Left atrial dissection after a supra-annular mitral valve replacement for endocarditis.

BACKGROUND: Left atrial dissection is a rare and a potentially fatal complication of cardiac surgery. Multi-modal imagery is helpful for the diagnosis and to guide the treatment. CASE PRESENTATION: We report the case of a 66-year-old female patient who underwent a combined mitral and aortic valve replacement for degenerative valvular disease. She presented an infectious endocarditis revealed by a third-degree atrioventricular bloc and had a redo mitral- and aortic valve replacement. Mitral valve was inserted in supra-annular position due to annular destruction. Post-operative course was marked by a refractory acute heart failure explained by a left atrial wall dissection confirmed by transoesophageal echocardiography and synchronized cardiac CT-scan. Surgical treatment was theoretically indicated but considering the high risk of a third surgery, a palliative care support was collegially decided. CONCLUSIONS: Left atrial dissection can occur after a redo surgery and supra-annular mitral valve implantation. Multi-modal imagery including transoesophageal echocardiography and cardiac CT-scan is helpful for the diagnosis.

Catheter versus surgical approach for the management of concomitant aortic stenosis and coronary artery disease: An inverse probability treatment weighting analysis.

BACKGROUND: Two therapeutic strategies are available when aortic stenosis and coronary artery disease coexist: a transcatheter approach, with percutaneous coronary intervention followed by transcatheter aortic valve replacement; and a surgical approach, consisting of surgical aortic valve replacement combined with coronary artery bypass graft. AIM: We sought to compare the outcomes of these two strategies. METHODS: The study population consisted of 241 patients who benefited from aortic valve replacement and coronary revascularization (transcatheter, n=150; surgery, n=91). RESULTS: Patients in the transcatheter population were older (83.5 vs. 71.8years; P<0.001) and had a higher Logistic EuroSCORE (11.1% vs. 5.7%; P<0.001). At 30days postprocedure, patients who had surgery exhibited more life-threatening bleedings (12.1% vs 4.5%; P=0.034), acute kidney injury (12.1% vs. 1.3%; P<0.001) and atrial fibrillation (55.6% vs. 8.7%; P<0.001). After a median follow-up of 27months, the risk of major adverse cardiovascular or cerebrovascular events did not differ significantly between the two strategies (hazard ratio [HR] 1.41, 95% confidence interval [CI] 0.97-2.04; P=0.07), whereas estimated glomerular filtration rate<60mL/min (HR 2.22, 95% CI 1.58-3.12; P<0.001), peripheral artery disease (HR 2.00, 95% CI 1.37-2.91; P<0.001) and left ventricular ejection fraction<50% (HR 1.69, 95% CI 1.12-2.55; P=0.012) were associated with a negative prognosis. CONCLUSIONS: In our study, patients with aortic stenosis and coronary artery disease treated by catheter were older and had a higher co-morbidity burden than those treated by surgery. The surgical strategy was associated with a higher rate of 30-day complications, but long-term outcomes were similar between the two strategies.

Obesity and Preoperative Anaemia as Independent Risk Factors for Sternal Wound Infection After Coronary Artery Bypass Graft Surgery with Pedicled (Non-Skeletonized) Internal Mammary Arteries: The Role of Thoracic Wall Ischemia?

PURPOSE: Obesity remains statistically associated with coronary artery disease, for which coronary artery bypass graft surgery (CABG) remains the standard of care. However, obesity is also associated with sternal wound infection (SWI) which is a severe complication of CABG despite advances in surgery and in infection prevention and control. Strategies to reduce the incidence of SWI are still being investigated, and we therefore conducted a retrospective study to revisit factors other than obesity associated with SWI after CABG. PATIENTS AND METHODS: Data were extracted from the medical records of 182 patients who underwent elective on-pump CABG using one or both pedicled internal mammary artery grafts in Reims University Hospital between May 2015 and May 2016. All preoperative or perioperative variables with a p value<0.10 in univariate analysis were entered into a stepwise logistic regression model. RESULTS: Among the 182 patients (145 male (79.6%), median age 68.0 [45.0-87.0] years), 138 (75.8%) underwent CABG using bilateral internal mammary artery grafts. Median BMI was 27.7 [18.7-50.5] kg/m2, and there were 51 (28.0%) and 79 (43.4%) patients with obesity and overweight, respectively. Twenty-three out of the 182 patients (12.6%) developed SWI. In-hospital mortality was not statistically different between patients with and without SWI but the median length of stay was (6.0 [2.0-38.0] versus 5.0[3.0-21.0] days in the intensive care unit, p=0.03, and 26.0 [9.0-134.0] versus 9.0 [7.0-51.0] days in hospital, p<0.0001). Obesity and preoperative anaemia were independently associated with SWI, as was the number of red blood cell (RBC) units transfused (OR 14.61 [2.64-80.75], OR 4.64 [1.61-13.34] and OR 1.27 [1.02-1.58], respectively). CONCLUSION: The independent association of SWI with the number of RBC units transfused and the existence of preoperative anaemia and obesity suggests a mechanism of thoracic wall ischemia in SWI after CABG, thus leaving insufficient perfusion of the thoracic wall in patients with obesity. Medical strategies are warranted to try to prevent this costly complication.

Negative Pressure versus Conventional Sternal Wound Dressing in Coronary Surgery Using Bilateral Internal Mammary Artery Grafts.

BACKGROUND: Sternal wound infection (SWI) is a major complication occurring often after coronary artery bypass grafting (CABG) using bilateral internal mammary artery (BIMA) grafts. The aim of this study is to assess whether such a risk may be reduced by using incision negative pressure wound therapy (INPWT). METHODS: Data on patients undergoing isolated CABG using BIMA grafts at the Reims University Hospital, France, from 2013 to 2016 without or with INPWT was prospectively collected.  Results: INPWT was used in 161 patients and conventional sterile wound dressing was used in 266 patients. Propensity score matching resulted in 128 pairs with similar characteristics. SWIs were similarly distributed between the conventional sterile wound dressing (10.9%) and the INPWT cohorts (10.2%) (P = 1.00). Patients treated with INPWT had a lower rate of deep SWI/mediastinitis than patients who had conventional sterile dressing (5.5% versus 10.2%, P = .210), but the difference did not reach statistical significance. Tests for interaction confirmed these findings in different patient subgroups. CONCLUSION: The routine use of INPWT may not significantly reduce the risk of SWI in patients undergoing BIMA grafting. In view of previous reports showing a benefit with the use of this method, a large randomized study is justified to assess the efficacy of INPWT in patients undergoing cardiac surgery.

How to perform a haemodialysis using the arterial and venous lines of an extracorporeal life support.

Continuous renal replacement therapy is particularly suited in the setting of acute renal failure, occurring after cardiac surgery, in patients requiring extracorporeal life support (ECLS) or membrane oxygenation. In such patients, temporary catheters are not necessary since the circuit of haemodialysis or haemofiltration may be connected on the ECLS cannulae. We report how to modify a classical ECLS circuit to connect directly the haemodialysis (Prismaflex device, Gambro-Hospal, Lyon, France) to the ECLS. We also detail parameters used to initiate the haemodialysis. Actually, we modify all our ECLS circuits as described here, at implantation time, allowing rapid haemodialysis initiations. Since 2004, 21 patients have been treated, as described here, without supplemental mortality or related complication.

Diaphragmatic rupture during labour, two years after an intra-oesophageal rupture of a bronchogenic cyst treated by an omental wrapping.

We report the case of a 27-year-old pregnant woman, presenting a rare but potentially fatal complication of an omental wrapping, transposed in the thorax by a phrenotomy due to an intra-oesophageal rupture of a bronchogenic cyst. Two years later, on time of delivery of her first pregnancy, she has presented a diaphragmatic rupture with a complete transposition of the volvuled stomach. The diagnosis was done using the Gastrographin transit and the CT-scan, showing the specific 'Collar sign'. An urgent surgical correction was performed including the re-instatement of all abdominal organs in the peritoneum, the omental wrapping section and the diaphragmatic closure. The two-year follow-up was uneventful. We discuss the case, the investigations needed and the possibility to cut the omental wrapping without any complication two years after this oesophageal re-inforcement. In conclusion, we believe that omental transpositions must always be done using the retrosternal route or by transhiatal approach to avoid this serious complication after delivery.

How to replace an extracorporeal life support without interruption of the cardiopulmonary assistance.

The extracorporeal life support (ECLS) allows a maximum of a few weeks of cardio-respiratory assistance. Using standard ECLS, the circuit must be replaced after a few days or sometimes more frequently, in case of dysfunction. Classically, the replacement needs the interruption of the support inducing a temporarily hemodynamic instability. We report a simple technique, allowing this replacement without interruption of the assistance, based on the implantation of a new circuit in parallel. We describe the original modification, the complete procedure and our results. This method has been used in 34 ECLS replacements in 14 patients without any incident or thrombo-embolic events. This simple technique is safe, reliable, and avoids the hemodynamic instability induced by classical replacements.

A safe option to perform an apparent difficult redo surgery.

A 50-year-old female operated of Bentall five years before was referred to our hospital for an aneurysm of both right subclavian artery and brachiocephalic trunk associated with a false anastomotic aneurysm on the insertion of the left coronary artery. The procedure was performed under moderate hypothermic circulatory arrest; the false aneurysm was repaired, the brachiocephalic trunk and the subclavian aneurysm were resected, an aorto-carotid and axillary bypass were finally performed. The postoperative course was uneventful. She was discharged to home on postoperative day 7. At six-month follow-up, she was still asymptomatic.

FTIR protein secondary structure analysis of human ascending aortic tissues.

The advent of moderate dilatations in ascending aortas is often accompanied by structural modifications of the main components of the aortic tissue, elastin and collagen. In this study, we have undertaken an approach based on FTIR microscopy coupled to a curve-fitting procedure to analyze secondary structure modifications in these proteins in human normal and pathological aortic tissues. We found that the outcome of the aortic pathology is strongly influenced by these proteins, which are abundant in the media of the aortic wall, and that the advent of an aortic dilatation is generally accompanied by a decrease of parallel beta-sheet structures. Elastin, essentially composed of beta-sheet structures, seems to be directly related to these changes and therefore indicative of the elastic alteration of the aortic wall. Conventional microscopy and confocal fluorescence microscopy were used to compare FTIR microscopy results with the organization of the elastic fibers present in the tissues. This in-vitro study on 6 patients (three normal and three pathologic), suggests that such a spectroscopic marker, specific to aneurismal tissue characterization, could be important information for surgeons who face the dilemma of moderate aortic tissue dilatation of the ascending aortas.

New technique of aortic root reconstruction with aortic valve annuloplasty in ascending aortic aneurysm.

We describe a new technique of aortic valve conservation for ascending aortic aneurysm with aortic valvular insufficiency. This technique allows a total anatomic aortic root reconstruction associated with an aortic annuloplasty preventing late annulus dilation and reoperation. Preliminary results demonstrate the feasibility and the safety of this new original procedure.

Anterior mitral leaflet augmentation with autologous pericardium.

The results of mitral repair for rheumatic valve insufficiency are still suboptimal. Anterior leaflet augmentation with autologous pericardium is a useful adjunct to compensate leaflet and chordae retraction. The technique and its indication are described in this article.

Endovascular treatment of an acute subdiaphragmatic aortic rupture.

We report the case of a 23-year-old man presenting an acute rupture of the subdiaphragmatic aorta in front of a T12 vertebral fracture after a road accident. Because of the location of this lesion, the operative risk and a cardiac instability, we opted for an endovascular treatment with a new and original approach in covering a small part of the aorta using commercial devices. We also describe the probable mechanism of this uncommon aortic rupture. The surgical outcome was uneventful and the 3 month computed tomographic scan confirmed the complete exclusion of the aortic disruption.

Posterior leaflet preservation in mitral valve prolapse: a new approach to mitral repair.

The most common repair technique for P2 prolapse is quadrangular resection of the posterior leaflet associated with a plication of the mitral annulus or with a sliding plasty. Although effective, these techniques do not respect the anatomy of the mitral valve, especially the physiological role of the posterior leaflet. Herein is described another technique which does not include P2 removal, thus preserving the posterior leaflet mobility. This technique represents a new approach to mitral valve repair that respects the motion of the two leaflets, allowing a more physiological opening of the mitral valve.

Combined Fourier transform infrared and Raman spectroscopic approach for identification of multidrug resistance phenotype in cancer cell lines.

Cancer cells escape cytotoxic effects of anticancer drugs by a process known as multidrug resistance (MDR). Identification of cell status by less time-consuming methods can be extremely useful in patient management and treatment. This study aims at evaluating the potentials of vibrational spectroscopic methods to perform cell typing and to differentiate between sensitive and resistant human cancer cell lines, in particular those that exhibit the MDR phenotype. Micro-Raman and Fourier transform infrared (FTIR) spectra have been acquired from the sensitive promyelocytic HL60 leukemia cell line and two of its subclones resistant to doxorubicin (HL60/DOX) and daunorubicin (HL60/DNR), and from the sensitive MCF7 breast cancer cell line and its MDR counterpart resistant to verapamil (MCF7/VP). Principal components analysis (PCA) was employed for spectral comparison and classification. Our data show that cell typing was feasible with both methods, giving two distinct clusters for HL60- and MCF7-sensitive cells. In addition, phenotyping of HL60 cells, i.e., discriminating between the sensitive and MDR phenotypes, was attempted by both methods. FTIR could not only delineate between the sensitive and resistant HL60 cells, but also gave two distinct clusters for the resistant cells, which required a two-step procedure with Raman spectra. In the case of MCF7 cell lines, both the sensitive and resistant phenotypes could be differentiated very efficiently by PCA analysis of their FTIR and Raman point spectra. These results indicate the prospective applicability of FTIR and micro-Raman approaches in the differentiation of cell types as well as characterization of the cell status, such as the MDR phenotype exhibited in resistant leukemia cell lines like HL60 and MCF7.

Traumatic aorto-right atrial fistula and tricuspid valve rupture. Post-operative cardiac and respiratory support with extracorporeal membrane oxygenation.

We report the case of a 30-year-old man admitted for a crushed chest trauma. The echocardiography found an aorto-right atrial fistula, a tricuspid valve rupture and a myocardial contusion. The fistula was closed using an autologous pericardial patch and a bioprosthetic tricuspid valve replacement was performed because the lesions did not allow for any valvular sparing. Because of the proximity between the right coronary ostium and the rupture, a venous aorto-right coronary bypass was performed. The ostium was also closed by the pericardial patch. A peripheral ECMO was implanted at the end of the surgical repair because of a right ventricle dysfunction and a respiratory failure related to severe bilateral pulmonary contusions. A few days later, renal, hepatic and coagulation failures were also noticed, justifying hemodialysis and transfusions. Despite an initial worsening of these five organ failures, the outcome was finally favorable and the patient was discharged 108 days after surgery. A 3-year follow-up revealed a complete recovery of all organ failures. To conclude, we firmly believe that the ECMO can be successfully applied in selected cases of severe right ventricular dysfunction and respiratory failure after cardiac surgery.

Retrograde aortic dissection after a stent graft repair of a type B dissection: how to improve the endovascular technique.

To date, endovascular repair of thoracic dissections is a reality, associated with acceptable morbidity and mortality. We present the case of a 72-year-old woman presenting a retrograde aortic dissection at the postoperative day 12, after an endovascular repair for a 60-mm thoracic dissecting aneurysm. Two years earlier, she had presented an uncomplicated thoracoabdominal type B aortic dissection between the isthmic aorta and the iliac bifurcation. Despite an acceptable blood pressure control, a 62-mm thoracic dissecting aneurysm was observed on the 24-month CT-scan. Due to a chronic obstructive pulmonary disease, we chose the endovascular approach to exclude the thoracic entry tear leading to the complete false lumen thrombosis around the endoprosthesis. However, the inferior part of the false lumen remained patent due to a second abdominal entry tear. The initial outcome was uneventful but the patient presented a sudden death syndrome twelve days after the endovascular repair. During the autopsy, we discovered an intrapericardial rupture of a retrograde dissection, starting at the level of the proximal bare spring of the endoprosthesis. We discuss some important technical details to improve the safety, and to reduce the risk of immediate or delayed complications.