Results after orthotopic heart transplantation accepting donor hearts >50 years: experience at La Pitie Salpetriere, Paris.

INTRODUCTION: We sought to examine the results of orthotopic heart transplantation accepting hearts from donors >50 years of age with special regard to the usefulness of peripheral extracorporeal membrane oxygenation for posttransplant graft dysfunction. PATIENTS: Between January 2000 and December 2004, a total of 247 patients underwent orthotopic heart transplantation. In 143 patients (58%) the heart donor was <50 years (group I, mean age of donor hearts 36 +/- 11 years; range, 8-49 years). In 104 recipients (42%) the heart donor was >50 years (group II, mean age of donor hearts 56 +/- 15 years; range, 50-67 years). Pretransplant characteristics of the two groups showed no significant differences. RESULTS: The in-hospital mortality was slightly increased in group II (24% vs 20% in group I, NS) and the 5-year survival rate significantly increased in group I (75% vs 63% in group II). Freedom from transplant vasculopathy after 3 years was similar in both groups (86% in group I vs 87% in group II). A total of 25 patients (17%) in group I and 27 patients (26%) in group II developed graft dysfunction. Eleven patients in group I and 10 patients in group II were treated using peripheral extracorporeal membrane oxygenation, whereas 3 of the 11 patients in group I and 5 of the 10 patients in group II were discharged following a complete recovery. Two patients in group I and 4 patients in group II were survivors beyond year. CONCLUSION: In our experience it was possible to increase the cardiac donor pool by accepting allografts from donors >50 years of age in selected cases. The incidence of transplant vasculopathy was not increased, whereas in-hospital mortality was slightly higher. In our limited cohort, patients with older donor hearts was developed graft dysfunction profited from primary extracorporeal membrane oxygenation implantation, an indication that should be examined further without delay.

[Annuloplasty reduces the mitral leaflets mobility]. / L'annuloplastie réduit la mobilité des deux feuillets mitraux.

The posterior mitral leaflet is usually motionless following mitral valve repair. The aim of this study was to assess (1) the geometric changes of the left ventricular base following prosthetic ring annuloplasty and (2) their impact on the anterior mitral leaflet (AML) mobility. Thirty five patients operated upon for mitral valve repair underwent an intraoperative transesophageal echographic study before and after annuloplasty. A posterior leaflet resection was achieved in 29 cases and ring annuloplasty alone in 6 cases. No repair technique was performed on the AML. Four parameters were assessed: the anteroposterior mitral annulus diameter, the aortomitral angle, the opening and closure angles of the AML. Annuloplasty resulted in a drastic reduction of the mitral annulus from 36.8 +/- 5.6 mm to 20.9 +/- 3.8 mm (systole, long axis view) (p < 0.0001). The aortomitral angle decreased following annuloplasty from 115.1 +/- 8.3 to 108.0 +/- 9.60 (systole, long axis view) (p < 0.0001). No difference was observed between systolic and diastolic measurments concerning the mitral annulus or the aortomitral angle. The opening angle of the AML remained unchanged whereas the closure angle increased from 17.8 +/- 6.10 to 26.6 +/- 6.70 (long axis view) (p = 0.0001) resulting in a displacement of the coaptation point towards the apex. Consequently, the excursion of the anterior leaflet throughout the cardiac cycle decreased following annuloplasty from 43 +/- 130 to 32.5 +/- 11 (long axis view) (p < 0.0001).

Dynamic cardiomyoplasty: effect of discontinuing latissimus dorsi muscle stimulation on left ventricular systolic and diastolic performance and exercise capacity.

OBJECTIVES: This study sought to assess the short-term effect of discontinuing latissimus dorsi muscle stimulation on left ventricular systolic and diastolic performance and exercise tolerance in patients with improved functional status by cardiomyoplasty, in whom latissimus dorsi muscle was fully conditioned. BACKGROUND: Cardiomyoplasty has consistently improved the functional status of patients, but the short-term effect of latissimus dorsi muscle contraction has not been assessed in these patients. METHODS: Right-heart catheterization, Doppler-echocardiography and maximal exercise testing with expired gas analysis were performed in 10 patients with congestive heart failure who had undergone cardiomyoplasty at least 6 months earlier. Data were obtained when the latissimus dorsi muscle was stimulated every other systole and after stimulation was discontinued for 1 h. The power of this study to detect a 10% difference was > 80%. RESULTS: After cardiomyoplasty, left ventricular ejection fraction increased from 0.22 +/- 0.08 (mean +/- SD) to 0.27 +/- 0.07 after 6 months (p < 0.02 vs. before cardiomyoplasty) and to 0.24 +/- 0.09 after 1 year; functional class went from 3.0 +/- 0.0 to 2.0 +/- 0.5 after 6 months and to 2.0 +/- 0.7 after 1 year (both p < 0.001 vs. before cardiomyoplasty). After discontinuation of latissimus dorsi muscle stimulation, cardiac index did not change (2.28 +/- 0.45 vs. 2.30 +/- 0.46 liters/min per m2). Mean systemic arterial and pulmonary capillary wedge pressures were also similar (85.2 +/- 6.0 vs. 88.4 +/- 5.6 mm Hg and 14.9 +/- 7.1 vs. 13.6 +/- 6.8 mm Hg, respectively). Doppler E/A ratio decreased from 1.04 +/- 0.33 to 0.83 +/- 0.25 (p < 0.02), suggesting that left ventricular diastolic function may have been improved by latissimus dorsi muscle stimulation. Peak oxygen consumption was unaltered (1,633 +/- 530 vs. 1,596 +/- 396 ml/min). CONCLUSIONS: Alterations in left ventricular diastolic rather than systolic function may be responsible for the long-term clinical benefits of cardiomyoplasty.

Doppler echocardiography for the diagnosis of acute cardiac allograft rejection.

To evaluate the changes in left ventricular filling associated with acute cardiac rejection, serial Doppler echocardiographic examinations were prospectively performed on the same day as endomyocardial biopsy in 55 consecutive patients who successfully underwent orthotopic transplantation and were free of a previous episode of rejection. On average, 8.6 Doppler studies per patient were performed within a 6 month period after transplantation. Recordings of mitral flow were made with pulsed Doppler and two-dimensional echocardiography from an apical four chamber view; isovolumic relaxation time, peak early mitral flow velocity and pressure half-time were measured. The patients were classified into two groups on the basis of the histopathologic findings: group I (25 patients with at least one episode of mild or moderate rejection) and group II (30 patients without rejection). In group I, rejection was associated with a significant decrease of isovolumic relaxation time (p less than 0.005) and especially pressure half-time (p less than 0.0005) with no change in heart rate and peak early mitral flow velocity. In group II, Doppler indexes remained unchanged. These changes were not associated with alterations in left ventricular systolic function assessed by echocardiography. Isovolumic relaxation time and pressure half-time both returned to values similar to baseline values after immunosuppressive therapy (p less than 0.05 and p less than 0.0005, respectively). With 20% decrease in pressure half-time as a criterion for acute rejection, sensitivity was 88%, specificity 87% and positive predictive value 85%. Thus, Doppler echocardiographic evaluation of left ventricular diastolic function provides an excellent tool for early detection of acute rejection and noninvasive monitoring of the cardiac transplant recipient.

Peripheral extracorporeal membrane oxygenation (ECMO) in patients with posttransplant cardiac graft failure.

INTRODUCTION: We sought to report the usefulness of extracorporeal membrane oxygenation (ECMO) in heart transplant patients. PATIENTS: Between March 2002 and August 2004, 14 heart transplant patients (11 men and three women, 36 +/- 15 years old, range = 12 to 50) with primary graft failure underwent peripheral ECMO implantation. Three patients had pulmonary hypertension and three had been transplanted with hearts from marginal donors. At the time of implantation, all were in severe cardiogenic shock despite maximal inotropic support. In six patients, the ECMO was implanted in the operating room since cardiopulmonary bypass could not be weaned. In the eight remaining patients, ECMO was implanted in the intensive care unit, during the first 48 hours in seven cases. In one patient, implantation was performed during external resuscitation. In all cases, femoral vessels were canulated using the Seldinger technique after anterior wall exposure. Distal arterial perfusion of the lower limb was systematically used. RESULTS: Pump outflow was high enough in all the cases (mean: 2.6 +/- 0.2 L/min/m(2)). Three patients died on circulatory support. One patient was implanted with a total artificial heart after a few hours and another one underwent unsuccessful emergent retransplantation. Nine patients were weaned from ECMO after a mean duration of 5 +/- 2.5 days. Among them, one died of infection at 10 days after weaning and seven others were discharged to rehabilitation centers. CONCLUSION: Fast operating room or bedside implantation of a peripheral ECMO allows the physician to stabilize the hemodynamic status of patients with cardiac graft failure, potentially leading toward myocardial recovery.

Pacemaker infective endocarditis.

We identified 33 patients with definite pacemaker endocarditis--that is, with direct evidence of infective endocarditis, based on surgery or autopsy histologic findings of or bacteriologic findings (Gram stain or culture) of valvular vegetation or electrode-tip wire vegetation. Most of the patients (75%) were > or = 60 years of age (mean 66 +/- 3; range 21 to 86). Pouch hematoma or inflammation was common (58%), but other predisposing factors for endocarditis were rare. At the time that pacemaker endocarditis was found, the mean number of leads was 2.4 +/- 1.1 (range 1 to 7). The interval from the last procedure to diagnosis of endocarditis was 20 +/- 4 months (range 1 to 72). Endocarditis appeared after pacemaker implantation, early (< 3 months) in 10 patients and late (> or = 3 months) in 23 patients. Fever was the most common symptom, being isolated in 36%, associated with a poor general condition in 24%, and associated with septic shock in 9%. Transthoracic echocardiography showed vegetations in only 2 of 9 patients. Transesophageal echocardiography demonstrated the presence of lead vegetations (n = 20) or tricuspid vegetations (n = 3) in 23 of 24 patients (96%; p <0.0001 compared with transthoracic echocardiography). Pulmonary scintigraphy showed a typical pulmonary embolization in 7 of 17 patients (41%). Pathogens were mainly isolated from blood (82%) and lead (91%) cultures. The major pathogens causing pacemaker endocarditis were Staphylococcus epidermidis (n = 17) and S. aureus (n = 7). S. epidermidis was found more often in early than in late endocarditis (90% vs 50%; p = 0.05). All patients were treated with prolonged antibiotic regimens before and after electrode removal. Electrode removal was achieved by surgery (n = 29) or traction (n = 4). Associated procedures were performed in 9 patients. After the intensive care period, only 17 patients needed a new permanent pacemaker. Overall mortality was 24% after a mean follow-up period of 22 +/- 4 months (range 1 to 88). Eight patients who were significantly older (74 +/- 3 vs 63 +/- 3 years; p = 0.05) died < or = 2 months after electrode removal, whereas 25 were alive and asymptomatic.

Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries.

From November, 1976, to June, 1983, 100 patients, 84 male and 16 female patients ranging in age from 13 to 74 years, were operated on for aortic insufficiency associated with an aneurysm of the ascending aorta. Twenty patients were in New York Heart Association Class I, 22 in Class II, 51 in Class III, and seven in Class IV. The surgical treatment in all cases consisted of total replacement of the ascending aorta with a tube graft containing a prosthetic aortic valve and reimplantation of the coronary arteries by an intermediate tube graft according to the technique already reported. In 68 patients an uncomplicated annulo-aortic ectasia existed, and in 32, an aortic dissection; nine of the latter group were operated on during the acute phase. The operative mortality for the entire group was 4% (four deaths). One patient has been lost to follow-up during a period ranging from 18 months to 8 years (average 54 months). The late mortality has been 11/96. Among the 84 survivors, clinical improvement is readily apparent (89% are in Class I or II). Twenty-five patients have been restudied by angiography, which revealed a satisfactory coronary and aortic appearance in all cases with neither stenosis nor aneurysm. The actuarial survival rate is 75% at 8 years. In conclusion, the treatment of aortic insufficiency associated with an aneurysm of the ascending aorta by insertion of a composite graft and reimplantation of the coronary arteries through an intermediate Dacron tube is a reliable method with low mortality and excellent long-term results.

Cardiac echinococcosis. Surgical treatment and results.

During the last 15 years, eight patients with a diagnosis of hydatid cysts of the heart and one patient with a diagnosis of alveolar hydatid disease with intracardiac parasitic thrombus underwent successful operation at La Pitié Hospital. Only five cases had symptoms, and the remaining four cases were diagnosed incidentally. Serologic tests achieved a variety of results and were not determinant. All patients were examined with echocardiography and angiography, and almost all patients underwent magnetic resonance scanning. Sternotomy was the approach used, and all patients underwent operation with cardiopulmonary bypass. Surgical treatment included puncture and aspiration of the cyst content, previous sterilization with hypertonic saline solution, and excision of the cyst with closure of the cavity in seven patients with different concomitant procedures. No case of intraoperative rupture was reported, and the only complication was an atrioventricular block in a patient with a cyst of the left ventricular wall invading the intraventricular septum. There was no operative mortality, and only one late death was observed. No recurrences or associated complications were reported in the late follow-up.

Prosthetic valve endocarditis with ring abscesses. Surgical management and long-term results.

From January 1978 to December 1988, 71 patients underwent surgical intervention at our institution for prosthetic valve endocarditis with ring abscesses. These procedures involved 59 aortic prostheses and 12 mitral prostheses. No causative agent could be identified in 19 patients (26.7%). The operation was performed during antibiotic therapy in 63 patients and after a planned course of antibiotic therapy in 8 patients. At the aortic level, abscesses were remedied by suturing in 3 cases, by pericardial patches in 34 cases, and by complex procedures in 22 cases (subcoronary valved conduit in 11 cases, supracoronary valved conduit with coronary bypass grafts in 10 cases, apicoaortic valved conduit in 1 case). At the mitral level, ring abscesses were cured in 10 cases by intraatrial implantation of the prosthesis. In one case, the prosthesis was anchored inside the left ventricle; and in one case the valve could be seated on the anulus. The overall operative mortality rate was 17%. Long-term survival was 54% +/- 8% at 6 years. Fifteen (26%) of the survivors needed a third valve replacement (four operative deaths); a complex reconstruction was performed in seven patients. Better detection of ring abscesses and earlier surgical intervention before annular destruction and hemodynamic failure can improve the operative mortality rate for prosthetic valve endocarditis. When it is necessary, complex reconstruction, in spite of a high mortality rate, seems to eradicate the infectious seat, and the outlook for the patient's condition appears good.

Heart and unilateral lung transplantation in patients with end-stage cardiopulmonary disease and previous thoracic operations.

Orthotopic en bloc transplantation of the heart and one lung has been done in two patients with end-stage cardiopulmonary disease and a prior thoracic operation. The first patient had undergone right pulmonary thromboembolectomy with caval ligation 5 years earlier, and the second had had left lower lobectomy for bronchiectasis 15 years before the heart and contralateral lung transplantation. Surgical procedures followed the techniques that had been developed in animals. Transplantation of the unoperated contralateral lung made it possible to avoid dissection in the obliterated pleural space and to minimize bleeding, which simplified the procedure considerably. Dramatic reduction in pulmonary artery pressure and improved respiratory function allowed both patients to be weaned from cardiopulmonary bypass without problems. Although the first patient died of liver and renal failure soon after the operation, an intact cough reflex facilitated recovery in the second patient, who has been discharged with essentially normal respiratory function. This report describes heart and unilateral lung transplantation as a procedure of choice for patients with extensive pleural adhesions that made total cardiopulmonary replacement unfeasible.

Orthotopic transplantation after implantation of a Jarvik 7 total artificial heart.

A total artificial heart was used to support the circulation in 33 heart transplantation candidates who were expected to die before procurement of a donor heart. Twelve of these patients (mean age 35 +/- 10 years) underwent cardiac transplantation. Another patient is still being supported with the total artificial heart 90 days after implantation. The other 20 patients died during mechanical support because their condition could not be stabilized for transplantation, despite blood flow restoration. Fifty-six percent of the patients younger than 40 years underwent successful transplantation and six of nine patients are long-term survivors. By comparison, in the older group, 17.6% of patients underwent transplantation and one of three survived long term. Forty-four percent of patients in the acute decompensation group had successful transplantation and four of seven patients are long-term survivors. In the chronic decompensation group these figures were 29.4% and three of five patients. All patients who were heavily immunosuppressed (n = 4) died of sepsis. Transplantation was considered and performed only when the patient's condition was correct and stable. In six patients an infection developed in the immediate posttransplant period. Three of the infections were resolved with antibiotic therapy. One originated in the mediastinum and is still unresolved, although the patient's condition is improving. Another patient died of an anoxic coma caused by ventilatory problems. There were two late deaths at 14 and 19 months, one resulting from a combination of toxoplasmosis and rejection and the other from a Kaposi sarcoma caused by azathioprine treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic disease of the ascending aorta. Surgical treatment and long-term results.

Between January 1979 and December 1991, we operated on 339 patients for chronic disease of the ascending aorta. The operation was elective in all. Endocarditis and its sequelae have been excluded. Thirty-one patients had a previous operation on the ascending aorta or the aortic valve; 268 patients had aneurysms of the ascending aorta without dissection; 72 had chronic aortic dissections, of whom 33 had a preexistent aneurysm. The patients included 272 men and 67 women. Mean age was 53.58 +/- 7 years. Eight percent of the patients had clinical stigmata of Marfan's disease. A tubular graft replacement was used in 7 patients, a tubular graft and valve replacement in 72 patients, and a composite valve graft replacement with reattachment of the coronary arteries using a 8 mm Dacron graft was performed in 260 patients. Concomitant procedures were used in 74 patients: coronary artery bypass grafts in 25, mitral valve replacement in 9, and aortic arch reconstruction in 40. The 30-day mortality rate was 7.6% (n = 26). For the whole group, multivariate analysis using stepwise logistic regression showed that operative risk factors were concomitant coronary artery bypass grafting, age (increased), aortic valve regurgitation, and previous cardiac surgery. Follow-up was conducted in 303 patients, and risk factors for late mortality were studied. Long-term survival was 59.6% +/- 3.7% at 9 years. It was 67% +/- 3.5% at 9 years for patients without aortic arch reconstruction and 56% +/- 4.5% for patients with aortic arch reconstruction (p = 0.0018). Reoperation was needed in 14 patients. Actuarial freedom from reoperation was 90% +/- 0.2% at 9 years for all the patients. Only one patient with composite valve graft replacement and reattachment of the coronary arteries had required reoperation for problems related to this procedure. This technique is used routinely by our team, especially in patients with large chronic aneurysms, dissected or not, and in those who had previous operations. The long-term results are good.

Factors affecting survival after heterotopic heart transplantation.

In an attempt to identify the factors that influence survival after heterotopic heart transplantation, 42 consecutive recipients of heterotopic heart transplant were reviewed. Preoperative pulmonary artery pressures, pulmonary vascular resistance, and donor age significantly differed between hospital survivors and nonsurvivors. Postoperative survival analysis between pairs of groups of patients divided by each of these variables disclosed a significant difference, which confirmed the effects of these variables on survival. Evolution of pulmonary hemodynamics was compared between patients with preoperative pulmonary artery diastolic pressure greater than 25 mm Hg (pulmonary hypertension; n = 22) or less than 25 mm Hg (nonpulmonary hypertension; n = 20). Despite marked differences in preoperative pulmonary hemodynamics, pulmonary artery pressures were dramatically reduced immediately after transplantation, and pulmonary vascular resistance diminished to upper normal limits at 10 days when there were no longer differences in pulmonary vascular resistance between the two groups. Immediate deaths were related to left ventricular failure, and the incidence was similar between the groups. Despite such normalization of pulmonary hemodynamics, patients with preoperative pulmonary hypertension experienced more frequent ventricular fibrillation, required longer respiratory support, and developed lethal pulmonary or systemic infection, which resulted in a 32% (7/22) hospital survival rate compared with 90% (18/20) in patients without pulmonary hypertension. Despite the dramatic improvement in pulmonary hemodynamics, heterotopic heart failed to demonstrate the expected advantages because of frequent pulmonary complications and infection, which resulted in failure to improve the prognosis of patients with preoperative pulmonary hypertension.

Bridge to transplantation with the Jarvik-7 (CardioWest) total artificial heart: a single-center 15-year experience.

BACKGROUND: At our institution, the total artificial heart (TAH) Jarvik-7 (CardioWest) has been used since 1986 as a bridge to transplantation for the most severely ill patients with terminal congestive heart failure. METHODS: Between 1986 and 2001, 127 patients (108 males, mean age 38 +/- 13) were bridged to transplantation with the Jarvik-7 TAH. All were in terminal biventricular failure despite high-dose inotropic support. Nine patients had a body surface area (BSA) of <1.6 m(2). In Group I patients (78%), the etiology of cardiac failure was dilated cardiomyopathy, either idiopathic (n = 60) or ischemic (n = 38). The other 29 patients (Group II) had disease of miscellaneous origin. We analyzed our experience with regard to 3 time periods: 1986 to 1992 (n = 63); 1993 to 1997 (n = 36); and 1998 to 2001 (n = 33). RESULTS: Although Group II patients represented 30% of indications before 1992, they comprised only 15% during the 2 subsequent periods. Duration of support for transplant patients increased dramatically after 1997, reaching 2 months for the most recent period (5 to 271 days). In Group I, the percentage of transplanted patients increased from 43% before 1993 to 55% between 1993 and 1997, and reached 74% thereafter. The major cause of death was multiorgan failure (67%). The clinical thromboembolic event rate was particularly low with no instance of cerebrovascular accident and 2 transient ischemic attacks. Total bleeding complication rate was 26%, including 2 deaths related to intractable hemorrhage and 2 others related to atrial tamponade. The cumulative experience was 3,606 total implant days with only 1 instance of mechanical dysfunction. CONCLUSIONS: TAH is a safe and efficient bridge for patients with terminal congestive heart failure awaiting cardiac transplantation.

Intraatrial insertion of a mitral prosthesis in a destroyed or calcified mitral annulus.

Infectious lesions and extreme calcification of the mitral valve annulus can make classic anatomic implantation of a prosthesis impossible. Confronted with these circumstances, we have developed a technique of intraatrial insertion of a mitral prosthesis. The prosthesis has been modified by enlarging the circumference of the sewing ring with a Dacron collar. The collar can be sutured to the left atrial wall above the mitral annulus. From 1981 to 1989, this technique has been employed in 36 patients: 15 had acute valve endocarditis with destruction of the mitral annulus and 21 had extensive annular calcification. In all cases, circumferential or partial intraatrial insertion permitted a secure implantation of the prosthesis. One operative death was related to the technique. It was an intractable bleeding caused by tearing of the very thin and fragile wall of the left atrium in a kidney transplant patient. Four patients were reoperated on for periprosthetic leak, in 3 of whom healing and cleaning of the mitral annulus permitted annular implantation of a prosthetic valve. There was no ventricular wall rupture. Our results suggest that the technique can be performed in high operative risk patients when mitral valve replacement is impossible by conventional techniques.

Myocardial protection by blood cardioplegia and warm reperfusion in heart transplantation.

We describe the technique of blood cardioplegia delivery as we routinely use it in clinical heart transplantation. This technique needs a specific circuit. Perfusion of a first dose of blood cardioplegia is immediately started on the arrival of the graft in the operating room. Cardiac reperfusion of a half-dose of blood solution without potassium is performed each 20 minutes. Myocardial warm reperfusion is started at the end of the aortic suture. This technique of blood cardioplegia and warm reperfusion during heart transplantation provided an improvement in heart preservation when compared with standard crystalloid solution.

Cardiac tumors: clinical experience and surgical results in 74 patients.

A series of 75 cardiac tumors in 74 patients were operated on at La Pitie Hospital between 1972 and 1989. There were 73 primary and 2 metastatic tumors. Among the benign neoplasms, 58 were myxomas; seven of the nine malignant tumors were primary heart tumors. The mean age of the patients was 48 years (range, 9 to 75 years); 46 patients were female and 28 male. Fifty-seven percent of the patients had congestive heart failure, 13% had chest pain, 17% had neurological symptoms, and only 1 patient was totally asymptomatic. The cardiac tumors were incidental findings in 3 patients. Complete resection was carried out in 66 benign lesions and only four of the malignant tumors. All patients survived operation, although 4 died in the early postoperative period. Long-term results were excellent in patients with benign lesions, and no recurrences were found. In patients with malignant tumors, surgical procedures were only palliative and aimed at prolonging life; hence, prognosis remained unchanged.

Total artificial heart: survival and complications.

A total artificial heart was implanted in 28 patients as a bridge to transplantation. Mean time of mechanical support was 14.8 +/- 10 days. The 70-mL Jarvik-7 was used in 12 patients and the 100-mL Jarvik-7 in the remaining 16. No clinical thromboembolic complications occurred during implantation. There was no postoperative bleeding requiring operation. Both survival and the rate of complications were similar in the two Jarvik-7 groups. Eleven patients underwent successful transplantation, and 1 patient is still on mechanical support. Sepsis and multiple-organ failure were the most important causes of death. All patients receiving the total artificial heart for severe acute rejection after transplantation died of infection. Early implantation of the total artificial heart is advised in younger patients and in older patients with acute cardiac failure. The use of this device should be contraindicated in immunosuppressed patients because of the high risk of infection.

Active native valve endocarditis: determinants of operative death and late mortality.

BACKGROUND: In this report, we reviewed 247 patients who underwent operation by our team for active native valve endocarditis between January 1979 and December 1993. METHODS: There were 201 male and 46 female patients (mean age, 45.4 +/- 6 years). The aortic valve was involved in 163 cases, the mitral valve in 36 cases, both mitral and aortic valves in 44 cases, and the tricuspid valve alone in 4 cases. The most common microorganisms were streptococci. Univariate Pearson (chi2 test) and multivariate (stepwise logistic regression [BMDPLR]) analyses were used to identify significant predictors of operative mortality, reoperation, and recurrent endocarditis. Cox proportional hazards regression model was used to study late survival. RESULTS: Operative mortality was 7.6% (n = 19). Increased age, cardiogenic shock at the time of operation, insidious illness, and greater thoracic ratio (>0.5) were the predominant risk factors; the length of antibiotic therapy appeared to have no influence. Two hundred thirteen patients were followed up. Median follow-up time was 6 years (range, 2 to 19 years). Overall survival rate (operative mortality excluded) was 71.3% +/- 3.8% at 9 years. Increased age, preoperative neurologic complications, cardiogenic shock at the time of operation, shorter duration of the illness, insidious illness before the operation, and mitral valve endocarditis were the predominant risk factors for late mortality. The probability of freedom from reoperation (operative mortality included) was 73.3% +/- 4.2% at 8 years; risk factors were younger age and aortic valve endocarditis. The rate of prosthetic valve endocarditis was 7%. No significant risk factor was found. CONCLUSIONS: Increased age, insidious illness, and hemodynamic failure are the main risk factors for operative mortality. Long-term survival is good except for patients with preoperative neurologic complications and mitral valve endocarditis.

Current problems in cardiac transplantation.

Since our initial orthotopic heart transplant (OHT) in 1968, the first in Europe, 1130 patients with ages ranging from 1 month to 66 years have been referred to us. The cause of irreversible myocardial damage was idiopathic cardiomyopathy in 74%, ischemic heart disease in 19% and left ventricular failure after valvular replacement in 7%. A total of 540 transplantations, 463 orthotopic, 40 heterotopic and 37 heart-lungs were carried out. Features of the early post-operative course include temporary (first week) cardiac instability treated by isoproterenol. Later complications included rejection (95%) and side-effects of immunosuppressive therapy; infection (83%), osteoporosis, malignancy, graft atherosclerosis (2%). Cyclosporine (Cy) was responsible for diastolic hypertension, renal dysfunction, hirsutism, hyperplasia of the gingiva, hepatic dysfunction, and seizures. The survival rate of the Cy-treated patients was 68% at 7 years. All survivors have virtually normal social and professional lives, included the longest survivor 14 years after the operation. Recently in 34 patients in acute irreversible cardiac failure and who cannot have a transplant in time, we implant a total artificial heart (TAH) type JARVIK 7 during a period from 1-150 days. There has been no mechanical failure, hemolysis or thrombo-embolism and only one right ventricular device malposition; 20 patients died before transplantation, 13 were successfully transplanted, 1 is still on the artificial heart. Heart transplantation, and TAH used as a bridge to transplantation are now an accepted therapeutic means for irreversibly cardiac failure in selected patients.(ABSTRACT TRUNCATED AT 250 WORDS)