Results of triple valve replacement: perioperative mortality and long term results.

Between 1970 and 1984, 37 patients underwent simultaneous triple valve replacement by the same surgeon, all for rheumatic valve disease. Björk-prosthesis were used for aortic, Starr, Björk or St. Jude for mitral and bioprosthesis for tricuspid replacements. The median follow-up was 68 months (range, 2 months to 9.6 years). Two patients died in the first postoperative month (5.4%). Most late deaths were of cardiac origin. 85% of all deaths were in Functional Class IV. Five and ten year actuarial survival rate was 75% and 58% for the entire group. Twenty three long-term survivors were followed; all were improved for at least one Functional Class (p = 0.001). Moderate but significant (p = 0.05) cardiothoracic ratio regression was observed. Seven patients had postoperative non lethal complications. In summary, when necessary, triple valve replacement carried an excellent symptomatic improvement. Surgical intervention before patients reach Functional Class IV is preferable. The use of bioprosthesis in tricuspid position is suggested.

Prospective randomized study of St Jude Medical versus Björk-Shiley or Starr-Edwards 6120 valve prostheses in the mitral position. Three hundred and fifty-seven patients operated on from 1979 to December 1983.

During a 5 year period (January 1979-December 1983) 357 patients were submitted to mitral valve replacement. These were performed by the same surgeon and were randomized in 2 groups: Group A consisted of 179 patients who received a St Jude Medical (SJM) prosthesis in the mitral position. Group B comprised 178 patients with a Björk-Shiley valve (BSM) initially (113 patients from 1979 to December 1981 matched with 111 SJM) and later a Starr-Edwards 6120 valve prosthesis (65 patients matched with 63 SJM). Analysis of 21 preoperative clinical, hemodynamic data and operative variables showed the groups to be well randomized. All patients were anticoagulated postoperatively. A follow-up study was performed each year postop: at the end of 1986 there was a 35 to 95 months follow-up with a mean of 64.7 months (1596 patient years follow-up). Fifteen patients were lost to follow-up. There were 8.4% deaths related to the prosthesis in group A and 20.2% in group B (p less than 0.001). The difference was due mainly to deaths from thromboembolic complications and sudden deaths. The rate of peripheral arterial embolic complications was 2.3% in group A and 4.3% in group B per patient year (NS). The difference between the 2 groups is significant for all thromboembolic events including sudden deaths: 3.1% in group A and 7.9% per patient year in group B (p less than 0.001). There were no statistical differences in the rates of endocarditis per patient year (0.3% in group A, 0.9% in group B), reoperation (0.75% in group A, 0.89% in group B), or anticoagulant related hemorrhage (1.6% in group A, 2.4% in group B). Actuarial survival rate, including all postoperative deaths, is significantly different (p less than 0.05) at 5 years, 87.6% +/- 4.5 (group A) versus 77.4% +/- 6 (group B) and at 7 years follow-up, 83.4% +/- 6.5 (group A) versus 73.2% +/- 7.2 (group B). The probability of freedom from death and complications related to the prosthesis is significantly different (p less than 0.001) at 5 years postoperatively: 79% +/- 6.5 for group A versus 54% +/- 7.5 for group B and at 7 years: 72% +/- 7.5 (group A) versus 46% +/- 8.5 (group B). Comparison of subgroups, 113 BSM versus 111 SJM (1979-81) and 65 SE 6120 versus 63 SJM (1982-83) showed similar significant differences in the results: however there were more early deaths, valve thrombosis, valve dysfunctions and sudden late deaths in the BSM group and more peripheral arterial emboli in the SE 6120 group.(ABSTRACT TRUNCATED AT 400 WORDS)

Aorto-coronary artery saphenous vein bypass surgery. A ten-year follow-up.

The 10-year follow-up of consecutive series of 126 patients who underwent coronary bypass surgery from January 1970 through December 1972 without associated procedures is reported. There were 112 men and 14 women with a mean age of 50.3 +/- 8.0 years. Indications for operation were stable angina pectoris in 35 cases and unstable angina in 91 cases. Eleven patients had one-vessel disease, 55 patients had two-vessel disease and 60 patients had three-vessel disease. The mean number of grafts per patient was 1.8. Graft patency rate was 78.4% at the time of early angiographic control (from one to 24 months). There were two early deaths and 47 late deaths. One patient was last to follow-up. Twenty-six of the late deaths were cardiac in nature (57.7%). The overall 10-year survival rate was 68.0 +/- 4.1%. The factors most clearly related to survival rate were: age (p less than 0.05) ischaemic ST-segment depressions on resting preoperative electrocardiogram (p less than 0.005), preoperative electrocardiographic evidence of anterior, septal or lateral myocardial infarction (p less than 0.05), ventricular function as assessed by preoperative left ventriculography (p less than 0.05). During the follow-up period 35.1% of survivors had had no recurrence of angina and 64.9% had experienced at least one episode of angina. At the ten-year evaluation 33 surviving patients considered themselves free of angina, 27 patients considered the angina to be less severe than before the operation and four considered it to be the same or more severe. A significant positive correlation was noted between clinical response and completeness of revascularization (p less than 0.05).

[Reoperations in valve surgery. Apropos of 194 cases]. / Les réinterventions en chirurgie valvulaire. A propos de 194 cas.

Between 1970 and 1985, 194 patients underwent one or several reoperations after conservative valvular surgery (Group A) or valvular replacement surgery (Group B). Group A: comprised 141 patients with a previous history of closed heart mitral commissurotomy (114 cases), open heart mitral commissurotomy (20 cases), mitral valvuloplasty (5 cases) or aortic commissurotomy (2 cases) reoperated after an average period of 153 +/- 44 months. At reoperation, prosthetic valve replacement of the previously operated valve was systematic and another valvular procedure was also performed in 66 cases. Hospital mortality was 7.8 p. 100. Mortality was high in patients reoperated in functional Class IV of the NYHA classification, after closed heart mitral commissurotomy performed over 10 years before hand. The global mortality rate was 17 p. 100 (average postoperative follow-up of 70 +/- 44 months). The actuarial 5 year survival rate was 85 +/- 6 p. 100 and the 10 year survival was 70 +/- 13 p. 100; NYHA Class IV cardiac failure was a significant poor prognostic factor (p less than 0.05). The prognosis of reoperation after commissurotomy depended mainly on the interval between the relapse of symptoms and reoperation. Group B: comprised 53 patients with valvular prostheses reoperated after an average period of 58 +/- 41 months. The indications of reoperation were prosthetic valve dysfunction (31 cases), perivalvular leak (5 cases), prosthetic valve thrombosis (6 cases), infective endocarditis (7 cases), haemolysis (1 case) and associated valvular disease (10 cases). Reoperation concerned mechanical prostheses in 26 cases and bioprostheses in 24 cases. It consisted in valvular replacement (51 cases) or reinsertion (2 cases). Eight patients underwent second reoperation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Results of myomectomy in obstructive cardiomyopathy. Apropos of 28 cases]. / Résultats de la myomectomie dans la cardiomyopathie obstructive. A propos de 28 cas.

Hypertrophic obstructive cardiomyopathy, the pathogenesis of which is controverted, exposes the patient to the risk of sudden death and often evolves towards heart failure. When medical treatment is inadequate, surgery may be considered. The authors report their experience of myectomy performed in 28 subjects with pure obstructive cardiomyopathy. Despite a medical treatment based, in most cases, on beta-blockers, all patients showed severe symptoms, with syncopes in 39 p. 100 of the cases, stage 2 or over angina (Canadian Cardiovascular Society grading) in 57 p. 100 of the cases, and stage 3 or over dyspnoea (New York Heart Association grading) in 61 p. 100 of the cases. The intraventricular pressure gradient, measured in 25 patients, was 81.7 +/- 44.9 mmHg. The operation always consisted of myectomy according to the Morrow procedure, i.e. double myotomy of the subaortic septum extended on a length of at least 4 cm, with excision of the muscle between the two incisions. In addition, mitral valve replacement was performed in 13 patients who had severe mitral regurgitation. Three patients (7 p. 100) died with low cardiac output in the peri-operative period; pre-operatively, these patients were in a particularly poor condition. One patient died suddenly during the 4th post-operative month. The annual mortality rate therefore was 2.3 p. 100, and the actuarial survival rate at 8 years was 89.3 p. 100.(ABSTRACT TRUNCATED AT 250 WORDS)

[Results of venous aortocoronary bypass with a minimum follow-up of more than 10 years]. / Résultats des pontages veineux aorto-coronaires avec un recul minimal supérieur à 10 ans.

The results of saphenous vein coronary bypass alone were assessed in 126 patients operated between 1970 and 1972 with a postoperative follow-up period of 10 to 12 years. Spontaneous or unstable angina was observed in 72% and incapacitating effort angina in 27.7%. An average of 1.8 grafts per patient was carried out but revascularisation remained incomplete in 51.6% of cases. The early postoperative mortality was 1.58%; the early postoperative infarct rate was 12.7%. There were 47 late deaths, most of which were of cardiac origin (53.2%) or due to cerebrovascular accidents (12.8%). Actuarial survival studies showed an annual mortality rate of 3.2%. The overall 10 to 12 year survival rate was 68.4. The secondary infarction rate was 13.7%, an annual rate of less than 1.5%. Control coronary angiography was carried out in 112 patients; 78% of the grafts remained patent at 2 years. Age (p less than 0.008), basal ECG changes (p less than 0.003) and left ventricular function (p less than 0.05) were significant prognostic factors for survival. One year after surgery, 63.5% of patients were angina free. Thereafter, the annual recurrence rate for angina was 3.1%. After 10 years, 35.4% of patients remained free of angina. A statistical analysis of the factors influencing the recurrence of angina showed that the number of coronary stenoses (p less than 0.02) and the quality of revascularisation (p less than 0.001) were significant factors. After an average follow-up of 75.7 months, 9 patients were reoperated using the internal mammary to revascularize the left anterior descending artery. Sixty per cent of the operated patients were able to return to work.

[Study of the late results of reimplantation of heart valve prostheses based on 15-year experience]. / Odlegle wyniki reoperacji protez zastawkowych na podstawie 15-letnich doswiadczen.

Authors studied two groups of patients, in which a cardiac valvular prosthesis was reimplanted within 15 years. Data of patients reoperated on (group A) were used to estimate indications, surgical methods, postoperative course and late results. Data of patients which underwent surgery and then requiring reoperation (group B) were used to evaluate the percentage of reoperation falling to 1 patient/1 year according to a primary implanted valvular prosthesis: 42 patients were divided into two groups. 3 perioperative and 12 late deaths (totally 28.3%) were stated in the group A. 5- and 10-year survival rates were 83.3% and 65.6%, respectively. In the group B the lowest percentage of reoperation (1 patient/1 year) were stated in patients with mitral Starr-Edwards 6120 valve (029) and Björk-Shiley aortic valve (0.13). The highest percentage of reoperation was observed in patients with biological prosthetic valves (homograft or heterograft--4.64) and in comparison with patients with primary implanted mechanical prostheses (0.24). Those differences were statistically significant (p less than 0.001).