[Acute nontraumatic limb ischemia]. / Ischemies aigues on traumatiques des membres.

Twenty four patients (18 males, 6 females, Mean age 50 years) with acute non traumatic limb ischemia were operated on in our institution. The ischemia has been observed after 24 hours in 15 patients (62,5 % versus 7 patients (37,5 %) within 24 hours. The arterial femoral was often (54,1 %) the site of occlusion. Embolism (29,2 %) and thrombosis (54,2 % were the cause of acute limb ischemia. All patients were treated by embolectomy or thrombectomy. The overall mortality was 29,2 % with a limb salvage rate of 45,8 % and secondary amputation rate of 29,2 %. According to our experience, the diagnosis of acute non traumatic limb ischemia is not instituted early and the rate of hospital mortality and morbidity remain high.

Ischemies aigue on traumatiques des membres

Twenty four patients (18 males; 6 females; Mean age 50 years) with acute non traumatic limb ischemia were operated on in our institution. The ischemia has been observed after 24 hours in 15 patients (62;5versus 7 patients (37;5) within 24 hours. The arterial femoral was often (54;1) the site of occlusion. Embolism (29;2) and thrombosis (54;2were the cause of acute limb ischemia. All patients were treated by embolectomy or thrombectomy. The overall mortality was 29;2with a limb salvage rate of 45;8and secondary amputation rate of 29;2. According to our experience; the diagnosis of acute non traumatic limb ischemia is not instituted early and the rate of hospital mortality and morbidity remain high

The hypolipidemic effects of Afzelia Africana in type II diabetic patients in Nigeria

Background: The projected rise in the world prevalence of diabetes mellitus poses new challenges in poor countries. Soluble fibre incorporation into the diet of diabetic patients has been shown to reduce the glyceamia and lipaemia of diabetes mellitus. Design and method: The hypolipidemic effect of soluble fibre supplementation using the seed of locally available legume tree plant - Afzelia africana was studied in 13 Nigerian patients with type 2 diabetes mellitus. The subjects were randomly selected from the out patient diabetes mellitus clinic of Nnamdi Azikiwe University Teaching Hospital; Nnewi. They were fed with unsupplemented and supplemented standardized diet for the first 2 days and subsequent 4 days respectively. The fibre supplementation was prepared and incorporated into the meal portions according to previously described technique and acceptability study. Outcome measures: The fasting serum levels of TC; TG; HDL-C; LDL-C and HDL/TC ratio were estimated before and after the unsupplemented and fibre supplemented meals. The data obtained were analyzed using paired t-test. The correlation between the total energy requirement and the reduction in TC; pre and post fibre supplemented meals were determined using the linear coefficients. Result: The results showed a significant reduction (P0.05) in mean fasting TG; LDL-C and improvement in HDL/TC ratio following a 4 day supplemented meal. The relation between the difference in TC before and after the supplemented meal and total energy requirement was not significant (P 0.05). Conclusion: The exploitation and incorporation of this source of soluble fibre in diabetic diets reduced the lipaemia of diabetes mellitus

[Conduction disorders in chronic parietal endocarditis or endomyocardial fibrosis. 170 cases at the Cardiology Institute of Abidjan]. / Troubles de conduction dans l'endocardite pariétale chronique ou fibrose endomyocardique. A propos de 170 cas colligés à l'Institut de Cardiologie d'Abidjan.

The authors have conducted research on conduction disturbances in the endomyocardial fibrosis, synonymous with chronic parietal endocarditis, about 170 cases at the Institute of Cardiology in Abidjan, from January 1977 to June 1991. The anatomical and/or angiographic examination have permitted to describe 64 cases of right fibrosis, 24 cases of left fibrosis and 82 cases of bilateral fibrosis. Conduction anomalies have been observed among 42.9% of the patients. Among 92 anomalies recorded, the most frequent has been the first degree heart block (43.5%) and the incomplete right bundle branch block (30.4%). The old age of the patients and the right localization were the factors associated with conduction disturbances in endomyocardial fibrosis (difference not significant). Yet, fibrosis surgery, especially the decortication of the fibrous endocardium of the right ventricle, have generated one or many conduction anomalies among most of our operated patients. The right branch of the fasciculus of the His has been the most injured by the fragmented techniques of METRAS who had, therefore, the merit to have minimized the incidence of the complete post-operative heart blocks still high in European and Brazilian series. In term of prognosis, no conduction disturbance has directly caused a patient's death, even if those anomalies cannot be totally ruled out in the 16 cases of sudden death.

Surgical treatment of patent ductus arteriosus (PDA). Analysis of 145 cases operated on in Abidjan (Cote D'Ivoire).

This retrospective study aims to analyse our surgical procedures and our results after surgery of patent ductus arteriosus (P.D.A.) in children. Since 1978 to 1992 we have reported Abidjan Cardiology Institute 145 children operated cases. The average age was 4.7 years, the average weight 16 kg. There was female predominance with a sex ratio of 2.3/1. All patent ductus arteriosus had been confirmed by two dimensional echocardiography (2D echocardiography) and cardiac catheterization. Type 11a of NADAS' Classification was the most frequent (50%). Double or triple ligation supported on teflon felt was the most frequent technique used (86 times ie 59.3%). This technique gave good results in view of the absence of hospital mortality, only 4 cases of ductus "recanalization" supervened, a low rate of ductus arteriosus recurrence patency at long follow up of all patients from one to 10 years (mean 5 years). Double or triple ligation on teflon felt according to Wright procedure seems to be a securising technique alternative in our countries.

L'aspergillome pulmonaire symptomatique: a propos de 71 cas operes

De 1976 a 1992; 71 patients ont ete operes pour aspergillome pulmonaire. Il s'agissait de 61 hommes et 10 femmes. L'age moyen etait de 35;8 ans. Soixante deux fois (87;3 pour cent); les lesions etaient developpees dans des excavations sequellaires de tuberculose pulmonaire. Tous les patients etaient symptomatiques. L'hemoptysie (52 fois) et la bronchorrhee (19 fois) etaient les motifs de l'indication operatoire. L'exerese pulmonaire partielle (55 fois) a ete l'intervention la plus frequente; seulement seize pneumonectomies ont ete realisees devant l'etendue de certaines lesions. Dans tous les cas les interventions etaient longues; difficiles et hemorragiques. Deux patients sont decedes (2;8 pour cent); 29 ont presente des complications non mortelles (2 hemorragies; 16 defauts de reexpansions; 4 infections parietales et 7 empyemes dont 3 avec fistules bronchiques). Les auteurs concluent que malgre les risques majeurs de complications post-operatoires; la chirurgie est le seul traitement efficace chez ces malades

Les dilations des bronches post-tuberculeuses: soixante seize cas operes

De janvier 1980 a avril 1993; 74 patients ont ete operes pour les dilatations des bronches. Il s'agissait de 53 hommes et 21 femmes; d'un age moyen de 32 ans. Toutes les lesions etaient secondaires a une tuberculose guerie. Soixante douze patients presentaient des lesions unilaterales et seulement deux avaient des dilatations bilaterales localisees. L'indication operatoire etait motivee par des episodes de bronchopneumonie recidivante avec des crachats purulents stries de sang (50 fois); d'hemoptysie franche (5 fois); de bronchorrhee trainante (19 fois). L'exerese pulmonaire a ete possible dans tous les cas: 32 lobectomies; 27 pneumonectomies; 10 bilobectomies; 5 exereses combinees; 2 segmentectomies. Les suites operatoires etaient globalement difficiles: un patient est decede; 18 ont eu des complications non mortelles (6 defauts de rehabilitation; 5 accroissements rapides du liquide de substitution; 3 infections parietales benignes; 2 reevolutions tuberculeuses; 1 empyeme sans fistule bronchique; 1 hemorragie massive). Nous concluons que la chirurgie des dilatations des bronches post-tuberculeuses comporte des risques parfois majeurs. Toutefois l'exerese pulmonaire reste la seule possibilite therapeutique radicale chez ce type de malade

Trouble de conduction apres chirurgie de l'endocardite parietale chronique ou fibrose endomyocardique: à propos de 81 patients opérés

Les auteurs ont rapporte 81 patients operes d'endocardite parietale chronique (EPC) ou fibrose endomyocardique (PEM) par la technique fragmentee de Metras a l'Institut de Cardiologie d'Abidjan de janvier 1978 a juillet 1991. Cette etude; apres un recul d'une dizaine d'annees; confirme l'objectif de cette methode qui etait de diminuer l'incidence des blocs auriculoventriculaires complets (2;5 pour cent des patients) encore elevee dans les series europeennes et bresiliennes. En revanche; comme dans toute chirurgie endoventriculaire; les branches de division du faisceau de His ont ete lesees. Parmi celles-ci; la branche droite a paru avoir paye le plus lourd tribut a cette chirurgie mutilante. Le risque operatoire d'apparition du bloc de branche droit a ete de 81;6 pour cent contre 22;2 pour cent pour le bloc de branche gauche et 7;4 pour l'hemibloc anterieur gauche. Cette plus grande vulnerabilite de la branche droite tient au caractere superficiel et compact de ses fibres

[Isolated replacement of the tricuspid valve with a bioprosthesis. Apropos of 22 cases in Abidjan]. / Le remplacement valvulaire tricuspidien isolé par bioprothèse. A propos de 22 cas observés à Abidjan.

The authors reviewed the operative and function results of 24 isolated tricuspid valve replacements with bioprostheses in 22 patients. The patient population was young (average age 15 +/- 8 years). The surgical indication was massive tricuspid regurgitation due to chronic parietal endocarditis in 19 cases and to bacterial endocarditis in 3 cases. Tricuspid valve replacement was associated with 19 right ventricular endocardectomies, 2 direct closures of ventricular septal defects, 2 Wooler mitral valvuloplasties and 1 pericardectomy. The operative mortality was 13.5% and the secondary mortality 13.5%. Of the 16 survivors, 13 are in the NYHA Class I with no regular medical therapy. Their cardiothoracic ratio has slightly decreased. Two patients have permanent atrial fibrillation, and 12 have acquired definitive complete right bundle branch block. Eight of these patients had significant improvement of atrial and right ventricular pressures, of Yu's index and cardiac index at postoperative catheterisation. Three of the 16 patients developed progressive calcific degeneration of their bioprostheses. They are among the 6 patients who have been followed up for more than 3 years. There was no mortality at reoperation. Isolated tricuspid valve replacement by bioprosthesis was chosen despite the young age of these patients because of the disadvantages of mechanical prostheses which are associated with a much higher mortality related to incarceration and thrombosis of the prosthesis. The relatively high operative and secondary mortality in this series of isolated tricuspid valve replacement compared to mitral, aortic or micro-aortic valve replacement, is related to the gravity of the underlying causal pathology.

[Infectious endocarditis surgically treated during the acute phase. 26 cases]. / L'endocardite infectieuse à la phase aiguë traitée chirurgicalement. Vingt-six observations.

Twenty-six patients with infective endocarditis were operated upon during the active phase. The endocarditis was native in 24 cases and developed on cardiac valve prosthesis in 2 cases. Depending on the valve involved, the patients were divided into 3 groups: Ao (aortic valve, n = 13), M (mitral valve, n = 10) and T (tricuspid valve, n = 3). The overall mortality rate was 26% (group Ao 20%, group M 20%); death was due, in most cases, to haemodynamic failure. The duration of pre-operative antibiotic therapy, the functional stage of the disease and the cardiothoracic ratio had no influence on post-operative prognosis. In contrast, the presence of vegetations (notably on the aortic valve) at echocardiography and the pumping and aortic clamping times played a role in operative mortality. Twelve patients were followed up for a mean period of 23.9 months. They are all in stage I or II with significant decrease in cardiothoracic index. In Africa, where bacteriological facilities are often inadequate and cardiac valve diseases are diagnosed at a late stage, infective endocarditis is active in many cases. Under these conditions, early surgery is justified when heart failure is present and the infection is not clinically controlled.

[Pulmonary artery aneurysms in patent ductus arteriosus]. / Les anévrysmes pulmonaires au cours de la persistance du canal artériel.

Two cases of pulmonary artery aneurysm are reported in patients with persistent ductus arteriosus (PDA). The first was a mycotic aneurysm complicating staphylococcal pneumonia; the other was a calcific aneurysm of the right pulmonary artery. The mycotic origin was confirmed in the first case. The aetiological roles of pulmonary hypertension and previous endocarditis are discussed in the second case. Based on these two observations, the authors analyse the aetiology and evolution of mycotic aneurysms and review the therapeutic problems posed by their association with PDA.

[Reconstructive mitral valvuloplasty. Results apropos of 53 cases]. / La valvuloplastie mitrale reconstitutive. Résultats à propos de 53 cas.

In the last three years, 53 patients have undergone a valvuloplasty according to the Carpentier's principles. The patients age ranged from 5 to 35 years, with a mean of 14.3 years. The aetiology was congenital in one case, RHD in 45 cases, and endomyocardial fibrosis (EMF) in 7. The pre-operative condition was severe with 25 patients in class III and 10 patients in class IV. There was a cardiomegaly with a mean CTR of 0.70 (extremes 0.50 and 0.85). The mitral lesions were pure mitral insufficiency in 49 cases, and mixed lesions with predominant insufficiency in 4 cases. There were also 6 aortic and 4 tricuspid significant insufficiencies. The patients have had a valvuloplasty with chordae shortening (n: 46) valvular resection (n: 3), chordae resection (n: 8), annuloplasty without ring (n: 38) or with ring (n: 2). There were associated procedures: endocardectomy (n: 7), aortic valvuloplasty (n: 3), aortic valve replacement (n: 3), tricuspid annuloplasty (n: 4). There were 3 post-operative deaths in children in class IV, with cardiomegaly (CTR 0,80), and systemic pulmonary hypertension. There were 3 mitral valve replacements (MVR) in the first month for failure of the plasty, 2 late MVR for endocarditis and rheumatic evolution. There were 3 mitral valve replacements (MVR) in the first month for failure of the plasty, 2 late MVR for endocarditis and rheumatic evolution. There were 2 late deaths (recurrent mitral insufficiency, serum hepatitis), Among 43 long-term follow-up of patients with a plasty (mean follow-up 18 months), the result has been very good 39 times. There were 4 patients with a significant residual mitral incompetence.(ABSTRACT TRUNCATED AT 250 WORDS)

The surgical treatment of endomyocardial fibrosis: results in 55 patients.

Over a 5 year period we have operated on 55 patients with endomyocardial fibrosis (EMF). The patients were from 4 to 56 years old (mean 13) and they were usually in poor condition at the time of surgery, with 47% in class III, and 24% in class IV with respect to cardiac function. They presented with right heart restrictive diastolic filling pattern (n = 17), mitral insufficiency (n = 18), or a combined syndrome (n = 20). All patients were operated upon during cardiopulmonary bypass and were submitted to a combination of the following procedures: endocardiectomy (30 right ventricular, 28 left ventricular), valvular replacement (21 tricuspid valve, 27 mitral valve), and/or valvuloplasty (10 mitral, five tricuspid). Nine patients, all with left ventricular or bilateral EMF, died in the postoperative period (16%), mainly of low cardiac output. There were five late deaths (three valve related). All other patients were functionally improved at the mean follow-up of 32 months. Twenty-two underwent a late catheterization study. We conclude the following from our experience: EMF is a very severe disease that is seen mainly in childhood and adolescence, carries a poor spontaneous prognosis, and is frequently seen in tropical countries. Surgical treatment is beneficial, but surgical mortality is high. Our technical modifications have totally eliminated the occurrence of postoperative complete heart block. A conservative valvular procedure has been shown to be possible even in some patients with severe mitral insufficiency and left ventricular EMF. The late objective improvement is better in those with left ventricular EMF than in those with right ventricular EMF.(ABSTRACT TRUNCATED AT 250 WORDS)

[Open-heart valvular surgery in children. Apropos of 127 cases]. / La chirurgie valvulaire à coeur ouvert chez l'enfant. A propos de 127 cas.

In view of the frequency and the severity of rheumatic heart disease (RHD) and of endomyocardial fibrosis (EMF) in the african child, the indication of a valvular surgical procedure is frequent in Abidjan. Between 1978 and 1983, 127 open-heart procedures have been performed in 113 patients. The ages ranged from 2 to 15 years, with a mean of 11 years. There were 67 RHD, 37 EMF, 9 bacterial endocarditis. The status of the patients was severe, there was a cardiomegaly (mean CTR of 0.70). 3 patients were in atrial fibrillation. The patients underwent 97 valve replacements (70 mitral, 18 tricuspid, 9 aortic) essentially by a bioprosthesis (n : 87). A mitral valvuloplasty was done in 27 cases. Associate procedures have been employed including : 35 endocardectomies, 11 aortic valvuloplasties, 6 tricuspid annuloplasties. 12 patients have been reoperated for bacterial endocarditis of a mitral prosthesis (n : 4), calcification of a mitral bioprosthesis (n : 5), failure of mitral valvuloplasty (n : 3). There were 13 deaths (10.2 p. 100 mostly in EMF surgery : 7 deaths (5.5 p. 100). No patient with a bioprosthesis received anticoagulants post-operatively. All surviving patients have been improved, with a mean post-operative follow-up of 32 months. There were 11 late deaths (8.6 p. 100). The authors discuss several points including : severity of children valvular diseases in tropical areas; necessity to use the bioprosthesis in this area of the world; increasing tendency to conservative surgery in the mitral and also the aortic position.

[Echocardiographic, angiographic and hemodynamic development of surgically treated endomyocardial fibrosis]. / Evolution échocardiographique, angiographique et hémodynamique des fibroses endomyocardiques opérées.

The echocardiographic, angiographic and haemodynamic evolution of endomyocardial fibrosis (EMF) was assessed in 19 patients: 8 patients with isolated right sided EMF, 3 with predominantly right-sided EMF, and 8 with isolated left sided EMF with mitral regurgitation. Echocardiographic controls were preformed in 16 patients, on average 11.3 months after surgery; angiographic and haemodynamic controls were preformed in 14 patients, on average 14 months after surgery. In isolated or predominantly right-sided EMF, echocardiographic abnormalities of septal motion (paradoxal) disappeared. Although the volume of the right heart chambers decreased, they remained dilated. The syndrome of adiastole disappeared in patients operated early. In left EMF with mitral regurgitation, the M-shaped motion of the septum regressed in the 4 cases in which this abnormality was observed preoperatively. The size of the left heart chambers decreased on post-operative echo and angiographic studies. Left ventricular function returned to normal after surgery. The author underline the differences between right and left-sided EMF with mitral regurgitation. In right-sided EMF the evolution is that of adiastole and surgery should be preformed early because the right ventricular reserve is small. In left-sided EMF with mitral regurgitation, the evolution is that of a valvular lesion with a good postoperative result.

[Conservative valve surgery in endomyocardial fibrosis. Apropos of 8 cases among 46 surgically treated patients]. / La chirurgie valvulaire conservatrice dans la fibrose endomyocardique. A propos de 8 cas sur 46 opérés.

The authors report their experience of conservative valvular surgery in endomyocardial fibrosis (EMF) (8 cases among 46 surgical cases). These patients were divided into 3 groups: Group I: bilateral EMF predominating on the left side with associated tricuspid involvement (n: 3). Group II: bilateral EMF predominating on the right side with moderate associated mitral involvement (n: 3). Group III: unilateral EMF with massive mitral insufficiency, (n: 2). At surgery, on the side of the conserved valve, the patients had a transvalvular endocardectomy (n: 3) and a valvuloplasty either tricuspid (n: 3) or mitral (n: 5). The results of the valvuloplasty were satisfactory. Two patients died in the post-operative period. Their death was unrelated with the conservative procedure. The authors study the literature concerning the cases of valvular conservative surgery in EMF (n: 4) and define the conditions under which this surgery can be done. They report 2 original cases of pure left sided limited EMF with massive mitral insufficiency successfully treated by a valvuloplasty.

[Post-infarct posterior aneurysm of the left ventricle. Apropos of a successful surgical case in an African]. / Anévrisme postérieur du ventricule gauche post infarctus. A propos d'un cas opéré avec succés chez un africain.

The authors report the first case in the literature of a post-infarction left ventricular (LV) aneurysm operated in a black African man of 31 years. The episode of infarction had been ignored, and the patient presented a posterior LV aneurysm with moderate mitral insufficiency and heart failure. The diagnosis was made by a cineangiogram in the LV and a coronary angiogram showing a total obliteration of the right coronary. The patient underwent a resection of the aneurysm with closure of the LV-aneurysm communication. Six months after surgery, the patient was asymptomatic and the size of the heart had decreased. With regard to this unique case, the authors discuss the literature on LV aneurysms in African, and on coronary atherosclerosis in Africa. They discuss also the surgical indication in case of post-infarction LV aneurysm.