[The autologous pericardial tube-flap. A new technic for restoring the continuity between the right ventricle and the pulmonary artery]

Re-establishing continuity between the right ventricle and the division of the pulmonary trunk may prove difficult in surgical correction of transposition of the great vessels. Although prosthetic tubes, which had many drawbacks, have been replaced by direct anastomoses, partial reconstruction of the pulmonary arterial wall is still often necessary. The materials commonly used are segments of gore-tex, stored pericardium and fresh or glutaraldehyde-treated pericardium. However, retractions may develop in these reconstructions resulting in pulmonary stenosis. These complications have revived the debate on the best technique for re-establishing continuity, and it is mandatory to use a growing tissue to keep pace with the child's development. We report here an original technique used in an infant. Previous studies have shown that the autologous pericardial flap, transformed here into a tube, retains its potential for growth.

[Syndrome of vagal hypertonia in a newborn infant manifested during the surgical repair of aortic coarctation associated with banding of the pulmonary artery]

We report a case of vagal hypertonia syndrome in a newborn infant, developed after surgical repair of an aortic coarctation combined with banding of the pulmonary artery trunk. The parasympathetic activity had adverse repercussions on haemodynamics. The diagnosis was confirmed by prolonged asystole on the oculocardiac reflex and by concomitant arrhythmia and disorders of conduction demonstrated by Holter recordings. To our knowledge, no other case of vagal hypertonia associated with a congenital cardiopathy has yet been reported. Infants with this syndrome are at a high risk of sudden death. Treatment with vagolytic drugs is of questionable value, and prolonged supervision of the patient is mandatory.

Effects of droperidol on peripheral vasculature: use of cardiopulmonary bypass as a study model

The effects of droperidol on the systemic vascular resistance (SVR) and the venous capacitance were studied during cardiopulmonary bypass (CPB) in 24 patients. CPB was performed with either pulsatile or non-pulsatile flow. During non-pulsatile flow, droperidol (0.15 mg X kg-1 and 0.30 mg X kg-1) decreased SVR and increased venous capacitance. These values were significantly different after the 2nd and the 7th min, respectively. During pulsatile flow, the initial SVR was lower. The decremental effect of 0.30 mg X kg-1 droperidol on SVR was proportional to the preinjection level of SVR (r = 0.64). The increase in venous capacitance related to droperidol was independent of the dose and of the type of flow in all patients. It can be concluded that the vasodilating action of droperidol during CPB on the arterial bed is transient, independent of dose, and related to the preinjection level of SVR. The effect of droperidol on venous capacitance is not as rapid but has a longer duration.

[Magnetic resonance imaging in the evaluation of the postoperative results in tetralogy of Fallot. Apropos of a case]

The magnetic resonance images obtained post-operatively in a case of Fallot's tetralogy are presented. These images provide perfect visualization of the intracardiac structures, notably those which make it possible to evaluate the results of surgery, namely the patency of the pulmonary out flow tract. Magnetic resonance imaging (MRI) is still of limited use, but this examination will no doubt be more frequently performed when forthcoming techniques enabling gradients and blood flows to be evaluated and dynamic images to be obtained will be available. With ultrasonography and MRI, we now possess two totally non-invasive methods of cardiac exploration, but MRI offers the advantage that its results do not depend on the operator.

[Hydatid cyst of the right heart and post-embolic pulmonary hypertension]

A 22-year old man with hydatid cyst of the right ventricle presented, for about 10 years, with clinical signs of post-embolic pulmonary hypertension. Despite tumoral resection, the patient died post-operatively of his pulmonary hypertension. Post-mortem examination showed a hydatid cyst on the main pulmonary artery and fixed post-embolic pulmonary hypertension, but we were unable to determine whether we were dealing with old migrated cysts or blood clot emboli developed in contact with the cardiac tumour.

[Reconstruction of pulmonary artery branches with pedicled flaps from the autologous pericardium]

A new reconstruction technique using pedicled flaps from autologous pericardium was applied in a case of long hypoplastic segments of the two branches of the pulmonary artery in a 6-year old child. The pericardial sac was incised vertically on the midline, and two rotating flaps, one on the left, the other on the right, were created to bring the pericardium in front of the corresponding arterial branches. Each branch was split open all along its hypoplastic segment which was then widened to normal diameter, using the pericardial flap for reconstruction. Control echocardiography, performed one year later, showed that the excellent post-operative results persisted. This is of particular interest as it is well known that all other materials previously utilized to reconstruct the pulmonary artery do not grow or even shrink, resulting in progressive stenosis.

[Total pericardectomy. Exceptional treatment for recurrent idiopathic cortico-dependent pericarditis]

The authors report a case of definitive treatment of idiopathic relapsing pericarditis by total pericardectomy in the absence of signs of constrictive pericarditis after a 15 month period marked by multiple invalidating recurrences and the development of dependence on corticosteroid therapy. The indications of total pericardectomy must be discussed in these exceptional cases of failure of medical therapy in idiopathic relapsing pericarditis.

[Mitral stenosis with notable or important subvalvular changes. Complete open commissurotomies supported by chorda transfer]

Since 1983, 40 consecutive patients with mitral stenosis (MS) and significant disease of the subvalvular apparatus underwent open heart mitral commissurotomy (OHMC). The aim of the study was to evaluate the effects of an unrestricted dilatation of the two commissures followed by repair of the subsequent mitral regurgitation. The mitral regurgitation created by this procedure in 24 cases was corrected by transferring 2 to 6 chordae tendinae to the free border of the anterior and/or posterior leaflet in the commissural region. A central regurgitant lesion due to lack of coaptation of the valvular surfaces was treated by annuloplasty with a Carpentier prosthesis in 12 cases. The subvalvular abnormalities were treated by the conventional techniques of fenestration, resection and division of the papillary muscles. Thirty of the 38 survivors had no residual murmur, and 6 had a short low intensity systolic murmur. The 2D echocardiographic study showed no residual stenosis. The residual systolic murmurs were evaluated by pulsed Doppler and corresponded to very localised regurgitation. This extensive operative technique gives very good immediate valvular results which, associated with an adequate subvalvular procedure, are considered to be an important prognostic factor.

[Surgical treatment of complete atrioventricular canals, regular and irregular forms, in 75 patients]

The cases of 75 consecutive patients operated for complete atrioventricular canal between 1/1/1978 and 1/1/1985 at Marie-Lannelongue Hospital were reviewed. The age ranged from 1.5 months to 16 years. Forty-nine per cent of patients were operated in the first year of life in the period 1982-1984. Seventy-eight per cent of patients were operated before one year of age. Certain anatomical characteristics enable regular and irregular forms of the condition to be distinguished. Regular forms are characterised by the association of a defect of the inter atrio-ventricular septum, of a common atrioventricular orifice and of ventricles of equal volume without other associated malformations. Irregular forms include the parachute mitral valve, the double mitral orifice, deficient mitral valvular tissue, ventricular hypoplasia, subaortic stenosis, abnormal right ventricular muscular bands, associated cardiac malformations and pulmonary obstructive vascular disease. Surgery comprises repair of the ventricular septal defect and the ostium primum with two separate patches, respecting the anterior and posterior valves and partial or complete closure of the cleft valve. The hospital mortality rate was 33 p. cent. It was 16 p. cent in regular forms and 58 p. cent in irregular forms (p less than 0.01). The hospital mortality of patients operated before 1 year of age with the regular form of the malformation was 22 p. cent. Six children were reoperated secondarily with 2 deaths. Four pacemakers were implanted for complete atrioventricular block. The secondary mortality was 10 p. cent. Thirty-nine patients were followed up for an average of 28 months (range 3 months to 5.5 years).(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical anatomy of the interventricular communications of the septal trabecula]

Muscular ventricular septal defects (VSD) are a special anatomical and surgical entity. They are observed in 85% of cases of multiple VSD. This study was based on the operative findings in 70 patients and 20 pathological specimens of muscular VSD. A surgical topographic classification is proposed, superior, intermediate and inferior, with a specific surgical approach for each of the three types. The superiorly situated muscular VSDs are approached through the right ventricle, the intermediate ones through the right atrium and the inferior through the right atrium or left ventricle. Section of the moderator band greatly facilitates the exposure of the intermediate and inferior segments of the septum through the tricuspid valve. Left ventriculotomies should be reserved for inferiorly situated muscular VSD with right ventricles of small volume.

[Long-term course after palliative surgery in children with a single ventricle]

Single ventricle or univentricular heart is a rare congenital malformation (1/10 000) which has a very poor prognosis. The cases of 68 children with single ventricles who had palliative surgery between January 1964 and December 1982 were studied. The average age of the patients at surgery was 4.41 +/- 5.8 years; 36% of the children were under 1 year of age. Surgery consisted in 48 systemico-pulmonary anastomoses and 20 pulmonary artery bandings. The global mortality was 22% (16% in the anastomosis group and 35% in the banding group). Age seemed to be an important factor: 25% mortality in children under the age of 1; 2.4% in children over 1 year (p less than 0.05). The 15 year survival rate was 43 +/- 23% overall; 56 +/- 28% in children with anastomoses and 20 +/- 28% at 8 years in children with banding. Although surgery did not appear to improve survival it probably did improve survival it probably did improve the quality of life; 73% of the survivors has satisfactory functional results and the efforts of everyday life were well tolerated. However, the evolution was complicated in 10% of cases by infection and neurological complications, and atrioventricular regurgitation was observed in 7 patients, requiring valve replacement in 2 cases. Our results are globally comparable with those of similar previously reported studies. The best published results of physiological correction of single ventricle (Fontan, septation) are relatively unsatisfactory with a mortality rate of about 35%. Therefore, palliative surgery still appears justified in these cases.

[Repair of rheumatic mitral lesions by transfer of a segment of the posterior valve with its chordae onto the anterior valve]

Since 1981, 100 patients have undergone mitral valve repair alone or in association with aortic or tricuspid valve surgery. The basic technique used was that described by Carpentier. However, in 13 of these patients, the repair was performed by a technical innovation consisting in transferring a one to two centimetres segment of the posterior leaflet with its chordae to the anterior leaflet. The lesions in which this particular technique was required were extensive chordal rupture of the anterior leaflet (5 cases), localised retraction of the surface of the anterior leaflet (2 cases), and perforation near the valve free edge due to endocarditis (1 case). The valvular disease was due to rheumatic fever in all cases. None of the patients had active endocarditis. The age of the patients varied from 4 to 60 years. Eight patients were under 15 years of age. Postoperative echocardiography and pulsed Doppler studies showed results comparable to the other patients who had undergone mitral valve repair although the valvular lesions were more severe in this particular group of patients. Only one patient had a poor operative result and had to be reoperated.

[Surgical closure of interventricular communications before 2 years of age. Long-term clinical and electrocardiographic course]

The long-term follow-up of the first 100 children under 2 years of age, presenting with ventricular septal defect (VSD) who underwent surgical closure between 1972 and 1976 at the Centre Chirurgical Marie-Lannelongue, was studied. Only cases with isolated VSD were taken into account except for 18 cases with ductus arteriosus related to operation and 41 cases with atrial septal defect (ASD) or persistent foramen ovale. This study included clinical and electrocardiographic investigations focused on the long-term follow-up of conduction disorders. Clinical tolerance was excellent with only one Eisenmenger's syndrome induced by a residual VSD. Three secondary cases of aortic regurgitation without present functional repercussions were observed. Conduction disorders were considered as unchanged or even improved. There were no sudden death, no secondary atrioventricular block (AVB), no trifascicular block even after one case with transitory immediate postoperative AVB.