Complete replacement of the ascending aorta with reimplantation of the coronary arteries: new surgical approach.

Thirty patients had total replacement of the ascending aorta with reimplantation of the coronary arteries, 20 for a fusiform aneurysm of the ascending aorta and 10 because of a dissection of the ascending aorta, of which there were acute. All had associated aortic insufficiency. The technique consists of implantation, within the aneurysmal sac, of a Dacron prosthesis containing a Björk-Shiley aortic valve. The coronary orifices are anastomosed to the tubular Dacron prosthesis by means of a second smaller Dacron tube. The aneurysmal pouch is then closed over the entire appliance and a fistula between the aneurysmal sac and the right atrial appendage is created to drain oozing from the prosthesis. The operative mortality was 10% (three deaths) and the late mortality has been 14.8% (four deaths). The deaths, early and late, have been confined to the first 10 cases, during which time the technique was being developed. There has been no mortality among the last 20 patients. The 23 survivors followed for an average of 19 1/2 months (range 6 months to 5 1/2 years) are in NYHA Functional Class I (21) or II (two). The technical modifications utilized in this series have simplified the operation and permit the proposal of this technique for aneurysm involving the entire ascending aorta.

Encircling endocardial ventriculotomy: a new surgical treatment for life-threatening ventricular tachycardias resistant to medical treatment following myocardial infarction.

Ventricular tachycardias occurring after myocardial infarction (MI) and resistant to medical treatment were successfully treated in 5 patients by encircling endocardial ventriculotomy. All patients had a history of MI. The delay between MI and ventricular tachycardias ranged from 1 month to 8 years. A reentrant mechanism was demonstrated by laboratory studies. Under cardiopulmonary bypass, the left ventricle was entered through the thin fribrous scar. Encircling endocardial ventriculotomy was carried out from the inside of the ventricle, through the whole thickness of the normal myocardium, and along the border of the endocardial fibrosis, which delineated the area of diseased myocardium. The ventriculotomy was placed in the free wall or in the septum or in both of these locations. It was repaired and the left ventricle was closed. Drug therapy was discontinued after operation. No ventricular tachycardias recurred during a follow-up period of 6 to 24 months. The effectiveness of encircling endocardial ventriculotomy is explained by the exclusion of the entire diseased area, especially the border zone and the septum. This technique is useful in any location of MI.

Surgical treatment of acute dissection of the aorta superimposed on pre-existing aneurysm of the ascending aorta. Total replacement of the ascending aorta with reimplantation of the coronary arteries. A report on five cases.

Five cases of acute dissection of the ascending aorta superimposed on a pre-existing aneurysm, including two with propagation of the dissection into the coronary arteries, were treated by total replacement of the ascending aorta utilizing a valve containing tube graft and reimplantation of the coronary arteries. Diverse techniques such as the use of an intermediate tube for reconnecting the coronary arteries, correction of the coronary dissection by reapproximation of the two layers or with bypass grafting, support of the distal aortic suture line with Teflon felt and fistulization of the periprosthetic space to the right atrium, greatly simplified the treatment of these lesions, permitting survival of four out of five patients, who are in excellent health one, four, and seven years respectively after surgery.

[Evaluation of the size of atrial septal defects by subxiphoid approach in two-dimensional echocardiography]. / Estimation de la taille des communications interauriculaires par voie sous-xiphoïdienne en échocardiographie bidimensionnelle.

In order to assess whether subxiphoid two-dimensional echography is a reliable method to evaluate the size of atrial septal defects (ASD), we compared echocardiographic and per-operative measurements. We then tried to determine whether the size of the defect correlated with the importance of the shunt at catheterization. The records of 23 patients (16 female, 7 male) operated upon for uncomplicated ASD were selected. Mean age was 23.5 +/- 17.3 years (range: 8 months to 62 years). Two-dimensional echocardiography was performed by the "reversed" subxiphoid route, using two projections: "4-cavity section" and an oblique section, perpendicular to the first one, through the atria and the aortic arch. The greater echographic diameter was compared with the greater diameter measured at surgery. The ASD area, assimilated at echography to a circle, was compared with the per-operative area (elliptic or circular opening depending on whether 1 or 2 dimensions were available). Per-operative diameter and area related to body surface were then correlated with the haemodynamic QP/QS ratio. The location of the ASD proved correct in all cases (ostium secundum 19, sinus venosus 3, inferior vena cava 1). Mean diameters were 22.4 +/- 6.4 mm (range: 12-40 mm) at echocardiography and 23.6 +/- 7 mm (range: 12-45 mm) at surgery. The mean area at echography was slightly superior to that measured per-operatively: 4.3 +/- 2.6 cm2 (1.4-12.5 cm2) versus 3.8 +/- 2.1 cm2 (1.4-8.9 cm2). There was a very good correlation between echographic and per-operative diameters (r = 0.91; p less than 0.001) and areas (r = 0.89; p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Truncular auriculo-ventricular block disclosing isolated corrected transposition of great vessels]. / Bloc auriculo-ventriculaire tronculaire révélateur d'une transposition corrigée des gros vaisseaux isolée.

A case of atrioventricular and ventriculo-arterial discordance with L-transposition of the great arteries (corrected transposition of the great arteries), complicated by complex atrioventricular block is reported. The points of interest in this case were the association of an atrioventricular block and isolated corrected transposition, revealing the underlying malformation, and the intrahisian location of the block which seems only to have been reported on three previous occasions in this context.

[Mitral valve insufficiency due to ballooning. A surgical series of 70 cases]. / Insuffisance mitrale par ballonisation. A propos d'une série chirurgicale de 70 observations.

The authors report 70 cases of mitral regurgitation due to ballooning. For the surgeon this is the most frequent cause of degenerative mitral regurgitation in patients around 60-years-old. The aetiology still remains unknown. There are two opposing theories--the congenital and the acquired. The appearances at operation are characteristic--a localised or diffuse ballooning of one or both cusps with elongation of the chordae attached to the ballooned portion. Two histological features are noted--myxomatous degeneration of the cusp and the absence of any inflammatory process. Ballooning may be asymptomatic and bening for a long time before evolving progressively or suddenly into important mitral regurgitation. The pre-operative diagnosis is aided by left ventricular angiography and echocardiography. Surgical treatment, guided by the findings at operation, usually involves mitral valve replacement or, less frequently, mitral valve repair.

[Coronary endarterectomy associated with coronary artery bypass in severe coronary artery disease. 50 cases]. / L'endartériectomie coronaire associée au pontage dans les lésions coronariennes sévères. A propos de 50 observations.

The surgical indications of coronary endarterectomy were defined from a study of 50 cases in which endarterectomy was associated with aorto-coronary bypass surgery. This total represented 6 p. 100 of all the aorto-coronary bypass operations performed in the same period. Coronary endarterectomy was performed "on principal" for the right coronary artery, and "of necessity" for the left anterior descending artery. The special techniques of endarterectomy on the left anterior descending artery are described. Endarterectomy does not increase the operative risk and enables revascularisation of vessels unsuitable for bypass surgery. 85 p. 100 patients are asymptomatic with an average follow up period of 2 years after endarterectomy and aorto-coronary bypass graft of the right coronary artery.

[Early postoperative (10th day) thrombosis of a Starr mitral prosthesis. Successful fibrinolytic treatment]. / Thrombose postopératoire précoce (10e jour) d'une prothèse de Starr mitrale. Succès du traitement fibrinolytique.

The authors report a case of early postoperative thrombosis of a Starr-Edwards mitral valve prosthesis in a 36 year old female who had undergone closed heart surgery nine years previously for tight mitral stenosis. Severe restenosis led to mitral valve replacement in 1980, and the insertion of a Starr-Edwards prosthesis. On the 8th postoperative day thrombosis of the prosthesis presented with pulmonary oedema and a change in the prosthetic valve sounds which regressed with therapy. The diagnosis was confirmed on the 9th postoperative day by left heart catheterisation and angiography. Fibrinolytic treatment was instituted on the 10th postoperative day with 4500 u/Kg of Urokinase for 24 hours. Pulmonary oedema regressed at the 6th hour of treatment and the prosthetic valve sounds reverted to normal. No significant complication was observed. The good result has been maintained up to the 6th postoperative month. This case demonstrates the possibility of using fibrinolytic therapy in the early postoperative period after valve replacement: this should be weighed in the balance against the mortality of reoperation in such cases of early thrombosis of prosthetic heart valves.

[Double aortic arch with coarctation. Apropos of a case]. / Coarctation sur double arc aortique. A propos d'une observation.

One case of double aortic arch with coarctation is reported. Anatomically, partial atresia of the anterior arch presented as a Kommerel's diverticulum; the coarctation was situated on the dominant posterior arch just proximal to the origin of the subclavian artery. This malformation had been diagnosed clinically during childhood. The operative indications were increasingly severe hypertension with associated left ventricular hypertrophy, and dramatic epistaxis from a nasal angioma which necessitated repeated arterial embolisation. The surgical treatment comprised the insertion of a prosthetic tube from the brachiocephalic trunk, proximal to the coarctation, to the descending thoracic aorta distal to the coarctation. The immediate operative result was excellent with return of normal peripheral pulses and blood pressure. The diagnostic difficulties of this malformation and its associations with other vascular malformations are emphasised. The surgical indications are discussed and the different techniques reviewed:--resection and end-to-end anastomosis,--tubular prosthesis,--associated procedures for double aortic arch. The choice of technique depends on the age of the patient, the anatomical conditions (double arch, coarctation, collateral circulation), and the quality of the aortic wall (atheroma).

[Surgical treatment of patent ductus arteriosus in adults]. / Traitement chirurgical du canal artériel de l'adulte.

The surgical treatment of patent ductus arteriosus (PDA) in adults as in children, usually comprises section and suture, but a certain number of technical precautions must be taken. The aortic wall is often fragile due to atheromatous lesions which are more common with increasing age. Associated hypertension may add to the fragility. Controlled medicated hypotension and reinforcement of sutures with a piece of pericardium may be useful in reducing the risk of haemorrhage. It is sometimes necessary to use partial femoro-femoral cardiopulmonary bypass circuit. The presence of an aneurysm at the aortic end of a calcified ductus necessitates the same precautions. When PDA is complicated by pulmonary hypertension, the surgical indication can only be considered when the left-to-right shunt remains voluminous and when pulmonary artery pressures fall significantly during catheter or peroperative trials of closure. The operative risk in these cases increases with age. Cardiopulmonary bypass may also be very useful in these cases. Secondary repermeabilisation of an operated ductus, and cases complicated by endocarditis require an endopulmonary approach under cardiopulmonary bypass because of the fragility of the ductus region and difficulty in controlling haemorrhage. This technique is also preferred when an associated intracardiac malformation is to be corrected. Between 1965 and 1981, 37 patients were operated in the department of thoracic and cardiac surgery at the Pitié Hospital. The ages ranged from 20 to 65 years with a mean of 34 years. Cardiopulmonary bypass was necessary in 5 cases, (partial in 4, and total in 1 case of endoaortic closure).(ABSTRACT TRUNCATED AT 250 WORDS)

[Postoperative course of systolic and diastolic indices of left ventricular function in aortic valve stenosis in adults. Exercise test with radionuclide angiography]. / Evolution postopératoire des indices systoliques et diastoliques de fonction ventriculaire gauche dans la sténose aortique de l'adulte. Etude par angioscintigraphie à l'effort.

Resting and stress radionuclide angiography was performed before and, on average, one year after surgery for adult aortic stenosis in 26 patients. The left ventricular ejection fraction, ventricular volumes, left ventricular stroke volume and peak velocity of ventricular filling were studied under basal conditions and at the peak of exercise. Right and left heart catheterisation and coronary angiography were performed before surgery with determination of the conventional indices of left ventricular function. Investigations were completed by pre and postoperative echocardiography. The same procedures were carried out in a control population of the same age. Before surgery, hemodynamic adaptation to exercise, judged by the change in left ventricular stroke volume, solicits the passive properties of the left ventricle: the left ventricular stroke volume increases by an increase in the end diastolic volume. In the control group, the increase in stroke volume is obtained by a decrease in end systolic volume, that is to say by increasing systolic shortening. The peak velocity of ventricular filling increases on exercise but to a lesser degree than in the control population. After surgery the hemodynamic adaptation to exercise results from an improved systolic shortening of the left ventricle but also from an increase in end diastolic volume. The peak velocity of left ventricular filling increases with respect to the preoperative values but remains less than that observed in the control population. No relationship was observed between the hemodynamic adaptation to exercise, the peak velocity of ventricular filling and myocardial mass whichever method was used for calculating the latter parameter.(ABSTRACT TRUNCATED AT 250 WORDS)

[Heparin-induced thrombocytopenia. Practical management of vascular complications]. / Thrombopénies induites par l'héparine. Attitude pratique face aux complications vasculaires.

The authors report 23 cases of heparin-induced thrombocytopenia with vascular complications. The clinical presentation consisted of arterial ischaemia in 16 cases, hemiplegia in 1 case, 4 cases of blue thrombophlebitis, 1 case of bilateral thrombophlebitis, 1 case of pulmonary embolism. The vascular surgeon faced with such emergency complications must be aware of the difficulties of clinical (atypical forms) and laboratory diagnosis (unreliability of platelet aggregability tests). Arterial occlusions are generally accessible to treatment with a Fogarty catheter during an operation performed without the use of heparin. The excessively frequent delay in diagnosis explains the severity of these complications and 2 deaths, 1 case of paraplegia, 4 cases of amputation secondary to arterial occlusion, 4 cases of severe postphlebitis disease, including 2 cases requiring transmetatarsal amputation and one case of pulmonary sequelae after pulmonary embolism were observed in our series of 23 patients. The diagnosis of heparin-induced thrombocytopenia requires immediate discontinuation of heparin therapy. Replacement by low molecular weight heparin is not devoid or risks and can only be considered with a negative platelet aggregability test (in the presence of low molecular weight heparin). As these test can be rarely performed as an emergency procedure, the use of rapid-acting oral anticoagulants appears to be the most reliable solution. The place of platelet antiaggregants and partial interruption of the inferior vena cava is discussed.

[Isolated rupture of the pericardium after closed trauma of the thorax (author's transl)]. / Rupture isolée du péricarde après traumatisme fermé du thorax.

Rupture of the pericardium after closed trauma of the thorax is rare. There are two main clinical presentations: one of severe thoracic trauma with hemothorax requiring an operation which permits the diagnosis, the other of pain and pericardial signs on auscultation which should attract attention. The treatment requires closure of the pericardial tear as a routine owing to the risk of fatal complications due to dislocation of the heart.

[Primary iliac arterio-venous fistula from spontaneous rupture of an atheromatous aneurysm (author's transl)]. / Fistule artério-veineuse iliaque primitive par rupture spontanée d'un anévrysme athéromateux.

The case of a patients, with a spontaneous arterio-venous fistula between the right common iliac vessels secondary to an atherosclerotic aneurysm of the artery, is presented. The authors, with the aid of the literature, recall the characteristic physical findings, the clues of the diagnosis and the modalities of the surgical treatment of such lesions. They insist on the importance of an early diagnosis as far as aneurysms are concerned, which allows to treat the lesions before complications arise.