[The best of valvular heart disease in 1999]. / L'essentiel de 1999 dans les valvulopathies.

The year 1999 confirmed important changes in the clinical presentation, the methods of investigation and the treatment of valvular heart disease. The near disappearance of acute rheumatic fever in the developed world, associated with the increase in life expectancy has resulted in degenerative aetiologies becoming the most common causes of valvular heart disease with a dominance of aortic stenosis and mitral incompetence. The increase in average age of the operated patients explains the increasing role of comorbidity and the higher incidence of mixed (valvular and coronary artery) surgery. Doppler echocardiography is now the reference method of investigating valvular heart disease, both pre- and post-operatively (especially in mitral incompetence). The value of tri-dimensional echocardiography is beginning to be recognised. The technical advances in surgical techniques are also important, especially the extension of conservative methods both in mitral incompetence and parietal lesions of dystrophic aortic incompetence. The good long-term results of homograft aortic valves have been confirmed, especially in young patients and infectious endocarditis complicated by abscess. The Ross procedure is an interesting alternative in children and adolescents in the absence of available homografts. The persistence of good results in the long term has made percutaneous mitral commissurotomy the reference in mitral stenosis. The improvement in surgical and interventional methods has widened the operative indications which are now considered in patients who are pauci- or a-symptomatic.

[Lumbar intraspinal synovial cysts: imaging and treatment by percutaneous injection. Report of thirteen cases]. / Kystes synoviaux intraspinaux lombaires: imagerie et traitement par infiltration.

PURPOSE: The CT and MR imaging findings in 13patients with lumbar intra spinal synovial cysts were retrospectively analysed and the results of facet corticosteroid injection were evaluated. PATIENTS AND METHODS: Over a 7 year period, 13patients with radicular pain were identified as having lumbar intra spinal synovial cysts. They ranged from 42 to 87 years of age. All patients were evaluated by CT without contrast material and underwent facet arthrography associated with corticosteroid injection and CT arthrography. MR imaging was performed in all patients either before or after percutaneous treatment. CT scans and MR images were reviewed and patient outcome was evaluated at 1and 6month followup. RESULTS: CT scan revealed a cystic structure adjacent to a degenerated facet joint in 9 patients (69% sensitivity). MRI showed more accurately the cyst on T2 weighted and/or axial images. Complete or good relief of radicular pain and functional restrictions were achieved in 9 patients (69%) at 1 month follow up, still to be found in 6patients (46%) at 6months. CONCLUSION: In patients with radiculopathy and facet degenerative changes, intra spinal synovial cysts must be looked for. Facet corticosteroid injection is a useful alternative to surgical removal.

Peripheral vascular involvement in heart transplant patients.

Between 1984 and 1991 a total of 200 patients underwent heart transplantation in our unit. The records of 121 patients who were followed up for more than 1 year were reviewed for peripheral vascular abnormalities, which were found in 12 (9.9%). Most of these patients underwent transplantation for ischemic heart disease, and peripheral vascular disease preceded the heart transplantation in 80%. Although surgical risks are low in this setting, particular caution should be exercised to prevent septic complications in the femoral triangle. Among the risk factors studied, only elevated blood cholesterol was frequently found in the vascular patients before or after transplantation. Peripheral vascular involvement in heart transplant patients corresponds to the natural course of atheroma rather than to an accelerated process of atherosclerosis.

Dynamic cardiomyoplasty at seven years.

Since January 1985, the date of the first dynamic cardiomyoplasty, until April 1992, 52 patients with end-stage heart disease were operated on in our institution. Mean preoperative New York Heart Association functional class was 3.3 and ventricular ejection fraction 16% +/- 3%. Associated procedures in 23 patients comprised ventricular aneurysm resection (10), valve surgery (9), coronary artery bypass (8), and tumor resection (3). Thirty-eight patients had a ventricular reinforcement, 13 a ventricular substitution, and 1 an atrial reinforcement using the left latissimus dorsi muscle. Preassist mortality rate before full latissimus dorsi muscle stimulation was 7 of 13 patients (54%) in the 1985 to 1987 period and 5 of 39 (12%) in the 1988 to 1992 period. The causes of death were heart failure (4), multiorgan failure (4), septicemia (2), ventricular fibrillation (1), and sudden death (1). Multivariate analysis of factors influencing hospital mortality showed that age, cardiac suture technique, associated surgical procedures, biventricular heart failure, and hemodynamic instability plus inotropic drug support were predictors of unfavorable outcome. All patients were followed up for from 2 months to 7 years (mean 21 months). Postassist mortality rate was 8 of 40 (20%). Causes of death included heart failure (5), ventricular fibrillation (1), myocardial infarction (1), and gastric bleeding (1). Preoperative risk factors influencing long-term mortality were permanent New York Heart Association functional class IV, biventricular heart failure, atrial fibrillation, cardiothoracic ratio greater than 60%, and ejection fraction less than 15%. Actuarial survival at 7 years was 70.4% (preassist mortality excluded). Surviving patients were in a mean New York Heart Association functional class of 1.8 (preoperatively 3.3, p < 0.05). The average ejection fractions (rest/stress) were 25%/28% at 1 year, 26%/30% at 2 years, and 23%/28% at 3 years. Average cardiothoracic ratios were 57% +/- 3% at 1 year, 56% +/- 2% at 2 years, and 57% +/- 2.5% at 3 years. Catheterization obtained in 20 patients showed no significant changes at rest in capillary wedge pressure, pulmonary artery pressure, and diastolic left ventricular pressure when compared with preoperative pressures. Average ejection fractions increased from 24% to 30.6%. Maximal oxygen consumption increased from 12.8 +/- 3.5 to 18.6 +/- 4 ml/min per kilogram. The number of rehospitalizations resulting from congestive heart failure was reduced to 0.4 hospitalizations per patient per year (preoperatively 2.4, p < 0.05). In 62% of the patients, pharmacologic therapy was diminished after the operation. Three patients required orthotopic heart transplantation 6 months, 4 years, and 5 years after cardiomyoplasty.

[Evaluation of treatments with beta-blockaders after myocardial infarction]. / Le bilan des traitements bêtabloquants après un infarctus du myocarde.

Beta-blockers have been used after myocardial infarction since 1965: however, it was not until the beginning of the 80s that the large multicentre clinical trials published results showing clearly their beneficial effects and leading to their widespread usage: betablockers significantly reduce the medium term (1 to 3 years) risk of death (-22 to -24%), especially sudden death (-32%) and the frequency of recurrent infarction (-27%). The cardio-protection so obtained is multifactorial, essentially related to their antiarrhythmic, antiischemic and antihypertensive effects. It has been established that beta-blockade should be instituted as soon as possible in the hours following the infarct (intravenous relayed by oral administration) and may be useful associated with aspirin. Although the large scale clinical trials did not determine the optimal dosage or the duration for which treatment should be administered, they did show that the groups of high risk patients were those to benefit the most from this therapy. Beta-blockers are usually well tolerated. However, it must be pointed out that 18% of patients were excluded from the two principal trials (only 25 to 30% of infarct patients were included) because of contraindications to beta-blockers and that 25 to 30% of the patients initially included had to interrupt the treatment because of side effects.