Suppressive antibiotic therapy for infectious endocarditis.

OBJECTIVES: Suppressive antibiotic therapy (SAT) is a long-term antibiotic strategy at times applied when an indicated surgical management of infective endocarditis (IE) is not possible. Our aim was to describe the characteristics and outcomes of patients having received SAT for IE. METHODS: We conducted a retrospective, observational study at Strasbourg University Hospital, France between January 2020 and May 2023. We reviewed all medical files taken into consideration at weekly meetings of the local Multidisciplinary Endocarditis Team (MET) during the study period. We included patients having received SAT following the MET evaluation. The primary endpoint was all-cause mortality at most recent follow-up. Secondary endpoints included all-cause mortality at 3 and 6 months, infection relapse, and tolerance issues attributed to SAT. RESULTS: The MET considered 251 patients during the study time, among whom 22 (9 %) had received SAT. Mean age was 77.2 ± 12.3 years. Patients were highly comorbid with a mean Charlson index score of 6.6 ± 2.5. Main indication for SAT was surgery indicated but not performed or an infected device not removed (20/22). Fourteen patients had prosthetic valve IE, including 9 TAVIs. Six patients had IE affecting cardiac implantable electronic devices. Staphylococcus aureus and enterococci were the main bacteria involved (6/22 each). Median follow-up time was 249 days (IQR 95-457 days). Mortality at most recent follow-up was 23 % (5/22). Three patients (14 %) presented tolerance issues attributed to SAT, and two patients suffered late infectious relapse. CONCLUSION: Mortality at most recent follow-up was low and tolerance issues were rare for patients under SAT, which might be a palliative approach to consider when optimal surgery or device removal is not possible.

Remote effects of lower limb ischemia-reperfusion: impaired lung, unchanged liver, and stimulated kidney oxidative capacities.

Remote organ impairments are frequent and increase patient morbidity and mortality after lower limb ischemia-reperfusion (IR). We challenged the hypothesis that lower limb IR might also impair lung, renal, and liver mitochondrial respiration. Two-hour tourniquet-induced ischemia was performed on both hindlimbs, followed by a two-hour reperfusion period in C57BL6 mice. Lungs, liver and kidneys maximal mitochondrial respiration (V(max)), complexes II, III, and IV activity (V(succ)), and complex IV activity (V(TMPD)) were analyzed on isolated mitochondria. Lower limb IR decreased significantly lung V(max) (29.4 ± 3.3 versus 24 ± 3.7 µmol O2/min/g dry weight, resp.; P = 0.042) and tended to reduce V(succ) and V(TMPD). IR did not modify liver but increased kidneys mitochondrial respiration (79.5 ± 19.9 versus 108.6 ± 21.4, P = 0.035, and 126 ± 13.4 versus 142.4 ± 10.4 µmol O2/min/g dry weight for V(max) and V(succ), resp.). Kidneys mitochondrial coupling was increased after IR (6.5 ± 1.3 versus 8.8 ± 1.1, P = 0.008). There were no histological changes in liver and kidneys. Thus, lung mitochondrial dysfunction appears as a new early marker of hindlimb IR injuries in mice. Further studies will be useful to determine whether enhanced kidneys mitochondrial function allows postponing kidney impairment in lower limb IR setting.

Acute myocardial ischaemia induces specific alterations of ventricular mitochondrial function in experimental pigs.

AIMS: As cardiac metabolic flexibility is crucial, this study examined whether acute ischaemia can induce specific qualitative alterations of the mitochondrial metabolic pathways as well as energy transfer systems. METHODS: Left descending coronary artery ligation was performed after sternotomy in eight pigs and the heart was excised after 45 min of ischaemia. Maximal O2 uptake (V(max), micromol O2 min(-1) g(-1) dry weight) of saponin-skinned myofibres were measured from ischaemic and non-ischaemic area of ventricular myocardium. RESULTS: V(max) decreased by approximately 20% in ischaemic myocardium with both glutamate-malate (18.1 +/- 1.3 vs. 22.1 +/- 1.7 in control, P < 0.05) and pyruvate substrates (19.3 +/- 1.0 vs. 23.3 +/- 2.0 in control, P < 0.05) whereas no difference was observed with palmitoyl carnitine (15.6 +/- 1.8 vs. 16.6 +/- 0.9 in control). The K(m) of mitochondrial respiration for ADP decreased in ischaemic heart by 24% (679 +/- 79 vs. 899 +/- 84 microm of ADP in control, P < 0.05). Moreover, the mitochondrial creatine kinase efficacy (K(m) without creatine/K(m) with creatine), representative of the coupling of oxidative phosphorylation process with the mitochondrial creatine kinase, was reduced in ischaemic heart (11.6 +/- 2.5 in ischaemic vs. 18.0 +/- 2.2 in control, P < 0.05). CONCLUSIONS: These findings argue for specific mitochondrial impairments at the level of pyruvate oxidation and creatine kinase channelling system after an acute period of in vivo ischaemia, whereas the lipid mitochondrial oxidation pathway seems to be preserved. Such a loss of metabolic flexibility following acute ischaemia could become an early feature of metabolic dysregulation of the heart.

[Postoperative infections after heart surgery under extracorporeal circulation]. / Infections postopératoires après chirurgie cardiaque sous circulation extracorporelle.

Postoperative infection is still an important cause of mortality and morbidity after cardiac surgery. The aim of this study was to assess its incidence and causes in order to optimise treatment. Between January 1996 and December 1997, 1,000 consecutive patients (253 women and 747 men) were operated for cardiac aortic pathology under cardiopulmonary bypass. The mean age was 66 +/- 11 years. The initial pathology was coronary artery disease (N = 663), valvular heart disease (N = 193), an association of the two (N = 94), thoracic aortic pathology (N = 38) or other pathologies (N = 12). The global postoperative infection rate was 4.9% (N = 49). The incidence of sternal and/or mediastinal infections was 0.7%, of bronchopneumonia 0.9%, urinary infection 2.1%, and septicaemia 1.7%. Nine patients died of the consequences of an infection. The hospital stay was significantly longer in infected patients, irrespective of the site of infection. Statistical analysis of the whole population did not show any predictive factor related to the preoperative clinical status of the patients. The only predictive factor demonstrated was the day on which surgery was performed: the infection rate in patients operated during the first 4 days of the week was 2.2% compared with 7.3% for the patients operated during the last 3 days (p = 0.004, odds ratio (OR) = 3.57). In those patients who had an urinary infection, the two identified risk factors were the female gender (p = 0.006, OR = 3.34) and an operation performed at the end of the week (p = 0.017, OR = 3.77). In patients with sternal and medistinal infections, the only identified predictive factor was combined coronary artery and valvular surgery (p = 0.009, OR = 7.43). With respect to pulmonary infections, the only predictive factor was recent preoperative myocardial infarction (< 1 month) (p = 0.004, OR = 7.5). Finally, no predictive risk factors were identified in those patients who developed septicaemia. In conclusion, this study showed that postoperative infection remains a serious complication of cardiac surgery. The prevention of these complications should be a priority for quality health care.

[Pericardial drainage. The right indication for the right technique]. / Drainage péricardique. A chaque technique suffit son indication....

The only valid criterion for comparing surgical (or medical) techniques is the extent of the beneficial effect compared with the risk of the underlying disease. The paper on echoguided pericardial puncture published in this issue of La Presse Médicale offers an excellent opportunity to apply this criterion in an area of clinical therapeutics where the temptation to promote "minimally invasive" techniques is so great. For pericardial effusion, as for all medical conditions, it is the underlying disease which determines the long-term outcome and not the pericardial effusion itself, even in emergency situations. The objective should then go beyond symptom relief and include, when possible, a search for an etiological diagnosis. Pericardial biopsy is one element which can be contributive in a significant number of cases further adding to the beneficial effect of the surgical technique. Consequently, indications for echoguided pericardial puncture cannot be broadened beyond patients suffering from compressive pericardial effusion secondary to a perfectly recognized cause. In other less urgent situations, and when the etiology has not been identified, videoscopic techniques appear to be indicated rather than conventional surgical drainage or echoguided puncture. Other cases, such as infected or recurrent effusions, also raise specific problems requiring a careful evaluation of the expected benefit and risk of each technique. After videosurgery and videoscopy, conventional pericardial drainage, a particularly simple, rapid and effective procedure, is once again challenged by a new, more "medical" technique, emphasizing that the ever renewed story of progress in medicine must not avert our attention from the fundamental goal of combating disease.

Mechanical circulatory support towards the permanent implantation.

Experience on wearable LVAS Novacor support accumulated since the first implantation in March 1993, includes in November 1995, seven cases (six male, one female, mean age 34) of cardiogenic shock, unresponsive to optimal medical management referred for urgent transplantation. Post-implantation period was free of any major incident in all but one, allowing transplantation in five, on an elective basis, and prolongation of the waiting period, at home in two. This experience suggests that a major breakthrough in the technology of mechanical support has been achieved: patients awaiting transplantation can be discharged home, which is both the result and an contributing factor of a satisfactory quality of life. This improvement allows speculations on coming studies on permanent implantation of the wearable LVAS Novacor, as an alternative therapy to cardiac transplantation.

Immunoglobulins and complement deposits in mitroflow pericardial bioprosthetic heart valves--a contributing factor to structural deterioration.

BACKGROUND AND AIMS OF THE STUDY: Twenty-two bovine pericardial Mitroflow prostheses were explanted after 73-114 months from either the aortic or mitral position because of clinical failure. All the samples exhibited cuspal tears and foldings. Eleven prostheses were calcified. The aim was to study biological factors involved in the structural deterioration. METHODS: Histologic and biochemical assays were carried out on the deteriorated, non-calcified and on the calcified leaflets. Labelled antibodies and avidinbiotinyilated peroxydase complex were used to detect plasma proteins and cells in the cusps. RESULTS: Fibrin covered the cuspal surface and accumulated in the deep disrupted layers (19/22). Scattered fibronectin filaments were seen across the transversal sections (20/22). IgG, complement fractions C1q, C3, C4 (20/22), macrophages (sixteen) and cells containing granulocyte elastase were revealed in the altered matrix. These plasma proteins and cells were detected in the disintegrated matrix of non-calcified and of calcified leaflets. IgA was present in amorphous cuspal thickenings with lipid infiltration (12/22). Western blot analysis of the PBS-2% SDS extracts from the leaflets indicated the breakdown of fibrinogen/fibrin, fibronectin and of complement proteins C3, C4 and C5. CONCLUSIONS: The results suggest the activation of the complement by the non-hemocompatible, chemically processed bovine pericardium. The bioactive peptides generated in this process can stimulate monocyte migration, phagocytosis and exocytosis of proteases able to degrade the glutaraldehyde cross-linked macromolecular matrix. These biological factors can contribute, together with the mechanical stress, to the structural deterioration of the bioprosthesis.

Clinical outcome after coronary surgery with heparin-coated extracorporeal circuits for cardiopulmonary bypass.

In this prospective randomized trial, we studied whether heparin-coated extracorporeal circuits (ECC), known to reduce complement activation, could improve the clinical outcome of 200 patients undergoing coronary artery surgery. Patients have been divided into two groups (heparin-coated ECC and uncoated ECC groups) which were similar in terms of age, gender, left ventricle function, preoperative aspirin use and consequent intraoperative aprotinin use, number of grafts, duration of aortic cross-clamping and cardiopulmonary bypass. Univariate analysis showed that heparin coating did not reduce significantly postoperative bleeding (640 +/- 311 versus 682 +/- 342 ml with uncoated ECC) nor the need for transfusion (19% of patients versus 25% with uncoated ECC). Adverse events, including all mortality and morbidity noticed during the five first postoperative days, occurred in 20 patients of the uncoated ECC group and in eight patients of the heparin-coated ECC group (p = 0.013). The most frequent complications were supraventricular arrhythmias that occurred in 13 patients of the uncoated ECC group and in four patients of the heparin-coated ECC group (p = 0.02). Multivariate analysis by stepwise logistic regression showed that only heparin coating of the ECC was shown as a significant predictive factor of adverse events reduction (p = 0.01; odds ratio = 0.34). These data suggest that heparin coating reduced postoperative complications in patients undergoing coronary artery surgery.

Sympathetic stimulation overrides flow-mediated endothelium-dependent epicardial coronary vasodilation in transplant patients.

BACKGROUND: Abnormal coronary vasomotor responses have been described in transplant patients. The aim of this study was to evaluate the graft epicardial vasomotor responses to different stimuli that increase coronary blood flow. METHODS AND RESULTS: Twelve heart transplant recipients with angiographically normal epicardial coronary arteries were compared 2.7 +/- 1.2 months after surgery with 6 control subjects. Coronary flow velocity was measured with a guidewire Doppler. Coronary diameter changes of the proximal and midportion of the left anterior descending coronary artery were assessed by quantitative coronary angiography during rapid atrial pacing, cold pressor test, supine exercise, and subselective infusion of papaverine and after intracoronary injection of linsidomine (SIN-1). Catecholamine plasmatic levels were determined at the different stages of the protocol. In 6 other transplant patients, a cold pressor test was performed before and after intracoronary infusion of phentolamine (10 micrograms.kg-1.min-1). Coronary flow velocity increased significantly in both groups during each phase of the protocol. In control subjects, dilation was observed in response to atrial pacing (8.7 +/- 7.6%; P < .05), CPT (8.8 +/- 2.3%; P < .01), exercise (14.5 +/- 9.4%; P < .001), and papaverine infusion (14.2 +/- 6.1%; P < .001) and after injection of SIN-1 (26.8 +/- 11.9%; P < .001). In transplant patients, similar dilation was observed during atrial pacing (8.2 +/- 8.3%; P < .05) and papaverine infusion (14.6 +/- 7.8%; P < .001) and after SIN-1 (25.8 +/- 10.8%; P < .001). CPT and exercise caused slight constriction (-3.5 +/- 4.5% and -2.7 +/- 10.5%, respectively; both P < .001 versus control subjects). Norepinephrine plasmatic levels increased in both groups during CPT and exercise. Slight constriction during the cold pressor test (-4.5 +/- 9.6%) changed to dilation (6.8 +/- 7.0%) after alpha-blockade with phentolamine (P < .001). CONCLUSIONS: These results show that flow-mediated, endothelium-dependent vasodilation is preserved early after trans-plantation. Sympathetic stimulation, which overrides the endothelium-dependent mechanism, can be related to hypersensitivity to catecholamines due to denervation.

[Wearable mechanical ventricular support]. / L'assistance mécanique ventriculaire portable.

Progressive technological developments have permitted clinical use of the wearable Baxter-Novacor left ventricular assist system. The system allows total bypass of the left ventricular function, and recovery of an adequate circulation in patients about in cardiogenic shock. Since the first clinical use, in March 1993, six patients about to die have been supported with a cardiac transplantation. This experience suggests that an acceptable answer to the problem of organ shortage is non available.

[Orthotopic cardiac transplantation with caval anastomosis: a comparative randomized study with standard procedure in 81 cases]. / Transplantation cardiaque orthotopique avec anastomoses caves: étude randomisée comparative avec la technique standard sur 81 procédures.

Complete resection of the right atrium with conservation of a strip of left atrium around the 4 pulmonary veins followed by direct anastomosis on the vena cava has recently been proposed as an alternative to the standard orthotopic cardiac transplantation described by Shumway and Lower. In order to determine whether this "anatomical" transplantation should now be considered to be the procedure of choice, a prospective randomised study was undertaken in 1991 including 78 patients undergoing 81 cardiac transplantations by one of the two techniques: gr. I: classical transplantation (n = 40), gr. II: "anatomical" transplantation (n = 41). The groups were comparable in age, sex, weight, nature of the underlying cardiac disease and clinical status at the time of transplantation. Similarly, the parameters of the donors were comparable with respect to age, sex, weight and dosage of inotropic drugs at the time of explantation. All patients came of cardiopulmonary bypass with comparable ischaemia time of the graft (gr. I: 136 +/- 46 min; gr. II: 138 +/- 51 min). Immediate return to sinus rhythm occurred in 20 cases in gr. I and 36 cases in gr. II. Atrial arrhythmia persisted in 5 cases in gr. I but in no cases of gr. II. These differences were very significant (p < 0.001). There were 13 early deaths in gr. I and 8 in gr. II. Doppler echocardiography was performed two to three months after transplantation. The right atrial surface was significantly decreased in gr. II (18 +/- 4.7 cm2) compared with gr. I (24 +/- 7 cm2): the same difference was observed for the left atrium (gr. I: 24 +/- 4.5 cm2; gr. II: 20 +/- 5 cm2), p = 0.001. Tricuspid regurgitation was observed in 82% of patients in gr. I compared with 57% in gr. II (p < 0.005). Exercise stress tests during the same period showed no difference in peak oxygen consumption between the groups. Holter ECG monitoring led to permanent pacing in 2 patients of gr. I (5%). The technical simplicity and reduction of postoperative morbidity, especially with respect to arrhythmias, suggest an advantage with the "anatomical" technique considering the lack of surgical complications.

The superiority of hollow fiber membrane over bubble oxygenator in a perfusion circuit for the evaluation of small caliber endothelialized arterial prostheses.

A perfusion circuit was constructed from a pneumatic ventricular assist device, 2 compliance chambers, 4 small-diameter silicone tubes (ID 4 mm) simulating shear inducing vascular prostheses, and an oxygenator with a heat exchanger. A bubble oxygenator (in a BO circuit) and a hollow fiber membrane oxygenator (in an MO circuit) were studied. The circuits were perfused with 30% human serum containing culture medium for 7 days at 37 degrees C. The pH, Po2, PCo2, Na+, K+, Ca2+, Cl, glucose, and total protein concentrations remained the same in BO and MO circuits during the 7 days of perfusion. The differences between the values measured in the perfusion medium and in the medium maintained in the static conditions of cell culture were not significant. In the BO circuit, the amount of cholesterol and triglyceride concentrations decreased whereas the relative amounts of albumin, alpha 1, alpha 2, beta, and gamma globulins remained stable in the perfusion medium. The medium from the BO circuit did not promote the proliferation of cultured human saphenous vein endothelial cells. In the medium from the MO circuit, the cholesterol and triglyceride concentrations did not change with perfusion time; the proliferation rate and anticoagulant function of endothelial cells were maintained. The hollow fiber membrane oxygenator preserves the biological characteristics of the cell culture medium in a perfusion circuit. The MO circuit permits the performance of relevant studies on shear stress resistance and functional activity of human endothelial cells seeded onto vascular prostheses.

Mechanical bridge to transplantation: when is too early? When is too late?

BACKGROUND: Optimal timing of implantation of a mechanical circulatory support system in the treatment of acute cardiogenic shock is still unsettled. The issue has been addressed in a retrospective analysis of a group of 98 patients in cardiogenic shock refractory to medical therapy who were candidates for cardiac transplantation, admitted from 1987 to 1994. METHODS: The treatment included reinforced inotropic support by addition of phosphodiesterase inhibitors to sympathomimetic agents. The patients who did not improve were immediately brought to the operating room for mechanical circulatory support system implantation. RESULTS: The overall survival in the group of 28 patients selected for mechanical bridge is 50%. No predictive factors of death or multiorgan failure while on the device could be identified, suggesting a lack of contraindications to mechanical circulatory support system implantation. CONCLUSIONS: The high death rate in patients maintained on medical therapy because of initial improvement as they are awaiting transplantation suggests the benefit of a rapid semielective implantation of an intracorporeal device.

Effects of cryopreservation on the proliferation and anticoagulant activity of human saphenous vein endothelial cells.

Human saphenous veins were cryopreserved in 4% human albumin and 10% dimethyl sulfoxide. The effect of cryopreservation on endothelial cells was studied in terms of the anticoagulant activity of thrombomodulin and in terms of cell proliferation. After storage for 2 weeks at -150 degrees C, 0.45 +/- 0.07 x 10(5) endothelial cells/cm2 were detected in cryopreserved veins and 1.03 +/- 0.04 x 10(5) endothelial cells/cm2 in fresh veins (p < 0.01). The thrombin-catalyzed activation of protein C decreased after cryopreservation, indicating altered thrombomodulin activity in the endothelial cells. On a cell number basis, the release of soluble thrombomodulin was three times higher from the cryopreserved endothelium than from the fresh endothelium (p < 0.05). The amount of spontaneous release of von Willebrand factor from the endothelial surface was not significantly different between fresh and cryopreserved veins. Endothelial cells were cultured from fresh veins and from their cryopreserved counterparts. On plating of endothelial cells in primary culture, the number of adhered cells was 0.9 +/- 0.09 x 10(3) cells/cm2 from fresh veins and 0.25 +/- 0.03 x 10(3) cells/cm2 from cryopreserved veins (p < 0.01). The positive immunohistochemical stain for von Willebrand factor indicated that the endothelial cell character was maintained after cryopreservation. The endothelial desquamation with loss of anticoagulant function and the slow proliferation of surviving cells in vitro suggest an impaired endothelial healing in vivo. The loss of anticoagulant activity complicates the problems of the exposure of thrombogenic subendothelial matrix to blood in implanted cryopreserved veins.

[Cardiac transplantation; results after 5 years]. / La transplantation cardiaque; résultats après 5 ans.

After cardiac transplantation, long-term results were assessed in a group of 46 patients who survived more than 5 years after surgery. They were the survivors (50%) of a group of 92 patients who underwent transplantation before January 1990. On January 1995, mean follow-up was 82 +/- 14 months. Quality of life was estimated satisfactory (mean score 8.4 +/- 2); 60% of the patients were active; 89% were class NYHA I or II. Nevertheless, several problems have been identified: rise in body weight for all, over 10 kg in 31%; hypertension, renal failure, considered to be severe (serum creatinine > 250 micrograms/l) in 26%, diabetes in 13%, osteoarthropathy in 33%, cancer in 6%, and, above all, chronic alteration of the coronary arterial bed in 53% of the patients. These problems reflect the immunological conflict and complications of immuno-suppression.

In vitro and in vivo evaluation of a small caliber vascular prosthesis fixed with a polyepoxy compound.

A small caliber vascular prosthesis obtained from an ovine internal thoracic artery (3.8-4.5 mm ID) fixed with a polyepoxy compound and treated with heparin has been evaluated. Cytocompatibility was evaluated in vitro using human endothelial cells (HEC). HEC were obtained from human saphenous vein and cultivated in culture medium supplemented with 25% human serum. Graft segments were rinsed using a standard protocol proposed by the manufacturer. Tissue reaction was tested on a rabbit model of subcutaneous implantation. The patency rate and healing patterns were evaluated comparatively with polytetrafluorethylene (PTFE) 4 mm ID prosthesis in a canine model of carotid interposition. Cytocompatibility assay showed that there was low adhesion on vascular grafts (20 +/- 2% of endothelial cells seeded) and no growth of HEC on the graft surface. The graft patency rate was 55% in both groups, and actuarial freedom from occlusion was not different at 3 months (37.7 +/- 15% in Denacol-fixed grafts versus 38.1 +/- 14% in PTFE). Histological studies on the biological grafts shows a frequent neointimal hyperplasia at the anastomosis (5/12), a lack of endothelial cells lining the graft surface, a good preservation of the media, and a moderate inflammatory response in the adventicia. The Denacol-fixed graft has presented excellent surgical properties and preservation of the histological structure. Nevertheless, the patency rate was not improved when compared with the PTFE control graft.

Coronary artery response to cold-pressor test is impaired early after operation in heart transplant recipients.

OBJECTIVES: The aim of the present study was to evaluate the coronary vasomotor response to the cold-pressor test within 3 months after heart transplantation. BACKGROUND: Normal epicardial coronary arteries dilate in response to sympathetic stimulation evoked by the cold-pressor test. In transplant recipients, abnormal coronary vasomotion has been described shortly after operation. METHODS: Fourteen heart transplant recipients were compared 52 +/- 15 days (mean +/- SD) after operation with 10 control subjects. All had angiographically normal epicardial coronary arteries. Coronary blood flow velocity was measured with a Doppler catheter placed in the proximal left anterior descending coronary artery. Four segments in each patient were analyzed by quantitative coronary angiography to assess the diameter changes during the cold-pressor test and after intracoronary injection of isosorbide dinitrate. RESULTS: Coronary flow velocity increased similarly during the cold-pressor test in control subjects and in transplant recipients, from 7.5 +/- 2.3 to 11.0 +/- 3.9 cm/s and from 10.3 +/- 3.2 to 13.7 +/- 4.8 cm/s (both p < 0.01). In control subjects, 39 of 40 segments analyzed dilated during the cold-pressor test. In transplant recipients, 48 of 56 segments analyzed did not change or constricted. The mean epicardial coronary diameter increased significantly during the cold-pressor test in control subjects (+13 +/- 6%, p < 0.001), whereas it did not change significantly in transplant recipients (-2 +/- 9%, p = NS). In transplant recipients, isosorbide dinitrate elicited coronary vasodilation similar to that in control subjects. CONCLUSIONS: These data indicate that in human transplanted denervated hearts, coronary vasodilation in response to sympathetic stimulation by cold exposure is impaired shortly after operation.

Durability of the Mitroflow pericardial valve at ten years.

From 1983 to 1992, 366 patients received 407 Mitroflow pericardial valves. Mean age was 62 +/- 14 years. Average follow-up was 72 +/- 28 months. Total follow-up was 1,791 patient-years. Overall survival in all patients was 77.2% +/- 2.2% at 5 years and 56.2% +/- 6.4% at 10 years. Freedom from structural valve deterioration was 95% +/- 1.2% and 36.7% +/- 8.1% at 5 and 10 years for all valves, 96.9% +/- 1.3% and 39.2% +/- 9.8% for aortic valve replacement, and 91.7% +/- 3.2% and 36.4% +/- 10% for mitral valve replacement (p = not significant). The freedom from structural valve deterioration in patients older than 70 years of age was 100% and 93.9% +/- 5.8% at 5 and 10 years, respectively. At 10 years, linearized rate of thromboembolism was 0.73% +/- 0.2% per patient-year and freedom from valve-related mortality for all valves was 88.8% +/- 2.8%. The best indication for the implantation of a Mitroflow valve is mitral or aortic disease in patients more than 70 years of age.

The Mitroflow pericardial valve: clinical performance to 10 years.

From 1983 to 1992, 366 patients received 407 Mitroflow pericardial bioprostheses at our institution. Mean age was 62 +/- 14 years (range: 15-86 years). There were 229 isolated aortic valve replacements (AVR), 96 isolated mitral valve replacements (MVR), 39 double mitral and aortic valve replacements (DVR) and four tricuspid replacements. Mean follow up was 6 +/- 2.33 years ranging from 1.67 to 10.9 years. Total follow up was 1791 patient-years. Overall survival was 77.2 +/- 2.2% at five and 56.2 +/- 6.4% at 10 years. It was 74 +/- 3% and 56.2 +/- 5.3% after AVR, 78.3 +/- 4.4% and 55.7 +/- 8.8% after MVR, 81 +/- 6.4% and 36.6 +/- 16.5% after DVR at five and 10 years, respectively. Freedom from structural valve deterioration (SVD) was 95 +/- 1.2% and 36.7 +/- 8.1% at five and 10 years for all valves, 96.9 +/- 1.3% and 39.2 +/- 9.8% for AVR, 91.7 +/- 3.2% and 36.4 +/- 10% for MVR. There was no difference in freedom from SVD between AVR and MVR. The freedom from SVD in patients older than 70 years of age was 100% and 93.9 +/- 5.8% at five and 10 years, respectively. Freedom from reoperation was 94.7 +/- 1.37% and 28.36 +/- 7.5% at five and 10 years for all valves, 96.2 +/- 1.5% and 38.6 +/- 9.7% for AVR, 91.7 +/- 3.2% and 36.4 +/- 10% for MVR. The denaturation process did not lead to acute hemodynamic deterioration. Pathologic findings were cuspal tears (one or more) associated with structural tissue changes.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mechanical assistance of circulation. 42 cases]. / Assistance mécanique de la circulation. 42 observations.

OBJECTIVES: Mechanical circulatory support was proposed in patients in cardiogenic shock, as a bridge to cardiac transplantation or weaning. The aim of the present study is an analysis of the first 42 cases. METHODS: The 42 cases included 31 patients in cardiogenic shock unresponsive to medical therapy, good cardiac transplant candidates, and 11 patients unweanable off ventricular assist, or in shock in the intensive care unit. Results are evaluated in terms of transplantability and hospital survival. RESULTS: Overall success rate is 67%, ranging from 25% in previously transplanted patients to 46% following acute myocardial infarction and 57% in cardiomyopathy. Age and learning curve played a significative role. CONCLUSION: These data suggest that mechanical support improves survival in patients in cardiogenic shock. Earlier implantation should improve the patient outcome.