Use of the Carpentier-Edwards porcine bioprosthesis: assessment of a patient selection policy.

The Carpentier-Edwards bioprosthesis was implanted in 369 patients (414 valves) between May 1977 and December 1987 (age 67.2 +/- 0.5 years); 242 had aortic valve replacement, 80 had mitral valve replacement, 44 had multiple valve replacement, of which 41 were aortic and mitral valve replacement, 2 had isolated tricuspid valve replacement, and 1 had a pulmonary valve replacement. The selection criteria were the following: shorter life expectancy (253 patients) or contraindications to anticoagulants for organic (113 patients) or psychologic (38 patients) reasons, or both. The early mortality rate was 11.1% (aortic valve replacement, 9.1%; mitral valve replacement, 12.4%; aortic and mitral valve replacement, 23.1%). Total cumulative follow-up was 1456 pt-yr (mean 4.4 years, range 1 to 148 months), and the patient evaluation was 99.5% complete. Late mortality was 4.9%/pt-yr. Five-year survival was 70.4% +/- 2.7% overall, 74.3% +/- 3.2% after aortic valve replacement, 60.9% +/- 6.2% after mitral valve replacement (p < 0.03), and 60.7% +/- 8.1% after aortic and mitral valve replacement. Eight patients were reoperated on for primary tissue failure, and freedom from reoperation for structural valve deterioration was 97.5% +/- 1.2% at 5 years and 95.6% +/- 1.8% at 8 years. Failing aortic bioprostheses were explanted in four patients (0.4%/pt-yr) and mitral bioprostheses in seven (1.6%/pt-yr). No patient whose valve was inserted after the age of 70 had to be reoperated on for structural valve dysfunction. The probability of freedom from thromboembolism after 5 and 8 years of follow-up was 93.1% +/- 1.6% and 92.2% +/- 1.8%, respectively. The prevalence of anticoagulant-related hemorrhage was 0.8%/pt-yr (major 0.6%, minor 0.2%). Anticoagulants had to be maintained in 16.3% of the patients: 5.9% after aortic valve replacement, 35.7% after mitral valve replacement, and 45.8% after aortic and mitral valve replacement, while 80.0% were on a regimen of antiplatelet drug therapy. Prosthetic valve endocarditis happened in five patients (0.3%/pt-yr). Freedom from all valve-related morbidity and mortality, including hospital deaths, was 71.0% +/- 2.7% at 5 years and 58.6% +/- 4.6% at 8 years and was significantly better in the aortic valve replacement group (61.3% +/- 6.6% at 8 years) compared with the mitral valve replacement group (54.4% +/- 7.7% at 8 years; p = 0.04). This study confirms the satisfactory performance of the Carpentier-Edwards valve after aortic valve replacement in elderly patients.(ABSTRACT TRUNCATED AT 400 WORDS)

Surgical repair of coarctation of the aorta in infants under one year of age. Long-term results in 146 patients comparing subclavian flap angioplasty and modified end-to-end anastomosis.

Between July 1976 and February 1991, 146 consecutive infants underwent surgical repair of coarctation of the aorta. Age at operation varied from 2 days to 11 months (median 1 month). Ninety-two (63%) were less than 2 months. Isolated coarctation was present in 65 patients (group 1), associated ventricular septal defect in 49 patients (group 2) and complex anomalies in 32 patients (group 3). The majority (65%) were in a critical condition and 45 patients (31%) were artificially ventilated. Subclavian flap angioplasty was performed in 39 patients and resection and end to end anastomosis in 107 patients. Neither hospital mortality was significantly different between subclavian flap angioplasty (15%) and end-to-end anastomosis (18%) nor was the postoperative hypertension. Actuarial survival at 10 years were 100% for group 1, 94% for group 2, and 62% for group 3. Seventeen patients had recurrent coarctation. No significant difference was found in terms of types of repair or age at operation. As no major advantage in terms of mortality and morbidity to either technique was found, we recommend resection and end-to-end anastomosis. This technique not only relieves the obstruction whatever the level is but also eliminates the ductal tissue, preserves the subclavian artery and avoids the use of prosthetic material.

Aortic valve replacement thirty-one months after orthotopic heart transplantation.

Aortic valve replacement with a St. Jude prosthesis was performed 31 months after orthotopic heart transplantation in a 28-year-old male patient with Steinert's disease and idiopathic cardiomyopathy. The donor heart was reported as being normal by the cardiologist of the referring hospital. During implantation, a bicuspid aortic valve was noted, and early after the operation mild aortic regurgitation became apparent. Aortic incompetence advanced to a severe degree within 2 years after transplantation. Valve replacement, instead of retransplantation, was undertaken after careful consideration of the advantages and disadvantages of the therapeutic choice. This case report demonstrates the feasibility of valve replacement after heart transplantation and emphasizes the need for careful evaluation of potential donor hearts before harvesting.

[Myocardial revascularization with internal mammary artery graft: analysis of early and late post-operative respiratory morbidity]. / Revascularisation myocardique avec greffon mammaire: analyse de la morbidité respiratoire post-opératoire immédiate et tardive.

To evaluate the respiratory morbidity resulting from myocardial revascularization with internal mammary artery (IMA) graft, we reviewed 153 patients operated on between April and November 1988. There were 124 men with a mean age of 61 years. A bilateral IMA graft was used in 30 patients (20%). During the harvesting of the mammary graft, the homolateral pleura was systematically opened. Acute respiratory failure was more frequent in patients with bilateral IMA (13%) than in patients with unilateral IMA graft (3%) (p less than 0.05). Consequently, the mean duration of mechanical ventilation was longer in patients with bilateral IMA graft: 56 versus 23 hours (p less than 0.05). Lung volume measurements were altered according to a restrictive pattern. On the 9th post-operative day, forced vital capacity was reduced to 59.6% of the pre-operative value in patients with unilateral IMA and to 47.1% in patients with bilateral IMA graft (p less than 0.001). Late results were obtained in 111 patients. After a mean follow-up of 7 months, forced vital capacity was still reduced to 86.8% of the pre-operative value in patients with single IMA and to 78.1% in patients with bilateral IMA graft (p less than 0.001). In conclusion, respiratory morbidity is not negligible. Bilateral IMA grafting should generally be reserved to young patients (less than 65 years) with normal pre-operative pulmonary function tests.

Surgical treatment of subvalvular aortic stenosis. Long-term results.

From 1966 till May 1988, 53 patients underwent surgery for fixed subaortic stenosis. Subvalvular obstruction was isolated in 27 patients (Group I) and associated with aortic valve lesions in 26 (Group II). A membranous stricture was documented in 5 patients and a fibromuscular ring in 48. Excision of the ring and myectomy were performed in all patients, and an associated aortic valve replacement or reconstruction in 7 and 4 patients respectively. There were no hospital deaths. Follow-up evaluation in 50 patients ranged from 6 months to 22 years. Eight patients had to be reoperated upon (1 from group I, 7 from group II): aorto-ventriculoplasty was performed in 3, aortic valve replacement with redo myectomy in 3 and mitro-aortic valve replacement in 2. One of them had 2 reoperations. Functional status at the time of the last outpatient visit was most satisfactory. Continued evaluation remains necessary as obstruction may reappear despite the absence of symptoms.

Sequential mammary grafting. Clinical, functional, and angiographic assessment 6 months postoperatively in 231 consecutive patients.

Between September 1985 and November 1987, 246 sequential mammary grafts were performed in 231 consecutive patients. Seventy-eight percent had triple vessel disease, and 33% required an urgent procedure. The length of the internal mammary artery pedicle was the only limitation to its use. No account was taken of the free cut-end flow of the internal mammary artery. There were 14 bilateral sequential mammary grafts and 15 free sequential mammary grafts. Of the 531 sequential mammary anastomoses, 482 were built with the left internal mammary artery; 113 (21%) were diamond-shaped anastomoses. The right internal mammary artery was brought through the transverse sinus in 44 cases, 10 times for sequential grafting of circumflex branches. Taking into account the adjunctive venous anastomoses and the single internal mammary artery anastomoses, there were 4.5 distal anastomoses per patient, 2.8 being mammary anastomoses and 2.3 being sequential mammary anastomoses. The hospital mortality rate was 2.6%. The prevalence of perioperative myocardial infarction was 5.2%. Follow-up was complete and averaged 15.4 months. Six patients (2.7%) still had angina pectoris. One hundred fifty-seven (71%) patients were recatheterized 6 months after the operation, and 95% of the sequential mammary anastomoses were still patent. The patency rate of the diamond-shaped mammary anastomoses was 94.5% and that of the anastomoses corresponding to the right internal mammary arteries brought through the transverse sinus was 94.3%. The gratifying functional results (maximal stress test combined with exercise thallium scintigraphy) obtained at an average of 6 months postoperatively illustrated the surprising physiologic adaptability of the internal mammary artery. As the attrition rate of the mammary artery grafts beyond 6 months postoperatively is thought to be minimal, gratifying long-term results with widespread use of sequential mammary grafts can be anticipated.

Sequential mammary artery grafts in one hundred and twenty consecutive patients: indications, operative technique, 6 months postoperative functional and angiographic controls.

In the hope of establishing the internal mammary artery (IMA) as a true but superior substitute for the saphenous vein (SV) we reviewed our initial experience in complex IMA grafting. The first 120 consecutive patients, having received at least one sequential IMA graft were analyzed. The length of the IMA pedicle was the only limitation imposed on its use. Technical artifices enhancing the versatility of the IMA are described. The significant peri-operative myocardial infarction rate was 3.3%. There was no cardiac operative mortality, and 1 late mortality (0.8%). Excellent functional results were illustrated by a 2.5% rate of residual angina and dyspnoea. Six months postoperative angiographic controls could be performed in 70% of the patients: all of the sequential mammary conduits were patent, as were 95% of the anastomoses. By contrast 87.2% of the concomitant venous anastomoses were still functioning. With the expanding utilization of the free graft, IMA is expected to become a true, better and all round substitute for the saphenous vein.

Assessment of two venous drainage techniques in coronary artery bypass graft surgery.

We compared the influence on immediate postoperative cardiac performance, incidence of supraventricular tachyarrhythmia, fluid balance, and respiratory function of two methods of venous drainage during cardiopulmonary bypass (CPB). Two groups of 50 patients were studied. All 100 patients were operated electively for coronary artery bypass grafting. In group 1, cardiac drainage was achieved by using a two-stage cavo-atrial cannula, group 2 patients had drainage cannulae in the superior and inferior vena cava with caval tapes. There were no significant differences between both groups regarding postoperative hemodynamics. Right ventricular stroke work index in groups 1 and 2 differed insignificantly. The incidence of episodes of supraventricular tachyarrhythmia were 19 in group 1 and 23 in group 2 (p NS). Peroperative fluid balance was higher in group 1, but hematocrit during CPB was in the same range. Blood gas analysis values did not differ among the groups during the first 32 hours. The average duration of assisted ventilation was 30.3 +/- 5.4 hours in group 1 and 27.8 +/- 3.1 hours in group 2 (p NS). Thus, in patients undergoing coronary artery bypass grafting with standard techniques of intermittent cardioplegia, double caval cannulation is not superior to single atrio-caval drainage as far as postoperative left and right heart performance, and prevention of supraventricular tachyarrhythmia is concerned. Single cannulation did not increase the risk of undue hemodilution or respiratory dysfunction.

[Surgical plasty of the left main coronary artery]. / La plastie chirurgicale du tronc commun de l'artère coronaire gauche.

Critical stenosis of left main coronary artery (LMCA) is usually treated by conventional bypass surgery. However, this approach consumes an appreciable length of conduit, leads to occlusion of LMCA, and restores only a retrograde perfusion of a rather extensive myocardial area. As from June 1985, we performed 13 LMCA patch plasties in 12 patients. LMCA was approached either posteriorly via a curved aortotomy (9 cases), or anteriorly (4 cases) after retraction, partial or complete division of the main pulmonary artery. In 1 patient, a posterior LMCA plasty failed and a conventional double by-pass graft was needed. This patient underwent, 8 months later, a successful repeat patch plasty using a transpulmonary anterior approach. There was no perioperative myocardial infarction. There was no mortality. All of the patients underwent a 6 months postoperative angiographic control, with an excellent result in 12 cases: a significant restenosis of LMCA was successfully treated by percutaneous coronary angioplasty in 1 asymptomatic patient having concomitantly received a sequential mammary graft. All of the 4 patients are asymptomatic. A direct surgical approach to critical stenosis of LMCA is a valuable alternative treatment for this condition.

Total anomalous pulmonary venous connection. Long-term results following repair under 3 months of age.

The surgical experience with total anomalous pulmonary venous connection (TAPVC) at the University of Louvain (Brussels) between the years 1975 and 1986 is reviewed. Nineteen patients aged two days to three months with TAPVC were studied. The types of TAPVC were supracardiac in 9 patients, cardiac in 4, infracardiac in 4 and mixed in 2. Profound hypothermia induced by surface cooling, limited cardiopulmonary by-pass and total circulatory arrest were used in all cases. The 4 early deaths concerned the first four neonates who were critically ill. All operative survivors are followed for a mean of 3.5 years (12 months to 8 years). There are two late deaths due to reoperation for pulmonary venous obstruction. All 13 survivors are well at last review. Eleven of them have been recatheterized 4 to 33 months after repair (19 months in average). The pulmonary artery and capillary pressures fell to a normal level after a few months. Ventricular function which was markedly depressed preoperatively, was evaluated by quantitative angiocardiography and echocardiography. It returned to normal late postoperatively. The hospital mortality for the repair of TAPVC in the neonates remains appreciable. Total correction at one operation is advisable. The incidence of postoperative pulmonary venous obstruction is of particular concern. The late postoperative functional and hemodynamic results are excellent. The repair of TAPVC can be considered curative.

Comparative results after endarterectomy of the internal carotid artery performed with or without a shunt.

One hundred endarterectomies of the internal carotid artery have been performed from March 1984 to December 1985; 50 were carried out with a Javid shunt, and 50 were performed without using a shunt. There was no peroperative or hospital deaths. Five operations performed with the use of a shunt and 4 performed without a shunt were followed by a central nervous system deficit. The frequency of central neurological complications is thus not statistically different, but the time of onset and the likely cause of the deficit are different.

Twenty years' experience with the Model 6120 Starr-Edwards valve in the mitral position.

A total of 549 nonconsecutive patients underwent isolated mitral valve replacement with a Starr-Edwards valve prosthesis (Model 6120) at the University of Louvain (Belgium) from 1965 to 1985. Ninety-seven percent of the patients could be traced and only 17 patients were lost to follow-up. Cumulative follow-up totalled 3,130 patient-years. Actuarial and linearized statistical techniques were used to describe the survival and the incidence of valve-related complications (according to stringent criteria). Long-term overall survival rate including early deaths was 79% +/- 0.02% at 5 years, 65% +/- 0.03% at 10 years, and 54% +/- 0.04% at 19 years, with a linearized incidence of late deaths of 3.9% +/- 0.5% per patient-year. The incidence of late valve-related deaths was 1.25% per patient-year. Valve-related complications occurred at the following rates: thromboembolism 3.1% per patient-year, anticoagulant-related hemorrhage 1.08% per patient-year, endocarditis 0.26% per patient-year, reoperation and periprosthetic leak 0.45% per patient-year, and structural failure 0% per patient-year. All valve-related mortality and morbidity were calculated at 4.9% per patient-year and the rate of valve failure (deaths and reoperations) at 1.4% per patient-year. Among 376 survivors, 352 clinical functions could be obtained: 95% of patients belong to Class I or II of the New York Heart Association after operation versus 24% before operation. The study shows the structural durability of the Starr-Edwards mitral valve with a follow-up over 20 years. The Model 6120 valve may be considered a faithful standard.

Long-term follow-up of the Senning operation for transposition of the great arteries in children under 3 months of age.

Twenty-six patients aged 6 days to 3 months (mean 57 days) underwent a Senning procedure for transposition of the great arteries. Twenty-two had intact ventricular septum and four had a small ventricular septal defect. They were followed up for 1 month to 8 years (mean 4 years). There were no late deaths. At late examination, 25 patients were asymptomatic and there was no clinical or echographic evidence of caval or pulmonary venous obstruction. Growth was normal in all but two patients. Neurologic assessment was abnormal in eight patients. The electrocardiogram showed sinus rhythm in 22 patients and asymptomatic arrhythmias in four. Twenty-three patients underwent cardiac catheterization and angiographic studies 2 to 72 months postoperatively (mean 15 months), which demonstrated effective left and right atrial contraction. An atrial shunt was noted in one patient and a ventricular shunt in one. Two infants (8%) had a residual left ventricular outflow tract obstruction (gradients of 26 and 37 mm Hg). Two had mild superior vena caval obstruction (gradients of 4 and 5 mm Hg). We conclude that the Senning procedure can be performed in early infancy with good results and a low incidence of late complications.

Perigraft seroma following axillofemoral bypass: report of three cases.

One hundred and twenty-three axillofemoral or bifemoral bypasses were performed in the Department of Cardiovascular and Thoracic Surgery of the Catholic University of Louvain, Belgium between 1975 and 1986. Three cases of perigraft seroma were noted. A polytetrafluoroethylene (PTFE) graft had been inserted in all three cases. In one case, the seroma recurred rapidly after surgical drainage. The two others were not drained. In all three cases appearance remained unchanged throughout the observation period. The three bypasses are patent at 5, 14 and 24 months. Observation is advocated for this complication especially in high risk patients.

Experience with the selective use of the Carpentier-Edwards bioprosthesis.

Between April, 1977, and November 1984, 136 porcine bioprosthetic valves were implanted in 122 patients principally selected on the basis of age and contraindication to anticoagulants. The following procedures were carried out: aortic valve replacement (AVR) 88, pulmonary valve replacement (PVR) 1, mitral valve replacement (MVR) 38, and tricuspid valve replacement (TVR) 9. The ages ranged from 25 to 84 years (mean 64.6 years). The 30-day mortality was 11.5% overall. Survivors were followed up to 7 years (mean 29.2 months). Actuarial survival rates at 5 years, including operative deaths, were as follows: AVR 76.2 +/- 9.3%, MVR 59.7 +/- 12.6% and combined valve replacement (CVR) 47.1 +/- 19.4%. The 5-year probability of freedom from valve-related complications was 76.8 +/- 6.9% for all patients. The rate of thromboembolic events was 3.80% per patient-year after AVR and 2.72% per patient-year after MVR and CVR. The embolic rate did not differ between patients treated with anticoagulants and those treated with platelet antiaggregators. Primary tissue valve failure occurred in 2 patients for a linear incidence of 0.77% per patient-year. Postoperative echocardiography was performed in 83% of the survivors. Patients are now prospectively followed up by bidimensional echography and pulsed Doppler in order to detect early valvular dysfunction. The performance of the Carpentier-Edwards porcine bioprosthesis is, thus, satisfactory in this group of elderly patients.

Inotropic effects of amrinone and milrinone on contraction and relaxation of isolated cardiac muscle.

The inotropic response to amrinone and milrinone in isolated cat papillary muscle is characterized by a dose-dependent increase in contractility, with milrinone about five times as potent as amrinone, no effect on load dependence of relaxation, no change in timing and duration of the contraction-relaxation cycle, and marked temperature dependence. This response necessitates, at least in part, the presence of a well-functioning sarcoplasmic reticulum (SR). Amrinone and milrinone are less active when the SR is poorly developed, as in frog myocardium, mammalian atrial myocardium, Purkinje fibers, and ventricular muscle from fetal and newborn animals; when the SR has been destroyed, as in single mammalian cardiac cells; and when the SR, for reasons still under investigation, has become inactive, as in isolated human ventricular myocardium. Amrinone and milrinone are also less active or may depress contractility under conditions in which the SR is known to function near maximal calcium saturation (as in rat ventricular myocardium) or to be overloaded with calcium (as during reoxygenation). This depressant action suggests concomitant desensitization of the contractile proteins to calcium.

[Coarctation of the aortic isthmus in the adult]. / La coarctation de l'isthme aortique chez l'adulte.

Forty four patients over the age of eighteen operated upon for coarctation of the aorta from 1962 to 1983 at our institution were followed for one to 21 years (mean 13 years 3 months). Hypertension was found in 86% of the patients and 82% were preoperatively symptomatic. There were three late deaths. During the follow-up period, drug resistant hypertension persists in 31% of the patients at rest and/or exertion and 18% have functional symptoms. These data emphasize the importance of early diagnosis and treatment for patients with coarctation of the aorta.