[Iatrogenic lesions of the left main coronary artery]. / Lésions iatrogéniques du tronc commun coronaire gauche.

Reoccurrence of ischemic events several months after a percutaneous transcutaneous coronary angioplasty is usually due to a restenosis. Coronary angiography rarely shows a new stenosis on another site or on the left main coronary artery. In this series, we report 5 cases of left main coronary artery stenosis which have occurred from 3 to 12 months after a prior percutaneous angioplasty. This phenomenon which has previously been described after direct cannulation of the coronaries ostia during aortic valve replacement in the 70'. This complication is related to intimal damage caused by traumatic manipulation of the left main, which can be either already minimally altered or normal. This complication is rare after percutaneous transcutaneous coronary angioplasty (0.2-1.7%) according to various series. We compare our cases to the published cases in the literature.

[Iatrogenic dissection of the left main artery treated by direct stenting]. / Dissection iatrogène du tronc commun traitée par direct stenting.

A 70-year-old woman was referred to the department due to a symptomatic severe calcific-aortic stenosis. During pre-operative trans-radial approach coronagraphy occurred a iatrogenic dissection of the left main artery with total occlusion and cardiac arrest (asystole). Successful resuscitation is achieved with an emergency strategy of percutaneous direct stenting revascularization combined with cardiopulmonary resuscitation manoeuvres.

[Coronary subclavian steal syndrome after internal mammary artery bypass grafting. A cause of severe postoperative recurrent myocardial ischemia]. / Syndrome de vol coronaire sous-clavier après pontage mammaire interne gauche sur l'artère interventriculaire antérieure. Une cause d'ischémie myocardique résiduelle sévère postopératoire.

A 65-year-old underwent a triple bypass: internal artery mammary-descending coronary artery, aorta diagonal-lateral coronary (sequential). Three weeks later he started to have severe angina pectoris with ST depression in anterior EKG leads. A left transradial coronary angiography was performed. The examination showed a total occlusion of the left subclavian artery 2 cm after the aortic arch and a retrograde flow in the internal mammary artery (IMA). Via transfemoral approach, angiography showed the patency of the aorto-veinous sequential graft and a retrograde flow through anastomosis in the left mammary artery. The patient underwent a reimplantation of the IMA on the brachiocephalic artery. One month later the patient is doing well without chest pain. A coronary subclavian steal syndrome should be suspected in case of recurrent ischaemia after IMA bypass, particularly if there is more than 20 mmHg systolic pressure differential between the arms. Left transradial approach achieved diagnostic in case of total left subclavian artery occlusion.

[Harvesting of an internal saphenous graft for aorto-coronary bypass using video-surgery]. / Prélèvement du greffon saphène interne pour pontage aorto-coronaire par méthode vidéo-chirurgie.

Classical excision of saphenous vein grafts requires a continuous incision on the leg or the thigh or both. To minimise the trauma due to this method, an endoscopic method has been recently developed. The aim of this paper was to assess the benefits of this new method compared with the classical technique. One hundred and twenty patients requiring aorto-coronary grafts were included in this prospective study and divided into two groups according to the method of saphenous vein harvesting. Group A comprised 60 patients who underwent the classical method os saphenous vein harvesting and Group B 60 patients who benefited from the endoscopic method. No difference was observed between the two groups with respect to mean age, sex ratio, history of diabetes and obliterative arterial disease of the lower limbs. Parsonnet index number of bypass grafts and length of vein excised. The length of the skin wound in group A was 30.8 +/- 8.5 cm compared with only 4.1 +/- 1 cm in Group B (p = 0.006) but the harvesting time was longer by endoscopy (55.7 +/- 23.7 minutes: 72.5 +/- 22.6 minutes for the first 10 patients, 48.5 +/- 24.7 minutes for the last 50 patients) compared with the classical technique (39.8 +/- 6.6 minutes: p = 0.001). Moreover, patients who underwent videosurgery had less operative pain (8% versus 15%) (p = 0.001). The number of infectious complications was slightly lower in Group B (3.3%, 2/60, versus 10%, 6/60), (NS). The authors conclude that harvesting of the saphenous vein by videosurgery reduces postoperative pain and gives a more aesthetic result but with a slightly longer operative time at the beginning of the experience.

[Coronary surgery without extracorporeal circulation. Indications, methods and results. Apropos of 224 cases]. / Chirurgie coronaire sans circulation extracorporelle. Indications, technique et résultats. A propos de 224 patients.

Coronary revascularization without cardiopulmonary bypass is evolving as an important technique. From January 1988 to September 1997, 224 patients underwent consecutively coronary artery bypass grafting without cardiopulmonary bypass in our institution. Indications for this type of revascularization were essentially: patients with a single coronary lesion and patients which presented an increased risk for extra-corporeal circulation. Follow-up was complete. The majority of patients were men (176) and the median age was 62 years. Most patients were in CCS III and IV (79%). Unstable angina was found in 19%, 4% had a recent trans mural infarction (< or = 48 hr), and 36% had an older infarct (> 48 hr). 8% were operated in emergency, 29% presented a restenosis following angioplasty, with 4% having a complication from angioplasty, and 0.8% were operated in cardiogenic shock. Redo surgery was seen in 4% of patients. 12% of patients had an ejection fraction less than 30%, 47% an ejection fraction between 30 et 49%, and 40% patients an ejection fraction greater than 50%. Mean Parsonnet score was 10. 185 patients (82.5%) underwent single bypass, and 39 patients (17%) multiple bypasses. Ten patients (4.4%) underwent hybrid revascularization with primarily surgical grafting followed by angioplasty. Postoperative outcome included: myocardial infarction in 16 patients (7.1%), 8 patients (3.5%) were reoperated for tamponade or bleeding, 2 patients (0.8%) developed a mediastinitis, and 1 patient (0.4%) had a neurological event. Hospital mortality was 4% (9 patients). Univariate and multivariate analysis identified two risks factors: age greater than 70 (OR 4.2, CI 1-18.4), and an ejection fraction less than 30% (OR 5, CI 1.2-21.6). Survival was 99.1% at 1 year, 94% at 3 years and 83.2% at 7 years. Post operative angina occurred in 33 patients, linked to a coronary anastomosis dysfunction in 9 patients (4.1%). A significant reduction of cost was found, compared to patients operated with extra-corporeal circulation. We conclude that coronary revascularization without cardiopulmonary bypass can provide satisfactory results, for patients with single coronary lesion, or for patients with an increased risk and multiple coronary lesions.

[Aorto-coronary bypass]. / Pontage aorto-coronarien.

OBJECTIVES: Saphenous grafts used for coronary artery bypass are classically dissected via a continuous incision of the leg, the thigh or both. Recently, a new video-surgery technique has been introduced in an attempt to reduce the trauma of saphenous vein dissection. The aim of this work was to evaluate the possible benefits of this new technique compared with classical dissection. PATIENTS AND METHODS: Sixty patients requiring coronary artery bypass grafts were included in this study and randomly divided into two groups. In group I (30 patients) the saphenous vein was dissected according to the classical technique. The video-surgery technique was used for the other 30 patients in group II. The two groups were not significantly different for mean age, sex ratio, or history of diabetes or lower limb arteriopathy. The same number of bypasses was performed in both groups (2.6 +/- 0.7). Outcome was compared for: dissection related complications (hematomas, infections), length of the skin incision over the length of the dissected vein, duration of the dissection procedure, and post-operative pain. RESULTS: A leg incision was used in 28 cases out of 30 cases in both groups. The length of the saphenous vein dissected was 27.6 cm in group I and 21.8 cm in group II. The length of the skin incision was 27 cm in group I and only 4.7 cm in the video-surgery group II, giving an incision/vein ratio of 97% and 21% respectively. Operative time was however 37.9 min for group I and 48.5 min for group II. There was no significant difference between the groups for hematoma formation or infection but the patients in the video-surgery group experienced less post-operative pain. CONCLUSION: Besides an improvement in the esthetic result, video-surgery dissection of the saphenous vein reduces post-operative pain at the cost of a slightly longer operative procedure.

Coronary artery revascularisation without extracorporeal circulation. Indications and results.

OBJECTIVE: Coronary artery revascularisation without extracorporeal circulation is a technique which can be performed in selected patients in need of a coronary artery bypass graft. METHODS: Consecutive patients (210) underwent coronary artery bypass graft without extracorporeal circulation. Indications were high risk patients, or single coronary artery lesion. To predict perioperative mortality, preoperative risk factors were reviewed, and Parsonnet score was calculated. RESULTS: There were seven deaths (3.3%), and univariate analysis revealed greater age, NYHA, and poor ejection fraction to be the only predictors of early mortality. Perioperative myocardial infarction included 15 patients (7.1%), most of them seen in the multiple bypass group (10/39, 26%). Patients were divided into low risk (Parsonnet score < 15) 155 patients with two deaths (1.2%), and high risk (Parsonnet score > 15) 55 patients with five deaths (9%). Complete revascularisation was performed in the low risk group, while in the high risk only the symptomatic vessel was bypassed and other angiographic lesions treated with postoperative angioplasty (10 patients). A total of 12 patients developed early postoperative angina (5.7%), 9 presented an anastomosis dysfunction which was treated by angioplasty (5) and surgery (4), and 188 patients (85.7%) did not receive transfusions while 190 patients (90.4%) did not need postoperative inotropes. Length of stay, operating room time, and medical costs were all significantly reduced. CONCLUSIONS: Myocardial revascularisation without extracorporeal circulation can be performed with a low operative mortality, and minimal morbidity only in patients undergoing single bypass revascularisation. It can also be performed as part of a multiple revascularisation strategy in association with angioplasty in high risks patients.

Calcified embolus of the left coronary ostia after aortic valve replacement.

A patient with a left coronary calcified embolus causing acute myocardial dysfunction immediately after aortic valve replacement is described. Prompt diagnosis by transesophageal echocardiogram was made, which led to removal of the embolus and a subsequent satisfactory course.

[Contribution of multiplane transesophageal echocardiography in the study of mitral valve prostheses]. / Apport de l'échographie transoesophagienne multiplan dans l'étude des prothèses mitrales.

Many reports have confirmed the value of transoesophageal echocardiography in the diagnosis of mechanical mitral valve prosthesis dysfunction: new biplane and multiplane probes seem to provide additional information in the assessment of cardiac disease. The aim of this study was to quantify the additional value of these new probes in the assessment of mitral valve prostheses. Seventy-five mitral valve prostheses were assessed with the multiplane probe, 45 normal bileaflet prostheses, 17 with regurgitant dysfunction and 12 with non obstructive thrombi and/or strands, and one with a blocked leaflet. In order to compare the respective values of monoplane, biplane and multiplane probes, the recordings were performed at 0 degrees, 90 degrees and from 0 degrees to 180 degrees in continuous sweep mode through the scanning plane. Globally, with the monoplane assessment, it was only possible to visualise both leaflets simultaneously in 13% of cases. The majority of prostheses was correctly analysed between 60 and 100 degrees. This was of paramount importance for the diagnosis of blockage of one leaflet. With respect to para-prosthetic valve regurgitation, the transverse view allowed visualisation of the lateral and paraseptal annular regions. The addition of a longitudinal view allowed visualisation of anterior and posterior regurgitant jets: the supplementary views provided by the multiplane probe allowed detection of small regurgitant jets in the diagonal planes between the longitudinal and transverse views. The multiplane probe offers the possibility of identifying the precise origin of the jet and helps quantification and peroperative localisation of its position. Small, non-obstructive thrombi and strands are better seen using a multiplane probe, especially when of small size. Therefore, multiplane transoesophageal echocardiography improves the assessment of mitral valve prostheses, the majority of diagnoses being, however, accessible with biplane probes.

Percutaneous double balloon valvuloplasty for stenosis of porcine bioprostheses in the tricuspid valve position: a report of 2 cases.

The feasibility and results of percutaneous double balloon valvuloplasty were evaluated in 2 patients with stenosis of porcine bioprostheses in the tricuspid valve position. The procedures were performed with a Trefoil 3 x 10 and a 15 mm balloon. Long inflations (4 and 3 minutes) were well tolerated. A significant immediate increase in the valve area, without significant valvular regurgitation, was achieved in both cases, from 0.65 to 1.15 cm2 in case 1 and from 0.9 to 1.65 cm2 in case 2. Both patients required valve replacement during the follow-up, at 14 and 21 months. There was no restenosis, but echocardiography showed right atrial thrombosis in case 1. Progressive restenosis with peripheral edema and increase of the mean doppler gradient occurred in case 2. The procedure is feasible, safe, and well tolerated. It provides significant immediate hemodynamic improvement, but it should be considered as a palliative technique since a normal valve area can not usually be obtained and a restenosis is likely to occur at midterm follow-up.

[Value of early systematic postoperative transesophageal echocardiography in mitral valve replacements. A prospective study of 50 patients]. / Intérêts de l'échocardiographie transoesophagienne systématique postopératoire précoce des remplacements valvulaires mitraux. Une étude prospective sur 50 patients.

The aim of this study was to assess the value of routine transoesophageal echocardiography in the early postoperative period after mitral valve replacement. The authors report their experience in 50 consecutive operated patients (43 mechanical and 7 bioprostheses) investigated routinely by this method in the postoperative period in the surgical unit. Abnormal findings were observed in 36% of cases (18 patients): trans-prosthetic leaks (8 cases) and thrombosis (10 cases) in 2 bioprostheses and 8 mechanical prostheses; in 3 cases this led to haemodynamic dysfunction but in 7 cases the thrombus had no influence on the trans-prosthetic pressure gradient. No predisposing factor could be identified (spontaneous contrast, left atrial volume, left ventricular function, poor anticoagulation, blood clotting abnormalities). No abnormality of the mobile components of the prosthesis was observed at radioscopy. The outcome with heparin therapy was favourable with disappearance of the thrombi in 6 cases; the thrombi did not regress in 4 patients on heparin: 2 patients underwent thrombolytic therapy with a complete cure in 1 case and a severe embolic complication in the other; in 2 cases, the thrombus was so big that the patients were reoperated. Systematic early postoperative transoesophageal echocardiography before discharge from the surgical unit would seem to be necessary after early mitral valve replacement: it allows diagnosis of asymptomatic thrombosis which has an important emboligenic potential. The management of these thromboses remains controversial, but the poor natural outcome in cases of large thromboses should lead to referral for early reoperation.

[Asymptomatic postoperative thrombosis of a Saint Jude mitral valve prosthesis. Treatment by fibrinolysis with rt-PA]. / Thrombose postopératoire asymptomatique d'une valve de Saint-Jude mitrale: traitement par fibrinolyse au rt-PA.

Routine Doppler echocardiography after cardiac surgery demonstrated stenotic dysfunction of a Saint Jude Medical mitral valve prosthesis due to blockage of one hemidisc although the patient was totally asymptomatic. Despite the precocity of this thrombosis (14th postoperative day), thrombolytic treatment was undertaken. It led to normalisation of the Doppler parameters of prosthetic valve function and mobility of the two hemidiscs. Haemopericardium occurred at the end of thrombolytic therapy and was drained easily, a benign complication of early postoperative thrombolysis.

Late endocarditis-associated obstructive dysfunction of a tricuspid ball-cage-type valve. Doppler echocardiographic findings and therapeutic implications.

Thrombotic obstruction is rare in bacterial endocarditis involving prosthetic heart valves. A 45-year-old man who had three intracardiac, ball-cage-type prosthetic valves, presented with streptococcal septicemia. Major obstruction of the tricuspid Smeloff-Cutter valve and normal function of the two other prostheses were documented by Doppler echocardiography. Emergency replacement of the tricuspid valve alone was decided on the one basis of this echocardiographic diagnosis, and successfully performed. Operative findings confirmed the noninvasive findings.

[Visualization by bidimensional echocardiography of the trunk of the left coronary artery. Affirmation of its integrity before coronary angiography]. / Visualisation par échocardiographie bidimensionnelle du tronc de la coronaire gauche. Affirmation de son intégrité avant coronarographie.

The aim of this study was to visualise and analyse the status of the main left coronary artery by 2D echocardiography before coronary angiography. Fifty two patients were studied. The recordings were performed from the left parasternal position on video cassettes and played back frame by frame for each patient, to analyse the left main coronary artery and its bifurcation. The patients had known stenosis of this vessel; there were echocardiographic abnormalities in all 10 cases; the stenosis was visualised directly in 5 patients and the vessel was considered to be abnormal in the other 5 patients. Forty two patients underwent 2D echo before coronary angiography. The echo of the left main coronary artery was considered to be abnormal in 8 patients: these results were compared with those of coronary angiography. In 33 cases there were no echocardiographic abnormalities and there were no angiographic lesions. The false positive results were due to the inability to record the bifurcation (proximal stenosis of the LAD interpreted as stenosis of the left main coronary) or to the direction of the left main coronary which is curved and thus cannot be analysed in the plane of the transducer. False negative results corresponded to slight stenosis (less than 50 p. 100). The bifurcation can be visualised in 60 p. 100 of patients with normal left main coronary arteries. It is only in these cases that the absence of significant lesions can be confirmed before coronary angiography.

Left atrial myxoma in the elderly: diagnosis by M-mode and bidimensional echocardiography.

Two cases are reported of left atrial myxoma in elderly patients, diagnosed by combined M-mode and bidimensional echocardiography. One patient was an 80-year-old man presenting with typical signs of mitral obstruction by an atrial tumor. His symptoms were erroneously attributed to chronic bronchitis until an echocardiogram was obtained. The other patient was a 70-year-old woman with atrial fibrillation of one year's duration. Left atrial myxoma, although rarely observed in the elderly, may be diagnosed easily by means of echocardiography. Some cases may prove amenable to surgical treatment.

[Right pulmonary artery-left atrial fistula. Review of the literature apropos of a case]. / Communication entre artère pulmonaire droite et oreillette gauche revue de la littérature à propos d'une observation.

This is a rare congenital abnormality with only 17 other reported cases in the world literature. The most frequent sign is cyanosis with peripheral arterial desaturation. Angiography with selective injection in the main pulmonary shows early opacification of the left atrium, so confirming the diagnosis. Occasionally, a catheter can be passed through the fistula. Without surgical treatment there is a danger of systemic arterial embolism and two fatal cases were found in our review of the literature. The fistulous connection is often aneurysmal. It arises either from the right main pulmonary artery or from its branch to the inferior lobe. Associated vascular and pulmonary malformations are not rate. Surgical closure of the fistual is curative with immediate regression of the cyanosis and suppression of possible embolic complications.

[Veinous return from the inferior vena cava into the left atrium after surgical correction of Fallot's tetralogy]. / Retour veineux cave inférieure dans l'oreillette gauche après correction d'une tétralogie de Fallot.

A child of 6 presented with a syndrome of gross respiratory distress together with persistant arterial desaturation, requiring ventilation for maintenance of life, occurring after the apparently straightforward correction of a Fallot's tetralogy. Postoperative investigation on the 15th day showed the reasons for the desaturation: there was a massive right-left shunt caused by flow from the inferior vena cava into the auricle of the left atrium through a low atrial septal defect which had not been recognised. Reoperation on the 15th day to close the atrial septal defect corrected the condition satisfactorily.