François Bouchart

The present study evaluates our experience with coronary bypass grafting in patients with EF < or =25%. Myocardial revascularization in this setting remains controversial because of concerns over operative mortality and morbidity and lack of functional and survival benefit. One hundred and forty-one patients with coronary artery disease and left ventricular ejection fraction < or =25% underwent coronary artery bypass graft between January 1988 and December 1998. Mean age at operation was 63.3 years and 81.4% were male. The major indication for surgery was angina (114 patients, 80.8%). Ejection fraction (EF), left ventricular end diastolic pressure (LVEDP) and cardiac index (CI) were used to assess left ventricular function. The number of graft was 2.7+/-1.6/patient. Internal mammary artery was used in 119 patients (84.3%). Intra aortic balloon pump was placed preoperatively in 25 patients (17.7%). Five operative risk factors were associated with a higher mortality: emergency, female sex, LVEDP, CI and NYHA class IV. The operative mortality was 7% (10 patients). Left ventricular ejection fraction (assessed post operatively in 83 patients) improved from 22.2% preoperatively to 33.5% post operatively (P<0.001), mean end diastolic volume index fell from 98 to 83 ml/m(2) following surgery. Survival at 2, 5 and 7 years was respectively 84+/-3%, 70+/-4% and 50+/-5%. Two variables were associated with increased long term survival: congestive heart failure (NYHA class lower than IV (P=0.035) and cardiomegaly (P=0.04) In patients with left ventricular dysfunction, myocardial revascularization can be performed relatively safely with good medium term survival and improvement in quality of life and in left ventricular function. Coronary artery bypass graft may be offered to patients with impaired ventricular function, but careful patient selection and management when considering these patients for operation should assess potentially reversible dysfunction.

One hundred and forty aortic valve replacements (AVR) performed between 1986 and 1995 at Rouen University Hospital in octogenarians (52 men and 88 women), including 9 emergency procedures, were analysed. One hundred and fifteen patients had pure aortic stenosis, 25 had mixed aortic valve disease with mainly aortic incompetence. The surgical decision was taken by the patient with the surgeon after an interview, in order to exclude too handicapped or undecided patients. Significant coronary artery disease was observed in 42% of cases. Isolated AVR was undertaken in 74% of cases and associated coronary bypass surgery in 23% of cases. Bioprostheses were used in 90% of cases. The valvular lesions were predominantly those of Monckeberg disease. The operative mortality was of 13 patients (9.3%). Functional recovery was satisfactory in 78% of cases; the average duration of the hospital stay was 12 days. All known risk factors for AVR: age, coronary lesions, cardiac failure, low ejection fraction, aortic regurgitation, were associated with insignificant increases in mortality. The secondary mortality was of 28 patients; 99 patients are still alive 4 to 91 months after surgery. The actuarial survival graph showed a 56.5% probability of 5 year survival. Eighty per cent of survivors live at home without loss of autonomy.

One hundred and eleven patients with severe left ventricular dysfunction (EF < or = 25%) underwent coronary bypass surgery between January 1984 and December 1994. The selection criteria were based on the measurement of an EF < or = 25%, LVEDP and CI. All patients had angina and 83 had signs of pulmonary oedema or episodes of congestive failure. Patients with valvular disease, left ventricular aneurysms, reoperations, surgery for arrhythmias and prior angioplasty, were excluded. The coronary disease usually involved all three vessels. Seventeen patients had lesions of the left main stem associated with lesions of the right coronary artery. The average number of bypass grafts was 2.6 +/- 1.6 per patient. The average duration of aortic clamping was 60 +/- 19 minutes. Operative mortality (first month after surgery) was 10 patients (9%). The operative risk factors were: gender, stage of cardiac failure, emergency surgery, LVEDP > 23 mmHg (p < 0.05), CI < 21/min/m2 (p < 0.05). The mean follow-up period was 42 +/- months (3 lost to follow-up). Late mortality was 42 patients. The one year actuarial survival was 88 +/- 5.3%, 76 +/- 9% at 3 years, and 56 +/- 18% at 6 years. Long-term functional results were related to: preoperative stage of cardiac failure (NYHA stage IV) and the association of raised LVEDP and low CI. Surgical results remained satisfactory, however, and the surgical indication was justified in selected patients despite severe left ventricular dysfunction in cases usually with stable invalidating or unstable angina, in the knowledge that myocardial deterioration is progressive in the medium-term with a high incidence of cardiac failure.

Isolated stenosis of the aortic valve leads to left ventricular hypertrophy which makes myocardial protection difficult during cardiac, surgery and the choice of optimal cardioplegia remains controversial. The authors compared three protocols of cardioplegia in patients operated for isolated aortic stenosis with left ventricular hypertrophy. Sixty consecutive patients with these criteria were randomly attributed to one of the three following groups (20 in each group): cardioplegia with continuous warm blood; cardioplegia with intermittent cold blood with warm reperfusion; cardioplegia with intermittent cristalloid using SLF11 solution. The preoperative data was comparable in three groups. There were no deaths. Patients undergoing cardioplegia with warm blood came off cardio-pulmonary bypass more quickly (15 mn vs 21 mn for the other groups, p = 0.03). Cristalloid cardioplegia was associated with major acidosis in coronary sinus blood when the aorta was declamped (7.11 vs 7.38 for cardioplegia with cold blood and 7.39 for cardioplegia with warm blood, p < 0.0001) but with a low postoperative CPK-MB rise. Cardioplegia with cold blood induced higher CPK-MB liberation than the other forms of cardioplegia (at H-, 63 mcg/L vs 33 for warm blood and 45 for cristalloid cardioplegia, p = 0.0019). None of the protocols tested prevented myocardial lactate production at aortic declamping. Cardioplegia with warm blood offers therefore the best protection for hypertrophied myocardium during simple aortic valve replacement but it does not maintain strictly aerobic metabolism.

OBJECTIVE: This study concerns patients who underwent one or severalaortic balloon valvuloplasties at our institution and subsequently requiredcardiac surgery, either on an emergency basis after aortic valvuloplasty ordue to the development of aortic stenosis. METHODS: Between February 1987and December 1993, 137 patients (73 male, 64 female, mean age 72 +/- 9years) underwent aortic valve replacement for calcified aortic stenosisafter several percutaneous balloon aortic valvuloplasties. Thirty-onepatients were in NYHA stage II, 70 in stage III and 36 in stage IV. Seventypatients had angina (23 stage I or II, 47 stage III or IV) and 24 patientspresented syncope or lipothymia. Twenty-three percent had at least two ofthese three symptoms. The indications for balloon dilatation werenon-definitive surgical contraindication or high surgical risk (73),personal choice (49), refusal of surgery (9) and emergency (5:2 massiveaortic regurgitation, 1 left ventricle perforation, 1 cardiogenic shock, 1endocarditis in cardiogenic shock). Seven patients received preoperativeaortic valvuloplasty due to a very high operative risk. The average timebetween dilatation and surgery was 472 days and there was clinicalimprovement for an average period of 261 days. The aortic valvereplacements consisted of 58 mechanical prostheses and 79 xenografts with22 concomitant procedures. RESULTS: Operative mortality was eight patients(5.8%). During the follow-up (17.4 +/- 9.2 months), four patients died(3.6%), 91.2% of the patients were in class I and II and 95% were withoutangina. The actuarial survival rate was 90.5 +/- 6.6% including hospitalmortality. CONCLUSIONS: Both our experience and the literature show thatballoon aortic valvuloplasty is followed by an immediate improvement inhemodynamic status with a decrease in valve gradient and an increase invalve area. However, the hemodynamic benefit is typically short-lived witha very high restenosis rate. Balloon aortic valvuloplasty is not analternative to aortic valve replacement, which remains the best treatmentfor calcified aortic stenosis; the benefits and long-term results of aorticvalve replacement are well established, even in the elderly.

From March 1977 to November 1988, 99 patients were reoperated on after a first valvular replacement. Mean delay between the two operations was 53 months (10 days to 18 years). The patients were reoperated on mainly for mechanical disinsertion (30), bacterial endocarditis (25) and thrombosis (18 patients). Operative mortality was 11%, mainly following reoperation for bacterial endocarditis. Mean follow-up (85 patients) was 49 months (6 months-11 years). 75% were alive and doing well 4 years after reoperation and 66% at 6 years. Eight patients needed a third operation with two deaths.