Long-term evaluation of bioprosthetic valves: 615 consecutive cases.

From January 1975 to September 1983, 615 patients underwent valve replacement using 698 bioprosthetic valves for selected indications. This group represents the third of all patients having valve replacement during the same period. Children younger than 15 years were excluded. The mean pre-operative functional class was 2.9. The early mortality rate was less than 5% and the follow-up range 3 months to 9 years (3.2 yrs). The symptomatic improvement was attested by a mean post-operative functional class of 1.4. In a linear study the following rates of valve related complications were noted: thromboembolism 4.6%, endocarditis 2.5%, primary tissue valve degeneration 1.1%, paraprosthetic leak 2.5%. In an actuarial study, at 8 years, 83% of patients were free from any valve failure. The probability rates of complications were the following: thromboembolic events 8%, endocarditis 5%, degeneration 3%, reoperation 7%. The probability of survival at 8 yrs was 69% and the probability rates of late mortality were noted as follow: cardiac related mortality 27%, valve-related mortality 4%. Despite an expected increasing rate of degeneration, the results warrant the use of bioprostheses in a selected group of patients.

[Aortic insufficiency caused by incomplete rupture of the ascending aorta. Conservative surgical treatment]. / Un cas d'insuffisance aortique par rupture incomplète de l'aorte sus-sigmoïdienne. Traitement chirurgical conservateur.

Commissural disorganisation secondary to incomplete rupture of the ascending aorta was found at surgery for massive aortic incompetence in a young man with previous hypertension. The lesions were repared by a conservative procedure with an excellent result 3 years after surgery. Incomplete spontaneous rupture of the ascending aorta occurs in the same terrain as dissection of the aorta (hypertension, aortic media necrosis) of which it represents a minor form. It may remain asymptomatic but it is usually complicated either by secondary intrapericardial rupture, by aortic aneurysm or by aortic incompetence due to valvular prolapse. When valvular prolapse is associated with another lesion which aggravates the regurgitation (aortic valve disease, aortic ring dilatation) aortic valve replacement should be performed with a prosthesis; on the other hand, when commissural disorganisation giving rise to valvular prolapse is the cause, a conservative procedure may be envisaged.

[Minithoracotomy without muscle division. Value in surgery of the aortic isthmus in children (author's transl)]. / Minithoracotomie sans section musculaire. Intérêt dans la chirurgie de l'isthme aortique chez l'enfant.

A new approach to the aortic isthmus by left postero-lateral minithoracotomy without division is described. The technique is simple and rapid and provides excellent functional and cosmetic results. It is particularly suitable for surgery of the aortic isthmus in children.

Surgical management of acute dissections involving the ascending aorta. Early and late results in 38 patients.

Thirty-eight patients (32 men and six women, mean age 48.1 years) were operated upon for acute dissection involving the ascending aorta. The surgical procedure included multiple peripheral arterial cannulations, resection of the initial intimal tear if found (35 cases), and obliteration of the false channel by double cuffing with Teflon of the two layers of the dissecting process proximally and distally. When present (29 cases), aortic regurgitation was usually (21 cases) managed by conservative remodeling of the aortic anulus; 34 prosthetic replacements of the ascending aorta and four replacements of the arch were achieved. The operative mortality was 7.9% (3138) and the overall hospital mortality was 23.7% (9138). Nonfatal complications occurred in 11 patients (29%). There were three late deaths (10.3%). Mean follow-up was 3.4 years (2 months to 8 years, 8 months). Twenty-three (88.5%) of the 26 patients were asymptomatic. Contrast tomodensitometry was performed in 14 patients; in type II (two patients), the aorta was normal; in type I (12 patients), residual abnormalities were noted: patency of the false channel (10 cases), aneurysmal dilatation (seven cases), and reduction of the true lumen by the false channel (four cases). These results emphasize the need for scrupulous long-term follow-up in surgically treated aortic dissections.

[Interruption of the aortic arch and an aorto-pulmonary fistula. Simultaneous correction of lesions in a 5 1/2 month old infant]. / Interruption de l'arche aortique et fistule aorto-pulmonaire. Cure simultanée des lésions chez un enfant de 5 mois et demi.

Aortic arch hypoplasia is rare but carries a poor prognosis. It is usually associated with a left to right shunt at ventricular level. The association of an aorto-pulmonary fistula is exceptional. A case of a 5 1/2 month old infant treated successfully by simultaneous correction is reported with a review of the physiopathological changes. Pulmonary hypertension and aortic perfusion depend on the calibre of the ductus arteriosus and its evolution. The therapeutic problems which result are the suppression or palliation of pulmonary hypertension and resaturisation of distal aortic vascularisation. Surgery is the only hope of cure, and current techniques are reviewed: two stage procedures with revascularisation of the distal aorta and pulmonary artery banding, or simultaneous correction of aortic continuity with suppression of the left to right shunt under cardiopulmonary bypass. The technical conditions are analysed: perfusion of the different aortic segments, methods of reestablishing aortic continuity. Good results are as yet rare, and are obtained after complete correction under cardiopulmonary bypass.

Ventricular septal defect after acute myocardial infarction: Early repair.

Thirty-eight patients have been operated upon early after acute myocardial infarction with rupture of the ventricular septum. Preoperative management included bedside hemodynamic evaluation, mechanical left heart support, and pharmacologic agents. The results of the surgical repair reflected both the effectiveness and the duration of preoperative treatment. Operation was performed in 14 patients with refractory cardiogenic shock, 10 of whom died (71%). Hemodynamic and clinical stability was achieved in 24 patients. Early operation (average 46 hours of medical management) in 17 patients permitted accurate repair, even with friable tissues; four of these patients died (23%). Delayed operation (average 12 days of monoperative treatment) was performed in seven patients and resulted in a higher mortality rate, three patients dying (43%). The location of the ventricular septal defect (VSD) also influenced the operative risks, the prognosis for posterior defects being worse than that for anterior defects. Optimal myocardial preservation during the entire procedure is of crucial importance to the success of the operation.

[Aortocoronary bypass permeability explored by tomodensitometry. Preliminary study]. / Perméabilité des pontages aorto-coronaires explorés par tomodensitométrie. Etude préliminaire.

The patency of 24 aorto-coronary grafts was studied by tomodensitometry. --16 out of the 18 bypasses examined within the two weeks following surgery were seen. --4 older bypasses were not visible, either by scanner or by angiography and were therefore occluded: two more, performed more than a year previously, were patent on tomodensitometric examination. The interpretation of the results, discussed taking into account the small number of angiographic check ups does not permit any formal conclusion as to the validity of the procedure. The results of this technique seem satisfactory and quite comparable with other non invasive methods used in the study of aorto-coronary grafts.

[Intermdeiate forms of atrioventricular defects. Reflections apropos of 50 consecutively operated cases]. / Le canal atrio-ventriculaire dans ses formes partielles. Réflexions à propos de 50 cas opérés consécutivement.

Fifty cases of intermediate forms of atrioventricular defect were treated surgically. The operation was performed in the traditional manner in all cases. One post-operative death and three cases of severe mitral incompetence leading to reoperation were observed. The authors emphasise that it is essential to look for and excise the chordae and abnormal fibrous bands, that it is generally unnecessary to touch the tricuspid valve and that there is a danger of obstructing the aortic canal if the correction of the asymmetry of some mitral clefts is attempted. Analysis of the results leads them to tend to respect the cleft mitral valve when the regurgitation is minimal and to suture it all along its length when the regurgitation is severe. Mitral annuloplasty may be a useful complementary procedure and a left atrial approach may be proposed with this in mind in certain cases. Conduction defects remain a serious problem in this type of surgery; not so much complete heart block, which is exceptional, but trifascicular block, often present preoperatively, whose prognostic is, to say the least, uncertain.

[Technical development in aortocoronary bypass: multiple outlet saphenous vein graft]. / Evolution technique dans le pontage aorto-coronaire : le greffon saphène à issues multiples.

The technique of multiple outlet saphenous vein grafting with one or several alternating lateral anastamoses was used in 43 patients over a one year period; over half the patients had triple vessel disease, one third had double vessel disease; a total of 128 coronary arteries were revascularised 2.9 arteries per patient, with 60 side to side anastamoses, 1.4 per patient. The technique of this type of bypass necessitates paying particular attention to avoid kinking or twisting of the graft. The blood flow through multiple outlet graft is on average significantly greater than in the classical types of graft, and is one of the main points in favour of this technique and in keeping the graft permeable in the long term. The short term results of this technique are good with a hospital mortality of 4.6% and a peri-operational infarction rate of 6.9%, figures which are comparable with the results of classical bypass grafting techniques in multivessel coronary artery disease.

[Pathological data of 92 rheumatic mitral valve after surgical ablation : comparison with pre-operative echocardiography results]. / Données morphométriques recueillies sur 92 valvulites mitrales rhumatismales après exérèse chirurgicale : les corrélations avec les données échocardiographiques pré-opératoires.

The echocardiographic information obtained pre-operatively with an electronic linear scanning system (Multiscan) was compared with the results of pathological examination of the excised mitral valve in 92 patients, and showed a close correlation. The way in which the pathological changes influence the various parameters usually used to distinguish this type of rheumatic valvular disease is demonstrated. Two-dimensional imagery provides precise information : this is shown by comparison of the still frames of the videoscopic recording and the photographs of the corresponding pathological specimens. Valve thickness, length and thickness of the chordae, calcification, mitral valve surface and commissural separation are well shown, especially at the anterior leaflet. Study of transverse incidences seems the most reliable method of estimating mitral valve area. Systolic separation of mitral valve echos, according to the usual criteria, is a good sign of associated mitral incompetence and was found in 83% of cases of mixed mitral valve disease. The mean values of anterior mitral leaflet excursion, diastolic slope and opening speeds were compared in three groups of mitral stanosis with preferential antatomical features and a control group of pure mitral stenosis with supple valves. No individual parameter was found to be specific for a particular antatomical feature, showing multiple correlations to be indispensable. The difficulty of diagnosis by isolated traditional echocardiography is confirmed and the association of two dimensional imagery would seem essential not only in making the diagnosis but also in the pre operative work up.

[Resections of the left ventricle in the surgical treatment of parietal sequelae of myocardial infarct]. / Les résections due ventricule gauche dans le traitement chircurgical des séquelles pariétales de l'infarctus du myocarde.

Resection of left ventricular tissue seems to be playing an increasing part in the treatment of the sequelae of myocardial infarction. In a total of 700 patients who underwent surgery for some aspect of coronary atherosclerosis, 40 underwent resection of left ventricular tissue. In the majority of cases, diagnosis rested on left ventricular cine-angiography and in 3 cases this had to be carried out as an urgent procedure with circulatory assistance using diastolic counter-pressure (DCP) from an intra-aortic balloon. A selective contrast technique for the two coronary arteries was used whenever possible. The surgical anatomy of the lesions indicates a difference between a localised dyskinesia and diffuse dyskinesia, the latter having a severe effect on left ventricular function. In a group of localised dyskinesias, the territory supplied by the anterior descending artery was by far the most frequently affected. Resection of left ventricular tissue was associated with a myocardial bypass revascularisation procedure in 9 cases, valve repair in 7 cases, and closure of a septal perforation in 3 cases. The total inpatient mortality rate is still quite high (23.1%) because of the severity and widespread nature of the coronary disease. However, the mid-and long-term results are good, the criteria being functional improvement and the actuarial 4-year survival rate.

[Mitral replacement using a ball-valve prosthesis under hypothermic protection of the myocardium. 230 cases]. / Remplacements mitraux par prothèse à bille réalisés sous protection hypothermique du myocarde. 230 cas

A series of 230 mitral valve replacements using exclusively the Starr-Edwards ball valve prosthesis is presented. These 230 patients underwent surgery over a 4 year period, a uniform operative technique being used. Its essential feature was the use of a standardised technique for protection of the myocardium based upon continous clamping of the aorta and deep hypothermia at around 15 degrees. The technique of myocardial hypothermia, already reported, is briefly reviewed. The results are analysed, in the short and long term. Overall hospital mortality was 6.9 per cent, including multiple valve replacements and combined coronary surgery. The total number of thrombo-embolic complications was 8, including 1 early thrombosis out of 230 patients - i.e. 0.4 per cent and 7 late thrombo-embolic episodes out of 180 patients followed up for 1 month to 4 years - i.e. 3.8 per cent. Secondary and late mortality was 11 cases out of 180 patients. The survival rate at 4 years was 78 per cent by actuarial calculation, including operative mortality. These results justify the continued use of ball prosthesis, the long term thrombo-embolic risks of which are equal to or less than those of disc prosthesis, and the resistance of which to wear and tear is shown by the long postoperative survivals.

[Early neurological complications after cardiac surgery under ECC]. / Réflexions a propos des complications précoces neurologiques après chirurgie cardiaque sous C.E.C.

A non-trifling frequency (3,3 p. 100) of neurologic complications is observed after surgery under E.C.C. The part of some factors has been analysed and discussed, especially those played by the type of the system used, quality of the E.C.C., and the patients' conditions. Many problems are still unresolved. The actual gravity of observed troubles must bring a better harshness in preventive treatment, and to a more adjusted treatment when these troubles are noted.

[Proteins and blood volume after cardiac surgery under ECC and hemodilution]. / Protides et volémies aprés chirurgie cardiaque sous C.E.C. en hémodilution

The variations in protein, bodyweight and circulating blood volume during operation are studied in 18 patients operated under ECC. The frequency of hypovolemia with hypoproteinemia and over hydration of the interstitial medium is confirmed. The prolongation of ECC beyond 120 minutes is accompanied by a considerable reduction in the plasma sector. The frequency of hypovolemia must render the use of diuretics prudent. The existence of hypoproteinemia and interstitial overload suggests the value of albumin perfusions.