Search

We investigated the pulmonary vascular effects of prophylactic use of sildenafil, a specific phosphodiesterase-5 inhibitor, in late-gestation fetal lambs with chronic pulmonary hypertension. Fetal lambs were operated on at 129 ± 1 days gestation (term = 147 days). Ductus arteriosus (DA) was compressed for 8 days to cause chronic pulmonary hypertension. Fetuses were treated with sildenafil (24 mg/day) or saline. Pulmonary vascular responses to increase in shear stress and in fetal PaO2were studied at, respectively, day 4 and 6. Percent wall thickness of small pulmonary arteries (%WT) and the right ventricle-to-left ventricle plus septum ratio (RVH) were measured after completion of the study. In the control group, DA compression increased PA pressure (48 ± 5 to 72 ± 8 mmHg, P < 0.01) and pulmonary vascular resistance (PVR) (0.62 ± 0.08 to 1.15 ± 0.11 mmHg·ml−1·min−1, P < 0.05). Similar increase in PAP was observed in the sildenafil group, but PVR did not change significantly (0.54 ± 0.06 to 0.64 ± 0.09 mmHg·ml−1·min−1). Acute DA compression, after brief decompression, elevated PVR 25% in controls and decreased PVR 35% in the sildenafil group. Increased fetal PaO2did not change PVR in controls but decreased PVR 60% in the sildenafil group. %WT and RVH were not different between groups. Prophylactic sildenafil treatment prevents the rise in pulmonary vascular tone and altered vasoreactivity caused by DA compression in fetal lambs. These results support the hypothesis that elevated PDE5 activity is involved in the consequences of chronic pulmonary hypertension in the perinatal lung.

the aim of this study was to document the choice between prosthesis and bioprosthesis in cases of valvular replacement during the seventh decade of life.a retrospective and cooperative study linking eleven cardiac surgical teams and five medical cardiology teams combined 497 subjects born between 1915 and 1925 (average age 64.4 years) who underwent aortic (313 cases) or mitral (184 cases) valvular replacement with mechanical prosthesis (259 cases) or bioprosthesis (238 cases). Information was collected at each centre during the year 2000 on the long term evolution (going back 15 years), in particular on the mortality, non-fatal complications linked to the valve, cardiac complications and extra-cardiac events. These results were subjected to statistical analysis.the operative mortality of this group was 4.8%. The 15 year survival was 46% for the aortic mechanical prostheses, 32% for the aortic bioprostheses (p=0.04). 34% for the mitral bioprostheses and 33% for the mitral mechanical prostheses. Events linked to the valve were more frequent for the mitral valvulopathies than for the aortic valves (49% vs 26%, p0.001). The absence of events linked to the valve at 15 years was 69% for the aortic mechanical prostheses and 68% for the aortic bioprostheses. This was the case in only 57% of mitral mechanical prostheses and 36% of the mitral bioprostheses (p=0.11). Thromboembolic accidents were three times more frequent in the mitrals than in the aortics (11.5 vs 3.8%, p=0.002). Haemorrhage was four times more frequent for the mechanical prostheses than for the bioprostheses (7.7 vs 2%, p=0.01). The risk of degeneration for the aortic bioprostheses was 20% at 15 years, three times less so after 65 years of age (p=0.03). At 48% it was much higher in the mitral valves at 15 years with no significant difference before and after 65 years of age (p=0.3).the current life expectancy of subjects in their seventh decade is important. The greatly elevated risk of bioprosthesis degeneration in the mitral position does not allow this alternative to be advocated before 70 years of age. In the aortic position, this risk is elevated before 65 years of age. It is lower after 65 years old. Nevertheless, this means the risk of reoperation in certain octogenarians must be accepted, balanced with the linear risk of haemorrhagic accidents for which a future reduction is expected thanks to milder anticoagulation for aortic mechanical prostheses and anticoagulation autocontrol.

Cardiac papillary fibroelastoma (CPF) is a rare and histologically benign tumor, but may have a malignant propensity for life-threatening complications; thus, surgical removal is justified. Case histories were reviewed of four patients who underwent surgical management after diagnosis of CPF located on aortic (n = 2) or mitral (n = 2) valves. Our aim was to provide explanations for the clinical diversity of the lesions and, using histological and immunohistochemical methods, to hypothesize the genesis of these tumors.Among four patients with a diagnosis of valvular CPF, two had previous and recent history of neurological embolic symptoms with small echographically located tumors attached to the ventricular side of aortic cusps. Two other patients (one with paroxysmal atrial fibrillation, one with no neurological or rhythmically related stroke) had CPFs located on the posterior or anterior mitral leaflets.Surgical excision was performed with a conservative valve-sparing approach. Histological and specific immunohistochemical (IHC) studies were conducted on all samples. The postoperative course was uneventful, and histological analysis confirmed the diagnosis of CPF with typical fronds characterized by three successive layers. In the first two patients there was correlation between neurological events and the presence of thrombus aggregated on the injured superficial endothelial layer. In the other patients, no endothelial damage or thrombus was found. IHC studies showed dysfunction of the superficial endothelium, a centrifugal mesenchymal cellular migration arising from the central layer to the superficial layer with differentiation steps, the presence of dendritic cells in the intermediate layer, and remnants of cytomegalovirus (CMV) in the intermediate layer.Despite their benign histological aspect, and independent of their size, CPFs justify surgical excision because of their high potential to systemic embolization. In most cases, valve sparing management is possible with no observed recurrence after complete excision. The presence of dendritic cells and CMV strongly suggests the possibility of a virus-induced tumor, therefore evoking the concept of a chronic form of viral endocarditis.

We report the case of a 22-year-old woman in whom a focal aplasia of the pulmonary valve annulus associated with a multiple aneurysmal compensatory dysplasia was found. This patient had been followed since the age of seven years for a congenital asymmetric hypertrophic cardiomyopathy. Cardiac Doppler analysis showed significant pulmonary valvular insufficiency. The patient underwent heart transplant surgery because of total and refractory cardiac insufficiency. Pathological examination of the explanted heart (at the European Homograft Bank) enabled us to describe this valvular malformation. To date, this anomaly has not been described in the literature. Whether it is a malformation discovered fortuitously, or whether it is responsible in part for some of the signs associated with congenital hypertrophic cardiomyopathy is unclear. However, its role might be disclosed by a rigorous investigation of the patient's family.

Valve ring abscesses in acute infective aortic endocarditis have a low, though not insignificant, prevalence. Surgical treatment with implantation of prosthetic valves may lead to major life-threatening complications, such as recurrent endocarditis and partial or complete prosthetic dislocation. Valvular homografts may offer a higher resistance to recurrent infection and have thus become recognized as an excellent and safe substitute for orthotopic left ventricular outflow reconstruction.Between May 1991 and July 1996, 25 patients underwent surgical treatment for aortic endocarditis with annular destruction. Staphylococcus spp. were present in 32% of patients and Streptococcus spp. in 48%. Seven aortic valve replacements (AVR) and 18 aortic root replacements (ARR) were performed using cryopreserved valvular homografts. All grafts were implanted in the subannular position.The overall outcome was good in 23 patients, two died in the early postoperative period. Mean follow up was 38 +/- 18 months (range: 14 to 76 months). No recurrence of endocarditis was detected and no significant alterations of the implants were described. Transvalvular gradients were significantly lower in ARR patients than in AVR patients.Despite the severity of the tissue damage, cryopreserved homografts, when implanted in the subannular position, constitute a safe and reproducible surgical treatment of aortic endocarditis with annular involvement.

There is no consensus in regard to vascular explorations and therapeutical management of Takayasu's arteritis. The objective of this study was therefore to establish the most appropriate vascular explorations and to analyze current treatments.Clinical, biological and morphological findings related to either diagnosis or treatment were retrospectively evaluated in sixteen patients diagnosed with Takayasu's arteritis according to the American College of Rheumatology criteria.Median delay between the occurrence of the first symptoms and the diagnosis was 9 months. Aortic lesions and aortic valvular incompetence were more frequent. Statistical analysis showed the existence of a correlation between the lack of relapse and corticosteroid therapy (Fisher exact test, P = 0.021). Percutaneous transluminal angioplasty led to stabilization of vascular lesions. Surgical management led to satisfactory results, except for patients with aortic lesions, as survival was then less than 1 year.Early diagnosis is mandatory in patients with Takayasu's arteritis in order to propose appropriate therapy, particularly corticosteroid therapy. Surgery and angioplasty prove to be useful in occlusive forms. Late diagnosis is accompanied by severe aortic lesions and fatal outcome.

The long-term outcome (64.3 +/- 45 months) of 44 patients operated for acute dissection of at least the ascending aorta was assessed by regular clinical examination and annual CT scan. The diameter of the aorta at different levels was measured at each CT scan for all patients. Initially, 7 patients (16%) had acute dissection limited to the ascending aorta; none had a false lumen after surgery. No signs of aneurysmal dilatation were observed during follow-up of these patients. In the 37 other cases (84%) dissection of the aorta extended beyond the innominate artery; the false lumen remained patent distal to the prosthetic tube replacing the ascending aorta in 34 patients (92%). The false lumen was partially thrombosed in 8% of patients, leading to distal emboli in 1 patient. Moderate increases (less than 15 mm) in diameter of the false lumen were observed in 32% of patients; more severe dilatation (over 20 mm) was observed in 12% of patients. The management of dilatation of the false lumen is not standard; it depends mainly on the rate of progression and the clinical consequences. It is hoped that extension of the initial repair to the aortic arch, when the intimal tear is situated in this zone, will reduce the short and long-term progression of the false lumen.

A multicenter study was designed to evaluate the Pericarbon pericardial bioprosthesis for up 10 years after implantation in the aortic position.Between January 1986 and November 1996, 321 patients (mean age 75.8 +/- 7.3 years) received 325 Pericarbon pericardial valves in the aortic position. Four patients underwent redo surgery and each received a second Pericarbon prosthesis. Associated cardiac procedures in 80 patients were mainly coronary bypass (n = 66). Follow up extended up to 10 years (cumulative follow up of 931.0 patient-years; mean follow up 3.1 +/- 2.2 years).There were 19 late deaths, with seven valve-related. Twelve patients suffered an embolic complication (transient cerebral attack in four, peripheral in six and induction of a myocardial infarction in two). Of these complications, five occurred within 30 days of surgery and seven beyond the first year. Ten patients were reoperated on, six for primary tissue failure, two for prosthetic endocarditis and two for paraprosthetic leak. Primary failure was due in all cases to leaflet mineralization. No primary tear of the leaflet was reported. Actuarial freedom after 10 years from primary tissue failure was 83.9 +/- 7.4% and from major embolic events 97.6 +/- 1.0%. Freedom from valve-related mortality at 10 years was 92.1 +/- 4.9%.These results indicate that, over a period of up to 10 years, the Pericarbon pericardial bioprosthesis compares favorably with other replacement valves.

Systematic transthoracic echocardiography in all cases of pulmonary embolism may demonstrate right heart thrombi. The results of this monocentric series of 28 consecutive cases observed between 1987 and 1996 were analysed. Twenty-four patients were in NYHA Class IV: thirteen were in cardiogenic shock. Echocardiographic signs of acute cor pulmonale were usually observed: 96.3% of patients had right ventricular dilatation, 85.2% paradoxical interventricular septal motion, 88.9% pulmonary hypertension. The thrombus was typical serpentine (27/28 cases) arising from the lower limb veins. Passage into the left heart chambers through a patent foramen ovale was observed in 3 cases. Pulmonary embolism was confirmed in all cases. This is an extreme therapeutic emergency and 13 patients (46.4%) died despite treatment: surgery (7/16), thrombolysis (2/5), heparin (3/4) or interventional radiology (1/3). After the acute phase, the prognosis was generally good, as demonstrated by the 100% survival rate at 28.6 +/- 25 months. This study confirms the gravity of mobile right heart thrombi in pulmonary embolism. The diagnosis is echocardiographic. No significant difference in mortality was observed between the different therapeutic approaches used in this series. The echocardiographic finding of these thrombi is a traditional indication for emergency surgical embolectomy. Thrombolysis is rapid and readily available and seems to provide promising results alone or before surgery. In patients with contraindications to thrombolysis, interventional radiology or simple heparin therapy may be proposed.

We describe a case of Takayasu's arteritis discovered at the early systemic phase. Ultrasonography and computed tomography show thickening of the walls of the superior mesentery and common carotid arteries despite normal findings on angiography. Diagnosis was confirmed by arterial biopsy. We emphasize the importance of noninvasive vascular investigation to support the diagnosis of Takayasu's arteritis.

We report the case of a patient with five primary pneumococcal multilocular mycotic aneurysms located in the left femoral artery, the descending thoracic aorta and the right internal iliac artery. A successful treatment combining three different procedures was performed, including the use of two cryopreserved thoracic homografts. At a 54-month follow-up, the patient is alive and leads a normal life. Regular evaluation including computed tomographic scans of the thorax and abdomen showed no recurrence of infectious aneurysmal process. Moreover, this latter examination confirmed no dilatation nor significant calcifications of the thoracic arterial allograft, though chest roentgenogram showed discrete calcifications along the borders at the 50th month.

The authors analysed survival of 160 patients (121 men and 31 women; average age 57.2 +/- 12.5 years; follow-up 29 +/- 20 months) treated for malignant ventricular arrhythmias (sustained ventricular tachycardia, ventricular fibrillation, syncope with inducible ventricular tachycardia). The therapeutic evaluation was frequently invasive (145 patients underwent at least programmed ventricular stimulation, 108 patients underwent full endocavitary electrophysiological studies) and non-pharmacological therapy was widely used (defibrillator n = 44; antiarrhythmic surgery n = 28; ablative procedures n = 19; transplantation n = 7). The following underlying pathologies were observed: ischaemic heart disease n = 120; non-ischaemic left heart disease n = 19; right heart cardiac disease n = 4; and apparently normal hearts n = 17). The average ejection fraction was 40.5 +/- 15.5% and 29 patients were in the NYHA functional classes III or IV. Fifty-five patients had life-threatening arrhythmias whilst receiving amiodarone. At 2 years, the actuarial sudden death rate was 5.9 +/- 2.1% and the actuarial total cardiac mortality rate was 13.1 +/- 2.9%. Univariate analysis showed age, the presence of underlying cardiac disease, the presence of dilated cardiomyopathy, the absence of an invasive approach, the need for basal pacing in electrical cardioversion, the absence of betablocker therapy, a decreased left ventricular ejection fraction and a high NYHA functional class, to be predictive of sudden death. In multivariate analysis, age, the NYHA class for total cardiac mortality and the NYHA class for sudden death, were the only independent predictive factors. The authors conclude that in the era of invasive methods of evaluation and widespread use of non-pharmacological therapeutic methods, the symptomatology of cardiac failure assessed by the NYHA classification remains the most powerful independent prognostic factor after an episode of malignant ventricular arrhythmia.

This study, which included 153 heart transplant patients, was designed to determine whether the cytomegalovirus (CMV) status of both donor and recipient may influence graft rejection. The follow-up was 1 year and they all received the same triple-drug immunosuppressive regimen with induction (antilymphocyte serum). There was no difference in the total rejection rate, but an increase in repeated rejection rate was shown in transplant recipients with hearts from CMV seropositive donors (P0.05). These data strongly suggest the impact of CMV in enhancement but not in induction of rejection. To prevent iterative rejection in the CMV seropositive donor group, antiviral therapy could be proposed during enhancement of antirejection therapy.

This study, which included 153 heart transplant patients, was designed to determine whether the cytomegalovirus (CMV) status of both donor and recipient may influence graft rejection. The follow-up was 1 year and they all received the same triple-drug immunosuppressive regimen with induction (antilymphocyte serum). There was no difference in the total rejection rate, but an increase in repeated rejection rate was shown in transplant recipients with hearts from CMV seropositive donors (P < 0.05). These data strongly suggest the impact of CMV in enhancement but not in induction of rejection. To prevent iterative rejection in the CMV seropositive donor group, antiviral therapy could be proposed during enhancement of antirejection therapy.

From December 1986 to December 1994, 36 patients underwent surgical treatments for intractable ventricular tachyarrhythmias after myocardial infarction. Preoperative electrophysiological studies confirmed inducibility of sustained monomorphic ventricular tachycardia and its resistance to antiarrhythmic drugs in all patients, 2 different concepts were assessed: 1) 22 non-guided surgical procedures were performed. 17 patients underwent Encircling thermic exclusion by Nd-Yag laser beam (Group A) and 5 patients underwent extended cryoablations (n = 5) with endocardial resections. Mean preoperative value of left ventricular function in Groups A and B were 35.23% and 30.20% respectively. 10 coronary bypasses (Group A: n = 8; Group B: n = 2) and 1 mitral valve replacement (Group A) were also performed. Perioperative mortality was 5.5% in Group A. No perioperative deaths occurred in Group B. Ventricular tachycardias recurred spontaneously in 2 patients (Group A) and 7 remained inducible after evaluation by electrophysiological studies. 2) 14 patients underwent extended cryoablations guided by intraoperative cardiac mapping, including endocardial resections in all cases. Mean preoperative value of left ventricular function was 32.80%. Mitral valve replacements were achieved in 2 cases, 1 perioperative death occurred (7.14%). Clinical recurrence of ventricular tachycardias concerned 1 patient (7.69%) and 2 remained inducible after electrophysiological studies (15.38%). We conclude that the better results obtained with cardiac mapping and cryoablations may be due to available detection and destruction of deep septal arrhythmogenic substrates. Moreover, cryoablation creates a nonarrhythmogenic scar and can be performed in papillary muscles while preserving the structure of the tissue. No postoperative alteration of left ventricular function was therefore observed.

The automatic implantable defibrillator (AID) and antiarrhythmic surgery are the two therapeutic options after failure of catheter ablation and/or antiarrhythmic therapy for sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) in patients with coronary artery disease. The authors undertook retrospective study of the characteristics of two groups of patients treated between November 31st 1987 et December 31st 1993 either by AID (28 men and 4 women with an average age of: 56.1 +/- 11.2 years) or by surgery (19 men and 2 women with an average age of: 60.6 +/- 6.8 years). The "surgical" patients differed from "defibrillator" patients in the fewer number of cardiac arrests, a higher proportion of sustained monomorphic VT, better tolerated sustained monomorphic VT (rarely syncopal), fewer early post-infarction arrythmias (or = 8 weeks), more anterior wall infarction and a higher proportion of aneuvrysms. The perioperative mortality was 6.2% in the "defibrillator" group and nil in the "surgical" group (p = NS). At 2 years, the sudden death rate in the "defibrillator" and "surgical" groups was 7.5% and 0% respectively and total cardiac mortality was 17% and 20% respectively (p = NS). The authors conclude that perioperative mortality and the sudden death rate at 2 years are relatively low in the two groups. However, the total cardiac mortality remains high, largely related to perioperative death and secondary cardiac failure. Nevertheless, compared with defibrillator patients and with identical average ejection fractions, there was no extra mortality due to cardiac failure after antiarrhythmic surgery.

The aim of this study was to analyse the efficacy and survival after implantation of an automatic cardioverter-defibrillator.. Forty-five patients including 37 men were followed up for 0 to 51 months. The indications were ventricular fibrillation with no curable cause (n = 27) and sustained resistant or poorly tolerated ventricular tachycardia (n = 17) when programmed ventricular pacing with antiarrhythmic therapy was not applicable or gave poor results. One patient was implanted with this device for torsades de pointes. The underlying cardiac disease was ischaemic in 34 cases, non-ischaemic in 8 cases, and 3 patients had no apparent cardiac disease. Twenty patients were implanted with an epicardial system (group I) and 25 patients with endocardial system (group II). In group II, there was one complete failure of implantation requiring the use of an epicardial system and 2 partial failures requiring an additional epicardial patch electrode. The perioperative mortality was 2/45 (4.4%), both cases being due to permanent arrhythmias. In 5 patients, the minimal effective energy of defibrillation was over 25 Joules at implantation, without any untoward consequences on the clinical outcome. Ten non-fatal complications were observed including two major problems (haemopericardium); there were two cases of late increase of the minimal effective energy of defibrillation requiring the addition of a subcutaneous patch. Twenty-four patient (53%) received at least one appropriate therapy; 14 patients (36%) had at least one inappropriate shock during follow-up. During follow-up, 7 patients died, 6 of a cardiac cause and 3 of an arrhythmic problem.(ABSTRACT TRUNCATED AT 250 WORDS)

We evaluated the value of dynamic transcutaneous oxygen pressure measurement (TcPO2) in 17 patients with stage II occlusive arterial disease of the lower limbs treated with exercise only. We studied 17 patients (15 men, two women) with an average age of 63 years (range 39-80 years). Claudication perimeter and dynamic TcPO2 were evaluated before and after 6 month walking exercise and tabac stopping. Four different sites of TcPO2 were studied: precordium (reference probe), thigh, calf and foot in the dorsal recumbent position after 30 minutes rest, during a standardised exercise stress test at 50 watts and during the recovery phase. The results were expressed as ratio of tissue oxygenation (RTO): thigh, calf or foot TcPO2/precordial TcPO2 x 100 in order to take into account the patients cardiorespiratory status and adaptation to exercise. Claudication perimeter was 255 m +/- 221 before 6 months exercise and 835 m +/- 539 after (P0.01). The duration of significative ischemia was significantly reduced after 6 months exercise (P = 0.02 calf, P0.01 foot). Dynamic transcutaneous oxymetry would therefore seem to be a useful method of assessing stage II occlusive peripheral arterial disease and the topography of tissue hypoxia. It could be valuable in orientating treatment and the first method to provide and objective evaluation of the efficacy of medical or surgical treatment.

Refractory ventricular tachycardia, resistant to antiarrhythmic drug therapy either because of inefficacy unwanted secondary effects or failure to comply with treatment, is not rare in the chronic phase of myocardial infarction. These considerations reinforce the value of curative therapeutic options, especially those related to antiarrhythmic surgery in these patients. Surgery is usually reserved for those with a ventricular aneurysm where the exclusion of arrhythmogenic zones may be performed with the scalpel, a cryoprobe, laser ... Procedures guided by peroperative endo end epicardial mapping, if possible simultaneous with computerised assistance, are more effective than procedures relying only on visual guiding. The clinical success rate is about 90% and the operative mortality tends to decrease (5 to 6%) with successive improvements to surgical technique. These satisfactory results show the reliability of this therapeutic approach applied to patients exposed to malignant arrhythmias.

Four cases, three fatal and one with long term recovery, of patients treated surgically for primary aorto duodenal fistulas are reported. The involved lesion was an infrarenal aortic aneurysm. Two patients had an extra-anatomic vascular procedure and two patients an in situ repair. In connection with these cases, two hundred and fifty three primary aorto enteric fistulas were reviewed in the world's literature. The difficulties in the diagnosis and treatment are pointed out. Emergency operation should be performed in all cases of gastrointestinal bleeding associated with an abdominal aneurysm. The best diagnostic approach is CT scan combined to gastro-duodenoscopy. Overall mortality in our review of the literature was seventy one per cent. Closure of the enteric component should be performed with lateral repair. Management of the aortic component remains controversial: closure of the aorta and axillo-bi femoral by pass or in situ repair. The operative mortality in our review of the literature was thirty seven per cent. Interposition of viable tissue is necessary according to the risk of recurrent infection and bleeding with consequent death (twelve per cent). So, long term control is of paramount importance.

In patients with systemic lupus erythematosus (SLE) heart valve lesions are usually discovered at echocardiography; their haemodynamic repercussions are uncommon, and valve replacement is exceptional. We report the case of a woman who had undergone aortic and mitral valve replacement before antiphospholipid antibodies were found associated with 4 ARA criteria of SLE. Histopathological examination confirmed the diagnosis of Libman-Sachs specific endocarditis. The presence of antiphospholipid antibodies leads to a discussion of their role in the physiopathology of the heart valve lesions and vascular accidents that occurred in this patient. The overlap observed between the diagnostic criteria of SLE and those of primary antiphospholipid syndrome is discussed. Heart valve lesions may be one of the modes of access to the antiphospholipid syndrome.

The authors report a case of primary aspergillus endocarditis with endophthalmitis and vertebral osteomyelitis. No underlying disease and no predisposing factors were found. Valve replacement plus combined antifungal chemotherapy proved to be effective as the patient is asymptomatic 18 months after the first symptoms. 48 cases of aspergillus endocarditis, without prior cardiac surgery have been reported in the literature. Aspergillus endocarditis was valvular or mural. Extracardiac dissemination was common but endophthalmitis and osteomyelitis were infrequent. In 11 cases, the diagnosis was made by histologic examination of embolectomy or ocular, skin biopsy tissue. All patients were febrile. Blood cultures showed no Aspergillus species. Clinical manifestations of endocarditis were described in less than fifty per cent of cases. Echocardiographic visualization of vegetations was obtained in 5 cases. Many patients experienced embolic phenomena. Mortality from Aspergillus endocarditis is extremely high (96%). Surgery is the main treatment, consisting of valve replacement. Antifungal chemotherapy should be combined. The proper duration and dosage and the combination of antifungal drugs have not been clearly defined.

Ventricular late potentials are post-infarction markers of the risk of ventricular tachycardia and sudden death. In order to assess their prognostic value and evolution after coronary bypass surgery, 100 patients underwent signal-averaged electrocardiographic recordings 24 hours before and 9 days after surgery, and were then prospectively followed up for 40 +/- 8 months. Patients who displayed late ventricular potentials underwent an additional recording at 5 months with 24 hour Holter monitoring. The average age of the patients was 57.0 +/- 8.4 years; 55 had previous myocardial infarction; 32 had triple vessel disease; the mean left ventricular ejection fraction was 59.7 +/- 12.4%. Ventricular late potentials were recorded in 17 patients before surgery and their left ventricular ejection fraction was significantly lower (51.4 +/- 11.5% vs 61.4 +/- 11.9%: p less than 0.05). There was one operative death in a patient with late ventricular potentials. After surgery, late ventricular potentials were only recorded in 6 patients: at the 9th postoperative day in 3 cases and at the 5th postoperative day in 3 cases. Ventricular late potentials appeared postoperatively in 5 patients, 4 of whom had suffered perioperative myocardial infarction. The recordings became normal at the 5th month in 2 of these 5 patients. Holter monitoring at the 5th month compared with a control group, showed a significant correlation between left ventricular potentials and frequent repetitive or polymorphic ventricular extrasystoles. The 40 month survival rate was excellent: 2 patients were lost to follow-up; there were 3 cardiac deaths, one of which was sudden and 4 non-cardiac deaths. All patients with late ventricular potentials were still alive. These results show that late ventricular potentials persist after coronary bypass surgery in 2/3 of patients; their prognostic significance is not obvious. The low incidence of postoperative sudden death could be attributed to the favourable overall effects of revascularisation rather than on the arrhythmogenic substrate.

The clinical and prognostic value of transcutaneous oxygen pressure measurements at rest has been established in Leriche Stage III and IV occlusive peripheral arterial disease but is controversial in Stage II because there is an overlap of transcutaneous pO2 (Tc pO2) values with those of normal subjects. The authors report the results of Tc pO2 measurements during exercise testing in a group of patients with Stage II occlusive arterial disease of the lower limbs. Seventy-eight patients with an average age of 53 years (range 40 to 65 years) whose claudication perimeter and site of pain had been carefully assessed and who had also recently undergone Doppler arterial examination and arteriography and 35 control subjects with an average age of 54 years (range 45 to 70 years) were studied. The Tc pO2 was continuously measured with a multimodular Kontron Supermon at 4 different sites simultaneously: precordium (reference probe), thigh, calf and foot in the dorsal recumbent position after 30 minutes rest, during a standardised exercise stress test at 50 watts and during the recovery phase. The results were expressed as ratio of tissue oxygenation (RTO): thigh, calf or foot Tc pO2/precordial Tc pO2 X 100 in order to take into account the patients cardiorespiratory status and adaptation to exercise. The RTO in normal subjects remained at the upper limits of the resting value throughout exercise and then returned slowly to basal values during the recovery phase.(ABSTRACT TRUNCATED AT 250 WORDS)

813 patients underwent aortic (AVR) or mitral valve replacement using the Carpentier-Edwards bioprosthesis from 1976 to 1983. Operative mortality was 5.49% for AVR and 4.59% for MVR. Late mortality and complications were classified using criteria described by the Stanford Group. Actuarial survival at 5 years was 87.9% +/- 2.7% for AVR and 91.1% +/- 1.4% in MVR. Thromboembolism occurred at low rates of 0.48% pt yr for AVR and 0.90% pt yr for MVR. 98.2% +/- 0.90% of AVR and 96.9% +/- 1.3% of MVR pts were free from thromboembolism at 5 years. The low incidence of thromboembolism during the early postoperative period played a role in the low rates observed in the complete study. There was no valve thrombosis. Anticoagulation with warfarin was used in 35% AVR and 75% MVR with rates of bleeding complications of 1.20% pt yr and 1.10% pt yr. Overall valve failure rate was 2.04% pt yr at 5 years for AVR and 1.55% pt yr for MVR. Rates of reoperation for tissue failure remained low (0.24% pt yr for AVR and 0.32% pt yr for MVR). The advantage of a low rate of thromboembolism was not outweighed by the specific problems of bioprosthesis at 5 years.

Coronary artery spasm has been described as occurring frequently in Prinzmetal variant angina. The relatively poorer results obtained after aorto-coronary by pass grafting carried out in patients with Prinzmetal angina may be due to recurrence of spasm despite the grafts. Accordingly it has been our recent policy since February 1973 to carry out cardiac denervation in all patients with Prinzmetal variant angina. The patients fall into two groups depending on the presence or absence of organic disease in the coronary vessel. The technique of cardiac denervation (plexectomy) as described by Arnulf is fully described and the early and late results of this procedure in the two groups are documented and discussed.

The results of surgery for aorto-iliac obliterative arterial disease deteriorate progressively over 10 years to leave only 44% good results, 39% deaths, 3% poor results and 14% amputations. Nevertheless, the quality of the surviving patients is satisfactory with 72% good functional results at 10 years and a permeability rate of 76% of reparative procedures at the same period. It is certain that current improvements having resulted in a decrease in early mortality will affect the long-term results in view of the tendency to horizontalisation of graphs beyond the first six months.

A double aneurism, located in the abdominal aorta and left common iliac was found complicating a salmonella typhimurium infection which had been present for 7 months. A by-pass operation between the inaffected iliac arteries was followed by resection of the two aneurisms. Cultures taken from the walls of the aneurisms showed the presence of salmonella typhimurium. The authors stress the particular seriousness of the spontaneous evolution of such mycotic aneurisms.

The action of the contrast material over the various contractility indices was assessed five minutes after left ventriculography. There was an increase of the contractility index in normal subjects. On the contrary, in coronary patients, the contractility function remained unchanged or was depressed, related to the presence or not, of signs of cardiac failure. Depression of the various indices was noted in subjects with primary cardiomyopathy. After recalling the mechanism of action of the contrast products on the cardiovascular haemodynamic parameters, the following practical conclusions were drawn in relation with a series of 65 cases of coronary heart disease: the late diastolic left ventricular pressure remained lower than 20 mmHg after ventriculography in the subjects with a normal ejection fraction; it incraeased between 20 and 30 mmHg in most of the subjects with an ejection fraction ranging from 0.4 and 0.6, finally it was constantly found above 35 mmHg in the subjects with severely disturbed ventricular contraction with an ejection fraction lower than 0.4. These results underline the interest of this simple test, easy to perform, consisting in measuring the left ventricular late diastolic pressure before and 5 minutes after left ventriculography.

Two patients presenting an unsettled mitral cardiopathy had to receive a valve replacement under cardiopulmonary by-pass in spite of a circulating anticoagulant with antiprothrombinase activity. A higher risk of thromboembolic trouble required an increase of heparin administration, under a strict biological control. Nevertheless both patients died: the first of coronary thrombosis, the second of cataclysmic bleeding, associated to severe and diffused thrombosis. Thus it is essential to insist upon the risk occurred by those patients and the difficulty of adaptation and control of heparin administration.

In a series of 2000 coronary arteriographies, spasm of the coronary artery was found in 52 cases, which were divided into three groups: 41 cases of "iatrogenic" spasm caused by stimulating the ostium of the coronary artery (usually the right) with the tip of the catheter; 8 cases of spasm on top of an organic fixed lesion; 4 cases of coronary spasm on a coronary artery which was reported as "radiologically normal". The study includes a review of the circumstances which favour or impede discovery of coronary spasm, as well as a provocation test using methyl ergometrine. This test seems to be specific in that it only produced coronary spasm in patients with Prinzmetal's syndrome, and excluded the cases of angina with normal coronary arteriography. The patients with spasm on top of a fixed organic lesion underwent a successful aorto-coronary bypass graft together with resection of the pre- and sub-aortic nerve plexus. Patients with a spasm in an artery which was "arteriographically normal" were treated medically by nitrate compounds and vaso-dilators. Three of these patients had an excellent result with medical treatment. Treatment failed in the fourth patient, who then obtained benefit from straight-forward resection of the pre- and sub-aortic nerve plexus with an excellent result which has been maintained for over six months.