[Contribution of closed mitral commissurotomy in the surgery of rheumatic mitral stenosis]

The objective of this work was to study the indications, techniques and results of closed heart mitral commissurotomy in patients with rheumatic mitral stenosis in Morocco.

METHODS

All patients who had undergone closed heart mitral commissurotomy for rheumatic mitral stenosis, operated between 1999 and 2008 were collected in this study. Mitral stenosis was diagnosed and evaluated using Doppler echocardiography. Patients with commissural calcification, severe mitral regurgitation, and surgical tricuspid or aortic valvular disease were excluded from this study.

RESULTS

Six hundred and twenty-five patients have been collected. 62.2% were young with an age between 18 and 35 years and 491 (78.8%) were female. Seventy-nine percent of patients had stage III or IV NYHA and were in sinus regular rhythm. The closed heart mitral commissurotomy was performed for all patients through a left thoracotomy using either digital or dual dilatation. The mitral area was significantly increased postoperatively to 2.11 ± 0.32 with 100% opening of the anterior commissure, while the posterior commissure was opened only for 93.7% of patients. There were nine perioperative deaths (4.9%) and all patients who died had severe mitral stenosis (<0.8 cm(2)) with an elevated systolic pulmonary artery pressure (>60 mmHg).

CONCLUSION

The closed heart mitral commissurotomy provides excellent results in young patients with rheumatic mitral stenosis.

[Cardiac myxomas (a series of 23 cases)]

OBJECTIVE

This study aims to report clinical particularities, treatment concepts, potential evolution related to cardiac myxoma to the light of our initial experience and reviewed of the literature.

METHODS AND RESULTS

Between May 1980 and January 2005: 23 patients were operated in our service for cardiac myxoma. There were 21 left-atrium myxomas and two in right atrium. The mean age was 42.73 years (range 21 to 60 years). The sex-ratio was 2.28 (16 women and seven men). In four cases, the myxomas were chance findings at echocardiography but the 19 symptomatic patients had different symptoms: dyspnea, palpitations, left ventricular failure, positional syncope, systemic embolism, chest pain or right ventricular failure. The diagnostic of myxoma was realized in all cases by echocardiography. The resection of the tumor and a wide part of the inter-atrial septum were performed in all case. The post-operative course was usually uncomplicated: only one patient had double recurrence and died of mediastinitis after the third operation.

CONCLUSION

The myxoma is considered to be rare, and remains classical emergency with low operative risk, however the risk of recurrence imposes a long-term follow-up by echocardiography.

Right atrial rupture following a hoof kick to the chest wall

We report a case of right atrial rupture due to blunt trauma by a hoof kick to the anterior chest wall. We describe our successful management of this case. We suggest that a diagnosis of cardiac chamber rupture should be considered in all cases of blunt thoracic trauma.

[Survey of anesthesia practice in Morocco]

OBJECTIVE

To estimate qualitatively and quantitatively the anaesthetic activity in Morocco to identify of the priorities and the norm to recommend.

STUDY DESIGN

The investigation was realised from July 1999 to December 1999. It lasted seven days from Tuesday 8 PM to the following Tuesday 8 PM. A questionnaire was addressed to each hospital. One responsible has been chosen for each city. Data has been processed using the programming languages Microsoft Visual Basic.

SETTING

All Moroccan's hospitals practicing anaesthesia: university hospitals (UH), public hospitals (PH), and private sector (PS).

PATIENTS

All anaesthetic procedures realised by an anaesthetists; anaesthesia in medical office or dental surgery was excluded.

RESULTS

An inventory of 2,630 anaesthesia was made. Anaesthesia distribution according to the type of hospitals was the same; PH = 35.7%, UH = 34.3% and PS = 29.96%. The preanaesthetic consultation was achieved in 47% of cases. Premedication was done in 28.5% of cases. General anaesthesia represented 3/4 of total anaesthesia. Thiopental was the drug the more frequently used. Gallamine and pethidine were still used in PH. Locoregional anaesthesia was realised in only 15% of cases. Electrocardioscopic surveillance not constant (65%), capnography almost absent in PH, pulse oximetry used in UH and PS. Ambulatory anaesthesia was used in 20% and emergency surgery in 30% of cases.

CONCLUSION

Questioning about the Moroccan practice of anaesthesia is raised by this survey mostly because of drugs and monitoring use.

[Acute meningomyelitis and polyradiculoneuritis disclosing systemic lupus erythematosus]

A 25-year-old male presented purulent meningitis associated with transverse myelitis. Spinal T2-weighted MRI showed a large spinal cord with an intramedullary high signal. Infection resolved with antibiotic therapy but spastic paraplegia persisted. Four months later, he developed a Guillain-Barré syndrome with clinical and biological signs of systemic lupus erythematosus. Final outcome was fatal despite corticosteroid and immunoglobulin treatment.

[Ruptures of the posterior wall of the left ventricle after mitral valve replacement: surgical repair and prevention]

We report two cases of type III rupture of the left ventricle posterior wall, situated midway between the mitral annulus and the posterior papillary muscle and occurring in immediate continuations of a mitral valvular replacement. The first case has occurred at the moment of the canulas removal in a 28 years old patient operated for mitral stenosis. The tear was repaired with horizontal mattress sutures through felt strips on the external surface of the heart. The immediate post operative course was marked by bleeding recurrence and cardiac failure which has led to death. In the second case, a 68 years old man was operated for degenerative mitral insufficiency. The rupture has occurred just before closing the chest. The repair was realized successfully by using an intra-ventricular patch. The chordae tendinae removal constitutes a factor predisposing to the left ventricle posterior wall rupture. The repair has to use an intra-ventricular patch. The prevention is based on the preservation of the continuity between the mitral annulus and papillary muscles by preserving the sub-valvular apparatus or by using synthetic chordae.

[Multiple pulmonary hydatidosis with floating balloon appearance and cardiac localization]

Multiple hydatidosis in a thoracic localization is unusual and a cardiac localization very exceptional. We report a case of multiple hydatidosis greatly improved by medical treatment with albendazole which was associated with a cardiac cyst successfully treated by surgical resection. No recurrence has been observed at 4 year follow-p. We point out therapeutic management options in these unusual forms of the disease.

[Traumatic left ventricle-right atrial communication. A case report]

The authors report the case of an acquired left ventricle-right atrial communication after open chest trauma. The initial clinical presentation was a haemothorax and haemopericardium responding well to emergency surgical drainage. Secondarily, a systolic murmur suggesting a ventricular septal defect and signs of right heart failure were observed. Colour Doppler echocardiography led to the diagnosis of a left ventricle-right atrial communication associated with tricuspid regurgitation with dilatation of the right heart chambers and pulmonary hypertension. At surgery, a defect in the membranous interventricular septum was confirmed with rupture of the septal tricuspid leaflet causing tricuspid regurgitation. The surgeon closed the defect with a patch and performed a De Vega tricuspid valvuloplasty. The postoperative outcome was uneventful.

[Multiple myxoma of the right ventricle with infiltration of the pulmonary infundibulum and arteries]

The authors report a case of multiple myxoma of the right ventricle treated surgically. One of the myxomas infiltrated the right ventricular ourflow tract, the main pulmonary artery and its branches. This case underlines the difficulty of radical resection of infiltrating cardiac myxomas.

[Double recurrence of myxoma of the left atrium. Apropos of a case]

Multiple recurrences of cardiac myxomas are rare and high-light the problem of re-operation. We report a case of double recurrence of left atrial myxoma and analyse the causes of recurrence. In our case, the first myxoma was inserted in the left inter-atrial septum, and the first recurrent tumor was inserted near the pulmonary vein, forming adhesion with the inter-atrial septum. The second recurrent tumor was inserted in the inter-atrial septum. The first operation resected the tumor, including part of the inter-atrial septum, and the sides of the septum were sutured. The two following operations used a patch for the septoplasty. This case is sporadic and not included in the high risk myxoma recurrence syndrome. Incomplete tumor resection is incriminated in one third of recurrences but seems unlikely in our case.

[A case of an adult triatrial heart, associated with partial abnormal venous return from the left lung]

The authors underline the value of echocardiography in the diagnosis and postoperative management of a case of cor triatrium. The patient was a 22 year old male who presented with dyspnoea of effort (stage III of the NYHA classification) and clinical signs of an infundibulo-pulmonary syndrome with tricuspid regurgitation. Chest X-ray revealed cardiomegaly (CTI = 61%) and filling-in of the aorto-pulmonary window. The electrocardiogram showed left atrial and right ventricular hypertrophy. The echocardiogram, the key to diagnosis, showed an abnormal echogenic structure within the left atrium. Cardiac catheterisation demonstrated pulmonary hypertension and a difference of pressure between the two lungs. The membrane dividing the left atrium and partial anomalous pulmonary venous drainage from the left lung into the superior vena cava were visualised on late stage pulmonary angiography. Surgical excision of the membrane in the left atrium and ligation of the anomalous venous drainage provided a radical cure to all these malformations.