Aortic valve repair versus mechanical valve replacement for root aneurysm: the CAVIAAR multicentric study.

OBJECTIVES: Despite growing evidence that aortic valve repair improves long-term patient outcomes and quality of life, aortic valves are mostly replaced. We evaluate the effect of aortic valve repair versus replacement in patients with dystrophic aortic root aneurysm up to 4 years. METHODS: The multicentric CAVIAAR (Conservation Aortique Valvulaire dans les Insuffisances Aortiques et les Anévrismes de la Racine aortique) prospective cohort study enrolled 261 patients: 130 underwent standardized aortic valve repair (REPAIR) consisting of remodelling root repair with expansible aortic ring annuloplasty, and 131 received mechanical composite valve and graft replacement (REPLACE). Primary outcome was a composite criterion of mortality, reoperation, thromboembolic or major bleeding events, endocarditis or operating site infections, pacemaker implantation and heart failure, analysed with propensity score-weighted Cox model analysis. Secondary outcomes included major adverse valve-related events and components of primary outcome. RESULTS: The mean age was 56.1 years, and valve was bicuspid in 115 patients (44.7%). Up to 4 years, REPAIR did not significantly differ from REPLACE in terms of primary outcome [Hazard Ratio (HR) 0.66 (0.39; 1.12)] but showed significantly less valve-related deaths (HR 0.09 [0.02; 0.34]) and major bleeding events (HR 0.37 [0.16; 0.85]) without an increased risk of valve-related reoperation (HR 2.10 [0.64; 6.96]). When accounting for the occurrence of multiple events in a single patient, the REPAIR group had half the occurrence of major adverse valve-related events (HR 0.51 [0.31; 0.86]). CONCLUSIONS: Although the primary outcome did not significantly differ between the REPAIR and REPLACE groups, the trend is in favour of REPAIR by a significant reduction of valve-related deaths and major bleeding events. Long-term follow-up beyond 4 years is needed to confirm these findings.

Standardized approach to valve repair using an expansible aortic ring versus mechanical Bentall: early outcomes of the CAVIAAR multicentric prospective cohort study.

OBJECTIVE: The study objective was to compare the 30-day outcomes of a standardized aortic valve repair technique (REPAIR group) associating root remodeling with an expansible aortic ring annuloplasty versus mechanical composite valve and graft (CVG group) replacement in treating aortic root aneurysms. METHODS: A total of 261 consecutive patients with aortic root aneurysm were enrolled in this multicentric prospective cohort (131 in the CVG group, 130 in the REPAIR group) in 20 centers. The main end point is a composite criterion including mortality; reoperation; thromboembolic, hemorrhagic, or infectious events; and heart failure. Secondary end points were major adverse valve-related events. Crude and propensity score adjusted estimates are provided. RESULTS: The mean age was 56.1 years, and the valve was bicuspid in 115 patients (44.7%). The median (interquartile range) preoperative aortic insufficiency grade was 2.0 (1.0-3.0) in the REPAIR group and 3.0 (2.0-3.0) in the CVG group (P = .0002). Thirty-day mortality was 3.8% (n = 5) in both groups (P = 1.00). Despite a learning curve and longer crossclamp times for valve repair (147.7 vs 99.8 minutes, P < .0001), the 2 groups did not differ significantly for the main criterion (odds ratio, 1.31; 95% confidence interval, 0.72-2.40; P = .38) or 30-day mortality (odds ratio, 0.99; 95% confidence interval, 0.28-3053; P = .99), with a trend toward more frequent major adverse valve-related events in the CVG group (odds ratio, 2.52; 95% confidence interval, 0.86-7.40; P = .09). At discharge, 121 patients (96.8%) in the REPAIR group had grade 0 or 1 aortic insufficiency. CONCLUSIONS: A new standardized approach to valve repair, combining an expansible aortic annuloplasty ring with the remodeling technique, presented similar 30-day results to mechanical CVG with a trend toward reducing major adverse valve-related events. Analysis of late outcomes is in process for 3- and 10-year follow-ups.

An uncommon cause of renovascular hypertension.

Renovascular hypertension is usually due to an atherosclerotic artery stenosis or a fibromuscular dysplasia. We describe an uncommon cause of renal ischemia. A 66-year-old woman was admitted for severe hypertension. During her stay, she presented an acute myocardial infarction with normal coronary angiography. After a flank pain, a contrast-enhanced abdominal computed tomography scan was performed which revealed a stenosis of the left main renal artery. However, renal angiography displayed a thrombosis. Transesophageal echocardiography showed a mobile mass attached to the mitral valve. A diagnosis of renal artery thrombosis and acute myocardial infarction both resulting from a cardiac tumour embolism was established.

Percutaneous drainage of postoperative pericardial effusion in cardiac surgery.

BACKGROUND AND AIM OF THE STUDY: Postoperative pericardial effusion is frequent and can be complicated by cardiac tamponade. Although the different drainage techniques are well described in the setting of medical effusion, there is not a standard postoperative effusion treatment. The aim of this work was to assess the feasibility and effectiveness of the percutaneous pericardial drainage. METHODS: This a retrospective study involving 197 patients from 1990 to 2008. Drainage was performed by subxiphoid puncture (91.9%) or left parasternal puncture (8.1%) between 3 and 690 days following a cardiac procedure via median sternotomy. Effusion thickness was at least 10 mm in the subcostal echocardiography view. RESULTS: No deaths directly related to the procedure were observed. Complete and enduring drainage was achieved in 158 patients (80.2%). The procedure failed for 22 patients (11.2%) because no fluid was drained in 14 cases (7.1%) and a right ventricular puncture in 8 cases (4.1%). Recurrence of the effusion, which occurred for 17 patients (8.6%), was more frequent if an effusion of more than 5 mm persisted after the first drainage (P = 0.024) and if the drainage was performed outside the operating room because of emergency (P = 0.046). Risk factors for mortality were recurrence of the effusion (P = 0.04) and drainage performed outside the operating room (P = 0.007). CONCLUSIONS: Percutaneous pericardial drainage is effective to treat postoperative pericardial effusion. When the effusion is thicker than 10 mm and accessible, it can be the initial strategy and surgical drainage can serve as an alternate strategy in case of failure and complications of this procedure.

Benefits of home-based endurance training in lung transplant recipients.

BACKGROUND: To investigate the effect of home-based exercise training on exercise tolerance, muscle function and quality of life in lung transplant recipients (LTR). METHODS: Twelve LTR and 7 age-matched healthy subjects underwent exercise training (ET, 12-wk, 3×/wk, 40 min). Peak aerobic capacity VO2peak, endurance time (T(end)), minute ventilation (VE) quadriceps strength, percentage of type I fiber (%Ifb), fiber diameters and chronic respiratory questionnaire were assessed before and after ET. A positive response to ET was defined as an improvement in T(end) at least comparable to the mean change observed in healthy subjects. RESULTS: Training significantly improved T(end) (+12 ± 11 min), isowatt during exercise (-5.5 ± 2.6L/min), muscle strength (+4.6 ± 2.6 kg) and dyspnea score (+0.6 ± 0.9) in LTR (p < 0.05), leading to recovery of T(end) and muscle strength up to healthy subjects' values. In responders (n = 6), VO2peak, %Ifb and fatigue score were improved after training (p < 0.05). Non-responders had lower %Ifb and greater delay between surgery and the beginning of the study than responders (56 [21-106] vs. 8 [2-59] months respectively, p = 0.03). CONCLUSIONS: Home-based ET was effective to improve exercise tolerance, muscle strength and quality of life in LTR but more successful in patients with moderate muscle dysfunction and in the first years after transplantation. Multicenter and controlled-studies are needed to confirm the benefits and optimal modalities of home training in LTR.

Remodeling of the aortic root combined to an expansible aortic ring annuloplasty.

Aortic root aneurysms are characterized by dilation of both functional aortic annulus diameters (aortic annular base and sino-tubular junction), preventing coaptation of otherwise pliable valves often associated with cusp prolapse. Multiple techniques of aortic valve sparing procedures try to restore the complex interplay of aortic valve and root function in order to improve durability of the repair. Ideally, procedures should treat dilatation of the aortic annular base, while preserving dynamics of the aortic root with vortices (neosinuses of Valsalva) and root expansibility (interleaflet triangles). We describe a standardized approach, combining the advantages of both the remodeling and reimplantation technique by adding an external subvalvular ring annuloplasty to the physiological remodeling of the aortic root. To address the need for a dedicated aortic annuloplasty device, a new expansible aortic ring was designed in order to achieve a complete and calibrated annuloplasty in diastole, while maintaining systolic expansibility of the aortic root.

An aortic ring: from physiologic reconstruction of the root to a standardized approach for aortic valve repair.

OBJECTIVE: We suggest standardizing aortic valve repair using a physiologic approach by associating root remodeling with resuspension of the cusp effective height and external subvalvular aortic ring annuloplasty. METHODS: A total of 187 patients underwent remodeling associated with subvalvular aortic ring annuloplasty (14 centers, 24 surgeons). Three strategies for cusp repair were evaluated: group 1, gross visual estimation (74 patients); group 2, alignment of cusp free edges (62 patients); and group 3, 2-step approach, alignment of the cusp free edges and effective height resuspension (51 patients). The composite outcome was defined as recurrence of aortic insufficiency of grade 2 or greater and/or reoperation. RESULTS: The operative mortality rate was 3.2% (n = 6). Treatment of a cusp lesion was most frequently performed in group 3 (70.6% vs 20.3% in group 1 and 30.6% in group 2, P < .001). Nine patients required reoperation during a follow-up period of 24 months (range, 12-45), 6 patients in group 1 and 3 patients in group 2. At 1 year, no patients in group 3 presented with composite outcome events compared with 28.1% in group 1 and 15% in group 2 (P < .001). Residual aortic insufficiency and tricuspid anatomy were independent risk factors for the composite outcome in groups 1 and 2. The annulus diameter, the presence of Marfan syndrome, and cusp repair had no effect on aortic insufficiency recurrence or reoperation. CONCLUSIONS: A standardized and physiologic approach to aortic valve repair, considering both the aorta (root remodeling) and the valve (resuspension of the cusp effective height and subvalvular ring annuloplasty) improved the preliminary results and might affect their long-term durability. The ongoing Conservative Aortic Valve Surgery for Aortic Insufficiency and Aneurysm of the Aortic Root (CAVIAAR) trial will compare this strategy to mechanical valve replacement.

Giant intracardiac neoplasic thrombus of a large cell neuroendocrine carcinoma of the lung.

Cardiac invasion by lung cancer is associated with a poor prognosis. We describe the case of a large cell neuroendocrine carcinoma of the lung with left intra-atrial extension in a patient presenting with a catastrophic nutritional status.

[Percutaneous extracorporeal life support in acute severe hemodynamic collapses: single centre experience in 100 consecutive patients]. / Assistance circulatoire extracorporelle percutanée dans les défaillances hémodynamiques aiguës graves: expérience monocentrique chez 100 patients consécutifs.

BACKGROUND: Extracorporeal life support (ECLS) is a circulatory assistance device that is increasingly used in adults undergoing cardiopulmonary arrest (CPA) or hemodynamic collapse when conventional therapies fail. OBJECTIVES: To assess the feasibility and outcomes of 100 consecutive arteriovenous percutaneous ECLS procedures at the Grenoble University Hospital between January 2002 and September 2007. METHODS: Monocentric descriptive registry with one-year prospective follow-up. RESULTS: An ECLS device was successfully used in 93% of patients. Its indication was cardiogenic shock in 50% of the cases, CPA in 38% of the cases and unsuccessful weaning of cardiopulmonary bypass (CPB) after cardiothoracic surgery in 12% of the cases. Direct complications of ECLS were observed in 56% of patients, the most frequent being hemorrhage at the intravenous puncture site requiring red blood cell transfusions (26%), and lower limb ischemia (19%). Weaning from ECLS was achieved in 33 patients (44% cardiogenic shocks, 13% CPAs, 50% CPB weaning failures) and 20 patients were discharged from the hospital (26% cardiogenic shocks, 10.5% CPAs and 25% CPB weaning failures). All are still living without any serious sequelae (mean follow-up period of 16.8 months). CONCLUSION: The use of ECLS in CPA patients, especially with cardiogenic shock, is feasible with satisfactory survival rates, given the extreme severity of their initial state.

Endovascular stent-graft management of aortic intramural hematomas.

PURPOSE: To report initial experience with endovascular stent-grafting in aortic intramural hematoma (IMH). MATERIALS AND METHODS: From 2000 to 2006, 15 patients (mean age, 67 years; range, 54-83 y) underwent endovascular treatment of aortic IMH. Thirteen patients were admitted for acute aortic syndrome and two for traumatic aortic injury. An endovascular procedure was performed as primary treatment for four patients (type A IMH, n = 3; type B IMH, n = 1) and as a second-line therapy in 11 patients because of unfavorable evolution (type A IMH, n = 1; type B IMH, n = 10). All stent-grafts were placed in the descending aorta, even for type A IMH. The mean follow-up was 21 months (range, 6-72 months). RESULTS: The primary success rate was 93%, with complete exclusion of the lesion (n = 14). Exclusion was partial for one patient with a type I endoleak (7%). The 30-day mortality rate was zero. IMH evolution was favorable in all cases, with decreased aortic wall thickening (n = 8) or complete regression (n = 7). Complications associated with endovascular repair were mainly related to aneurysm formation (20%). The late death rate was 7%. CONCLUSIONS: Endovascular stent-graft treatment can be performed in the management of complicated IMH, even in some cases of type A IMH, when an intimal lesion is located in the isthmus or descending aorta with contraindications to surgery. This procedure offers low morbidity and mortality rates, representing a feasible therapeutic option especially for elderly patients with comorbidities. Further studies are necessary to confirm these preliminary results.

Prevalence, therapeutic management and medium-term prognosis of spontaneous coronary artery dissection: results from a database of 11,605 patients.

OBJECTIVE: To assess the prevalence, clinical presentation, therapeutic management and medium-term prognosis of spontaneous coronary artery dissection (SCAD). METHODS: Over a 5-year period, and out of a cath-lab database of 11,605 files, 23 cases of SCAD were confirmed by re-analysis of angiograms. Therapeutic management and in-hospital outcome were obtained from medical files and prospective follow-up was performed. RESULTS: The population consisted of 17 women and 6 men (mean age 45 years). A total of 83% of men had >/=2 cardiovascular risk factors versus only 35% of women (p=0.07). Acute coronary syndrome (ACS) was the clinical presentation in 21 cases (ST+ 61%). The prevalence of SCAD was: 0.2% in the whole population (men: 0.07%, women: 0.6%, p<0.001), and 8.7% and 10.8% in women <50 years with ACS and ST+ ACS, respectively. Left and right coronary arteries were involved in 20 (87%) and 3 (13%) cases, respectively. Coronary stenting alone was performed in 8 (35%), bypass surgery alone in 2 (9%), and both in 3 (13%) cases. Ten patients (44%) were medically managed. One patient died during hospitalization. At 1-year follow-up (100%), 77% of discharged patients were event-free. One patient died, four experienced heart failure, and none had angina or new ACS. CONCLUSION: SCAD is observed in as much as 1 out 10 women <50 years presenting with ACS. After immediate coronary angiography, medical therapy is the chosen strategy in half of cases. Most patients who survive the acute phase are free from coronary events at 1 year.

[Isolated coronary surgery in the octogenarian. Immediate results and analysis of long-term survival rate and quality of life]. / Chirurgie coronaire isolée chez l'octogenaire: Résultats immédiats et analyse du taux de survie et de la qualité de vie à long terme.

BACKGROUND: There are almost three million octogenarians living in France, many of whom present with a coronaropathy. Moreover, it appears that life expectancy at 80 years of age is still important. OBJECTIVE: To evaluate the results of coronary surgery among these patients. METHODS: Eighty-eight consecutive octogenarians who had an isolated coronary artery bypass surgery between 1996 and 2002 were compared with 165 patients 60 to 70 years of age; the two groups had been paired according to the main risk factors. Patients were contacted by telephone and then received a quality-of-life-related questionnaire. RESULTS: Operative mortality was 2.3% in the octogenarian versus 1.2% in the 60- to 70-year-old group (P not significant). There was more low cardiac output syndrome, postoperative acute renal failure and transfusion in octogenarians. Long-term survival (average duration of follow-up was 3.8 years) was higher in the 60- to 70-year-old group: 89.7% versus 77.9% (P=0.025). Four independent risk factors of long-term increased mortality were found: age, diabetes, history of stroke and postoperative blood transfusion. Finally, the long-term survival in the octogenarians who had this surgery was higher than in the octogenarians of the general French population to a significant degree, with a quality of life considered to be satisfactory. CONCLUSION: For selected octogenarians, an isolated coronary surgery can be proposed, with short- and long-term results comparable with those of a younger population.

Giant aneurysm of the proximal segment of the left anterior descending artery in a patient with Behçet's disease--a combined approach.

Behçet's disease is an autoimmune, multisystem disease presenting with recurrent oral and genital ulceration as well as ocular involvement. Aneurysmal degeneration of coronary arteries remains a rare phenomenon in Behçet's disease. The case of a patient with Behçet's disease who presented with severe stenosis of the left anterior descending artery associated with a giant aneurysm of the proximal segment is described. Surgical revascularization was proposed, followed by percutaneous embolization of the aneurysm.

Preoperative predictive factors for mortality in acute type A aortic dissection: an institutional report on 217 consecutives cases.

Surgical treatment of type A acute aortic dissection remains a challenge, especially in elderly patients or in patients with a critical preoperative status. We have retrospectively assessed our series over a 15-year period starting in 1990, including patients operated under cardiac massage for preoperative cardiac arrest occurring in the operating room. There were 217 patients (mean age, 61.5+/-13.5 years; 16 patients >80 years). Preoperative shock was noted in 21.7%, including 14 patients operated under cardiac massage. Operating procedures were: modified Bentall (31%), aortic tube (67.1%), other (1.9%), aortic arch procedure in 26.4%. Overall mortality rate was 19.8% with an exponential increase with age (50% over 80 years). Of 14 patients operated under cardiac massage, three have been discharged: one ventricular fibrillation due to an acute myocardial infarction and two among the 13 with acute aortic ruptures in cardiac arrest (one being a redo, the adhesions limiting the tamponade). Our results confirmed age and preoperative shock prior to surgery as risk factors, and the fact that operating on a patient under cardiac massage for cardiac arrest due to an aortic rupture is probably not a reasonable therapeutic choice.

Emergency endovascular stent graft repair for acute blunt thoracic aortic injury: a retrospective case control study.

OBJECTIVE: To compare surgical and endovascular stent graft (ESG) treatment of blunt thoracic aortic injury (BAI) in the emergency setting. DESIGN AND SETTING: Retrospective case control study in two surgical intensive care units of a university hospital. PATIENTS: 30 patients who presented with BAI between 1995 and 2005: 17 treated surgically and 13 by ESG. The two groups were comparable for the severity of trauma and mean delay before treatment; the mean age was higher in the ESG group (46+/-18 vs. 35+/-15 years). RESULTS: In the surgical group time spent in the operating theater was longer (310+/-130 vs. 140+/-48 min) and blood losses higher (2000+/-1300 vs. no significant bleeding); aortic clamping time was 48+/-20 min. The mortality rate was 15% with ESG (n=2) and 23% with surgery (n=4). Complications of the procedure were more frequent in the surgical group (1 vs. 7). In the ESG group there was one pulmonary embolism. In the surgical group there were three neurological complications, one acute aortic dissection, one perioperative rupture, one periprosthetic leak, and one septic shock. Two complications (postoperative aortic dissection and paraplegia) appeared in the same patient in the surgical group. Intensive care unit length of stay, duration of mechanical ventilation, and catecholamine support were similar in the two groups. CONCLUSIONS: Stent graft for emergency treatment of BAI is efficient and is associated with fewer complications than surgical treatment.

Functional coupling of adenine nucleotide translocase and mitochondrial creatine kinase is enhanced after exercise training in lung transplant skeletal muscle.

Mechanisms responsible for limitation of exercise capacity in lung transplant recipients (LR) and benefits gained by exercise training were studied. Mitochondrial respiration parameters, energy transfer, and cell structure were assessed in vastus lateralis biopsies using the permeabilized fiber technique with histochemical and morphometric measurements. Twelve male controls (C) and 12 LR performed exercise training over 12 wk. Before exercise training, there were strong correlations between exercise capacity (maximal O(2) consumption and endurance time at 70% maximal power output) and cellular events, as assessed by percentage of type I fibers and apparent K(m) for exogenous ADP. Anticalcineurins were not involved in LR exercise limitation, since there were no differences in maximal mitochondrial rate of respiration before exercise training and no abnormalities in respiratory chain complexes compared with C. Training resulted in a significant increase in physiological parameters both at the cellular (apparent K(m) for exogenous ADP and stimulating effect of creatine) and integrated (maximal O(2) consumption, power output at ventilatory threshold, maximal power output, and endurance time at 70% maximal power output) levels in LR and C. After the training period, improvements in maximal O(2) consumption and in maximal mitochondrial rate of respiration were noted, as well as changes in endurance time and percentage of type I fibers. Because there were no changes in diameters and fiber types, baseline alteration of apparent K(m) for exogenous ADP and its improvement after training might be related to changes within the intracellular energetic units. After the training period, intracellular energetic units exhibited a higher control of mitochondrial respiration by creatine linked to a more efficient functional coupling adenine nucleotide translocase-mitochondrial creatine kinase, resulting in better exercise performances in C and LR.

Coronary artery bypass grafting with left internal mammary artery and right gastroepiploic artery, with and without bypass.

BACKGROUND: Total arterial and off-pump revascularization are increasingly used in coronary artery bypass grafting. This study describes our experience with the exclusive use of both left internal thoracic artery and gastroepiploic artery by means of a median sternotomy, with and without cardiopulmonary bypass, in a subgroup of patients with two-vessel disease. METHODS: From January 1995 to July 2000, 171 consecutive patients were reviewed in a prospective database. Ninety-one patients underwent coronary artery bypass grafting without cardiopulmonary bypass (group A), and 80 patients were operated on under cardiopulmonary bypass with aortic cross-clamp and cardioplegia (group B). RESULTS: Patient data were similar in both groups except for the Euroscore (mean; 3.4+/-6.1, group A versus 2.5+/-4.5, group B; Euroscore > 6: 26.4%, group A versus 10%, group B; p < 0.05) and ejection fraction (mean, 54.6%+/-15.8%, group A versus 63.1%+/-12.7%, group B; p < 0.001). Severe aortic calcification was present in 6 group A patients, versus no patient in group B. Operative time was shorter in group A (185 versus 213 minutes, p < 0.0001), with less distal anastomoses (2.26 versus 2.5, p < 0.05). Conversion to cardiopulmonary bypass occurred in 1 patient, who was excluded from the study. Bleeding was higher in group A (852.6+/-288 mL versus 712.4+/-274 mL, p < 0.05), but transfusion was similar in both groups. Atrial fibrillation, postoperative inotropic support, and hospital stay were similar in both groups. Myocardial infarction was less frequent in group A (1 versus 4). Postoperative intraaortic balloon pump was used in 2 patients (group B). One patient died (group A) and 1 had an embolic stroke (group B). After discharge, 2 more patients died (group A, day 91; group B day 141), and 1 patient suffered an embolic stroke (group B). One patient in each group presented with dysfunction of the gastroepiploic artery graft requiring successful percutaneous transluminal angioplasty on the right posterolateral artery. CONCLUSIONS: These results suggest that off-pump coronary artery bypass grafting using the left internal thoracic artery and gastroepiploic artery is safe even in high-risk patients. This approach allows an absolute no-touch technique of the aorta.