[Acute poststreptoccocal chorea: an atypical postoperative reaction following cardiac surgery for mitral valvulopathy]. / Chorée aiguë post-streptococcique : une étrange réaction après chirurgie d'une insuffisance mitrale rhumatismale.

We report on a 12-year-old patient from Congo who presented acute chorea following cardiac surgery for poststreptococcal mitral valvulopathy. She showed severe and asymmetrical chorea, associated with motor impersistence and agitation. Biological investigations disclosed inflammatory signs and brain MRI was normal. Due to the negative results of the biological and morphological investigations, the diagnosis of Sydenham chorea was suspected. High doses of oral steroids resulted in a dramatic improvement of the chorea as well as the behavior disturbance within 1 month. Sydenham chorea is not an unusual complication of rheumatic fever. Usually, patients develop chorea a few weeks after beta-hemolytic streptococcal pharyngitis. Details on its pathophysiology remain to be determined. Our case highlights its possible onset in the postoperative period if alternative etiologies of infantile chorea have been excluded.

[Systolic anterior motion (SAM): a rare cause of late failure in mitral valve repair]. / Le SAM: une cause exceptionnelle d'echec tardif de plastie mitrale.

Systolic anterior motion (SAM) of the mitral valve is a rare complication of mitral valve repair. The treatment of the large majority of cases is purely medical. Nevertheless, an early degradation may require reoperation (revision of the repair or valve replacement). The authors report two cases of post-repair SAM with a poor outcome with medical therapy which required reoperation after several years. In both cases, an excess of bivalvular tissue with respect to the size of the mitral orifice was observed. A second repair was possible (sliding valvuloplasty associated with an oval resection of the anterior leaflet) with satisfactory long-term results. The identification of the risk factors and careful analysis of the lesions in cases of SAM after mitral valve repair may lead to a repeat repair and the avoidance of mitral valve replacement.

[Five years experience with non-pulsatile flow]. / Enseignement de 5 années d'expérience avec les assistances circulatoires à flux non pulsé.

Mechanical circulatory assistances now belong to the therapeutic stock in case of advanced heart failure. Their mainspring lays on the substitution of the failing left and/or right ventricle function with a pump. The goal being to maintain or restore the system main functions. Their main indication is a bridge to transplant mechanical circulatory assistance, allowing the patient to await transplantation. However, indications for definitive implantation appear in case of transplantation counter indication, mechanical circulatory assistances already emerging as a possible alternative to transplantation. For over 10 years, we have used pulsatile flow assistances, either with pneumatic ventricles or electro-mechanic implantable left ventricles. We henceforth observe the development of a new generation of implantable assistance providing a non-pulsatile flow. These are axial pumps. We evaluated the first model, the DeBakey axial pump which became the most used axial pump worldwide. We now observe the development of other axial pumps as well as the development of new implantable centrifugal pumps.

[Pediatric mechanical circulatory assistance. Biventricular assistance for fulminant myocarditis in a 5 year old child]. / Assistance circulatoire mécanique pédiatrique. A propos d'une assistance biventriculaire pour une myocardite fulminante chez un enfant de 5 ans.

The authors report the case of a 5 years old infant with cardiogenic shock due to a fulminant myocarditis. The severity of the shock which was refractory to conventional therapies necessitated to require to a cardiopulmonary bypass on emergency, followed by an external pneumatic bi-ventricular assistance. After 10 days (3 days with cardioplumonary bypass and 7 days of bi-ventricular assistance), the patient had been able to be disconnected of any mechanical circulatory supply with total recovery of the cardiac function.

[Results of 17 months' surgical experience in the Cardiological Centre of Phnom-Penh (CCPP). The challenge of sanitation in a developing country]. / Bilan de 17 mois d'activité chirurgicale au Centre de cardiologie de Phnom-Penh.

The authors report the preliminary results of the first 17 months' experience at the Cardiological Centre of Phnom-Penh (CCPP), set up by the initiative of the "Chaîne de l'Espoir" organisation. The CCPP has only two operative theatres, 8 intensive care beds and 32 hospital beds. During the 17 months, 1193 patients under 30 years of age were examined. Nine hundred and five had cardiac disease. Three hundred and twenty-two patients underwent surgery for congenital and valvular heart disease. The commonest operated congenital lesions were left-to-right shunts (71%) and tetralogy of Fallot (24%). In the valvular group, 53% had mitral insufficiency, 40% had mitral stenosis and 7% had aortic insufficiency. The selection of patients and surgical strategy depended on the economic constraints specific to developing countries: --strict selection of operable patients: exclusion of severe pulmonary hypertension, left ventricular dysfunction or cachexia and neonates with complex congenital heart disease; --simple, effective and low cost surgical procedures are preferred, repair in the majority of cases, preference given to valvuloplasty over valve replacement. The quality of the results with low morbid-mortality, justifies the creation of such cardiac surgical centres; surgery must be accompanied by strict measures of prevention of endemic rheumatic fever which remains a major public health problem.

Bridge to transplantation with the DeBakey VAD axial pump: a single center report.

AIMS: To report our experience with a left ventricular assist device axial pump as a bridge to transplantation: the DeBakey Ventricular Assist Device (VAD). METHODS: From February 1999 to February 2002, nine patients (among which eight males), with a mean age of 47 years, all in NYHA functional class IV, were proposed for a bridge to transplantation with the DeBakey VAD. Five patients had primary dilated cardiomyopathy, four had ischemic cardiomyopathy. All the patients had inotropic support prior to the intervention (dobutamine with a mean dose of 12 mcg/kg per min), six had an intra-aortic counterpulsation, four presented ventricular rhythm disorders. Interventions were performed through sternotomy alone (no need for an abdominal pocket) under extra-corporeal circulation on beating heart (except in one patient suffering from an apical thrombosis for which cardioplegic arrest was performed) as followed: implantation of the apical inflow cannula, tunneling of the percutaneous cable, implantation of the outflow graft under aortic side clamping, starting of the DeBakey VAD during CPB weaning-off. RESULTS: Mean support duration was 81+/-62 days (16-224 days). Eight reoperations were required (three for bleeding or cardiac tamponade, one for haemoperitoneum, one for aortic bifurcation thrombectomy, one for right ventricular assist device implantation, two for iterative replacements of the DeBakey VAD). A significant hemolysis was observed in two patients. No device infection or dysfunction were observed. Secondary recovery of a pulsed flow was observed either clinically or by Echo-Doppler in six patients. Five patients were transplanted, four died prior to transplantation (three from multi-organ failure on post-operative day 35, 16 and 50, respectively, and the last patient was found disconnected at day 109). CONCLUSIONS: The DeBakey VAD is at the origin of renewed interest for continuous flow assist devices. Still under evaluation, the advantages of miniaturization and facility of implantation of this new device seem to be promising.

[Beating heart in "aortic no-touch off-pump" techniques: a simple answer to complex surgical situations]. / Le coeur battant en "no-touch aortique complet": une solution simple à des problémes chirurgicaux complexes.

Three cases reports illustrate the concept of beating heart cardiac surgery and its advantages regarding the prevention of arterial emboli.

Tricuspid bioprosthesis replacement with cryopreserved mitral homograft.

We report the case of replacement of a dysfunctional tricuspid Hancock bioprosthesis by a cryopreserved mitral homograft. Tricuspid bioprosthesis was approached on a beating heart. The mitral homograft was orientated so as the anatomic anterior leaflets corresponding and a semi rigid prosthetic ring was inserted. At 1 year follow-up, the patient's clinical condition and echocardiographic results were satisfactory.

Very long-term results (more than 20 years) of valve repair with carpentier's techniques in nonrheumatic mitral valve insufficiency.

BACKGROUND: Mitral valve repair is considered the gold standard in surgery of degenerative mitral valve insufficiency (MVI), but the long-term results (>20 years) are unknown. METHODS AND RESULTS: We reviewed the first 162 consecutive patients who underwent mitral valve repair between 1970 and 1984 for MVI due to nonrheumatic disease. The cause of MVI was degenerative in 146 patients (90%) and bacterial endocarditis in 16 patients (10%). MVI was isolated or, in 18 cases, associated with tricuspid insufficiency. The mean age of the 162 patients (104 men and 58 women) was 56+/-10 years (age range 22 to 77 years). New York Heart Association functional class was I, II, III, and IV in 2%, 39%, 52%, and 7% of patients, respectively. The mean cardiothoracic ratio was 0.58+/-0.07 (0.4 to 0.8), and 72 (45%) patients had atrial fibrillation. Valve analysis showed that the main mechanism of MVI was type II Carpentier's functional classification in 152 patients. The leaflet prolapse involved the posterior leaflet in 93 patients, the anterior leaflet in 28 patients, and both leaflets in 31 patients. Surgical technique included a Carpentier's ring annuloplasty in all cases, a valve resection in 126 patients, and shortening or transposition of chordae in 49 patients. During the first postoperative month, there were 3 deaths (1.9%) and 3 reoperations (2 valve replacements and 1 repeat repair [1.9%]). Six patients were lost to follow-up. The remaining 151 patients with mitral valve repair were followed during a median of 17 years (range 1 to 29 years; 2273 patient-years). The 20-year Kaplan-Meier survival rate was 48% (95% CI 40% to 57%), which is similar to the survival rate for a normal population with the same age structure. The 20-year rates were 19.3% (95% CI 11% to 27%) for cardiac death and 26% (95% CI 17% to 35%) for cardiac morbidity/mortality (including death from a cardiac cause, stroke, and reoperation). During the 20 years of follow-up, 7 patients were underwent surgery at 3, 7, 7, 8, 8, 10, or 12 years after the initial operation. Valve replacement was carried out in 5 patients, and repeat repair was carried out in 2 patients. At the end of the study, 65 patients remained alive (median follow-up 19 years). Their median age was 76 years (age range 41 to 95 years). All except 1 were in New York Heart Association functional class I/II. CONCLUSIONS: Mitral valve repair using Carpentier's technique in patients with nonrheumatic MVI provides excellent long-term results with a mortality rate similar to that of the general population and a very low incidence of reoperation.

Long-term (29 years) results of reconstructive surgery in rheumatic mitral valve insufficiency.

BACKGROUND: Results of conservative surgery are well established in degenerative mitral valve (MV) insufficiency. However, there are controversies in rheumatic disease. This study is the evaluation of one center for rheumatic MV insufficiency based on a functional approach. METHODS AND RESULTS: From 1970 to 1994, 951 patients with rheumatic MV insufficiency were operated on with the reconstructive techniques elaborated by Alain Carpentier. Aortic valve diseases were excluded. Mean age was 25.8 years (4 to 75), and sinus rhythm was present in 63%. The functional classification used was type I, normal leaflet motion, 71 patients (7%); type II, prolapsed leaflet, 311 patients (33%); and type III, restricted leaflet motion, 345 patients (36%). The combined lesion of prolapse of the anterior leaflet and restriction of the posterior was present in 224 patients (24%). Surgical techniques used were implantation of a prosthetic ring in 95%, shortening of the chords and leaflet enlargement with autologous pericardium, and commissurotomy. Hospital mortality rate was 2%. The mean follow-up was 12 years (maximum, 29 years): 8618 patients per year. Actuarial survival was 89+/-19% at 10 years and 82+/-18% at 20 years. The rate of thromboembolic events was 0.4% patients per year (33 events), with 3 deaths. Freedom from reoperation was 82+/-19% at 10 years and 55+/-25% at 20 years. The main cause (83%) of reoperation was progressive fibrosis of the MV. The actuarial rate of reoperation was 2% patients per year and was correlated to the degree of preoperative fibrosis. CONCLUSIONS: Conservative surgery of rheumatic MV insufficiency has a low hospital mortality rate and an acceptable rate of reoperation. The results are excellent regarding the minimal risk of thromboembolic events.

[Coronary bypass surgery on the beating heart and surgery of an abdominal aortic aneurysm. Immediately sequential surgical treatments]. / Pontages coronaires à coeur battant et anévrisme de l'aorte abdominale. Traitement chirurgical en un temps.

The authors report sequential association during the same general anaesthetic of coronary bypass surgery on the beating heart and surgery of an abdominal aortic aneurysm. Two aorto-coronary bypass grafts were carried out without cardiopulmonary bypass using the two pediculated internal mammary arteries (without manipulation of the ascending aorta), followed, after closure of the chest and monitoring in the operating theatre for one hour, by reinstallation of the patient for treatment of an infra-renal abdominal aortic aneurysm by classical prosthetic implantation. The postoperative course was uncomplicated. Sequential management of coronary revascularisation without cardiopulmonary bypass and aortic aneurysmal lesions during the same anaesthetic provides an alternative to classical two-stage surgery in selected patients.

Left ventricular reconstruction after resection of a large fibroma.

Cardiac fibromas are rare tumors that are histologically benign but potentially lethal because of their location. The prognosis is related to complete resection. We report the case of a 15-year-old boy who, 1 year after partial excision of a large fibroma, underwent successful complete resection through a conventional surgical approach with left ventricular reconstruction.

Severe intermittent intraprosthetic regurgitation after mitral valve replacement with subvalvular preservation.

Preservation of the subvalvular apparatus during mitral valve replacement preserves left ventricular function and improves long-term survival. Complications of subvalvular preservation include left ventricular outflow tract obstruction and prosthesis impingement. We report a case of severe intermittent intraprosthetic mitral regurgitation detected by transesophageal echocardiography after mitral valve replacement by a bileaflet mechanical prosthesis with subvalvular preservation. Intravalvular prosthetic valve regurgitation was caused by remnants of the subvalvular apparatus, which were shown at reoperation to interfere with prosthetic leaflet motion and which were excised. Postoperative transesophageal echocardiography showed neither abnormal mitral regurgitation nor residual mass. The use of intraoperative transesophageal echocardiography could enable the detection of this rare complication.

[Human valvular substitutes for the treatment of complex progressive endocarditis. Application to aortic, mitral and tricuspid valves]. / Substituts valvulaires humains dans le traitement des endocardites évolutives complexes. Application sur les orifices valvulaires aortiques, mitraux et tricuspides.

The aim of this study was to assess the immediate and long-term results of human valvular substitutes (homografts and autografts) in the treatment of complex progressive endocarditis in aortic, mitral and tricuspid valves. Since 1992, 80 patients (64 men, 16 women) aged 44 +/- 16 years (range 15 to 76 years), were treated. In 53 patients, the endocarditis involved native valves, 4 on previously plastified valves, or prosthetic valves in 27 patients. The endocarditis was recurrent 6 patients. The lesions were situated on the aortic valve (N = 59), mitral valve (N = 5), aortic and mitral valves (N = 12), aortic and tricuspid valves (N = 3), mitral and tricuspid valves (N = 1). The peroperative findings confirmed the lesions diagnosed at echocardiography: prosthetic valve dehiscence (27 patients), prosthetic cusp tear (N = 7), vegetations (N = 61), perforations (N = 48), periannular abscess (N = 47), aorto-ventricular discontinuity (N = 12), aorto-mitral discontinuity (N = 7), right ventricular aortic fistula (N = 1), aorto-pulmonary fistula (N = 1), pseudo-aneurysm (N = 1), ventricular septal defect (N = 1). Eighty-six human valvular substitutes were used (double homograft in 6 patients): aortic homograft (N = 63), pulmonary in the aortic position (N = 1), the mitral position (N = 12), of which 8 were in the mitral and 4 in the tricuspid position, pulmonary autograft (N = 10). Ten mitral valve repairs were performed on infected lesions. Associated procedures included mitral valve repair (N = 5), tricuspid valve repair (N = 1) for non-infarcted valve lesions, replacement of the ascending aorta (N = 2), the aortic arch (N = 1), coronary bypass surgery (N = 2) and one nephrectomy. The hospital mortality was 5% (4 patients). The causes of death were: infarction (N = 2), myocardial failure (N = 1) and multiorgan failure (N = 1). Four early reoperations were required for technical problems, none for endocarditis. Seventy-three of the 76 survivors were followed up for 43 +/- 24 months (range 1 to 84 months). Eight patients died during follow-up, but only 1 of cardiac causes (operation for recurrent endocarditis in a drug abuser). Seven operations were performed, 3 for technical problems or structural failure, 4 for recurrent endocarditis. At 5 years' follow-up, the survival was 81 +/- 5%; 88 +/- 6% of patients were free of endocarditis, 77 +/- 6% had no reoperation: no patient had thromboembolic complications. These results show that human valvular substitutes are adapted for the treatment of complex, progressive aortic, mitral and tricuspid valve endocarditis when techniques of valvular repair are no longer feasible.

[Cardiac fibroelastoma. Six operated cases and review of the literature]. / Fibroélastomes cardiaques. Six cas opérés et revue de la littérature.

The authors reviewed the cases of 6 patients operated between September 1994 and February 1999 for a rare benign tumour: papillary fibroelastoma of the heart. These patients, aged 51 +/- 14 years, all have single valvular involvement: mitral (N = 3), aortic (N = 2), tricuspid (N = 1). Five patients were symptomatic: transient ischaemic cerebral events (N = 3) associated with mesenteric infarction requiring ileal resection in 1 case; constituted cerebrovascular accident (N = 1); syncope (N = 1). In this last patient, the fibroelastoma was diagnosed fortuitously on the tricuspid valve. The features and location of the tumours were determined by transoesophageal echocardiography. Surgical treatment in all patients consisted in excising the tumour and preserving the valve. One aortic cusp was reconstructed after excising the tumour with a cryopreserved partial aortic homograft. Peroperative transoesophageal echocardiography confirmed the absence of regurgitation after the procedures in all patients. There were no postoperative complications in any of the cases. No cases of valvular regurgitation or of tumour recurrence were observed during follow-up. Despite the benign histology, cardiac fibroelastomas should be excised because of their embolic complications. Absence of recurrence justifies conservative reconstruction of the affected valve.

Coronary reoperations: indications, techniques and operative results. Retrospective study of 240 coronary reoperations.

BACKGROUND: We review twelve-year experience with coronary reoperations so as to better identify indications, techniques and results. METHODS: Between January 1986 and March 1998, 240 coronary reoperations (228 redux, 12 tridux) were performed. There were 223 male and 17 female patients, with a mean age of 63.6+/-7.9 years at the time of reoperation. Mean time interval between operations was 10+/-4.8 years. Symptomatology consisted of: stable recurrent angina (40%), unstable (57%), or congestive heart failure (3%). Pathological feature of the primary grafts was implicated in 95% of cases and atheroma sole progression over native network in 5% of cases. During reoperations 521 (2.2+/-0.8/patient) bypass [venous (40%), arterial (60%)] were performed as well as 15 associated procedures. RESULTS: Operative mortality represented 10% (n=24). Causes of death included infarct (7), left ventricular failure (12), rhythm disorders (2), mediastinitis (1) and multiorgan failure (2). Mortality risk factors were operation date (16.6% before 1992 and 7.4% after, p=0.03), age (13.1% after 60 years old, 2.7% before, p=0.01) time interval between intervention (12% after 8 years, 4% before, p=0.05) and anterograde cardioplegia only (11.8% versus 4.5% when a combined anterograde and retrograde access was used, p=0.06). Morbidity was 31% (71/240). Among the survivors 169 patients (78%) did not experience any complication. CONCLUSIONS: Thanks to a better medico-surgical management, the mortality rate of coronary reoperations is steadily decreasing.

[Left ventricular reconstruction after excision of a large fibroma]. / Reconstruction ventriculaire gauche après exérèse d'un volumineux fibrome.

The authors report the case of a 15 year old boy with a large left ventricular fibroma discovered after a series of syncopal episodes due to obstruction to ejection. The first attempt to remove the fibroma in Columbia was only partially successful. In view of the risk of death associated with this type of tumour, it was decided to offer the patient complete excision after a full morphological and functional evaluation of myocardial function and the consequences of the tumour on mitral valve function and on the coronary circulation. The operation was performed under cardiopulmonary bypass and aortic clamping by conventional surgery, associated with reconstruction of the cardiac free wall with a large patch of autologous pericardium which was necessary to avoid cardiac transplantation, the ultimate sanction in this indication.