[Clinical case of the month. Spontaneous pneumopericardium after sternal dehiscence]. / Pneumopéricarde dans les suites d'une déhiscence de sternum.

We report a case of pneumopericardium occuring after cardiac surgery. Pneumopericardium is a rare condition; trauma is the most frequent etiology. Nontraumatic causes include fistulae in relationship with the bronchial tree or oesophagus and intrapericardial gazeous production due to bacterial pericarditis. Pericardiocentesis is indicated in case of air tamponade and local infection.

Usefulness of thromboendarterectomy in association with coronary artery bypass grafting.

Thromboendarterectomy is sometimes performed in association with coronary artery bypass graft surgery (CABG). Right coronary arteries and severely narrowed coronary arteries mainly undergo thromboendarterectomy, but perioperative acute myocardial infarctions (AMI) are possible complications. One hundred seventy-six consecutive patients with rest and stress thallium-201 scintigraphy and angiography were studied before and after surgery. To compare patients with and without thromboendarterectomy, 48 patients who had undergone thromboendarterectomy and whose characteristics matched closely those of patients who had not were selected. Twenty patients had previous AMI before CABG in each group. Analysis accounted for the severity of vessel lesion (complete or incomplete) and for the patency of the graft and of the native coronary artery. In these 96 patients, graft patency was lower than in the overall group and similar among patients with and without thromboendarterectomy among the 56 patients without previous AMI. In patients with previous AMI and thromboendarterectomy, however, reperfusion was achieved more often through the native vessel than through the graft. New AMI or residual ischemia occurred in 32% of the areas undergoing thromboendarterectomy and in only 5% of the standard grafts (p less than 0.001). Best results were obtained in patients with incomplete occlusion after AMI. Patients without previous AMI had worse results. Thus, thromboendarterectomy can yield 64 to 75% good results in selected subgroups when CABG is otherwise impossible, but should be avoided in mildly or moderately stenotic arteries perfusing noninfarcted myocardium.

Coronary artery reoperations.

From June 1976 to June 1989, 138 previously revascularized coronary patients were reoperated upon. This represents 3.28% of all aortocoronary bypass procedures performed during the same period in our institution. Characteristics of this group, risk factors, coronarographic data, perioperative morbidity and mortality are analyzed and compared to the data of the general population undergoing bypass surgery. The mean age of individuals requiring reoperation was 59 years. The mean interval between the two operations reached 73 months (5 to 180 months). Angiographic lesions were more extensive with three-vessel disease in 65% of the reoperated patients. The mean ejection fraction was 55%. A mean of 2.1 bypass grafts per patient were inserted with 60% of cases having an internal mammary artery graft. Perioperative infarction occurred in 8.0% of the reoperations and an intraaortic balloon counterpulsation was necessary in 4.3% at the end of the procedure. Operative mortality was 5%. Symptomatic improvement was obtained in 85% of the cases. In recent years, cardiac transplantation has been performed for 11 previously bypassed patients with severely impaired ventricular function. There were no postoperative deaths. Cardiac transplantation can be considered as a more valuable alternative to repeat coronary artery bypass grafting in such cases.

[Aortic media necrosis in Marfan's disease in young adults. Apropos of 5 surgically treated cases, with 3 survivals]. / Médianécrose aortique dans la maladie de Marfan chez l'adulte jeune. A propos de 5 cas opérés, avec 3 survies.

Five cases of Marfan's syndrome with cardiovascular lesions are presented. Among these five patients, two with type I aortic dissection, one with true aneurysm of the ascending aorta and one with aortic regurgitation underwent composite grafting of the ascending aorta according to the Bentall technique. The fifth patient died preoperatively, due to extensive dissection of the transverse aorta. Marfan's syndrome is transmitted in an autosomal dominant manner. Fifty percent of the patients die at a mean age of 32 years, and 95 p. 100 of the deaths are caused by cardiovascular lesions. These lesions predominantly affect the left cardiac valves (aortic or mitral regurgitation) and the ascending aorta. Except in emergencies, replacement of the ascending aorta by a composite graft must be envisaged in subjects with Marfan's syndrome presenting with aortic regurgitation and dilatation of the aortic root.

[The treatment of aorto-enteric fistulas. Remark apropos of 2 case reports]. / Le traitement des fistules aorto-digestives. Note à propos de deux observations.

Aorto-enteric fistulas: about two cases. In this paper, on the occurrence of two new cases records, we resume the current data of the publications about aorto-enteric fistulas. We emphasize the symptomatology inasmuch the diagnostic approaches of primary and secondary aorto-enteric fistulas. The different ways of the operative treatment are discussed. The conclusion is extra-anatomic bypass associated with graft excision is currently the best therapeutic choice in case of secondary fistulas. About primary fistulas, the treatment is still controversial immediately by extra-anatomic bypass or arterial graft in situ and closure of the digestive fistula.

[Simultaneous coronary and carotid surgery: apropos of 73 cases]. / Chirurgie coronarienne et carotidienne en simultané: à propos de 73 cas.

A series of 73 simultaneous carotid and coronary revascularizations (Group I) is presented (January 1980-December 1988). Age, sex, risk factors, severity of angina, coronarography, neurological symptoms, angiographic carotid lesions and operative outcome of these 73 patients are compared with the aspects of 3544 coronary bypass patients (Group II) and 1001 carotid endarterectomized patients (Group III) during the same period. The angina in Group I is more severe, with 22% belonging to NYHA class IV and 26% having a stenosis of the left main coronary artery, vs 14% and 13% in Group II. Seventy percent of the carotid lesions in Group I are asymptomatic vs 33% in Group III. Group I patients had more problems in the perioperative period, with 16.4% needing prolonged high-doses analeptics and 5.4% intraaortic counterpulsation balloon. Operative mortality is higher (7%) in Group I compared with Group II (2.3%) and Group III (1.7%). These results permit to define a population of polyvascular patients with concomitant coronary and carotid disease, characterized by a more diffuse atherosclerosis and a higher operative risk. Operative morbidity and mortality after combined myocardial and cerebral revascularization remains nevertheless inferior to the cumulated surgical risk of the sequential procedures (74 patients with coexistant coronary and carotid lesions operated in two sessions before 1986).

[Reoperation for aortocoronary bypass]. / Les réopérations pour pontages aorto-coronaires.

Iterative aorto-coronary bypass. From 1978 to 1988, 106 previously revascularized coronary patients were reoperated. This represents 3.01% of all aorta-coronary bypass procedures performed in the same period. Characteristics of this group, risk factors, coronary anatomical data, perioperative morbidity and mortality are analyzed and compared to the data of primary revascularization. The progression of atherosclerotic disease, with an annual 2% attrition rate of bypass grafts after the first year, is evidenced by this study. The success rate of coronary reoperations approaches the results of primary bypass surgery. The causes of recurrent angina and graft failure are discussed. The mean age of individuals requiring reoperation is 58.5 years. The mean interval between the two operations reaches 66 months (5 to 168 months). Angiographic lesions are more extensive, with a three vessel disease in 75% of the reoperated patients and an ejection fraction lowered at 55%. A mean of 2.7 bypass grafts per patient is realized, with in 60% of cases an internal mammary artery graft. Perioperative infarction occurs in 10.5% of the reoperations and in 4.5%, an intraaortic counterpulsation balloon is necessary at the end of the procedure. Symptomatic improvement is obtained in 85% of cases. Operative mortality is 5.7%. These findings suggest that coronary reoperation can be accomplished with low morbidity, low mortality and a therapeutic benefit in the majority of cases. In recent years, cardiac transplantation has been considered for some patients with impaired ventricular function. This procedure is only limited by the insufficient number of donors.

Nicardipine protocol for CABG using the radial artery clinical and angiographic data.

The routine use of arterial grafts in coronary surgery is facilitated by peroperative adjunction of antispasmodic drug to reduce the event of spasm. Diltiazem has been favoured in most clinical studies devoted to the radial artery graft. The aim of this study was to assess the efficacy of a spasm preventing protocol associating hydrostatic dilation of the graft with a diluted solution of papaverine and nicardipine infusion, starting preoperatively and continued postoperatively in i.v. and per os forms. Between September 1996 and March 1997, a consecutive series of 50 patients underwent myocardial revascularization using the radial artery. The radial artery was prepared by hydrostatic dilation with papaverine (1%) and nicardipine was administrated at 0.25 microgram/kg/min and titrated according to the arterial systemic pressure. Operative mortality was 4% (sepsis). There was no evidence of perioperative MI nor hypoperfusion syndrome. Mean CKMB level at 18 hours was 36 micrograms/l. No ischaemic anomalies of the ECG were detected. Angiography performed in the last 20 patients showed a 98% (51/52) permeability rate for all graft; 19/20 radial grafts (95%) were patent. One radial graft presented a 50% stenosis at the proximal anastomosis, and another a moderate spasm (40%) in the middle part of the conduit. This study confirms that the radial artery conduit can be used with satisfactory results for routine coronary artery bypass. The use of nicardipine allows the control the vasoreactivity of the radial graft without totally obviating at least angiographic spasm. This drug is easy to titrate, and well tolerated in association to beta-blockers in the routine perioperative management of the coronary patients.

[Minimal cardiac surgery]. / Chirurgie cardiaque a minima.

In general surgery, the aim of new techniques is to reduce the length of the skin incisions and/or to use endoscopic or laparoscopic instruments. The cardiac surgery makes not an exception. During the last two years, the material and the techniques are following a progressive evolution. Concerning the cardiac surgery of the adult, three techniques which are the mini-incision or thoracotomy and the surgery of the port-access are in full evolution. We describe the advantages and disadvantages.

[Early diagnosis of coarctation of the aorta in children: a challenge]. / Le diagnostic précoce de la coarctation de l'aorte chez l'enfant: un défi.

Coarctation of the aorta presents with characteristic and distinctive physical findings. Because delayed detection of severe forms may be fatal and late detection of classic forms is associated with premature cardiovascular disease in adult life, early detection and treatment is important. However, in our survey a few patients in whom aortic coarctation was ultimately diagnosed had the correct diagnosis made by the referring physician. Our survey suggests that an incomplete physical examination explains the diagnostic failure. This survey reaffirms the need for palpation of pulses and proper measurement of blood pressure in all infants and children to facilitate early recognition of coarctation.

[Place of the Ross procedure (pulmonary autograft) in aortic valve surgery]. / La place de l'intervention de Ross (autogreffe pulmonaire) dans la chirurgie de la valve aortique.

The pulmonary autograft operation consists of an aortic replacement using the autologous pulmonary valve. The pulmonary valve is substituted by a cryopreserved pulmonary homograft. This operation is in fact a delicate double valve replacement whose benefits are linked to the viability of the new aortic substitute. The pulmonary autograft has superb hemodynamic features and very low thrombogenicity. The report of a selected observation offers the occasion of defining the current indications of this operation in aortic valve surgery.

[Clinical case of the month. Subvalvular aortic stenosis]. / Le cas clinique du mois. Membrane sous-valvulaire aortique.

A case of fixed subvalvular aortic stenosis is reported. This clinical observation is the occasion to review the pathophysiology of this lesion and the last developments in the surgical treatment.

[Clinical case of the month. Complete replacement of the ascending aorta and aortic arch in a case of chronic aortic dissection]. / Le cas clinique du mois. Remplacement complet de l'aorte ascendante et de la crosse aortique dans un cas de dissection aortique chronique.

We report the case of a patient who developed an evolutive chronic aortic dissection after ascending aorta replacement for acute type A aortic dissection. Owing to the development of severe aortic regurgitation, aortic root pseudoaneurysm and aneurysmal dilatation of the arch and descending aorta, reoperation was adviced. Reoperation included Cabrol modification of the Bentall operation and aortic arch replacement with elephant trunk performed under deep hypothermic circulatory arrest. The incidence of late aneurysmal formation in type 1 aortic dissection has been reported to be 30%. Close postoperative follow-up of the aortic diameter is necessary to detect a critical dilatation and to permit elective reoperation.

[Coronary revascularization of the beating heart using complete arterial grafts]. / Revascularisation coronaire à coeur battant par pontages exclusivement artériels.

A case of complete arterial revascularization using both mammary arteries and the left radial artery is reported. The operation was done on the beating heart with the adjunct of a Y graft owing to a severely calcified ascending aorta. This observation is the occasion to review the basic principles of beating heart surgery.

[Shone's syndrome: report of four cases and review of the literature]. / Le syndrome de Shone: présentation de quatre cas et revue de la littérature.

The observation of four clinical cases of Shone's complex, two of them presenting first with predominant coarctation of the aorta, prompted us to review the pertinent literature. Patients with multiobstructive lesions of the left heart, including Shone's complex, represent a surgical challenge where the adequate management of mitral valve anomalies, subaortic stenosis, and coarctation constitutes the key prognostic factor for satisfactory mid-term outcome.

[Congenital abnormalities of the vessels of the base of the heart: "ring" and "sling" vascular abnormalities. Case report]. / Les anomalies congénitales des vaisseaux de la base du coeur: "ring" et "sling" vasculaires. A propos d'un cas.

We present a case of double aortic arch corrected by surgical interruption and full mobilization of the trachea and the esophagus. The vascular malformations of the supraaortic trunks, which form more or less complete vascular rings encircling the esophagus and the trachea, are reviewed. The different presentations of double aortic arch, aberrant subclavian arteries, and abnormal development of the pulmonary arteries are discussed.

[Extensions of mitral valve repair techniques: surgery for endocarditis and valvular tumors]. / Extensions des techniques de réparation valvulaire mitrale: chirurgie de l'endocardite et des tumeurs valvulaires.

Mitral valve repair has demonstrated its superiority over valve replacement. Mitral valve repair constitutes the optimal therapeutic option in case of degenerative dystrophic, rheumatic, congenital or ischemic mitral valve disease. These surgical techniques can also be successfully and advantageously applied in case of bacterial endocarditis or tumoral valvular disease. We report a case of staphylococcal endocarditis and another case of posterior leaflet fibroelastoma to show the place of conservative mitral surgery in these unusual indications.

[Medico-surgical management of childhood cardiopathy: results of the Liège experience]. / Prise en charge médico-chirurgicale des enfants cardiopathes: résultats de l'expérience liégeoise.

OBJECTIVE: Evaluation of the results obtained in the management of congenital heart diseases in Liège. MATERIAL AND METHODS: We evaluated the results, the mortality and the morbidity of diagnostic and interventional cardiac catheterization, and of the cardiac surgery in the 123 cardiac children who were referred to us during the three first years of operation of our medico-surgical team. RESULTS: 89 children underwent a catheterization, including 12 therapeutic interventions, whereas 68 were operated. In the two domains, the results are completely comparable with those of the established centers. CONCLUSIONS: The widening of the activity of paediatric cardiology and the creation of an activity of pediatric cardiac surgery in Liège appeared important to us for the quality of management of the cardiac children. This goal could be reached only if our results were comparable with those of the literature. The bet seems to be held. The ultimate objective is to contribute by an adequate policy of management to the quality of life and the health of the cardiac children.