The Omni design: evolution of a valve.

The Lillehei-Kaster prosthesis has been the subject of an engineering evolution to close the gap between engineering expectations and clinical performance. Advanced engineering development in response to users has narrowed this gap with the Omni design (Omniscience titanium and omnicarbon Pyrolite cages). Our studies on mitral Omniscience valves demonstrated that because anatomic and surgical variations, the anterior orientation was more forgiving than the posterior orientation, resulting in lower thrombotic complications (0.5% versus 3.3% patient-year). A subsequent thicker cuff was used to reduce the probability of anatomic interference and incomplete opening after cardiac recovery. Such findings were also incorporated in the Omnicarbon design. Five European centers implanted 354 patients (198 atrial valve replacement, 115 mitral valve replacement, and 41 double valve replacement with Omniscience valves between August 1984 and January 1986. No restrictive patient selection criteria were used. As of June 1987, 96% of the patients at risk were accounted for. Average follow-up was 1.7 +/- 0.4 years (range, 0.3 to 2.8 years), with a total follow-up of 555 years. There were no cases of structural failure or clinically significant hemolysis. Ninety-one percent of the patients improved one or more functional classes. Actuarial analysis of survival probability at 3 years is 92.5% for atrial valve replacement, 97.9% for mitral valve replacement, and 93.6% overall. There were no late deaths from valve thrombosis or thromboembolism. The actuarial freedom from all thromboembolic events (valve thrombosis, thromboembolism, and transient ischemia) is 97.8% at 2 1/2 years. Through close rapport between user surgeons and designers, the evolution of a valve with improved performance becomes a reality.

Cancer of the kidney invading the vena cava and heart. Results after 11 years of treatment.

Between October, 1973, and October, 1983, 18 patients with cancer of the kidney or adrenal gland that had invaded the vena cava, and in 11 cases had reached the heart, were operated on by seven surgical teams. The surgical excision in all patients was performed with extracorporeal circulation, circulatory arrest and deep hypothermia. No deaths occurred. If there are no detectable metastases before operation, the 5 year survival rate is 75% as compared to 6 months with medical treatment. This clinical situation is not uncommon, as 3% to 10% of cancers of the kidney invade the inferior vena cava and 40% of them reach the heart. The possibility of curing the cancers with minimal operative risk should prompt a systematic search for venous invasion with any cancer of the kidney.

Direct current catheter ablation of an accessory pathway in a recipient with refractory reciprocal tachycardia.

A recurrent reciprocating tachycardia developed in a 45-year-old man 2 years after heart transplantation. Electrocardiograms of both donor and recipient were normal, without patent preexcitation. An electrophysiologic study showed a left-sided Kent bundle with only retrograde conduction property. Because antiarrhythmic therapy was unsuccessful, direct current catheter ablation was performed. Since this procedure the patient remained asymptomatic without antiarrhythmic therapy.

Influence of post-surgery time after cardiac transplantation on exercise responses.

Influence of post-surgery time after cardiac transplantation on exercise responses. Med. Sci. Sports Exerc., Vol. 28, No. 2, pp. 171-175, 1996. To test the hypothesis that exercise response changes with time after cardiac transplantation, we investigated the cardiorespiratory responses of nine orthotopic heart transplant patients (52.4 +/- 2 yr) during graded exercise tests (30 W.3 min-1) done at 1, 3, 6, 9 and 12 months post-surgery. At peak exercise, 1) oxygen uptake per kg of body weight (VO2), minute ventilation (VE) and oxygen pulse (O2 pulse) did not change significantly between 1 and 12 months postsurgery; 2) transplanted heart rate (HRt) and delta heart rate (peak exercise heart rate--resting heart rate) increased significantly over time (P < 0.01; P < 0.05) with a marked increase between 1 and 3 months (P < 0.05); and (3) a significant negative correlation existed between O2 pulse and HRt (r = -0.36, P < 0.05), whereas no correlation was found between delta heart rate and delta VO2 (peak exercise VO2- resting VO2, l.min-1). During submaximal exercise, HRt increased significantly over time (P < 0.001); VO2, VE, and O2 pulse showed no significant change; and the VO2-HRt relationship shifted toward higher values of HRt. We conclude that, in the absence of formal physical training, the exercise response of denervated transplanted heart increases in relation to post-surgery time but does not affect oxygen uptake at submaximal and peak levels of exercise.

Long term follow up of 292 patients after valve replacement with the Omnicarbon prosthetic valve.

In a prospective study, 292 consecutive patients received 336 Omnicarbon cardiac valves from September 1984 through September 1992 at the Montpellier University Hospital. There were 153 aortic (52%), 95 mitral (33%) and 44 double (15%) mitral and aortic replacements. Mean age was 58 years; 57% were male. Total follow up was 1,383 patient-years, with a maximum of nine and a mean of 4.87 years. Early mortality was 2.75% overall. Late mortality occurred at a rate of 1.9%/patient-year. Nine-year probability of freedom from mortality (including early mortality) was 85.0% +/- 2.6% overall. There were no cases of structural failure. Thromboembolic events occurred in nine patients, producing a linearized rate of 0.7%/patient-year. Hemorrhage associated with anticoagulant therapy occurred at a rate of 0.8%/patient-year. Therefore, the combined rate of thromboembolic/hemorrhagic events was 1.5%/patient-year. Cumulative overall freedom from thromboembolism and hemorrhage was 91.5% +/- 1.9% at nine years; it was 86.2% +/- 4.3% after mitral and 95.1% +/- 2.0% after aortic valve replacement. Hemolytic anemia was not observed. Endocarditis occurred eight times (0.6%/patient-year), and there were seven cases of perivalvular lead (0.5%/patient-year). At the end of the follow up, 86% of the patients were in NYHA class I. It is concluded that clinical results over a nine-year period are excellent with the Omnicarbon prosthesis.

False aneurysm of the ascending aorta following aortic valve replacement.

False aneurysm of the ascending aorta is a rare and life-threatening complication of open heart surgery, usually occurring late after operation. Echocardiography, especially transesophageal echocardiography, is a non-invasive method of examination which can be very helpful in its diagnosis. Deep hypothermia and circulatory arrest allow a bloodless field during surgery and provide an adequate patient protection. Infection is a very well known predisposing factor, but cystic medial necrosis of the aortic wall also seems to play a role in this complication. We report three cases, two of them had cystic medial necrosis and the presence of infection could be proved in none.

Lillehei-Kaster prosthesis in the aortic position with and without anticoagulants.

Sixty-two patients after aortic valve replacement were given aspirin in place of anticoagulants post operatively. This group is compared with another of 125 patients receiving anticoagulants. In the former group there was one instance of valve thrombosis, five of transient embolic episodes and six late deaths. In the latter group there were two instances of valve thrombosis--both occurring when the anticoagulation was inadequate, one embolic episode and six late deaths. Anticoagulant therapy is recommended for all patients with the Lillehei-Kaster prosthesis. However, where anticoagulants cannot be used control with aspirin is nearly as effective, but with a somewhat higher risk. Long-term results with Lillehei-Kaster valves as regards survival and thromboembolism compare favourably with all contemporary mechanical prostheses and porcine heterografts.

Symmetric enlargement of the ascending aorta in supravalvular aortic stenosis of the diffuse type (an alternative to apico-aortic conduit).

Surgical repair of the diffuse form of supravalvular aortic stenosis, (tubular hypoplasia of ascending aorta) is a difficult problem because complete relief of the pressure gradient is not achieved by the insertion of a prosthetic graft across the non coronary sinus of Valsalva. An alternative is to use a left ventricular-aortic by-pass shunt. A more rational reconstructive operation was carried out in a 9 years old boy and consisted of an extended aortic endarterectomy and symmetrical enlargement of the supravalvular ring in all three sinuses of Valsalva with a small patch in the left coronary sinus and a large tubular prosthesis tailored with two tips into the right and the non coronary sinuses of Valsalva and the distal end sutured up to origin of the innominate artery. Relief of pressure gradient has been excellent with control study at one year.

Dissecting aneurysms of the ascending aorta occurring late after aortic valve replacement.

In 4 patients who had undergone aortic valve replacement, a dissection of the ascending aorta appeared between 7 and 16 years later (mean 12 years). This is a rare complication, occurring in less than one percent of cases. Three cases of aortic regurgitation and one of aortic stenosis developed, and 3 of the cases had dilatation of the ascending aorta and hypertension. The symptoms of dissection were accompanied by signs of either the superior vena caval syndrome or compression of the pulmonary artery. The diagnosis was confirmed by echography and by CT scan. Despite the advances made in the surgery of dissection the prognosis was serious, and 2 of the 4 patients died. Avoidance of this complication depends on replacement of the ascending aorta (composite tube or supracoronary graft according to the involvement of the sinuses of Valsalva) as soon as the diameter of aorta exceeds 55 mm. In cases of moderate dilatation (45-50 mm), systemic reinforcement with Dacron mesh has been shown to have long-term effectiveness.

Surgical repair of vertebral artery stenoses.

During an eight year period (1973-1980) 290 patients were submitted to surgery for correction of obstructive lesions at the origin of the vertebral arteries. The pathologic process was atherosclerotic stenosis in 283, kinks in 25 and extrinsic compression in 17 cases. The operative procedures, mostly supraclavicular, on 325 arteries were: ostial endarterectomy (111), subclavian-vertebral endarterectomy (153) with patch (17), reimplantation in subclavian artery (14), subclavian-vertebral anastomosis (6), subclavian resection-anastomosis (5). Associated procedures included supra-aortic trunk reconstruction (9) and carotid endarterectomy (36 simultaneous, 51 pre and 21 post). Postoperative arteriograms were obtained in 33% of the patients with 5% occlusion and 81% excellent results. Hospital mortality was 0.6%. Long-term results with a follow-up from 2 to 9 years (mean 5 years) was the following: mortality 12%, asymptomatic 68%. Obstructive lesions of the vertebral artery are responsible for symptoms of vertebrobasilar insufficiency and are often neglected. Their frequency is suggested by the observation that during a 20-year period, 1,382 carotid, 789 supra-aortic trunk and 683 vertebral operations were performed. This series indicates that trans-subclavian vertebral ostial endarterectomy is a simple and safe procedure, providing durable results.

Fibromuscular dysplasia of the internal carotid artery: long-term surgical results.

Fifty-eight patients underwent 72 operations for symptomatic fibromuscular dysplasia (FMD) between 1970 and 1986. There were 35 females and 23 males aged between 36 and 76 years (average 56). Among the 72 operated on lesions (11 bilateral) FMD stenotic lesions (string of beads, tubular, focal) were isolated (32) or associated with elongation (tortuosity, coiling, kink) in 24 cases, FDM aneurysms (7), and dissecting pseudoaneurysms (9). The surgical techniques included graduated or balloon intra-luminal dilatation either isolated (29) or associated with resection-anastomosis (35), saphenous graft (4) and reconstructive aneurysmorrhaphy (4). Bifurcation endarterectomy was combined in 14 patients. There was no hospital death. There were 2 neurologic deficits after operation (1 transient) and 12 transient nervous disorders due to dissection near the base of the skull required in one third of the cases. The follow-up period extends from 6 to 22 years. Five patients were lost to follow-up. Out of the 53 remaining patients, 44 (83%) are living and asymptomatic. Nine patients died: 4 from myocardial infarction, 3 from cancer, 2 from neurologic disease. Three late successful reoperations were observed: 1 aneurysm formation following graduated dilatation, 2 anastomotic stenosis. Surgical intraluminal dilatation either isolated or combined with reconstructive techniques is a safe and durable operation relieving symptoms. The benefits of repair are long lasting and should be offered to patients with symptomatic FMD carotid lesions. The medical management of asymptomatic cases allows to study the natural history of the disease whose causes are not so far fully known.

Results following surgical correction of renovascular hypertension.

During a 12 year period, 110 patients were submitted to surgery for correction of renovascular hypertension. The pathologic process was atherosclerosis in 65, fibrodysplasia in 28, aneurysms in 6 abdominal coarctation in 5, aortoarteritis in 2 and 3 miscellaneous lesions. Operative procedures used on 148 renal arteries have been: nephrectomy (12), reconstructive surgery (133). Among them: endarterectomy (89), aorto-renal grafts (20) venous, dacron or arterial autografts, resection and anastomosis (10), direct reimplantation (8), angioplasty (5), arterial spleno-renal anastomosis (1). Postoperative arteriograms have been obtained in 98% of the patients, 4 occlusions occurred in aorto renal grafts, no thrombosis in endarterectomy. Progression of dysplasia and atherosclerosis was observed in 5 patients. The overall clinical results show: cure 55%, improvement 34% and no change 11%. With a difference between atherosclerosis (45% cured, 40% improved, 15% no change) and fibrodysplasia (63% cured, 29% improved and 8% no change). Several parameters are studied correlated with the surgical result. This series support interest to treat operatively renovascular hypertension: 89% of patients benefited from surgery.

Adult coronary aneurysms related to Kawasaki disease.

Kawasaki disease (KD) is an acute illness encountered in infancy and childhood. Cardiovascular complications of this syndrome are recognized as being part of the adult coronary artery disease population. Reported herein is the surgical treatment of multiple coronary artery aneurysms, severe stenotic lesions and thrombotic involvement of the coronary arterial tree that could be ascribed to childhood KD in two adult patients with no risk factors for atherosclerotic heart disease. Surgical management of such patients reveals safe and provides satisfactory quality of life.

Doppler echocardiographic evaluation of the Omnicarbon cardiac valve prostheses.

Comprehensive 2 D/Doppler examination of 98 patients (mean age 56), implanted between September 1984 and February 1991, with normally functioning aortic (n = 49) and mitral (n = 49) Omnicarbon valves (OC) were analyzed in order to characterize the normal hemodynamic profiles of the OC valves. The mean time from implantation was 36.4 months (range 6 to 78). The following parameters were assessed (average of 5 measurements): peak transvalvular velocity (peak V), peak instantaneous gradient (peak G), mean transvalvular gradient (mean G), effective aortic valve area (ef Va), modified aortic valve area (m Va), aortic permeability index (PI), mitral valve area (Mit Va). Doppler data were correlated to prosthetic sizes (ranging from 21-29 mm for aortic OC and from 23-31 mm for mitral OC). The study establishes normal Doppler hemodynamics for each size (especially in aortic position) of OC valves and shows excellent performance. Significant correlations between peak G, mean G, Pl, and prosthetic aortic valve size (AS) were moderate. By contrast there were strong relationships between AS and ef Va (r = 0.56, p < 0.001) or mVa (r = 0.55, p < 0.001). These data should be helpful to identify OC prosthetic dysfunction.

Upper limb arteritis in Takayasu's disease. Surgical treatment and results.

Non specific inflammatory involvement of the subclavian arteries due to Takayasu's disease is rare, compared to the frequency of atherosclerosis. A personal series of 23 cases of brachiocephalic arteritis, observed between 1967 and 1980 is presented. Mean age of the patients is 30 years, 60% are females. Supra-aortic trunks are only involved in 15 patients and associated with abdominal aorta and renal arteries in 8. By passes with prosthetic grafts or saphenous veins have been most frequently used in revascularization techniques performed in 23 patients, 2 patients have shown progressive evolution with multiple involvement between 4 and 6 years. One death occurred during recurrent active process with occlusion of all brachiocephalic arteries. With a mean follow up of 8 years, 80% of the surgical patients are stabilized with a satisfactory clinical and anatomical result. Operative indication must take into account the sites of occlusive lesions, symptoms and anatomical stage of arteritis.

[Late cardiac tamponade by localized compression of the left cavities after heart valve surgery. Apropos of 2 cases]. / Tamponnade tardive par compression localisée des cavités gauches après chirurgie valvulaire. A propos de 2 cas.

The authors report two cases of left cardiac failure occurring three and ten months after aortic valve replacement. Echocardiography established the diagnosis of localized compression of left heart chambers by hemopericardium. Surgical drainage dramatically improved patients with a follow-up of 4 years and 18 months. The authors emphasize the interest of left thoracotomy for drainage and discuss the etiology.

[Floating thrombus in the right atrium and severe pulmonary embolism. Value of intravenous thrombolysis]. / Thrombus flottant de l'oreillette droite et embolie pulmonaire grave. Intérêt de la thrombolyse intraveineuse.

Mobile right atrial thrombi carry a high risk of pulmonary embolism which may be massive and are a medical emergency. Although surgery is commonly indicated, treatment with intravenous thrombolytics is an alternative and was successful in 4 out of 6 cases reported by the authors. Six patients, admitted for severe pulmonary embolism confirmed by pulmonary scintigraphy (6 cases) and by angiography (2 cases), underwent echocardiography which demonstrated a mobile right atrial thrombus. One patient was operated as an emergency and died immediately afterwards. Another, treated with heparin because of contraindications to surgery and thrombolysis had a recurrent fatal pulmonary embolism. In the other four cases, intravenous thrombolytic therapy was started immediately after echocardiography with 250,000 IU of streptokinase in 30 minutes, followed by 100,000 IU per hour for 48 to 72 hours associated with heparin 300 to 500 IU/kg/day. The biological efficacy of the treatment was confirmed in all cases (fibrinogen < 1 milligram; TCA > 60 s). A clinical improvement with improved blood gases was rapidly obtained in all 4 cases. The thrombus had totally disappeared at control echocardiography 8 to 12 hours after the initial examination. There were no complications, in particular no haemorrhages. After 6 months' follow-up, the outcome was good with oral anticoagulants (4 cases) associated with implantation of a caval filter in 1 case. Thrombolysis seems to be an effective alternative to surgery as there four cases demonstrate.

[Iliac-femoral artery involvement in relapsing polychondritis]. / L'atteinte artérielle ilio-fémorale dans la polychondrite atrophiante.

A patient presenting a relapsing polychondritis with ruptured iliac arterial aneurysm and lower limbs arteritis is described. The analysis of the results compared with the literature's cases confirm the no response for surgical and medical treatments.

[Synovial cyst of the hip. 2 cases presenting with vascular symptomatology]. / Kyste synovial de la hanche. Deux cas révélés par une symptomatologie vasculaire.

Two cases of synovial cysts of the hip are reported beside any rheumatoid context. One presented as a pseudoaneurysmal inguinal mass, the other one as a venous compression of the lower limb, both of them were operative discovery. Through a review of the literature, pathogenic, diagnosis and therapeutic aspects of this rare disease are developed.

[Pre- and postoperative Doppler ultrasound findings in coarctation of the aorta]. / Données de l'ultrasonographie en mode Doppler pré- et post-opératoire dans les coarctations de l'aorte.

A retrospective study was done about 73 patients who had undergone a surgical operation for correction of coarctation of the aorta, between 1975 and 1985. Among these patients, 45 had both pre- and post-operative continuous wave Doppler ultrasound examination of cervical, upper, and lower limbs arteries, with pressure measurement. The age was under 14 years for 18 patients, between 14 and 25 for 10 patients, and more than 25 for the remaining 17 patients. The surgical procedure was resection with end-to-end anastomosis for 27 patients, tube graft insertion for 8 patients, dacron patch for 7 patients, subclavian arterioplasty or shunt for the others. Systolic Pressure Index and femoral Pulsatility Index showed a highly significant increase after operation (P less than 0.001) (tables I, II) regardless of the age or the surgical technique, thus demonstrating a satisfying hemodynamic efficiency of the correction (fig. 1-6) (2-6, 9). Nevertheless, 17 patients had, after operation, a greater than 15 Hg mm pressure gradient between left and right arm: the retrospective study showed that most of them had congenital abnormalities involving the left subclavian artery and/or had undergone a surgical procedure using the left subclavian artery for arterioplasty (10).