Acute kidney injury in infective endocarditis: A retrospective analysis.

BACKGROUND: Acute kidney injury (AKI) is associated with high case fatality in infective endocarditis (IE), but epidemiological data on the frequency of AKI during IE is scarce. We aimed to describe the frequency and risk factors for AKI during the course of IE using Kidney Disease: Improving Global Outcomes consensual criteria. METHODS: Using the French hospital discharge database (French acronym PMSI), we retrospectively reviewed the charts of 112 patients presenting with a first episode of probable or definite IE between January 2010 and May 2015. RESULTS: Seventy-seven patients (68.8%) developed AKI. In univariate analysis, risk factors for AKI were cardiac surgery for IE (n=29, 37.7% vs. n=4, 1.4%, P<0.0005), cardiac failure (n=29, 36.7% vs. n=1, 2.9%, P<0.0005), diabetes mellitus (n=14, 18.2% vs. n=1, 0.9%, P=0.034), and prosthetic valve IEs (n=24, 31.2% vs. n=4, 11.4%). No differences were observed for gentamicin exposure (n=57, 64% vs. n=32, 86.5%, P=0.286). Prosthetic valve IE, cardiac failure, and vancomycin exposure were independently associated with AKI with respective odds ratio of 5.49 (95% CI 1.92-17.9), 4.37 (95% CI 4.37-465.7), and 1.084 (1.084-16.2). Mean length of hospital stay was significantly longer in patients presenting with AKI than in controls (respectively 52.4±22.1 days vs. 39.6±12.6, P<0.005). CONCLUSION: AKI is very frequent during IE, particularly in patients with prosthetic valve IE, cardiac failure, and those receiving vancomycin.

Pharmacokinetic/pharmacodynamic model for unfractionated heparin dosing during cardiopulmonary bypass.

BACKGROUND: High-dose heparin is used during cardiopulmonary bypass (CPB) to prevent thrombosis in the circuits used for extracorporeal circulation. The aim of this study was, initially, to develop a population pharmacokinetic/pharmacodynamic (PK/PD) model to assess the variability of PK/PD parameters and their correlation with the results of the routine haemostatic test activated clotting time (ACT) and thereafter to develop a Bayesian estimator enabling an individualized dosing strategy. METHODS: Fifty consecutive patients undergoing cardiac surgery with CPB were included in the study. Heparin was administered as an initial bolus of 300 IU kg -1 followed by additional boluses of 5000 IU to maintain ACT <400 s. In total, 361 blood samples were collected. The PK and PD data were analysed using a non-linear mixed effect model. RESULTS: A two-compartment model with a linear elimination link to an E max model best described heparin anti-factor Xa activities and ACT. Covariate analysis showed that body weight was positively correlated with clearance and central compartment volume. Inclusion of body weight with these parameters decreased their variability by 11 and 15%, respectively. The Bayesian estimator performed well in predicting individual parameters in an independent group of patients. CONCLUSIONS: A population PK/PD analysis of heparin during CPB, using a routine haemostatic test, shows that Bayesian estimation might help to predict ACT on the basis of only one or two blood samples.

[Microcirculatory dysfunction after cardiac surgery: Interest of NIRS technology with two case reports]. / Dysfonction microcirculatoire lors de la chirurgie cardiaque : intérêt de la technique NIRS à propos de deux cas cliniques.

Near infrared spectroscopy (NIRS) seems to be an interesting technology to study microcirculatory dysfunction. These alterations have been described after cardiac surgery under cardiopulmonary bypass. We report two case study reports with monitoring of StO(2) and reperfusion slope after an ischemic challenge. These two parameters are early altered notably in case of cardiac dysfunction (decrease of StO(2) and reperfusion slope). We discuss the interest of microcirculatory measurement in this context.

[Primary cardiac lymphoma: diagnosis and treatment. Report of 6 cases and review of the literature]. / L ymphome cardiaque primitif: démarche diagnostique et thérapeutique. A propos de 6 cas et revue de la littérature.

Primary cardiac lymphoma (PCL) is the rarest primary cardiac tumour and carries a poor prognosis. Early diagnosis, often difficult, to introduce appropriate treatment as soon as possible, seems to have a positive impact on prognosis. The authors report their experience of 6 patients with PCL. None of the patients had immune depression. The presentations were tamponade (N= 2), right heart failure (N= 1), general ill health (N= 3). A PCL was suspected on echocardiography and thoracic CT scan showing tumour invading the right heart chambers in all cases. The diagnosis of PCL was confirmed by surgical biopsy in 5 patients and by endomyocardial biopsy in 1 patient. A diffuse large cell type B lymphoma was found in 5 patients and an anaplastic lymphoma in 1 patient. One patient died of right heart failure 4 days after diagnosis and before starting chemotherapy. All the other patients received chemotherapy. Two patients died during their first course. The other three patients had several courses of chemotherapy: there are two survivors 17, 5 months later and one patient died 62 months after diagnosis. The diagnosis of PCL should be suspected in patients with a cardiac tumour associated or not with pericardial effusion. Early, appropriate chemotherapy seems to have a positive impact on the prognosis, justifying aggressive approaches to obtain a rapid histological diagnosis.

[Chronic dissection of the aorta after coronary bypass surgery]. / Dissection aortique chronique après pontages coronaires. Une stratégie chirurgicale difficile.

Dissection of the aorta is a potential complication of all forms of cardiac surgery. It occurs after a variable interval. When observed in the long term, surgery may be complex with greater technical difficulties resulting in increased postoperative morbidity and mortality compared with other types of dissection. These difficulties are all the more marked when the initial surgery is coronary bypass grafting and when the grafts, especially internal mammary artery grafts, remain patent. A surgical strategy has to be elaborated to prevent certain per- and postoperative complications. The authors report the case of a patient who developed a chronic dissection of the aorta 9 months after coronary bypass surgery with patent internal mammary artery grafts. In this situation, a strategy associating anterograde cerebral perfusion before the sternotomy and endovascular control of the internal mammary grafts was proposed.

[Fibroelastoma of the tricuspid valve presenting with syncope]. / Fibroélastome de la valve tricuspide révélé par des syncopes.

Cardiac fibroelastomas are rare benign tumours. Initially observed as a chance finding at autopsy or during cardiac surgery, the diagnosis has become more common since the introduction of echocardiography. These tumours are usually asymptomatic. When the left heart valves are involved, embolic complications may be threatening. When the right heart valves are affected they are usually asymptomatic. The authors report the case of a fibroelastoma of the tricuspid valve responsible for several syncopal attacks. The tumour was excised with preservation of the native valve. There has been no recurrence of syncope since surgery. The authors believe this to be the second reported case of fibroelastoma of the tricuspid valve presenting with syncope.

Long-term (29 years) results of reconstructive surgery in rheumatic mitral valve insufficiency.

BACKGROUND: Results of conservative surgery are well established in degenerative mitral valve (MV) insufficiency. However, there are controversies in rheumatic disease. This study is the evaluation of one center for rheumatic MV insufficiency based on a functional approach. METHODS AND RESULTS: From 1970 to 1994, 951 patients with rheumatic MV insufficiency were operated on with the reconstructive techniques elaborated by Alain Carpentier. Aortic valve diseases were excluded. Mean age was 25.8 years (4 to 75), and sinus rhythm was present in 63%. The functional classification used was type I, normal leaflet motion, 71 patients (7%); type II, prolapsed leaflet, 311 patients (33%); and type III, restricted leaflet motion, 345 patients (36%). The combined lesion of prolapse of the anterior leaflet and restriction of the posterior was present in 224 patients (24%). Surgical techniques used were implantation of a prosthetic ring in 95%, shortening of the chords and leaflet enlargement with autologous pericardium, and commissurotomy. Hospital mortality rate was 2%. The mean follow-up was 12 years (maximum, 29 years): 8618 patients per year. Actuarial survival was 89+/-19% at 10 years and 82+/-18% at 20 years. The rate of thromboembolic events was 0.4% patients per year (33 events), with 3 deaths. Freedom from reoperation was 82+/-19% at 10 years and 55+/-25% at 20 years. The main cause (83%) of reoperation was progressive fibrosis of the MV. The actuarial rate of reoperation was 2% patients per year and was correlated to the degree of preoperative fibrosis. CONCLUSIONS: Conservative surgery of rheumatic MV insufficiency has a low hospital mortality rate and an acceptable rate of reoperation. The results are excellent regarding the minimal risk of thromboembolic events.

Correlation between clinical and histologic patterns of degenerative mitral valve insufficiency: a histomorphometric study of 130 excised segments.

The objectives of this study were to examine quantitatively the histological changes in incompetent degenerative mitral valves obtained at surgery for mitral valve repair, and to determine whether Barlow's disease (BD) and fibroelastic deficiency (FED) can be distinguished by histology. The billowing mitral leaflet syndrome (or Barlow's disease) and FED can be distinguished on the basis of clinical patterns and gross features, but their histologic patterns have not been described. One hundred thirty patients were studied. Thirty-nine (24 males) had BD; 44 (38 males) FED; 15 (7 males) Marfan's syndrome (MS); and 32 patients (25 males) a non-determined degenerative disease. Histological changes of the resected segment of the valve were quantitatively evaluated using scores of severity. A discriminant analysis was performed. The groups defined by the computer were checked for concordance with groups defined by the surgeon. Collagen alterations were found the most severe in MS patients. BD and MS had the most myxoid infiltration. MS and FED patients had the most elastic fiber alterations. No BD in males and only one in females were misclassified by the discriminant procedure into the FED group. Overall, the percentages of correct matchings were 54% in males and 62% in females. When the age of patients and the size of ring were added to histology to determine whether this additional information provided more discrimination, the percentages of correct matchings reached 90% in males and 100% in females. BD and FED are two fairly distinct entities, which can be distinguished by quantitative histology, whereas only modest differences were found in qualitative histology.

Aortic valve surgery in osteogenesis imperfecta: report of two cases and review of the literature.

Aortic insufficiency is a well known but uncommon valvular dysfunction in patients with osteogenesis imperfecta. In such cases, aortic valve surgery has rarely been performed, and carries a high risk of perioperative complications. We report two patients with osteogenesis imperfecta, who underwent elective successful aortic valve replacement. The surgical problems encountered in this connective tissue disorder are also reviewed.

[Cavo-pulmonary anastomosis associated with intracardiac repair of Ebstein anomaly. Value in high-risk patients]. / Anastomose cavo-bipulmonaire associée à la réparation intracardiaque de la maladie d'Ebstein. Intérêt chez les patients à haut risque.

The surgical prognosis of Ebstein's anomaly depends on the quality of tricuspid valve repair and right ventricular function. In patients with right ventricular failure, a decrease in afterload was attained by a cavo-bipulmonary anastomosis associated with the intraventricular repair. Fifty-nine out of 111 patients operated for Ebstein's anomaly were considered to be at high risk and were selected for this study. The inclusion criteria were one or more of the following factors: massive tricuspid regurgitation, extensive atrialisation of the right ventricle, poor right ventricular function, chronic atrial fibrillation. This population was divided into two groups with the same preoperative features: Group I (45 operated patients: tricuspid valvuloplasty with longitudinal plicature of the right ventricule: Group II (14 operated patients): same intracardiac repair as Group I and associated cavo-bipulmonary anastomosis. The operative mortality was 24% (11/45) in Group I and 7% (1/14) in Group II (p < 0.05). The 5 year actuarial was 68.6% in Group I and 61.8% in Group II (NS). The reoperation rate was 11% (5/45) in Group I and 0% in Group II. In Group II, the persistence of significant tricuspid regurgitation was better tolerated and the frequence of reoperation was decreased with respect to Group I. The authors conclude that high risk patients with Ebstein's anomaly have a lower operative mortality and improved functional tolerance when there is persistent tricuspid regurgitation after cavo-bipulmonary anastomosis.

Surgical management of mitral regurgitation associated with Marfan's syndrome.

BACKGROUND: The surgical treatment of mitral regurgitation associated with Marfan's syndrome remains controversial because of the underlying degenerative process. METHODS: From October 1986 to June 1996, 33 patients with Marfan's syndrome underwent a mitral valve procedure. The mean age was 30 years (range, 2 to 55 years). Mitral regurgitation was caused by annulus dilatation in 2 patients, leaflet prolapse in 30 patients, and restricted leaflet motion in 1 patient. Mitral valve repair was performed in all patients except 1 who had mitral valve replacement. RESULTS: Two patients died in the perioperative period. All survivors were available for follow-up, which ranged from 1 month to 122 months (mean follow-up, 39 months). There were three late deaths, two of which were related to aortic complications. The actuarial survival rate was 78.9% at 10 years. Freedom from mitral valve reoperation was 87.1% at 10 years. Echocardiographic studies were obtained in all survivors and showed absent or mild (1+) mitral regurgitation in 21 patients and moderate (2+) mitral regurgitation in 3. CONCLUSIONS: Mitral valve repair for mitral regurgitation in patients with Marfan's syndrome can be performed safely in almost all instances. This technique provided stable midterm results comparable with those obtained for other degenerative mitral valve diseases.

Bi-directional cavopulmonary shunt associated with ventriculo and valvuloplasty in Ebstein's anomaly: benefits in high risk patients.

OBJECTIVE: The prognosis for surgical repair of Ebstein's anomaly depends on the tricuspid valve repair and on the right ventricular function. In order to decrease the preload of the compromised right ventricle, a bi-directional cavopulmonary shunt was added to the intracardiac repair. METHODS: Among 113 patients operated on for Ebstein' s anomaly at our institution from 1980-1997, a cohort of 60 patients was selected for high risk for postoperative complications. Patients presented with one or more several criteria: massive tricuspid valve dysfunction, extended atrialized right ventricle, poor right ventricular contractility, or long standing atrial fibrillation. After prior informed consent, this cohort was divided into two groups. Both groups had similar preoperative clinical patterns: Group I (45 patients), surgical technique included longitudinal right ventricular plication and tricuspid valve valvuloplasty; Group II (15 patients), where the surgical technique was similar to Group I except a bi-directional cavopulmonary shunt was added at the end of the procedure. RESULTS: Operative mortality was 24% (11/45) in Group I and 0% (0/15) in Group II (P < 0.05). The survival at 5 years was 66.1 +/- 14% in Group I and 80 +/- 16% in Group II (not significant). Reoperation rate was 11% (5/45) in Group I and 0% (0/15) in Group II. No deleterious effects of the bi-directional cavopulmonary shunts were observed clinically. Residual tricuspid valve insufficiency rate was 26% in both groups. However, patients with the bi-directional cavopulmonary shunt had a better tolerance and have not needed reoperations to date. CONCLUSIONS: In high risk patients with Ebstein's anomaly, an associated bi-directional cavopulmonary shunt seems to offer several distinct advantages including decreased operative mortality and better tolerance of the residual tricuspid valve dysfunction.

Surgical treatment of aortic root aneurysm related to Marfan syndrome in early childhood.

The prognosis of Marfan syndrome in both adult and pediatric patients is primarily related to the cardiovascular complications. In infantile Marfan syndrome, although involvement of the mitral valve is the most frequently encountered cardiovascular lesion, the aortic root can be more worrisome because of its excessive dilatation, leading to aortic insufficiency or dissection. If the role of elective surgery is relatively well defined for adult patients, it is still debated during childhood. We report two patients, aged 22 months and 5 years, each presenting an aortic root aneurysm related to Marfan syndrome, and each treated with the Bentall procedure without specific age-related mortality or morbidity. These two patients experienced normal growth and were free of any complication for a follow-up period of 8 and 2 years, respectively. More than an absolute value of the aortic root dimension, it is the conjunction of the rate of progression of the aortic root dilatation, the degree and the duration of the aortic valve regurgitation, and its resulting left ventricular dysfunction that must be taken into consideration in choosing the surgical option.

Reconstructive surgery in congenital mitral valve insufficiency (Carpentier's techniques): long-term results.

BACKGROUND: Previous publications have stressed the benefits of mitral valve repair over mitral valve replacement in children. However, few communications have reported the long-term results and none with a follow-up of more than 10 years. This article reports our results in a series of 145 patients operated on for congenital mitral valve insufficiency by means of the same technique (Carpentier's technique) in a single center. METHODS: Between 1970 and 1995, 145 patients younger than 12 years old underwent surgery for congenital mitral valve insufficiency. Mean age was 5.7 +/- 3.1 years, ranging from 0.17 to 12 years. Mitral valve insufficiency associated with atrioventricular defect, atrioventricular discordance, straddling mitral valve, acquired diseases, Marfan syndrome, and degenerative disease was excluded from this study. According to Carpentier classification, 31 patients had type I mitral valve disease (normal leaflet motion), 79 patients type II (leaflet prolapse), and 35 type III (restricted leaflet motion), with 15 having normal papillary muscles and 20 abnormal papillary muscles. Associated lesions were present in 51 patients (35%). A conservative operation was possible in 138 patients (95%). Among them, 70 patients required a prosthetic annuloplasty and 21 patients valve extension with a pericardial patch. Valve replacement was necessary in seven patients (5%). RESULTS: In-hospital mortality was 5% (95% CL: 2.5% to 9.9%) (seven patients). No early death was observed in the group of patients who underwent valvular replacement. In-hospital mortality was as follows: type I, 9.6%; type II, 2.5%; and type III, 13%. No statistically significant difference was noted among patients with the different types of disease. Mean follow-up was 9.3 +/- 6.9 years (1 to 26 years), and cumulative follow-up was 1142 patient-years. Ten late deaths occurred. Actuarial survival at 10 years was 88% in patients who underwent valve repair and 51% in patients who underwent valve replacement. Late reoperation was required in 15% (n = 21) of patients who had undergone valve repair and 28% (n = 2) in patients with valve replacement. Causes of reoperation were recurrent left ventricular failure (n = 1), residual or recurrent mitral valve insufficiency (n = 17), mitral valve stenosis (n = 3), and calcification of the bioprosthesis (n = 2). No failure resulting from leaflet extension was observed. In the repair group, actuarial freedom from reoperation was 68% (95% CL: 80.5% to 51.5%) at 15 years, and the linearized rate of exposure to reoperation was 1.9% per patient-year. No thromboembolic event was observed in any group. CONCLUSION: Congenital mitral valve insufficiency can be repaired in infancy with a low mortality. Conservative surgery with Carpentier's techniques is feasible in the majority of cases of congenital mitral valve insufficiency. This technique offers stable long-term results with a low rate of reoperation. Leaflet extension associated with prosthetic ring annuloplasty could prevent reoperations in selected cases.

Extensive calcification of the mitral valve anulus: pathology and surgical management.

Extensive calcification of the mitral valve anulus is a pathologic entity frequently associated with degenerative valvular disease. The calcification process remains localized to the anulus in 77% of the cases. It may extend, however, to the underlying myocardium. Whenever an operation is necessary for an associated valve insufficiency, the question arises whether it is preferable to repair or to replace the valve and how to manage the calcification. In the first part of this paper the pathology of this disease is studied, and in the discussion a mechanism is proposed to explain the development of the process of calcification. In the second part, a new operation is described, which comprises the temporary detachment of the leaflets, en bloc resection of the calcium deposit, annular reconstruction, and valve repair. For patients in whom the calcification extends to the myocardium a "sliding atrioplasty" of the left atrium is described, which allows the area of exposed muscular fibers to be covered. Between 1986 and 1994, among 68 patients with extensive calcification of the anulus and severe mitral valve insufficiency, 67 benefited from these repair techniques. Ages ranged from 18 to 82 years (mean 62 years). Thirty-two patients had a billowing mitral valve (Barlow), 27 a fibroelastic deficiency, and two Marfan's disease. The calcification involved more than one third of the anulus in 88% of the patients, the posterior anulus in 10.5%, and the whole anulus in 1.5%. The calcification process extended to the myocardial wall in 12% of the patients and to the papillary muscles in 4.5%. In the group of 67 valve repairs, there were two hospital deaths (2.9%), no instances of anulus dehiscence, and no early reoperations. The follow-up period extended from 4 months to 8 years (mean 3 years 8 months). There were two late deaths, 2 and 17 months after the operations, for an actuarial survival of 93% at 7 years. Late reoperation (6 to 62 months) was necessary in four patients (6.4%) for residual mitral valve incompetence (n=2), hemolysis (n=1), or endocarditis (n=1). In one of these patients a new repair was possible, whereas the three other patients required a valve replacement. All patients but one survived the reoperation. Actuarial freedom from reoperation was 87% at 7 years. All 60 patients with valve repair were reviewed for this study by clinical examination and echocardiography. All but one were in functional class I or II. There was no incompetence or trivial residual mitral valve incompetence in 55 patients and moderate incompetence in five. Two thromboembolic events have been recorded for a linearized rate of 1%/pt-yr. This study shows that complete anulus decalcification and valve repair can be done safely in patients with mitral valve insufficiency and extensive calcification of the anulus, even when the calcification process deeply involves the myocardium. It also demonstrates that an initially good result remained stable up to 7 years.

Association of latissimus dorsi muscle expansion with electrostimulation before cardiomyoplasty.

BACKGROUND: The principle of cardiomyoplasty is chronic electrostimulation of the latissimus dorsi muscle (LDM) flap wrapped around the heart to obtain a phasic activity that can be integrated to ventricular kinetics. In clinical cardiomyoplasty procedures, a complete wrap of both ventricles by the LDM cannot always be obtained in cases of extremely dilated hearts. This is due to the limited LDM length available for wrapping. In most of these cases, benefits of cardiomyoplasty are very limited. We have investigated the feasibility of progressive LDM expansion associated with electrostimulation. The aim was to increase the muscle area before cardiomyoplasty, while preserving the electrophysiologic characteristics of muscle fibers. METHODS: In 5 goats, a silicone LDM expander with two incorporated muscular pacing electrodes was inserted deep into the LDM through a paravertebral incision along the posterior edge of the muscle. The pacing leads were connected to a myostimulator implanted in a subcutaneous pocket. The expander was progressively inflated over 8 weeks, up to 500 mL. Simultaneously the LDM was electrostimulated. RESULTS: At 2 months planimetric studies demonstrated an increase of the LDM surface from 175 +/- 12 to 229 +/- 17 cm2 (+31% +/- 4%; p < 0.05). The expanded LDM showed preserved electrophysiologic characteristics. The analysis of biopsy samples revealed histologic integrity of muscle fibers and preservation of their mean diameter. CONCLUSIONS: Potential benefits of this procedure are (1) increase of muscle surface, (2) training of muscular fibers and preservation of muscular tone, and (3) division of the distal vascular supply at implantation, which may potentiate vascularization from the LDM main pedicle. An LDM expansion could be considered before cardiomyoplasty in cases of significant heart dilatation. This device was successfully implanted in 2 patients, 2 months before cardiomyoplasty. Cardiomyoplasties were performed without difficulty, and a complete biventricular wrap was obtained in both patients in spite of massive cardiomegaly.

Improvement of postischemic kidney function by reperfusion with a specifically developed solution (BT01).

Reperfusion is a critical phase of organ preservation. The purpose of this study was to develop a solution specifically for postischemic kidney reperfusion. Unilateral left normothermic kidney ischemia was induced for 60 minutes in two groups of micropigs. In group 1 (control pigs, n = 6) the kidney was reperfused immediately with pure blood at systemic pressure by unclamping the renal artery. In group 2 (test animals, n = 6) the kidney was initially reperfused with an intracellular flush solution enriched with solution BT01 composed of cytoprotectors (natriuretic factor, PGI2), free radical chelating agents (allopurinol, mannitol), and substrates for the mitochondrial respiratory chain (aspartate, glutamate). This solution was mixed immediately before use with blood in a ration of 1:4 parts and injected into the left renal artery with a perfuser at a constant pressure of 60 mm Hg. After 20 minutes, the kidney was reperfused with systemic blood for 100 minutes. Glomerular filtration rate (GFR) was determined by measuring inulin clearance. Kidney blood flow was measured throughout the experiment. After 120 minutes of reperfusion, the kidneys were removed for histologic examination. In the control pigs (group 1) 50% of the animals were anuric. The ratio between GFR measured in the left kidney at the end of perfusion and at equilibrium in the remaining animals was 0.16 +/- 0.01. In test animals (group 2) all animals recovered diuresis. The ratio between GFR measured in the left kidney at the end of perfusion and equilibrium was 0.51 +/- 0.12 (p < 0.001, group 2 vs. group 1). In group 2 postperfusion kidney blood flow was higher than in group 1 (63.0 ml/min vs. 27.4 ml/min; p < 0.05) because of a decrease in renal vascular resistance. Light microscopic examination of kidneys form animals in group 1 revealed tubular necrosis that extended to the parenchyma, with exposure of tubular interstitium. In group 2 only degenerative lesions with edema of tubular cells and disappearance of brush borders were observed. Our findings indicate that flushing the kidneys with BT01 solution mixed with blood improves postischemic kidney function by reducing reperfusion damage.

[Mitral valvuloplasty during the acute phase of endocarditis]. / Plasties mitrales au cours de la phase aiguë de l'endocardite.

Thirty-five patients were operated in the acute phase of mitral valve endocarditis between 1986 and 1991. The surgical indications were hemodynamic (22), echocardiographic (9), embolic (2) and infectious (2). There were pre-existing valve lesions in 45% of cases. The causal organism was identified in 90% of cases: streptococcus (19), staphylococcus (9) and Gram negative bacilli (4). Preoperative antibiotic therapy was prescribed for an average of 18 days. The aortic valve was infected in 9 patients and tricuspid valve in 1 patient. The mitral lesions were: abscess (11), vegetations (11), perforations (16), and ruptured chordae tendinae (22). All patients underwent Carpentier's mitral valvuloplasty. The operative mortality was 5.7% (2 patients). Early reoperation was required in 1 case. Follow-up was possible in 96% of cases for an average of 23 months. No recurrences of endocarditis were observed. One patient was reoperated and 3 died. All the others were in Classes I and II of the NYHA. None had significant mitral regurgitation or stenosis. These results show that mitral valvuloplasty is possible in the acute phase of endocarditis in 90% of cases. The mortality and morbidity are low and long-term results are stable.

Mitral valve repair in patients with endomyocardial fibrosis.

Between 1987 and 1990, 12 patients were operated on for endomyocardial fibrosis at our institution. Nine were treated by endocardectomy and mitral valve repair and constitute the material of this study. Ages ranged from 9 to 58 years (mean age, 32.5 years). Biventricular involvement was present in 3 cases, and 6 patients had predominantly left ventricular endomyocardial fibrosis. Six patients were in New York Heart Association class III/IV. Six patients had severe mitral insufficiency (3 to 4/4) and 3 patients had moderate mitral insufficiency (2/4). The operation consisted of left ventricular endocardectomy with complete detachment and mobilization of the posterior leaflet of the mitral valve in all cases. An autologous pericardial patch was used to reconstruct posterior leaflet continuity in 4 patients. In 7 patients a prosthetic mitral ring was used. In 3 patients right ventricular endocardectomy and tricuspid valve repair were also performed. All patients survived and none required early reoperation. Follow-up was complete and ranged from 9 to 38 months. No late deaths occurred, and 1 patient required mitral valve replacement for recurrent mitral regurgitation. Doppler echocardiographic studies were performed in 7 patients and revealed no or mild mitral insufficiency. In conclusion, mitral valve repair is safe and offers good early and late results in patients with endomyocardial fibrosis.