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Objective: We sought to evaluate the effect of a strict glycemic control protocol on a series of diabetic patients undergoing surgical myocardial revascularization., Methods: Between January 2003 and June 2004, 300 diabetic patients undergoing myocardial revascularization received a local protocol of insulin administration (protocol, group P). Patients were divided into 2 risk classes, according to their additive EuroSCORE value: low-moderate risk (0-4) and moderate-high risk (>4). The logistic EuroSCORE algorithm was used to calculate the expected probability of death. A control group was selected, including a series of 300 consecutive diabetic patients (no protocol group, group NP) who underwent coronary artery bypass grafting between March 2001 and September 2002, just before the introduction of the protocol. A propensity analysis was performed to control for selection bias., Results: Both groups showed similar EuroSCORE risk profiles: mean additive and logistic EuroSCORE values were 4.16 and 4.29 in group P versus 3.93 and 3.91 in group NP. Observed and expected mortalities of group P were 0.6% versus 1.8% (low-moderate risk), 2.5% versus 8.0% (moderate-high risk, P = .03), and 1.3% versus 4.3% (entire group, P = .01). Observed and expected mortalities of group NP were 1.6% versus 1.9% (low-moderate risk), 8.3% versus 7.5% (moderate-high risk), and 4.0% versus 3.9% (entire group). Logistic regression confirmed observed mortality in group P to be significantly lower than the expected logistic EuroSCORE mortality. After risk adjustment, the protocol allowed us to reduce the mortality odds by 72% (odds ratio, 0.282; 95% confidence interval, 0.092-0.859; P < .03). Subgroup analysis for moderate- to high-risk patients showed the protocol to improve mortality (odds ratio, 0.24; P < .05), whereas no significant improvement was found in low- to moderate-risk patients. Addition of the propensity score to the multivariable analysis did not significantly displace P values and odds ratios. Sensitivity analysis of patients who underwent coronary artery bypass grafting without additional procedures showed the protocol to maintain its protective effect (odds ratio, 0.15; P < .05)., Conclusion: Optimal glucose control highly reduces EuroSCORE expected mortality in diabetic patients undergoing myocardial revascularization, especially in moderate- to high-risk patients.

Background: Coronary artery disease (CAD) is the leading cause of mortality after the first year of heart transplantation. End-stage renal failure (ESRF) is more frequent because of long-term survival. Impact of ESRF on cardiac mortality in heart transplant patients is unappreciated. The hypothesis of accelerated CAD in uremic patients has been suggested., Methods: In Pitié La Salpêtrière hospital, 1211 heart transplants have been performed between 1982 and 2001. Thirty-three patients have reached ESRF. A case-control study was performed to identify risk factors responsible for ESRF and to appreciate the impact of ESRF on cardiac mortality., Results: In cases at 6 months, serum creatinine tended to be higher (159 +/- 31 micromol/L vs. 141 +/- 44 micromol/L, p = 0.06) and cyclosporine (CSA) dosage (mg/kg) was significantly lower (5.4 +/- 1.8 mg/kg vs. 7.7 +/- 2.7 mg/ kg, p = 0.002). Mean triglyceride level after transplantation until dialysis was significantly lower in cases (2.18 +/- 0.82 mmol/L vs. 1.48 +/- 0.62 mmol/L, p = 0.002). In cases and controls, cardiac mortality was responsible for 67% (10 of 15) and 38% (three of eight) of all deaths, respectively. High triglyceride level (> or = 2 mmol/L) was associated with cardiac mortality [p < 0.03, hazard ratio (HR) = 3.89]. Kaplan Meier cardiac free survival rates were significantly lower in cases than in controls (p < 0.03)., Conclusion: These data suggest that CSA nephrotoxicity could result from individually determined susceptibility and that hypertriglyceridemia may have a negative impact on renal function and cardiac mortality. The risk of cardiac mortality is increased in heart transplant patients with ESRF. The hypothesis of accelerated atherosclerosis in ESRF patients after heart transplantation leading to higher cardiac mortality incidence needs further study.

Aim: Cardiac surgery carries a high risk in hemodialysis patients and has been questioned for its results; the purpose of this study is to focus on the short and long term results in our institution., Methods: We retrospectively analyzed the data from 124 hemodialysis patients who underwent cardiac surgery in our unit between January 1980 and December 1998; 14.5% were diabetic; 46% had isolated coronary artery disease (group 1); 29.8% had valvular disease alone (group 2); 14.5% valve and coronary disease (group 3) and 9.6% miscellaneous disease at highest risk (group 4). We analyzed the relationship between several variables (age, sex, hypertension, diabetes, previous myocardial infarction, type of disease, preoperative ejection fraction) and operative mortality (30 days) and late survival., Results: The overall operative mortality was 16.9%. The only risk factor was the type of cardiac disease: operative mortality was higher in groups 3 and 4 combined than in groups 1 and 2 combined (30% versus 12.7%, p=0.07). Ninety-nine patients were followed until January 2002. Late survival rate was 46.6+/-5% at 6 years for all patients, it was significantly better in groups 1 and 2 combined than in groups 3 and 4 combined. The only risk factor for late mortality was arterial hypertension. Fifty-seven patients are still alive, 46 in groups 1 and 2, 11 in groups 3 and 4. Progression of coronary lesions occurred in 6 patients and valvular lesions in 3 patients. The remainder are doing well., Conclusion: Cardiac surgery seems to be justified by the severity of the lesions. Its actual results can perhaps, be improved by earlier detection of cardiac disease and better prevention of myocardial hypertrophy and cardiac calcifications.

Objective: It is important to apply the same rules used for classical coronary revascularization to beating heart coronary surgery. The surgeons must have a strategy, and be prepared for adverse events, and complications., Methods: A careful analysis of the coronarography is essential to predict eventual contraindications or causes of possible operative difficulties. All the team must be involved in the surgical protocol. Three main problems need to be solved: the prevention of ischemia during the procedure, good stabilization of the anastomotic site and arterial occlusion. The first goal is reached by using a pre-conditioning technique or an intracoronary shunt. Vessel stabilization may be obtained by several methods: pressure adhesion devices, patch technique or suction devices. The final problem is to have a blood free field, this requires arterial occlusion which may be achieved in several ways: silastic Snares or sutures, aclan clamps, coronary occluder., Results: We have developed at la Pitié a protocol to apply all these principles. From February 1997 to November 1998, multiple revascularization was performed on 167 patients. A total of 344 coronary anastomosis were carried out (mean: 2.05 graft/patient)., Conclusion: Some simple rules had to be applied to reduce the rate of complications to the minimum: a good clinical case selection, use of a routine protocol, and recognize the need to adapt the indications to the learning curve of the operator.

Primary pulmonary hypertension (PPH) is often associated with angina-like chest pain, the mechanism of which is controversial. A 37-year-old woman with severe PPH and angina had transient ischemic ECG changes and reversible anterior perfusion defect on 201thallium scintigraphy. Coronary angiography revealed severe stenosis of the left main coronary artery (LMCA) and otherwise normal vessels. After heart-lung transplantation, examination of the explanted heart showed normal coronary arteries. Compression of the LMCA by the dilated pulmonary artery trunk was responsible for myocardial ischemia. This mechanism should be considered in patients with PPH and angina and might contribute to the high sudden death rate.

Objective: Clinical experience with a video-assisted coronary artery bypass grafting procedure using the internal mammary artery is reported. The technique consists of a videoscopic harvesting of the left internal mammary artery (LIMA) to revascularise the left anterior descending artery (LAD) through a 4-cm left thoracotomy., Methods: Between September 1995 and July 1996, we performed this procedure on 30 patients (29 males, 1 female; aged 38-71) with an isolated proximal LAD stenosis (n = 21) or occlusion (n = 9). All patients were symptomatic despite appropriate medication. A history of non-transmural myocardial infarction with myocardial viability was found in nine patients. Fourteen patients had a restenosis after previous percutaneous transluminal coronary angioplasty (PTCA). Mean left ventricular ejection fraction was 0.61 (< 0.3 in two patients). The LAD LIMA anastomosis was performed on the beating heart without cardiopulmonary bypass (CPB) in 26 patients. Femoral-femoral CPB was used in three patients because of unstable angina (n = 1) and intramyocardial LAD (n = 2). Conversion to sternotomy and standard CPB was necessary in one patient for extensive endarterectomy of the LAD., Results: There were no operative complications and no reoperations for haemorrhage. Pulmonary infection was observed in one patient and wound infection in one patient. Patients who underwent the complete procedure on the beating heart without conversion or CPB were ready for discharge on the 5th postoperative day (36 h-13 days). Control coronary angiography was performed in 20 patients. In all cases, the graft was patent. In 17 cases, there was a patent graft with no evidence of anastomotic stenosis. An occlusion of the distal segment of the LAD with a retrograde perfusion of the proximal segment and septal branches by the LIMA was found in one case. This patient was symptom-free and the stress test was negative. An anastomotic stenosis was noted in two patients and was treated by angioplasty (n = 1) or conventional surgery (n = 1)., Conclusion: In conclusion, the efficiency of this minimally invasive approach should be prospectively compared with similar revascularisation with PTCA or surgical approaches using sternotomy with or without CPB.

A series of 13 patients (11 male, 2 female, average age 61 +/- 6 years) with previous aortocoronary bypass surgery and reoperated for aortic valve replacement (AVR) were analysed retrospectively. At coronary bypass, 8 patients (Group I) has insignificant aortic stenosis (AS) (mean transvalvular pressure gradient < 40 mmHg and/or aortic valve surface > 1 cm2). The other 5 had no aortic valvular lesion (Group II). The average time interval between the two operations was 7 +/- 3.3 years (Group I: 6.7 +/- 3.5 years; Group II: 7.4 +/- 3.2 years). In Group I, 2 patients required early AVR (2 years) whereas the time of reoperation varied from 6 to 12 years in the other 6 patients. No operative complications related to the sternotomy or dissection of adhesions were observed. In 3 cases, it was necessary to free the implanted grafts on the right coronary artery to gain access to the initial part of the aorta. A transverse low aortotomy allowed AVR in good conditions in all cases. One patient in Group II died on the 5th postoperative day of a low output syndrome complicated by pneumonia. After an average follow-up of 3 +/- 2 years, 9 patients are still alive. Three patients in Group I died, two of cardiac failure and one of unknown causes. The authors conclude that "prophylactic" AVR in cases of insignificant AS in patients referred for coronary bypass surgery is not justified. Regular echocardiographic follow-up should lead to AVR at the most appropriate moment, sometimes after an interval of several years, with a low operative risk.

The authors report a case of an iatrogenic fistula between the left circumflex coronary artery and left atrium. The fistula was a complication of reoperation to replace a mitral valvuloplasty annulus by a mechanical hemi-disc prosthesis (Saint Jude Medical). Diagnosis was made by transoesophageal echocardiography and confirmed by coronary angiography. The patient underwent external ligature under cardio-pulmonary bypass.

The purpose of this study was to bring up-to-date the immediate risks and long-term benefits of coronary surgery in elderly people. The results obtained in a series of 475 patients in their seventies suffering from coronary disease who underwent myocardial revascularization alone or combined with heart valve replacement at the La Pitié Hospital, Paris, between 1984 and 1989 were analyzed. Coronary disease was associated with heart valve disease in two-thirds of the cases. The mean number of bypasses was 2.3 per patient. Aortic valve replacement was performed in 119 cases and mitral valve replacement in 12 cases. The operative mortality rate was 10.8 percent in patients with stable angina who underwent elective surgery. The factors which increased the mortality rate were: age (19.6 percent over 75 versus 13 percent under 75, P = 0.05); sex (23.5 percent in women versus 13.2 percent in men, P = 0.01) and emergency (25.8 percent, P = 0.02). No significant difference in mortality was noted between patients who had and those who did not have aortic valve replacement (15.8 versus 10.8 percent, P = 0.14). Fifteen patients (3.1 percent) developed perioperative myocardial infarction. During the follow-up, period myocardial infarction occurred in 7 patients. Out of 29 late deaths, 8 were of cardiac origin (infarction in 5, terminal heart failure in 3). The survival rate at 4 years was 76 percent. Among the patients who could be followed up, 80 percent are now asymptomatic, 15 percent are in stage I or II and 5 percent in stage III or IV of the Canadian Cardiovascular Society classification. Thus, despite a non negligible operative risk the functional improvement and survival rates obtained justify an increase in the indications for myocardial revascularization in elderly patients.

The results of coronary artery surgery in young adults have not been extensively studied. We analysed the results of 221 patients under 40 years of age operated between 1979 and 1989 at the Pitié-Salpêtrière Hospital. The patients were 200 men and 21 women with an average age of 36.2 years. The most common cardiovascular risk factors were smoking (69.6%) and hyperlipidaemia (52%). One hundred and eighteen patients (53.4%) had previous myocardial infarction (MI). Triple vessel disease was present in 129 cases, double vessel disease in 59 cases and single vessel disease in 33 cases. Twenty three patients had significant left main coronary disease. The number of bypass grafts per patient averaged 2.3. The operative mortality was 2.07% (6 cases), death being due to myocardial infarction in 4 cases. Perioperative myocardial infarction was diagnosed in 12 cases (5.05%). One hundred and ninety nine patients were followed up for an average of 7.4 years. Seven of the 17 late fatalities were of cardiac origin. The actuarial 9 year survival rate was 84%. Five patients were reoperated after an average of 6.4 years. Eighty five per cent of patients were asymptomatic at the last follow-up examination. In conclusion, the symptoms of coronary artery disease in young adults can be effectively treated with a low operative risk by myocardial revascularisation surgery. Long-term follow-up remains essential to define the outcome in these patients. Systematic use of internal mammary artery bypass grafting should improve these results in the future.

Graft coronary disease is a frequent and devastating complication with rapid development after heart transplantation. Until now, non-invasive and invasive methods have proved to be insensitive in the prediction and detection of the early stages of this disease. Conventional arteriography is considered as the only reliable means of diagnosis, but it remains insensitive in the accurate evaluation of the severity of graft coronary lesions (obliterative, diffuse and distal lesions). Precise quantitation of coronary lumen changes may be a sensitive method for the accurate evaluation of graft coronary disease and help in the understanding of the natural course of development of this disease. The pathogenesis of the disease is still unclear. It is possible that graft coronary disease is a consequence of non-treated low-grade cellular rejections. In most cases, retransplantation must be considered as the unique solution.

Coronary artery disease (CAD) is a well-known complication of mediastinal irradiation. We report a case of subocclusive ostial stenosis of the left main coronary artery, in a 27 years old man, who had been irradiated 14 years before for a stage 4 Hodgkin's disease. Among the 68 reported cases of CAD attributed to radiotherapy, 11 involved an ostial stenosis of either right coronary artery, or left main coronary artery or both. Thus mediastinal irradiation seems to be a definite cause of ostial coronary artery stenosis; several types of myocardial revascularization have been suggested for this kind of CAD.

Compared with continuous-wave lasers, excimer lasers exhibit several in vitro advantages: nonthermal ablation process and linear relation between the number of pulses and the depth of the crater. A 308 nm, 20 nsec pulse duration, 1 to 5 repetition rate laser was specifically designed for clinical application. At the time of cardiopulmonary bypass in 10 symptomatic patients, before bypass grafting, a 1 mm diameter core specifically ultraviolet-tipped fiberoptic scope was introduced via the coronary arteriotomy and placed upstream (seven patients) and downstream (three patients) in contact with the stenosis. Laser power was increasingly delivered up to the clearing of the stenosis or occlusion. Quality of angioplasty was controlled by calibration of the neolumen, cardioplegic solution output through the laser-treated segment, and an eighth day or sixth month coronary arteriogram. In the first three patients studied on the eighth day, all laser-treated coronary artery segments showed an early parallel-linked patent neolumen despite competitive bypass graft flow. In the patients studied after 6 months, all recanalized segments were patent except one; in one patient the venous graft was occluded, but the upstream laser angioplasty was patent. The main limitation of the method lies in the fact that laser coronary recanalization is confined to the fiber core diameter. We conclude that (1) excimer laser angioplasty may be safe and efficient during surgical procedure and (2) as catheter flexibility remains the most critical problem, we are now assuming an appropriate tool with a multifiber system that is suitable for intraoperative as well as percutaneous routes.

Patients with coronary disease associated with carotid artery stenosis and/or abdominal aortic aneurysm often raise problems of operative strategy; in particular, the order in which these lesions must be treated is a frequent source of controversy. We report the results of sequential or simultaneous combined surgery for multiple arterial lesions. Between 1979 and 1988, 65 patients with such lesions underwent either cerebral revascularization simultaneously with coronary bypass (n = 48) or repair of infrarenal aortic aneurysm a few weeks after myocardial revascularization (n = 17). After simultaneous surgery on the carotid and coronary arteries, the postoperative mortality rate was 4.2 per cent (2 patients). Myocardial infarction occurred in 3 cases (6.2 per cent). No neurological disorder consecutive to carotid endarterectomy was observed. Late postoperative mortality involved 5 patients; in 2 of these the cause of death was non-cardiovascular. No other late complication due to coronary or carotid artery disease was noted. The 5-year survival rate, operative mortality included, was 74.8 +/- 8.6 per cent. After coronary bypass followed by abdominal aortic aneurysm repair, there was no operative death, and no perioperative complication due to coronary disease was observed. Late mortality involved 2 patients. One patient underwent bilateral femoro-popliteal bypass 4 years after repair of an aortic aneurysm. Percutaneous angioplasty for proximal stenosis of a venous coronary graft implanted 8 years previously was performed in one patient with primary success. All other patients are now asymptomatic as regards both coronary and peripheral arteries. The 7-year survival rate is 85.7 +/- 9.4 per cent. The absence of neurological disorders after simultaneous myocardial and cerebral revascularization, and the absence of cardiac complications after aortic aneurysm repair preceded by coronary bypass enable us to recommend systematic combined or sequential vascular surgery. The long-term survival rate obtained in this series supports this recommendation.

Normalisation of abnormal segmental wall motion is rarely observed after myocardial revascularisation by aorto-coronary bypass when the territory revascularised is the site of post-transmural infarction dyskinesia. In particular, normalisation of segmental wall motion is extremely rare when dynamic tests designed to detect potential for improvement (trinitrin test and post-extrasystolic potentiation) are negative. We present the case of a 41 year old man who had anterior and septal wall dyskinesia 2.5 months after antero-septal infarction which was not improved by trinitrin. Dilatation of the left anterior descending artery by percutaneous coronary angioplasty was undertaken because of recurrent effort angina. Control angiography at 6 months showed almost complete normalisation of left ventricular contraction. This myocardial recovery is paradoxical because the trinitrin test did not show potential for improvement. The case illustrates the possibility of normalisation of segmental abnormalities of left ventricular contraction after revascularisation of the dyskinetic zone by percutaneous coronary angioplasty.

The surgical indications of coronary endarterectomy were defined from a study of 50 cases in which endarterectomy was associated with aorto-coronary bypass surgery. This total represented 6 p. 100 of all the aorto-coronary bypass operations performed in the same period. Coronary endarterectomy was performed "on principal" for the right coronary artery, and "of necessity" for the left anterior descending artery. The special techniques of endarterectomy on the left anterior descending artery are described. Endarterectomy does not increase the operative risk and enables revascularisation of vessels unsuitable for bypass surgery. 85 p. 100 patients are asymptomatic with an average follow up period of 2 years after endarterectomy and aorto-coronary bypass graft of the right coronary artery.

Coronary revascularisation by bilateral internal mammary artery grafting was performed in 39 patients. The left internal mammary was anastomosed to the left anterior descending (N = 22), the left lateral (N = 12) or diagonal artery (N = 5). The right internal mammary was implanted on the right coronary (N = 17), the left anterior descending (N = 16), the left lateral (N = 3) or diagonal artery (N = 3). In two cases, the inferior myocardial segments were revascularised by grafting the gastroepiploic artery. Three patients died and one patient had signs of postoperative myocardial infarction. Respiratory complications, usually mild, occurred in 5 patients. Bilateral internal mammary artery grafting should be reserved for: 1) young patients, 2) those without usable leg veins (varicose veins, previous stripping or coronary bypass surgery). The gastroepiploic artery is a useful arterial graft for revascularizing regions of the heart inaccessible to the internal mammary arteries.

The favourable clinical results of cardiac transplantation merit wider application of this therapeutic measure in the management of non-obstructive primary cardiomyopathies and diffuse myocardial fibrosis secondary to coronary artery disease and in its terminal phase, in the absence of any absolute contraindication (pulmonary resistance too high, diabetes, gastrointestinal disorder, infection, patient too old.). Close cooperation between departments of cardiology and surgical transplantation centres, with systematic study of the patients pre-operatively and the setting up of a waiting list of recipients, will make possible in the future the improvement of the already encouraging results of cardiac transplantation.

Coronary bypass on the circumflex artery network was performed by left thoracotomy in 5 patients. All presented with pericardial adhesions due to coronary artery surgery (n = 4) or to mediastinal irradiation (n = 1). The left thoracotomy route provides excellent exposure of the lateral aspect of the heart and may be an advantageous alternative to sternotomy when pericardial adhesions are present.

Forty-five patients presenting with unstable angina having 70 p. 100 stenosis of the left anterior descending artery judged acceptable for coronary bypass surgery were randomly allocated, using a table of random numbers, for medical (21 patients) or surgical treatment (24 patients). There were no significant differences between the two groups with regards to age (53 +/- 10 years for the medical group; 55 +/- 9 years for the surgical group), the length of follow-up (55 +/- 26 vs 61 +/- 28 months), left ventricular end diastolic volumes (87 +/- 27 vs 84 +/- 18 ml/m2) or ejection fraction (62 +/- 8 vs 59 +/- 11 p. 100). There were no deaths in the medical group; two patients developed uncomplicated myocardial infarction 19 days and 7 months after coronary angiography, respectively. 5 patients had recurrent angina and were referred for surgery. This operation of second intention did not pose any special problems. 6 of the 14 patients with stenosis of the LAD before the origin of the first septal artery had complications (infarction in 1 case, recurrent angina in 5 cases). In the surgical group, 1 patient died in the immediate postoperative period, of resistant cardiac arrhythmia; 2 patients developed uncomplicated peroperative myocardial infarction; 21 patients had no complications at all. The surgical patients were heparinised in the immediate postoperative period and anticoagulant therapy was continued with oral vitamin K antagonists for 6 months to 1 year, followed in some cases, by platelet antiaggregant therapy. 20 patients in this group underwent maximal exercise stress testing which was negative in 19 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Out of 3,678 patients who underwent aorto-coronary bypass between May, 1979 and October, 1987 at the La Pitié Hospital, Paris, 48 had simultaneous myocardial and cerebral revascularization. Operative mortality rate was 4.2 p. 100. Peri-operative myocardial infarction occurred in 3 cases (6.2 p. 100). No neurological complication was observed. The survival rate at 5 years (operative mortality included) was 74.8 +/- 8.66 p. 100. These results obtained in patients with multiple arterial disease are in agreement with those found in the literature. The lack of neurological complications is in favour of a systematic combined surgical treatment of severe carotid and coronary lesions.

A new method of myocardial protection, profound selective myocardial hypothermia has been employed in order to avoid the effects of cardiac ischaemia during aortic cross clamping in the course of operations undertaken under extracorporeal circulation. It consists of the irrigation of the aortic root immediately after cross clamping with 4 liters of Ringer Lactate at 4 degrees C which perfuses the entire coronary bed and induces complete uniform profound coling of the intrapericardial mass to a temperature of approximately 10 degrees C with resultant flat electrocardiogram and cessation of all electrical activity of the myocardium. This inactivity remains complete until the aorta is unclamped permitting reoxygenation and rewarming of the heart with resumption of its function. This method has been used in the course of 250 cardiac procedures involving the use of extracorporal circulation including 177 valve replacements, either aortic or mitral and aortic, 54 saphenous vein bypass procedures, either simple or with valve replacement and 19 other assorted procedures including cardiac transplantation and complex congenital malformations. Thermal, electrocardiographic, hemodynamic, histologic, histochemical and enzymatic observations have proven the minimal significance of the ischemic lesions produced in hearts protected in this manner. The total mortality was 6.4% which proves the value of this method and its superiority over the 2 techniques most often used at the present time, coronary perfusion or topical myocardial hypothermia according to Shumway's method.

From experimental and clinical experience, safe coronary angioplasty cannot be performed with CW lasers. The excimer laser does present a number of advantages in vitro: non-thermal ablation of plaques and a linear relationship between the number of pulses and the depth of the crater, so that tissue ablation is quantitatively predictable. A 308 nm, 20 ns pulse duration, 1 to 5 repetition rate laser was specifically designed for clinical application. During cardiopulmonary bypass prior to bypass grafting in 10 symptomatic patients, a 1 mm diameter core UV-tipped fiberoptic was introduced via the coronary arteriotomy and directed in contact with the coronary stenosis. Laser power was progressively increased until the stenosis or occlusion was recanalized. The quality of this angioplasty was controlled by calibration of he neo-lumen, cardioplegia solution flow through the lased segment, and 8th day coronary angiography. The laser treated coronary segments of the first 4 patients showed clearly parallel-lined patent neo-lumen despite competitive bypass graft flow. The main limitation of the method is that laser coronary recanalization is confined to the fiber core diameter. The authors conclude that: 1) excimer laser angioplasty is a safe and efficient intra-operative procedure; 2) the most critical problem for percutaneous laser angioplasty remains flexibility of the apparatus as the fiber diameter must be large enough to provide an adequate arterial neo-lumen.

The aim of this study was to evaluate the thermal diffusion of a pulsed laser beam in atheroma and to obtain in vitro vaporisation of the plaque without causing arterial wall lesions. A computerised mathematical model integrated 4 parameters: reflectivity, thermal conduction, the absorption factor and coefficient of diffusion. The thermal diffusion was shown to be dependent on the time constant and the temperature of vaporisation may be best attained with a short burst (200 ns) with a high peak power (6000 w). The experimentation was performed on fresh debris and segments of epicardial coronary arteries which were exposed to a pulsed laser beam with a frequency of 1000 Hz in bursts of 200 ns at wave lengths of 1060 and 532 nm. The results were evaluated by microscopic examination of transverse sections perpendicular to the lumen of the artery. Effective vaporisation of atheroma was observed with weak mean dissipating powers (0.4 w) about 10 times weaker than with continuous node emission; examination of the underlying arterial wall showed no thermal or mechanical damage.

Over a period of 36 months, 357 patients have had one or several aorto-coronary bypass graft operations, either alone (305 patients) or in combination with another surgical procedure. 230 (66.4%) of these patients had acute coronary insufficiency: unstable angina or "menance syndrome" in 177, Printzmetal's angina in 34, threatened extension of an infarction in 14, and post-cannulation stenosis in 5. 75 patients had chronic coronary insufficiency, and in the 52 others the coronary lesions were associated with valvular or myocardial lesions. A total of 489 grafts were carried out, 261 of which (53.4%) were on the anterior descending artery. Of the 305 patients with grafting and no other surgical procedure, 190 (62,3%) had one single graft, 104 (34.1%) had 2 grafts, and 11 (3.6%) had 3 grafts. For theses 305 patients, the mortality during the first month (6.9%, or 4.5% for the last six months of the series) was influenced by age (a mean of 52.1 in the survivors and 57.1 in the deceased, p less than 0.001), a preoperative infarction less than 8 days old (p less than 0.001), significant changes in left ventricular function (a mean ejection fraction of 44.9% +/- 0.20 in the deceased, and 61.5% +/- 0.19 in the survivors, p less than 0.001), a mean end-diastolic volume of 252 ml +/- 98 in the former and of 136 ml +/- 51 in the latter, p less than 0.001). The advent of a postoperative infarct thus increases the mortality. An infarct complicated the progress of 11.1% of patients. The probability of such a complication occuring depends upon the state of the vascular bed distal to the bypassed artery and on the duration of the extracorporeal circulation.

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.

Performed for the first time in the world, in December 1967, by Barnard in Capetown, and for the first time in Europe by our team in April 1968, cardiac transplantation has now 20 years of clinical applications. A best selection of the recipients, a more precise selection of donors, refinements in surgical technique, a better and earlier diagnosis of post-operative complications, more effective therapeutic means especially cyclosporin, have brought us, from 1981, such major improvements that many teams were prompted to resume the procedure. In our experience of more than 400 transplants at La Pitié Hospital, a five-year follow-up shows that 70 p. cent of the patients are alive, having resumed a normal familial, social, professional and often sporting life. Much progress remains to be achieved, but this procedure now seems to be quite common if not routine, only limited by the insufficient number of donors.