A recovery model of minimally invasive cardiopulmonary bypass in the rat

This study was undertaken to develop a rodent (rat) model of cardiopulmonary bypass (CPB) that has been designed to mimic functionally the minimally invasive clinical setting. The circuit is similar to the clinical model in terms of its construction, configuration, material surface area to blood volume ratio, and priming volume to blood ratio. The overall priming volume was 10 mL. Thirty-six male Sprague-Dawley rats (422 +/- 32 g) were anaesthetized while maintaining spontaneous ventilation. Anticoagulation was achieved with heparin (500 IU/kg). Blood arterial pressure was monitored continuously. Normal central temperature was maintained throughout. Intermittent arterial blood gas levels also were monitored. All animals were cannulated in preparation for CPB; however, CPB, utilizing a double roller pump and a flow rate of 100 mL/kg/minute for 60 min, was initiated in only 18 animals, the remaining 18 animals acting as non-CPB controls (Sham). The animals were haemodynamically stable. After the operative procedure, the animals were allowed to recover from the anaesthesia and, after transfer to a recovery facility, were monitored for a period of 1 week. There were no differences between the groups in terms of blood gas analysis and blood pressure data; all animals survived the procedure and had an uneventful follow-up. Differences were found between the CPB animals and the Sham group in terms of TNFalpha used as a marker of inflammatory processes. This trend tends to support this model as an analogue for the clinical scenario for future studies of CPB-related inflammation. Overall, the CPB procedure was easy to perform and was associated with excellent survival. This recovery model is an effective tool to perform pathophysiological studies associated with minimally invasive CPB.

Pulmonary vascular effects of sildenafil on the development of chronic pulmonary hypertension in the ovine fetus

We investigated the pulmonary vascular effects of prophylactic use of sildenafil, a specific phosphodiesterase-5 inhibitor, in late-gestation fetal lambs with chronic pulmonary hypertension. Fetal lambs were operated on at 129 +/- 1 days gestation (term = 147 days). Ductus arteriosus (DA) was compressed for 8 days to cause chronic pulmonary hypertension. Fetuses were treated with sildenafil (24 mg/day) or saline. Pulmonary vascular responses to increase in shear stress and in fetal PaO2 were studied at, respectively, day 4 and 6. Percent wall thickness of small pulmonary arteries (%WT) and the right ventricle-to-left ventricle plus septum ratio (RVH) were measured after completion of the study. In the control group, DA compression increased PA pressure (48 +/- 5 to 72 +/- 8 mmHg, P < 0.01) and pulmonary vascular resistance (PVR) (0.62 +/- 0.08 to 1.15 +/- 0.11 mmHg x ml(-1) x min(-1), P < 0.05). Similar increase in PAP was observed in the sildenafil group, but PVR did not change significantly (0.54 +/- 0.06 to 0.64 +/- 0.09 mmHg x ml(-1) x min(-1)). Acute DA compression, after brief decompression, elevated PVR 25% in controls and decreased PVR 35% in the sildenafil group. Increased fetal PaO2 did not change PVR in controls but decreased PVR 60% in the sildenafil group. %WT and RVH were not different between groups. Prophylactic sildenafil treatment prevents the rise in pulmonary vascular tone and altered vasoreactivity caused by DA compression in fetal lambs. These results support the hypothesis that elevated PDE5 activity is involved in the consequences of chronic pulmonary hypertension in the perinatal lung.

[The long term (15 years) evolution after valvular replacement with mechanical prosthesis or bioprosthesis between the age of 60 and 70 years]

OBJECTIVE

the aim of this study was to document the choice between prosthesis and bioprosthesis in cases of valvular replacement during the seventh decade of life.

METHODS

a retrospective and cooperative study linking eleven cardiac surgical teams and five medical cardiology teams combined 497 subjects born between 1915 and 1925 (average age 64.4 years) who underwent aortic (313 cases) or mitral (184 cases) valvular replacement with mechanical prosthesis (259 cases) or bioprosthesis (238 cases). Information was collected at each centre during the year 2000 on the long term evolution (going back 15 years), in particular on the mortality, non-fatal complications linked to the valve, cardiac complications and extra-cardiac events. These results were subjected to statistical analysis.

RESULTS

the operative mortality of this group was 4.8%. The 15 year survival was 46% for the aortic mechanical prostheses, 32% for the aortic bioprostheses (p=0.04). 34% for the mitral bioprostheses and 33% for the mitral mechanical prostheses. Events linked to the valve were more frequent for the mitral valvulopathies than for the aortic valves (49% vs 26%, p<0.001). The absence of events linked to the valve at 15 years was 69% for the aortic mechanical prostheses and 68% for the aortic bioprostheses. This was the case in only 57% of mitral mechanical prostheses and 36% of the mitral bioprostheses (p=0.11). Thromboembolic accidents were three times more frequent in the mitrals than in the aortics (11.5 vs 3.8%, p=0.002). Haemorrhage was four times more frequent for the mechanical prostheses than for the bioprostheses (7.7 vs 2%, p=0.01). The risk of degeneration for the aortic bioprostheses was 20% at 15 years, three times less so after 65 years of age (p=0.03). At 48% it was much higher in the mitral valves at 15 years with no significant difference before and after 65 years of age (p=0.3).

CONCLUSION

the current life expectancy of subjects in their seventh decade is important. The greatly elevated risk of bioprosthesis degeneration in the mitral position does not allow this alternative to be advocated before 70 years of age. In the aortic position, this risk is elevated before 65 years of age. It is lower after 65 years old. Nevertheless, this means the risk of reoperation in certain octogenarians must be accepted, balanced with the linear risk of haemorrhagic accidents for which a future reduction is expected thanks to milder anticoagulation for aortic mechanical prostheses and anticoagulation autocontrol.

Stent-graft repair of the thoracic aorta: short-term results

The purpose of this study was to evaluate clinical feasibility and immediate outcome of stent-graft repair of the thoracic aorta. From December 1999 to January 2001, a total of 14 patients underwent stent-graft repair of the thoracic aorta. The underlying etiologies were traumatic rupture of the aortic isthmus in four cases, Stanford type B dissection in four, thoracic aortic aneurysm in three, penetrating atherosclerotic ulcer in two cases, and postoperative aortoesophageal fistula in one case. Stent-graft placement was performed under angiographic control in all cases in association with transesophageal echography in seven cases. The procedure was performed under emergency conditions in five cases. Thirteen patients presented contraindications for surgery. Stent-graft placement was successful in all cases. No further surgery has been performed in any case. Thus we conclude that endovascular treatment of the thoracic aorta using stent grafts is a promising therapeutic modality in patients with contraindications for conventional surgical treatment.

Anterior chordal transection impairs not only regional left ventricular function but also regional right ventricular function in mitral regurgitation

BACKGROUND

Preservation of annuloventricular continuity through the chordae tendinae aims to maintain left ventricular (LV) function and thus improve postoperative prognosis. This study was designed to prospectively investigate the effect of anterior chordal transection on global and regional LV and right ventricular (RV) function in mitral regurgitation (MR).

METHODS AND RESULTS

Sixty-five patients with severe MR underwent radionuclide angiography before and after either mitral valve (MV) repair (42 patients) or replacement with anterior chordal transection (23 patients). LV and RV ejection fractions (EF) were determined at rest. Both ventricles were divided into 9 regions to analyze regional EF and the effect of anteromedial translation related to surgery. After surgery there was a significant decrease in LVEF (P=0.038) and an increase in RVEF (P=0.036). However, LVEF did not change after MV repair (63.8+/-9.9% to 62.6+/-10.3%), whereas RVEF improved (40.7+/-10.1% to 44.5+/-8.1%, P=0.027). In contrast, LVEF decreased after MV replacement (61.7+/-10.1% to 57.2+/-9.9%, P=0.03), and RVEF was unchanged (40.9+/-10.9% to 41.3+/-9.1%). LVEF 4 and 5, in the area of anterior papillary muscle insertion, were impaired after MV replacement compared with MV repair (region 4, 77.6+/-16.7% versus 87.7+/-10.8%, P=0.005, and region 5, 73.9+/-19.3% versus 89.9+/-13.1%, P<0.001). Moreover, anterior chordal transection led to a significant impairment in the apicoseptal region of the RV (RVEF 4, 50.3+/-15.6% versus 59.3+/-13.8%, P=0.02).

CONCLUSIONS

Anterior chordal transection during MV replacement for MR impairs not only regional LV function but also regional RV function.

Pilot study with air-automated sigmoid capnometry in abdominal aortic aneurysm surgery

BACKGROUND

and objective Ischaemic colitis can be a serious complication after aortic surgery. The paucity of clinical symptoms makes its diagnosis particularly difficult and often delayed. Automated on-line tonometry is now proposed to monitor intestinal perfusion. This study was designed to assess the use of semi-continuous sigmoid-to-arterial [P(r-a)CO(2)] PCO(2) gap monitoring in aortic surgery to detect colonic ischaemia.

METHODS

This prospective clinical study was realized at the University Hospital of Lille, France, including eight males scheduled for abdominal aortic aneurysm surgery. Intraoperative and postoperative P(r-a)CO(2) values were compared with conventional monitoring and colonic mucosa aspect performed by sigmoidoscopy 48 h after surgery. Haemodynamic variables, O(2) delivery (DO(2)), O(2) consumption (VO(2)), O(2) extraction (ERO(2)), lactate, P(v-a)CO(2), P(r-a)CO(2) were measured peroperatively and every 4 h during a 48-h postoperative period.

RESULTS

Intraoperative P(r-a)CO(2) values increased significantly with the highest value (4.36 +/- 3.42 kPa) observed during aortic clamping when DO(2) was the most altered. P(r-a)CO(2) continued to deteriorate after surgery with the maximal values between 8 (4.79 +/- 3.85 kPa) and 12 (4.68 +/- 3.26 kPa) h after surgery. This peak was associated with a significant ERO(2) increase counterbalancing an increase of VO(2) whereas DO2 tended to decrease. P(r-a)CO(2) values began to decrease only at the end of the study. The highest values of P(r-a)CO(2) were registered in patients with the most altered haemodynamic variables, severe ischaemic colitis along with higher hospital lengths of stay.

CONCLUSION

Taken together, these data suggest that regional and automated capnometry may be easily used non-invasively to detect peroperative intestinal ischaemia in aortic surgery.

Total orthotopic heart transplantation for primary cardiac rhabdomyosarcoma: factors influencing long-term survival

BACKGROUND

Primary cardiac sarcomas are uncommon and rare, with an unequal distribution in the population. A dismal prognosis is usually admitted that is related to a high propensity to develop distant metastasis with survival rarely exceeding 2 years. We report a case of a patient with a primary cardiac rhabdomyosarcoma characterized by an exceptional long-term survival after surgical treatment by a total orthotopic heart transplantation. From this limited experience, we reviewed factors that may influence survival to optimize therapeutic strategy.

METHODS

A 33-year-old man was found to have a 10-cm primary cardiac rhabdomyosarcoma located in the right atrium and extending to the atrioventricular groove; therefore, resection was not possible. Since no metastases were detected, the patient was scheduled for urgent cardiac transplantation, which was performed after adjuvant radiotherapy.

RESULTS

Postoperative outcome was uneventful and the patient is still alive, with regular follow-up, at 102 months.

CONCLUSIONS

In a case of primary rhabdomyosarcoma, heart transplantation, despite immunosuppressive therapy, can provide long-term survival and can be considered for selected patients after rigorous analysis of predictors of survival.

Diagnosis and treatment of type II endoleak after stent placement for exclusion of an abdominal aortic aneurysm

After endovascular treatment of AAA, regular clinical and radiologic surveillance is necessary for early diagnosis and treatment of mid-term and long-term complications. The purpose of this report was to evaluate the efficacy of magnetic resonance imaging (MRI) in screening for type II endoleaks and assessing the results of treatment by embolization. From March 1996 to November 1999, 64 patients with uncomplicated infrarenal abdominal aortic aneurysm (AAA) were treated by endovascular exclusion with a covered aortic stent. Radiological surveillance included plain abdominal roentgenogram (PAR), CT scan, and pelvioabdominal MRI at 1 month, 3 months, 6 months, and every 6 months thereafter. Arteriography was performed routinely after 1 year or sooner if an endoleak was suspected. Based on the results of this study, MRI seems to be more sensitive than CT scanning for detection of type II endoleaks. The negative predictive value of MRI is also better. In this series, all endoleaks were treated by embolization. In most cases, the maximum transverse diameter and maximum anteroposterior diameter decreased after embolization. Further follow-up will be necessary to confirm these findings.

Effect of mitral valve surgery on exercise capacity, ventricular ejection fraction and neurohormonal activation in patients with severe mitral regurgitation

OBJECTIVES

The purpose of this study was to prospectively investigate the effects of surgical correction of mitral regurgitation (MR) on exercise performance, cardiac function and neurohormonal activation.

BACKGROUND

Little is known about the effect of surgical correction of MR on functional status or on neurohormonal activation.

METHODS

Cardiopulmonary exercise test, radionuclide angiography and blood samples for assessment of neurohormonal status were obtained in 40 patients with nonischemic MR before and within one year (216+/-80 days) after surgery. Twenty-four patients underwent mitral valve repair (MVr), and 16 underwent valve replacement (VR) with anterior chordal transection.

RESULTS

Despite an improvement in New York Heart Association functional class, exercise performance did not change (peak oxygen consumption: 19.3+/-6.1 to 18.5+/-5.6 ml/kg/min, percentage of maximal predicted oxygen consumption: 79.5+/-18.2% to 76.8+/-16.9%). After surgery, left ventricular (LV) ejection fraction (EF) decreased (64.2+/-10.3% to 59.9+/-11.4%, p = 0.003) while right ventricular (RV) EF increased (41.4+/-9.6% to 44.7+/-9.5%, p = 0.03). Left ventricular EF did not change after MVr (64.3+/-11.5% to 61.5+/-12.2%), but RVEF improved (40.4+/-9.2% to 46.0+/-10.0%, p = 0.02). In contrast, VR was associated with an impairment of LV function in the apicolateral area and a decrease in LVEF (64.1+/-8.5% to 57.4+/-10.0%, p = 0.01), whereas RVEF did not change (42.9+/-10.3% to 42.8+/-8.6%). Moreover, there was only a slight decrease in neurohormonal activation after surgery.

CONCLUSIONS

Despite an improvement in symptomatic status, exercise performance was not improved seven months after either MVr or VR for MR, and neurohormonal activation persisted. Compared with MVr, VR resulted in a significant impairment of cardiac function in this study.

Cardiac valve papillary fibroelastomas: clinical, histological and immunohistochemical studies and a physiopathogenic hypothesis

BACKGROUND AND AIM OF THE STUDY

Cardiac papillary fibroelastoma (CPF) is a rare and histologically benign tumor, but may have a malignant propensity for life-threatening complications; thus, surgical removal is justified. Case histories were reviewed of four patients who underwent surgical management after diagnosis of CPF located on aortic (n = 2) or mitral (n = 2) valves. Our aim was to provide explanations for the clinical diversity of the lesions and, using histological and immunohistochemical methods, to hypothesize the genesis of these tumors.

METHODS

Among four patients with a diagnosis of valvular CPF, two had previous and recent history of neurological embolic symptoms with small echographically located tumors attached to the ventricular side of aortic cusps. Two other patients (one with paroxysmal atrial fibrillation, one with no neurological or rhythmically related stroke) had CPFs located on the posterior or anterior mitral leaflets.

RESULTS

Surgical excision was performed with a conservative valve-sparing approach. Histological and specific immunohistochemical (IHC) studies were conducted on all samples. The postoperative course was uneventful, and histological analysis confirmed the diagnosis of CPF with typical fronds characterized by three successive layers. In the first two patients there was correlation between neurological events and the presence of thrombus aggregated on the injured superficial endothelial layer. In the other patients, no endothelial damage or thrombus was found. IHC studies showed dysfunction of the superficial endothelium, a centrifugal mesenchymal cellular migration arising from the central layer to the superficial layer with differentiation steps, the presence of dendritic cells in the intermediate layer, and remnants of cytomegalovirus (CMV) in the intermediate layer.

CONCLUSION

Despite their benign histological aspect, and independent of their size, CPFs justify surgical excision because of their high potential to systemic embolization. In most cases, valve sparing management is possible with no observed recurrence after complete excision. The presence of dendritic cells and CMV strongly suggests the possibility of a virus-induced tumor, therefore evoking the concept of a chronic form of viral endocarditis.

Mid-term comparative follow-up after aortic valve replacement with Carpentier-Edwards and Pericarbon pericardial prostheses

BACKGROUND

The first generation of pericardial valves had a high rate of premature deterioration. The aim of this study was to compare the outcome after aortic valve replacement with second generation pericardial prostheses (Pericarbon and Carpentier-Edwards).

METHODS AND RESULTS

Between 1987 and 1994, 162 patients underwent aortic valve replacement with either a Pericarbon (n=81, 69+/-11 years) or a Carpentier-Edwards (n=81, 70+/-11 years) pericardial prosthesis. Mean follow-up was 4.4+/-2.7 years for Pericarbon and 4.8+/-2.4 years for Carpentier-Edwards valves (P=0. 27), giving a total follow-up of 745 patient-years. Thirty-day mortality and 5-year actuarial survival were, respectively, 6.2% and 63.2+/-5.7% in the Pericarbon group and 6.2% and 63.5+/-5.6% in the Carpentier-Edwards group. At 8 years, freedom from (and linearized rates per patient-year) thromboembolism, structural failure, and all valve-related events were, respectively, 91.8+/-3.6% (1.4%), 76. 9+/-8.7% (2.5%), and 58.4+/-9.3% (5.6%) in the Pericarbon group and 94.4+/-2.7% (1%), 100% (0%, P<0.01), and 88.8+/-3.7% (2%, P<0.05) in the Carpentier-Edwards group. There were 9 (11.1%) Pericarbon structural failures related predominantly to severe calcification and stenosis. The actual reoperation rate was 7.4% (1.6% per patient-year) in the Pericarbon group for fibrocalcific degeneration (n=3), periprosthetic leak (n=1), endocarditis (n=1), and aortic dissection (n=1). There was neither structural valve failure nor valve reoperation in the Carpentier-Edwards group. Echocardiographic review of 70 patients from 85 survivors (82.3%) found 4 additional Pericarbon valves with signs of early structural failure but no Carpentier-Edwards valve with such changes.

CONCLUSIONS

Eight years after aortic valve replacement, Pericarbon pericardial prostheses compared unfavorably with Carpentier-Edwards pericardial prostheses, with a high incidence of structural valve failure and reoperation.

Multiple aneurysmal dysplasia of pulmonary valvular sinuses with congenital focal aplasia of the annulus

We report the case of a 22-year-old woman in whom a focal aplasia of the pulmonary valve annulus associated with a multiple aneurysmal compensatory dysplasia was found. This patient had been followed since the age of seven years for a congenital asymmetric hypertrophic cardiomyopathy. Cardiac Doppler analysis showed significant pulmonary valvular insufficiency. The patient underwent heart transplant surgery because of total and refractory cardiac insufficiency. Pathological examination of the explanted heart (at the European Homograft Bank) enabled us to describe this valvular malformation. To date, this anomaly has not been described in the literature. Whether it is a malformation discovered fortuitously, or whether it is responsible in part for some of the signs associated with congenital hypertrophic cardiomyopathy is unclear. However, its role might be disclosed by a rigorous investigation of the patient's family.

Free-floating thrombi in the right heart: diagnosis, management, and prognostic indexes in 38 consecutive patients

BACKGROUND

Floating right heart thrombi (FRHTS) are a rare phenomenon, encountered almost exclusively in patients with suspected or proven pulmonary embolism and diagnosed by transthoracic echocardiography. Their management remains controversial.

METHODS AND RESULTS

We report on a series of 38 consecutive patients encountered over the past 12 years. Thirty-two patients were in NYHA class IV, 20 in cardiogenic shock. Echocardiography usually demonstrated signs of cor pulmonale: right ventricular overload (91.7% of the population), paradoxical interventricular septal motion (75%), and pulmonary hypertension (86. 1%). The thrombus was typically wormlike (36 of 38 patients). It extended from the left atrium through a patent foramen ovale in 4 patients. Pulmonary embolism was confirmed in all but 1. Mortality was high (17 of 38 patients) irrespective of the therapeutic option chosen: surgery (8 of 17), thrombolytics (2 of 9), heparin (5 of 8), or interventional percutaneous techniques (2 of 4). The in-hospital mortality rate was significantly linked with the occurrence of cardiac arrest. Conversely, the outcome after discharge was usually good, because 18 of 21 patients were still alive 47.2 months later (range, 1 to 70 months).

CONCLUSIONS

Severe pulmonary embolism was the rule in our series of FRHTS (mortality rate, 44.7%). The choice of therapy had no effect on mortality. Emergency surgery is usually advocated. However, thrombolysis is a faster, readily available treatment and seems promising either as the only treatment or as a bridge to surgery. In patients with contraindications to surgery or lytic therapy, interventional techniques may be proposed.

[Effect of resection of the anterior chordae on cardiac function after surgical correction of mitral valve insufficiency]

The preservation of cardiac function in surgical correction of mitral regurgitation implies partially or totally preserving the subvalvular apparatus. However, the conservation of the whole subvalvular apparatus during mitral valve replacement is technically difficult as the anatomical conditions are not always favourable. In order to determine the consequences of isolated resection of the anterior chordae, the authors studied global and segmental cardiac function by isotopic angiocardiography after mitral valve repair (n = 23) or replacement with conservation of the posterior chordae (n = 16) in 39 patients with isolated, non-ischaemic mitral regurgitation. The left ventricular ejection fraction decreased after valve replacement (64.1 +/- 8.5% to 57.4 +/- 10%, p = 0.01) but not after mitral valve repair (65 +/- 11.3% to 62.1 +/- 12.2%, p = NS). The ejection fractions of segments 4 and 5, corresponding to the zones of insertion of the anterior papillary muscle, decreased after valve replacement compared with repair (segment 4: -9 +/- 13.7 versus +2 +/- 11.3, p = 0.01) (segment 5: -15 +/- 13.2 versus 2 +/- 11.7, p = 0.003). The right ventricular ejection fraction improved after valve repair (40.9 +/- 9.1% to 46.4 +/- 10.1%, p = 0.03), whereas it remained unchanged after valve replacement (42.9 +/- 10.3% to 42.8 +/- 8.6%, p = NS). These results indicate a deleterious effect of isolated resection of the anterior chordae on cardiac function during mitral valve replacement with localised abnormalities of left ventricular function. This study supports the rationale of mitral valve repair or conservation of the anterior and posterior chordae during valve replacement for isolated mitral regurgitation.

Intraoperative computerized mapping of ventricular tachycardia: differences between anterior and inferior myocardial infarctions

INTRODUCTION

Although direct ventricular tachycardia (VT) surgery has been shown to be effective for treatment of inferior myocardial infarction (MI), the differences in the arrhythmia substrates compared to anterior MI have not been systematically delineated. We sought to compare operative procedures and VT substrates between anterior and inferior MI locations.

METHODS AND RESULTS

Computerized mapping was performed in 30 patients with a 128-electrode system using epicardial sock and transatrial left ventricular endocardial balloon arrays, followed by combined endocardial resection and cryoablation. At surgery, there were 51 and 34 different VTs in 18 patients with anterior MI and 12 patients with inferior MI, respectively. The proportion of aneurysms was lower in inferior MI (25% vs 78%, P = 0.008). Total activation times accounted for 65% +/- 23% and 50% +/- 22% of the VT cycle length in anterior and inferior infarcts, respectively (P = 0.005). Complete superficial reentry was identified in 12 VTs related to anterior infarcts and in only two VTs associated with inferior infarction (P = 0.038). Involvement of papillary muscles occurred in two patients with inferior MI. Patients with inferior infarcts received more cryolesions and required epicardial cryolesions or mitral valve replacement more frequently, and their operative mortality was greater (2/12 vs 0/18). Noninducibility rate (89.3%) and 2-year survival (76% +/- 8%) did not differ according to infarct location.

CONCLUSION

VT associated with inferior MI can be ablated successfully; however, the substrate is more complex, with frequent participation of intramural layers rendering the ablative procedure more difficult.

Acute aortic endocarditis with annular destruction: assessment of surgical treatment with cryopreserved valvular homografts

BACKGROUND AND AIM OF THE STUDY

Valve ring abscesses in acute infective aortic endocarditis have a low, though not insignificant, prevalence. Surgical treatment with implantation of prosthetic valves may lead to major life-threatening complications, such as recurrent endocarditis and partial or complete prosthetic dislocation. Valvular homografts may offer a higher resistance to recurrent infection and have thus become recognized as an excellent and safe substitute for orthotopic left ventricular outflow reconstruction.

METHODS

Between May 1991 and July 1996, 25 patients underwent surgical treatment for aortic endocarditis with annular destruction. Staphylococcus spp. were present in 32% of patients and Streptococcus spp. in 48%. Seven aortic valve replacements (AVR) and 18 aortic root replacements (ARR) were performed using cryopreserved valvular homografts. All grafts were implanted in the subannular position.

RESULTS

The overall outcome was good in 23 patients, two died in the early postoperative period. Mean follow up was 38 +/- 18 months (range: 14 to 76 months). No recurrence of endocarditis was detected and no significant alterations of the implants were described. Transvalvular gradients were significantly lower in ARR patients than in AVR patients.

CONCLUSIONS

Despite the severity of the tissue damage, cryopreserved homografts, when implanted in the subannular position, constitute a safe and reproducible surgical treatment of aortic endocarditis with annular involvement.

[Takayasu's arteritis: vascular investigations and therapeutic management. Experience with 16 patients]

PURPOSE

There is no consensus in regard to vascular explorations and therapeutical management of Takayasu's arteritis. The objective of this study was therefore to establish the most appropriate vascular explorations and to analyze current treatments.

METHODS

Clinical, biological and morphological findings related to either diagnosis or treatment were retrospectively evaluated in sixteen patients diagnosed with Takayasu's arteritis according to the American College of Rheumatology criteria.

RESULTS

Median delay between the occurrence of the first symptoms and the diagnosis was 9 months. Aortic lesions and aortic valvular incompetence were more frequent. Statistical analysis showed the existence of a correlation between the lack of relapse and corticosteroid therapy (Fisher exact test, P = 0.021). Percutaneous transluminal angioplasty led to stabilization of vascular lesions. Surgical management led to satisfactory results, except for patients with aortic lesions, as survival was then less than 1 year.

CONCLUSION

Early diagnosis is mandatory in patients with Takayasu's arteritis in order to propose appropriate therapy, particularly corticosteroid therapy. Surgery and angioplasty prove to be useful in occlusive forms. Late diagnosis is accompanied by severe aortic lesions and fatal outcome.

Bicarbon valve -- European multicenter clinical evaluation

OBJECTIVE

Fifteen collaborating centers in eight countries present their pooled experience with the new Bicarbon bileaflet valve.

METHODS

Between 4/90 and 4/96, 1351 patients, 806 males and 545 females, aged 10 to 83, mean 58.4 +/- 12.4, underwent valve implantation.

OPERATIONS

aortic valve replacement (AVR), 726; mitral valve replacement (MVR), 475; double valve replacement (DVR), 150. Additional procedures: CABG, 211; TV repair, 64; other, 152.

RESULTS

Mortality: 67 early (seven valve related) and 56 late (40 valve related). Valve thrombosis: six obstructive, three non-obstructive; embolism: nine major cerebral, 37 other. Major bleeding: 29. Hemolysis: two clinically significant. Non-structural dysfunction: 24 paravalvular leaks, one leaflet interference. No structural failure! Endocarditis: 24. Reoperation 48: 22 non-structural dysfunctions, 14 endocarditis, seven thrombosis and embolism, five other. Estimated 5-year freedom from valve-related deaths is 97.2% for AVR and 92.4% for MVR; 4-year freedom from valve related deaths for DVR is 90.5%. Mean calculated NYHA improvement is 1.24.

CONCLUSIONS

The Bicarbon mechanical prosthesis is well designed, durable, has good hemodynamic features and an acceptably low incidence of complications.

Long-term results with the Sorin Pericarbon valve in the aortic position: a multicenter study

BACKGROUND AND AIM OF THE STUDY

A multicenter study was designed to evaluate the Pericarbon pericardial bioprosthesis for up 10 years after implantation in the aortic position.

METHODS

Between January 1986 and November 1996, 321 patients (mean age 75.8 +/- 7.3 years) received 325 Pericarbon pericardial valves in the aortic position. Four patients underwent redo surgery and each received a second Pericarbon prosthesis. Associated cardiac procedures in 80 patients were mainly coronary bypass (n = 66). Follow up extended up to 10 years (cumulative follow up of 931.0 patient-years; mean follow up 3.1 +/- 2.2 years).

RESULTS

There were 19 late deaths, with seven valve-related. Twelve patients suffered an embolic complication (transient cerebral attack in four, peripheral in six and induction of a myocardial infarction in two). Of these complications, five occurred within 30 days of surgery and seven beyond the first year. Ten patients were reoperated on, six for primary tissue failure, two for prosthetic endocarditis and two for paraprosthetic leak. Primary failure was due in all cases to leaflet mineralization. No primary tear of the leaflet was reported. Actuarial freedom after 10 years from primary tissue failure was 83.9 +/- 7.4% and from major embolic events 97.6 +/- 1.0%. Freedom from valve-related mortality at 10 years was 92.1 +/- 4.9%.

CONCLUSIONS

These results indicate that, over a period of up to 10 years, the Pericarbon pericardial bioprosthesis compares favorably with other replacement valves.

Takayasu's arteritis diagnosed at the early systemic phase: diagnosis with noninvasive investigation despite normal findings on angiography

We describe a case of Takayasu's arteritis discovered at the early systemic phase. Ultrasonography and computed tomography show thickening of the walls of the superior mesentery and common carotid arteries despite normal findings on angiography. Diagnosis was confirmed by arterial biopsy. We emphasize the importance of noninvasive vascular investigation to support the diagnosis of Takayasu's arteritis.

[Long-term outcome of a false lumen after surgical correction of type A acute aortic dissection]

The long-term outcome (64.3 +/- 45 months) of 44 patients operated for acute dissection of at least the ascending aorta was assessed by regular clinical examination and annual CT scan. The diameter of the aorta at different levels was measured at each CT scan for all patients. Initially, 7 patients (16%) had acute dissection limited to the ascending aorta; none had a false lumen after surgery. No signs of aneurysmal dilatation were observed during follow-up of these patients. In the 37 other cases (84%) dissection of the aorta extended beyond the innominate artery; the false lumen remained patent distal to the prosthetic tube replacing the ascending aorta in 34 patients (92%). The false lumen was partially thrombosed in 8% of patients, leading to distal emboli in 1 patient. Moderate increases (less than 15 mm) in diameter of the false lumen were observed in 32% of patients; more severe dilatation (over 20 mm) was observed in 12% of patients. The management of dilatation of the false lumen is not standard; it depends mainly on the rate of progression and the clinical consequences. It is hoped that extension of the initial repair to the aortic arch, when the intimal tear is situated in this zone, will reduce the short and long-term progression of the false lumen.

[Mobile thrombi of the right heart in pulmonary embolism]

Systematic transthoracic echocardiography in all cases of pulmonary embolism may demonstrate right heart thrombi. The results of this monocentric series of 28 consecutive cases observed between 1987 and 1996 were analysed. Twenty-four patients were in NYHA Class IV: thirteen were in cardiogenic shock. Echocardiographic signs of acute cor pulmonale were usually observed: 96.3% of patients had right ventricular dilatation, 85.2% paradoxical interventricular septal motion, 88.9% pulmonary hypertension. The thrombus was typical serpentine (27/28 cases) arising from the lower limb veins. Passage into the left heart chambers through a patent foramen ovale was observed in 3 cases. Pulmonary embolism was confirmed in all cases. This is an extreme therapeutic emergency and 13 patients (46.4%) died despite treatment: surgery (7/16), thrombolysis (2/5), heparin (3/4) or interventional radiology (1/3). After the acute phase, the prognosis was generally good, as demonstrated by the 100% survival rate at 28.6 +/- 25 months. This study confirms the gravity of mobile right heart thrombi in pulmonary embolism. The diagnosis is echocardiographic. No significant difference in mortality was observed between the different therapeutic approaches used in this series. The echocardiographic finding of these thrombi is a traditional indication for emergency surgical embolectomy. Thrombolysis is rapid and readily available and seems to provide promising results alone or before surgery. In patients with contraindications to thrombolysis, interventional radiology or simple heparin therapy may be proposed.

Successful treatment of primary pneumococcal multilocular mycotic aneurysms

We report the case of a patient with five primary pneumococcal multilocular mycotic aneurysms located in the left femoral artery, the descending thoracic aorta and the right internal iliac artery. A successful treatment combining three different procedures was performed, including the use of two cryopreserved thoracic homografts. At a 54-month follow-up, the patient is alive and leads a normal life. Regular evaluation including computed tomographic scans of the thorax and abdomen showed no recurrence of infectious aneurysmal process. Moreover, this latter examination confirmed no dilatation nor significant calcifications of the thoracic arterial allograft, though chest roentgenogram showed discrete calcifications along the borders at the 50th month.

[Prognostic factors after sustained ventricular fibrillation or tachycardia. A multivariate study apropos of 160 cases]

The authors analysed survival of 160 patients (121 men and 31 women; average age 57.2 +/- 12.5 years; follow-up 29 +/- 20 months) treated for malignant ventricular arrhythmias (sustained ventricular tachycardia, ventricular fibrillation, syncope with inducible ventricular tachycardia). The therapeutic evaluation was frequently invasive (145 patients underwent at least programmed ventricular stimulation, 108 patients underwent full endocavitary electrophysiological studies) and non-pharmacological therapy was widely used (defibrillator n = 44; antiarrhythmic surgery n = 28; ablative procedures n = 19; transplantation n = 7). The following underlying pathologies were observed: ischaemic heart disease n = 120; non-ischaemic left heart disease n = 19; right heart cardiac disease n = 4; and apparently normal hearts n = 17). The average ejection fraction was 40.5 +/- 15.5% and 29 patients were in the NYHA functional classes III or IV. Fifty-five patients had life-threatening arrhythmias whilst receiving amiodarone. At 2 years, the actuarial sudden death rate was 5.9 +/- 2.1% and the actuarial total cardiac mortality rate was 13.1 +/- 2.9%. Univariate analysis showed age, the presence of underlying cardiac disease, the presence of dilated cardiomyopathy, the absence of an invasive approach, the need for basal pacing in electrical cardioversion, the absence of betablocker therapy, a decreased left ventricular ejection fraction and a high NYHA functional class, to be predictive of sudden death. In multivariate analysis, age, the NYHA class for total cardiac mortality and the NYHA class for sudden death, were the only independent predictive factors. The authors conclude that in the era of invasive methods of evaluation and widespread use of non-pharmacological therapeutic methods, the symptomatology of cardiac failure assessed by the NYHA classification remains the most powerful independent prognostic factor after an episode of malignant ventricular arrhythmia.

[Value of mapping in surgical treatment of ventricular tachycardia]

Surgery may be proposed for patients with a localised aneurysm or akinesia for treatment of monomorphic ventricular tachycardia resistant to antiarrhythmic therapy after myocardial infarction. The multiplicity of tachycardia forms in the same patient, the variability of their mechanism which is not necessarily limited to the subendocardia layers, require mapping to guide the surgeon in the destruction of the anatomical substrates. In a series of 57 ventricular tachycardias recorded in 17 patients with myocardial infarction the authors demonstrated that a system of computerised mapping of the epicardial and endocardial regions optimised the results of this form of surgery. Mapping localised, sometimes at a distance from the scar, classical subendocardial reentry, implicated on occasion the mitral papillary muscle in the mechanism or a tachycardia in cases of inferior or lateral infarction and localised the reentry in the epicardium of the lower layers of the septum. The identification of these "atypical" mechanisms significantly improves the number of patients without inducible arrhythmias after surgery (from 50 to 87% in the authors' experience), without changing the operative mortality. The only really curative approach because of the limitations of catheter ablation, this surgery is a complementary method to implantable defibrillators in the management of post-infarction ventricular tachycardia.

Relationship between CMV and graft rejection after heart transplantation

This study, which included 153 heart transplant patients, was designed to determine whether the cytomegalovirus (CMV) status of both donor and recipient may influence graft rejection. The follow-up was 1 year and they all received the same triple-drug immunosuppressive regimen with induction (antilymphocyte serum). There was no difference in the total rejection rate, but an increase in repeated rejection rate was shown in transplant recipients with hearts from CMV seropositive donors (P < 0.05). These data strongly suggest the impact of CMV in enhancement but not in induction of rejection. To prevent iterative rejection in the CMV seropositive donor group, antiviral therapy could be proposed during enhancement of antirejection therapy.

[Automatic implantable defibrillator and antiarrhythmic surgery in ischemic cardiopathies. Apropos of 53 cases]

The automatic implantable defibrillator (AID) and antiarrhythmic surgery are the two therapeutic options after failure of catheter ablation and/or antiarrhythmic therapy for sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) in patients with coronary artery disease. The authors undertook retrospective study of the characteristics of two groups of patients treated between November 31st 1987 et December 31st 1993 either by AID (28 men and 4 women with an average age of: 56.1 +/- 11.2 years) or by surgery (19 men and 2 women with an average age of: 60.6 +/- 6.8 years). The "surgical" patients differed from "defibrillator" patients in the fewer number of cardiac arrests, a higher proportion of sustained monomorphic VT, better tolerated sustained monomorphic VT (rarely syncopal), fewer early post-infarction arrythmias (< or = 8 weeks), more anterior wall infarction and a higher proportion of aneuvrysms. The perioperative mortality was 6.2% in the "defibrillator" group and nil in the "surgical" group (p = NS). At 2 years, the sudden death rate in the "defibrillator" and "surgical" groups was 7.5% and 0% respectively and total cardiac mortality was 17% and 20% respectively (p = NS). The authors conclude that perioperative mortality and the sudden death rate at 2 years are relatively low in the two groups. However, the total cardiac mortality remains high, largely related to perioperative death and secondary cardiac failure. Nevertheless, compared with defibrillator patients and with identical average ejection fractions, there was no extra mortality due to cardiac failure after antiarrhythmic surgery.

[Automatic implantable defibrillators. Clinical experience apropos of 45 patients]

The aim of this study was to analyse the efficacy and survival after implantation of an automatic cardioverter-defibrillator.. Forty-five patients including 37 men were followed up for 0 to 51 months. The indications were ventricular fibrillation with no curable cause (n = 27) and sustained resistant or poorly tolerated ventricular tachycardia (n = 17) when programmed ventricular pacing with antiarrhythmic therapy was not applicable or gave poor results. One patient was implanted with this device for torsades de pointes. The underlying cardiac disease was ischaemic in 34 cases, non-ischaemic in 8 cases, and 3 patients had no apparent cardiac disease. Twenty patients were implanted with an epicardial system (group I) and 25 patients with endocardial system (group II). In group II, there was one complete failure of implantation requiring the use of an epicardial system and 2 partial failures requiring an additional epicardial patch electrode. The perioperative mortality was 2/45 (4.4%), both cases being due to permanent arrhythmias. In 5 patients, the minimal effective energy of defibrillation was over 25 Joules at implantation, without any untoward consequences on the clinical outcome. Ten non-fatal complications were observed including two major problems (haemopericardium); there were two cases of late increase of the minimal effective energy of defibrillation requiring the addition of a subcutaneous patch. Twenty-four patient (53%) received at least one appropriate therapy; 14 patients (36%) had at least one inappropriate shock during follow-up. During follow-up, 7 patients died, 6 of a cardiac cause and 3 of an arrhythmic problem.(ABSTRACT TRUNCATED AT 250 WORDS)

[Follow-up study, using dynamic transcutaneous oximetry in 17 patients with stage II Leriche and Fontaine occlusive arterial disease of the lower limbs]

We evaluated the value of dynamic transcutaneous oxygen pressure measurement (TcPO2) in 17 patients with stage II occlusive arterial disease of the lower limbs treated with exercise only. We studied 17 patients (15 men, two women) with an average age of 63 years (range 39-80 years). Claudication perimeter and dynamic TcPO2 were evaluated before and after 6 month walking exercise and tabac stopping. Four different sites of TcPO2 were studied: precordium (reference probe), thigh, calf and foot in the dorsal recumbent position after 30 minutes rest, during a standardised exercise stress test at 50 watts and during the recovery phase. The results were expressed as ratio of tissue oxygenation (RTO): thigh, calf or foot TcPO2/precordial TcPO2 x 100 in order to take into account the patients cardiorespiratory status and adaptation to exercise. Claudication perimeter was 255 m +/- 221 before 6 months exercise and 835 m +/- 539 after (P < 0.01). The duration of significative ischemia was significantly reduced after 6 months exercise (P = 0.02 calf, P < 0.01 foot). Dynamic transcutaneous oxymetry would therefore seem to be a useful method of assessing stage II occlusive peripheral arterial disease and the topography of tissue hypoxia. It could be valuable in orientating treatment and the first method to provide and objective evaluation of the efficacy of medical or surgical treatment.

[Surgical treatment of ventricular tachycardia]

Refractory ventricular tachycardia, resistant to antiarrhythmic drug therapy either because of inefficacy unwanted secondary effects or failure to comply with treatment, is not rare in the chronic phase of myocardial infarction. These considerations reinforce the value of curative therapeutic options, especially those related to antiarrhythmic surgery in these patients. Surgery is usually reserved for those with a ventricular aneurysm where the exclusion of arrhythmogenic zones may be performed with the scalpel, a cryoprobe, laser ... Procedures guided by peroperative endo end epicardial mapping, if possible simultaneous with computerised assistance, are more effective than procedures relying only on visual guiding. The clinical success rate is about 90% and the operative mortality tends to decrease (5 to 6%) with successive improvements to surgical technique. These satisfactory results show the reliability of this therapeutic approach applied to patients exposed to malignant arrhythmias.

[Double heart valve replacement disclosing antiphospholipid syndrome]

In patients with systemic lupus erythematosus (SLE) heart valve lesions are usually discovered at echocardiography; their haemodynamic repercussions are uncommon, and valve replacement is exceptional. We report the case of a woman who had undergone aortic and mitral valve replacement before antiphospholipid antibodies were found associated with 4 ARA criteria of SLE. Histopathological examination confirmed the diagnosis of Libman-Sachs specific endocarditis. The presence of antiphospholipid antibodies leads to a discussion of their role in the physiopathology of the heart valve lesions and vascular accidents that occurred in this patient. The overlap observed between the diagnostic criteria of SLE and those of primary antiphospholipid syndrome is discussed. Heart valve lesions may be one of the modes of access to the antiphospholipid syndrome.

Bipolar atrial triggered pacing to restore normal chronotropic responsiveness in an orthotopic cardiac transplant patient

A not uncommon arrhythmia in cardiac orthotopic transplantation patients is sinus node dysfunction with chronotropic incompetence. This is a result of the surgical procedure that denervates the donor heart while the native sinus node may be normal but isolated in the remnant of the recipient atrial wall that serves as the anastomotic site. We were able to restore "normal sinus node function" in a heart transplant patient utilizing a bipolar single chamber pacemaker programmed to the triggered mode. A single unipolar active fixation lead was positioned in each atria. Both leads were connected to a bipolar AAT pulse generator utilizing a Y adaptator. The native atrium with its innervated intact sinus node effectively drove the donor atrium and thus the heart.

[Circumferential laser thermo-exclusion of post-infarction ventricular tachycardia. Apropos of 11 cases]

Circumferential laser thermoexclusion was assessed in the treatment of postinfarction ventricular tachycardia resistant to drug therapy in 11 patients between December 1986 and April 1989. There were 10 men and 1 woman with an average age of 63.7 +/- 5.6 years whose ventricular tachycardia occurred 10.7 +/- 7.5 years after infarction. All had left ventricular aneurysm or an akinetic plaque. Circumferential thermoexclusion was carried out by Mesnildrey's method, systematically associated with resection of the aneurysm or, when this was not feasible, with coronary revascularisation. Programmed ventricular stimulation was performed before and after surgery in 8 patients. Sustained ventricular tachycardia remained inducible in 4 patients after surgery but the prescription of antiarrhythmic drugs in 2 of these cases resulted in tachycardia becoming non-inducible. The increase in the left ventricular ejection fraction after surgery was not statistically significant (36.9 +/- 9.4% to 44.4 +/- 12.8%). After an average follow-up of 16.7 +/- 10.6 months, there were 2 cardiac deaths not related to arrhythmias (18%), 1 early at the 20th postoperative day and 1 late, 10 months after surgery. There were 2 recurrences of tachycardia (18%) controlled by antiarrhythmic therapy. Late ventricular potentials were recorded in 9 out of the 11 patients before surgery but in only 3 of these cases (33%) after surgery. Circumferential laser thermoexclusion guided visually in the border zone of the infarct scar would seem to be a simple, safe, rapid and therefore attractive, surgical antiarrhythmic technique, the efficacy of which should be evaluated by programmed ventricular stimulation. This should be undertaken on a large scale in order to define the indications and results of this method.

[Prognostic value and development of late potentials after aortocoronary bypass. A prospective study of 100 patients]

Ventricular late potentials are post-infarction markers of the risk of ventricular tachycardia and sudden death. In order to assess their prognostic value and evolution after coronary bypass surgery, 100 patients underwent signal-averaged electrocardiographic recordings 24 hours before and 9 days after surgery, and were then prospectively followed up for 40 +/- 8 months. Patients who displayed late ventricular potentials underwent an additional recording at 5 months with 24 hour Holter monitoring. The average age of the patients was 57.0 +/- 8.4 years; 55 had previous myocardial infarction; 32 had triple vessel disease; the mean left ventricular ejection fraction was 59.7 +/- 12.4%. Ventricular late potentials were recorded in 17 patients before surgery and their left ventricular ejection fraction was significantly lower (51.4 +/- 11.5% vs 61.4 +/- 11.9%: p less than 0.05). There was one operative death in a patient with late ventricular potentials. After surgery, late ventricular potentials were only recorded in 6 patients: at the 9th postoperative day in 3 cases and at the 5th postoperative day in 3 cases. Ventricular late potentials appeared postoperatively in 5 patients, 4 of whom had suffered perioperative myocardial infarction. The recordings became normal at the 5th month in 2 of these 5 patients. Holter monitoring at the 5th month compared with a control group, showed a significant correlation between left ventricular potentials and frequent repetitive or polymorphic ventricular extrasystoles. The 40 month survival rate was excellent: 2 patients were lost to follow-up; there were 3 cardiac deaths, one of which was sudden and 4 non-cardiac deaths. All patients with late ventricular potentials were still alive. These results show that late ventricular potentials persist after coronary bypass surgery in 2/3 of patients; their prognostic significance is not obvious. The low incidence of postoperative sudden death could be attributed to the favourable overall effects of revascularisation rather than on the arrhythmogenic substrate.

End-to-side aortoprosthetic anastomoses: long-term computed tomography assessment

Fifty-two asymptomatic patients underwent routine computed tomographic evaluation of aortobifemoral bypass grafts implanted end-to-side on the aorta five to 10 years after operation. Anteroposterior diameters were measured at the level of the stem and the limbs of the graft, the aortoprosthetic anastomosis, and the infraanastomotic aorta. The stems of the prostheses were found to be dilated between 30 and 110% (mean 58%) of initial values. The limbs of the graft were dilated between 15 and 150% of initial values, the mean being 52%. The anteroposterior diameter of the aortoprosthetic anastomosis measured between 27 and 48 mm with a mean of 32 mm. Eight patients (15%) had an anastomotic false aneurysm. The aorta distal to the prosthetic anastomosis was completely occluded in 48 cases (92%). A mural thrombus was encountered at the level of the aortoprosthetic anastomosis in 21 (40%) patients. These findings raise questions as to the possible role of side-to-end aortoprosthetic anastomoses in the genesis of anastomotic dilatations, false aneurysms, intraprosthetic thrombosis, and thrombosis of the branches of aortofemoral bifurcation prosthetic grafts.

[Value of transcutaneous staged dynamic oximetry of stage II arteritis of the leg]

The clinical and prognostic value of transcutaneous oxygen pressure measurements at rest has been established in Leriche Stage III and IV occlusive peripheral arterial disease but is controversial in Stage II because there is an overlap of transcutaneous pO2 (Tc pO2) values with those of normal subjects. The authors report the results of Tc pO2 measurements during exercise testing in a group of patients with Stage II occlusive arterial disease of the lower limbs. Seventy-eight patients with an average age of 53 years (range 40 to 65 years) whose claudication perimeter and site of pain had been carefully assessed and who had also recently undergone Doppler arterial examination and arteriography and 35 control subjects with an average age of 54 years (range 45 to 70 years) were studied. The Tc pO2 was continuously measured with a multimodular Kontron Supermon at 4 different sites simultaneously: precordium (reference probe), thigh, calf and foot in the dorsal recumbent position after 30 minutes rest, during a standardised exercise stress test at 50 watts and during the recovery phase. The results were expressed as ratio of tissue oxygenation (RTO): thigh, calf or foot Tc pO2/precordial Tc pO2 X 100 in order to take into account the patients cardiorespiratory status and adaptation to exercise. The RTO in normal subjects remained at the upper limits of the resting value throughout exercise and then returned slowly to basal values during the recovery phase.(ABSTRACT TRUNCATED AT 250 WORDS)

[Compression of the right pulmonary artery by chronic aortic dissection]

The authors report the case of a 56-year old woman who had presented with clinical symptoms resembling those of pulmonary embolism and due to chronic dissection of the first aortic segment compressing the right branch of the pulmonary artery. Eighteen months after the acute episode, the diagnosis was suspected at echocardiography, but the other paraclinical examinations performed (scintigraphy of the lung, angiography, computerized tomography) failed to display the aortic dissection, although they enabled the diagnosis to be approached and the physiopathology to be determined. At surgery, a type II dissection was discovered, the compression was relieved and the pulmonary artery was recanalized. The post-operative period was uneventful, with return to normal of the scintigraphic and CT images. This case is exceptional in that it is extremely rare (this is the 6 th case reported) and the lesion was well tolerated, probably due to the presence of a systemic-pulmonary circulation.

Acute traumatic rupture of the thoracic aorta: place of delayed surgical repair

Acute traumatic rupture of the thoracic aorta (ATRTA) is considered as an emergency which requires immediate surgery. However surgical mortality is high with an average of 20% in the literature. Twenty seven patients were observed from 1973 to 1986. Three patients were not operated upon (Group I), twenty patients had immediate surgery (Group II) with 60% mortality, four patients underwent delayed surgery (Group III) with 25% mortality. Analysis of cause of death show that associated lesions were present in 72% of pts who did not survive and in only 37% among survivors. Associated lesions may be lethal initially (e.g. brain trauma) or they may be aggravated by the thoracic procedure. Complications from associated lesions may also compromise the outcome. It is well known that the majority of deaths from ATRTA occur within 24 hours. Immediate repair of the aortic lesion should be the rule when aortic rupture is isolated or associated with moderate injuries. It may be however that in some cases with severe and multiple associated lesions who survive the initial aortic injury, delayed repair of ATRTA could be considered.

Persistent sciatic artery: case report, anatomy, and review of the literature

We report the case of a 64-year-old woman with an aneurysm of a left persistent sciatic artery presenting with arterial insufficiency from distal embolization. Treatment was exclusion of the aneurysm and femoropopliteal bypass after distal embolectomy with a Fogarty balloon catheter. We reviewed 71 cases in the literature to define characteristics of this anomaly which has many synonyms: including persistent sciatic artery, persistent axial artery, ischiopopliteal trunk. The persistence of the sciatic portion of the embryonic dorsal axial artery and failure of development of anastomoses with the ventral femoral network results in the anomaly. The persistent sciatic artery was "complete" in 75% of cases. In this configuration, it arises from the internal iliac artery, leaves the pelvic cavity through the lower part of the greater sciatic foramen caudad to the pyriformis muscle, reaches the posterior compartment of the thigh and continues as the popliteal artery. In 35% of cases, the artery is aneurysmal with a pulsatile mass in the buttock or a complication of the aneurysm. Arteriography required for diagnosis of the mass leads to discovery of the anomaly in many cases. The treatment of choice is exclusion followed by femoropopliteal vein bypass.

Treatment of lymphorrhea with exposed or infected vascular prosthetic grafts in the groin using sartorius myoplasty

Thirteen myoplasties using the sartorius muscle were performed on 12 patients from 1980 to 1985 for "healing problems" in the groin with subjacent synthetic grafts. Persistant aseptic lymphorrhea was the indication for 4 patients. In 3 other cases, bacterial cultures from the wound were positive. In 2 other patients there was clinical evidence of sepsis with purulent discharge from the wound and an exposed graft. In 3 cases myoplasty was used as a preventive measure after reoperation on patients in poor general condition. Follow-up extends from 3 to 54 months. There was only one recurrence observed at 19 months which was successfully treated by segmental resection of the infected graft and insertion of a new prosthesis through the obturator canal. No recurrence was observed among the other patients as judged by clinical observation and biological tests for inflammation, echotomography, CT scan and indium scintigraphy. The treatment of choice for an infected prosthesis should be removal of the graft and extra-anatomic bypass in the majority of cases. However in some situations, excision of the wound and myoplasty using the sartorius muscle may be of some value and needs further evaluation.

Chronic traumatic aneurysms of the descending thoracic aorta (19 cases)

From 1973 through 1983, 19 cases of chronic traumatic aneurysms (CTA) were observed. Initial trauma was well documented in every case. Patients mean age at time of trauma was 22; mean age at time of surgery was 34. Sixty per cent of patients had no apparent thoracic injury at time of trauma. Ninety-five per cent had associated injuries. Ten/nineteen were asymptomatic. Eighteen were operated on. Rupture was complete in 11, partial in 7. One of the partial ruptures was a simple scar on the aorta. Eighteen were located at the site of the aortic isthmus, one was at level T8-T9. Seventeen had a prosthetic dacron graft sutured from inside the aneurysm. The case where a simple scar was found had a dacron wrapping. Spinal cord protection was used in all cases except in one who was already paraplegic preoperatively. Various shunts were used in 12 cases; 1 patient in the by-pass group had paraplegia. CTA is not a benign disease and all cases, even asymptomatic, should be operated on with a very low risk of mortality (0/18). Occurrence of paraplegia still remains a possible complication although the risk of spinal cord ischemia seems lower than in arteriosclerotic dissecting aneurysms. We favour the "old" technique of temporary dacron shunt graft in CTA for simplicity and easy assessment of function ot the shunt.