Long-term outcomes following repair or replacement in degenerative mitral valve disease.

BACKGROUND: We studied whether mitral valvuloplasty (MVP) was superior to mitral valve replacement (MVR) in patients with degenerative mitral regurgitation (MR), and analyzed the independent risk factors for survival and reoperation. METHODS: 326 patients with degenerative MR underwent MVP (n = 241), mitral valve replacement (MVR) (n = 78) or emergent MVR due to failure of repair (EMVR). Clinical data were analyzed retrospectively. RESULTS: Thirty-day mortality was lower after MVP (2.5 %) compared to MVR (9.0 %) ( P < 0.05). Late survival at 1 and 5 years in the MVP group was 94.4 % and 84.3 % versus 80.4 % and 64.6 % in the MVR group ( P < 0.05), respectively. After adjusting the baseline characteristics by the propensity score method, a significant survival benefit was found for patients who underwent MVP. Multivariable analysis showed that MVR was an independent predictor of thirty-day mortality and survival. There was no significant difference in thirty-day mortality and survival between the EMVR and MVR groups. The need for reoperation was not significantly different between the MVP and MVR groups. In the MVP group, the risk factors for survival and reoperation were identified. CONCLUSIONS: MVP is superior to MVR for the treatment of degenerative MR despite the impact of repair failure. Age less than 60 years, ring size to body surface area greater than 19.0, absence of a prosthetic ring and residual MR at the end of surgery (≥ 1/4) reduce the durability of MVP.

[Cardiac tumors: CT and MR imaging features]. / Tumeurs cardiaques: aspects en scanner et en IRM.

The CT and MR imaging features of the main cardiac tumors will be reviewed. Cross-sectional imaging features may help differentiate between cardiac tumors and pseudotumoral lesions and identify malignant features. Based on clinical features, imaging findings are helpful to further characterize the nature of the lesion. CT and MR imaging can demonstrate the relationship of the tumor with adjacent anatomical structures and are invaluable in the presurgical work-up and postsurgical follow-up.

Oxygen-regulated protein-150 prevents calcium homeostasis deregulation and apoptosis induced by oxidized LDL in vascular cells.

Oxidized LDLs (oxLDLs) induce apoptosis, which contributes to the pathogenesis of atherosclerosis. The 150 kDa oxygen-regulated protein (ORP150), an endoplasmic reticulum (ER)-resident chaperone, is upregulated by hypoxia and prevents ischemia-induced cell death. The aim of this work was to investigate whether and how ORP150 can prevent apoptosis induced by oxLDLs in vascular cells. OxLDLs induced ORP150 expression in the ER of human microvascular endothelial cell line (HMEC-1). ORP150 expression was blocked by antioxidants, by the permeant calcium chelator BAPTA-AM, and by inhibitors of the inositol-1,4,5 trisphosphate (IP3) receptors, 2-aminoethyl diphenylborinate (2-APB) and xestospongin C. ORP150 silencing by siRNA-enhanced oxLDL-induced apoptosis, while forced ORP150 expression increased the resistance of cells via an inhibition of the oxLDL-induced calcium rise, and of subsequent calpain activation, cytochrome c release, caspase 3 activation and apoptosis. A similar protective effect was achieved by BAPTA-AM, 2-APB and xestospongin C. Altogether, these data indicate that (i)ORP150 inhibits oxLDL-induced apoptosis by blocking calcium signaling and subsequent apoptosis, (ii)calcium released from ER stores through IP3 channels is involved in the oxLDL-induced calcium rise and apoptosis, and is inhibited by ORP150. Finally, ORP150 is expressed in advanced atherosclerotic lesions, where it may locally participate to reduce the apoptotic effect of oxLDLs and the subsequent risk of plaque rupture.

[Combined surgery of acute type A aortic dissections by ascending aorta replacement and bare stent]. / Chirurgie combinée des dissections aiguës de type A, par remplacement de l'aorte ascendante et endoprothèse non couverte.

UNLABELLED: Aim. After surgical treatment of type A aortic dissections a long segment of these aortas often remain dissected. Our goal was to analyse feasibility and first clinical and pathophysiological results of a combined treatment by ascending aorta replacement and stenting of the arch or descending aorta with Djumbodis(R) bare stents. PATIENTS AND METHODS: Twenty two cases from two centres were analyzed (Universitary Hospital of Parma and Rangueil Universitary Hospital of Toulouse). RESULTS: All the stents have been implanted with short times of circulatory arrest. Average follow-up was 278 days (0-2005). There were two peroperative deaths (9.1%). One year cumulate survival rate was 72.7%. Postoperative complications were mainly respiratory and renal. We have shown a reduction in number of perfused false lumen for aortic arches, more often stented, than for descending aortas (p=0.0104), and for dissected and stented segments versus dissected unstented segments (p=0.0083). CONCLUSION: Our study demonstrates feasibility of this combined procedure and its positive effect on pathophysiologic evolution. Long term results have to be evaluated, but we think promising to extend this treatment to the whole dissected aorta.

Differential display fingerprints: new approach to characterize smooth muscle cells and human coronary atherectomy tissues.

AIM OF THE STUDY: Smooth muscle cells build up the normal media and stabilize atherosclerotic lesions whereas an inflammatory component is determinant for unstable angina. Smooth muscle cells, currently identified by alpha-actin, present a phenotypic heterogeneity and alpha-actin can be reduced in pathology. We tried to characterize vascular cell types, particularly smooth muscle cells, and coronary atherosclerotic tissues, by random genes expression fingerprints. MATERIALS AND METHODS: Expression fingerprints (cDNA electrophoresis) were performed by differential display reverse transcriptase-polymerase chain reaction. Variability of fingerprints was studied for a panel of arterial muscle cell phenotypes and comparisons were made with fingerprints from other cell types (endothelial cells and macrophages). The technique was then applied to human coronary atherectomy samples compared to control human arterial (mammary) smooth muscle. RESULTS: Arterial smooth muscle cells fingerprints were overall similar whatever the cell phenotype (native contractile, dedifferentiated in culture or epithelioid). Moreover, with two primer pairs, the muscular fingerprints markedly differed from the endothelial and the monocytic fingerprints. Application of differential display to coronary atherectomy samples was feasible. Interestingly, the pathological tissues exhibited either smooth muscle-like or smooth muscle-divergent fingerprints. CONCLUSIONS: Smooth muscle cells and inflammatory cells exhibited distinct differential display fingerprint patterns. Thus, a simple expression profile of arbitrary genes provides a molecular bar code tool (pattern signature) useful to characterize vascular cell cultures or tissues. The present work proposes a method to analyze coronary atherectomy samples which estimates their whole quality, muscular versus non muscular (inflammatory), this is of interest for clinical research.

[A new approach to the tricuspid valve in Ebstein's anomaly by real time 3D echocardiography]. / Nouvelle approche de la valve tricuspide par échocardiographie 3D temps réel dans la maladie d'Ebstein.

Ebstein's anomaly affects the tricuspid valve with a large range of anatomical forms. Successful tricuspid valvuloplasty depends mainly on the ability to mobilise the leaflets. Evaluation of the leaflet surface is difficult with 2D echocardiography whereas 3D echocardiography provides intracardiac views of the valve. The authors used this method in 10 patients with 3 modes of imaging: biplane, real time and total volume. The study population (age: 1 day to 30 years) included: 1 prenatal diagnosis, 1 neonate with refractory cyanosis, 5 patients with mild tricuspid regurgitation, 3 patients with severe tricuspid regurgitation, 2 of whom underwent valvuloplasty. 3D echocardiography was disappointing in the foetus and neonate because of poor spatial resolution. The ventricular view of the tricuspid valve in older children and adults allowed analysis of tricuspid leaflet coaptation and of the mechanism of regurgitation. The commissures and leaflet surfaces were assessed. The results of surgical valvuloplasty could be evaluated by 3D echocardiography. 3D echocardiography is now transthoracic and a real time investigation. Technical advances are required before it comes into routine usage: a more manoeuvrable matricial probe (integrating pulsed and continuous wave Doppler) and larger volume real time 3D imaging with better resolution. Its role in the assessment of Ebstein's anomaly should be evaluated in a larger series of patients.

Acute ischemia of a limb as a complication of multiple hereditary exostoses. Case report and literature review.

The authors present a case of acute ischemia of a limb as a complication of multiple hereditary exostoses. They discuss surgery, complications, and review the literature.

[Cardiac factors predictive of 10-year survival after coronary surgery]. / Facteurs cardiaques prédictifs de survie à 10 ans après chirurgie coronaire.

Although the predictive factors of postoperative mortality after coronary artery surgery are well known, those predictive of long-term survival have received less attention. This study reviews the outcome of a group of 480 patients between 50 and 65 years of age, operated between 1984 and 1986. The patients were classified in two groups according to the presence or absence of internal mammary artery bypass grafts: Group I (304 patients with saphenous vein bypass grafts alone) and group II (176 patients with an internal mammary artery +/- saphenous vein bypass grafts). The long-term results were assessed according to 3 criteria: isolated cardiac mortality: cardiac mortality associated with a repeat revascularisation procedure and cardiac mortality associated with reoperation or recurrence of angina. Cardiac survival at 10 years was significantly better after internal mammary-LAD bypass: 91.4% (CI 87.1-95.1) than after saphenous vein bypass grafting alone: 79.6% (CI 74.8-84.4) (p = 0.012). Univariate analysis identified the following poor predictive factors: three vessel disease (p = 0.03), preoperative left ventricular dysfunction with an ejection fraction inferior to 45% (p = 0.0001), incomplete revascularisation (p = 0.0003), use of venous bypass graft alone (p < 0.014) and perioperative infarction (p = 0.0254). For each criterion of survival (cardiac isolated or associated with a new revascularisation and/or recurrence of angina), multivariate analysis identified three independent predictive factors of long-term extramortality: not using internal mammary artery-LAD bypass graft, incomplete revascularisation and preoperative hypertension. This study confirms the beneficial effects of internal mammary-LAD artery grafting on long-term survival after coronary artery surgery, and also demonstrates the prejudicial effects of hypertension.

A new rejection criteria in the heterotopically placed rat heart by non-invasive measurement of Dp/Dtmax.

BACKGROUND: The heterotopic heart of rats has been a useful model in the evaluation of immunomodulatory protocols. Graft palpation usually determines the day of rejection. We present in this paper an original method of graft monitoring in allograft rejection. METHODS: Heterotopic cardiac abdominal transplantation was performed in Lewis isografts (n = 15) and in ACI to Lewis allograft (n = 15). A balloon connected to a measurement device was inserted in the left ventricle, and calculation of Dp/Dtmax was possible by recording the intra-left ventricular pressure. A ten-day follow-up was achieved with a daily comparison of palaption, ECG, and Dp/Dtmax. RESULTS: In transplanted hearts, Dp/Dtmax did not change in isografts but significantly decreased in allograft on posttransplantation Day 5 (PTD 5) vs PTD 0.1 and 3 (p < .01). Dp/Dtmax values on PTD 5 and 6 were also statistically significant in allograft vs isograft group (p < .01). Histological analysis at this time showed the occurrence of acute rejection in the allograft group. Graft palpation, and ECG remained normal until PTD 10 and no difference was observed between iso and allo groups. CONCLUSION: This study shows that daily measurement of Dp/Dtmax in heterotopic heart is made possible by our implantable system without interrupting the graft, and gives a more accurate definition of graft rejection than a combination of palpation and ECG. In addition, this method would seem desirable when differences in survival may be expected to be of lesser magnitude.

[Bartonella endocarditis on native valves. Apropos of 2 cases]. / Endocardite a Bartonella sur valve native. A propos de 2 cas.

The authors report two cases of Bartonella endocarditis in native valves. The first case was a 15 year old North African Girl who lived in poor social conditions and was admitted to hospital with pyrexia and congestive heart failure. Investigations revealed massive mitral regurgitation due to ruptured chordae tendinae, vegetations on the pulmonary valve with severe pulmonary hypertension due to persistent ductus arteriosus. After antibiotic therapy, the patient underwent surgery for mitral valve replacement, pulmonary valvuloplasty and closure of the patent ductus arteriosus. The second case was a 39 year old man with no fixed abode with a history of alcoholism who presented with a recurrent ischaemic stroke in a context of infection with a murmur of aortic regurgitation. Echocardiography showed a vegetation on the aortic valve with grade III/IV regurgitation requiring aortic valve replacement with a homograft after antibiotic therapy. The aetiological diagnosis was made a posteriori by the finding of high antibody titres and specific genetic amplification of Bartonella. In patients with negative blood cultures, Bartonella infection should be looked for systematically especially in those living under poor social conditions. The practical diagnostic investigation of endocarditis with negative blood cultures is reviewed.

Modular component separation and reperfusion of abdominal aortic aneurysm sac after endovascular repair of the abdominal aortic aneurysm: a case report.

Transluminal placement of a stent graft in patients with an abdominal aortic aneurysm is a new endovascular technique that offers a potentially less invasive and less risky alternative to open surgery. Complications after stent graft placement are not infrequent, but in most cases secondary endovascular intervention is successful. We describe a late major leak in the aneurysmal sac caused by a distal migration of the iliac limb of a bifurcated graft. This late complication was successfully treated by covered stent placement, excluding and thrombosing completely the reformed aneurysm.

Abdominal aortic aneurysm and congenital pelvic kidney. A rare association.

We report the case of a 65-year-old man who presented with an infrarenal aortic aneurysm in association with a congenital right pelvic kidney vascularized by 2 aortic arteries, 1 of which arose from the aneurysmal aorta and the other from the common right iliac artery. Successful surgery consisted of excising the aneurysmal aortic segment and replacing it with a Dacron tube graft, then implanting the upper renal artery (supplemented by a short segment of saphenous venous graft) in the Dacron prosthesis. We review 6 other cases of this rare pathologic association, found in our search of the literature, and discuss techniques of renal protection and (when necessary) reimplantation of the anomalous arteries.

[Long-term results of the surgical treatment of acute type A thoracic aortic dissection]. / Résultats à distance du traitement chirurgical des dissections aiguës de l'aorte thoracique de type A.

Out of a population of 110 patients operated as an emergency for acute Stanford type A dissection of the thoracic aorta between 1985 and 1994, there were 84 survivors. Seventy-nine were assessed after a mean follow-up period of 47.3 months. The corrected 1 year, 5 year and 10 year survival rates were 69 +/- 5.1%, 53.1 +/- 6% and 42.1 +/- 7.1% respectively. There were 19 deaths during the study period: in two thirds of cases death was due to cardiovascular complications related to the aortic pathology or hypertension. There were 13 reoperations in 12 patients for complications on the initial site of repair or for progression of the pathological process. The average time to reoperation was 21.5 months with an operative mortality of 3 patients (25%). Predictive factors of reoperation were young age (52 +/- 4.4 years vs 60.1 +/- 1.4 years; p = 0.037), the persistence of a patent false lumen (p = 0.033) and the initial surgical techniques as the incidence of reoperation seemed to be higher after treatment with biological glue alone or resuspension of the aortic valve compared with replacement of the ascending aorta or Bentall's procedure (p = 0.08). The incidence of reoperation also varies with time as it was 1.8 +/- 0.7% at 1 year, 18.5 +/- 6.5% at 5 years and 26% +/- 7.8 at 10 years. In spite of improvements in surgical technique and postoperative care, acute type A dissection of the aorta carries a poor prognosis in both the short and the long-term with a notable number of cardiac or other complications related to repair of the initial aorta. Analysis of these and other reported results suggest that initial surgery should be as complete as possible with extension to the aortic arch when involved: this more aggressive attitude should improve the long-term results by reducing the risk of reoperation responsible for a high mortality rate.

[Fissured leiomyosarcoma of the descending thoracic aorta. Apropos of a case and review of the literature]. / Léiomyosarcome fissuré de l'aorte thoracique descendante. A propos d'un cas, revue de littérature.

The authors report a case of leiomyosarcoma of the descending thoracic aorta presenting with dissection and operated as an emergency. Palliative repair from the oncological point of view comprised the insertion of an aorto-aortic tube. Local radiotherapy was completed by a course of chemotherapy controlling multiple bone and adrenal metastases at 15 months. A review of the literature did not reveal any other cases of haemorrhagic leiomyosarcoma of the descending thoracic aorta. Histological findings were similar to those of the reported case as were the therapeutic attitudes to limit or extinguish disseminated metastases explained by the arterial character of the tumour.

[Reconstruction of the anterior chest wall by a sandwich-type combination of a synthetic support and a muscle flap from the latissimus dorsi. Apropos of a case]. / Reconstruction de la paroi thoracique antérieure par l'association, en sandwich, d'un support synthétique et d'un lambeau musculaire de latissimus dorsi. A propos d'un cas.

Reconstruction of the chest wall after balistic or other trauma requires good and muscle cover and creation of a new, stable and airtight wall. The authors present a case of balistic trauma of the right anterolateral chest wall which was urgently debrided and subsequently reconstructed by sandwich combination of a latissimus dorsi muscle flap and synthetic material composed of a sheet of PTFE and creation of two methylmethylacrylate ribs. The advantage of this technique is that it avoids the use of autologous tissue from an already weakened chest wall and confers a new chest stability in several sites corresponding to the wall defect with easily available and easy-to-use materials.

Cardiac surgery in the ninth decade of life.

This study considers 96 consecutive patients of more than 80 years of age who were referred for surgery for either valve replacement (n = 51) or myocardial revascularization (n = 45) between 1985 and 1992. The patients having valve surgery consisted chiefly or aortic valve replacements (AVR), with a total of 48 (isolated in 44 and combined with another valve in 4 cases) being performed. Some 70% were in New York Heart Association (NYHA) class III and IV and 21.5% had experienced syncope. Bioprosthetic valves were implanted in all patients with an average aortic cross-clamping time of 58 min. The 1-month mortality rate was 9.8% (5/51, one mitral valve replacement and four aortic valve replacements). Death was caused by perioperative haemorrhage (one), low cardiac output (one), cardiopulmonary failure (two) and multiorgan failure (one). The morbidity rate was 64%. The actuarial survival rate was 76, 67 and 46% at 1, 2 and 4 years, respectively. By 4 years 89% were in NYHA stages I and II, of the 45 patients having coronary artery bypass grafts, 85% were in NYHA class III or IV and 69% had progressive unstable angina. Some 29% had a stenosis of the left main coronary artery and 51% had multivessel disease. Each patient had a mean of two venous grafts. The in-hospital mortality rate was 11% (5/45) and 13% had a postoperative myocardial infarction. The actuarial survival rate was 80, 77, 60 and 58% at 1,2,3 and 5 years, respectively, with 85% in NYHA class I or II. In spite of their chronological age, many octogenarian patients who are in good physical condition can be operated upon for coronary artery bypass grafts or aortic valve replacement with an acceptable operative risk, good surgical outcome with improved quality of life.

[Traumatic rupture of the thoracic aorta]. / Roturas traumáticas de la aorta torácica.

This is a retrospective analysis of 50 postraumatic aortic rupture (1968-1996, 39 males, mean age: 34.5). Group A is composed of 35 patients with an acute aortic rupture and a prompt diagnosis. Group B includes 13 patients with a chronic rupture. All patients from group A had a severe politraumatism with abdominal, cranial, extremities or hip fractures. Mediastinal thickening with or without hemothorax indicated an angiography or a transesophageal echocardiography lately. In group A, 36 patients have been operated on urgently (12-24 hours); cardiopulmonary bypass was performed on 20 patients; an aorto-aortical bypass was done in 27 cases and a direct suture in the remaining 9. In group B, cardiopulmonary bypass was performed on 9 patients; a aorto-aortical bypass was done in 11 cases and a direct suture in 2. Overall hospital mortality was 16%; 19% in group A and 7.6% in group B. Ischemic paraplejia appeared in 5 patients (10%), all from group A. No false aneurysm developed after 4.5 years of follow-up (3-135 months) in the 38 survivors. The usefulness of transesophageal echocardiography, the importance of medular protection and the utility of several interventionist radiologic techniques are discussed.