Pure ipsilateral central facial palsy and contralateral hemiparesis secondary to ventro-medial medullary stroke.

Medullary infarcts are occasionally associated with facial palsy of the central type (C-FP). This finding can be explained by the course of the facial corticobulbar (F-CB) fibers. It is believed that fibers that project to the upper facial muscles decussate at the level of the facial nucleus, whereas those destined to the lower facial muscles decussate more caudally, at the level of the mid or upper medulla. It has been proposed that the lower F-CB fibers descend ventromedially near the corticospinal tract to the upper medulla where they cross midline and ascend dorsolaterally. Accordingly, ventromedial medullary infarcts are expected to result in contralateral facial and limb weakness. We report a patient with a medial medullary infarct restricted to the right pyramid and associated with ipsilateral C-FP and contralateral hemiparesis. The neurological findings are discussed in light of the hypothetical course of the F-CB fibers in the medulla.

[Value of transesophageal echocardiography in the diagnosis of peripheral embolic event]. / Interet de l'echocardiographie transoesophagienne dans le bilan d'un accident embolique peripherique.

Ischemic cerebro-vascular events are in 15% of cases secondary to a cardiac embolus. The prevalence of echocardiographic anomalies, susceptible of being at the origin of a cerebral embolus may reach 50%. Transesophageal echocardiography (TEE) is superior to transthoracic echocardiography (TTE) in the detection of a thrombus of the left atrial appendage, spontaneous echocontrast, intra-aortic atherosclerotic plaque lesion, patent foramen ovale or an atrial septal aneurysm. The high prevalence of these anomalies in a population who presented an ischemic cerebrovascular accident does not suffice to establish a causal relationship between the anomaly and the cerebral event. Further studies seem to be necessary to establish the responsibility of these different anomalies and determine their embolic risk, by defining certain risk factors. Pending the results of such studies, TEE should be indicated more systematically in the case of an ischemic cerebrovascular accident of the young patient without a clinically evident cardiopathy, independently of the results of TTE.

[First Lebanese series of percutaneous mitral commissurotomies]. / La première série libanaise de commissurotomie mitrale percutanée.

From January 1993 to January 1994, we realized at Risk Hospital 11 percutaneous mitral commissurotomies (PMC). This first Lebanese series comprised 9 women and 2 men. The mean age was 36 y (18-73 y). Ten patients were en class III of the NYHA and one in class IV (pregnant woman on the end of the 7th month). The predilatation evaluation was done by transthoracic echocardiography for the just 2 patients and by transthoracic with transesophageal multiplane echocardiography for the 9 others. The mean gradient was at 20 mmHg (10-24 mmHg) and the mean mitral area at 1 cm2 (0.65-1.5 cm2). We used the Inoue balloon for all these procedures with a stepwise technique and a color echo-doppler control between inflations. We obtain bicommissural opening in 8 patients and unicommissural opening in 3 patients. The mean gradient post dilatation was at 4 mmHg (3-8 mmHg) and the mean mitral area at 2.3 cm2 (1.5-2.8 cm2). No mitral regurgitation > 2/4 was noted. After a general review, we concluded the PMC is at present the treatment of choice of non or discrete calcified mitral stenosis and this procedure has to be taken on charge by the Ministry of Health in Lebanon.

[Coronary artery-cardiac fistulas. Review of the literature. Two accidentally discovered cases]. / Les fistules coronaro-cardiaques. Revue de la littérature. A propos de deux cas de découverte fortuite.

We report two cases of coronary artery fistula discovered accidentally during coronary-angiography. One case between the left anterior descending and the pulmonary artery and another case between the circumflex and the left ventricule. Both cases were associated with hypertrophic cardiomyopathy. There was a spontaneous closure of the fistula in the first case. A brief review of the literature is presented because this anomaly is being discovered frequently because of the possibility of diagnosis with transesophageal echocardiography.

[Should closed-heart mitral commissurotomies still be performed? Apropos of 168 operations, 108 open-heart and 60 closed-heart]. / Faut-il encore faire des commissurotomies mitrales à coeur fermé? A propos de 168 interventions dont 108 à coeur ouvert et 60 à coeur fermé.

Mitral commissurotomy is known to give good results but the best surgical technique (open heart or closed heart) remains uncertain. Results of open heart commissurotomy (OC), 108 patients (Group I) and closed heart commissurotomy (CC), 60 patients (Group II) were compared. The population comprised 81% females and the average age was 39 +/- 12 years. Only cases of pure or very predominant mitral stenosis (MS) were included. The preoperative state of the patients in Group I was poorer than the one in Group II (repeat commissurotomy 8.3% compared to 1.7%, p less than 0.04; associated mitral regurgitation 41% compared to 27%, p less than 0.04; cardiothoracic ratio 0.54 +/- 0.07 compared to 0.51 +/- 0.06, p less than 0.01). A more complete surgical cure was possible in Group I. Both commissures were liberated in 99% of OC compared to 25% CC (p less than 0.001). Mitral valvuloplasty was associated in 87% of OC (63 cases on the papillary muscles, 21 cases on the chordae tendinae and 60 cases on the mitral annulus). Operative mortality was low and did not differ significantly between the two groups (zero in CC; 1.8% in OC). Overall survival rates were excellent (95% 5 year survival, 85% 7 year survival). The reoperation rate at 5 years was 7.4% and at 7 years, 23.9%, and did not differ with the surgical technique used. The functional result was good (patients in Class I or II of the NYHA classification 84% at 5 years; 75% at 7 years; identical for both groups). Significant late valvular "dysfunction" was rare after OC.(ABSTRACT TRUNCATED AT 250 WORDS)