[Long term results of the surgical treatment of obstructive hypertrophic cardiomyopathies]

Between January 1973 and December 1993, 66 patients underwent surgery in our department for hypertrophic obstructive cardiomyopathy; mean basal outflow gradient was 48.4 +/- 36 mmHg, 20 patients had mitral valve lesions. Thirty six patients underwent myotomy-myomectomy alone, 13 mitral valve replacement alone, and 17 both myotomy-myomectomy and mitral valve replacement. The 30-day mortality rate was 7.5% for all patients; predominant risk factors were gender (female), greater cardiothoracic ratio, preoperative episodes of atrial fibrillation and lack of syncope. Overall survival rate (operative mortality included) was 65.3 +/- 8.6% at 13 years. Predominant risk factors for late mortality were the same than above, plus mitral valve replacement; so mitral valve repair, whenever feasible should be undertaken. Forty nine patients are still followed up: 46 are asymptomatic; Doppler mean basal outflow gradient was reduced to 10 +/- 1.4 mmHg. In conclusion, surgery relieves symptoms and outflow obstruction, and allows mitral valve reconstruction.

Heart transplant for the failing ischaemic ventricle

Clinical application of heart transplantation goes beyond 28 years experience. Ischaemic heart diseases remain, with idiopathic cardiomyopathies, the main indications for cardiac transplant. A combination of haemodynamic, contractile and viability measurements may be useful to choose between transplant and coronary revascularization for the failing ischaemic ventricle. Advances in the detection of early rejection, improved organ preservation procedures, and the introduction of new immunosuppressive therapy protocols have produced dramatic results in heart transplantation. Late graft atherosclerosis remains a serious threat despite retransplantation and, in some cases, mechanical circulatory support.

[Reoperation for aortic valve replacement after myocardial revascularization]

A series of 13 patients (11 male, 2 female, average age 61 +/- 6 years) with previous aortocoronary bypass surgery and reoperated for aortic valve replacement (AVR) were analysed retrospectively. At coronary bypass, 8 patients (Group I) has insignificant aortic stenosis (AS) (mean transvalvular pressure gradient < 40 mmHg and/or aortic valve surface > 1 cm2). The other 5 had no aortic valvular lesion (Group II). The average time interval between the two operations was 7 +/- 3.3 years (Group I: 6.7 +/- 3.5 years; Group II: 7.4 +/- 3.2 years). In Group I, 2 patients required early AVR (2 years) whereas the time of reoperation varied from 6 to 12 years in the other 6 patients. No operative complications related to the sternotomy or dissection of adhesions were observed. In 3 cases, it was necessary to free the implanted grafts on the right coronary artery to gain access to the initial part of the aorta. A transverse low aortotomy allowed AVR in good conditions in all cases. One patient in Group II died on the 5th postoperative day of a low output syndrome complicated by pneumonia. After an average follow-up of 3 +/- 2 years, 9 patients are still alive. Three patients in Group I died, two of cardiac failure and one of unknown causes. The authors conclude that "prophylactic" AVR in cases of insignificant AS in patients referred for coronary bypass surgery is not justified. Regular echocardiographic follow-up should lead to AVR at the most appropriate moment, sometimes after an interval of several years, with a low operative risk.

Clinical experience with a total artificial heart as a bridge for transplantation: the pitie experience

Since April 1986, 82 patients have received a pneumatic total artificial heart, 62 a JARVIK-7, and 20 a Cardiowest. The duration of support ranged from less than 1 day to 603 days (mean duration: 27 +/- 82). The indications were for acute shock (38 cases) or for chronic deterioration on the transplant waiting list (44 cases). The etiology was mainly due to idiopathic and ischemic cardiomyopathy. With the help of our scoring system, we divided our patients in three groups: Chronic Implantation, represented by two females staying on device for 6 and 19 months, respectively; a High-Risk group of 29 patients characterized by high-risk indications; graft failure, rejection, postcardiotomy patient, postpartum cardiomyopathy, and valvular and congenital reoperation. In addition, the dilated and ischemic cardiomyopathy patients with a score over 6 were included in this group; and an Elective Indication group (51 patients) represented all of the dilated and ischemic cardiomyopathy patients with a score under 6. Due to the shortage of donors, our criteria for transplantation are very strict. Transplants should be made only in cases of hemodynamic stability, on an extubated patient with normal renal and liver functions, without coagulation problems or infection. With such criteria, in the high-risk group, only four patients could be transplanted and of these two are still alive. In contrast, in the elective group, 31 were transplanted (61%), and 71% of these patients were discharged. The rate is improved in the most recent cases, with 90% of the Cardiowest patients being survivors.

Dynamic cardiomyoplasty: effect of discontinuing latissimus dorsi muscle stimulation on left ventricular systolic and diastolic performance and exercise capacity

OBJECTIVES

This study sought to assess the short-term effect of discontinuing latissimus dorsi muscle stimulation on left ventricular systolic and diastolic performance and exercise tolerance in patients with improved functional status by cardiomyoplasty, in whom latissimus dorsi muscle was fully conditioned.

BACKGROUND

Cardiomyoplasty has consistently improved the functional status of patients, but the short-term effect of latissimus dorsi muscle contraction has not been assessed in these patients.

METHODS

Right-heart catheterization, Doppler-echocardiography and maximal exercise testing with expired gas analysis were performed in 10 patients with congestive heart failure who had undergone cardiomyoplasty at least 6 months earlier. Data were obtained when the latissimus dorsi muscle was stimulated every other systole and after stimulation was discontinued for 1 h. The power of this study to detect a 10% difference was > 80%.

RESULTS

After cardiomyoplasty, left ventricular ejection fraction increased from 0.22 +/- 0.08 (mean +/- SD) to 0.27 +/- 0.07 after 6 months (p < 0.02 vs. before cardiomyoplasty) and to 0.24 +/- 0.09 after 1 year; functional class went from 3.0 +/- 0.0 to 2.0 +/- 0.5 after 6 months and to 2.0 +/- 0.7 after 1 year (both p < 0.001 vs. before cardiomyoplasty). After discontinuation of latissimus dorsi muscle stimulation, cardiac index did not change (2.28 +/- 0.45 vs. 2.30 +/- 0.46 liters/min per m2). Mean systemic arterial and pulmonary capillary wedge pressures were also similar (85.2 +/- 6.0 vs. 88.4 +/- 5.6 mm Hg and 14.9 +/- 7.1 vs. 13.6 +/- 6.8 mm Hg, respectively). Doppler E/A ratio decreased from 1.04 +/- 0.33 to 0.83 +/- 0.25 (p < 0.02), suggesting that left ventricular diastolic function may have been improved by latissimus dorsi muscle stimulation. Peak oxygen consumption was unaltered (1,633 +/- 530 vs. 1,596 +/- 396 ml/min).

CONCLUSIONS

Alterations in left ventricular diastolic rather than systolic function may be responsible for the long-term clinical benefits of cardiomyoplasty.

Extra-annular procedures in the surgical management of prosthetic valve endocarditis

Severe acute endocarditis can be associated with major destruction of the annulus. Meticulous surgical debridement of friable necrotic material is always necessary and major damage to the annulus of the valve may impair secure seating of the prosthesis. Extra-annular implantation of a prosthesis may be a life-saving procedure when annular implantation is impossible. Between 1978 and 1989, 36 patients underwent extra-annular complex procedures for annular abscesses. The infection involved the aortic prosthesis and the annulus in 22 patients, and the mitral prosthesis and the annulus in 14 patients. In cases of aortic root abscess, a subcoronary valved graft (11 patients), a supracoronary valved conduit (ten patients) or a left ventricle-abdominal aorta valved conduit (one patient) were implanted. In cases of mitral valve endocarditis with extensive annular abscess, intra-atrial insertion of a mitral prosthesis was performed. In such cases, repair of the aortic root with a valved conduit or intra-atrial implantation of a mitral valvular prosthesis can be life saving and can be expected to give excellent long-term results.

[Septicemia and endocarditis related to transvenous pacing leads of pacemakers: surgical indications and results]

Endocarditis of transvenous pacing leads is a rare condition. The authors review a series of 15 patients who developed bacteriologically proven septicaemia and/or endocarditis related to transvenous pacing leads, operated between 1988 and 1993. The interval between the last manipulation of the pacemaker and the onset of endocarditis was about 6 months. Six patients had had haematoma and/or infection of the pacemaker site. Endocarditis presented with chronic pyrexia (14 cases) associated with septicaemia (6 cases) and chronic local suppuration (1 case). The interval between the beginning of the pyrexia and the diagnosis was 3.4 months. Echocardiography showed a mass attached to the pacing lead in 8 cases and tricuspid valve vegetations in 4 cases. Blood cultures were positive in 13 patients and local wound swabs identified the organism in 1 patient. The commonest causal agent was the staphylococcus (epidermis in 7 cases, aureus in 4 cases). Appropriate antibiotic therapy was only effective in 1 case. The surgical indication in 13 cases was persistence of infection associated with pulmonary embolism (3) or tricuspid regurgitation (2). Complete ablation of the prosthetic material was performed by a peripheral vascular approach (2 cases), by a right atrial approach (1 case) and under cardiopulmonary bypass in 12 cases. The peroperative findings were of tricuspid valve vegetations (4 cases), thrombi on the pacing lead (7 cases) or in the right heart chambers (2 cases) or pulmonary artery (2 cases). The associated procedures performed under cardiopulmonary bypass were tricuspid valve repair (2 cases) and pulmonary thrombectomy (2 cases). Temporary and permanent epicardial leads were implanted in 10 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic disease of the ascending aorta. Surgical treatment and long-term results

Between January 1979 and December 1991, we operated on 339 patients for chronic disease of the ascending aorta. The operation was elective in all. Endocarditis and its sequelae have been excluded. Thirty-one patients had a previous operation on the ascending aorta or the aortic valve; 268 patients had aneurysms of the ascending aorta without dissection; 72 had chronic aortic dissections, of whom 33 had a preexistent aneurysm. The patients included 272 men and 67 women. Mean age was 53.58 +/- 7 years. Eight percent of the patients had clinical stigmata of Marfan's disease. A tubular graft replacement was used in 7 patients, a tubular graft and valve replacement in 72 patients, and a composite valve graft replacement with reattachment of the coronary arteries using a 8 mm Dacron graft was performed in 260 patients. Concomitant procedures were used in 74 patients: coronary artery bypass grafts in 25, mitral valve replacement in 9, and aortic arch reconstruction in 40. The 30-day mortality rate was 7.6% (n = 26). For the whole group, multivariate analysis using stepwise logistic regression showed that operative risk factors were concomitant coronary artery bypass grafting, age (increased), aortic valve regurgitation, and previous cardiac surgery. Follow-up was conducted in 303 patients, and risk factors for late mortality were studied. Long-term survival was 59.6% +/- 3.7% at 9 years. It was 67% +/- 3.5% at 9 years for patients without aortic arch reconstruction and 56% +/- 4.5% for patients with aortic arch reconstruction (p = 0.0018). Reoperation was needed in 14 patients. Actuarial freedom from reoperation was 90% +/- 0.2% at 9 years for all the patients. Only one patient with composite valve graft replacement and reattachment of the coronary arteries had required reoperation for problems related to this procedure. This technique is used routinely by our team, especially in patients with large chronic aneurysms, dissected or not, and in those who had previous operations. The long-term results are good.

Intraatrial insertion of a mitral prosthesis in a destroyed or calcified mitral annulus

Infectious lesions and extreme calcification of the mitral valve annulus can make classic anatomic implantation of a prosthesis impossible. Confronted with these circumstances, we have developed a technique of intraatrial insertion of a mitral prosthesis. The prosthesis has been modified by enlarging the circumference of the sewing ring with a Dacron collar. The collar can be sutured to the left atrial wall above the mitral annulus. From 1981 to 1989, this technique has been employed in 36 patients: 15 had acute valve endocarditis with destruction of the mitral annulus and 21 had extensive annular calcification. In all cases, circumferential or partial intraatrial insertion permitted a secure implantation of the prosthesis. One operative death was related to the technique. It was an intractable bleeding caused by tearing of the very thin and fragile wall of the left atrium in a kidney transplant patient. Four patients were reoperated on for periprosthetic leak, in 3 of whom healing and cleaning of the mitral annulus permitted annular implantation of a prosthetic valve. There was no ventricular wall rupture. Our results suggest that the technique can be performed in high operative risk patients when mitral valve replacement is impossible by conventional techniques.

[Chronic constrictive pericarditis. A retrospective study of a series of 84 patients]

Chronic constrictive pericarditis still poses diagnostic and therapeutic problems. A series of 84 cases (59 men-25 women; men age: 46 years) operated between 1979 and 1989 at the Pitié Hospital was reviewed. The majority of patients (72%) were in functional Classes III or IV; 88% had clinical signs of right ventricular failure and 18% had anasarca. The average duration of symptoms before diagnosis was 20 months. Chest X-ray showed pericardial calcification in 40% of cases. A characteristic dip-plateau pressure tracing was obtained in 76% of cases. A specific aetiology was only found in 36 cases (45%), only 12% being of tuberculous origin. A subtotal pericardectomy from phrenic to phrenic was carried out in 75 patients. The absence of planes of cleavage in 9 cases imposed a special operative technique consisting of "patchwork" sectioning of the visceral pericardium. The operative mortality was 2.3% (2 patients: pulmonary embolism and septicaemia). Non-fatal post-operative complications occurred in 8.2% of cases (7 patients). The survival rate excluding operative mortality was 94% at 3 years and 87% at 7 years. No patient was reoperated for recurrent constrictive pericarditis. At the last follow-up appointment, all patients were in functional Classes I or II. The authors conclude that the absence of specific symptoms, the low prevalence of the condition and the change in aetiology related to the decline in tuberculous infection make the diagnosis of chronic constrictive pericarditis very difficult. The diagnostic contributions of new imaging techniques such as CT and MR scanning should be assessed. This series confirms the efficacy of surgical treatment by subtotal pericardectomy.

Cardiac echinococcosis. Surgical treatment and results

During the last 15 years, eight patients with a diagnosis of hydatid cysts of the heart and one patient with a diagnosis of alveolar hydatid disease with intracardiac parasitic thrombus underwent successful operation at La Pitié Hospital. Only five cases had symptoms, and the remaining four cases were diagnosed incidentally. Serologic tests achieved a variety of results and were not determinant. All patients were examined with echocardiography and angiography, and almost all patients underwent magnetic resonance scanning. Sternotomy was the approach used, and all patients underwent operation with cardiopulmonary bypass. Surgical treatment included puncture and aspiration of the cyst content, previous sterilization with hypertonic saline solution, and excision of the cyst with closure of the cavity in seven patients with different concomitant procedures. No case of intraoperative rupture was reported, and the only complication was an atrioventricular block in a patient with a cyst of the left ventricular wall invading the intraventricular septum. There was no operative mortality, and only one late death was observed. No recurrences or associated complications were reported in the late follow-up.

Prosthetic valve endocarditis with ring abscesses. Surgical management and long-term results

From January 1978 to December 1988, 71 patients underwent surgical intervention at our institution for prosthetic valve endocarditis with ring abscesses. These procedures involved 59 aortic prostheses and 12 mitral prostheses. No causative agent could be identified in 19 patients (26.7%). The operation was performed during antibiotic therapy in 63 patients and after a planned course of antibiotic therapy in 8 patients. At the aortic level, abscesses were remedied by suturing in 3 cases, by pericardial patches in 34 cases, and by complex procedures in 22 cases (subcoronary valved conduit in 11 cases, supracoronary valved conduit with coronary bypass grafts in 10 cases, apicoaortic valved conduit in 1 case). At the mitral level, ring abscesses were cured in 10 cases by intraatrial implantation of the prosthesis. In one case, the prosthesis was anchored inside the left ventricle; and in one case the valve could be seated on the anulus. The overall operative mortality rate was 17%. Long-term survival was 54% +/- 8% at 6 years. Fifteen (26%) of the survivors needed a third valve replacement (four operative deaths); a complex reconstruction was performed in seven patients. Better detection of ring abscesses and earlier surgical intervention before annular destruction and hemodynamic failure can improve the operative mortality rate for prosthetic valve endocarditis. When it is necessary, complex reconstruction, in spite of a high mortality rate, seems to eradicate the infectious seat, and the outlook for the patient's condition appears good.

[Evaluation of a new cardiotonic agent on human isolated atrium]

The action of a phosphodiesterase inhibitor, RGW 29 38, was analysed experimentally. A preliminary study with guinea pig isolated heart, using Langhendorf's method, revealed a cardiotonic effect, though less than with isoprenaline and dobutamine, with which it was compared. The inotropic action of the compound was then studied using human isolated atrium. The model is described. It consisted of measurement by a strain gauge of the contractions obtained in a stimulated atrial fragment obtained during a surgical procedure. The following parameters were analysed, expressed as percentage increase in relation to baseline conditions: maximum tension developed, positive dP/dt and negative dP/dt. The effect of RGW (n = 6) was compared with that of isoprenaline (n = 7). RGW caused an increase in maximum tension of 195% +/- 91%, in positive dp/dt of 110% +/- 72% and in negative dp/dt of 168 +/- 54%. This increase was, however, less than that seen in the isoprenaline group. Thus RGW had a definite positive inotropic effect on guinea pig isolated heart and human isolated atrium, though less than that of the catecholamines with which it was compared. Isolated human atrium appears to be a useful study model, in particular for analysis of the inotropic action of drugs.

Results of subtotal pericardiectomy for constrictive pericarditis

The operative approach to constrictive pericarditis still remains a surgical challenge. Subtotal pericardiectomy through median sternotomy was analyzed retrospectively in a series of 84 patients operated on for chronic constrictive pericarditis at our institution between 1979 and 1989. The mean duration of symptoms prior to diagnosis was 20 +/- 6 months (1-264 months). Preoperatively, 72% of patients were in NYHA class III or IV, presented signs of right cardiac failure (88%) or anasarca (18%). Chest X-ray showed pericardial calcifications in 40% of the patients. Echocardiography revealed pericardial thickening in 62%. Among 62 patients in whom cardiac catheterization was performed, a characteristic dip-and-plateau was found in 47 patients (76%). A specific etiologic factor was identified in only 37 patients: tuberculosis (12%), recurrent acute pericarditis (9%), hemopericardium (9%), radiotherapy (5%), previous cardiac surgery (4%), bacterial infection (2%), myocardial infarction (2%) and connective tissue disease (2%). In 47 patients (55%), the constrictive pericarditis remained idiopathic. In seven patients we performed a redo-operation for previous incomplete pericardiectomy. Subtotal pericardiectomy (from phrenic nerve to phrenic nerve) was performed in 75 patients. A palliative procedure consisting of pericardial "meshing" was performed in nine patients due to an unsatisfactory cleavage plane. Cardiopulmonary bypass was used in four patients for coexistent cardiac lesions. The operative mortality was 2.3% (two patients: septicemia and pulmonary embolism). Seven patients (8.2%) developed early on-lethal complications. The probability of survival for patients discharged for the hospital was 94% at 3 years and 87% at 7 years. There were four late deaths and no reoperation for recurrent constriction.(ABSTRACT TRUNCATED AT 250 WORDS)

Five-year experience with the Medtronic Hall prosthesis in isolated aortic valve replacement

We reviewed clinical data in 216 patients who underwent isolated aortic valve replacement with the Medtronic Hall prosthesis. Between January 1983 and December 1990, a total of 216 prosthetic valves were implanted in 180 males and 36 females. Preoperatively, 45.5% of patients were in New York Heart Association (NYHA) Class III to IV. Cumulative follow-up was 682 years, and 3.2% of patients were lost to follow-up. The actuarial 5-year survival rate was 90% for the whole group. All the patients were anticoagulated with aceno-coumarol (Sintrom). There were no cases of structural dysfunction and one patient presented with valve thrombosis. The Medtronic Hall valve has a low rate of thromboembolic events without structural failure. It is an excellent device for aortic valve replacement.

["Monobloc" resection in heart and lung transplantation. Technique and advantages of a new procedure]

Hemostasis is a usual problem in surgical heart and lung recipient removal. Since April 1990, we have been using as surgical technique an "en bloc" removal of heart and lungs in order to reduce postoperative bleeding and cardiopulmonary bypass duration.

Survival prediction in staged heart transplantation using Jarvik-7 artificial heart

BACKGROUND

Because mechanical circulatory assist as a bridge to heart transplantation places a further strain on current donor shortage as well as on medical cost containment, safe and effective use of the device is essential.

METHODS AND RESULTS

To predict survival before undertaking staged heart transplantation with the Jarvik-7 artificial heart, our 58 attempts were reviewed retrospectively. Scores of 1-4 were given for six preoperative factors based on results obtained by univariate and multivariate analyses between survivors and nonsurvivors of staged heart transplantation: transplant rejection (scored 4: S4) or postoperative heart failure (S3) as the indication, recipient height < 175 cm (S3), body surface area < 1.8 m2 (S3), hyperbilirubinemia > 24 microM/l (S2), weight < 60 kg (S2), and age > 40 years (S1). Of 14 survivors, 13 had a total score < 4 (sensitivity, 93%), with an average score of 1.6 in contrast to 5.5 for 44 nonsurvivors (p < 0.001). Among 26 patients scored < 4, 21 had heart transplantation, of whom 13 left the hospital. Of 32 patients scored > or = 4, only four could be discharged after transplantation (specificity, 70%).

CONCLUSIONS

Multiple preoperative factors successfully predicted transplantability and survival in staged heart transplantation. The results underscore the importance of preoperative condition and patient selection to achieve successful and effective use of Jarvik-7 as a bridge to heart transplantation.

[Results of myocardial revascularization in patients aged 70 years and over]

The purpose of this study was to bring up-to-date the immediate risks and long-term benefits of coronary surgery in elderly people. The results obtained in a series of 475 patients in their seventies suffering from coronary disease who underwent myocardial revascularization alone or combined with heart valve replacement at the La Pitié Hospital, Paris, between 1984 and 1989 were analyzed. Coronary disease was associated with heart valve disease in two-thirds of the cases. The mean number of bypasses was 2.3 per patient. Aortic valve replacement was performed in 119 cases and mitral valve replacement in 12 cases. The operative mortality rate was 10.8 percent in patients with stable angina who underwent elective surgery. The factors which increased the mortality rate were: age (19.6 percent over 75 versus 13 percent under 75, P = 0.05); sex (23.5 percent in women versus 13.2 percent in men, P = 0.01) and emergency (25.8 percent, P = 0.02). No significant difference in mortality was noted between patients who had and those who did not have aortic valve replacement (15.8 versus 10.8 percent, P = 0.14). Fifteen patients (3.1 percent) developed perioperative myocardial infarction. During the follow-up, period myocardial infarction occurred in 7 patients. Out of 29 late deaths, 8 were of cardiac origin (infarction in 5, terminal heart failure in 3). The survival rate at 4 years was 76 percent. Among the patients who could be followed up, 80 percent are now asymptomatic, 15 percent are in stage I or II and 5 percent in stage III or IV of the Canadian Cardiovascular Society classification. Thus, despite a non negligible operative risk the functional improvement and survival rates obtained justify an increase in the indications for myocardial revascularization in elderly patients.