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Sixty-four patients with one or more bioprostheses were reoperated between 1970 and 1982. Reoperation was performed for degenerative lesions in cases (48%), for aseptic periprosthetic leaks in 18 cases (28%), for infectious lesions in 13 cases (21%) and for thrombosis in 2 cases (3%). Degenerative and infectious lesions were commoner in aortic bioprostheses whilst periprosthetic leaks were commoner in mitral bioprostheses. The average interval between operations was 38 months. This was shorter in patients reoperated for mechanical problems (6 months) than those with infections (28 months) or degenerative (5 years) complications. At reoperation 14 prostheses were reinserted and 50 were replaced. The global hospital mortality was 21% (14 deaths). The mortality was related to the surgical indication: mechanical lesions (11%), degenerative lesions (16%), infectious endocarditis (38%), thrombosis (100%). The mortality rate also varied with time (36% during the period 1970-1978 and 18% during the period 1979-1982). This improvement was related to two factors: the use of cardioplegic solutions for myocardial protection and earlier recognition of surgical indications before the onset of irreversible haemodynamic complications. When choosing a valvular prosthesis, the mortality of reoperation for degenerative changes is the only disadvantage of the bioprosthesis which is silent, rarely complicated by thromboembolism and which does not require anticoagulant therapy for life. The mortality has decreased with time and will continue to fall if the indications for reoperation are based on stethacoustic, electrical, radiological and echocardiographic criteria of valvular dysfunction and not on the presence of overt cardiac failure as is still often the case.

The authors studied 115 surgical cases of calcific aortic stenosis (AS) with coronary angiography. Between 1970 and 1981, 56 of these patients also had one or more aortocoronary bypass grafts (ACBG) (Group I). The other 59 cases, recruited from 1978 to 1981, comprise the control group who underwent isolated aortic valve replacement either with a normal coronary angiogram (Group II: 50 cases) or with such extensive coronary artery disease that ACBG was impossible (Group III: 9 cases). 93% of patients in Group I had preoperative angina compared to 80% in Group II and 78% in Group III. The incidence of previous myocardial infarction was 19%, 4% and 44% respectively. The number of main coronary arterial lesions per patient was 2 in Group I and 1.8 in Group III. In Group I, aortic valve replacement (AVR) was associated with a single aorto-coronary bypass in 70% of cases, a double bypass in 27% and a triple bypass in 3% of cases. The revascularisation ratio was 1.3 bypass per patient. The number of "complete" revascularisations rose from 56% (1970-1976) to 73% from 1977 to 1981. Overall hospital mortality per group (less than 1 month) was 16%, 4% and 0% respectively. The mortality rate in Group I fell from 31% (1970-1976) to 10% from 1977 to 1981. The perioperative rate of myocardial infarction in each group was 9%, 0% and 11% respectively. This figure fell considerably in Group I from 12.5% (1970-1976) to 7.5% from 1977 to 1981.(ABSTRACT TRUNCATED AT 250 WORDS)

Twenty four patients were reoperated on the tricuspid valve alone between 1967 and 1981. The first operation had been performed for mitral valve disease and consisted of 23 mitral valve replacements and one commissurotomy associated with two aortic valve replacements. The surgical decision with regard to the tricuspid valve at the initial operation had been abstention (10 cases), tricuspid valvuloplasty (10 cases) and tricuspid valve replacement (4 cases). Reoperation on the tricuspid valve is rare (0,2 p. 100 of mitral valve operations, 1 p. 100 of mitro-tricuspid valve operations). The 24 cases were divided into 2 groups: --Group I, in which reoperation was indicated for curable tricuspid lesions: .4 reoperations for prosthetic valve dysfunction (4 mechanical prostheses were responsible for 3 thromboses and 1 perivalvular leak); .3 reoperations for failed valvuloplasty (2 Kay valvuloplasties and 1 Carpentier annuloplasty); .2 reoperations for aggravation of neglected functional lesions at the first operation and which were reoperated after 3,5 and 4,5 years, because of increased dilatation of the annulus; .5 reoperations for aggravation of organic lesions which had been neglected in 3 cases and treated by valvuloplasty in 2 cases. Five prosthetic valve replacements were carried out, on average 17 months after the first operation. --Group II, in which reoperation was unable to improve congestive heart failure; dilatation of the tricuspid annulus was only a consequence of the cardiac failure. The secondary tricuspid valve surgery (5 valvuloplasties, 5 annuloplasties) did not alter the extremely poor prognosis of these patients (5 hospital deaths, 3 postoperative deaths within 2 years).(ABSTRACT TRUNCATED AT 250 WORDS)

The results of a consecutive series of 24 patients reoperated for coronary bypass grafting between May 1977 and February 1983 are reported. The overall incidence of reoperation was 1.4 p. 100 (24 out of 1 716 cases); the incidence is tending to increase (2.3 p. 100 in 1982). Preoperative assessment revealed the persistence of cardiovascular risk factors: 75 p. 100 of patients had continued to smoke; 61 p. 100 had persistent hyperlipidaemia. The usual presenting syndrome was recurrence of chest pain (21 out of 24 cases) leading to control coronary arteriography on the results of which the surgical indication was based. The average time between the two operations was 38.7 months. The patients were classified into two groups; early reoperation (6 cases) for a technical problem or incomplete revascularisation, and late reoperation (8 cases) for disease of the graft and atherosclerosis. Progression of coronary atherosclerosis was the major long-term cause of occlusion of the saphenous graft (10-14 cases). The arteries most commonly bypassed at reoperation were the left anterior descending and right coronary arteries (12 times each). Reoperation comprised single bypass (13 cases), double bypass (10 cases) and triple bypass (1 case) with an average of 1.5 grafts per patient. The most commonly used vein was the internal saphenous vein (32 out of 36 grafts). Myocardial protection was insured by cardioplegia (13 cases) and intermittent clamping (10 cases) after cooling (general hypothermia at 22 degrees C). Global reoperative mortality (4 p. 100) was higher than for elective primary coronary surgery (2.3 p. 100). The incidence of perioperative infarction was 8 p. 100.(ABSTRACT TRUNCATED AT 250 WORDS)

From 1968 to 1980, 34 patients with atrioventricular discordance underwent intracardiac repair. Thirty three patients had a ventriculoarterial discordance (corrected transposition) and one patient had a double outlet right ventricle. The age at operation ranged from 12 months to 59 years (mean 19 years). The lesions were ventricular septal defect (26 cases), pulmonary stenosis (22 cases), atrioventricular valve anomalies (20 cases). Lesions were associated in 80% of the cases. Ventricular septal defect and pulmonary stenosis were combined in eleven patients. Seven patients had had palliative operations. Pulmonary stenosis was mostly of subvalvular type and treated with a conduit. A patient with double outlet right ventricle and pulmonary atresia had a conduit on the left pulmonary artery because the right one was non-functional. Ventricular septal defects were closed through the right A-V valve, and the stitches placed on the free edge of the defect. The tricuspid valve (systemic) was replaced in 10 cases. Hospital mortality was 38% but only 3 out of 14 (21,4%) patients operated upon since 1975 have died. Late mortality was 24% (5 patients) related to conduction problems in 3 patients. Three patients were reoperated with good results. Out of twelve patients with a long-term follow-up, eleven have a good functional result. 7 patients with preoperative A-V block and 3 patients with atrial fibrillation had pacemakers implanted. 16 patients had postoperative A-V block. The incidence of conduction problems is now reduced with the use of conduit for subvalvular pulmonary stenosis.

In 17 patients with a partial form of atrioventricular canal, at least one valve was replaced. The mitral valve was the most commonly affected (16 cases), sometimes in association with the tricuspid valve (5 cases) or the aortic valve (1 case); the tricuspid valve alone was replaced in one case. 7 cases were ranked as operative deaths, and the longer term mortality was of 4 cases. The factors leading to this high mortality figure are discussed. The future treatment policy for this condition is discussed.

A surgical operation with a "curative" aim has been performed on four patients with a lone ventricle. It consisted of a IA type in 3 cases and IC type in one. There were one operative death and three long-term survivals. The operation consisted essentially in: a delicate step of partition of the lone cavity and the treatment of the often combined, and sometimes complex, heart malformation. The trauma to the conduction pathways is one of the major dangers of this type of operation and should be avoided or decreased by the detection during operation of the His bundle. Operation should be indicated in badly tolerated forms. Stenosis of the infundibulo-pulmonary pathway interferes with the development of a hypertensive pulmonary arteriolitis, seems to be a favourable element for surgical correction. In the absence of such stenosis, one should perform a banding early enough or discuss the indication for an intracardiac operation in relation with the pulmonary artery resistance.

Ninety patients, aged 17 to 59 years (average 39.8 yrs) underwent triple valve replacement from January 1967 to December 1979. The aetiology was rheumatic carditis in 84% of cases. There had been previous surgery in 29 cases (19 mitral commissurotomies). All patients were severely symptomatic: 68 (76%) had atrial fibrillation and the cardiothoracic ratio was 0.70 +/- 0.085. In 24 cases, triple valve stenosis (aortic, mitral and tricuspid) was observed; 13 patients had triple regurgitation and 53 patients had mixed lesions (stenosis and regurgitation). Triple mechanical valve prostheses were implanted in 35 cases (Björk or Starr), triple bioprostheses were implanted in 12 cases, and 43 patients received a combination of mechanical and bioprostheses (tricuspid bioprostheses in all 43 cases). The patients were divided into two groups according to the type of valve replacement; Group I: 57 patients, subdivided into Group IA (35 cases, 39%) with triple mechanical prosthesis, and Group IB (22 cases, 25%) with mechanical aortic and mitral valve prostheses and tricuspid bioprostheses; Group II, 33 patients, subdivided into Group IIA (12 patients, 13%) with triple bioprostheses, and Group IIB (21 patients, 23%) with mitral and tricuspid bioprostheses and a mechanical aortic valve prosthesis. Techniques of myocardial protection have have improved since the beginning of this series and at present comprise cardioplegia associated with general hypothermia to 25 degrees C and pericardial irrigation with ice cold saline. The overall operative mortality was 37% (34/90) but in 1979 alone it was only 10%.(ABSTRACT TRUNCATED AT 250 WORDS)

This study comprises 15 patients operated for syphilitic coronary ostial stenosis by Dubost's team between 1959 and 1975. Three operative deaths (20%) were observed. Three other late deaths occured, but only one of his coronary pathology. Of the nine survivors, seven have been reviewed and five have undergone control coronary angiography. The long term results of the 9 survivors, reviewed from 3 1/2 to 11 years after operation, illustrate the difficulties of disobliteration of the right coronary ostium, the necessity of changing the aortic valve systematically when incompetent and the maintenance of the good results obtained by this surgery.

An 11 to 15 year follow up (mean 12.7 years) of 90 patients undergoing surgery for coarctation of the isthmus of the aorta is reported. There were 7 late deaths. Of the survivors 87% were normotensive (B.P. less than or equal to 160/100 mmHg) and 90% were asymptomatic and leading a normal life. Five cases-all with an aortic prosthesis-had to be reoperated for recurrent coarctation. These figures are comparable with those found in the literature. The best long-term results are obtained in patients who have the operation while young (less than 20 years), who have no associated abnormality, and whose coarctation can be treated by resection with direct anastamosis.

The present study deals with a series of 40 reoperations in a group of 1279 patients undergoing mitral valve replacement. All reoperations were late following the immediate post-operative period, the earliest being 5 months after the primary operation. The factors which were analyzed are: causes of reoperation, the most frequent being paravalvular leaks and valve thrombosis, diagnostic methods, surgical techniques and results following reoperation.

The results of 4 groups of 100 patients undergoing mitral valvuloplasty (group I), isolated mitral valve replacement by a bioprosthesis (group II), a Starr-Edwards prosthesis (group III) and a Björk prosthesis (group IV) between 1974 and 1977 were compared. The selection of patients for each group was identical and made according to strict criteria. The average age was between 47.1 +/- 12.5 years and 51.8 +/- 10.5 years according to the particular group; the average functional classification was 2.4 +/- 0.4 to 2.5 +/- 0.6; the average cardiothoracic ratio was 0.58 +/- 0.07. Most patients were in atrial fibrillation. Ninety-seven per cent of patients were followed-up by questionnaires. The results were expressed with respect to simple clinical events used in all previously reported series. The long-term mortality was identical in the 3 groups undergoing valve replacement (40 p. 100 at 7 years) but was much less in the group undergoing valvuloplasty (18 p. 100 at 7 years). The mortality rate due to valvular problems was significantly less in the valvuloplasty group (2 p. 100 at 7 years) than in the groups with mechanical prostheses (20 p. 100 at 7 years). Intermediate results were observed in the bioprosthetic group (9 p. 100 at 7 years). Thrombo-embolism was significantly less common in the groups undergoing valvuloplasty and bioprosthetic valve replacement (2 p. 100 and 6 p. 100 at 7 years) than in the group with Starr-Edwards and Björk prostheses (30 p. 100 and 32 p. 100 at 7 years).(ABSTRACT TRUNCATED AT 250 WORDS)

In order to find out the long-term results of mitral valvotomy as a closed heart operation, the authors investigated the fate of patients who underwent surgery twenty years ago. In 1955, 148 mitral valvotomies by the closed technique were carried out in the Cardiovascular Department of the Broussais Hospital under the direction of Professor F. D'Allaines. There were 15 operative deaths (10 p. 100) and 12 late deaths of non-cardiac origin; only 55 of the patients could be traced for follow-up. After 20 years, 24 of them had still a good or moderate result, and 34 had a bad result. A study of the various characteristic features of the heart defect before operation, and of the operative findings, has allowed us to determine a certain number of factors which presage good immediate and long-term results. The authors have concluded that, if these factors are present, mitral valvotomy as a close technique, with its advantages of simplicity and economy, remains a perfectly valid operation.

Cardiac catheterisation was carried out on an unselected series of 148 patients who had undergone complete correction of Fallot's tetralogy after an average postoperative period of si and a half years (range 2 to 20 years). 4% residual significant interventricular shunts (Qp/Qs > 1.3), 11% residual stenosis on the infundibulo-pulmonary tract (gradient greater than or equal to 10 mmHg) and 60% pulmonary incompetence was found. These findings do not reflect the excellent clinical results. All patients had normal lives: 89% remain asymptomatic since their operation and symptoms in the other patients are limited to moderate dyspnoea on effort or to arrhythmias which are usually periodic. A synthesis of the clinical and haemodynamic data shows that only a quarter of patients may be considered to be cured, that although the surgical results in 2/3 patients are not perfect, they are satisfactory, and that the results of complete correction in the remaining 12% are poor. The results do not appear to be related to the age at which correction was performed or to previous palliative surgery. On the other hand, the long-term haemodynamic results were related to the surgical method of infundibulo-pulmonary repair. Systolic right ventricular pressures of over 60 mmHg recorded at the end of operation in 33 patients, had returned to normal in 76% cases. These results suggest that the indications for prosthetic remodeling of the infundibulo-pulmonary tract should be increased, although this does not always prevent residual stenosis.

In relation with 128 cases of surgical operation for mitral incompetence through ruptured chordae tendinae, the aetiological, anatomical and clinical characteristics of these cases were described. Bacterial endocarditis and spontaneous rupture were present in 77 percent of cases. In 94.4 percent of the cases, the patient coming to operation was in a high functional class (class III and IV of the NYHA). Operation included valve replacement in 100 cases (by a Starr-Edwards prosthesis), while the mitral valve was preserved in 28 patients. The conservative operation presently performed combined the resection-suture of the deinserted area and a reconstitutive valvuloplasty over a Carpentier's ring. Results of this surgery are good in more than 90 percent of the cases.

A study of a serie of 45 cases of coarctation of the aorta associated with a severe cardiac lesion or malformation, and treated at a single operative session (18 cases) or in two consecutive stages (27 cases) has produced the following conclusions: --Treatment at a single operation is possible, usually at the cost of two consecutive surgical approaches, thus making the operation rather long. This plan, which has given good results in the 18 cases studied (only one death and no serious complications) should be adopted only for young patients who are well-balanced psychologically, and whose cardiac defect is well-compensated. --Treatment in two stages is a more reasonable course for the remainder of the patients, but it must be decided which lesion to treat first: this could be the coarctation if it is a difficult or poorly tolerated one and if the cardiac defect (especially when an aortic valve lesion) is well compensated. It will be the cardiac lesion if, by contrast, the coarctation is simple and well-tolerated, and the cardiac lesion is severe and decompensated (especially a mitral malformation with shunts and major pulmonary hypertension). Current techniques of open heart surgery allow us to employ extracorporeal circulation easily and safely with the coarctation still in place; this will then be treated later. In every case in which a two-stage treatment plan has been chosen, it should be carried out as a planned procedure so that the second stage of the operation is not put off unduly.