Adult T-cell leukemia/lymphoma revealed by a surgically cured cardiac valve lymphomatous involvement in an Iranian woman: clinical, immunopathological and viromolecular studies.

A 60-year-old woman from the town of Mashhad in northeastern Iran developed cardiac failure due to aortic and mitral regurgitations which needed cardiac valve replacement. Histopathological study of the valves revealed a T-cell non-Hodgkin's lymphoma. Blood examination showed leukemic features with 32% of abnormal white blood cells. Human T-cell leukemia/lymphoma virus type I (HTLV-I) antibodies were present in the serum and the specific env HTLV-I sequences were detected in the DNA extracted from the valves and peripheral blood mononuclear cells (PBMC) using polymerase chain reaction technique. Clonal integration of two HTLV-I copies was found in both the valves and PBMC DNA, thus the diagnosis of adult T-cell leukemia/lymphoma (ATL) was established. In contrast to the acute life-threatening cardiac localization, our case met the diagnostic criteria of chronic ATL, this was confirmed by favorable evolution without chemotherapy during the 24 months after diagnosis. According to our knowledge, this is the first report of an isolated lymphomatous cardiac valve involvement, without other cardiac abnormalities. It seems important to underline that the patient originated from Iran where endemicity of HTLV-I has only recently been discovered.

[Pseudo-aneurysms of the ascending aorta in patients previously operated for acute aortic dissection]. / Pseudo-anévrismes de l'aorte ascendante chez les patients déjà opérés d'une dissection aortique aiguë. Diagnostic, traitement.

Pseudo-aneurysms of the ascending aorta are a rare but serious complication of surgery for acute dissection of the aorta. The diagnostic methods and surgical technique have changed in recent years. The authors report their experience over a period of 20 years. From January 1981 to December 2001, 21 patients underwent reoperation for pseudo-aneurysms of the ascending aorta. The average age was 54.2 +/- 3 years. Diagnosis is no longer based on aortography but on transthoracic or oesophageal multiplane echocardiography, thoracic spiral computed tomography or magnetic resonance imaging. Four patients presented with a recent history of severe pulmonary oedema. The risk associated with reopening the sternum is avoided by current operative techniques. The authors have chosen anterograde perfusion of the cervical arteries by direct canulation for cerebral protection. The operative mortality at one month is high (30%). All patients who had pulmonary oedema or cardiogenic shock in the immediate preoperative period died. There were no neurological complications. Twelve patients survived and one has to undergo a further operation for recurrence of the pseudo-aneurysm. The authors conclude that patients operated for dissection of the aorta must be followed up. It is important to resect as much as possible of the pathological aorta during the initial operation to avoid the risk of pseudo-aneurysm formation, at least in the proximal segment of the ascending aorta.

Chronic disease of the ascending aorta. Surgical treatment and long-term results.

Between January 1979 and December 1991, we operated on 339 patients for chronic disease of the ascending aorta. The operation was elective in all. Endocarditis and its sequelae have been excluded. Thirty-one patients had a previous operation on the ascending aorta or the aortic valve; 268 patients had aneurysms of the ascending aorta without dissection; 72 had chronic aortic dissections, of whom 33 had a preexistent aneurysm. The patients included 272 men and 67 women. Mean age was 53.58 +/- 7 years. Eight percent of the patients had clinical stigmata of Marfan's disease. A tubular graft replacement was used in 7 patients, a tubular graft and valve replacement in 72 patients, and a composite valve graft replacement with reattachment of the coronary arteries using a 8 mm Dacron graft was performed in 260 patients. Concomitant procedures were used in 74 patients: coronary artery bypass grafts in 25, mitral valve replacement in 9, and aortic arch reconstruction in 40. The 30-day mortality rate was 7.6% (n = 26). For the whole group, multivariate analysis using stepwise logistic regression showed that operative risk factors were concomitant coronary artery bypass grafting, age (increased), aortic valve regurgitation, and previous cardiac surgery. Follow-up was conducted in 303 patients, and risk factors for late mortality were studied. Long-term survival was 59.6% +/- 3.7% at 9 years. It was 67% +/- 3.5% at 9 years for patients without aortic arch reconstruction and 56% +/- 4.5% for patients with aortic arch reconstruction (p = 0.0018). Reoperation was needed in 14 patients. Actuarial freedom from reoperation was 90% +/- 0.2% at 9 years for all the patients. Only one patient with composite valve graft replacement and reattachment of the coronary arteries had required reoperation for problems related to this procedure. This technique is used routinely by our team, especially in patients with large chronic aneurysms, dissected or not, and in those who had previous operations. The long-term results are good.

Prosthetic valve endocarditis with ring abscesses. Surgical management and long-term results.

From January 1978 to December 1988, 71 patients underwent surgical intervention at our institution for prosthetic valve endocarditis with ring abscesses. These procedures involved 59 aortic prostheses and 12 mitral prostheses. No causative agent could be identified in 19 patients (26.7%). The operation was performed during antibiotic therapy in 63 patients and after a planned course of antibiotic therapy in 8 patients. At the aortic level, abscesses were remedied by suturing in 3 cases, by pericardial patches in 34 cases, and by complex procedures in 22 cases (subcoronary valved conduit in 11 cases, supracoronary valved conduit with coronary bypass grafts in 10 cases, apicoaortic valved conduit in 1 case). At the mitral level, ring abscesses were cured in 10 cases by intraatrial implantation of the prosthesis. In one case, the prosthesis was anchored inside the left ventricle; and in one case the valve could be seated on the anulus. The overall operative mortality rate was 17%. Long-term survival was 54% +/- 8% at 6 years. Fifteen (26%) of the survivors needed a third valve replacement (four operative deaths); a complex reconstruction was performed in seven patients. Better detection of ring abscesses and earlier surgical intervention before annular destruction and hemodynamic failure can improve the operative mortality rate for prosthetic valve endocarditis. When it is necessary, complex reconstruction, in spite of a high mortality rate, seems to eradicate the infectious seat, and the outlook for the patient's condition appears good.

Intraatrial insertion of a mitral prosthesis in a destroyed or calcified mitral annulus.

Infectious lesions and extreme calcification of the mitral valve annulus can make classic anatomic implantation of a prosthesis impossible. Confronted with these circumstances, we have developed a technique of intraatrial insertion of a mitral prosthesis. The prosthesis has been modified by enlarging the circumference of the sewing ring with a Dacron collar. The collar can be sutured to the left atrial wall above the mitral annulus. From 1981 to 1989, this technique has been employed in 36 patients: 15 had acute valve endocarditis with destruction of the mitral annulus and 21 had extensive annular calcification. In all cases, circumferential or partial intraatrial insertion permitted a secure implantation of the prosthesis. One operative death was related to the technique. It was an intractable bleeding caused by tearing of the very thin and fragile wall of the left atrium in a kidney transplant patient. Four patients were reoperated on for periprosthetic leak, in 3 of whom healing and cleaning of the mitral annulus permitted annular implantation of a prosthetic valve. There was no ventricular wall rupture. Our results suggest that the technique can be performed in high operative risk patients when mitral valve replacement is impossible by conventional techniques.

Active native valve endocarditis: determinants of operative death and late mortality.

BACKGROUND: In this report, we reviewed 247 patients who underwent operation by our team for active native valve endocarditis between January 1979 and December 1993. METHODS: There were 201 male and 46 female patients (mean age, 45.4 +/- 6 years). The aortic valve was involved in 163 cases, the mitral valve in 36 cases, both mitral and aortic valves in 44 cases, and the tricuspid valve alone in 4 cases. The most common microorganisms were streptococci. Univariate Pearson (chi2 test) and multivariate (stepwise logistic regression [BMDPLR]) analyses were used to identify significant predictors of operative mortality, reoperation, and recurrent endocarditis. Cox proportional hazards regression model was used to study late survival. RESULTS: Operative mortality was 7.6% (n = 19). Increased age, cardiogenic shock at the time of operation, insidious illness, and greater thoracic ratio (>0.5) were the predominant risk factors; the length of antibiotic therapy appeared to have no influence. Two hundred thirteen patients were followed up. Median follow-up time was 6 years (range, 2 to 19 years). Overall survival rate (operative mortality excluded) was 71.3% +/- 3.8% at 9 years. Increased age, preoperative neurologic complications, cardiogenic shock at the time of operation, shorter duration of the illness, insidious illness before the operation, and mitral valve endocarditis were the predominant risk factors for late mortality. The probability of freedom from reoperation (operative mortality included) was 73.3% +/- 4.2% at 8 years; risk factors were younger age and aortic valve endocarditis. The rate of prosthetic valve endocarditis was 7%. No significant risk factor was found. CONCLUSIONS: Increased age, insidious illness, and hemodynamic failure are the main risk factors for operative mortality. Long-term survival is good except for patients with preoperative neurologic complications and mitral valve endocarditis.

Video-assisted coronary bypass surgery: clinical results.

OBJECTIVE: Clinical experience with a video-assisted coronary artery bypass grafting procedure using the internal mammary artery is reported. The technique consists of a videoscopic harvesting of the left internal mammary artery (LIMA) to revascularise the left anterior descending artery (LAD) through a 4-cm left thoracotomy. METHODS: Between September 1995 and July 1996, we performed this procedure on 30 patients (29 males, 1 female; aged 38-71) with an isolated proximal LAD stenosis (n = 21) or occlusion (n = 9). All patients were symptomatic despite appropriate medication. A history of non-transmural myocardial infarction with myocardial viability was found in nine patients. Fourteen patients had a restenosis after previous percutaneous transluminal coronary angioplasty (PTCA). Mean left ventricular ejection fraction was 0.61 (< 0.3 in two patients). The LAD LIMA anastomosis was performed on the beating heart without cardiopulmonary bypass (CPB) in 26 patients. Femoral-femoral CPB was used in three patients because of unstable angina (n = 1) and intramyocardial LAD (n = 2). Conversion to sternotomy and standard CPB was necessary in one patient for extensive endarterectomy of the LAD. RESULTS: There were no operative complications and no reoperations for haemorrhage. Pulmonary infection was observed in one patient and wound infection in one patient. Patients who underwent the complete procedure on the beating heart without conversion or CPB were ready for discharge on the 5th postoperative day (36 h-13 days). Control coronary angiography was performed in 20 patients. In all cases, the graft was patent. In 17 cases, there was a patent graft with no evidence of anastomotic stenosis. An occlusion of the distal segment of the LAD with a retrograde perfusion of the proximal segment and septal branches by the LIMA was found in one case. This patient was symptom-free and the stress test was negative. An anastomotic stenosis was noted in two patients and was treated by angioplasty (n = 1) or conventional surgery (n = 1). CONCLUSION: In conclusion, the efficiency of this minimally invasive approach should be prospectively compared with similar revascularisation with PTCA or surgical approaches using sternotomy with or without CPB.

Results of subtotal pericardiectomy for constrictive pericarditis.

The operative approach to constrictive pericarditis still remains a surgical challenge. Subtotal pericardiectomy through median sternotomy was analyzed retrospectively in a series of 84 patients operated on for chronic constrictive pericarditis at our institution between 1979 and 1989. The mean duration of symptoms prior to diagnosis was 20 +/- 6 months (1-264 months). Preoperatively, 72% of patients were in NYHA class III or IV, presented signs of right cardiac failure (88%) or anasarca (18%). Chest X-ray showed pericardial calcifications in 40% of the patients. Echocardiography revealed pericardial thickening in 62%. Among 62 patients in whom cardiac catheterization was performed, a characteristic dip-and-plateau was found in 47 patients (76%). A specific etiologic factor was identified in only 37 patients: tuberculosis (12%), recurrent acute pericarditis (9%), hemopericardium (9%), radiotherapy (5%), previous cardiac surgery (4%), bacterial infection (2%), myocardial infarction (2%) and connective tissue disease (2%). In 47 patients (55%), the constrictive pericarditis remained idiopathic. In seven patients we performed a redo-operation for previous incomplete pericardiectomy. Subtotal pericardiectomy (from phrenic nerve to phrenic nerve) was performed in 75 patients. A palliative procedure consisting of pericardial "meshing" was performed in nine patients due to an unsatisfactory cleavage plane. Cardiopulmonary bypass was used in four patients for coexistent cardiac lesions. The operative mortality was 2.3% (two patients: septicemia and pulmonary embolism). Seven patients (8.2%) developed early on-lethal complications. The probability of survival for patients discharged for the hospital was 94% at 3 years and 87% at 7 years. There were four late deaths and no reoperation for recurrent constriction.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical treatment of chronic aortic dissections.

Between January 1976 and March 1987, 78 patients underwent surgery for chronic aortic dissection at our institution. The ascending aorta was involved in 66 cases (Stanford type A) and was not involved in 12 cases (Stanford type B), wherever the initial dissection was suspected. Aortography remains the main preoperative investigation. The surgical technique varies according to the type of dissection. It seems essential to exclude the primary intimal tear and all dilated segments of the aorta must be replaced. The overall operative mortality was 11.5% (7.5% in type A, 33.3% in type B dissection). Sixty-three patients have been followed for a period varying between 6 months and 10 years (mean 5 years). The overall survival at 6 years is 60% +/- 5.6%. Because of the ultimate risk of aneurysmal dilatation of the false channel, these patients must be followed by CT scanning, colour flow Doppler echocardiography, magnetic resonance imaging, and in some cases, aortography.

Cardiac surgery in patients receiving long term hemodialysis. Short and long term results.

AIM: Cardiac surgery carries a high risk in hemodialysis patients and has been questioned for its results; the purpose of this study is to focus on the short and long term results in our institution. METHODS: We retrospectively analyzed the data from 124 hemodialysis patients who underwent cardiac surgery in our unit between January 1980 and December 1998; 14.5% were diabetic; 46% had isolated coronary artery disease (group 1); 29.8% had valvular disease alone (group 2); 14.5% valve and coronary disease (group 3) and 9.6% miscellaneous disease at highest risk (group 4). We analyzed the relationship between several variables (age, sex, hypertension, diabetes, previous myocardial infarction, type of disease, preoperative ejection fraction) and operative mortality (30 days) and late survival. RESULTS: The overall operative mortality was 16.9%. The only risk factor was the type of cardiac disease: operative mortality was higher in groups 3 and 4 combined than in groups 1 and 2 combined (30% versus 12.7%, p=0.07). Ninety-nine patients were followed until January 2002. Late survival rate was 46.6+/-5% at 6 years for all patients, it was significantly better in groups 1 and 2 combined than in groups 3 and 4 combined. The only risk factor for late mortality was arterial hypertension. Fifty-seven patients are still alive, 46 in groups 1 and 2, 11 in groups 3 and 4. Progression of coronary lesions occurred in 6 patients and valvular lesions in 3 patients. The remainder are doing well. CONCLUSION: Cardiac surgery seems to be justified by the severity of the lesions. Its actual results can perhaps, be improved by earlier detection of cardiac disease and better prevention of myocardial hypertrophy and cardiac calcifications.

Position-related factors in mitral and tricuspid bioprostheses degenerative changes.

We report clinicopathological findings in 15 patients in whom the same bioprosthesis (BP) had been implanted simultaneously in both mitral and tricuspid positions. The aim of the study was to investigate whether position-related factors played an important role in BP degeneration. There were 14 women and 1 man with a mean age of 34 +/- 11 years. The indications for the initial operation were rheumatic in 14 cases and endocarditis in one patient. The mean interval before reoperation was 7.5 +/- 3.3 years. Predominant cause of reoperation was: structural deterioration of both mitral and tricuspid BPs (6), mitral regurgitation (5), tricuspid BP dysfunction (1), para-aortic leak (1), mitro-aortic thrombi (1). Calcific deposits were the principal cause of early deterioration of mitral BPs and the major cause of late tricuspid BPs dysfunction. This lesion was predominantly related to local factors. Cuspal tears were the principal cause of late (> 9 yrs) mitral BP failure and most probably related to mechanical stress. Extensive fibrosis affected only tricuspid bioprostheses. In 7 patients more extensive degenerative changes occurred in bioprostheses in the mitral rather than the tricuspid position (Group I). However, in the remaining eight the magnitude of the changes was very similar in the two positions (Group II). The interval before reoperation was significantly longer in patients of Group II (9.8 yrs, range 5-13) than patients in Group I (4.9 yrs, range 3-6), (p < 0.01). We concluded that position-related factors exert a major role in bioprosthetic failure. These factors are more deleterious in the mitral position than in the tricuspid position.

[Should aortic atheromatous plaques be excised?]. / Faut-il effectuer l'exérèse des plaques d'athéro-thrombose aortique?

Aortic atheromatous plaque is common condition which has no clinical or therapeutical consequences in the majority of cases. Nevertheless, in some cases, clinical symptoms or potential complications may lead to discussion of the therapeutic indications. The usual diagnostic methods are pre- or peroperative transoesophageal echocardiography. CT scan, magnetic resonance imaging and, rarely, arteriography. These investigations are also valuable in assessing the composition of the plaque and evaluating the risk of thrombosis and therefore of systemic embolism. The surgical indications are discussed in three situations. When the atheroma is large, exuberant and stenotic. This is often the case in the abdominal aorta, much less commonly so in the descending thoracic aorta. Secondly, when the atheroma has been complicated by embolism: this applies to all segments of the aorta. Finally, when there is a potential embolic risk, especially neurological, during open heart surgery; this is usually the case in the ascending aorta. The surgical technique in the first two indications is either excision of the atheromatous plaque or of a segment of the aorta with restoration of continuity by a Dacron patch or tube. In the third indication, two attitudes are possible: either not to manipulate the ascending aorta by changing the site of arterial cannulation, not clamping the aorta, and using pediculated arterial grafts to suppress the aortic implantation of the graft, or, conversely, replacing a fragment of the aorta carrying the atheromatous plaque and reestablishing continuity by a Dacron patch or tube, where a saphenous vein graft may be implanted. In conclusion, excision of atheromatous plaque is always possible but rarely justified. It is essentially a palliative procedure.

[Pulmonary thrombectomy in a patient with antiphospholipid syndrome]. / Thrombectomie pulmonaire chez un patient présentant un syndrome des antiphospholipides.

Chronic pulmonary embolism may occur in the antiphospholipid syndrome. Antiphospholipid antibodies including the lupus anticoagulant and anticardiolipin should therefore be searched for systematically in these patients. Blood clotting (lupus anticoagulant) and immunological (anticardiolipin) investigations are complementary; their positivity may be dissociated. If the thrombus is located in the proximal pulmonary artery, surgical thrombectomy is possible. Operative mortality ranges from 12.6% to 20%. The association of oral anticoagulants with low dose aspirin is indicated for the long term treatment of these patients. The role of steroid therapy is discussed. The authors report the case of a patient with antiphospholipid antibodies who successfully underwent surgical removal of a chronic pulmonary embolism.

[Value of myocardial revascularisation surgery before correction of sub-renal aortic aneurysms]. / Intérêt de la chirurgie de revascularisation myocardique préalable à la cure des anévrysmes de l'aorte sous-rénale.

The value of aortocoronary bypass (ACB) before surgical correction of infrarenal abdominal aortic aneurysm (AAA) was studied in three groups of patients. Group I: 6 patients undergoing both procedures; group II: 14 coronary patients operated for AAA without prior ACB surgery; group III: 16 patients without coronary artery disease operated for AAA. The hospital mortality was nil in group I; 2 patients died of myocardial infarction in group II; 2 patients died of infection and of cerebrovascular accident respectively, in group III. The patients in group I were asymptomatic on follow-up (mean = 29.7 months) whilst 1 patient in group II developed angina. The essential problem associated with this type of patient remains the complexity of the diagnostic investigations which must include coronary and cervical arteriography. Although the indications for ACB before cure of AAA are obvious in symptomatic patients and/or with previous myocardial infarction, they remain debatable in other patients.

[Iatrogenic left coronaro-atrial fistula after mitral valve replacement: apropos of a case]. / Fistule coronaro-atriale gauche iatrogène après remplacement valvulaire mitral. A propos d'une observation.

The authors report a case of an iatrogenic fistula between the left circumflex coronary artery and left atrium. The fistula was a complication of reoperation to replace a mitral valvuloplasty annulus by a mechanical hemi-disc prosthesis (Saint Jude Medical). Diagnosis was made by transoesophageal echocardiography and confirmed by coronary angiography. The patient underwent external ligature under cardio-pulmonary bypass.

[Cardiac and extracardiac abscesses in bacterial endocarditis]. / Les abcès cardiaques et extracardiaques dans l'endocardite infectieuse.

Cardiac abscesses are observed in 20 to 30% of cases of infective endocarditis and in at least 60% of prosthetic valve endocarditis. The aortic valve ring is more frequently affected than the mitral valve ring. A cavity contiguous with a cardiac chamber forming a pseudo-aneurysm or a closed purulent collection, the abscess may extend to the neighbouring cardiac structures or to the ascending aorta. This extension may cause conduction defects, abnormal communications between the cardiac chambers, pericardial disease and, exceptionally, myocardial ischaemia, complications which are clinical signs of abscess formation in patients with infective endocarditis. The presence of a cardiac abscess is a poor prognostic factor in infective endocarditis. The diagnosis must be made at an early stage when surgical treatment is optimal. The most valuable investigation is transoesophageal echocardiography with a sensitivity of over 80% and a specificity of about 95%. This investigation has become practically routine in all patients with endocarditis in order to diagnose abscesses at an early stage, especially in cases of aortic or prosthetic valve endocarditis. Information about the site, size and extension of the abscess may be obtained and existing or potential complications may be envisaged with a view to surgery. Other imaging diagnostic techniques, such as angiography, CT scanning and nuclear magnetic resonance imaging have a number of disadvantages and are not more sensitive than transoesophageal echocardiography. Surgical techniques depend on the site and extension of the abscess. They are sutured or closed with dacron or pericardial patches after having been cleaned and filled with formulated resorcin glue. The valvular prosthesis is inserted either in anatomical position or in a sub or supracoronary dacron tube necessitated by the perivalvular extension of the infectious lesions. These complex procedures may require associated coronary reimplantation or revascularisation when the coronary ostia are affected. The highest operative mortality is observed in prosthetic valve endocarditis with abscess and extra-annular prosthetic implants. The risk of secondary valvular dehiscence, often recurrent, is much higher when there is an abscess at operation. Extracardiac abscesses in cases of infective endocarditis are mainly observed in the cerebral and/or splenic territories. They may become the main problem, especially cerebral abscesses, but they rarely require surgery.

[Acute native endocarditis. The results of surgical treatment]. / Endocardites aiguës natives. Résultat du traitement chirurgical.

Between January 1978 and December 1984, 141 cases of acute native valve endocarditis were treated surgically in the Department of Thoracic and Cardiovascular Surgery of the Pitié Hospital. The diagnostic criteria of acute native valve endocarditis were the duration of treatment (antibiotic therapy for less than 40 days), the characteristic operative appearances of the lesions, and the results of anatomo-pathological examination of the excised valves. The infecting organism was not isolated in 35% of cases. The aortic valve was the commonest site of infection (65.2% with a high incidence of abscess of the aortic ring, irrespective of the causal organism. The operative mortality was 5.6%. This depended mainly on the preoperative haemodynamic status of the patient. The duration of antibiotic therapy prior to surgery did not seem to be relevant. The 3 years survival rate was 78%. The secondary reoperation rate was 7%. There was a higher incidence of secondary perivalvular regurgitation in patients who had previously had an abscess of the aortic ring.

[Results of simultaneous myocardial and cerebral revascularization surgery]. / Résultats de la chirurgie de revascularisation simultanée myocardique et cérébrale.

Out of 3,678 patients who underwent aorto-coronary bypass between May, 1979 and October, 1987 at the La Pitié Hospital, Paris, 48 had simultaneous myocardial and cerebral revascularization. Operative mortality rate was 4.2 p. 100. Peri-operative myocardial infarction occurred in 3 cases (6.2 p. 100). No neurological complication was observed. The survival rate at 5 years (operative mortality included) was 74.8 +/- 8.66 p. 100. These results obtained in patients with multiple arterial disease are in agreement with those found in the literature. The lack of neurological complications is in favour of a systematic combined surgical treatment of severe carotid and coronary lesions.

[Left thoracotomy: an alternative to median sternotomy in coronary bypass in cases of pericardial adhesions]. / La thoracotomie gauche: une alternative à la sternotomie médiane pour les pontages coronaires en cas d'adhérences péricardiques.

Coronary bypass on the circumflex artery network was performed by left thoracotomy in 5 patients. All presented with pericardial adhesions due to coronary artery surgery (n = 4) or to mediastinal irradiation (n = 1). The left thoracotomy route provides excellent exposure of the lateral aspect of the heart and may be an advantageous alternative to sternotomy when pericardial adhesions are present.

[Surgical result of 48 Bigelow myotomies for obstructive myocardiopathy]. / Résultat chirurgical de 48 myotomies de Bigelow pour myocardiopathie obstructive.

Bigelow's myotomy is one of the surgical options available for the treatment of hypertrophic obstructive cardiomyopathy (HOCM). The results of this operation were analysed in 48 cases operated between 1965 and May 1983. The average age of the patients was relatively low (38 years) but preoperative symptoms were severe (34 patients in Class III and 6 patients in Class IV of the NYHA Classification). The diagnosis was confirmed in all cases by echocardiography, carotid pulse tracings and cardiac catheterisation. 28 patients had associated lesions including 21 cases of mitral regurgitation (minimal in II cases, moderate in 6 cases and severe in 4 cases). All patients underwent Bigelow myotomy which was associated with a complementary procedure in 9 cases (including 2 mitral valve replacements and 2 semi-circular annuloplasties). The hospital mortality was 6 patients; surgical morbidity resulted from permanent intraventricular conduction defects (27 cases). At long-term, 3 more patients died, 2 from cardiac causes. Of the remaining 39 patients followed-up for an average of 32 months, functional improvement was marked, except in very advanced stages of the disease (Class IV) or forms with severe or uncorrected mitral regurgitation. The indications for Bigelow myotomy are discussed with reference to three parameters of HOCM (intraventricular pressure gradient, mitral regurgitation, decreased left ventricular compliance). This procedure has a beneficial effect on the subaortic stenosis and left ventricular compliance. It should be completed by mitral valve surgery in patients with significant regurgitation.