Fibroma and inflammatory myofibroblastic tumor of the heart.

Cardiac fibroma and inflammatory myofibroblastic tumor (IMT) of the heart are rare lesions occurring in young patients and having pathologic similarities. We compared the morphologic and immunohistochemical features of seven cardiac fibromas, including one biopsied at birth and removed 4 years later, and two IMTs of the heart diagnosed at Marie Lannelongue Surgical Center (Le Plessis Robinson, France) between 1980 and 1999. Cardiac fibromas occurred in five females and two males and were surgically biopsied (n = 2) or removed (n = 6) between the ages of 8 days to 31 years (mean 7 +/- 12 years). Inflammatory myofibroblastic tumors were removed in two male patients, aged 13 weeks and 1 year, both alive and well 9 months and 5 years after surgery, respectively. Fibromas were ventricular lesions measuring 3 to 10 cm (mean, 5.7 +/- 2.2 cm). They contained entrapped myocytes and wavy elastic fibers. Three cases contained calcifications. Spindle cells were monomorphic. Their nucleus had a thin chromatin without nucleolus. Mitoses and extramedullary hematopoiesis were only observed in fibromas from patients younger than 5 months (n = 5) while prominent collagen fibrosis was present in fibromas from patients older than 4 years (n = 3). Inflammatory myofibroblastic tumors were endocardial lesions measuring 2 and 2.5 cm. They were covered by fibrin. Spindle cells were larger than in fibromas. Their nucleus had obvious nucleoli. They were associated with numerous inflammatory cells in a variable amount of myxoid background. Occasional mitoses and foci of necrosis were present. Spindle cells in both fibromas and IMTs strongly expressed smooth-muscle actin and were negative for desmin, CD34, S-100 protein, and p53. Our study shows that IMT must be considered in the differential diagnosis of cardiac fibroma especially in cases of inflammatory syndrome, location outside the ventricular myocardium, or multinodular lesions. Morphologic analysis permits the correct diagnosis, while immunochemistry shows a myofibroblastic differentiation in both lesions.

Congenital mitral stenosis with or without associated defects: An evolving surgical strategy.

BACKGROUND: Congenital mitral stenosis (CMS) remains a surgical challenge, particularly when it is associated with other heart defects. As in other groups of heart defects, there is a trend toward early single-stage complete repair, but the optimal surgical approach remains unanswered. METHODS AND RESULTS: This study was designed to analyze the evolution of surgical strategies in patients with CMS and associated defects through single-stage and staged repair. Between 1980 and 1999, 72 children were operated on for congenital heart defects, including CMS. Preoperative transmitral gradient was 12.6+/-7 mm Hg. Preoperatively, all the patients were NYHA class III to IV. Thirteen patients had an isolated CMS; in 59, it was associated with other heart defects, mainly ventricular septal defect (n=28) or multilevel left ventricular obstruction (n=41). In this group of patients, 33 had a staged approach, and 26 had a single-stage approach. Early mortality was 12.5% (9 patients). There were no deaths in the isolated CMS and single-stage repair groups. Logistic regression revealed that early mortality was influenced by association with left ventricular outflow tract obstruction (P:<0.001) and by use of a staged approach (P:<0.01). There was no late mortality in isolated CMS; there were 2 late deaths in the group of single-stage repair and 6 late deaths in the staged approach group (P:<0.01). Reoperation was required in 24 patients, mainly for residual mitral valve dysfunction or residual left ventricular outflow tract obstruction. Including the reoperations, 10 patients received a prosthetic mitral valve. At 15 years after surgery, survival was 69.6+/-7.5%, freedom from reoperation was 70.8+/-6.3%, and freedom from mitral valve replacement was 69+/-6%. CONCLUSIONS: Surgery for isolated CMS gives excellent early and long-term results. In patients with associated heart defects, a single-stage operation seems superior to a staged approach. Mitral valve replacement in this category of patients should be reserved as a salvage procedure.

Warm blood cardioplegia in high risk patients.

OBJECTIVE: Despite overall good clinical results, cardiac surgery in high risk patients, such as those with poor left ventricular function or heavily hypertrophied myocardium, is still challenging. This study was designed to assess the efficacy of warm blood cardioplegia (WBC) in these two subgroups of patients. METHODS: Fifty-two patients, with an ejection fraction less than 50%, who underwent surgical revascularization, and 36 patients, with marked left ventricular hypertrophy (LVH), who were operated on for aortic valve replacement (AVR), were consecutively studied. All of them received continuous retrograde 'warm' blood cardioplegia. Results were assessed on clinical outcomes and compared with those predicted from a risk-stratifying index which has been previously validated in a large multicenter population-based study (Ontario score). RESULTS: For cardiac revascularization, the rates of overall hospital mortality, Q-wave infarctions and inotropic use were respectively 5.8%, 9.6% and 21.1%, comparing favorably with those of the Ontario Group. For aortic valve replacement, the incidence of hospital mortality and Q-wave infarction was 2.8%. CONCLUSIONS: By virtue of the study design, these data cannot conclusively establish the superiority of warm blood cardioplegia over other methods of myocardial protection. However, they support the safety of this technique, and suggest that these subgroups of high risk patients might represent the elective indication for aerobic arrest.

[Value and indication of the use of 2 internal mammary arteries in repeated coronary surgery]. / Intérêt et indication de l'utilisation des 2 artères mammaires internes dans la chirurgie coronaire redux.

Forty-nine patients who had coronary artery reoperations were divided into two groups: the 29 patients of the first group were operated conventionally with use of one internal mammary artery or a saphenous vein; the 20 patients of the second group were reoperated using both internal mammary arteries. Three patients (6%) died prematurely: two in the first and one in the second group. The rates of peri-operative infarction were 7% and 15% respectively. The average postoperative bleeding was 472 +/- 385 ml in the first group and 700 +/- 628 ml in the second group (NS). All patients are pauci-symptomatic and have a negative exercise stress test. The mortality and morbidity of coronary reoperation does not seem to be greater with double internal mammary artery bypass grafting. However, this technique should be reserved for patients who can derive long-term benefit from reoperation with arterial grafts, that is to say in patients in good clinical condition, less than 65 years of age with good left ventricular function. In these patients, double internal mammary artery bypass grafting may avoid a third operation for myocardial revascularisation.

[Decrease of postoperative morbidity in coronary surgery using the two internal mammary arteries]. / Diminution de la morbidité post-opératoire dans la chirurgie coronaire utilisant les deux artères mammaires internes.

The surgical risk of bilateral internal mammary artery grafting was analyzed in 100 successive patients separated chronologically into two groups. These groups were not statistically different in terms of age, severity of angina, and extent of coronary artery disease. The number of grafts per patient and the time of aortic cross clamping were not statistically different in the two groups. The postoperative mortality was 1% in the 100 patients. The incidence of perioperative myocardial infarction was not statistically different in the two groups. No mediastinal suppuration was observed. The mean postoperative hemorrhage was 633 +/- 558 ml in the first 50 patients and 560 +/- 410 ml for the last 50 patients (p < 0.05). The percentage of patients receiving no homologous blood transfusion was 64% in the first 50 patients and 94% in the last 50 patients. The percentage of phrenic palsy was 36% in the first 50 patients and 6% in the last 50 patients (p < 0.05). With surgical experience, the risk of coronary bypass with bilateral internal mammary artery was lowered and very similar to the surgical risk of conventional aorto-coronary bypass with saphenous veins or one mammary artery.