 65 (32%) and in 14 (7%) patients, at a mean follow-up of 10.5 and 9.3 years, respectively. CONCLUSION: Long-term results are good after open surgery for AAA or AIOD. Prosthesis infection and anastomotic pseudo-aneurysm are the main causes of graft-related mortality and morbidity, respectively. Because of high incidence of asymptomatic supraanastomotic aortic dilatation, all patients with a history of AAA repair should have regular abdominal US.

[Aortic pseudo-aneurysm after coarctation repair]. / Pseudo-anévrysme de l'isthme aortique après correction chirurgicale de la coarctation aortique.

Aortic pseudo-aneurysm is a well-known late complication after surgical repair of aortic coarctation. We report two cases of pseudo-aneurysm of the aortic isthmus evidenced after previous surgical repair of congenital aortic coarctation. These clinical observations give us the opportunity to underline the importance of a specific lifelong medical follow-up for patients who have undergone such surgery.

[Myxomatous mitral valve degeneration: biochemical aspects and physiopathological considerations]. / L'insuffisance mitrale par dégénerescence myxoïde: aspect biochimique et considérations physiopathologiques.

Mitral valve is a complex structure which is submitted to repeated mechanical constraints. In clinical practice, an increasing incidence of mitral insufficiency resulting from myxomatous degeneration is observed. Since myxomatous degeneration is also observed in defined genetic diseases of connective tissues, we propose the hypothesis that idiopathic mitral insufficiency might result from a minor alteration of the interstitial valvular cells and/or their interactions with their support. After a brief review of the role of the extracellular matrix in the heart, some histopathological and biochemical aspects of myxomatous degeneration are presented. Our data and those of the literature will be summarized and a physiopathological hypothesis proposed for myxomatous mitral valve degeneration.

Catamenial pneumothorax: a case report and review of the literature.

Catamenial pneumothorax is a rare condition that is often misdiagnosed. It is defined as spontaneous pneumothorax occuring within 72 hours before or after onset of menstruation. Etiology is unknown but could be linked to endometriosis. Treatment is medicosurgical: thoracoscopy for pleural abrasion and hormonotherapy to avoid recurrence.

Description and evaluation of a simplified technique for replacement of the ascending aorta and proximal arch in degenerative aneurysmal disease.

The distal extension of ascending aorta pathology often requires prosthetic grafting into the proximal arch. In order to perform optimal distal anastomosis, an open technique under a short period of circulatory arrest (CA) was adopted. For this purpose we evaluated prospectively a simplified technique for surgery and perfusion. The aneurysmal aorta was directly cannulated to cool down the patient to 26 degrees C. Under CA and retrograde cerebral perfusion, the diseased aorta and aortic cannulation site were resected. After completion of the distal anastomosis, antegrade rewarming was performed via recannulation of the AAo graft (side branch graft) whilst surgery was proceeded on the root and/or aortic valve. This technique clearly addresses the safety of cannulation into the aneurismal aorta. The issues of cerebral and visceral protection during CA and antegrade reperfusion and rewarming have been analysed prospectively in eight patients operated on over a period of 6 months. Our preliminary results indicate that this technique of arterial cannulation and CA at 26 degrees C for the management of degenerative AAo disease involving the proximal arch appears safe both in terms of cerebral and systemic (visceral, muscular) protection. By this way, the complications related to deep hypothermia and prolonged cardiopulmonary bypass are avoided. This assumption may be only valid for a CA period less than 30 min. This preliminary study is limited by its small size and heterogeneity of the pathologies. However, the simplicity, surgical ease, rapidity and efficacy conveyed by this technique warrant further consideration and evaluation.

[Recent advances in cardiac and vascular surgery]. / Acquisitions récentes en chirurgie cardiaque et vasculaire.

Significant advances in cardiac surgery include hypothermic circulatory arrest for complex aortic surgery, stentless valve for aortic valvulopathies, conservative treatment of the insufficient aortic valve, surgical interruption of the electrical circuits involved in atrial fibrillation and new extra-corporeal circuits (SMA) to decrease inflammatory systemic reactions, and for, the same reason, heart beating coronary surgery. Advances in vascular surgery include aortic endoprosthesis, coeliscopic aortic surgery and less invasive superficial veins surgery.

[Strategies to shorten the time from urgent admission to coronary angioplasty: a recent publication in the New England Journal of Medicine]. / Strategies visant à diminuer le délai entre l'admission aux urgences et l'angioplastie coronaire: à propos d'un article rècent du New England Journal of Medicine.

A recent publication in New England Journal of Medicine stresses the fact that the mere presence of a coronarography equipment to dilate acute myocardial infarction is not sufficient to obtain the opening of the related myocardial infarction artery in due time.

[New therapeutic guidelines in lower limb arteriopathy]. / Actualités thérapeutiques à propos de l'artériopathie des membres inférieurs.

This article describes the recent therapeutic options for lower limb arteriopathy and, as much as possible, analyzes the medical and surgical treatments according to the recommendations and levels of evidence.

[The ostium primum or partial atrioventricular septal defect]. / La CIA, de type ostium primum ou canal atrio-ventriculaire partiel.

Often assimilated to simple inter-atrial communication, the ostium primum, or partial atrio-ventricular septal defect, is an entity that is characterized by a different embryological mechanism and requires some specific surgical expertise. Basically, knowledge of the morphology of the common atrioventricular valve with 5 components, the topography of the A-V node and His bundle, and the ventricular consequences of the absence of atrio-ventricular septal structures must be taken into account.

[Clinical case of the month. Constrictive pericarditis with a macroscopically normal pericardium: apropos of a case]. / Le cas clinique du mois. Péricardite constrictive à péricarde macroscopiquement normal: à propos d'un cas.

The diagnosis of constrictive pericarditis is not easy to make. This rare condition can be suggested by clinical, echocardiograohic, hemodynamic, and radiological signs. It must be distinguished from restrictive cardiomyopathy as therapeutic options are radically different. We present an ambiguous case of constrictive pericarditis with macroscopically normal pericardium recognized 10 years after open-chest cardiac surgery: a large pericardiectomy rapidly induced clinical improvement.

[Rupture of a giant external iliac aneurysm six years after an aorto-bifemoral bypass]. / Rupture d'un anévrysme iliaque externe six ans après un bypass aorto-bifémoral.

We report the case of a patient operated on for an aorto-iliac aneurysm with an aorto-bifemoral bypass who presented a metachronous iliac aneurysm rupture, six years later, because of aneurysmal degeneration. We performed bipolar ligation of the external iliac artery and an end-to-end anastomosis of the prosthetic limb to the common femoral artery. We discuss aneurysms of the external iliac artery, characterised by their rarity, their specific morbidity and mortality.

Abdominal aortic aneurysm.

Abdominal aortic aneurysms cause 1.3% of all deaths among men aged 65-85 years in developed countries. These aneurysms are typically asymptomatic until the catastrophic event of rupture. Repair of large or symptomatic aneurysms by open surgery or endovascular repair is recommended, whereas repair of small abdominal aortic aneurysms does not provide a significant benefit. Abdominal aortic aneurysm is linked to the degradation of the elastic media of the atheromatous aorta. An inflammatory cell infiltrate, neovascularisation, and production and activation of various proteases and cytokines contribute to the development of this disorder, although the underlying mechanisms are unknown. In this Seminar, we aim to provide an updated review of the pathophysiology, current and new diagnostic procedures, assessment, and treatment of abdominal aortic aneurysm to provide family practitioners with a working knowledge of this disorder.

Lessons learnt from carotid artery trials.

The objective of the authors is to assess the natural history of carotid artery disease and the role of carotid intervention in preventing ipsilateral stroke. The development of endovascular techniques for correction of carotid artery stenoses made this less invasive technique very popular, with an inherent risk of unregulated overuse by a variety of medical specialists, who are not always well informed on the natural history of carotid artery disease. It re-opened the discussion on the value of carotid endarterectomy for stroke prophylaxis. This ongoing debate offers the opportunity to distil evidence-based guidelines for the management of extracranial carotid artery stenoses. In recent papers, some authors expressed doubts on the validity and general applicability of the results of the pivotal randomised trials of carotid endarterectomy. The excellent results in terms of operative outcome and long term stroke prevention would, according to certain comments, not be attainable in routine practice. Another criticism of carotid endarterectomy is its higher operative morbidity in terms of cranial nerve lesions and myocardial infarctions, compared to endovascular procedures. This consideration is, for some authors, the main reason to espouse carotid artery stenting as a better alternative to carotid endarterectomy. Any evidence supporting this point of view is missing. The supposed equivalence or non-inferiority of carotid artery stenting is purely speculative. The aim of this review paper is to summarize the crude data of carotid surgery trials. The authors aim to answer four questions. For which lesions is carotid endarterectomy most beneficial ? Are the results of randomised carotid surgery trials biased by the selection of patients ? Is operative morbidity, other than stroke, under-estimated ? Is carotid artery stenting safe and efficacious ? An in-depth review with a critical analysis is made of recently published and on-going trials, comparing carotid surgery with percutaneous carotid angioplasty.

Surgical treatment of thoraco-abdominal and low thoracic aneurysms of the aorta. One single center experience over ten years.

This work presents the results of surgery in thoraco-abdominal aortic aneurysms (TAA) and thoracic descending aortic aneurysms (TDA) in one single center between January 1rst, 1996 and December 31, 2005. It concerns open surgery in 42 and endovascular procedures in ten patients. Forty two patients (11 TDA and 31 TAA (4 type I, 12 type II , 6 type III and 9 type IV)) define the open surgery series. Twenty six patients were operated on elective basis and 16 patients in emergency condition. Surgical correction was made under partial cardio-pulmonary bypass (PCPB) in 70% of cases via femoral vessels; most significant intercostal arteries were reimplanted and cerebro-spinal fluid (CSF) drainage used in half of the cases. Operative mortality was zero in the elective group (0/26) and attained 19% in the emergent group (3/16). Mortality was linked to cerebrovascular accidents (CVA) in two cases and post-pump left lung hemorrhagic infarction in one case. The paraplegia accounts 2/26 in the elective group and one in the emergent group (1/16). That is 7.1% in both groups. At the end of five years, survival is 66% in elective group and 74% in the emergency group. Ten patients (5 TDA and 5 TAA (2 type I, 3 type III)) were treated endovascularly. Operative mortality and postoperative paraplegia were nil.

Intra-arterial thrombolysis of thrombosed popliteal artery aneurysm. A series of six cases.

AIM OF THE STUDY: To evaluate the role of perioperative, catheter-guided fibrinolysis in the management of thrombosed popliteal artery aneurysms. MATERIAL: From 1990 to 2005, six patients suffering subacute limb ischemia, secondary to thrombosis of a popliteal artery aneurysm, benefited selective intra-arterial fibrinolysis, followed by subsequent aneurysm exclusion and bypass grafting. This represents ten percent of all popliteal aneurysms operated on in that time period and 28% of all thrombosed popliteal artery aneurysms. RESULTS: The lytic procedure was successful in all cases, restituting patency in two (n = 3), one (n = 2) or all (n = 1) crural arteries. The venous bypass graft remained patent in all but one patient. In one patient, the graft occluded at 10 months without limb loss. This outcome compares more favorable than the result obtained with emergent surgery alone for thrombosed popliteal artery aneurysms with profound limb ischemia (eight patients, of whom one required amputation at day 5 and one lost his limb at nine months following graft thrombosis). CONCLUSION: Preoperative intra-arterial lytic therapy, in the setting of subacute limb ischemia caused by thrombosis of a popliteal artery aneurysm, can be considered as safe and effective.

[The beginnings of cardiac surgery]. / Abregé des débuts de la chirurgie cardiaque. Conférence prononcée le 6 mai 2006, a l'occasion du 30 eme anniversaire de la chirurgie cardiaque a Liège.

Beginnings of cardiac surgery were primarily pericardiac surgery: persisting ductus ligation (Gross), coarctation repair (Crafoord) and Blalock's seminal operation of arterio-pulmonary shunt. The first really open cardiac procedure is due to Gibbon who worked up an apparatus capable to assume heart and lungs function. In the same time, Lillehei operated on congenital cardiac lesions in children with the concept of "cross-circulation". For a long time confined in Minneapolis and Rochester, cardiac surgery spread all over USA. Starr lead the valvular surgery with the use of caged ball prosthesis (Starr-Edwards); Effler and Favaloro developed coronary surgery; outside USA, the Russian Kolessov used for the first time an internal mammary artery. As far as cardiac transplantation is concerned, a debt is due to Hardy, but the merit of the-first successful cardiac transplantation goes to South-African Barnard.