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In order to determine the prognosis of reoperation for valvular replacement, we reviewed the results of a consecutive series of 124 patients operated in the department between 1974 and 1992 (163 multi redo operations). There were 69 women and 55 men, with a mean age 48 years; 77% of the patients were in functional class III or IV. Operations were performed as an emergency in 30% of cases. Endocarditis was found in 24% of cases and was an important risk factor in this content. The main indications for reoperation were periprosthetic leakage in 28.8% of cases and failure of bioprostheses in 23.7%. The valvular replacement was simple in 61%, double in 32% and triple in 7% of cases. An associated procedure was necessary in 27% of cases. Mechanical devices were implanted in 62.3% of cases. Peroperative mortality was 3% and hospital mortality, mainly from cardiac causes, was 21.7% for the second, 20% for the third and 55.6% for the fourth reoperations. Operative mortality was dependent on the number or reoperations, functional class, emergency surgery, duration of bypass and cross-clamping time. Four per cent of patients were lost to follow-up and 30 patients died secondarily. The actuarial survival rate was 52% at 5 years and 33% at 10 years, actuarial survival rate without valvular complication was 41% at 5 years and 19% at 10 years but the functional results remained good with over 90% of patients in functional class I or II at the end of follow-up.

Early diagnosis of acute cardiac graft rejection by non-invasive methods is required for medical, organizational, psychological and economic reasons. We have monitored 18 heart recipients over a period of 2.5 years using endomyocardial biopsies (EMB), cardiac Doppler-echography (CDE) and proton NMR spectroscopy assay of plasma glycosylated residues. Diastolic parameters of CDE and assay of the glycosylated residues by NMR spectroscopy respectively detect 42 and 45% of the acute low grade (mild or moderate) histological rejections. The combination of the two methods allows the detection of 65% of rejections. The strategy combining plasma NMR spectroscopy and echography is pertinent to the non-invasive detection of acute cardiac rejections with low histological grade.

The authors' laboratory is developing a device for heterotopic left ventricular assistance. It consists of a titanium Wankel-type rotary pump, driven by an hermetically sealed electric motor. In our animal experiments, the motor-pump unit was implanted in the thoracic wall. The pump was connected to the left heart chambers by left atrial cannulation, and to the descending aorta. The motor was connected to the power and control unit by an electric wire through the skin. In this report, the authors describe the first significant animal survival with this system. Laboratory results were encouraging for hemolysis. The pump failed at 13 days due to a deposit of fibrin and blood cells in the gear housing. This problem was not surprising since similar events have been encountered with centrifugal devices. However, further design improvements should allow longer animal survival and clinical application.

When ventricular assistance is achieved with a volumetric pump driven by an electric actuator, overpumping can cause venous collapse. To prevent this problem, pump speed must be monitored and controlled. The authors developed a regulatory system based on the current intensity signal from the electric motor. This signal is processed and compared with predicted values calculated according to a mathematical model at the beginning of each ejection phase. If a difference is detected, pump speed is adequately adjusted. The great advantage of this system is elimination of the need for an implantable pressure sensor. It requires a simple and ubiquitous electronic component, i.e., a resistor, that can be easily integrated into the motor control circuit and does not require calibration.

Chronic pericarditis can take the form of localised annular bands constricting the atrioventricular grooves, the pulmonary infundibulum and, rarely, the atria. The authors report two cases of pericardial bands surrounding the ventricles and involving the atrioventricular groove resulting in a biloculation of the left ventricle. One case was complicated by adiastole and one by mitral regurgitation due to involvement of the posterior mitral leaflet. Magnetic resonance imaging gave precise definition of these bands and of their extension into the myocardium. This investigation was a valuable complement before surgery of the localised constriction.

Operated upon in November, 1968, the last survivor of heart transplant recipients in those times has died on May 11, 1987, having survived 18 years and 6 months. The active life of this patient, however, was marred by episodes of graft rejection during the first post-operative years and by various incidents. It was mainly the complications of the immunosuppressive treatment that hampered his activities (osteoporosis) and provoked his death. Post-mortem examination confirmed that the heart was in good condition, found an active bronchial epithelioma and revealed iatrogenic lesions, namely adenomas, adenocarcinoma of the kidney and "regenerative" nodular hyperplasia of the liver with portal hypertension. Such lesions are observed in patients under long-term treatment with immunosuppressants. A "sleep apnoea" syndrome might have accounted for the formation of pulmonary hypertension lesions. The authors wish to pay their respects to this man who devoted himself to the service of other men.

The authors present three eases of subvalvular aortic stenosis caused by an abnormality of the mitral valve mechanism which required placement of a prosthetic valve. They describe the types of mitral valve abnormality which are reported in the literature to have caused obstruction to the aortic outflow tract. They analyse the criteria for diagnosis of this condition, and the surgical treatment. The placement of a prosthetic mitral valve does not always remove the obstruction to the aortic outflow, especially if there is an abnormality in the position of the mitral ring.

Fifty-nine patients operated for Fallot's tetralogy were reviewed over 3 years after surgery. The average age at surgery was 7.4 years (range 6 months to 37 years). The review included ECG, chest X-ray, echocardiography, exercise stress testing and Holter monitoring, completed by cardiac catheterisation in 10 cases and electrophysiological investigation in 4 cases. Forty-eight of the 59 patients (81.3 p. 100) had no signs of ventricular arrhythmia or only benign ventricular extrasystoles (Group I). Four patients (6.8 p. 100) had severe ventricular arrhythmias (Group II). Seven patients (11.9 p. 100) had one or more episodes of ventricular tachycardia (VT) (Group III) and, in 3 of these patients, VT was recorded during Holter monitoring or exercise stress testing. One patient in Group III died after reoperation, but there were no cases of sudden death in this series. The high risk patients Groups II and III) were operated late (after 5 years), had bi- or trifascicular block (7 out of 11 cases), ventricular extrasystoles on resting ECGs (9 out of 11 cases), cardiomegaly (6 out of 7 cases in Group III), echocardiographic dilatation of the infundibulum (6 out of the 8 patients undergoing echocardiography in Groups II and III). They had significant residual malformation but without right ventricular hypertension (as judged mainly by immediate postoperative data). Ventricular arrhythmias occurred over 6 years after surgery. However, none of the patients operated before 2 years of age had ventricular arrhythmias or VT with a mean follow-up period of 7.5 years, perhaps because LV function was protected.(ABSTRACT TRUNCATED AT 250 WORDS)

Forty seven bioprostheses were used for mitral valve replacement between January 1975 and June 1980, with no operative mortality, in children under 19 years of age. This study was undertaken to evaluate the medium and longterm outcome of 43 patients followed up for at least 2 years. The late mortality was higher in children under 13 years of age (11.1% per patient/year) than in older children (3% per patient/year). The incidence of reoperation for deterioration of the bioprosthesis was 5,5% per patient/year. The actuarial longevity of bioprostheses without any complications was 48 +/- 16% at 5 years. After a review of the literature, the authors discuss their present therapeutic attitude: whenever possible, mitral valvuloplasty is the operation of choice, but when valve replacement is necessary, two criteria must be considered: the age of the patient and conditions of follow up. If medical follow-up facilities are good: mechanical prostheses are preferred in patients under 13 years of age: after puberty especially in girls, the bioprosthesis is the valve of choice. If medical follow-up facilities are poor: the valve of choice is a bioprosthesis at all ages because of the risk of thromboembolism and the relatively slow clinical aggravation in cases of bioprosthetic deterioration.

The "bifocal pacemaker achieves a sequential" stimulation which reproduces the physiological atrio-ventricular sequence. This type of stimulation has the advantages of atrial stimulation without the disadvantages of being inefficient when an atrio-ventricular block exists or supervenes. The pacemaker was used by the endocavity route in 12 patients. The indications included a disease of the sinus node (8 cases), supra-ventricular arrhythmias associated to conduction disorders (3 cases) and a cardiomyopathy with conduction disorders (1 case). The preliminary results were appraised after two to twenty four months. One displacement of the ventricular electrode was noted. On the other hand no displacement of the atrial electrode was reported. One battery was worn out after 19 months. The "bifocal" pacemaker was efficient in the treatment of symptoms which justified its implantation. Or particular interest were the results obtained in patients with no supraventricular arrhythmias. This pacemaker may be of use: 1) in the disease of the sinus node, in particular in the tachycardia-bradycardia syndrome; 2) in supraventricular arrhythmias associated to paroxystic conduction disorders; 3)in patients with an alteration of the myocardial function and for whom the atrial contribution to cardiac output is essential.

The authors report the case of a dissecting aneurysm of the ascending aorta compressing the right pulmonary artery in a 62 year old man, 6 years after aortic valve replacement. The clinical presentation was that of pulmonary embolism. The diagnosis was confirmed by angiopneumography and CT scanning. The ascending aorta was successfully replaced with a Dacron prosthesis. One other case was found in a review of the literature. After discussing the predisposing factors of aortic dissection during cardiac surgery, the authors underline the diagnostic value of CT scanning in cases of suspected aneurysms of the thoracic aorta.

The authors report one case of torsade de pointe which occurred immediately after fast intravenous injection of a 1-gram dose of erythromycin lactobionate in a female patient who had undergone surgical replacement of the mitral and triscuspid valves 24 hours before. The responsibility of erythromycin was strongly suggested by the clinical data (syncope), electrocardiographic findings (electrocardiogram typical of torsade de pointe, slow rhythm and lengthened QT interval in the basal ECG) and the chronology of the sequence of intravenous injection of the antibiotic and the rhythm disorder. A literature search revealed six similar cases. Its seems that the arrythmogenic property of this drug is related to abnormally elevated serum levels following rapid administration.