[A global evaluation of the quality of care in cardiac surgery]. / Valutazione globale della qualità delle cure in cardiochirurgia.

Until now, all reflections about cardiac surgery have been quantitative. Currently, quantitative saturation of cardiac surgery needs in France has been reached or even exceeded in some areas. Consequently, a qualitative approach becomes fundamental: to provide each patient, prior to the operation, with an assessment of his/her vital risk at a specific site; to allow cardiologists to objectively and statistically know the complete results obtained by various surgical teams; to incite improvements among surgical teams; and lastly, to allow the administration to assess services provided to patients. This study concerns 1271 patients consecutively operated on between January 1990 and December 1993 by the very same surgeon and represents the outline of a logical method of controlling clinical results.

Valvular injuries resulting from blunt chest trauma.

The occurrence of valvular lesions alone as a result of nonpenetrating trauma is not common. Most reports have shown mainly isolated rupture of the aortic valve, whereas, reports of traumatic rupture of the tricuspid valve without associated injuries are rare in the literature. At our center, three patients were treated for traumatic valvular rupture-one had aortic insufficiency and the other two had tricuspid insufficiency. The time interval between trauma and surgery was 10 weeks for the aortic rupture, 18 months for one tricuspid valve rupture, and 18 years for the other. After surgical treatment, all three patients have continued to be asymptomatic.

[Aortic valve replacement in infectious destruction of the aortic annulus. A new technic]. / Remplacement valvulaire aortique en cas de destruction infectieuse de l'anneau aortique. Nouvelle technique.

The results of aortic valve replacement in the acute phase of valvular endocarditis are dependent upon the degree of destruction by sepsis of the left ventricle-aorta junction. The stability of the prosthesis installed is conditioned by the extent of the lesion. Numerous techniques have been described to maintain the prosthesis firmly in place. In the technique reported here, the prosthesis is implanted in the usual position, but the sutures are tied outside the heart. Depending on the site of the lesion, this is done by opening the left atrium or the infundibulum of the right ventricle, and by passing the stitches through the aortic wall. This quick and simple technique ensures good stability of the prosthesis.

Reconstructive surgery for mitral and tricuspid valves--principles and personal experience.

We have experienced 246 cases of reconstructive surgery for mitral and tricuspid valves, with 17 deaths in the immediate post-operative period or during follow-up. This gives an overall mortality rate of 6.9 per cent whereas in 72 cases of mitral valve reconstruction we recorded only 2 deaths i.e. a mortality rate of 2.7 per cent although the post-operative period remains relatively short. Thus, we feel fully justified in pursuing our conservative surgery program, especially for younger patients who, given their superior myocardial state, can lead a fuller life after mitral reconstruction than after mitral replacement. It is our conviction that mitral and tricuspid valve reconstruction should not be overlooked and that prior to resection and replacement, the surgeon and the team should pause and scrupulously examine the valvular components with a view to conservative surgery. For certain lesions, reconstruction can be carried out rapidly and reliably. The mortality rate is not higher than conventional cardiac surgery and the patient's long term prognosis is considerably improved.

[Trans-septal catheterization. Technic and indications]. / Cateterismo transettale. Tecnica e indicazioni.

We report our experience with transseptal catheterization of the left side of the heart via the right femoral vein. This technique was attempted in 50 patients undergoing left heart catheterization for hemodynamic evaluation of aortic valve stenosis (15 patients) and prosthetic valves (35 patients). The importance of some manoeuvres, especially within the right atrium, to avoid some of the most usual complications, like cardiac or aortic perforations, intramyocardial injection of contrast medium, and embolization of left atrial masses, is underlined.

[Surgery in complex forms of transposition of the great vessels: long-term results in a series of 100 cases]. / La chirurgie des formes complexes de la transposition des gros vaisseaux: résultats à distance d'une série de 100 cas.

A series of 100 patients with complex forms of transposition of the great arteries (TGA) were operated upon over a 10 year period. Group 1 consisted of 13 TGA with pulmonary stenosis (PS), usually treated by an atrial baffle and direct repair of the stenosis. There was no operative or late mortality in this group and the long-term results were generally good (10/13). Group II comprised 29 TGA with ventricular septal defect (VSD) and PS. Seven Rastelli procedures gave 4 good results. Twenty two operations, associating atrial baffle, repair of VSD and PS (17 direct procedures, 5 left ventricle-pulmonary artery tube) were associated with a high mortality (5 operative and 4 late deaths) and 10 good long-term results. Group III comprised 58 TGA with VSD. Up to 1977 (n = 33) treatment consisted of atrial baffle + repair of VSD +/- removal of previous banding. Mortality was high (11 operative and 8 late deaths) with only 8 good long-term results. Since 1977, these patients have been treated by complete anatomical repair, the operative mortality of which is higher in the period under study (9/23) but the long-term results are much better. The surgical indications in our Department are based on the analysis of these results. In Group I only very significant PS is treated, either by left ventricle-pulmonary artery tube or direct repair depending on the form of the stenosis. In Group II, where the results based on atrial baffle are poor, a Rastelli procedure is preferred and especially its variants which avoid the use of prosthetic materials on the pulmonary trunk. In Group III, anatomical correction at the level of the great arteries is the routine procedure, the only point of discussion being the possibility of prior banding.

Anatomic correction of transposition of the great arteries.

A new technique of anatomic correction of transposition of the great arteries with ventricular septal defect is presented. The procedure described, which avoids the use of a prosthetic conduit in the reconstruction of the pulmonary outflow tract, has been used in nine consecutive patients. Six remain alive and well 4 to 24 months postoperatively. Details and illustrations of the technique utilized are presented. Avoiding the use of a prosthetic conduit in the procedure re-established the basic appeal of arterial correction of transposition of the great arteries with ventricular septal defect.