[Demographic evolution of patients with a surgical aortic valvular replacement in the era of percutaneous replacement]. / Evolution démographique des patients bénéficiant d'un remplacement valvulaire aortique chirurgical à l'ère du remplacement percutané.

INTRODUCTION: Percutaneous aortic valve replacement has been performed in daily practice for less than 10 years. This technique was until recently reserved for patients with very high surgical risk. There is little data in the literature documenting the impact of this percutaneous technique on the patient population continuing to benefit from a surgical replacement of the aortic valve. We studied the characteristics of these patients immediately before and after the introduction of the percutaneous technique in the CHU Brugmann. MATERIALS AND METHODS: Two separate cohorts of patients were retrospectively studied: one before the percutaneous era between 2005 and 2010 and the other after introduction of the percutaneous technique in our daily practice between 2010 and 2015. Demographic, intraoperative, mortality and postoperative morbidity indices were compared. RESULTS: The number of surgical replacements of the aortic valve was 194 before and 132 after introduction of the percutaneous technique. The demographic, operative characteristics and postoperative morbidity and mortality of the patients remained the same between the two cohorts. Only the incidence of pulmonary arterial hypertension (12.1 vs 25 %, p = 0.015) and recent myocardial infarction (0 vs 3 %, p = 0.003) were higher in the second cohort. CONCLUSION: Replacement of the aortic valve percutaneously did not significantly change the demographic characteristics and postoperative morbidity and mortality of patients candidate for surgical replacement of the aortic valve. Nevertheless, after its introduction, the number of surgical replacements dropped considerably in our center.

INTRODUCTION: Le remplacement valvulaire aortique percutané est réalisé en pratique quotidienne depuis moins de dix ans. Cette technique était jusqu'il y a peu réservée aux patients à très haut risque chirurgical. Il existe peu de données dans la littérature documentant l'impact de cette technique percutanée sur la population de patients continuant à bénéficier d'un remplacement chirurgical de la valve aortique. Nous avons étudié les caractéristiques de ces patients immédiatement avant et après l'introduction de la technique percutanée au CHU Brugmann. Matériel et méthodes : Deux cohortes distinctes de patients ont été étudiées rétrospectivement : l'une avant l'ère percutanée entre 2005 et 2010 et l'autre après introduction dans notre pratique quotidienne de la technique percutanée entre 2010 et 2015. Les données démographiques, peropératoires, la mortalité et des indices de morbidité postopératoire ont été comparés. Résultats : Le nombre de remplacements chirurgicaux de la valve aortique était de 194 avant et 132 après introduction de la technique percutanée. Les caractéristiques démographiques, opératoires et la morbi-mortalité postopératoire des patients sont restées identiques entre les deux cohortes. Seules les incidences d'hypertension artérielle pulmonaire (12,1 vs 25 %, p = 0,015) et d'infarctus myocardiques récents (0 vs 3 %, p = 0,003) étaient supérieures dans la seconde cohorte. CONCLUSION: Le remplacement de la valve aortique par voie percutanée n'a pas considérablement modifié les caractéristiques démographiques et la morbimortalité postopératoire des patients candidats à un remplacement chirurgical de la valve aortique. Le nombre total de remplacement chirurgical de la valve aortique a considérablement chuté.

Three years follow-up after cryoablation of a right atrial myxoma arising from the Koch's triangle.

We reported 3 years ago the use of cryoablation in the treatment of a right atrium myxoma arising from the Koch's triangle. The atrioventricular conduction was successfully preserved. Today, after 3 years follow-up, the patient remains with a conducted sinus rhythm and is free of recurrence. Even if extensive resection of the stack of the myxoma remains the first choice attitude, cryoablation could be considered as a serious second choice alternative.

Impact of balanced tetrastarch raw material on perioperative blood loss: a randomized double blind controlled trial.

BACKGROUND: As 6% hydroxyethyl starch (HES) 130/0.40 or 130/0.42 can originate from different vegetable sources, they might have different clinical effects. The purpose of this prospective, randomized, double-blind controlled trial was to compare two balanced tetrastarch solutions, one maize-derived and one potato-derived, on perioperative blood loss in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). METHODS: We randomly assigned 118 patients undergoing elective cardiac surgery into two groups, to receive either a maize- or a potato-derived HES solution. Study fluids were administered perioperatively (including priming of CPB) until the second postoperative day (POD#2) using a goal directed algorithm. The primary outcome was calculated postoperative blood loss up to POD#2. Secondary outcomes included short-term incidence of acute kidney injury (AKI), and long-term effect (up to one yr) on renal function. RESULTS: Preoperative and intraoperative characteristics of the subjects were similar between groups. Similar volumes of HES were administered (1950 ml [1250-2325] for maize-HES and 2000 ml [1500-2700] for potato-HES; P=0.204). Calculated blood loss (504 ml [413-672] for maize-HES vs 530 ml [468-705] for potato-HES; P=0.107) and the need for blood components were not different between groups. The incidence of AKI was similar in both groups (P=0.111). Plasma creatinine concentration and glomerular filtration rates did vary over time, although changes were minimal. CONCLUSIONS: Under our study conditions, HES 130/0.4 or 130/0.42 raw material did not have a significant influence on perioperative blood loss. Moreover, we did not find any effect of tetrastarch raw material composition on short and long-term renal function. CLINICAL TRIAL REGISTRATION: EudraCT number: 2011-005920-16.

[Acute myocardial infarction due to an acute aortic dissection]. / Infarctus myocardique aigu dû à une dissection de l'aorte ascendante.

Myocardial ischemia secondary to dissection of the ascending aorta remains a relatively rare complication. A 76-year old man with no prior history developed sudden chest pain. The electrocardiogram showed a ST-segment elevation in leads II and III suggesting an inferior wall acute myocardial infarction. Upon arrival, he received anticoagulation and antiplatelet aggregation intravenously and orally respectively. Coronary angiography showed an anomalous origin of the right coronary and extrinsic stenosis by a false lumen. Computed tomography confirmed the diagnosis of type A aortic dissection with an extension to the right coronary. Emergency ascending aorta replacement with Dacron graft and a right coronary artery graft was perfomed. This case illustrates how myocardial infarction can mask an aortic dissection. The initial treatment of a myocardial infarction with anticoagulation and/or oral antiplatelet aggregation should not be modified, even if it increases postoperative bleeding when emergent cardiac surgery is necessary.

Prevalence of early postoperative arrhythmias in children with delayed open-heart surgery for severe congenital heart disease.

UNLABELLED: BACKGROUND; Our aim was to determine the incidence, risk factors and outcome of early postoperative arrhythmias in children with delayed treatment of severe congenital heart disease. METHODS: A prospective study was conducted in 141 consecutive children with delayed referral from emerging countries, who underwent open-heart surgery. RESULTS: Sinus node dysfunction was noted in 5 cases. Preoperative moderate extrasystoly was common and its incidence significantly increased in the postoperative phase. Overall, 9 patients required specific antiarrhythmic therapy: 6 for sustained atrioventricular reciprocating tachycardia, and 3 respectively for atrial flutter, atrial fibrillation and junctional ectopic tachycardia. Non-sustained atrioventricular and ventricular tachycardia required no therapy in respectively 6 and 1 case. Postoperative complete atrioventricular block was observed in 6 patients and remained permanent in 3. No major complications resulted from those arrhythmias. Preoperative low oxygen saturation, preoperative arrhythmias, as well as long cardiopulmonary bypass time and aortic cross-clamp time, were risk factors for early postoperative arrhythmias. CONCLUSIONS: Children with delayed surgery for congenital heart disease are at risk of developing early postoperative arrhythmias depending on the complexity of their disease and of its treatment. However, their prevalence (14%) is not higher than in the general population of cardiac children.

[Cor triatriatum in the adult]. / Coeur triatrial chez l'adulte.

A 18-year old girl suffering from effort dyspnea presented to our hospital. She had no previous medical history. The first investigations revealed a linear structure traversing the left atrium. A transoesophageal echocardiogram demonstrated a thin mobile membrane in the atrium. Many investigations were realized to describe better this structure and its contribution to the symptoms. Cor triatrium is a rare congenital disease and its discovery is rare in adulthood. So, there are no guidelines for the optimal management.

Redo valve surgery nowadays: what have we learned?

Re-operative valvular surgery is common nowadays. Increased mortality and morbidity are generally associated. Re-operations in cardiac surgery are technically more difficult because of adhesions and a more advanced cardiac status of the patient. Results reported 20 years ago carried a high mortality risk. Experience and technological evolution have produced a substantial reduction in postoperative mortality nowadays. The present review focuses on historical results of redo valve surgery, risks factors for postoperative mortality, technical progress and surgical strategies contributing to better results.

Surgical treatment of coronary artery fistula with aneurysm.

Two operations for coronary artery aneurysm with fistula are reported. This rare congenital malformation can be associated with acute and chronic complications. Surgical treatment is generally recommended. The surgical strategy remains controversial and is discussed. Retrograde cardioplegic cardiac arrest and retrograde dissection of the fistula are favoured. Conservative treatment of the dilated coronary segments was adopted. In both cases, the postoperative course was uneventful and no residual shunts were diagnosed at postoperative echocardiography.

Continuous versus pulsatile pulmonary hemodynamics in canine oleic acid lung injury.

Pulmonary hypertension occurs commonly in the acute respiratory distress syndrome (ARDS), but associated right ventricular failure is relatively rare. We tested the hypothesis that this apparent contradiction is explained by a peripheral location of the increased pulmonary vascular resistance (Rpva). Experimental ARDS was induced in eight dogs by injection of oleic acid (0.07 ml/kg). Changes in Rpva were evaluated by measurements of pulmonary artery pressure (Ppa) at several levels of flow (Q), which was altered by manipulation of venous return. The analysis of Ppa decay curves after arterial balloon occlusion was used to partition Rpva into arterial and venous segments. Right ventricular afterload was evaluated by determination of pulmonary vascular impedance (Zpva), which was calculated from spectral analysis of Ppa and Q waves. Oleic acid lung injury was associated with an increase in both the slope and the extrapolated pressure intercept of Ppa/Q plots, no change in the partitioning of Rpva, no change in time-domain indices in wave reflection or in pulmonary arterial compliance, and a decrease in both the characteristic impedance and pulsatile component of total right ventricular hydraulic load. We conclude that the site of increased Rpva in oleic acid lung injury is the smallest pulmonary arterioles, which, together with a decreased characteristic impedance, contributes to minimize right ventricular afterload.

Pulmonary vascular impedance response to hypoxia in dogs and minipigs: effects of inhaled nitric oxide.

The pig has been reported to present with a stronger hypoxic pulmonary vasoconstriction (HPV) than many other species, including dogs. We investigated [pulmonary arterial pressure (Ppa)-pulmonary arterial occluded pressure (Ppao)] vs. pulmonary blood flow (Q) relationships and pulmonary vascular impedance (PVZ) spectra in nine minipigs and nine weight-matched dogs. The animals were anesthetized and ventilated in hyperoxia [inspired O2 fraction 0.4] or hypoxia (inspired O2 fraction 0.12). PVZ was computed from the Fourier series for Ppa and Q. In hyperoxia, the pigs had a higher Ppa (26 +/- 1 vs. 16 +/- 1 mmHg), a higher first-harmonic impedance (Z1), and a more negative low-frequency phase angle but no different characteristic impedance (Zc) compared with the dogs at the same Q. Hypoxia in the dogs increased (Ppa-Ppao) at all levels of Q studied by an average of 2 mmHg but did not affect Z1 or Zc. Hypoxia in the pigs increased (Ppa-Ppao) at all levels of Q by an average of 13 mmHg and increased Z1 and Zc. Inhaled NO (150 ppm) reversed the hypoxia-induced changes in (Ppa-Ppao)/Q plots and PVZ in the dogs and pigs. However, differences in (Ppa-Ppao)/Q plots and PVZ between the dogs and pigs in hyperoxia and hypoxia were not affected by inhaled NO. We conclude 1) that minipigs present with an elevated pulmonary vascular resistance and impedance in hypoxia more than in hyperoxia and 2) that baseline differences in pulmonary hemodynamics between dogs and minipigs are structural rather than functional.

Effects of dexfenfluramine on hypoxic pulmonary vasoconstriction and embolic pulmonary hypertension in dogs.

There has been suggestion of a possible relationship between the intake of the appetite suppressant dexfenfluramine and the development of primary pulmonary hypertension. We investigated the pulmonary vascular effects of acute intravenous dexfenfluramine in pentobarbital-anesthetized dogs ventilated in hyperoxia (fraction of inspired oxygen, FIO2, 0.4) and either challenged with a FIO2 of 0.1 to induce hypoxic pulmonary hypertension (n = 20) or given autologous blood clots to induce embolic pulmonary hypertension (n = 6). Pulmonary vascular tone was evaluated by multipoint (mean pulmonary artery pressure [Ppa] - pulmonary artery occluded pressure [Ppao])/cardiac output (Q) plots. Hypoxia increased Ppa - Ppao over the entire range of Q studied, from 1.5 to 4.0 L/min/m2, in 12 dogs (responders) and had no significant effect on (Ppa - Ppao)/Q plots in 8 other dogs (nonresponders). Dexfenfluramine did not affect (Ppa - Ppao)/Q plots in 6 responders but shifted (Ppa - Ppao)/Q plots to higher pressures in hypoxia in 6 nonresponders (p < 0.001). Dexfenfluramine had no effect on (Ppa - Ppao)/Q plots in the 6 dogs with embolic pulmonary hypertension. Because dexfenfluramine has serotoninergic properties, we compared the effects of ketanserin, a serotonin (5-hydroxytryptamine, 5-HT) S2 receptor antagonist, on naturally present versus dexfenfluramine-restored hypoxic pulmonary vasoconstriction. Ketanserin did not affect hyperoxic or hypoxic pulmonary vascular tone, neither in 6 responders nor in 2 nonresponders with dexfenfluramine-restored hypoxic vasoconstriction. We conclude that dexfenfluramine restores hypoxic pulmonary vasoconstriction in dogs with weak or absent hypoxic pressor response and that this effect is unlikely to be mediated by activation of 5-HT S2 receptors.