Doppler analysis of the left venting line: an effective and simple technique to control heart de-airing.

Air embolism is still a major risk of open-heart surgery. Different techniques of air removal have been established, even though none is completely effective. Since 1989 the authors have used a new technique to avoid air passage into the left vent line when the left heart cavities are open. A specially designed probe attached to a vascular Doppler analyser is fixed to the left vent tubing. Air passage is detected by a characteristic acoustic signal. Air removal procedures are continued until no audible signals are detected. This technique was carried out in 150 open left heart operations in which there were no clinical signs of air embolism. To validate this procedure, simultaneous assessment of air removal was made using transoesophageal echocardiography (TEE) and carotid Doppler (CD) in six patients. When Doppler signs of air in the left vent disappeared, TEE revealed that a small amount of air was still present in two patients; carotid Doppler showed only minimal passage of air bubbles in three patients after left vent removal while the heart was freely ejecting. These results demonstrate that this technique is a reliable method of assessing air removal, which is especially useful when de-airing is difficult during reoperation.

[Tetralogy of Fallot. 20 years' experience in 144 cases]. / Tétralogie de Fallot. Vingt ans d'expérience portant sur 144 cas.

Between 1968 and December 1987, 144 patients with tetralogy of Fallot were examined at La Pitié Hospital, Paris. 76 were female and 68 male, with a mean age of 8.1 years at the first visit. The patients were regularly followed up by the same physician relying on radiography of the chest, electrocardiography and, since 1982, two-dimensional echocardiography. These visits were coupled with an interview with the welfare officer attached to our department for information on the patient's way of life as well as his socio-professional and familial problems. 129 patients of mean age 14.8 years underwent corrective surgery preceded in 81 cases by palliative surgery. The overall immediate mortality rate was 12.4% (16 cases), falling from 19.5% between 1968 and 1977 to 3% during the last 10 years. The mean follow-up period was 10.7 years, with 51 patients being followed up for more than 10 years and 18 for more than 20 years. Late mortality now stands at 5.3% (7 patients, 6 of whom died of a cardiac cause). Residual lesions consisted in significant (27%) pulmonary insufficiency in 35 patients, residual interventricular septal defect in 16 patients (12.4%) and pulmonary obstruction in 11 patients (8%). 18 patients presented with dysrhythmias, including 7 cases of ventricular arrhythmia; 5 two-bundle blocks and 5 complete atrioventricular blocks were also observed. 11 patients required reoperation with a 27.2% mortality rate (3 cases).(ABSTRACT TRUNCATED AT 250 WORDS)

[54 cases of infectious endocarditis seen in 32 years in a population of 2038 congenital heart diseases]. / A propos de 54 cas d'endocardites infectieuses observées en 32 ans sur une population de 2,038 cardiopathies congénitales.

A longitudinal study of a 32-year period (1954-1987) involving 2038 patients with congenital heart defects followed by the same physician yielded 54 cases of infective endocarditis (IE). Complex cyanogenic cardiopathies were particularly exposed to the risk of infection (8.2 IE for 1000 patient-years), then came ventricular septal defects (2.4), tetralogy of Fallot (2.3), aortic stenosis (2.0) and atrioventricular canal (1.7). The risk was smaller in patients with Eisenmerger complex (1.2), persistent arterial canal (1.4) and coarctation (0.7). Patients under 10 years of age (16.7%) were less affected than young adults in the 20-29 years age-group (33.4%). The organisms most frequently isolated were streptococci (42%); staphylococci ranked second (23%). Less common organisms were found in 14% of the cases, and blood cultures were negative in 21%. Systemic prophylaxis with penicillin V, introduced 16 years ago, seems to have almost halved the incidence of infective endocarditis due to penicillin-sensitive organisms.

[Shock caused by glafenine. Apropos of 7 complications]. / Les chocs à la glafénine. A propos de sept accidents.

Glafenine-induced shock. Seven cases. Glafenine is a widely prescribed analgesic drug, and shock is one of its severe side-effects. We report six documented and one highly probable cases of such accidents. From these seven cases and a review of the literature, we have extracted the clinical characteristics of glafenine-induced shock. Shock usually occurs about 30 minutes on average after taking one single tablet. Previous use of the drug is found in more than 50 per cent of the patients, and it was often followed by a neglected side-effect. A series of cutaneous and respiratory manifestations precedes or accompanies the shock. Two physiopathological mechanisms of glafenine-induced shock have been postulated: either anaphylaxis or idiosyncratic reaction involving the prostaglandins. In vitro tests give highly variable results and therefore are of limited value. Glafenine-induced shock is rare; its incidence, probably underestimated, is about 0.7 in 10(5) treatments. Prevention is essential, cure relies on adrenaline.

[Atrial septal defect and cyanosis. Apropos of 6 cases related to abnormal drainage of the inferior vena cava into the left atrium]. / Communication interauriculaire et cyanose. A propos de 6 observations en rapport avec un drainage anormal de la veine cave inférieure dans l'oreillette gauche.

The authors report six cases of atrial septal defect (ASD) associated with abnormal drainage of the inferior vena cava into the left atrium responsible for right-to-left shunting, without pulmonary hypertension. The abnormal drainage could be due either to an anatomical malposition of the inferior vena cava opening into the left atrium, or to an abnormal blood flow from this vein, normally located through a low ASD, under the influence of anatomical, mechanical and haemodynamic factors. Clinically, all patients presented with light cyanosis and with the usual signs of ASD. None of them had elevated pulmonary pressure. The lesion, suggested by clinical findings, was diagnosed either at angiography, which in four cases demonstrated an abnormal pulmonary venous return, or at colour-coded doppler echocardiogram, or at surgery. In every case, surgical correction consisted of closure of the often low-sited ADS by a patch which diverted the inferior vena cava into the right atrium and the abnormal venous return towards the left atrium. The short--and long-term results of surgery were excellent. The authors review the literature concerning this unusual association of ASD with an abnormal drainage of the inferior vena cava into the left atrium.

[Percutaneous transluminal angioplasty in complex congenital cardiopathies. Apropos of 2 cases]. / Angioplastie transluminale percutanée dans des cardiopathies congénitales complexes. A propos de deux cas.

Percutaneous transluminal angioplasty (PTA), already widely used in stenosis of peripheral, renal or coronary arteries, has now been extended to congenital heart diseases. Thus, in pulmonary or aortic orificial stenosis this simple and fairly safe method has proved to be a suitable alternative to surgery. In other cases it may be used for tiding the patient over a critical period pending surgery. Finally, PTA may be performed as a palliative treatment of lesions that are too complex for surgery or carry an excessively high operative risk. This applies to the two cases reported here, where PTA enabled us to dilate: the ductus arteriosus in a patient with single ventricle--an application which, to our knowledge, has not yet been reported--and a strongly stenotic pulmonary orifice associated with a complex heart disease. In both cases PTA was successful both haemodynamically and angiographically and was followed by marked clinical improvement. The published cases of complex congenital heart diseases where PTA has been used are reviewed.

[Transmural myocardial infarction. An impossible electrocardiographic diagnosis]. / Infarctus myocardique transmural. Un diagnostic électrocardiographique impossible.

The anatomical and experimental data clearly show that transmural myocardial infarction does not always produce a pathological Q wave on the ECG, but may sometimes only cause abnormalities of the ST segment and the T wave. Conversely, a sub-endocardial myocardial infarction may present with pathological Q waves. Schematically, the histology of transmural myocardial infarction usually reveals so-called coagulation necrosis, while sub-endocardial myocardial infarction generally corresponds to myofibrillary degeneration (contraction band necrosis), which promotes a reperfusion process. Very often, however, the histological appearance is not so clear-cut and the features tend to overlap. Consequently, in practice, it does not seem justified to use the electrocardiogram as a basis to distinguish between transmural and sub-endocardial infarctions, in terms of prognosis, or to select possible candidates for coronary angiography following a first myocardial infarction.