Midterm results of the Ross procedure in a pediatric population: bicuspid aortic valve is not a contraindication.

Our objective was to analyze retrospectively the short- and midterm results of the Ross operation in children and the impact of bicuspid aortic valve (BAV) disease on outcome. From 1991 to 2003, 41 patients (26 male, 15 female) underwent a Ross procedure. Aortic disease was congenital in all but one. Sixty-six percent had BAV. Mean age at operation was 10.13 +/- 5.6 years (range, 0.4-18.3 years). Root replacement technique was performed in all but two (inclusion technique). There were two early deaths. Mean follow-up was 6 +/- 3.8 years (range, 0.1-14 years). The autograft (neo-aorta) presented absent, trivial, mild, and moderate regurgitation in 42%, 46%, 10%, and 2%, respectively, at latest follow-up. Root dilation was seen in 64% of the patients (mean Z-score, +3.53 +/- 0.04). Four patients (9%) required allograft replacement, two for endocarditis and two for stenosis. Allograft stenosis (gradient >20 mmHg) was detected in 44% of the remaining patients, without symptoms or the need for reintervention. Estimated freedom from allograft replacement at 5 and 10 years was 97% and 89%. Left ventricular dimensions and function were normal in all patients. No difference was found between patients with BAV and those with tricuspid aortic valves in aortic regurgitation or root dilation. BAV was not identified as a risk factor for root dilation. In conclusion, the Ross operation remains an excellent option for aortic valve replacement in children. BAV is not associated with a worse outcome and is not a risk factor for aortic root dilation at medium-term follow-up. Long-term follow-up is, however, required.

Does moderate mitral regurgitation impact early or mid-term clinical outcome in patients undergoing isolated aortic valve replacement for aortic stenosis?

OBJECTIVE: The early and mid-term impact of functional mitral regurgitation (MR) in patients undergoing isolated aortic valve replacement (AVR) for aortic stenosis remains unresolved. METHOD: Through our institutional databank, using a case-match study, we identified 58 patients with MR grades 0-1 and 58 patients with MR grades 2-3 (patients matched for sex, age, ejection fraction (EF), NYHA, diabetes, and CVA). Data were collected prospectively (mean duration of follow-up: 3.2 +/- 2.4 years). RESULTS: Perioperative morbidity (re-operation for bleeding, low cardiac output, CVA, renal failure) was comparable among groups. Difference in mortality between the two groups was non-significant (7.0 vs. 3.5%, P = 0.67 in groups MR 2-3 vs. 0-1, respectively). At early echocardiographic follow-up, 7/58 patients (12.1%) within group MR grades 0-1 increased their MR to grades 2-3; among which only two remained with MR grades 2-3 at mid-term follow-up. Within MR group 2-3, 18/58 (31.0%) remained with MR grades 2-3 among which 7/18 (38.9%) decreased of at least one grade at follow-up. Eight year actuarial survival was comparable in both groups: MR grades 0-1 = 60.9% vs. MR grades 2-3 = 55.0%; P = 0.1. Actuarial survival of patients with MR grades 2-3 postoperatively was similar to patients with MR grades 0-1 (MR grades 0-1 = 59.0%, MR grades 2-3 = 58.9%, P = NS). CONCLUSIONS: Presence of preoperative moderate functional MR (grades 2-3) in patients undergoing isolated AVR for aortic stenosis regresses in the majority of patients postoperatively and has no significant impact on perioperative morbidity or mortality, nor mid-term survival. Thus, moderate functional MR should be treated conservatively in the majority of patients especially in the elderly subjected to isolated AVR for aortic stenosis.

Mucinous cystadenocarcinoma of the appendix. A rare tumour of the right iliac fossa.

A case of mucinous cystadenocarcinoma of the appendix is presented. The clinical feature is a painful syndrome of the right iliac fossa. In our observation, the diagnosis was not allowed by preoperative imaging. Appendectomy was initially performed and completed by right hemicolectomy and lymphadenectomy after histological diagnosis of the appendicular malignant tumour was forwarded. The prognosis of this tumour is generally excellent providing early diagnosis and wide enough surgery.

Cholecystectomies: from laparotomy to laparoscopy.

Retrospective study of a series of 397 consecutive cholecystectomies among which 289 by laparotomy, 100 by coelioscopy and 8 by coelioscopy first and laparotomy in a second time (conversion rate 8/108 = 7.4%). The results of the whole series are comparable to those of the literature (mortality: 0.7% and morbidity: 8.5%). The results of the first 100 cholecystectomies completely performed by laparoscopy are comparable to the last 100 cholecystectomies performed by laparotomy (no mortality and low morbidity). The coelioscopic approach can reasonably be proposed when indication for cholecystectomy exists, with the exception of undissectable adhesions, a Mirizzi's syndrome or a very acute cholecystitis, and providing a good preoperative imagery of the biliary ducts. In our series, we did not observed wounds of the main biliary duct. We recommend a systematic subhepatic drainage.