Chromosomal aberrations and neutrophil activation induced by reperfusion in the ischaemic human heart

Imperfect myocardial protection during prolonged ischaemia results in adverse changes during reperfusion. Clinical studies carried out during cardiac surgery show that: (1) Oxygen free radicals produced during reperfusion can lead to chromosomal damage in leukocytes. However, this effect seems to be prevented by the addition of allopurinol in the cardioplegic solution. (2) Polymorphonuclear leukocytes are directly implicated in situ in the genesis of free radicals responsible for reperfusion injury. (3) Pre-treatment with trimetazidine, an anti-ischaemic drug with antioxidant properties, and addition of the drug to the cardioplegic solution reduced oxygen free radical damage, as shown by a reduced release of malondialdehyde increase and of myosin; moreover, pre-treatment with trimetazidine enabled patients to undergo surgery with improved left ventricular function.

Left ventricular outflow tract obstruction after mitral valve repair. Results of the sliding leaflet technique

BACKGROUND

Left ventricular outflow tract obstruction (LVOTO) occurs in 4% to 5% of patients after prosthetic ring mitral valve repair. Major anatomic factors incriminated in the genesis of LVOTO include degenerative mitral valve insufficiency with excess leaflet tissue, nondilated left ventricular cavity, and narrow mitro-aortic angle. We have previously reported a 14% incidence of LVOTO after prosthetic ring mitral valve repair in this high-risk group of patients. Serial echo Doppler studies demonstrated an overlapping and/or inversion of the left ventricular functional compartments generating systolic anterior motion of the posterior leaflet and paradoxical opening (eversion) of the anterior leaflet. In an attempt to eliminate LVOTO after mitral valve repair, a new surgical procedure was developed in 1988 by Carpentier: the sliding leaflet technique, which reduces the height of the posterior leaflet. The purpose of this study was to analyze the results of the new technique in terms of the occurrence of LVOTO:

METHODS AND RESULTS

Eighty-two patients undergoing prosthetic ring mitral valve repair between 1988 and 1991 and identified as high risk for LVOTO were operated on using the sliding leaflet technique. There were 52 men and 30 women. Ages ranged from 28 to 75 years. The surgical techniques used included prosthetic ring annuloplasty (n = 82), leaflet resection (n = 82), chordal shortening or transposition (n = 36), and other (n = 19). Intraoperative and/or immediate postoperative echo Doppler studies were obtained in all cases. Two patients (2.4%) died, and 2 (2.4%) required reoperation. Nonsignificant LVOTO was identified in 2 cases (2.4%), in whom instantaneous maximal subaortic gradients were 20 and 18 mm Hg, respectively.

CONCLUSIONS

This study was not done on a concomitant series of patients but on patients with the same type of pathology. It demonstrates that (1) the sliding leaflet technique eliminates significant LVOTO in the high-risk patients; (2) the sliding leaflet technique is associated with a low mortality; and (3) no reoperations for mitral insufficiency were required in this series.

Cyclosporine-induced stimulation of the renin-angiotensin system after liver and heart transplantation

To analyze the status of the renin-angiotensin system in hypertensive transplant recipients on cyclosporine, we prospectively explored 21 cardiac (CTR: 52 +/- 8.2 yr) and 12 liver (LTR: 45 +/- 10 yr) transplant recipients on a normal salt diet with 19 normotensive controls in the same age range. Systolic and diastolic blood pressure was measured in the supine and standing positions. Renal function was assessed by serum creatinine values, and 24-hr urinary sodium and potassium excretion were recorded. Plasma renin activity (PRA), active renin, total renin, angiotensinogen, aldosterone, and cortisol plasma levels were simultaneously determined. Results were expressed as mean +/- SD, and between-group differences were compared using variance analysis. Supine blood pressure (+/- SD) was 158 +/- 15/103 +/- 8.4 in CTR and 155 +/- 21.4/102 +/- 11.7 mmHg in LTR. Serum creatinine was higher in CTR (159 +/- 52 mumol/L) than in LTR (117 +/- 24.7, P < 0.05) and values in both groups were above controls (83 +/- 14.1, P < 0.05). Urinary sodium excretion tended to be lower in transplant recipients (59 +/- 42 mmol/L) for CTR and 44 +/- 36.7 in LTR than in healthy controls (117 +/- 24.7 mmol/L). Supine and upright PRA values tended to be higher in hypertensive transplant recipients than in healthy volunteers, although not significantly. Supine active renin was significantly higher in CTR (47 +/- 42 pg/ml) and in LTR (44 +/- 29.8 pg/ml) than in normal subjects (17 +/- 4.8 pg/ml, P < 0.05). Total renin levels in CTR (supine: 716 +/- 357 pg/ml) and in LTR (supine: 647 +/- 365 pg/ml) were 3- to 4-fold higher than in controls (supine: 207 +/- 69 pg/ml) (P < 0.05), as were inactive renin levels (P < 0.01). Active renin was effectively correlated with PRA (P < 0.001) and with total renin (P < 0.001) in the supine and in the upright position. Plasma aldosterone was almost within the normal range in CTR and in LTR, and it did not correlate with PRA values. Plasma angiotensinogen levels were normal in LTR (1032 +/- 226 ng/ml) but were significantly lower in CTR (938 +/- 216 ng/ml, P < 0.05). Cortisol plasma levels were lower in both CTR (7 +/- 4.4 micrograms/L) and LTR (6 +/- 1.9 micrograms/L) than in healthy controls (11 +/- 4 micrograms/L, P < 0.01).(ABSTRACT TRUNCATED AT 400 WORDS)

Dynamic cardiomyoplasty at seven years

Since January 1985, the date of the first dynamic cardiomyoplasty, until April 1992, 52 patients with end-stage heart disease were operated on in our institution. Mean preoperative New York Heart Association functional class was 3.3 and ventricular ejection fraction 16% +/- 3%. Associated procedures in 23 patients comprised ventricular aneurysm resection (10), valve surgery (9), coronary artery bypass (8), and tumor resection (3). Thirty-eight patients had a ventricular reinforcement, 13 a ventricular substitution, and 1 an atrial reinforcement using the left latissimus dorsi muscle. Preassist mortality rate before full latissimus dorsi muscle stimulation was 7 of 13 patients (54%) in the 1985 to 1987 period and 5 of 39 (12%) in the 1988 to 1992 period. The causes of death were heart failure (4), multiorgan failure (4), septicemia (2), ventricular fibrillation (1), and sudden death (1). Multivariate analysis of factors influencing hospital mortality showed that age, cardiac suture technique, associated surgical procedures, biventricular heart failure, and hemodynamic instability plus inotropic drug support were predictors of unfavorable outcome. All patients were followed up for from 2 months to 7 years (mean 21 months). Postassist mortality rate was 8 of 40 (20%). Causes of death included heart failure (5), ventricular fibrillation (1), myocardial infarction (1), and gastric bleeding (1). Preoperative risk factors influencing long-term mortality were permanent New York Heart Association functional class IV, biventricular heart failure, atrial fibrillation, cardiothoracic ratio greater than 60%, and ejection fraction less than 15%. Actuarial survival at 7 years was 70.4% (preassist mortality excluded). Surviving patients were in a mean New York Heart Association functional class of 1.8 (preoperatively 3.3, p < 0.05). The average ejection fractions (rest/stress) were 25%/28% at 1 year, 26%/30% at 2 years, and 23%/28% at 3 years. Average cardiothoracic ratios were 57% +/- 3% at 1 year, 56% +/- 2% at 2 years, and 57% +/- 2.5% at 3 years. Catheterization obtained in 20 patients showed no significant changes at rest in capillary wedge pressure, pulmonary artery pressure, and diastolic left ventricular pressure when compared with preoperative pressures. Average ejection fractions increased from 24% to 30.6%. Maximal oxygen consumption increased from 12.8 +/- 3.5 to 18.6 +/- 4 ml/min per kilogram. The number of rehospitalizations resulting from congestive heart failure was reduced to 0.4 hospitalizations per patient per year (preoperatively 2.4, p < 0.05). In 62% of the patients, pharmacologic therapy was diminished after the operation. Three patients required orthotopic heart transplantation 6 months, 4 years, and 5 years after cardiomyoplasty.

[Phosphocalcium metabolism in patients with calcified valvular bioprosthesis]

Calcium and gla-protein content are increased in the calcifications of cardiac bioprostheses. Such calcifications are more frequent during growth, pregnancy and renal failure when bone gla-protein levels are elevated. We investigated whether bone gla-protein and other markers of calcium metabolism play a role in bioprostheses calcifications. Forty-seven patients were separated into 2 groups according to the presence (group A, n = 9) or absence (group B, n = 38) of bioprostheses calcifications, as assessed by echo-doppler and surgery. Plasma levels of calcium, phosphorus, magnesium, creatinine and alkaline phosphatases were measured by standard laboratory methods, parathormone and those of bone gla-protein by specific radioimmunoassays. Results (mean +/- SEM) were compared (group A versus group B, P < 0.01) using Student's test and one-factor variance analysis (ANOVA). Age was similar in both group (53 +/- 12.9 vs 50 +/- 12.3 yrs), whereas duration of implant was greater in group A (104 +/- 12.4 vs 66 +/- 6.5 months, P < 0.01). No statistically significant difference was found between group A and B concerning biochemical and/or hormonal markers of calcium metabolism. These negative results merit to be discussed, and further studies will be needed to explore the potential role of circulating bone gla-protein in bioprostheses calcifications.

Assessing human cardiac allograft rejection using MRI with Gd-DOTA

To explore the potential role of MRI in detecting cardiac allograft rejection in transplant recipients using gadolinium tetraazacyclododecane tetraacetic acid (Gd-DOTA) for contrast enhancement, we examined 7 normal healthy volunteers and 39 patients separated into three groups according to histological findings. Quantitative myocardial enhancement (ME), expressed as the ratio of maximum signal intensity after intravenous Gd-DOTA injection to signal intensity before intravenous injection of Gd-DOTA, was significantly lower for patients without histological rejection (n = 14; regional ME = 83 +/- 41%; mean ME = 53 +/- 24%) when compared with patients with grade 1 histological rejection (n = 18; regional ME = 122 +/- 20%, p = 0.02; mean ME = 70 +/- 14%, p < 0.05) and with patients with grade 2 or 3 rejection (n = 7; regional ME = 135 +/- 44%, p = 0.02; mean ME = 81 +/- 27%, p < 0.05). Myocardial enhancement was not significantly different in patients with grade 1 histological rejection compared with patients with grade 2 or 3 rejection. Because predominant focal areas of ME were observed in all patients, regional ME seemed a better measurement than mean ME to distinguish focal histological changes when the rejection process is beginning. More sophisticated software analysis is necessary to quantify and map high ME to establish the exact relationship between the extent of edema and the severity of rejection.

[Mitral valvuloplasty during the acute phase of endocarditis]

Thirty-five patients were operated in the acute phase of mitral valve endocarditis between 1986 and 1991. The surgical indications were hemodynamic (22), echocardiographic (9), embolic (2) and infectious (2). There were pre-existing valve lesions in 45% of cases. The causal organism was identified in 90% of cases: streptococcus (19), staphylococcus (9) and Gram negative bacilli (4). Preoperative antibiotic therapy was prescribed for an average of 18 days. The aortic valve was infected in 9 patients and tricuspid valve in 1 patient. The mitral lesions were: abscess (11), vegetations (11), perforations (16), and ruptured chordae tendinae (22). All patients underwent Carpentier's mitral valvuloplasty. The operative mortality was 5.7% (2 patients). Early reoperation was required in 1 case. Follow-up was possible in 96% of cases for an average of 23 months. No recurrences of endocarditis were observed. One patient was reoperated and 3 died. All the others were in Classes I and II of the NYHA. None had significant mitral regurgitation or stenosis. These results show that mitral valvuloplasty is possible in the acute phase of endocarditis in 90% of cases. The mortality and morbidity are low and long-term results are stable.

[Double mitral orifice. Apropos of a case]

The authors report a case of Double Mitral Orifice (DMO), existing in isolation and type 3 by the Floch Prigent classification. This rare anomaly is often associated with another congenital malformation, dominated by intra-atrio-ventricular defect. Two-dimensional echocardiography is the essential diagnostic factor. Hemodynamic consequences may be nil, but mitral insufficiency and/or stenosis may complicate this malformation. Treatment may be summarised as abstention, surgical repair or valve replacement, according to the severity of lesions.

[Is spontaneous regression of pulmonary metastasis of renal cancer possible? Apropos of a case with review of the literature]

A 64-year-old man was hospitalized with a cancer of the right kidney associated with pulmonary images suggestive of parenchymatous metastases. After nephrectomy and no further treatment, we observed an involution of the images which disappeared completely within a few months and did not recur. Twenty months after the nephrectomy, the chest X-ray remained normal. This case raised the problem of possible spontaneous regression of renal cancer pulmonary metastases. Seventy-two observations were found in the literature: those sufficiently described were analyzed, but certain observations were questionable; a formal pathology diagnosis was only confirmed in two cases in 1959 and in 1977. Because of the rarity of these documented cases and due to the large number of possible causes of round, sometimes transitory, opacities on the chest X-ray, it would appear that one must be very sceptical about the existence of true spontaneous regression of renal cancer pulmonary metastases.

[Circulatory assistance through cardiomyoplasty and aortomyoplasty. Experience and first clinical results]

The finding that skeletal muscles can be made resistant to fatigue by progressive electrical stimulation has been used as a means of providing circulatory support in cardiac surgery. The first application of this discovery was dynamic cardiomyoplasty, performed for the first time in man in 1985 at the Broussais Hospital, Paris. The latissimus dorsi muscle is transposed into the thorax, then attached around the heart and finally stimulated synchronously with the ventricular systole. So far, more than 200 patients in the whole world (including 57 at the Broussais Hospital) have undergone this operation with results that are increasingly encouraging. In these cases the muscle is used to reinforce or replace the left or right ventricle, but other applications are being studied, such as double cardiomyoplasty (left latissimus dorsi and right pectoralis major muscles), cardiomyoplasty of the right atrium and aortomyoplasty which produces aortic counterpulsation. The development of these techniques underlines the ever growing interest raised by this type of autologous circulatory support.

Mitral valve repair using Carpentier techniques in patients more than 70 years old. Early and late results

BACKGROUND

Mitral valve incompetence in elderly patients raises the problem of whether to replace or to repair the mitral valve. The purpose of this study is to review our experience with mitral valve repair in patients > 70 years old.

METHODS AND RESULTS

Between 1986 and 1991, 79 consecutive patients > 70 years old underwent mitral valve repair by Carpentier techniques. The most frequent cause was degenerative valve disease (65 of 79). Preoperative echocardiography showed that 6% of the patients had type I, 88% type II, and 5% type III mitral valve dysfunction. Anatomic lesions encountered at surgery confirmed the preoperative echocardiographic findings, with 88% of the patients with a leaflet prolapse either of the posterior leaflet (56%) or of both the anterior and posterior leaflets (32%). Multiple surgical procedures were required in each patient. Posterior leaflet resection was the most common technique used (76%). Prosthetic ring annuloplasty was used in 96% of patients. Associated procedures were performed in 21.5% of cases. Three patients died, for an operative mortality of 3.8%. One patient (1.3%) required reoperation for residual mitral insufficiency. Nonfatal complications related to the patients' preoperative condition were noted in more than half of the patients. Echocardiography obtained before discharge revealed absent or minimal mitral insufficiency in 91% of patients and mild mitral insufficiency (2+/4+) in 9%. Follow-up was available for 74 of 76 patients (97.3%) and ranged from 3 months to 6 years (mean, 22 months). Two patients (2.6%) were lost to follow-up. Sixty patients (89%) were in New York Heart Association functional class I or II. Seven patients died and one required reoperation. Actuarial analysis of the results showed overall survival at 5 years 81 +/- 11%; freedom from thromboembolism, hemorrhage, and reoperation 97 +/- 5%, 97 +/- 5%, and 98 +/- 4%, respectively. Color-coded echo Doppler studies obtained in 67 patients at the time of follow-up showed absent or minimal MI (91%) (n = 61), and mild MI in 9% (n = 6).

CONCLUSIONS

These data suggest that mitral valve repair using Carpentier techniques should now be considered as the procedure of choice in patients of any age referred for mitral insufficiency.

[Mycotic aneurysm of the carotid artery secondary to acute bacterial endocarditis]

Mycotic aneurysms of the extracranial carotid arteries are rare. A new case of mycotic aneurysm of the bifurcation of the carotid artery secondary to acute bacterial endocarditis affecting the aortic valve is reported. Simultaneous treatment of the two lesions was instituted. The twenty six cases of mycotic aneurysm of the extracranial carotid arteries previously described in the literature are reviewed by the authors.

Cardiac surgery in patients with human immunodeficiency virus infection: indications and results

Ten patients with human immunodeficiency virus (HIV) infections underwent cardiac surgery using cardiopulmonary bypass. All were in Centers for Disease Control (CDC) group II. The cardiac involvement was either urgent or severely symptomatic in all cases. One patient died due to acquired immunodeficiency syndrome (AIDS) unrelated cause. No complications were encountered in this series. Eight of the nine survivors were available for follow-up. Three of these eight patients progressed to AIDS (CDC group IV) and subsequently died. Five patients are alive and in CDC group II. Prognosis of the HIV infection and the natural history of the cardiac disease are the two main elements to be considered whenever cardiac surgery is required.

[Changes in the vascular wall induced by surgical glues. Experimental study]

The effects on vascular tissues of two different types of surgical glue, gelatin-resorcinol-formaldehyde (GRF) and fibrin (Tissucol) were tested on the rat abdominal aorta. The GRF glue induced destruction of the vascular wall: multiple inclusions of the glue were noted in the media. Conversely, the fibrin glue preserved the normal architecture of the three arterial layers. The use of GRF glue therefore should be avoided on particularly fragile tissues (e.g. coronary arteries), and it seems preferable in such cases to use the fibrin glue.

Cardioprotective effect of trimetazidine during coronary artery graft surgery

Reperfusion injury remains the most uncontrolled phenomenon during cardiac surgery. Potential myocardial protection by trimetazidine was tested in a double blind placebo controlled study on 19 patients undergoing aorto-coronary bypass surgery. The trimetazidine group was composed of 10 patients and the placebo group of 9 patients. Pretreatment was started three weeks before surgery with 1 tablet (trimetazidine 20 mg) t.i.d. and the same drug was added to the cardioplegic solutions (trimetazidine: 10(-6) M). The cross clamping time was 41.1 +/- 3.8 minutes in the trimetazidine group and 39.8 +/- 2.3 minutes in the placebo group. Metabolic measurements showed that the increase of malondialdehyde measured in the coronary sinus 20 minutes after reperfusion was significantly (p = 0.014) less in the trimetazidine group (from 1.60 +/- 0.11 to 1.79 +/- 0.2 mumol/L-1) than in the placebo group (from 1.17 +/- 0.11 to 2.84 +/- 0.58 mumol/L-1). Myosin was present 4 hours after surgery in all patients in the placebo group and in 5 of the 10 of the trimetazidine group (p = 0.036). Haemodynamic measurements showed that patients pretreated with trimetazidine had a better ventricular function, as assessed by the stroke work index (SWI) significantly (p = 0.01) higher in the trimetazidine group (0.0391 +/- 0.0029 g/min/m2/beta) than in the placebo group (0.0282 +/- 0.0026 g/min/m2/beat), the evolution of SWI during surgery was not significantly different between the two groups. Thus trimetazidine seems to reduce ischaemia-reperfusion damage during cardiac surgery; moreover pretreatment with trimetazidine allows the patient to face the operation with better ventricular function.

Traumatic ventricular septal defects. Report of 3 cases with tricuspid valve rupture in 2 cases

Traumatic ventricular septal defects (TVSD) are rare complications of cardiac trauma. This report describes 3 cases of TVSD secondary to penetrating trauma in 2 patients and to blunt trauma in one case. Echocardiography confirmed the diagnosis in all cases. Surgical correction was performed in the 3 cases. In 2 patients associated tricuspid trauma was present requiring tricuspid valve repair.

[Heart surgery and human immunodeficiency virus]

The authors report their experience of cardiac surgery in 9 carriers of the human immunodeficiency virus (HIV). Eight HIV seropositive patients underwent surgery under cardiopulmonary bypass for valve repair or replacement. Eight patients were asymptomatic with respect to their viral infection: one patient had generalised lymphadenopathy. The hospital mortality was 1/9 (11.1%). There was no infectious morbidity. Five patients are alive with an average follow-up of 29.6 months and in NYHA Stages I or II. One patient deteriorated and presented symptoms of an AIDS-related complex. These results suggest that if the operative indications are justified, cardiac surgery under cardiopulmonary bypass may be performed in asymptomatic HIV seropositive patients.

[Use of a synthetic prostacyclin in extracorporeal circulation]

Using a prostacyclin in conjunction with standard heparin might limit the occurrence of post-extracorporeal circulation (ECC) thrombopathy and reduce the risk of haemorrhage inherent in this technique. For this reason, we studied the effect of the prostacyclin analogue Iloprost (ZK 36 374), a drug which is active in man when given orally with a biological half-life of 30 min, and devised a double-blind randomized trial to evaluate the potential benefit of Iloprost versus placebo in 2 groups of 15 patients (A: placebo, B: Iloprost). An infusion of the drug in incremental doses (up to 12 ng kg-1 min-1) was begun before starting the ECC and was stopped at the end of the cardiopulmonary bypass, at the time of protamine injection. Significant arterial hypotension was observed during ECC in two patients of the Iloprost group. Comparison between Iloprost and placebo groups showed that the mean number of platelets was not significantly higher in the Iloprost group 20 min after the ECC and during the early post-operative recovery period. Platelet aggregability was higher after surgery in the Iloprost group than in the placebo group. There was no significant difference in post-bypass bleeding between the two groups. Thus, Iloprost does not reduce the fall in circulating platelets observed during cardiopulmonary bypass, but it might help in preserving the platelet function. However, the potential usefulness of the drug is limited by adverse haemodynamic reactions.

Dynamic cardiomyoplasty for long-term cardiac assist

The principle of cardiomyoplasty is long-term electrostimulation of a latissimus dorsi muscle (LDM) wrapped around the failing heart. Technically, this procedure consists of placing the left LDM flap around the heart via a window created by partial resection of the 2nd or 3rd rib, and subsequent muscle electrostimulation in synchrony with ventricular systole. The aim of cardiomyoplasty is to support ventricular function in ischemic or dilated cardiomyopathies, or to partially replace the ventricular myocardium after large aneurysm or tumor resections. Our clinical experience at Broussais Hospital involves 44 patients. The functional class and quality of life improved after cardiomyoplasty. Improvement of the ventricular performance and limitation of cardiac dilatation were demonstrated over the long-term. The actuarial survival at 6 years was 71%. Risk factors influencing perioperative mortality were: age > 65 years, associated surgical procedures, pulmonary vascular hypertension, and patients hemodynamically unstable or on inotropic drug support. Preoperative risk factors influencing the long-term mortality were: permanent NYHA functional class 4, cardiothoracic ratio > 0.60, LV ejection fraction < 15%, bi-ventricular heart failure, and atrial fibrillation. Cardiomyoplasty does not preclude the use of future orthotopic heart transplantation.

Primary gastrointestinal malignant lymphomas associated with Epstein-Barr virus after heart transplantation

Gastrointestinal involvement has been reported in 12-21% of post-transplant lymphoproliferative disorders but is unusual in the setting of heart transplantation. We report four post-transplant lymphoproliferative disorders observed among the 174 heart transplant recipients of our series, all of which were primary malignant lymphomas of and confined to the digestive tract. The mean onset time from transplantation was 22 months. Small intestine lesions were present in all four patients, with gastric involvement in one. Histologically, the tumour was monomorphic of immunoblastic type in one case and polymorphic in the three other cases. Analysis of cytoplasmic immunoglobulins demonstrated the presence of a major monoclonal subset in all patients. Epstein-Barr virus genome was found in numerous tumour cells by in situ hybridization. The exclusive localization to the digestive tract and the lymphoepithelial lesions observed in two cases suggest that these lymphoproliferations might originate from mucosa-associated lymphoid tissue.

MR tissue characterization of a right atrial mass: diagnosis of a lipoma

A case of histologically confirmed benign lipoma of the right atrium is presented. Magnetic resonance imaging was successfully used to visualize and characterize the tumor previously detected by echocardiography. T1-weighted MR was superior to echocardiography and was in surgical agreement with examination in identifying the relationship of the lipoma to the right atrial wall, the coronary sinus, and the interatrial septum. Comparison of measurements of the tumor's signal intensities on T1- and T2-weighted images and T2 relaxation time with those of surrounding myocardium and mediastinal fat allowed a preoperative diagnosis of lipoma. Magnetic resonance may obviate surgical intervention in selected asymptomatic cases where the diagnosis of benign lipoma appears likely.

Traumatic mitral insufficiency following percutaneous mitral dilation: anatomic lesions and surgical implications

Percutaneous mitral dilation is a widely accepted technique for treating pure mitral stenosis. Traumatic mitral insufficiency may occur secondary to this technique raising the problem of the feasibility of mitral valve repair. Twenty patients were operated on for traumatic mitral insufficiency following percutaneous mitral dilation. Three patients required emergency operations (within 6 h). In the other cases, surgery was carried out within the following days or weeks. Operative analysis of the mitral valves showed the following lesions: tear of the anterior leaflet (n = 4), tear of the posterior leaflet (n = 2), anterior (n = 4) or posterior (n = 9) paracommissural tear and papillary muscle rupture (n = 1). Associated chordal rupture was found in 3 patients. Septal perforation secondary to transseptal puncture was found in all cases. A septal tear of more than 10 mm was present in 4 patients. Surgery consisted of mitral valve reconstruction (n = 12) or mitral valve replacement (n = 8). Anatomic lesions following percutaneous mitral dilation may affect all the elements of the mitral valve apparatus. The possibility of repair depends more on the degree of calcification of the valve than on the extent of the leaflet tear.

[Mitral valvuloplasty for endomyocardial fibrosis in a child with acute leukemia and hypereosinophilia]

The authors report the case of a child with acute lymphoblastic leukaemia and hypereosinophilia complicated by left sided endomyocardial fibrosis. Despite the need for urgent treatment and severe mitral valve disease, a complex mitral valvuloplasty was performed, consisting of mobilisation and reconstruction of the posterior leaflet, burying the chordae with plicature of the papillary muscle of the anterior leaflet associated with an annuloplasty. Decortication was performed by a transvalvular approach. The technique of mobilisation-reconstruction of the posterior mitral leaflet with a pericardial patch should widen the indication of conservative surgery in this condition, in the presence of dominant mitral regurgitation in the child.

Comparative anatomy and histology of the radial artery and the internal thoracic artery. Implication for coronary artery bypass

Anatomical characteristics of the radial a. were compared to those of the internal thoracic a., considered as a gold standard in coronary surgery. The length, the diameter, the collateral distribution and the wall thickness of these two arteries were studied comparatively. In addition, a comparative histological analysis was carried out. Anatomical and histological characteristics of these two arteries have important implications for coronary artery bypass.