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The L-arginine-nitric oxide (NO) pathway was investigated in human internal mammary artery (HIMA) in vitro. HIMA rings were mounted in organ bath, and then incubated in Krebs buffer for 1 to 8 hrs, relaxing agents were tested. Under these conditions, L-arginine (0.1 microM - 1 mM) elicited only minor relaxation after 2 hr incubation, whereas with increased incubation time (4, 6, 8 hrs), the concentration-dependent relaxation to L-arginine increased significantly in endothelium-intact and -denuded vessels. NG-nitro-L-arginine (100 microM) or NG-monomethyl-L-arginine (100 microM) or methylene blue (2.7 microM) partially inhibited L-arginine relaxation. In endothelium-intact HIMA and in both types of rings A23187 (10 microM) and L-arginine (100 microM), respectively, increased the concentration of NO in medium and cGMP content of vascular tissues. These increases were partially inhibited by NG-nitro-L-arginine (100 microM) or methylene blue (2.7 microM).in smooth muscle of HIMA L-arginine-NO conversion is calcium independent, which is different from that in endothelium.

In two patients who had Budd-Chiari syndrome secondary to carcinoma, the diagnosis was made intraoperatively at the time of emergency right atrial clearance required for severe cardiovascular distress. Curative resection was not possible and both patients died. As previously noted in the literature, it is extremely difficult to relate carcinoma to the origin of Budd-Chiari syndrome. Retro- and suprahepatic involvement of the vena cava is associated with a very poor prognosis. Complete resection of these tumors is the only potentially curative treatment. We suggest ways to obtain a simple and early histologic diagnosis before initiating appropriate and radical surgical treatment.

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

Five patients, 3 months to 13 year old with atresia (4) or stenosis (1) of the left coronary artery underwent myocardial revascularisation at Marie Lannelongue Hospital. The preoperative symptoms were dominated in one case by cardiac failure due to myocardial infarction and in the other cases by effort angina with syncope. The operative technique of revascularisation in one case was angioplasty with enlargement of the left main coronary artery with a patch and, in the others, bypass graft of the left coronary artery with the left internal mammary artery. All 5 patients survived surgery and are asymptomatic with a follow-up of 6 months to 7 years. Control coronary angiography confirmed the patency of the different procedures of myocardial revascularisation. In 3 children, exercise electrocardiography was normal. Myocardial revascularisation of a child with a congenital stenotic abnormality of the left coronary network is possible, the technique of which depends on the diameter of the left main stenosis when the vessel is absent or atresic, left internal mammary artery bypass graft is the only solution. When the left main coronary is stenosed but patent, direct reconstructive surgery is an interesting alternative.

Patients with both resectable lung cancer and coronary artery disease require preoperative cardiac evaluation in order to determine and prevent the surgical risk and to discuss the desirability of preventive myocardial revascularization. The results of thoracic surgery in coronary disease patients have been studied in a series of 51 patients operated upon for lung cancer at the Marie Lannelongue hospital, Paris, between 1985 and 1988. Thirty-two patients underwent non invasive exploration prior to surgery (exertion ECG in 22, myocardial radioisotope scanning in 10); 35 patients had coronary arteriography at the last moment, and 9 asymptomatic patients with an old history of myocardial infarction had no specific exploration. Forty-nine patients had lung surgery alone, preceded in 5 cases by percutaneous coronary angioplasty; one patient had pulmonary surgery and coronary surgery simultaneously, and another patient had coronary surgery first, later followed by lung surgery. No perioperative death was due to cardiovascular causes. A 75-year old male patient died of respiratory failure 30 days after lobectomy. The postoperative period was totally uneventful in 39 patients. No perioperative myocardial infarction was recorded; 4 patients experienced an episode of thoracic pain with ECG signs of myocardial infarction but no rise in serum enzyme concentrations. One patient had a cerebral vascular accident responsible for hemiplegia. Two late sudden deaths, probably of cardiac origin, occurred 4 and 11 months respectively after surgery. The actuarial survival rate at 3 months was 48 percent. In all survivors, the coronary symptoms were controlled by medical treatment. It seems, therefore, that perioperative complications in this type of patient can be avoided by preoperative evaluation of the coronary disease and by preventive myocardial revascularization in case of critical coronary stenosis.

The authors report the medico-surgical experience of Marie Lannelongue hospital of a rare condition: accessory mitral valve tissue. Seven patients aged 2 to 28 years (average: 8.7 years) had left ventricular outflow obstruction due to accessory mitral valve tissue. The diagnostic was not obvious clinically and was based on the association of echocardiographic and angiographic data. This condition was associated with another intra-cardiac malformation in 6 of the 7 patients. Surgical treatment included resection of the accessory mitral valve tissue by an aortic or combined aorto-left atrial approach, together with correction of the associated intracardiac abnormality. The postoperative results were excellent with the regression of the ventriculo-aortic pressure gradient and the physiological integrity of the mitral valve.

Systematic angiographic surveillance of ascending aorta dissections demonstrates the frequency and diversity of often asymptomatic anatomical lesions. A study in 10 previously operated cases enabled differentiation with the prosthetic tube, usually implanted in the ascending aorta, of proximal postoperative lesions (residual dissection, aortic incompetence, aneurysm) which may require further surgery in the more or less long term, and distal lesions (the usual persistence of a false channel in type I dissections) which are generally left untouched.

Hypoxemia is a relatively common complication in the immediate postoperative period after cardiac surgery under cardio-pulmonary bypass, usually due to pulmonary disease. When this does not improve with oxygen therapy and in the absence of pulmonary disease, it may be due to a right-to-left shunt. We report a case with a right-to-left intracardiac shunt due to persistence of a patent foramen ovale, which became functional again under the new hemodynamic conditions after surgery under cardiopulmonary bypass and assisted ventilation. The diagnosis and physiopathological mechanism were studied by cardiac catheterisation and angiography. Contrast echocardiography should be able to detect these acquired shunts relatively easily. The diagnosis requires appropriate therapy: discontinuation of ineffective assisted ventilation as this may aggravate the situation by increasing pulmonary resistance, and anticoagulant therapy to prevent potentially disastrous paradoxical thromboembolism.

The authors studied 115 surgical cases of calcific aortic stenosis (AS) with coronary angiography. Between 1970 and 1981, 56 of these patients also had one or more aortocoronary bypass grafts (ACBG) (Group I). The other 59 cases, recruited from 1978 to 1981, comprise the control group who underwent isolated aortic valve replacement either with a normal coronary angiogram (Group II: 50 cases) or with such extensive coronary artery disease that ACBG was impossible (Group III: 9 cases). 93% of patients in Group I had preoperative angina compared to 80% in Group II and 78% in Group III. The incidence of previous myocardial infarction was 19%, 4% and 44% respectively. The number of main coronary arterial lesions per patient was 2 in Group I and 1.8 in Group III. In Group I, aortic valve replacement (AVR) was associated with a single aorto-coronary bypass in 70% of cases, a double bypass in 27% and a triple bypass in 3% of cases. The revascularisation ratio was 1.3 bypass per patient. The number of "complete" revascularisations rose from 56% (1970-1976) to 73% from 1977 to 1981. Overall hospital mortality per group (less than 1 month) was 16%, 4% and 0% respectively. The mortality rate in Group I fell from 31% (1970-1976) to 10% from 1977 to 1981. The perioperative rate of myocardial infarction in each group was 9%, 0% and 11% respectively. This figure fell considerably in Group I from 12.5% (1970-1976) to 7.5% from 1977 to 1981.(ABSTRACT TRUNCATED AT 250 WORDS)

It is very rare that the knowledge of the human embryology helps the medical diagnosis and guides the surgical treatment when it is necessary. With the oesophagogramm it is possible to obtain the exact topography of the abnormal vascular ring and to perform live saving operation. Our experience of 322 cases is the most important published up to now.

The surgical team of Pr Ch. Dubost operated 5 cases of idiopathic subvalvular left ventricular aneurysm with associated mitral incompetence over a 6 year period (from 1976 to 1981). These 5 cases closely resemble Abraham's et al's classical description of "annular subvalvular left ventricular aneurysms". They occur in black Africans, often young adults (mean age of our five cases 31,8 years) in the absence of coronary artery disease. The common feature is the peculiar anatomical localisation of the aneurysm on the posterior or lateral wall of the left ventricle, which explains the common finding of mitral regurgitation. They are often calcified and thrombosed, the thrombosis tending to extend into the left heart chambers. This was the case in 3 of the reported cases. Mitral regurgitation was controlled in one case by closure of a fistula into the left atrium with a very good result, and in 2 cases by simple section-suture of the neck of the aneurysm with good results and a small residual mitral leak. In a fourth case (Case n degree 1) the mitral valve was normal, regurgitation being the result of an extensive thrombosis. The valve was replaced but, in the light of the following cases, it is possible that the valve might have been unnecessarily sacrificed. Despite their sometime vast size and the association with mitral regurgitation, these subvalvular idiopathic left ventricular aneurysms are reasonable surgical indications for the following three reasons: the neck is often narrow, enabling closure under satisfactory surgical conditions; the structure of the valve is normal which, in the majority of cases, means that it can be respected at surgery; the absence of coronary artery disease.

Cardiac catheterisation was carried out on an unselected series of 148 patients who had undergone complete correction of Fallot's tetralogy after an average postoperative period of si and a half years (range 2 to 20 years). 4% residual significant interventricular shunts (Qp/Qs1.3), 11% residual stenosis on the infundibulo-pulmonary tract (gradient greater than or equal to 10 mmHg) and 60% pulmonary incompetence was found. These findings do not reflect the excellent clinical results. All patients had normal lives: 89% remain asymptomatic since their operation and symptoms in the other patients are limited to moderate dyspnoea on effort or to arrhythmias which are usually periodic. A synthesis of the clinical and haemodynamic data shows that only a quarter of patients may be considered to be cured, that although the surgical results in 2/3 patients are not perfect, they are satisfactory, and that the results of complete correction in the remaining 12% are poor. The results do not appear to be related to the age at which correction was performed or to previous palliative surgery. On the other hand, the long-term haemodynamic results were related to the surgical method of infundibulo-pulmonary repair. Systolic right ventricular pressures of over 60 mmHg recorded at the end of operation in 33 patients, had returned to normal in 76% cases. These results suggest that the indications for prosthetic remodeling of the infundibulo-pulmonary tract should be increased, although this does not always prevent residual stenosis.

Myocardial protection by a combination of cardiac hypothermia and chemical cardioplegia (high concentration of K+ and Mg++, hyperosmolarity, acid pH), was studied during 20 valve replacements. Essentially assessed on the basis of repeated measurements of postoperative cardiac output, the results were compared with those obtained previously using local hypothermia only (20 patients) and hypothermic cardioplegia using Ringer Lactate (20 patients). Analysis of haemodynamic data, which thus involved 60 patients, indicated the superiority of physicochemical cardioplegia, and this for clamping periods of up to 2 hours, but also showed the desirability of changes in the protection protocol during the ischaemia phase and during reperfusion which might improve the results.

The continuous measurement of intratissular NADH concentration allows early detection of cellular respiration arrest during clinical situations, i.e. allows a non-destructive, in situ, continuous measurement of ATP formation. This detection enables the physician or surgeon to intervene during a phase of cellular respiration arrest, before structural cellular alterations occur, thereby preventing potential tissular necrosis. The method has now been validated in experimental cardiac surgery for the monitoring of myocardial preservation techniques during cardiopulmonary by-pass, and in cardiac pharmacology, for analysis of drugs' effects on myocardial energetic metabolism. Its industrial development is currently under way. Preliminary investigation strongly suggests the vast potential of this diagnostic method in both clinical and experimental fields.

After blunt chest trauma, early diagnosis of associated bronchial, vascular, and esophageal injuries must be attempted, as those lesions may be produced by the same mechanism. We report a case of successful management of associated bronchial transection and injury of the ascending aorta. Aortic repair required cardiopulmonary bypass and the use of prosthetic materials, although gross contamination of the mediastinum from the bronchial disruption is a theoretical contraindication to such a procedure. A separate approach to the vascular and airway injuries allowed successful management of both lesions.

Cardiac localizations in hydatid disease are uncommon and often latent. A mass at the apex of the heart was discovered in a 42-year-old patient who presented with abnormal EKG repolarization. This mass was anechoic. Coronography demonstrated an avascular lesion with displaced coronary arteries. A hydatid cyst was suspected. No other visceral localizations of hydatid disease were detected. The patient refused surgery and was seen two years later with acute pericarditis and rapidly developing cardiac tamponade. A very large amount of pericardial fluid and a single hydatid cyst were discovered upon surgery. The cyst was aspirated and sterilized and the protruding cyst wall was resected. A severe postpericardotomy syndrome and positivation of hydatid disease serological tests occurred during the postoperative course. The patient was then given flubendazole. Prompt recovery occurred and the patient is still doing well under therapy two years later. In hydatid disease, an isolated cardiac localization is uncommon and often latent and may be revealed by complications. Prompt diagnosis should be made by echocardiography.

We present our 7 years' experience in the treatment of repeated stitch failure of the suture line on aortic valve replacements. We used a valved tube placed in the supra-coronary position. This technique prevented further stitch failure and also prevented postop infections. Of eight patients operated on, five had survived.