The midterm (6 years) clinical results of the Carpenter-Edwards supra-annular bioprosthesis]

We present here the clinical results with a second-generation porcine bioprosthesis, the Carpentier-Edwards supra-annular valve (CESA). Two-hundred and twenty-two CESA bioprostheses were implanted in 189 patients during a four-year period (from 1984 to 1987), either as an isolated procedure or associated to mitral or tricuspid repair. The mid-term clinical results have been evaluated after a mean follow-up of 3.4 years, being 96% complete. There were 16 in-hospital deaths (8.4%) and 6 late, potentially valve-related, cardiac deaths (1.1% patients/year). Overall, 86.7 +/- 2% of the patients were free from cardiac death at 6 years (95.1 +/- 2% of the patients surviving the operative period). Linearized rates of valve related complications were the following: 1.4% patients/year for thromboembolism (including valve thrombosis), 0.5% patients/year for treatment-related hemorrhage and 0.7% patients/year for endocarditis. We did not found any case of either intrinsic or extrinsic valve failure, unrelated to infection of thrombosis. Two patients were reoperated, one because of valve thrombosis and the other due to prosthetic valve endocarditis (reoperation rate of 0.3% patients/year). When lethal and nonlethal valve-related complications (including in-hospital deaths) were considered all together, 75.8 +/- 8.4% of the patients remained alive and free of morbid events at 6 years. When patients were grouped according to the valve replaced (aortic, mitral and multiple), best results were found with patients submitted to isolated aortic valve replacement. We conclude that the CESA bioprosthesis has an excellent mid-term clinical performance. However, longer follow-up is necessary to know if improvement in valve design and manufacturing results in increased valve durability.     

Myocardial revascularization surgery during a developing infarction

Our results with surgical revascularization for evolving myocardial infarction in 30 patients are analyzed. There were 25 men and 5 women (mean age 55 +/- 10 years), most with unstable angina (80%), which sustained an acute myocardial infarction secondary to either a severe stenosis (23%) or a complete obstruction (77%) of a mayor coronary artery during a diagnostic coronarography (27%) or a percutaneous transluminal coronary angioplasty (73%). The most frequently involved vessels were the left anterior descending and right coronary arteries (11 cases), followed by the left main stem (5 cases) and the circumflex artery (3 cases). Nineteen patients (group I) developed electrocardiographic and/or enzymatic evidence of established myocardial necrosis despite early reperfusion, whereas 11 patients did not (group II). These groups were compared according to different clinical, angiographic, hemodynamic, and operative variables. Group I patients had a more recent disease and a better segmentary contraction. The same variables were compared between the 5 patients with early cardiac death (group III) and the remainder 25 (group IV). Refractory cardiac arrest, jeopardized myocardial mass and coronary perfusion indexes after the infarction-related complication, all were more desfavorable in group III. The ischemic interval between infarction onset and reperfusion was not different between the groups. The potential of surgery for myocardial salvage in the setting of evolving necrosis is emphasized as well as the influence of the magnitude of involved myocardium and its clinical repercussion on early mortality.     

Guidelines of the Spanish Society of Cardiology for cardiopulmonary resuscitation]

Cardiac arrest, consistent on cessation of cardiac mechanical activity, is diagnosed in the absence of consciousness, pulse and breath. The totality of measurements applied to revert it is called cardiopulmonary resuscitation. Two different levels can be distinguished: basic vital support and advanced cardiac vital support. In the basic vital support methods which do not require special technology are used: opening of air lines, mouth to mouth ventilation, cardiac massage; recently, there is a tendency to include the use of defibrillator. Advanced cardiac vital support should be the continuation of basic vital support. In this situation defibrillator, venous cannulation, orotracheal intubation, mechanical ventilation with high content in oxygen and drugs are used. Before beginning cardiopulmonary resuscitation, one should make sure that a real cardiac arrest is present, less than 10 min have elapsed, the victim does not have an immediately fatal prognosis and there is no deny by the victim or his/her family to receive cardiopulmonary resuscitation. In case of doubt it should be always practised. It is important to know the diagnosis and prognosis of the cause of cardiac arrest as soon as possible, in order to treat it and decide if the maneuvers should be continued. Hydro-electrolytic disturbances must be treated and neurological damage after cardiopulmonary resuscitation must be assessed. Only 20% of patients who recover an effective cardiac rhythm after cardiopulmonary resuscitation are discharged from hospital without neurological sequelae.     

Eight years' experience with the Medtronic-Hall valve prosthesis

During the period January 1981 to September 1986, 444 Medtronic-Hall heart valve prostheses were implanted in 351 patients (mean age, 45 +/- 10 years) mainly for rheumatic valve disease (63.2%). Most of the patients were in New York Heart Association functional class III. Concomitant surgical procedures, mainly conservative tricuspid or mitral procedures or coronary artery bypass grafting, were performed in 101 patients (28.7%). Single-valve replacement was performed in 262 patients (74.6%) (aortic in 117 patients, mitral in 143, and tricuspid in 2), double-valve replacement in 85 (24.2%) (mitral and aortic in 83 and mitral and tricuspid in 2), and triple-valve replacement in 4 (1.1%). Hospital mortality was 6.2%. Follow-up was 97.7% complete. The overall actuarial 8-year survival rate was 77.2%. The linearized incidence of valve-related complications was as follows: thromboembolism, 1.5%/patient-year; reoperation, 1.5%/patient-year; endocarditis, 1.25%/patient-year; hemolysis, 0.52%/patient-year; anticoagulant-related hemorrhage, 0.39%/patient-year; and noninfection-related paraprosthetic leak, 0.33%/patient-year. There were no instances of structural failure. We conclude that after 8 years of follow-up, the Medtronic-Hall valve prosthesis has an excellent clinical performance and a low range of valve-related complications.