Outcome of atrial fibrillation after mitral valve repair.

OBJECTIVE: The aim of the study was to evaluate the prognostic factors for return to sinus rhythm after mitral valve repair. METHOD: One hundred ninety-one patients underwent surgery for mitral valve repair, including 142 procedures for valve repair only (74%). The patients with preoperative atrial fibrillation (50.5%) were older, clinically more symptomatic, and had a greater degree of left atrial dilation than the patients who had sinus rhythm. RESULTS: Preoperative cardiac rhythm, the duration of preoperative atrial fibrillation, and a lesser degree of left atrial hypertrophy are significant prognostic factors independent of the maintenance of sinus rhythm. The probability of return to stable sinus rhythm was 93.7% when sinus rhythm was already present before the operation and 80% when atrial fibrillation was intermittent or of less than 1 year's duration; probability declined abruptly for durations over 1 year. No significant difference in patient survival was noted between those who had sinus rhythm (99% +/- 0.9% at 1 year and 86% +/- 6.6% at 5 years) and those who had atrial fibrillation in the preoperative period (95% +/- 3.1% at 1 year and 86% +/- 8.4% at 5 years). In contrast, the postoperative return to sinus rhythm was associated with 99% +/- 0.9% and 94% +/- 4.8% survivals at 1 and 4 years versus 97% +/- 1.5% and 77% +/- 13% in the event of postoperative atrial fibrillation. CONCLUSION: The aim of restoring postoperative sinus rhythm after mitral valve repair should lead to surgery being conducted on patients who have sinus rhythm or recent-onset atrial fibrillation. Surgery for atrial fibrillation may be of value in patients with a long history of atrial fibrillation, providing that it does not induce prohibitive excess mortality.

Long conservation organs in heart transplantation: postoperative results and long-term follow-up in fourteen patients.

Between 1988 and 1995, 14 heart transplantations were performed after a long preservation period (10 to 13 hours). The transplantation procedure (Shumway) was standard, and our results were achieved through the implementation of a very strict reperfusion technique that included low pressure and low cardiopulmonary bypass output for the first 10 minutes. Three patients died during the postoperative period, and the survival rate was 75% at 1 year and 71% at 5 years. The results obtained with hearts stored for such long periods are comparable to the results obtained with hearts stored for less than 4 hours.

Long-term follow-up of small (size 20 and 21) Medtronic-Hall aortic valve prostheses.

BACKGROUND: Our goal was to study the long-term follow-up of patients having aortic valve replacement and to focus particularly on the patients receiving small prostheses. METHODS: Four hundred twenty-eight Medtronic-Hall valves were implanted (156 size 20 or 21 mm, 149 size 22 or 23 mm, and 123 size 25 or 27 mm). Group 20-21 had a higher number of female patients, more associated coronary lesions, and more patients with aortic stenosis. RESULTS: The actuarial survival rate at 8 years was 80% for group 20-21, 80% for group 22-23, and 76% for group 25-27 (p = not significant). In group 20-21, the actuarial event-free rates at 8 years were as follows: thromboembolic complications, 94%; prosthetic valve endocarditis, 99%; reoperation, 98%; and hemorrhagic complications, 78%. The only factors of prognostic value in this group were age and associated coronary lesions. CONCLUSIONS: The durable nature of the results obtained with the Medtronic-Hall 20- and 21-mm prostheses compared with large-diameter prostheses allows the use of a simple and reliable surgical technique and should mean that indications for ring enlargement become rare.

Subdiaphragmatic implantation of implantable cardioverter defibrillator generator.

Despite several improvements in the surgical technique and in the technologic design of cardioverter defibrillators made over the past years, abdominal placement of the generator device, done as Mirowski did it in his first implantation performed in 1980, remains the widely used method. Although smaller defibrillators are available, they remain bulky and are a source of local complications. To prevent such complications and to enhance patient comfort, we performed a subdiaphragmatic implantation in 31 patients.

Effect of cardiopulmonary bypass on plasma concentrations of diltiazem and its two active metabolites.

Diltiazem is often used to prevent myocardial ischaemia during the perioperative period of coronary artery bypass surgery. The purpose of this study was to investigate the effect of cardiopulmonary bypass (CPB) on plasma concentrations of diltiazem and of its two main and active metabolites (N-monodemethyldiltiazem (N-desmethyldiltiazem) and desacetyldiltiazem). The patients were administered their usual treatment during the preoperative days. The last dose was administered immediately before anaesthesia. At the onset of CPB, a significant decrease in the plasma concentrations of diltiazem and its metabolites was observed, whereas the variation was slight and not significant when the plasma concentrations were corrected for haemodilution. These results confirm that the decrease observed at the initiation of the bypass procedure can be ascribed to the haemodilution induced by the CPB. During CPB, the concentrations of diltiazem and its metabolites remained constant suggesting that the rate of metabolism and excretion of the drug was altered during the bypass procedure. At the end of CPB, there was no increase of drug plasma concentrations suggesting that no redistribution of diltiazem from tissues to plasma occurred. Furthermore, this study shows that only 33% of subjects have therapeutic levels of diltiazem before anaesthesia, and that all subjects have subtherapeutic levels during and after the CPB. These results suggest that a higher chronic oral dose of the drug should be given in patients undergoing cardiac surgery with CPB.

Valvular replacement for aortic stenosis on patients in NYHA class III and IV. Early and long term results.

From January 1972 to June 1990, 112 patients between 39 and 83 years old, divided into 68 NYHA class III (60.72%) and 44 NYHA class IV, underwent surgery for aortic stenosis. There were 67 male (59.82%) and 45 female (40.18%). Early mortality included 8 patients (7.14%). Actuarial survival (including early postoperative mortality) for all 112 patients was 88.39%, 77.67%, 67.85% and 65.7% t one year, five, ten and fifteen years respectively. Clinical criteria are subjective but they remain the best prognostic factor. Surgery is indicated at occurrence of first symptoms, but, even in advanced cases, aortic valvular replacement can significantly improve survival and functional status. Even if operative risk is increased and secondary cardiomyopathy often progresses after surgery, aortic valve replacement results seem better than those of medical treatment alone.

Defibrillation threshold and electrode configurations: an experimental study testing three configurations in twelve pigs.

OBJECTIVE: The choice between epicardial or subcutaneous patches remains unclear and depends essentially on the team's habits. This study tested how much an additional patch can decrease defibrillation threshold (DFT), and compared a Subcutaneous Array and an epicardial patch. Today most implantable automatic defibrillators have a transvenous endocardial configuration alone but when the DFT remains high an additional patch is necessary. EXPERIMENTAL DESIGN: Three different configurations were tested with biphasic shocks in 12 pigs: Endovenous lead (Endo), Endovenous lead + subcutaneous patch (Endo + SQ) and Endovenous lead + epicardial patch (Endo + Epi). For each animal DFTs were determined in a balanced random order for the 3 configurations. Ventricular fibrillation was induced by pacing (30 Hz, 8 V, for 5 seconds). DFT was accurately measured with the up/down procedure until 3 reversal of defibrillation success or failure occurred. DFTs (mean +/- SD) were extracted and compared using paired t test and analysis of variance. RESULTS: DFTs were 14.6 +/- 11.0 J for Endo and significantly decreased (p < 0.01) when an additional SQ (9.4 +/- 7.2 J) or epicardial patch (8.9 +/- 6.5 J) was added to endovenous lead, without significant difference between Endo + SC and Endo + Epi configurations. CONCLUSIONS: Regarding this important decrease of DFT (respectively -35% for Endo + SC and -39% for Endo + Epi), additional patches should be more often recommended in patients with low safety margin of DFT. In those cases subcutaneous patches should be preferred instead of epicardial patches. Moreover, an additional reason to recommend this attitude could be the possible generator batteries saving.

[Thoracic aortic aneurysm in Marfan syndrome]. / Anévrysme de l'aorte thoracique dans la maladie de Marfan.

Thoracic aortic aneurysms are the main cardiovascular complication of Marfan's syndrome. Elastic tissue dystrophy of the ascending aorta is responsible for appearances of cystic medial necrosis in the major forms. Dilatation of the ascending aorta is progressive with time. The risk of dissection and rupture, an acute complication of Marfan's syndrome, is very high when the aortic dilatation reaches 60 mm, although dissection may be observed with dilatation of 50 mm. Aortic regurgitation is found in half the cases. Echocardiography, CT scan and MRI provide accurate assessment of the anatomy of the lesions and help in following up the dilatation. Betablocker therapy slows down the progression of the dilatation. Bentall's procedure was first described in 1968 with its technical variants for reimplantation of the coronary arteries: Cabrol's procedure, technique of periostal lean-to, the button technique, are major advances in the surgical treatment of ascending aortic aneurysms. The life expectancy is reported to be about 90% at 5 years and 75 to 80% at 10 years. Reoperation is sometimes necessary because of pseudo-aneurysms occurring as a late complication at the operation site or because of other aneurysms developing. Progress in the field of genetics is a hope for the future.

[Automatic implantable defibrillators; subdiaphragmatic insertion]. / Défibrillateur automatique implantable; mise en place sous-diaphragmatique du boîtier.

Although the material and techniques of implantation of the electrodes of implantable defibrillators have been improved, the abdominal implantation of the generator remains widely used as described by Mirowski in 1980. Despite a progressive reduction in their size, the generators remain bulky and a source of local complications. The risks and discomfort of implantation in the abdominal wall led the authors to try subdiaphragmatic implantation in 22 patients. There was no morbidity with perfect healing in all 22 cases. The mean follow-up period was 11 months. The patients felt very comfortable, a significant advance with respect to abdominal implantations.

[Tricuspid valve replacement by Hancock's prosthesis]. / Le remplacement valvulaire tricuspidien par la prothèse de Hancock.

The medium term results of tricuspid valve replacement with the Hancock bioprosthesis are reported. Twenty eight patients underwent tricuspid valve replacement with this prosthesis between December 1974 and January 1978: mitral valve replacement with a Starr-Edwards or Cooley-Cutter prosthesis was associated in all cases and aortic valve replacement with a Björk-Shiley prosthesis in 11 cases. Follow-up at an average of 36,2 months after operation examined functional status, cardiac size and haemodynamics (in 12 patients). Three patients died in the immediate postoperative period and four others died later: the number of survivors was greater in the triple valve replacement (9/11) than in the double valve replacement group (12/17) but the difference was not statistically significant. Of the 23 surviving patients (average follow-up of 36,2 +/- 9,6 months), 17 were classified in functional Classes I or II of the NYHA classification. All patients had been Class III or IV before operation. The cardiothoracic ratio did not decrease significantly in patients undergoing triple valve replacement. Control cardiac catheterisation showed a significant increase in cardiac index (2,53 +/- 0,11 1/mn/m2, compared to 1,87 +/- 0,35 1/mn/m2 before operation; p less than 0,001) without significant reduction in pulmonary artery or right atrial pressures. The resting gradient across the Hancock bioprosthesis was not related to the size of the prosthesis (No 29-30: 2,17 +/- 2,57 mm Hg; No 31-33: 2,78 +/- 3,53 mm Hg) or with the quality of the functional result. However, on exercise, the gradient across the prosthesis was high, reaching an average of 10,3 +/- 5,2 mm Hg). The operative mortality of tricuspid valve replacement is relatively bioprosthesis associated with mitral and/or aortic valve replacement is relatively bioprosthesis associated with mitral and/or aortic valve replacement is relatively low (about 10%) and could be an argument in favour of broadening the indications for tricuspid valve replacement as resting tricuspid function with a bioprosthesis is satisfactory. However, the stenotic effects on exercise and the uncertainty over the long-term outcome of bioprostheses suggest that surgery should be limited to severe tricuspid stenoses and/or major tricuspid regurgitation organic or functional uncontrolled by digitalis and diuretic therapy.

[Aneurysms of the left ventricle without atheromatous coronary artery disease. Apropos of 2 cases]. / Les anévrysmes du ventricule gauche sans lésions coronaires athéromateuses. A propos de deux observations.

Left ventricular aneurysms are usually secondary to myocardial infarction with atheromatous coronary artery disease. The authors report two rare cases of non-atheromatous left ventricular apical aneurysms. The first case was clearly post-traumatic but the diagnosis in the second case was more difficult. The authors discuss the aetiological diagnosis of these rare non-atheromatous aneurysms in adults and the therapeutic management with respect to these two cases and a review of the literature.

[Course of the results observed in the 1st 100 coronary angioplasties performed in 96 patients. Experience in Lyons]. / Evolution des résultats observés pour les 100 premières angioplasties coronaires réalisées chez 96 patients. Expérience lyonnaise.

TCA is an original method of myocardial revascularisation which, when successful, enables coronary bypass surgery to be avoided. However, a certain number of failures and complications are inherent to the development of a new therapeutic technique. The object of this study is to analyse the evolution of our results with this technique to determine which factors changed as our experience increased. The methodology used was that initially described by A. Gruntzig. TCA was carried out 72 times on the left anterior descending, 20 times on the right coronary and 8 on the left circumflex coronary artery (72 single vessel, 28 multivessel disease). The primary success rate was 75% (72% for the first 50 and 78% for the second 50 procedures). Coronary bypass surgery was required within the first 24 hours of TCA in 7% of cases. Myocardial infarction (Q wave changes) was observed in 5% of cases. One patient died on the third day (occlusion of an aorto-coronary venous graft). In retrospect, taking into account the experience gained and the development of the material now available, a certain number of failures and complications could probably have been avoided. However, a certain number of complications seems to be unavoidable. TCA remains an inviting but not infallible alternative in the treatment of coronary artery disease and should be included in the medico-surgical management of this condition.

[Reversible graft dysfunction after cardiac transplantation]. / Dysfonction réversible du greffon après transplantation cardiaque.

The authors report 3 cases of major graft dysfunction after cardiac transplantation which recovered completely with biventricular mechanical assistance in 4 to 8 days. All three cases were primary biventricular graft failures in patients with normal preoperative pulmonary resistances. These early dysfunctions (with no signs of myocardial infarction on electro- or echocardiography and in the absence of abnormal increased peri-operative enzyme levels) associated with total functional recovery conforming to the definition of the phenomenon of myocardial stunning. These results argue in favour of aggressive management of primary graft dysfunction.

[Implantation of automatic defibrillators by means of video-thoracoscopy. Authors' experience]. / L'impianto dei defibrillatori automatici mediante video-toracoscopia. La nostra esperienza.

The implantable cardioverter-defibrillator represents an effective option for some potentially lethal ventricular arrhythmias. Nowadays defibrillation electrodes are often endoluminal only. In some patients, however, the presence of high defibrillation thresholds mandates the implantation of a subcutaneous patch. If the subcutaneous patch does not allow a sufficient decrease in defibrillation threshold, then two epicardial patches are generally implanted by different surgical approaches. Nevertheless surgical trauma could be a serious hazard in unstable patients. In 6 patients in whom endoluminal electrodes did not allow a safe defibrillation threshold, an extrapericardial patch has been implanted by means of a video-thoracoscopic approach: a left subcostal incision is performed and the subdiaphragmatic extraperitoneal space is reached; a patch electrode is then introduced into the left pleural cavity by blunt dissection of the diaphragm. This patch is positioned under thoracoscopic control in contact to the left pericardial surface and fixed by single stitches sutures. The impulse generator is finally implanted into the subdiaphragmatic pocket. In all the patients the patch electrode configuration sufficiently decreased defibrillation thresholds. In one of the patients a stellectomy was thoracoscopically performed to treat the long QT syndrome which was the cause of the ventricular fibrillation episodes. Defibrillation thresholds were confirmed after 8 day and 2 months postoperatively. In conclusion, the thoracoscopic implantation of an extrapericardial patch has allowed a significant reduction of defibrillation thresholds, without recurring to a major surgical procedure.

[New approach to implantation of automatic defibrillators using video-thoracoscopy]. / Nouvelle approche pour l'implantation des défibrillateurs automatiques utilisant la vidéo-thoracoscopie.

Nonthoracotomy lead systems are increasingly used in patients (pts) with implantable cardioverter defibrillator (ICD). In this setting, due to high energy requirements, a subcutaneous patch may be necessary in addition to endocardial leads. However in some patients, high defibrillation threshold (DT) may persist leading to thoracotomy for epicardial patch placement. In a preliminary experience, 3 patients with high DT (> 20J) following endocardial lead system, underwent the insertion of a extrapericardial patch under video-thoracoscopic control. A left subcostal incision extended to the left pleural cavity was performed. Using thoracoscopy the patch was positioned on the pericardium, sutured and connected to the defibrillator. DTs were 10, 10 and 20 J respectively in our 3 patients. Postoperative course was uneventful. Thoracoscopy allows other techniques such as a stellectomy, which we performed in a 33 year old woman with long QT syndrome. Patients were reassessed after 8 days and 2 months. Termination of induced ventricular fibrillation was achieved with the same minimal energy levels used peroperatively. In conclusion, extrapericardial patch insertion using thoracoscopy may help reduce DT in ICD patients with a non thoracotomy lead system. Comparison with other lead configurations requires further investigation.

[Long-term development of aortic valve stenosis surgically treated at an advanced stage]. / Evolution à long-terme des rétrécissements aortiques opérés à un stade évolué.

From January 1972 to June 1990, 112 patients (39 to 83 years old), 67 males and 45 females were submitted to surgery for sever calcified aortic stenosis. 68 patients were in NYHA III (60.72%) and 44 in NYHA IV. Early mortality included 8 patients (7.14%), 6 died for cardiac reasons. Late mortality was 27.67%. Actuarial survival rate (including postoperative mortality) was 88.39%, 77.67%, 67.85% and 65.17% at one year, five, ten and fifteen years, respectively. Results were significantly correlated to left branch block on preoperative EKG, episodes of complete heart failure, significant coronary stenosis, the cardioplegia technique and the association with coronary bypass.

[Interposition of a prosthetic graft between the ascending aorta and the abdominal aorta in the treatment of complicated or longstanding coarctations in adults]. / Interposition d'un greffon prothétique entre l'aorte ascendante et l'aorte abdominale dans le traitement des coarctations de l'adulte compliquées ou vieillies.

Although the direct approach to the aortic isthmus is unquestionable for an isolated coarctation of the thoracic aorta, recurrent coarctations of coarctation with associated cardiac lesions require a concomitant procedure, raise difficult surgical problems and expose to a high operative risk. Another technique consists of performing an ascending aorta-abdominal aorta by-pass, with a prosthetic tube. From 1977 to 1988, this technique was performed in 8 patients: 3 with recurrent coarctations, 4 with coarctation associated with a surgical aortic insufficiency (2 ascending aortic aneurysms with aortic insufficiency) and 1 with abdominal aorta coarctation. The mean age was 48.3 years (range from 31 to 72 years), the mean follow-up was 44.3 months (range from 4 months to 10 years 5 months). There was no mortality and no morbidity during the follow-up. The functional result is good, without high blood pressure and with no blood pressure difference between the arms and the legs. Postoperative angiographies showed that all the by-passed were patent.

[Use of the internal mammary artery as a free graft with reimplantation of the proximal end onto the ascending aorta. Apropos of 39 cases]. / Utilisation de l'artère mammaire interne comme greffon libre avec réimplantation de l'extrémité proximale sur l'aorte ascendante. A propos de trente-neuf cas.

From January 1987 to January 1991, 104 patients received bilateral internal mammary artery grafts and 39 of them had coronary bypass with a free graft implanted on the ascending aorta. There were 35 men, with a mean age of 57.35 years (range 41 to 70 years). 87% of them had stable angina, and 23 had preoperative myocardial infarction. The left ventricular function was good in 77 per cent of cases. 23 patients had three vessel disease (61.5%), 13 two vessel diseases (30.7%), 2 one vessel disease (5.12%) and one a left main coronary stenosis. Left internal mammary artery was used in two patients on the left descending artery and the right internal mammary artery was used in 37 patients: 15 on the circumflex, 15 on the right coronary, 4 on the LDA and 3 on the diagonal artery. Five patients had one graft, 32 two grafts and one three grafts (bilateral mammary and saphenous vein). Hospital mortality was 2.56% (1 patient) and there were 2 late deaths (5.12%). There were 5 perioperative myocardial infractions (12.8%) and no sternal infections. The mean follow up is 21 months (range 3 to 46 months). At follow-up, 34 patients (87.2%) were asymptomatic, and there were no myocardial infarctions. Postoperative angiography in 8 patients (mean postoperative time 2.5 months) showed that all the grafts were patent. This analysis demonstrates that free IMA graft has a low operative risk and provides excellent long term functional improvement and survival.

[Retrospective study of 412 aortic valve replacements by Bjork-Shiley prosthesis implanted between January 1972 and October 1984. Actuarial survival, mortality, complications]. / Etude rétrospective de 412 remplacements valvulaires aortiques par prothèse de Bjork-Shiley implantées entre janvier 1972 et octobre 1984. Survie actuarielle, mortalité, complications.

Between January 1972 and October 1984, 412 aortic valve replacements by Bjork-Shiley disk prosthesis were performed. 183 patients suffered from aortic incompetence, 132 from an aortic disease and 97 from aortic stenosis. 116 associated procedures (28%) were performed = 36 myocardial revascularizations, 61 Bentall operations, 12 patch grafts to the ascending aorta and 7 Wheat operations. The mean age was 53.6 years and 25% of the patients were over the age of 65 years. Fifty percent of the patients had stage III or IV disease according to the NYHA classification. The cardiac index was less than 2.3 l/min/m2 in 44.26% of cases. The early postoperative mortality was 4.85% and 20% of these deaths were related to the prosthesis. The late mortality was 17.25%, with 20% of deaths related to the valve. The mean follow-up 59.75 +/- 2 months (range: 1 to 166 months) with a cumulative survival of 2.092 patients-years. It was significantly influence by the existence of preoperative angina, another operation associated with AVR and a cardiac index less than 2.3 l/min/m2. Seventy-one complications were related to the prosthesis including dysfunction (0.05% patient-year), 3 valve thromboses (0.15% patient-year), 6 infected valves (0.31% patient-year), 12 cases of peri-prosthetic dehiscence (0.61% patient-year), 10 embolic complications (0.61% patient-year) and 37 complications related to anticoagulants, including 26 major complications (1.48% patient-year). The valve failure rate was 1.19% patient-year. The results of our series are comparable to those reported in the literature, which confirm the reliability of the Bjork-Shiley Valve.

[New approach for implantation of automatic defibrillators using videothoracoscopy]. / Nouvelle approche pour l'implantation des défibrillateurs automatiques utilisant la vidéo-thoracoscopie.

Nonthoracotomy lead systems are increasingly used in patients (pts) with implantable cardioverter defibrillator (ICD). In this setting, due to high energy requirements, a subcutaneous patch may be necessary in addition to endocardial leads. However in some patients, high defibrillation threshold (DT) may persist leading to thoracotomy for epicardial patch placement. In a preliminary experience, 3 patients with high DT (> 20 J) following endocardial lead system, underwent the insertion of a extrapericardial patch under video-thoracoscopic control. A left subcostal incision extended to the left pleural cavity was performed. Using thoracoscopy the patch was positioned on the pericardium, sutured and connected to the defibrillator. DTs were 10, 10 and 20 J respectively in our 3 patients. Postoperative course was uneventful. Thoracoscopy allows other techniques such as a stellectomy, which we performed in a 33 year old woman with long QT syndrome. Patients were reassessed after 8 days and 2 months. Termination of induced ventricular fibrillation was achieved with the same minimal energy levels used peroperatively. In conclusion, extrapericardial patch insertion using thoracoscopy may help reduce DT in ICD patients with a non thoracotomy lead system. Comparison with other lead configurations requires further investigation.