[Aortic insufficiency and degenerative aortic disease. Anatomic study and etiology]

Degenerative (or dystrophic) artery disease is the most recently recognized etiology of aortic regurgitation (AR) and has been observed since the sixties. This condition concerns about one third of the pure AR cases, which now undergo surgery and involves two populations (with a marked predominance of men): subjects over 50 years of age, with no special history, and some post-adolescent patients suffering from Marfan's disease. The anatomical lesions are identical in three respects: the ascending aorta, with a spindle-like aneurysm, thin or slack, collapsed aortic sigmoids, dilated aortic ring. The histopathologic observations involve two features, the relative importance of which varies from one case to another: a loss of elastin and collagen fibers (the main cause of the disease) and an accumulation of acidic mucopolysaccharides (known as mucoid or myxoid degeneration) which involves some reaction to hemodynamic turbulence and is somewhat secondary to fragilization of the aorta or sigmoid wall. Rupture of the aorta wall, which is restricted to the inner two thirds of the media or complicated by a dissecting hematoma, may aggravate both the distention of the ascending aorta and the AR. One hundred of the 150 cases of pure AR which underwent surgery at Lyon (France) during 1986 and 1987 belonged to this dystrophic etiologic category and called for a special procedure (Bentall).

Pulmonary Wegener's granulomatosis. A clinical and imaging study of 77 cases

We studied 77 patients with biopsy-proven WG and pulmonary manifestations, to characterize the nature and frequency of the clinical, imaging and endoscopic features of this condition. Pulmonary symptoms were cough, mild dyspnea, hemoptysis and chest pain. Five patients had no pulmonary symptoms. Imaging features consisted of nodules, infiltrates and pleural opacities. A CT scan proved useful by disclosing cavities in opacities or opacities which were not seen on an x-ray film. Fiberoptic bronchoscopy was performed in 74 patients, and it was macroscopically abnormal in 55 percent (showing bronchial inflammation or stenosis or both or isolated hemorrhage). Six patients presented with alveolar hemorrhagic syndrome. Four patients had a pleural exudate rich in polymorphonuclear leukocytes. The WG was limited to the lung in seven patients. Sixteen patients died because of active disease or iatrogenic complications (two). An improved knowledge of clinical and imaging features of WG could help the clinician reach an earlier diagnosis.

Human epithelial thymic tumours: heterogeneity in immunostaining of epithelial cell markers and thymic hormones

Different hormones (thymulin, thymosin alpha 1, vasopressin), antigenic markers of cortical and subcapsular/medullary thymic areas and tumour associated antigens were studied on paraffin or frozen section and cultures of human epithelial thymic tumours ('thymomas'). Thymulin, thymosin alpha 1 and for the first time vasopressin are found in most tumours. The epithelial cells of five 'thymomas' had markers of both cortical (TE3) and subcapsular/medullary thymic regions (A2B5 and/or TE4 and/or anti-p19). Leu-7, a marker of subcapsular epithelial cells was positive only in two tumours. The histological classification into cortical and medullary tumours does not correspond to our immunofluorescence results. The presence of these markers does not support the theory of different embryologic origin of the cortical and subcapsular/medullary epithelial cells. Transferrin receptors were detected on only some epithelial cells of thymic 'carcinomas'. Adenocarcinoma related antigen and carcino embryonic antigen only stained a few epithelial cells of all the tumours. There is no expected correlation between the presence of epidermal growth factor receptors on cell membranes and the number of proliferative cells stained by the anti-Ki67 antibodies. Immunostainings were heterogeneous according to the epithelial thymic tumours, independent of histological classification and not yet useful for prognosis.

Idiopathic bronchiolitis obliterans organizing pneumonia. Definition of characteristic clinical profiles in a series of 16 patients

Bronchiolitis obliterans organizing pneumonia (BOOP) is a pathologic finding common to various injuries to the lung of either definite or idiopathic etiology. Since the presentation of patients with idiopathic BOOP varies, we studied 16 patients with BOOP on pulmonary histology to define more distinct and homogeneous clinical and imaging profiles of idiopathic BOOP. We distinguished three groups of patients: group 1 (n = 4), with multiple patchy migratory pulmonary involvement of the pneumonia type. Their clinical course was subacute, with cough, fever, weight loss, mild dyspnea, and increased ESR. Chest x-ray film and CT scan showed multiple alveolar opacities. All patients completely recovered with corticosteroid therapy but relapsed when therapy was stopped too rapidly. Group 2 (n = 5) had solitary pulmonary involvement of the pneumonia type occurring in a similar clinical context. Since carcinoma was suspected, they underwent surgical excision of the pneumonic area and recovered without relapse. Group 3 patients (n = 7) presented with diffuse pulmonary involvement of the interstitial lung disease type. They had more progressive onset of more severe dyspnea, crackles heard over all lung surfaces, and interstitial opacities with or without alveolar opacities on chest imaging. Improvement with corticosteroid therapy was obtained in only three patients. In all three groups, lung function test results showed a restrictive pattern. The obstructive pattern characteristic of pure bronchiolitis obliterans was found in none. BAL showed a mixed pattern (increase of both lymphocytes and polymorphonuclear cells) in the patients of the first two groups. Thus, we distinguished three characteristic clinical and imaging profiles in patients with idiopathic BOOP: multiple patchy pneumonia, solitary pneumonia, and diffuse interstitial lung disease. These profiles are so different that they should be distinguished in clinical studies of idiopathic BOOP.

Bone marrow metastases in small cell lung cancer: detection with magnetic resonance imaging and monoclonal antibodies

The detection of bone marrow involvement might be of prognostic value and may influence therapeutic decisions in small cell lung cancer. By unilateral bone marrow aspiration and biopsy, evidence of bone marrow metastases is seen in 15-30% of patients with this disease. Since magnetic resonance imaging of the lower body and immunostaining with monoclonal antibodies have recently been shown to be very sensitive detection methods, we investigated the value of these two techniques in detecting bone marrow involvement in 35 consecutive patients with small cell lung cancer. The results were compared to those obtained with conventional cytohistological analysis. In all cases when cytology and/or bone marrow biopsy were positive, monoclonal antibodies immunostaining and magnetic resonance imaging also detected malignant cells. Furthermore, evidence of bone marrow involvement was shown with magnetic resonance imaging and/or immunostaining in 10 of 26 cases (38%) where routine procedures were unable to detect malignant cells. In one of these 26 patients, magnetic resonance imaging and immunostaining provided the only evidence of metastatic disease. These data suggest that the rate of bone marrow metastases is underestimated by routine procedures. Further investigation is needed to determine whether or not these new non-invasive methods have prognostic value or affect therapeutic choices in small cell lung carcinoma.

[Aortic insufficiency caused by dystrophic aneurysm of the ascending aorta: study of development in 95 cases. Value of cutaneous biopsy in the etiologic diagnosis]

We present 95 cases of aortic valve incompetence (AI) due to a dystrophic aneurysm of the ascending aorta; the aneurysm was idiopathic in 83 cases and associated with Marfan's syndrome in 12 cases. The diagnosis was confirmed by histological examination of the aorta and aortography. Functional signs were not always present, since 42 p. 100 of patients were in NYHA classes I and II and 58 p. 100 in classes III and IV. The prevalence of angina was 26 p. 100. The cardiothoracic ratio was increased up to 0.62 +/- 0.07, and projection to the right was noted in 63 p. 100 of the cases. Sokolow's index was 5 mv or more in 24 p. 100 of the patients. The aortic root, measured in 42 patients, was dilated up to 54 +/- 13 mm. The end-diastolic left ventricular diameter was increased to 70 +/- 10 mm. Haemodynamic studies yielded the following results: cardiac index 2.33 +/- 0.6 1/min/m2, end-diastolic left ventricular pressure 24.7 +/- 12 mmHg, mean pulmonary wedge pressure 12 +/- 6 mmHg, left ventricular end-diastolic volume 199 +/- 67 ml/m2, and angiographic ejection fraction 53 +/- 12 p. 100. The angiographic volume of aortic regurgitation, graded according to Sellers' classification, was 3/4 or 4/4 in 89 patients; the maximum diameter of the dilated ascending aorta was 73 +/- 18 mm. Evolutive data confirmed that aortic incompetence due to dystrophy is more severe than that due to other causes: 36 months after surgery, the overall mortality rate was 30%. Only two factors in our series seemed to be predictive of a poor prognosis: the fact that the patient belonged to NYHA class III or IV, and a mean pulmonary wedge pressure above 10 mmHg. This, however, must be taken with caution in view of the small population samples studied. The value of skin biopsy was confirmed. This examination, performed in 27 patients, was compared with the pathological examination of the aorta. Skin biopsy is specific and provides a major argument in favour of dystrophic AI in patients under 40 years of age.

Acute heart failure due to Q fever endocarditis

We report a case of Q fever endocarditis in a patient who presented with a slight pyrexia and acute cardiac failure due to aortic incompetence. The diagnosis was made by detecting high titres of serum IgG and IgA antibody against Coxiella burnetii phase I antigens and confirmed by demonstrating C. burnetii on the excised aortic valve using immunofluorescence and electron microscopy. Aortic valve replacement was followed by initially successful antibiotic treatment for 15 months. Reappearance of IgA anti-phase I antibodies 5 months later suggested continued presence of bacteria, although the patient's condition remained satisfactory. In endemic areas, such as rural southern France, Q fever endocarditis should be considered when there is evidence of acute heart valve damage but are few other features of infection.

Infective endocarditis on stenotic aortic valves

Charts were reviewed of 42 adult patients (27 men, 15 women, mean age 55 years, with 17 older than 60) hospitalized and/or autopsied between 1970 and 1986 with diagnosis of definite or highly probable infective endocarditis (IE) on pure aortic stenosis (AS). Ring and/or septal abscesses were found in 18/37 patients who were operated upon and/or autopsied. IE was recognized in 32 patients, undiagnosed in 10 (revealed at autopsy in seven, at operation in three). Infecting organisms were identified in 26 patients (Str. viridans, 16; Str. D, three; Staphylo., four; other, three). Twenty-seven patients were treated in our institution, 14 of them more than four weeks after the beginning of the symptoms. Echocardiograms were recorded in 17, with vegetations in only six. Severe cardiac failure was present in 17 cases. One patient was lost to follow-up. Fourteen patients died (mean delay between IE and death 22.4 months): eight of the 13 non-operated patients (cardiac failure, four; myocardial infarction, two; neurological complications, two) and six of the 14 operated patients (peri-operative death, four; late sudden death, two). Twelve patients are alive (mean follow-up 51.6 months), eight of them in NYHA class 1. IE on pure AS is rare, difficult to recognize echocardiographically, and of poor prognosis. It usually requires rapid aortic valve replacement.

The anatomical aspects of adult aortic stenosis

Since the recent introduction of percutaneous balloon valvuloplasty, there has been a renewed interest in anatomical studies. This study was based on a retrospective analysis of 100 autopsy reports and 269 surgical reports from adult patients with AS. Valvular calcification, which was always found over the age of 50 years, plays an important part in the origin of aortic stenosis (AS). Congenital or acquired aortic valvular lesions are a common pre-condition for calcified AS. Three anatomical types were found: (i) calcified bicuspid valves with anterior and posterior cusps (more frequent than a left and a right cusp) were found in 41% of autopsy reports and 40% of surgical reports. The resultant rigidity due to calcification makes the valve stenotic; (ii) post rheumatic calcified AS with strong fusion of the commissures and calcified cusps was found in 30% of autopsy reports and 8% of surgery reports; and (iii) degenerative calcific aortic stenosis was the most frequent form found over 70 years of age. The sinuses of Valsalva were filled with calcium deposits. The three commissures were apparently free, but cusp fusion was found on the ventricular aspect of the valve (29% of autopsy cases and 52% of surgical reports). Percutaneous balloon valvuloplasty is more efficient in this anatomical type.

[Current perspectives in the treatment of infectious endocarditis of a natural heart valve]

In view of the severity of infective endocarditis, which is due to local and general infectious processes and the hemodynamic consequences of valvular destruction, a policy of earlier valve replacement has been adopted. Clinical, bacteriologic and pathologic data collected over two years suggest that early surgery can be recommended in the following cases: congestive heart failure, inadequate results of antimicrobial therapy, and multiple emboli. Further studies should validate this policy, but the necessity of general prophylaxis for infective endocarditis must always be borne in mind.

Amyloidosis of the lower respiratory tract. Clinical and pathologic features in a series of 21 patients

Twenty one cases of amyloidosis of the lower respiratory tract were seen at a single center. In three patients, multifocal bronchial amyloid plaques led to stenosis and atelectasis, and in two, small pseudotumor masses were an incidental bronchoscopic finding. Two patients had nodular parenchymal amyloidosis, in one of whom the lesions were progressive and in the other static. Fifteen patients had diffuse parenchymal amyloidosis. Two of these had severe interstitial involvement and died in respiratory failure; eight had congestive cardiac failure, and parenchymal amyloidosis was a post-mortem finding; two had senile cardiorespiratory amyloidosis, also found at autopsy; and in three, the amyloidosis was associated with malignancy. The degree of respiratory embarrassment seemed to be related to the amount of amyloid in the gas diffusion zones, irrespective of the etiology of amyloidosis.

Epidermoid cysts, sulci, and mucosal bridges of the true vocal cord: a report of 157 cases

Presented is a summary of our experience with 157 patients having a diagnosis of epidermoid cyst, glottic sulcus, or mucosal bridge of the true vocal cord. Each patient in this group was diagnosed and treated jointly by a phoniatrist and microlaryngoscopist and then evaluated for results of surgical and phoniatric therapy. Included in the discussion are methods of examination and diagnosis, microanatomy and histopathology of the lesions, methods of treatment, and results of treatment. An argument for a common etiology for these lesions is advanced.

[Cardiac abscess in infectious endocarditis. Apropos of 25 anatomo-clinical cases]

Although rarely suspected clinically, cardiac abscesses are a serious and not uncommon complication of infective endocarditis (IE). Twenty-five cardiac abscesses were found at autopsy in 125 cases of IE on native valves. The anatomoclinical features of these cases are described. Cardiac abscesses usually occur in patients with previous valvular heart disease (21/25) and more commonly in aortic valve endocarditis (15/25) especially when complicating calcific aortic stenosis (9/25). The predominant infecting organism was staphylococcus aureus (9 cases). An iatrogenic portal on entry was confirmed in 9/25 cases. Conduction defects (14/25) commonly led on to sudden death (9 cases) despite attempts at temporary pacing (14/25) commonly led on to sudden death (9 cases) despite attempts at temporary pacing (2 cases%. The clinical history was shorter than 2 months in 4/5 cases. The average age of the patients was 53.3 years. The commonest site of infection was the aortic valve (16/25), affecting the posterior cusp in all cases. It is difficult to summarise the localisation of the abscesses as collection of pus extended in all directions. Involvement of the valve rings (aortic 10 cases--mitral 5 cas), of the interventricular septum (15 cases), of the LV free wall (17 cases), was common, sometimes in association, and fistula formation between two different cavities was observed in 4 cases. The abscess may communicate with a cardiac chamber or remain enclosed in the parietal structures (17 cas) reaching an average size of 2 cm diameter. Histological examination distinguished collected forms with an identifiable pyogenic membrane from the extensive, gangrenous, necrotic form with detectable microbial colonies in 9 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Coronary embolism. Apropos of 61 anatomo-clinical cases]

We reviewed 61 autopsy cases of coronary embolism observed over an 18 year period (up to the end of 1983) out of a total of 4 860 post-mortems performed on adults dying of cardiovascular causes in order to determine the nature and site of embolisation, the site of origin and establish the clinical features and evolution. A total of 75 emboli were found in the 61 cases (47 single, 11 double and 3 triple emboli). The emboli were recent fibrinothrombi in 43 cases; there were 9 associated calcific emboli, 2 embolized fragments of myocardium, 1 of Teflon and 1 of malignant tissue; the diagnosis was made "retrospectively" in 5 cases on a number of criteria. The main site of embolisation was the left anterior descending artery (34 cases) followed by the right coronary (20 cases), left circumflex (14 cases) and left main coronary artery (7 cases); obstruction was observed at the coronary ostium (7 left, 2 right) in 9 patients. The origins of the emboli were varied: 19 intracardiac thromboses (left atrial 10, left ventricule 6, suture of left atriotomy 3) 12 bacterial vegetations in cases of infective endocarditis, 10 thrombosis of prosthetic valves, 9 calcific emboli (8 aortic stenosis, 1 calcification of the ascending aorta) and 10 others.(ABSTRACT TRUNCATED AT 250 WORDS)

Lesions of digital arteries in Dupuytren's disease. A study of twelve cases

Twelve cases of histologically examined digital collateral arteries severed accidentally during surgery for Dupuytren's disease are presented. All arteries were repaired immediately after specimen retrieval for histological examination. Only one artery had a normal structure; 11 cases showed subendothelial fibrosis while two arteries thrombosed. These changes might account for the confusion of these arteries with adhesions and might explain their severance. Typically the zone involved was the distal part of the palm, in which the neurovascular bundle twists around the spiral cord. We believe that the lesions are a consequence rather than a cause of Dupuytren's disease.

Prognostic factors and indications for surgical treatment of acute aortic dissections: a report based on 191 observations

A total of 191 acute aortic dissections were examined to define prognostic factors for surgical intervention. Overall survival rate reached 40% in the 94 patients operated upon and 8% in the 97 patients not operated upon. Among the 122 patients with involved ascending aorta, survival rate was 2% in the 42 nonoperated patients versus 42% in 80 patients undergoing surgery. Since 1977, overall survival rate has reached 60% in the surgical group (21 of 35 patients) and 20% in the nonsurgical group (5 of 25 patients). Factors that showed a significant correlation with postoperative death include: persistent shock; persistent anuria; persistent neurologic deficit; diffuse intravascular coagulation; and involvement of either the celiac trunk, superior mesenteric artery, or both renal arteries at angiography. With the exception of those patients exhibiting any of these high-risk factors, emergency surgical treatment is recommended for all dissections that involve the ascending aorta.