Search

Summary Introduction Thromboembolic accidents and haemorrhage are the main complications observed during long-term follow-up of mechanical heart valve patients. Several suggestions for improving anticoagulation quality have been made, including international normalised ratio (INR) self-monitoring. Objectives We report the preliminary results of a single-centre, open, randomised study (scheduled population of 200 patients), which compares monthly laboratory monitoring (group A) versus weekly self-monitoring of INR (group B). The primary aim is INR stability improvement within the target range, and the secondary aim is adverse events reduction. Patients and methods Between May 2004 and June 2005, 67 patients with an average age of 56.6 years (± 9.6), were enrolled in the study (group A: 34 patients, group B: 33 patients). The mean follow-up was 47 weeks (± 11.5). The two groups differed only in the sex ratio (44.1 and 21.2% of women in groups A and B respectively, p = 0.0459). Mechanical heart valves were aortic in 73% of patients, mitral in 13.5%, and multiple in 13.5%. Sixty-five patients (97%) were treated with fluindione, the others with acenocoumarol. The intraclass correlation coefficient between the self- and laboratory-monitored INR was 0.75. Results The time spent in the INR target range (group A: 53 ± 19%, group B: 57 ± −19%, p = 0.45) and the time spent in the INR therapeutic range, between 2 and 4.5, (group A: 86 ± 14%, group B: 91 ± 7%, p = 0.07) are longer in group B, but not significantly so. For patients outside the range, the absolute mean deviation of INR from the target or therapeutic range (range standardized between 0 and 100) is lower for the self-monitoring group (41.1 ± 39.3 and 11.27 ± 11.2) than for the control group (62.4 ± 72.6 and 39.2 ± 52.8). This difference is significant ( p = 0.0004 and p = 0.0005). Eighteen adverse events were reported: 17 haemorrhages, 13 in group A (9 mild, 4 serious) and four in group B (all mild), and one sudden death in group B, two days after the patient's discharge. No thromboembolic events were reported. Six patients (8.8 %), 3 in each group, dropped out of the study. Conclusion This first study evaluating INR self-monitoring in France shows that this method leads to better stability of the INR within the target range. On the basis of these preliminary data, this appears to be related to a decrease in serious haemorrhages (11.8% serious haemorrhage cases in group A versus 0% in group B, p = 0.06, NS).

Background . Stabilization of the posterior annulus seems to be a critical factor to achieve a stable mitral valve repair. To assess the benefit of softer mural annuloplasty, we analyzed results obtained with the flexible linear reducer. Methods . From 1985 to 1993, 120 patients, with pure mitral regurgitation, mainly degenerative, had a mitral reconstruction. Mean age was 64 ± 11 years and 74% of the patients were in New York Heart Association functional class III or IV. Results . Hospital mortality was 3.3%. Mean follow-up was 56 ± 24 months. There were 23 late deaths; 10 valve-related including 7 sudden deaths. Two patients (1.7%) required a reoperation. Doppler echocardiographic studies revealed excellent valve function; 5-year freedom from significant regurgitation was 85.8% ± 5.4%. Mean mitral valve area was 2.76 ± 0.77 cm 2 . Although 105 patients were in class I or II, 23 patients were not functionally improved. Previous myocardial infarction and shorter deceleration time of early filling were risk factors for worsening functional disability. Conclusions . This support provides stable repair with excellent clinical and echographic results. Previous myocardial infarction and noncompliant left ventricle negatively influence outcome.

and regained normal immunity to ensure success. In agreement with other authors, ~ we never found that cervicothoracic access was not needed for simple repair of a TEF. Thus the risks of postoperative assisted ventilation (which constitute the main cause of relapse) are greatly reduced, resulting in an acceptable rate of mortality (about 10% according to Marzelle and associates1). A left lateral cervical incision gives very satisfactory access for simple closure of a TEF, with better visibility and adequate operative space compared with the median approach, and has the advantage of being able to be transformed to a cervical incision at the neck if necessary. Placement of a muscular flap between the two viscera is another indispensable element for success. The partial relapse in our second patient was due, in our opinion, to the insertion of a muscular flap that was too thin (omohyoidal muscle). In cases of associated tracheal stenosis, which occurs in about 22% of patients with a TEF, 1 the possible anastomotic resection of even a small segment (a rare event) greatly increases the surgical risk. For this reason, in two of our patients with associated tracheal lesions, we opted for t reatment with a dilating endoprosthesis.

Background. To procure a cosmetic incision in female patients, we performed operation on atrial septal defects through a right anterolateral thoracotomy. Methods. From 1984 to 1994, 80 female patients with a mean age of 24 ± 13 years (ranging from 12 to 62 years) underwent right anterolateral thoracotomy for atrial septal defect repairs. Defects repaired included 62 ostium secundum, 12 sinus venosus, 2 low septal defect, and 4 ostium primum. The right iliac external artery was systematically used for arterial cannulation, through a cosmetic incision. Repairs were always performed under fibrillation, except in the 4 ostium primum defects, for which cardioplegia was used. Results. There was no operative or late mortality, and no morbidity directly related to the thoracotomy approach. Conclusions. The right thoracotomy incision appears to be a safe and effective alternative to median sternotomy for repair of atrial septal defects.

A 19-day-old child suffering from cyanosis due to tetralogy of Fallot was palliated by using his right retroesophageal subclavian artery. It was anastomosed side-to-side onto the ascending aorta and end-to-side onto the right pulmonary artery. The palliation obtained with this systemic-pulmonary shunt was satisfying. The right brachial vascular flow was normal.