Aortic valve repair by cusp extension with the use of fresh autologous pericardium in children with rheumatic aortic insufficiency.

OBJECTIVES: Our goal was to evaluate the midterm results of aortic valve repair by a more sophisticated tailoring of cusp extension-taking into account the dimensions of the native aortic cusps-with the use of fresh autologous pericardium. PATIENTS AND METHODS: Forty-one children who had severe rheumatic aortic insufficiency (mean age 11.5 +/- 2.7 years) underwent aortic valve repair by means of this cusp extension technique over a 5-year period. Twenty-four of them underwent concomitant mitral valve repair for associated rheumatic mitral valve disease. All children were then followed up by transthoracic echocardiography before discharge, at 3 and 6 months after the operation, and at yearly intervals thereafter. RESULTS: Follow-up was complete in all patients and ranged from 3 months to 5 years (median 3 years). No operative and no early postoperative deaths occurred. Only 1 patient died, 9 months after the operation, of septicemia and multiple organ failure. Actuarial survival was 97% at 1 year and has remained unchanged at 3 years. On discharge, the degree of aortic insufficiency was grade 0 for 27 children and grade I for 14. Exacerbation of aortic insufficiency from grade I to grade II was observed in only 1 patient, and none of the children required reoperation for aortic insufficiency during the follow-up period. Mean peak systolic aortic valve gradients at discharge were lower than preoperative values (P =.04), and no significant increase in the peak systolic transvalvular gradient was detected thereafter during the follow-up period. Mean left ventricular dimensions were significantly reduced at discharge when compared with preoperative values (P <.0001). CONCLUSIONS: Functional results of aortic valve repair with cusp extension using fresh pericardium have been satisfactory at medium term, particularly in children with a small aortic anulus at the time of initial repair, because the expansion potential of fresh autologous pericardium is equivalent to that of the growing sinotubular junction and aortic anulus diameters.

Tricuspid valve repair by septal of posterior leaflet transposition.

We report 2 patients who presented extensive rupture of chordae tendineae caused by blunt thoracic trauma leading to flail anterior leaflet of tricuspid valve. Transposing a segment of septal leaflet in 1 patient and the posterior leaflet in the other patient onto the flail anterior leaflet's margin abolished massive tricuspid regurgitation. Fifteen and 33 months postoperatively the patients are in good clinical condition and the echocardiographic controls show a competent tricuspid valve.

Conversion from routine CPB to centrifugal mechanical assist by transaortic inflow cannulation of the left ventricle.

We describe a technique of conversion from cardiopulmonary bypass to centrifugal mechanical assist that consists of using the existing aortic cannula for outflow and inserting a cannula into the left ventricle through a Dacron tube and across the aortic valve for inflow.

Ascending aortic aneurysm associated with aortic insufficiency due to Takayasu's arteritis.

We report the case of a child with an ascending aortic aneurysm associated with aortic insufficiency. Histopathological examination of the ascending aorta and aortic valve showed findings in favor of Takayasu's arteritis, and subsequent evaluation of the entire aorta demonstrated the presence of multiple steno-occlusive lesions. This unusual clinical problem in the young population is discussed with regard to other eventual pathologies that should be taken into account in the differential diagnosis.

Right gastroepiploic artery used as a pedicled graft in a retrograde fashion.

The right gastroepiploic artery is currently regarded as a most valuable arterial conduit for myocardial revascularization. We have documented a particular case wherein the proximal (pyloric) part of the right gastroepiploic artery could not be freed and was damaged because of previous cholecystectomy. The pedicle was divided at the pyloric side and raised up to be anastomosed to the posterior descending artery in a retrograde fashion. The purpose of this report is to emphasize the fact that a previous abdominal operation does not necessarily hamper the use of the gastroepiploic artery as a pedicled graft. It is also pointed out that retrograde flow in the pedicle was sufficient in this case to provide good revascularization.

[Severe mitral insufficiency with ejection fraction below 40%: cardiac surgery is still indicated]. / L'insuffisance mitrale sévère avec fraction d'éjection inférieure à 40%: la chirurgie cardiaque est encore indiquée.

Mitral insufficiency with an ejection fraction < 40% derives varying benefit from surgery according to its etiology: ischemic, degenerative or post-endocarditis. The impairment of the ejection fraction is also a determining factor. Analysis of a series of 26 cases confirms these findings.

Floating thrombus in the ascending aorta: a rare cause of peripheral emboli.

The ascending aorta may be the site of origin of systemic embolization in some cases that do not have an identifiable source. We report a case in which a free-floating thrombus in the noncoronary sinus of Valsalva was detected by transesophageal echocardiography as a source of left axillary artery embolism. After removal of this pedunculated thrombus of unknown cause, which was attached on a macroscopically and histologically normal aortic wall, the patient made an uneventful recovery.

Hypoplasia of the posterior leaflet as a rare cause of congenital mitral insufficiency.

A rare case of congenital mitral insufficiency characterized by the hypoplasia of the posterior leaflet is reported. At operation, the mitral valve was successfully repaired by a ring annuloplasty, which created a satisfactory surface of coaptation between the anterior leaflet and the bulky posterior muscular structure. The presence of this posterior muscular structure represents a developmental arrest at the stage of conversion from muscular chordae and leaflets to thin connective structures.