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.

A comparison of the inotropic effects of dopamine and epinine in human isolated cardiac preparations.

The positive inotropic effects of epinine and dopamine have been studied in isolated preparations obtained from human heart in the absence and in the presence of the selective beta adrenoceptors antagonists practolol and ICI 118,551. ED50 values of the two agonists were similar (about 3 x 10(-5) M). The inotropic efficacy of epinine was significantly higher than that of dopamine in adult ventricular and papillary muscles, it was similar to that of dopamine in juvenile myocardial preparations and in adult atria and pectinate muscles. The dopamine-evoked response was significantly more sensitive to practolol than epinine-evoked response, but it was less sensitive to ICI 118,551. pA2 values of practolol and ICI 118,551 were considerably different with epinine but not with dopamine as agonist. The results indicate that, compared to dopamine in isolated human heart preparations, epinine was more potent at beta-2 relative to beta-1 adrenoceptors.

[Revision of midline sternotomies after cardiac surgery in 1988: retrospective study]. / Reprises de sternotomie médiane après chirurgie cardiaque en 1988: étude rétrospective.

Twenty-three of 514 (4.6%) patients who underwent cardiac surgery in 1988 with cardiopulmonary bypass were later reoperated for sternal complications. Several risk factors, including pre-, intra and postoperative variables, have been investigated. A significant correlation was found with the presence of diabetes mellitus, the type of operation (bilateral internal mammary artery grafting), early reoperations, haemodynamic alterations, pulmonary infections and incidence of serious non infectious complications. The different sternal complications are analyzed from a clinical and therapeutic point of view.

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.

Inhibition by amlodipine of activity evoked in isolated human coronary arteries by endothelin, prostaglandin F2 alpha and depolarization.

Amlodipine, a dihydropyridine calcium antagonist has been examined on the rhythmic activity of isolated human coronary arteries. Amlodipine inhibited both the spontaneous rhythmic activity and the rhythmic activity evoked by prostaglandin F2 alpha and endothelin in isolated human coronary arteries. It also inhibited the contraction evoked by potassium depolarization. The action of amlodipine was characterized by slow onset and voltage dependency.

Ventricular paired pacing to control intractable junctional tachycardia following open heart surgery in a child.

A 5-month-old girl presented postoperatively with an atrioventricular (A-V) junctional tachycardia at a rate of 245/min following surgical repair of tetralogy of Fallot. The systolic blood pressure dropped to 60 mmHg with this rapid heart rate, and the infant became shocked. Drugs and overdrive pacing were ineffective in suppressing the A-V junctional tachycardia and in improving cardiac output. Ventricular paired pacing was used successfully to halve the mechanically effective ventricular rate and to restore cardiac output. When ventricular paired pacing was stopped after 12 h, the spontaneous rhythm was an atrial rhythm with 1-1 A-V conduction. The patient was discharged in sinus rhythm on the 5th postoperative day.

[Various aspects of the medical treatment of newborn infants with heart disease]. / Quelques aspects du traitement médical des nouveau-nés cardiaques.

Some aspects of the medical treatment of newborns with congenital heart disease. The outcome of new-born babies with critical congenital heart disease has dramatically improved over the last 25 years. Better understanding of the abnormal hemodynamic situations and thus more appropriate intensive care decisions, increased accuracy of the diagnosis obtained by color-doppler and echocardiography and improved surgical and anesthetic skills and technics, are the main factors of these better results. The authors describe the benefits of prostaglandin infusion in situations where anatomic anomalies prevent the parallel foetal circulation to change into a serial circulation system: severe stenosis or atresia of right or left cardiac valves, transposition of great vessels. Another example of improved medical treatment concerns balloon valvuloplasty. This new technic offers a valuable alternative to surgery in cases of severe isolated stenosis of aortic or pulmonary valves in the neonatal period.

[Surgery of congenital cardiopathies]. / La chirurgie des cardiopathies congénitales.

Based on their experience, the authors are demonstrating that early surgery of cardiac abnormalities is justified. This has become possible, during the last few years, because of a better understanding of cardiac anatomy, metabolism and function in the small child. Results are showing that 75% of operated children are leading a normal life. Further improvements have to be pursued with as final objective the prevention of cardiac abnormalities.

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.

[Congenital heart diseases and obstructive pulmonary vascular diseases in Down's syndrome. Apropos of 142 children with trisomy 21]. / Cardiopathies congénitales et maladie vasculaire obstructive pulmonaire dans le syndrome de Down.

Trisomy 21 accounts for 3 p. 100 of reasons for admission to the Paediatric Cardiology unit of the St Luc University Clinics, Brussels. In a series of 142 cardiac children with trisomy 21 evaluated by catheterization between 1969 and 1987, 54 p. 100 of the cardiac malformations observed consisted of persistent common atrioventricular canal (complete in 45 p. 100 of the cases). The other heart diseases were ventricular septal defect (23 p. 100), atrial septal defect of the ostium secundum type (10 p. 100) and tetralogy of Fallot (9 p. 100). In 40 p. 100 of the patients other cardiovascular abnormalities were associated with these predominant intracardiac shunts. These findings were in agreement with those usually reported in the literature. At the time of investigation (mean age 24 months), pulmonary vascular resistance had already reached a pathological level in 88 p. 100 of the cases. Oxygen tests only slightly improved these results, which suggested that the conditions were favourable to the early development of a pulmonary obstructive vascular disease in Down's syndrome, thus darkening the prognosis of congenital heart disease in mongoloid children. In this series to overall mortality rate of corrective surgery was 23 p. 100. The risk was maximum in infants aged less than 3 months with severe and rapidly symptomatic lesions. The outcome in patients successfully operated upon was satisfactory, with benign residual lesions.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

The actions of nifedipine and nisoldipine on the contractile activity of human coronary arteries and human cardiac tissue in vitro.

We have studied the action of nifedipine and nisoldipine on the contractile activity of human isolated coronary arteries and human isolated auricular and ventricular muscles. Nisoldipine depressed dose dependently the spontaneous rhythmic contractions displayed by the coronary artery preparations and at 1 nM abolished these contractions. Nisoldipine was twenty times more potent than nifedipine as an inhibitor of increase in tone induced by depolarization (100 mM K+). The rhythmic activity induced by serotonin (10 microM) was about five times more sensitive to nisoldipine than to nifedipine. In both auricular and ventricular preparations, isoprenaline evoked an increase in the rate of force development and in the rate of relaxation. Nifedipine was five times (ventricular muscles) and ten times (auricular muscles) more potent than nisoldipine as a negative inotropic agent. The present observations in human isolated preparations indicate that nisoldipine shows a higher vascular selectivity than nifedipine.

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.

[Role of catheterization and pneumoangiography in moderately severe pulmonary embolism]. / Place du cathétérisme et de l'angiopneumographie dans les embolies pulmonaires de gravité moyenne.

In patients with moderate pulmonary embolic disease, angiography is regarded as the most reliable procedure for establishing the diagnosis. Digital subtraction angiography (DSA) is easier to perform than conventional pneumoangiography (presently carried out in some selected cases only) and has become the diagnostic procedure of choice for pulmonary embolism. DSA achieves satisfactory results and is still more accurate when it is performed after perfusion/ventilation lung scans. In patients with acute embolus, usually hospitalized in the intensive care unit. Swan-Ganz catheterization provides the clinician with a great degree of haematologic information that enables him to select the appropriate therapeutic choice, which most often has to be determined in emergency.

[Pulmonary embolectomy. Clinical experience]. / L'embolectomie pulmonaire. Expérience clinique.

Between 1969 and 1984, twenty-three patients underwent an emergency pulmonary embolectomy under extracorporeal circulation in the Catholic University of Louvain (UCL), Department of Cardiovascular and Thoracic Surgery. The aim of this paper is to delineate the indications of this procedure. Patients were 23 to 70 years old. Diagnosis of Pulmonary Embolism was made according to clinical signs, ECG and Chest X Ray with Swan-Ganz catheter insertion into the pulmonary artery and the help of pulmonary angiogram if time permitted. The surgical technique is briefly described. Four patients died during the immediate postoperative period and three died later. The sixteen survivors all enjoy a normal life.

[Treatment of the first episode of pulmonary embolism in the hospital. Anticoagulants, anti-platelet aggregation drugs and thrombolysis stimulants]. / Traitement du premier épisode d'embolie pulmonaire en milieu hospitalier. Anticoagulants, anti-agrégants plaquettaires et stimulants lytiques.

The treatment of the first pulmonary embolic accident in Hospital consist in the administration of anticoagulants. Heparin will be first used intravenously or subcutaneously during 10 to 12 days and will be followed by oral anticoagulants (VKA) during 3 to 12 months. These treatments must be controlled following national or international standardized technics and can be associated with antiplatelet drugs or thrombolytic activators. The most important and frequent complications observed are haemorrhages. They are consecutive to a non conformed administration of the drugs or overdosage bound to a non correct control or drugs interferences or to a misappreciated counterindication. They will be corrected in most of the cases by a simple anticoagulant dosage reduction and exceptionally by the interruption of the therapy with administration of antidotes and plasma substitutes. Other complications are extremely rare and bound to the nature of the drugs used.