[Results of surgical treatment of calcified aortic valve stenosis: report of a series of 4,129 interventions]. / Résultats du traitement chirurgical du rétrécissement valvulaire aortique calcifié: à propos d'une série de 4,129 interventions.

Aortic stenosis (AS) is the most common lesion currently encountered among valvular heart disease, particularly in elderly people. Severe functional impairment and risk of sudden death explain that surgical treatment is largely accepted. We report a retrospective analysis of institutional experience with aortic valve replacement (AVR) for AS from 1971-1997 in 4,129 patients. Age ranged from 13 to 91 years (mean 68 +/- 10) and degenerative disease was largely predominant (86%). For AVR, mechanical prostheses were used in 2,054 patients (50.2%) and bioprostheses in 2,075 (48.8%) in elderly group. Coronary artery revascularization was associated in 670 patients (16%). Operative mortality was 7% (303 pts) and main cause was left ventricular failure (52%). Late results were studied with a maximum follow-up of 26 years. Total follow-up represents 21,533 pt-years. Late death occurred in 1,108 patients between 1 month and 24 years after operation (mean 6.6 years). Reoperation was necessary in 136 cases. Actuarial survival--including operative mortality--was 77% and 56% at 5 and 10 years. A large functional improvement was observed in the vast majority of patients, 73% being I or II subgroups of the NYHA classification. Incremental risk factors for death (immediate as well as late) were older age, preoperative functional status, emergency, presence of cardiac failure, coronary artery lesions and associated morbidity. The choice of valvular prosthesis remains controversial, but the results show that AVR is the procedure of choice for the vast majority of patients wtih significant aortic valve disease.

Prospective evaluation of coronary arteries: influence on operative risk in coronary artery surgery.

OBJECTIVE: Coronary angiography data included in the analysis of operative mortality after coronary artery surgery are generally limited to left main coronary artery stenosis and classification into one-, two- or three-vessel disease, but the role of stenoses and quality of distal runoff on each main coronary artery have never been analysed. The aim of this study was to assess the influence of coronary artery status (stenoses and distal runoff) on operative mortality in patients undergoing coronary artery surgery. METHODS: Stenoses of the five main coronary arteries and their distal runoff were prospectively evaluated in a series of 2461 patients undergoing isolated coronary artery surgery. These angiographic variables were included in analysis of operative mortality in combination with conventional preoperative data. RESULTS: Univariate analysis founded 21 preoperative variables being significant: age >70, body surface area <1.8 m2, arterial disease of lower limbs, history of peptic ulcer, CCS class IV angina, unstable angina, post-infarction unstable angina, congestive heart failure, left ventricular ejection fraction <50%, urgency, preoperative intra-aortic balloon pump, previous myocardial infarction, previous cardiac surgery, previous coronary bypass graft, presence of significant stenosis on the left main coronary artery or the circumflex marginal branch or the distal circumflex artery or the right coronary artery, absence of significant stenosis on the left anterior descending artery, impaired distal runoff on the left anterior descending artery or the circumflex marginal branch (for all, P < 0.05). Multivariate analysis identified poor quality distal runoff in the left anterior descending artery and circumflex marginal branch as independent risk factor (P = 0.0005 and P = 0.04, respectively), while left main coronary artery stenosis was not. This lesion appears to be a significant risk factor only in a small subgroup of patients with CCS class IV angina. Other independent risk factors were CCS class IV angina, previous cardiac surgery, body surface area <1.8 m2, diabetes mellitus, age <70, history of peptic ulcer, left ventricular ejection fraction <50%. Impaired distal runoff or the presence of stenoses on the diagonal branch, right coronary artery, or distal circumflex artery does not significantly influence the operative mortality rate. CONCLUSIONS: The quality of distal runoff of the most frequently grafted vessels is a significant risk factor for operative mortality in coronary artery surgery. Left main coronary artery stenosis was not identified as a risk factor when these angiographic variables were included in the analysis. Functional status remains the most powerful predictive factor.

Aortic Carpentier-Edwards supraannular porcine bioprosthesis: a 12-year experience.

BACKGROUND: After 35 years of cardiac valve replacement, the ideal substitute remains to be found. Homografts are considered best but, due to their scarcity, cannot meet the need of valve replacement. Artificial valves (mechanical or biological) remain the most commonly used but controversy is still present as to the better choice. We tested the Carpentier-Edwards bioprosthesis for its efficacy in valve replacement operations. METHODS: From 1983 to 1995, 1,108 consecutive patients had an isolated aortic valve replacement with a porcine Carpentier-Edwards bioprosthesis, model 2650 supraannular valve. Mean age was 73.8+/-8.3 years. Aortic stenosis was the most common lesion (1,049 patients, 94.7%). The follow-up of 980 operative survivors was 96% complete and represented a total of 4,735 patient-years (maximum, 13.8 years; mean, 4 years and 10 months). RESULTS: Actuarial survival including operative mortality (128 patients, 11.6%) was 43.6%+/-2.3% at 10 years and 27.3%+/-3.3% at 12 years and, at that time, was not statistically different from those of the normal French population matched for age and sex. Structural deterioration of the valve was observed in 27 patients, an actuarial freedom of 94.2%+/-1.5% at 10 years and 83.8%+/-4.5% at 12 years. Hazard function revealed a stable and low risk of structural deterioration until 10 years and significantly increased risk after that. Young age was found to be an increasing risk factor of deterioration. Reoperation for valve-related complications was necessary in 30 patients, an actuarial freedom of 94.5%+/-1.4% at 10 years. CONCLUSIONS: The Carpentier-Edwards porcine supraannular valve affords a good durability up to 10 years, with a low rate of reoperation. The risk of structural deterioration decreases with older age. It is our valve of choice in elderly patients.

[Cardiac abscess in infectious endocarditis. A multicenter study apropos of 233 cases. The Working Group on Valvulopathy of the French Society of Cardiology]. / Abcès cardiaques dans l'endocardite infectieuse. Etude multicentrique à propos de 233 cas. Groupe de travail sur les valvulopathies de la Société française de cardiologie.

The aim of this retrospective multicenter study was to determine present characteristics of infectious endocarditis complicated by abscess and to identifying predictive factors of mortality. The files of 233 patients with infectious endocarditis complicated by perivalvular abscesses between January 1989 and December 1993 were analysed. Two hundred and thirteen patients underwent medico-surgical treatment (175 aortic and 38 mitral abscesses) and 20 patients underwent medical treatment alone (17 aortic and 3 mitral abscesses). The abscess was observed on native valves in 156 cases and valve prostheses in 77 cases. The causative organism was identified in 69% of cases : the commonest organism was the staphylococcus. The diagnostic sensitivity of transthoracic and transoesophageal echocardiography was 36 and 80% respectively. The operative mortality at one month was 16%. Patients over 65 years of age, staphylococcal infection, renal failure and fistulisation of the abscess, were identified as independent predictive factors of mortality at one month. The survival rate three months after surgery was 75 +/- 10% and 59 +/- 11% at 27 months. An age over 65, staphylococcal infection, uncontrolled infection, circumferential abscess and fistulisation were independent predictive factors of global mortality (the first month and after). The mortality rate in unoperated patients was 40%: cardiac failure and fistulisation of the abscess detected by echocardiography were predictive factors of mortality on univariate analysis.

Spontaneous recovery from severe parvovirus B19 pure red cell aplasia, in a heart transplant recipient, as demonstrated by marrow culture.

A 61-year-old heart transplant recipient with parvovirus B19 infection, presented as a severe pure red cell aplasia (PRCA) with hemoglobin level of 5 g/dl. Both blood and bone marrow cells were positive for parvovirus B19 DNA, whereas specific immunoglobulins IgG and IgM were not informative. Bone marrow smears revealed erythroid hypoplasia without giant pronormoblasts. Autologous and allogenic bone-marrow cultures revealed a high inhibition by patient's serum on BFU-E growth whereas the number of CFU-GM were normal. Spontaneous remission of the anemia was observed despite the persistence of severe immunodeficiency as demonstrated by development of a monoclonal EBV lymphoproliferative disorder two months later. The "recovery" serum reversed the initial serum BFU-E inhibiting property. This case pinpointed the usefulness of blood or marrow cultures in parvovirus B19 infection of immunocompromised patients without normal Ig responses, as in other PRCA. Further, it argues that the usual immunoglobulin therapy may not be necessary in order to obtain a viral clearance.

Gastric mucosal oxygen delivery decreases during cardiopulmonary bypass despite constant systemic oxygen delivery.

UNLABELLED: Previous studies report a decrease in gastric mucosal oxygen delivery during cardiopulmonary bypass (CPB). However, in these studies, CPB was associated with a reduction in systemic oxygen delivery (DO2). Conceivably, this decrease in DO2 could have contributed to the observed decrease in gastric mucosal oxygen delivery. Thus, in the present study, we assessed the effects of the maintenance of DO2 (at pre-CPB values) during hypothermic (30-32 degrees C) CPB on the gastric mucosal red blood cell flux (GMRBC flux) using laser Doppler flowmetry. In 11 patients requiring cardiac surgery, the pump flow rate during CPB was initially set at 2.4 L x min(-1) x m(-2) and was adjusted to maintain DO2 at pre-CPB values (flow 2.5-2.7 L x min[-1] x m[-2]). Despite a constant DO2, the GMRBC flux was decreased during CPB. These decreases averaged 50% +/- 16% after 10 min, 50% +/- 18% after 20 min, 49% +/- 21% after 30 min, and 49% +/- 19% after 40 min of CPB. The rewarming period was associated with an increase in GMRBC flux. Thus, maintaining systemic DO2 during CPB seems to be an ineffective strategy to improve gastric mucosal oxygen delivery. IMPLICATIONS: In the present study, we tested the hypothesis that gastric mucosal red blood cell flux assessed by laser Doppler flowmetry could be improved by maintaining baseline systemic flow and oxygen delivery during hypothermic cardiopulmonary bypass. Despite this strategy, gastric mucosal red blood cell flux decreased by 50% during hypothermic cardiopulmonary bypass.

Aortic valve replacement in the elderly: bioprosthesis or mechanical valve?

BACKGROUND: With increased life expectancy, valve operations are more and more common in elderly patients. The choice of valve substitute-mechanical valve or bioprosthesis-remains debated. METHODS: Two groups of patients of the same age (69, 70, and 71 years) with isolated aortic valve replacement (mechanical 240, bioprostheses 289) were compared for mortality, morbidity, and valve-related complications. RESULTS: No significant difference was found in survival, valve-related mortality, valve endocarditis, and thromboembolism. Mechanical valve had more bleeding events; bioprostheses had more structural deterioration, reoperation, and valve-related morbidity and mortality. CONCLUSIONS: To avoid reoperations in octogenarians, the 10-year durability of current bioprostheses should be matched with the life expectancy of the particular patient. Bioprostheses should be used after 74 years in men and 78 years in women.

[The Carpentier-Edwards porcine valve in the supra annular aortic position. Results after 12 years in a series of 1108 patients]. / Valve porcine de Carpentier-Edwards supra annulaire en position aortique.

In the decision concerning the choice of valvular prosthesis, certain prostheses are considered to be standards of reference: this is the case of the Carpentier-Edwards Supra Annular 2650 porcine bioprosthesis. This study reports the results in a series of patients followed up for 12 years. Between 1983 and 1995, 1108 patients were implanted with this prosthesis for isolated aortic valve replacement. The majority of patients was elderly (mean 78.3 +/- 8.3 years). The follow-up rate was 94%, representing a total of 3 925 patient-years (average 4 +/- 3 years). The survival at 5, 10 and 12 years, operative mortality included, was 70.7%, 46% and 28%. Thromboembolic events to dehiscence represented the commonest complication (0.7% per patient-year). Structural valve degeneration (21 cases) (0.5% per patient-year) was a low risk complication up to 10 years but increased suddenly at the 11th year: age and gender were risk factors for this complication. The actuarial complication-free rate was 94% at 10 years and 82% at 12 years. Other complications were much less common (infectious endocarditis, haemorrage). The Carpentier-Edwards Supra Annular porcine bioprosthesis is associated with a low risk of complications after 10 years' follow-up, especially of valve degeneration. It remains a competitive choice in the register of valve prostheses. As with the other bioprostheses, the main indications are observed in elderly patients.

[Long-term results over 20 years of aortic valve replacement with the standard Björk-Shiley prosthesis]. / Résultats éloignés à 20 ans du remplacement valvulaire aortique par prothèse de Björk-Shiley standard.

Between January 1971 and December 1978, 865 standard Björk-Shiley prostheses (spheric or conic carbon disc) were implanted in the Department of Thoracic and Cardiovascular Surgery of the University Hospital of Rennes. Three hundred and fifty seven consecutive patients who underwent isolated aortic valve replacement were included in the study : 246 men (69%) and 111 women (31%) with an average age of 57.5 years (range : 24-80 years). One hundred and sixty eight patients (48%) were in NYHA Class II. 141 (39%) in Class III and 48 (13%) in Class IV. The valvular disease was stenotic in 304 cases (85%) and regurgitant in 53 cases (15%). The hospital mortality was 35 (9.8%). The main causes of death were cardiac (23 cases, 66%). The long-term results contain 322 survivors of surgery (mean follow-up 12 years, follow-up rate 99%, representing 3726 patient-years). The actuarial survival (including hospital mortality) was 76% at 5 years. 61% at 10 years, 47% at 15 years and 26% at 20 years. The average age of the survivors at present is 71 years and 95% are NYHA classes I or II. The causes of the 171 late fatalities were cardiac in 49 cases (1.3% per patient-year). Death was related to the prosthesis in 32 cases (0.8% per patient-year) : 3 endocarditis, 17 bleeding complications, 12 systemic emboli. Deaths were extracardiac in 58 cases (1.5% per patient-year). Prosthesis-related complications were : 9 paravalvular leaks (0.2% per patient-year), 3 dysfunctions (0.1% per patient-year). 24 haemorrhages (0.6% per patient-year), 5 thromboembolic episodes (0.1% per patient-year). 5 endocarditis (0.1% per patient-year). No structural abnormalities of the prostheses were observed. The authors confirm the reliability of the standard Björk-Shiley valve prosthesis in the aortic position and the value of the aortic valve replacement by a mechanical prosthesis even at very long term.

[Mediastinitis after cardiac surgery. A 10-year evaluation (1985-1995)]. / Les médiastinites après chirurgie cardiaque. Bilan sur 10 ans (1985-1995).

UNLABELLED: From June 1985 to May 1995, 9,814 patients were operated for a cardiac procedure with cardiopulmonary by-pass. Mean age was 61,3 years. The most frequent procedure was coronary surgery (45%), followed by valvular surgery (34%) then combined surgery (11%) and other surgery (4%). 66 cases of mediastinitis were observed: 38 from June 1985 to May 1990 (first group), 28 from June 1990 to May 1995 (second group). The changes between the two groups was antibiotic prophylaxis using Cefuroxime in the first group and Cefamandole in the second and also an impairment of general status of the patients in the second group. Staphylococcus remains the most frequent organism in both groups and for Gram negative bacteria was less frequent in the second group. Several risks factors mediastinitis were identified (males, emergency, diabetes mellitus, obesity, redo, patient of first group, duration of Cardiopulmonary by pass for 100 minutes, mechanical ventilation greater than 48 hours) and the most important factor was the need for mechanical ventilation for more than 48 hours. The mortality rate was 39.4% (26 patients). Identified risk factors of mortality were age over 65 years, females, poor constitution, and cardio/thoracic ratio > 0.55. CONCLUSION: Mediastinitis after cardiac surgery remains a serious complication. In this series we observed a decrease of mediastinitis rates, especially in the second group (p < 0.001). In high risk patients, specific preoperative methods of patient care may be able to prevent such complications. When mediastinitis appears, and when debridement is necessary, a cover procedure seems necessary in elderly or poor constitution patients.

[Coronary artery disease in patients with aortic abdominal aneurysm. Apropos of a consecutive series of 172 cases]. / Insuffisance coronaire chez les patients ayant un anévrysme de l'aorte abdominale. A propos d'une série consécutive de 172 opérés.

Coronary artery disease is common in patients with abdominal aortic aneurysms (AAA). It is responsible for half the operative deaths explaining the necessity of diagnosing asymptomatic coronary patients. Between 1980 and 1993, 172 patients aged 47 to 92 years (average 69 years) were operated for AAA. Fifty-four of them (31%) were known to have coronary artery disease; 30 preoperative coronary angiograms and 16 prophylactic coronary revascularisation procedures were performed before operating the AAA. In cases with ruptured AAA (42 cases) the operative mortality was 31% (13 patients) compared with 6% (8 patients) in those without rupture (130 cases). Myocardial disease was responsible for 25% of all deaths (2 out of 8) and for 40% of deaths (2 out of 5) in the subgroup of 54 coronary patients. The majority of non-lethal cardiac complications also occurred in this subgroup. On the other hand, no deaths were observed in the group of 16 patients who underwent myocardial revascularisation beforehand. Follow-up of the 151 patients discharged from hospital was complete (100%). With an average follow-up period of 3.5 years (range 5 months to 13 years), 39 secondary deaths have been observed (26%) including 6 (15%) of cardiac causes. In addition, 3 patients in the coronary subgroup and 1 patient from the non-coronary group underwent myocardial revascularisation after surgical cure of their AAA. Coronary artery disease may be totally asymptomatic and severe lesions go unrecognised; the main problem is therefore to detect silent myocardial ischaemia in the absence of totally reliable non-invasive techniques, in order to perform preventive coronary revascularisation in high risk patients before their surgery. Coronary angiography is essential in all documented cases of severe coronary artery disease; exercise testing and thallium scintigraphy should be proposed in cases with clinical or electrocardiographic presumption of angina. However, systematic investigation is not required in the absence of suggestive symptoms.

[A rare complication of mediastinitis: rupture of the right ventricle]. / Une complication rare des médiastinites: la déchirure du ventricule droit.

Two cases of right ventricular free wall rupture secondary to mediastinitis after cardiac surgery are reported. This complication is unusual and characterized by the singular mechanism of rupture (traction involving right ventricular free wall and chest adhesion) which occurs during episodes of coughing. Treatment by omentoplasty en sureda favorable outcome in both cases.

[Postoperative autotransfusion and transfusion evaluation in cardiac surgery]. / Autotransfusion postopératoire et bilan transfusionnel en chirurgie cardiaque.

In cardiac surgery, blood retransfusion from the thoracic drainages, though already ancient, still remains controversial either for its quantitative or its qualitative interests. A retrospective study has been conducted, between the 1st january 1992 and the 30th june 1993, over 1.655 consecutive operations. Most of the patients suffered from coronary disease (937) or a valvular disease (605), others had been operated for a combined valvular and coronary revascularization surgery (113). The safety of this technique, guaranteed by strict rules, allowed a "transfusional strategy" which tends to reduce the homologous blood consumption. Twenty-nine percent of all the patients received homologous red cells units and only 23% of the patients operated for a coronary revascularization. This strategy aims to reduce both the risks of blood transfusion and the health cost.

Serum and tissue distribution of a fragment of cytokeratin 19 (cyfra 21-1) in lung cancer patients.

A sensitive and relatively specific tumoral marker for lung epidermoid carcinomas could be used to identify patients likely to benefit from new therapeutic protocols. The cyfra 21-1 fragment of cytokeratin 19 has raised much hope in this regard amongst both technologists and clinicians. In a study of 195 subjects, we have shown by means of a serum assay that the usual cut-off value for this marker (3.3 ng/ml) can be lowered to 1.5 ng/ml without loss of specificity, and with an increase in sensitivity. There was a good correlation between serum marker level and tumor extension, but though cyfra 21-1 was not predictive of the suitability of a patient for surgery. A decrease of cyfra-21-1 was observed after complete resection of the tumor. There was no relation between serum assay results and immunohistochemical findings.

Aortic valve replacement for aortic stenosis in 200 consecutive octogenarians.

From 1978 to 1992, 200 consecutive patients aged between 80 and 90 years had aortic valve replacement for calcified aortic stenosis. Valve replacement was isolated in 187 cases (93.5%), and it was in combination with coronary bypass (n = 12; 6%), mitral valve replacement (n = 1; 0.5%) or surgery of the ascending aorta (n = 4; 2%). These 200 octogenarians represented 7.4% of the 2716 patients operated for aortic stenosis during the study period. One hundred and forty-eight of them (74%) were in NYHA class III or IV. Operative mortality was 11.5% (23 deaths) and the mean duration of hospitalization was 12.7 +/- 4.83 days. After discharge, all 177 surviving patients were followed up for a mean period of 2.8 +/- 2.1 years (range one month to 10.6 years). There have been 49 deaths during the follow up. At the end of the follow up, 127 of the 128 survivors (98.6) were in NYHA classes I or II. Actuarial survival at one, three and five years was 81.7%, 74.8% and 57.14% respectively, which is equivalent to the life expectancy for subjects of the same age without aortic stenosis. It is suggested that despite the increased, yet acceptable, operative risk, valve replacement in octogenarians is justified due to its beneficial effect on life expectancy and quality of life.

[Changes in operative risk and its predictive factors in coronary surgery]. / Evolution du risque opératoire et de ses facteurs prédictifs en chirurgie coronarienne.

The operative risk of coronary bypass surgery has been reported by many surgical groups. Although the 1970's were characterised by a progressive decline in this risk related to improved surgical techniques and myocardial protection, the following decade saw a new rise in operative mortality. In order to assess this problem, the authors undertook a review of 3,632 consecutive cases of coronary bypass surgery (without any other procedure) from 1982 to 1991. The operative risk increased from 2% in 1982 to 7.7% in 1989 and was related to an increase in patients' age, in left ventricular dysfunction and in the number of emergency and redux operation. The development of interventricular cardiology in the last few years (angioplasty for double or triple vessel disease, thrombolysis in the acute phase of myocardial infarction) has also increased the number of patients operated as emergencies with a high operative risk. The reduction of the operative risk observed since 1989 is due to better overall management (pre, per and postoperative), especially of the high risk patients (patients over 70 years of age, women, left ventricular dysfunction, left main coronary stenosis, emergencies, reoperation). Although many variables indicating extramortality were found to be statistically significant (p < 0.05) on univariate analysis, multivariate analysis by two year periods showed the following independent prognostic factors of operative mortality: persistence of the concept of "emergency surgery" throughout the period under study and, from 1986, the appearance of gender and NYHA Class; and, from 1988, the factor "reoperation" with different values of "p" according to the years under consideration.

[Valvular replacement for aortic stenosis in octogenarians. Apropos of a consecutive series of 200 cases]. / Le remplacement valvulaire pour rétrécissement aortique chez les octogénaires. A propos d'une série consécutive de 200 patients.

From 1978 to 1992, 200 patients aged 80 to 90 (average 82.16 +/- 2.04 years) with calcific aortic stenosis, underwent isolated aortic valve replacement (187 cases, 93.5%), or associated with coronary bypass surgery (12 cases, 6%), or mitral valve replacement (MVR) (1 case, 0.5%), or surgery of the ascending aorta (4 cases, 2%). These 200 patients represented 7.4% of the 2,716 cases of aortic stenosis operated during the same period. One hundred and forty-eight patients (74%) were in NYHA classes III or IV. The operative mortality was 11.5% (23 patients) and the average hospital stay in the surgical department was 12.7 days (4.83%). The follow-up of the 177 patients who were discharged from hospital was complete (100%) with an average of 2.8 years +/- 2.1 (1 month to 10.6 years). Forty-nine secondary fatalities were observed (28%). Of the 128 survivors at the end of the study, 127 (98.6%) were in the NYHA classes I or II. The actuarial 1, 3 and 5 year survivals were 81.7, 74.8 and 57.1%, respectively. The survival curve of the operated patients was identical to subjects of the same age without aortic stenosis. Despite the high but acceptable operative risk due to the age, valvular replacement surgery is justified by the double benefit of increased longivity and improved quality of life.

[Surgical treatment of aneurysms of the left ventricle. Immediate and long-term results. Apropos of a consecutive series of 121 cases]. / Traitement chirurgical des anévrysmes du ventricule gauche. Résultats immédiats et éloignés. A propos d'une série consécutive de 121 cas.

From 1978 to 1992, 121 cases of postinfarction left ventricular aneurysm (99 males, 22 females, mean age 60 years) were operated on. The authors insist on a high rate of clinical arhythmogenicity (31.4%) and associated mechanical complications (21%). 76% of patients were in functional NYHA class III or IV. Resection was performed in 90% of patients, plication in 10%. 58% underwent coronary artery bypass grafting (1.7 graft/patient), 16% encircling ventriculotomy, 8% mitral valve replacement and 13% closure of ventricular septal defect. Operative mortality was 14.9% (10% when other mechanical complications where excluded). 5-year survival is 67.9%. Late cardiac deaths are as follow: left ventricular failure (1.8% A/P), Sudden death (1.4% A/P), Myocardial infarction (0.6% A/P). 82% of survivals are in functional NYHA class I or II. Only functional class NYHA III or IV is predictive of late death. We conclude that postinfarction left ventricular aneurysm remains a high risk complication especially when associated with other mechanical complications. When arhythmogenicity is present we suggest rhythmologic surgery and in all cases, complete revascularization.

Surgery for aortic stenosis in elderly patients. A study of surgical risk and predictive factors.

BACKGROUND: Aortic stenosis is the most common valvular lesion occurring among elderly patients and has become extremely frequent because of changing demographics in industrialized countries. Surgical risk after the age of 70 has increased. The increasing older age of patients having surgery justifies an analysis of mortality predictive factors. METHODS AND RESULTS: Between 1976 and February 1993, we performed 2871 operations for aortic stenosis. This study concerns 675 patients (278 men and 397 women) who were > or = 75 years old. Mean age was 78.5 +/- 3 years. Associated lesions were found in 226 patients. A bioprosthesis was implanted in 632 patients (93.6%). Concomitant surgical procedures were performed in 133 patients. Surgical mortality was 12.4% (84 deaths). A longitudinal analysis has been carried out over four successive time periods to evaluate population evolution during these 17 years. Statistical analysis was performed on 46 variables. Multivariate analysis found age (P < .0001), left ventricular failure (P < .0001), lack of sinus rhythm (P < .01), and emergency status (P < .02) to be presurgical independent predictive factors of mortality. CONCLUSIONS: Risk-reducing strategy should both favor relatively early surgery to avoid cardiac failure and emergency situations and pay careful attention to the use of myocardial protection and cardiopulmonary bypass. Indications for surgery should remain broad since analysis failed to determine specific high-risk groups to be eliminated, and surgery remains the only treatment for aortic stenosis.

[A study of predictive factors of the operative risk in the surgery of aortic valve stenosis in aged patients]. / Etude des facteurs prédictifs du risque opératpore dans la chirurgie du rétrécissement aortique des patients âgés.

Aortic stenosis, the most extensive form of valvular disease in elderly subjects, has become very common because of demographic reasons in industrialised countries. The operative risk in patients over 70 years of age is significantly higher. The progressive rise in age of patients referred for surgery justifies this analysis of predictive factors of operative mortality. Between 1976 and February 1993, out of 2871 aortic valve replacements, 675 (278 men and 397 women) patients were over 75 years of age and were included in this study. The average age was 78.5 +/- 3 years. Associated pathology was present in 226 patients. A bioprosthesis was chosen in 632 cases (93.6%). An associated surgical procedure was required in 133 cases. The operative mortality was 12.4 +/- 1.3% (84 deaths). Longitudinal analysis was performed for 4 successive periods to assess the outcome of the study population over the 17 years. A statistical study was made of 50 variables and multivariate analysis showed age (p < 0.0001), left ventricular failure (p < 0.0001), non sinus rhythm (p < 0.0005) and emergency procedures (p < 0.02) to be independent preoperative predictive factors of mortality. In order to reduce this risk, the authors recommend early surgical referral to avoid emergency procedures and cardiac failure, and increased efforts of myocardial protection during cardiopulmonary bypass. Despite the risk, surgery is the only radical treatment of aortic stenosis, including elderly patients.