A 5 1/2 year experience with the St. Jude Medical cardiac valve prosthesis. Early and late results of 737 valve replacements in 671 patients.

Between June 12, 1978, and June 12, 1983, 737 St. Jude Medical valves were implanted in 671 patients (431 males, 240 females) ranging in age from 9 months to 82 years (mean 55 years); 16 of these patients (2.3%) were less than or equal to 15 years and 82 (12.2%) were greater than or equal to 70 years. Associated procedures were performed in 28.2% of the 500 aortic valve replacements, 13.3% of the 105 mitral valve replacements, and 10.6% of the 66 double mitral and aortic valve replacements. Hospital mortality (less than or equal to 30 days) was 3.6% (18/500 patients) for aortic, 4.7% (5/105 patients) for mitral, and 0% for double valve replacement. Only one of these 23 hospital deaths was possibly valve-related. Complete follow-up was achieved during December, 1983, and January, 1984, to provide a minimum follow-up of 6 months. Follow-up has been 100% for a total of 1,619 patient-years, with a mean follow-up of 2 1/2 years. There were 41 late deaths (6.1%): 30 in the aortic group, eight in the mitral group, and three in the double valve replacement group. Fourteen (34.2%) of these late deaths have been considered valve-related. At 5 1/2 years, the actuarial survival rate, hospital mortality excluded, is 91% for aortic, 90% for mitral, and 95% for double valve replacement. Functional improvement of these patients is quite satisfactory: Preoperatively, 60.3% were in Class III or IV of the New York Heart Association, whereas postoperatively, 99.5% of the patients are in Class I or II. As 78 patients (65 aortic, 10 mitral, and three double valve replacement) did not receive anticoagulation therapy for a total period of 84 patient-years, the incidence of valve thrombosis, systemic embolism, and sudden or suspicious deaths in this group was compared with that in a group of 630 patients (including 60 patients from the first group who were given anticoagulants afterwards) subjected to long-term anticoagulation for a total period of 1,535 patient-years. A significantly higher incidence of valve thrombosis and systemic embolism was observed in the absence of anticoagulation. Anticoagulant-related complications occurred in 10 patients, with an incidence of 0.65/100 patient-years. On the basis of this 5 1/2 years of experience, the St. Jude Medical valve appears to be an excellent mechanical prosthesis for cardiac valve replacement, in terms of hemodynamic performance and low thrombogenicity, in patients receiving anticoagulants.

Isolation of the right subclavian artery.

Loss of continuity between subclavian artery and aorta with persistent connection to the homolateral pulmonary artery through a ductus arteriosus is an uncommon malformation, involving generally the left subclavian artery and associated with intracardiac or aortic arch anomalies. We report a case of right subclavian isolation with a left-sided aortic arch, presenting as a single anomaly and surgically corrected by aortic reimplantation.

Long term results of cardiac valve replacement in patients aged 75 years and older.

From June 1978 to December 1989, 158 patients over 75 years of age (mean: 78 years; range 75 to 86 years) underwent 164 valve replacements: 134 in the aortic, 18 in the mitral and 6 in double mitral and aortic positions. One hundred and seven of these valves (66%) were bioprostheses, 93 aortic and 14 mitral and 57 valves (34%) were mechanical prostheses; 47 aortic and 10 mitral. Hospital mortality (less than or equal to 30 days) was 7% (11 patients, all in NYHA class III or IV) but was higher in patients who had undergone associated procedures (9.8%; 6/61 patients) or in patients who had mitral valve replacements (11%) and in double valve replacement (16.6%). Because of a minimal delay of one year, long term follow-up information (100%) was only obtained from the first 110 patients discharged from hospital. Late mortality has been 13.6% and actuarial survival at 11 years was 71.5% +/- 5. Therefore, despite a hospital mortality of more than twice that of patients operated upon under 75 years of age (3.3%), an actuarial survival at 11 years, similar to that of patients under 75 years (77 +/- 5%) and the functional improvement obtained (95% of survivors are NYHA class I or II) certainly justify surgery in these patients. Because of the incidence of anticoagulant related hemorrhages in these patients (1.7% patient year) and since, structural deterioration of the bioprostheses was non existent in this series, a bioprosthesis appears to be the best valvular substitute in patients over 75 years of age.

Results of carotid endarterectomy in patients 75 years of age and older.

From April 1980 to September 1989, 69 patients over 75 years of age (mean 78 years, range 75 to 86) underwent 81 carotid endarterectomies. Twenty three percent were asymptomatic, 56.5% had symptoms appropriate to lesion location and 20.5% had a non hemispheric syndrome. Nine patients required an associated procedure (combined cardiac surgery 6 pts; vascular surgery 3 pts). Perioperative mortality was 3.7%. The combined early lethal and non lethal stroke rate was 6.1%. Actuarial survival, at 10 years, was 58.4% +/- 10, and the incidence of freedom from stroke at 10 years was 86.2% +/- 5. Despite the fact that the hospital mortality of patients over 75 years undergoing carotid endarterectomy is more than three times that of patients operated on under 75 years of age (1.2%), the combined stroke and neurologic mortality rate is similar to that of patients under 75 years (5.3%). Carotid surgery in patients over 75 years of age does not increase life expectancy but does improve the quality of survival which depends mainly on cardiac events.

Rupture of donor ascending aorta following heart transplantation.

Among 81 patients who underwent orthotopic heart transplantation between July 1986 and December 1990, we found rupture of the donor ascending aorta in three patients, all with severe ventricular dysfunction secondary to aortic valvular disease. The mechanism for this may be compliance mismatch between the recipient ascending aorta and the donor ascending aorta. This situation is a unique complication in heart transplantation for the recipients who have severe athero-sclerotic changes in the systemic aortic wall, especially for those with valvular diseases caused by calcification.

[Early and long-term results of 233 heart transplant patients in University Bordeaux in France: quality of life following heart transplantations].

Between March 1986 and December 1993 we had 233 heart transplant patients who were 218 males and 15 females and had a mean age of 50.9 years (range, 2 to 65 years). We analyzed the actuarial survival for these patients and investigated the status of rehabilitation and return-to-work from the view point of quality of life after heart transplant. Actuarial survival (Kaplan-Meier) was 81.7% at 1 year, 76.3% at 3 years, and 72.2% at 5 years. In 57 dead patients 24 patients (42%) died in 1 month after heart transplant. In 176 living patients 165 patients (53%) returned to life. In 129 patients except 76 retired patients only 69 patients (53%) returned to work. In 60 patients, who didn't return to work, 38 patients (63%) were physically able to work.