[Choice of surgical method in the child or adult (excluding infants) suffering from coarctation of the aorta and severe cardiopathy]

A study of a serie of 45 cases of coarctation of the aorta associated with a severe cardiac lesion or malformation, and treated at a single operative session (18 cases) or in two consecutive stages (27 cases) has produced the following conclusions: --Treatment at a single operation is possible, usually at the cost of two consecutive surgical approaches, thus making the operation rather long. This plan, which has given good results in the 18 cases studied (only one death and no serious complications) should be adopted only for young patients who are well-balanced psychologically, and whose cardiac defect is well-compensated. --Treatment in two stages is a more reasonable course for the remainder of the patients, but it must be decided which lesion to treat first: this could be the coarctation if it is a difficult or poorly tolerated one and if the cardiac defect (especially when an aortic valve lesion) is well compensated. It will be the cardiac lesion if, by contrast, the coarctation is simple and well-tolerated, and the cardiac lesion is severe and decompensated (especially a mitral malformation with shunts and major pulmonary hypertension). Current techniques of open heart surgery allow us to employ extracorporeal circulation easily and safely with the coarctation still in place; this will then be treated later. In every case in which a two-stage treatment plan has been chosen, it should be carried out as a planned procedure so that the second stage of the operation is not put off unduly.

[Surgical treatment of the double outlet right ventricle with pulmonary stenosis. Apropos of 7 cases]

The double outlet right ventricle is a rare malformation, and its surgical correction has been well defined. The authors present seven cases of double outflow of the right ventricle and stenosis of the pulmonary outflow. If the technical problems of those variants with a subaortic septal defect seem to have been overcome, those with a subpulmonary ventricular septal defect present a much more difficult problem. Of the seven cases presented, the authors report the death of one patient who had a right ventricle with a double outlet associated with pulmonary stenosis and a sub-pulmonary ventricular septal defect. The post-operative course of the other 6 patients, who had a subaortic ventricular septal defect, was simple. One patient suffered secondary dehiscence of the repaired septal defect, and was reoperated on. The maximum follow-up period has been 7 years.

The effect of coronary artery reperfusion on the extent of myocardial infarction

The effect of the reperfusion on myocardial infarction has been studied in the rat in order to assess the possible reversibility of myocardial damage. The present study deals with reperfusion of experimental myocardial infarction in the rat. Two groups of animals were compared: one was subjected to permanent ischemia and the other was subjected to ischemia of variable duration 1) hour to 24 hours). The differences between infarction caused by permanent ischemia and the evolution of infarction following reperfusion were studied by means of histologic (121 specimens) histoenzymatic (56 specimens), ECG (100 specimens), techniques and study of the mcirocirculation (70 specimens). The size of the infarctions caused by temporary ischemia was found to be significantly smaller in 60% of the cases as compared to the infarctions caused by permanent ischemia. Histoenzymatic study (phosphorylase activity and succinodehydrogenase activity) confirmed the existance of a marginal zone extending over one third of the surface of the ischemic myocardium: reperfusion permitted the salvage of this zone and thereby diminished the extent of necrosis. The latter findings were further confirmed by the ECG study showing earlier regression of ischemic ST changes following early reperfusion. Microcirculatory changes secondary to anoxia may account for the fact that, in a certain percentage of the cases, early reperfusion does not prevent extension of infarction.

[Constrictive fibrous endocarditis. Surgical treatment]

An anatomo-clinical entity, fibrous constrictive endocarditis can betreated srugically, and we carried out this procedure for the first time in 1971, since when we have used it seven times; it consists of an internal stripping of one or both centricles, with removal of one or both the mitral and tricuspid valves. The results were encouraging in the first two cases, and so good in the succeeding ones that this endocardial resection could be put forward as the treatment of choice for a condition whose aetiology is still unclear.

Emergency myocardial revascularization

From 1969 to 1975, 175 patients with acute coronary insufficiency underwent emergency saphenous vein aorto-coronary bypass grafting (SVBG). The patients were divided into two groups: group I, unstable angina (165 patients) and group II, acute evolving myocardial infarction (ten patients). In group I, the hospital mortality was 8-4%, the incidence of post-operative myocardial infarction was 10-3%. Long-term follow-up was obtained for an average of 25 months, functional improvement was definite in the majority of the patients and actuarial survival curves show 87% patients alive at the end of 48 months. In group II, the hospital mortality was 30%; seven of ten patients had good results.

[Large esophagogastric caustic burns in the adult]

The authors treated, as an emergency, severe caustic burns in adults. They present 13 cases and discuss four deaths. Critical analysis of these observations,compared with the findings of pathology and in the literature, permit one to consider the therapeutic indications. The place of often major surgical operations is discussed in relation to further specialist investigations or the appearance of complications. The results are assessed in 8 patients who were followed up for a long period.

The surgical treatment of constrictive fibrous endocarditis

Constrictive fibrous endocarditis is a pathological entity described by Loëffler in 1936. Its etiology is unknown. The clinical course is characterized by an evolution towards cardiac insufficiency leading rapidly to a fatal outcome. Moderen paraclinical investigations are necessary to assess the diagnostic. Caridac catheterization brings the proof of adiastole and angiogardiography reveals the shape of amputation of the ventricle with auriculoventricular regurgitation. The operative procedure consists of resection of the ventricular fibrosis including the valves and auriculo-ventricular valve replacement by a prosthetic valve. The disease affects both Caucasians and Negros. Our experience includes 5 cases. The indications for operation and their results are discussed.

[Place of conservative surgery in acquired valve diseases]

There is still a place for conservative surgery in valvular disease of the heart to the extent that artificial prostheses have not yet been perfected sufficiently for them to be regarded as the method of choice. While these conservative operations are rarely applicable to the aortic valve, techniques such as Carpentier's ring occupy an important place in the treatment armamentarium for disorders of the mitral valve, and even more so of the tricuspid valve.

[Enlarged heart caused by massive subepicardial lipomatosis with idiopathic dilatation of the right cavities]

The case is reported of a man of 48 with known longstanding gross cardiomegaly which was completely asymptomatic. Angiocardiography and coronary arteriography showed dilatation of the right side of the heart, and especially of the auricle. In addition, the ventricle was separated from the diphragm by a transparent non-fluid area. At operation, gross dilatation of the right atrium was confirmed, but no causative lesion could be found; there was also marked lipomatosis which involved particularly the area beneath the right ventricle. It is difficult to classify this most unusual case as either a classical dilatation of the right atrium, idiopathic or secondary, or as a cardiac lipoma or lipomatosis.

[Endocardial resection: surgical treatment of constrictive fibrous endocarditis]

A new operation, the resection of the endocardium, is proposed in the case of fibrous constrictive endocarditis. I performed this operation in 1971, for the first time, with good results. I operated on two other patients with success in 1973 and 1975. The results I have obtained indicate that this new technique is possibly the answer to a disease which otherwise ultimately results in death.

[Re-operations on mitral valve prostheses. Apropos of 40 cases]

The present study deals with a series of 40 reoperations in a group of 1279 patients undergoing mitral valve replacement. All reoperations were late following the immediate post-operative period, the earliest being 5 months after the primary operation. The factors which were analyzed are: causes of reoperation, the most frequent being paravalvular leaks and valve thrombosis, diagnostic methods, surgical techniques and results following reoperation.

[Hyperparathyroidism. Reoperations]

Sixteen patients were re-operated on for treatment of their hyper-parathyroidism. After analysis of the cause of failure or relapse, the authors discuss the examinations which led to a definite diagnosis and, in some cases, pre-operative localisation of the lesion. All the patients were treated by the cervical route only. Operation may be very difficult Technical advice is given here. Tetany and recurrent laryngeal nerve paralysis are common complications. They are often due to an inefficacious or incomplete first operation.