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The posterior mitral leaflet is usually motionless following mitral valve repair. The aim of this study was to assess (1) the geometric changes of the left ventricular base following prosthetic ring annuloplasty and (2) their impact on the anterior mitral leaflet (AML) mobility. Thirty five patients operated upon for mitral valve repair underwent an intraoperative transesophageal echographic study before and after annuloplasty. A posterior leaflet resection was achieved in 29 cases and ring annuloplasty alone in 6 cases. No repair technique was performed on the AML. Four parameters were assessed: the anteroposterior mitral annulus diameter, the aortomitral angle, the opening and closure angles of the AML. Annuloplasty resulted in a drastic reduction of the mitral annulus from 36.8 +/- 5.6 mm to 20.9 +/- 3.8 mm (systole, long axis view) (p < 0.0001). The aortomitral angle decreased following annuloplasty from 115.1 +/- 8.3 to 108.0 +/- 9.60 (systole, long axis view) (p < 0.0001). No difference was observed between systolic and diastolic measurments concerning the mitral annulus or the aortomitral angle. The opening angle of the AML remained unchanged whereas the closure angle increased from 17.8 +/- 6.10 to 26.6 +/- 6.70 (long axis view) (p = 0.0001) resulting in a displacement of the coaptation point towards the apex. Consequently, the excursion of the anterior leaflet throughout the cardiac cycle decreased following annuloplasty from 43 +/- 130 to 32.5 +/- 11 (long axis view) (p < 0.0001).

The object of this report is to describe the surgical treatment of a rare clinical form of homozygotic familial hypercholesterolaemia (HFH) associating valvular and supravalvular stenosis with coronary ostial stenosis. Three patients, two male and one female, aged 15, 23 and 41 respectively, suffering from HFH diagnosed in early childhood, presented with obstacles to left ventricular ejection and myocardial ischaemia due to coronary ostial stenosis. Surgery consisted of corrections in a single procedure of all abnormalities by aortic valve replacement, ascending aortic replacement and widening of the coronary artery ostia which were reimplanted on the aortic tube. The postoperative course of all three patients was favourable. Postoperative echocardiography showed the normal position of the valvular prosthesis, normalisation of the left ventricular ejection fraction with no significant residual obstruction. Angioscan of the coronary arteries showed a good result of coronary ostial widening. The authors conclude that HFH is a rare condition and that disease of the ascending aorta is common in this variety with involvement of the aortic valve, the ascending aorta and the coronary ostia. The surgical procedure described by the authors allows correction of all the abnormalities with the hope of a good long-term result.

Over the years, mechanical circulatoryassistance has progressively improved with the evolution of the clinical indications and the introduction of new devices. The management of situations of extreme emergency, cardiac arrest, acute myocardial infarction with cardiogenic shock, drug overdose, acute myocarditis, postoperative cardiac failure and post-transplantation right ventricular failure, may be undertaken with relatively simple systems such as the ECMO, in the catheter laboratory or at the bedside in the intensive care unit. These systems enable stabilisation of the circulatory problems in order to pass a difficult situation and then withdraw the assistance when myocardial function has been restored. When this is not possible and there is no contra-indication to cardiac transplantation, patients may benefit from more complex assistance devices as a bridge to transplantation. Many continuous flow pumps have been introduced recently. These small mono, left ventricular, assist devices provide improved patient comfort and suggest wider indications of long duration assist devices.

Pseudo-aneurysms of the ascending aorta are a rare but serious complication of surgery for acute dissection of the aorta. The diagnostic methods and surgical technique have changed in recent years. The authors report their experience over a period of 20 years. From January 1981 to December 2001, 21 patients underwent reoperation for pseudo-aneurysms of the ascending aorta. The average age was 54.2 +/- 3 years. Diagnosis is no longer based on aortography but on transthoracic or oesophageal multiplane echocardiography, thoracic spiral computed tomography or magnetic resonance imaging. Four patients presented with a recent history of severe pulmonary oedema. The risk associated with reopening the sternum is avoided by current operative techniques. The authors have chosen anterograde perfusion of the cervical arteries by direct canulation for cerebral protection. The operative mortality at one month is high (30%). All patients who had pulmonary oedema or cardiogenic shock in the immediate preoperative period died. There were no neurological complications. Twelve patients survived and one has to undergo a further operation for recurrence of the pseudo-aneurysm. The authors conclude that patients operated for dissection of the aorta must be followed up. It is important to resect as much as possible of the pathological aorta during the initial operation to avoid the risk of pseudo-aneurysm formation, at least in the proximal segment of the ascending aorta.

The fully implantable complete electric artificial heart "AbioCor" is the ultimate stage in the 3rd generation assistance systems. It has been authorized for clinical use since last year by the Food and Drug Administration (F.D.A.). It is an electrohydraulic heart developed by Abiomed. It consists of implanted internal components: the cardiac pump, an internal lithium battery, a controller and an internal coil allowing electrical energy transfer across the skin, and external components: an external coil and external batteries. The one-piece heart includes two ventricular chambers: right and left. All of the surfaces in contact with blood as well as the four three-leaved valves are made of polyurethane. An electro-hydraulic energy converter powers the ventricles. A stroke volume of 60 to 65 ml allows an output of between 4 and 10 L.min-1. Between 2 July 2002 and 4 November 2002, seven males, aged between 51 and 70 years, underwent implantation. They were suffering from ischaemic cardiopathy (6 cases) or idiopathic dilated cardiopathy (1 case). Among the late complications, 3 severe embolic cerebrovascular accidents occurred. Four late deaths occurred.

Objective: Study of the medium term results of aortic and mitral valve replacement with the Bicarbon' prosthesis., Method: From 1990 to 1996, 109 valves were implanted (70 in aortic position, 31 in mitral position and 4 double replacements). The average age was 61 years and 75% were male. According to the NYHA, 59% of patients were stage III or IV. The average pre-operative ejection fraction was 59.6%. There was re-intervention in 21.1% of patients and 35.3% had an associated procedure during the intervention., Results: The average follow up was 5.4 +/- 1.98 years in 98 patients (that is 522 patient years). One patient died post-operatively and 19 died later. The overall survival at 7 years was 69.4 +/- 6.3%. Complications, expressed in patient years, were 1.15% for thrombo-embolic complications, 2.1% for haemorrhagic complications. 0.38% for endocarditis, 1.72% for non-infectious peri-prosthetic leaks, and 0.76% for re-interventions. At 7 years, the absence of thrombo-embolic, haemorrhagic, endocarditis, and re-intervention complications was 91.8 +/- 4.2%, 85.3 +/- 4.8%, 95.8 +/- 3.2%, 93.8 +/- 3.5% respectively. According to the NYHA, 95% of patients were in stage 1 or II (p < 0.001)., Conclusion: Valvular replacement in the aortic or mitral position with the Bicarbon' valve is satisfactory as much in terms of survival as of clinical complications.

In the light of a new case revealed by a stroke, the authors confirm the importance of transesophagal echocardiography (TEE), and show that multislide computered tomography can be used as a new efficient tool for the diagnosis of cardiac papillary fibroelastoma (CPF). These benign tumours of endocardium are rare and case reports have been published sporadically. Stroke is an usual clinical complication and the most frequent symptom associated with CPF. Transesophageal echocardiography is the reference for diagnosis of CPF when transthoracic echocardiography is normal. When TEE is contraindicated or technically impossible, multislide computered tomography appears as an interesting alternate solution for diagnosis because of its fast acquisition and high spatial resolution. Symptomatology may be connected to either tumoral embolisation or cruoric emboli. Surgery is required for any symptomatic tumour.

Endomyocardial fibrosis is very rare in Behcet's disease. The authors report the case of a 28 year old patient with Behcet's disease complicated by a pseudo-tumoral right ventricular formation on echocardiography. This misleading appearance suggested the diagnosis of cardiac thrombus or tumour and led to a surgical approach which revealed a fibrous moderator band suggesting endomyocardial fibrosis, confirmed by antomopathological analysis. Besides the originality of this case and the unusual pseudo-tumoral presentation, the authors underline the difficulties of establishing the diagnosis, despite the advances of medical imaging. The pseudo-tumoral intra-cardiac lesion in a suggestive clinical context (Behcet's disease) should raise suspicion of the diagnosis of endomyocardial fibrosis.

A 31 year old woman with Marfan's syndrome had a dilatation of the aortic root (55-60 mm at the beginning of pregnancy). Pregnancy was continued with beta-blocker therapy and with regular echocardiographic follow-up. The aortic dilatation increased (62-65 mm) at the last control and, at the 34th week of pregnancy, the patient suffered a dissection of the ascending aorta. A caesarean section was performed with a Bentall procedure during the same operative session. The mother and baby girl are well two years later. The problems of pregnancy in patients with Marfan's syndrome are discussed.

The authors studied the outcome of multi-organ failure in 29 patients with terminal cardiac failure and maintained with a Cardiotest total artificial heart whilst waiting for cardiac transplantation. Pre-implantation organ dysfunction was defined by the following criteria; assisted respiration of over 3 days, total billirubin and creatinine levels of over 2 mg/dL, a platelet count of less than 80,000/mL or a prothrombin ratio of less than 50% and central nervous system disturbances. Fourteen patients died during the period of circulatory assistance and 71% of deaths were due to multi-organ failure. Pre-implantation plasma total bilirubin levels were significantly higher in patients who died of multi-organ failure (p = 0.04). Eighty per cent of patients who died of multi-organ failure had at least 3 criteria of organ dysfunction before implantation of the artificial heart compared with only 37% in the other patients (p = 0.04). Finally, systemic vascular resistances before implantation were significantly lower in patients who died of multi-organ failure. The results of this study suggest that multi-organ failures does not develop during the period of circulatory assistance but represents an aggravation of a preexisting morbid condition. This observation should lead to a limitation of the indications of total circulatory assistance in some cases and, above all, to earlier intervention before multi-organ failure becomes irreversible.

The recognition of alcoholic cardiomyopathy in patients with dilated cardiomyopathy is essential as they may regress, at least partially in a relatively short period, with abstention. The clinical history is the key to diagnosis because no other specific feature can identify the cause. Between January 1984 and July 1995, 26 candidates for cardiac transplantation with dilated cardiomyopathy and chronic alcoholism improved after withdrawal of alcohol. None of these patients was placed on the surgical waiting list. Patients with ischaemic cardiomyopathy, valvular disease or previous surgery for valvular hypertensive or congenital heart disease, documented viral myocarditis or connective tissue diseases, were excluded. The diagnostic criterion of chronic alcoholism was a total alcohol consumption of 292 kg and a duration of alcohol abuse of over 10 years. In addition to the clinical features, biological, electrocardiographic, echocardiographic and haemodynamic parameters were analysed. The mean age of the patients was 48 +/- 8 years. There were 25 men and 1 woman. The total mean alcohol consumption was 1,492 kg. The average follow-up period was 63 +/- 41 months. The interval between the onset of symptoms and abstention was 25 months. Haemodynamic improvement was observed in 25 cases. The average interval between alcoholic abstention and recovery was 11.7 months. One patient died suddenly. Improvement of symptoms, decrease of the cardiothoracic ratio and improvement of echocardiographic parameters were statistically significant. The increase in angiographic or isotopic ejection fraction and cardiac index and the decrease in mean pulmonary artery pressures were also statistically significant. These results confirmed the diagnosis of alcoholic cardiomyopathy. Therefore, patients with chronic alcohol abuse and dilated cardiomyopathy must be identified and treated for this problem and not placed on the waiting list for cardiac transplantation unless no improvement is observed after about 3 months of abstention.

Aortic atheromatous plaque is common condition which has no clinical or therapeutical consequences in the majority of cases. Nevertheless, in some cases, clinical symptoms or potential complications may lead to discussion of the therapeutic indications. The usual diagnostic methods are pre- or peroperative transoesophageal echocardiography. CT scan, magnetic resonance imaging and, rarely, arteriography. These investigations are also valuable in assessing the composition of the plaque and evaluating the risk of thrombosis and therefore of systemic embolism. The surgical indications are discussed in three situations. When the atheroma is large, exuberant and stenotic. This is often the case in the abdominal aorta, much less commonly so in the descending thoracic aorta. Secondly, when the atheroma has been complicated by embolism: this applies to all segments of the aorta. Finally, when there is a potential embolic risk, especially neurological, during open heart surgery; this is usually the case in the ascending aorta. The surgical technique in the first two indications is either excision of the atheromatous plaque or of a segment of the aorta with restoration of continuity by a Dacron patch or tube. In the third indication, two attitudes are possible: either not to manipulate the ascending aorta by changing the site of arterial cannulation, not clamping the aorta, and using pediculated arterial grafts to suppress the aortic implantation of the graft, or, conversely, replacing a fragment of the aorta carrying the atheromatous plaque and reestablishing continuity by a Dacron patch or tube, where a saphenous vein graft may be implanted. In conclusion, excision of atheromatous plaque is always possible but rarely justified. It is essentially a palliative procedure.

Between 1983 and 1992, 9 patients with traumatic tricuspid regurgitation underwent surgical correction. The population consisted of young male adults (mean age 39 years). The trauma was usually due to a road traffic accident (n = 6). The mean interval to diagnosis was long (11 years). Echocardiography was diagnostic and showed the mechanisms. The usual lesion observed at surgery was subvalvular rupture of the anterior papillary muscle (n = 5). Surgery consisted of valve repair with annuloplasty and eight valve replacements for chronic retractile lesions. Six patients are still being followed up (average 7 years). There were no peroperative complications. Two patients underwent a second valve replacement for degeneration of a bioprothesis. Conduction defects requiring permanent cardiac pacing were not uncommon (n = 3) The delay before diagnosis may be explained by the diversity of lesion of the tricuspid valve, associated cardiac disease and the requesting of echocardiography. Surgical indications are mainly based on clinical signs. Even if long-term results are satisfactory, earlier diagnosis would probably allow more conservative surgery with preservation of right ventricular geometry and function.

A pseudosubaortic left ventricular aneurysm was discovered in a 32 year old African presenting with pyrexia after a long history of chest pains and dyspnea. Echographic and radiological techniques showed a large pulsatile mediastinal mass and the patient was referred for aneurysmorrhaphy. The actiology of this pseudo-aneurysm is discussed with reference to data in the literature. Infection is the first cause to be excluded in view of the pyrexia truncated by "blind" anti-inflammatory and antibiotic therapy. The hypothesis of an interventricular septal abscess secondary to septicaemia with secondary rupture into the pericardium is discussed. Precessive endocarditis with an aseptic abscess is unlikely because of the minimal aortic valve lesions, the absence of vegetations and the very long clinical evolution. Finally, idiopathic pseudo-aneurysms in sub-Saharian Africans, due to a congenital defect of the fibrous aortico-mitral and subannular zones must be considered. The risk of complications of these pseudo-aneurysms justifies surgical intervention on the accurate anatomical description of the lesions provide by transthoracic and transoesophageal echocardiography and magnetic resonance imaging.

The lack of donor organs in France has led to a decrease in the number of cardiac transplantations (636 in 1990. 429 in 1994), despite the fact that the number of indications remains high. The reasons for this inadequation are multiple, but family refusal remains the major cause (65% of cases of non-donation). Efforts should continue to try and reverse this attitude to make this unequaled treatment available. The difficulties should in no case influence the indications of transplantations.

Between January 1973 and December 1993, 66 patients underwent surgery in our department for hypertrophic obstructive cardiomyopathy; mean basal outflow gradient was 48.4 +/- 36 mmHg, 20 patients had mitral valve lesions. Thirty six patients underwent myotomy-myomectomy alone, 13 mitral valve replacement alone, and 17 both myotomy-myomectomy and mitral valve replacement. The 30-day mortality rate was 7.5% for all patients; predominant risk factors were gender (female), greater cardiothoracic ratio, preoperative episodes of atrial fibrillation and lack of syncope. Overall survival rate (operative mortality included) was 65.3 +/- 8.6% at 13 years. Predominant risk factors for late mortality were the same than above, plus mitral valve replacement; so mitral valve repair, whenever feasible should be undertaken. Forty nine patients are still followed up: 46 are asymptomatic; Doppler mean basal outflow gradient was reduced to 10 +/- 1.4 mmHg. In conclusion, surgery relieves symptoms and outflow obstruction, and allows mitral valve reconstruction.

A series of 13 patients (11 male, 2 female, average age 61 +/- 6 years) with previous aortocoronary bypass surgery and reoperated for aortic valve replacement (AVR) were analysed retrospectively. At coronary bypass, 8 patients (Group I) has insignificant aortic stenosis (AS) (mean transvalvular pressure gradient < 40 mmHg and/or aortic valve surface > 1 cm2). The other 5 had no aortic valvular lesion (Group II). The average time interval between the two operations was 7 +/- 3.3 years (Group I: 6.7 +/- 3.5 years; Group II: 7.4 +/- 3.2 years). In Group I, 2 patients required early AVR (2 years) whereas the time of reoperation varied from 6 to 12 years in the other 6 patients. No operative complications related to the sternotomy or dissection of adhesions were observed. In 3 cases, it was necessary to free the implanted grafts on the right coronary artery to gain access to the initial part of the aorta. A transverse low aortotomy allowed AVR in good conditions in all cases. One patient in Group II died on the 5th postoperative day of a low output syndrome complicated by pneumonia. After an average follow-up of 3 +/- 2 years, 9 patients are still alive. Three patients in Group I died, two of cardiac failure and one of unknown causes. The authors conclude that "prophylactic" AVR in cases of insignificant AS in patients referred for coronary bypass surgery is not justified. Regular echocardiographic follow-up should lead to AVR at the most appropriate moment, sometimes after an interval of several years, with a low operative risk.

Videosurgery is a relatively non-invasive method of draining the pericardium by the creation of a pleuropericardial window. It provides an excellent view of the thoracic cavity and allows selection of pericardial and pleural, pulmonary or mediastinal biopsy sites. The authors report their preliminary results with this technique. Between May 1994 and May 1995, 22 patients with pericardial effusions were operated by videosurgery at the Pitié Hospital. None of the patients had clinical signs of tamponade. The technique consists in introducing, through 2 or 3 thoracic incisions of 15 mm, trocarts allowing passage of an endoscopic camera and different surgical instruments. Access to the thoracic cavity enabled assessment of the pleura, evacuation of pleural effusions (n = 8) and biopsy of pleural nodules (n = 2). One pulmonary biopsy was performed. Opening the pericardium enabled evacuation of pericardial effusions averaging 622 ml. Pericardial biopsies showed appearances suggesting tuberculosis (n = 2), lupic vasculitis (n = 1) and post-radiation pericarditis (n = 1). In other cases, a histologic diagnosis of non-specific pericarditis was made. A biopsy of a pleural nodule showed undifferentiated carcinoma in one case. A pulmonary biopsy revealed the presence of relatively undifferentiated carcinoma. There were no complications related to the technique. There was one recurrence of pericardial effusion at one month in a patient with carcinoma of the lung who had previously had subxiphoid drainage. There were no cases of secondary pericardial constriction. Therefore, videosurgery is a relatively non-invasive and effective technique of pericardial drainage and biopsy. When there is no emergency, it is probably the method of choice in the treatment and diagnosis of pericardial effusions.

The authors report a case of an iatrogenic fistula between the left circumflex coronary artery and left atrium. The fistula was a complication of reoperation to replace a mitral valvuloplasty annulus by a mechanical hemi-disc prosthesis (Saint Jude Medical). Diagnosis was made by transoesophageal echocardiography and confirmed by coronary angiography. The patient underwent external ligature under cardio-pulmonary bypass.

Chronic pulmonary embolism may occur in the antiphospholipid syndrome. Antiphospholipid antibodies including the lupus anticoagulant and anticardiolipin should therefore be searched for systematically in these patients. Blood clotting (lupus anticoagulant) and immunological (anticardiolipin) investigations are complementary; their positivity may be dissociated. If the thrombus is located in the proximal pulmonary artery, surgical thrombectomy is possible. Operative mortality ranges from 12.6% to 20%. The association of oral anticoagulants with low dose aspirin is indicated for the long term treatment of these patients. The role of steroid therapy is discussed. The authors report the case of a patient with antiphospholipid antibodies who successfully underwent surgical removal of a chronic pulmonary embolism.

Endocarditis of transvenous pacing leads is a rare condition. The authors review a series of 15 patients who developed bacteriologically proven septicaemia and/or endocarditis related to transvenous pacing leads, operated between 1988 and 1993. The interval between the last manipulation of the pacemaker and the onset of endocarditis was about 6 months. Six patients had had haematoma and/or infection of the pacemaker site. Endocarditis presented with chronic pyrexia (14 cases) associated with septicaemia (6 cases) and chronic local suppuration (1 case). The interval between the beginning of the pyrexia and the diagnosis was 3.4 months. Echocardiography showed a mass attached to the pacing lead in 8 cases and tricuspid valve vegetations in 4 cases. Blood cultures were positive in 13 patients and local wound swabs identified the organism in 1 patient. The commonest causal agent was the staphylococcus (epidermis in 7 cases, aureus in 4 cases). Appropriate antibiotic therapy was only effective in 1 case. The surgical indication in 13 cases was persistence of infection associated with pulmonary embolism (3) or tricuspid regurgitation (2). Complete ablation of the prosthetic material was performed by a peripheral vascular approach (2 cases), by a right atrial approach (1 case) and under cardiopulmonary bypass in 12 cases. The peroperative findings were of tricuspid valve vegetations (4 cases), thrombi on the pacing lead (7 cases) or in the right heart chambers (2 cases) or pulmonary artery (2 cases). The associated procedures performed under cardiopulmonary bypass were tricuspid valve repair (2 cases) and pulmonary thrombectomy (2 cases). Temporary and permanent epicardial leads were implanted in 10 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Between January 1986 and December 1986, 106 Sorin-Pericarbon (new prostheses made of bobine pericardium) valves were implanted by our group: the object of this paper is to report the medium-term results of this new bioprosthesis. The probability of degeneration-free function at 4 years was 96.5 +/- 3.7% in patients with aortic valve replacement; the probability of reoperation-free survival for all patients was 95.2 +/- 3.3% and 96.5 +/- 3.7% for patients with aortic valve replacement with this prosthesis. The results of this new Sorin-Pericarbon bioprosthesis at medium-term are satisfactory and need to be confirmed at long-term by further follow-up.

The authors report the case of a very large deterged aortic valve ring abscess detected at long-term after infective endocarditis during investigation of symptomatic consequent aortic regurgitation. The different imaging methods of diagnostic import are reviewed with special emphasis on the role of transoesophageal echocardiography during infective endocarditis.

Cardiac abscesses are observed in 20 to 30% of cases of infective endocarditis and in at least 60% of prosthetic valve endocarditis. The aortic valve ring is more frequently affected than the mitral valve ring. A cavity contiguous with a cardiac chamber forming a pseudo-aneurysm or a closed purulent collection, the abscess may extend to the neighbouring cardiac structures or to the ascending aorta. This extension may cause conduction defects, abnormal communications between the cardiac chambers, pericardial disease and, exceptionally, myocardial ischaemia, complications which are clinical signs of abscess formation in patients with infective endocarditis. The presence of a cardiac abscess is a poor prognostic factor in infective endocarditis. The diagnosis must be made at an early stage when surgical treatment is optimal. The most valuable investigation is transoesophageal echocardiography with a sensitivity of over 80% and a specificity of about 95%. This investigation has become practically routine in all patients with endocarditis in order to diagnose abscesses at an early stage, especially in cases of aortic or prosthetic valve endocarditis. Information about the site, size and extension of the abscess may be obtained and existing or potential complications may be envisaged with a view to surgery. Other imaging diagnostic techniques, such as angiography, CT scanning and nuclear magnetic resonance imaging have a number of disadvantages and are not more sensitive than transoesophageal echocardiography. Surgical techniques depend on the site and extension of the abscess. They are sutured or closed with dacron or pericardial patches after having been cleaned and filled with formulated resorcin glue. The valvular prosthesis is inserted either in anatomical position or in a sub or supracoronary dacron tube necessitated by the perivalvular extension of the infectious lesions. These complex procedures may require associated coronary reimplantation or revascularisation when the coronary ostia are affected. The highest operative mortality is observed in prosthetic valve endocarditis with abscess and extra-annular prosthetic implants. The risk of secondary valvular dehiscence, often recurrent, is much higher when there is an abscess at operation. Extracardiac abscesses in cases of infective endocarditis are mainly observed in the cerebral and/or splenic territories. They may become the main problem, especially cerebral abscesses, but they rarely require surgery.

In the period between January 1979 and January 1989, 72 patients (46 women and 26 men, average age 46 years) out of 697 patients undergoing a tricuspid valve procedure, underwent prosthetic valve replacement for organic tricuspid valve disease. Sixteen patients had pure tricuspid regurgitation (Group I). The causal pathology was essentially traumatic (6 cases) and infections (endocarditis) (5 cases). Fifty-six patients (Group II) had organic tricuspid valve disease associated with a left-heart valvular lesion. The causal pathology was rheumatic fever in 52 cases and endocarditis in 4 cases. In 40 patients (71.5%) the procedure was a reoperation of a mitral and/or aortic and/or tricuspid valve prosthesis. In 21 cases, the initial operation had involved the tricuspid valve. All patients in Group I underwent valvular replacement with a bioprosthesis. In Group II, 40 patients were implanted with a bioprosthesis and 16 with a mechanical valve prosthesis. The follow-up was complete for an average period of 7 years (range 2 to 12 years) for a total of 295 patient-year. The hospital mortality was nil in patients with isolated tricuspid valve disease. Reoperation for deterioration of a porcine bioprosthesis was required after 4 years in 1 case. Terminal cardiac failure was responsible for one late death 7 years after surgery. The hospital mortality was 26.7% (15 patients) in Group II. The actuarial rate of patients free of reoperation at 7 years was 80 +/- 8%. The actual rate of patients free of any prosthetic valve related complication was 78 +/- 2%. The 7 year survival rate excluding operative mortality was 65 +/- 8%.(ABSTRACT TRUNCATED AT 250 WORDS)

The results of coronary artery surgery in young adults have not been extensively studied. We analysed the results of 221 patients under 40 years of age operated between 1979 and 1989 at the Pitié-Salpêtrière Hospital. The patients were 200 men and 21 women with an average age of 36.2 years. The most common cardiovascular risk factors were smoking (69.6%) and hyperlipidaemia (52%). One hundred and eighteen patients (53.4%) had previous myocardial infarction (MI). Triple vessel disease was present in 129 cases, double vessel disease in 59 cases and single vessel disease in 33 cases. Twenty three patients had significant left main coronary disease. The number of bypass grafts per patient averaged 2.3. The operative mortality was 2.07% (6 cases), death being due to myocardial infarction in 4 cases. Perioperative myocardial infarction was diagnosed in 12 cases (5.05%). One hundred and ninety nine patients were followed up for an average of 7.4 years. Seven of the 17 late fatalities were of cardiac origin. The actuarial 9 year survival rate was 84%. Five patients were reoperated after an average of 6.4 years. Eighty five per cent of patients were asymptomatic at the last follow-up examination. In conclusion, the symptoms of coronary artery disease in young adults can be effectively treated with a low operative risk by myocardial revascularisation surgery. Long-term follow-up remains essential to define the outcome in these patients. Systematic use of internal mammary artery bypass grafting should improve these results in the future.

Cardiac localisation of hydatid cysts is rare representing 0.5 to 2% of all clinical forms of this condition. Hydatid cysts are usually observed in the left ventricle and involvement of the interventricular septum is exceptional. The principal diagnostic and preoperative investigations are serology and imaging by echocardiography and computed tomography, which can give conflicting results. The authors report a case of hydatid cyst of the interventricular septum in which computed tomography was non-contributory whereas echocardiography (the key investigation in all cases of hydatid cyst) associated with nuclear magnetic resonance imaging provided particularly accurate preoperative information. The latter investigation also allowed diagnosis of pulmonary, hepatic, splenic and renal involvement of the disease.

Coronary artery disease (CAD) is a well-known complication of mediastinal irradiation. We report a case of subocclusive ostial stenosis of the left main coronary artery, in a 27 years old man, who had been irradiated 14 years before for a stage 4 Hodgkin's disease. Among the 68 reported cases of CAD attributed to radiotherapy, 11 involved an ostial stenosis of either right coronary artery, or left main coronary artery or both. Thus mediastinal irradiation seems to be a definite cause of ostial coronary artery stenosis; several types of myocardial revascularization have been suggested for this kind of CAD.

Blood cardioplegia at 8 degrees C results in cardiac standstill whilst maintaining minimal metabolic functions of the cardiac cell. Reinjection every 20 minutes allows cellular reoxygenation, the delivery of essential elements (Tham, CPD), and the elimination of products of myocardial degradation accumulated during ischemia. Before declamping the aorta, a reperfusion with warm blood (34 degrees C) containing glutamate and GTN enables restocking of the energy reserves (Krebs' cycle) and a lowering of coronary and systemic resistances. This technique used systematically if even more effective when the ischemic time is prolonged as is the case in cardiac transplantation. The 50 transplants performed since January 1989 with this form of myocardial protection were compared with 50 procedures performed in 1988 with crystalloid cardioplegia. There was no significant difference in the duration of ischemia or of cardiopulmonary bypass between the two groups. Patients benefitting from blood cardioplegia defibrillated spontaneously more frequently, required lower doses of Dopamine for shorter periods and were extubated earlier.

Seventeen polyarteriosclerotic patients underwent coronary bypass surgery before repair of an abdominal aortic aneurysm between December 1979 and November 1988 in the Cardiovascular Surgical Department of the Pitié Hospital. Sixteen patients had triple vessel disease and 1 patient had single vessel disease but with mitro-aortic valvular disease. The abdominal aortic aneurysm was asymptomatic in 9 cases. The diameter of the aneurysm was over 5 cm in all patients. The average time between the two operations was 6.3 +/- 5.4 months. One myocardial infarction was observed following the coronary bypass surgery. There were no complications related to the coronary artery disease or operative deaths after repair of the abdominal aortic aneurysm. Two late deaths occurred, one due to an aortoduodenal fistula and the other to extra cardiovascular causes. One patient underwent femoro-popliteal bypass surgery 4 years after repair of the aortic aneurysm. One patient had successful percutaneous transluminal angioplasty of an aorto-coronary venous bypass graft 8 years after its implantation. All the other patients are asymptomatic from the coronary and peripheral arterial points of view. The 7 year survival was 85.7 +/- 9.4 per cent. These results seem to justify immediate and late preventive myocardial revascularisation in patients with coronary artery disease requiring surgery prior to repair of an abdominal aortic aneurysm.

Between January 1980 and June 1988, 51 patients over 80 years of age underwent open heart surgery at the La Pitié hospital (26 women and 25 men; average age 82 +/- 2 years, range 80-90 years). The cardiac pathology was calcific aortic stenosis (AS) in 40 cases, associated with coronary artery disease in 7 cases, mitral valve prolapse in 3 cases, coronary artery disease alone in 6 cases [complicated by a post-infarction ventricular septal defect (VSD) in one patient] or associated with aortic regurgitation in 1 case, and degeneration of an aortic bioprosthetic valve in 1 case. Forty patients (78%) were in Stage III or IV or the NYHA Classification. There was no other major pathology associated with the cardiac disease. Aortic valve replacement (AVR) was carried out in 42 patients, with a bioprosthetic valve in 38 patients. This procedure was associated with coronary bypass surgery in 7 cases and carotid artery surgery in 1 case. A mitral bioprosthesis was implanted in 2 patients and mitral valvuloplasty was carried out in 1 patient. An isolated myocardial revascularisation procedure was performed in 5 cases; the VSD was closed in 1 case. The hospital mortality was 17.6 per cent (9 patients). All deaths were of cardiac origin. Eleven patients had no postoperative complications at all. The 3 year survival rate of those who survived surgery was 71 per cent. Of the current 31 survivors, 29 are in Stage I or II of the NYHA Classification. These results suggest that surgery can be offered to octogenarians with invalidating cardiac disease alone carrying a poor short term prognosis.

Between 1973 and 1987, 33 patients underwent pulmonary thromboendarterectomy for chronic pulmonary embolism. Twenty-six patients were in Class III of the NYHA Classification, 5 in Class IV with overt right ventricular failure and 2 in Class II. The average pO2 was 60 mmHg under basal conditions without oxygen therapy. The amputation of the pulmonary vascular tree was greater than 50 per cent in all patients. The average systolic pulmonary artery pressure was 70 mmHg. Twenty patients were operated by a lateral thoracotomy without CPB and 6 by sternotomy with CPB under normothermia with or without cardiac fibrillation. The later method avoids having to open the pleura and seemed to give better haemodynamic control. Interruption of the inferior vena cava was systematic in all cases. The global operative mortality was 20 per cent but this seemed to be less in the patients operated by sternotomy under normothermic CPB (no deaths in 6 patients). The authors consider that this technique should be studied in a larger series of patients. Eighteen patients are still being followed up; the clinical and scintigraphic and/or angiographic improvement is clearcut in the majority of cases.

Interatrial septal aneurysm is a rare abnormality and can now be diagnosed by echocardiography. We report the case of a 52 year old woman in whom this condition was diagnosed after an embolic cerebrovascular accident. M mode recordings showed a linear echo in the left atrial cavity in early and mid systole. The aneurysm was directly visualised by 2D echo as a hemispherical bulge in the mid portion of the interatrial septum, which was mobile and had a to-and-fro motion between the two atria in relation to the different phases of the cardiac cycle. The diagnosis was confirmed by angiography, and at surgery. A feature of this case was the close correlation between echocardiographic, angiographic and operative findings. The pathogenesis of this type of aneurysm remains conjectural as does its role in the production of cerebral embolism, the evidence for which was circumstantial in the absence of other demonstrable causes and in the light of previously reported cases.

The value of aortocoronary bypass (ACB) before surgical correction of infrarenal abdominal aortic aneurysm (AAA) was studied in three groups of patients. Group I: 6 patients undergoing both procedures; group II: 14 coronary patients operated for AAA without prior ACB surgery; group III: 16 patients without coronary artery disease operated for AAA. The hospital mortality was nil in group I; 2 patients died of myocardial infarction in group II; 2 patients died of infection and of cerebrovascular accident respectively, in group III. The patients in group I were asymptomatic on follow-up (mean = 29.7 months) whilst 1 patient in group II developed angina. The essential problem associated with this type of patient remains the complexity of the diagnostic investigations which must include coronary and cervical arteriography. Although the indications for ACB before cure of AAA are obvious in symptomatic patients and/or with previous myocardial infarction, they remain debatable in other patients.

Between January 1978 and December 1984, 141 cases of acute native valve endocarditis were treated surgically in the Department of Thoracic and Cardiovascular Surgery of the Pitié Hospital. The diagnostic criteria of acute native valve endocarditis were the duration of treatment (antibiotic therapy for less than 40 days), the characteristic operative appearances of the lesions, and the results of anatomo-pathological examination of the excised valves. The infecting organism was not isolated in 35% of cases. The aortic valve was the commonest site of infection (65.2% with a high incidence of abscess of the aortic ring, irrespective of the causal organism. The operative mortality was 5.6%. This depended mainly on the preoperative haemodynamic status of the patient. The duration of antibiotic therapy prior to surgery did not seem to be relevant. The 3 years survival rate was 78%. The secondary reoperation rate was 7%. There was a higher incidence of secondary perivalvular regurgitation in patients who had previously had an abscess of the aortic ring.

Normalisation of abnormal segmental wall motion is rarely observed after myocardial revascularisation by aorto-coronary bypass when the territory revascularised is the site of post-transmural infarction dyskinesia. In particular, normalisation of segmental wall motion is extremely rare when dynamic tests designed to detect potential for improvement (trinitrin test and post-extrasystolic potentiation) are negative. We present the case of a 41 year old man who had anterior and septal wall dyskinesia 2.5 months after antero-septal infarction which was not improved by trinitrin. Dilatation of the left anterior descending artery by percutaneous coronary angioplasty was undertaken because of recurrent effort angina. Control angiography at 6 months showed almost complete normalisation of left ventricular contraction. This myocardial recovery is paradoxical because the trinitrin test did not show potential for improvement. The case illustrates the possibility of normalisation of segmental abnormalities of left ventricular contraction after revascularisation of the dyskinetic zone by percutaneous coronary angioplasty.

Between 1975 and 1983, 305 Hancock bioprostheses were implanted at the La Pitié Hospital, Paris, including 133 on the aortic valve and 172 on the mitral valve. The operative mortality rate was 6 p. 100 in patients with isolated aortic valve replacement and 12.8 p. 100 in patients with isolated mitral valve replacement (including 4 reoperations for mechanical valve thrombosis). 245 patients were followed up for a mean period of 5 1/2 years. The actuarial survival rate, operative mortality excluded, was 77.5 +/- 4.4 p. 100 in the aortic valve group and 76 +/- 4.4 p. 100 in the mitral valve group (non significant difference). Later after surgery, 8 embolic accidents (5 in the mitral valve group, 3 in the aortic valve group) occurred, and 20 patients developed endocarditis. Forty-nine patients required reoperation, 33 of them for deterioration of the bioprosthesis. The probability of being free from such deterioration varied significantly according to the patient's age at the time of the operation. In the aortic valve group this probability at 8 years was 97 p. 100 +/- 2.7 p. 100 for patients over 35 and 63.3 p. 100 +/- 1.7 p. 100 for patients under 35; the corresponding figures at 8 years in the mitral valve group were 80 p. 100 +/- 3.8 p. 100 for patients over 35 and 55.2 p. 100 +/- 2.2 p. 100 for patients under 35. There was no significant difference between the mitral and the aortic valve groups with regard to the percentage of prosthetic valve deterioration. The operative mortality rate in reoperations was 14.2 p. 100 irrespective of the cause of death.

Ventricular aneurysm formation in the 3 months following transmural myocardial infarction is rare but may cause serious complications. Cardiac failure and/or ventricular arrhythmias resistant to medical treatment are indications for ventricular resection. The operative mortality is high in this group of patients. 8 patients with ventricular aneurysms of average volume (124 +/- 117 ml/m2) and very impaired left ventricular function (EF : 21 +/- 10%, akinesia : 53 +/- 10%) were operated on with two early deaths and one death in the 7th post operative month. The long term clinical result was satisfactory in the surviving patients, and confirmed by haemodynamic investigation in two of them. The benefical effects of intra-aortic balloon pumping, used preoperatively in all patients, and associated myocardial revascularisation procedures performed in some of them are discussed.

One case of double aortic arch with coarctation is reported. Anatomically, partial atresia of the anterior arch presented as a Kommerel's diverticulum; the coarctation was situated on the dominant posterior arch just proximal to the origin of the subclavian artery. This malformation had been diagnosed clinically during childhood. The operative indications were increasingly severe hypertension with associated left ventricular hypertrophy, and dramatic epistaxis from a nasal angioma which necessitated repeated arterial embolisation. The surgical treatment comprised the insertion of a prosthetic tube from the brachiocephalic trunk, proximal to the coarctation, to the descending thoracic aorta distal to the coarctation. The immediate operative result was excellent with return of normal peripheral pulses and blood pressure. The diagnostic difficulties of this malformation and its associations with other vascular malformations are emphasised. The surgical indications are discussed and the different techniques reviewed:--resection and end-to-end anastomosis,--tubular prosthesis,--associated procedures for double aortic arch. The choice of technique depends on the age of the patient, the anatomical conditions (double arch, coarctation, collateral circulation), and the quality of the aortic wall (atheroma).

In an attempt to determine predictive factors of spontaneous death in patients needing heart transplantation, we studied 27 clinical and paraclinical variables in 171 patients aged from 14 to 61 years. Sixty-one of these patients died before transplantation could be performed, 59 were still alive awaiting transplantation and 51 received a heart transplant. The actuarial survival rate with or without transplantation was 65 percent at 1 year and 51 percent at 2 years. Univariate analysis showed that the following factors were associated with a higher mortality rate: age, history or symptoms of right heart failure, poor general condition, end-diastolic left ventricular diameter and ejection fraction. There was no correlation between high mortality rate and type of heart disease, sex, duration of symptoms, NYHA functional class, cardiothoracic ratio and data obtained from electrocardiography and right heart catheterization. At multivariate analysis (Cox's model), no variable could be selected as predictive factor of mortality. The natural outcome of patients needing heart transplantation therefore is globally unfavourable. This means that once has been decided to perform heart transplantation the operation should not be delayed.

A case of pericardial hemolymphangioma revealed by palpitations is reported. X-ray films of the chest provided a diagnosis of mediastinal tumour. Full evaluation was performed using echocardiography, computerized tomography of the mediastinum, coronary arteriography and cardiac ventriculography. The tumour could be removed in toto. Pericardial hemolymphangioma is a rare benign vascular tumour. It is often discovered accidentally during examinations for non-suggestive cardiac functional disorders. The threat of compression or invasion of adjacent structures and that of hemopericardium by bleeding make surgical excision mandatory.

Of the 318 patients surviving the first postoperative month 14 died secondarily, 5 were lost to follow-up, and 299 were therefore reviewed with a mean follow-up of 16.6 months (extremes of 2 and 42 months). The percentage of late infarcts was 5.9%. Complete disappearance of the angina occurred in 80.3% of patients. Persistant angina was commoner in females (p less than 0.05) and in patients with a lesion affecting all three trunks (p less than 0.05). On the other hand age, the clinical indications for bypass, the presence of an infarct preoperatively, and the development of an infarct immediately postoperatively did not affect the functional result. The cardio-thoracic ratio decreased significantly, from0.51 +/- 0.07 to 0.47 +/- 0.05 (p less than 0.001). 45 coronary arteriograms in a total of 63 grafts were analysed. 73% were patent after a follow-up period of 10.5 months. The patency rate was 88.6% when coronary arteriography was carried out systematically, and 63% (p less than 0.002) when it was indicated by persistant or recurrent angina. The actuarial survival curve in patients with 2 or 3 trunk involvement demonstrates clearly the superiority of surgical over medical treatment.

Open heart mitral commissurotomy was performed in 85 patients between January 1973 and January 1976. This series comprised 38 patients with pure mitral stenosis and 47 patients with associated mitral and aortic or tricuspid lesions. Mitral commissurotomy, always complete, was associated with correction of mitral incompetence, either preexisting or peroperative, in 19 cases; in 44 cases with correction of an aortic lesion and in 10 cases with correction of a tricuspid lesion. The surgical mortality was 2.3 p. 100 (2 deaths); one post-operative myocardial infarction and one spontaneously regressive post-operative jaudice was observed. No cases of post-operative systemic embolism was observed. A short apical systolic murmur was detected in 12 cases. The results of this series together with those already published suggest that the indications of this operation should be widened and that it should be employed whenever the best immediate anatomical result and long-term prognosis are desired.

The surgical indications of coronary endarterectomy were defined from a study of 50 cases in which endarterectomy was associated with aorto-coronary bypass surgery. This total represented 6 p. 100 of all the aorto-coronary bypass operations performed in the same period. Coronary endarterectomy was performed "on principal" for the right coronary artery, and "of necessity" for the left anterior descending artery. The special techniques of endarterectomy on the left anterior descending artery are described. Endarterectomy does not increase the operative risk and enables revascularisation of vessels unsuitable for bypass surgery. 85 p. 100 patients are asymptomatic with an average follow up period of 2 years after endarterectomy and aorto-coronary bypass graft of the right coronary artery.

The case of a 36 year old woman with a calcified tumour of the tricuspid valve is reported. The clinical signs suggested tricuspid stenosis with a right to left shunt via a patent foramen ovale simulating a cyanotic heart lesion. Preoperative diagnostic investigations were discordant. Echocardiography showed a stenotic tumoural tricuspid valve. Catheterisation and selective right ventriculography were more suggestive of dominant tricuspid incompetence. The patient was referred for surgery because of the severity of her shortness of breath and cyanosis, and tumoral involvement of the three tricuspid leaflets was found. This was removed and replaced by a bioprosthesis with good results 27 months after surgery. 17 other cases of tricuspid tumours have been previously reported. Their clinical presentation was usually that of a right ventricular tumour with stenosis of the right failure, positional syncope and pericardial effusion in the malignant forms. Signs of tricuspid stenosis with cyanosis and polycythaemia are very rare. The relative diagnostic values of angiography and echocardiography are discussed.

Coronary revascularisation by bilateral internal mammary artery grafting was performed in 39 patients. The left internal mammary was anastomosed to the left anterior descending (N = 22), the left lateral (N = 12) or diagonal artery (N = 5). The right internal mammary was implanted on the right coronary (N = 17), the left anterior descending (N = 16), the left lateral (N = 3) or diagonal artery (N = 3). In two cases, the inferior myocardial segments were revascularised by grafting the gastroepiploic artery. Three patients died and one patient had signs of postoperative myocardial infarction. Respiratory complications, usually mild, occurred in 5 patients. Bilateral internal mammary artery grafting should be reserved for: 1) young patients, 2) those without usable leg veins (varicose veins, previous stripping or coronary bypass surgery). The gastroepiploic artery is a useful arterial graft for revascularizing regions of the heart inaccessible to the internal mammary arteries.