Aortic Carpentier-Edwards supraannular porcine bioprosthesis: a 12-year experience.

BACKGROUND: After 35 years of cardiac valve replacement, the ideal substitute remains to be found. Homografts are considered best but, due to their scarcity, cannot meet the need of valve replacement. Artificial valves (mechanical or biological) remain the most commonly used but controversy is still present as to the better choice. We tested the Carpentier-Edwards bioprosthesis for its efficacy in valve replacement operations. METHODS: From 1983 to 1995, 1,108 consecutive patients had an isolated aortic valve replacement with a porcine Carpentier-Edwards bioprosthesis, model 2650 supraannular valve. Mean age was 73.8+/-8.3 years. Aortic stenosis was the most common lesion (1,049 patients, 94.7%). The follow-up of 980 operative survivors was 96% complete and represented a total of 4,735 patient-years (maximum, 13.8 years; mean, 4 years and 10 months). RESULTS: Actuarial survival including operative mortality (128 patients, 11.6%) was 43.6%+/-2.3% at 10 years and 27.3%+/-3.3% at 12 years and, at that time, was not statistically different from those of the normal French population matched for age and sex. Structural deterioration of the valve was observed in 27 patients, an actuarial freedom of 94.2%+/-1.5% at 10 years and 83.8%+/-4.5% at 12 years. Hazard function revealed a stable and low risk of structural deterioration until 10 years and significantly increased risk after that. Young age was found to be an increasing risk factor of deterioration. Reoperation for valve-related complications was necessary in 30 patients, an actuarial freedom of 94.5%+/-1.4% at 10 years. CONCLUSIONS: The Carpentier-Edwards porcine supraannular valve affords a good durability up to 10 years, with a low rate of reoperation. The risk of structural deterioration decreases with older age. It is our valve of choice in elderly patients.

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.

Red blood cell polyamine level changes following heart transplantation in man.

Follow-up of orthotopic heart transplanted patients has revealed the existence of abnormally high red blood cell (RBC) spermidine (Spd) levels during the first two months after surgical procedure (A-period). From the third month after heart transplantation (B-period), RBC Spd concentrations went back to normal values in early cardiac rejection (ECR) patients. During A- and B-periods, significantly higher Spd levels and Spd/Spm ratios were observed in late cardiac rejecting (LCR) patients than in ECR ones. The lack of a direct relationship between the histological grade of rejection and RBC Spd levels leads us to consider these polyamine blood levels as a new biological instrument in the diagnosis of heart rejection.

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.

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.

Extracorporeal circulation with deep hypothermia and circulatory arrest in the treatment of intracranial arterial aneurysms.

Extracorporeal circulation with circulatory arrest and deep hypothermia in surgery on certain giant intracranial arterial aneurysms or on aneurysms difficult to access is described. The series includes a giant left carotid aneurysm, an aneurysm of the basilar artery bifurcation, a patient with two aneurysms, one on the right middle cerebral artery and the other at the end of the basilar artery, and a fourth patient with two aneurysms, one on the right middle cerebral and the other on the right carotid. Closed-thorax extracorporeal circulation with femoral cannulation was performed on all the patients. Surgical procedure is described and the advantages and disadvantages discussed. Results are encouraging. The authors suggest that the technique be used during surgical treatment of certain intracranial aneurysms that are in awkward positions or are very large in size. They emphasize that the procedure should be confined to exceptional cases.

[Long-term results of Carpentier-Edwards and Saint-Jude Medical mitral valve prosthesis]. / Résultats à distance des prothèses de Carpentier-Edwards et de Saint-Jude Médical en position mitrale.

Between 1980 and 1985, 239 patients underwent mitral valve replacement with a Saint Jude Medical (130) or Carpentier-Edwards (109) prosthesis alone or associated with correction of tricuspid regurgitation. Age, NYHA grade and pulmonary artery pressures were comparable in the two groups. Two hundred and seventeen of the 221 survivors were contacted (98.6% follow-up): the long-term prosthesis-related mortality was 35% in the Saint Jude Medical group and 22.5% in the Carpentier-Edwards group. The global survival at 9 years was 82% in the Saint Jude Medical group but only 63% in the Carpentier-Edwards group. The actuarial thromboembolic-free rate at 9 years was 96% in the Saint Jude Medical and 86% in the Carpentier-Edwards group (not significant). Two Saint Jude Medical and one Carpentier-Edwards bioprosthesis thrombosed--a linear rate of 0.2% PY and 0.1% PY respectively. Furthermore, there was no significant difference in the actuarial rate of haemorrhagic complications between the two groups. Endocarditis and valve degeneration were more common in the Carpentier-Edwards group (1.3% and 1.6% PY respectively). Over the 9 year period, the thromboembolic complications of the Saint Jude Medical and Carpentier-Edwards prostheses were similar in actuarial and linear terms. With respect to long-term mortality and morbidity, the results with the Saint Jude Medical valve seem to be superior to those of the Carpentier-Edwards bioprosthesis.

[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.

[Surgical correction of chronic tricuspid insufficiency following infarction of the right ventricle]. / Correction chirurgicale d'une insuffisance tricuspidienne chronique secondaire à un infarctus du ventricule droit.

The case of a 69 year old man with isolated tricuspid regurgitation secondary to right ventricular infarction is reported. The poor long-term tolerance of the regurgitation resulting in severe right ventricular failure in the absence of any left ventricular dysfunction led to tricuspid valve replacement with a bioprosthesis 13 years after the causal infarct.

[Myocardial infarct in 2 stages]. / L'infarctus du myocarde en 2 temps

The two-step myocardial infarction is defined by a peculiar course: the initial stage is a temporary rudimentary infarction, the late stage a typical transmural necrosis, separated by a free interval of a variable duration. A coronary arteriography undertaken when the recurrence starts might eventually lead to recommend an emergency operation: two-step myocardial infarction might represent one of the best indications for emergency aorta-to-coronary artyery by-pass operation.

[Partial interruption of the inferior vena cava by an endovenous filter. Apropos of 98 patients]. / Interruption partielle de la veine cave inférieure par filtre endoveineux. A propos de 98 malades.

94 partial interruptions of the inferior vena cava (PIIVC) were carried out in 98 patients between May 1979 and November 1983 with a Mobin-Uddin umbrella filter (58 cases) or a Kim-Ray Greenfield filter (36 cases); one patient who had a double inferior vena cava underwent double PIIVC with a Greenfield filter. The patients (56 women and 42 men) were between 22 and 84 years old (average 60.6 years). Phlebocavography was performed pre-operatively in 93 patients (95 p. 100) and showed thrombus in the IVC (21 cases), common iliac vein (20 cases), ilio-femoral vein (32 cases), femoral vein (15 cases), popliteal and/or sural vein (4 cases); the investigation was considered normal in 1 patient. The diagnosis of pulmonary embolism (PE) was made in 86 patients (87.7 p. 100) on clinical and/or pulmonary scintigraphy and/or angiography data. The main indications for PIIVC were major PE (56 cases) or a threatening venous thrombosis (27 cases); other indications included recurrent PE despite adequate anticoagulation, patients with contra-indications to anti-coagulant therapy and pulmonary hypertension due to thromboembolism; 4 PIIVC were carried out during pulmonary embolectomy on cardiopulmonary bypass. The operative mortality was 3.06 p. 100 (3/98) with a global early mortality of 10.2 p. 100 (10/98); morbidity was 12.2 p. 100 (12/98); there were 5 failures of PIIVC. The long-term outcome was studied in the first 80 cases with a mean follow-up of 18 months (4 to 48 months).(ABSTRACT TRUNCATED AT 250 WORDS)

[Mitral stenosis and partial abnormal pulmonary venous return. 3 case reports]. / Rétrécissement mitral et retour veineux pulmonaire anormal partiel. Apropos de trois observations

The association of mitral stenosis with an abnormal pulmonary venous return in the absence of an atrial septal defect, is a rare occurrence, and three cases are reported here. If this diagnosis is suggested by the chest Xray, it is confirmed by haemodynamic investigation, which defines the abnormal pulmonary drainage, guages the size of the left-right shunt, and demonstrates the degree of mitral steonsis. If the defect is poorly tolerated, surgical treatment is required.

[Abnormal pulmonary venous return from the right lung into the inferior vena cava or scimitar syndrome. 2 cases: hemodynamic study and surgical correction]. / Le retour veineux pulmonaire anormal du poumon droit dans la veine cave inférieure ou syndrome du cimeterre. Deux observations: étude hémodynamique et correction chirurgicale

Two cases of abnormal venous return from the right lung into the inferior vena cava, or the scimitar syndrome, have been studied. The essential features of this condition are given, emphasis being laid on the haemodynamic findings. Surgical correction of the abnormal pulmonary venous return seems to be a logical solution when the left-right shunt is of significant size.

[Calcified aortic stenosis in patients over 80 years of age. Results of surgical treatment. Observations in 67 consecutive cases]. / Rétrécissement aortique calcifié chez les octogénaires. Résultats du traitement chirurgical. A propos d'une série consécutive de 67 cas.

The authors report the results of surgery performed between 1978 and 1988 for calcific aortic stenosis in 67 consecutive patients over 80 years of age; the operative risk is assessed ant the results are compared with those of balloon valvuloplasty. The operative risk seems to be relatively low (6 deaths; 8.9%). All survivors were followed-up and evaluated. The long-term results show a big improvement in survival (78.2% at 3 years) and in functional class (96% of patients in Classes I and II of the NYHA Classification). By comparison, the results of balloon valvuloplasty were very mediocre and are now generally considered to be disappointing to such an extent that the indications of dilatation seem very limited and difficult to define.

[20 years of mitral valve replacement. Development of a patient profile and operative mortality]. / Vingt ans de remplacements valvulaires mitraux. Evolution du profil des opérés et de la mortalité opératoire.

Between 1971 and 1991, 1,179 mitral valve replacements (MVR) were carried out in 1,134 patients. The sex ratio was stable over this period (0.7 men/women) whereas the average age of the patients increased by 10 years (50 years in 1971, 61 years in 1991). Since 1980, patients over 60 years of age represent about 60% and those over 70 years of age 16 to 22% of the population. The functional status of the patients has tended to be less severe, the NYHA stages III and IV which were initially preponderant, only represent 50 to 60% of patients operated nowadays. This reduction in the severity of symptoms is reflected in the average value of the cardio thoracic index which was 60 in 1971 and 54.8 in 1991. Similarly, the mean pulmonary artery pressures (measured in 823 patients, 69.8%) have decreased from 37.4 mmHg in 1971 to 29.9 mmHg in 1991. Rheumatic fever has tended to be replaced by degenerative etiologies which, since 1985, represent 40 to 50% of cases. Ischemic mitral regurgitation rare before 1980, is more common, presently making up 5 to 15% of MVR cases. In relation with the etiological changes mitral stenosis is giving way to mitral regurgitation as the commonest valve lesion (40 to 50% of cases in 1991). The annual operative mortality is lower (6 to 8%) than in 1982, despite the increasing number of emergency cases (7 to 10% of cases since 1985). The number of MVR with associated tricuspid valve repair has decreased with respect to isolated MVR or associated with aortocoronary bypass grafting. The only constant feature is the death rate due to myocardial dysfunction which remains over 50% whereas mortality related to the prosthetic valves varied over the years.

[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.

[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.