Late results with bioprosthetic valves in the elderly.

AIM: We report the long-term outcome of aortic and mitral bioprostheses in patients over 65 years of age at the time of implantation. The aim was to determine actuarial patient survival, causes of death, and the rate of documented primary structural deterioration. METHODS: One hundred ten patients > or = 65 years of age (mean, 73.4; range, 65-82) underwent successful bioprosthetic valve replacement (aortic, n = 71; mitral, n = 32; both, n = 7) from 1979 to 1985. The valve was pericardial in 39 cases and porcine in 78. The mean follow-up was 8.5 years (101.9 months-total; 934 patient-years; range, 2 months to 15 years). RESULTS: Actuarial patient survival was 79.6% (71-86) at 5 years and 62.4% (52-71) at 10 years. Forty-four patients died, 21 from valve-related causes and 23 from other causes. Thirteen patients (11.8%) had reoperation for valve-related complications: 10 structural deteriorations, 2 paravalvular leaks, and 1 case of endocarditis. One surgical death occurred (7.7%). Twenty-six percent of the patients were receiving anticoagulants because of atrial fibrillation, and 6.4% developed severe bleeding (2.9% patient-years). CONCLUSIONS: Long-term follow-up of these patients > 65 years of age, undergoing bioprosthetic value replacement surgery revealed a low rate of documented primary structural deterioration (0.95% per patient-year), a low mortality rate on reoperation (7.7%), and a high mortality rate due to non-value-related causes (52.3%).

Bioprosthetic valve replacement in the elderly.

One hundred and ten patients aged more than 65 years (mean, 73.4; range, 65-82) underwent successful bioprosthetic valve replacement (aortic, n = 71; mitral, n = 32; both, n = 7) from 1979 to 1985. The valve was pericardial in 39 cases and porcine in 78. The mean follow-up was 75 months (total, 688 patient-years; range, 2 months to 12 years). Actuarial patient survival was 79.4% at 5 years and 55.2% at 10 years. Thirty-seven patients died: 18 from valve-related causes and 19 from other causes. Eight patients have been reoperated on for valve-related complications (1.17% per patient-year): five primary deteriorations, two paravalvular leaks and one case of endocarditis. One surgical death occurred (12.5%). Twenty-five percent of the patients were receiving anticoagulants because of atrial fibrillation, and 5.4% developed severe bleeding (3.8% patient-year). Mid-term follow-up of these patients aged more than 65 years and undergoing bioprosthetic valve replacement surgery revealed a low rate of documented primary structural deterioration (0.9% per patient-year), a low mortality rate on reoperation (12.5%) and a high mortality rate due to non valve-related causes (51.4%).

[Mid-term results of bioprosthesis in patients over 65 years]. / Résultats à moyen terme des bioprothèses après 65 ans.

Between 1979 and 1985, 79 patients over 65 years of age (mean 70.8; range 65-82 years) underwent valvular replacement with a bioprosthesis (aortic: 48, mitral: 26, aortic and mitral: 5). Of the 84 valves implanted, 56 were porcine and 28 were pericardial bioprostheses. The average follow-up was 66 months (total: 434 patient-years; range: 2 months-12 years). Twenty-three patients (29%) died; 13 of these deaths were related to the prosthesis and 10 were not formally related to the bioprosthesis. Of the latter 10 deaths, 7 were caused by malignant disease. Seven patients were reoperated for a complication due to the prosthesis (1.6% per patient-year): 5 primary tissue failure, 1 endocarditis, 1 perivalvular leak. Sixteen patients (20.3%) received oral anti-coagulants for atrial fibrillation; 6 of them (7.6%) had severe haemorrhagic complications (3 deaths). The actuarial survival was 76.2% at 5 years and 53.4% at 10 years. Actuarial survival without reoperation was 76% at 5 years and 42% at 10 years. Analysis of survival with respect to the type of bioprosthesis (porcine of pericardial), the valve orifice (mitral or aortic) and age (under or over 70 years) did not show any significant differences. Follow-up of patients over 65 years of age showed a high rate of haemorrhagic complications related to oral anticoagulant therapy for atrial fibrillation (6.8% per patient-year), a low rate of primary tissue failure (1.1% per patient-year) and a low reoperative mortality (1 death for 7 reoperations).

["White-coat" effect in 35 consecutive patients with hypertension. Quantification method, role of physician-patient dialogue]. / L'effet "blouse blanche" chez 35 hypertendus consécutifs. Méthode de quantification, rôle du dialogue médecin-patient.

The "white coat" effect, an alarm reaction to the presence of a doctor, is an important cause of blood pressure variability, the frequency, amplitude and mechanisms of which are only partially understood. In order to evaluate these factors, a prospective study was undertaken in 35 consecutive patients referred for assessment of clinical hypertension. The alarm reaction was investigated during the consultation, at the time of interrogation, in periods of silence, in the sitting and upright positions. Twenty-four to forty-eight measurements (average 36.8) of the blood pressure and heart rate were performed in each patient with a Diasys 200 R monitor. The ambulatory period of 3 to 5 hours after the consultation provided 12 to 24 measurements (average 20.7) which were considered to be the reference for comparison with the consultation period. A total of 2,038 measurement were made and analysed. Analysis of variance (GLM) for each patient and for the whole group gave an assessment of the alarm reaction during the patient-doctor dialogue and periods of silence with reference to the ambulatory period. During the ambulatory period, the average and standard deviation for systolic pressure were 134 +/- 0.7 mmHg, and for diastolic pressure 93.1 +/- 0.6 mmHg. These pressures were significantly lower than during the two periods of consultation, with and without dialogue (p < 0.0001). During the consultation, the systolic and diastolic blood pressure values were significantly higher during the dialogue than during the periods of silence (p < 0.0001). During the dialogue, the systolic pressure attained 153.7 +/- 0.7 mmHg and the diastolic pressure: 107.2 +/- 0.6 mmHg.(ABSTRACT TRUNCATED AT 250 WORDS)

[Can patients with severe left ventricular dysfunction be treated by coronary artery bypass surgery?]. / Peut-on ponter les coronariens ayant une dysfonction ventriculaire gauche sévère?

Forty three men and 3 women, with an average age of 59 years (13 to 78 years) underwent aorto-coronary bypass surgery despite severe left ventricular dysfunction (ejection fraction < 35%); 96% of the patients had previous infarction; 60% (N = 28) had unstable angina, 52% (N = 24) had had pulmonary oedema or an episode of congestive cardiac failure. The average ejection fraction was 29 +/- 4%, range 17 to 35%. Thirteen patients had ventricular aneurysms, 4 had grade 3 or 4 mitral regurgitation. The coronary lesions were usually multivessel left main coronary (6), triple vessel disease (27), double vessel disease (12), single vessel disease (1). The average number of bypass grafts per patient was 2.3. The average aorting clamping time was 63 minutes (range 26 to 133 minutes). There were 4 mitral valve replacements, 4 resections of ventricular aneurysms and 1 double procedure (aneurysmectomy and valve replacement). The operative mortality was 2.1% (1 death). During an average follow-up period of 27 months (range 3 to 90 months), there were: 2 recurrent infarctions, 13 episodes of cardiac failure and 8 cardiac deaths (cardiac failure: 5, sudden death: 2, recurrent infarction: 1). Two patients underwent cardiac transplantation. The regression of angina (90% of operated patients were asymptomatic) and the low operative risk, justify aortocoronary bypass surgery despite left ventricular dysfunction in patients with severe symptoms (unstable angina, chronic, invalidating angina). The medium-term results indicate a high risk of cardiac failure which is partially responsible for the secondary mortality rate of 17% at 2 years.

[Clinical and angiographic results of delayed revascularization by angioplasty or bypass after intravenous thrombolysis in myocardial infarction]. / Résultats cliniques et angiographiques de la revascularisation différée par angioplastie ou pontage après thrombolyse intraveineuse dans l'infarctus myocardique.

Between 1988 and 1990, 150 patients treated for an infarction by intravenous thrombolysis underwent coronary arteriography. Sixty seven were managed by revascularisation by angioplasty (n = 49) or bypass (n = 18) more than 48 hours after thrombolysis. In this delayed revascularisation group, the time before initial fibrinolysis was 114 +/- 55 minutes. The artery responsible for the infarction was patent in 88 per cent of cases at 12 +/- 9 days, with ejection fraction being 56 +/- 12 per cent. Indications for revascularisation were: recurrence of angina, Thallium stress test showing redistribution (n = 9), diffuse lesions (n = 11) or tight (greater than 75 per cent) proximal stenosis without vessel wall sequelae (n = 10). Comparison of the bypass and angioplasty groups showed a lower ejection fraction in the former than the latter (47% VS 58%, p less than 0.01), more frequent three-vessel disease (50% VS 6%, p less than 0.01) and more frequent revascularisation of the anterior interventricular (100% VS 37%, p less than 0.01). There were 2 deaths and 5 recurrences of infarction at one year. Follow-up arteriography was performed between at 2 and 6 months in 72% of the patients: 16 had restenosis after angioplasty and 4 occlusion of the graft after bypass. A second revascularisation procedure was necessary 15 times (14 angioplasties, 1 bypass). The outcome after bypass or angioplasty was favourable in 90% of cases in this group of patients exposed to a recurrence of infarction.

[Doppler parameters of systolic function and heart rate]. / Paramètres Doppler de fonction systolique et fréquence cardiaque.

This prospective study had two aims, to study the Doppler parameters of left ventricular systolic function with respect to heart rate, and to determine the influence of ischaemic heart disease on these variations. The Doppler indices (velocity time integral, maximum velocity and average acceleration of systolic flow in the left ventricular outflow tract) were measured and averaged over 3 beats after digitization: the measurements were repeated in 30 patients under basal conditions and after 2 minutes transoesophageal atrial pacing at 150 beats/min. These 30 patients were divided into 3 groups: group 1 control subjects with normal coronary arteries, n = 13, EF = 71 +/- 8.9%; group 2 coronary patients without myocardial infarction (greater than 70% stenosis on coronary angiography), n = 9, EF = 64.3 +/- 10.3%; group 3, coronary patients with previous infarction, n = 8, EF = 51.8 +/- 10.9% (p less than 0.0006). Variance analysis for repeated measurements showed significant decreases in velocity time integrals and maximum velocities after pacing (11.8% +/- 2.2 and 0.86 +/- 0.1 versus 18.3 +/- 2.2 and 0.91 +/- 0.1, p less than 0.0001 and p less than 0.05 respectively). This decrease was identical in the three groups. The variations observed were therefore related to the increase in heart rate and not to coronary status or left ventricular function.

[Holter electrocardiography before and after coronary angioplasty. Angiographic correlation after 24 hours and 6 months]. / Electrocardiogramme Holter avant et après angioplastie coronaire. Corrélations angiographiques à 24 heures et à 6 mois.

Myocardial ischaemia was searched for by Holter monitoring before and after coronary angioplasty with primary success in 31 patients. Control angiography was performed at 24 hours and 6 months after angioplasty. Twelve patients had signs of myocardial ischaemia before angioplasty (cumulated ischaemia: 743 minutes). The degree of coronary stenosis was 92 +/- 6% before angioplasty, 25 +/- 17% immediately after the dilatation increasing to 34 +/- 25% at the 24th hour (p less than 0.002). Despite successful angioplasty myocardial ischaemia persisted in 6 patients (cumulated ischaemia: 184 minutes) and was silent in 5 of the 6 cases. In these 6 cases, control angiography at 24 hours showed either a dissection (n = 4) or a filling defect (n = 2). The angiographic outcome of the postangioplasty stenosis and at 24 hours was the same in Group I without restenosis (25 +/- 14% versus 33 +/- 22%) as in Group II with restenosis (25 +/- 22% versus 37 +/- 30%). In Group I, the degradation of the result at 24 hours was reversible at 6 months (33 +/- 22% vs 23 +/- 14%). After angiographic success, postangioplasty ischaemia present in 20% of cases was frequently silent. No correlation was observed with restenosis at 6 months which raises the possibility of a reversible microthrombotic etiology. These results justify antiaggregant and anticoagulant therapy in the 48 hours following angioplasty.

[Prognosis of ischemic mitral valve insufficiency]. / Pronostic de l'insuffisance mitrale ischémique.

Seventy-nine patients with ischemic mitral regurgitation were followed up for a period of 20 +/- 8 months. The risk of death increased with age and cardiac failure at the time of inclusion. The risk of cardiac events increased with these factors and also with raised serum creatinine and decreased echocardiographic fractional shortening. The global 2 year survival was 72.8% and survival without a further cardiac event was 48.7%. Surgery and angioplasty increased global survival and freedom from cardiac events of patients with severe regurgitation (74.9% and 68.8% versus 59.4% and 46.1% for medical therapy alone). The functional improvement was also greater in patients undergoing surgery or angioplasty (80% of patients in NYHA Stage I versus 53.8% in the medical group). Angioplasty was only performed in cases of paroxysmal mitral regurgitation by reversible papillary muscle ischemia. Surgery (coronary bypass usually associated with mitral valve replacement) was associated with better results than medical therapy alone in permanent mitral regurgitation by papillary muscle dysfunction or rupture. Despite a high immediate mortality, this option should be considered rapidly in cases of severe ischemic mitral regurgitation with pulmonary oedema.

[Late occlusive thrombosis of mitral prosthesis with sinus rhythm. Report of two surgically treated patients]. / Thrombose tardive occlusive de bioprothèse mitrale avec rythme sinusal. A propos de deux cas opérés.

Two cases are reported of late occlusive thrombosis of a mitral bioprosthesis with sinus rhythm. Two men were concerned (40 and 54 years of age), hospitalized for acute pulmonary oedema which was resistant to medical treatment, 3 years after replacement of a mitral valve (Carpentier Edwards No. 31 and Liotta No. 25). Catheterization showed that in both cases there was an average transmitral holodiastolic gradient greater than 25 mmHg. Emergency surgery revealed two anatomical forms of occlusive thrombosis: in one case, a localized red thrombus hindered the opening of a valve cusp; in the other, exuberant fibrin deposits lined the ventricular face of the valve cusps. There were no signs of degeneration of the bioprostheses and, in particular, there was no calcification. Both patients were asymptomatic 1.5 years and 3 years respectively after their operations. Late occlusive thromboses of mitral bioprostheses are exceptional (13 detailed cases collected from the literature).

[Is the prognosis of non-thrombolysed inferior infarction benign?]. / Le pronostic des infarctus postérieurs non thrombolysés est-il bénin?

Between 1978 and 1983, 2,970 coronary angiographies were performed at the Cardiology Clinic of Necker Hospital; 220 survivors of an initial Q-wave inferior infarction who had not received thrombolytic therapy were selected. The ejection fraction was 55 +/- 11 per cent, and the indexed end diastolic left ventricular volume was 108 +/- 29 ml/m2. The left anterior descending artery was diseased in 57 per cent of cases. The incidence of multivessel disease was 67 per cent. Two hundred and eleven patients (96%) were followed up for 79 +/- 22 months. The prevalence of cardiovascular events was: cardiac deaths: 22 (10%), recurrent infarction: 20 (9%), angina requiring coronary bypass surgery: 60 (28%), cardiac failure: 22 (10%). The 10 year actuarial survival was significantly lower in patients with an ejection fraction less than 45 per cent (46% vs 91%) and in patients with triple vessel disease (62% vs 92% and 88%). The survival was not lower in patients with stenosis of the left anterior descending artery.

[Restenosis after transluminal coronary angioplasty. Clinical and therapeutic aspects]. / Les resténoses après angioplastie coronaire transluminale. Aspects cliniques et thérapeutiques.

To assess the incidence and clinical presentation of restenosis after successful coronary angioplasty, and the short- and mid-term results of its treatment, 160 patients, who underwent a first coronary angioplasty between May 1987 and December 1988, were closely monitored. Restenosis is defined as a loss of 50% or more of the initial gain in area and/or 30% or more in diameter, or chronic coronary occlusion. These criteria were met in 43 patients (27%) within 5.1 months (1-6 months), on the average, after angioplasty. Restenosis was expressed as unstable angina in 51% of the patients, stable angina in 30%, and abnormal thallium myocardial scintigraphy under exercise in 14%. Myocardial infarction was never the revealing symptom. In 63% of the cases, the pain caused by restenosis repeated the initial angina. A second angioplasty was performed in 75% of the patients with a success rate of 93%, in the absence of an occlusion, and a 37% rate of further restenosis.

[Auricular flutter disclosing cardiac tumor]. / Le flutter auriculaire une circonstance révélatrice de tumeur cardiaque.

It is unusual that an atrial flutter reveals a tumor of the atrium. Two cases are reported: one occurred in a patient with a myxoma of the left atrium, the other was found in a patient with a non-hodgkinian lymphoma of the right atrium. The diagnosis was made possible by sonocardiography in both cases. The transesophageal view improves the quality of the images. MRI provided further informations regarding the lymphoma. Modern techniques of cardiac imaging permit the early diagnosis and treatment of cardiac tumors which must be investigated in case of apparently isolated atrial arrhythmias.

[Kingella denitrificans endocarditis on an aortic valve prosthesis]. / Endocardite à Kingella denitrificans sur prothèse valvulaire aortique.

Kingella denitrificans is a Gram-negative bacillus which does not grow readily on the usual media. This organism, normally a commensal of the upper airways, may exceptionally be responsible for endocarditis. We report here the sixth case known in the literature. Cure was obtained with an intravenous combination of vancomycin and rifampicin.

[10-year outcome of aortocoronary bypass. Apropos of a consecutive series of 114 patients]. / Devenir à 10 ans des pontages aorto-coronaires. A propose d'une série consécutive de 114 patients.

The cases of 114 consecutive patients undergoing saphenous vein coronary bypass surgery over 10 years ago were reviewed. The perioperative mortality was 2.6% and the incidence of non-fatal myocardial infarction in the same period was 6.1%. The 10 year survival rate was 80%; the most important prognostic factor for survival was left ventricular function (89% vs 51%; p less than 0.001). Other significant prognostic factors were the degree of revascularization (p less than 0.05) and the severity of the coronary artery disease (p less than 0.05). The incidence of recurrent ischaemia during follow-up depended mainly on the quality of myocardial revascularisation (p = 0.003). Taking into account the high proportion of patients with single vessel disease in this series (38.6%), our results were comparable with other reported studies of the same subject and the same period (1970-1976).

[Drug-induced cardiovascular complications]. / Accidents cardiovasculaires d'origine médicamenteuse.

Many drugs, including those prescribed in cardiology, can induce adverse cardiovascular side effects. Most of the anti-arrhythmia drugs have a negative inotropic action and proarrhythmic effects. Estroprogestative contraceptive drugs favor thromboembolitic events and increase the incidence of hypertension. Due to the risk of coronary insufficiency, substitutive hormonotherapy in hypothyroidism must be introduced gradually. Tricyclic anti-depressive drugs and neuroleptics can induce orthostatic hypotension. However, all these adverse effects can usually be avoided if every drug-specific contra-indication is respected, if doses are individually adjusted to the patient's age and physical condition and if the patient is closely monitored.

[Annulo-ectasing disease of the aorta: apropos of 10 cases]. / La maladie annulo-ectasiante de l'aorte: a propos de dix observations.

Ten patients were investigated and operated for severe aortic regurgitation due to dystrophic aortic dilatation. This is the third commonest cause of pure aortic regurgitation (18 p. 100) operated at Necker Hospital during the same period. This condition, comprising aneurysm of the ascending aorta, dilatation of the aortic ring and dystrophic aortic valves, is often responsible for severe aortic regurgitation and is noteworthy because of the associated risk of aortic dissection. Cardiovascular surgery is indicated and usually includes replacement of the ascending thoracic aorta with aortic valve replacement.

[Fitness for sports of patients with Wolff-Parkinson-White syndrome]. / Aptitude au sport chez les patients porteurs d'un syndrome de Wolff-Parkinson-White.

The fitness of patients with Wolff-Parkinson-White syndrome to indulge in sporting activities is a practical cardiology problem. The major risk is sudden death due to atrial fibrillation deteriorating to ventricular fibrillation. This risk is small or even theoretical, but signing a fitness certificate engages the clinician's responsibility. Non invasive complementary examinations are useful. Echocardiography may detect a heart disease that would preclude any sport. Exercise tests explore the behaviour of the accessory pathway and rarely trigger off arrhythmias. Holter recordings mainly investigate disorders of the atrial rhythm. The decision concerning fitness may be based on clinical symptoms. Exercise-induced tachycardia is a classical contra-indication to competitive sports. In patients whose tachycardia is unrelated to exercise, fitness may be discussed according to the results of exercise tests and of the electrophysiological study. A refractory period which would be considered as rather prolonged at rest does not protect against fast ventricular rate during passage to atrial fibrillation. If pre-excitation disappears during the exercise test in an asymptomatic patient, then competitive sports can be authorized without limitations. If not, only surgical excision or fulguration would provide full protection against a potentially dangerous fibrillation. It is concluded that Wolff-Parkinson-White syndrome contra-indicates competitive sports in most cases. Games played outside competitions remain possible in the absence of symptoms or when arrhythmias are well controlled by medical treatment.