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Embolic thrombus on mitral anulus calcification (MAC) was demonstrated in an 83-year-old woman with retinal embolism. Mitral anulus calcification has been associated with a significant increase of stroke in elderly people. Atrial fibrillation and calcific emboli have been reported, and embolic thrombus by MAC may be another potential cause.

The concept of a heart valve prosthesis made from autologous pericardium is based on the idea of creating and developing a valve with a longer life than heterografts or homografts due to the absence of tissue degeneration causing the deterioration of both of these types of bioprostheses. The first attempts using the fascia lata or the pericardium, implanted in the seventies, were unsuccessful due to problems with pretreatment of the pericardium and other purely technical difficulties. J. Love et al then developed a technique based on Carpentier's earlier work, where a valve is made extemporaneously using the autologous pericardium. We applied this technique in 14 patients from June 1994 to 1995. The mean age of the patients was 68 years (7 males, 7 females). The aortic valve was replaced in all cases. Preoperative findings were: aortic stenosis (n = 7), aortic regurgitation (n = 1), aortic valve disease (n = 6). Two patients also had mitral valve disease and 3 had coronary artery disease. There were no operative deaths and no patients were lost to follow up. Clinical state was satisfactory with a follow-up of 1 to 10 months. Postoperative Doppler echocardiography was performed at 3 and 6 months and showed gradients were very low. This group of patients demonstrated the value and applicability of the concept. The validity of the technique will be evaluated as a function of the long-term results.

The authors report two cases of anterior mitral valve myxoma. This is an exceedingly rare localisation and these cases add to the other 8 previously reported cases. Intracardiac tumours and valvular endocarditis may be detected non-invasively by echocardiography but the precise diagnosis may be extremely difficult: mitral valve myxoma is an exceptionally rare condition. Treatment was surgical in both reported cases.

We describe a patient who died due to thrombosis of the abdominal aorta and its branches after placement of an intraaortic balloon pumping device. This rare complication, which occurred despite careful insertion technique, underscores the need to select balloon size as a function of the individual patient's morphology.

The survival of a patient with irreversible cardiac failure on the cardiac transplantation waiting list was assured for 38 days by circulatory assistance with heterotopic Pierce Donachy prosthetic ventricles and followed by successful cardiac transplantation. This method of circulatory assistance is relatively simple to install from the technical point of view and provides a satisfactory haemodynamic result whilst waiting for a compatible donor organ. Several complications, some of them serious, were observed. Some were related to the patient's poor preoperative condition: acute renal failure, disorders of coagulation. These regressed slowly when the patient's haemodynamic status improved. On the other hand, septic problems and local haemorrhage were inherent to this technique. These are the commonest complications reported by other authors. Although the mortality rate during the period of circulatory assistance may appear to be high, this technique remains a valuable method of survival for selected patients and does not affect the chances of success of ulterior cardiac transplantation.

In the context of a personal series of fifteen cases of hydatid cyst of the heart, the authors present a computerized review of the last one hundred cases published in the literature. The modern features of the disease are discussed together with its severity (mortality of 23.47% in 98 recent cases). Despite the considerable contribution of ultrasonography, computed tomography and magnetic resonance imaging, a certain number of pejorative criteria appear to persist:delayed diagnosis, diagnostic error, acute pulmonary oedema and incomplete surgical cure.

The authors report a special cases of precise evaluation of threatened myocardium during coronaro-ventriculography. Two elements provided this evaluation: 1) spasm in the tight stenosis of the middle part of the anterior interventricular artery with immediate left ventricular dyskinesia (EF: 37%, EDP/EVD: 1.74; EDV: 98 cc/m2). 2) Complete instantaneous recovery after injection of 2 mg of trinitrine into the left ventricle (EF: 69%, EDP/EVD: 4.33; EDV: 28 cc/m2). This loss, in the order of 50%, in the left ventricular function led us to perform an angioplasty (ACT) with success. A further clinical and angiographic stenosis, three months later, in this 72 years old patient with arteritis, led us to perform an aorto-coronary graft, rather than another ACT.

Results are reported of the use of autotransfusion by means of the blood cell saver in a group of patients at high risk for hemorrhage in Heart Surgery Department. Methods employed are described, and results are discussed: these were encouraging both from the clinical and biological viewpoints. The cost benefits of this procedure are emphasized and technical perspectives outlined with respect to recovery of plasma and platelets.

An original technique used to remove obstructions of the inferior vena cava under cardiopulmonary bypass is described. This technique is indicated in pulmonary embolectomy or to dispose of a vena cava clot prolapsed into the right cardiac cavities. Through a rigid and blunt thoracic drain introduced via the right atrium, a Fogarthy venous catheter is pushed into the inferior vena cava, thus avoiding the risks of accidental passage into the supra-hepatic or renal veins and blockage in a thebesian valve. The catheter is inflated, then removed together with the drain, thereby freeing the caval lumen. The technique is reliable and reproducible, and it has proved very effective.

The indications of coronary bypass surgery in single vessel disease remain controversial. Therefore, we carried out a retrospective study of the coronary angiogrammes and left ventriculography of 93 patients with single vessel disease (greater than 70 p. 100 stenosis) involving the left anterior descending (LAD) or dominant right coronary arteries (RCA) to evaluate the quantity of myocardium at risk. Five angio-hemodynamic parameters were compared: the ejection fraction (EF), the ratio of end systolic left ventricular pressure to volume (LVESP/LVESV), the velocity of circumferential fibre shortening (VCF), end diastolic volume (EDV) and end systolic volume (ESV). Six subgroups were defined: 28 proximal LAD stenosis (16 without and 12 with myocardial infarction (MI], 37 mid LAD stenosis (20 without and 17 with MI), and 28 RCA stenosis (8 without and 20 with MI). In all, there were 44 single vessel stenoses without MI and 49 with previous necrosis. Left ventricular function was normal in the absence of MI but deteriorated progressively in cases with MI and LAD disease. In cases of proximal LAD stenosis without and with MI, the hemodynamics showed: EF (p. 100) = 67,12 +/- 2,07 leads to 43,83 +/- 4,7 (p less than 0,001); LVESP/LVESV = 3,24 +/- 0,34 leads to 1,92 +/- 0,50 (p less than 0,05); VCF (s-1) = 1,28 +/- 0,05 leads to 0,74 +/- 0,06 (p less than 0,001); in cases of mid LAD stenosis without and with MI: EF = 69,1 +/- 2,08 leads to 45,11 +/- 3,42 (p less than 0,001); LVESP/LVESV = 3,64 +/- 0,39 leads to 1,46 +/- 0,12 (p less than 0,001); VCF = 1,32 +/- 0,008 leads to 0,74 +/- 0,06 (p less than 0,001). In contrast the change in LV function was minimal in patients with necrosis and RCA stenosis: EF = 70,37 +/- 3,85 leads to 56,4 +/- 3,19 (p less than 0,05); LVESP/LVESV = 5,20 +/- 1,83 leads to 2,56 +/- 0,36 (p less than 0,05); VCF less than 1,42 +/- 0,17 leads to 1,03 +/- 0,08 (p less than 0,05).(ABSTRACT TRUNCATED AT 400 WORDS)

The authors report an uncommon case of giant leiomyoma of the inferior vena cava with intracardiac extension and arising from the external iliac vena. This case report illustrates the diagnostical problems usually encountered with this type of tumour. Indeed, despite ultrasound and transverse CT scan, the diagnosis was only assessed by histopathological analysis following a successful surgical removal of the leiomyoma. Only 7 cases of leiomyoma of the inferior vena cava are already reported in the literature. Relationship with intravenous leiomyomatosis of the uterus is also discussed.

A case of hemopericardium after coronary recanalisation with streptokinase during the acute phase of myocardial infarction is reported, emphasising the value of routine daily echocardiography in all cases of intracoronary thrombolysis. The patient was a 48 year old man with a primary antero-lateral infarct in whom coronary angiography was performed at the 4th hour, showing total proximal obstruction of the left anterior descending artery. The streptokinase protocol of intracoronary thrombolysis was performed, resulting in recanalisation of the left anterior descending artery at the 30th minute. Improved left ventricular function and persistance of coronary patency were confirmed 14 hours after recanalisation. In the following days the patient showed signs of right ventricular failure with successive echocardiogrammes demonstrating an increasing pericardial effusion. On the 4th day, 600 ml of blood were drained surgically and aorto-coronary bypass carried out on the left anterior descending artery. This procedure maintained coronary patency and the improvement in left ventricular function. Several studies have shown that the hemorrhage of reperfusion only occurs in the zones of necrosis, and thrombolytics, especially streptokinase, may aggravate this condition.

The ever increasing age of the general population and the frequency of coronary and aortic lesions in patients aged 70 or older make cardiac surgery in the elderly a topic of current interest. In a retrospective study of 170 cases the overall mortality rate was 14 p. 100 (4.7 p. 100 in 1986). During the past two years (1985 and 1986), the mortality rates in patients with coronary disease who underwent elective surgery were 10 p. 100 and 4 p. 100 respectively. Emergency surgery (left coronary trunk and unstable angina excluded) and associated operations on the heart made the prognosis worse with overall mortality rates of 13 p. 100 and 15 p. 100 respectively (9 p. 100 in 1985, 10 p. 100 in 1986). In aortic valve surgery, hospital mortality rates were 28 p. 100 in 1985 and 6 p. 100 in 1986. Post-operative morbidity was high (52 p. 100 of patients) and consisted mostly of respiratory and neurological complications (14.7 p. 100 and 9.4 p. 100 respectively of all patients). Only 4 p. 100 of the patients developed peri-operative myocardial infarction. Functional results were satisfactory in both coronary disease and heart valve disease patients. The survival rate at 4 years was 74.5 +/- 10 p. 100 globally and 87.3 +/- 9 p. 100 in coronary patients operated upon electively. Thus, the considerable advances in surgical techniques and post-operative intensive care achieved during the last few years have significantly improved the results obtained in this population.(ABSTRACT TRUNCATED AT 250 WORDS)

Between 1977 and 1987, 27 consecutive patients (16 men, 11 women, mean age 66 years, range 54 to 75 years) with ventricular septal rupture complicating acute myocardial infarction underwent surgical repair. The purpose of this retrospective study was to analyse the post-operative mortality factors from clinical, haemodynamic and operative data in all patients and also from coronary angiographic data in 23/27 patients whose haemodynamic status allowed this type of exploration. Seventeen patients (63 p. 100) died during the first post-operative month, 10 survived and were discharged. Factors that influenced the prognosis were: (1) inferiorly-located necrosis associated with a 75 p. 100 mortality rate (9 out of 12 patients), as opposed to 53 p. 100 (8 out of 15 patients) with anterior necrosis; (2) right ventricular dysfunction, observed in 83 p. 100 of patients with inferior necrosis and 53 p. 100 with anterior necrosis, which was responsible for 7 out of 9 deaths in the inferior necrosis subgroup and contributed to 3 out of 8 deaths in the anterior necrosis subgroup; this established a cause-effect relationship between right ventricular function and the overmortality of patients with inferior necrosis; (3) independently of the haemodynamic status, two- and three-vessel lesions (56 p. 100 of all lesions) which had an 84 p. 100 mortality rate as opposed to 40 p. 100 with one-vessel lesions; (4) the presence of a state of shock which was associated with a 78 p. 100 mortality rate as opposed to 55 p. 100 in patients without shock. We conclude that when permitted by the patient's haemodynamic status coronary angiography should be part of the pre-operative evaluation to assess the operative risk and guide the surgical procedure.

The authors consider that the indications for surgery should take into account three unknowns: the natural history of the valvulopathies, our incomplete state of knowledge about the outcome in operated cases, and surgical progress, which may transform the whole subject in a short time. They emphasize the seriousness of the disorders in which mitral incompetence is associated with aortic stenosis and/or incompetence; such cases justify earlier surgery. By contrast, some cases of aortic incompetence, when associated with a predominant mitral valve lesion, may not constitute an indication for valve replacement. Tricuspid annuloplasty is a noteworthy advance which provides a simple answer to some of the problems.

The authors report a case of Staphylococcus epidermidis prosthetic valve endocarditis. After two unsuccessful treatments, the association Gentamicin-Fosfomycin provided adequate serum bactericidal titers and had a good efficacy.

The authors report the case of a 52 year old patient with a significant stenosis of the medial portion of the left anterior descending artery (LAD) with excellent left ventricular function. Transluminal coronary angioplasty (TCA) was indicated following a positive exercise stress test. This was initially performed successfully. Fifteen minutes after the end of the procedure, a total obstruction occurred at the site of dilatation immediately eliciting significant precordial chest pain and massive elevation of the ST segment. Isosorbide dinitrate (ISDN) at a dose of 2 mg was injected into the artery 3 times without success as was an attempt to pass through the obstruction with a guide wire. Another TCA was then attempted without administration of the thrombolytic agent. The dilating catheter passed easily by the obstruction permitting several dilatations which restored rapid coronary artery flow, relieved completely the chest pain, and normalized electrocardiographic abnormalities. This procedure represents a new therapeutic approach to obstruction, an often unpredictable and serious complication of coronary angioplasty in the absence of collateral circulation, thereby preventing the development of a myocardial infarction and an emergency aortocoronary bypass operation.

A technique for suspending the heart, thereby facilitating exposure of the coronary arteries, is described. In this perfectly simple and safe technique, the heart is suspended by a gauze compress passed behind the inferior vena cava and forming a sling.