[Surgical treatment of infective endocarditis: Surgical indications, complications, intrahospital and long-term mortality]. / Endocardites infectieuses opérées : indications chirurgicales, complications, mortalité intrahospitalière et à long terme.

BACKGROUND: In addition to medical treatment, half of the patients with infective endocarditis (IE) receive surgical treatment. Despite clear recommendations on the indications and the operating delays, the decision remains difficult and must take into consideration several factors. METHODS: A retrospective study was performed at Foch Hospital. All patients operated for IE between 2005 and 2018 were included. Patient characteristics, indications and operating delays, as well as intrahospital mortality, were noted. Patient follow-up was provided by phone calls. RESULTS: Fifty-two patients were operated on for IE between 2005 and 2018. The most frequent surgical indications were the presence of a massive symptomatic regurgitation, an uncontrolled infection and large vegetations with embolism. The average operative delay was 13.2 days with 56.5% of patients operated within the first 10 days. The most common postoperative complications were acute kidney injury (AKI) in 57.7% of cases, with 9.6% of dialysis, shock in 50% of cases, rhythm disorders in 40.4% of cases, infectious complications in 19.2% of cases, conductive disorders in 25% of cases, of which 17.3% require a definitive pacemaker implementation. The intrahospital mortality was 7.7% and the average length of hospital stay was 35 days. Survival at one year and 5 years was 95% and 85%, respectively. CONCLUSION: The indications and the operating delays were conformed to international recommendations. Intrahospital and long-term mortality rate was low.

Combined heart and kidney transplantation in a patient with Fabry disease in the enzyme replacement therapy era.

Fabry disease (FD) is an X-linked genetic disease, resulting from the deficiency of alpha-galactosidase A, a lysosomal enzyme responsible for the cleavage of glycosphingolipids. In absence of enzyme replacement therapy (ERT), globotriaosylceramide (Gb3) accumulates in tissue, leading to progressive organ damage with severe renal, cardiac and central nervous system complications. We herein describe the first case of successful combined and simultaneous heart and kidney transplantation in a young male patient with FD complicated by end-stage renal disease and severe heart failure not responding to late-onset ERT. Combined heart and kidney transplantation can be recommended for Fabry patients with end-stage renal disease and overt hypertrophic cardiomyopathy, severe ischemic or valvular heart disease.

[Combined heart and kidney transplantation in Fabry's disease: Long-term outcomes in two patients]. / Transplantation combinée cœur­rein au cours de la maladie de Fabry : suivi à long terme de deux patients.

INTRODUCTION: Fabry disease is a lysosomal storage disorder linked to an alpha-galactosidase A deficiency that can lead to heart and kidney failure. There is little data about the prognosis of patients who undergo a combined heart and kidney transplantation. CASE REPORTS: Two brothers who were diagnosed with Fabry disease after the age of 30 years underwent a combined heart and kidney transplantation at respectively 49 and 42 years of age because of a severe hypertrophic cardiomyopathy with end stage renal failure. They are alive respectively 4 and 9 years after the transplantation. No recurrence of the disease in the transplanted organs has been found. CONCLUSION: Combined heart and kidney transplantation in Fabry disease is an efficient therapy for the cardiomyopathy and kidney failure. Its prognosis can be good when the patients are carefully selected. However, an early diagnosis is critical in order to avoid a procedure associated with a high perioperative mortality.

[Long term results for the ATS valve, the first open pivot valve: 182 cases]. / Résultats a long terme de la valve ATS, premiere valve a pivot ouvert: 182 observations.

Between May 1995 and May 2004, 197 ATS valves were implanted in 182 patients: 120 males and 62 females with an average age of 58 +/- 13 years. 149 cases were for aortic valvular replacement and 48 cases were for the mitral valve. Fifteen patients had a double mitral and aortic replacement. Twelve tricuspid procedures were necessary, 17 patients underwent coronary revascularisation and 58 underwent an aortic procedure (Bentall, aortic sub-coronary, aortic cross). The in-hospital mortality (31 days) was 1.6%. The long term mortality at up to 9 years included 23 deaths. No death was attributed to the ATS valve. Nine thrombo-embolic events occurred, but six were minor. One mitral valve thrombosis was due to the voluntary cessation of anticoagulants and another was linked to a reduction in anticoagulant treatment. There were ten haemorrhagic events. They were all linked with an organic visceral lesion. Only one death was recorded. All patients received standard anticoagulant treatment with a target INR between 2.5 and 4. 155 patients were asked about the problem of valve noise. 139 (89.6%) stated that they did not notice any noise from their valves in everyday life. Conclusions The ATS valvular prosthesis is currently the only open pivot valve, fundamentally differentiating it from other valves with 2 leaflets. As a result of this, it has a very low rate of thrombo-embolic complications and a reduction in anticoagulant treatment could therefore be envisaged (Westaby, Van Nooten, Stefanidis). The haemodynamic characteristics are excellent and the ease of rotation of the leaflets allows optimal orientation. Finally, thanks to its structural characteristics, there is less leaflet closure noise and it is less perceptible than with other prostheses. It therefore offers an excellent quality of life.

Cardiac operations in octogenarians: perioperative risk factors for death and impaired autonomy.

BACKGROUND: With the progressive aging of western populations, cardiac surgeons are increasingly faced with elderly patients. METHODS: We reviewed the records of 191 consecutive patients aged 80 years or older (mean age, 83 +/- 2.4 years) who underwent a cardiac surgical procedure at our institution from 1991 through 1996. RESULTS: Ninety-eight patients were men. Preoperatively, 32% of patients were in New York Heart Association class III or IV, and mean left ventricular ejection fraction was 0.55 +/- 0.02. One hundred ten patients (58%) underwent aortic valve replacement, 47 (25%) had coronary artery bypass grafting, 26 (14%) had combined aortic valve replacement and coronary artery bypass grafting, 5 (3%) underwent mitral valve replacement, and 3 (1.6%) had other procedures. Postoperative complications occurred in 69.1% of patients. The hospital mortality rate was 16.2%. Actuarial survival estimates at 1 year, 3 years, and 5 years were 79.2%, 74.9%, and 56.2%, respectively. Multivariate predictors (p < 0.05) of hospital death were preoperative pulmonary hypertension and lower left ventricular ejection fraction. Multivariate predictors of late death were combined aortic valve replacement and coronary artery bypass grafting and female sex. Sixty-four percent of long-term survivors were fully autonomous, and female sex was the only independent predictor of impaired autonomy. Eighty-three percent of survivors were satisfied with their present quality of life. CONCLUSIONS: Cardiac operations can be performed in octogenarians with a favorable long-term outcome. Earlier referral and intervention is mandatory to improve results in this patient population.

Abdominal aortic aneurysmectomy in renal transplant patients.

Because renal transplantation is allowing an increased number of patients to survive for prolonged periods, abdominal aortic aneurysms can be expected to occur with growing frequency in these patients. Surgical management of such cases involves the provision of allograft protection. To date, the literature contains 15 reports of abdominal aortic aneurysms in renal allograft recipients. We describe a 16th case and discuss the management of these patients.

[Extracardiac pulmonary bypass in the treatment of tricuspid atresia]. / Dérivation bicavo-pulmonaire extracardiaque dans le traitement de l'atrésie tricuspide.

Six patients aged 1.5 to 4 years with type 13 tricuspid atresia underwent extracardiac bicavopulmonary repair. This corrective procedure comprises control of palliative aorto-pulmonary anastomosis, the construction of an anastomosis between the superior vena cava and right pulmonary artery and the interposition of an extracardiac tube of autologous pediculated pericardium between the inferior vena cava and the main pulmonary artery. This tube, fashioned from a rectangular flap, remains attached along its right border, conserving its vascular pedicle with the pericardium. Its diameter is calibrated to that of the inferior vena cava. The postoperative course was uncomplicated: all children survived. Assisted respiration was discontinued 24 to 36 hours after surgery, and the pleural drains withdrawn after 48 to 72 hours. The rhythm remained sinusal. Central venous pressure ranged from 8 to 12 mmHg. Peripheral arterial situation was over 95%. At follow-up at 3 to 15 months, the children were very active, reflecting good exercise capacity. Holter monitoring was normal. Saturation was 94 to 97%. Doppler echocardiography showed laminar blood flow. This technique insures good venous drainage without any prosthetic thrombogenic material. In addition, the pediculated pericardium conserves a potential for growth, justifying its use in small children. Long-term evaluation is essential but the initial results are encouraging and encourage perseverance with this method.

[Thrombosis of heart valve prostheses: favourable and prognostic factors based on a study of 41 patients]. / Thromboses de prothèses valvulaires cardiaques: facteurs favorisants et pronostiques à partir d'une étude portant sur 41 patients.

Forty one patients were admitted with a diagnosis of prosthetic valve thrombosis. One patient was thrombolysed successfully, and 40 underwent surgical procedures. In 13 cases, prosthetic valve thrombosis occurred in the first month after valve replacement. 18 patients were in functional class IV of the NYHA classification. Among the thrombosed prostheses, 91% were mechanical, and 61% in mitral position. Adequacy of anti-coagulation was the most important risk factor, as this treatment was inappropriate in 20 patients. In 10 other patients, it had been changed for medical (bleeding events, pregnancy) or surgical (non cardiac surgery) reasons. The perioperative mortality rate was high (32.4%). It was 12% in patients in functional class II and 46% in those in class IV (p < 0.05). This underlines the value of early diagnosis, in which echocardiography, especially with a transesophageal probe, takes a major place, allowing prompt surgical treatment.

[Thromboses of heart valve prostheses: predisposing and prognostic factors based on a study of 41 patients]. / Thromboses de prothèses valvulaires cardiaques: facteurs favorisants et pronostiques à partir d'une étude portant sur 41 patients.

Forty one patients were admitted with a diagnosis of prosthetic valve thrombosis. One patient was thrombolyzed successfully, and 40 underwent surgical procedures. In 13 cases, prosthetic valve thrombosis occurred in the first month after valve replacement. 18 patients were in functional class IV of the NYHA classification. Among the thrombosed prostheses, 91% were mechanical, and 61% in mitral position. Adequacy of anticoagulation was the most important risk factor, as this treatment was inappropriate in 20 patients. In 10 other patients, it had been changed for medical (bleeding events, pregnancy) or surgical (non cardiac surgery) reasons. The perioperative mortality rate was high (32.4%). It was 12% in patients in functional class II and 46% in those in class IV (p < 0.05). This underlines the value of early diagnosis, in which echocardiography, especially with a transesophageal probe, takes a major place, allowing prompt surgical treatment.

[Hemodynamic diagnosis of aortocaval fistula complicating abdominal aortic aneurysm]. / Diagnostic hémodynamique d'une fistule aortocave compliquant un anévrysme de l'aorte abdominale.

A 78-year-old man with a history of hypertension was admitted for a fall with back pain. The blood pressure was at 110/50 mmHg and the pulse at 115 b.min-1. A pulsatile abdominal mass was palpated. No signs of respiratory insufficiency or congestive heart failure were found. The diagnosis of abdominal aortic aneurysm was promptly confirmed by echography. Before laparotomy, a pulmonary artery catheter was inserted for haemodynamic monitoring which showed a high cardiac output, low systemic vascular resistances, increased pulmonary artery wedge pressure and a high SvO2 (93%). This was not consistent with a hypovolaemic shock but rather an aortocaval fistula. After incision and aortic clamping, surgical procedure consisted of transaortic closure of the fistula and restoration of arterial continuity with a prosthetic graft. Initial control of venous bleeding was obtained by passing a Foley's catheter distally and by clamping the vena cava. The postoperative course was initially satisfactory. The patient was extubated, but remained with a major renal insufficiency. After a stay of 15 days in the intensive care unit, he died from nosocomial pneumonia. Aortocaval fistulas are either traumatic or spontaneous. Spontaneous fistulas are more common, and in about 90% of the cases result from a rupture of an atherosclerotic aortic aneurysm. Clinical findings include signs of high cardiac output symptoms of venous hypertension and regional arterial insufficiency. Haemodynamic changes can be of value for the recognition of an aortocaval fistula. Most authors emphasize the importance of preoperative diagnosis, allowing the use of appropriate operative techniques and a prompt control of the fistula. This could decrease haemodynamic instability and transfusion requirements.

[Management of suspected heart injuries]. / Prise en charge des suspicions de plaie du coeur.

Penetrating cardiac injury has to be ruled out in any patients with penetrating thoracic injuries, even in those with no alterations in vital functions. Undelayed echocardiography should be performed to screen for the presence of pericardial effusion. The first case underlines the risk of cardiac tamponade if the diagnosis is missed. Echocardiography was not performed because no echocardiographist was present at the time, and a high suspicion of a neck vascular injury existed. Sudden deterioration due to the onset of acute tamponade was only reversed by an immediate pericardiocentesis followed by surgical haemostasis. The second patient, although stable, had a large echographic pericardial effusion. Emergent sternotomy revealed a large amount of blood in the pericardial space and two cardiac wounds with one on a coronary artery. Penetrating wounds in proximity to the heart, even in a stable patient, require aggressive attempts at ruling out a cardiac injury. Immediate echocardiography should be systematically performed to screen for pericardial fluid.