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A case of a 49-year-old man with a history of buprenorphine-substituted heroin was admitted for acute heart failure after three months of bioprosthetic aortic replacement to treat infective endocarditis. Transthoracic echocardiography (TTE) showed a left ventricular ejection fraction (EF) was 35% and a periprosthetic mass with an aorto-ventricular fistula. Thoracic computed tomography revealed a left ventricular outflow tract (LVOT) pseudoaneurysm measuring 69 x 45 mm that compressed left anterior descending (LAD) artery with downstream myocardial ischemia. Patient was treated by an urgent surgery, including an exclusion of the pseudoaneurysm, a left ventricular reconstruction surgery and a bioprosthetic aortic replacement. Patient went through a difficult postoperative period. Finally, he was safely discharged with a low EF (34%) from hospital to rehabilitation center with a Life vest. This case spotlights a rare devastating complication of a LVOT pseudoaneurysm compresses LAD artery and how surgery could decompress the false aneurysm and stabilize ischemia.

No guidelines for the treatment of Kommerell diverticulum (KD) have been established. Endovascular treatment with arch vessel reconstruction of 4 patients with a right-sided aortic arch and aberrant left subclavian artery are presented herein. A 39-year-old woman and 47-year-old man experienced dyspnea and retrosternal pain. The first patient concomitantly underwent left subclavian transposition and thoracic endovascular aortic repair (TEVAR). The second patient underwent bilateral carotid-subclavian bypass grafting, followed by TEVAR and KD embolization. The 2 other patients were 72- and 75-year old men who presented with KD and type B dissection, in which these conditions were characterized by acute thoracic pain in the former patient and were noted on incidental body scan for prostatic adenocarcinoma in the latter. The third patient underwent carotid-subclavian bypass grafting, followed by TEVAR and subclavian plugs, and in the fourth patient, regular follow-up with antihypertensive therapy was scheduled. After a mean follow-up period of 12 months, all patients were alive.

Background We evaluated short- and mid-term outcomes with use of aortic valve-sparing root replacement to treat bicuspid aortic valves. Methods From December 2007 to January 2022, all patients with bicuspid aortic valves who underwent aortic root replacement using Tirone’s procedure were included. This study based on department database information for retrospective and follow-up data. Results Among 51 adults undergoing aortic root replacement using Tirone’s procedure, the mean age was 47.4±12.5 years, and most were men (92.2%). Three presented with a dysmorphic syndrome and one had Marfan’s syndrome. All patients were alive at 30 days, and as of January 2022, 45 were alive, two were lost to follow-up, and there were four noncardiac deaths. Two patients had infectious endocarditis and needed a Bentall’s procedure. One patient had a double biologic valve replacement in the context of severe mitral insufficiency with moderate aortic stenosis at 4.5 years post-procedure. Echocardiographic follow-up showed a left ventricular ejection fraction of 63±7% (n=36), V 2±0.6 m/s (n=17), and a mean gradient of 9.4±5.4 mmHg (n=27). No patients had grade 3 or 4 aortic regurgitation, one patient had grade 2, and four had grade 1. Conclusion Tirone’s procedure is an option for bicuspid aortic valve surgery, with good safety and outcomes, especially in younger patients.

Van Praet proposed a classification to predict the ease of minithoracotomy aortic valve replacement (MT-AVR) based on the position of the aorta in the thorax. We have evaluated the relevance of complex computed tomography (CT) scan measurements to predict the ease of performing a MT-AVR. The first 57 patients who underwent MT-AVR from February 2018 to June 2020 were selected prior to surgery using Van Praet's IA and IB classes. We made additional measurements on aorta position related to the chest and the incision on the preoperative CT scan. The main objective was to correlate complex CT measurements with different operating durations. Van Praet criteria were significantly related to the distance from the center of the aorta to the midline (p value 0.001), the distance from the center of the aortic ring to the midline (p value = 0.013) and aorto-sternal angle (p

International audience; Objective: To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay. Design: A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Societe francaise d'anesthesie et de reanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Societe francaise de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence. Methods: Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method. Results: The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions. Conclusions: Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery. (C) 2022 The Authors. Published by Elsevier Masson SAS on behalf of Societe francaise d'anesthesie et de reanimation (Sfar).

Highlights • Aortic valve infective endocarditis with annular abscess is the most devastating complication of destructive aortic valve endocarditis and requires extensive surgical debridement. • Annular skeletonization and reconstruction of the aortic annulus with glutaraldehydetreated autologous pericardium permits radical removal of infected tissue and effective. • Ozaki’s procedure is a good option for patients with infective endocarditis., Introduction Aortic valve infective endocarditis with annular abscess is associated with high mortality rate and surgery is usually the choice of treatment. Plasty or reconstruction of aortic valve is being performed more widely. Presentation of case We report a case study of a 56-year-old male who was diagnosed with congenital bicuspid aortic valve, severe aortic stenosis and regurgitation, and annular abscess. This patient underwent operation in december 2019 and Ozaki’s procedure was used to measure the distance between two commissures to reconstruct new leaflets and close the abscess using autologous pericardium. A bicuspid valve was reconstructed based on the anatomical feature of the patient. 6 months after surgery, aortic valve function was good with no residual insufficiency, maximum gradient was 8 mmHg. Discussion Reconstruction of aortic valve by Ozaki’s procedure has been reported with many advantages for the patient. In case of infectious endocarditis, this technique helps avoid the use of artificial materials. Bicuspid aortic valve reconstruction surgery following the novel methods of reconstructing three leaflets or maintaining the bicuspid morphology could both be performed with good results. Conclusion Reconstruction of aortic valve by Ozaki’s procedure in infectious endocarditis has good results. In case of true bicuspid aortic valve, reconstruction bi-leaflets can be performed.

Aim We aimed to report the experience of aortic valve reconstruction with autologous pericardium using Ozaki’s procedure in Vietnam. Methods The study included consecutive patients with isolated aortic valve disease who underwent Ozaki’s procedure in our hospital between June 2017 and August 2019. Aortic valve leaflets were reconstructed with autologous pericardium using Ozaki’s procedure. Results Sixty-one patients were included (mean age 55.8 years; 41 were male): 24 with aortic stenosis, 17 with aortic regurgitation, and 20 with both. Of the 61 patients, 16 had a bicuspid aortic valve, and 5 had infective endocarditis. The preoperative peak and mean gradient pressure gradients were 91.7 ± 16.1 mm Hg and 55.3 ± 10.3 mm Hg, respectively. Surgery was performed via a full or partial sternotomy. The procedure was successful in 59 cases. Two patients were converted to prosthetic valve replacement. The aortic crossclamp time was 110.9 ± 20.5 minutes. Intraoperative transesophageal echocardiography showed a mean pressure gradient of 8 ± 2 mm Hg and an aortic valve area of 3.04 ± 0.44 cm2. The mean follow-up period was 18.5 ± 5.7 months. One patient died in hospital due to cardiac tamponade. One patient underwent reoperation due to infective endocarditis 6 months after surgery. Another died at 8 months after surgery due to a mediastinal abscess. The surviving patients had no aortic regurgitation or mild aortic regurgitation at the last follow-up visits. Conclusions Aortic valve reconstruction with autologous pericardium provided good outcomes in our study.

BackgroundTo study the evolution of platelet count during patient treatment with Extra-Corporeal Membrane Oxygenation (ECMO) and the causes of Membrane Oxygenation (MO) exchange. Assessment of the morbidity and mortality rate was our secondary objective. MethodsA single center retrospective study was conducted from January 2014 to December 2015. One-hundred and thirty-nine MO exchanges were studied over 73 patients who received 66 MO exchange. Alterations in biological parameters were compared before and after each MO exchange, to study the device-related platelet count evolution. ResultsMean patient age was 56.8 ± 13.4 years. The mean duration of the MO was 5.9 ± 3.1 days, exchanged 26 times (68%) after clot formation. The median Survival After Veno-arterial ECMO score (SAVE score) was -3.5 [-4; -1] interquartile range [IQR]. The median Respiratory Extra-corporeal membrane Oxygenation Survival Prediction score (RESP score) was -1 [-3; 0] [IQR]. A significant decrease (p

Background: This study evaluated the midterm outcomes, the valve related events and quality of life of patients treated by valve-sparing aortic root replacement (VSRR). Methods: From January 2003 to December 2014, 88 con-secutive patients diagnosed with an aortic root aneurysm or ascending aortic aneurysms underwent VSRR surgery. The mean age was 55±14 (range 19–77) years. A total of 84% of the patients were male; 89% were in New York Heart Association functional class I or II, 55% had aortic regurgitation (AR) grade III or IV. Twenty-four patients (27.3%) had bicuspid aortic valve. The mean left ventricular ejection fraction (LVEF) was 61%±9% (range 29–78%). Patients were yearly followed by family doctors and referent cardi-ologists. Doppler echocardiographic examinations were obtained annually in all patients. The midterm clinical, echocardiographic results and quality of life were analyzed. The mean follow-up was 5.3±3 (range 1–12) years. Results: Hospital mortality was 1%. There were ten late deaths (11%) including 5 cardiac cases. Two patients (2%) required an aortic valve or graft prosthesis reoperation. Aortic valve endocarditis occurred in two patients. Thromboembolic events were reported in 3 patients. None of the following morbidity has been observed: structural valve deterioration, nonstructural dysfunction, valve thrombosis, bleeding event. The 5- and 8-year survival were 92% and 88%, respectively. The 8-year survival free from cardiac death was 88%. The mean of EuroQoL visual analogue scale (EQ VAS) and EQ index were respectively 83±15 (range 30–100) and 0.94±0.12 (range 0.5–1). Conclusions: Eight-year clinical improvement, function of the spared aortic valve and quality of life after valve sparing aortic root surgery appear excellent.

Primary cardiac lymphoma (PCL) represents a very exceptional clinical entity whose treatment is based on chemotherapy. In this case report, the authors highlight the key role of cardiac surgery in the diagnosis of PCL in a 66-year-old female patient. She was given chemotherapy and so far was on remission.Cardiovasc. j. 2018; 11(1): 86-88

Anomalies of the coronary arteries mainly concern a pediatric population, bringing together a wide range of defects. In adults, the evolution is linked to the hemodynamic consequences of fistula. Several therapeutic options have been proposed such as surgery or embolization. We report the case of a 55 years old patient addressed because of dyspnea secondary to aortic insufficiency. The preoperative assessment shown the coexistence of coronary abnormality corresponding to a coronaro-pulmonary fistula. This type of coronary anomaly is rarely described in the adult population, because of its consequences secondary to the closure of the foramen ovale, resulting in angina symptoms in childhood. Without treatment, mortality from this type of malformation is important (90%).

Background Cardiac sarcoidosis (CS) is a challenging diagnosis. Patients may progress to end-stage congestive heart failure and require cardiac transplantation without ever having been diagnosed. Characteristics and outcomes of patients with granulomas in the explanted hearts are unknown. Methods All French heart transplantation centers were contacted to participate in the study. Each center searched through local databases for the cases of non-caseating granuloma in the explanted hearts between 2000 and 2017. Data before and after transplantation were recorded from medical charts. Survival of CS and all- cause heart transplantation patients were compared. Results Fifteen patients (10 men, 5 women) received a diagnosis of CS based on pathologic data of the explanted heart and were recruited for the study. All patients were diagnosed as non-ischemic dilated or hypertrophic cardiomyopathy and presented congestive heart failure. Eight patients (53%) had ventricular rhythm disturbances, and 3 (20%) a complete heart block. Ten out of 13 patients (77%) had extracardiac radiological signs compatible with sarcoidosis on chest computed tomography (CT) scans. One patient died 3 months after transplantation from infectious complications. The 14 remaining patients were still alive at the end of the study (median follow-up of 28.8 months). One patient had a second heart transplantation 5 years later because of chronic allograft vasculopathy. One patient presented a relapse of CS confirmed by myocardial biopsies 9 years after transplantation, requiring an escalation of immunosuppressive therapy. Conclusion CS may be undiagnosed before heart transplantation. In 77% of cases, sarcoidosis could have been detected before transplantation with non-invasive imaging techniques.

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.

Pseudoaneurysm is a rare long-term complication following coarctation of aorta repair. Thoracic endovascular aortic repair is the most common approach. However, under some circumstances, this cannot be performed. Therefore, the traditional open approach is indicated. Although the potential ischemia of spinal cord is related to this approach, it remains an efficient alternative. The authors report a case of late pseudoaneurysm of the distal aortic arch following coarctation of aorta repair in a 26-year-old male that has been successfully repaired by left thoracotomy.

Resume Introduction Les patients aux antecedents de pontage aorto-coronarien et presentant une valvulopathie aortique sont un groupe a risque eleve pour la chirurgie conventionnelle redux. L’implantation de valve aortique par voie trans-catheter (TAVI) pourrait etre une alternative pour leur prise en charge. Le but de cette etude est d’evaluer l’impact des TAVI dans la prise en charge des valvulopathies aortiques apres une revascularisation coronaire chirurgicale prealable. Methodes Il s’agit d’une etude retrospective, observationnelle monocentrique incluant 87 patients ayant beneficie d’une chirurgie traditionnelle ou d’un TAVI dans le periode allant de janvier 2007 a decembre 2013. Les abords pour le TAVI etait trans-femoral, trans-apical et par l’artere sous-claviere. Resultats L’introduction des techniques interventionnelles a multiplie par deux le nombre de patients redux de pontage traites pour une valvulopathie aortique. Sur la deuxieme periode 30 % de moins de patients ont ete operes par la chirurgie conventionnelle, ce qui a permis une amelioration des resultats postoperatoires. Cette etude nous a permis de remarquer une difference des populations de patients traites en termes de facteurs de risques operatoires n’autorisant dans cette serie aucune comparaison sans biais entre les deux techniques. La mortalite hospitaliere etait de 6,4 % pour la chirurgie conventionnelle aortique et de 20 % pour les implantations aortiques trans-catheter. Conclusion La chirurgie conventionnelle reste le traitement de reference pour la prise en charge des valvulopathies mais le TAVI devient un complement indispensable pour permettre de mieux selectionner les patients avant la chirurgie offrant des perspectives therapeutiques nouvelles pour les autres.

Antiplatelet agents have a predominant role in the therapeutic treatment of acute coronary syndrome (ACS) and myocardial infarction. Recently, ticagrelor has been incorporated in the European Society of Cardiology guidelines for the management of ACS with ST elevation and non-ST elevation.1 The AHA/ACC guidelines further advocate the choice of ticagrelor over clopidogrel in patients with ACS with non-ST elevation treated with an early invasive strategy.2 In fact, major studies have proven the benefits of ticagrelor on cardiovascular death, myocardial infarction, and stroke without an increase in major bleeding risk

The authors report a case of a 44-year-old pregnant woman with Marfan syndrome who was diagnosed with type A aortic dissection at 25 weeks of pregnancy. She underwent a mechanical Bentall procedure with cardiopulmonary bypass and circulatory arrest. Postoperatively, the fetus was not distressed; echocardiogram and magnetic resonance imaging were repeated, and a prophylactic cesarean section was performed at 36 weeks. Both the mother and the baby were followed up for 1 year and presented no clinical issue.

Progress in the medical management of patients with heart failure with systolic dysfunction has been accompanied by a significant improvement in survival and quality of life. These strategies have also resulted in changes in the clinical profile as well as an increase in the number of patients with advanced heart failure. The technological developments in left ventricular assist devices provide real hope for these patients. This article related our experience of management and the rehabilitation program realized.

Background Commonly the frequency of international normalized ratio (INR) monitoring with a conventional laboratory test in stable patients is once a month. When using a dedicated personal device for INR assessment, the frequency may be increased to two or more times a month. Objective To show that INR assessed by self-measurement at home is reliable and feasible in the mid-term and improves medical care. Patients and methods All patients in the study on INR self-measurement (clinical trial.gov: NCT00925197 ), conducted between 2004 and 2007, were re-contacted for mid-term follow-up. One hundred and seventy eight out of 192 patients who participated in the study answered a questionnaire. The average follow-up time was 4.2 years (± 1) for the self-measurement group and 4.9 years (± 1) for the laboratory-analyzed control group. Results Only 26 patients (group A) continued to use INR self-measurement to monitor treatment with vitamin K antagonists (VKA). The main reasons to stop INR self-measurement were its high cost and difficulty in obtaining strips. There were significantly fewer bleeding complications (p = 0.04) and complications related to VKA (p = 0.01) in self-measured patients compared to the control group. Feelings of security and quality of life were also significantly better (p = 0.002) for self-measured patients. Conclusion Many patients with a mechanical heart valve, who self-measured INR, continue to use this method for their follow-up because of its positive effects on their health and quality of life.

Introduction Surgical-site infection (SSI) is the second most frequent cause of healthcare-associated infection worldwide and is associated with increased morbidity, mortality and healthcare costs. Cardiac surgery is clean surgery with low incidence of SSI, ranging from 2% to 5%, but with potentially severe consequences. Perioperative skin antisepsis with an alcohol-based antiseptic solution is recommended to prevent SSI, but the superiority of chlorhexidine (CHG)–alcohol over povidone iodine (PVI)–alcohol, the two most common alcohol-based antiseptic solutions used worldwide, is controversial. We aim to evaluate whether 2% CHG–70% isopropanol is more effective than 5% PVI–69% ethanol in reducing the incidence of reoperation after cardiac surgery. Methods and analysis The CLEAN 2 study is a multicentre, open-label, randomised, controlled clinical trial of 4100 patients undergoing cardiac surgery. Patients will be randomised in 1:1 ratio to receive either 2% CHG–70% isopropanol or 5% PVI–69% ethanol for perioperative skin preparation. The primary endpoint is the proportion of patients undergoing any re-sternotomy between day 0 and day 90 after initial surgery and/or any reoperation on saphenous vein/radial artery surgical site between day 0 and day 30 after initial surgery. Data will be analysed on the intention-to-treat principle. Ethics and dissemination This protocol has been approved by an independent ethics committee and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals. Trial registration number EudraCT 2017-005169-33 and NCT03560193.

Objective: Early and long-term valve stability following VSRR, were comparatively analyzed between tricuspid aortic valve (TAV) and bicuspid aortic valve (BAV).Methods: From January 2003 to Februar...

Nowadays transcatheter aortic valve implantation (TAVI) is an accepted alternative to surgical aortic valve replacement for high-risk patients (pts). Successful TAVI procedures for failed aortic surgical bioprosthesis (TAV-in-SAV) have already been reported. In the presented two cases of TAV-in-SAV implantation a strut distortion of the stent was revealed on angiographic imaging and confirmed on control CT scan. In both procedures, a dislocation of the medtronic core valve (MCV) prosthesis during implantation led to valve retrieval, with a necessity of reloading it in the 18F introducer before subsequent implantation of the same valve in correct position.

Summary Introduction Thromboembolic accidents and haemorrhage are the main complications observed during long-term follow-up of mechanical heart valve patients. Several suggestions for improving anticoagulation quality have been made, including international normalised ratio (INR) self-monitoring. Objectives We report the preliminary results of a single-centre, open, randomised study (scheduled population of 200 patients), which compares monthly laboratory monitoring (group A) versus weekly self-monitoring of INR (group B). The primary aim is INR stability improvement within the target range, and the secondary aim is adverse events reduction. Patients and methods Between May 2004 and June 2005, 67 patients with an average age of 56.6 years (± 9.6), were enrolled in the study (group A: 34 patients, group B: 33 patients). The mean follow-up was 47 weeks (± 11.5). The two groups differed only in the sex ratio (44.1 and 21.2% of women in groups A and B respectively, p = 0.0459). Mechanical heart valves were aortic in 73% of patients, mitral in 13.5%, and multiple in 13.5%. Sixty-five patients (97%) were treated with fluindione, the others with acenocoumarol. The intraclass correlation coefficient between the self- and laboratory-monitored INR was 0.75. Results The time spent in the INR target range (group A: 53 ± 19%, group B: 57 ± −19%, p = 0.45) and the time spent in the INR therapeutic range, between 2 and 4.5, (group A: 86 ± 14%, group B: 91 ± 7%, p = 0.07) are longer in group B, but not significantly so. For patients outside the range, the absolute mean deviation of INR from the target or therapeutic range (range standardized between 0 and 100) is lower for the self-monitoring group (41.1 ± 39.3 and 11.27 ± 11.2) than for the control group (62.4 ± 72.6 and 39.2 ± 52.8). This difference is significant ( p = 0.0004 and p = 0.0005). Eighteen adverse events were reported: 17 haemorrhages, 13 in group A (9 mild, 4 serious) and four in group B (all mild), and one sudden death in group B, two days after the patient's discharge. No thromboembolic events were reported. Six patients (8.8 %), 3 in each group, dropped out of the study. Conclusion This first study evaluating INR self-monitoring in France shows that this method leads to better stability of the INR within the target range. On the basis of these preliminary data, this appears to be related to a decrease in serious haemorrhages (11.8% serious haemorrhage cases in group A versus 0% in group B, p = 0.06, NS).

Resume Objectif Rapporter les modalites du diagnostic et du traitement des endofuites de type III observees dans notre centre compliquant l’implantation d’endoprothese couverte (EC) pour le traitement d’anevrysme de l’aorte thoracique descendante (AATD). Patients et methodes Etude retrospective des circonstances du diagnostic, des modalites therapeutiques et de l’evolution de la prise en charge d’endofuites de types III compliquant l’implantation d’EC chez trois patients parmi 18 traites entre avril 1998 et juillet 2005. Ces endofuites survenaient sur des protheses deployees pour traiter des AATD 22 mois (19-24) apres leur implantation. Resultats Ces endofuites de type III etaient des decouvertes systematiques sur scanner de controle, sans signe clinique d’appel. Un traitement complementaire par voie endovasculaire etait propose en moyenne 4,4 mois (1 semaine – 11 mois) apres le diagnostic, rencontrant un succes immediat pour les trois procedures. Au terme du suivi, nous deplorons un deces un mois apres traitement de la recidive, la necessite d’une reprise chirurgicale a 14 mois pour une nouvelle recidive, et une evolution favorable deux mois apres la nouvelle procedure. Conclusion La surveillance des AATD traites par EC est indispensable. Le traitement des complications tardives peut faire appel a un nouveau traitement endovasculaire, sous reserve d’un delai bref de reintervention, mais il peut aussi necessiter une reprise chirurgicale.

Summary Surgical site infection after heart surgery increases morbidity and mortality. The method of presurgical hand disinfection could influence the infection risk. From February to April 2003, we compared the microbiological efficacy of hand-rubbing (R) and hand-scrubbing (S) procedures. The surgical team alternately used hand-scrubbing or hand-rubbing techniques every two weeks. Fingertip impressions were taken before and immediately after hand disinfection, every 2 h and at the end of the operation. Acceptability of hand rubbing was assessed by a questionnaire. Mean durations of surgical procedures were 259 ± 68 and 244 ± 69 min for groups S and R respectively ( P = 0.43). Bacterial counts immediately after hand disinfection were comparable with the two techniques, but significantly lower in group R at the end of surgery. No differences were observed between the percentages of negative samples taken after 2 h, 4 h and at the end of surgery between the two groups. Bacterial skin flora reduction immediately after hand disinfection, after 2 h and 4 h of operating time and at the end of surgery was better in group R, but the difference was not statistically significant. Before surgery, the hand-rubbing method with alcohol solution preceded by hand washing with mild neutral soap is as effective as hand scrubbing to reduce bacterial counts on hands. It decreased the bacterial counts both immediately after hand disinfection and at the end of long cardiothoracic surgical procedures. The acceptability of hand rubbing was excellent and it can be considered to be a valid alternative to the conventional hand-scrubbing protocol.

Resume Objectif Evaluer retrospectivement l’interet de l’IRM pour la surveillance a long terme des dissections aortiques (DA) et son impact sur la prise en charge therapeutique. Patients et methodes L’evolution radiologique sur 215 IRM effectuees dans le meme centre de 1991 a 2002 chez 56 patients (2 a 12 explorations par patient, moyenne: 4), a ete confrontee a l’evolution clinique. Resultats Vingt-six patients (46%) avaient une evolution anormale de l’aorte dissequee, cliniquement asymptomatique pour 14 d’entre eux (54%). Huit (31%) relevaient d’un traitement chirurgical: anomalies en amont d’un remplacement prothetique sus coronaire chez 3 patients; evolution anevrysmale du faux chenal pour les 5 derniers. Cinq de ces 8 patients (63%) etaient asymptomatiques. Le delai entre l’episode initial et le traitement chirurgical secondaire etait de moins de 5 ans pour 5, et de plus de 10 ans pour 3. Les 30 autres patients (54%) avaient une evolution radiologique stable apres un recul moyen de 3,5 ans (6 mois - 9 ans). Conclusion Dans la surveillance a long terme des DA, l’IRM a permis de detecter une progression de la maladie souvent cliniquement silencieuse, et ainsi d’adapter la prise en charge therapeutique chez 26 de nos patients (46%).

Les anomalies des arteres coronaires concernent essentiellement une population pediatrique, regroupant un tres large eventail de malformations. Chez l’adulte, l’evolution est alors liee au retentissement hemodynamique de la fistule. Plusieurs possibilites therapeutiques ont ete proposees a ce titre, chirurgicales ou par embolisation. Nous rapportons le cas d’un patient de 55 ans adresse en raison d’une dyspnee secondaire a une maladie aortique. Le bilan preoperatoire permettait de mettre en evidence la co-existence d’une anomalie anatomique coronaire correspondant a une fistule coronaropulmonaire. Ce type d’anomalie coronaire est peu decrite dans la population adulte en raison de ses consequences des la fermeture du trou de Botal, aboutissant a une symptomatologie angineuse des l’enfance. En l’absence de traitement, la mortalite de ce type de malformation est importante (90 %).

Resume But de l'etude : Le but de ce travail etait d'analyser les resultats de la nephrectomie avec thrombectomie cavo-atriale sous circulation extracorporelle (CEC) chez six patients ayant un cancer du rein avec envahissement cave supra-diaphragmatique et de discuter les indications operatoires. Patients et methode : Six patients, cinq adultes (âges de 57 ± 10 ans) et une fillette de quatre ans, ont ete operes d'un cancer du rein avec extension cave supra-diaphragmatique. Dans tous les cas, l'echographie abdominale a detecte l'extension veineuse. La limite superieure du thrombus etait formellement identifiee par l'examen tomodensitometrique trois fois, et par l'echographie abdominale et la resonance magnetique nucleaire dans tous les cas. Tous les patients ont ete operes sous CEC a cœur battant ; deux en hypothermie moderee a 28 °C et quatre en normothermie. Resultats : Il n'y a eu aucun deces postoperatoire. La duree du sejour en reanimation a ete de 3,8 jours. Tous les patients ont eu a distance une dissemination metastatique. Les cinq patients adultes, dont la graisse peri-renale etait envahie, ont eu une mediane de survie de 9,4 mois (de 6 a 19). La fillette a eu une metastasectomie pulmonaire un an apres la nephrectomie et etait toujours en vie sept ans apres la nephrectomie. Conclusion : La CEC autorise l'exerese des thrombi atriocaves avec une mortalite et une morbidite postoperatoires acceptables mais les resultats a distance ont ete decevants. Cette intervention ne peut etre proposee qu'aux patients n'ayant aucune extension locoregionale et generale decelable, ce qui souligne l'importance des examens morphologiques preoperatoires.

We present the case of a 57-year-old woman with severe aortic regurgitation and ventricular dysfunction (ejection fraction 34%) requiring surgical intervention. In pre-operative period, no left ventricular (LV) asynchrony was detected by QRS duration and current echocardiographic techniques, including tissue Doppler imaging. A new echocardiographic technology, the timing of regional volumetric changes by three-dimensional echocardiography (3DEcho), demonstrated an intraventricular mechanical asynchrony. Indeed, during surgery, epicardial leads were attached to the right atrium and the right ventricle as part of the standard management. Two additional epicardial leads were attached to the left ventricle on the most delayed wall localized precisely by 3DEcho on the inferolateral wall. In post-operative period, biventricular (BiV) pacing showed improvement in the LV mechanical synchronization, resulting in improvement in the LV systolic function compared with right ventricular pacing or no pacing. This case shows the potential utility of 3DEcho in prediction of favourable response of the BiV pacing in patients with depressed LV systolic function ongoing cardiac surgery.

Background —In human ventricular cells, the inwardly rectifying K + current ( I K1 ) is very similar to that of other mammalian species, but detailed knowledge about the K + -dependent distribution of open and blocked states during rectification and about the K + -dependent modulation of inactivation on hyperpolarization is currently lacking. Methods and Results —We used the whole-cell patch-clamp technique to record I K1 in myocytes isolated from subendocardial layers of left ventricular septum from patients with nonfailing hearts with aortic stenosis and cardiac hypertrophy who were undergoing open-heart surgery. Outward currents were very small at voltages positive to the reversal potential but increased at high external [K + ]. Chord conductance measurements and kinetic analyses allowed us to estimate the proportion of channels in the open state and of those showing either slow unblock or instantaneous unblock (the so-called slow or instantaneous “activation”) on hyperpolarization: the distribution in the individual states was dependent on external [K + ]. The proportion of channels unblocking slowly was greater than that of channels unblocking instantaneously on hyperpolarization from the plateau voltage range. Hence, because of the previously reported link between the presence of highly protonated blocking molecules and slow unblock kinetics, it is suggested that high cellular concentrations of spermine may account for the low outward current density recorded in these cells. The current decrease observed on extended hyperpolarization was significantly relieved by an increase in external [K + ]. Conclusions —The pattern of I K1 current alterations observed in the present model of human ventricular hypertrophy might favor enhanced excitability and underlie ventricular arrhythmias, possibly via increased intracellular polyamine levels.

Background . Stabilization of the posterior annulus seems to be a critical factor to achieve a stable mitral valve repair. To assess the benefit of softer mural annuloplasty, we analyzed results obtained with the flexible linear reducer. Methods . From 1985 to 1993, 120 patients, with pure mitral regurgitation, mainly degenerative, had a mitral reconstruction. Mean age was 64 ± 11 years and 74% of the patients were in New York Heart Association functional class III or IV. Results . Hospital mortality was 3.3%. Mean follow-up was 56 ± 24 months. There were 23 late deaths; 10 valve-related including 7 sudden deaths. Two patients (1.7%) required a reoperation. Doppler echocardiographic studies revealed excellent valve function; 5-year freedom from significant regurgitation was 85.8% ± 5.4%. Mean mitral valve area was 2.76 ± 0.77 cm 2 . Although 105 patients were in class I or II, 23 patients were not functionally improved. Previous myocardial infarction and shorter deceleration time of early filling were risk factors for worsening functional disability. Conclusions . This support provides stable repair with excellent clinical and echographic results. Previous myocardial infarction and noncompliant left ventricle negatively influence outcome.

Introduction Les experts du Scenihr [1] ont mis en evidence que l’ECMO (oxygenation membranaire extracorporelle) fait partie des situations a haut risque d’exposition au DEHP. Le DEHP est un plastifiant present dans le PVC et reconnu comme toxique. Les laboratoires ont ainsi limite la quantite de DEHP dans les dispositifs medicaux et l’on remplace par d’autres plastifiants dont le TOTM. L’objectif de cette etude consiste a etudier le relargage des plastifiants du circuit en fonction des debits et des contraintes mecaniques et de le comparer a la dose limite d’exposition (DNEL). Materiel et methodes Un modele d’ECMO a ete realise a 2 debits (1,5 et 5,5 L/min) et compare a une situation statique pendant 6 jours. Un melange d’ethanol absolu/eau (50/50 v/v) a ete utilise comme simulant du sang, selon les donnees de la litterature [2] . Des prelevements de simulant ont ete realises quotidiennement pour une analyse des plastifiants par chromatographie en phase gazeuse couplee a la spectrometrie de masse (CG-SM). Les concentrations obtenues en mg/L ont ete extrapolees en mg/kg/j pour etre comparees aux derived no effect level (DNEL). La composition en plastifiants des circuits et des accessoires a egalement ete etudiee. Enfin, une experience de clampage a ete realisee, afin d’evaluer le relargage potentiel de cette contrainte. Resultats Les differents plastifiants retrouves dans le simulant apres contact avec les tubulures d’ECMO sont les suivants : le DEHP, le TOTM, le DEHT et le DEHA. La composition initiale en plastifiants du circuit et de la poche d’amorcage est presentee dans le Tableau 1 . Le TOTM, plastifiant majoritaire, migre peu dans le simulant et les doses d’exposition du patient sont inferieures a la DNEL ( Fig. 1 ). Le DEHP quant a lui presente des doses d’exposition superieures a la DNEL malgre une faible presence dans le circuit. Le DEHT et le DEHA sont presents a l’etat de traces dans le simulant. Le debit n’impacte pas le relargage des plastifiants de meme que le clampage ( p > 0,05). Discussion Cette etude montre la presence majoritaire d’un nouveau plastifiant alternatif au DEHP, le TOTM, dans ces circuits d’ECMO. Le relargage du TOTM est faible, d’ou un risque d’exposition acceptable. Les taux de DEHP retrouve depassent la DNEL. Ceci peut s’expliquer par la presence de DEHP en grande quantite dans la poche d’amorcage. Le remplacement du DEHP par le TOTM dans le circuit a permis de limiter l’exposition a un compose toxique (CMR1B). L’utilisation d’une poche sans PVC permettrait d’eliminer le DEHP et donc de securiser l’ensemble du circuit. Enfin, ces resultats demontrent l’absence d’influence des hauts debits et des contraintes mecaniques sur le relargage des plastifiants.

Myocardial protection is usually studied in vitro on perfused heart preparations, but never directly on cultured cardiomyocytes. We evaluated a model of cultured newborn rat cardiomyocytes to study both the cytotoxicity and the protective effect against chemical hypoxia of three cardioplegic solutions (St Thomas' I, Bretschneider, St Thomas' II) under normothermic (37°C) and hypothermic (4°C) conditions. Cytotoxicity was evaluated in 50% and 100% concentrations of the cardioplegic solutions with incubation times from 90 to 360 min. Myocardial protection was studied in 50% cardioplegic solution with metabolic inhibitors. Immediate and late viabilities, after 24 h of recovery in the medium, were evaluated by simultaneous staining with fluorescein diacetate and propidium iodide.

A 13-year-old boy with tetralogy of Fallot and pulmonary atresia after a Waterston and Blalock-Taussig shunt underwent successful repair using a cryopreserved pulmonary homograft as a valved extracardiac conduit. Aortic transection gave a good operative field for pulmonary angioplasty and closure of the Waterston anastomosis. The cryopreserved pulmonary homograft provided excellent handling characteristics. The postoperative course was good, and postoperative echocardiography showed good function of the valved conduit.

The 18F-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT) offers an excellent negative predictive value. Consequently, it is a reliable tool for excluding an infectious phenomenon in case of negativity. In case of persistent fever of unknown origin after cardiac surgery and in combination with other bacteriological examinations and medical imaging, we can rely on FDG-PET/CT to confirm or eliminate deep infections and prosthetic endocarditis. For this reason, FDG-PET/CT should be considered among the examinations to be performed in case of suspected infection after cardiac surgery. We have reported the case of a 76-year-old man who presented with a fever of unknown origin and recurrent septic shocks after a biological Bentall procedure combined with left anterior descending (LAD) coronary artery revascularization by the left internal thoracic artery. We performed a FDG-PET/CT which showed external iliac vein and right common femoral vein hyperfixation with infiltration of adjacent soft tissues, highly suspected to be an infectious process.Learning objectiveThe aim of this case report is to show that FDG-PET/CT, in combination with other bacteriological examinations and medical imaging, can be extremely helpful in detecting deep infectious sources, even during the early postoperative period.

In this single-center French study, the conventional management of patients receiving vitamin K antagonists (VKAs) was compared with an International Normalized Ratio (INR) self-testing program. The aim was to determine the reliability of self-testing devices, and to estimate the variability of the self-measured INR within the therapeutic and target range.A total of 206 patients who had undergone valve replacement with a mechanical prosthesis, with or without myocardial revascularization, between May 2004 and September 2007 was randomized into two groups. Group 1 patients (n = 103) underwent INR monitoring at a laboratory, while Group 2 patients (n = 103) underwent self-testing INR using either the CoaguChek (Roche) (Group 2A; n = 55) or INRatio (Hemosense) (Group 2B; n = 48) system. Patients in Group 1 underwent at least once-monthly INR measurement, while those in Group 2 carried out once-weekly self-testing, and also underwent once-monthly INR measurement at the laboratory. The large majority of patients (97.9%) were treated with fluindione.The mean follow up period was 49.0 +/- 10.3 weeks. Self-testing was reliable, with a correlation coefficient between device- and laboratory-measured INRs of 0.80 [CI: 0.78, 0.82] (p0.0001). The proportion of time spent within the INR target range was significantly higher for Group 2 (61.5 +/- 19.3% versus 55.5 +/- 19.9%; p0.05), while the absolute mean deviation of INR from the target range was higher in Group 1 (60.1 +/- 70.2% versus 47.4 +/- 51.5%). Adverse events were reported by seven patients in Group 1, but by no patients in Group 2 (p0.01).INR self-testing devices are reliable and beneficial. Moreover, INR self-monitoring allows an enhanced stability within a target range, and also helps to prevent serious postoperative complications.

OBJECTIVE To present the analyzed results on mechanical circulatory support (MCS) collected over a 7-year period, from 2000 to 2006, in France. METHODS A cohort of 520 patients was analyzed. Mean age was 43.7 ± 13.6 years. The main causes of cardiac failure were ischemic cardiomyopathy (39%), idiopathic dilated cardiomyopathy (41.3%), or myocarditis (6.4%). Bridge to transplantation was indicated in 87.8% of patients, bridge to recovery in 9%, while destination therapy was proposed in 3.2% of patients. RESULTS For patients in cardiogenic shock or advanced heart failure undergoing device implantation as bridge to transplantation or recovery (n=458), overall mortality was 39% (n=179). The main causes of mortality under MCS were multi-organ failure (MOF) (57.4%), neurological events (14.1%), or infections (11.9%). Heart transplantation was performed in 249 (54.3%) patients. The main causes of death following heart transplantation were primary graft failure (22.4%), MOF (14.3%), neurological event (14.3%), or infection (10.2%). Long-term survival in transplanted patients was 75 ± 2.8% at 1 year and 66 ± 3.4% at 5 years. CONCLUSIONS MCS is an essential therapeutic tool to save the life of young patients with cardiogenic shock or advanced cardiac failure. Early MCS implantation and the availability of a device that is adapted to the patient's clinical status are prerequisites for reducing overall mortality rates.

Cardiac papillary fibroelastoma (CPF) is a rare and histologically benign tumour. It is the most common valvular tumour and the third cardiac benign tumour, after myxoma and lipoma (less then 16% of all cardiac tumours). CPF is a surgically correctable cause of cerebrovascular and myocardial infarction, making its identification by echocardiography beneficial. We report an unusual case of double localization on both chordae and leaflet of the mitral valve.

and regained normal immunity to ensure success. In agreement with other authors, ~ we never found that cervicothoracic access was not needed for simple repair of a TEF. Thus the risks of postoperative assisted ventilation (which constitute the main cause of relapse) are greatly reduced, resulting in an acceptable rate of mortality (about 10% according to Marzelle and associates1). A left lateral cervical incision gives very satisfactory access for simple closure of a TEF, with better visibility and adequate operative space compared with the median approach, and has the advantage of being able to be transformed to a cervical incision at the neck if necessary. Placement of a muscular flap between the two viscera is another indispensable element for success. The partial relapse in our second patient was due, in our opinion, to the insertion of a muscular flap that was too thin (omohyoidal muscle). In cases of associated tracheal stenosis, which occurs in about 22% of patients with a TEF, 1 the possible anastomotic resection of even a small segment (a rare event) greatly increases the surgical risk. For this reason, in two of our patients with associated tracheal lesions, we opted for t reatment with a dilating endoprosthesis.

Objective The progress made in the supportive care of allografts and the identification of mesenchymal stem cells in adult human bone marrow (BM) has prompted renewed interest in the use of BM as a form of cell therapy. With the aim of optimizing the collection of BM cells, we evaluated the hematopoietic and mesenchymal immature cell contents of BM hematon units (HUs), which usually are eliminated during graft processing. Materials and methods Hematopoietic CD34 + progenitors from HU and buffy coat (BC) compartments were characterized in short-term culture. The sorted CD34 + CDw90(Thy-1) + primitive subset was assessed in colony-forming cell (CFC) and long-term culture-initiating cell (LTC-IC) assays, then further characterized by the expression of additional antigens. In parallel, we evaluated the colony-forming unit fibroblast (CFU-F) number and phenotyped the fresh adherent (D1-3) cells. Results The plating efficiencies of CD34 + cells derived from HU and BC were identical. However, the HU CD34 + CDw90(Thy-1) + subset was enriched in colony-forming unit megakaryocyte (2.3×), LTC-IC (4.6×), and cells coexpressing CD105 (5×). We found a higher frequency of CFU-F (4.7×), considered to be the mesenchymal stem cell-containing population, correlated with an enrichment in fresh adherent (CD45/GPA) − CD14 − cells. Conclusions We show for the first time that functional properties of the CD34 + CDw90 + subset are related to its in vivo location in HU, which may represent the BM mesenchymal reserve compartment. The location in HU of 35.6%, 59.1%, and 58.7% of CD34 + cells, CD34 + CDw90 + LTC-IC, and CFU-F, respectively, justifies the development of a procedure to collect them in order to reduce the therapeutic BM volume.