[Long term survival with the Bentall button operation in 150 patients]. / Suivi à long terme de l'opération de Bentall avec collerettes sur 150 patients.

Between May 1980 and May 2000, 150 patients (123 males and 27 females) underwent surgery with the same surgeon for ascending aortic replacement with a valvular conduit and coronary reimplantation with the aid of a collar of aortic wall (button technique). The average age was 50 +/- 16 years. Within this population, 114 patients had isolated annulo-ectasial disease, 36 had Marfan syndrome and 20 had dissection (5 acute and 15 chronic). A carbon fibre valve with 2 leaflets was implanted in 124 patients, a mono-leaflet valve in 20 and 6 others required a heterograft due to their age or a contra-indication to anticoagulation. The associated procedures were: 12 arch replacements, 5 myocardial revascularisations, 4 mitral replacements, 1 tricuspid plasty, 1 inter-atrial communication closure. In 30 patients (20%) there was a cardiovascular surgical re-intervention. The operative and first month mortality amounted to one sudden death on the 19th day, ie 0.6%. Three patients were lost to follow up. The average survival was 7.87 +/- 5.37 years (minimum 1, maximum 20 years). The actuarial survival was 85% at 10 years and 60% at 20 years. These figures are much higher than those reported in our previous statistics from 1994 when the percentage of survivors at 12 years was only 61%. In the group of patients undergoing surgery before 60 years of age, the survival at 14 years was 94% and 81% at 20 years. Only four late re-interventions were attributable to the Bentall procedure, of which 2 were left coronary ostium stenoses. The rate of thrombosis and embolism was 0.42 per 100 patient-years and the rate of haemorrhagic accidents was identical, including minor accidents. This considerable improvement in long-term prognosis is explicable by the adoption of a single operative technique, considered to be the best, with the best myocardial protection thanks to coronary retro-perfusion and cold or hot cardioplegia, and also without doubt with the best medical survival.

[Remodelling the aortic root by resection of the ascending aorta and non-coronary sinus in annular dilatation of the aorta and acute dissection of the descending aorta. 29 observations]. / Remodelage du culot aortique par résection de l'aorte ascendante et du sinus non coronaire dans la maladie annulo-ectasiante aortique et la dissection aiguë de l'aorte ascendante. 29 observations.

The first conservative surgical procedures of the native aortic valve in annular dilatation were performed by Yacoub and David [1, 2]. These so-called remodelling and inclusion procedures provided hope for a normal life without long-term anticoagulant therapy for patients with Marfan's syndrome, with protection from the complication of an acute dissection of the ascending aorta. The authors reported their experience in the Archives des Maladies du Coeur et des Vaisseaux in 1999, with excellent results [3]. However, a certain number of cases are encountered in which the Yacoub and David procedures cannot be performed because of the presence of a pseudo-bicuspid valve, isolated asymmetrical dilatation of the non-coronary sinus or acute dissection of the aorta without dilatation of the aortic root. In these forms, the authors have developed a technique of remodelling the aortic root with conservation of the native valve by resecting the ascending aorta and non-coronary sinus, rather than carrying out a Bentall procedure. Twenty-nine cases of this type have been treated in this way for three different indications: aneurysm of the ascending aorta with bicuspid aortic valve, aneurysm of the ascending aorta with aortic insufficiency and extension to the posterior sinus, and type A acute dissection of the aorta.

[Coronary surgery of the beating heart. First year of experience in a series of 317 non-selected coronary patients]. / Chirurgie coronaire à coeur battant. Première année d'expérience sur une série de 317 patients coronariens non sélectionnés.

From May 1999 to May 2000, 317 unselected patients, representing 92.7% of all coronary artery surgery procedures, underwent open heart surgery of the beating heart by median sternotomy with the aid of a cardiac stabilising device. The main preoperative characteristics were: mean age = 66.1 years; men = 78.9%; left main stem disease = 31.8%; mean left ventricular ejection fraction = 54.1%; mean Parsonnet index = 16.9. These 317 patients were compared with a group of 303 patients who underwent coronary bypass surgery the year before by the same surgical team with cardiopulmonary bypass (CPB) and cardiac standstill. Seven hundred and eighty-six distal anastomoses were carried out in the beating heart group (2.48 grafts per patient) compared with 2.91 in the CPB group: p < 0.001). There were 10.1% single bypass, 37.5% double bypass, 47.3% triple bypass and 5% quadruple bypass procedures. A cardiopulmonary bypass was required in 13 patients (4.1%). The mortality at 30 days was 3.1% versus 4.6% in the CPB group (p = NS). The need for blood transfusion was reduced by nearly 40% in the beating heart group (23.7% versus 39.9%, p < 0.001). The incidence of cerebrovascular complications was reduced from 3% in the CPB group to 0.6% in the beating heart group (p = 0.06). The peak postoperative troponine I levels were much lower in the beating heart group (2.5 versus 6.4 ng/ml, p < 0.001). The authors conclude that surgery on the beating heart is feasible in most patients. Compared with conventional surgery under CPB, there seems to be less requirement for blood transfusion and a tendency to reduce the cerebral risk. Nevertheless, a large prospective randomised trial is required to validate the potential advantages and limitations of this technique with respect to conventional surgery and to determine the optimal indications of surgery on the beating heart.

[Thrombolytic treatment of obstructions of mechanical valve prostheses. Apropos of 4 cases and analysis of the literature]. / Traitement thrombolytique des obstructions des prothèses valvulaires mécaniques. A propos de quatre cas et analyse de la littérature.

The obstruction of the mechanical valve prothesis (OMVP) is a serious complication. The treatment of this complication was classically surgical. Recently, the thrombolytic treatment was introduced as an alternative approach for patients with high perioperative risk and for those in whom the mechanism of the obstruction is a recently formed thrombus. The authors report four cases of OMVP treated by a thrombolytic agent (Streptokinase, SK, Streptase). Immediate success was obtained in all theses four cases. One late recurrence with fatal issue was noted. All four prostheses were Saint Jude medical (SJM), three in mitral and one in aortic position respectively. The details of the clinical presentation (acute or progressive dyspnea) as well as the contribution of the echocardiography to the diagnosis were presented. The evolution of this therapeutic approach and the international recommendations were reviewed.

[Right-to-left interatrial shunt with normal pulmonary pressures after pneumonectomy. Apropos of a case with severe cyanosis following left pneumonectomy]. / Shunt droite-gauche auriculaire à pressions pulmonaires normales après pneumonectomie. A propos d'un cas de cyanose sévère à distance d'une pneumonectomie gauche.

Atrial septal defects usually give rise to left-to right in the absence of obstruction of the pulmonary outflow tract or pulmonary hypertension. The authors report a case of atrial septal defect with a right-to-left shunt despite normal pulmonary pressures at catheterisation in a 56 year-old-man who had undergone left pneumonectomy 6 months previously. The shunt was responsible for major arterial desaturation aggravated by the left lateral or dorsal decubitus position. Surgical closure of the defect resulted in cure with disappearance of cyanosis and normalisation of blood gases. The physiopathological mechanisms of these right-to-left shunts with normal pulmonary pressures are discussed with reference to previously reported cases in the literature.

[Tumors of the heart in newborn infants and infants. Apropos of 5 cases]. / Tumeurs du coeur du nouveau-né et du nourrisson. A propos de cinq cas.

Between February 1985 and March 1987, 5 children underwent resection of primary cardiac neoplasms, 3 of them in the first days of life and 2 before the age of 6 months. Routine echocardiographic follow-up of pregnancies allowed detection of cardiac tumors in 2 foetuses 30 and 36 weeks old. In 3 children the diagnosis was suspected by the discovery of cardiac murmur or congestive heart failure. The first case was a hemangioma, originating from outside the left ventricular wall, and was resected without cardiopulmonary bypass (CPBP). The other case was a pseudomyxoma, spreading extensively in to the right atrium. The third case was a rhabdomyoma arising from the pulmonary infundibulum with clinical manifestations of tuberous sclerosis. The last two patients had intraseptal lesions, just above the aortic valve; complete resection was therefore impossible, particularly in one patient with multiple tumors. There was one death related to congestive heart failure. The remaining four survivors were followed up for an average of 18.4 months (+/- 12.9) and all were in functional class I. Echocardiographic follow-up showed evidence of a residual subaortic lesion in one asymptomatic patient.

[Heart tumors in newborn infants and infants. Apropos of 5 cases]. / Tumeurs du coeur du nouveau-né et du nourrisson. A propos de cinq cas.

Between February 1985 and March 1987, 5 children underwent resection of primary cardiac neoplasms, 3 of them in the first days of life and 2 before the age of 6 months. Routine echocardiographic follow-up of pregnancies allowed detection of cardiac tumors in 2 foetuses 30 and 36 weeks old. In 3 children the diagnosis was suspected by the discovery of cardiac murmur or congestive heart failure. The first case was an hemangioma, originating from outside of the left ventricular wall, which could be resected without cardiopulmonary bypass (CPBP). The other case was a pseudomyxoma, spreading extensively inside the right atrium. The third case was a rhabdomyoma arising from the pulmonary infundibulum with clinical manifestations of tuberous sclerosis. The last two patients had intraseptal lesions, just above the aortic valve; complete resection was therefore impossible, particularly in one patient with multiple tumors. There was one death related to congestive heart failure. The remaining four survivors were followed up for an average of 18.4 months (+/- 12.9) and all were in functional class I. Echocardiographic follow-up showed evidence of a residual subaortic lesion in one asymptomatic patient.