Orthotopic cardiac transplantation with direct caval anastomosis: is it the optimal procedure?

Total excision of the right atrium with a minimal cuff of left atrium remaining around the four pulmonary veins, followed by direct anastomoses on venae cavae, has been proposed as an alternative to the standard procedure described by Shumway and Lower for orthotopic cardiac transplantation. To investigate whether this "anatomic" transplantation should be proposed as the optimal procedure, we prospectively randomized 78 patients having 81 procedures since 1991 into two groups: group I, standard transplantation (n = 40), and group II, "anatomic" transplantation (n = 41). The two groups were statistically similar in recipient age, sex, weight, disease, and status at the time of transplantation. Also similar were donor age, sex, weight, and drug dependency at the time of harvesting. All patients could be weaned from cardiopulmonary bypass with comparable graft ischemic times (group I, 136 +/- 46 minutes; group II, 138 +/- 51 minutes). Immediate recovery of sinus rhythm occurred in 20 cases of group I and 36 cases of group II. Delayed recovery of sinus rhythm in the first postoperative week occurred in 15 cases of group I and 5 cases of group II. Persistence of atrial arrhythmia occurred in 5 cases of group I and never in group II. These differences were highly significant (p < 0.001). Postoperative hemodynamics showed a higher cardiac index at day 1 in group II (4.12 +/- 0.85 L/min per square meter) than in group I (3.77 +/- 0.65 L/min per square meter) (p = 0.04). There were 13 early deaths in group I and 8 early deaths in group II. One death in group I was related to an acute atrioventricular block at 3 weeks with no evidence of cardiac rejection at histologic examination. Two patients in group I (5%) required definitive pacemaker implantation for prolonged sinus node dysfunction. Echocardiographic and Doppler studies of survivors have been performed 2 to 3 months after transplantation. Right atrial area was significantly reduced (p < 0.01) in group II (18 +/- 4.7 cm2) versus group I (24 +/- 7 cm2), as was left atrial area (group I, 24 +/- 4.5 cm2; group II, 20 +/- 5 cm2) (p = 0.01). Mild tricuspid regurgitation was observed in 82% of group I patients versus 57% of group II patients (p < 0.05), inasmuch as mitral regurgitation was comparable (71% in group I, 67% in group II).(ABSTRACT TRUNCATED AT 400 WORDS)

Cardiac troponin I release after open heart surgery: a marker of myocardial protection?

BACKGROUND: Unlike creatine kinase MB isoenzyme, cardiac troponin I (cTnI) is a highly specific marker of myocardial injury. Its release has recently been studied after coronary artery bypass grafting operation. However, its significance after open heart surgery (OHS) remains to be determined. This protein release could be a marker of myocardial protection. We sought to study cTnI release after OHS in patients with normal coronary arteries and to compare it with cTnI release in patients after coronary artery bypass graft (CABG) surgery. METHODS: Eighty-five patients undergoing OHS and 86 patients undergoing CABG were enrolled in the study. CTnI concentrations were measured in serial venous blood samples drawn before surgery and immediately, 12 hours, 24 hours, 48 hours, and 5 days after aortic unclamping. RESULTS: In the OHS group and in the CABG group without acute myocardial infarction (AMI), cTnI peaked at 12 hours postoperatively (6.35 +/- 6.5 and 5.38 +/- 8.55 ng/mL, respectively) and normalized on day 5 postoperatively (0.57 +/- 2 and 0.72 +/- 1.62 ng/mL, respectively). CTnI concentration did not differ significantly between the OHS group and the CABG group in the absence of AMI for any samples considered. In the CABG group, 2 patients had AMI. In the OHS group, cTnI levels at 12 hours postoperatively were found to correlate closely with CPB and aortic cross-clamping (ACC) times, contrary to the CABG group, which correlated only with occurrence of AMI. CTnI release was independent of age and ejection fraction in either group. CONCLUSIONS: cTnI release in patients after OHS with normal coronary arteries has the same profile as cTnI release in patients after CABG in the absence of AMI. However, its peak at 12 hours postoperatively is only correlated to ACC and CPB times, which is contrary to cTnI release after CABG surgery. This observation suggests that cTnI could be a marker of myocardial ischemia after OHS.

Closed drainage using redon catheters for poststernotomy mediastinitis: results and risk factors for adverse outcome.

BACKGROUND: Several different surgical techniques have been described for the treatment of poststernotomy mediastinitis. The present study was undertaken to evaluate the midterm results of primary closed drainage using Redon catheters and to identify risk factors for adverse outcome. METHODS: Hospital records of 72 patients in whom poststernotomy mediastinitis developed and who underwent closed drainage with Redon catheters between April 1, 1996, and December 31, 1999, were reviewed. Follow-up was complete and averaged 11.8 +/- 11.5 months. RESULTS: Of the 25 deaths (34.7%) recorded, 15 were directly attributable to mediastinitis. Actuarial estimates for freedom from mediastinitis-related death were 80.1% at 1 month and 77.4% at 1 year, 2 years, and 3 years. Logistic regression identified older age (odds ratio, 1.1; 95% confidence interval, 1.02 to 1.18), incubation time of 14 days or less (6.5; 1.33 to 31.4), and methicillin-resistant Staphylococcus aureus (5.8; 1.2 to 27.2) as independent risk factors for mediastinitis-related death. Reintervention for recurrent mediastinitis was necessary in 9 patients (12.5%) and occurred at a mean interval of 18.7 +/- 13.5 days from the first debridement. Actuarial estimates for freedom from reintervention were 87.1% at 1 month and 85.2% at 1 year, 2 years, and 3 years. The combined end point of treatment failure (mediastinitis-related death or reintervention) was recorded in 9 patients (26.4%). Actuarial estimates for freedom from treatment failure were 74.3% at 1 month and 72.7% at 1 year, 2 years, and 3 years. Logistic regression identified older age (1.01; 1.02 to 1.18), preoperative renal insufficiency (6.8; 1.04 to 44.5), and methicillin-resistant S aureus infection (4.8; 1.04 to 22.33) as independent risk factors for treatment failure (includes mediastinitis-related death and reintervention [with or without death]). CONCLUSIONS: Primary closed drainage using Redon catheters is an effective and simple treatment for most patients in whom poststernotomy mediastinitis develops. However, patients with methicillin-resistant S aureus infection or recurrent mediastinitis may benefit from a more aggressive approach.

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.

Severe aortic stenosis in octogenarians: is operation an acceptable alternative?

From 1981 to 1989, 60 patients more than 80 years of age were referred for operation for severe calcific aortic stenosis. All patients were symptomatic: 13 in New York Heart Association (NYHA) functional class II, 28 in class III, and 19 in class IV. The preoperative mean cardiothoracic ratio was 0.58 +/- 0.09; the mean valve area, 0.52 +/- 0.14 cm2; and the mean aortic valve gradient, 62 +/- 18 mm Hg. Left ventricular function was impaired in 30 patients (ejection fraction less than 0.40). Coronary arteriography was performed in 10 patients. Aortic replacement used bioprosthesis in all 60 patients associated with aortocoronary bypass (in 5) and mitral valve replacement (in 1). One-month mortality rate was 28% (17 patients) due to cardiac failure (in 9), pulmonary complications (in 6), and neurological complications (in 2). Early mortality was not correlated with preoperative angina, cardiothoracic ratio, associated operation, and cross-clamping time. It was not obviously correlated with preoperative functional class but correlated positively with urgent operations and with left ventricular function (40% mortality in patients with ejection fraction less than 0.40 versus 16% mortality in others). Hospital morbidity was 68%. Mean hospitalization was 15 +/- 7 days. There were four late deaths. Thirty-nine patients are long-term survivors (3 months to 7 years): 27 in class I, 10 in class II, and 2 in class III due to primary valve failure. The actuarial survival probability is 65% at 1 year and 61% at 5 years. In summary, the good long-term quality of life justifies the high postoperative risk in octogenarians. Early operation before cardiac function impairment improves the results.

Preservation of the aortic valve in acute aortic dissection: long-term echocardiographic assessment and clinical outcome.

The aim of the present study was to determine the long-term status of the native aortic valve after surgical treatment of acute aortic dissection involving the ascending aorta. From 1972 to 1991, 93 patients underwent operation for type I or II aortic dissection. There were 76 men and 17 women. Mean age was 54 +/- 13 years. Eighty patients (86%) had a conservative procedure regarding the aortic root and aortic cusps: 74 had prosthetic replacement of the ascending aorta and 6, complete replacement of the aortic arch. Thirteen patients (14%) had simultaneous replacement of the aortic valve and the ascending aorta. The overall hospital mortality rate was 29% (27/93). The overall actuarial survival rate was 60.2% +/- 5.2%, 49.7% +/- 6.1%, and 35.9% +/- 8.1% at 5, 10, and 15 years, respectively. The survival rates for patients who had an ascending aortic procedure only were 63% +/- 5.5%, 54% +/- 6.5%, and 39% +/- 8.5% at 5, 10, and 15 years, respectively, and for patients who required aortic valve replacement, 45% +/- 14% and 22% +/- 17.5% at 5 and 10 years, respectively. Fifty long-term survivors (94% follow-up) with preservation of the aortic valve and aortic root were studied. Among them, 9 (18%) died within a mean interval of 97 +/- 46 months after operation. Causes of death were ischemic cardiac failure (2), aortic rupture or extension of dissection (4), renal disease (1), stroke (1), and sudden death (1). Forty-one patients had long-term clinical and echocardiographic evaluation.(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiographic demonstration of intracardiac glue after endoscopic obturation of gastroesophageal varices.

Systemic embolism is an unusual complication of endoscopic obturation of gastroesophageal varices with glue. This report describes a case of cerebral embolism after this procedure. Intracardiac glue within the left atrium was demonstrated by echocardiography. Cardiac fluoroscopy demonstrated an abnormal vessel connecting periesophageal veins with the right upper pulmonary vein. Cardiac surgery was performed. Intracardiac glue was removed and the entering orifice of the abnormal vessel in the right upper pulmonary vein was sutured. To our knowledge, this is the first reported case of intracardiac glue after variceal obturation. Echocardiography is useful in the diagnosis of this rare complication.

Silzone-coated St. Jude medical valve: a safe valve.

Careful follow up studies in patients receiving a Silzone-coated St. Jude Medical valve (67 aortic valves, 36 mitral valves, nine double valves) did not support the fear of a high risk of perivalvular leak and embolism rate. Freedom from perivalvular risk at 12 and 24 months follow up was 98.5+/-1.5% and 100% for the aortic and mitral valves, respectively. Freedom from any thromboembolic event was 96.6+/-2.4% at 12 and 24 months follow up in the aortic group, and 97+/-3% at 12 and 24 months in the mitral group. The risk of bleeding (92.2+/-3.8% at 12 and 24 months in the aortic group; 85.5+/-6.0% in the mitral group) illustrated the risk of mechanical valve implantation in an elderly population.

Preliminary experience with Silzone-coated St. Jude medical valves in acute infective endocarditis.

BACKGROUND AND AIM OF THE STUDY: The rate of recurrent postoperative endocarditis after valve replacement in early-stage acute infective endocarditis is extremely high. Metallic silver coating of the sewing ring may improve the short- and long-term outcome after valve implantation. This report details our experience with the St. Jude Medical Silzone prosthesis in early surgical treatment of acute infective endocarditis. METHODS: Ten patients (mean age 66.4 years) referred for native valve or prosthetic valve endocarditis were operated on between April 1998 and June 1999. The microorganisms responsible for the acute infection were Staphylococcus (n = 1), Streptococcus (n = 1) and Pseudomonas aeruginosa (n = 1); blood cultures remained negative in two cases. The indication for surgical treatment was related to hemodynamic condition (n = 5), a major cerebral event (stroke; n = 1), annulus abscess (n = 1), and echocardiographic evidence of large cuspal vegetations (n = 3). All patients had received preoperative intravenous antibiotics (mean 7.8 days). Four mitral, five aortic valve replacements, and one double mitral-aortic valve replacement, were performed after extensive debridement of the infected and necrotic tissues. Mean duration of postoperative antibiotic treatment was 32.3 days. Postoperative follow up (mean 6 months; range: 2-14.2 months) was 100% complete, and included prospective repeated transthoracic echocardiography at one week, and one, six and 12 months postoperatively. RESULTS: One patient died early in the immediate postoperative period from pneumonia and major hypoxemia. All other patients are symptom-free, without evidence of recurrent infection and perivalvular leak. CONCLUSION: Although these early results with the St. Jude Medical Silzone prosthesis require confirmation by more extensive studies, they infer that silver coating of the sewing ring may dramatically improve management of patients with active endocarditis.

Lack of durability of the Mitroflow valve does not affect survival.

BACKGROUND AND AIM OF THE STUDY: The aim of the study was to compare the durability and risk of reoperation in patients undergoing isolated aortic valve replacement with either a porcine standard Carpentier Edwards or a Mitroflow pericardial valve. METHODS: Follow up evaluation was performed in 118 patients receiving a Mitroflow valve (M) and 94 patients receiving a standard Carpentier Edwards porcine valve (CE) between 1980 and 1987. The two groups were identical in terms of clinical characteristics; only prosthesis size differed, with small-sized valves used more frequently among the Mitroflow group. RESULTS: The risk of structural valve deterioration (SVD) was 2.3% per patient-year (pt-yr) in CE valves, and 5.4 per pt-yr in M valves. Freedom from SVD was 100%, 87 +/- 4% and 63 +/- 8% at 5, 10 and 15 years for CE valves, and 96 +/- 2%, 56 +/- 7% and 5 +/- 4% for M valves. Freedom of reoperation was 98 +/- 1%, 83 +/- 5% and 76 +/- 7% at 5, 10 and 15 years respectively for CE valves, and 94 +/- 2%, 55 +/- 7% and 11 +/- 9% for M valves. Despite the high number of valve-related reoperations, survival at 5, 10 and 15 years was not affected in M valve patients. Multivariate analysis (Cox model) showed that age and valve type were the two main risk factors for SVD and reoperation, though the latter factor had no impact on survival. CONCLUSIONS: In younger patients (aged < 75 years), the CE valves offer superior results to the M counterpart in valve replacement. However, in patients aged > 75 years, pericardial and porcine bioprostheses demonstrate equivalent durability, despite post-implantation tissue changes in the former material.

Are there indications for reconstructive surgery in severe mitral regurgitation after acute myocardial infarction?

From 1972 to 1988, early surgery were performed in 26 patients with acute mitral regurgitation (MR) unresponsive to medical management complicating a recent acute myocardial infarction (AMI). The indication was acute pulmonary oedema (11), major left ventricular insufficiency (5), cardiogenic shock (10). Surgery was performed within 3 weeks following AMI. Mitral lesions were as follows: rupture of chordae tendinae (9) of papillary muscle (6), haemorrhagic necrosis of one (17) or two (9) papillary muscles. The mitral annulus was never found to be enlarged. The LV posterior wall was necrotic in 23, with a septal rupture in 3 and a giant aneurysm in 5. Valve replacement was performed in all but one patient. The 30-day mortality included 8 patients (31%). The cause of death was myocardial insufficiency in 5, early thrombosis of a disk valve in 1 and unrelated complications in 2. One patient deteriorated rapidly and had a Jarvik device implanted. Late results (1 month-15 years) showed 4 cardiac related deaths within the first year. One patient had to be transplanted after 1 year. Two patients died of non-cardiac problems at 3 months and 5 years. The probability of survival at 5 years is 43% and at 10 years 22%. In conclusion, there are still indications for early surgery in MR post AMI. Anatomical lesions of both papillary muscles and ventricular wall do not allow conservative surgery and new non-invasive technics provide a more promising strategy in such desperately ill patients.

Combined heart and kidney transplantation using the same donor.

A 45-year-old man received a combined heart and kidney transplant provided by the same donor. The patient was in the terminal stage of renal failure and was submitted to 3 sessions of haemodialysis per week for 2 years before transplantation. A dilated cardiomyopathy with severe impairment of left ventricular (LV) function was discovered, precluding renal transplantation alone. In the postoperative course, a cardiac rejection episode was detected by echocardiography and documented by endomyocardial biopsy; no simultaneous rejection of the kidney could be detected. The patient was discharged after 2 months, and he resumed a normal and active life. The specific problems raised by the management of such multi-organ transplantation are briefly reviewed.

Pharmacological bridge to cardiac transplantation.

From September 1985 to August 1988, 32 patients were referred from various intensive care units throughout Paris for urgent cardiac transplantation or for a mechanical bridge to transplantation. At time of admission, under maximal sympathomimetic therapy, the cardiac index (CI) was 1.81 +/- 0.26 l/min per m2, the pulmonary capillary wedge pressure (PCWP 31 +/- 7 mmHg), systemic vascular resistances (SVR) 2053 +/- 469 dynes s cm-5. In 25, diuresis was less than 25 ml/h. Five were anuric. Prior to any final decision, a new inotropic agent, enoximone, was infused in addition to previous treatment as a 10 min bolus iv 1.5-2 mg/kg every 8 h. In 3, the situation further deteriorated, leading to a Jarvik 7-70 implantation within 12 h. In 29 however, within 3 h, the Cl increased to 2.69 +/- 0.56 as SVR dropped to 1410 +/- 453 and PCWP to 18 +/- 7. Diuresis increased to more than 100 ml/h in all. This permitted an indepth evaluation of the transplant candidates leading to contraindications to transplantation in 16. Nine patients could be weaned off iv enoximone. Four of these are still living (NYHA class III) with a follow up of 6-17 months. In 11, transplantation was performed within 2 days. Four died within a month, 2 with multiple organ failure. One patient died after 5 months. Six are back to normal life, NYHA class I (follow up 10 months-2.5 years). This protocol suggests that in patients with extreme heart failure, immediate survival may be increased by iv enoximone therapy, permitting a better selection of the recipients, more efficient pre-transplantation intensive care and consequently a decrease in the indications for a temporary mechanical bridge to a staged transplantation.

Irreversible drop of systemic vascular resistances in patients implanted with a Jarvik total artificial heart.

Maintenance of the body's perfusion by a total artificial heart (TAH) may result in physiological alterations to the circulatory system. Little has been said about modifications to systemic vascular resistances (SVR) during TAH assistance. This paper reports on two patients implanted with a Jarvik - 70 cc TAH, who died after 1 and 3 days, both with an irreversible drop of SVR related to a complete loss of vascular tone but not related to sepsis. Activation of multiple cascades of inflammation, triggered by the extracorporeal circulation (ECC), is maintained during TAH support. Desperately sick patients might not be able to face the vaso-active situations created by the inflammatory response.

[Long-term results of surgery for type A acute aortic dissection]. / Résultats à long terme du traitement chirurgical des dissections aortiques aiguës de type A.

The cases of 160 patients (126 men, mean age 57.5 +/- 13.3 years) operated consecutively as an emergency for a Stanford type A dissection of the aorta between 1980 and 2000 were reviewed. The cumulative follow-up was 716.7 patient-years with an average follow-up of 4.51 +/- 5.6 patient-years. The risk factors for early postoperative mortality (up to 3 months), late mortality (> 3 months) and reoperation (cardiac and/or vascular) were determined by multivariate analysis. The hospital mortality was 27.5%. Older ages, obesity, previous cardiac surgery, preoperative shock, medullary, renal or mesenteric ischaemia were significant risk factors for early mortality. The probability of actuarial survival was 66.1 +/- 3.8%, 57.7 +/- 4.2%, 52.2 +/- 4.6% and 45.3 +/- 5.5% respectively at 1, 5, 10 and 15 years. Chronic obstructive airways disease and a more recent operation date were significant risk factors for late mortality. Thirty patients underwent 37 reoperations after an average of 5.7 +/- 4.5 years. The actuarial probability for no reoperation was 96.9 +/- 1.8%, 74.7 +/- 5.3%, 60.8 +/- 6.8% and 39.3 +/- 9.1% at 1, 5, 10 and 15 years respectively. The presence of severe preoperative aortic regurgitation was the only significant risk factor for reoperation. Type A acute dissection of the aorta continues to have a high early mortality and a significant incidence of late complications. Patients with severe aortic regurgitation before surgery are at high risk for reoperation and should probably have more radical aortic repair at the initial operation.

[Pure epicarditis after surgical repair of atrial septal defect: a rare form of constrictive pericarditis. Apropos of a case]. / Epicardite pure après correction chirurgicale d'une communication interauriculaire: une forme rare de péricardite constrictive. A propos d'un cas.

The authors report a case of constrictive pericarditis occurring two years after surgical repair of an atrial septal defect in a 37 year-old-man. The diagnosis was made by right heart catheterisation and magnetic resonance imaging. The special feature of this clinical case was the exclusive localisation of the fibrosis on the visceral pericardium or epicarditis. The outcome was favourable after resection of the visceral pericardium respecting the parietal pericardium. Magnetic resonance imaging and right heart catheterisation performed 6 months after surgery were normal. Constrictive pericarditis is a classical complication of cardiac surgery but relatively rare after repair of an atrial septal defect. Isolated involvement of the visceral pericardium is rare and allows surgical correction by exclusive epicardectomy respecting the parietal pericardium.

[External ventricular support in primary cardiogenic shock]. / Dérivations ventriculaires externes dans le choc cardiogénique primaire.

Primary cardiogenic shock is a common condition with a high mortality rate. In this indication, mechanical assist plays an important part and has improved a lot over the last decade. The authors report their experience with the same assist device in patients with primary cardiogenic shock. Nineteen patients (9 dilated cardiomyopathies, 7 myocardial infarctions, 2 myocardities, 1 undetermined) were treated with an external mechanical ventricular assist device (Thoratec, Berkeley, U.S.). Fourteen patients received a biventricular assist and 5 had a uni-left ventricular assist device. Four of the 19 patients were completely weaned off their ventricular assist after 13, 27, 36 and 94 days, respectively. Ten patients underwent transplantation after an average of 43 days (range 8-95 days). Of the 19 patients, 7 had a portable console allowing autonomous ambulation. Five patients died under mechanical assistance (26.9%) and 3 patients died after transplantation. Three patients required temporary haemodialysis; 4 suffered embolic complications; 4 had mediastinal haemorrhages; 4 had bleeding from other sites, and 6 suffered from late tamponnade. Fourteen patients had at least one infectious episode. The authors conclude that, in patients referred for severe primary cardiogenic shock, the implantation of an external biventricular assist is a reliable option, allowing sequential weaning or being a bridge to transplantation in non-dependent patients, providing they are severely selected.

[Severe calcified aortic stenosis in patients aged 80 or older. Apropos of 65 cases surgically treated]. / Le rétrécissement aortique calcifié serré de l'octogénaire. A propos de 65 cas opérés.

From 1981 to 1989, 65 patients over 80 years were submitted to surgery for severe calcific aortic stenosis. Thirteen patients were in NYHA II, 31 in NYHA III, 21 in NYHA IV. Mean valve area was 0.52 +/- 0.14 cm2 and mean aortic valve gradient was 62 +/- 18 mmHg. Left ventricular function was altered (ejection fraction less than 40%) in 33 patients. Six patients had a previous balloon aortic valvuloplasty. Bioprosthesis were used in all 65 patients associated to CABG (in 5) and mitral valve replacement (in 1). One month mortality was 19 cases (29%) due to cardiac failure (in 10) pulmonary (in 7) and neurological (in only 2) complications. Early mortality was nearly significantly correlated to NYHA stage (p = 0.08) and preop renal insufficiency (p = 0.07). It was significantly correlated to function (40% mortality when ejection fraction less than 40%, 16% in others) and to operations on emergency basis (5 deaths over 6). Hospital morbidity was 68%. There were 5 late deaths. Among the 41 long-term survivors (3 mths-7yrs) 29 are in NYHA I, 10 in NYHA II and 2 in NYHA III due to valve failure. The actuarial survival probability is 65% at one year, 50% at 5 years. In summary good long-term results justify to take a high post operative risk in octogenarians. Early surgery before left ventricular impairment improves the survival.

[Preservation of the aortic valve in acute dissection of the ascending aorta]. / Préservation de la valve aortique dans les dissections aiguës de l'aorte ascendante.

The aim of this study was to evaluate the status of the native aortic valve in patients operated for acute dissection of the ascending. aorta (ADAA). Between November 1972 and November 1991, 93 patients were operated for ADAA. There were 76 men and 17 women (average age 54 +/- 12 years). The aortic valve was reserved in 80 cases (86%). In 13 patients (14%) aortic valve replacement was associated with replacement of the ascending aorta. The early mortality was 29% (27/93). The global actuarial survival rates at 5, 10 and 15 years were 60.2 +/- 5.2%, 49.7 +/- 6.1% and 26.9 +/- 9.9% respectively. Fifty patients (94%) in whom the native aortic valve was preserved were followed up. Nine patients (18%) died and average of 97 +/- 46 months after surgery. The causes of death were aortic rupture or extension of the dissection (N = 4), ischemic cardiac failure (N = 2), renal failure (N = 1), cerebrovascular accident (N = 1) and sudden death (N = 1). Forty one patients underwent transthoracic echocardiography. Seven patients developed severe aortic regurgitation, 6 of whom had to be reoperated for aortic valve replacement. Echocardiography showed absence of of minimal aortic regurgitation in 22 cases and mild aortic regurgitation with normal left ventricular function in 12 cases (in 2 cases, aortic valve replacement was associated with surgical treatment of another valvular lesion or of coronary artery disease). Therefore, aortic valve replacement was performed in 8 patients 61.5 +/- 51.2 months after the initial operation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Coronary reoperations: indications and results]. / Réinterventions coronaires: indications et résultats.

The aim of this study was to assess the results of coronary reoperations and to determine the indications. Between January 1972 and December 1990, 166 coronary reoperations were performed in 161 patients (5 patients were operated three times). The interval between the first and second operation was 93 +/- 46 months. The interval between recurrence of symptoms and reoperation was 27 +/- 40 months. Recurrence of symptoms was related to isolated problems with the bypass grafts in 23% of cases, to an aggravation of the coronary disease without problems with the bypass grafts in 17% of cases and to an association of the two conditions in 60% of cases. Mortality in the first 30 postoperative days was 7.8% (13/161). The predictive factors of mortality were age over 70 years and an interval between recurrence of symptoms and reoperation of over 12 months. The causes of death were myocardial infarction (n = 5), left ventricular failure (n = 4), sudden death (n = 3), and arrhythmias (n = 1). The average follow-up period of survivors (n = 134) was 40 +/- 32 months. Four patients have been transplanted. Seven patients died secondarily. The cause of death was cardiac in 4 cases and non-cardiac in 3 cases. The actuarial 5 year and 10 year survival rates were 85 +/- 3%. Actuarial absence of myocardial infarction, angina, Class III-IV cardiac failure and transplantation was 87 +/- 4% at 5 years and 69 +/- 10% at 10 years. These figures show that coronary reoperation gives good functional results and long-term survival.(ABSTRACT TRUNCATED AT 250 WORDS)