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The authors report a case of paradoxical embolism presenting with syncope and a transient cerebrovascular accident. A large thrombus was observed entrapped in the foramen ovale during transthoracic echocardiography and confirmed at transoesophageal echocardiography. Despite the recent cerebrovascular event surgery was successfully performed. This clinical situation, and a review of the literature illustrate the diagnostic value of transoesophageal echocardiography, the finding of an intra-atrial thrombus being a possible surgical indication when the clinical context is favourable.

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BACKGROUND: The first generation of pericardial valves has been withdrawn from the market because of excessively high rates of premature failure. With its original design, the Carpentier-Edwards pericardial valve has promised improved results. METHODS: In our institution, 589 patients underwent an isolated aortic valve replacement with a Carpentier-Edwards pericardial bioprosthesis between July 1984 and December 1993. The patients' mean age was 67.5 +/- 11.2 years, and 49% of the patients were in New York Heart Association clinical class III or IV. The operative mortality rate was 2.3% (14 of 595). All patients but 4 were followed up for an average of 4.1 years after their operation, and total follow-up was 2,408 patient-years. RESULTS: At the time of the study, more than 85% of the patients were in New York Heart Association class I or II. There were 79 late deaths. After 10 years, the actuarial survival rate was 71% +/- 7%. Nineteen patients died of valve-related causes (3 endocarditis, 7 thromboembolic complications, 1 structural failure, and 8 sudden deaths). The actuarial rate of freedom from valve-related death was 94% +/- 3% at 10 years. Valve-related complications included 23 thromboembolic episodes (0.9% per patient-year), 14 endocarditis (0.5% per patient-year), 9 reoperations (0.4% per patient-year), and 4 structural valve failures with calcification and stenosis (0.2% per patient-year). After 10 years, freedom from valve-related complications was 84% +/- 6%, from reoperation 97% +/- 2%, and from valve failure 96% +/- 4%. CONCLUSIONS: Because of its low rate of valve-related events at 10 years and low rate of structural deterioration with no leaflet tears, this prosthesis is an outstanding choice for patients who need tissue valves and for patients aged 60 years or older.

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Between July 1984 and December 1993. 110 patients, younger than 60 years, underwent aortic valve replacement with a Carpentier-Edwards pericardial valve. 75.5% were male, with a mean age of 49.6 years (range: 16 to 59 years). Mean clinical status was 2.25. Operative mortality was 0%. All patients but 3 were followed up with a total follow-up of 454 patient-years and an average of 4.8 years. The 10-year actuarial survival is 91 +/- 6%. We observed 8 valve-related complications (1.7% patient-years): 3 cases of endocarditis, 3 structural failures, 1 thromboembolic event, and 1 perivalvular leak. 1 patient died from a valve-related cause, and 2 reoperations were necessary. The 8-year actuarial probability of absence of valve-related death is 99 +/- 1%, thromboembolism 98 +/- 2%, endocarditis 96 +/- 4%; reoperations 96 +/- 4%, and valve failure 97 +/- 3%. The 10-year valve-related complication rate is satisfactory, but the durability of the prosthesis in this group of young patients remains unknown. A longer follow-up is mandatory to draw definitive conclusions.

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From the first of June 90 to the thirty first of January 94, transesophageal echocardiography was performed in 235 consecutive patients (mean age 56+/-16 years), presenting either with cerebral ischemic event (n = 202) or a peripheral arterial embolism (n = 33). All patients had normal echocardiographic and Doppler examinations of the carotid arteries, and transthoracic echocardiography did not show any possible cardiac origin for stroke. Ninety seven patients (41.2%) had documented cardiac disease and/or atrial fibrillation (group 1); 138 patients (58.8%) had no previous cardiovascular history (group 2). Transesophageal echocardiography revealed a possible embolic source in 65.9% of cases (group 1) compared with 29.7% of cases in group 2 (p < 0.001). Intracavitary thrombus and spontaneous contrast in the left atrium were detected only in group 1 (21.6% vs 0%, p < 0.001 and 24.7% vs 0%, p < 0.001 respectively). Patent foramen ovale was more frequent in group 2: 14.5% of cases vs 4.1% of cases, p < 0.01. There was no significant difference between atheromatous aortic plaques and interatrial septam aneurysm incidence in the two groups. Patent foramen ovale and interatrial septal aneurysm were more frequent in group 2: 85% of cases vs 10% of cases in group 1. Transesophageal echocardiography contributes more in patients with a history of cardiac disease. In patients without cardiac disease, patient with foramen ovale and interatrial septal aneurysm were mainly detected: their association represented a risk factor of cerebral ischemic event. Therefore transesophageal echocardiography should be performed in young patients or in case of recurrent event.

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From July 1984 to December 1991, 641 Carpentier-Edwards pericardial valves were used in 585 consecutive patients. There were 420 aortic valve replacements, 121 mitral valve replacements, and 50 double valve replacements. Mean age was 65.5 +/- 12 years. All patients but 10 were followed up at 3 months periods with a total follow-up of 2074 patients years and a mean follow-up of 3.7 years. Patients were subdivided in 4 groups: Group I: < 50 years, Group II: 50 < age < 65, Group III: 65 < age < 75, Group IV: > 75 years. Actuarial survival rates were 100% in group I, 80 +/- 9% in group II, 68 +/- 11% in group III, and 64 +/- 13% in group IV. Valve related complications included 54 patients and valve related deaths 17. Valve related death rates were 100%, 96 +/- 3%, 95 +/- 4%, 89 +/- 10% respectively (NS). We observed 4 structural failure of the values with respective rates of freedom from valve deterioration of: 92 +/- 6%, 98 +/- 2%, 100%, 100% (NS). No leaflet tears were observed. No difference was found between the 4 age groups in terms of valve related events except for thromboembolic accidents which were more frequent in patients older than 75 years. The absence of difference at 8 years and the absence of leaflet tears indicate the superiority of the Carpentier-Edwards pericardial over previous bioprostheses and the better stress behaviour of this valve. The coming years will allow us to determine the precise place of this pericardial device, especially in young patients and in the mitral position.

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Between July 1984 and December 1991, 541 Carpentier-Edwards pericardial prostheses were implanted in 536 patients (420 aortic and 121 mitral prostheses). The operative mortality was 2.9% for aortic and 3.3% for mitral valve replacement. All but 8 patients were followed up for an average of 3.9 years, making a total follow-up of 1930 patient-years. There were 61 deaths during follow-up (41 AVR, 20 MVR). The actuarial 8 year survival was 80 +/- 6% for AVR and 74 +/- 10% for MVR. There were 15 deaths related to the prostheses. The probability of absence of valve-related mortality was 97 +/- 3% for AVR and 92 +/- 6% for MVR (NS). The valve-related complications included 15 thromboembolic events (AVR: 12; MVR: 3), 10 endocarditis (AVR: 7; MVR: 3), 8 anticoagulant-related haemorrhages (AVR: 4; MVR: 4), 4 degeneration (AVR: 2; MVR: 2). There were no cases of cusp tear. The probability of absence of thromboembolic events at 8 years was 96 +/- 3% for AVR and 96 +/- 4% for MVR (NS), of absence of endocarditis 97 +/- 2% for AVR and 97 +/- 3% for MVR (NS) and of absence of valve degeneration 99 +/- 1% for AVR and 99 +/- 2% for MVR (NS). These results show that the position of the bioprosthesis had no influence on valve-related morbidity and that pericardium is a satisfactory tissue for the manufacture of mitral bioprostheses.

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The ideal artificial heart valve still does not exist among the various cardiac valves available to the clinician. Morbidity and mortality are directly related to the valve itself. Despite the promising hemodynamic results obtained in the 70s with pericardial prosthesis, these valves were progressively abandoned due to their poor long-term resistance. Based on an analysis of the causes of failures, modifications were made in the manufacturing method and current results with pericardial valves has greatly improved, inciting new interest in their clinical use. Today, the pericardium is recognized as a valid substitution material for bioprostheses. Results of long-term series should confirm current studies. Research is under way to determine how to improve pericardium longevity since tissue deterioration remains the limiting factor.

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Primary tissue failure is a major problem with pericardial or porcine heterografts, and the causes of calcification of the tissue are not yet known. The deterioration of bioprostheses may be due in part to immunologic response. Using autologous tissue is a current approach of research. We present a case of replacement of the aortic valve using an original procedure with autologous pericardium.

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From July 1984 to December 1991, 420 patients underwent isolated aortic valve replacement with a Carpentier-Edwards pericardial bioprosthesis in our Institution. Of the patients 71.5% were male, the mean age was 66.9 +/- 11.9 years and 48% were in NYHA clinical stage III or IV. The operative mortality rate was 2.9% (12/420). All patients but six were followed up for an average of 3.9 years after their operation and total follow-up was 1444 patient-years. At this time of the study, over 80% of the patients are in NYHA class I or II, 6% are in atrial fibrillation and 7% receive anticoagulation treatment. There were 41 late deaths. After 8 years the actuarial survival rate is 80% +/- 6%. Nine patients died of valve-related causes (three endocarditis, three thromboembolic complication, one structural failure, and two sudden deaths). The actuarial rate of freedom from valve-related death was 97% +/- 3% at 8 years. Valve-related complications included 12 thromboembolic episodes (0.8% patient-year), 7 endocarditis (0.5% patient-year), 4 anticoagulant-related complications (0.2% patient-year), 6 reoperations (0.4% patient-year) and 2 structural valve failures (0.1% patient-year). After 8 years, freedom from thromboembolic complication was 96% +/- 3%, from endocarditis 97% +/- 2%, from reoperation 98% +/- 2% and from valve failure 99% +/- 1%. There were only two structural deteriorations (calcification and stenosis) and one explanation. No leaflet tear was observed. We conclude that these intermediate results are better than those obtained with previous pericardial bioprostheses.

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The authors report the case of a systemic embolism of a cusp of a Hancock pericardial aortic bioprosthesis. This rare complication has not been previously reported to the authors' knowledge, and should lead to immediate valve replacement.

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Intravenous thrombolysis during the acute phase of myocardial infarction is successful in restoring perfusion in 60 to 80% of cases. When it is unsuccessful, there is disagreement about the best approach to adopt. The article reports the results obtained in 40 consecutive patients treated by angioplasty after thrombolysis had been unsuccessful. Reperfusion was achieved in 92.5% of cases, with a hospital mortality rate of 7.5% (2.5% if patients admitted in a stage of cardiogenic shock are excluded). There was no mortality related to the procedure itself and an emergency aorto-coronary by-pass was not required in any case. Since it is accepted that the subsequent prognosis depends on coronary patency, coronary artery assessment after thrombolysis, followed by angioplasty if the occlusion persists seems to be a logical strategy if the myocardial territory is compromised.

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