Coarctation of the aorta in adults: surgical results and long-term follow-up.

BACKGROUND: The aim of this retrospective study was to determine the impact of coarctation surgical repair on arterial blood pressure in adults more than 20 years of age. METHODS: Thirty-five adults (23 men), mean age 28.1 +/- 5.7 years (range, 21 to 52 years), underwent coarctation surgical repair between 1977 and 1997. All patients had preoperative hypertension. Mean systolic blood pressure was 178 +/- 37 mm Hg (range, 110 to 230 mm Hg). Thirty-three patients were taking at least one hypertension medication at the time of operation. All patients had preoperative catheterization and angiography (mean gradient across the coarctation was 62 +/- 27 mm Hg [range, 32 to 130 mm Hg]). Operative technique was resection and end-to-end anastomosis for 30 patients, resection with Dacron (C. R. Bard, Haverhill, MA) graft for 4 patients, and a prosthetic bypass graft for 1 patient. There were no hospital deaths and no late morbidity. RESULTS: All patients were reviewed. Follow-up was 165 +/- 56 months (range, 25 to 240 months). Of the 35 patients with preoperative hypertension, 23 were normotensive (systolic blood pressure < or = 140 mm Hg, diastolic blood pressure < or = 90 mm Hg) with no medication. Twelve patients were receiving medication: 6 required single-drug therapy and 6 patients required two drugs. Exercise testing was performed at an average of 6 +/- 4 months after repair and revealed hypertensive response to exercise in 8 of the 23 patients who were normotensive at rest and without medication. There were no recoarctation or repeat operations. Six aortic valve diseases were observed: three aortic incompetences (two bicuspid valves) treated by two valve replacements and one Bentall procedure, and three aortic stenoses (two valve replacements). No patient had evidence of a cerebrovascular accident. CONCLUSIONS: Surgical repair of coarctation in adults has proved to be an effective procedure and significantly reduces arterial hypertension. However, long-term surveillance is mandatory and should include exercise testing to identify patients with potential hypertension.

Pseudomonas aeruginosa coronary stent infection.

Stent infection is a rare complication of coronary angioplasty. We report a case of a coronary stent bacterial infection due to Pseudomonas aeruginosa, shortly after implantation of the stent in the left circumflex artery, which presented as an acute pericarditis. Surgical treatment consisted of stent removal and partial excision of the circumflex artery without coronary artery bypass grafting.

[Long-term outcome of a false lumen after surgical correction of type A acute aortic dissection]. / Evolution, à long terme, du chenal externe après cure chirurgicale des dissections aortiques aiguës de type A.

The long-term outcome (64.3 +/- 45 months) of 44 patients operated for acute dissection of at least the ascending aorta was assessed by regular clinical examination and annual CT scan. The diameter of the aorta at different levels was measured at each CT scan for all patients. Initially, 7 patients (16%) had acute dissection limited to the ascending aorta; none had a false lumen after surgery. No signs of aneurysmal dilatation were observed during follow-up of these patients. In the 37 other cases (84%) dissection of the aorta extended beyond the innominate artery; the false lumen remained patent distal to the prosthetic tube replacing the ascending aorta in 34 patients (92%). The false lumen was partially thrombosed in 8% of patients, leading to distal emboli in 1 patient. Moderate increases (less than 15 mm) in diameter of the false lumen were observed in 32% of patients; more severe dilatation (over 20 mm) was observed in 12% of patients. The management of dilatation of the false lumen is not standard; it depends mainly on the rate of progression and the clinical consequences. It is hoped that extension of the initial repair to the aortic arch, when the intimal tear is situated in this zone, will reduce the short and long-term progression of the false lumen.

[Aortic valve replacement in patients over 80 years of age. Short- and medium-term results in 140 patients]. / Remplacement valvulaire aortique chez les patients de plus de 80 ans. A propos de 140 patients, résultats à court et moyen termes.

One hundred and forty aortic valve replacements (AVR) performed between 1986 and 1995 at Rouen University Hospital in octogenarians (52 men and 88 women), including 9 emergency procedures, were analysed. One hundred and fifteen patients had pure aortic stenosis, 25 had mixed aortic valve disease with mainly aortic incompetence. The surgical decision was taken by the patient with the surgeon after an interview, in order to exclude too handicapped or undecided patients. Significant coronary artery disease was observed in 42% of cases. Isolated AVR was undertaken in 74% of cases and associated coronary bypass surgery in 23% of cases. Bioprostheses were used in 90% of cases. The valvular lesions were predominantly those of Monckeberg disease. The operative mortality was of 13 patients (9.3%). Functional recovery was satisfactory in 78% of cases; the average duration of the hospital stay was 12 days. All known risk factors for AVR: age, coronary lesions, cardiac failure, low ejection fraction, aortic regurgitation, were associated with insignificant increases in mortality. The secondary mortality was of 28 patients; 99 patients are still alive 4 to 91 months after surgery. The actuarial survival graph showed a 56.5% probability of 5 year survival. Eighty per cent of survivors live at home without loss of autonomy.

Mid-term comparative follow-up after aortic valve replacement with Carpentier-Edwards and Pericarbon pericardial prostheses.

BACKGROUND: The first generation of pericardial valves had a high rate of premature deterioration. The aim of this study was to compare the outcome after aortic valve replacement with second generation pericardial prostheses (Pericarbon and Carpentier-Edwards). METHODS AND RESULTS: Between 1987 and 1994, 162 patients underwent aortic valve replacement with either a Pericarbon (n=81, 69+/-11 years) or a Carpentier-Edwards (n=81, 70+/-11 years) pericardial prosthesis. Mean follow-up was 4.4+/-2.7 years for Pericarbon and 4.8+/-2.4 years for Carpentier-Edwards valves (P=0. 27), giving a total follow-up of 745 patient-years. Thirty-day mortality and 5-year actuarial survival were, respectively, 6.2% and 63.2+/-5.7% in the Pericarbon group and 6.2% and 63.5+/-5.6% in the Carpentier-Edwards group. At 8 years, freedom from (and linearized rates per patient-year) thromboembolism, structural failure, and all valve-related events were, respectively, 91.8+/-3.6% (1.4%), 76. 9+/-8.7% (2.5%), and 58.4+/-9.3% (5.6%) in the Pericarbon group and 94.4+/-2.7% (1%), 100% (0%, P<0.01), and 88.8+/-3.7% (2%, P<0.05) in the Carpentier-Edwards group. There were 9 (11.1%) Pericarbon structural failures related predominantly to severe calcification and stenosis. The actual reoperation rate was 7.4% (1.6% per patient-year) in the Pericarbon group for fibrocalcific degeneration (n=3), periprosthetic leak (n=1), endocarditis (n=1), and aortic dissection (n=1). There was neither structural valve failure nor valve reoperation in the Carpentier-Edwards group. Echocardiographic review of 70 patients from 85 survivors (82.3%) found 4 additional Pericarbon valves with signs of early structural failure but no Carpentier-Edwards valve with such changes. CONCLUSIONS: Eight years after aortic valve replacement, Pericarbon pericardial prostheses compared unfavorably with Carpentier-Edwards pericardial prostheses, with a high incidence of structural valve failure and reoperation.

Aortic valvular replacement in octogenarians. Short-term and mid-term results in 140 patients.

Aortic valvular replacements were performed between 1986 and 1995 at Rouen University Hospital on 140 octogenarians (52 male and 88 female). Pure or predominant aortic stenosis was present in 115 patients, 25 had associated aortic stenosis and insufficiency or predominant aortic insufficiency. Significant coronary lesions were present in 42% of patients. An isolated aortic valvular replacement was performed in 74% of patients, associated with a bypass in 23% and a bioprosthesis was used in 90%. Valvular lesions were mainly caused by Mönckeberg disease. Thirteen operative deaths occurred (9.3%). Functional recovery was satisfactory in 78%, mean hospital stay was 12 days. All well-known risk factors for aortic valvular replacement: age, coronary lesions, cardiac insufficiency, impaired ejection fraction and aortic insufficiency, led to an increase in operative mortality but were not statistically significant. Late mortality occurred in 28 patients, 99 patients are still alive at 4-91 months after surgery. The actuarial survival curve shows a 56.5% probability of surviving 5 years. Eighty per cent of survivors are able to live independently at home.