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Background: Mitral valve (MV) repair is preferred over replacement in clinical guidelines and is an important determinant of the indication for surgery in degenerative mitral regurgitation. However, the level of evidence supporting current recommendations is low, and recent data cast doubts on its validity in the current era. Accordingly, the aim of the present study was to analyze very long-term outcome after MV repair and replacement for degenerative mitral regurgitation with a flail leaflet. Methods: MIDA (Mitral Regurgitation International Database) is a multicenter registry enrolling patients with degenerative mitral regurgitation with a flail leaflet in 6 tertiary European and US centers. We analyzed the outcome after MV repair (n=1709) and replacement (n=213) overall, by propensity score matching, and by inverse probability-of-treatment weighting. Results: At baseline, patients undergoing MV repair were younger, had more comorbidities, and were more likely to present with a posterior leaflet prolapse than those undergoing MV replacement. After propensity score matching and inverse probability-of-treatment weighting, the 2 treatments groups were balanced, and absolute standardized differences were usually P P P P P Conclusions: Among patients with degenerative mitral regurgitation with a flail leaflet referred to mitral surgery, MV repair was associated with lower operative mortality, better long-term survival, and fewer valve-related complications compared with MV replacement.

The authors describe their experience with the Djumbodis system, reporting the findings of a comparative study focussing on the outcomes of surgical management of patients presenting with real type I aortic dissection. The most common feature observed in patients receiving a 9 or 14 cm stent into the proximal descending aorta was stabilization of the dissected thoracic segments. Clinical outcomes were, however, comparable between the groups of stented patients and controls. This clinical result is to be shared with other endovascular devices used in acute dissections and which might require a hybrid operating room, since they might compromise blood flow in collateral arteries. Carefully analysing our data and current literature we propose to consider real type I aortic dissections complicated by dynamic malperfusion symptoms or for which the diameter of the proximal descending aorta is already noticeably dilated as justified indications according to the current knowledge about stenting of acute dissections.

Le traitement du canal arteriel chez le premature peut etre base sur la prescription d'anti-prostaglandines mais leur utilisation est difficile car elle doit etre precoce et n'est pas denuee de complications a la fois sur le plan renal, hematologique et digestif. L'autre alternative est le traitement chirurgical; celui-ci doit etre realise le plus precocement possible des que le diagnostic clinique et echographique a ete porte. Sur le plan anatomique il faut signaler la grande taille du canal arteriel chez le premature par rapport a l'enfant plus âge. La fermeture du canal utilise de preference la mise en place d'un clip evitant toute dissection complete du canal dangereuse chez le premature de petit poids de naissance. Nous rapportons notre experience de 68 enfants operes

Papillary fibroelastoma is a rare, benign, primary cardiac tumour. The authors report three cases presenting with transient or full cerebrovascular accidents. The tumours were diagnosed during investigation by echocardiography, especially transoesophageal echocardiography. In view of the severity of symptoms and the high risk of recurrence, the patients were rapidly referred for surgery. In two cases, the tumour was located on the aortic valve at several sites. In one case, the tumour was single and implanted on the mitral valve. Surgery was successful with the pathology reports confirming complete ablation. The patients have not had any recurrence to date. The multiple nature of these tumours raises the questions of local spread, secondary degeneration of valvular nodes? The problem of possible recurrences is discussed.

The authors report the case of a patient presenting with pulmonary embolism in which transthoracic echocardiography showed the presence of an intracardiac thrombus trapped in a patent foramen ovale; this was confirmed at surgery. It is rare to see this type of thrombus (which usually gives rise to paradoxical embolism) by transthoracic echocardiography. Previously, this used to be a postmortem diagnosis but the condition is often suspected nowadays when deep venous thrombosis and/or pulmonary embolism, an unexplained systemic embolism and a right-to-left interatrial shunt, are associated. However, the diagnosis can only be confirmed by the visualisation of the thrombus crossing the interatrial septum.

The authors report two cases of cardiac rupture during acute myocardial infarction successfully treated surgically. In the first case, rupture occurred 7 days after hospital admission for anteroseptal myocardial infarction. The patient developed sudden cardiogenic shock with signs of venous hypertension without left ventricular failure. The second patient was admitted for syncopal chest pain with transient hypotension which regressed after volume repletion and pressor amine therapy. On admission, the patient had signs of cardiac tamponade. The ECG showed recent inferolaterobasal myocardial infarction. In both cases the diagnosis was made by 2D echocardiography which showed voluminous circumferential pericardial effusions probably due to haemorrage, with an image very suggestive of a blood clot in the effusion of the second patient. The two patients underwent emergency cardiac surgery and both survived with a 4 and 1.5 month follow-up respectively. These two cases confirm the value of 2D echocardiography as an emergency bedside procedure for the diagnosis of cardiac rupture, especially when images of intrapericardial thrombosis are observed, as in our second patient. In addition, the first case raises once again the question of the role of late thrombolysis as a predisposing factor of cardiac rupture at a time when this technique is proposed up to 24 hours after the onset of symptoms.

Long-term performance of the first one hundred bioprostheses (BP) implanted was evaluated in 100 patients (pts) surviving isolated aortic valve replacement, mitral valve replacement and tricuspid replacement from October 1975 to March 1978. Follow-up was always more than 10 years. Cumulative duration of follow-up was 7,048 months. Follow-up ranged from 112 to 139 months. Overall late mortality was 16.13 thromboembolic episodes occurred in 11 pts. Reoperation was performed in 14 pts due to primary tissue failure in 11 pts. 64 patients were free from mortality and valve-related reoperation.

The technique of multiple outlet saphenous vein grafting with one or several alternating lateral anastamoses was used in 43 patients over a one year period; over half the patients had triple vessel disease, one third had double vessel disease; a total of 128 coronary arteries were revascularised 2.9 arteries per patient, with 60 side to side anastamoses, 1.4 per patient. The technique of this type of bypass necessitates paying particular attention to avoid kinking or twisting of the graft. The blood flow through multiple outlet graft is on average significantly greater than in the classical types of graft, and is one of the main points in favour of this technique and in keeping the graft permeable in the long term. The short term results of this technique are good with a hospital mortality of 4.6% and a peri-operational infarction rate of 6.9%, figures which are comparable with the results of classical bypass grafting techniques in multivessel coronary artery disease.

Thirty-eight patients (32 men and six women, mean age 48.1 years) were operated upon for acute dissection involving the ascending aorta. The surgical procedure included multiple peripheral arterial cannulations, resection of the initial intimal tear if found (35 cases), and obliteration of the false channel by double cuffing with Teflon of the two layers of the dissecting process proximally and distally. When present (29 cases), aortic regurgitation was usually (21 cases) managed by conservative remodeling of the aortic anulus; 34 prosthetic replacements of the ascending aorta and four replacements of the arch were achieved. The operative mortality was 7.9% (3138) and the overall hospital mortality was 23.7% (9138). Nonfatal complications occurred in 11 patients (29%). There were three late deaths (10.3%). Mean follow-up was 3.4 years (2 months to 8 years, 8 months). Twenty-three (88.5%) of the 26 patients were asymptomatic. Contrast tomodensitometry was performed in 14 patients; in type II (two patients), the aorta was normal; in type I (12 patients), residual abnormalities were noted: patency of the false channel (10 cases), aneurysmal dilatation (seven cases), and reduction of the true lumen by the false channel (four cases). These results emphasize the need for scrupulous long-term follow-up in surgically treated aortic dissections.

Commissural disorganisation secondary to incomplete rupture of the ascending aorta was found at surgery for massive aortic incompetence in a young man with previous hypertension. The lesions were repared by a conservative procedure with an excellent result 3 years after surgery. Incomplete spontaneous rupture of the ascending aorta occurs in the same terrain as dissection of the aorta (hypertension, aortic media necrosis) of which it represents a minor form. It may remain asymptomatic but it is usually complicated either by secondary intrapericardial rupture, by aortic aneurysm or by aortic incompetence due to valvular prolapse. When valvular prolapse is associated with another lesion which aggravates the regurgitation (aortic valve disease, aortic ring dilatation) aortic valve replacement should be performed with a prosthesis; on the other hand, when commissural disorganisation giving rise to valvular prolapse is the cause, a conservative procedure may be envisaged.

The echocardiographic information obtained pre-operatively with an electronic linear scanning system (Multiscan) was compared with the results of pathological examination of the excised mitral valve in 92 patients, and showed a close correlation. The way in which the pathological changes influence the various parameters usually used to distinguish this type of rheumatic valvular disease is demonstrated. Two-dimensional imagery provides precise information : this is shown by comparison of the still frames of the videoscopic recording and the photographs of the corresponding pathological specimens. Valve thickness, length and thickness of the chordae, calcification, mitral valve surface and commissural separation are well shown, especially at the anterior leaflet. Study of transverse incidences seems the most reliable method of estimating mitral valve area. Systolic separation of mitral valve echos, according to the usual criteria, is a good sign of associated mitral incompetence and was found in 83% of cases of mixed mitral valve disease. The mean values of anterior mitral leaflet excursion, diastolic slope and opening speeds were compared in three groups of mitral stanosis with preferential antatomical features and a control group of pure mitral stenosis with supple valves. No individual parameter was found to be specific for a particular antatomical feature, showing multiple correlations to be indispensable. The difficulty of diagnosis by isolated traditional echocardiography is confirmed and the association of two dimensional imagery would seem essential not only in making the diagnosis but also in the pre operative work up.

From January 1975 to September 1983, 615 patients underwent valve replacement using 698 bioprosthetic valves for selected indications. This group represents the third of all patients having valve replacement during the same period. Children younger than 15 years were excluded. The mean pre-operative functional class was 2.9. The early mortality rate was less than 5% and the follow-up range 3 months to 9 years (3.2 yrs). The symptomatic improvement was attested by a mean post-operative functional class of 1.4. In a linear study the following rates of valve related complications were noted: thromboembolism 4.6%, endocarditis 2.5%, primary tissue valve degeneration 1.1%, paraprosthetic leak 2.5%. In an actuarial study, at 8 years, 83% of patients were free from any valve failure. The probability rates of complications were the following: thromboembolic events 8%, endocarditis 5%, degeneration 3%, reoperation 7%. The probability of survival at 8 yrs was 69% and the probability rates of late mortality were noted as follow: cardiac related mortality 27%, valve-related mortality 4%. Despite an expected increasing rate of degeneration, the results warrant the use of bioprostheses in a selected group of patients.

Resection of left ventricular tissue seems to be playing an increasing part in the treatment of the sequelae of myocardial infarction. In a total of 700 patients who underwent surgery for some aspect of coronary atherosclerosis, 40 underwent resection of left ventricular tissue. In the majority of cases, diagnosis rested on left ventricular cine-angiography and in 3 cases this had to be carried out as an urgent procedure with circulatory assistance using diastolic counter-pressure (DCP) from an intra-aortic balloon. A selective contrast technique for the two coronary arteries was used whenever possible. The surgical anatomy of the lesions indicates a difference between a localised dyskinesia and diffuse dyskinesia, the latter having a severe effect on left ventricular function. In a group of localised dyskinesias, the territory supplied by the anterior descending artery was by far the most frequently affected. Resection of left ventricular tissue was associated with a myocardial bypass revascularisation procedure in 9 cases, valve repair in 7 cases, and closure of a septal perforation in 3 cases. The total inpatient mortality rate is still quite high (23.1%) because of the severity and widespread nature of the coronary disease. However, the mid-and long-term results are good, the criteria being functional improvement and the actuarial 4-year survival rate.

A series of 230 mitral valve replacements using exclusively the Starr-Edwards ball valve prosthesis is presented. These 230 patients underwent surgery over a 4 year period, a uniform operative technique being used. Its essential feature was the use of a standardised technique for protection of the myocardium based upon continous clamping of the aorta and deep hypothermia at around 15 degrees. The technique of myocardial hypothermia, already reported, is briefly reviewed. The results are analysed, in the short and long term. Overall hospital mortality was 6.9 per cent, including multiple valve replacements and combined coronary surgery. The total number of thrombo-embolic complications was 8, including 1 early thrombosis out of 230 patients - i.e. 0.4 per cent and 7 late thrombo-embolic episodes out of 180 patients followed up for 1 month to 4 years - i.e. 3.8 per cent. Secondary and late mortality was 11 cases out of 180 patients. The survival rate at 4 years was 78 per cent by actuarial calculation, including operative mortality. These results justify the continued use of ball prosthesis, the long term thrombo-embolic risks of which are equal to or less than those of disc prosthesis, and the resistance of which to wear and tear is shown by the long postoperative survivals.

Thirty-eight patients have been operated upon early after acute myocardial infarction with rupture of the ventricular septum. Preoperative management included bedside hemodynamic evaluation, mechanical left heart support, and pharmacologic agents. The results of the surgical repair reflected both the effectiveness and the duration of preoperative treatment. Operation was performed in 14 patients with refractory cardiogenic shock, 10 of whom died (71%). Hemodynamic and clinical stability was achieved in 24 patients. Early operation (average 46 hours of medical management) in 17 patients permitted accurate repair, even with friable tissues; four of these patients died (23%). Delayed operation (average 12 days of monoperative treatment) was performed in seven patients and resulted in a higher mortality rate, three patients dying (43%). The location of the ventricular septal defect (VSD) also influenced the operative risks, the prognosis for posterior defects being worse than that for anterior defects. Optimal myocardial preservation during the entire procedure is of crucial importance to the success of the operation.

Emergency myocardial vascularization through an aorta-to-coronary by-pass has been extended recently to acute evolutive accidents of coronary artery disease: either to its minor forms, as the menace syndrome, or its more severe forms, such as complicated myocardial infarction. This study aimed at a retrospective analysis of 50 patients, all operated upon as an emergency, by the same surgical team. The problems peculiar to any group of indications, and the practical and theoretical problems posed by extension of this type of emergency surgery were discussed.

31 survivors of a group of 49 patients with septal rupture during acute myocardial infarction were operated on average 8 days after the onset of necrosis. The operation was performed after a period of circulatory assistance in 23 cases and consisted of septal reinforcement, closure of the perforation and resection of necrotic tissue. The results were satisfactory in patients operated on early after effective resuscitation (91 p. 100 survival), and better than in the patients operated on after the maximum possible delay (50 p. 100 survival) and in patients in whom poor tolerance of the VSD led to an emergency salvage operation (29 p. 100 survival).

Gangrenous cellulitis of the face of dental origin had a very abrupt onset, spread rapidly in spite of treatment and led to severe pleuropericardial complications. The outcome was favorable after repeated thoracic surgery. Preventive therapeutic measures for these major accidents are discussed, following a detailed report on the case presented and treatment modalities applicable, fatal outcomes still being possible in 1984 in spite of progress in therapy.

Aortic arch hypoplasia is rare but carries a poor prognosis. It is usually associated with a left to right shunt at ventricular level. The association of an aorto-pulmonary fistula is exceptional. A case of a 5 1/2 month old infant treated successfully by simultaneous correction is reported with a review of the physiopathological changes. Pulmonary hypertension and aortic perfusion depend on the calibre of the ductus arteriosus and its evolution. The therapeutic problems which result are the suppression or palliation of pulmonary hypertension and resaturisation of distal aortic vascularisation. Surgery is the only hope of cure, and current techniques are reviewed: two stage procedures with revascularisation of the distal aorta and pulmonary artery banding, or simultaneous correction of aortic continuity with suppression of the left to right shunt under cardiopulmonary bypass. The technical conditions are analysed: perfusion of the different aortic segments, methods of reestablishing aortic continuity. Good results are as yet rare, and are obtained after complete correction under cardiopulmonary bypass.

The results of conventional operative resection of diffuse subaortic stenosis (tunnel subaortic stenosis and diffuse idiopathic hypertrophic subaortic stenosis) have been less than satisfactory. A new approach using the concept of aortoventriculoplasty was designed to allow adequate surgical resection of a diffuse subvalvular aortic stenosis. The aorta, the right ventricle, and the septum are incised in the same way as during aortoventriculoplasty , with the aortic anulus being divided carefully across the commissure between the left and right aortic cusps. The septotomy is extended beyond the limits of the stenosis, and fibrous and/or muscular tissue is removed from each edge of the septal incision. After adequate widening of the subvalvular area, the various incisions are closed and the aortic valve is reconstructed. This aortoseptal approach was studied experimentally in the dog and then carried out on two patients, both of whom had excellent hemodynamic and functional results. The aortoseptal approach may be the procedure of choice in the treatment of diffuse stenoses limited to the subvalvular area, whereas other procedures ( aortoventriculoplasty , and apico-aortic valved conduit) should be used when the valvular and/or supravalvular levels are involved.