Review of 387 isolated mitral valve replacements by the Model 6120 Starr-Edwards prosthesis.

Between February, 1965, and July, 1980, 387 patients underwent an isolated mitral valve replacement with the non-cloth covered Starr-Edwards ball valve (Model 6120) at the University of Louvain. The mean age of the patients was 48.765 years. The overall operative mortality was 6.1%. The mean age of the patients who died was 52.3 years and all but four were in New York Heart Association (NYHA) Functional Class III or IV. The actuarial survival rate is 78% at 5 years after operation, 72% at 10 years, and 70% at 13 years. The overall incidence of thromboembolic complications is 3.4% per patient-year with a total follow-up of 1,675 patient-years. Valve dysfunction has never occurred, and endocarditis, hemolysis, and paravalvular leakage have never reached a significant incidence. Hemodynamics investigations show a residual diastolic gradient of 6.6 mm Hg for the size 3M valves and 7.92 mm Hg for the size 2M valves. These current data over an extended follow-up interval (15 years) indicate that the Starr-Edwards Model 6120 prosthesis continues to perform satisfactorily in terms of mortality and morbidity, and there have been no instance of late failure due to valve dysfunction.

Sequential mammary grafting. Clinical, functional, and angiographic assessment 6 months postoperatively in 231 consecutive patients.

Between September 1985 and November 1987, 246 sequential mammary grafts were performed in 231 consecutive patients. Seventy-eight percent had triple vessel disease, and 33% required an urgent procedure. The length of the internal mammary artery pedicle was the only limitation to its use. No account was taken of the free cut-end flow of the internal mammary artery. There were 14 bilateral sequential mammary grafts and 15 free sequential mammary grafts. Of the 531 sequential mammary anastomoses, 482 were built with the left internal mammary artery; 113 (21%) were diamond-shaped anastomoses. The right internal mammary artery was brought through the transverse sinus in 44 cases, 10 times for sequential grafting of circumflex branches. Taking into account the adjunctive venous anastomoses and the single internal mammary artery anastomoses, there were 4.5 distal anastomoses per patient, 2.8 being mammary anastomoses and 2.3 being sequential mammary anastomoses. The hospital mortality rate was 2.6%. The prevalence of perioperative myocardial infarction was 5.2%. Follow-up was complete and averaged 15.4 months. Six patients (2.7%) still had angina pectoris. One hundred fifty-seven (71%) patients were recatheterized 6 months after the operation, and 95% of the sequential mammary anastomoses were still patent. The patency rate of the diamond-shaped mammary anastomoses was 94.5% and that of the anastomoses corresponding to the right internal mammary arteries brought through the transverse sinus was 94.3%. The gratifying functional results (maximal stress test combined with exercise thallium scintigraphy) obtained at an average of 6 months postoperatively illustrated the surprising physiologic adaptability of the internal mammary artery. As the attrition rate of the mammary artery grafts beyond 6 months postoperatively is thought to be minimal, gratifying long-term results with widespread use of sequential mammary grafts can be anticipated.

Strut fracture of the Björk-Shiley aortic valve.

The following case report describes a fatal complication of a convexo-concave Björk-Shiley prosthetic valve in the aortic position (60 degree orifice opening).

Factors influencing postoperative survival in aortic regurgitation. Analysis by Cox regression model.

From 1965 to 1981, 114 patients underwent aortic valve replacement for severe aortic regurgitation in our institution. Catheterization was performed preoperatively in 103 patients. Follow-up was possible in 98% of the survivors. Long-term survival was significantly different between patients in preoperative Functional Class I-II and those in Class III-IV (p less than 0.03); those with a preoperative cardiothoracic ratio less than 0.64 versus greater than or equal to 0.64 (p less than 0.001); and those with a preoperative ejection fraction greater than 0.50 versus less than or equal to 0.50 (p less than 0.03). A multifactorial analysis was used to identify the dominant preoperative prognostic variables affecting survival. Three of the 13 parameters examined simultaneously were found to independently influence survival rates: cardiothoracic ratio (p = 0.001), strain pattern on the electrocardiogram (p = 0.072), and left ventricular end-systolic pressure (p = 0.127). After stratification of the population into two groups according to preoperative functional class, the predictive variables were cardiothoracic ratio (p = 0.014), strain pattern (p = 0.050), and acute/chronic form of aortic regurgitation (p = 0.034). This statistical analysis enabled us to derive a mathematical equation for predicting an individual patient's probability of survival. We found a close fit between the survival rate predicted by the mathematical model and the observed survival rate.

Use of the Carpentier-Edwards porcine bioprosthesis: assessment of a patient selection policy.

The Carpentier-Edwards bioprosthesis was implanted in 369 patients (414 valves) between May 1977 and December 1987 (age 67.2 +/- 0.5 years); 242 had aortic valve replacement, 80 had mitral valve replacement, 44 had multiple valve replacement, of which 41 were aortic and mitral valve replacement, 2 had isolated tricuspid valve replacement, and 1 had a pulmonary valve replacement. The selection criteria were the following: shorter life expectancy (253 patients) or contraindications to anticoagulants for organic (113 patients) or psychologic (38 patients) reasons, or both. The early mortality rate was 11.1% (aortic valve replacement, 9.1%; mitral valve replacement, 12.4%; aortic and mitral valve replacement, 23.1%). Total cumulative follow-up was 1456 pt-yr (mean 4.4 years, range 1 to 148 months), and the patient evaluation was 99.5% complete. Late mortality was 4.9%/pt-yr. Five-year survival was 70.4% +/- 2.7% overall, 74.3% +/- 3.2% after aortic valve replacement, 60.9% +/- 6.2% after mitral valve replacement (p < 0.03), and 60.7% +/- 8.1% after aortic and mitral valve replacement. Eight patients were reoperated on for primary tissue failure, and freedom from reoperation for structural valve deterioration was 97.5% +/- 1.2% at 5 years and 95.6% +/- 1.8% at 8 years. Failing aortic bioprostheses were explanted in four patients (0.4%/pt-yr) and mitral bioprostheses in seven (1.6%/pt-yr). No patient whose valve was inserted after the age of 70 had to be reoperated on for structural valve dysfunction. The probability of freedom from thromboembolism after 5 and 8 years of follow-up was 93.1% +/- 1.6% and 92.2% +/- 1.8%, respectively. The prevalence of anticoagulant-related hemorrhage was 0.8%/pt-yr (major 0.6%, minor 0.2%). Anticoagulants had to be maintained in 16.3% of the patients: 5.9% after aortic valve replacement, 35.7% after mitral valve replacement, and 45.8% after aortic and mitral valve replacement, while 80.0% were on a regimen of antiplatelet drug therapy. Prosthetic valve endocarditis happened in five patients (0.3%/pt-yr). Freedom from all valve-related morbidity and mortality, including hospital deaths, was 71.0% +/- 2.7% at 5 years and 58.6% +/- 4.6% at 8 years and was significantly better in the aortic valve replacement group (61.3% +/- 6.6% at 8 years) compared with the mitral valve replacement group (54.4% +/- 7.7% at 8 years; p = 0.04). This study confirms the satisfactory performance of the Carpentier-Edwards valve after aortic valve replacement in elderly patients.(ABSTRACT TRUNCATED AT 400 WORDS)

Long-term follow-up of the Senning operation for transposition of the great arteries in children under 3 months of age.

Twenty-six patients aged 6 days to 3 months (mean 57 days) underwent a Senning procedure for transposition of the great arteries. Twenty-two had intact ventricular septum and four had a small ventricular septal defect. They were followed up for 1 month to 8 years (mean 4 years). There were no late deaths. At late examination, 25 patients were asymptomatic and there was no clinical or echographic evidence of caval or pulmonary venous obstruction. Growth was normal in all but two patients. Neurologic assessment was abnormal in eight patients. The electrocardiogram showed sinus rhythm in 22 patients and asymptomatic arrhythmias in four. Twenty-three patients underwent cardiac catheterization and angiographic studies 2 to 72 months postoperatively (mean 15 months), which demonstrated effective left and right atrial contraction. An atrial shunt was noted in one patient and a ventricular shunt in one. Two infants (8%) had a residual left ventricular outflow tract obstruction (gradients of 26 and 37 mm Hg). Two had mild superior vena caval obstruction (gradients of 4 and 5 mm Hg). We conclude that the Senning procedure can be performed in early infancy with good results and a low incidence of late complications.

Twenty years' experience with the Model 6120 Starr-Edwards valve in the mitral position.

A total of 549 nonconsecutive patients underwent isolated mitral valve replacement with a Starr-Edwards valve prosthesis (Model 6120) at the University of Louvain (Belgium) from 1965 to 1985. Ninety-seven percent of the patients could be traced and only 17 patients were lost to follow-up. Cumulative follow-up totalled 3,130 patient-years. Actuarial and linearized statistical techniques were used to describe the survival and the incidence of valve-related complications (according to stringent criteria). Long-term overall survival rate including early deaths was 79% +/- 0.02% at 5 years, 65% +/- 0.03% at 10 years, and 54% +/- 0.04% at 19 years, with a linearized incidence of late deaths of 3.9% +/- 0.5% per patient-year. The incidence of late valve-related deaths was 1.25% per patient-year. Valve-related complications occurred at the following rates: thromboembolism 3.1% per patient-year, anticoagulant-related hemorrhage 1.08% per patient-year, endocarditis 0.26% per patient-year, reoperation and periprosthetic leak 0.45% per patient-year, and structural failure 0% per patient-year. All valve-related mortality and morbidity were calculated at 4.9% per patient-year and the rate of valve failure (deaths and reoperations) at 1.4% per patient-year. Among 376 survivors, 352 clinical functions could be obtained: 95% of patients belong to Class I or II of the New York Heart Association after operation versus 24% before operation. The study shows the structural durability of the Starr-Edwards mitral valve with a follow-up over 20 years. The Model 6120 valve may be considered a faithful standard.

Aortic valve replacement thirty-one months after orthotopic heart transplantation.

Aortic valve replacement with a St. Jude prosthesis was performed 31 months after orthotopic heart transplantation in a 28-year-old male patient with Steinert's disease and idiopathic cardiomyopathy. The donor heart was reported as being normal by the cardiologist of the referring hospital. During implantation, a bicuspid aortic valve was noted, and early after the operation mild aortic regurgitation became apparent. Aortic incompetence advanced to a severe degree within 2 years after transplantation. Valve replacement, instead of retransplantation, was undertaken after careful consideration of the advantages and disadvantages of the therapeutic choice. This case report demonstrates the feasibility of valve replacement after heart transplantation and emphasizes the need for careful evaluation of potential donor hearts before harvesting.

A case of candida albicans endocarditis 3 years after an aortic valve replacement. Successful combined medical and surgical therapy.

The authors report a case of candida albicans endocarditis occurring 3 years after aortic valve replacement and bacterial endocarditis. They may attempt to the difficulty of the diagnosis, the successful combined surgical and medical treatment, the duration and the follow-up of the therapy and finally the aspect of the side effects of the used antifungal drugs.

Correction of tetralogy of Fallot after Waterston shunt.

The authors have reviewed their experience concerning twenty-seven patients who underwent intracardiac repair of Fallot's Tetralogy after a previous Waterston shunt. They are divided into 4 groups according to the classification of Shinebourne, Anderson and Bowyer. The risk factors are analyzed in group 1 patients in whom primary total correction is contra-indicated and in whom the mortality at repair is high in presence of kinking of right pulmonary artery. The type of surgery is still debatable. For the symptomatic patients of the other groups, primary total correction at any age seems, at this time, to be the treatment of choice. The contra-indications are an anterior descending coronary artery arising from the right coronary artery or associated complex anomalies which would make total correction difficult.

Surgical treatment of mitral stenosis.

Analysis of 239 patients who underwent a commissurotomy for mitral stenosis (196 closed technique, 43 open technique). Total operative mortality was 2%. Long term follow-up is illustrated by an actuarial survival curve and long-term functional results are studied up to 15 years after operations. It allows the authors to consider commissurotomy alone as a good palliative procedure with good functional results in the majority of cases. However, in view of the collected data, they now elect to restudy all the patients 6 years after the primary correction and to perform a heart catheterization to consider appropriate reoperation in some cases.

Tricuspid valve surgery.

Our purpose was to study the long-term results of the tricuspid valve replacement. It is obvious that tricuspid annuloplasty (Kay, De Vega) has its place in the treatment of functional tricuspid insufficiency that accompanies mitral or mitral and aortic valve disease. The Carpentier ring appears justified for some cases. However tricuspid valve replacement can be the operation of choice for some patients. Our study demonstrated that the Björk-Shiley and Starr-Edwards prostheses remain good substitutes in tricuspid valve surgery and that the long-term results are better than it was anticipated a decade ago.

Comparative results after endarterectomy of the internal carotid artery performed with or without a shunt.

One hundred endarterectomies of the internal carotid artery have been performed from March 1984 to December 1985; 50 were carried out with a Javid shunt, and 50 were performed without using a shunt. There was no peroperative or hospital deaths. Five operations performed with the use of a shunt and 4 performed without a shunt were followed by a central nervous system deficit. The frequency of central neurological complications is thus not statistically different, but the time of onset and the likely cause of the deficit are different.

Early surgery for severe aortic regurgitation.

One hundred and fourteen consecutive patients who underwent aortic valve replacement (AVR) for isolated aortic regurgitation (AR) from 1965 to 1981 are presented. Sixty eight (60%) were preoperatively in NYHA class I-II and 46 (40%) were in NYHA class III-IV. Eighty-two patients had left and right heart catheterization prior to the operation and the severity of regurgitation was assessed angiographically in 93% of those in functional class (FC) I-II. Left ventricular (LV) end-diastolic volume index and end-systolic volume index were elevated even in the mildly symptomatic patients (156.1 and 61.0 ml/m2 respectively). The ratio of LV end-systolic pressure to LV end systolic volume index was diminished in the FC I-II patients. Two patients in FC III died in hospital (operative mortality: 1.7%) and there were 21 late deaths with a 5-year survival of 82.7%. Late survival differed significantly between patients who were preoperatively in FC I and II or III and IV (P less than 0.03). These data suggest that severe AR with altered LV function is an indication for early operation regardless of the presence of absence of symptoms.

Idiopathic hypertrophic subaortic stenosis: long-term surgical results.

The results of surgery in 21 patients with I.H.S.S. are reported. Dyspnea, angina pectoris and syncope were the most common symptoms in decreasing frequency. Before the operation, 5 patients were in New York Heart Association's functional class II, 10 in class III and 6 in class IV. The mean resting peak systolic pressure gradient was 66 mm Hg in 20 patients and mean left ventricular end-diastolic pressure was 14 mm Hg in 19 patients. The ventriculoseptomyectomy accomplished through a transaortic approach is the procedure of choice. The operative mortality rate was 14% (3 of 21 patients). There were 2 late deaths from congestive heart failure. Any sudden death did not occur. The remaining 16 patients have been followed up for a mean of 75 months (range 12 months to 11 years), 11 patients are in functional class I, 4 in class II and 1 in class III. Complete left-bundle-branch block occurred in 3 patients. Our study with a long post-operative follow-up period, documents that surgery results in good to excellent alleviation of symptoms in survivors. The elevated pre-operative left ventricular end-diastolic pressure has a significantly poor prognosis. We currently recommend surgery for the symptomatic patients who have not responded to medical therapy, not late in the symptomatic course of the disease.

Surgical treatment of subvalvular aortic stenosis. Long-term results.

From 1966 till May 1988, 53 patients underwent surgery for fixed subaortic stenosis. Subvalvular obstruction was isolated in 27 patients (Group I) and associated with aortic valve lesions in 26 (Group II). A membranous stricture was documented in 5 patients and a fibromuscular ring in 48. Excision of the ring and myectomy were performed in all patients, and an associated aortic valve replacement or reconstruction in 7 and 4 patients respectively. There were no hospital deaths. Follow-up evaluation in 50 patients ranged from 6 months to 22 years. Eight patients had to be reoperated upon (1 from group I, 7 from group II): aorto-ventriculoplasty was performed in 3, aortic valve replacement with redo myectomy in 3 and mitro-aortic valve replacement in 2. One of them had 2 reoperations. Functional status at the time of the last outpatient visit was most satisfactory. Continued evaluation remains necessary as obstruction may reappear despite the absence of symptoms.

Total anomalous pulmonary venous connection. Long-term results following repair under 3 months of age.

The surgical experience with total anomalous pulmonary venous connection (TAPVC) at the University of Louvain (Brussels) between the years 1975 and 1986 is reviewed. Nineteen patients aged two days to three months with TAPVC were studied. The types of TAPVC were supracardiac in 9 patients, cardiac in 4, infracardiac in 4 and mixed in 2. Profound hypothermia induced by surface cooling, limited cardiopulmonary by-pass and total circulatory arrest were used in all cases. The 4 early deaths concerned the first four neonates who were critically ill. All operative survivors are followed for a mean of 3.5 years (12 months to 8 years). There are two late deaths due to reoperation for pulmonary venous obstruction. All 13 survivors are well at last review. Eleven of them have been recatheterized 4 to 33 months after repair (19 months in average). The pulmonary artery and capillary pressures fell to a normal level after a few months. Ventricular function which was markedly depressed preoperatively, was evaluated by quantitative angiocardiography and echocardiography. It returned to normal late postoperatively. The hospital mortality for the repair of TAPVC in the neonates remains appreciable. Total correction at one operation is advisable. The incidence of postoperative pulmonary venous obstruction is of particular concern. The late postoperative functional and hemodynamic results are excellent. The repair of TAPVC can be considered curative.

Sequential mammary artery grafts in one hundred and twenty consecutive patients: indications, operative technique, 6 months postoperative functional and angiographic controls.

In the hope of establishing the internal mammary artery (IMA) as a true but superior substitute for the saphenous vein (SV) we reviewed our initial experience in complex IMA grafting. The first 120 consecutive patients, having received at least one sequential IMA graft were analyzed. The length of the IMA pedicle was the only limitation imposed on its use. Technical artifices enhancing the versatility of the IMA are described. The significant peri-operative myocardial infarction rate was 3.3%. There was no cardiac operative mortality, and 1 late mortality (0.8%). Excellent functional results were illustrated by a 2.5% rate of residual angina and dyspnoea. Six months postoperative angiographic controls could be performed in 70% of the patients: all of the sequential mammary conduits were patent, as were 95% of the anastomoses. By contrast 87.2% of the concomitant venous anastomoses were still functioning. With the expanding utilization of the free graft, IMA is expected to become a true, better and all round substitute for the saphenous vein.

Surgical repair of coarctation of the aorta in infants under one year of age. Long-term results in 146 patients comparing subclavian flap angioplasty and modified end-to-end anastomosis.

Between July 1976 and February 1991, 146 consecutive infants underwent surgical repair of coarctation of the aorta. Age at operation varied from 2 days to 11 months (median 1 month). Ninety-two (63%) were less than 2 months. Isolated coarctation was present in 65 patients (group 1), associated ventricular septal defect in 49 patients (group 2) and complex anomalies in 32 patients (group 3). The majority (65%) were in a critical condition and 45 patients (31%) were artificially ventilated. Subclavian flap angioplasty was performed in 39 patients and resection and end to end anastomosis in 107 patients. Neither hospital mortality was significantly different between subclavian flap angioplasty (15%) and end-to-end anastomosis (18%) nor was the postoperative hypertension. Actuarial survival at 10 years were 100% for group 1, 94% for group 2, and 62% for group 3. Seventeen patients had recurrent coarctation. No significant difference was found in terms of types of repair or age at operation. As no major advantage in terms of mortality and morbidity to either technique was found, we recommend resection and end-to-end anastomosis. This technique not only relieves the obstruction whatever the level is but also eliminates the ductal tissue, preserves the subclavian artery and avoids the use of prosthetic material.

[Prognosis and treatment of bacterial endocarditis. Review of 70 cases]. / Prognostic et traitement de l'endocardite bacterienne. Revue de 70 cas

The long term results of medical and surgical treatments have been reviewed in 70 cases examined during the last 8 years. In 24 of them, bacterial endocarditis developed after valvular replacement. Antibiotic treatment was administered during at least 6 weeks. Determinations of the minimum inhibitory concentration of the antibiotic and of the bactericidal power of the serum were considered as the most important laboratory controls. In the post-operative cases with prosthetic valves, numerous pathogenic organisms were found, including gram (minus) bacilli and monilia, which may partly account for the high mortality in this group. Despite surgical reinterventions, 20 of the 24 patients died. For the gram (+) cocci, prognosis is however statistically worse (at the 99% confidence limit) when prosthetic valves are present. Out of the 46 patients without prosthetic valves, 31 (68%) had a favourable bacteriological and haemodynamic evolution; in this group, gram (minus) bacilli and monilia were never found to be the pathogenic organisms. For streptococci infections, recovery was obtained in 73% of the cases (24 out of 33). Percentages of long term recovery are very similar in mitral (67%) and aortic (69%) valvular involvment, but the frequency of surgical indication was very different in either group. In cases of aortic valvular disease, valvular replacement was indicated for bacteriological or haemodynamic reasons in 19 of the 20 patients who recovered. Amongst the 9 patients who died, 6 were not operated upon. Valvular replacement is by far less frequently necessary in cases of bacterial endocarditis on the mitral valve : one prosthetic valve amongst 8 patients who recovered. Finally, the authors discuss the place of surgery in the treatment of bacterial endocarditis. According to their experience, recent improvement in the prognosis of the disease seems to depend more on the surgical approach of the problem than on the discovery of new antibiotics.