[Mycotic coronary aneurysm with Escherichia coli sepsis: a case report]

We report the case of a patient who was admitted for acute coronary syndrom associated with fever originating from urinary tract. Coronary arteriography revealed a huge coronary aneurysm which ruptured a short time after diagnosis. After surgery, it was proven to be mycotic aneurysm related to Escherichia Coli sepsis.

[Treatment with lepirudin in heparin-induced thrombocytopenia. A case report]

We report the case of a 71 old woman presenting a bilateral massive pulmonary embolism with intraventricular right thrombus complicating heparin induced thrombocytopenia (HIT) persistent after one month of conventional anticoagulant processing. We underline the effectiveness of lepirudin (Refludan) in the curative processing of pulmonary embolism allowing here to avoid a complex surgical thromboembolectomy. We evoke the place of this molecule in the curative therapeutic strategy of HIT with thrombotic phenomena.

[Comparative outcome of aortic valve endocarditis with or without annular abscess]

Annular abscess is a not uncommon but serious complication of aortic valve endocarditis. The aim of this retrospective study was to evaluate the prognosis of aortic valve endocarditis with and without annular abscess. Between January 1981 and 1989, 122 consecutive cases of aortic endocarditis fulfilling the diagnostic criteria of Duke University were admitted to hospital. Group I included 40 cases with aortic ring abscess confirmed at surgery, in 35 patients; group II comprised 43 cases of operated aortic valve endocarditis without annular abscess in 41 patients and group III comprised 38 cases of aortic valve endocarditis treated medically without echocardiographic or angiographic signs of annular abscess in 36 patients. The patients in group III were significantly older than those in group I (57 +/- 14 years vs 44 +/- 17 years; p < 0.001). From the clinical point of view, endocarditis of prosthetic valves was slightly more common, but without reaching statistical significance, in group I, but the abscess was associated with more severe cardiac failure. Systemic embolism, atrioventricular block and pericardial effusion were equally common in the three groups. On the other hand, endocarditis with annular abscess was more often the result of infection with streptococci A, B, C or pneumoniae, than forms without abscess (22.5% vs 5% and 3% respectively in the 3 groups; p < 0.05). Of the patients treated surgically, destructive lesions of the valves were more common in cases of abscess (57.5% vs 35%; p < 0.05): the hospital mortality was higher in cases of abscess (17.5% vs 7%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Development of indications in surgery of coronary revascularization. Current role of mammary-coronary anastomoses]

At a time when the cardio-surgical community has become aware that arterial revascularizations are superior to venous bypasses, GRUNTZIG (24) initiated the now well-known, and highly successful techniques of endoluminal angioplasty (P.T.C.A.) thus leading many teams to explore non-surgical revascularizations. These fast changing events somewhat overshadowed the interest placed in arterial anastomoses in general, and in particular, in mammary-coronary anastomoses. We believe that in 1993, many centres have not used this technique to its fullest and propose to the Académie de Chirurgie a programme of operative indications reinstating mammary-coronary anastomosis to its proper place in the treatment of coronary artery disease.

[Emergency coronary surgery after transluminal angioplasty. Immediate results and long-term outcome of 100 operations]

The increasing application of percutaneous transluminal coronary angioplasty (PTCA) requires evaluation of emergency coronary artery surgery for complications of this procedure. In a consecutive series of 2,576 angioplasties performed between April 1980 and January 1990, 100 patients (82 men and 18 women, average age 54 +/- 10 years, 3.9%) underwent emergency coronary artery surgery because of complications. The artery involved was the left anterior descending artery in 81% of cases. The causal lesion was a dissection and/or thrombus in 95% of cases; 85% of patients were referred for surgery with acute myocardial infarction. The average delay before surgery was 110 +/- 15 minutes (interval between coronary occlusion and starting cardiopulmonary bypass) and 155 coronary grafts were implanted (1.5 per patient). The hospital mortality was 19%; the infarction rate was 57%. The left ventricular ejection fraction decreased from 63 +/- 10% (preoperatively) to 52 +/- 9% (postoperatively), p less than 0.001. Hospital mortality was significantly related to three factors, old age, unstable angina before PTCA, and cardiogenic shock or the necessity for external cardiac massage. In the subgroup of patients developing cardiogenic shock (n = 7) or requiring external cardiac massage during transfer to the operating theatre (n = 16) the mortality was 44%. Among the 81 survivors, the global 7 year survival rate was 96% (Kaplan-Meier) with 3 cardiac deaths, 2 other patients developing myocardial infarction and 4 undergoing repeat angioplasty. After an average follow-up of 55 +/- 38 months, 80% of patients are asymptomatic, 34% have no antianginal drugs and 73% of those who were previously employed have returned to work.(ABSTRACT TRUNCATED AT 250 WORDS)

Early and long-term outcome after emergency coronary artery bypass surgery after failed coronary angioplasty

From April 1980 to January 1990, among 2,576 percutaneous transluminal coronary angioplasty (PTCA) procedures, 100 patients (82 men and 18 women; mean age, 54 +/- 10 years [3.9%]) underwent emergency coronary artery bypass graft surgery. Before PTCA 56 had unstable angina, 34 had prior myocardial infarction, and 60 had single-vessel coronary artery disease. The mean time period from the onset of ischemia to surgical reperfusion was 147 +/- 16 minutes; 155 grafts were placed (1.5 grafts per patient). In-hospital mortality was 19%; operative mortality was significantly related to older age (59 +/- 9 versus 53 +/- 10 years, p less than 0.05), presence of unstable angina (74% versus 53%, p less than 0.05), and development of cardiogenic shock or necessity of cardiac massage before surgery (53% versus 16%, p less than 0.0001). In addition, 57 patients developed a Q wave myocardial infarction. For hospital survivors, overall survival at 7 years was 94% (Kaplan-Meier method), with three cardiac deaths during follow-up; two additional patients had late myocardial infarction, and four had late PTCA. At a mean follow-up of 55 +/- 38 months, 78% of the patients had no chest pain, and 80% reported no dyspnea. All patients received antiplatelet agents or oral anticoagulants; 34% had no antianginal medications. Among the 40 previously employed patients, 73% resumed work after surgery. All patients with cardiogenic shock or cardiac massage who survived the initial hospital period were alive at follow-up. After an initial critical period, the long-term clinical outcome of patients with emergency coronary bypass surgery after failed PTCA is satisfactory.

Proximal rupture and intracoronary entrapment of a rotating device during low-speed rotational coronary angioplasty

While attempting to recanalize a right coronary artery obstruction by using a low-speed rotating catheter (Rotacs), proximal rupture of the catheter body occurred with entrapment of the blunt tip in the obstruction. To retrieve the device, it was necessary to severe the guiding catheter and the flexible tube of the Rotacs. At low-speed rotation the flexible segment of the catheter was then pulled back.

[Intra-arterial fibrinolysis of superior mesenteric artery embolism]

Intra arterial fibrinolysis for acute mesenteric embolism. Acute mesenteric ischemia has a poor prognosis because the diagnosis is often too late (greater than 12 h), leading to a difficult surgery in old patients. The lesions of the bowel don't always allow a single operative embolectomy but often need a resection when there is a long time interval between onset of symptoms and therapy. We report a case of acute embolism in the superior mesenteric artery with the clot located in its terminal part. A rapid diagnosis was made by arteriography and intra-arterial fibrinolysis was attempted with success permitting the complete cure of the affection, without sequellae. This treatment is only likely to be successful if it is carried out within 10-12 hours of the onset of clinical signs and symptoms.

[Contribution of color echocardiography to the diagnosis of post-traumatic left ventricular-right atrial septal defect]

The authors report the case of an acquired left ventricle--right atrial communication after closed chest trauma. This communication was associated with rupture of the aortic isthmus and complete atrioventricular block. The left-to-right shunt which was assumed for a long time to be a small, well-tolerated, ventricular septal defect, finally required surgical repair. The diagnosis was eventually made clear by Doppler color flow mapping which was of great value in orienting the surgical procedure.

[Prognostic value of two-dimensional echocardiography before aneurysmectomy in anterior aneurysm of the left ventricle]

The prognostic value of echocardiographic apical 4 chamber recordings was assessed retrospectively in 18 patients who underwent left ventricular aneurysmectomy following anterior wall myocardial infarction. After an average follow-up period of 2 years, 7 patients had died or remained in functional Classes III or IV (Group 1) and 11 patients had satisfactory clinical outcomes (Group 2). There were no significant clinical or coronary angiographic differences between the two groups. The left ventricular surface area, transverse diameter and fractional shortening of the surface were also comparable in the two groups. The surface area of the aneurysm was greater in patients in Group 1 (37.4 +/- 11.8 cm2 vs 21.1 +/- 15.8 cm2, p less than 0.05). However, the more discriminating parameters were those related to the non-aneurysmal contractile zones (NACZ). Patients in Group 1 had a smaller relative surface area of the NACZ than those in group 2; 6 of the 7 patients in Group 1 had NACZ of less than 40 per cent of the left ventricle compared with none of the patients in Group 2 (p less than 0.001). In addition, the function of the NACZ was significantly worse in Group 1: surface fractional shortening: 9.6 +/- 10.2% vs 32.6 +/- 8.3% (p less than 0.001); ejection fraction: 20.7 +/- 9.1% vs 41.6 +/- 6.1% (p less than 0.001). All patients in Group 1 and none in Group 2 had ejection fractions of the NACZ of less than 30 per cent. Therefore, the apical 4 chamber view provides valuable prognostic information in patients who are candidates for surgical resection of left ventricular anterior wall aneurysms.

[Difficulties in the echocardiographic diagnosis of false aneurysm of the left ventricle. Apropos of 2 cases]

The echocardiographic diagnostic criteria of left ventricular pseudo-aneurysm are well established: the demonstration of a narrow-necked communication between the left ventricular cavity and the aneurysm and endocardial discontinuity at the site of myocardial rupture. The authors report two cases in which these criteria were fulfilled, leading to an echocardiographic diagnosis of pseudo-aneurysm which was erroneous as the operative findings were those of true left ventricular aneurysms.

[Cardiac pheochromocytoma. Failure of classic non-invasive diagnostic methods]

We report an exceptional case of cardiac pheochromocytoma which raised problems of localization. A 30-year old man who for several years had been hypertensive was admitted for attacks of paroxysmal hypertension. Very high levels of urinary catecholamines suggested a diagnosis of pheochromocytoma, but no tumour was found at computerized tomography (CT) and metaiodobenzylguanidine (MIBG) scintigraphy. However, regional venous samplings detected two para-carotid phaeochromocytomas which were surgically removed. Thereafter, the symptoms persisted and investigations were resumed. As new regional venous samplings persisted and investigations were resumed. As new regional venous samplings showed high levels of catecholamines in the right atrium, a mediastinal and, chiefly, cardiac phaeochromocytomas was suspected. No tumour was visible at CT or ultrasonography and another MIBG scintigraphy proved negative. Coronary angiography showed a very large tumour behind the left atrium, well supplied by the circumflex artery and by a branch of the right coronary artery. The patient was operated upon and is now totally asymptomatic after a 9-month follow-up. This case emphasizes the value of invasive methods (i.e. regional venous sampling and coronary angiography) in the localization of this ectopic tumour. In most cases, however, phaeochromocytomas can be localized by MIBG scintigraphy.

[Percutaneous transluminal angioplasty. Is there still a role for the surgeon?]

Relating their own clinical experience and that of the medical literature, the authors examined the role of the surgeon in coronary angioplasty. Despite the considerable progress made in the management of accidents, they believe that one must be able to resort to surgery--even if the percentage of patients who undergo emergency surgery decreases significantly--in the form of a standby procedure organized according to the difficulty of the angioplasty. Moreover, the surgeon uses this technique during the procedure for additional revascularization above the graft on collateral arteries and angioplasty can and should be used in a higher number of cases as a supplement for coronary bypass procedures.

[10-year results of anastomoses of the left internal mammary artery to the anterior interventricular artery. Angiographic and radionuclide controls]

The long term patency of left internal mammary artery graft is better than that of saphenous vein graft. The aim of this study was to determined if this high patency rate was accompanied by a satisfactory myocardial perfusion. Among 143 patients treated with an internal mammary artery graft on the left anterior descending artery between 1972 and 1976, 42 patients underwent coronary angiogram and exercise tomoscintigraphy (thallium 201) over 10 years after surgery. The left internal mammary artery was patent in 92% without any atheromatous lesions. The myocardial perfusion in the area supplied by the left anterior descending artery was normal in 74%. A slight ischemia appeared during exercise in 19% without any clinical symptoms. This long term study shows excellent anatomical results correlated with a good myocardial perfusion during exercise in most cases.

[Rupture of a retro-esophageal diverticulum on a right aortic arch. Apropos of a case]

Right aortic arch with retro-oesophageal left subclavian artery usually is an asymptomatic vascular abnormality. The evolutive potential of the associated retro-oesophageal diverticulum is unknown. Complications caused by the malformation are rare, but they may be extremely severe. A case of ruptured diverticulum in an adult patient is reported. The vascular abnormality, as well as the rupture, were confirmed by computerized tomography (CT) and angiography. Complications of retro-oesophageal diverticula are due to these formations being transformed into aneurysms, with compression of the oesophagus, dissection of the aorta or rupture. Such accidents raise the problems of detection of the abnormality, long-term surveillance of the diverticulum (facilitated by CT) and decision to be made when signs of transformation develop (resection of the diverticulum under extracorporeal circulation).

[Demonstration of the arterial system during phlebography of the leg for blue phlebitis]

Massive filling of thigh and calf arterial network was noted during phlebography in a patient with a typical clinical picture of "blue" phlebitis of lower limb. This paradoxical vascular injection allows support of current physiopathologic concepts of "blue" phlebitis (phlegmasia cerulea dolens).

[Aneurysm of the sinistro-anterior sinus of Valsalva causing coronary insufficiency. Apropos of a case]

The aneurysm of the sinistro-anterior sinus of Valsalva (ASASV) can very rarely be disclosed by symptoms of coronary insufficiency. The authors report the case of a 73 old man suffering from unstable angina pectoris, in whom the diagnosis of ASASV was evoked by two-dimensional echocardiography and confirmed by aortography. Coronary angiography revealed an external compression of IVA by the ASASV and allowed to exclude the presence of associated autonomous coronaropathy. The interest of this observation lies in the fact that the preoperative diagnosis was made after the two-dimensional echocardiography allowing the evaluation of the importance and volume of the ASASV. Aortography and coronary angiography are indispensable procedures in the presence of chest pain suspect of coronary insufficiency. These investigations will guide the surgical treatment which should always associate a closure of the aneurysmal neck, an aortic valvular replacement and a bypass of the compressed coronary artery.

[Clinical, echocardiographic and evolutive aspects of right atrial thrombosis]

The clinical and echocardiographic features of right atrial thrombi were examined in 9 patients, 5 men and 4 women aged 16 to 86 years. The 2D echocardiographic diagnosis was confirmed at autopsy (4 cases) or by the association of severe recurrent pulmonary embolism (5 cases). Three patients had associated ischaemic heart disease and on patient had dilated cardiomyopathy. The clinical presentation was: acute cor pulmonale (5 cases including 2 patients which biventricular myocardial infarction), chronic post-embolic cor pulmonale (1 case), tricuspid valve obstruction (1 case), general ill health with pyrexia (1 case) and heparin-induced thrombocytopenia (1 case). Predisposing factors included: absence of anticoagulent therapy (7 cases), previous supraventricular arrhythmias (2 cases) and right ventricular failure (6 cases, including 2 of right ventricular infarction). In 2 patients the thrombi were relatively immobile and had a wide base of implantation on the interatrial septum; in 1 patient, multiple thrombi were observed lining the right heart cavities from the inferior vena cava to the pulmonary infundibulum. In the other 6 patients, the thrombi were very mobile with a visible pedicule of implantation (2 cases) or totally free (4 cases). The variable polylobulated appearances, completely irregular whirling motion and intermittent prolapse into the tricuspid valve were characteristic features of the latter 4 cases. They disappeared spontaneously (2 cases) or after fibrinolytic therapy (2 cases) in under 36 hours. Three patients were operated with one postoperative death. The global hospital mortality was 22%. The present occasional detection of right atrial thrombosis will certainly become more common if patients with pulmonary embolism, right ventricular infarction or deep venous thrombosis are systematically examined by 2D echocardiography in the acute phase of their illness.

[Emergency coronary surgery after transluminal coronary angioplasty]

Twenty-five patients underwent emergency coronary arterial bypass surgery immediately after attempted percutaneous transluminal coronary angioplasty (PTCA). The average time between the onset of PTCA complication and revascularization was 90 min (30-120 min). The surgical indications, the anaesthesia and the perioperative intensive care were analysed. No acute complication was observed during the anaesthesia. Peroperative findings defined two groups: the first "organic" (coronary arterial dissection and/or occlusive coronary thrombi; n = 15), the second "functional" (coronary arterial spasm; n = 10). The rate of perioperative myocardial infarction was significantly higher in the "organic" group. In this group, at the end of the cardiopulmonary bypass, a higher number of patients required circulatory assistance and/or an antiarrhythmic agent, as well inotropic drugs.

[Surgery of the left coronary trunk by the transpulmonary approach. 10 cases]

The most common lesions of the left main coronary artery are atheromatous lesions (1% of all "coronary patients") but traumatic lesions may occur during coronary arteriography or percutaneous coronary angioplasty. To these must be added severe infectious lesions of the aortic annulus in acute endocarditis affecting the valve or a valvular prosthesis. The 10 cases reported here (4 atheromatous, 1 traumatic and 5 infectious lesions) were treated by transpulmonary repair surgery of the left main vessel. The operations performed were endarterectomy alone (2 cases) or associated with venous graft (2 cases), resection and venous graft (1 case) and suprasigmoidal prosthetic reimplantation (5 cases). There were two early post-operative deaths (one due to major hypocoagulation with secondary hypoxia and one from irreversible cardiogenic shock); another patient died of a ruptured intracerebral mycotic aneurysm 2 months after the operation. The 7 remaining patients have been asymptomatic for 1 year, and angiographies performed on 4 occasions since surgery have given "satisfactory results". The transpulmonary route gives direct access to the left main coronary artery and facilitates a reconstructive surgery adapted to the lesions encountered.

[Early coronary spasm after myocardial revascularization surgery]

Six cases of early post-operative coronary artery spasm were observed in a series of 460 consecutive patients who underwent myocardial revascularization. This is a rare accident, only quite recently described. The spasm involves the coronary arterial network or the graft and is reflected in an elevated ST segment accompanied by collapse and ventricular dysrhythmia. The condition may be lethal or may result in myocardial infarction. Treatment consists of calcium inhibitors. The cause of the spasm is unknown, but it seems to be encouraged by trauma of the coronary arteries during surgery and by metabolic changes (production of thromboxane A2) induced by the cardio-pulmonary bypass. This particular spasm must be watched by heart surgeons and their team in order to avoid some deaths and peroperative necroses, as it appears that we are only confronted with its more severe forms.

[Contribution of surgery in advanced valvular diseases]

Technical advances and progress in resuscitation over the last ten years have led to an appreciable improvement in the surgical results of valve replacements. However, it appears that the decision to operate is sometimes difficult in cases of advanced valvular disease. A study of the literature and our own experience lead us believe that despite a significant peri-operative mortality, surgical treatment remains the best form of treatment for these types of valvular disease, whether aortic, mitral or multivalvular. Surgery ensures a longer survival of better quality than does medical treatment. A better understanding of the natural history of valvular disease should enable us to refer those patients to surgeons who will benefit most from a valve replacement.