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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)

This prospective study was undertaken to assess the results of 2D echocardiography in the assessment of valvular and subvalvular lesions in mitral stenosis. The echocardiographic findings (E) were compared with peroperative and laboratory anatomical examination of the excised valve (A). The following criteria were compared: 1) planimetry of mitral valve surface area, 2) mobility of the anterior leaflet, assessed anatomically by the flexibility of the tissue, and echocardiographically by the amplitude of early diastolic excursion, 3) length of anterior and posterior leaflets, 4) presence of calcification, 5) length of the longest tendinae chordae, measured from the papillary muscle to the insertion of the valve, 6) thickness of the thickest tendinae chordae attached to each leaflet. Echocardiography was carried out preoperatively by two different operators without knowledge of the haemodynamic and later anatomical findings. The anatomical results were taken as reference. Mitral valve surface area measured by both methods was comparable (A = 0,96 +/- 0,28 cm2; E = 1,04 +/- 0,33 cm2, N = 17, t = NS) and a good correlation was found between the two measurements (r = 0,79; p less than 0,01). 2D echo assessed the loss of valvular mobility by limitation of early diastolic opening of the AML with a sensitivity of 71 p. 100 and a specificity of 70 p. 100. Measurement of valve length of the anterior (N = 14) and posterior leaflets (N = 15) may be difficult in the presence of severe calcification. The results of both measurements were comparable. AML, 25,2 +/- 1,9 mm (A) and 24,6 +/- 2,1 mm (E); PML, 13,9 +/- 1,9 mm (A) and 14,2 +/- 2,2 (E) correlated well, r = 0,71 and r = 0,71 respectively (p less than 0,01).(ABSTRACT TRUNCATED AT 400 WORDS)

Between June 1983 and September 1984, 3 patients operated for mitral valve disease presented with acute right heart failure due to right atrial compression. Emergency echocardiography did not show pericardial separation around the ventricles but in the apical 4 chamber view severe right atrial compression by an extracardiac mass was observed. Emergency surgery was performed in all three cases to evacuate a localised haemopericardium despite the absence of pericardial fusion. These cases of acute right ventricular failure underline the importance of multiplying the number of echocardiographic views in order to detect localised pericardial effusion. The diagnosis should be made as soon as possible as clinical deterioration may be rapid despite effusions of small volume. The main differential diagnoses are right atrial thrombosis and acute postoperative pulmonary embolism. In these cases of localised tamponade, the clinical signs are the result of vena caval compression or extrinsic compression of the tricuspid orifice. The preferential localisation of the haemopericardium around the right atrium is difficult to explain. It is probably related to the low pressures in this region. The echocardiographic appearances of this condition have been established allowing reliable diagnosis.

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)

The surgical team of Pr Ch. Dubost operated 5 cases of idiopathic subvalvular left ventricular aneurysm with associated mitral incompetence over a 6 year period (from 1976 to 1981). These 5 cases closely resemble Abraham's et al's classical description of "annular subvalvular left ventricular aneurysms". They occur in black Africans, often young adults (mean age of our five cases 31,8 years) in the absence of coronary artery disease. The common feature is the peculiar anatomical localisation of the aneurysm on the posterior or lateral wall of the left ventricle, which explains the common finding of mitral regurgitation. They are often calcified and thrombosed, the thrombosis tending to extend into the left heart chambers. This was the case in 3 of the reported cases. Mitral regurgitation was controlled in one case by closure of a fistula into the left atrium with a very good result, and in 2 cases by simple section-suture of the neck of the aneurysm with good results and a small residual mitral leak. In a fourth case (Case n degree 1) the mitral valve was normal, regurgitation being the result of an extensive thrombosis. The valve was replaced but, in the light of the following cases, it is possible that the valve might have been unnecessarily sacrificed. Despite their sometime vast size and the association with mitral regurgitation, these subvalvular idiopathic left ventricular aneurysms are reasonable surgical indications for the following three reasons: the neck is often narrow, enabling closure under satisfactory surgical conditions; the structure of the valve is normal which, in the majority of cases, means that it can be respected at surgery; the absence of coronary artery disease.

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.