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Left ventricular assist devices (LVADs) have reduced the mortality of patients with advanced heart failure both as bridge-to-transplant and as destination therapy. However, LVADs are associated with various complications, including bleedings, which affect the prognosis. The aim of the study was to explore the prevalence, management, and outcomes of haemorrhagic adverse events in LVAD recipients.We conducted a retrospective, single-centre, cohort study including all patients who received an LVAD from January 2008 to December 2019 in our tertiary centre (Rangueil University Hospital, Toulouse, France). Bleeding events, death, and heart transplantation were collected from electronic medical files. Eighty-eight patients were included, and 43 (49%) presented at least one bleeding event. Gastrointestinal (GI) bleeding was the most frequent (n = 21, 24%), followed by epistaxis (n = 12, 14%) and intracranial haemorrhage (n = 9, 10%). Bleeding events were associated with increased mortality [hazard ratio (HR) 3.8, 95% confidence interval (CI) 1.5-9.3, P 0.01], particularly in case of intracranial haemorrhage (HR 14.6, 95% CI 4.2-51.1, P 0.0001). GI bleedings were associated with a trend towards increased mortality (HR 3.0, 95% CI 0.9-9.3, P = 0.05). Each bleeding episode multiplied the risk of death by 1.8 (95% CI 1.2-2.7, P 0.01). Finally, only early bleedings (9 months post-implantation) had an impact on mortality (HR 4.2, 95% CI 1.6-11.1, P 0.01). Therapeutic management was mainly based on temporary interruption of anticoagulation and permanent interruption of antiplatelet therapy. Invasive management was rarely performed.Haemorrhagic events in LVAD recipients are frequent and associated with increased mortality. GI bleedings are the most frequent, and intracranial haemorrhages the most associated with mortality. Management remains empirical requiring more research.

Despite unusual high rates of patient-prosthesis mismatch (PPM), excellent midterm clinical outcomes have been reported after surgical aortic valve replacement (SAVR) with the Avalus™ bioprosthetic valve (Medtronic). To elucidate this "PPM conundrum," the Avalus valve haemodynamics were assessed during exercise testing.Of the 148 patients who had undergone SAVR with the Avalus valve at our institution, 30 were randomly selected among those in whom stress test was deemed feasible and underwent a resting transthoracic echocardiography immediately followed by exercise echocardiography. Severe PPM was defined as indexed effective orifice area (iEOA)Measured EOA significantly increased from rest to peak exercise in all PPM groups (p .05) and the rates of moderate and severe measured PPM decreased from 40% and 20% to 27% and 0%, respectively. The patients with low-flow state (flow 250 ml/s) had significantly lower measured rest EOA (p = .03). On the basis of the estimated iEOA, there was no severe PPM and 19 patients had moderate PPM (63.3%), with a significantly lower opening reserve than the patients without estimated PPM (p = .04). The estimated iEOA was more reliably correlated to the measured iEOA at maximal stress than the measured iEOA at rest, especially in patients with a low-flow state.This study supports the concept of an opening reserve of the Avalus valve to explain the PPM conundrum and promotes the use of exercise Doppler-echocardiography to complete the assessment of mismatch, especially in patients with a low-flow state. Published estimated EOA seems reliable to predict the haemodynamic performance of the Avalus valve, whether the flow conditions at rest.

BackgroundAmong mechanical complications of acute myocardial infarction, ventricular septal defect (VSD) is uncommon but still serious. The evolution of emergency coronary revascularisation paradoxically decreased our knowledge of this disease, making it even rarer.AimTo describe ischaemic VSD incidence, management, and associated in-hospital and 1-year outcomes over a 12-years period.MethodsA retrospective single-centre register of patients managed for ischaemic VSD between January 2009 and December 2020.ResultsNinety-seven patients were included representing 8 patients/ years and an incidence of 0.44% of ACS managed. The majority of the patients were 73-years-old males (n = 54, 56%) with STEMI presentation (n = 75, 79%) and already presented with Q necrosis on ECG (n = 70, 74%). Forty-nine (51%) patients underwent PCI, 60 (62%) inotrope/vasopressors infusion, and 70 (72%) acute mechanical circulatory support (IABP 62%, ECMO 13%, and Impella® 3%). VSD surgical repair was performed for 44 patients (45%) and 1 patient was transplanted. In-hospital mortality was 71%, and 86% at 1 year, without significant improvement over the decade. Surgery appears to be a protective factor [0.51 (0.28–0.94) p = 0.003], whereas age [1.06 (1.03–1.09), p < 0.001] and lactate [1.16 (1.09–1.23), p < 0.001] were linked to higher 1-year mortality. None of the patients that were managed medically survived 1 year.ConclusionPost-ischaemic VSD is a rare but serious complication still associated with high mortality. Corrective surgery is associated with better survival, however, timing, patient selection, and a place for mechanical circulatory support need to be defined.

Background Left ventricular overload is frequent under veno‐arterial extracorporeal membrane oxygenation, which is associated with a worsening of the prognosis of these patients. Several left heart decompression (LHD) techniques exist. However, there is no consensus on their timing and type. We aimed to describe characteristics and outcomes of patients undergoing LHD and to compare percutaneous atrioseptostomy (PA) to other LHD techniques. Methods and Results Retrospective analysis was conducted of consecutive and prospectively collected patients supported by veno‐arterial extracorporeal membrane oxygenation for refractory cardiac arrest or cardiogenic shock between January 2015 and April 2018, with a 90‐day follow‐up in our tertiary center. Patients were divided according to the presence of LHD, and then according to its type (PA versus others). Thirty‐nine percent (n=63) of our patients (n=163) required an LHD. Patients with LHD had lower left ventricular ejection fraction, more ischemic cardiomyopathy, and no drug intoxication‐associated cardiogenic shock. PA was frequently used for LHD (41% of first‐line and 57% of second‐line LHD). PA appears safe and fast to realize (6.3 [interquartile range, 5.8–10] minutes) under fluoroscopic and echocardiographic guidance, with no acute complications. PA was associated with fewer neurological complications (12% versus 38%, P =0.02), no need to insert a second LHD (0% versus 19%, P =0.04), and higher 90‐day survival compared with other techniques (42% versus 19%, log‐rank test P =0.02), despite more sepsis (96% versus 73%, P =0.02) and blood transfusions (13.5% versus 7%, P =0.01). Multivariate analysis confirms the association between PA and 90‐day survival (hazard ratio, 2.53 [1.18–5.45], P =0.019). Conclusions LHD was frequently used for patients supported with veno‐arterial extracorporeal membrane oxygenation, especially in cases of ischemic cardiomyopathy and low left ventricular ejection fraction. PA seems to be a safe and efficient LHD technique associated with greater mid‐term survival justifying the pursuit of research on this topic.

The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for the treatment of refractory cardiogenic shock has increased significantly. Nevertheless, early weaning may be advisable to reduce the potential for severe complications. Only a few studies focusing on ECMO weaning predictors are currently available. Our objective was to evaluate factors that may help predict failure during VA ECMO weaning. We included 57 patients on VA ECMO support previously considered suitable for weaning based on specific criteria. Clinical, haemato-chemical and echocardiographic assessment was considered before and after a “weaning test” (ECMO flow 7 days (OR 24 [2–269]) were predictors of weaning failure. The VA ECMO weaning test failed in less than 40% of patients considered suitable for weaning. Clinical and echocardiographic criteria, which are easily accessible by a non-expert intensivist, may help increase the probability of successful weaning.

International audience; Objective: ascending aortic aneurysm growth prediction is still challenging in clinics. In this study, we evaluate and compare the ability of local and global shape features to predict the ascending aortic aneurysm growth. Material and methods: 70 patients with aneurysm, for which two 3D acquisitions were available, are included. Following segmentation, three local shape features are computed: (1) the ratio between maximum diameter and length of the ascending aorta centerline, (2) the ratio between the length of external and internal lines on the ascending aorta and (3) the tortuosity of the ascending tract. By exploiting longitudinal data, the aneurysm growth rate is derived. Using radial basis function mesh morphing, iso-topological surface meshes are created. Statistical shape analysis is performed through unsupervised principal component analysis (PCA) and supervised partial least squares (PLS). Two types of global shape features are identified: three PCA-derived and three PLS-based shape modes. Three regression models are set for growth prediction: two based on gaussian support vector machine using local and PCA-derived global shape features; the third is a PLS linear regression model based on the related global shape features. The prediction results are assessed and the aortic shapes most prone to growth are identified. Results: the prediction root mean square error from leave-one-out cross-validation is: 0.112 mm/month, 0.083 mm/month and 0.066 mm/month for local, PCA-based and PLS-derived shape features, respectively. Aneurysms close to the root with a large initial diameter report faster growth. Conclusion: global shape features might provide an important contribution for predicting the aneurysm growth.

Background After cardiac surgery, postoperative delirium (POD) is common and is associated with long-term changes in cognitive function. Impact on health-related quality of life (QOL) and long-term dependence are not well known. This aim of this study is to evaluate the role of POD in poor evolution at three years after surgery including poor QOL and dependence and mortality. Patients and methods We enrolled and followed 173 patients 60 years of age or older who were planning to undergo cardiac surgery with cardiopulmonary bypass. The primary composite outcome was death of any causes, or patients with either a loss of QOL (evaluated with of EuroQuol verbal 5D EQ5D less than 50), or a loss of two points on the instrumental activities of daily living occurring three years after surgery. POD was diagnosed with the use of Confusion Assessment Method. Multivariate logistic regression was performed. Results At three years, 74 patients (42.8%) had a poor evolution. Independent risk factors in poor patient evolution were sex (female gender; OR: 3.6; 95%CI: 1.45-8.7; p=0.006), metabolic status (diabetic patients; OR: 4; 95%CI: 1.6-10.2; p=0.002), Euroscore 2 (Euroscore 2 >1.5; OR: 5.2; 95%CI: 1.7-15.4; p=0.003) and POD (OR: 3.3; 95%CI 1.4-7.8; p=0.006). Coronary disease was protective (OR: 0.3; 95%CI: 0.14-0.71; p=0.006). Conclusion After cardiac surgery, POD significantly altered patient evolution and increased risk of dependence and loss of QOL.

OBJECTIVES Our goal was to study the immediate outcome after an emergency frozen elephant trunk procedure with a Thoraflex™ Hybrid prosthesis (THP) in patients included in the EPI-Flex national registry and operated on in 21 French centres. METHODS All patients operated on in France between April 2016 and April 2019 for acute aortic syndromes and who had an frozen elephant trunk procedure with a THP were included in the study. The main end point was in-hospital mortality. The secondary end point was neuromorbidity, including paraplegia. The evolution of the main end point was monitored using a variable life-adjusted display graph with cumulative sum derivatives in order to stop inclusions in case the observed mortality became out of range compared to an expected mortality between 15% and 20%. RESULTS Enrolment ended on the scheduled date and included 109 patients. Most cases (54%) were performed at 3 centres, where more than 10 THP each were implanted (10–26). The observed mortality in the large-volume centres (22%) was comparable to that observed in the low-volume centres (20%). The individually risk-adjusted cumulative sum revealed that observed in-hospital mortality was statistically in line with that predicted by the log EuroSCORE. Analysis of the secondary end point revealed 8% cases of paraplegia, all of which appeared after treatment of the thoracic type A aortic dissection. CONCLUSIONS In France, THP for emergency frozen elephant trunk surgery outside high-volume centres did not result in excessive in-hospital deaths. However, a word of caution must be expressed regarding the prevention of medullar ischaemia even in emergency aortic surgery.

Objective The aim of this study was to evaluate the mid and long term patency of elective renal artery reconstructions during open surgical repair of suprarenal aortic aneurysms (SRAA) and type 4 thoraco-abdominal aortic aneurysms (T4AAA). Methods This retrospective, single centre study included all consecutive patients who underwent surgery for SRAA or T4AAA between January 2009 and December 2019 at Toulouse University Hospital. All patients underwent strict pre-operative planning with computed tomography angiography (CTA) and 3D reconstruction of the aortic aneurysm, visceral and renal artery anatomy to choose the most appropriate surgical technique for each case. Primary patency, primary assisted patency, and rates of re-intervention were calculated using the Kaplan–Meier method. Results In total, 103 patients, having undergone 159 renal artery revascularisation procedures, were enrolled in the study. Fifty-five patients presented with a type T4AAA and 48 patients with a SRAA. In hospital mortality was 2.9%. In association with aortic surgery, 100 direct re-implantation (62.8%), 48 retrograde bypasses (30.1%), and 11 anterograde bypasses (6.9%) of the renal arteries were performed. Median follow up was 45.9 ± 36 months. Renal artery primary patency rates were 99.4%, 96.4%, and 93.1% at one, three, and five years, respectively. Assisted primary patency rates were 99.4%, 97.7%, and 97.7% at one, three, and five years, respectively, with five cases of renal stenosis > 70% successfully treated by renal stenting. No significant difference in patency was found regarding the type of renal revascularisation. Conclusion This retrospective study suggests that the mid term patency of elective open renal artery reconstruction during SRAA and type T4AAA surgery preceded by pre-operative planning with 3D-CTA reconstruction, yields excellent outcomes whatever the technique used.

OBJECTIVE Participating in either competitive or leisure sports is restrictive after surgical mitral valve repair (MVR). In this study, we examine the impact of sports on outcomes after MVR. DESIGN Retrospective cohort study. SETTING Patients aged 18 to 65 years who underwent a first-time MVR for primary mitral regurgitation (MR) in a tertiary care center. PATIENTS One hundred twenty-one consecutive patients were included in the study. The exclusion criteria were as follows: other concomitant procedures, early perioperative death or repeat intervention, noncardiac death or endocarditis during follow-up, and general contraindications for normal physical activity. ASSESSMENT OF RISK FACTORS Participation in sports was quantified by the number of hours per week during the past 6 months, classified according to the Mitchell classification and assessed with the International Physical Activity Questionnaire (IPAQ) short form. MAIN OUTCOME MEASURES The primary composite endpoint was MVR failure defined as MR grade ≥2 or mean transmitral gradient ≥8 mm Hg, signs and symptoms of heart failure, or late-onset postoperative AF (>3 months). RESULTS The mean age was 50 ± 11 years, and there were 85 (71%) men. The median follow-up was 34 months [interquartile range (IQR): 20-50]. Fifty-six (46%) patients participated in sports regularly (median of 3 h/wk; IQR: 2-5). Twenty (17%) patients reached the primary composite endpoint with no correlation with participation in sports (P = 0.537), IPAQ categories (P = 0.849), in any of the Mitchell classification subgroups and a high level of participation in sports ≥6 hours (P = 0.679). CONCLUSIONS Sports seem to be unrelated to the worst outcome after MVR.

Thrombocytopenia after transcatheter aortic valve implantation (TAVI) is common and has been related to worse clinical outcomes. Comparison of platelet kinetics among different types of valves is limited. Our objectives were to analyze the differences in drop platelet count (DPC) between balloon-expandable valves (BEVs) and self-expanding valves and their prognostic implications after TAVI. Patients who underwent transfemoral TAVI from 2008 to 2016 were included. Exclusion criteria were severe baseline thrombocytopenia and periprocedural death. Postprocedural platelet counts were collected. Two groups were created: DPC ≤30 and DPC30%. Valve Academic Research Consortium-2 criteria were used to define outcomes. Study population included 609 patients (age 84.7 ± 6.0, 46.6% males). The mean DPC was 32.5 ± 13.9%. The DPC was higher in the BEV arm (33.9 ± 14.2 vs 30.7 ± 13.4%, p = 0.006), and the nadir was reached later in comparison to the self-expanding valve arm (3.0 ± 1.3 vs 2.5 ± 1.1 days, p0.001). After multivariable analysis, the use of BEV, known coronary artery disease, and left ventricle ejection fraction were the factors associated with a higher rate of DPC30%. At 30 days, the DPC30% was related with a higher rate of life-threatening and/or major bleeding (6.8 vs 2.1%, p = 0.009) and death (3.5 vs 0.8%, p = 0.036). At 1 year, the difference in mortality disappeared. In conclusion, in this cohort of patients, the use of BEV seems to be associated with a higher risk of DPC after TAVI. A DPC ≥30% was related with increased risk of life-threatening and/or major bleeding and death at 30 days. Larger and prospective studies are needed to understand this phenomenon.

Objectives The effectiveness of a multidisciplinary heart team in the management of patients with severe symptomatic aortic stenosis is unknown. This study evaluated the impact of a heart team on the outcomes of surgical aortic valve replacement in octogenarians. Methods Between May 2007 and January 2016, 528 patients aged 80 years or more were referred to our institutional heart team for a transcatheter aortic valve replacement. Among these, 101 were redirected to surgical aortic valve replacement (heart team group). These patients were compared with a surgical aortic valve replacement cohort (n = 506) without prior heart team screening (non-heart team group), taken from the same time period. Propensity score matching with bootstrap analysis was performed; 76 heart team patients were matched to 76 non-heart team patients. Early and late outcomes including survival and readmission for cardiovascular causes were compared. Results Matched subgroups were largely comparable; congestive heart failure and echocardiographic pulmonary hypertension were more prevalent in the heart team group. In-hospital mortality was significantly lower in the matched heart team group (0% vs 6.0%, bootstrap mean difference 6.0%, 95% confidence interval, 2.2-9.8). The risk of stroke, low cardiac output state, reexploration for bleeding, pneumonia, and prolonged ventilation was also significantly lower in the heart team group. There was no significant between-group difference regarding late survival (hazard ratio, 0.86, 95% confidence interval, 0.55-1.33, P = .49) or readmission for cardiovascular reasons (hazard ratio, 0.70, 95% confidence interval, 0.41-1.20, P = .19). Conclusions Preoperative multidisciplinary assessment of octogenarians by a heart team was associated with lower in-hospital mortality and adverse events after surgical aortic valve replacement.

Background Extracorporeal membrane oxygenation (ECMO) is increasingly used in intensive care units and can modify drug pharmacokinetics and lead to under-exposure associated with treatment failure. Ceftolozane/tazobactam is an antibiotic combination used for complicated infections in critically ill patients. Launched in 2015, sparse data are available on the influence of ECMO on the pharmacokinetics of ceftolozane/tazobactam. The aim of the present study was to determine the influence of ECMO on the pharmacokinetics of ceftolozane-tazobactam. Methods An ex vivo model (closed-loop ECMO circuits primed with human whole blood) was used to study adsorption during 8-h inter-dose intervals over a 24-h period (for all three ceftolozane/tazobactam injections) with eight samples per inter-dose interval. Two different dosages of ceftolozane/tazobactam injection were studied and a control (whole blood spiked with ceftolozane/tazobactam in a glass tube) was performed. An in vivo porcine model was developed with a 1-h infusion of ceftolozane–tazobactam and concentration monitoring for 11 h. Pigs undergoing ECMO were compared with a control group. Pharmacokinetic analysis of in vivo data (non-compartmental analysis and non-linear mixed effects modelling) was performed to determine the influence of ECMO. Results With the ex vivo model, variations in concentration ranged from − 5.73 to 1.26% and from − 12.95 to − 2.89% respectively for ceftolozane (concentrations ranging from 20 to 180 mg/l) and tazobactam (concentrations ranging from 10 to 75 mg/l) after 8 h. In vivo pharmacokinetic exploration showed that ECMO induces a significant decrease of 37% for tazobactam clearance without significant modification in the pharmacokinetics of ceftolozane, probably due to a small cohort size. Conclusions Considering that the influence of ECMO on the pharmacokinetics of ceftolozane/tazobactam is not clinically significant, normal ceftolozane and tazobactam dosing in critically ill patients should be effective for patients undergoing ECMO.

To evaluate the contribution and performance of multimodal imaging in the diagnostic and therapeutic management of cardiac masses. We carried out a monocentric retrospective study on patients referred for cardiac mass assessment between 2006 and 2019, and analyzed the respective contribution of transesophageal echocardiography (TEE), cardiac computed tomography (CT), cardiac magnetic resonance (CMR) and 18F-fluorodeoxyglucose positron emission tomography coupled with CT (18F-FDG PET-CT). For each test, we determined strategy before and after its completion (need for another imaging or decision-making) as well as result on benign, malignant or indeterminate nature. For the 119 patients included, all imaging modalities increased decision-making rates, which rose from 2 to 54%, 23 to 62%, 31 to 85% and 49 to 100% before and after TEE, CT, CMR and 18F-FDG PET-CT, respectively (P

Despite advances in intensive care medicine, management of cardiogenic shock (CS) remains difficult and imperfect, with high mortality rates, regardless of aetiology. Predictive data regarding long-term mortality rates in patients presenting CS are sparse.To describe prognostic factors for long-term mortality in CS of different aetiologies.Two hundred and seventy-five patients with CS admitted to our tertiary centre between January 2013 and December 2014 were reviewed retrospectively. Mortality was recorded in December 2016. A Cox proportional-hazards model was used to determine predictors of long-term mortality.Most patients were male (72.7%), with an average age of 64±16 years and a history of cardiomyopathy (63.5%), mainly ischaemic (42.3%). Leading causes of CS were myocardial infarction (35.3%), decompensated heart failure (34.2%) and cardiac arrest (20.7%). Long-term mortality was 62.5%. After multivariable analysis, previous use of beta-blockers (hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.41-0.89; P=0.02) and coronary angiography exploration at admission (HR 0.57, 95% CI 0.38-0.86; P=0.02) were associated with a lower risk of long-term mortality. Conversely, age (HR 1.02 per year, 95% CI 1.01-1.04; P0.001), catecholamine support (HR 1.45 for each additional agent, 95% CI 1.20-1.75; P0.001) and renal replacement therapy (HR 1.66, 95% CI 1.09-2.55; P=0.02) were associated with an increased risk of long-term mortality.Long-term mortality rates in CS remain high, reaching 60% at 1-year follow-up. Previous use of beta-blockers and coronary angiography exploration at admission were associated with better long-term survival, while age, renal replacement therapy and the use of catecholamines appeared to worsen the prognosis, and should lead to intensification of CS management.

Left ventricular unloading during extracorporeal life support aims to minimize potential side effects of increased left ventricular afterload. A transaortic catheter vent implanted through a subclavian approach was used in 2 patients. Patient 1 was a 48-year-old man with a recent history of ST-elevation myocardial infarction who developed refractory cardiogenic shock due to severe biventricular dysfunction. Patient 2 was a 56-year-old man admitted for severe flu. The unloading procedure was successful in both patients, with bridge to heart transplantation in the first case and bridge to recovery in the other.

AIMS We aimed to compare the long-term outcomes of transaortic (TAo-AVR) and transfemoral (TF-AVR) transcatheter aortic valve replacement. METHODS AND RESULTS Between January 2012 and December 2015, consecutive TAo-AVR and TF-AVR cases were compared using a propensity score-matching analysis. Primary endpoints were 30-day and one-year mortality; 644 TAVR patients were included (163 TAo-AVR and 481 TF-AVR). Peripheral artery disease (31.9% vs. 5%, p

This study aimed at evaluating the efficacy and safety of the transaortic approach for the transcatheter aortic valve implantation procedure using balloon-expandable and self-expanding devices.From January 2012 to December 2016, the transaortic-transcatheter aortic valve implantation procedure was performed in 206 consecutive patients at the Rangueil University Hospital. All procedures were performed by a multidisciplinary heart team. The ascending aorta (27%) or innominate artery (73%) was exposed through a J-type manubriotomy. Events were adjudicated according to Valve Academic Research Consortium-2 criteria.Mean age and logistic European System for Cardiac Risk Evaluation II were 83.9 ± 6.7 years and 16.8% ± 10.8%, respectively. Balloon-expandable and self-expanding valves were implanted in 59.7% and 40.3% of patients, respectively. Device success rate was 98.1%. Thirty-day overall mortality, cardiovascular mortality, cerebrovascular event, myocardial infarction, and permanent pacemaker implantation rates were 5.3%, 4.4%, 1.5%, 1.0%, and 9.7%, respectively (1-year rates: 15.5%, 9.2%, 3.9%, 3.4%, and 10.2%, respectively). Life-threatening bleeding and major vascular complications (7.3% and 3.9%, respectively) were not related to the central access site in approximately half of the cases. Multivariable Cox regression analysis identified preoperative renal failure as an independent predictor of overall mortality (odds ratio, 2.82; 95% confidence interval, 1.73-4.59; P .0001). At the 1-year follow-up, most patients had experienced improved functional status and 98.4% of them were free of moderate to severe paravalvular leak.In a higher-risk subgroup within the patient population receiving transcatheter aortic valve implantation, transaortic-transcatheter aortic valve implantation was successfully performed in 98.1% of cases, with high functional improvement and low rates of mortality and adverse events, especially neurologic complications.

Heart failure may be the current trend of many heart diseases. Among them, valve diseases are still the source of nearly 10 % of heart failure cases. The occurrence of heart failure in a patient with valvular stenosis or regurgitation is usually an evolutionary turning point of the disease and requires to consider a correction of this valve disease. Indeed, when valvular disease is managed correctly and pre-emptively, its adverse consequences on ventricular function can be ameliorated. Thus, surgical therapies and percutaneous interventions commonly integrated in heart failure management include aortic valve replacement and mitral valve repair or replacement. However, even if valve disease may cause or aggravate heart failure, the issue of liability of this valve disease in heart dysfunction is sometimes difficult to determine.

Despite the intrathoracic part being short, the right laryngeal recurrent nerve is often injured during thoracic surgery. The aim of this cadaver study was to understand the mechanisms of right laryngeal recurrent nerve injuries during thoracic surgery and to describe anatomical landmarks for its preservation.Dissections were performed on 10 fresh human cadavers. A right anterolateral thoracic wall segment was removed, preserving the first rib. Dissections were carried out to identify the following structures: first rib, esophagus, trachea, right main bronchus, right brachiocephalic and subclavian vessels, azygos vein, phrenic nerve, vagus nerve, and right laryngeal recurrent nerve.The distance between the origin of the right laryngeal recurrent nerve and its adjacent structures was assessed. Moderate traction of the thoracic part of the vagus nerve resulted in a downward translation of the right laryngeal recurrent nerve's origin. In such conditions, the right laryngeal recurrent nerve's origin was distant of 14.8 mm (±2.89 mm) from the subclavian artery.Intraoperative incidence of right laryngeal recurrent nerve direct injury could be decreased by understanding the detailed course of its intrathoracic part. Moreover, traction on the intrathoracic part of the right vagus nerve may result in indirect lesions of the right laryngeal recurrent nerve: stretch induced lesions and nerve vasculature's lesions.

of a proximal elephant trunk facilitating the repair of the downward thoracic aorta. The mortality of this second operative stage is 10% and 50% of the patients only have the first stage. The treatment of these aneurisms can be completed by an endovascular route. The purpose of the study was to evaluate the effectiveness of this second endovascular stage and the perioperative morbimortality. Materials and Methods: The study was retrospective and monocentric. All the patients having the exclusion of a proximal thoracic aneurysm with a stentgraft after the realization of an elephant trunk were studied. The extension of the aneurysmal lesions of the thoracic aorta and the length of endovascular covering were reported. The rates of success, of perioperative mortality, of paraplegia and endoleak were determined. Results: Five patients profited from the second stage of elephant trunk with a stentgraft over a five years period. The mean age was 77 years. The time between the 1st and the 2nd operative stages was between 4 and 167 months. The material used was in three cases a Valiant (Medtronic) stentgraft, in one case a Relay NBS+ (Bolton) and in one case a custommade Relay NBS + (Bolton). The average diameter of the thoracic aneurysms was 55 mm. The artery of Adamkiewicz had been located in all the cases and was never covered. In two cases an anterior and superior spinal artery was covered. The stentgrafts covered the thoracic aorta from D7 to L1.The rate of postoperative paraplegia was null. Postoperative mortality was null. The primary success rate was of 100%. The average length of the trunks for the proximal anchoring of the stentgraft was 18 cm. The median follow-up was of 22 ± 21 months. Only one early type II endoleak was observed during the follow-up. Only one patient died during the followup, of a non-aortic cause. Conclusion: The endovascular second stage of the replacements of the aortic arch with elephant trunk offers a good immediate success rate in particular with a satisfactory proximal sealing, provided that the length of the elephant trunk is sufficient. The morbidity of this procedure is low, with the advantage of treating with precision the distality of the aortic lesions in contrast to the techniques of ‘‘frozen elephant trunk’’.