[1-benzylpiperazine (BZP) and 1-(3-trifluorométhylphényl)pipérazine (TFMPP): emergence of two agents which lead to misuse]

1-benzylpiperazine (BZP) and 1-(3-trifluoromethylphenyl)piperazine (TFMPP) are psychoactive agents which have become available on the illicit drug market in France since 2006. These compounds are employed for their stimulating, enacting, and "recreational" properties. The combination of BZP and TFMPP enables drug users to reproduce the domaminergic and serotoninergic components of amphetamine derivatives. Intoxication can be life threatening for BZP. This compound has been detected, in association with other psychoactive agents with similar action, in several fatal cases. In addition, there is a potential risk of addiction, confirmed in animal models. The toxicity of TFMPP appears to be weaker with no apparent risk of addiction. There is however a risk of serious psychiatric manifestations and serotoninergic syndrome. There are certain national regulations, but to date no international regulations have been developed for BZP and TFMPP. In the European Union, BZP is now being monitored in compliance with the 10 May 2005 decision of the Commision on information sharing, risk evaluation, and control relative to new psychoactive agents.

[Urinary uranium analysis results on Gulf war or Balkans conflict veterans]

During the 1991 Gulf War, the 1995 Bosnia conflict and the 1999 Kosovo conflict, munitions containing depleted uranium (DU) have been employed by the coalition forces. Altough the radioactivity of this metal is about 40-50% lower than that of natural uranium, and that health concerns are based primarily on the metal's kidney toxicity, DU has been quoted among the causes of the different pathologies developped by some soldiers a few time after they went back home. In order to evaluate the potential relation between a DU exposition and some of the pathologies described, more than 200 urine uranium analysises have been done between 1999 and 2003 by the laboratory of the french Army radioprotection service. The method used is the standard method for determining uranium in excretion of nuclear workers: a chemical uranium isotopes separation (including 234, 235+236 and 238) followed by an alpha ray spectrometry. All results were negative and quite all of the detection limits were lower than the ones recommanded by the International Commission on Radiological Protection (10mBq/L per isotope). The summary is that none of the available analysises for uranium excreted in urine suggests that any subjects examined had incorpored DU that could explain pathologies appeared after the conflicts.

[The Williams-Beuren syndrome: reconstruction of the thoracic aorta combining surgery and endovascular treatment]

The Williams-Beuren syndrome is the association of elf-like facies, mental retardation with cardiovascular anomalies, the most common of which is supravalvular aortic stenosis. This lesion may be focal or associated with hypoplasia of the distal aorta. The treatment is surgical and the role of interventional cardiological treatment is poorly defined. The authors report the case of a child with typical Williams-Beuren syndrome. An initial, very localised surgical aortic repair was performed at 3 months of age for a discrete supravalvular aortic stenosis. Two months later, a second operation was required for a new stenosis of the distal anastomosis associated with marked hypoplasia of the aortic arch. The progressive constitution of an isthmic coarctation led to the percutaneous implantation of a stent followed by two balloon dilatations. Only the first two endoluminal procedures successfully reduced the transisthmic pressure gradient. An antihypertensive treatment was given and regular echocardiography allows monitoring of the adaptation of the left ventricle.

Diagnosis of internal radionuclide contamination by mobile laboratories

To support patient management of possible radiation casualties in case of a radiological or a nuclear event, the Defence Radiation Protection Service (SPRA) is able, 24 h a day, to supply intervention means in France and overseas if requested by military authorities or civilian institutions. SPRA has developed mobile laboratories for the diagnosis of internal radionuclide contamination. The mission of this mobile unit is to study health and environment risks linked to radiological hazards for exposed people: workers, soldiers and also civilians. The mobile laboratories are able to be deployed in all types of nuclear or radiological events, and give the results of analysis to physicians and authorities in a short time. The vehicles are fully equipped to detect and to survey exposure to alpha, beta and gamma emitters for the supervision of people exposed to ionising radiation, by whole body counting or analysis of biological samples. Environmental survey by analysis of wipes, soil, water, vegetation or air filters can also be achieved.

[West African tick-borne relapsing fever]

West African tick-borne relapsing fever is an endemic disease due to Borrelia crocidurae. The tick Alectorobius sonrai is the only known vector of this bacterium. Several species of rodents and insectivores may be reservoir for this spirochete. The geographic distribution of Borrelia crocidurae is not well known. The zone where the presence of the vector has been recorded is situated in Sahelian regions, from Mauritania and northern Senegal up to Chad. In Senegal, it has been shown that the persistence of drought is responsible for a considerable spread of tick-borne relapsing fever to the south. Few epidemiological data are available about West African tick-borne relapsing fever. In Senegal, epidemiological investigations indicate that Borrelia crocidurae is a major cause of morbidity (annual incidence rate of 5.1%). The relapsing nature of tick-borne borreliosis depends on Borrelia's antigenic variability. Except relapsing febrile episodes, this illness presents no pathognomonic signs. Borrelia crocidurae relapsing fever is generally benignant but neurologic or ocular complications can occur. The diagnosis of tick-borne relapsing fever is made by demonstrating the presence of Borrelia in peripheral blood in thick smear, by intraperitoneal inoculation of mice or more recently with quantitative buffy coat method (QBC test). The best treatment for relapsing fever is tetracycline or doxycycline. When tetracyclines are contraindicated, the alternative is erythromycin. In neurologic complications, the effective treatment is intravenous penicillin G or ceftriaxone. West African tick-borne relapsing fever must be systematically mentioned in case of fever in a patient returning from the endemic area.

Pericardial reinforcement after partial atrial resection in idiopathic enlargement of the right atrium

A 2-year-old boy in whom idiopathic enlargement of the right atrium was diagnosed in utero by fetal echocardiography underwent surgical intervention because of progression of right atrial dilatation. During operation, the lateral right atrial wall was externally reinforced after partial resection by approximating and fixing the neighboring autologous pericardium around the external circumference of the right atrium. This technique is a useful means of preventing recurrence of dilatation in histologically abnormal right atrial tissue that predisposes the patient to possible reintervention.

Transcatheter closure of apical ventricular muscular septal defect combined with arterial switch operation in a newborn infant

This report describes a case of transposition of the great arteries and apical muscular ventricular septal defect in a newborn infant successfully treated by transcatheter closure of the septal defect with the Amplatzer duct occluder device followed by an arterial-switch operation within the first 2 weeks of life. Cathet. Cardiovasc. Intervent. 49:173-176, 2000.

Cardiac surgery by transxiphoid approach without sternotomy

OBJECTIVE

In a attempt to avoid the potential drawbacks associated with sternotomy coupled with a desire for a smaller scar led us to investigate the transxiphoid approach without sternotomy. We present our preliminary experience and a comparison between the sternal and thoracic approaches.

METHODS

From June 1996, at the Institut Cardiovasculaire Paris Sud, Massy, France (ICPS) and the Heart Institute, Sao Paulo, Brazil (HI) the transxiphoid approach was adopted for the correction of selected congenital cardiac defects. The xiphoid was resected through a 6 cm long vertical skin incision. With a special retractor the sternum was elevated cephalad and anteriorly. Closure of the defect was performed in the conventional manner. Twenty-six patients; 17 boys and 9 girls were entered into the study from representing 19 atrial septal defects (ASDs), 4 ventricular septal defects (VSDs) and 3 partial atrio ventricular septal defect (AVSDs). In addition at ICPS the transxiphoid approach for correction of ASD was compared to the thoracic and sternal approaches performed in the same period.

RESULTS

Both the aortic cross clamp time as well as the duration of extracorporeal circulation were increased when compared to either standard sternotomy or thoracotomy approaches. There were no differences within the groups when comparing body surface area, amount of chest drainage or length of either ICU or hospital stay. However the patients in the transxiphoid group showed less pain and respiratory discomfort.

CONCLUSION

Our initial experience with the transxiphoid approach without sternotomy confirms that it is a promising technique that can be considered an alternative to conventional sternotomy. The access is adequate for surgical procedures performed through a right atriotomy. The advantages include a better cosmetic scar, less surgical trauma, minimal respiratory discomfort and a potentially lower risk of infection. However cardiopulmonary bypass and cross clamp times are increased. There were no complications, and patient satisfaction was high.

"Classic" repair of congenitally corrected transposition and ventricular septal defect

BACKGROUND

This study examined the results of "classic" repair of congenitally corrected transposition of the great arteries and ventricular septal defect.

METHODS

From 1974 to 1994, 52 patients underwent a classic complete repair of lesions associated with congenitally corrected transposition. They were divided into two groups: ventricular septal defect plus left ventricular outflow tract obstruction (group I, 37 patients) and isolated ventricular septal defect (group II, 15 patients). Tricuspid plasty or replacement was performed primarily in 1 patient of group I (3%) and in 8 patients of group II (53%).

RESULTS

The overall operative mortality was 15% (8/52 patients), and the incidence of postoperative atrioventricular block was 27% (14/52 patients). Eight patients died secondarily, 5 of heart failure. Survival rates were 83% +/- 6% at 1 year and 55% +/- 14% at 10 years for group I and 86% +/- 9% at 1 year and 71% +/- 12% at 10 years for group II (not significant). Redo tricuspid plasty or replacement was performed in 12 patients.

CONCLUSIONS

Results of classic complete repair of lesions associated with congenitally corrected transposition are not satisfactory in our experience because (1) the operative mortality and the incidences of tricuspid valve replacement and atrioventricular block are high and (2) secondary heart failure is frequent. However, a retrospective review of morphologic findings shows that "anatomic" complete repairs would not have been feasible in 6 of our patients.

Percutaneous double balloon valvuloplasty for stenosis of porcine bioprostheses in the tricuspid valve position: a report of 2 cases

The feasibility and results of percutaneous double balloon valvuloplasty were evaluated in 2 patients with stenosis of porcine bioprostheses in the tricuspid valve position. The procedures were performed with a Trefoil 3 x 10 and a 15 mm balloon. Long inflations (4 and 3 minutes) were well tolerated. A significant immediate increase in the valve area, without significant valvular regurgitation, was achieved in both cases, from 0.65 to 1.15 cm2 in case 1 and from 0.9 to 1.65 cm2 in case 2. Both patients required valve replacement during the follow-up, at 14 and 21 months. There was no restenosis, but echocardiography showed right atrial thrombosis in case 1. Progressive restenosis with peripheral edema and increase of the mean doppler gradient occurred in case 2. The procedure is feasible, safe, and well tolerated. It provides significant immediate hemodynamic improvement, but it should be considered as a palliative technique since a normal valve area can not usually be obtained and a restenosis is likely to occur at midterm follow-up.

[Value of early systematic postoperative transesophageal echocardiography in mitral valve replacements. A prospective study of 50 patients]

The aim of this study was to assess the value of routine transoesophageal echocardiography in the early postoperative period after mitral valve replacement. The authors report their experience in 50 consecutive operated patients (43 mechanical and 7 bioprostheses) investigated routinely by this method in the postoperative period in the surgical unit. Abnormal findings were observed in 36% of cases (18 patients): trans-prosthetic leaks (8 cases) and thrombosis (10 cases) in 2 bioprostheses and 8 mechanical prostheses; in 3 cases this led to haemodynamic dysfunction but in 7 cases the thrombus had no influence on the trans-prosthetic pressure gradient. No predisposing factor could be identified (spontaneous contrast, left atrial volume, left ventricular function, poor anticoagulation, blood clotting abnormalities). No abnormality of the mobile components of the prosthesis was observed at radioscopy. The outcome with heparin therapy was favourable with disappearance of the thrombi in 6 cases; the thrombi did not regress in 4 patients on heparin: 2 patients underwent thrombolytic therapy with a complete cure in 1 case and a severe embolic complication in the other; in 2 cases, the thrombus was so big that the patients were reoperated. Systematic early postoperative transoesophageal echocardiography before discharge from the surgical unit would seem to be necessary after early mitral valve replacement: it allows diagnosis of asymptomatic thrombosis which has an important emboligenic potential. The management of these thromboses remains controversial, but the poor natural outcome in cases of large thromboses should lead to referral for early reoperation.

Infundibular septal defect with severe aortic regurgitation: a new surgical approach

Aortic regurgitation associated with prolapse of an aortic cusp and an infundibular septal defect is caused by the lack of anatomical support for the aortic annulus by the conal septum. This fact is taken into consideration in the new surgical approach that we performed in 5 children 3 to 16 years of age with infundibular ventricular septal defect and severe aortic regurgitation. The ventricular septal defect is closed by a patch anchored to another patch through the prolapsed cusp. This second patch is pulled up with the prolapsed cusp and is then fixed in the aortic wall. In all 5 patients, all clinical signs of aortic insufficiency disappeared, and only minimal aortic regurgitation could be demonstrated by color Doppler mapping.

Heart-lung transplantation in situs inversus. A case report in a patient with Kartagener's syndrome

After a long history of recurrent chronic pulmonary infections in a 25-year-old woman with Kartagener's syndrome, a heart-lung transplantation was performed. A modified surgical procedure was needed to perform transplantation because of the presence of a situs inversus, which is usually associated with bronchiectasis and sinusitis in this congenital syndrome. A large single atrium was created with both the right and left recipient atria used to facilitate anastomosis with the donor's right atrium. The patient was discharged after resolution of early ventilatory complications and is in good condition 8 months after transplantation.

[Ventriculo-arterial malpositions with ventricular septal defect. Surgical indications]

Cardiac anomalies with ventriculo-arterial malposition are defined as malformations in which the aortic and/or pulmonary rings are in abnormal relation with the atrioventricular rings. When a high ventricular septal defect is also present, resection of the conal septum enables the reconstitution of normal or close to normal anatomy, without tubal interposition. Experience based upon 188 operations leads us to suggest surgical indications based upon the positions of the aortic and pulmonary rings in relation to the atrioventricular valves. Creation of the left ventricle-aorta channel may require widening of a tight ventricular septal defect, or result in resection or tilting of the conal septum onto which the tricuspid is inserted. Otherwise, left ventricle-aorta passage will be made impossible by the interposition of a straddling mitral or of tricuspid insertions which come to be inserted around the aortic ring. If the pulmonary ring is in a high, normal, position, it will not interfere with fashioning of the left channel. If situated too low, it must be shifted and reimplanted on the right ventricle. Creation of the right ventricle-pulmonary artery channel depends upon the presence or absence of concomitant pulmonary artery hypertension. In the presence of pulmonary artery hypertension, devalvulation and hence pulmonary reimplantation is poorly tolerated and is therefore contraindicated. If the pulmonary ring is in a high position (tricuspid-pulmonary distance of one normal aortic diameter for the child or more), partitioning without pulmonary displacement is the best solution.(ABSTRACT TRUNCATED AT 250 WORDS)

[Results of the surgical treatment of tetralogy of Fallot before 6 months of age. A consecutive series of 62 cases with 49 complete repairs]

From January 1980 to July 1988, 62 infants aged under 6 months with an uncomplicated Tetralogy of Fallot (single ventricular septal defect, normal coronary arteries, no localised pulmonary artery branch stenosis) underwent 64 surgical procedures. The indications for surgery were increasing cyanosis and/or anoxic spells. Fourteen systemic-pulmonary shunts (21.5%), 49 complete repairs (75.4%) and one enlargement of the right ventricular outflow tract and of the main pulmonary artery without closure of the ventricular septal defect, were performed. The results of palliative shunts are preoccupying: cumulative mortality of 36 per cent; high rate of early reoperation for complete repair: 14 per cent. Complete repair was associated with an operative mortality of 14 per cent. Only one child had to be reoperated. There was no late death after complete repair compared with 2 late deaths after shunt. Ultimate results of complete repairs are good. Some risk factors were statistically significantly associated with complete repair: age (2.5 months or less), weight (4,500 g or less), measurements of the pulmonary arteries estimated by the diameter of the right pulmonary artery (5 mm or less). Conversely there was no death in the subgroup of 31 infants aged more than 2.5 months without major pulmonary hypoplasia (diameter of the right pulmonary artery over 3.5 mm). One-stage complete repair give the best short and medium-term surgical results in treatment of uncomplicated Tetralogy of Fallot in infants, irrespective of age and weight providing they have no diminutive pulmonary arteries.(ABSTRACT TRUNCATED AT 250 WORDS)

Single-cannula venovenous bypass for respiratory membrane lung support

Clinical use of a single cannula would make extracorporeal membrane oxygenation simpler and less aggressive. It would probably limit the occurrence of the complications of currently used techniques (double-cannula, venoarterial, or venovenous bypass). In this experimental study an original system is described that is composed of a single cannula, an alternating clamp, and a nonocclusive roller pump, the characteristics of which permit its use as a venous reservoir. To overcome the limitations of the oxygenation in any venovenous bypass, we used the method of "apneic oxygenation" through the natural lungs, which we previously proved efficient in infants and children. The optimal setting of the alternative clamp was first tested in vitro to obtain the maximal flow in the circuit and the minimal amount of recirculation. The single-cannula bypass then was compared with a two-cannula circuit regarding the efficiency of carbon dioxide removal and the hemodynamic consequences. At less than 50% of the maximal speed of the pump, flows were equivalent in both types of circuits. The efficiency of carbon dioxide removal was only slightly decreased by the use of a single cannula (30 +/- 2 ml/min versus 36 +/- 2 ml/min with two cannulas). This could easily be offset by increasing the gas flow/blood flow ratio in the oxygenator. Arterial carbon dioxide tension was maintained at normal levels in both types of circuits. Hemodynamic condition was only slightly affected by the alternative flow of the bypass. This system of single-cannula membrane lung support thus seems to be adequate for clinical use.

[Atresia of the left coronary ostium. Repair in a 2-month-old infant]

A case of atresia of the left coronary ostium revealed by neonatal heart failure is reported. The initial diagnosis was anomalous origin of the left coronary artery from the pulmonary artery. At surgery performed in this 6-week old infant the diagnosis was amended and the malformation was repaired. Soon after the operation the child rapidly developed hypertrophic "myocardiopathy" of the left ventricle. Seven and a half months later, he is asymptomatic and the echocardiographic parameters of left ventricular systolic function are gradually returning to normality. Atresia of the left coronary ostium is an exceptional anomaly which must be considered, together with the other anomalous origins of the left coronary artery, when confronted with a case of severe heart failure caused by coronary ischaemia during the first months of life. The diagnosis rests on opacification of the coronary network during cardiac catheterization. Coronary "revascularization" may be performed either by aortocoronary bypass or by anatomical repair of the malformation.

Mediastinal infection after cardiac operation. A simple closed technique

From March 1984 to March 1987, a simple closed method, previously described for the treatment of osteomyelitis after orthopedic operations, was used to treat deep sternal infection in 11 patients. The basis of this technique is, after meticulous débridement of the wound, to drain all the infected areas with small catheters connected to a bottle inside of which a strong (700 mm Hg) negative pressure is created (Redon drainage device). The method does not require irrigation. The maximum duration of the drainage was 24 days and complete recovery was obtained in all patients without further surgical treatments. The comfort of the patients was optimal.

Aortic coarctation with hypoplastic aortic arch. Results of extended end-to-end aortic arch anastomosis

Between 1980 and 1986, 80 infants (less than or equal to 3 months old) with symptomatic aortic coarctation and associated severe tubular hypoplasia of the transverse aortic arch underwent surgical treatment. Extended end-to-end aortic arch anastomosis was used in an attempt to correct both the isthmic stenosis and the hypoplasia of the transverse arch. After complete excision of the coarctation tissue, a long incision was made in the inferior aspect of the aortic arch, which was then anastomosed to the obliquely trimmed distal aorta. Pure coarctation was present in 17 patients (group I); 24 infants had an additional ventricular septal defect (group II), and 39 patients had associated complex heart disease (group III). The overall early mortality rate was 26% (confidence limits 21% to 32%) (18% in group I, 17% in group II, and 36% in group III). The early risk declined with time and was 18% (confidence limits 12% to 26%) for the last 2 years (seven deaths in 39 patients). Follow-up was 100% for a mean of 19 months. Actuarial survival rate at 3 years was 82% for group I, 78% for group II, and 32% for group III. Recurrent coarctation (gradient greater than or equal to 20 mm Hg) occurred in six operative survivors (10%, confidence limits 6% to 16%) and necessitated reoperation in three. Freedom from recoarctation at 4 years was 88%. Because extended end-to-end aortic arch anastomosis provides adequate correction of the aortic obstruction and entails a low risk of restenosis, it is our procedure of choice in infants with coarctation and severe hypoplasia of the aortic arch.

Acute Budd-Chiari syndrome as first manifestation of adrenocortical carcinoma

We report the case of a young woman in whom investigations for acute Budd-Chiari syndrome disclosed an hormone-secreting but clinically nonfunctioning adrenocortical carcinoma. We supply a very brief review of the literature.

Anatomic repair of anomalies of ventriculo-arterial connection (REV). Results of a new technique in cases associated with pulmonary outflow tract obstruction

From November 1980 to November 1986, 63 patients aged 4 months to 13 years (mean 3.4 years) underwent repair of anomalies of ventriculo-arterial connection with ventricular septal defect and pulmonary outflow tract obstruction, using a technique (REV) first described by us in 1982. The selection of patients was based on preoperative criteria, namely the measurement of the distance between the tricuspid and the semilunar valves. These measurements enabled us to select from patients with an abnormal ventriculo-arterial connection, those in whom the anomaly could be repaired by intra-ventricular partition alone. In the remaining cases, REV was indicated in the presence of pulmonary stenosis. The principles of the technique are: (1) resection of the infundibular septum creating a large, direct and subarterial communication between the left ventricle and the aorta; (2) construction of a straight left ventricle to aorta tunnel by intraventricular partition; (3) direct anastomosis of the pulmonary trunk to the right ventricle. There were 12 hospital deaths (19%). The mean follow-up was 32 months. One patient died suddenly 1 year after repair. Six patients required reoperation. All survivors are in NYHA class I, except for 3 patients who are in class II. No stenosis of the left ventricular outflow tract was found but 5 patients had a significant pressure gradient at the pulmonary outflow tract level. Our present experience suggests that in properly selected patients, REV allows anatomic repair in a wide variety of anomalies of the ventriculo-arterial connection associated with VSD and pulmonary outflow tract obstruction with an acceptable rate of mortality and morbidity.

Anatomic repair of anomalies of ventriculoarterial connection associated with ventricular septal defect. I. Criteria of surgical decision

The feasibility of anatomic repair (defined as the reconstruction of normal ventriculoarterial connection) was investigated in 104 patients who underwent an operation for anomalies of ventriculoarterial connection associated with ventricular septal defect. Three types of anatomic repair were used: intraventricular rerouting, REV (association of intraventricular rerouting with translocation of the pulmonary arterial trunk on the right ventricle), and arterial switch associated with closure of the ventricular septal defect. Intraventricular repair was considered to be the best and simplest method when possible. In the other cases, REV was indicated if pulmonary outflow tract obstruction was present, and arterial switch was performed when the tract was patent. The feasibility of intraventricular repair was related to the distances between the tricuspid valve and the semilunar valves. Preoperative measurement of these distances is an essential criterion to choose the appropriate repair of anomalies of ventriculoarterial connection associated with ventricular septal defect.

Anatomic repair of anomalies of ventriculoarterial connection associated with ventricular septal defect. II. Clinical results in 50 patients with pulmonary outflow tract obstruction

From November 1980 to November 1985, 50 patients underwent anatomic repair of anomalies of ventriculoarterial connection associated with ventricular septal defect and pulmonary outflow tract obstruction. The technique used was one that we have previously described, which we call REV. The principles of this technique are resection of the infundibular septum, construction of a tunnel connecting the left ventricle to the aorta, and direct anastomosis, without a prosthetic conduit, of the pulmonary arterial trunk with the right ventricle. The tunnel is situated beneath the aortic valve and occupies very little space in the right ventricular cavity. Age at operation ranged from 4 months to 13 years (mean 3.5 years). Twenty-six patients had a classic type of transposition of the great arteries; all other patients had various types of anomalies of ventriculoarterial connection in which it was impossible, after the intraventricular connection of the left ventricle to the aorta, to use the natural pulmonary orifice for the pulmonary outflow tract reconstruction. There were nine hospital deaths (18%) and one late death. Twenty-six of 29 patients whose follow-up time exceeded 1 year had an excellent clinical result. No stenosis of the aortic outflow tract was found. Four patients had significant pressure gradients on the pulmonary outflow tract. Our present experience with REV suggests that this technique allows anatomic repair in a wide variety of anomalies of ventriculoarterial connection associated with ventricular septal defect and pulmonary outflow tract obstruction, even in infants, with an acceptable rate of mortality and morbidity.

[Postoperative inotropic treatment in cardiac surgery of the newborn infant and infant]

Corrective cardiac surgery in infants and neonates induces acute circulatory and anatomical changes which, together with the myocardial ischaemia of cardiopulmonary bypass, impair cardiac function. Although this cardiac dysfunction usually disappears without any after-effects, inotropic treatment is mandatory for a short time. There, however, is no easy way to monitor cardiac output in these small patients. Neither is there much universally recognized objective data available to help choose between these drugs available or between different protocols. Physiologically, infants are not small adults. In the neonatal period, the heart works virtually at its maximum, with little reserve : the stroke volume has a limited capacity to increase because of poor compliance, and the heart rate is high. Cardiac output is therefore rate dependent. To improve therapeutic adjustment, an attempt is made to rationalize the use of inotropic drugs in the postoperative period. Cardiac dysfunction can frequently be recognized already in theatre. It is of paramount importance to exclude faulty surgical repair by measuring the pressures and oxygen saturation in all the cardiac chambers and vessels. The severity of haemodynamic impairment will then have to be defined. As well as the usual clinical criteria (blood pressure, diuresis), the trend in the capnographic curve during a reduction of extracorporeal blood flow rate and acid-base measurements are most helpful. If no further immediate surgery is found to be necessary, the most serious cases are treated by cardiopulmonary support (right to left, or cardiac left to left, or exceptionally biventricular), usually for 1 to 3 h.(ABSTRACT TRUNCATED AT 250 WORDS)

[Transposition of the great vessels with interventricular defect and stenosis of the left ventricular efflux channel: anatomical correction by the intraventricular repair technic]

New technique of anatomical correction of transposition of the great arteries (TGV) with ventricular septal defect (VSD) and pulmonary stenosis (PS) without using a prosthetic conduit was reported by Lecompte in 1982. We analyse our recent experience with this procedure in three patients and we describe the main advantages and the wide surgical indications with reference to the Rastelli procedure.

Prosthetic valve endocarditis. The case for prompt surgical management

Clinical and morphologic features are described in 27 patients with prosthetic valve endocarditis. The interval from valve replacement to onset of symptoms of prosthetic valve endocarditis was less than 2 months in 10 patients, longer than 2 months but less than 6 months in seven patients, and longer than 6 months in 10 patients. The most frequent infecting organism was Staphylococcus (11 patients). In nearly all patients, infection spread behind the site of attachment of the valve prosthesis and resulted in valve ring abscesses. Twenty-three of the 28 infected prostheses were partially or almost completely detached, and in 15 patients the infection destroyed the entire valve anulus, burrowing to adjacent structures in six. Despite prolonged bactericidal antibiotic therapy, bacterial cultures of prosthetic valves removed at operation or autopsy were positive in 14 patients. Standard valve replacement was attempted in nine patients. All were hospital survivors, but two of these patients evidenced rapid postoperative valve dehiscence and required a complex surgical procedure at reoperation. The 14 other surgically treated patients had almost complete destruction of the annular root, and surgical repair was achieved by complex surgical techniques. There were five postoperative deaths, but nine patients survived with no further evidence of infection (mean follow-up 34 months). All patients with early prosthetic valve endocarditis who recovered underwent this type of operative technique. Total exclusion of the infected annular root, as described, may offer in patients with extensive endocarditic lesions the only possibility to eradicate the infection and to reduce the mortality.

[Abnormal origin of the left coronary artery. Pre- and postoperative hemodynamic and metabolic studies]

The authors report the case of an asymptomatic 45 year old man in whom an abnormal origin of the left coronary artery was discovered fortuitously. Coronary angiography was carried out for electrocardiographic signs of anterior myocardial infarction and showed the left coronary artery arising from the pulmonary artery: there was apical dyskinesia with alteration of global left ventricular function. The ostium of the left coronary artery was closed and a saphenous vein aorto-left anterior descending artery bypass was performed. There were no complications. Left ventricular function has not improved 8 months after surgery. The haemodynamic and coronary signs of myocardial ischaemia demonstrated preoperatively regressed after surgery: the coronary "steal" caused by the malformation which led to poor perfusion of the territory of the left coronary artery has therefore been corrected by surgery. This procedure should be carried out as early as possible in order to limit extension of the myocardial lesions.

Portoatrial shunt in Budd-Chiari syndrome

It is now well accepted that mesoatrial bypass is an efficient treatment of Budd-Chiari syndrome and that it is indicated when the inferior vena cava is obstructed. This report presents a patient in whom the superior mesenteric vein was thrombosed after a previous mesocaval shunt. A bypass was constructed between the left side of the portal vein and the right atrium with a 16 mm diameter reinforced polytetrafluoroethylene prosthesis. The prosthesis passed between the left lobe of the liver and the caudate lobe and had a direct trajection. The procedure was simple, the postoperative course was uneventful, and the patient was well 20 months later. This observation suggests that portoatrial shunt is a good alternative to mesoatrial shunts in patients with Budd-Chiari syndrome and unavailable inferior vena cava and superior mesenteric vein.

Chronic tricuspid regurgitation and bifascicular block due to blunt chest trauma

Closed-chest trauma in a young man was followed by rupture of a right ventricular papillary muscle and bifascicular block. This produced signs and symptoms of tricuspid regurgitation and recurrent syncope. Treatment by valve replacement and pacemaker implantation was successful. Review of 30 cases of traumatic tricuspid regurgitation reveals that this patient had characteristic findings: adult onset of isolated tricuspid regurgitation, a history of trauma, right bundle branch block, and cardiomegaly without signs of left ventricular failure. In addition, right atrial hypertension of longstanding may produce cyanosis because of right-left shunting through a patent foramen ovale.

[Aortic coarctation with hypoplasia of the arch: description of a new surgical technic]

The aortic coarctation is frequently associated with aortic arch tubular hypoplasia, especially in early infancy. The treatment in one time of both lesions is mandatory in these cases. We propose therefore a new surgical technique: after resection of the isthmic coarctation and appropriate cutting of both ends, the anastomosis is widely extended in the concavity of transverse aortic arch, beyond the hypoplastic region. We discuss the advantages of this technique over the classic end-to-end anastomosis, patch graft and subclavian flap angioplasty.

[Interruption of the aortic arch and malformative cardiac lesions requiring repair under extracorporeal circulation. Apropos of 3 cases]

Interruption of the aortic arch is practically always associated with intracardiac malformations of variable complexity, at the least, a ventricular septal defect. Surgery is usually performed in two stages: aortic repair and pulmonary artery banding after intravenous prostaglandin administration. The second stage comprises debanding and repair of the intracardiac lesions under cardiopulmonary bypass. However, in some cases, interruption of the aortic arch is associated with intracardiac lesions which necessitate correction under cardiopulmonary bypass from the onset, this was the situation in two of the three cases described by the authors: aorto-pulmonary window, a lesion which can only be corrected under circulatory arrest and deep hypothermia. One of these two children, operated in the neonatal period, did not survive: the other, operated at 6 weeks, had an excellent result. In the third case, the association of tricuspid atresia and a restrictive ventricular septal defect necessitated enlargement of the septal defect and therefore, open heart surgery under circulatory arrest; the results were favourable.

[Aortic valve replacement in infectious destruction of the aortic annulus. A new technic]

The results of aortic valve replacement in the acute phase of valvular endocarditis are dependent upon the degree of destruction by sepsis of the left ventricle-aorta junction. The stability of the prosthesis installed is conditioned by the extent of the lesion. Numerous techniques have been described to maintain the prosthesis firmly in place. In the technique reported here, the prosthesis is implanted in the usual position, but the sutures are tied outside the heart. Depending on the site of the lesion, this is done by opening the left atrium or the infundibulum of the right ventricle, and by passing the stitches through the aortic wall. This quick and simple technique ensures good stability of the prosthesis.

Anatomic correction of transposition of the great arteries associated with ventricular septal defect: midterm results in 50 patients

From May 1977 to August 1982 50 patients who were 1.5 to 44 months old underwent anatomic correction of transposition of the great arteries (TGA) and closure of ventricular septal defect (VSD) at our institution. Thirty-nine patients underwent preliminary pulmonary arterial banding. Hospital mortality was 32%: four patients died as a result of technical problems, seven as a result of associated lesions, three of pulmonary hypertension, and two of left ventricular failure. Three other patients died after the first postoperative month (one of mediastinitis, one at reoperation for a residual VSD, and one of pulmonary hypertension). All 31 survivors are in excellent clinical condition and are in sinus rhythm after a mean follow-up period of 31 +/- 14 months. Twenty-five patients were reinvestigated by echocardiography (M mode and two-dimensional) and/or catheterization. Parameters of left ventricular contractility were within normal limits, but systolic aortic diameter was larger than normal (p less than .01). Seven patients had stenosis of the right ventricular outflow tract and five of these required reoperation. The two persistent problems with the anatomic correction of TGA associated with VSD are a relatively high operative mortality and secondary right outflow tract stenosis. However, use of this procedure results in better left ventricular function and fewer arrhythmias than does use of atrial repair techniques and also results in the use of the anatomically left ventricle as the systemic ventricle.