[A left intraventricular mass]. / Le cas clinique du mois. A propos d'une masse intra-ventriculaire gauche.

We report the case of a 29-years-old male presenting with a large mass inserted at the hypokinetic apex of the left ventricle. Without any early regression under anticoagulant therapy and taking into account recent neurological manifestations, surgical extraction was decided. The mass corresponded to a chronic thrombus lying on a non-transmural myocardial necrosis. This case gives us the opportunity to review all causes of intracardiac masses.

Extended transsternal thymectomy for myasthenia gravis: a report of 19 consecutive cases.

BACKGROUND: Thymectomy is considered as an effective therapeutic option for patients with myasthenia gravis (MG). This study reports the experience of our centre's investigation into the efficacy and the safety of the procedure and the influence of different pre-operative factors on the surgical outcome. METHODS: A retrospective chart review/interview was made of 19 consecutive patients who underwent extended transsternal thymectomy for MG from 1992 to 2003. The severity of the disease was determined according to the Osserman Classification. Efficacy was measured by determining the change in clinical status, the rate of remission during follow-up, and the reduction in medication requirements after thymectomy. Complete remission (CR) was defined as asymptomatic off medication for 6 months. The CR rate was calculated using the Kaplan-Meyer method. RESULTS: The mean age of the patients at surgery was 34 years (range, 9-63) and 78.9% were female. Mean length of follow up was 86 months (range, 24-163). The overall complication rate was 10.6% (1 episode of atrial fibrillation and a left recurrent laryngeal nerve palsy that resolved after the first postoperative month). There was no operative mortality. The mean hospital stay was 9.4 days (range, 5-23). The crude CR rate was 32% (n = 6). The Kaplan-Meier estimate of CR was 42% at 6 years. Age, gender, duration of symptoms, thymic histology, Osserman stage and the presence of thymoma were not identified as prognostic variables. The average daily dose of Medrol and Mestinon decreased significantly between the pre-operative period and the last follow-up (Medrol, p = 0.0081; Mestinon, p = 0.0013). CONCLUSIONS: Transsternal thymectomy for MG is safe and effective. It benefits patients with MG at all stages. Patients with thymoma are not associated with poorer remission rates. Complete responses are durable, as the CR rate remains stable over time.

Catamenial pneumothorax: a case report and review of the literature.

Catamenial pneumothorax is a rare condition that is often misdiagnosed. It is defined as spontaneous pneumothorax occuring within 72 hours before or after onset of menstruation. Etiology is unknown but could be linked to endometriosis. Treatment is medicosurgical: thoracoscopy for pleural abrasion and hormonotherapy to avoid recurrence.

SMA circuits reduce platelet consumption and platelet factor release during cardiac surgery.

BACKGROUND: Platelet count and function are particularly damaged by cardiopulmonary bypass (CPB). This study evaluated the effects of a novel CPB circuit in terms of platelet count and activation, and postoperative need for blood products. METHODS: One hundred patients undergoing coronary grafting were randomized in two groups: control group (n = 50) and test group (n = 50, surface modifying additives circuit, SMA group). Blood samples were taken before, during, and after CPB. Postoperative blood loss, number of transfused blood products, and postoperative variables were recorded. RESULTS: The platelet count decreased less in the SMA group compared to the control group (end of CPB: respectively, 165 +/- 9 x 10(3)/mm3 vs 137 +/- 8 x 10(3)/mm3; p < 0.01). This was paralleled by a reduction in beta-thromboglobulin plasma levels in the SMA group. There was a trend to decreased blood loss in the SMA group, but the difference was significant only in patients taking aspirin preoperatively (p < 0.05). In the SMA group nearly 50% less fresh frozen plasma and platelet units were administered (p < 0.01). No operative deaths were observed. CONCLUSIONS: The use of circuits with surface additives is clinically safe, preserves platelet levels, and attenuates platelet activation. This may lead to a reduced need for blood products.

Thermodynamics of unfolding for Kazal-type serine protease inhibitors: entropic stabilization of ovomucoid first domain by glycosylation.

A synthetic gene for chicken ovomucoid first domain (OMCHI1) has been overexpressed in Escherichia coli. The resulting recombinant protein, rOMCHI1, is expressed and correctly folded without the use of fusion proteins or export secretion signal peptides incorporated into the gene. The thermostability of rOMCHI1 has been compared to that of the naturally occurring glycosylated OMCHI1 (gOMCHI1). The results of differential scanning calorimetry (DSC) studies show that the heat capacity change for unfolding, deltaCp, for both rOMCHI1 and gOMCHI1 is approximately 600 cal/(mol x K). At any given pH, however, the presence of N-linked carbohydrate increases the Tm for thermal unfolding of gOMCHI1 over rOMCHI1 by 2-4 degrees C, without changing the enthalpy of unfolding, delta H(degree)m. This suggests that the increased thermal stability of gOMCHI1 is entropic. Comparison of the unfolding thermodynamics of rOMCHI1 with those of turkey ovomucoid third domain (OMTKY3), which is 36% identical to rOMCHI1, reveals similar deltaCp values for both proteins, about 600 cal/(mol x K), but a reduction in delta H(degree)m of about 5 kcal/mol for rOMCHI1 at all temperatures. Decreases in delta H(degree)m for rOMCHI1 versus OMTKY3 may be explained by an overall less ordered native state in rOMCHI1. In the absence of a native structure for OMCHI1, the change in accessible surface area upon unfolding, deltaASA, was calculated using unfolding parameters and structural energetic relationships [Murphy & Freire (1992) Adv. Protein Chem. 43, 313-361; Murphy et al. (1993), Proteins: Struct., Funct., Genet. 15, 113-120]. These calculations suggest that the larger protein rOMCHI1 (Mr 7500) exposes less surface area than OMTKY3 (Mr 6100) upon thermal denaturation. Overall, structural energetic relationships may provide a useful framework for interpretation and comparison of thermodynamic data for structurally homologous proteins.

Calorimetrically-derived parameters for protein interactions with urea and guanidine-HCl are not consistent with denaturant m values.

A recent study used calorimetric data and a stoichiometric binding model to derive binding constants, enthalpies, and stoichiometries describing the interaction between proteins and the chemical denaturants, urea and guanidine-HCl (Makhatadze and Privalov, J. Mol. Biol., 226 (1992) 491). In the present study, these parameters have been used to calculate the excess free energy, delta Gex, associated with interactions between chemical denaturants and the three proteins examined in the calorimetric study: ribonuclease A, cytochrome c, and lysozyme. This free energy and its dependence on denaturant concentration, the denaturant m value, have then been compared to experimental results from chemical denaturation experiments. The magnitudes of m values calculated from the calorimetric studies are significantly greater, 20 to 100%, than the observed values in urea. Calculated m values for guanidine-HCl range from about 10% greater than observed values for cytochrome c to over 100% greater for lysozyme. Discrepancies between calculated and observed m values are probably attributable to incomplete binding isotherms in the calorimetric studies. An additional issue raised in this study concerns the correlation of m values with changes in accessible surface areas upon unfolding. For proteins that undergo a two-state unfolding reaction, experimental m values can vary by more than a factor of two for a given protein, depending on the solution conditions. This observation suggests that factors beyond changes in accessible surface areas play a major role in determining m values.

Cold denaturation of CheY.

The thermal stability of the bacterial chemotaxis protein CheY from Salmonella typhimurium has been examined by thermal denaturation at pH 7.0 in the presence of guanidine-HCl and urea. For both denaturants, thermal denaturation monitored by circular dichroism spectropolarimetry consists of transitions both above and below 25 degrees C, which is strong evidence for a heat capacity change that is > or = 1500 cal/(mol K) upon unfolding. While many data for chemical and thermal denaturation are consistent with data for CheY from Escherichia coli, the observation of cold denaturation for S. typhimurium CheY is inconsistent with the small heat capacity change, 600 to 850 cal/(mol K), reported for denaturation of the E. coli protein.

Successful revascularization of an orthotopic liver transplant (OLT) with the recipient right gastroepiploic artery.

A technique for revascularizing the arterial supply to an orthotopic liver transplant (OLT) in a 55-year-old male afflicted with end-stage alcoholic liver cirrhosis with portal hypertension is reported. The presence of well-developed portosystemic collaterals and an unsuitable recipient common hepatic artery necessitated the dissection and liberation of the right gastroepiploic artery (RGEA) for its subsequent use as the recipient arterial source. Posttransplantation, save for an early biliary leak which was corrected promptly, the patient's evolution was uneventful. Two separate celiac angiographic series at 6 weeks and 20 months posttransplantation revealed an excellent flow through the recipient and donor arterial systems. Additionally, the RGEA demonstrated an adaptation in caliber when pre- and posttransplantation angiograms were compared. It was concluded that the RGEA is a suitable rescue option for revascularization of OLT's provided it satisfies elementary hemodynamic requirements.

Mycotic aneurysm of the upper abdominal aorta ruptured into the stomach.

We report a case of primary aortogastric fistula with erosion of a mycotic aneurysm of the upper abdominal aorta into the stomach. The patient was successfully operated on with an in situ aortoaortic tube graft, incorporating the splanchnic vessels, and direct suture of the gastric erosion.

Truncal vagotomy and pyloroplasty combined with valvular replacement in patients with ulcer disease.

In 1988, 5 patients (3 men and 2 women) with ulcer disease (mean age 56 +/- 8 years) underwent valvular replacement for aortic (No. = 4) or mitral disease (No. = 1). All patients had had gastroduodenal ulcers. Preoperative gastroscopy demonstrated active ulcers (No. = 4) and a healed pyloric ulcer with pyloric stenosis (No. = 1). Despite the presence of ulcers, a non-biologic prosthesis was preferred in each patient because of their young age (No. = 3), chronic atrial fibrillation requiring anticoagulant therapy (No. = 1), and refusal of the eventuality of subsequent reoperation (No. = 1). In each patient, a truncal vagotomy with pyloroplasty was performed simultaneously with the valvular procedures by the same incision. The postoperative courses were uneventful. With a mean follow-up of 15 +/- 3 months, no gastrointestinal bleeding was observed during anticoagulant therapy. With anticoagulant drugs, bleeding may occur with a frequency of 4% per patient treatment-year, half of which are gastrointestinal in origin. Nevertheless, in selected patients with gastroduodenal ulcers, performing a vagotomy-pyloroplasty simultaneously with valvular replacement allows implantation of a non-biologic prosthesis, with greater durability than bioprosthesis.

[Leiomyosarcoma of the inferior vena cava: literature review and surgical treatment. Apropos of 2 retrohepatic localizations]. / Léiomyosarcome de la veine cave inférieure: revue de la littérature et traitement chirurgical. A propos de deux localisations rétrohépatiques.

Two cases of leiomyosarcoma of retrohepatic inferior vena cava are reported. The two patients are women and are currently alive with metastases one, seven years, and the other one year postoperatively. Leiomyosarcoma of inferior vena cava s a rare tumor which has an unexplained predilection for women. Clinical symptoms are non specific and depend mostly on the segment of the vessel involved. Preoperative diagnosis is based on ultrasonography, computed tomography and cavography. Although the prognosis is poor due to local recurrence and metastasis, we recommend an aggressive approach by radical tumor resection and caval reconstruction.

[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).

Primary pulmonary hemangiopericytoma: early local recurrence after perioperative rupture of the giant tumor mass (two cases).

We report two recent observations of giant hemangiopericytoma of the lung, one in a 4-year-old child and another in a 65-year-old man. There were no specific clinical signs, but the radiologic appearance was rather characteristic in both cases, as were the histologic findings. Pneumonectomy was carried out, complicated in each case by rupture of the fragile, incomplete pseudocapsule and diffuse dissemination of necrotic tumor tissue in the operative field and opposite bronchial tree. Outcome was fatal in both cases within a few months, with extensive, rapidly growing metastases in the subcutaneous scar tissue of the thoracotomy and in the other lung and in one case with diffuse diaphragmatic and intraabdominal metastases. These two observations will offer some guidelines for better understanding of this rare localization of hemangiopericytoma, its natural history, and its optimal treatment, with special reference to the malignant potential and local recurrence rate.

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.

[Mitral valve replacement in post-infarction rupture of the papillary muscle. Apropos of 13 cases surgically treated during the acute phase of infarction]. / Le remplacement valvulaire mitral pour rupture de pilier mitral post-infarctus. A propos de 13 cas opérés à la phase aiguë de l'infarctus.

Between 1983 and 1988, thirteen patients (12 men and 1 women, average age 63 years) were operated in the acute phase of myocardial infarction for papillary muscle rupture (PMR). The rupture involved the posterior papillary muscle in 12 cases. The average left ventricular ejection fraction was 47 +/- 9 per cent (range 34 to 63%). Pulmonary capillary pressures ranged from 76 to 41 mmHg (average 35 mmHg). Eleven patients presented with acute pulmonary oedema and 7 had cardiogenic shock. Coronary arteriography showed triple vessel disease in 3 cases, double vessel disease in 7 cases and single vessel disease in 3 cases. Surgery was carried out on average 2.7 days after the rupture and 10 days after the initial infarct. In addition to mitral valve replacement (N = 13), 11 patients underwent a myocardial revascularisation procedure. The operative mortality was 15 per cent (N = 2). Papillary muscle rupture in the acute phase of myocardial infarction causes cardiac failure which is related more to the mechanical abnormality than to an alteration of left ventricular function. Considering the operative mortality and the natural history of PMR treated medically, the authors recommend early surgery as the only management which can improve the precarious haemodynamic status of patients with this complication.

[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.