Acid stress suggests different determinants for polystyrene and HeLa cell adhesion in Lactobacillus casei.

Adhesion has been regarded as one of the basic features of probiotics. The aim of this study was to investigate the influence of acid stress on the functional properties, such as hydrophobicity, adhesion to HeLa cells, and composition of membrane fatty acids, of Lactobacillus probiotics strains. Two strains of Lactobacillus casei were used. Adhesion on polystyrene, hydrophobicity, epithelial cells adhesion, and fatty acids analysis were evaluated. Our results showed that the membrane properties such as hydrophobicity and fatty acid composition of stressed strains were significantly changed with different pH values. However, we found that acid stress caused a change in the proportions of unsaturated and saturated fatty acid. The ratio of saturated fatty acid to unsaturated fatty acids observed in acid-stressed Lactobacillus casei cells was significantly higher than the ration in control cells. In addition, we observed a significant decrease in the adhesion ability of these strains to HeLa cells and to a polystyrene surface at low pH. The present finding could first add new insight about the acid stress adaptation and, thus, enable new strategies to be developed aimed at improving the industrial performance of this species under acid stress. Second, no relationship was observed between changes in membrane composition and fluidity induced by acid treatment and adhesion to biotic and abiotic surfaces. In fact, the decrease of cell surface hydrophobicity and the adhesion ability to abiotic surface and the increase of the capacity of adhesion to biotic surface demonstrate that adhesive characteristics will have little relevance in probiotic strain-screening procedures.

[Retrospective study on 100 cases of infective endocarditis, Rabta University Hospital, Tunis, from 1980 to 2004]. / Etude retrospective à propos de 100 cas d'endocardite infectieuse, au CHU La Rabta de Tunis de 1980 à 2004.

This retrospective study describes 100 cases of infective endocarditis (IE), collected between 1980 and 2004. Patients were subdivided into 2 groups, according to the use of trans-esophageal echocardiography (TOE) in the institution where the study was performed: group A (GA=55 patients, between 1980 and 1991) and group B (GB=45 patients, between 1992 and 2004). The IE cases of 59 men and 41 women were analyzed. Patients had a mean age of 33 years (range 15-75 years). An underlying heart disease was involved in all cases, mainly rheumatic heart disease (93% of cases). Native valve endocarditis (NVE) was seen in a majority of cases (93%), and the localization of IE was aortic in 36 cases, mitral in 36 cases, mitro-aortic in 26 cases and mitro-aortic-tricuspid in 2 cases. Prosthetic valve endocarditis (PVE) occurred in 12 cases. Blood cultures were positive in 31 cases, with 14 staphylococcal infections (3 in GA and 11 in GB) (p < 0.05), of which 6 were coagulase-negative; 13 were streptococci and 4 were Gram negative bacilli. All patients had a transthoracic echocardiography (TTE), and patients in group B also had a TOE. Seventeen patients had a favorable outcome without need of a surgical intervention. Early surgery was necessary in 71 cases (85.5%), and elective surgery in 12 cases (14.5%). Mortality while awaiting surgery was 27%, and has been decreasing for the past decade (41.8% in GA and 8.9% in GB) [p < 0.05]. Postoperative mortality after early surgery intervention was 13.6% (6 among 44 patients), and it was 8.3% (1 among 12 patients) after elective surgery intervention. Overall mortality was 34%: 27 deaths with NVE (30.7% [27/88]), and 7 deaths with PVE (58.3% [7/12]) [NS]. Predictors of mortality in this observational study were positive blood cultures involving staphylococci, the presence of valve mutilations, unstable prostheses, and heart failure.

Results of percutaneous mitral commissurotomy in 200 patients.

To assess the feasibility and efficacy of percutaneous mitral commissurotomy (PMC), the procedure was attempted in 200 patients with severe mitral stenosis. There were 154 women and 46 men, their mean age was 43 +/- 16 years (range 13 to 79) and 15 were older than 70 years of age. Forty-four had had previous surgical commissurotomy. Forty were in New York Heart Association class II, 152 in class III and 8 in class IV. In regard to valvular anatomy, 67 had calcified valves, 58 had pliable valves and only mild subvalvular disease, and 75 had flexible valves but extensive subvalvular disease. Grade 1+ mitral regurgitation was present in 62 and grade 2+ in 2. In 11 patients the procedure was discontinued because of complications in 3 and technical failure in 8. Six of the 8 technical failures occurred during the first 15 attempts. Effective PMC was performed in 189 patients using 1 balloon in 23 and 2 balloons in 166. After PMC, there was a significant improvement in mean left atrial pressure (21 +/- 7 to 12 +/- 5 mm Hg, p less than 0.0001), mean mitral gradient (16 +/- 6 to 6 +/- 2 mm Hg, p less than 0.0001), cardiac index (2.6 +/- 0.8 to 3.1 +/- 0.8 liters/min/m2, p less than 0.001) and valve area assessed by hemodynamics (1.1 +/- 0.3 to 2.2 +/- 0.5 cm2, p less than 0.0001) and 2-dimensional echocardiography (1 +/- 0.3 to 1.9 +/- 0.4 cm2, p less than 0.0001). No patient died. Embolism occurred in 8 (4%), with no further sequelae. Sixteen (8%) had atrial septal defect detected by oxymetry.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic valve replacement in children under 16 years of age with congenital or rheumatic valvular disease. A study of 64 cases.

Sixty-four children have had a single aortic valve replacement under 16 years of age, 50 for rheumatic disease (47) or bacterial endocarditis (3) (group I) and 14 for a congenital aortic valve lesion (group II), 38 were disk prostheses and 26 were ball prostheses. Associated procedures had to be performed 31 times, with widening of a small aortic annulus by a patch in 7 patients. The early mortality was 12.5%. Of 56 survivors, 55 were followed postoperatively for a mean period of 7 years (group I: 44, group II: 11). Forty of the 55 patients were anticoagulated (correctly maintained in only 24 patients), 15 were not anticoagulated. A high rate of late complications was observed. Thrombo-embolic accidents in 5 patients with inefficient anticoagulant treatment, 2 haemorrhagic episodes, 7 prosthetic leaks; specific problems related to this group of young patients were: recurrence of rheumatic fever with increasing severity of mitral valve disease requiring mitral valve replacement in 5 patients and outgrowth of the prosthesis, which affected 7 patients; this complication is the result of either fibrous deposit around the valve annulus or such a small annulus that the surgeon could only implant a small prosthesis. Ten patients required 11 reoperations for various reasons. The main reason for reoperation was mitral valve replacement for worsening of mitral valve disease caused by recurrence of rheumatic fever. A high late mortality 10/55 (18%) was noted. The main cause of death was a perivalvular leak (5); 1 late death was caused by a stenotic number 17 Björk-Shiley valve.(ABSTRACT TRUNCATED AT 250 WORDS)

[Long-term results of tricuspid prostheses]. / Devenir au long cours des prothèses en position tricuspide.

The results of a series of 38 patients with a tricuspid valve prostheses (:76% Starr-Edwards ball valves) associated with correction of one or two left heart valvular lesions are presented. 24 patients underwent clinical and haemodynamic assessment on average 4,2 years after surgery. The conclusions were that signs of systemic venous hypertension were mainly related to residual right ventricular failure despite normal valve function and secondarily to the poor hemodynamic profile of these prostheses and their paradoxical motion. Using these results: 18% early mortality; 24% late mortality; 24% late thrombosis amongst survivors and 52% residual right ventricular failure; and 47,5% of excellent results. The clinical and haemodynamic profiles of the patients were analysed to determine the surgical indications. Apart from the correction of associated left heart valve lesions, it seems that the prognosis in tricuspid valve repair depends on the duration of tricuspid regurgitation and the severity of right ventricular myocardial disease. In elderly patients with chronic tricuspid regurgitation and severe right ventricular failure, long-term analysis showed 87,5% poor results, whilst in younger patients with a shorter history of tricuspid regurgitation and less severe right ventricular failure, there was 77,7% excellent long-term results. Semi circular annuloplasty is widely indicated in mild or severe functional tricuspid regurgitation. Tricuspid valve replacement, a much more serious operation, remains essential in chronic organic lesions and in some cases of massive functional tricuspid regurgitation. A regards the choice of prosthesis, the authors suggest the Hancock bioprosthesis as a logical choice in cases of severe right ventricular failure as they are less prone to thrombosis than mechanical prostheses and have good haemodynamic profiles. The evolution of the right ventricular failure even after correction of tricuspid regurgitation underlines the importance of preventative therapy by early correction of left heart lesions.

[Indications and results of surgery of organic involvement of the tricuspid valve]. / Indications et résultats de la chirurgie des atteintes organiques de la valve tricuspide.

In this study the long-term results of 121 repairs for organic lesions of the tricuspid valve are presented, and a attempt is made at selecting the respective indications for valve replacement (VR) and valvoplasty. Tricuspid valve correction was effected by VR in 37 cases (mechanical prosthesis 26, bioprosthesis 11) and by plastic procedures in 84 cases (commissurotomy 62, alone in 12 cases and combined with annuloplasty in 51 cases; annuloplasty alone in 21 cases). The early mortality rate was 9 p. 100. Subsequently, 28 patients (25 p. 100) died and 12 were lost sight of. Deaths related to the tricuspid valve (n = 7) comprised occlusive thrombosis of mechanical prosthesis (MP) in 4 cases and 3 failures of plastic surgery including 2 commissurotomies alone (TC) and 1 commissurotomy combined with annuloplasty (CA). Among the 70 survivors who could be followed up for 36 to 230 months (mean 98 months), there were: --8 failures, 5 of which required reoperation: 3 belonged to the MP group (3 occlusive thromboses) and 5 to the TC group (failure expressed as major tricuspid valve leakage); --4 mediocre results (1 bioprosthesis, 3 plastic operations). The failures of plastic surgery were mostly due to inadequate right ventricular function; --58 successful results, principally with bioprosthesis, CA and annuloplasty alone. Altogether, 93 p. 100 of CA and 92 p. 100 of bioprostheses were free from complications, as against 37 p. 100 of TC and 65 p. 100 of MP. It is concluded that TC completed by annuloplasty ensures satisfactory results, thus allowing the indications conservative tricuspid valve surgery to be enlarged.(ABSTRACT TRUNCATED AT 250 WORDS)

[Long-term results of heterografts in the mitral position]. / Evolution à long terme des hétérogreffes en position mitrale.

The long term results in 43 patients who underwent mitral valve replacement with a bioprosthesis are reported. The average age of the patient was 25, and nearly half of them were under fifteen. The underlying valvular disease was rheumatic in the great majority. Small bioprostheses were used in 40 p. 100 of cases. Hospital mortality was nil. Two patients developed atrioventricular block and needed permanent pacing; this was the principal complication observed in this study. After 34 months, 17 serious complications were recorded including two episodes of thromboembolism. The main problem arose from restenosis of the bioprosthesis, either because of its small size (3 cases) or because of degeneration (6 cases), all in children (33 p. 100 of our paediatric cases). The actuarial survival rate without degeneration shows only 48,2 p. 100 of patients to be without this problem at 5 years. Late mortality reached 29 p. 100 and the five year survival rate showed only 57 p. 100 of patients to be still alive, and only 35 p. 100 with their bioprosthesis. The haemodynamic profile of these prostheses with regards to transvalvular pressure gradient and mitral surface area, was very good for the large size valves, in contrast to the small size. In the absence of degeneration, the gradient was found to be stable. This study has shown that small bioprosthetic valves should be avoided in mitral valve replacement because of the risk of stenosis. Despite the low incidence of thromboembolism, they should not be used in children because of the high incidence of degeneration in paediatric patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Neurologic manifestations of infectious endocarditis]. / Les complications neurologiques des endocardites infectieuses.

Thirty out of 287 patients (10.4%) admitted to hospital for infective endocarditis between December 1970 and January 1990 had neurological complications. Twenty-three patients had native valve infectious endocarditis and 7 had prosthetic valve endocarditis. The clinical features were characterized by the frequency of aortic valve involvement (23 out of 30) and other complications, especially cardiac failure (16 cases) and peripheral vascular manifestations (7 cases). The commonest organism was the staphylococcus (53% of identified organisms) but the number of negative blood cultures was high (50% of cases). The neurological complication was often the presenting symptom of the endocarditis (19 cases) but it occurred after bacteriological cure in 4 cases. The complications observed were cerebral ischemia (16 cases), cerebral haemorrhage (11 cases), coma (2 cases), and one peripheral neuropathy causing a Claude Bernard Horner syndrome. These complications presented with hemiplegia in 17 cases, a meningeal syndrome in 8 cases, a convulsion in 1 case, a Von Wallenberg syndrome in 1 case, and a Claude Bernard Horner syndrome in 1 case. Twelve patients had a transient or permanent neurological coma. Cerebral CT scan showed ischemic lesions in 7 cases and haemorrhagic lesions in 10 cases. Carotid angiography demonstrated mycotic aneurysms in 6 patients. Twelve patients died: the cause of death was neurological coma (7 cases), low cardiac output (4 cases) and haemorrhagic shock (1 case). Four patients underwent neurosurgery: 3 for clipping a mycotic aneurysm and 1 for drainage of an intracerebral haematoma. Poor prognostic factors were: coma, cardiac failure, cardiac valve prosthesis and, above all, the extent and multiplicity of the neurological lesions. The authors propose the following measures to improve the prognosis: early surgery in cases of large and/or mobile vegetations especially when the infecting organism is a staphylococcus and when a systemic embolism has occurred; routine CT scanning and/or digitised cerebral angiography in all patients with infective endocarditis to detect surgically accessible mycotic aneurysms.

[Late thromboses of prosthetic heart valves. Apropos of 15 cases]. / Thromboses tardives sur prothèses valvulaires. A propos de 15 cas.

15 patients developed late thrombosis of their prosthetic heart valves: --9 mitral, 4 tricuspid and 2 aortic valve prostheses. --12 thromboses occurred on Starr-Edwards ball prostheses (7M, 3T and 2 Ao), 2 on Starr-Edwards disc prostheses (1M, 1T) and one on a Björk-Shiley valve. 14 patients were on anticoagulant drugs but treatment was only effective in 5 patients; only 1 patient was not anticoagulated. Thrombosis of mitral and aortic valves presented with signs of pulmonary oedema and/or systemic (especially cerebral) embolism and tricuspid valve thromboses presented with signs of right heart failure or were discovered on routine examination. Paraclinical investigations, when performed, showed valve movement to be an unreliable sign but phonocardiography was useful. Differing pathological appearances were observed, either peroperatively (7 cases) or at autopsy (8 cases). Late thrombosis is a rare but dangerous complication which should be avoided by effective anticoagulation and diagnosed at an early stage.

[Heart valve prostheses in children with reference to 95 cases]. / Prothèses valvulaires chez l'enfant. A propos de 95 cas.

Over a 10 year period, 95 children aged 15 years and less underwent replacement of one or several of their heart valves, usually by a Starr-Edwards ball prosthesis. The predominant pathology was rheumatic heart disease and the most commonly affected valve was the mitral. Severe symptomatology, heart failure, cardiomegaly and high wedged-capillary and pulmonary arterial pressures were practically constant findings. Operative mortality was low (3.2%) and the long-term mortality was 10 patients. With an average follow-up of 40 months, results were excellent in the great majority of patients, with complete regression of symptoms, cardiomegaly and high capillary and pulmonary arterial pressures. Anticoagulant therapy was not systematic and only half the series were so treated. Thromboembolic complications were rare, 5.5% patients, but only affected those without anticoagulant therapy. The problems of evolving rheumatic disease and, above all, of tricuspid incompetence, the persistence of which after surgery on the mitral valve seems to be a sign of advanced myocardial damage, are discussed.

[Mitral commissurotomy in children. Apropos of 100 cases]. / Commissurotomie mitrale chez l'enfant. a propos de 100 cas.

We report 100 cases of mitral commissurotomy in children, 15-years-old or less, suffering from rheumatic mitral stenosis. Mitral stenosis in children is characterised by the severity of functional impairment and the considerable radiological, electocardiological and haemodynamic changes, with pulmonary arterial hypertension which is always present and often well marked. The early results of mitral commissurotomy are very satisfactory with clinical improvement and a low mortality. But, in the long term, we have seen progressive deterioration in the clinical state of these patients resulting from re-stenosis or from the progression of another valve lesion. Three problems have been discussed. First, the progression of the rheumatic process which seems to account to a large extent for the late failures of mitral commissurotomy in children. Secondly, the problem of tricuspid insufficiency, which is often associated with mitral stenosis in childhood and which usually disappears during the post-operative period. Finally, the problem of pre-capillary pulmonary arterial hypertension which always showed a tendency towards regression.

[Fate of Starr-Edwards prostheses in the mitral position. Prognostic factors. Apropos of 309 cases]. / Evolution des prothèses de Starr Edwards en position mitrale. Facteurs de pronostics. A propos de 309 cas.

The authors report the long-term results of 309 patients undergoing isolated mitral valve replacement with a 6120 Starr Edwards mitral valve prosthesis in the great majority of cases, mainly for rheumatic mitral valve disease, with predominant mitral regurgitation. The average age was 26 +/- 14 years with 25% of children. The operative mortality was 9% and late mortality after a mean follow-up period of 4 years was 13,5% mainly due to thromboembolic complications and to myocardial dysfunction. The long-term results with an average 45 month follow-up showed a 10 year survival rate of 70,6% with an excellent clinical result in 71% of cases and an acceptable result in 10%; 20% of patients were considered poor long-term results because of myocardial dysfunction and thromboembolic complications. Endocarditis and perivalvular leaks were rarely observed (9 cases). A study of preoperative parameters which could influence long-term results showed that the quality of long-term survival was significantly correlated to age, the duration of cardiac disease before surgery, cardiomegaly and the presence of preoperative cardiac failure and tricuspid regurgitation. The incidence of thromboembolism was 4,7% patient years and the frequency of these complications was not related to the quality of anti-vitamin-K therapy. Patients under effective anticoagulant therapy had the highest incidence of haemorrhage (10%). This study confirms that the Starr Edwards 6120 prosthesis is a satisfactory choice for mitral valve replacement considering its durability (no cases of abnormal wear) and the 70% ten year survival rate. The problem of myocardial dysfunction could be resolved by earlier surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Late thromboses on tricuspid valve prostheses. Apropos of 6 cases]. / Thromboses tardives sur prothèses tricuspidiennes. A propos de 6 cas.

Six out of 24 patients with tricuspid valve prostheses, operated between 1968 and 1978, followed-up from 1 to 10 years (average 4,2 years) developed thrombosis. This complication occurred between 15 and 59 months after operation (average 37 months). All patients were female with ages ranging from 18 to 44 years (average 38 years). Starr-Edwards prostheses were used in all cases. Five of these patients were on anticoagulants therapy, which was well within therapeutic limits in 3 patients. In contrast to thrombosis of mitral or aortic valve prostheses, the presenting symptoms were slowly progressive and discreet in 4 patients; in 1 case, the thrombosis was diagnosed on routine follow-up examination. The slow clinical presentation allows time for useful complementary investigations, catheterisation and angiocardiography being the most reliable methods of confirming this difficult diagnosis: these investigations were carried out in 2 patients, and in both cases, very high right atrial pressure with diastolic gradients between the right atrium and right ventricle of over 10 mm Hg were recorded. Cineangiography showed tricuspid regurgitation in both cases with reflux in the vena cavae and very dilated right atria, stagnation of contrast and poor right ventricular filling. Five patients were reoperated with two postoperative deaths. Particular anatomical appearances were observed at operation or autopsy with fibrin and platelet deposits at different levels of the prosthesis (sewing ring and/or struts) interfering and even blocking the function of the ball or disc. Organized thrombus on the cage was only observed in one patient. In this case, the struts on the prosthesis were set in the right ventricular cavity. Thrombosis of tricuspid valve prostheses is generally a slowly progressive complication and may be diagnosed in time by regular follow-up, so that reoperation may be considered without unnecessary delay.

[Outcome more than 10 years later of mechanical mitral valve prostheses in children]. / Evolution au-delà de 10 ans des prothèses valvulaires mécaniques en position mitrale chez l'enfant.

Between 1966 and 1975, fifty-one children aged from 8 to 15 years underwent mitral valve replacement for mitral valve disease of rheumatismal origin. The mechanical prosthesis was a Starr Edwards 6120 N degrees 2 valve in 48 of the children. Late mortality was 20 p. 100; death was due to valve thrombosis in 3 cases, aortic valve regurgitation in 2 cases and left ventricular dysfunction in 2 cases; it was of unknown origin in 3 cases. Four patients were lost sight of, and 36 have survived up to now with a mean follow-up period of 13 years. The life of these 36 patients has been marked by three types of complication. The first complication was thromboembolic accidents which occurred in 10 patients, were virtually always isolated and regressed completely. The incidence of these accidents was highest in patients treated with antivitamin K irregularly. In 23 patients who did not receive antivitamin K the incidence was only 2.27 thromboembolic accidents per 100 patient-years. The second complication, which affected only 4 patients, was functional stenosis of the prosthesis; it developed very late and was always due to periannular fibrosis either isolated or associated with remodelling of the mitral valve left in situ. The third complication was the development, with or without patent rheumatismal activity, of a lesion of the aortic orifice which required reoperation in 5 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparison of long-term results of the Starr and Saint-Jude mitral valve prostheses]. / Comparaison des résultats à long terme des prothèses de Starr et de Saint-Jude en position mitrale.

Two groups of patients having undergone mitral valve replacement with a Starr-Edwards (Group A = 149 patients) or Saint Jude (Group B = 87 patients) prosthesis between 1981 and 1987 were included in this study. The aim of the study was to evaluate and compare the mortality, the morbidity--especially with respect to thromboembolic events--and echo Doppler haemodynamic profiles of the two types of prosthesis. The two patient groups were comparable with respect to age, aetiology and preoperative haemodynamic status. Late mortality was greater in Group A (13% versus 4.5%) and the 5 year survival was significantly better in Group B (95% versus 89%). Thromboembolic events were significantly more common in Group A (2.6% per patient year versus 0.5% per patient year in Group B, p = 0.01). Five years survival without thromboembolic event was 94% in Group B versus 86% in Group A. The haemodynamic Doppler echocardiography profiles were compared on random samples of 30 cases from each group, the only exclusion criterion being suspected or confirmed prosthetic valve dysfunction.

[Detachment of valve prostheses. Apropos of 24 cases]. / Désinsertions de prothèses valvulaires. A propos de 24 cas.

A series of 24 cases of paraprosthetic valvular regurgitation, 10 mitral and 14 aortic, in 19 out of a group of 634 operated patients with a total of 822 prosthetic heart valves is reported. The presenting features are dominated by auscultatory changes, though inconstant episodes of heart failure, and, in aortic prostheses, the high incidence of infective endocarditis. Paraclinical investigations are of variable value; cineradiography in aortic valves and phonocardiography in mitral valves are useful; catheterisation with ventriculography or aortic angiography according to the case under study are the investigations of choice, especially in mitral regurgitation where it is essential. Typical clinical settings for these problems are valve ring dilatation calcification, and previous or active infective endocarditis. The indications for urgent surgery depend on the clinical signs, the presence of heart failure, haemolysis, active endocarditis and deterioration despite medical treatment. The series compares the data in mitral paraprosthetic regurgitation, difficult to diagnose but with a reasonably good prognosis, and aortic paraprosthetic regurgitation, easier to diagnose but associated with a poor prognosis due to the high incidence of associated endocarditis.

[Reoperations on heart valve prostheses. Apropos of 58 cases]. / Réinterventions sur prothèses valvulaires cardiaques. A propos de 58 cas.

In the period from 1968 to November 1980, 1 023 patients underwent surgery for single or multiple valve replacement. Fifty three patients (6,6% of the follow-up population) had to be reoperated, including 5 patients who had to be reoperated twice, giving a total of 58 reoperations. The average interval before reoperation was 30 months. The incidence was similar in monovalvular (7,5 p. 100 mitral valves, 5 p. 100 aortic valves) and polyvalvular (7 p. 100) cases. On the other hand, the incidence of reoperation of tricuspid prostheses (17 p. 100) was significantly superior to that of mitral valve (5,3 p. 100) or aortic valve (3,8 p. 100) prostheses. In 91 p. 100 of cases, the indication for reoperation was prosthetic valve dysfunction related to endocarditis in over a third of cases (21). In 32 cases, reoperation was required in the absence of any infectious process: 13 spontaneous perivalvular leaks, 10 thromboses, and 9 stenosing prostheses. There were no reoperations for wear of the prosthetic material. Only 9 p. 100 of patients were reoperated for uncorrected valvular disease. The prognosis of these reoperations was poor; hospital mortality being 42,5 p. 100. This high mortality rate is explained by the frequency of reoperation for infective endocarditis (36 p. 100) in our series, the mortality of which was 73,6 p. 100 and even higher when reoperation was an emergency for infectious or hemodynamic reasons. There was also a high mortality rate with reoperation for thrombosis (30 p. 100) because of the severe myocardial dysfunction in thrombosis of tricuspid prostheses and the emergency situation associated with mitral prosthetic valve thrombosis. Excluding these two complications, the average mortality was 21 p. 100. Although the surgical indications are relatively easy for thrombosis, perivalvular leak and stenosing prostheses, they are particularly difficult in infectious endocarditis especially with regards to the timing of reoperation. We believe that, ideally, reoperation should be delayed as long as possible to allow the antibiotic therapy the maximum time to take effect. Surgery can then be performed after controlling the infection and before the installation of severe hemodynamic distress.

[Heart valve prosthesis and pregnancy]. / Prothèses valvulaires cardiaques et grossesse.

Sixteen pregnancies were followed up in 13 patients with prosthetic heart valves: 8 pregnancies went to term under oral anticoagulation, 4 under heparin and 4 without anticoagulation. 9 healthy normal children were delivered; there were 2 still births and 5 abortions. On the maternal side 3 haemorrhages and thromboembolic episodes which involved 2 patients on heparin, one of whom died, were observed. The following points are apparent from our observations and a review of the existing medical literature: --the risk of thromboembolism is not increased. The marked clotting tendency of maternal blood post-partum contraindicates the withdrawal of anticoagulants during this critical period; --haemorrhagic complications are common with anticoagulants; --foetal loss is greatly increased; --the teratogenecity of vitamin-K antagonists is certain, but the risk is small. The problems of anticoagulation are discussed; theoretically heparin should be given during the 1st trimestre and from the 38th week to the second post-partum week. The patients should be closely supervised by both obstetrician and cardiologist and hospitalisation is advised for the last month of pregnancy. Normal vaginal delivery is usually possible.

[Hydatid cyst of the heart. Apropos of 9 cases]. / Le kyste hydatique du coeur. A propos de 9 cas

The authors report 9 cases of hydatic cyst of the heart which they have encountered over an 8 year period. They illustrate the variable nature of this parastic illness, which may stimulate almost and cardiovascular disorder. The various clinical presentations and the methods of diagnosis and treatment are presented: the clinical picture is of little help in establishing the diagnosis. This is made at three levels: the history (country of origin where the disease is endemic, or other associated cyst), the presence of Xray of a swelling of the heart which is later calcified, and the presence on the electrocardiograph of ischaemic changes, which may be severe enough for necrosis. They emphasise the importance of serological tests to make a formal diagnosis of the condition, and a repetition of such tests as part of the postoperative follow-up. Surgical treatment (usually by an open heart technique) is the rule. It may be coupled with medical treatment with anti-malarials (paludrin of flavoquin).

[Infectious endocarditis surgically-treated in the active phase. Apropos of 46 cases]. / Endocardites infectieuses opérées à la phase active. A propos de 46 cas.

The clinical and microbiological characteristics, the surgical indications and procedures, the evolution and the principal prognostic factors were reviewed in 46 cases of infectious endocarditis operated in the active phase. Using this date, the authors try to determine the optimal time for surgery during the acute active phase of infectious endocarditis. The study population comprised 28 men and 18 women aged 7 to 64 years (average age: 30). The patients were selected on strict criteria: positive blood cultures during the 48 hours prior to surgery (29 cases), positive valve or valve prosthesis culture (15 cases), the presence of an active cardiac abscess at surgery (7 cases), the presence of a large number of bacteria on histological examination of the valve (17 cases). The patients were divided into two groups: those with endocarditis of native valves (27 cases) and those with endocarditis on prosthetic valves (19 cases). The preoperative clinical features included all the classical signs of IE but congestive cardiac failure was particularly prevalent (62% of cases). Microbiologically, most cases of native valve endocarditis (67%) were due to sensitive organisms (streptococci) whilst the more virulent organisms (staphylococci, gram-negative bacteria and fungi) were observed in prosthetic valve endocarditis (64% of cases). The commonest surgical indication was haemodynamic deterioration (30 cases). The indications were mixed in 15 cases but only one case was operated for uncontrolled infection alone in this series. The surgical procedure was technically complex in 6 cases. Operative mortality was high (18 cases, 39%). The main cause of death was low cardiac output (13 cases).(ABSTRACT TRUNCATED AT 250 WORDS)