[Persistence of the 5th aortic arch associated with interruption of the aortic arch]. / Persistance du 5ème arc aortique associé à une interruption de l'arche aortique.

We report a case of persistence of the 5th aortic arch associated with total interruption of the aortic arch. This clinical case shows the diagnostic pitfall of the persistence of the 5th aortic arch and its beneficial hemodynamic effect. Preoperative clinical picture was misleading, due to the persistence of femoral pulses and clinical signs of left-to-right shunt via a wide ductus arteriosus. The diagnosis was intraoperatively adjusted on the basis of blood pressure monitoring using catheter placed into the femoral artery.

[Subaortic diaphragm surgery]. / La chirurgie du diaphragme sous aortique.

Subaortic diaphragm is characterized by a certain clinical latency and low morbi-mortality. Surgery remains the treatment of choice despite the real risk of long-term recurrence. Our study involved 18 patients with subaortic diaphragm operated between April 1994 and March 2011. The average age was 18.1 ± 9.7 years, 11 patients were male. The diaphragm was fibrous in 13 patients and fibromuscular in 5 patients. All patients underwent diaphragm resection associated with myectomy, aortic plasty, closure of ventricular septal defect and permeable ductus arteriosus ligation in 3, 3, 2 and 2 patients respectively. Operative mortality was zero and there were no cases of postoperative conduction disorder. With a median follow-up of 44.3±36.8 months, there was no late death. Two patients had a diaphragm recurrence which required reoperation with good evolution. The current trend in diaphragm surgery is towards early interventions and more extensive resections. However, the risk of recurrence requires a systematic and close ultrasound monitoring.

Traumatic leaflet injury during the use of percutaneous valves: a comparative study of balloon- and self-expandable valved stents.

OBJECTIVES: No comparison of balloon- or self-expandable valved stents (VSs) regarding tissue injury (if any) has been reported yet. The objective was to evaluate the occurrence and compare the severity of traumatic injury to leaflets from balloon- or self-expandable VSs. METHODS: Twelve homemade VSs were used for this experiment. These three-leaflet bovine pericardial bioprostheses had either a stainless steel (Group A) or a nitinol stent (Group B). After a 30-min period of compression (external diameter of VS reduced to 7 mm), the prostheses were deployed by balloon inflation (Group A) or by unsheathing (Group B). After H&E staining, pericardial leaflets were subsequently analyzed qualitatively and quantitatively for microscopic lesions. Non-crimped pericardial leaflets were used as a control group (Group C). RESULTS: All deployed VSs had microscopic lesions evocating traumatic injury to pericardial leaflets. Transverse fractures and longitudinal cleavages were the two main lesions encountered. Transverse fractures (no. per field) were significantly more frequent in the VS in comparison with the control group: 5 (range: 0-13), 4 (range: 0-9) and 0 (range: 0-1) in Groups A, B and C, respectively (P < 0.001). Cleavages (no. per field) were also more frequent with balloon-expandable VSs compared with self-expandable VSs [3 (range: 0-7) vs 1(range: 0-8); P = 0.03]. CONCLUSIONS: Traumatic injury to the pericardial leaflets does occur during crimping and deployment of balloon- or self-expandable VSs. Injury may be more severe with the balloon-expandable VSs. The impact of such an injury on prosthesis durability requires a further investigation.

A new endovascular size reducer for large pulmonary outflow tract.

Around 75% of patients with severe pulmonary insufficiency requiring valvular replacement are excluded from percutaneous pulmonary valve implantation (PPVI) due to a large ventricular outflow tract. To extend the indication of PPVI to these patients, a new size reducer has been designed. This 35-mm size reducer was successfully deployed inside the main pulmonary artery through a 21-Fr delivery catheter in six sheep. A 20-mm pericardial valved stent was subsequently deployed inside the size reducer to restore pulmonary valve continence. We successfully verified the efficiency of the delivery catheter by controlling the deployment precisely and reversibly. In all six cases, device positioning was satisfactory. There was no post-procedural residual stenosis in the right ventricular outflow tract in haemodynamic (9.5+/-3 mm Hg), echocardiographic and angiographic studies. After 8-12 weeks of follow-up, no prosthetic migration occurred. The transprosthetic systolic gradient remained low (4+/-2.5 mm Hg) during follow-up. There was one trivial persistent paraprosthetic leak. This study confirmed the feasibility and the effectiveness of this new size reducer to reduce the size of the pulmonary artery.

Congenital mitral valve regurgitation in adult patients. A rare, often misdiagnosed but repairable, valve disease.

OBJECTIVE: Congenital mitral valve regurgitation (MVR) is a rare disease occurring in infancy or childhood. Although congenital MVR has been described in adults, no surgical series has been reported so far. We describe here a 6-year surgical experience of congenital MVR in adults at a single institution. METHODS: We reviewed the data of 15 consecutive patients (8 men), aged more than 16 years (median: 38 years; range: 16-70 years) operated on for severe congenital MVR from June 2000 to March 2006. Congenital MVR represented 2.1% of mitral valve surgery performed in adults during the same period. Patients with atrio-ventricular septal defect or atrio-ventricular discordance were excluded. RESULTS: The congenital MVR was preoperatively diagnosed in six (40%) cases. Two (13%) patients had a Williams-Beuren syndrome. The lesions consisted in annular dilation (100%), prolapsed leaflet (87%), chordal abnormalities (80%), papillary muscle abnormalities (40%) or valvular cleft (33%). Mitral valve repair was performed in all cases using Carpentier's techniques. There was no hospital death or late mortality. At last follow-up (median: 60 months; range: 6-83 months), all patients were in NYHA functional class I or II and in a sinus rhythm. On transthoracic echocardiography, 11 (73%) patients had no or trivial MVR. Mild MVR was present in four (27%) patients. No patient was reoperated and endocarditis did not occur. CONCLUSION: Congenital MVR is rare in adults, often misdiagnosed and accessible to valve repair with excellent mid-term results.

Changing management of cardiac myxoma based on a series of 40 cases with long-term follow-up.

BACKGROUND: Cardiac myxoma is generally considered to be a surgical emergency. However, as a result of progress in echocardiography and the increasing age of the patients presenting with this disease, the clinical presentation has changed and the management of cardiac myxoma now needs to be reviewed. METHODS: Between 1978 and 2001, 40 patients (16 men and 24 women) between the ages of 6 months and 82 years (mean age, 55.6 years) were operated on for cardiac myxoma. Signs of heart failure with pulmonary congestion (22%) or pulmonary embolism (20%) indicated a high-risk emergency situation in some cases, whereas, in other cases (58%), the patient's condition was stable and the clinical presentation was less worrying. However, the tumor was always removed within 24 hours of admission. Most cases of cardiac myxoma observed over the last decade correspond to stable forms, as echocardiography has revealed smaller tumors in generally elderly patients. RESULTS: The postoperative mortality was 7.5% (3 patients). No patients were lost to follow-up, and the mean follow-up was 13.6 years. One patient was reoperated for recurrence 3 years postoperatively. Five patients required further cardiac surgery: three mitral valve replacements, one coronary artery bypass graft, and one angioplasty. The 15-year survival rate was 69%. CONCLUSIONS: Myxoma tends to be observed in a more elderly and higher risk population, often at an early stage. The classic approach of emergency surgery is not always appropriate in these stable forms, allowing more thorough preoperative assessment of these patients.