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36 patients with a total of 39 pericardial Ionescu-Shiley bioprostheses (20 aortic, 13 mitral and 3 double valve replacements) were studied. The population consisted if 12 women and 24 men with an average age of 33 +/- 11 years. The control was performed on average 7 +/- 4 months after surgery. At the time of investigation all patients were in functional classes I or II of the NYHA. The average cardio-thoracic ratio was 0.51 +/- 0.05. The catheter data showed a mean pulmonary capillary pressure of 10 +/- 2.7 mmHg, a mean cardiac index of 3.2 +/- 0.9 l/min/m2, a mean end diastolic volume of 132 +/- 33 ml/m2 and a mean ejection fraction of 0.53 +/- 0.12. Haemodynamic data was obtained under basal conditions and during intravenous infusion of isoproterenol. The average transvalvular pressure gradient was measured by transseptal catheterisation. The cardiac output was measured by dye dilution and the functional surface area calculated using the Gorlin formula (k = 44.5 for the aortic valve and k = 31 for the mitral valve). Perivalvular leaks were excluded by selective left ventriculography or aortography. The average transvalvular pressure gradients for the aortic valve prostheses (no 19 = 1, no 21 = 4, no 23 = 3, no 25 = 7, no 27 = 8) were 17 +/- 7 mmHg for no 19 and 21, 12 +/- 5 mmHg for no 23 and 25, and 9.7 +/- 2.7 mmHg for no 27.(ABSTRACT TRUNCATED AT 250 WORDS)

The benefits of surgical correction of mitral incompetence were assessed in 51 patients by comparing pre and postoperative catheter and quantitative angiographic results. The mean age of the patients was 43.5 +/- 12.3 years. The mitral lesions were elongation or ruptured chordae (27 cases), valvular perforation due to endocarditis (1 case) and the usual rheumatic disease in 23 cases. Hemodynamic investigation was carried out on average 2 months before operation and 29 +/- 22 months after surgery. The following angiographic parameters were measured : indexed end diastolic and end systolic volumes (EDV and ESV), ejection fraction (EF), myocardial mass (MM) and its ratio to EDV (hypertrophy coefficient : HC) and the geometry of the ventricle as assessed by diastolic and systolic coefficients of excentricity (DE and SE). Surgery comprised 13 mitral valvuloplasties and 38 valve replacements. Patients who suffered perioperative myocardial infarction or who had a residual valvular lesion were excluded from the study. After surgery, the hemodynamic state was considerably improved with a significant decrease in pulmonary capillary pressures (11 +/- 5 compared to 17 +/- 6 mmHg, p less than 0.09) and mean pulmonary artery pressures (19 +/- 7 compared to 27 +/- 11, p less than 0.01) and increase in cardiac index (2.8 +/- 0.7 compared to 2.3 +/- 0.6 l/min/m2, p less than 0.01). There was an associated decrease in ventricular volumes (EDV : 115 +/- 44 compared to 165 +/- 43, p less than 0.01) (ESV : 60 +/- 39 compared to 77 +/- 22, p less than 0.001). The reduction in myocardial mass was less spectacular (129 +/- 40 compared to 148 +/- 32, p less than 0.01) with a resulting increase in the HC (1.10 +/- 0.26 compared to 0.88 +/- 0.17, p less than 0.001). The geometry of the LV was less spherical in diastole (DE 0.76 +/- 0.08 compared to 0.70 +/- 0.08, p less than 0.001) and in systole (SE = 0.83 +/- 0.06 compared to 0.77 +/- 0.08, p less than 0.001). The EF fell slightly but this was not statistically significant (0.51 +/- 0.13 compared to 0.53 +/- 0.09 NS). The surgical result of 14 patients with PCP greater than or equal to 13 mmHg was considered hemodynamically incomplete, and this was confirmed by a lower cardiac index than in the remaining 37 patients (2.4 +/- 0.5 compared to 3.0 +/- 0.7, p less than 0.01).(ABSTRACT TRUNCATED AT 400 WORDS)

The echocardiographic appearances of a patient with a rare congenital malformation, interatrial septal aneurysm (IASA) associated with a hemodynamically significant left-to-right shunt, are described. A 52 year old man with Noonan's syndrome was admitted to hospital for atrial flutter with right heart failure, which, on investigation, led to the diagnosis of a rare type of atrial septal defect; 2D echocardiography showed an isolated aneurysm of the interatrial septum; cardiac catheterisation demonstrated a significant left-to-right (5 volumes of oxygen per 100 ml). The patient underwent surgery which confirmed the presence of a multiperforated aneurysm of the interatrial septum in the region of the fossa ovalis. This abnormality was resected and the interatrial defect closed; there were no postoperative complications and the cardiomegaly regressed significantly. The authors underline the M mode and 2D appearances of this condition; although it may be difficult on M mode examination to distinguish an IASA from other conditions giving rise to mobile intra-right atrial echos, such as Chiari's malformation, tricuspid valve vegetations, intraatrial tumour or thrombus or Eustachian valve, 2D examination using different incidences and contrast injections generally confirms the diagnosis. Surgery is often necessary after the detection of this echocardiographic abnormality: the surgical indications are described.

Distorsion due to inappropriate gain settings interferes significantly with the measurement of mitral valve surface area by 2D echocardiography. The problem is general and applies equally to all makes of echocardiographs whether they are mechanical or phased array scanners. The measured mitral surface area may even be false if the level of the recording gain is disregarded. We established a graph of the global distorsion of a system comprising an Aloka SSD 800 phased array sector scanner and a Tektronics hard copy recorder using a "tissue-equivalent" model and only varying the level of gain. Using these results a computerised program for automatic correction of the mitral surface area, with respect to the gain level used, was developed. The program was validated on a series of 56 patients with mitral stenosis by comparison with the catheter results obtained with the Gorlin formula, peroperative and pathological findings on resected valves. With this echo system in the zone of gain settings studied there was a significant underestimation of the uncorrected surface area. After correction, the distinction between severe and moderate stenosis was better and an improved correlation with the anatomical surface area was obtained. It would therefore appear necessary to calibrate the system used taking both the echocardiography and the recorder into account. Despite certain limitations, we believe that distorsion curves could be established using "tissus-equivalent" models.

Twenty seven cases of late thrombosis of ball and floating or tilting disc prostheses were studied. All patients were on anticoagulant therapy which appeared to be well adapted in 33% patients. Signs suggestive of thrombosis were inconsistant and the diagnosis was made on the association of severl of the following features: -- systemic embolism (44%); -- radiographic signs of left ventricular failure (51%); -- absence of opening click, variable A2 -- opening click intervals, apparition or aggravation of a systolic regurgitant murmur or a distolic murmur suggestive of obstruction on the phonocardiogramme; -- delayed opening of the mobile component or the presence of abnormal echos between the ball and anterior cage echo on the echocardiogramme; -- a gradient of over 12 mmHg across the prosthesis. An isolated episode of systemic embolism when the rest of the work-up is negative may be managed by the addition of a platelet antiaggregant and reinforcement of the anticoagulant therapy; further investigaton is advisable in the face of progressive symptoms. Fibrinolytic treatment and/or surgery is justified when systemic emboli recur or if the work-up is positive.

The purpose of this study was to determine the value of two-dimensional echocardiography and doppler ultrasound in the evaluation of the results and mechanism of percutaneous mitral valvuloplasty. The study involved 200 patients (77 p. 100 female) of mean age 43 +/- 15 years (range 13 to 79 years), most of whom were in NYHA class III or IV. The patients were divided into three groups according to the severity of the anatomical lesions. Group I patients (n = 58) had flexible valves and only minor alterations of the subvalvular structures; group II patients (n = 75) had flexible valves but deeply altered subvalvular structures; group III patients (n = 67) had calcified valves. Following valvuloplasty, the mean transmitral doppler gradient fell from 16 to 5 mmHg (p less than 0.0001) and the mitral valve area, as measured by two-dimensional echocardiography, increased from 1 to 1.9 cm2 (p less than 0.00001); the corresponding values at doppler measurement were 1 and 2 cm2 respectively. In patients successfully dilated, two-dimensional echocardiography showed that the mechanism involved was complete opening of one or both commissures. Before dilatation, 68 patients (34 p. 100) had an usually small degree of mitral regurgitation. After dilatation, grade 3/4 mitral regurgitation was observed in 9 patients (4.5 p. 100). The quality of the results obtained depended on the anatomical lesions.(ABSTRACT TRUNCATED AT 250 WORDS)

163 patients aged from 27 to 70 years (mean 52 +/- 10 years), including 152 men and 11 women, received a thrombolytic treatment within the first 6 hours (mean 192 +/- 73 mn) of a myocardial infarction. 61 patients received streptokinase (SK) intravenously (group 1), 64 patients, single-chain rt-PA (group 2), 11 patients, two-chain rt-PA (group 3), 11 patients, rt-PA followed by intracoronary streptokinase (group 4), and 16 patients, acyl enzyme (group 5). In addition, all patients had heparin and 86 (53%) had aspirin. Immediately after thrombolysis, coronary arteriography was performed in 95 patients (58%), and this was followed by transluminal angioplasty in 49 of them (30%). The infarction was either anterior (n = 81) or inferior (n = 78) or lateral (n = 4). No fatal or neurological bleeding occurred. 17 haemorrhagic complications were observed; 5 of these (3%) were severe, requiring blood transfusion and, in 1 case, surgery; 12 were significant (7.4%) and produced changes in haematocrit. Nine of the 17 haemorrhages were associated with catheterization and localized to the site of arterial puncture. Severe bleeding occurred in patients treated with intravenous SK (3/61) or with rt-PA followed by intracoronary SK (2/11). There was a significant difference in the incidence of spontaneous bleeding between the SK group (4/61) and the single-chain rt-PA group (0/64; p less than 0.05). In the latter group, the minimum fibrinogen level was lower in patients who had a haemorrhagic complication.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma antidiuretic hormone (ADH) was greater in patients with cardiac failure than in healthy subjects. Plasma ADH increased significantly with age in both groups. Covariance analysis showed that the difference between patients and controls occurred whatever the age. Plasma sodium and plasma osmolality were lower in cardiac patients than in healthy subjects. This showed that increase in plasma ADH observed in patients was inappropriate since it coexisted with inhibitory levels of plasma osmolality. Plasma creatinine was greater in cardiac patients than in healthy subjects and for each group in elderly than in young people. But there was no significant correlation between plasma ADH and creatinine. This suggested that increase in plasma ADH observed in cardiac failure was due more to an augmented release than to a diminished catabolism. No clear influence of etiology, severity, length of the disease and treatment with diuretics could be demonstrated.

From a series of 10 patients undergoing surgery with a homograft, two cases are reported in which stenosis of the graft occurred, one in the mitral and the other in the aortic position. The macroscopical appearances of the lesions showed sclerosis and calcification. In the case where histological material was available, there were marked changes in the collagen and elastin, disseminated calcified deposits in the valve, and inflammatory cellular changes over the surface, with a tendency to penetrations into the substance of the valve. One of the factors leading to these graft disorders is the type of chemical treatment which the valve undergoes; a combination of glutaraldehyde solution and oxidation using sodium metaperiodate would appear to be unsuitable in this respect. Emphasis is laid on the very particular clinical features of these two cases (stenosis and valvular incompetence), and on the difficulties in diagnosis of this condition.

The aim of this cooperative study was to analyse the clinical profile of subvalvular aortic stenosis (SVAS) in adults. Thirty one cases were collected : patients aged 17 to 60 years (average 34 years). The diagnosis was confirmed in all patients either at surgery (30 cases) or at autopsy (1 case). The overall incidence of SVAS in patients with fixed obstruction to left ventricular ejection operated in the same period was 3.5%. Associated congenital malformations were detected in 15% of cases but intracardiac shunts were rare. Adult SVAS is a purer malformation than in children, probably because of spontaneous and surgical selection. The anatomical type of stenosing lesion in this series was a subaortic ring or membrane; 45% of patients, usually over 40 years of age (7 out of 9) had localised septal hypertrophy at the level of the diaphragmatic obstruction. The clinical presentation was that of mixed aortic disease with associated stenosis and regurgitation. Over 80% of patients had aortic incompetence diagnosed clinically (26 out of 31 cases) or on aortography (24 out of 25 cases); the regurgitant flow was assessed as mild in 15 cases, moderate in 6 cases and severe in 3 cases. There were obvious valvular lesions at surgery in 19 cases, especially in patients over 40 years of age (8 out of 9 cases). The mechanism was variable : non-specific (8 cases), destructive (6 cases), rheumatic (2 cases) or congenital (3 cases). Bacterial endocarditis was particularly common (26% of cases). Adult SVAS is a particularly difficult clinical diagnosis : the electrocardiogram and chest X-ray are not very informative.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiopulmonary bypass (CPB) may be a cause of myocardial damage in a small number of patients undergoing valve replacement (4 out of 1576 valve replacements). The responsibility of CPB can only be presumed when: the degree of myocardial dysfunction after surgery can be quantified, other causes of myocardial dysfunction are excluded. the type of valvular disease is taken into consideration. Variations in load after correction of certain lesions (mitral regurgitation) makes changes of LV systolic function difficult to interpret. The first case concerned a 23 year old patient operated for aortic regurgitation (Björk prosthesis) under local and general hypothermia and followed-up for 1 year after surgery. Ventricular extrasystoles and left bundle branch block were observed during surgery and radiological and echocardiographic LV dilatation persisted with deterioration of echographic, isotopic, haemodynamic and angiographic parameters of LV function: ejection fraction fell from 62% before surgery to 35% with diffuse hypokinesia and persistent LV dilatation (191 vs 188 ml). In the absence of prosthetic valve dysfunction, associated valve lesions or coronary artery disease, LV deterioration was attributed to CPB and inadequate myocardial protection. In two other cases (60 and 62 years) correction of aortic stenosis (Starr 1260) with coronary perfusion was followed by cardiac failure with left bundle branch block, deterioration of LV function, and death after 3 years in one case and precarious survival at 10 years in the other. In a fourth case (mixed mitral valve disease corrected by a Starr prosthesis under aortic clamping), the variation of cardiac load before and after surgery made changes in LV function difficult to interpret. (ABSTRACT TRUNCATED AT 250 WORDS)

A 56-year-old woman with familial heterozygous type II hyperlipoproteinaemia and tendinous xanthomas, presented the unusual findings of acquired supravalvular aortic stenosis associated with a congenital stenosis of the orifice. Analysis of clinical, paraclinical, and particularly pathological data confirmed the existence of several associated lesions: congenital hypoplasia of the aortic ring and proximal aorta, calcified valve stenosis probably increased by the dyslipidaemia, and finally and principally, supravalvular stenosis formed of a veritable circular rim of atheromatous material, making up a second haemodynamic obstacle. It is probable that the pre-existing congenital aortic lesions in this case, apart from the hyperlipoproteinaemia, account for the observation, not previously reported in a heterozygous type II hyperlipoproteinaemia, of massive supravalvular atheromatous deposits. This latter of acquired lesion is described in 9 cases reported in the literature with a homozygous form of familial hypercholesterolaemic xanthomatosis, the atheromatous deposits in the proximal aorta appearing earlier in these patients, and in the absence of pre-existing anatomical anomalies.

A 38 year-old man, operated upon two years previously for combined mitral and tricuspid valve disease of rheumatic origin, presented with signs of a severe biological inflammatory syndrome, and a mild proliferative glomerulonephritis (normal complement with exclusively mesangial deposits of IgM, Clq, and C3 on immunofluorescence), which developed slowly over a period of 3 years in the absence of any fever. Blood cultures were always negative, and prolonged antibiotic therapy on two occasions had no effect on the clinical or biological picture. Mitral prosthesis replacement was necessary 6 months after the onset of the affection, a second leakage 16 months later leading to rapidly fatal heart failure. Pathological examination confirmed the presence of an endocarditis at the zone of insertion of the prosthesis. The slow progression of the disorder in this case, and the absence of fever, emphasize diagnostic difficulties of certain cases of endocarditis, due to low virulence germs, that progress under cover of a generalized disease of renal expression. The value of renal biopsy, which provided almost specific indications in the present case, is also stressed.

The frequent coexistence in adults of a tight aortic stenosis and coronary arterial lesions raises problems of therapeutic and diagnostic approach. In an attempt at selecting indications for coronary arteriography, we studied 253 patients with severe aortic stenosis who were explored by that method. 177 patients (70 p. 100) had no coronary disease (group I); 76 patients (30 p. 100) had significant coronary lesions (group II). Group II patients differed from group I patients in several respects: they were older: 65 +/- 9 years on average as against 61 +/- 9 years (p less than 0.01); there was a greater proportion of men in that group: 76 p. 100 vs 58 p. 100 (p less than 0.01); more patients had a history of myocardial infarction: 7 p. 100 vs 0.5 p. 100 (p less than 0.05); calcifications of the coronary arteries were found in 43 p. 100 of the cases as against 15 p. 100 in group I (p less than 0.001); the transvalvular pressure gradient was lower: 50 +/- 30 mmHg vs 72 +/- 31 mmHg (p less than 0.01). There were no other significant differences in risk factors between the two groups, except for overweight which was greater in group II. Attacks of angina were not statistically more frequent in group II (80 p. 100) than in group I (73 p. 100, N.S.). A multifactorial analysis enabled us to establish a discriminant relation involving the patient's age, sex and history of infarction as well as coronary calcifications.(ABSTRACT TRUNCATED AT 250 WORDS)

Twenty two cases of recurrent perivalvular leaks in aortic valve prostheses were reviewed in a multicentre cooperative study. From 1963 to 1978, 22 patients, mean age 39 years, underwent aortic valve replacement; 18 patients had aortic regurgitation, 6 due to infective endocarditis, and 4 patients had calcific aortic stenosis. Eight Starr-Edwards, 6 Smeloff-Cutter, 2 Braunwald-Cutter, 3 Björk, 1 Lillehei-Kaster and 2 bioprostheses were inserted. All 22 patients had to be reoperated for perivalvular leaks due to active or previous infective endocarditis in 7 cases. The prostheses implanted (3 reinsertions, 19 valve replacements) were 10 Starr-Edwards, 4 Smeloff-Cutter, 5 Björk, 1 Lillehei-Kaster, 1 Magovern and 1 bioprosthesis. All 22 patients had further perivalvular leaks, 6 caused by infective endocarditis, and 15 patients underwent a third operation. The prostheses implanted this time (2 reinsertions, 13 valve replacements) were 4 Starr-Edwards, 3 Smeloff-Cutter, 7 Björk and 1 bioprosthesis. Four patients had a third perivalvular leak, and 2 patients a fourth perivalvular leak. The first and second episodes of perivalvular leak were detected early in over half the cases. They were associated with cardiac failure, angina and hemolysis in 20 to 45% of cases. The average period between the first and second operations, and the 2nd and 3rd operations were 15 months and 9 months respectively. Overall, 11 patients died (50%), 4 due to cardiac failure and 3 of sudden death; 3 patients have been lost to follow-up (14%), and there are 8 survivors (36%) with a mean follow-up period of 5 years. However, the mortality rate when the cause of perivalvular leak was infective, was 82%, and only 18% when the cause was mechanical. The factors which favour recurrent perivalvular leaks are infection (30% of cases) and technical difficulties related to the poor quality of the aortic ring (calcification, dystrophy or dilatation). The prevention of this complication depends on careful peroperative technique, the use of certain surgical bypass techniques, a constant battle against infection, and regular examination of operated patients.

There is increasing number of cases of acquired immune deficiency syndrome (AIDS) and in France there have been about 100 cases. The authors report one case who died within 10 months. The patient presented a Pneumocystis carinii pneumonia, extensive peri-anal herpes, gastro-intestinal candidiasis and, in the final stage, severe diarrhoea. In the context of this case, the authors review the principal manifestations of this new clinical entity.

During the course of their preoperative assessment, 41 patients with severe mitral valve disease underwent left ventricular cineangiography, AP and lateral at rapid speed (100 images per second). This gave a particularly precise anatomical and physiopathological inventory of the lesions, as was confirmed by preoperative findings. The presence of mitral stenosis was confirmed in all cases and an indication of its degree in the majority.

Studies of the serological development after 26 renal transplants confirm the high frequency of antibody rises not only against the herpes virus group, but also against other virus groups such as measles, Coxsackie B viruses. These antibody rises correlate with febrile episodes and hepatic dysfunction in which CMV is the most often involved. However, the frequency of antibody rises against various viral antigens without any clinical event to suggest viral etiology; the lack of concomitant virus isolation (except the herpes group), as well as the ocurrence of simultaneous antibody rises against several viruses, all suggest that some of these various antibody rises observed may be related to immunological dysfunction rather than to virus infection.

Cardiovascular manifestations of Lobstein's disease are rare, probably unrecognized, and determining factors for the final prognosis, the most frequent lesion being aortic incompetence. The eleventh case to be reported with pathological findings in the literature is described. This complication is usually found in men, blood regurgitation being large in amount, symptomatic, and progressive. Its mechanism is related less to dilatation of the aorta and its ring than to valvular changes, they being frequently bicuspid and dysplasic. Histological findings, not however pathognomonic, are myxoid degeneration in the valves and parietal cystic necrosis in the aortic wall. Apart from the absence of an aneurysm and aortic dissection, macro- and microscopic lesions are similar to those observed in Marfan's syndrome and osteogenesis imperfecta. Operative therapy was employed in all eleven cases, with three postoperative deaths and three later deaths. Certain complications arise from uncontrollable severe hemorrhage, which justifies the use of valve heterografts not requiring antivitamin K administration.

This study analyses the echocardiographic findings in 41 cases of severe mitral regurgitation due to chordal rupture (33 cases), elongation of chordae (4 cases) or valve trauma (4 cases). The operative findings are given. It was possible to make the diagnosis of chordal rupture in 60% of cases by recording one or more of the following signs:--For the anterior cusp: amplitude of motion equal to or greater than 38 mm; co-existence of chaotic diastolic fluttering and multiple systolic echoes; recording of several diastolic wave forms of the anterior cusp, out of phase and crossing each other;--For the posterior cusp: paradoxical movement of the cusp in systole and diastole; presence of an echo in the left atrium in systole. The group studied was compared with a group of 40 normal subjects and 48 cases of other types of mitral regurgitation which were severe and received surgery. The various signs had good specificity. The sensitivity of the different signs varied from 33 to 50% of cases. It was greater when the number of chordal ruptures was greater. Whichever cusp was affected, it was sometimes the site of high frequency and large amplitude systolic vibrations, which were found in a quarter of the patients. The specificity of this sign is discussed. The diagnosis of rupture of chordae is possible in a large proportion of cases and the causes of error are analysed.

The case reported here concerns a female of 33 who presented, during the course of an acute bacterial aortitis which had been treated, with an inflammatory perforation of the membranous septum. The clinical picture consisted of an association of very severe heart failure with severe aortic incompetence, an apical pansystolic murmur, and atrioventricular conduction defects. Although it was carried out in the presence of active endocarditis (valve cultures positive for streptococci), operative intervention (Patch + Starr) allowed rapid healing and excellent cardiovascular function after a 30 month follow-up period. Careful study of this case and of the eleven others in the literature has enabled us to underline the following points:--the sudden appearance, in a case with infective aortic incompetence, of a gross pansystolic murmur associated with atrial or intraventricular conduction defects, should be taken as suggesting a septal perforation;--examination of the haemodynamic system in such a case runs certain risks, and should never be allowed to delay the operation, which must always be carried out urgently;--despite the unfavourable operative conditions, the results strongly support the need for surgical intervention in these patients in good time.

Seventy nine patients were operated for aortic regurgitation due to bacterial endocarditis confirmed anatomically at surgery between 1968 and 1984. They were classified into 3 groups according to the stage of endocarditis at the time of operation: progressive endocarditis (21 cases), recent endocarditis (39 cases) and late endocarditis (19 cases). The patients were adults (21 to 70 years) and predominantly male (82 p. 100). Previous valvular disease was found in 38 cases, bicuspid aortic valves were found in 21 cases. Most of the patients operated early (recent progressive endocarditis) had cardiac failure and the surgical indication was nearly always poor haemodynamic tolerance. In addition, this indication was also retained in late forms of the disease in patients usually panci-symptomatic in the presence of signs of increasing left ventricular dysfunction. The aortic lesion was the only pathology in 55 cases and was associated with periannular abscess in 8 cases, septal abscess in 5 cases including one with septal perforation, and mitral endocarditis in 12 cases. Seven patients died during surgery, in low output states in 6 cases (global mortality 8.9 p. 100). The 72 survivors were followed up for an average period of 5 years (4 to 168 months); three patients were lost to follow-up. The actuarial survival rate including the operative mortality was 77 p. 100 at 5 years and 64.6 p. 100 at 10 years. Valve dehiscence was common (52 p. 100); although the perivalvular leak was usually small, in 11 cases it was quite severe and 7 patients had to be reoperated. An excellent functional result was observed in 30 cases, especially in those patients operated early.

The authors report a case of traumatic left ventricular aneurysm, presenting with recurrent cerebral embolism, 36 years after a thoraco-brachial bullet wound. The 58 year old man had no symptoms of angina or particular cardiovascular risk factors. The ECG showed changes of chronic anterior wall infarction, observed 10 years previously on a routine preoperative recording. There was a calcified circular para-apical shadow on chest X-Ray. The antero-apical region showed hypofixation on myocardial scintigraphy, and hypokinesia on isotopic angiography. The coronary arteries were normal. Indium III platelet marking revealed a focus of hyperfixation within the left ventricle. At surgery, a true calcific para-apical left ventricular aneurysm was discovered, containing a fresh thrombus. This lesion was resected. Peroperative Indium III platelet test confirmed that the thrombus was the site of high uptake. The surgical result was good at 6 months follow-up. This case illustrates: the value of the Indium test which would appear to be a very specific and sensitive method of detecting intraventricular thrombi. This test, which appreciates the thrombotic activity of intracardiac masses is a useful complement to other non-invasive methods such as 2D echocardiography; the special characteristics of post-trauma left ventricular aneurysms which are rare, often diagnosed late, at the time of complications such as systemic embolism, commonly pose medico-legal problems, and for which surgical treatment seems to be indicated in symptomatic patients.

The aim of this study was to assess the outcome of 79 patients operated for chronic, pure, severe aortic incompetence with little or no symptoms (Grades I or II of the NYHA Classification). The average age of the patients was 42 years (range 14 to 76 years) and the average follow-up period was 59.4 months (range 3 to 190 months). The preoperative left ventricular volumes on angiography were: end diastolic volume 224 +/- 47 ml/m2, end systolic volume 121 +/- 39 ml/m2. The ejection fraction was 48 +/- 10 p. 100. Forty two mechanical prostheses and 37 bioprostheses were implanted. There were no operative deaths. The 8 year survival rate was 87 p. 100. Ninety four per cent of the survivors remained asymptomatic; 91 p. 100 have had no thromboembolic complications and 90 p. 100 have not been reoperated. The incidence of myocardial dysfunction was 8.8 p. 100 during this period. The most significant poor prognostic factor was a preoperative ejection fraction of less than 40 p. 100. These results show that early surgery in patients with aortic incompetence and little or no symptoms has a low operative risk and a low incidence of late myocardial dysfunction despite severe left ventricular dilatation with decreased left ventricular function.

By their frequency and their gravity thrombo-embolic accidents (TEA) represent the principal complication provoked by prosthetic valves. They rarely manifest themselves by an occlusive thrombosis of the valve but more usually by systemic embolisms, particularly neurological, which entail sequelae or death in more than a third of the patients. These embolisms are recurrent in one case in three. Several factors which favour TEAs are the mitral position of the valve, its mechanical nature, embolisms being rarer and less severe and occlusive thromboses exceptional with bioprostheses, and the imperfect quality of anticoagulant treatment. This last factor introduces an additional risk at least as serious as the TE risk (1 to 6 percent of patients/year with severe haemorrhage). The prevention of TEAs depends on the type of treatment with antivitamins K (AVK) and possibly on the combination of AVK--anti-aggregating agents. The best means of prevention lies in the rational choice of the prosthesis in each individual case. It is beyond question that the frequency of TEAs with mechanical valves in the mitral position and the requirement for anti-coagulant treatment entailing its own risks encourage extension of the indications for biological valves.

The timing of surgery in chronic aortic regurgitation depends to a large extent on the operative results that may be expected in this type of valve disease. In 88 cases of chronic aortic regurgitation submitted to surgery there were 6 operative deaths (6.8%). Five years after operation the actuarial survival was 58% for the whole of the group and 68% for cases of rheumatic aortic regurgitation. Analysis of the causes of failures, late deaths, persistence or recurrence of severe impairment of activity, and of serious disturbances of ventricular rhythm, showed that the most important cause was myocardial dysfunction, which was responsible for two thirds of the bad results. Analysis of the late prognosis as a function of the various pre-operative parameters revealed the bad influence of cardiomegaly as measured by radiological examination (cardio-thoracic ratio and cineangiography) and of disturbances in left ventricular function. The actuarial survival curves showed very significant differences according to whether the cardiothoracic ratio was greater or smaller than 58%, and according to the amount of heart failure pre-operatively. Similarly, an end-diastolic volume index of 240 ml/m2 and an ejection fraction less than. 40 seemed to be serious findings. These facts, taken in conjunction with the natural history of this valve lesion, suggest that the indications for surgery should not only be symptomatic aortic regurgitation but also well tolerated regurgitation in which cardiomegaly, end-diastolic volume and/or the ejection fraction have reached a certain level.

A false aneurysm of the left ventricle was successfully operated upon in a patient who had developed postoperative purulent pericarditis after resection of a post-infarction ventricular aneurysm 5 months previously. The authors describe the clinical, anatomical, radiological, and ultrasonographic characteristics of false aneurysms, which occur more frequently after myocardial infarction than postoperatively. Other, more rare causes are described, as well as recent data reported in published literature. The role of infection in certain postoperative forms is emphasized. Apart from angiography, non-invasive methods such as bidimensional ultrasonography and angioscintigraphy play an important role in establishing the diagnosis, avoiding explorations which are not without risk in debilitated patients. The frequency with which rupture of false aneurysms is observed, in contrast with true aneurysms, entails early recognition and operation on a regular basis, even when signs of intolerance are absent.

Molsidomine, one of the sydnonimine group of drugs; the object of this study was to evaluate its efforts in refractory cardiac failure. In the first part of the study, the haemodynamic effects of a single oral dose of 2 or 4 mg of molsidomine were compared with placebo controls in 23 patients. This showed molsidomine to be an active venous vasodilator reducing pulmonary artery and right atrial pressures without changing cardiac index or systemic pressures. The peak effect was observed after 1 to 1,5 hours. In the second phase, molsidomine was used in 9 patients aged 32 to 71 years (mean 47 +/- 12 years) over an average period of 19 months (3,5 to 42 months). The maintenance dose varied from 8 to 24 mg/24 hours. These patients had refractory cardiac failure secondary to primary cardiomyopathy with dilatation (6 cases) or ischemic heart disease (3 cases). The 9 patients were in functional classes IV (5 cases) or III (4 cases). Four patients were theoretically good indications for transplantation. Haemodynamic control was performed 1,8 +/- 5 months after a washout period of 8 hours, and after initial right heart catheterisation, the measurements were repeated 1 hour after oral administration of a 4 mg dose of molsidomine. Two patients did not respond initially to molsidomine; one died, the other remained in functional Class III. Another patient who responded initially was improved for over two years but died in cardiac failure after 42 months' treatment. The other six patients have been significantly improved and were in functional Class II at their last control.(ABSTRACT TRUNCATED AT 250 WORDS)