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Fifty-three patients (42 men; 11 women) with Streptococcus bovis infective endocarditis attended a tertiary cardiology hospital between 1980 and 1991, and constituted 11% of the total number of infective endocarditis cases hospitalized there during that period. The mean age was 59 +/- 15 years; 15 had previously suffered valvular disease (12) or had a valvular prosthesis (3); one patient had had a previous infective endocarditis. The infective episode involved the aortic valve in 26 patients, both the aortic and mitral valves in 18 patients, the mitral valve only in six and other valves in three. Echocardiographic examination showed one or more vegetations in 44 patients. Cardiac failure was diagnosed in 35 patients and embolic episodes in 22, of whom 11 were cerebrovascular accidents. The patients became afebrile 19 +/- 39 days after starting antibiotic treatment. Valve replacement was performed in 37 patients during their initial hospitalization, and in four during follow-up. After a mean follow-up of 4.6 +/- 3.1 years with a 100% follow-up, 15 patients died: 1 preoperatively, one in the first 30 days after operation, 13 later (8141 operated patients and 5/12 non-operated patients). Actuarial survival was 73% at 5 years. Gastrointestinal signs were present in 12 patients; 43 patients (81%) had a full colonic examination which showed polyps in 20 patients and adenocarcinomas in seven. Of 11 late deaths four were related to a malignant colonic tumour. This study confirms that Streptococcus bovis infective endocarditis is 'relatively benign', but it stresses the frequency and potential severity of the associated colonic lesions, requiring colonoscopy and making the treatment of high risk lesions mandatory.

Coronary balloon angioplasty with stent implantation has emerged as a possible alternative to bypass grafting or repeat transplantation in left main coronary stenosis in heart transplant patients. We report 2 new cases of stent implantation for unprotected and isolated left main stenosis in heart transplant patients. Despite an initially successful procedure, restenosis prompted the performance of bypass surgery in both patients. The relative advantages and disadvantages of available techniques of revascularization are discussed in the context of the literature.

From 1978 to 2000, 692 patients underwent a heart transplantation (HT). 137 survived beyond the 10th year. We evaluated morbidity, mortality and immunosuppressive therapy. Population : 103 men and 34 women : Group (G) I : 10-30 y.o.(n515) G II : 30 250 y.o. (n556) GIII : 50 70 y.o. (n566). For those who had survived already 10 years, actuarial survival was 80% at 15 years following HT and 62.5% at 20 years . Mortality slope of 3%/ year was similar to the 0-to-10 year survival curve. 5 women gave birth to 7 children and 4 men had 5 kids, all healthy. Discussion : probability of surviving 20 years following HT is above 60% in this group of 10 year surviving patients. 50 % of the patients transplanted before being 50 y.o. worked after HT and 45% acknowledged no complication. Conclusion : Immunosuppression in HT patients having survived 10 years after their HT is associated with a high rate of complications relative to the low incidence of clinically relevant chronic rejection. Mortality causes (n527)

Between 1983 and 1991, 104 patients (average age: 52 +/- 13 years) with aortic endocarditis (94 on native and 10 on prosthetic valves), were operated, 81 before the end of antibiotic therapy. Blood cultures were negative in 17 patients, identified a streptococcus in 49 patients, a staphylococcus in 16 patients, and a Gram negative or other organism in 22 patients. The following complications were observed before surgery: severe cardiac failure in 67 patients, renal failure in 24 patients, conduction defects in 13 patients, neurological complications in 13 patients, systemic or coronary embolism in 12 patients. Aortic valve replacement was performed in all patients, associated with mitral valve replacement in 25 patients and tricuspid valve replacement in 1 patient. Twelve patients died after surgery (11/81 of early operations, 1/23 operated later; NS). During a follow up of 3.5 +/- 2.8 years, there were 24 late deaths, 12 of non cardiovascular causes. Of the 20 variables tested, 3 were related to perioperative and late mortality (age, cardiac and renal failure). The 5 year survival (58.1 +/- 5.7%) is identical to that of the period 1970-1982 despite a very significant drop in perioperative mortality. Some of the causes of late mortality (older age of patients, changes in the infecting organisms) provide little hope of improving the prognosis in the near future. Others suggest that earlier surgery could improve the long term prognosis.

Twenty patients (17 men and 3 women: average age 50 +/- 14 years) with asymptomatic or paucisymptomatic aortic regurgitation were studied to compare the values of radionuclide left ventricular ejection fraction (EF) at rest and on exercise before (1) and 6 +/- 1 months (2) and 5.7 +/- 1.1 years (3) after surgery. The resting EF was similar at all three examinations: 53 +/- 8 (1); 57 +/- 8 (2); 55 +/- 16 (3). However, it increased significantly on exercise from 40 +/- 10 (1) to 54 +/- 12 (2) (p0.001) and to 52 +/- 20 (3) (p = 0.036 versus 1). In the 7 patients with resting EF greater than 55 before surgery, there was no postoperative improvement: 61 +/- 6 (1); 61 +/- 5 (2); 65 +/- 9 (3). However, the exercise EF increased from 44 +/- 13 (1) to 55 +/- 17 (2) and 69 +/- 11 (3) (p = 0.004 vs 1). In 13 patients with resting EF55%, the value increased in the early postoperative phase but not later: resting: 49 +/- 5 (1); 55 +/- 8 (2) (p = 0.04); 49 +/- 17 (3) (NS vs 1); effort: 38 +/- 7 (1); 54 +/- 10 (2) (p0.001); 40 +/- 16 (3) (NS vs 1). Left ventricular systolic function only returns to normal and exercise after surgery in patients with resting preoperative EFor = 55%, but nothing indicates that this normalisation is an absolute condition for a successful surgical result in aortic insufficiency in terms of survival and quality of life.

A better understanding of diseases such as primary hyperoxaluria and multiorgan failure have led to the performance of combined organ transplantation. We present here the indications and results of combined kidney and heart or liver, and discuss whether we can select the candidates for combined organ transplantation.

The aim of this retrospective study was to review the outcome of 216 patients (pts), investigated for severe mitral regurgitation (MR) between January 1980 and December 1987. Definition of 'severe' was mainly clinical: MR sufficiently advanced for the cardiologist to investigate whether surgery should be imminent. One hundred and sixty two pts (group 1) were operated on; 54 (group 2) did not undergo surgery. Baseline characteristics were similar in the two groups, except for aetiology (less dystrophic and more ischaemic MR in group 2), functional class (88.3% class III or IV in group 1 vs 48.1% in group 2; P = 0.001), pulmonary pressures (lower in group 2) and left ventricular ejection fraction (group 1: 0.66 +/- 0.13; group 2: 0.56 +/- 0.17; P = 0.001). Mean follow-up after hospital admission or surgery was comparable in the two groups (group 1: 3.9 +/- 2.5 years; group 2: 3.5 +/- 2.7 years). Three pts (group 2) were lost to follow-up. Sixty-three pts died; 35 of the 162 operated on; 28 of the 54 non-operated on. Actuarial survival rate at 8 years was 74.0 +/- 4.3% in group 1 vs 33.2 +/- 9.2% in group 2 (P = 0.001). These results confirm that the prognosis of severe MR is poor if it is not operated on, whereas the postoperative course of severe MR, when operated on in time, is good.

In order to determine the value of a positive exercise test (ET) (i.e. ischaemic ST depression) without chest pain observed after a myocardial infarction (MI), 102 ET's were reviewed. ET was performed without anti-ischaemic drugs. The mean time-lag between MI and ET was 51 +/- 55 months. The MI was inferior in 26 cases, inferior and/or posterior in 74 cases and of undetermined location in 2 cases. Thirty patients had both ST depression and chest pain (group 1); 35 had electrocardiographic signs of ischaemia without pain (group 2), and 37 had neither chest pain nor signs of ischaemia (group 3). Age, sex ratio, site of infarction and time-lag between MI and ET were similar in all three groups. The post-ET follow-up period was 33 +/- 18 months (range: 6 to 66 months); 2 patients in group 3 were lost sight of. There was no significant difference between groups 1 and 2 as regards total duration of ET, workload attained, heart rate, systolic arterial pressure, pressure-rate product and amplitude of ST depression at maximum exercise level. Group 3 differed from the other 2 groups in workload attained (p less than 0.05) and in pressure-rate product (p less than 0.05 vs group 1, p less than 0.01 vs group 2). There was no significant difference between groups 1 and 2 as regards post-ET events (recurrent angina, reinfarction, coronary bypass, transluminal angioplasty).(ABSTRACT TRUNCATED AT 250 WORDS)

The purpose of this retrospective study of 28 cases of staphylococcal endocarditis on cardiac valve prosthesis was to evaluate the prognosis of that disease and the possible causes of its recent improvement. Between March 1977 and May 1987, 69 patients were treated for bacterial endocarditis on cardiac valve prosthesis. Among these, 28 patients (19 men, 9 women, mean age 53.2 +/- 14.3 years) had staphylococcal endocarditis (Staph. epidermidis in 18 cases, Staph. aureus in 10 cases) of early (10 cases) or late (18 cases) onset. Complications were present in no less than 27 out of 28 patients, the most frequent being heart failure, embolism or neurological disorders. The mortality rate was high (61 p. 100). Among the clinical variables studied, only a state of shock seemed to be predictive of death. Mortality was higher in the group treated medically (100 p. 100) than in the group treated surgically (50 p. 100). Since 1984, however, a significant decrease of mortality was noted; it coincided with the systematic use of vancomycin but also with surgical treatment in all cases. As a result of this study, we suggest that all patients with staphylococcal endocarditis on cardiac valve prosthesis should be operated upon and that this should be done as soon as possible, before the end of the classical antibiotic therapy period.