[Valvular aortic stenosis, left anterior cusp hypoplasia and obstruction of left main coronary artery ostium by a congenital membrane]. / Sténose aortique, hypoplasie de la sigmoïde antérogauche et obstruction de l'ostium coronaire gauche par une membrane congénitale.

Aortic stenosis and obstruction of the left main coronary artery ostium is very rare. This report describes the case of one patient with valvular aortic stenosis, left anterior cusp hypoplasia and obstruction of the left main coronary artery by a congenital membrane. Surgical treatment with aortic valve removal and excision of the congenital membrane was successful.

[Multi-plane transesophageal echocardiography in cardiac angiosarcoma. Apropos of a case]. / Apport de l'échocardiographie transoesophagienne multiplan dans l'angiosarcome cardiaque. A propos d'un cas.

The authors report the case of a right atrial angiosarcoma extending to the right ventricle, presenting with a massive pericardial effusion, in a 30 year old man. The patient underwent surgical ablation of the tumour with right atrial reconstruction, tricuspid valvuloplasty, plicature of the right ventricle and a right coronary artery bypass graft with complementary chemotherapy. This case illustrates the decisive contribution of multiplane transoesophageal echocardiography in the preoperative investigation, providing accurate information about the site and extension of the tumour, and even about the malignant character of the pathology. Magnetic resonance imaging, though useful, did not provide any further information in this case. Unfortunately, thoracic CT scan, performed 15 days after surgery, showed the presence of pulmonary metastases, confirming the very poor prognosis of these tumours.

[Complex cardiac lesion diagnosed more than 20 years after the causal injury]. / Lésion cardique complexe diagnostiquée plus de 20 ans après. Le traumatisme causal.

Penetrating wounds of the heart, when not immediately fatal, may give rise to complex lesions associating valvular regurgitations and fistulous connections. The authors report the case of a patient with mitral and aortic regurgitation associated with an aorto-left atrial fistula of traumatic origin and causing invalidating cardiac failure. The interest of this particular case lies in the duration of the interval between the causal trauma and the appearance of symptoms (over 20 years). Complete surgical repair of the lesions provided a good functional result. The authors discuss the different types of lesions which may be caused by wounds of the heart and their modes of presentation.

[Early postoperative thrombolysis of Saint-Jude aortic valve prosthesis]. / Thrombolyse postopératoire précoce d'une valve de Saint-Jude aortique.

The authors report a case of thrombolytic therapy with streptokinase in the early postoperative period after aortic valve replacement with a Saint Jude medical prosthesis. After good initial progress, the patient had to be reoperated on the 12th postoperative day for sternal disunion. Reoperation was followed rapidly by progressive thrombosis of the aortic prosthesis demonstrated by repeated Doppler echocardiographic examination. The impossibility of eliminating mediastinitis led to medical thrombolysis. The outcome was favourable after a regressive cerebral embolic event. This case illustrates the value of Doppler echocardiographic examination in the postoperative period. Thrombolysis may constitute an alternative to reoperation when the operative risk is high. The risk of thrombolysis may not be as great as some believe.

[New valvular homografts. Prospects and limits of their viability. Report of 42 implantations]. / Les nouvelles homogreffes valvulaires. Espoirs et contraintes de leur viabilité. A propos de 42 implantations d'homogreffes.

The regain of interest in aortic homograft bioprostheses is related to the prospects of improved viability resulting from explanation from organ donors, preservation in rich tissue culture media, together with the progress made in techniques of cryopreservation. Viability studies examining morphology of electron microscopy and tests of tissue culture confirm this notion of longer viability. These properties raise hopes of satisfactory long-term results while acknowledging outstanding antigenic problems which require strict A-B-O system compatibility. The results of a preliminary series of 42 valve homografts implanted at Henri Mondor Hospital over the last 5 years are reported. Twenty-one bioprostheses were implanted on the right side in congenital heart disease with good results in every case. Twenty-one were implanted in the aortic position in children and show no signs of degeneration as yet. One poor result was related to a technical error in calibration. The rebirth of this technique raises certain hopes, especially in aortic valve replacement.

[Viability of new valvular homografts. An evaluation at the Henri Mondor Hospital]. / Viabilité des nouvelles homogreffes valvulaires. Bilan de l'Hôpital Henri-Mondor.

The renewed interest in valvular homograft is due to the new concept of their viability. This viability requires procurement from organ donors and preparation in rich tissue culture medium immediately prior to cryopreservation. This viability, confirmed by morphological tests especially electron microscopy, and by cell culture tests is the basis for satisfactory long-term results. Antigenic aspects justify rigorous respect of A-B-O compatibility. A preliminary clinical series of 35 valvular homografts (16 on the right side and 19 in the aortic position), implanted especially in children over the last five years at the Henri Mondor Hospital, is reported here, No tissue failures have been reported to date.

[Echocardiographic-Doppler study of a case of subacute and incomplete parietal rupture after myocardial infarction]. / Etude échocardiographique-doppler d'un cas de rupture pariétale incomplète et subaiguë après infarctus du myocarde.

The authors report the case of a 55 year old man who suffered a silent, laterobasal myocardial infarction which was complicated by a subacute pseudo-false aneurysm of the lateral wall of the left ventricle. They underline: The importance of two-dimensional echocardiography in the diagnosis of a neo-para left ventricular cavity showing systolic expansion and communicating with the left ventricle by a narrow neck indicating rupture of the free ventricular wall; The value of two-dimensional color coded Doppler which enables the operator to distinguish the active nature of the neo-left ventricular cavity before surgery and its inactivity after surgery. The surgical indication for emergency resection of the pseudo aneurysm was based on these preoperative non-invasive observations. This case confirms the value of cardiac two-dimensional echo-Doppler studies in the investigation of ischaemic heart disease.

[Viability of new valvular homografts. Myth or reality?]. / La viabilité des nouvelles homogreffes valvulaires. Mythe ou réalité?

Use in cardiac surgery of aortic homografts as a valvular substitute is old and was specially developed in France by F. Fontan. In fact, these first allografts were non-viable and the results, in aortic position, were not better than current bioprosthesis. Renewed interest is related to the important notion of "viability" allowed by an immediate procurement (organ donors), preparation in nutrient medium RPMI with low doses of antibiotics and final storage at -196 degrees C (cryopreservation). We have reviewed our initial experience concerning 32 implanted homografts in children either in reconstruction of the right ventricular outflow tract (in many forms of congenital heart disease) or in aortic position. No mortality was observed. The only failure was due to an initial sizing mistake leading to an aortic valve replacement at 13 months. No late deterioration (mean follow-up: 12.5 months) was detected by echocardiography. These results seem to confirm other larger series (as O'Brien's, Brisbane, Australia). Biologic, histological and immunological assessments of "viable" homografts are discussed. The limits of the technique are reported.

Aortic 125I-albumin transport in patients with Marfan's syndrome and annuloaortic ectasia.

The morphologic, biochemical, and mechanical abnormalities of connective tissue fibrous proteins in Marfan's syndrome have been well studied, and their role in cardiovascular complications is well accepted. Less is known, however, about the state of the amorphous components of the aortic connective tissue. In the course of a study of transmural transport in blood vessels, we have had the opportunity to study dystrophic aorta from two young men who survived elective surgery; both with aortic insufficiency (AI) histologically compatible with Marfan's syndrome. One had recurrent chronic dissecting aneurysm (RCDA) as well. The aorta of the first (but not the second) was histologically compatible with Marfan's syndrome. Fresh specimens of intact ascending aorta were incubated in Krebs solution, pH 7.4, containing 125I-labelled bovine serum albumin for 2 h at 37 degrees C. The samples were then frozen, and serially sectioned in the plane of the lumenal surface. The radioactivity of the 20-micron thick sections was then determined, and expressed as a tissue/labelled solution concentration ratio. Transmural profiles of these ratios revealed no difference between the aorta of the RCDA patient with non-specific aortic dystrophy, and that of a 70-year-old man undergoing aortocoronary bypass. However, in the patient with aortic histology compatible with Marfan's syndrome, the average media concentration ratio was 5-fold less (4% vs. 20%).

[Cor triatriatum. Anatomical forms and surgical treatment of 6 consecutive cases]. / Coeur triatial. Formes anatomiques et traitement chirurgical de 6 cas consécutifs.

Six cases of cor triatriatum documented and operated on at Henri-Mondor hospital between 1980 and 1984 are reported. Ages at the time of surgery ranged from 8 months to 57 years. Four of the 6 patients presented with pulmonary hypertension. Anatomic types consisted of 4 diaphragmatic types and 2 more complex malformations. Associated lesions were present in all but one patients. They consisted mostly of interatrial defects (depending on their position with regard to the intra-atrial membrane, they play a determinant role in the symptomatology) and of a left superior vena cava (which might play a role in the embryogenesis of the malformation). Except for one early postoperative death, results of surgery were excellent for all patients, with a mean follow-up of 5 years. This series, compared with the literature, allows precising the embryologic and anatomic aspects of the malformation and the surgical techniques in complex types.

[Ventricular dysplasia. Nosology and sudden death]. / La dysplasie ventriculaire. Nosologie et mort subite.

The arrhythmia generating dysplasia of the right ventricle is a congenital anomaly suggesting a hereditary substratum. It usually manifests itself as follows: a young patient, with recurrent episodes of ventricular tachycardiac. There is no "pathognomonic sign" of dysplasia. The latter may only be determined by anatomical examination of the heart, macroscopically as well as microscopically. The most difficult differential diagnosis concerns minor or localized forms of dilated idiopathic myocardiopathy or sequelae of myocarditis with ventricular tachycardia originating in the right ventricle. It seems, currently, more appropriate to talk about "arrhythmia generating syndrome of the right ventricle" rather than arrhythmia generating dysplasia of the right ventricle, in these particular cases. The arrhythmia generating syndrome of the right ventricle could cause a sudden death in these young patients, especially during a violent physical exercise or practise of sports. The current nosological classification is based on an experience acquired by comparing a few isolated cases. The search for late potentials by summation-mean measurements and nuclear magnetic resonance could provide a new diagnostic approach.

[Aortic subvalvular obstructions. Anatomical forms and surgical treatment of 82 consecutive cases]. / Les obstacles sous-valvulaires aortiques. Formes anatomiques et traitement chirurgical de 82 cas consécutifs.

The authors report their experience of surgery for subvalvular aortic obstruction in 82 patients aged from 4 to 44 years (mean 15 years). Nearly one-half of the patients presented with symptoms; the others were operated upon for various reasons: gradient exceeding 60 mmHg, development or aggravation of aortic regurgitation, positive exercise test, electrocardiographic or echocardiographic signs of left ventricular repercussions. Nineteen children had previously undergone surgery for another malformation, but the subvalvular aortic obstruction had either been missed during this first operation or had developed subsequently. The diaphragmatic pattern was the most frequent (62 cases); the fibromuscular pattern was less common (9 cases) and the tunnel pattern (6 cases) was regularly associated in this series with hypoplasia of the aortic ring. Obstruction due to faulty insertion of the mitral valve was encountered on 3 occasions. The operative technique for each anatomical pattern is described. Tunnel obstructions did not require primary aortoventriculoplasty without prosthetic valve replacement of apicoaortic conduits. In addition to treatment of associated lesions (including 4 cases of ventricular septal defect), 9 aortic commissurotomies, 6 aortic valvuloplasties and 4 aortic valve replacements were performed. The transaortic gradient was dramatically improved. The aortic regurgitation murmur subsided with or, usually, without valvuloplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Rupture of the right ventricular free wall. An unusual complication of mediastinitis after cardiac surgery.

Of 2171 patients who underwent open heart surgery between 1981 and 1986, 41 (1.8%) developed postoperative mediastinitis and were treated by closed irrigation drainage or open chest therapy. Six patients, (mean age 59 years) developed rupture of the right ventricular free wall. The primary procedures were: resection of akinetic fibrous plaque (2), mitral valve replacement (1), coronary bypass grafting (1), removal of a left atrial myxoma (1) and repair of post-infarction rupture of the left ventricle (1). In 2 patients, rupture occurred in the operating theatre during revision of the irrigation drainage. Both patients died after repair. In 4 patients, rupture occurred during coughing. One died before surgery. In the 3 other cases, the defects were repaired either by direct suture (2 patients) or with a pericardial patch (1 patient) with the aid of normothermic extracorporeal circulation. Three days later, a muscular flap (pectoral or dorso-lumbar) was mobilized to protect the mediastinal viscera. All 3 patients are alive and well. When bleeding occurs during treatment of mediastinitis, an immediate exploration with extracorporeal circulation to close the defect should be considered.

Nd-YAG laser-induced injury in dog myocardium: optical and ultrastructural study of early lesions.

To characterize myocardial lesions induced by Nd-YAG laser in vivo, laser pulses were delivered on the epicardial surface of beating dog hearts. Acute lesions were studied at the optical and ultrastructural levels. The size of the lesions depended on the power of the laser beam. Tissue vaporization could be avoided if total delivered energy did not exceed 350 J. Laser energy induced different types of myocardial necrosis distributed in concentric layers of coagulation necrosis, and contraction band necrosis. Thus, laser energy can produce controlled irreversible lesions without crater formation. These effects may be of use in the treatment of arrhythmias.

[Ventricular tachycardia of ischemic origin. Surgical treatment by encircling thermo-exclusion using the Nd-Yag laser]. / Tachycardies ventriculaires d'origine ischémique. Traitement chirurgical par thermo-exclusion circonférentielle au laser Nd-Yag.

Refractory and recurrent ventricular tachycardias are a common cause of death after myocardial infarction. The occurrence of intraventricular re-entries can be prevented by a new surgical treatment based on encircling thermic exclusion. The Nd-YAG laser beam offers 2 major advantages over previous techniques: it acts rapidly with minimal myocardial damage and can even be used in patients with left ventricular dysfunction.

Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries.

From November, 1976, to June, 1983, 100 patients, 84 male and 16 female patients ranging in age from 13 to 74 years, were operated on for aortic insufficiency associated with an aneurysm of the ascending aorta. Twenty patients were in New York Heart Association Class I, 22 in Class II, 51 in Class III, and seven in Class IV. The surgical treatment in all cases consisted of total replacement of the ascending aorta with a tube graft containing a prosthetic aortic valve and reimplantation of the coronary arteries by an intermediate tube graft according to the technique already reported. In 68 patients an uncomplicated annulo-aortic ectasia existed, and in 32, an aortic dissection; nine of the latter group were operated on during the acute phase. The operative mortality for the entire group was 4% (four deaths). One patient has been lost to follow-up during a period ranging from 18 months to 8 years (average 54 months). The late mortality has been 11/96. Among the 84 survivors, clinical improvement is readily apparent (89% are in Class I or II). Twenty-five patients have been restudied by angiography, which revealed a satisfactory coronary and aortic appearance in all cases with neither stenosis nor aneurysm. The actuarial survival rate is 75% at 8 years. In conclusion, the treatment of aortic insufficiency associated with an aneurysm of the ascending aorta by insertion of a composite graft and reimplantation of the coronary arteries through an intermediate Dacron tube is a reliable method with low mortality and excellent long-term results.