Retroesophageal subclavian artery aneurysm arising from Kommerell's diverticulum.

This report describes a novel technique used for management of retroesophageal subclavian artery aneurysm arising from Kommerell's diverticulum. The procedure consists of endoaortic exclusion of the aneurysmal neck, using a prosthetic patch after sternotomy during circulatory arrest, and antegrade cold blood cerebroplegia. The advantages of this technique are avoidance of hemorrhagic complications during clamping of the aneurysmal neck, limiting of the extent of dissection of the aortic arch, and elimination of the risk of inadvertent left recurrent nerve paralysis. Antegrade cold blood cerebroplegia provides good cerebral protection and decreases the duration and consequences of extracorporeal circulation.

Ventricular patch endocarditis caused by Propionibacterium acnes: advantages of gallium scanning.

Propionibacterium acnes is a weakly pathogenic commensal of the skin. When isolated from blood cultures it is often considered a contaminant. However, P. acnes may be responsible for severe infections and its role in certain cases of infectious endocarditis has now been definitely established.(1) We report a case of endocarditis due to P. acnes stemming from a ventricular patch and revealed by a gallium 67 scan.

[Technical problems during coronary revascularization in case of massive calcified aorta]. / Problèmes techniques rencontrés au cours des revascularisations coronariennes avec aorte massivement calcifiée.

A massively calcified ascending aorta which may make aortic clamping impossible, is a major obstacle to coronary revascularisation surgery. The aim of this study was to demonstrate that by the use of certain technical modifications, these patients can be treated even in multivessel disease. In the author's experience, two patients with this condition underwent complete revascularisation with a good surgical result controlled by angiography. The sites of arterial cannulation were the aortic arch in one case, the brachiocephalic artery and the common femoral artery in the other case. The ascending aorta was not clamped in either patient or used as the origin of the coronary bypass grafts. Myocardial protection was performed by systemic cooling with ventricular fibrillation without cardioplegia. The feasibility of these methods has led to the suggestion of a classification of the aortic wall according to peroperative palpation. This classification would provide indications for the use of technical modifications not only in extreme cases of aortic calcification but also in patients with severe atherosclerotic changes at high neurological risk; it would not, however, interfere with the classical technique of revascularisation.

[Postoperative acute aortic dissection. Apropos of two cases]. / Dissection aortique aiguë post-opératoire. A propos de deux cas.

Aortic dissection after cardiac surgery is a rare complication. The prognosis is often poor: 33-78% of mortality. The study of two cases out of 2100 patients operated upon during the last three years, and the review of the literature, allows to recall the mechanism, the anatomic origin and the different surgical techniques. Early diagnosis is essential. Some preventive techniques may reduce the incidence of the iatrogenic dissections.

Spontaneous dissecting aneurysm of the common iliac artery.

A 52-year-old man sought medical advice for sudden onset of intermittent claudication of the left lower limb after 50 meters walking. Aortography documented a dissecting aneurysm limited to the left common iliac artery. After resection, a prosthetic graft was inserted. Pathology showed that the cause of the dissection was atheroma. Spontaneous dissecting aneurysm of the common iliac artery is rare. Rupture represents the principal hazard. A high index of suspicion should lead to diagnosis as soon as signs of lower limb ischemia, occasionally transient, appear.

[Protection and reperfusion of the myocardium by cardioplegia with blood enriched in aspartate and glutamate. Technique and initial results. Report of 60 cases]. / Protection et reperfusion du myocarde par cardioplégie au sang enrichie en aspartate et glutamate. Technique et résultats préliminaires. A propos de soixante patients.

From 1st November 1987 to 30th September 1988, 27 patients with recent myocardial infarction and 33 patients at high risk of postoperative circulatory failure were operated according to the same protocol. In each case, myocardial protection, at the time of aortic clamping, consisted of an intra-coronary injection of a cardioplegic solution of blood enriched with aspartate and glutamate, administered in 3 phases (normothermic induction, hypothermic induction, normothermic reperfusion) according to the protocol described by Buckberg et al. The operative mortality was 11.6% (7/60) and 46.6% (28/60) of patients did not develop any postoperative complications. It is difficult to draw any conclusions concerning the superiority of the method on the basis of a non-comparative clinical study, but its simple application and its safety appear to be clearly demonstrated.

[Intra-aortic balloon counterpulsation. Percutaneous insertion at surgical units. Apropos of 170 cases]. / Contre-pulsion par ballon intra-aortique. Insertion par voie percutanée en milieu chirurgical. A propos de 170 cas.

From 1st January 1985 to 31st December 1987, an intra-aortic balloon counterpulsation device (IABCP) was inserted in 170 patients: 166 balloons were inserted percutaneously and 4 surgically after failure of the percutaneous route. The indications for insertion of IABCP are classified into 3 categories. Category 1 (N = 28) consists of non-operated patients, category 2 (N = 60) consists of patients in whom IABCP balloons were inserted by necessity before, during of after a surgical operation under cardiopulmonary bypass (CPB) and category 1 (N = 82) consists of patients in whom the IABCP balloons were inserted prophylactically prior to an operation under CPB in patients at high risk. Sixteen patients with a percutaneous IABCP balloon developed a major complication related to the balloon (9.6 +/- 2.3%). The early mortality for the entire population was 49.4 +/- 3.8% (84/170). The mortality was 89 +/- 6% (25/28), 65 +/- 6% (39/60) and 24 +/- 5% (20/80) respectively in categories 1, 2 and 3. In category 3, 56 IABCP balloons (68.3%) were retrospectively considered to be necessary (group A). Nineteen patients in group A died (34 +/- 6%). The mortality observed in the 30 patients in category 2 in whom an IABCP balloon was required during the intra- or post-operative period (group B) was 76.6 +/- 7.7% (23/30). It was significantly higher than that observed in group A (p less than 0.001). However, the retrospective nature of this study prevented any formal conclusions concerning the benefit provided by prophylactic IABCP.

[Coronary endarterectomy associated with by-pass. A series of 111 patients controlled angiographically]. / Endartériectomie coronaire associée au pontage. Une série de 111 patients contrôlés angiographiquement.

Out of 2 638 patients undergoing coronary bypass surgery at the Arnault Tzanck Centre from 1973 to September 1984, 305 (12%) also required coronary endarterectomy. One hundred and eleven of these patients had control angiographies at the Centre and were the object of this study. Endarterectomy was carried out on a totally occluded artery in 38% of cases and was performed out of necessity in the other cases. One hundred and twenty-nine disobliterations were performed in these 111 patients. The average number of bypass grafts per patient was 2.8. The overall hospital mortality was 6% (19 out of 305) which was higher than for bypass surgery alone. The postoperative myocardial infarction rate was 10%. The 117 control angiographies were performed on average during the 8th month after surgery; these controls were routine in 99 cases (84.5%) in Stage I of the NYHA classification and for recurrent angina in 18 cases (15.5%). The endarterectomised vessel was patent in 72% of cases, which was less than the patency rate of the bypass grafts. Considering the indications of necessity, this result is satisfactory and is compared which those of other reported series.

[Congenital tracheal stenosis associated with aberrant left pulmonary artery. Apropos of a severe form with neonatal disclosure]. / Sténose trachéale congénitale associée à une artère pulmonaire gauche aberrante. A propos d'une forme sévère à révélation néonatale.

The case report is presented of a newborn infant afflicted with extensive congenital tracheal stenosis associated with anomalous left pulmonary artery, proving rapidly fatal. The possibility of tracheal anomaly must be envisaged in the face of any neonatal respiratory distress unexplained by pulmonary parenchymatous pathology. Diagnosis of this complex malformation relies on endoscopy and oesophagogram and tracheo-bronchogram contrasts.

[Transluminal coronary angioplasty. Experience apropos of 155 procedures]. / L'angioplastie coronaire transluminale. Expérience à propos de 155 procédures.

The authors report their experience of transluminal coronary angioplasty (TCA) from February 1980 to November 1983. 140 patients underwent TCA and 155 procedures were performed. The mean age was 55 years (range 33 to 74 years). Clinically, the patients presented with Stage I angina in 26 cases (18 p. 100), Stage II in 18 cases (13 p. 100), Stage III in 24 cases (17 p. 100) and Stage IV in 72 cases (52 p. 100), according to the NYHA Classification. 23 patients (16.5 p. 100) underwent combined thrombolysis - TCA. The coronary artery disease was limited to a single vessel in 135 cases (96 p. 100) and involved 2 vessels in 5 cases (4 p. 100). The overall results showed a 71 p. 100 primary success rate. There were no fatalities. The incidence of myocardial infarction was 3 p. 100 (5 patients) and emergency coronary bypass surgery was necessary in 16 patients (10 p. 100). The results in two groups of patients were compared: Group A: 69 patients treated with a conventional balloon catheter. Group B: 86 patients treated with a balloon catheter with a guide wire. The coronary stenosis was catheterised in 73 p. 100 of patients in Group A, and 90 p. 100 of patients in Group B (p less than 0.01). The primary success rate was 56 p. 100 in Group A and 83 p. 100 in Group B. The use of this new material improves the primary success rate and also makes more distal, anatomically atypical lesions, accessible.

[Emergency surgical revascularization in establishing myocardial infarctions. Treatment of subtotal coronary occlusions]. / Revascularisation chirurgicale urgente dans l'infarctus du myocarde en voie de constitution. Traitement des occlusions coronaires subtotales.

The introduction of intracoronary thrombolysis as a treatment for myocardial infarction has led to an increase in the number of very early coronary angiographies carried out in the acute phase of myocardial infarction. These investigations can be performed without excessive risk. In some cases, severe stenosis with significant distal circulatory impairment without evidence of thrombosis is found. In these very early investigations, these findings may represent a "pre-thrombolic" lesion in an evolving myocardial infarction. Six cases of very severe pre-thrombolitic stenosis of the LAD were observed in a series of 67 coronary angiographies performed in the early stages of myocardial infarction. These six cases were selected on strict clinical, ECG and angiographic criteria. One patient was hospitalised with cardiogenic shock. The six patients underwent emergency coronary bypass surgery: average time from admission to coronary angiography was 55 minutes; average time from coronary angiography to surgery was 3 hours. These 6 pre-thrombolic lesions of the LAD were also associated with lesions of the left circumflex and right coronary arteries. There were no operative complications but two patients had stormy immediate postoperative periods. There was no hospital mortality. All patients were reinvestigated at 1 month and all grafts were shown to be patent. The left ventricular ejection fractions improved in 3 cases, remained unchanged in 2 cases, and deteriorated in 1 case (the patient with cardiogenic shock). These results suggest that emergency coronary bypass surgery is a rational treatment of pre-thrombolic coronary stenosis observed at early coronary angiography in patients with evolving myocardial infarction in order to preserve as much myocardial muscle as possible.

[Effect of open heart surgery on intellectual efficiency. Prospective study apropos of 40 cases]. / Retentissement des interventions à coeur ouvert sur l'efficience intellectuelle. Etude prospective à propos de 40 cas.

Neurological accidents following open heart surgery have become exceptionaly rare because of technical advances. However, some minor intellectual problems are quite common (loss of memory, lack of concentration...). The results of previous studies on this subject have been quite contradictory. A prospective study of 40 patients was undertaken to determine the repercussions of open heart surgery with cardiopulmonary bypass on intellectual efficiency. The protocol chosen used Wechsler's intelligence test, the calculation of mental deterioration based on this test and Wechsler's clinical scale of memory. The tests were performed before surgery, in the immediate postoperative period and after six months (30 patients). The purely cardiological side of these cases and social considerations were also taken into account. In the immediate postoperative period, 55% of patients showed signs of intellectual deterioration, with respect to their age. After six months, the overall incidence was 25%. Some patients showed intellectual deterioration before surgery. The influence of the type of surgery is difficult to determine. The cardiopulmonary bypass time was significant. The preoperative intellectual level was also important, as was the return to normal activities after surgery. Finally, age, of course, played an important part. These results cannot be isolated from the study of the psychological reactions of the patients to cardiac surgery and their influence on the outcome and rehabilitation after surgery.