Biomedical subjects
Publications and source records attributed to C Christides.
Chondroid hamartomas disseminated in both lung fields were discovered in a 76 year old man presenting with recurrent haemoptysis. In view of this metastatic cannonball appearance and the negative investigations, exploratory thoracotomy was performed, revealing the correct diagnosis. Although classical, this form of hamartoma is rare and warrants a case report.
The authors report about one case of bacterial endocarditis complicated by fungal aneurysms in a superior mesenteric and a popliteal site. While the diagnosis was easy for the popliteal aneurysm, it was not so for the mesenteric aneurysm. Arteriography must have wide indications. The treatment of such aneurysms must always be medical, but surgical as well. The surgical tactics must be carefully discussed, and the restoration of vascular continuity with autologous venous material through an extra-anatomic course should be preferred.
We report about a 66-years-old obese and diabetic female patient, treated with anti-inflammatories for osteoarthritis of the hip and operated for varices of the lower limbs by a bilateral stripping of the internal saphenous veins, who presented with a mortal necrotizing fasciitis during the postoperative period. Necrotizing fasciitis is a severe, infrequent disease jeopardizing the vital prognosis, in which an appropriate and early treatment (medical, using antibiotics, and surgical by extensive debridement) can prevent a fatal outcome. The most often involved germs are streptococci (45%). The association of anaerobic and aerobic germs sometimes causes mixed cellulitis. The vital prognosis is always threatened by postoperative fasciitis. The mortality rate ranges from 50 to 75%, the main causes of death being a septic shock or pulmonary embolism. The functional prognosis of the surviving patients depends on the extent and quality of surgery.
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Four patients aged over 70 received mechanical circulatory assistance for a period of 2 to 48 hours after myocardial revascularisation surgery. Three patients survived. The simplicity and modest cost of the method encourage the authors to use such assistance whenever necessary. This attitude is shared by other authors.
We investigated the role of continuous-wave Doppler ultrasound in predicting the presence of an aortic dissection prospectively in 28 patients whose diagnosis was confirmed either by arteriography or surgery (26 cases) or at autopsy (two cases). We hypothesized that dissections, by creating two channels for flow, would produce velocity disturbances detectable in accessible arteries such as the carotid, brachial, and femoral arteries. Of the 28 patients, 20 had Type I, two Type II, and six Type III dissections. Two abnormalities of the Doppler signals were found: in 18 of Type I dissections, notching was found in the systolic upslope of the velocity tracing from those arteries that were either involved in or distal to the dissection sites. Notching was much less frequent for Type II and III dissections: only one patient with Type II and two patients with Type III dissections showed notching. In addition diastolic backflow with marked aortic valvular insufficiency was present. Notching in brachiocephalic artery continuous-wave Doppler signals appears to have a high positive predictive value for Type I dissections.
The authors report a case of surgical treatment of aortic stenosis in a pregnant woman (first pregnancy after four years treatment of sterility). The aortic valve replacement was performed at 16 weeks of amenorrhea. The valve was replaced by an Ionescu-Shiley bioprosthesis. Delivery was performed by caesarean section after 39 weeks of amenorrhea. There was no complication either for the mother or the child. Review of the literature allows analysis of the influence of aortic stenosis on pregnancy, and of the pregnancy on the tolerance of aortic stenosis. Some aspects of cardiopulmonary bypass for valve replacement in pregnant women are also analysed.
170 patients with suspected temporal arteritis underwent Doppler investigation before temporal artery biopsy. Doppler study included the large cervical trunks, the ophthalmic system and analysis of the terminal branches of the external carotid with recording of the temporal territory on 3 points. Biopsy confirmed the diagnosis of temporal arteritis in 48 cases; it was negative in 122 cases. Doppler study and histological examination agreed in 137 patients (80%). There was disagreement in 33 cases (20%). The Doppler signal was pathological in 43 of the 48 cases of temporal arteritis (90%). There were 5 false negatives (10%). In subjects free from temporal arteritis, the Doppler examination was normal in 94 cases (77%), and was pathological in 28 cases (23%). The sensitivity of Doppler examination in the diagnosis of temporal arteritis was 90%, its specificity was 77%. The predictive value of a positive Doppler vis-a-vis the condition was only 61%. On the other hand, the predictive value of a normal examination was very high (95%). The high level of false positives is explained by technical problems, but especially by a high incidence of sometimes very stenosing senile arteritis. Finally, 3 of the 28 false positives (11%) subsequently developed authentic inflammatory arteritis. The authors conclude that a positive Doppler examination does not allow reliable prediction of the presence of temporal arteritis. On the other hand, a normal examination almost always allows the diagnosis of temporal arteritis to be excluded with a risk of error of less than 5%.
A study of the eyeball was carried out using a double frequency Doppler transducer in 31 patients suffering from histologically confirmed temporal arteritis. These patients were divided into 3 groups depending on the results of the ophthalmological examination: group A: 20 patients; normal ophthalmological exam, group B: 5 patients; non specific ocular anomalies, group C: 6 patients; ocular lesions specific to temporal arteritis (ischemic optic neuropathy with amaurosis, dysoric nodules). Doppler examination demonstrated normal curves in the patients in groups A and B. The mean amplitude of systolic peaks was 7.9 mm in group A and 10.3 mm in group B (P = NS). These data did not differ from those of a control population of 22 subjects not suffering from temporal arteritis. On the other hand, group C demonstrated important anomalies on Doppler examination: lack of ophthalmic signal in one case; marked dampening of curves in 4 cases; zones of turbulence in one patient. The mean amplitude of systolic peaks was drastically decreased (1.8 mm). After steroid treatment, a significant increase in blood velocity was seen leading to a normalization of tracings in the majority of cases, including the patients in group C. Doppler examination would appear capable of reliably assessing the risk of ophthalmic complications of temporal arteritis when blood flow anomalies exist. On the other hand, patients with normal Doppler curves may be considered to be at little risk. Subjects at high risk should be urgently treated with high doses of steroids and can be regularly monitored by repeated Doppler examination.
A technique for the surgical treatment of bronchial fistulae developed after pneumonectomy is presented. This technique, which resembles that of Abruzzini, consists of resection of the carina followed by tracheo-bronchial suture in a healthy area away from any purulent focus of infection. It is easy to perform and facilitates the treatment of thoracic empyema which is no longer maintained by the fistula.
Continuous sutures are generally used to perform anastomoses on vessels less than 2 mm in diameter, but some surgeons advocate interrupted sutures which they claim cause less stenosis and provide better vascular potency in the long term. Arteriovenous fistula for chronic haemodialysis is a good model of anastomosis on 1 to 2 mm wide vessels. We used this model to compare the 2 techniques in 2 randomized groups of 20 patients each. The type of suture (continuous or interrupted) was drawn by lot in non diabetic patients who were having their first fistula for chronic haemodialysis. All anastomoses were performed by end-to-side implantation of a superficial vein onto the radial artery. Prolene 8/0 was used as suture material. The maximum follow-up period was 2 years. No significant difference in vascular potency could be demonstrated between the 3 groups. Thus, continuous sutures performed under suitable conditions can be used to perform with greater ease anastomoses which are as patent as those performed with interrupted sutures.
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Left ventricular ejection impediment is one of the complications of mitral valve replacement, especially in case of isolated mitral stenosis with small left ventricle. The use of a "low profile" valve does not prevent this complication. The diagnosis is based on catheterization but the advent of the ultrasound-Doppler may make it easier.
Impairment of the left ventricular ejection induced by a mitral prosthesis remains an infrequent complication, perhaps because it often is unrecognized. This complication would mainly be seen with ball prostheses or standard bioprosthesis used in mitral valve replacements with a small ventricle. Two cases have been recently reported during mitral valve replacement. The two patients were successfully re-operated upon, one after five weeks and the second immediately after the first procedure. A review of the literature enable to specify the etiology and diagnostic criteria with the assistance of Doppler-sonocardiography. Early re-operation may prevent death, often due to a post-operative myocardial dysfunction.
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A 27-year old female was discovered at 4 a.m. lying in a wet field, the ambient temperature being of 4 degrees C. Her rectal temperature had fallen to 19 degrees C. She was comatose and failed to respond to noxious stimuli. Her pupils were dilated and fixed. Her respiratory rate was reduced to three to four breaths per min. Her blood pressure was not measurable and neither femoral or carotid pulse could be detected. The heart was in sinus rhythm with a rate of 40 b X min-1. During her transfer to hospital, she was ventilated with oxygen, a tidal volume of 300 ml and a rate of 10 b X min-1. On arrival in the emergency room, a short period of ventricular fibrillation preceded cardiac arrest. Cardiac massage and sodium bicarbonate infusion were continued during the transfer of the patient to the operating theatre. A femoro-femoral cardiopulmonary bypass was started with a bloodless priming, 3 mg X kg-1 heparin and a flow of 3,000 to 3,500 ml X min-1. Mean arterial pressure was maintained between 65 and 85 mmHg; cardiac massage was discontinued during the bypass. Within 50 min, ventricular fibrillation appeared, rectal temperature had increased to 33 degrees C. Electrical defibrillation (300 J) was successful. Cardiopulmonary bypass was stopped after 63 min. The postoperative course was uneventful, apart from transient pulmonary oedema. At the time of discharge, a week later, no loss of intellect or change in behaviour could be perceived.(ABSTRACT TRUNCATED AT 250 WORDS)
Thrombosis of a Björk-Shiley tricuspid valve prosthesis was observed 4 years after its implantation. The resulting dysfunction was intermittent blocking the disc in the closed position leading to recurrent near-syncopal malaises probably due to a temporary fall in cardiac output and cerebral blood flow and a right to left interatrial shunt which was detected at pulmonary scintigraphy performed to exclude pulmonary embolism. The Björk-Shiley prosthesis was replaced with a Carpentier-Edwards n. 29 prosthesis with a good result after a follow-up of one year.
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