[Evaluation of valve surgery in acquired diseases of the aortic orifice].
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Aortic Valve↗
Biomedical subjects
A Pavie
Publications and source records attributed to A Pavie.
[Choice of a valve prosthesis in patients between 25 and 70 years of age].
In patients over the age of 70, the choice is unanimously in favour of a bioprosthesis. In children and adolescents, the rapid deterioration of bioprostheses makes them unsuitable for these patients. However, between the ages of 25 and 70, the situation is much more open to discussion. In the aortic orifice, because of the low risk of thrombo-embolism, there is a preference for a mechanical valve, except in the case of a young woman wishing to have a child or in the case of a contraindication to anticoagulants. In the mitral orifice, the higher incidence and the greater severity of the thrombo-embolic complications present an argument in favour of bioprostheses, which should be selected in the case of anticoagulant risks (contraindication, exposure to trauma, impossibility of following a female patient who wishes to become pregnant), in the case of a high thrombogenic risk (ectatic thrombosed left auricle or replacement of a thrombosed prosthesis) and, finally, the preference of the patient and the doctor. The bioprosthesis is unequivocally indicated in the case of tricuspid valve replacement.
Adult↗
Severe hypoxemia revealing traumatic tricuspid regurgitation with right-to-left intracardiac shunt.
A case of traumatic tricuspid regurgitation immediately following chest trauma in an 18-year-old man is reported. The cardiac lesion was revealed by right-to-left shunt due to the reopening of the foramen ovale leading to hypoxemia exacerbated by controlled ventilation. Early surgical repair led to hypoxemia correction.
Adolescent↗
[Surgical result of 48 Bigelow myotomies for obstructive myocardiopathy].
Bigelow's myotomy is one of the surgical options available for the treatment of hypertrophic obstructive cardiomyopathy (HOCM). The results of this operation were analysed in 48 cases operated between 1965 and May 1983. The average age of the patients was relatively low (38 years) but preoperative symptoms were severe (34 patients in Class III and 6 patients in Class IV of the NYHA Classification). The diagnosis was confirmed in all cases by echocardiography, carotid pulse tracings and cardiac catheterisation. 28 patients had associated lesions including 21 cases of mitral regurgitation (minimal in II cases, moderate in 6 cases and severe in 4 cases). All patients underwent Bigelow myotomy which was associated with a complementary procedure in 9 cases (including 2 mitral valve replacements and 2 semi-circular annuloplasties). The hospital mortality was 6 patients; surgical morbidity resulted from permanent intraventricular conduction defects (27 cases). At long-term, 3 more patients died, 2 from cardiac causes. Of the remaining 39 patients followed-up for an average of 32 months, functional improvement was marked, except in very advanced stages of the disease (Class IV) or forms with severe or uncorrected mitral regurgitation. The indications for Bigelow myotomy are discussed with reference to three parameters of HOCM (intraventricular pressure gradient, mitral regurgitation, decreased left ventricular compliance). This procedure has a beneficial effect on the subaortic stenosis and left ventricular compliance. It should be completed by mitral valve surgery in patients with significant regurgitation.
Adolescent↗
[Open heart cardiac surgery in severe renal insufficiency and dialysis patients].
Surgically remediable cardiovascular complications are common in patients with renal failure treated by dialysis. 20 such patients were operated in our department (16 men and 4 women), aged 27 to 61 years (mean 44.5 years). 12 patients had undergone haemodialysis for 1 to 84 months; 4 patients were treated by peritoneal dialysis; the remaining four patients all had severe renal failure with creatinine clearances of less than 10 ml per minute. All patients were operated immediately after a session of dialysis. Particular attention was paid to preserving the peripheral arterial and venous vessels during anaesthesia and cardiopulmonary bypass. The jugular veins were used whenever possible to spare the upper limb veins and the dorsalis pedis arteries were used for the monitoring of systemic blood pressure to spare the radial arteries for eventual arteriovenous fistulae. Weight gain during the operation was limited by cardiopulmonary bypass techniques. The circuit was filled with 200 cc of B 21, 500 cc of isotonic bicarbonate solution and 800 cc of frozen plasma with potassium supplements. Mean weight gain was moderate (1.1 +/- 0.4 kg). 12 patients underwent valve replacement. The surgical indication was acute endocarditis in 6 cases. The aortic valve was replaced in 10 cases and the mitral valve in 2 cases by mechanical valve prostheses because of the high risk of calcification of bioprostheses in severe renal failure. 8 patients underwent coronary bypass graft surgery. Arterial blood pressure was maintained at over 60 mmHg and large doses of heparin were used to protect the arteriovenous shunts.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
[Recurrent post-infarction ventricular tachycardias. Treatment combining circular ventriculotomy, myocardial revascularization and aneurysmal plication].
The efficacy of encircling endocardial ventriculotomy (EEV) with treatment of recurrent persistent post-infarction VT has been established. The relative simplicity of the operation has enables it to be easily integrated into the surgical therapeutic arsenal for the treatment of coronary artery disease and its complications. Several electrophysiological studies have clearly demonstrated the origin of reentry pathways in the border zone of the aneurysm so that peroperative mapping can be dispensed with except in special cases. Sixteen patients with post-infarction LV aneurysm causing recurrent VT resistant to antiarrhythmic therapy for over 3 months were operated between January 1979 and June 1983. The average age was 51 years, range 36 to 70 years. The causal myocardial infarction dated from 3 months to 22 years; the site of infarction was anterior in 12 cases (anteroseptal 5 cases), posterior in 3 cases and circumferential in 1 case. Surgery was performed under cardiopulmonary bypass and comprised EEV in the border zone of the aneurysm without prior mapping studies. A myocardial revascularisation procedure was associated in 10 cases (aortocoronary saphenous vein bypass) with single grafts in 4 patients. Thirteen patients also underwent plicature of the aneurysm to remodel the ventricular cavity. There was one death in the immediate postoperative period due to a low output state (6.25%). The 15 survivors have been followed up for 1 to 45 months during which period 3 deaths occurred, on at the 2nd month due to cardiac failure and 2 sudden deaths at the 5th and 22nd months. These 2 patients had not had recurrences of their arrhythmia.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
[Role of surgery in the treatment of infectious endocarditis].
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Acute Disease↗
Surgery of prosthetic valve thrombosis.
From January 1978 to August 1983, 41 prosthetic valve thromboses in 34 patients were operated upon in our service. They comprised 15 aortic, 25 mitral and one tricuspid valve thromboses. Seven patients had massive thrombus with dysfunction of the prosthesis; others had small and disseminated thrombi on their prosthesis (34 patients). In the aortic position, valve thrombosis occurred on 10 ball valves and 5 pivoting disc valves. In the mitral position, they occurred on 17 ball valves, 7 pivoting disc valves and one bioprosthesis. In 2 cases, aortic valve thrombectomy was successfully done. Others had valve replacement. Hospital mortality was high: 13 deaths. Survivors are free of recurrent valve thrombosis. One had a minor peripheral embolus. Prosthetic valve thrombosis is a serious condition. There are special problems related to diagnosis and treatment of these patients which we discuss, according to our experience of more than 4000 valvular replacements.
Adult↗
Unipolar electrode system for an implantable defibrillator: new experimental approaches.
Defibrillation thresholds are studied in normal dog hearts after induction of ventricular fibrillation by alternating current. Shocks of progressively increasing energies are tried after a period of 10 seconds of sustained ventricular fibrillation. The endocardial electrode system may be either unipolar or bipolar, the distal electrode being situated at the right ventricular apex. The results suggest that for an optimal capacitor in the range of 9-20 uF, unipolar shocks are more effective than bipolar shocks (3-10 versus 10-30 Joules). In addition, several cardiac arrhythmias, including rapid ventricular tachycardia, accelerated idioventricular rhythm, and transient AV block are frequently observed. We conclude that (1) an implantable unipolar endocardial defibrillator seems feasible; and (2) the design should include the appropriate circuits to treat the arrhythmias observed after the shocks.
Animals↗
[Isthmic coarctation of the aorta: characteristics and results of surgical treatment in subjects surgically-treated after 35 years of age].
From 1965 to 1981, 27 patients over 35 years of age were operated for isthmic coarctation of the aorta. Surgery consisted of resection and direct suture in 16 cases, implantation of a Dacron prosthesis in 7 cases, isthmoplasty in 1 case, aortotomy-graft in 1 case, insertion of a Dacron tube between the left subclavian artery and the descending thoracic aorta in 1 case; finally, one patient presented with a rare form of coarctation in a double aortic arch and was treated by a bypass from the brachiocephalic trunk to the descending thoracic aorta. Ten patients had associated pathology. This was treated at the same time in 4 cases: closed heart mitral commissurotomy, cardiac plexectomy, section-suture of patent ductus arteriosus, and a resection of aneurysms of four intercostal arteries. A Bjork aortic valve prosthesis had been inserted nine months previously in a women with calcific aortic stenosis. There were 2 deaths (7,4%) in the immediate postoperative woman with calcific aortic stenosis. There were 2 deaths (7,4%) in the immediate postoperative period (one acute pulmonary oedema, one pulmonary embolism). There has been no operative mortality in the last 10 years. Twenty-three of the 25 survivors have been followed-up for an average period of 91,5 months (range 1 to 18 years). Two patients died of cardiovascular causes. Analysis of these results show: that the mortality rate is not prohibitive compared to that of the natural history of the condition (the average survival rate of unoperated patients is 35 years), good secondary results despite frequent technical difficulties, the possibility of residual hypertension (especially in older patients) which responds well to drug therapy.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
[Endocavitary removal of catheter fragments which had migrated into central cardiac cavities].
Five cases of endocavitary recovery of embolised fragments of catheter are reported. In three cases, the Dotter apparatus was used with a percutaneous approach. In the other two cases, a Dormia catheter was introduced after surgical venous cut-down. The embolised catheters were all recovered successfully in periods ranging from 10 minutes to 1 hour. Local anaesthetic was used in one case. The interval between initial rupture and recovery of the catheter ranged from several hours to 2 months. No complications occurred during or after these manoeuvres. This is a simple, rapid, and economical method which may save the patient from thoracic surgery, and should always be kept in mind.
Catheterization↗
[Surgical atrioventricular disconnection in Wolff-Parkinson-White syndrome].
Surgical atrioventricular disconnection is a possible means of treating patients with severe paroxysmal arrhythmias resistant to medical treatment due to the Wolff-Parkinson-White syndrome. Between 1971 and April 1982 we operated 50 patients (38 men and 12 women) with the WPW syndrome. Thirty seven patients were operated for arrhythmias (paroxysmal tachycardia) resistant to medical therapy or with a high risk of sudden death. Thirteen patients had associated cardiac disease with less severe arrhythmias (aortic valve disease: 6 cases; mitral and aortic valve disease: 3 cases; mitral valve disease: 3 cases, and atrial septal defect: 1 case). The causes of paroxysmal tachycardia were atrial fibrillation (13 cases), atrial flutter (2 cases), orthodromic reciprocating tachycardia (30 cases), with associated atrial fibrillation in 9 cases, and with associated atrial flutter in 4 cases. Antidromic reciprocating tachycardia was present in 2 cases. In 3 cases, the preexcitation was a chance finding. Electrophysiological studies performed before and after antiarrhythmic drug administration showed type A WPW (LV preexcitation) in 23 cases, and type B WPW (RV preexcitation) in 20 cases. The ECG was normal in the horizontal plane in 7 cases. The atrioventricular accessory pathway was permeable in both directions in 39 cases; in 9 cases the pathway was permeable only in the retrograde direction and in 2 cases it was permeable only in the anterograde direction. In 7 patients an atrio-hisian short circuit was demonstrated. The site of the accessory conduction pathway was located by epicardial mapping, the first surgical stage, in the left lateral region of the atrioventricular junction (28 cases), in the right lateral region (6 cases), in the posterior septal region (15 cases) (right sided in 4 cases, left sided in 11 cases), and in the anterior septal region (1 case). The accessory pathway (so-called Bundle of Kent) was interrupted by atrioventricular disconnection. Six patients died during surgery, mainly at the beginning of the series; the operative risk is now low (1 death in the last 34 cases: 2,95%). Complete interruption of the accessory pathway was obtained in 38 cases, 1 of which had to be reoperated. Three patients had an incomplete result due to partial interruption or the presence of a second accessory pathway. However, these patients no longer have severe arrhythmias. Surgical section failed in 3 cases, but the patients are now controlled by medical therapy.(ABSTRACT TRUNCATED AT 400 WORDS)
Adolescent↗
[Significance of intraventricular conduction disorders observed in arrhythmogenic right ventricular dysplasia].
Correlations between surface ECGs, epicardial mapping and histological data in 15 cases of arrhythmogenic right ventricular dysplasia (ARVD) provide information about the possible mechanism of intraventricular conduction defects in about one third of cases. Two cases in this series had complete right bundle branch block and 4 cases showed diffuse intraventricular conduction defects. The other cases had normal ECGs. The point of origin of the activation in 11 cases was situated in the left ventricle, even in 6 of the 9 cases with normal ECGs. The points of latest activation were located over the right ventricular free wall near the atrio-ventricular groove. However, in all cases but one, a normal right ventricular point of origin was observed, suggesting participation of the right bundle within a free wall showing delayed activation. This activation showed very irregular delayed propagation due to the zones of dysplasia. These results suggest that in ARVD, the mechanism of the conduction defects is not disease of the bundle branch itself but a distal block probably situated in the right ventricular wall. This hypothesis is supported by the histological appearances of the dysplastic zones.
Adult↗
[Heart transplantation. Experience at La Pitié hospital. Apropos of 82 cases].
Since 1968, 320 patients with severe irreversible myocardial failure, have been referred to our department for transplantation; 78 p. 100 had dilated cardiomyopathies; 14 p. 100 had ischaemic heart disease and 8 p. 100 had valvular heart disease. One hundred and five patients had absolute contra-indications and were excluded (pulmonary hypertension, diabetes, gastro-duodenal ulcer, age, or other major organic disease). Of the remaining 215 patients, only 82 were transplanted because of the limited number of available donor hearts. The most commonly used technique was orthotopic grafting as described by Lower and Shumway; Barnard's method of heterotopic grafting was used in 1 case and a block heart and lung transplantation by Reitz and Shumway's method was performed in 3 cases. The main postoperative complications, apart from technical problems (7 deaths), were related to rejection (107 episodes, 27 deaths), infection (82 episodes, 13 deaths), atherosclerosis of the graft (4 cases, 2 deaths, 1 retransplantation) and malignant tumours (3 deaths). After transplantation, 82 p. 100 of patients were discharged after an average hospital stay of 2 months; 47 p. 100 survived the first year and lead almost normal socio-professional activities. Thirty patients are still alive, the longest postoperative survival being 9 years. Significant advances have been made in the last 3 years. Classical immuno-suppressor therapy (steroids, azathioprine, horse antilymphocytic serum) has given way to more effective antilymphocytic sera and more powerful immuno-suppressor drugs (cyclosporine A). This treatment has greatly changed the postoperative course of events. Rejection phenomena, though still as common, are much less serious and, above all, more insidious.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
[Open-heart surgery in patients over 65 years of age. Lesions encountered and immediate postoperative mortality].
Open heart surgery after 65 is more and more frequent (16% of our surgical cases). Between January 1971 and December 1982, 8 425 open heart operations were performed in this Department, 1 377 of them in patients over 65. Most were cases of aortic valvulitis (620), and calcific aortic stenosis in particular, but also dystrophic aortic insufficiency; 217 patients underwent surgery for mitral valvulitis (rheumatic or dystrophic in origin) and 84 for involvement of more than one valve. Of the 2 440 patients with coronary lesions who underwent surgery, 255 were over 65; beyond this age, a higher rate of association between coronary lesions and valvular disease was found (167 patients undergoing surgery). Surgical mortality (during the first postoperative month) was higher after 65: 11.1% in patients with valve disease, and 11.4% in those with coronary artery disease, whereas in patients under 65 the figures were 6.5% and 4% respectively. On the other hand, in those undergoing surgery for combined valve and coronary disease, mortality over 65 was hardly any higher than under 65 (13.7% as against 10.4%). This justifies screening for coronary artery disease in any candidate for valve surgery aged over 65. These results were achieved thanks to some technical and anaesthetic precautions, and though they may be less satisfactory than those for younger patients, they justify such surgery for all lesions that threaten survival in the short term.
Aged↗
[Heart transplantation. Current status at La Pitié Hospital].
Since 1972, 280 patients with severe irreversible myocardial damage have been referred to La Pitié Hospital, Paris, for heart transplantation; 95 were excluded on account of absolute contra-indications. Owing to the limited number of available transplants, only 66 of the 185 remaining patients were transplanted. Transplantation was orthotopic in all but 3 cases: 1 patient had heterotopic transplantation and 2 had heart-lung transplantation. The most common post-operative problems were graft rejection and complications of the immunosuppressive treatment; 82% of the transplanted patients were discharged 2 months on average after surgery; 47% overcame the first year problems and resumed an almost normal social and professional life; 21 are still alive, one of them after 9 years. During the last 2 years, technical refinements and the advent of more potent immunosuppressive agents (anti-lymphocyte serum from rabbits, cyclosporin A) and better diagnostic methods (repeated endomyocardial biopsies and immunological surveillance) have resulted in considerable improvement in the patients' outcome, with an actuarial survival rate of 77% at one year and 70% at two years. Since transplants are now better tolerated after the second year and since they possess remarkably good and durable functional properties, this reduction in early and late mortality, which used to be the main cause of failure, raises hopes of a marked increase in prolonged and satisfactory survival.
Cardiomyopathies↗
[Intra-atrial implantation of the mitral valve].
Infectious lesions of the mitral ring sometimes cause so much damage that insertion of the prosthesis in its normal place is impossible. In such cases, artificial valves with a dacron flange can be implanted into the left atrium, just above the mitral ring, and sutured to the atrial wall. These valves are generally used in first or second reoperations for recurrent desinsertion, but they have proved so reliable that their use can be extended to primary mitral valve replacement in cases where extreme calcification of the mitral ring throws considerable doubt on the success of conventional techniques.
Bioprosthesis↗
[Heart transplantations. Current status. Experience at the Hôpital de la Pitié].
The experience gathered over the last fifteen years of clinical application of heart transplants has resulted, in the last two years, in much improved results:the survival in our series is 77% at one year and 70% at 2 years. This progress is due to the following factors:improved patient selection, with strict respect of contraindications, in particular, patients over the age of 50 and patients with advanced multi-system failure; improved selection of donors, avoiding, within the limitations of immunological compatibility, grafts in poor condition from subjects over the age of 35 and a refinement of the operative techniques, especially the introduction of more potent immuno-suppressants such as Cyclosporin A and improved post-operative monitoring based on immunological examinations and repeated endo-myocardial biopsies. These advances will lead to a broadening of the operative indications and a wider use of this form of treatment.
Adolescent↗