Thorax, 1978, 33, 649-652
Aneurysm of the main stem of the left coronary artery associated with aortic insufficiency and aneurysm of the ascending aorta. Report of a case with successful surgical repair A LEGUERRIER, M BERCOT, AND A PIWNICA From the Clinique Chirurgicale Cardio-Vasculaire, Hopital Broussais, 75014, Paris, France
Leguerrier, A, Bercot, M, and Piwnica, A (1978). Thorax, 33, 649-652. Aneurysm of the main stem of the left coronary artery associated with aortic insufficiency and aneurysm of the ascending aorta. Report of a case with successful surgical repair. A case of aneurysm of the main stem of the left coronary artery associated with aortic insufficiency and an aneurysm of the ascending aorta is reported. The importance of coronary angiography in diagnosing this condition is illustrated. Surgical repair included isolation of the coronary aneurysm and replacement of the ascending aorta and aortic valve, combined with triple aortocoronary saphenous vein bypass grafts. A review of the aetiology, clinical features, and surgical management of coronary artery aneurysms is presented. department of cardiology for assessment. Her symptoms then were angina at rest, exertional dyspnoea, syncopal attacks, and palpitations. On examination the blood pressure was 160/45 mmHg with no clinical evidence of cardiac failure. The electrocardiogram was within normal limits, and the chest radiograph showed a cardiothoracic ratio of 053 (fig 1) but no calcification in the region of the aorta. Cardiac catheterisation produced the following results. At rest the mean pulmonary artery pressure was 14 mmHg and the mean pulmonary capillary wedge pressure was 95 mmHg. These Case report figures increased to 26 and 20 mmHg respectively after angiography despite the absence of mitral The patient was a 43-year-old woman in whom regurgitation. The cardiac index was 1-5 1/min/m2. a cardiac murmur had been present since childAn aortogram showed severe aortic regurgitahood, but it was only in 1970, after three unevent- tion, a slightly dilated left ventricle, a large ful pregnancies, that she began to experience any aneurysm of the ascending aorta, and a round symptoms. At that time she complained of con- para-aortic shadow. Coronary angiography showed stricting chest pain at rest radiating into the left this latter opacity to be an aneurysm situated bearm, and exertional dyspnoea. On auscultation tween the left coronary ostium and the bifurcathere was a loud, 4/6 early diastolic murmur along tion of the left coronary artery (fig 2). These the left sternal border. findings were confirmed at operation in September Despite medical treatment her condition deterio- 1976. rated. and in July 1975 she was referred to the The operative procedure was as follows. Two 649 Aneurysm of a coronary artery was first described by Morgagni in 1761. It was not until 1958, however, that Munkner et al (1958) diagnosed this uncommon condition in a living patient. Kaufman et al (1970) and Ebert et al (1971) reported the first two instances of surgical repair. Subsequently, Falsetti and Carroll (1976) found 34 published cases, of whom only 15 were treated surgically. In our case the aneurysm of the main stem of the left coronary artery was overshadowed by the presence of aortic regurgitation associated with an aneurysm of the ascending aorta.
650
A Leguerrier, M Bercot, and A Piwnica
Fig 1 Posteroanterior chest radiograph showing cardiomegaly and dilatation of ascending aorta.
Fig 2 Coronary arteriogram showing aneurysm of main stem of left coronary artery.
saphenous vein grafts were sutured to the aorta distal to its aneurysmal dilatation. Total cardiopulmonary bypass was initiated between the right femoral artery and both venae cavae. The left ventricle was vented via the right upper pulmonary vein. After lowering the patient's core temperature to 250C (oesophageal), ischaemic cardiac arrest was achieved by clamping the ascending aorta. A transverse incision in the aorta showed a dilated aortic annulus with retraction of
the valve cusps accompanied by gross dilatation of the left coronary ostium. Behind the main pulmonary artery, a heavily calcified fusiform aneurysm of the main left coronary artery, measuring 1 X [5 cm in diameter was seen. Since its resection would have been too dangerous, a single ligature was tied immediately proximal to the bifurcation of the left coronary artery, thus isolating the coronary aneurysm. The two saphenous vein grafts were anastomosed distally to the anterior descending and circumflex branches of the left coronary artery respectively. After removal of the clamps from these vein grafts, the right coronary artery was intubated and perfused to rewarm the myocardium to a temperature of 320C (oesophageal). The aortic valve and ascending aortic aneurysm were replaced with a 31 mm Bjork-Shiley mitral valve prosthesis, mounted in a 30 mm diameter woven Dacron tube. This prosthetic tube extended from the aortic annulus proximally to the distal ascending aorta. All sutures were buttressed with Teflon felt. As technical difficulties were anticipated with reimplantation of the right coronary ostium, a third saphenous vein graft was placed between the ascending aorta and the main stem of the right coronary artery. Finally, the Dacron prosthesis was enveloped in the remaining wall of the aortic aneurysm and cardiopulmonary bypass was discontinued without incident. Ventricular fibrillation related to hypokalaemia
Aneurysm of the main stem of the left coronary artery with aortic insufficiency
occurred one hour after operation and responded to a single external DC discharge. The later postoperative course was uneventful, and the patient was discharged after 15 days. One year after the operation she was asymptomatic with a blood pressure of 110/70 mmHg, a cardiothoracic ratio of 0-51, and no evidence of prosthetic valve dysfunction.
Discussion Coronary artery aneurysms are rare, and for many years they were encountered only in postmortem studies (Packard and Wechsler, 1929; Daoud et al, 1963). With the development of coronary angiography, however, they have been recognised more often and during life. Recently, Falsetti et al (1976) reviewed reports of 34 cases, and Markis et al (1976) reported on a further 30
patients. Coronary angiography is the most useful single investigation for diagnosing this condition. It has usually been performed because of a history of myocardial infarction (Ebert et al, 1971; Konecke et al, 1971; Ghahramani et al, 1972; Crook et al, 1973; Toussaint et al, 1976), on account of angina pectoris (Markis et al, 1976), unexplained dysrhythmias, or because of calcification observed on plain chest radiographs or during aortography
651
Surgical management of coronary aneurysms has continued to develop since the first cases described by Kaufman et al (1970) and Ebert et al (1971). The operative procedures have included reconstructive endo-aneurysmorrhaphy (David et al, 1972), or more commonly, resection of the aneurysm and its replacement with an autologous vein graft (Kaufman et al, 1970), or bypass of the aneurysm by means of an aortocoronary saphenous vein graft (Ebert et al, 1971; Ghahramani et al, 1972; Seabra-Gomes et at, 1974; Kitamura et al, 1975; Falsetti et al, 1976; Markis et al, 1976). No generalisation about operative management can be made. For example, excision of an aneurysm is not a reasonable proposition in the presence of multiple collaterals originating from the diseased vessel (Kitamura et al, 1975). However, as suggested by Toussaint et al (1976), mere isolation of the aneurysm is acceptable if an associated ventricular aneurysm in the area supplied by the vessel concerned is to be resected. In our patient the combination of a coronary and an aortic aneurysm complicated the surgical management. Extensive calcification in the wall of the former precluded any procedure except exclusion of this aneurysm. Furthermore, this had to be combined with replacement of the ascending aorta and the aortic valve and a double aortocoronary saphenous vein bypass graft. Reimplantation of the right coronary ostium into the Dacron prosthesis (Bentall and De Bono, 1968) was not attempted because of the risk of haemorrhage. This led us to undertake a third aortocoronary graft as suggested by Zubiate and Kay (1976).
(present report). The aetiology in most case reports has been atherosclerosis (Daoud et al, 1963, 52%, Falsetti et al, 1976, 50%). The aneurysms are usually located on the left coronary artery and tend to be associated with other manifestations of arterial disease, for example: (1) obstructive lesions of the coronary arteries. In these instances poststenotic References haemodynamic changes may be involved in the pathogenesis (Anabtawi and de Lion, 1974); (2) Anabtawi, I N, and de Lion, I A (1974). Arteriosclerotic aneurysms of the coronary arteries. Journal aneurysms of the abdominal aorta. These were reof Thoracic and Cardiovascular Surgery, 68, 226sponsible for the majority of deaths in Daoud's 228. series (Daoud et al, 1963); (3) aneurysms of the Bentall, H, and De Bono, A (1968). A technique for thoracic aorta. The association with this condition complete replacement of ascending aorta. Thorax, is illustrated by our case and those of Falsetti et 23, 338-339. al (1976); and (4) arterial hypertension, which has Crook, B R, Raftery, E B, and Oram, S (1973). been found to be frequent in all studies. Mycotic aneurysm of coronary arteries. British Apart from atherosclerotic coronary aneurysms, Heart Journal, 35, 107-109. other varieties have been encountered. Congenital Daoud, A S, Pankin, D, Tulgan, H, and Florentin, R A (1963). Aneurysms of the coronary artery: aneurysms (Seabra-Gomes et al, 1974), when report of ten cases and review of literature. Ameripresent, are usually located on the right coronary can Journal of Cardiology, 11, 228-237. artery (Frithz et al, 1968) and most have been David, M, Hauf, E, Faidutti, B, and Hahn, Ch (1972). associated with arteriovenous fistulae (Munkner Abord transpulmonaire du tronc de la coronaire et al, 1958; Seabra-Gomes et al, 1974). Traumatic gauche: a propos de la cure chirurgicale d'un (Konecke et al, 1971) and mycotic (Crook et al, anevrysme. A nnales de Chirurgie Thoracique et 1973; Toussaint et al, 1976) aneurysms are much Cardio-Vasculaire, 11, 367-371. more unusual. Ebert, P A, Peter, R H, Gunnells, J C, and Sabiston,
652 D C (1971). Resecting and grafting of coronary
aneurysm. Circulation, 43, 593-598. Falsetti, H L, and Carroll, R J (1976). Coronary artery aneurysm: a review of literature with a report of eleven new cases. Chest, 69, 630-636. Frithz, G, Cullhed, I, and Bjork, L (1968). Congenital localized coronary artery aneurysm without fistula: report of a preoperatively diagnosed case. American Heart Journal, 76, 674-679. Ghahramani, A, Iyengar, R, Cunha, D, Jude, D, and Sommer, L (1972). Myocardial infarction due to congenital coronary arterial aneurysm (with successful saphenous vein bypass graft). American Journal of Cardiology, 29, 863-867. Kaufman, H, Dubost, Ch, Guilmet, D, Cachera, J P, Ecoiffier, J, and Leduc, G (1970). Anevrysme solitaire de l'artere coronaire droite traite avec succes par resection et greffe saphene. Archives des Maladies du Coeur, 63, 1154-1166. Kitamura, S, Kawashima, Y, Miyamoto, K, Kobayashi, T, Matsuda, H, Ohgitani, N, Kodama, K, Minamino, T, and Manabe, H (1975). Multiple coronary artery aneurysms causing infarction in a young man. Journal of Thoracic and Cardiovascular Surgery, 70, 290-297. Konecke, L L, Spitzer, S, Mason, D, Kasparian, H, and James, P M (1971). Traumatic aneurysm of the left coronary artery. American Journal of Cardiology, 27, 221-223. Markis, J E, Joffe, C P, Cohn, P F, Feen, D J, Herman, M V, and Gorlin, R (1976). Clinical sig-
A Leguerrier, M Bercot, and A Piwnica nificance of coronary arterial ectasia. A merican Journal of Cardiology, 37, 217-222. Morgagni, J B (1761). De Sedibus et causis morborum per anatomen indagatis. Vol I, Book II, epistle 27, article 28. Venice, Remoudiniana. Munkner, T, Petersen, 0, and Veterdal, J (1958). Congenital aneurysm of the coronary artery with an arteriovenous fistula. Acta Radiologica, 50, 333340. Packard, M, and Wechsler, H F (1929). Aneurysm of the coronary arteries. Archives of Internal Medicine, 43, 1-14. Seabra-Gomes, R, Somerville, J, Ross, D N, Emanuel, R, Parker, D J, and Wong, D (1974). Congenital coronary artery aneurysms. British Heart Journal, 36, 329-335. Toussaint, C, Letac, B, and Soyer, R (1976). Anevrysme arteriel coronaire revel6 par un infarctus myocardique complique d'un anevrysme ventriculaire. Archives des Maladies du Coeur, 69, 97-101. Zubiate, P, and Kay, J H (1976). Surgical treatment of aneurysm of the ascending aorta with aortic insufficiency and marked displacement of the coronary ostia. Journal of Thoracic and Cardiovascular Surgery, 71, 415-421. Requests for reprints to: A Piwnica, Clinique Chirurgicale Cardio-Vasculaire, (Service du Professeur Charles Dubost), H6pital Broussais, 96 rue Didot, 75014, Paris, France.
Aneurysm of the main stem of the left coronary artery associated with aortic insufficiency and aneurysm of the ascending aorta. Report of a case with successful surgical repair A LEGUERRIER, M BERCOT, AND A PIWNICA From the Clinique Chirurgicale Cardio-Vasculaire, Hopital Broussais, 75014, Paris, France
Leguerrier, A, Bercot, M, and Piwnica, A (1978). Thorax, 33, 649-652. Aneurysm of the main stem of the left coronary artery associated with aortic insufficiency and aneurysm of the ascending aorta. Report of a case with successful surgical repair. A case of aneurysm of the main stem of the left coronary artery associated with aortic insufficiency and an aneurysm of the ascending aorta is reported. The importance of coronary angiography in diagnosing this condition is illustrated. Surgical repair included isolation of the coronary aneurysm and replacement of the ascending aorta and aortic valve, combined with triple aortocoronary saphenous vein bypass grafts. A review of the aetiology, clinical features, and surgical management of coronary artery aneurysms is presented. department of cardiology for assessment. Her symptoms then were angina at rest, exertional dyspnoea, syncopal attacks, and palpitations. On examination the blood pressure was 160/45 mmHg with no clinical evidence of cardiac failure. The electrocardiogram was within normal limits, and the chest radiograph showed a cardiothoracic ratio of 053 (fig 1) but no calcification in the region of the aorta. Cardiac catheterisation produced the following results. At rest the mean pulmonary artery pressure was 14 mmHg and the mean pulmonary capillary wedge pressure was 95 mmHg. These Case report figures increased to 26 and 20 mmHg respectively after angiography despite the absence of mitral The patient was a 43-year-old woman in whom regurgitation. The cardiac index was 1-5 1/min/m2. a cardiac murmur had been present since childAn aortogram showed severe aortic regurgitahood, but it was only in 1970, after three unevent- tion, a slightly dilated left ventricle, a large ful pregnancies, that she began to experience any aneurysm of the ascending aorta, and a round symptoms. At that time she complained of con- para-aortic shadow. Coronary angiography showed stricting chest pain at rest radiating into the left this latter opacity to be an aneurysm situated bearm, and exertional dyspnoea. On auscultation tween the left coronary ostium and the bifurcathere was a loud, 4/6 early diastolic murmur along tion of the left coronary artery (fig 2). These the left sternal border. findings were confirmed at operation in September Despite medical treatment her condition deterio- 1976. rated. and in July 1975 she was referred to the The operative procedure was as follows. Two 649 Aneurysm of a coronary artery was first described by Morgagni in 1761. It was not until 1958, however, that Munkner et al (1958) diagnosed this uncommon condition in a living patient. Kaufman et al (1970) and Ebert et al (1971) reported the first two instances of surgical repair. Subsequently, Falsetti and Carroll (1976) found 34 published cases, of whom only 15 were treated surgically. In our case the aneurysm of the main stem of the left coronary artery was overshadowed by the presence of aortic regurgitation associated with an aneurysm of the ascending aorta.
650
A Leguerrier, M Bercot, and A Piwnica
Fig 1 Posteroanterior chest radiograph showing cardiomegaly and dilatation of ascending aorta.
Fig 2 Coronary arteriogram showing aneurysm of main stem of left coronary artery.
saphenous vein grafts were sutured to the aorta distal to its aneurysmal dilatation. Total cardiopulmonary bypass was initiated between the right femoral artery and both venae cavae. The left ventricle was vented via the right upper pulmonary vein. After lowering the patient's core temperature to 250C (oesophageal), ischaemic cardiac arrest was achieved by clamping the ascending aorta. A transverse incision in the aorta showed a dilated aortic annulus with retraction of
the valve cusps accompanied by gross dilatation of the left coronary ostium. Behind the main pulmonary artery, a heavily calcified fusiform aneurysm of the main left coronary artery, measuring 1 X [5 cm in diameter was seen. Since its resection would have been too dangerous, a single ligature was tied immediately proximal to the bifurcation of the left coronary artery, thus isolating the coronary aneurysm. The two saphenous vein grafts were anastomosed distally to the anterior descending and circumflex branches of the left coronary artery respectively. After removal of the clamps from these vein grafts, the right coronary artery was intubated and perfused to rewarm the myocardium to a temperature of 320C (oesophageal). The aortic valve and ascending aortic aneurysm were replaced with a 31 mm Bjork-Shiley mitral valve prosthesis, mounted in a 30 mm diameter woven Dacron tube. This prosthetic tube extended from the aortic annulus proximally to the distal ascending aorta. All sutures were buttressed with Teflon felt. As technical difficulties were anticipated with reimplantation of the right coronary ostium, a third saphenous vein graft was placed between the ascending aorta and the main stem of the right coronary artery. Finally, the Dacron prosthesis was enveloped in the remaining wall of the aortic aneurysm and cardiopulmonary bypass was discontinued without incident. Ventricular fibrillation related to hypokalaemia
Aneurysm of the main stem of the left coronary artery with aortic insufficiency
occurred one hour after operation and responded to a single external DC discharge. The later postoperative course was uneventful, and the patient was discharged after 15 days. One year after the operation she was asymptomatic with a blood pressure of 110/70 mmHg, a cardiothoracic ratio of 0-51, and no evidence of prosthetic valve dysfunction.
Discussion Coronary artery aneurysms are rare, and for many years they were encountered only in postmortem studies (Packard and Wechsler, 1929; Daoud et al, 1963). With the development of coronary angiography, however, they have been recognised more often and during life. Recently, Falsetti et al (1976) reviewed reports of 34 cases, and Markis et al (1976) reported on a further 30
patients. Coronary angiography is the most useful single investigation for diagnosing this condition. It has usually been performed because of a history of myocardial infarction (Ebert et al, 1971; Konecke et al, 1971; Ghahramani et al, 1972; Crook et al, 1973; Toussaint et al, 1976), on account of angina pectoris (Markis et al, 1976), unexplained dysrhythmias, or because of calcification observed on plain chest radiographs or during aortography
651
Surgical management of coronary aneurysms has continued to develop since the first cases described by Kaufman et al (1970) and Ebert et al (1971). The operative procedures have included reconstructive endo-aneurysmorrhaphy (David et al, 1972), or more commonly, resection of the aneurysm and its replacement with an autologous vein graft (Kaufman et al, 1970), or bypass of the aneurysm by means of an aortocoronary saphenous vein graft (Ebert et al, 1971; Ghahramani et al, 1972; Seabra-Gomes et at, 1974; Kitamura et al, 1975; Falsetti et al, 1976; Markis et al, 1976). No generalisation about operative management can be made. For example, excision of an aneurysm is not a reasonable proposition in the presence of multiple collaterals originating from the diseased vessel (Kitamura et al, 1975). However, as suggested by Toussaint et al (1976), mere isolation of the aneurysm is acceptable if an associated ventricular aneurysm in the area supplied by the vessel concerned is to be resected. In our patient the combination of a coronary and an aortic aneurysm complicated the surgical management. Extensive calcification in the wall of the former precluded any procedure except exclusion of this aneurysm. Furthermore, this had to be combined with replacement of the ascending aorta and the aortic valve and a double aortocoronary saphenous vein bypass graft. Reimplantation of the right coronary ostium into the Dacron prosthesis (Bentall and De Bono, 1968) was not attempted because of the risk of haemorrhage. This led us to undertake a third aortocoronary graft as suggested by Zubiate and Kay (1976).
(present report). The aetiology in most case reports has been atherosclerosis (Daoud et al, 1963, 52%, Falsetti et al, 1976, 50%). The aneurysms are usually located on the left coronary artery and tend to be associated with other manifestations of arterial disease, for example: (1) obstructive lesions of the coronary arteries. In these instances poststenotic References haemodynamic changes may be involved in the pathogenesis (Anabtawi and de Lion, 1974); (2) Anabtawi, I N, and de Lion, I A (1974). Arteriosclerotic aneurysms of the coronary arteries. Journal aneurysms of the abdominal aorta. These were reof Thoracic and Cardiovascular Surgery, 68, 226sponsible for the majority of deaths in Daoud's 228. series (Daoud et al, 1963); (3) aneurysms of the Bentall, H, and De Bono, A (1968). A technique for thoracic aorta. The association with this condition complete replacement of ascending aorta. Thorax, is illustrated by our case and those of Falsetti et 23, 338-339. al (1976); and (4) arterial hypertension, which has Crook, B R, Raftery, E B, and Oram, S (1973). been found to be frequent in all studies. Mycotic aneurysm of coronary arteries. British Apart from atherosclerotic coronary aneurysms, Heart Journal, 35, 107-109. other varieties have been encountered. Congenital Daoud, A S, Pankin, D, Tulgan, H, and Florentin, R A (1963). Aneurysms of the coronary artery: aneurysms (Seabra-Gomes et al, 1974), when report of ten cases and review of literature. Ameripresent, are usually located on the right coronary can Journal of Cardiology, 11, 228-237. artery (Frithz et al, 1968) and most have been David, M, Hauf, E, Faidutti, B, and Hahn, Ch (1972). associated with arteriovenous fistulae (Munkner Abord transpulmonaire du tronc de la coronaire et al, 1958; Seabra-Gomes et al, 1974). Traumatic gauche: a propos de la cure chirurgicale d'un (Konecke et al, 1971) and mycotic (Crook et al, anevrysme. A nnales de Chirurgie Thoracique et 1973; Toussaint et al, 1976) aneurysms are much Cardio-Vasculaire, 11, 367-371. more unusual. Ebert, P A, Peter, R H, Gunnells, J C, and Sabiston,
652 D C (1971). Resecting and grafting of coronary
aneurysm. Circulation, 43, 593-598. Falsetti, H L, and Carroll, R J (1976). Coronary artery aneurysm: a review of literature with a report of eleven new cases. Chest, 69, 630-636. Frithz, G, Cullhed, I, and Bjork, L (1968). Congenital localized coronary artery aneurysm without fistula: report of a preoperatively diagnosed case. American Heart Journal, 76, 674-679. Ghahramani, A, Iyengar, R, Cunha, D, Jude, D, and Sommer, L (1972). Myocardial infarction due to congenital coronary arterial aneurysm (with successful saphenous vein bypass graft). American Journal of Cardiology, 29, 863-867. Kaufman, H, Dubost, Ch, Guilmet, D, Cachera, J P, Ecoiffier, J, and Leduc, G (1970). Anevrysme solitaire de l'artere coronaire droite traite avec succes par resection et greffe saphene. Archives des Maladies du Coeur, 63, 1154-1166. Kitamura, S, Kawashima, Y, Miyamoto, K, Kobayashi, T, Matsuda, H, Ohgitani, N, Kodama, K, Minamino, T, and Manabe, H (1975). Multiple coronary artery aneurysms causing infarction in a young man. Journal of Thoracic and Cardiovascular Surgery, 70, 290-297. Konecke, L L, Spitzer, S, Mason, D, Kasparian, H, and James, P M (1971). Traumatic aneurysm of the left coronary artery. American Journal of Cardiology, 27, 221-223. Markis, J E, Joffe, C P, Cohn, P F, Feen, D J, Herman, M V, and Gorlin, R (1976). Clinical sig-
A Leguerrier, M Bercot, and A Piwnica nificance of coronary arterial ectasia. A merican Journal of Cardiology, 37, 217-222. Morgagni, J B (1761). De Sedibus et causis morborum per anatomen indagatis. Vol I, Book II, epistle 27, article 28. Venice, Remoudiniana. Munkner, T, Petersen, 0, and Veterdal, J (1958). Congenital aneurysm of the coronary artery with an arteriovenous fistula. Acta Radiologica, 50, 333340. Packard, M, and Wechsler, H F (1929). Aneurysm of the coronary arteries. Archives of Internal Medicine, 43, 1-14. Seabra-Gomes, R, Somerville, J, Ross, D N, Emanuel, R, Parker, D J, and Wong, D (1974). Congenital coronary artery aneurysms. British Heart Journal, 36, 329-335. Toussaint, C, Letac, B, and Soyer, R (1976). Anevrysme arteriel coronaire revel6 par un infarctus myocardique complique d'un anevrysme ventriculaire. Archives des Maladies du Coeur, 69, 97-101. Zubiate, P, and Kay, J H (1976). Surgical treatment of aneurysm of the ascending aorta with aortic insufficiency and marked displacement of the coronary ostia. Journal of Thoracic and Cardiovascular Surgery, 71, 415-421. Requests for reprints to: A Piwnica, Clinique Chirurgicale Cardio-Vasculaire, (Service du Professeur Charles Dubost), H6pital Broussais, 96 rue Didot, 75014, Paris, France.
