[Pilot study of a strategy combining coronary angioplasty with valvular and/or coronary surgery on the same day]. / Etude pilote d'une stratégie combinée associant une angioplastle coronaire a une chirurgie valvulaire et/ou coronaire le même jour.

A strategy combining percutaneous coronary angioplasty followed by valvular and/or coronary surgery was recently proposed as an alternative to the classical surgical only approach. The aim of this study was to assess the feasibility and the results of such a combined strategy with the two procedures performed the same day. The population comprised 34 patients including 17 with valvular disease and revascularisable coronary lesions (15 symptomatic severe aortic stenoses and two acute mitral insufficiencies) plus 17 multitrunk coronary patients without valvular disease but with an indication for revascularisation. Angioplasty was performed several hours prior to surgery and a loading dose of 300mg clopidogrel was administered immediately postoperatively; all patients were on aspirin before the procedure. The average age was 67 +/- 11 years, NYHA class 2.3 +/- 0.7, angina 73%, LVEF 58 +/- 10%. Single coronary artery disease was present in 26%, two vessel disease in 35% and three vessel disease in 39%. The success rate for angioplasty plus stent was 98%. 60 stents were active. Bypasses were exclusively arterial (left or right internal mammary arteries). We observed 4 in-hospital deaths, one of which was due to an infarct and three due to extra-cardiac causes (1 non-cardiogenic acute respiratory distress syndrome, 1 respiratory tract infection and 1 pyelonephritis). Further surgery was necessary in 4 cases: for haemorrhage and one episode of digestive tract haemorrhage. There were no additional deaths, coronary events nor haemorrhage at the end of an average follow-up of 15 +/- 6 months. The results of this combined strategy are encouraging in this population and merit further evaluation in a prospective study.

Aortic valve replacement in the elderly: bioprosthesis or mechanical valve?

BACKGROUND: With increased life expectancy, valve operations are more and more common in elderly patients. The choice of valve substitute-mechanical valve or bioprosthesis-remains debated. METHODS: Two groups of patients of the same age (69, 70, and 71 years) with isolated aortic valve replacement (mechanical 240, bioprostheses 289) were compared for mortality, morbidity, and valve-related complications. RESULTS: No significant difference was found in survival, valve-related mortality, valve endocarditis, and thromboembolism. Mechanical valve had more bleeding events; bioprostheses had more structural deterioration, reoperation, and valve-related morbidity and mortality. CONCLUSIONS: To avoid reoperations in octogenarians, the 10-year durability of current bioprostheses should be matched with the life expectancy of the particular patient. Bioprostheses should be used after 74 years in men and 78 years in women.

Carpentier-Edwards supraannular porcine bioprosthesis in aortic position: 16-year experience.

BACKGROUND: The aim of the study was to evaluate the long-term results of aortic valve replacement with the Carpentier-Edwards supraannular porcine bioprosthesis. METHODS: A total of 278 patients who underwent aortic valve replacement between January 1983 and December 1986 were reviewed. Mean age was 69.4+/-11.0 years (range 24 to 90 years). RESULTS: The operative mortality was 8.6% (24 patients). The total follow-up was 2367.1 years (mean 9.3+/-4.3 years, maximum 15.5). The late mortality rate was 6.8%/patient-year (162 patients) and the overall survival at 15 years was 26.5%+/-3.6%. Structural valve deterioration (SVD) occurred in 19 patients (linearized rate 0.8%/ patient-year). The mean time to onset of deterioration was 10.9+/-2.9 years. This time was independent of the age at the time of implantation. The freedom from SVD at 10, 12, and 15 years for patients aged less than 60 was respectively 87.6%+/-6.8%, 77.8%+/-8.9%, and 44.2%+/-12.9% (linearized rate 3.3%/patient-year). For patients aged 61 to 70 years, freedom from SVD was, respectively, 100%, 97.3%+/-2.1%, and 80.8%+/-8.3% (linearized rate 0.63% patient-year). For patients older than 70 years, it was respectively 99.1%+/-0.9%, 95.6%+/-2.6%, and 93.3%+/-3.3% (linearized rate 0.31%/patient-year). No significant difference was observed below the age of 60 years (< or =50 vs 51 to 60 years) or in the older subgroups (61 to 70 years, vs >70 years). CONCLUSIONS: The Carpentier-Edwards supraannular bioprosthesis in aortic position provides low rate of structural valve deterioration at 15 years in patients aged more than 60 years at the time of implantation. The mean time to onset of SVD is independent of the subject's age at the time of implantation. After 60 years, the risk of deterioration is low and does not present any significant variation. The Carpentier-Edwards supraannular bioprosthesis can reliably be used for aortic valve replacement in patients over the age of 60 years because, beyond this age, SVD is observed much more rarely.

Azygos vein aneurysm: contribution of transesophageal echography.

We report a case of idiopathic aneurysm of the azygos vein associated with lung cancer. This abnormality is exceptional because we could find only 8 previous published cases. Computed tomographic scan and especially transesophageal echography were of major importance in identifying the vascular nature of the radiographic abnormality and thus excluding extension of lung cancer.

Serum and tissue distribution of a fragment of cytokeratin 19 (cyfra 21-1) in lung cancer patients.

A sensitive and relatively specific tumoral marker for lung epidermoid carcinomas could be used to identify patients likely to benefit from new therapeutic protocols. The cyfra 21-1 fragment of cytokeratin 19 has raised much hope in this regard amongst both technologists and clinicians. In a study of 195 subjects, we have shown by means of a serum assay that the usual cut-off value for this marker (3.3 ng/ml) can be lowered to 1.5 ng/ml without loss of specificity, and with an increase in sensitivity. There was a good correlation between serum marker level and tumor extension, but though cyfra 21-1 was not predictive of the suitability of a patient for surgery. A decrease of cyfra-21-1 was observed after complete resection of the tumor. There was no relation between serum assay results and immunohistochemical findings.

Echocardiographic assessment and preliminary clinical results after aortic valve replacement with the Medtronic Mosaic bioprosthesis.

BACKGROUND AND AIM OF THE STUDY: The study aim was to examine prospectively the clinical performance and durability of the Medtronic Mosaic bioprosthesis, a stented porcine aortic valve that combines improvements in tissue preservation, notably net zero differential pressure fixation of the leaflets, with antimineralization treatment using 2-amino-oleic acid (AOA). METHODS: A total of 158 Mosaic valves was implanted; 152 in patients aged over 70 years, and six in patients aged <70 years with contraindications to anticoagulant therapy. Mean age was 73.7 years. All valves were implanted in the supraannular position. Thirty-two patients (20%) required concomitant procedures, including coronary revascularization, ascending aorta replacement and/or mitral annuloplasty. Postoperative anticoagulation (heparin) was prescribed for ten days, followed by antiplatelet therapy. No long-term oral anticoagulants were prescribed, except in some patients with atrial fibrillation. The follow up included routine clinical and blood work-up, and echocardiography at six months and one year after surgery. RESULTS: There were seven early (0-30 days) and five late deaths (>30 days). One death was caused by a hemorrhagic stroke at three months in a patient without anticoagulant or antiplatelet therapy. No thromboembolic complications or structural valve deterioration were observed during follow up. At two years, freedom from endocarditis and reoperation was each 99.6%. NYHA class was excellent, with 98% of patients in class I or II at one year. Patient survival was 92% at two years. Hemodynamically, the valve was performing well, with mean systolic gradients of 13.6, 13.2, 12.6 and 9.6 mmHg for the 21, 23, 25 and 27 mm valves, respectively. There was no evidence of structural valve deterioration. CONCLUSION: Long-term evaluations are mandatory to confirm the durability of any new bioprosthetic valve. Satisfactory early clinical and hemodynamic results with the new Mosaic bioprosthesis warrant its continued implantation in the aortic position for patients over the age of 70 years.

Structural durability in Carpentier Edwards Standard bioprosthesis in the mitral position: a 20-year experience.

BACKGROUND AND AIM OF THE STUDY: Few long-term data are available on the Carpentier-Edwards Standard bioprosthesis in the mitral position. As for other bioprostheses, patient age at the time of implant is the main risk factor for structural deterioration, but no published report has analyzed the life-span of these bioprostheses with respect to this parameter. METHODS: A series of 139 patients who underwent mitral valve replacement with the Carpentier-Edwards Standard bioprosthesis between 1978 and 1987 was reviewed. Mean age at implant was 59.6+/-14.7 years (range: 17-79 years). Follow up was 98.4% complete; total follow up was 1,078.7 patient-years (pt-yr) (mean 8.4+/-4.1 years). Mean follow up in the subgroup of patients alive at the time of the survey was 10.4+/-3.4 years. RESULTS: Structural valve deterioration (SVD) occurred in 30 patients, with mean time to onset of deterioration 9.0+/-2.7 years (median 8.7 years). This time was independent of age at the time of implantation. Analysis by age group (< or =35, 36-50, 51-60, 61-65, 66-70, >70 years) showed deterioration to be more frequent in younger subjects (linear rates 7.9, 6.0, 3.3, 2.4, 0.6 and 0.4% pt-yr, respectively). Over the age of 65 years, the risk of SVD no longer varied with age, and was a rare complication. CONCLUSION: The mean time to onset of SVD was independent of patient age at the time of implant. After 65 years, the risk of SVD was low, without any significant variation. The Carpentier-Edwards Standard bioprosthesis may be used in the mitral position in subjects aged over 65 years, and with a low risk of deterioration.

Aortic valve replacement for aortic stenosis in 200 consecutive octogenarians.

From 1978 to 1992, 200 consecutive patients aged between 80 and 90 years had aortic valve replacement for calcified aortic stenosis. Valve replacement was isolated in 187 cases (93.5%), and it was in combination with coronary bypass (n = 12; 6%), mitral valve replacement (n = 1; 0.5%) or surgery of the ascending aorta (n = 4; 2%). These 200 octogenarians represented 7.4% of the 2716 patients operated for aortic stenosis during the study period. One hundred and forty-eight of them (74%) were in NYHA class III or IV. Operative mortality was 11.5% (23 deaths) and the mean duration of hospitalization was 12.7 +/- 4.83 days. After discharge, all 177 surviving patients were followed up for a mean period of 2.8 +/- 2.1 years (range one month to 10.6 years). There have been 49 deaths during the follow up. At the end of the follow up, 127 of the 128 survivors (98.6) were in NYHA classes I or II. Actuarial survival at one, three and five years was 81.7%, 74.8% and 57.14% respectively, which is equivalent to the life expectancy for subjects of the same age without aortic stenosis. It is suggested that despite the increased, yet acceptable, operative risk, valve replacement in octogenarians is justified due to its beneficial effect on life expectancy and quality of life.

Prospective evaluation of coronary arteries: influence on operative risk in coronary artery surgery.

OBJECTIVE: Coronary angiography data included in the analysis of operative mortality after coronary artery surgery are generally limited to left main coronary artery stenosis and classification into one-, two- or three-vessel disease, but the role of stenoses and quality of distal runoff on each main coronary artery have never been analysed. The aim of this study was to assess the influence of coronary artery status (stenoses and distal runoff) on operative mortality in patients undergoing coronary artery surgery. METHODS: Stenoses of the five main coronary arteries and their distal runoff were prospectively evaluated in a series of 2461 patients undergoing isolated coronary artery surgery. These angiographic variables were included in analysis of operative mortality in combination with conventional preoperative data. RESULTS: Univariate analysis founded 21 preoperative variables being significant: age >70, body surface area <1.8 m2, arterial disease of lower limbs, history of peptic ulcer, CCS class IV angina, unstable angina, post-infarction unstable angina, congestive heart failure, left ventricular ejection fraction <50%, urgency, preoperative intra-aortic balloon pump, previous myocardial infarction, previous cardiac surgery, previous coronary bypass graft, presence of significant stenosis on the left main coronary artery or the circumflex marginal branch or the distal circumflex artery or the right coronary artery, absence of significant stenosis on the left anterior descending artery, impaired distal runoff on the left anterior descending artery or the circumflex marginal branch (for all, P < 0.05). Multivariate analysis identified poor quality distal runoff in the left anterior descending artery and circumflex marginal branch as independent risk factor (P = 0.0005 and P = 0.04, respectively), while left main coronary artery stenosis was not. This lesion appears to be a significant risk factor only in a small subgroup of patients with CCS class IV angina. Other independent risk factors were CCS class IV angina, previous cardiac surgery, body surface area <1.8 m2, diabetes mellitus, age <70, history of peptic ulcer, left ventricular ejection fraction <50%. Impaired distal runoff or the presence of stenoses on the diagonal branch, right coronary artery, or distal circumflex artery does not significantly influence the operative mortality rate. CONCLUSIONS: The quality of distal runoff of the most frequently grafted vessels is a significant risk factor for operative mortality in coronary artery surgery. Left main coronary artery stenosis was not identified as a risk factor when these angiographic variables were included in the analysis. Functional status remains the most powerful predictive factor.

Feasibility of the utilisation of the right internal thoracic artery in the transverse sinus in off pump coronary revascularisation: early angiographic results.

OBJECTIVE: The objective of this study was to analyze the feasibility of beating heart coronary surgery and to angiographically assess complete revascularisations with routine use of the two internal thoracic arteries (ITA), with the right ITA pedicled and placed through the transverse sinus. The authors report the results of their initial experience of coronary surgery without CPB, which began in December 1998. METHODS: From December 1998 to October 1999, 50 patients underwent non-urgent beating heart coronary revascularisation via a median sternotomy with the 2 ITA. Stabilization of the anastomotic site was ensured by the Octopus stabilizer 1 then 2. A troponin Ic assay was systematically performed in the initial postoperative period. With the patient's consent, postoperative angiography was performed before discharge. RESULTS: The mean number of anastomoses was 2.5+/-0.6 per patient (range: 2-4). Distal anastomoses by arterial grafts were performed in 87% of cases. In one case, the right ITA could not be kept pedicled and tunnelled in the transverse sinus and a Y graft onto the left ITA had to be performed. Left anterior descending-diagonal sequential bypass with the left ITA was performed in seven patients (14%). There was no operative mortality. One patient developed postoperative myocardial infarction. Follow-up angiography was performed in 42 cases (84%), with 104 anastomoses reviewed (85%). The patency rate for all anastomoses was 98.1%, with 90.4% of excellent results. The patency rate of the right ITA was 100%, with 90.5% of excellent results. CONCLUSIONS: Beating heart coronary surgery allows revascularisation of all coronary territories. This technique is not an obstacle to the use of the pedicled right ITA tunnelled in the transverse sinus. It is not associated with an increased postoperative morbidity and mortality, and the early follow-up angiographic results are excellent.

Immunohistochemical expression of the intracellular component of galectin-8 in squamous cell metaplasia of the bronchial epithelium in neoplastic and benign processes.

Specified galectins are known to play a role in regulating cell proliferation, differentiation, adhesion and migration. Po66, a mouse IgG1 monoclonal antibody produced by immunization against squamous cell cancer, reacts against a carbohydrate-binding protein (Po66-CBP), recently shown to be a member of the galectin family with a strong homology with galectin-8 (PCTA-1), identified as a human tumor-associated antigen. We studied Po66 in squamous metaplasia of the bronchi in order to determine whether it could be specifically involved in neoplastic conditions and if so, if it would be helpful in distinguishing metaplasia at risk of cancer. Twenty-eight formalin-fixed, paraffin-embedded archival tissues of 17 metaplasias with SCC, 3 metaplasia with distant neoplastic disease and 8 metaplasias with an inflammatory process, were immunostained using a streptavidin biotin peroxydase method. The squamous metaplasias were positively stained in non-neoplastic disease as well as in neoplastic processes. Expression was also observed in stromal and normal cells. Po66-CBP was not associated with a pre-neoplastic character. We discussed the expression of this intra-cellular component of galectin-8 according to the functions of galectins in cellular differentiation, host reaction against tumor, and inflammation.

[Immediate and long-term results of replacement of the ascending aorta in aneurysm or dissection]. / Résultats immédiats et éloignés du remplacement de l'aorte ascendante pour anévrysme ou dissection.

Between April 1974 and November 1992, 181 patients were operated for aneurysm (106) or dissection (75) of the ascending aorta. Eighty patients had replacement with a valvular conduit with reimplantation of the coronary arteries (Bentall procedure), 48 had aortic valve replacement with replacement of the supra-coronary ascending aorta and 53 underwent isolated replacement of the ascending aorta. Twenty-nine patients (16%) died in the postoperative period, mainly of myocardial or neurological complications. Univariate statistical analysis completed by logistic regression analysis revealed the following predictive factors of early death: NYHA Stage IV, angina, reoperation for haemorrhage or tamponade (all < 0.05). All surviving patients were followed up (total follow-up: 788 years; mean: 62 months; range: 1 to 181 months). There were 20 secondary deaths, 40% of which were related to complications of aortic valve replacement. The 5 and 9 year survivals were 76 and 70% respectively, perioperative mortality included, and 89% of patients were in NYHA functional Stage I. Analysis of survival data did not reveal any predictive factor of secondary death. Eight patients were reoperated at long-term. The operative mortality of replacement of the ascending aorta remains high, especially in cases of dissection. The long-term results seem excellent with a low reoperation rate. Late mortality seems mainly due to complications of aortic valve replacement.

[A study of predictive factors of the operative risk in the surgery of aortic valve stenosis in aged patients]. / Etude des facteurs prédictifs du risque opératpore dans la chirurgie du rétrécissement aortique des patients âgés.

Aortic stenosis, the most extensive form of valvular disease in elderly subjects, has become very common because of demographic reasons in industrialised countries. The operative risk in patients over 70 years of age is significantly higher. The progressive rise in age of patients referred for surgery justifies this analysis of predictive factors of operative mortality. Between 1976 and February 1993, out of 2871 aortic valve replacements, 675 (278 men and 397 women) patients were over 75 years of age and were included in this study. The average age was 78.5 +/- 3 years. Associated pathology was present in 226 patients. A bioprosthesis was chosen in 632 cases (93.6%). An associated surgical procedure was required in 133 cases. The operative mortality was 12.4 +/- 1.3% (84 deaths). Longitudinal analysis was performed for 4 successive periods to assess the outcome of the study population over the 17 years. A statistical study was made of 50 variables and multivariate analysis showed age (p < 0.0001), left ventricular failure (p < 0.0001), non sinus rhythm (p < 0.0005) and emergency procedures (p < 0.02) to be independent preoperative predictive factors of mortality. In order to reduce this risk, the authors recommend early surgical referral to avoid emergency procedures and cardiac failure, and increased efforts of myocardial protection during cardiopulmonary bypass. Despite the risk, surgery is the only radical treatment of aortic stenosis, including elderly patients.

[Changes in operative risk and its predictive factors in coronary surgery]. / Evolution du risque opératoire et de ses facteurs prédictifs en chirurgie coronarienne.

The operative risk of coronary bypass surgery has been reported by many surgical groups. Although the 1970's were characterised by a progressive decline in this risk related to improved surgical techniques and myocardial protection, the following decade saw a new rise in operative mortality. In order to assess this problem, the authors undertook a review of 3,632 consecutive cases of coronary bypass surgery (without any other procedure) from 1982 to 1991. The operative risk increased from 2% in 1982 to 7.7% in 1989 and was related to an increase in patients' age, in left ventricular dysfunction and in the number of emergency and redux operation. The development of interventricular cardiology in the last few years (angioplasty for double or triple vessel disease, thrombolysis in the acute phase of myocardial infarction) has also increased the number of patients operated as emergencies with a high operative risk. The reduction of the operative risk observed since 1989 is due to better overall management (pre, per and postoperative), especially of the high risk patients (patients over 70 years of age, women, left ventricular dysfunction, left main coronary stenosis, emergencies, reoperation). Although many variables indicating extramortality were found to be statistically significant (p < 0.05) on univariate analysis, multivariate analysis by two year periods showed the following independent prognostic factors of operative mortality: persistence of the concept of "emergency surgery" throughout the period under study and, from 1986, the appearance of gender and NYHA Class; and, from 1988, the factor "reoperation" with different values of "p" according to the years under consideration.

[Valvular replacement for aortic stenosis in octogenarians. Apropos of a consecutive series of 200 cases]. / Le remplacement valvulaire pour rétrécissement aortique chez les octogénaires. A propos d'une série consécutive de 200 patients.

From 1978 to 1992, 200 patients aged 80 to 90 (average 82.16 +/- 2.04 years) with calcific aortic stenosis, underwent isolated aortic valve replacement (187 cases, 93.5%), or associated with coronary bypass surgery (12 cases, 6%), or mitral valve replacement (MVR) (1 case, 0.5%), or surgery of the ascending aorta (4 cases, 2%). These 200 patients represented 7.4% of the 2,716 cases of aortic stenosis operated during the same period. One hundred and forty-eight patients (74%) were in NYHA classes III or IV. The operative mortality was 11.5% (23 patients) and the average hospital stay in the surgical department was 12.7 days (4.83%). The follow-up of the 177 patients who were discharged from hospital was complete (100%) with an average of 2.8 years +/- 2.1 (1 month to 10.6 years). Forty-nine secondary fatalities were observed (28%). Of the 128 survivors at the end of the study, 127 (98.6%) were in the NYHA classes I or II. The actuarial 1, 3 and 5 year survivals were 81.7, 74.8 and 57.1%, respectively. The survival curve of the operated patients was identical to subjects of the same age without aortic stenosis. Despite the high but acceptable operative risk due to the age, valvular replacement surgery is justified by the double benefit of increased longivity and improved quality of life.

[Return to work after cardiac valvular surgery. Retrospective study of a series of 105 patients]. / La reprise du travail après chirurgie valvulaire cardiaque. Etude rétrospective d'une série de 105 patients.

This was a retrospective study realised by a mailed questionnaire of the medical and socio-professional conditions of return to work in patients with valvular heart disease aged 20 to 59 and operated in the cardiac surgery department of Rennes University Hospital in 1998. The results concern 105 patients of whom 78 were working before surgery and 27 were unemployed, and 53 were professionally active after surgery. The average age was 48 +/- 9 years and the male/female ratio was 2.38. After surgery, 78.4% of patients were NYHA Stages I or II, compared with 38.1% before surgery. Three main surgical procedures were carried out, sometimes in association: aortic valve replacement (71.4%), mitral valve replacement (21%) and mitral valvuloplasty (11.4%). Valve replacement was with a mechanical prosthesis in 83% of cases, a bioprosthesis in 11% of cases and a homograft in 6% of cases. Return to work (67.9%) after an average of 5.3 +/- 3.9 months was correlated with the following factors: age: 50 years old patients or more, were less likely to return to work (p < 0.02); postoperative NYHA stage: patients in stages III and IV were less likely to return to work (p < 0.03); the time off work before surgery: the longer the time (threshold > 6 months) the less likely the patients are to return to work (p < 0.03). Return to work was preferred to non-return (p < 0.03). This study shows the difficulties of professional rehabilitation of patients despite a satisfactory general condition. This is partially explained by the difficult economic context which favorises invalidity but also by the lack of information concerning the role of works doctors in the return to work. The realisation of a liaison file with permission of the person concerned between the general practitioner, the cardiologist and a medico-social security doctor and works doctor should remedy the difficulties in communication and sustain a policy of return to work.

[Long-term results over 20 years of aortic valve replacement with the standard Björk-Shiley prosthesis]. / Résultats éloignés à 20 ans du remplacement valvulaire aortique par prothèse de Björk-Shiley standard.

Between January 1971 and December 1978, 865 standard Björk-Shiley prostheses (spheric or conic carbon disc) were implanted in the Department of Thoracic and Cardiovascular Surgery of the University Hospital of Rennes. Three hundred and fifty seven consecutive patients who underwent isolated aortic valve replacement were included in the study : 246 men (69%) and 111 women (31%) with an average age of 57.5 years (range : 24-80 years). One hundred and sixty eight patients (48%) were in NYHA Class II. 141 (39%) in Class III and 48 (13%) in Class IV. The valvular disease was stenotic in 304 cases (85%) and regurgitant in 53 cases (15%). The hospital mortality was 35 (9.8%). The main causes of death were cardiac (23 cases, 66%). The long-term results contain 322 survivors of surgery (mean follow-up 12 years, follow-up rate 99%, representing 3726 patient-years). The actuarial survival (including hospital mortality) was 76% at 5 years. 61% at 10 years, 47% at 15 years and 26% at 20 years. The average age of the survivors at present is 71 years and 95% are NYHA classes I or II. The causes of the 171 late fatalities were cardiac in 49 cases (1.3% per patient-year). Death was related to the prosthesis in 32 cases (0.8% per patient-year) : 3 endocarditis, 17 bleeding complications, 12 systemic emboli. Deaths were extracardiac in 58 cases (1.5% per patient-year). Prosthesis-related complications were : 9 paravalvular leaks (0.2% per patient-year), 3 dysfunctions (0.1% per patient-year). 24 haemorrhages (0.6% per patient-year), 5 thromboembolic episodes (0.1% per patient-year). 5 endocarditis (0.1% per patient-year). No structural abnormalities of the prostheses were observed. The authors confirm the reliability of the standard Björk-Shiley valve prosthesis in the aortic position and the value of the aortic valve replacement by a mechanical prosthesis even at very long term.

[Mitral valve replacement in postinfarction mitral insufficiency. Immediate and long-term results apropos of a series of 39 surgically-treated patients]. / Le remplacement valvulaire mitral dans l'insuffisance mitrale postinfarctus. Résultats immédiats et à long terme à propos d'une série de 39 opérés.

Thirty nine patients, mainly males (84.6%) with an average age of 66 years underwent mitral valve replacement for postinfarction mitral regurtation between March 1971 and December 1987. Twenty four were in Class IV of the NYHA Classification, 9 in Class III and 6 in Class II. All had a history of myocardial infarction predominantly of the inferior wall. The 33 preoperative coronary angiogrammes showed 13 patients with triple vessel disease, 15 with double vessel disease and 5 with single vessel disease. At operation, 13 patients had ruptured papillary muscles; acute dysfunction was observed in 16 and chronic in 10 patients. The hospital mortality was 36%; over three quarters of deaths were due to myocardial dysfunction. Twenty two patients had an associated myocardial revascularisation procedure with mitral valve replacement. All 25 survivors were followed up for an average of 2.3 years (94 patient-years). The 5 year actuarial survival (operative mortality included) was 55% and 77% of the 17 survivors are in Stages I or II of the NYHA Classification. The quality of these long-term results justifies surgery despite the high operative risk.

[Long-term results of valve replacement using the Cobomedics prosthesis]. / Résultats éloignés des remplacements valvulaires avec la prothèse Carbomedics.

The Carbomedics valve prosthesis is a second generation mechanical prosthesis with a double hemi-disc. This study analysed long-term morbidity and mortality associated with this prosthesis. Between 1987 and 1996, 397 prostheses were implanted, 306 aortic, 42 mitral and 26 double replacements (3 combining a Carbomedics aortic prothesis with a mitral valve from another type) in 370 patients with a mean age of 62 (range 4 to 88 years). The global operative mortality was 7.4%. A questionnaire sent to treating cardiologists, general practitioners and patients updated the prospective data base of the cardiac surgical department. The follow-up was 99%, representing a total of 1244 patient-years with an average of 41 months (range 1.1 month to 9.9 years). The 1, 3, 5 and 7 year survival (operative mortality included) was 88%, 80%, 76% and 69.6% respectively. Haemorrhagic complications were the most common (17 cases, 1.36% per patient-year) and 11 thromboembolic episodes were observed (0.88% per patient-year) with a higher incidence (p < 10-4) in mitral valve replacement (3.8% in patient-year). The other complications observed were: 5 aseptic paravalvular leaks (0.4% per patient-year) and 5 prosthetic valve infections; no structural alterations were observed. In all, ten reoperations (0.8% per patient-year) were required for prosthetic valve complications. This study shows the reliability of Carbomedics valve prostheses with a low complication rate comparable to that of other modern mechanical valve prostheses.