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Papillary fibroelastoma is a rare, benign, primary cardiac tumour. The authors report three cases presenting with transient or full cerebrovascular accidents. The tumours were diagnosed during investigation by echocardiography, especially transoesophageal echocardiography. In view of the severity of symptoms and the high risk of recurrence, the patients were rapidly referred for surgery. In two cases, the tumour was located on the aortic valve at several sites. In one case, the tumour was single and implanted on the mitral valve. Surgery was successful with the pathology reports confirming complete ablation. The patients have not had any recurrence to date. The multiple nature of these tumours raises the questions of local spread, secondary degeneration of valvular nodes? The problem of possible recurrences is discussed.

The authors report the case of a patient presenting with pulmonary embolism in which transthoracic echocardiography showed the presence of an intracardiac thrombus trapped in a patent foramen ovale; this was confirmed at surgery. It is rare to see this type of thrombus (which usually gives rise to paradoxical embolism) by transthoracic echocardiography. Previously, this used to be a postmortem diagnosis but the condition is often suspected nowadays when deep venous thrombosis and/or pulmonary embolism, an unexplained systemic embolism and a right-to-left interatrial shunt, are associated. However, the diagnosis can only be confirmed by the visualisation of the thrombus crossing the interatrial septum.

The authors report two cases of cardiac rupture during acute myocardial infarction successfully treated surgically. In the first case, rupture occurred 7 days after hospital admission for anteroseptal myocardial infarction. The patient developed sudden cardiogenic shock with signs of venous hypertension without left ventricular failure. The second patient was admitted for syncopal chest pain with transient hypotension which regressed after volume repletion and pressor amine therapy. On admission, the patient had signs of cardiac tamponade. The ECG showed recent inferolaterobasal myocardial infarction. In both cases the diagnosis was made by 2D echocardiography which showed voluminous circumferential pericardial effusions probably due to haemorrage, with an image very suggestive of a blood clot in the effusion of the second patient. The two patients underwent emergency cardiac surgery and both survived with a 4 and 1.5 month follow-up respectively. These two cases confirm the value of 2D echocardiography as an emergency bedside procedure for the diagnosis of cardiac rupture, especially when images of intrapericardial thrombosis are observed, as in our second patient. In addition, the first case raises once again the question of the role of late thrombolysis as a predisposing factor of cardiac rupture at a time when this technique is proposed up to 24 hours after the onset of symptoms.

The echocardiographic information obtained pre-operatively with an electronic linear scanning system (Multiscan) was compared with the results of pathological examination of the excised mitral valve in 92 patients, and showed a close correlation. The way in which the pathological changes influence the various parameters usually used to distinguish this type of rheumatic valvular disease is demonstrated. Two-dimensional imagery provides precise information : this is shown by comparison of the still frames of the videoscopic recording and the photographs of the corresponding pathological specimens. Valve thickness, length and thickness of the chordae, calcification, mitral valve surface and commissural separation are well shown, especially at the anterior leaflet. Study of transverse incidences seems the most reliable method of estimating mitral valve area. Systolic separation of mitral valve echos, according to the usual criteria, is a good sign of associated mitral incompetence and was found in 83% of cases of mixed mitral valve disease. The mean values of anterior mitral leaflet excursion, diastolic slope and opening speeds were compared in three groups of mitral stanosis with preferential antatomical features and a control group of pure mitral stenosis with supple valves. No individual parameter was found to be specific for a particular antatomical feature, showing multiple correlations to be indispensable. The difficulty of diagnosis by isolated traditional echocardiography is confirmed and the association of two dimensional imagery would seem essential not only in making the diagnosis but also in the pre operative work up.

The technique of multiple outlet saphenous vein grafting with one or several alternating lateral anastamoses was used in 43 patients over a one year period; over half the patients had triple vessel disease, one third had double vessel disease; a total of 128 coronary arteries were revascularised 2.9 arteries per patient, with 60 side to side anastamoses, 1.4 per patient. The technique of this type of bypass necessitates paying particular attention to avoid kinking or twisting of the graft. The blood flow through multiple outlet graft is on average significantly greater than in the classical types of graft, and is one of the main points in favour of this technique and in keeping the graft permeable in the long term. The short term results of this technique are good with a hospital mortality of 4.6% and a peri-operational infarction rate of 6.9%, figures which are comparable with the results of classical bypass grafting techniques in multivessel coronary artery disease.

The aortic subvalvular region is difficult to approach. The results after resection through a pure transaortic approach are often unsatisfactory. An aorto-septal approach derived from the Konno-Rastan aortoventriculoplasty was experimented in animals. This technique involves opening the ascending aorta and the pulmonary infundibulum, section of the aortic annulus at the left anterior commissure and incising the muscular interventricular septum. The results of this aorto-septal approach show: - that the whole left ventricular ejection tract can be exposed; - that the incision can be closed without damage to the heart, i.e. creation of atrioventricular block, and with reconstruction of an intact interventricular septum and a normally functioning aortic valve. This approach could therefore be used for the treatment of diffuse subvalvular aortic stenosis: - subaortic fibromuscular tunnel without hypoplasia of the aortic ring (one personal case has already been reported); - severe forms of hypertrophic obstructive cardiomyopathy with asymmetric septal hypertrophy.

Commissural disorganisation secondary to incomplete rupture of the ascending aorta was found at surgery for massive aortic incompetence in a young man with previous hypertension. The lesions were repared by a conservative procedure with an excellent result 3 years after surgery. Incomplete spontaneous rupture of the ascending aorta occurs in the same terrain as dissection of the aorta (hypertension, aortic media necrosis) of which it represents a minor form. It may remain asymptomatic but it is usually complicated either by secondary intrapericardial rupture, by aortic aneurysm or by aortic incompetence due to valvular prolapse. When valvular prolapse is associated with another lesion which aggravates the regurgitation (aortic valve disease, aortic ring dilatation) aortic valve replacement should be performed with a prosthesis; on the other hand, when commissural disorganisation giving rise to valvular prolapse is the cause, a conservative procedure may be envisaged.

Emergency myocardial vascularization through an aorta-to-coronary by-pass has been extended recently to acute evolutive accidents of coronary artery disease: either to its minor forms, as the menace syndrome, or its more severe forms, such as complicated myocardial infarction. This study aimed at a retrospective analysis of 50 patients, all operated upon as an emergency, by the same surgical team. The problems peculiar to any group of indications, and the practical and theoretical problems posed by extension of this type of emergency surgery were discussed.

The "small aortic ring" was until recently an unresolved problem for surgeons operating on the aortic valves. It used to contraindicate valve replacement in the child, and sometimes led to the insertion of too small a valve in the adult. Some hope of a solution has appeared in the form of three new techniques: enlargement of the aortic ring over the mitral valve, aorto-ventriculoplasty, and apico-aortic shunt. Two adults have had the ring enlarged above the mitral valve with good results in both cases. Five children have had an aorto-ventriculoplasty with good results in two cases, post-operative atrio-ventricular block in one, and two deaths, one early and the other late. These deaths appear to be more closely related to the severity of the initial lesion and to the degree of decompensation of the myocardium than to the operation itself. There are advantages and problems with this technique. An attempt has been made to systematise indications for treatment as a function of the lesions and the state of the patient.

31 survivors of a group of 49 patients with septal rupture during acute myocardial infarction were operated on average 8 days after the onset of necrosis. The operation was performed after a period of circulatory assistance in 23 cases and consisted of septal reinforcement, closure of the perforation and resection of necrotic tissue. The results were satisfactory in patients operated on early after effective resuscitation (91 p. 100 survival), and better than in the patients operated on after the maximum possible delay (50 p. 100 survival) and in patients in whom poor tolerance of the VSD led to an emergency salvage operation (29 p. 100 survival).

Aortic arch hypoplasia is rare but carries a poor prognosis. It is usually associated with a left to right shunt at ventricular level. The association of an aorto-pulmonary fistula is exceptional. A case of a 5 1/2 month old infant treated successfully by simultaneous correction is reported with a review of the physiopathological changes. Pulmonary hypertension and aortic perfusion depend on the calibre of the ductus arteriosus and its evolution. The therapeutic problems which result are the suppression or palliation of pulmonary hypertension and resaturisation of distal aortic vascularisation. Surgery is the only hope of cure, and current techniques are reviewed: two stage procedures with revascularisation of the distal aorta and pulmonary artery banding, or simultaneous correction of aortic continuity with suppression of the left to right shunt under cardiopulmonary bypass. The technical conditions are analysed: perfusion of the different aortic segments, methods of reestablishing aortic continuity. Good results are as yet rare, and are obtained after complete correction under cardiopulmonary bypass.

Resection of left ventricular tissue seems to be playing an increasing part in the treatment of the sequelae of myocardial infarction. In a total of 700 patients who underwent surgery for some aspect of coronary atherosclerosis, 40 underwent resection of left ventricular tissue. In the majority of cases, diagnosis rested on left ventricular cine-angiography and in 3 cases this had to be carried out as an urgent procedure with circulatory assistance using diastolic counter-pressure (DCP) from an intra-aortic balloon. A selective contrast technique for the two coronary arteries was used whenever possible. The surgical anatomy of the lesions indicates a difference between a localised dyskinesia and diffuse dyskinesia, the latter having a severe effect on left ventricular function. In a group of localised dyskinesias, the territory supplied by the anterior descending artery was by far the most frequently affected. Resection of left ventricular tissue was associated with a myocardial bypass revascularisation procedure in 9 cases, valve repair in 7 cases, and closure of a septal perforation in 3 cases. The total inpatient mortality rate is still quite high (23.1%) because of the severity and widespread nature of the coronary disease. However, the mid-and long-term results are good, the criteria being functional improvement and the actuarial 4-year survival rate.

Fifty cases of intermediate forms of atrioventricular defect were treated surgically. The operation was performed in the traditional manner in all cases. One post-operative death and three cases of severe mitral incompetence leading to reoperation were observed. The authors emphasise that it is essential to look for and excise the chordae and abnormal fibrous bands, that it is generally unnecessary to touch the tricuspid valve and that there is a danger of obstructing the aortic canal if the correction of the asymmetry of some mitral clefts is attempted. Analysis of the results leads them to tend to respect the cleft mitral valve when the regurgitation is minimal and to suture it all along its length when the regurgitation is severe. Mitral annuloplasty may be a useful complementary procedure and a left atrial approach may be proposed with this in mind in certain cases. Conduction defects remain a serious problem in this type of surgery; not so much complete heart block, which is exceptional, but trifascicular block, often present preoperatively, whose prognostic is, to say the least, uncertain.