[Frequency of angiographic restenosis after 6 months and long-term outcome of coronary angioplasty]. / Fréquence des resténoses angiographiques à 6 mois et devenir à long terme après angioplastie coronaire.

Five hundred patients with a mean age of 59 years were followed up for an average of 32 months after coronary angioplasty. All patients were included in a prospective study comprising coronary angiography at 6 months for 379 patients (91% primary successes). The long-term outcome was evaluated by a questionnaire or telephone interview in all cases. The global primary success rate was 84.4% in this series. The primary failures include 1.8 fatalities, 0.6% myocardial infarction, 2% emergency coronary bypass surgery and 11.2% without immediate clinical consequences. At 6 months, there were 48% of restenoses (182/379 patients) and 28% underwent immediate repeat angioplasty (141/500 patients) with a primary success rate of 91%. After the repeat angioplasty, the restenosis rate was 43% but this varied according to the time from the first restenosis: 60% when the interval was short (under 2 months) compared with 21% when the interval was 6 months (p < 0.01). The actuarial survival rates at 4 years were 95% after successful angioplasty 96% after uncomplicated failures or medically treated restenosis and 98% after bypass surgery. The predictive factors for secondary death were age of over 70 years, previous non-thrombolized myocardial infarction and complications of angioplasty. The long-term outcome was good despite the 48% 6 months restenosis rate requiring revascularisation procedure in 73% of cases.

[Significant stenosis of the common trunk of the left coronary artery. Retrospective study of 227 cases]. / Sténose significative du tronc commun de l'artère coronaire gauche. Etude rétrospective de 227 cas.

Significant left main coronary artery disease is a separate disease entity in coronary artery disease. The prognosis is classically poor and the treatment of choice is surgical. A retrospective study of patients with left main coronary disease, diagnosed and treated at the CHRU Dupuytren, Limoges, between 1/01/80 and 15/06/91 was undertaken to determine the aetiological, clinical and therapeutic factors which influence mortality related to this condition. During this period, 8198 coronary angiographies were performed in the cardiology department. The diagnosis of significant left main coronary disease (> or = 50% stenosis) was made in 250 cases (3% of all investigations). Of these 250 cases, 227 were treated medically or surgically by our group during the study period. Twenty patients were treated in another centre and 3 underwent surgery after the 15/06/91. Seven patients died in the period immediately after coronary angiography. Of the 220 survivors of coronary angiography, 185 (85%) were referred for surgery (direct or sequential venous and/or arterial bypass or coronary endarteriectomy). Four patients died within 30 days of surgery. Thirty five patients were treated medically. The therapeutic decision was based on the absence of surgical contra-indications. The retrospective, non-randomized nature of this study with allocation of patients to surgical or medical treatment without control invalidated statistical analysis. At the date of the last follow-up appointment, arbitrarily chosen as the 1/01/93, 163 operated patients (88.1%) of which 130 (79.7%) were asymptomatic and 13 medically treated patients (37%) were alive. The prognostic factors after surgery in this study were: stage IV dyspnoea at the time of diagnosis, severe abnormalities on catheter study (end diastolic pressure over 18 mmHg after angiography), left ventricular wall abnormalities (functional score > 10) and incomplete revascularization. The risk of coronary angiography in this condition were confirmed in this study.

[Giant leiomyoma of the esophagus detected by echocardiography and corroborated by x-ray computed tomography and surgery]. / Léiomyome géant de l'oesophage détecté par échocardiographie et confirmé par tomodensitométrie et chirurgie.

The authors report the case of a 44 year old man with a giant leiomyoma of the lower third of the esophagus. The patient presented with chest pain and the tumour was detected by echocardiography. The diagnosis was confirmed by computerised tomography and histological examination of the surgical specimen weighing 501.5 g. The surgeon performed a large esophago-gastric resection and reestablished the continuity of the digestive track by interposing a section of colon. A good result was obtained with a follow-up of 4 years. The authors underline the potential value of a simple barium swallow during cardiological assessment.

[Coronary angiography after the age of 70 years]. / La coronarographie après 70 ans.

100 patients over the age of 70 years underwent coronary angiography. The indications for this examination at this age were different from those in younger patients. After the age of 70 years, 58 per cent of coronary angiographies are performed as part of the haemodynamic survey of valvular disease. The risk of the examination appears to be higher, as two deaths occurred in this small series, while the mortality is estimated to be 2 per thousand in younger patients. Coronary angiography is very useful at this age in patients with valvular disease to determine the need for an associated coronary graft and also to determine contraindications for operation because of the severity of the lesions. A surgical indication was confirmed in 50 patients, but surgery was only performed in 36 of them. The follow-up of these patients demonstrates that patients operated for valvular disease had a longer survival that those considered to be inoperable or who refused operation. On the other hand, there was no difference in survival between grafted and non-operated patients over the age of 70 years.

[Outcome of patients with inoperable multivessel coronary disease]. / Evolution des coronariens pluritronculaires impontables.

The authors studied the clinical course of 100 patients with two or three vessel coronary artery disease who were unsuitable for surgery because of the poor quality of the distal vascular bed or excessively depressed left ventricular function. The 6 year actuarial survival was 58 per cent; 43 of the 100 patients did not present any serious cardiac events causing death or requiring further admission to hospital, over this follow-up period. The severity of the clinical course in women and the presence of heart failure prior to coronary angiography were considered to be among the most important clinical prognostic factors. On the basis of the haemodynamic survey, the probability of survival or the risk of a further coronary accident appears to depend more on the extent of the left ventricular kinetic abnormalities than on the ejection fraction or the severity of the coronary lesions.

[Late chronic constrictive pericarditis following aortic valve replacement]. / Péricardite chronique constrictive tardive après remplacement valvulaire aortique.

The authors report a case of chronic constrictive pericarditis in a 54 year old patient who had undergone aortic valve replacement 6 years previously. The valve was replaced with a Starr-Edwards prosthesis because of aortic regurgitation due to infective endocarditis. The outcome after pericardectomy was favourable with a 3 year follow-up. This complication of cardiac surgery, of which there are now 45 reported cases, should not be overlooked because it can be cured surgically. The diagnosis is based on phonomechanographic, echocardiographic and, above all, haemodynamic investigations to distinguish the condition from irreversible myocardial dysfunction.

[Septicemia on endocavitary sounds for cardiac stimulation]. / Septicémies sur sondes endocavitaires de stimulation cardiaque.

Two cases of septicaemia on endocavitary cardiac pacemaker probes lead the authors to discuss the aetiological and therapeutic aspects of this type of infection. In both cases, the pacemaker had been in situ for a long time and had been replaced on several occasions, there was infection in the site of implantation and an attempt at removal of all of the pacemaker material failed, leaving a probe incarcerated in the right ventricle by one of its extremities with the other extremity floating free. The endocarditis associated with this septicaemia can, theoretically, be due to two mechanisms: metastatic implantation of infection form a distant site which must be detected or infection developing in contact with the pacemaker and propagated along the probe. The treatment of this type of septicaemia consists of appropriate antibiotics, which are only rarely sufficient to sterilize the infection. In most cases, all of the pacemaker material must be removed, which is easily achieved in the majority of cases. After cleansing of the site, the pacemaker has been successfully replaced. Sometimes, the probe is buried in the myocardium: surgical removal by cardiotomy, with or without extracorporeal circulation, seems to be preferable to the techniques of continuous traction which carry certain risks (tricuspid and myocardial lesions). Persistent floating probes must be removed surgically.

[Results of singular valve replacement with a mechanical prosthesis or bioprosthesis in valve diseases with advanced myocardial failure]. / Résultats du remplacement monovalvulaire par prothèse mécanique ou bioprothèse dans les valvulopathies en défaillance myocardique avancée.

Surgery may prolong survival in some patients in advanced cardiac failure due to valvular heart disease refractory to digitalo-diuretic and vasodilator therapy. The operative risk is high and myocardial dysfunction after surgery is also a problem. However, in some cases, surprising improvement is observed. An analysis of the principal publications in the literature on the natural history of valvular heart disease and the results of surgery in the last ten years show that: In chronic aortic valve disease complicated by congestive heart failure, the natural prognosis does not exceed 2 to 3 years in either aortic stenosis or regurgitation. On the other hand, prosthetic valve replacement is associated with a 57% 4 years survival in aortic regurgitation, and a 70% 5 years survival in aortic stenosis, but with an operative mortality of 20 to 27%. Surgery is even more valuable in acute aortic regurgitation due to endocarditis, leading to a 60% 2 years survival compared to only 6% with medical therapy alone. In chronic mitral valve disease with advanced cardiac failure, the natural prognosis does not exceed 4.5 years in mitral regurgitation, 8 years in mitral stenosis and an intermediate period in mixed mitral valve disease. On the other hand, prosthetic valve replacement with an operative risk of 21 to 26% is associated with a life expectancy of 56 to 60% at 5 years, and 46% at 10 years, operative mortality included. The surgical results depend on good myocardial protection and intensive pre-, per- and post-operative care using positive inotropic agents, vasodilators and, when necessary, intra aortic balloon pumping.(ABSTRACT TRUNCATED AT 250 WORDS)

[Complications of idiopathic mitral valve prolapse. Prevention and treatment]. / Complications du prolapsus valvulaire mitral idiopathique. Prévention et traitement.

Mitral valve prolapse is the most common form of heart disease, as it occurs in 4 to 6 per cent of the population. It has a benign course in the majority of cases, but 5 types of severe complication can occur in 15 per cent of cases. Mitral incompetence occurs in 14.8 per cent of cases. It may develop gradually or suddenly, following rupture of the chordae, which requires rapid surgical repair. Mitral valve prolapse is complicated by infectious endocarditis in 2.9 per cent of cases, hence the need for antibiotic prophylaxis prior to dental treatment or surgery in patients with a pan-systolic or end-systolic murmur. The only arrhythmias which should be considered as complications and treated as such are frequent ventricular extrasystoles of more than 30 per hour, usually associated with bigeminy, runs or polymorphism, ventricular tachycardia and ventricular fibrillation. Treatment consists, primarily, of beta-blockers. Sudden death is of course the major complication, occurring in 1.4 to 2.4 per cent of cases. The patients at risk of this complication are middle-aged women (40 years) with a past history of syncope or faintness due, in most cases, to episodes of ventricular tachycardia or ventricular fibrillation. Apart from arrhythmia, coronary artery spasm has also been found to be a cause of sudden death in these patients. Transient or definitive ocular and cerebral ischaemic episodes can also complicate mitral valve prolapse. Mitral valve prolapse is found in 20 to 30 per cent of patients with neurological accidents before the age of 45. Preventative treatment consists of anti-platelet aggregation agents and anticoagulants in recurrent cases.

Traumatic ventricular septal defect with tricuspid incompetence. Surgical treatment.

The authors report a case of traumatic ventricular septal defect associated with tricuspid incompetence after blunt injury of the chest. This case is the third one described in the literature. This case includes several unusual features: (1) the patient was a 52 year old man. Wounds of the heart usually happen to younger people; (2) clinical manifestations were immediately important; (3) there was a left bundle branch block on the electrocardiogram; (4) surgical treatment was performed as an emergency (less than a fortnight after the accident).

[Risks and median-term results of aortic valve replacement for calcifying aortic stenosis in 100 patients more than 70 years old]. / Risques et résultats à moyen terme du remplacement valvulaire aortique pour sténose calcifiée chez 100 sujets de plus de 70 ans.

100 patients with poorly tolerated calcific aortic stenosis underwent aortic valve replacement by the same surgical team (Starr-Edwards prosthesis: 52 cases, Bjäork prosthesis: 43 cases, Lillehei-Kaster prosthesis: 2 cases, and Hancock bioprosthesis: 3 cases) between July 1971 and April 1978. The hospital mortality was 17% and acute pulmonary oedema and cardiomegaly were poor preoperative prognostic factors. The late mortality was 14.5% with an average follow-up period of 25 months (range: 2 to 74 months). The survival rate expressed as an actuarial graph was 63.1 +/- 4% at 4 years. 90% of the patients operated move up at least one class in the New York Heart Association classification and 2/3 return to Stage I. The cardiothoracic ratio improved from 0.58 +/- 0.06 to 0.51 +/- 0.03 (p less than 0.02) and the Soko low-Lyon index from 40 +/- 13 to 25 +/- 6 (p less than 0.001). The main complication encountered at middle term was haemorrhage, observed in 17.5% patients. Comparison of the spontaneous outcome of the disease with the results of surgery favour surgical treatment of patients over 70 years old with poorly tolerated calcific aortic stenosis. The valve of choice should be the bioprosthesis when dependance on anticoagulant therapy and the associated risks of haemorrhage are taken into consideration.