Early and late hemodynamic evaluation after cardiac transplantation: a study of 28 cases.

Right heart catheterization was performed in 28 patients 1 week and 6 to 24 months after orthotopic cardiac transplantation. All patients were receiving cyclosporine and methylprednisolone orally. At early catheterization, right heart pressures as well as pulmonary capillary wedge pressure still remained above normal values in the majority of patients. Systemic arterial hypertension was already present in 29% of the patients and cardiac index was usually in the normal range, without any inotropic support. Results of late catheterization showed continuing improvement with return of right heart pressures to normal values in most but not all patients. Systemic arterial hypertension was noted in nearly all patients and is likely to be the result of hypervolemia secondary to cyclosporine-induced sodium retention. The increase in cardiac index, which was above normal values in 39% of the patients, was also consistent with hypervolemia in the setting of cardiac denervation. Thus, cardiac function at rest is satisfactory at short- and long-term assessment after cardiac transplantation, but the development and persistence of systemic arterial hypertension associated with cyclosporine use are a matter of concern in such patients.

Peripheral extracorporeal membrane oxygenation (ECMO) in patients with posttransplant cardiac graft failure.

INTRODUCTION: We sought to report the usefulness of extracorporeal membrane oxygenation (ECMO) in heart transplant patients. PATIENTS: Between March 2002 and August 2004, 14 heart transplant patients (11 men and three women, 36 +/- 15 years old, range = 12 to 50) with primary graft failure underwent peripheral ECMO implantation. Three patients had pulmonary hypertension and three had been transplanted with hearts from marginal donors. At the time of implantation, all were in severe cardiogenic shock despite maximal inotropic support. In six patients, the ECMO was implanted in the operating room since cardiopulmonary bypass could not be weaned. In the eight remaining patients, ECMO was implanted in the intensive care unit, during the first 48 hours in seven cases. In one patient, implantation was performed during external resuscitation. In all cases, femoral vessels were canulated using the Seldinger technique after anterior wall exposure. Distal arterial perfusion of the lower limb was systematically used. RESULTS: Pump outflow was high enough in all the cases (mean: 2.6 +/- 0.2 L/min/m(2)). Three patients died on circulatory support. One patient was implanted with a total artificial heart after a few hours and another one underwent unsuccessful emergent retransplantation. Nine patients were weaned from ECMO after a mean duration of 5 +/- 2.5 days. Among them, one died of infection at 10 days after weaning and seven others were discharged to rehabilitation centers. CONCLUSION: Fast operating room or bedside implantation of a peripheral ECMO allows the physician to stabilize the hemodynamic status of patients with cardiac graft failure, potentially leading toward myocardial recovery.

Chronic disease of the ascending aorta. Surgical treatment and long-term results.

Between January 1979 and December 1991, we operated on 339 patients for chronic disease of the ascending aorta. The operation was elective in all. Endocarditis and its sequelae have been excluded. Thirty-one patients had a previous operation on the ascending aorta or the aortic valve; 268 patients had aneurysms of the ascending aorta without dissection; 72 had chronic aortic dissections, of whom 33 had a preexistent aneurysm. The patients included 272 men and 67 women. Mean age was 53.58 +/- 7 years. Eight percent of the patients had clinical stigmata of Marfan's disease. A tubular graft replacement was used in 7 patients, a tubular graft and valve replacement in 72 patients, and a composite valve graft replacement with reattachment of the coronary arteries using a 8 mm Dacron graft was performed in 260 patients. Concomitant procedures were used in 74 patients: coronary artery bypass grafts in 25, mitral valve replacement in 9, and aortic arch reconstruction in 40. The 30-day mortality rate was 7.6% (n = 26). For the whole group, multivariate analysis using stepwise logistic regression showed that operative risk factors were concomitant coronary artery bypass grafting, age (increased), aortic valve regurgitation, and previous cardiac surgery. Follow-up was conducted in 303 patients, and risk factors for late mortality were studied. Long-term survival was 59.6% +/- 3.7% at 9 years. It was 67% +/- 3.5% at 9 years for patients without aortic arch reconstruction and 56% +/- 4.5% for patients with aortic arch reconstruction (p = 0.0018). Reoperation was needed in 14 patients. Actuarial freedom from reoperation was 90% +/- 0.2% at 9 years for all the patients. Only one patient with composite valve graft replacement and reattachment of the coronary arteries had required reoperation for problems related to this procedure. This technique is used routinely by our team, especially in patients with large chronic aneurysms, dissected or not, and in those who had previous operations. The long-term results are good.

Bridge to transplantation with the Jarvik-7 (CardioWest) total artificial heart: a single-center 15-year experience.

BACKGROUND: At our institution, the total artificial heart (TAH) Jarvik-7 (CardioWest) has been used since 1986 as a bridge to transplantation for the most severely ill patients with terminal congestive heart failure. METHODS: Between 1986 and 2001, 127 patients (108 males, mean age 38 +/- 13) were bridged to transplantation with the Jarvik-7 TAH. All were in terminal biventricular failure despite high-dose inotropic support. Nine patients had a body surface area (BSA) of <1.6 m(2). In Group I patients (78%), the etiology of cardiac failure was dilated cardiomyopathy, either idiopathic (n = 60) or ischemic (n = 38). The other 29 patients (Group II) had disease of miscellaneous origin. We analyzed our experience with regard to 3 time periods: 1986 to 1992 (n = 63); 1993 to 1997 (n = 36); and 1998 to 2001 (n = 33). RESULTS: Although Group II patients represented 30% of indications before 1992, they comprised only 15% during the 2 subsequent periods. Duration of support for transplant patients increased dramatically after 1997, reaching 2 months for the most recent period (5 to 271 days). In Group I, the percentage of transplanted patients increased from 43% before 1993 to 55% between 1993 and 1997, and reached 74% thereafter. The major cause of death was multiorgan failure (67%). The clinical thromboembolic event rate was particularly low with no instance of cerebrovascular accident and 2 transient ischemic attacks. Total bleeding complication rate was 26%, including 2 deaths related to intractable hemorrhage and 2 others related to atrial tamponade. The cumulative experience was 3,606 total implant days with only 1 instance of mechanical dysfunction. CONCLUSIONS: TAH is a safe and efficient bridge for patients with terminal congestive heart failure awaiting cardiac transplantation.

Active native valve endocarditis: determinants of operative death and late mortality.

BACKGROUND: In this report, we reviewed 247 patients who underwent operation by our team for active native valve endocarditis between January 1979 and December 1993. METHODS: There were 201 male and 46 female patients (mean age, 45.4 +/- 6 years). The aortic valve was involved in 163 cases, the mitral valve in 36 cases, both mitral and aortic valves in 44 cases, and the tricuspid valve alone in 4 cases. The most common microorganisms were streptococci. Univariate Pearson (chi2 test) and multivariate (stepwise logistic regression [BMDPLR]) analyses were used to identify significant predictors of operative mortality, reoperation, and recurrent endocarditis. Cox proportional hazards regression model was used to study late survival. RESULTS: Operative mortality was 7.6% (n = 19). Increased age, cardiogenic shock at the time of operation, insidious illness, and greater thoracic ratio (>0.5) were the predominant risk factors; the length of antibiotic therapy appeared to have no influence. Two hundred thirteen patients were followed up. Median follow-up time was 6 years (range, 2 to 19 years). Overall survival rate (operative mortality excluded) was 71.3% +/- 3.8% at 9 years. Increased age, preoperative neurologic complications, cardiogenic shock at the time of operation, shorter duration of the illness, insidious illness before the operation, and mitral valve endocarditis were the predominant risk factors for late mortality. The probability of freedom from reoperation (operative mortality included) was 73.3% +/- 4.2% at 8 years; risk factors were younger age and aortic valve endocarditis. The rate of prosthetic valve endocarditis was 7%. No significant risk factor was found. CONCLUSIONS: Increased age, insidious illness, and hemodynamic failure are the main risk factors for operative mortality. Long-term survival is good except for patients with preoperative neurologic complications and mitral valve endocarditis.

The effect of methylprednisolone treatment on the cardiopulmonary bypass-induced systemic inflammatory response.

OBJECTIVE: Cardiac surgery with cardiopulmonary bypass (CPB) is associated with an inflammatory response caused by contact of blood with artificial surfaces of the extracorporeal circuit, ischemia-reperfusion injury, and release of endotoxin. The inflammatory reaction involves activation of complement leucocytes, and endothelial cells with secretion of cytokines, proteases, arachidonic acid metabolites, and generation of oxygen derived free radicals (OFR) by polymorphonuclear neutrophils (PMN). Although this inflammatory response to CPB often remains at subclinical levels, it can also lead to major organ dysfunction. A number of studies have demonstrated that treatment of patients with a high-dose (30 mg/kg) of corticosteroids (methylprednisolone) attenuates the CPB-induced SIR and improves the outcome of patients undergoing cardiac surgery. However, large doses of steroids can cause abnormal metabolic responses such as metabolic acidosis and hyperglycemia. In the present study, we examined the efficacy of low doses of methylprednisolone (5 and 10 mg/kg) to attenuate the CPB-induced inflammatory response, during and after heart operations. METHODS: Thirty-six adult patients undergoing cardiac surgery, were randomized into three groups: (1) control group: group A; (2) methylprednisolone, 5 mg/kg body weight: group B; and (3) methylprednisolone, 10 mg/kg body weight: group C. Plasma levels of the cytokines interleukin-6 (IL-6) and TNF-alpha were analyzed by enzyme-linked immunosorbent assay, before, during, and after CPB. OFR production was determined by cytofluorometry (FACS) at the same end points. RESULTS: No significant differences in age, body weight, CPB time, and cross-clamp time were observed among the three groups. CPB induced a marked increased in cytokine release and OFR generation. Low-dose of methylprednisolone (5 mg/kg) effectively reduced the increase in TNF-alpha and IL-6 secretion (P<0.05 compared to control group) after release of the cross-clamp. However, OFR generation was significantly reduced with a greater dose of methylprednisolone (10 mg/kg). CONCLUSIONS: The results indicate that a single low-dose of methylprednisolone (10 mg/kg) reduces the inflammatory reaction during and after CPB, by inhibition of proinflammatory cytokine release and OFR generation after release of the aortic cross-clamp.

Surgical treatment of chronic aortic dissections.

Between January 1976 and March 1987, 78 patients underwent surgery for chronic aortic dissection at our institution. The ascending aorta was involved in 66 cases (Stanford type A) and was not involved in 12 cases (Stanford type B), wherever the initial dissection was suspected. Aortography remains the main preoperative investigation. The surgical technique varies according to the type of dissection. It seems essential to exclude the primary intimal tear and all dilated segments of the aorta must be replaced. The overall operative mortality was 11.5% (7.5% in type A, 33.3% in type B dissection). Sixty-three patients have been followed for a period varying between 6 months and 10 years (mean 5 years). The overall survival at 6 years is 60% +/- 5.6%. Because of the ultimate risk of aneurysmal dilatation of the false channel, these patients must be followed by CT scanning, colour flow Doppler echocardiography, magnetic resonance imaging, and in some cases, aortography.

Heart transplantation: La Pitié experience, 1968-1989.

Heart transplantation is now an accepted therapeutic modality for end-stage heart disease. However, better immunosuppressive treatments and new methods to monitor rejection or detect early atherosclerosis must be developed to improve the long-term results after heart transplantation.

[Left thoracotomy: an alternative to median sternotomy in coronary bypass in cases of pericardial adhesions]. / La thoracotomie gauche: une alternative à la sternotomie médiane pour les pontages coronaires en cas d'adhérences péricardiques.

Coronary bypass on the circumflex artery network was performed by left thoracotomy in 5 patients. All presented with pericardial adhesions due to coronary artery surgery (n = 4) or to mediastinal irradiation (n = 1). The left thoracotomy route provides excellent exposure of the lateral aspect of the heart and may be an advantageous alternative to sternotomy when pericardial adhesions are present.

[Results of thrombo-endarterectomy of chronic pulmonary embolism]. / Résultats de la thrombectomie des embolies pulmonaires chroniques.

Between 1973 and 1987, 33 patients underwent pulmonary thromboendarterectomy for chronic pulmonary embolism. Twenty-six patients were in Class III of the NYHA Classification, 5 in Class IV with overt right ventricular failure and 2 in Class II. The average pO2 was 60 mmHg under basal conditions without oxygen therapy. The amputation of the pulmonary vascular tree was greater than 50 per cent in all patients. The average systolic pulmonary artery pressure was 70 mmHg. Twenty patients were operated by a lateral thoracotomy without CPB and 6 by sternotomy with CPB under normothermia with or without cardiac fibrillation. The later method avoids having to open the pleura and seemed to give better haemodynamic control. Interruption of the inferior vena cava was systematic in all cases. The global operative mortality was 20 per cent but this seemed to be less in the patients operated by sternotomy under normothermic CPB (no deaths in 6 patients). The authors consider that this technique should be studied in a larger series of patients. Eighteen patients are still being followed up; the clinical and scintigraphic and/or angiographic improvement is clearcut in the majority of cases.

[Alcoholic cardiomyopathy and heart transplantation]. / Cardiomyopathie éthylique et transplantation cardiaque.

The recognition of alcoholic cardiomyopathy in patients with dilated cardiomyopathy is essential as they may regress, at least partially in a relatively short period, with abstention. The clinical history is the key to diagnosis because no other specific feature can identify the cause. Between January 1984 and July 1995, 26 candidates for cardiac transplantation with dilated cardiomyopathy and chronic alcoholism improved after withdrawal of alcohol. None of these patients was placed on the surgical waiting list. Patients with ischaemic cardiomyopathy, valvular disease or previous surgery for valvular hypertensive or congenital heart disease, documented viral myocarditis or connective tissue diseases, were excluded. The diagnostic criterion of chronic alcoholism was a total alcohol consumption of 292 kg and a duration of alcohol abuse of over 10 years. In addition to the clinical features, biological, electrocardiographic, echocardiographic and haemodynamic parameters were analysed. The mean age of the patients was 48 +/- 8 years. There were 25 men and 1 woman. The total mean alcohol consumption was 1,492 kg. The average follow-up period was 63 +/- 41 months. The interval between the onset of symptoms and abstention was 25 months. Haemodynamic improvement was observed in 25 cases. The average interval between alcoholic abstention and recovery was 11.7 months. One patient died suddenly. Improvement of symptoms, decrease of the cardiothoracic ratio and improvement of echocardiographic parameters were statistically significant. The increase in angiographic or isotopic ejection fraction and cardiac index and the decrease in mean pulmonary artery pressures were also statistically significant. These results confirmed the diagnosis of alcoholic cardiomyopathy. Therefore, patients with chronic alcohol abuse and dilated cardiomyopathy must be identified and treated for this problem and not placed on the waiting list for cardiac transplantation unless no improvement is observed after about 3 months of abstention.

[Cardiac surgery in patients over 80 years of age. Experience of a series of 51 patients]. / La chirurgie cardiaque au-delà de 80 ans. Expérience d'une série de 51 malades.

Between January 1980 and June 1988, 51 patients over 80 years of age underwent open heart surgery at the La Pitié hospital (26 women and 25 men; average age 82 +/- 2 years, range 80-90 years). The cardiac pathology was calcific aortic stenosis (AS) in 40 cases, associated with coronary artery disease in 7 cases, mitral valve prolapse in 3 cases, coronary artery disease alone in 6 cases [complicated by a post-infarction ventricular septal defect (VSD) in one patient] or associated with aortic regurgitation in 1 case, and degeneration of an aortic bioprosthetic valve in 1 case. Forty patients (78%) were in Stage III or IV or the NYHA Classification. There was no other major pathology associated with the cardiac disease. Aortic valve replacement (AVR) was carried out in 42 patients, with a bioprosthetic valve in 38 patients. This procedure was associated with coronary bypass surgery in 7 cases and carotid artery surgery in 1 case. A mitral bioprosthesis was implanted in 2 patients and mitral valvuloplasty was carried out in 1 patient. An isolated myocardial revascularisation procedure was performed in 5 cases; the VSD was closed in 1 case. The hospital mortality was 17.6 per cent (9 patients). All deaths were of cardiac origin. Eleven patients had no postoperative complications at all. The 3 year survival rate of those who survived surgery was 71 per cent. Of the current 31 survivors, 29 are in Stage I or II of the NYHA Classification. These results suggest that surgery can be offered to octogenarians with invalidating cardiac disease alone carrying a poor short term prognosis.

[Evaluation by Doppler echocardiography of left ventricular diastolic function in acute graft rejection after heart transplantation]. / Evaluation par échocardiographie-Doppler de la fonction diastolique ventriculaire gauche dans le rejet aigu du greffon après transplantation cardiaque.

In order to study abnormalities of left ventricular diastolic function (LVDF) in heart transplant patients and their possible association with graft rejection, 21 patients who had recently undergone orthotopic heart transplantation were evaluated prospectively, on the day of endomyocardial biopsy, by pulsed and continuous Doppler echocardiography (DEC). Investigation of the LVDF consisted of pulsed DEC of the mitral valve in apical projection (4 cavities) with measurement of isovolumetric relaxation time (IVR), peak velocity of rapid ventricular filling (E), peak velocity of graft atrial contraction (A) and transmitral gradient decrease half-time (mitral T1/2). Each patients had 5 DEC examinations on average over a 2-month period. In patients with subsevere to severe rejection mitral T1/2 decreased significantly from 76.46 +/- 11.6 ms in the absence of rejection to 47 +/- 13.7 ms during rejection (P less than 0.001). When mitral T1/2 decreased by 25 p. 100 or more between two successive DEC, rejection was present in 89 p. 100 of the cases. It is concluded that Doppler echocardiographic studies of left ventricular diastolic function provide useful information in the follow-up of heart transplant recipients and offer hopes, in a not too distant future, of non-invasive detection of cardiac graft rejection.

[Systematic peroperative use of an autotransfusion system in heart surgery. A prospective and comparative study in 283 patients]. / Utilisation peropératoire systématique d'un système d'autotransfusion en chirurgie cardiaque. Etude prospective et comparative sur 283 malades.

A series of 283 patients undergoing cardiac bypass surgery was studied to determine whether intraoperative autotransfusion, haemodilution, and a change in transfusion techniques of the same surgical team could reduce homologous blood requirements. The Cell-Save Haemonetics* system was used systematically in 167 consecutive patients (Group I). This group of autotransfused patients was analysed prospectively and compared with a control group (Group II) of 116 patients operated one year before and analysed retrospectively. During the whole hospitalisation, homologous blood products were required in 40.7% of patients in Group I compared with 73.3% of patients in Group II (p less than 0.0001). The average requirements of packed cells per patient were 2.7 +/- 1.3 in Group I compared with 4.1 +/- 2.5 in Group II (p less than 0.0001). The haematocrit on discharge from the department was 29.9 +/- 4% in Group I compared with 32 +/- 4.5% in Group II (p less than 0.0001). The average volume of blood recovered by the system and then autotransfused was 620.8 +/- 242.6 ml. There was no significant difference in postoperative bleeding in the first 24 hours between the two groups. This study confirms that peroperative autotransfusion during cardiac surgery and the acceptance of a clinically well tolerated normovolumic anaemia are associated with a significant reduction in homologous blood consumption.

[Fulminating myocarditis: myocardial recovery after circulatory assistance]. / Myocardite fulminante: récupération myocardique après assistance circulatoire.

The clinical expression of acute myocarditis is variable from paucisymptomatic to fulminating forms which are usually lethal within days. The latter presentation takes the form of very acute cardiac failure. During this phase, the severity of myocardial dysfunction may be such that death ensues. However, if the patient survives, paradoxically, these forms have a better long-term prognosis with complete recovery of myocardial function being possible after the acute phase. The authors report a typical case of fulminating myocarditis with electromechanical dissociation, which recovered completely after a period of circulatory assistance. This case illustrates the rapidity of deterioration of the haemodynamic status and the importance of organ dysfunction despite early management. In a review of the literature, the authors found about 150 reported cases of acute myocarditis treated with circulatory assistance. In the best series, about half the patients were weaned off the circulatory assistance without having to undergo cardiac transplantation. However, the potential recovery of myocardial function is difficult to predict.

[Immediate and long-term results of coronary surgery under age 40]. / Résultats immédiats et à distance de la chirurgie coronaire avant 40 ans.

The results of coronary artery surgery in young adults have not been extensively studied. We analysed the results of 221 patients under 40 years of age operated between 1979 and 1989 at the Pitié-Salpêtrière Hospital. The patients were 200 men and 21 women with an average age of 36.2 years. The most common cardiovascular risk factors were smoking (69.6%) and hyperlipidaemia (52%). One hundred and eighteen patients (53.4%) had previous myocardial infarction (MI). Triple vessel disease was present in 129 cases, double vessel disease in 59 cases and single vessel disease in 33 cases. Twenty three patients had significant left main coronary disease. The number of bypass grafts per patient averaged 2.3. The operative mortality was 2.07% (6 cases), death being due to myocardial infarction in 4 cases. Perioperative myocardial infarction was diagnosed in 12 cases (5.05%). One hundred and ninety nine patients were followed up for an average of 7.4 years. Seven of the 17 late fatalities were of cardiac origin. The actuarial 9 year survival rate was 84%. Five patients were reoperated after an average of 6.4 years. Eighty five per cent of patients were asymptomatic at the last follow-up examination. In conclusion, the symptoms of coronary artery disease in young adults can be effectively treated with a low operative risk by myocardial revascularisation surgery. Long-term follow-up remains essential to define the outcome in these patients. Systematic use of internal mammary artery bypass grafting should improve these results in the future.

[Valvular replacement with the Bicarbon mechanical valve. Results after 7 years in 104 patients]. / Remplacement valvulaire par la valve mécanique Bicarbon. Résultats à 7 ans chez 104 patients.

OBJECTIVE: Study of the medium term results of aortic and mitral valve replacement with the Bicarbon' prosthesis. METHOD: From 1990 to 1996, 109 valves were implanted (70 in aortic position, 31 in mitral position and 4 double replacements). The average age was 61 years and 75% were male. According to the NYHA, 59% of patients were stage III or IV. The average pre-operative ejection fraction was 59.6%. There was re-intervention in 21.1% of patients and 35.3% had an associated procedure during the intervention. RESULTS: The average follow up was 5.4 +/- 1.98 years in 98 patients (that is 522 patient years). One patient died post-operatively and 19 died later. The overall survival at 7 years was 69.4 +/- 6.3%. Complications, expressed in patient years, were 1.15% for thrombo-embolic complications, 2.1% for haemorrhagic complications. 0.38% for endocarditis, 1.72% for non-infectious peri-prosthetic leaks, and 0.76% for re-interventions. At 7 years, the absence of thrombo-embolic, haemorrhagic, endocarditis, and re-intervention complications was 91.8 +/- 4.2%, 85.3 +/- 4.8%, 95.8 +/- 3.2%, 93.8 +/- 3.5% respectively. According to the NYHA, 95% of patients were in stage 1 or II (p < 0.001). CONCLUSION: Valvular replacement in the aortic or mitral position with the Bicarbon' valve is satisfactory as much in terms of survival as of clinical complications.

[Video-surgery for pericardial effusion. Technique and results]. / Vidéo-chirurgie des épanchements péricardiques. Technique et résultats.

Videosurgery is a relatively non-invasive method of draining the pericardium by the creation of a pleuropericardial window. It provides an excellent view of the thoracic cavity and allows selection of pericardial and pleural, pulmonary or mediastinal biopsy sites. The authors report their preliminary results with this technique. Between May 1994 and May 1995, 22 patients with pericardial effusions were operated by videosurgery at the Pitié Hospital. None of the patients had clinical signs of tamponade. The technique consists in introducing, through 2 or 3 thoracic incisions of 15 mm, trocarts allowing passage of an endoscopic camera and different surgical instruments. Access to the thoracic cavity enabled assessment of the pleura, evacuation of pleural effusions (n = 8) and biopsy of pleural nodules (n = 2). One pulmonary biopsy was performed. Opening the pericardium enabled evacuation of pericardial effusions averaging 622 ml. Pericardial biopsies showed appearances suggesting tuberculosis (n = 2), lupic vasculitis (n = 1) and post-radiation pericarditis (n = 1). In other cases, a histologic diagnosis of non-specific pericarditis was made. A biopsy of a pleural nodule showed undifferentiated carcinoma in one case. A pulmonary biopsy revealed the presence of relatively undifferentiated carcinoma. There were no complications related to the technique. There was one recurrence of pericardial effusion at one month in a patient with carcinoma of the lung who had previously had subxiphoid drainage. There were no cases of secondary pericardial constriction. Therefore, videosurgery is a relatively non-invasive and effective technique of pericardial drainage and biopsy. When there is no emergency, it is probably the method of choice in the treatment and diagnosis of pericardial effusions.

[Surgical treatment of patent ductus arteriosus in adults]. / Traitement chirurgical du canal artériel de l'adulte.

The surgical treatment of patent ductus arteriosus (PDA) in adults as in children, usually comprises section and suture, but a certain number of technical precautions must be taken. The aortic wall is often fragile due to atheromatous lesions which are more common with increasing age. Associated hypertension may add to the fragility. Controlled medicated hypotension and reinforcement of sutures with a piece of pericardium may be useful in reducing the risk of haemorrhage. It is sometimes necessary to use partial femoro-femoral cardiopulmonary bypass circuit. The presence of an aneurysm at the aortic end of a calcified ductus necessitates the same precautions. When PDA is complicated by pulmonary hypertension, the surgical indication can only be considered when the left-to-right shunt remains voluminous and when pulmonary artery pressures fall significantly during catheter or peroperative trials of closure. The operative risk in these cases increases with age. Cardiopulmonary bypass may also be very useful in these cases. Secondary repermeabilisation of an operated ductus, and cases complicated by endocarditis require an endopulmonary approach under cardiopulmonary bypass because of the fragility of the ductus region and difficulty in controlling haemorrhage. This technique is also preferred when an associated intracardiac malformation is to be corrected. Between 1965 and 1981, 37 patients were operated in the department of thoracic and cardiac surgery at the Pitié Hospital. The ages ranged from 20 to 65 years with a mean of 34 years. Cardiopulmonary bypass was necessary in 5 cases, (partial in 4, and total in 1 case of endoaortic closure).(ABSTRACT TRUNCATED AT 250 WORDS)

[Heart transplant. Long-term follow-up]. / Transplantation cardiaque. Suivi à long terme.

The use of cyclosporin in the immuno-suppressive treatment has resulted in a spectacular improvement of the outcome of cardiac transplantation. But a number of complications, if they have become less severe, have note however totally disappeared. In order to detect them at an early stage, a strict monitoring is necessary. Systematic ambulatory visit are organized in the transplant center. In the interval between visits, a medical follow-up by cardiologist and attending physician is absolutely necessary.