Early and long-term (one-year) effects of the association of aspirin and oral anticoagulant on thrombi and morbidity after replacement of the mitral valve with the St. Jude medical prosthesis: a clinical and transesophageal echocardiographic study.

OBJECTIVES: The aim of the study was to test the value of low dose aspirin associated with standard oral anticoagulants (OAC) after mechanical mitral valve replacement (MMRV) to reduce strands, thrombi and thromboembolic events. BACKGROUND: Strands and thrombi are thought to increase the risk of embolic events after MMVR, particularly in the immediate postoperative period. METHODS: Two hundred twenty-nine patients were prospectively recruited: 109 patients (group A+) were randomly assigned to aspirin (200 mg per day) with OAC and 120 patients (group A-) to OAC alone (international normalized ratio 2.5 to 3.5). All patients were subjected to multiplane transesophageal echocardiography at nine days and five months and were followed up for one year. RESULTS: At nine days and five months, there was a high and comparable incidence of strands in the two groups (group A+: 44%, 58%; group A-: 49%, 63%). However, the incidence of nonobstructive periprosthetic valve thrombi was significantly lower in group A+ at 9 days: 5% versus 13%, p = 0.03. Total thromboembolic events were reduced in group A+ (9% vs. 25%, p = 0.004) although there was an increased incidence of gastrointestinal hemorrhage (7% vs. 0%). Overall mortality was 9% in group A+ and 4% in group A-. Valve-related events were similar in both groups. Early thrombi, but not strands, were associated with higher morbidity, especially thromboembolic events (30% vs. 13%, p = 0.003). CONCLUSIONS: One year after MMVR, the association of aspirin with OAC reduced thrombi and thromboembolic events, but not morbidity, due to an increase in hemorrhagic complications.

Long-term results of valve replacement with the St. Jude Medical prosthesis.

To assess with truly long follow-up the long-term results of valve replacement with the St. Jude Medical prosthesis (St. Jude Medical, Inc., St. Paul, Minn.), we reviewed the case histories of the first 1112 patients undergoing 1244 valve replacements with this valve between June 12, 1978, and June 12, 1987: 690 male (62%) and 422 female patients, mean age 56 years. A total of 773 patients (69%) had the aortic valve replaced, 207 (19%) the mitral valve, and 132 (12%) the aortic and mitral valves. There were 42 hospital deaths (3.8%). Follow-up was 97.5% complete (8988 patient-years). There were 213 late deaths. Ninety-one (43%) were considered valve-related: sudden death, n = 27; anticoagulant-related hemorrhage, n = 22; thromboembolism, n = 19; prosthetic valve endocarditis, n = 13; valve thrombosis, n = 9; and noninfectious perivalvular leak, n = 1. Overall actuarial survival, including hospital mortality, was 68% +/- 6% (95% confidence limits) 14 years after the operation. Linearized rates of late valve-related events were as follows: thromboembolism, 1.09% per patient-year; anticoagulant-related hemorrhage, 0.94% per patient-year; prosthetic valve endocarditis, 0.32% per patient-year; valve thrombosis, 0.33% per patient-year; and perivalvular leak, 0.19% per patient-year. Actuarial freedom, at 14 years, from thromboembolism was 89% +/- 3%, anticoagulant-related hemorrhage 83% +/- 8%, valve thrombosis 97% +/- 1%, and reoperation 95% +/- 3%. Actuarial freedom from all valve-related deaths and valve-related morbidity and mortality, at 14 years, was 84% +/- 6% and 61% +/- 8%, respectively. We conclude that, because of its low thrombogenicity, low incidence of valve-related events, and low valve-related mortality, the St. Jude Medical valve is one of the best performing mechanical prosthesis currently available. Nevertheless, the late valve-related complications and deaths illustrate that the quest for a "perfect" prosthesis remains unfulfilled.

Intermediate-term results after en bloc double-lung transplantation with bronchial arterial revascularization. Bordeaux Lung and Heart-Lung Transplant Group.

OBJECTIVE: Between May 1990 and January 1994, 18 patients underwent en bloc double-lung transplantation with tracheal anastomosis and bronchial arterial revascularization. Because at that time it was already suggested that chronic ischemia could be a contributing factor in occurrence of obliterative bronchiolitis, the purpose of this study was to evaluate, with a follow-up ranging from 22 to 69 months, the midterm effects of bronchial arterial revascularization on development of obliterative bronchiolitis. RESULTS: Results were assessed according to tracheal healing, functional results, rejection, infection, and incidence of obliterative bronchiolitis. There were no intraoperative deaths or reexplorations for bleeding related to bronchial arterial revascularization, but there were three hospital deaths and five late deaths, two of them related to obliterative bronchiolitis. According to the criteria previously defined, tracheal healing was assessed as grade I, IIa, or IIb in 17 patients and grade IIIa in only one patient. Early angiography (postoperative days 20 to 40) demonstrated a patent graft in 11 of the 14 patients in whom follow-up information was obtained. Ten patients are currently alive with a 43-month mean follow-up. Among the 15 patients surviving more than 1 year, functional results have been excellent except in five in whom obliterative bronchiolitis has developed and who had an early or late graft thrombosis. Furthermore, those patients had a significantly higher incidence of late acute rejection (p < 0.02), cytomegalovirus disease (p < 0.006), and bronchitis episodes (p < 0.0008) than patients free from obliterative bronchiolitis. CONCLUSION: We conclude that besides its immediate beneficial effect on tracheal healing, long-lasting revascularization was, at least in this small series, associated with an absence of obliterative bronchiolitis, thus suggesting but not yet proving the possible role of chronic ischemia in this multifactorial disease.

A 5 1/2 year experience with the St. Jude Medical cardiac valve prosthesis. Early and late results of 737 valve replacements in 671 patients.

Between June 12, 1978, and June 12, 1983, 737 St. Jude Medical valves were implanted in 671 patients (431 males, 240 females) ranging in age from 9 months to 82 years (mean 55 years); 16 of these patients (2.3%) were less than or equal to 15 years and 82 (12.2%) were greater than or equal to 70 years. Associated procedures were performed in 28.2% of the 500 aortic valve replacements, 13.3% of the 105 mitral valve replacements, and 10.6% of the 66 double mitral and aortic valve replacements. Hospital mortality (less than or equal to 30 days) was 3.6% (18/500 patients) for aortic, 4.7% (5/105 patients) for mitral, and 0% for double valve replacement. Only one of these 23 hospital deaths was possibly valve-related. Complete follow-up was achieved during December, 1983, and January, 1984, to provide a minimum follow-up of 6 months. Follow-up has been 100% for a total of 1,619 patient-years, with a mean follow-up of 2 1/2 years. There were 41 late deaths (6.1%): 30 in the aortic group, eight in the mitral group, and three in the double valve replacement group. Fourteen (34.2%) of these late deaths have been considered valve-related. At 5 1/2 years, the actuarial survival rate, hospital mortality excluded, is 91% for aortic, 90% for mitral, and 95% for double valve replacement. Functional improvement of these patients is quite satisfactory: Preoperatively, 60.3% were in Class III or IV of the New York Heart Association, whereas postoperatively, 99.5% of the patients are in Class I or II. As 78 patients (65 aortic, 10 mitral, and three double valve replacement) did not receive anticoagulation therapy for a total period of 84 patient-years, the incidence of valve thrombosis, systemic embolism, and sudden or suspicious deaths in this group was compared with that in a group of 630 patients (including 60 patients from the first group who were given anticoagulants afterwards) subjected to long-term anticoagulation for a total period of 1,535 patient-years. A significantly higher incidence of valve thrombosis and systemic embolism was observed in the absence of anticoagulation. Anticoagulant-related complications occurred in 10 patients, with an incidence of 0.65/100 patient-years. On the basis of this 5 1/2 years of experience, the St. Jude Medical valve appears to be an excellent mechanical prosthesis for cardiac valve replacement, in terms of hemodynamic performance and low thrombogenicity, in patients receiving anticoagulants.

Ex vivo leucocyte adhesion and protein adsorption on TiN.

Titanium nitride (TiN) is regarded as a potential biomaterial for blood-contact applications. Its in vitro haemocompatibility has been evaluated already and gave promising results. The purpose of this study was to continue studying its 'biological' behaviour through an ex vivo evaluation. The material was a physical vapour deposition elaborated TiN coating and the phenomena observed were leucocyte adhesion and albumin and fibrinogen adsorption. These ex vivo results were compared with in vitro results obtained previously. Two reference medical grade silicone elastomer and three TiN arterio-arterial extra-corporeal circuits were tested. No leucocyte was retained by TiN, as in in vitro experiments; the ex vivo fibrinogen adsorbed quantity was higher and albumin adsorption was about the same in in vitro and in ex vivo situations. TiN can be considered as a suitable blood-contacting material.

Isolated ventricular inversion with situs solitus: successful surgical repair.

A 7-month-old infant with ventricular inversion without transposition of the great arteries in situs solitus, associated with a ventricular septal defect, is reported. When the infant was 13 months of age, successful surgical repair was undertaken by performing an intraatrial transposition of venous return using the Senning procedure and by closing the ventricular septal defect with a patch. The postoperative course was uneventful except for a well-tolerated complete heart block. No systemic valve incompetence appeared during the 53 months of actual follow-up. A complete review of the literature suggests that this is the sixth reported instance of successful repair. Injury of the abnormally located conduction tissue is regarded as the most threatening complication.

Isolation of the right subclavian artery.

Loss of continuity between subclavian artery and aorta with persistent connection to the homolateral pulmonary artery through a ductus arteriosus is an uncommon malformation, involving generally the left subclavian artery and associated with intracardiac or aortic arch anomalies. We report a case of right subclavian isolation with a left-sided aortic arch, presenting as a single anomaly and surgically corrected by aortic reimplantation.

Bronchial revascularization in double-lung transplantation: a series of 8 patients. Bordeaux Lung and Heart-Lung Transplant Group.

Donor airway ischemia is the main cause for defective tracheal or bronchial healing after double-lung transplantation. Anatomical studies and bronchial arteriograms have shown that the right intercostal bronchial artery is constant (95% of instances) and provides an important blood supply to the distal trachea, the carina, and the right bronchial tree as well as to the left side through a subcarinal and periadventitial anastomostic network. To maintain this important bilateral bronchial circulation, it is of capital importance not to mobilize the arteries individually and to avoid large dissections around the carina. Both bronchi can thus be revascularized by indirect aortic reimplantation using a bypass graft to a single aortic patch that includes the origin of the right intercostal bronchial artery. Furthermore, the origin of other vessels (a common trunk and left arteries) can be found within a short distance of the right intercostal bronchial artery and possibly be contained within the same aortic patch. From a series of 56 lung transplantations, 8 patients underwent restoration of the bronchial vascularization using a recipient saphenous vein graft between the donor bronchial arteries and the anterior aspect of the recipient's ascending aorta. A lower tracheal anastomosis was performed. Bronchial arterial blood supply was evaluated both by endoscopy and by arteriography at about the 15th postoperative day. The bronchial circulation was visualized at this time in five of seven arteriographies, and this was associated with excellent tracheal healing in all 8 patients.

Surgical experience of coronary artery-right ventricular fistula in a heart transplant patient.

Routine follow-up catheterization 4 years after heart transplantation in a 55-year-old revealed a fistula from the main left anterior descending artery (LAD) to the right ventricle. The left anterior descending artery was dilated and tortuous because of this fistula. As he had effort dyspnea and fatigue 3 months after this catheterization, we decided to operate on the fistula, and direct closure of this through the LAD and coronary artery bypass grafting from the proximal to distal LAD were performed. Surgery and the postoperative course were uneventful. We discuss the surgical indication and technique for coronary artery fistula acquired as a result of endomyocardial biopsy after heart transplantation.

The short- and mid-term results of bidirectional cavopulmonary shunt with additional source of pulmonary blood flow as definitive palliation for the functional single ventricular heart.

OBJECTIVE: The purpose of this study was to demonstrate the early and late outcomes of bidirectional cavopulmonary shunt (BCPS) as a definitive procedure for the functional single ventricular heart. METHOD: From September 1991 to December 1997, 34 patients underwent a BCPS procedure without a routine conversion to Fontan circulation. The additional source of pulmonary blood flow was left in all patients. Conversion was performed only when it was required for excessive cyanosis. RESULTS: The hospital mortality rate was 8.8% (3/34, 95% confidence limit; 1.9-23%) and the 5-year survival rate was 75% for a mean follow-up period of 33+/-22 months. Seven patients underwent a conversion procedure for remnant or recurrent cyanosis and deterioration of exercise tolerance. Four of these patients died after conversion to Fontan circulation. Twenty-five long-term survivors with BCPSs maintained an arterial oxygen saturation of 84+/-6.1%, and 52% of them had a normal exercise tolerance or mild limitation. No patients developed severe late complications other than recurrent cyanosis. CONCLUSION: Due to the high mortality after conversion to Fontan circulation in patients whose conditions had deteriorated, we could not demonstrate the clear superiority of long-term BCPS over the construction of Fontan circulation for management of the functional single ventricular heart. If deteriorated conditions were successfully managed in the late period, the outcome of long-term BCPS would have been better.

Should circulatory arrest with deep hypothermia be revised in aortic arch surgery?

Our experience (January 1982-May 1987) concerns 41 patients, operated upon for aortic dissection (30 patients) or aneurysm (11 patients) using circulatory arrest with deep hypothermia. There were 24 male and 17 female patients (mean age: 55 years 9 months, range 32-73 years). The mean circulatory arrest time in minutes was 41 +/- 3 (mean rectal temperature before circulatory arrest was 18.4 degrees C +/- 0.3 degrees C). Total (24 patients) or partial (16 patients) replacement of the aortic arch was performed. One patient with a sacciform aneurysm had the aortic wall defect closed. Hospital mortality was 22% +/- 7% (9 patients): 8 of 30 patients with aortic dissection (26.6%) and 1 of 11 patients with aortic aneurysm (9%). Neurological complications occurred in 3 patients. These data lead us to prefer circulatory arrest with deep hypothermia as the method of choice for aortic arch surgery. However, when a short circulatory arrest time (less than 30 min) for the repair is foreseeable, mild hypothermia (20 degrees C-24 degrees C) may be preferred. In patients who will not tolerate excessive cardiopulmonary bypass times, expected difficulties with the repair should suggest mild hypothermia and short circulatory arrest in easier cases or moderate hypothermia with brachiocephalic perfusion in the others.

Early and long term results of coronary artery bypass grafts in patients with dialysis dependent renal failure.

OBJECTIVE: Coronary artery disease is the main cause of mortality and morbidity in patients on renal therapy replacement. The aim of this study was to define peri-operative risk and long term results of coronary artery bypass grafts (CABG) in dialysis patients. METHODS: this retrospective study included 82 patients in chronic dialysis who underwent CABG between 1978 and 1997. The mean age was 61+/-10 years (range 28-81 years), 84% of the patients were male and the average duration of dialysis was 57 months (range 1-148 months). Combined procedures were carotid endarterectomy in one case, left ventricular aneurysm resection in one and valvular replacement in 10 (nine aortic and one mitral replacements). The operation was elective in 42 patients (51 %) and urgent in the others. Previous myocardial infarction was found in 37 patients (45%) and left ventricular ejection fraction (LVEF) at less than 45% in 15 patients (18%); 23 patients (28%) were in NYHA class III or IV and regarding angina functional status, 77% in CCS class 3 or 4. Follow-up was complete. Statistical analysis included 30 and pre and peri-operative data. Statistical analysis used Chi-square analysis or Fisher's exact test, and the Mann-Whitney test when appropriate. The estimated probability of survival, including postoperative mortality, was calculated by the method of Kaplan-Meyer, and the Log-Rank test used to compare the results. RESULTS: the hospital mortality was 14.6 % (n = 12). Ischemic time and ECC time were significantly lengthened in dead patients (P = 0.01). Moreover, use of internal mammary artery was directly related to lower hospital mortality (P = 0.02). For previous myocardial infarction, LVEF at less than 45%, diabetes and combined procedure, a P-value of < or = 0.1 was calculated. The follow-up ranged from 1 to 140 months (mean 36 months). There were 39 late deaths. The survival rates (included hospital mortality) were 71+/-5%, 56+/-6% and 39+/-6% at 1, 3 and 5 years, respectively. All surviving patients improved their functional status and had symptomatic relief. Statistical analysis showed significant difference in favor of long term survival for patients younger than 60 years, LVEF > 45% and NYHA class I or II. CONCLUSION: these data confirm that CABG in patients with renal replacement therapy is associated with an high operative and long term mortality. However it allows an improvement of functional status, and so, let possible duration of dialysis. It may be expected that more active prevention and detection of coronary disease might improve these results.

Lung and heart-lung transplantation for end-stage lung disease. The Bordeaux Lung and Heart-Lung Transplant Group.

Between February 1988 and December 1989, 15 combined heart-lung, 2 double lung and 5 single lung transplants were performed at our institution for end stage lung disease. The indication for heart-lung transplantation was primary lung disease with associated secondary heart failure in 11 cases, diffuse pulmonary disease with extensive adenopathy of the hilum in 2 cases and profuse and antibiotic-resistant tracheobronchial infection due to Pseudomonas in 2 cases. A double lung transplant was performed in 2 patients with hypertensive emphysema. The indication for a single lung transplantation was emphysema in 2 cases and pulmonary fibrosis in 3 cases; in this last indication, transplantation should be performed on the right side with a slight lengthening of the main bronchus to avoid the side-effects of mediastinal shift. There were 2 early deaths, 7 secondary deaths (from the 2nd to the 5th month) due to viral or bacterial infectious complications, and 1 late death in the 7th month (infection due to a syncitial virus). All 12 surviving patients have an excellent functional result; the size of the tracheal or bronchial anastomosis ranges from 85% to 100% of normal. From this experience, we conclude that specificity and severity of lung hazards are mainly related to bronchial infection, dependence on steroids and pleural adhesions. Moreover, posttransplant pulmonary oedema, mucociliary dysfunction and the differential diagnosis between rejection and infection require careful endobronchial suction and periodical sampling.

Surgery of chronic traumatic aneurysm of the aortic isthmus: benefit of direct suture.

OBJECTIVE: Retrospective evaluation of long term results after direct suture repair of chronic traumatic aneurysm of the aortic isthmus. METHODS: From March 1979 to June 1998, a total of 19 patients with chronic traumatic aneurysm of the aortic isthmus were operated on, among whom 12 (63%) underwent direct suture. These 12 patients (age ranging from 19 to 68 years; mean 34.2 years) constitute the subject of this study. All but one suffered traffic accidents. Mean delay between trauma and surgery was 4 years (range 3 months to 12 years). All patients underwent a left posterolateral thoracotomy through the fourth intercostal space. Extracorporeal circulation for spinal cord protection was installed in six patients (five ilio-iliac shunts, one atrio-iliac shunt). Aortic rupture was partial in five and circumferential in seven patients. The mean clamping time was 25 min. The absence of loss of aortic substance and a careful mobilization of the aorta made the repair by direct suture easier; this technique could thus be achieved in 63.2% of all 19 patients operated on of chronic traumatic aneurysm within the same period. RESULTS: There was no in-hospital death and no postoperative paraplegia. With a median follow-up of 15 years 3 months (ranging from 22 to 10 years), there were no late complications. Chest X-ray was normal in all patients; eight of them underwent a control angiography between 18 and 72 postoperative months; all these angiographies but one (20% stenosis without gradient) demonstrated a normal appearance of aortic isthmus. CONCLUSION: Direct suture for repair of chronic traumatic thoracic aneurysm is a safe procedure: long-term outcome was excellent and the complications observed with prosthetic grafts or with aortic endoprosthetic stent-grafts were avoided.

Lung transplantation with bronchial revascularisation. Surgical anatomy, operative technique and early results.

Ischaemic anastomotic complications are an important cause of mortality and morbidity after lung transplantation. Anatomical studies have demonstrated that the pattern of bronchial arterial supply is relatively constant and therefore amenable to attempts at revascularisation. From May 1990, 10 patients who had a double lung transplantation (tracheal anastomosis) and 1 patient who had a right lung transplantation underwent concomitant bronchial revascularisation. There were two early and one late deaths. There were no anastomotic complications. Regular endoscopic examination showed satisfactory healing in all patients. Early angiography showed patent grafts in 7 of 9 patients. At a mean follow-up of 11 months (range 6-17 months) 8 patients are well and leading a normal life. This report describes the anatomical basis, technical aspects and early results of a promising operative procedure in the field of lung transplantation.

Is the Parsonnet's score a good predictive score of mortality in adult cardiac surgery: assessment by a French multicentre study.

OBJECTIVE: Parsonnet proposed a preoperative score ("initial Parsonnet's score", which predicts the hospital mortality of adult cardiac surgery. This score was then modified by including several risk factors used in the 'SUMMIT' system ("modified Parsonnet's score", 44 variables). We wanted to assess the predictive value of these two scores in a French surgical population. METHODS: From December 1992 to April 1993, in France, we organised a prospective multicentre study on adult cardiac surgery mortality and morbidity. Data on 6649 patients were included. We analysed statistically the predictive value of each risk factor and of the two scores on mortality and morbidity at one month. RESULTS: Only 6 of the 15 variables of the initial Parsonnet's score and 19 of the 44 variables of the modified Parsonnet's score significantly influence hospital mortality. Both scores are able to predict hospital mortality and severe morbidity, but the modified Parsonnet's score has the best predictive value (initial Parsonnet's score: odds ratio by point of score = 1.01, area under the roc curve = 0.64; modified Parsonnet's score: odds ratio by point of score = 1.05, area under the roc curve = 0.70). CONCLUSIONS: This study shows that the Parsonnet's scores are predictive, but that these scores remain imperfect: many risk factors are non significant, the initial Parsonnet's score has a moderate predictive value, and the modified Parsonnet's score is too complex (44 variables). Thus, we have built a new score for cardiac surgery in French adults.

Long term results of cardiac valve replacement in patients aged 75 years and older.

From June 1978 to December 1989, 158 patients over 75 years of age (mean: 78 years; range 75 to 86 years) underwent 164 valve replacements: 134 in the aortic, 18 in the mitral and 6 in double mitral and aortic positions. One hundred and seven of these valves (66%) were bioprostheses, 93 aortic and 14 mitral and 57 valves (34%) were mechanical prostheses; 47 aortic and 10 mitral. Hospital mortality (less than or equal to 30 days) was 7% (11 patients, all in NYHA class III or IV) but was higher in patients who had undergone associated procedures (9.8%; 6/61 patients) or in patients who had mitral valve replacements (11%) and in double valve replacement (16.6%). Because of a minimal delay of one year, long term follow-up information (100%) was only obtained from the first 110 patients discharged from hospital. Late mortality has been 13.6% and actuarial survival at 11 years was 71.5% +/- 5. Therefore, despite a hospital mortality of more than twice that of patients operated upon under 75 years of age (3.3%), an actuarial survival at 11 years, similar to that of patients under 75 years (77 +/- 5%) and the functional improvement obtained (95% of survivors are NYHA class I or II) certainly justify surgery in these patients. Because of the incidence of anticoagulant related hemorrhages in these patients (1.7% patient year) and since, structural deterioration of the bioprostheses was non existent in this series, a bioprosthesis appears to be the best valvular substitute in patients over 75 years of age.

Results of carotid endarterectomy in patients 75 years of age and older.

From April 1980 to September 1989, 69 patients over 75 years of age (mean 78 years, range 75 to 86) underwent 81 carotid endarterectomies. Twenty three percent were asymptomatic, 56.5% had symptoms appropriate to lesion location and 20.5% had a non hemispheric syndrome. Nine patients required an associated procedure (combined cardiac surgery 6 pts; vascular surgery 3 pts). Perioperative mortality was 3.7%. The combined early lethal and non lethal stroke rate was 6.1%. Actuarial survival, at 10 years, was 58.4% +/- 10, and the incidence of freedom from stroke at 10 years was 86.2% +/- 5. Despite the fact that the hospital mortality of patients over 75 years undergoing carotid endarterectomy is more than three times that of patients operated on under 75 years of age (1.2%), the combined stroke and neurologic mortality rate is similar to that of patients under 75 years (5.3%). Carotid surgery in patients over 75 years of age does not increase life expectancy but does improve the quality of survival which depends mainly on cardiac events.

A 8-year follow-up of the Edwards-Duromedics bileaflet prosthesis.

Following reports of leaflet escapes, distribution of the Edwards-Duromedics prosthesis (ED), introduced in 1982, was suspended from 1988 to 1990. From our experience of 257 patients operated on between March, 1983, and April, 1988, it appeared to us that, among the five key factors identified by extensive studies, surgical mishandling, specially in mitral position, could have been the main contributing factor. These 257 patients, mean age 57 years (range 2 to 75 years), underwent 138 aortic (AVR), 86 mitral (MVR), and 33 double valve (DVR) replacements. Hospital mortality was 2.3% (6 patients): 1.4% for AVR, 3.5% for MVR, and 3% for DVR, none of them being directly valve-related. But there were 3 early replacements of a mitral ED for intra or postoperative impingement of one leaflet. Follow-up has been 93%, with a total of 1.155 patient-years. Among the 20 late deaths (8%), 4 (20%) were considered as valve-related; there was one MV thrombosis and 7 non-fatal systemic emboli, the total incidence of thromboembolism being 0.7% patient-year. No structural failure or leaflet escape was observed in this series. At 8 years, actuarial survival, hospital mortality excluded, was 85.5% for AVR, 95% for MVR, and 89% for DVR. The ED prosthesis is, from a hydrodynamic point of view, an advance in terms of both mechanical and bileaflet valve: the valve design accounts for its low thrombogenicity. But its persistent drawback remains the prohibitive vertical exposure of leaflets in mitral position, that can be responsible for immediate or delayed leaflet entrapment, or for incautious handling for rotating the mechanism, leading to extensive fissuration of pyrolitic carbon and delayed rupture. (ABSTRACT TRUNCATED AT 250 WORDS)

[Chronic dissection of the thoracic aorta. Diagnosis, management and prognosis]. / Dissection chronique de l'aorte thoracique. Diagnostic, prise en charge, pronostic.

Dissection of the thoracic aorta becomes chronic after the 14th day following the first signs of dissection. It may be "primary", that is to say diagnosed at the chronic stage, the acute stage having passed undiagnosed, or "secondary" because the dissection diagnosed in the acute period was treated medically or surgically. Its outcome depends on the evolution of the false lumen which may thrombose or remain patent and stable or increase in size and progress to a false aneurysm. Management consists in following up the outcome of the false lumen by successive examination every 6 to 9 months: in general, CT scan or magnetic resonance imaging are used for this follow-up; transoesophageal echocardiography is another possibility but, when repeated, is not always accepted by the patients. Antihypertensive therapy is essential as it improves long-term survival in all cases. Surgery is justified but the operative risk is high should an acute complication occur with an immediate threat to life. This indication should be maintained in symptomatic patients (signs of compression of a false aneurysm, painful reactivation) after thorough preoperative preparations, given the poor prognosis of the natural history of chronic dissection of the thoracic aorta irrespective of its site. In asymptomatic patients with aortic diameters of more than 60 mm in the first segments of the aorta (ascending or transverse aorta), surgery provides better long-term survival rates than medical management. In disease of the descending thoracic aorta, no difference in survival is observed between medical or surgical treatment: the surgical indication should be more conservative, especially because of the high incidence of neurological complications (paraparesis-paraplegia) in the absence of peroperative medullary protection, which is always reproducible, effective and validated.