[Delayed and fortuitous diagnosis of right diaphragmatic rupture during preoperative evaluation]. / Rupture diaphragmatique droite, de découverte tardive et fortuite à la consultation d'anesthésie.

Although diaphragmatic rupture occurs after violent blunt trauma, its diagnosis is often delayed. The intra-thoracic displacement of abdominal organs through diaphragmatic rupture may lead to early or delayed complications because of compression of heart and lungs or strangulation of the abdominal viscera. A 49-year-old woman was scheduled to undergo elective lumbar disc surgery in prone position. The preoperative chest radiograph revealed an abnormally elevated right hemi diaphragm with loops of colon filling the right costophrenic angle. The CT-scan confirmed right chronic diaphragmatic rupture with colon and liver herniations. Fifteen months previously, this woman had been involved in a traffic accident, with blunt right trauma resulting in right pelvic fractures. Perianaesthetic course increase the pre-existing mechanical risk of complications of chronic diaphragmatic rupture. Primary repair of right chronic diaphragmatic rupture through thoracotomy must be recommended. When another surgery must be done in emergency, the feasibility of regional anaesthesia should be considered.

Methylcholanthrene but not phenobarbital enhances caffeine and theophylline metabolism in cultured adult human hepatocytes.

Biotransformation of caffeine and theophylline and the effect of two well-known inducers of P-450 isozymes, namely phenobarbital (PB) and methylcholanthrene (3-MC) were studied in cultured hepatocytes from six human adult donors. Hepatocytes co-cultured with rat liver epithelial cells maintained a higher metabolic capacity than pure cultures. PB treatment of cultured hepatocytes for 3 days slightly increased the rate of caffeine metabolism 1.4 +/- 0.5-fold (N = 6) vs controls, and theophylline metabolism 1.2 +/- 0.4-fold (N = 6), whereas 3-MC treatment increased metabolism markedly 5.8 +/- 2.3- and 3.3 +/- 1.1-fold (N = 6) vs controls for caffeine and theophylline, respectively. Paraxanthine and theophylline formations from caffeine were the most induced by 3-MC. Their increase was significantly correlated (rs = 0.89, P less than 0.007) but not with TB formation, suggesting that at least two isozymes of the P-450IA family are involved in the first demethylations of caffeine. In addition, the N-1 demethylation of theophylline (mean increase of 554% vs controls) was not correlated with the N-1 demethylation of caffeine (mean to increase 247% vs controls) for the same donor after 3-MC treatment, suggesting that these two demethylations are mediated by a different P-450.

Reimplantation of the right internal thoracic artery as a free graft into the left in situ internal thoracic artery (Y procedure). One-year angiographic results.

Reimplantation of the right internal thoracic artery, as a free graft, into the left in situ internal thoracic artery (Y procedure) has enabled us to bypass more distant marginal vessels, which was not possible by the bilateral technique alone. This prospective study was aimed at evaluating the clinical state of the patients and the degree of patency of grafts within 16 months of follow-up. All 80 patients who underwent the Y procedure between January 1988 and January 1992 were included. This group represented 10% of the 840 patients having coronary bypass during the same period. A total of 202 coronary anastomoses were performed in this series. Early postoperative (30 days) complications included three deaths (3.75%), eight myocardial infarctions (10%), one case of phrenic nerve paralysis (1.25%), two cases of respiratory failure (2.5%), and six wound infections (7.5%). At 3 months' follow-up, 96% of patients were free of symptoms. During the follow-up period, four patients died of noncardiac causes (lung, pancreatic, and brain cancer and rupture of an abdominal aortic aneurysm). At 1 year, 71 patients were free of symptoms (97%). Sixty-one patients underwent coronary angiography between 12 and 24 months. Six patients with peripheral arterial disease were not suitable for coronary angiography, and six refused to be tested. These 12 patients had normal thallium test results in the bypassed area (stress or dipyridamole test). The patency rate of the left internal thoracic artery was 98.3% (n = 60), occlusion rate 1.6% (n = 1), and incidence of threadlike arteries 4.9% (n = 3). Thus the rate of perfect patency was 93.4%. The patency rate of the right internal thoracic artery as a free graft was 93.4% (n = 57), occlusion rate 6.5% (n = 4), and the incidence of threadlike arteries 8% (n = 5). Thus the rate of perfect patency was 85.2%. A total of 169 anastomoses were studied. The rate of patency of the anastomoses to the left anterior descending coronary artery was 96% (n = 58) and the occlusion rate, 4% (n = 2). The patency rate of sequential anastomoses (side to side) to diagonal arteries was 100% (n = 16). Patency rate of anastomoses to obtuse marginal arteries was 95% (n = 58) and the rate of occlusion, 4.9% (n = 3). The patency rate of anastomoses to the posterior descending artery or distal branches of the right coronary artery was 80% (n = 4/5).(ABSTRACT TRUNCATED AT 400 WORDS)

Coronary artery reconstruction for extensive coronary disease: 108 patients and two year follow-up.

BACKGROUND: Surgical coronary artery reconstruction for diffuse coronary disease is described and assessed. METHODS: A long arteriotomy, internal thoracic artery graft, and exclusion of atheromatous plaques from the coronary lumen are the bases of the technique. One hundred eighteen reconstructions were performed in 108 patients with a mean age of 59 years. Stable angina was present in 62% of patients and unstable angina in 22%. Sixteen percent had had a recent myocardial infarction. The reconstructions involved 94 left anterior descending coronary arteries, 17 marginal, 5 diagonal, and 2 right coronary arteries. RESULTS: The perioperative mortality rate was 3.7% (4 patients). The rate of perioperative myocardial infarction was 6.3%. Mean follow-up was 29 months (standard deviation, 10 months). Two patients were lost to follow-up. Ninety patients were free from angina and cardiac-related events. Five patients sustained a myocardial infarction, 3 were in congestive heart failure, 3 had class II angina, and 1 died of stroke. Seventy-four of the surgical coronary artery reconstructions have been angiographically evaluated (29 months): 94.6% of the internal thoracic artery grafts were completely patent, and 70 of the reconstructions were patent without restenosis. String signs and occlusions were present in two internal thoracic arteries each. CONCLUSIONS: This technique allows revascularization of severely and diffusely diseased coronary arteries with encouraging results.

Intermittent left coronary occlusion caused by native aortic valve thrombosis in a patient with protein S deficiency.

A 77-year-old woman presented with chest pain and cardiogenic shock. Transesophageal echocardiography showed a mobile mass occluding intermittently the left coronary ostium. The mass was surgically resected, and histologic examination revealed an organized thrombus. Coagulation study demonstrated a protein S deficiency. This is the first case of aortic thrombosis associated with protein S deficiency, and it is the first time that transesophageal echocardiography provided definite evidence that a mass can cause intermittent left ostium coronary obstruction.

Surgical angioplasty with exclusion of atheromatous plaques in case of diffuse disease of the left anterior descending artery: 2 years' follow-up.

OBJECTIVE: A new surgical technique of coronary artery angioplasty for diffuse and extensive lesions of the left anterior descending artery (LAD) is evaluated in this study. METHOD: Ninety-four coronary artery reconstructions (CAR) using a new technique of angioplasty of the LAD were performed: mean age of patients was 59+/-8 years, there were 21 patients with unstable angina, and 21 with recent myocardial infarction (MI). SURGICAL TECHNIQUE: Diseased LAD is bypassed with the internal thoracic artery graft (ITA). The anastomosis is made downstream from the significant proximal lesion of the LAD. A long arteriotomy (from 2 to 12 cm) is performed along the LAD up to the healthy arterial wall, followed by coverage with the onlay graft of ITA in such a fashion as to exclude the plaques from the LAD lumen. The wall of the new reconstructed LAD consisted of 75% of ITA and 25% of native LAD. The remaining part of the native LAD forms a posterior gutter giving the origins of septal and diagonal branches. RESULTS: aortic cross-clamping time was 116 min, operative mortality rate was 3.2% (three patients), peri-operative infarction rate 6.6% (six patients). The follow-up was 29 months (SD=10). Of the 91 survivors, two were lost for follow-up and one died of non-cardiac causes. Of the 88 patients clinically evaluated, 81 were free from angina and other cardiac events, two had new myocardial infarction in a non-grafted area, two were in congestive heart failure, and three in angina class II. Sixty patients underwent angiography. There were 57 perfect-patency CAR (95%), two ITA string sign (competitive flow), two ITA occlusions (2.5%) and no re-stenosis. CONCLUSIONS: CAR allows revascularisation of diffusely diseased LAD with acceptable operative mortality and morbidity, 2 years' good clinical results and graft patency. In this series, exclusion of plaques prevented plaque complications.

[Patency of left border artery bypass after 1 year; comparison of three techniques]. / Perméabilité à 1 an des pontages de l'artère marginale gauche; comparaison de trois techniques.

The one year results of three techniques of bypass grafting of the artery of the left border of the heart were compared in a retrospective study in 120 patients all undergoing left anterior descending bypass grafting with an internal mammary artery. Group I comprised 38 consecutive patients: the left border artery was bypassed with a venous graft. Group II comprised 49 consecutive patients who had the left border artery bypassed by an internal mammary artery in situ. Group III comprised 33 consecutive patients who had the left border artery bypassed by an internal mammary graft issuing from a Y-shaped construction (right internal mammary artery as a free graft reimplanted into the left internal mammary artery). The operative mortality, morbidity and functional results were comparable in the three groups. The rate of angiographic success of the left border artery graft at one year was: 65.7% in group I, 89.5% in group II and 87.8% in group III. The one year patency of internal mammary artery grafting of the artery of the left border was higher than that of venous grafts (p < 0.05).

[Permanent cardiac stimulation after aortic valve replacement: incidence, predictive factors and long-term prognosis]. / Stimulation cardiaque définitive après remplacement valvulaire aortique: incidence, facteurs prédictifs et pronostic à long terme.

Between January 1981 and June 1992, 382 patients, operated by the same surgical team, underwent aortic valve replacement for pure severe aortic stenosis. This population was divided into 2 groups according to whether or not surgery was complicated by the development of a conduction defect (atrioventricular and/or intraventricular block), necessitating permanent cardiac pacing. The aim of this study was to analyse not only the incidence and predictive factors but also the long-term prognosis of the paced patients (Group II: 22 patients) in comparison with the control group (Group I: 360 patients). The results showed: the incidence of permanent cardiac pacing after this type of surgery remains low (5.7%); the predictive factors of atrioventricular block requiring permanent pacing were: pre-existing conduction defect (p < 0.02), decreased ejection fraction (p < 0.05), calcification extending to the subaortic interventricular septum (p < 0.0001); the long-term prognosis of the patients was good with 5 and 10 year actuarial survival rates of 95.4% and 68.9% respectively, identical to those of the control group.

[Evaluation of postoperative mortality and quality of life of patients over 75 years of age after valve replacement for aortic stenosis. Report of 110 cases]. / Evaluation de la mortalité et de la qualité de vie postopératoire des sujets de plus de 75 ans après remplacement valvulaire pour rétrécissement aortique. A propos de 110 cas.

The authors carried out a retrospective study of short and long-term mortality after aortic valve replacement and assessed the quality of life by the IRIS scale in patients over 75 years of age operated for severe aortic stenosis at the University Hospital of Brest between June 1990 and March 1995. The hospital files of 110 consecutive patients (71 women, 39 men; average age 78 +/- 2 years, range 75-85 years) were studied. The pre- per- and postoperative data was studied. Each survivor was contacted by telephone during the year 2000 and a health and IRIS quality of life questionnaire was sent to them. Precise information about patients who had died was obtained from the family and/or medical practitioner. In the preoperative period, 30.9% of patients had left ventricular failure. The average aortic valve surface area was 0.53 +/- 0.12 cm2. Of the patients who underwent coronary angiography (60%), one third had significant coronary lesions. Coronary artery bypass surgery was associated with aortic valve replacement in 10% of cases. Biological prostheses were used in 108 patients. The operative mortality was 8.2%. One year, 5 year and 10 year survival rates were 89.9%, 75.5% and 33.3% respectively. Of the survivors, 16.7% were in institutional care and 83.3% lived at home. A total of 77.8% were readmitted to hospital, about half of them for cardiac problems. Cardiac treatment was prescribed for 97% of patients. The quality of life questionnaire was completed by 35 patients: the quality of life was better than average in nearly 83% of these patients. Aortic valve replacement for aortic stenosis in patients over 75 years of age improves life expectancy which is almost the same as that of the normal population of the same age, and improves the quality of life by restoring functional autonomy, enabling the majority of them to live in their own houses most of the time.

[Sequential revascularization of anterior myocardium using the internal mammary artery. A year-long clinical and angiographic follow-up]. / Revascularisation séquentielle du territoire myocardique antérieur au moyen de l'artère mammaire interne. Suivi clinique et angiographique à 1 an.

One hundred and twenty-one consecutive patients (104 men, 17 women; mean age 56 +/- 7.8 years) underwent sequential mammary artery grafting for anterior (left anterior descending or diagonal arteries) wall revascularisation. There was one death (0.8%) and five myocardial infarctions (4.2%) including two anterior infarcts during the first 30 postoperative days. All survivors were reviewed at one year. Of these 120 patients, 77 (64%) accepted control coronary angiography on average 456 +/- 143 days after surgery. One internal mammary artery anastomosed to 2 diagonal arteries was occluded. All the other latero-lateral anastomoses were patent. There was, however, one 60% stenosis. Three termino-lateral anastomoses on the left anterior descending artery were occluded and 2 others stenosed (40% and 60% luminal narrowing, respectively). Four internal mammary arteries were narrowed 2 because of stenosis and 2 because of the small calibre of the receiving artery. The patency rate considering the total number of anastomoses was therefore 96.8%. These results show that sequential internal mammary artery grafting for myocardial revascularisation does not increase the number of perioperative complications and is associated with a low rate of occlusion on the left anterior descending artery at one year. This surgical technique may therefore be used routinely.

[Vascular complications of lumbar disk surgery. Report of two cases and review of the literature on 122 cases]. / Complications vasculaires de la chirurgie discale lombaire. A propos de deux cas et d'une revue de littérature de 122 cas.

We report two cases of right lumbar common iliac arteriovenous injury after an operation on the L4-L5 disk. One case was an arteriovenous fistula disclosed 5 years after the operation and in the other case, a postoperative acute haemorrhage. A retrospective study is carried out in the literature aiming at establishing the frequency of vascular injury in lumbar disk surgery, their nosologic definition, and the provided treatment. One hundred and twenty two observations were taken into account. The frequency cannot be determined. 78 of these observations (63.9%) reported an arteriovenous fistula between two elements of the aortic-cava intersection, with acute revelation (6.4%), sub-acute (19%) or late as a right cardiac failure (64%). Thirty one cases of acute haemorrhages through isolated arterial wound (25.4%), 3 cases of arterial or venous thrombosis (2.5%) and 10 cases of false aneurysms (8.2%) were found. The treatment was always surgical, sometimes in high emergency. In the case of haemorrhage the death rate was 21% and in the event of fistula 1.3%. Morbidity was 11.5%, mostly due to a post-phlebitic syndrome. These results reduce the mildness reputation of lumbar disk surgery all the more as recording of the complications is under estimated and most of them are found far from the initial act.

[Late spontaneous revascularization of an internal mammary graft onto the anterior interventricular artery]. / Reperméabilisation tardive spontanée d'un pontage mammaire interne sur l'artère interventriculaire antérieure (IVA).

The authors report a case of internal mammary artery graft anastomosed to the left anterior descending coronary artery (LADC) which was found to be non functional in the early post-operative period (one month) but second catheterization at one year revealed the graft to be patent with thrombosis of the LADC. This case shows the flow adjustment possibilities of internal mammary artery graft.

[Double and sequential mammary artery bypass grafts. Apropos of 184 patients]. / Doubles greffons mammaires et pontages mammaires séquentiels. A propos de 184 patients.

In this series of 184 patients (pts), 312 internal mammary arteries were used to graft 430 coronary arteries. Two mammary arteries were used in 104 pts and sequential anastomoses were performed in 118 pts. The operative mortality was 1.6% and the peri-operative myocardial infarction was 4.1%. 9% of patients had post-operative complications: 1% of bilateral phrenic paralysis, 2.1% of post-operative hemorrhage leading to reoperation, 1.6% of sternal infection, 0.5% of true mediastinal infection, 1.6% of sternal dehiscence and 2.7% of reversible psychiatric illness. A 3 month follow-up was available in 160 pts. 95% of patients became angina free, the thallium scan shown a normal uptake of thallium at maximal stress in the myocardial grafted area in 92% of the patients.

[Complex coronary reconstructions using the internal mammary artery. Technique of surgical angioplasty, preliminary results]. / Reconstructions coronaires complexes avec l'artère mammaire interne. Technique de l'angioplastie chirurgicale, résultats préliminaires.

A technique of coronary surgical angioplasty is described. The long arteriotomy of the coronary artery over the stenosis is closed with the Internal Thoracic Artery (ITA) giving an enlargement patch effect. The majority of the atheromatous plaque is excluded from the lumen of the anastomosis and placed outside the suture line. The origin of the collateral arteries is preserved in the vascular lumen. The remodeled coronary artery is composed of a small gutter of native coronary artery and the whole surface of the ITA wall. In some cases, it is useful to associate a limited endarterectomy with the angioplasty. 66 surgical angioplasties have been performed in extensive coronary disease. Operative mortality was 5.4% with a myocardial infarction rate of 5.4%.

[Distribution of cardioplegia by retrograde approach. Cannula of retrograde cardioplegia with manually inflating balloon versus self-inflating balloon]. / Distribution de la cardioplégie par voie rétrograde. Canule de cardioplégie rétrograde à ballonnet gonflable manuellement versus ballonnet auto-gonflable.

Retrograde cardioplegia is still debated due to heterogeneous left ventricular flow distribution. The purpose of this study was to compare retrograde flow distribution delivered through the coronary sinus with two patterns of cannula. Fifty four patients were prospectively randomized to receive cold crystalloid retrograde coronary sinus cardioplegia with lither a manual inflating balloon cannula (group I, 24 patients) or a self-inflating balloon cannula (group II, 30 patients). Left ventricular distribution of the cardioplegic solution was assessed by monitoring the left ventricular wall temperatures (anterior and posterior). The cardioplegic retrograde infusion was stopped as the anterior wall temperature reached 12 degrees C. In group II, 70.8% of patients had an identical cooling in the anterior and posterior wall of the left ventricle, versus 40.9% in group I (p < 0.05). The mean temperature difference between anterior and posterior wall was 2.9 degrees C (standard deviation: 2.9 degrees C) in group II versus 5.7 degrees C (standard deviation: 4.3 degrees C) for group I (< 0.05). The retroplegia cannula with the self-inflating balloon allows a better distribution of the cardioplegia flow than the manually inflating balloon. We think that this is due to the shape of the self-inflating balloon which more closely fits the morphology of the coronary sinus.

[Right internal mammary artery reimplantation into the left internal mammary artery. Y anastomosis. 25 cases]. / Réimplantation de l'artère mammaire interne droite dans l'artère mammaire interne gauche. Montage en Y--vingt-cinq cas.

Distal latero-circumflex arteries (DLCA) and posterior descending artery (PDA) are anatomically too far and cannot be revascularized with internal mammary artery (IMA) by a conventional procedure. The reimplantation of the right IMA into the left IMA in situ increases (2 times) the length of right IMA graft available. Fifty-five patients underwent this technique. Their preoperative status was: 22 males, 3 females; mean age: 57 years, 38% myocardial infarction (MI). Coronary angiography showed: stenosis of the left main coronary artery: 3; stenosis of 3 vessels: 15; 2 vessels: 10; 2.3 anastomoses by patient were performed with Y right and left IMA procedure: 24 LDA, 8 diagonals, 25 DLCA and 1 PDA anastomosis. No deaths were observed in this short series. Morbidity was: 1 MI, 2 sternal sepsis, 1 bilateral phrenic paralysis (all were cured without sequelae). To date (March 90) 15 patients have been followed for 3 to 12 months, 12 are angina-free, 3 are significantly improved, 11 have a negative exercise test. Thallium test is normal in the revascularized area in 14 patients. Seven angiographies have been performed (6 months to 1 year) and all Y right IMA are patent.

[One year results of sequential mammary artery anastomoses. 120 clinical cases. Angiographies: 71 patients]. / Résultats à un an des anastomoses mammaires séquentielles. Cliniques: 120 cas--Angiographies: 71 patients.

From 1985 to november 1989, 270 patients underwent sequential anastomosis with left internal mammary artery (LIMA) on left descending artery (LDA) and diagnonal artery (DA). The first 120 cases have 100% one year follow-up. The perioperative status was: angina stage III or IV: 59%; myocardial infarction (MI): 45%, stenosis of 3 vessels: 52.5%; stenosis of main coronary artery: 10.8%. 2.25 anastomoses were performed per patient. Side-to-side anastomosis (kissing) were not diamond anastomoses but axial and longitudinal. The use of fibrin gllude provides regular curves of the graft between anastomosis. Mortality was 0.8%, morbidity was: MI: 4.2% (2 small infarcts in anterior vessels, 3 others in non-grafted vessels); mediastinitis: 1%; severe bleeding (reoperation): 1%. At one year 93% of patients are free from angina and 71 patients underwent angiographic assessment (145 LIMA anastomosis). Results are as follow: side-to-side anastomosis patency: 98.5%; distal anastomosis obliteration: 3%; LDA anastomosis patency: 95.7% overall sequential anastomosis patency: 97.6%. These results have led our cardiologist in Brest to naturally prefer a surgical approach than percutaneous angioplasty when LDA and DA are involved.

[Prenatal diagnosis of congenital cystic adenomatoid malformation of lung: perinatal management. Apropos of 4 cases]. / Malformation kystique adénomatoïde pulmonaire congénitale de diagnostic anténatal: prise en charge périnatale. A propos de quatre observations.

BACKGROUND: Cystic adenomatoid malformation of the lung can be seen by ultrasonography during pregnancy. Surgical excision of the affected lobe is indicated during the first days of life. CASES REPORT: Four neonates were admitted to an intensive care unit from March 1988 to February 1992, due to cystic adenomatoid malformation of the lung, that had been diagnosed by ultrasonography at 19, 22, 34 and 37 weeks of gestational age, respectively. These malformations were not associated with other abnormalities and were type I (three cases) and II (one case) according to Stocker's classification. Only one patient became symptomatic, requiring intubation by 72 hours of age. Surgical excision of the affected lobe was performed in three patients at 4 hours, 2 and 7 days of life, respectively, with a normal long-term survival. A segmental resection was performed at 5 days of life in the remaining symptomatic patient but persistence of cystic lesions required lobectomy at 10 months. CONCLUSIONS: Early perinatal management of cystic adenomatoid malformations of the lung is necessary as surgical excision is indicated as soon as possible, even in asymptomatic patients.

[Left ventricular distribution of retrograde cardioplegia. Should the interventricular posterior vein be occluded in the coronary sinus?]. / Distribution ventriculaire gauche de la cardioplégie rétrograde. Faut-il obturer la veine interventriculaire postérieure dans le sinus coronaire?

Retrograde cardioplegia is still controversial due to the heterogeneous left ventricular flow distribution particularly in the posterior wall. The purpose of this study was to compare retrograde flow distribution delivered through the coronary sinus with two types of cannula. Fifty two patients were prospectively randomized to receive cold blood retrograde cardioplegia with manual inflating long balloon prototype cannula (group I, 26 patients) or with manual inflating short balloon cannula (group II, 26 patients). Left ventricular distribution of the cardioplegic solution was assessed by monitoring the left ventricular wall temperatures (anterior and posterior). The cardioplegic retrograde infusion was stopped as the anterior wall temperature reached 15 degrees C. In group I, 91% of the patients had identical cooling in the anterior and posterior wall of the left ventricle, versus 19% in group II (p < 0.05). The mean temperature difference between anterior and posterior wall was 0.5 degrees C (standard deviation = 1.7) in group I versus 8 degrees C (standard deviation = 4.1) in group II (alpha < 0.05). The cannula with the long balloon allows a better left ventricular distribution of the cardioplegia flow than the short one because it occludes the interventricularis posterior vein in the coronary sinus.

[Hypertrophic arteriovenous fistula for hemodialysis. Reduction by means of a constrictive perivenous mesh]. / Fistules artério-veineuses hypertrophiques d'hémodialyse. Réduction à l'aide d'un filet péri-veineux constrictif.

Aneurysmal arteriovenous fistulae (AVF) for haemodialysis often need surgical closure. We present a technique which consists of inserting the AVF into a constrictive perivenous mesh tube, thereby bringing the caliber of the AVF down to its normal size and restoring the normal shape of the forearm. Nine patients underwent AVF constriction without postoperative events. All AVFs were patent at 4 months. This technique also has the advantage of saving veins which, of course, is worthwhile in patients under haemodialysis.