[Interest of evaluation of teaching in thoracic and cardiovascular surgery].

The aim of this work is to reflect on different teaching methods can be used in a surgical teaching and its assessment methods. TWO sessions of Multiple Choice Questions (MCQ) have been proposed, the first before all education, the second after education in order to assess its impact on knowledge. Script Concordance Test (SCT) will replace the traditional interactive case report. Eighteen participants (Group 1) completed both sessions of MCQ: 9 residents (R), 2 equivalent resident (ER), 4 Clinical Fellow (CF), 1 Professor (Pr) and 2 senior surgeons (SS). Sixteen participants (group 2) were present at the first session of MCQ: 6 R, 1 ER, 4 CF, 2 Pr, 2 SS and 1 indeterminate status. Finally, 12 participants (group 3) were present at the second session: 6 R, 1 ER, 1 CF, 1 SS and 3 indeterminate status. The results of"seniors" in Group 1 were higher than those of "juniors" at the first session. MCQ results for the second session were higher in the subgroup CF. A more marked progression in knowledge was observed in resident and Clinical Fellow. Finally, the score obtained by the group 3 was lower than in group 1. The format of the MCQ was particularly heterogeneous. The SCT will help to assess the capacity of decision making in a context of uncertainty (as unexpected surgery requiring quick decisions with immediate effect, surgical strategy in an unusual clinical situation). The different tools available would allow the establishment of an evaluation of teaching, but also to assess the development of thinking skills in situations of uncertainty. Their implementation will take place with the participation and support of the largest number of teachers in our specialty.

Surgical site infection after central venous catheter-related infection in cardiac surgery. Analysis of a cohort of 7557 patients.

The aim of this study was to establish the relationship between the occurrence of a surgical site infection (SSI) and the presence of a central venous catheter-related infection (CVCRI). The Department of Thoracic and Cardiovascular Surgery, University Hospital, Rouen, has carried out a prospective epidemiological survey of all nosocomial infections (pneumonia, SSI and CVCRI) since 1997. The study group included all consecutive patients who underwent cardiac surgery over a 10-year period from 1997 to 2007. A nested case-control study was conducted to identify the risk factors for SSI after CVCRI. Cases were patients with SSI after CVCRI and controls were randomized from patients who presented with CVCRI not followed by SSI. In total, 7557 patients were included and 133 SSIs (1.7%) were identified. The rate of superficial SSI was 0.7% [95% confidence interval (CI): 0.5-0.9] and of mediastinitis was 1.0% (95% CI: 0.8-1.2). Among the 133 cases of SSI, 12 (9.0%; 95% CI: 5.0-14.8) occurred after a CVCRI with identical micro-organisms. CVCRI [adjusted odds ratio (aOR): 5.2; 95% CI: 3.2-8.5], coronary artery bypass grafting (aOR: 2.9; 95% CI: 1.6-5.2), and obesity (aOR: 11.4; 95% CI: 1.0-130.1) were independent factors associated with SSI. The new finding of this study is that patients with CVCRI were 5.2 times more likely to develop SSI compared to patients without CVCRI.

Preoperative tissue Doppler imaging differentiates beneficial from detrimental left ventricular hypertrophy in patients with surgical aortic stenosis. A postoperative morbidity study.

BACKGROUND: In a pressure overloaded left ventricle, regional systolic function has often deteriorated despite normal ejection fraction. OBJECTIVE: To correlate regional systolic function obtained by tissue Doppler imaging (TDI) with improvement in functional status after aortic valve replacement in patients with aortic stenosis (AS). METHODS AND RESULTS: 24 hours before aortic valve replacement, 32 patients with severe AS underwent conventional and TDI echocardiography for systolic peak velocity, peak strain and peak strain rate measurement in the short-axis posterior wall. At follow-up, a composite end point of cardiovascular death, worsening of heart failure and limited exercise capacity was recorded. Before surgery, mean (SD) aortic valve area and pressure gradient were 0.69 (0.22) cm(2) and 50 (14) mm Hg, respectively. Ejection fraction was 61 (10)% and septal thickness was 15 (3) mm. Fourteen events were recorded but no cardiac death. By using the multivariate regression analysis, systolic peak strain rate (p = 0.003) was the strongest predictor of limited recovery after aortic valve replacement. The peak strain rate cut-off point was 2/s by receiver operating characteristic analysis. CONCLUSION: Irrespective of ejection fraction and thickness, strain rate is a determinant which predicts recovery after aortic valve replacement in patients with severe AS.

[Cardiac troponin I and CK-MB mass after cardiac surgery with cardiopulmonary bypass]. / Troponine Ic et CK-MB masse en chirurgie cardiaque sous circulation extracorporelle.

Cardiac troponin I (cTnI) assay is used in the diagnosis of myocardial infarction after cardiac surgery. Variations in the cut-off value have been reported even with the same assay method. The aim of this work is to investigate the release profile of cTnI and CK-MB mass after cardiac surgery and to determine the cut-off value of cTnI and CK-MB mass allowing the diagnosis of perioperative myocardial infarction. In patients without postoperative cardiac complication, the cTnI peak was observed 24 hours after surgery both in coronary artery bypass grafting and in valve replacement. Moreover, the amount of cTnI released within the three hours after surgery is 2.5 fold higher in valve replacement than in coronary artery bypass grafting. The CK-MB peak was observed 3 hours after surgery in the two surgical procedures. In these patients, cTnI and CK-MB concentrations increased with the cross clamp time duration. In patients with postoperative myocardial infarction, the cTnI and CK-MB peaks were observed 24 hours after surgery. Diagnosis of perioperative myocardial infarction can be performed with a sensitivity of 100% at 24 hours with cut-off values of 32 and 7 microg/L for CK-MB and cTnI, respectively, both with Stratus (Dade Behring) and Immulite (DPC) analysers.

Mediastinitis after coronary artery bypass graft surgery: influence of the mammary grafting for diabetic patients.

Mediastinitis is a severe complication of coronary artery bypass graft surgery (CABG) particularly when harvesting internal mammary arteries (IMA). CABG in diabetic patients often uses two IMA because the saphenous graft is damaged. To our knowledge this risk of mediastinitis has not previously been reported in diabetic patients. All consecutive diabetic patients undergoing CABG over a three-year period from 1998 to 2000 were included in the study. Data recorded were: age, sex, duration of stay, whether one or two IMA were used, diagnosis of mediastinitis. Calculation of relative risk and analysis of trends by chi2 trend tests was also performed. In total 256 diabetic patients were included in the cohort. The incidence of mediastinitis was 4.3% (11/256). The risk of mediastinitis was higher in patients with two IMA than in patients with one IMA (relative risk 5.97, 95 CI 1.63-21.93, P=0.004). Age and sex were not confounding factors. No patients with mediastinitis died. Bilateral IMA grafting is associated with higher risk of mediastinitis in diabetic patients. The authors suggest that the risk of mediastinitis in diabetic patients should be taken into consideration when cardiac surgeons choose unilateral or bilateral IMA harvesting for surgery.

Myocardial revascularization in patients with severe ischemic left ventricular dysfunction. Long term follow-up in 141 patients.

OBJECTIVES: The present study evaluates our experience with coronary bypass grafting in patients with EF < or =25%. Myocardial revascularization in this setting remains controversial because of concerns over operative mortality and morbidity and lack of functional and survival benefit. MATERIALS AND METHODS: One hundred and forty-one patients with coronary artery disease and left ventricular ejection fraction < or =25% underwent coronary artery bypass graft between January 1988 and December 1998. Mean age at operation was 63.3 years and 81.4% were male. The major indication for surgery was angina (114 patients, 80.8%). Ejection fraction (EF), left ventricular end diastolic pressure (LVEDP) and cardiac index (CI) were used to assess left ventricular function. The number of graft was 2.7+/-1.6/patient. Internal mammary artery was used in 119 patients (84.3%). Intra aortic balloon pump was placed preoperatively in 25 patients (17.7%). Five operative risk factors were associated with a higher mortality: emergency, female sex, LVEDP, CI and NYHA class IV. RESULTS: The operative mortality was 7% (10 patients). Left ventricular ejection fraction (assessed post operatively in 83 patients) improved from 22.2% preoperatively to 33.5% post operatively (P<0.001), mean end diastolic volume index fell from 98 to 83 ml/m(2) following surgery. Survival at 2, 5 and 7 years was respectively 84+/-3%, 70+/-4% and 50+/-5%. Two variables were associated with increased long term survival: congestive heart failure (NYHA class lower than IV (P=0.035) and cardiomegaly (P=0.04) CONCLUSION: In patients with left ventricular dysfunction, myocardial revascularization can be performed relatively safely with good medium term survival and improvement in quality of life and in left ventricular function. Coronary artery bypass graft may be offered to patients with impaired ventricular function, but careful patient selection and management when considering these patients for operation should assess potentially reversible dysfunction.

[Acute traumatic rupture of the thoracic aorta and its branches. Results of surgical management]. / Ruptures traumatiques aiguës de l'aorte thoracique et de ses branches. Résultats du traitement chirurgical.

STUDY AIM: The aim of this retrospective study was to report a series of 102 patients with acute traumatic rupture of the thoracic aorta and its branches (TRA) and to evaluate long-term results. PATIENTS AND METHODS: From April 1977 to April 2000, 102 patients with RTA were admitted to our unit. Age ranged between 12 and 74 years (mean age: 33 years). Localisation was: ascending aorta (n = 3), aortic arch (n = 1), isthmus (n = 92), descending aorta (n = 1), innominate artery (n = 3), and left subclavian artery (n = 2). Associated injuries mainly included craniocerebral lesions (n = 76), rib fractures (n = 68), and thoracic (n = 38), and abdominal (n = 24) lesions. Average time between trauma and surgery was 37 hours. Aortography was used routinely for diagnosis. Five patients were inoperable; the procedure was delayed in three patients. In all but two patients with rupture of the isthmus, descending aorta and subclavian artery, the operation included venous arterial femorofemoral assistance. Rupture was partial in 37 patients (37 direct sutures), and complete in 55 patients (40 direct sutures). In two cases of left subclavian artery desinsertion, the operation included suture of the aortic tear and reimplantation of the artery. In patients with rupture of the ascending aorta and aortic arch, surgery was carried out under cardiopulmonary bypass with deep hypothermia for aortic arch rupture. Repair consisted of direct suture. In patients with rupture of the innominate artery, the lesion was treated under cardiopulmonary bypass by direct suture. In five cases, abdominal injuries required emergency procedure before aortic repair. RESULTS: Four patients died. No postoperative paraplegia occurred. The high morbidity rate was in relation to the associated injuries. Among the 93 survivors, the aortic clinical status was satisfactory in 91 patients (two patients were lost to follow-up). Two patients died from cancer and myocardial infarction 2 and 7 years later respectively. One patient had prosthetic sepsis and was reoperated on with homograft. Angiographic control by aortography (n = 60) and angioMRI (n = 22) was normal in 76 patients. There were five stenoses at the level of the prosthesis, four with a gradient < 20 mmHg and one with a gradient > 50 mmHg and one aneurysm at the level of the isthmus. These last two patients were reoperated on with good result. CONCLUSION: RTA remains a surgical emergency with multiple difficulties. Despite the development of new imaging modalities, angiography remains the gold standard for the work-up of these patients. Venous arterial femorofemoral assistance with a pump remains the best procedure in order to avoid paraplegia and vascular prosthesis implantation when possible. Endovascular stent graft insertion, although still under investigation, holds tremendous promise for non-surgical treatment of these patients.

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.

[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.

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.

Urgent surgical repair of postinfarction ventricular septal rupture: early and late outcome.

AIM: This retrospective analysis focuses on predictive factors of operative mortality and long-term survival after surgical repair of postinfarction ventricular septal rupture (VSR). METHODS: Sixty-seven patients (43 males, 24 females) with VSR underwent surgical repair between December 1977 and December 1995. The site of the rupture was anterior in 44 patients and posterior in 23. The mean interval between myocardial infarction (MI) and VSR was 3.6+/-4.1 days. Clinical condition on admission was critical in 63 patients (49 in cardiogenic shock). An intra-aortic balloon pump was inserted preoperatively in 54 patients. RESULTS: Operative mortality was 25% (17 patients). The main cause of death was cardiac failure. Factors influencing early deaths in univariate analysis were preoperative hemodynamic status (cardiogenic shock present in 30%; absent in 8%; p = 0.001), the location of the MI (anterior in 11.6%, posterior in 45.4%), the interval between infarction and surgery (<1 week was 33%, >1 week was 6.2%), and the response to initial active therapy. All patients were available for follow-up. The actuarial survival rates at 1 and 5 years are 74.6%+/-5.3% and 66.2%+/-6.2%, respectively. There were 12 late deaths and 40% were cardiac related. Two patients presented residual VSD (one reoperation). The left ventricular ejection fraction (LVEF) was mildly impaired in 9 patients. Three patients had moderate mitral insufficiency and two had moderate tricuspid insufficiency. CONCLUSION: Repair of the postinfarction VSR remains a challenge. Improvement should be rendered possible by optimizing techniques. Postoperative morbidity is high, and these patients require intensive hospital resources. The late results have been satisfactory.

Conventional and total orthotopic cardiac transplantation: a comparative clinical and echocardiographical study.

OBJECTIVE: Clinical interest has recently emerged in a new technique of heart transplantation with bicaval and pulmonary venous anastomosis. This technique is thought to improve left heart function and reduce thromboembolism. We have used this technique systematically since 1993. We compared the patients transplanted before September 1993 with the standard technique and the patients transplanted with the new technique. METHODS: A total of 135 patients were transplanted at our institution from 1987 to 1995, 100 with the standard technique and 35 with the new technique. of these, 95 survivors were studied by transthoracic and transesophageal echocardiography; 65 were transplanted with the standard technique ('standard' group) and 30 with the new technique ('total heart' group). All patients were free from rejection and in sinus rhythm when studied. RESULTS: Boths groups were similar in pretransplant characteristics. Operative data were similar with a limited increase in the ischemic time with the total heart technique (210 +/- 73 min for 'total heart' vs. 196 +/- 84 min for 'standard'). Right heart catheterization showed comparable cardiac output and pulmonary pressures. Peripheral embolic events occured in 9 patients in the 'standard' group and none in the 'total heart' group. The left atrium was larger in the 'standard' group (58 +/- 6 vs. 42 +/- 4 mm, P = 0.0006). Left atrial spontaneous echo contrast was present in 32 patients in group 'standard' and none in 'total heart' group (P < 0.0001), and left atrial thrombi were detected in 17 patients in group 'standard' vs. none in group 'total heart' (P = 0.01). All patients with a history of embolism had left atrial thrombus and spontaneous echo contrast. CONCLUSION: This study showed a high incidence of left atrial spontaneous echo contrast and thrombi when using the standard technique, which was absent when using the total heart technique. Total heart transplantation with bicaval and pulmonary venous anastomosis should be preferred for heart transplantation.

How to protect hypertrophied myocardium? A prospective clinical trial of three preservation techniques.

Protection of the hypertrophied myocardium during heart surgery is still a controversial matter. We prospectively studied 3 currently available preservation techniques in 60 patients operated on for isolated aortic stenosis. Patients were randomly assigned to one of the following groups: CWB: continuous warm blood cardioplegia ICB: intermittent cold blood with warm blood controlled reperfusion Cryst: intermittent cold crystalloid cardioplegia (SLF11, Biosédra Laboratory, Vernon, France). All groups were matched for age, ejection fraction, NYHA class, aortic valve surface, and operative risk score. There were no deaths. No statistically significant difference was found among the groups in terms of ventilatory support time, ICU stay time, hospitalization or atrial fibrillation occurrence. Blood gases in the coronary sinus at the time of clamp release showed deep acidosis with crystalloid cardioplegia (pH = 7.11 vs 7.39 for CWB and 7.38 for UCB, p < 0.0001) associated with a higher lactate production than in the other groups (1.3 mmol vs 0.5 for CWB and 0.58 for ICB, p < 0.0001). Acidosis was corrected at the end of bypass with no significant differences among groups. CK-MB samples were taken on arrival in ICU, then 6 and 24 hours later. These samples showed much higher levels with cold blood (H6: 70 mcg/l vs 33 for CWB and 45 for Cryst, p = 0.0019). Although the 3 types of cardioplegia may be safely used for isolated aortic stenosis surgery, continuous warm blood cardioplegia appears to be the best choice.

[Coronary bypass in patients with severe left ventricular dysfunction (EF < or = 25%). Apropos of 111 patients]. / Pontage coronaire chez les patients avec dysfonction ventriculaire gauche sévère (FE < or = 25%). A propos de 111 patients.

One hundred and eleven patients with severe left ventricular dysfunction (EF < or = 25%) underwent coronary bypass surgery between January 1984 and December 1994. The selection criteria were based on the measurement of an EF < or = 25%, LVEDP and CI. All patients had angina and 83 had signs of pulmonary oedema or episodes of congestive failure. Patients with valvular disease, left ventricular aneurysms, reoperations, surgery for arrhythmias and prior angioplasty, were excluded. The coronary disease usually involved all three vessels. Seventeen patients had lesions of the left main stem associated with lesions of the right coronary artery. The average number of bypass grafts was 2.6 +/- 1.6 per patient. The average duration of aortic clamping was 60 +/- 19 minutes. Operative mortality (first month after surgery) was 10 patients (9%). The operative risk factors were: gender, stage of cardiac failure, emergency surgery, LVEDP > 23 mmHg (p < 0.05), CI < 21/min/m2 (p < 0.05). The mean follow-up period was 42 +/- months (3 lost to follow-up). Late mortality was 42 patients. The one year actuarial survival was 88 +/- 5.3%, 76 +/- 9% at 3 years, and 56 +/- 18% at 6 years. Long-term functional results were related to: preoperative stage of cardiac failure (NYHA stage IV) and the association of raised LVEDP and low CI. Surgical results remained satisfactory, however, and the surgical indication was justified in selected patients despite severe left ventricular dysfunction in cases usually with stable invalidating or unstable angina, in the knowledge that myocardial deterioration is progressive in the medium-term with a high incidence of cardiac failure.

[What myocardial protection to select for isolated aortic valve replacement? A clinical prospective study of 3 cases of cardioplegia]. / Quelle protection myocardique lors du remplacement valvulaire aortique isolé? Etude clinique prospective de trois cardioplégies.

Isolated stenosis of the aortic valve leads to left ventricular hypertrophy which makes myocardial protection difficult during cardiac, surgery and the choice of optimal cardioplegia remains controversial. The authors compared three protocols of cardioplegia in patients operated for isolated aortic stenosis with left ventricular hypertrophy. Sixty consecutive patients with these criteria were randomly attributed to one of the three following groups (20 in each group): cardioplegia with continuous warm blood; cardioplegia with intermittent cold blood with warm reperfusion; cardioplegia with intermittent cristalloid using SLF11 solution. The preoperative data was comparable in three groups. There were no deaths. Patients undergoing cardioplegia with warm blood came off cardio-pulmonary bypass more quickly (15 mn vs 21 mn for the other groups, p = 0.03). Cristalloid cardioplegia was associated with major acidosis in coronary sinus blood when the aorta was declamped (7.11 vs 7.38 for cardioplegia with cold blood and 7.39 for cardioplegia with warm blood, p < 0.0001) but with a low postoperative CPK-MB rise. Cardioplegia with cold blood induced higher CPK-MB liberation than the other forms of cardioplegia (at H-, 63 mcg/L vs 33 for warm blood and 45 for cristalloid cardioplegia, p = 0.0019). None of the protocols tested prevented myocardial lactate production at aortic declamping. Cardioplegia with warm blood offers therefore the best protection for hypertrophied myocardium during simple aortic valve replacement but it does not maintain strictly aerobic metabolism.

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.

Mitral valve reconstruction: long-term results of 120 cases.

Between January 1977 and December 1992, 120 patients underwent mitral valve reconstruction for pure mitral valve regurgitation (n = 88), or associated with mitral stenosis (n = 32). The mean age was 57.6 years. Some 89 patients were in New York Heart Association (NYHA) class III and IV; 61% were in atrial fibrillation. Four mechanisms of mitral regurgitation were assessed: dilatation of the annulus (group I: n = 10); increased amplitude of valve motion (group II: n = 62); restriction of valve motion (group III: n = 23), and mixed lesions (group IV: n = 25). Mitral valve repair was carried out using techniques described by Carpentier. Ring annuloplasty was performed in all patients. There were two operative deaths, and six late deaths. Mean patient follow-up was 41 (range 2-142) months. The actuarial survival rate, excluding hospital deaths, was 91.7% at 5 years and 89.1% at 8 years. Actuarial freedom from reoperation at 8 years was 95(2)%. Freedom from all thromboembolic complications was 89.1% at 8 years. Most survivors had improved to NYHA class I or II and postoperative Doppler echocardiography revealed satisfactory mitral valve competence in 83 patients. Mitral valve reconstruction for mitral regurgitation using Carpentier techniques provides excellent long-term functional results and should be considered as the procedure of choice in patients referred for mitral regurgitation.

Aortic valve replacement after aortic valvuloplasty for calcified aortic stenosis.

OBJECTIVE: This study concerns patients who underwent one or several aortic balloon valvuloplasties at our institution and subsequently required cardiac surgery, either on an emergency basis after aortic valvuloplasty or due to the development of aortic stenosis. METHODS: Between February 1987 and December 1993, 137 patients (73 male, 64 female, mean age 72 +/- 9 years) underwent aortic valve replacement for calcified aortic stenosis after several percutaneous balloon aortic valvuloplasties. Thirty-one patients were in NYHA stage II, 70 in stage III and 36 in stage IV. Seventy patients had angina (23 stage I or II, 47 stage III or IV) and 24 patients presented syncope or lipothymia. Twenty-three percent had at least two of these three symptoms. The indications for balloon dilatation were non-definitive surgical contraindication or high surgical risk (73), personal choice (49), refusal of surgery (9) and emergency (5:2 massive aortic regurgitation, 1 left ventricle perforation, 1 cardiogenic shock, 1 endocarditis in cardiogenic shock). Seven patients received preoperative aortic valvuloplasty due to a very high operative risk. The average time between dilatation and surgery was 472 days and there was clinical improvement for an average period of 261 days. The aortic valve replacements consisted of 58 mechanical prostheses and 79 xenografts with 22 concomitant procedures. RESULTS: Operative mortality was eight patients (5.8%). During the follow-up (17.4 +/- 9.2 months), four patients died (3.6%), 91.2% of the patients were in class I and II and 95% were without angina. The actuarial survival rate was 90.5 +/- 6.6% including hospital mortality. CONCLUSIONS: Both our experience and the literature show that balloon aortic valvuloplasty is followed by an immediate improvement in hemodynamic status with a decrease in valve gradient and an increase in valve area. However, the hemodynamic benefit is typically short-lived with a very high restenosis rate. Balloon aortic valvuloplasty is not an alternative to aortic valve replacement, which remains the best treatment for calcified aortic stenosis; the benefits and long-term results of aortic valve replacement are well established, even in the elderly.

[Prevalence of intra-auricular thrombi detected by transesophageal echocardiography in patients with cardiac transplants]. / Fréquence des thrombus intra-auriculaires détectés par l'échocardiographie transoesophagienne chez les transplantés cardiaques.

The aim of this study was to determine the prevalence of intra-atrial thrombi or spontaneous contrast by transoesophageal echocardiography in patients who underwent cardiac transplantation by Lower and Shumway's technique. Transoesophageal echocardiography was performed in 52 transplant patients (43 men, 9 women: average age 51 years) with a high frequency biplane transducer. After surgery, all patients received platelet antiaggregant therapy. Despite this treatment, 4 patients had a sudden systemic embolic episode and were then placed on oral anticoagulants. All patients were in sinus rhythm at the time of the examination and some had signs of acute rejection on endomyocardial biopsy performed the same day. Spontaneous contrast was observed in 27 patients (52%) and was associated with thrombosis in 15 patients (29%). These thrombi were located in the left atrial appendage in 8 cases, on the left atrial posterior wall in 5 cases and on the left atrial sutures in 2 cases. None of these thrombi had been detected by transthoracic echocardiography. No significant difference was observed between those with and those without thrombosis with respect to left atrial dimensions, left ventricular ejection fraction, cardiac index, pulmonary pressures and the number of episodes of acute rejection. The 4 patients with a history of arterial embolism all had an intra-atrial thrombus. This study demonstrates a high incidence of spontaneous contrast and intracardiac thrombi in the dilated left atrium of patients transplanted by Lower and Shumway's technique. It also underlines the value of transoesophageal echocardiography in the follow-up of transplant patients.(ABSTRACT TRUNCATED AT 250 WORDS)