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[Display omitted] • Aortic valve repair is feasible in patients with Marfan syndrome. • Aortic valve repair showed excellent durability at 5 years in Marfan syndrome. • In Marfan syndrome with AI, aortic valve repair must be the first-line strategy. Although, valve sparing is commonly performed in patients with Marfan syndrome, feasibility and results of cusp repair for aortic insufficiency have not been studied. To report on the outcomes and durability of aortic cusp repair in valve sparing in patients with Marfan syndrome. All consecutive adult patients with Marfan syndrome who underwent remodelling and annuloplasty with aortic valve repair for aortic insufficiency between May 2005 and December 2020 were included. Patients with Marfan syndrome treated for aortic aneurysm, but without aortic insufficiency, were excluded. Data were collected prospectively and reviewed retrospectively from the Aorticvalve repair International Registry (AVIATOR). During the study period, 71 patients with Marfan syndrome were referred to surgery. Fifty-five patients with connective tissue disease and aortic insufficiency with aorta aneurysm were treated: 46 underwent aortic valve repair and nine underwent aortic valve replacement (five mechanical aortic valve replacements and four biological aortic valve replacements). The mean age was 42.9 ± 15.4 years, and the mean EuroScore II was 2.5 ± 2.2. No patient died, and no patient had significant aortic insufficiency (grade ≥ II) at discharge. The 5-year survival rate estimate was 94.4%, which seems statistically similar to that of the age- and sex-matched general population. At 5 years, freedom from reoperation was 94.6%, and the incidence of infective endocarditis was 2.6%. No valve thrombosis, aortic dissection, major bleeding events, thromboembolic events (stroke) or myocardial infarctions were noted during follow-up. Remodelling and aortic valve repair showed excellent durability at 5 years, even in connective tissue disorders. [ABSTRACT FROM AUTHOR]

Nevertheless guidelines recommend perioperative graft evaluation by Doppler control, Transit-Time Flow Measurement (TTFM) has not yet routinely adopted by surgical community as a standard of care. This retrospective review of the EFCAD (Evaluation of transit-time Flow in Coronary Artery Disease surgery) study assesses the impact of TTFM in patients undergoing on-pump coronary artery bypass grafting (CABG). EFCAD is a prospective, multicenter registry involving nine centers performing TTFM during isolated CABG. An EFCAD study sub-analysis was performed on patients undergoing on-pump procedures. Primary end-point was occurrence and risk factors of Major Adverse Cardiac Events, including perioperative myocardial infarction, urgent postoperative coronary angiogram and/or revascularization, and hospital mortality. Secondary end-points were rate of graft revision during surgery and factors affecting graft flow. TTFM measurements were performed with the MiraQ or VeriQ C devices (Medistim ASA, Surgitech, France). Cut-off values of TTFM assessment were mean Graft Flow (GF) >15 ml/min, Pulsatility Index (PI) < 5, and Diastolic Flow (DF) > 70% for left coronary bed, and > 50% for the right one. Between May 2017 and March 2021, 1616 patients were registered in EFCAD database. Of those, 1232 patients undergoing on-pump CABG were eligible for analyses. Seventeen patients (1.4%) underwent intraoperative graft revision, mainly due to incorrect TTFM values (Fig. 1a, b). Graft revision was associated with significant graft flow increase (4 ml/min. [1;10] vs 26 ml/min. [13;34], p < 0.01, Fig. 1c) and Pulsatility Index reduction (12 [4.5;21.8] vs 2.5 [1.9;4.3], p < 0.001, Fig. 1d). Primary end-point occurred in 38 (3.1%) patients, and it was associated, at multivariate analysis, with left anterior descending artery (LAD) Graft Flow <15 ml/min. (OR 3.12, p < 0.01). Data from EFCAD study suggest that TTFM is reliable to evaluate graft flow, and acceptance of incorrect flow on LAD anastomosis affect postoperative outcomes. In our opinion, TTFM assessment should be routinely used in on-pump CABG procedures, even if interpretation depends on learning curves. [ABSTRACT FROM AUTHOR]

Background and Aims: High-density lipoprotein (HDL) particles play atheroprotective roles by their ability to efflux cholesterol from foam cells and to protect low-density lipoproteins (LDLs) from oxidative damage in the arterial intima. We hypothesized that antioxidative properties of HDLs can be attenuated in the oxygen-rich prooxidative arterial environment, contributing to the development of atherosclerosis. To evaluate this hypothesis, we compared antioxidative activity of HDLs from arterial and venous plasmas.Methods and Results: Arterial and venous blood samples were simultaneously obtained from 16 patients (age 68 ± 10 years; 75% males) presenting with ischemic or valvular heart disease. Major HDL subfractions and total HDLs were isolated by density gradient ultracentrifugation and their chemical composition and the capacity to protect LDLs from in vitro oxidation were evaluated. HDL-cholesterol, triglycerides and apolipoprotein (apo) B-100 levels were slightly but significantly reduced by -4 to -8% (p < 0.01) in the arterial vs. venous samples. Total mass of HDL subpopulations was similar and HDL subpopulations did not reveal marked compositional differences between the arterial and venous circulation. Potent antioxidative activity of the small, dense HDL3c subpopulation was significantly reduced in the particles of arterial origin vs. their counterparts from venous plasma (increase of +21% in the propagation rate of LDL oxidation, p < 0.05). Interestingly, antioxidative properties of venous HDLs were enhanced in statin-treated patients relative to untreated subjects.Conclusion: Antioxidative properties of small, dense HDLs from arterial plasma are attenuated as compared to the particles of venous origin, consistent with the development of atherosclerosis in the arterial wall. [ABSTRACT FROM AUTHOR]

Available prospective data on infective endocarditis (IE) remain scarce, although further knowledge on this serious condition could help improving the prognosis of patients. To describe the characteristics and outcomes of left-sided IE and to determine the risk factors associated to in-hospital mortality in a high-volume center. From 15 September 2020 to 15 February 2023, all patients with left-sided IE managed in a tertiary center of cardiology were included in this prospective, observational study. Diagnosis of IE was made according to current guidelines and management was collegially discussed by the endocarditis team. Determinants of in-hospital death were assessed using a multivariate logistic regression model including any covariate associated in univariate analysis (P < 0.1). A total of 185 patients were included during the study period. Median age was 68 [56–76] years, 141 (76%) patients were males, and 75 (41%) cases involved a prosthetic valve. Aortic valve, mitral valve and involvement of both valves were observed in 111 (60%), 48 (26%) and 26 (14%) patients, respectively. Severe valvular regurgitation was identified in 56 (30%) patients, root abscess and/or false aneurysms in 57 (31%) patients. A pathogen agent was identified in 169 (91%) patients, and the most frequent germs were Staphylococcus (30%), Streptococcus (30%) and Enterococcus (17%). A severe initial presentation requiring intensive care unit (ICU) admission was observed in 42 (23%) patients. Cardiac surgery was performed in 102 (55%) cases, and 41 (22%) patients required an emergent surgery. A total of 37 (20%) patients died during the initial in-hospital phase, mostly from cardiac or neurovascular causes. In a multivariate analysis, hypertension (odds ratio [OR] = 3.3; 95% confidence interval [CI]: 1.4–10), bi-valvular endocarditis (OR = 3.1; 95%CI: 1.0–9.5), unidentified pathogen (OR = 4.3; 95%CI: 1.7–15) and chronic alcoholic abuse (OR = 16.4; 95%CI: 3.7–87.9) were independently associated with increased in-hospital mortality (Table 1). In this cohort, the patients have a severe initial status frequently requiring an ICU admission and/or urgent cardiac surgery. Chronic alcoholic abuse appears as a major determinant of mortality. IE remains a severe condition which should be managed by experienced teams. [ABSTRACT FROM AUTHOR]

Migration of a bullet to a distant part of the body after a gunshot is rarely observed in the clinical setting; migration to the heart is even rarer. There are usually no clear symptoms or signs from migration of a bullet. The case of a 28-year-old man with an intracardiac bullet migration 2 months after a gunshot wound to the right abdomen is presented. We propose that the bullet migrated along the vena cava to the right ventricle. Interventional radiology with a percutaneous transjugular extraction was used to recover this intracardiac projectile. [ABSTRACT FROM AUTHOR]

Copyright of Proges en Urologie is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Cardiac aging is characterized by cardiomyocyte loss, hypertrophy of the remaining cardiomyocytes and replacement fibrosis, leading to diastolic dysfunction. However, mechanisms involved in age-associated cellular loss such as apoptosis, necroptosis, and/or autophagy, remain controversial but are crucial in age-associated pathologies such as non-insulin dependent diabetes mellitus (NIDD) and atrial fibrillation (AF). The objectives of the present study are to identify the mechanisms involved in cardiomyocytes loss and atrial remodeling during aging. Atrial samples (residues of transection of the right atrial appendage for extracorporeal circulation placement) were collected from patients undergoing coronary artery bypass graft from 36 to 83 years old (yo), with or without history of myocardial infarction (MI), (INSERM IRB authorization n C-19-71). Only patients without NIDD and/or AF were studied (n = 41). After trabeculae dissection and protein extraction, Beclin-1, RIPK3, pro- and cleaved caspase 3 as well as JNK, ERK, AMPK, P38 MAPK and STAT3 pathways were quantified by western blotting in cytosolic fractions and expressed as normalized densitometric score. Phospho-ERK/ERK and phospho-p38 MAPK levels increased with age (factorial ANOVA; respectively P < 0.001 and P < 0.05) but not with MI. In addition, RIPK3 content increased in samples from patients without MI over 70 yo as compared to patients under 55 yo (1.88 ± 0.23 vs. 0.69 ± 0.27; P < 0.05) and was associated with an activation of JNK pathway (phospho-JNK/JNK level: 2.28 ± 0.98 vs. 0.37 ± 0.09; P < 0.05). In contrast, no significant change was observed for Beclin-1 or caspase 3 levels. In patients with MI over 70 yo, as compared to patients of the same age without MI, Beclin-1 (1.26 ± 0.17 vs. 0.83 ± 0.14, P < 0.05) and phospho-STAT3/STAT3 levels (3.09 ± 0.98 vs. 1.18 ± 0.75; P < 0.05) were increased but surprisingly RIPK3 levels were reduced (1.18 ± 0.19 vs. 1.88 ± 0.23; P < 0.05). The age-associated activation of JNK in atria may lead to the loss of Cx43 protein resulting in impaired conduction and contributing to the increasing risk of AF. In addition, the ERK activation, promoting cell survival, is counterbalanced by activation of p38 MAPK, mediating pro-inflammatory cytokine production, and increased RIPK3 suggesting increased necroptosis, without apoptosis. In patients with MI, the high level of Beclin-1 suggests an upregulation of autophagy. [ABSTRACT FROM AUTHOR]

Background: Conventional surgical treatment of Stanford type A acute aortic dissection (AAD) is associated with considerable in-hospital mortality. As regards very elderly or high-risk patients with type A AAD, some may meet the criteria for less invasive surgery likely to prevent the complications associated with aortic replacement. Methods: We have retrospectively analyzed a cohort of patients admitted to our center for Stanford type A AAD and having undergone surgery between 2008 and 2012. The outcomes of the patients having had an aortic replacement under cardiopulmonary bypass (group A) have been compared with the outcomes of the patients who underwent off-pump wrapping of the ascending aorta (group B). Results: Among the 54 patients admitted for Stanford type A AAD, 15 with a mean age of 77 years [46 to 94] underwent wrapping of the aorta. Regarding the new standard European system for cardiac operative risk evaluation (EuroSCORE II), the median result in our group B patients was 10.47 [5.02 to 30.07]. In-hospital mortality was 12.80% in group A and 6.6% in group B (p = 0.66). For patients who underwent external wrapping of the ascending aorta, follow-up mortality rate was 13.3% with a median follow-up of 15 months [range 0 to 47]. Conclusions: The gold standard in cases of Stanford type A AAD consists of emergency surgical replacement of the dissected ascending aorta. In some cases in which the aortic root is not affected a less invasive surgical approach consisting of wrapping the dissected ascending aorta can be suggested as an alternative. [Copyright &y& Elsevier]

Atrioesophageal fistula (AEF) is a rare but serious complication of radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF). Therapeutic options are surgery, esophageal stenting and conservative treatment. However, there are no guidelines regarding the treatment of AEF following RFCA. Since no article dwells on the technical considerations of this challenging surgery, we aim to present here our experience and share our surgical approach. From January 2012 to March 2020, we identified all consecutive patients treated for AEF following RFCA at our institution (Pitié-Salpêtrière Hospital, Paris, France). The diagnosis was made on a set of clinical and radiological signs. All patients benefited from a combined approach involving both digestive and cardiac surgeons. Femoro-femoral peripheral CBP was used. The surgical approach was a right posterolateral thoracotomy. Atrial repair was done on fibrillating-heart, using a left atriotomy. Then, the digestive surgeon achieved the esophagectomy. We identified 6 patients with AEF after RFCA. All of them were males and the median age was 53 [34–72] years old. They all underwent percutaneous ablation. Symptoms were neurological symptoms (n = 6), fever (n = 5) and chest pain (n = 3). Diagnostic modalities were cerebral imaging (n = 5), Chest-CT (n = 2) and transthoracic echocardiogram (n = 6). Atrial repair consisted in a suture of the atrium (n = 3) or by using a pericardial patch (n = 3). Aftermath mainly consisted in neurological disorders (n = 4). Most of the patients (n = 4, 66,7%) recovered a satisfying diet. With a median follow-up of 3.1 [0.1–7.7] years, only one patient died during the follow-up. Our experience shows that an aggressive surgery with a large resection of the esophagus and left atrial repair by right thoracotomy in the same time provides good results. The ability to have both skilled digestive and cardiac surgeons available at the same time and place is the key for this strategy (Fig. 1). [ABSTRACT FROM AUTHOR]

Intraoperative graft flow measurement in coronary artery bypass grafting (CABG) is recommended, but its clinical impact is still controversial. We evaluated the effect of Transient Time Flow Measurement (TTFM) on Major Cardiac Adverse Events (MACE) in CABG surgery. Between January 2017 and February 2020, 959 patients underwent total arterial CABG with internal thoracic arteries (ITAs). Thirty-four patients with critical preoperative status according Euroscore II definition or redo procedures were excluded from the analysis. According to the surgeon preference, TTFM were assessed in 433 patients (TTFM) with Medistim system (Fig. 1). They were compared with 492 patients without TTFM assessment (No TTFM). Complete arterial revascularisation with single or bilateral ITAs with a Y-configuration was planned for all patients. Patients' data were extracted from the French Society of Thoracic and Cardiovascular Surgery database (EPICARD). Primary end-point was the occurrence of MACE, including in-hospital cardiac mortality, perioperative myocardial infarction, cardiac arrest and the need for extra-corporeal membrane oxygenation (ECMO). Preoperative characteristics, operative data and postoperative outcomes are resumed in Table 1. TTFM is associated with longer cardio-pulmonary bypass (CPB) times, because of supplementary time needed for measurement (82 ± 24 vs. 78 ± 25 min., P = 0.023). Five patients in TTFM group underwent graft revision because of unsatisfying flow values. MACE were significantly lower in TTFM group (2.1% vs. 5.7%, P < 0.01). At multivariate analysis, TTFM was protective against MACE occurrence (OR 0.353, 95% CI 0.146–0.770, P = 0.013). Other independent risk factors for MACE occurrence were cross clamp time (OR 1.18, 95% CI 1.03–1.35, P = 0.016) and Euroscore II (OR 1.21, 95% CI 1.13–1.29, P < 0.001). TTFM reduces MACE occurrence and it should be mandatory for graft evaluation in coronary artery surgery. [ABSTRACT FROM AUTHOR]

Abstract: Traumatic injuries to the scapula have received little attention in the paleopathological literature. They are rarely encountered in medical emergencies today due to the overlying muscles that protect the bone; they comprise just 1% of all fractures. This collaborative project brings together five cases of bilateral fractures of the scapulae in four ancient populations from three different time periods and three continents (France, Sudan and USA). It is thus an opportunity to interpret bilateral scapula fracture etiology by suggesting a cause that could have been present in all contexts, namely direct trauma such as might take place during beating with heavy sticks or other blunt force weapons. We also argue that oval defects with rounded margins in scapular bodies are less likely to be congenital anatomical variants than the result of healed trauma. [Copyright &y& Elsevier]

Copyright of EMC-Radiologie is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background Multiple risk factors of cardiac allograft vasculopathy (CAV) have been described, particularly through the analysis of large northern American cohorts. However, discrepancies in donor selection between the US and European countries are important, particularly concerning donor age. Purpose To evaluate the risk factors for the early development and progression of CAV in a European heart transplantation high volume center. Methods We performed an observational, retrospective single center study. All patients with heart transplantation between 10/01/2008 and 12/31/2013 who had at least one coronary angiography were included. We searched for risk factors of #1 the occurrence of moderate to severe CAV (CAV grades 2 to 3) and #2 the evolution of CAV during follow-up (CAV grade+1 or more compared to baseline) by analyzing the effect of #1 donor risk factors (age, sex, cardiovascular risk factors…), #2 recipient cardiovascular risk factors and #3 recipient transplant-related risk factors (CMV infection, ischemic time, pre-formed donor specific antibodies, biopsy proven rejections…). Results During the study period, 398 patients were transplanted at our center. Among them, 287 had at least one coronary angiogram (analysis of risk factors for CAV 2–3 occurrences) including 206 patients with at least two coronary angiograms (analysis of the evolution of CAV during follow-up). The median follow-up was 5.2 years. After multivariate analyses, only donor risk factors were significantly associated with 1) the risk of occurrence of CAV 2 to 3 (donor age > 40 years: sHR = 6.3, CI = 2–20; smoking: sHR = 2.1, CI = 1.1–4.1; donor sex: female sex: sHR = 0.31, CI = 0.13–0.73) and the risk of CAV progression during follow-up (donor age > 40 years: sHR = 2.9, CI = 1.2–7.2; donor sex: female sex: sHR = 0.2, CI = 0.1–0.6). Conclusion Early moderate to severe CAV occurrence and early CAV progression after heart transplantation were mostly driven by donor characteristics. [ABSTRACT FROM AUTHOR]

ExtraCorporeal Life Support (ECLS) restores hemodynamic stability in patients with severe cardiocirculatory failure. However, this circulatory assistance technique has its limits, and the most strongly feared is left ventricular distention, of which the potentially serious consequences range from acute pulmonary edema (APE) to left intraventricular thrombosis. Our hypothesis is that in patients in refractory cardiogenic shock and with laminar flow under peripheral V-A ECLS, IABP use could help to diminish the incidence of acute pulmonary edema (APE). Methods The clinical evolution of patients with laminar flow under peripheral V-A ECLS who did not receive IABP (group A) has been compared to the clinical evolution of patients who received IABP as a means of APE prevention under peripheral V-A ECLS, while also being subjected to laminar flow under peripheral V-A ECLS (group B). A logistic regression model was used to identify the factors associated with occurrence of severe and symptomatic APE. Results Between December 2007 and 2012, 90 patients were subjected to laminar flow under peripheral V-A ECLS that had been implanted subsequent to cardiogenic shock. Mortality and mechanical ventilation duration was not significantly different in either of the two groups. However, clinical APE occurrence was far less frequent in group B (35.1% vs. 88.6% p<0.0001). Study of the radiologic score showed that pulmonary infiltrate was greater in group A (p≤0,001). Centralized pulmonary edema was likewise more frequent in group A (44.6% vs. 5.9%, p<0.0001). Multivariate analysis showed that the non-association of IABP with peripheral V-A ECLS (Odds Ratio [OR]=18.87) was an independent factor associated with the incidence of severe symptomatic APE. Conclusion Association of IABP and peripheral V-A ECLS can be considered therapeutically efficient in prevention of severe symptomatic pulmonary edema under peripheral V-A ECLS, even though confirmation would require a randomized study. Abstract 0077 – Figure: Percent survival free from pulmonary oedema [ABSTRACT FROM AUTHOR]

Purpose To analyze post-heart transplantation (HTx) outcomes in selected patients on ECMO support. Our local strategy is to transplant ECMO-patients without mechanical ventilation or kidney failure (creatinine clearance ≤ 30 mL/min or dialysis). In addition, specific pre-transplant (intra-aortic balloon pump, reperfusion canula) and post-transplant strategies (maintaining ECMO after HTx) were applied. Methods We performed a restrospective study in a high ECMO and HTx volume center. We included all-consecutive patients with a first non-combined HTx performed between 2012 and 2016. We aimed to compare outcomes between patients with or without ECMO support at the time of HTx. The primary outcome was all-cause mortality after HTx. Secondary outcomes included death-censored rejection-free survival and complications of ECMO (infection, vascular complications). Risk factors for death were identified using Cox proportional hazard model. Results We analyzed 415 patients, including 118 patients (28.4%) under ECMO support at the time of HTx. Median follow-up post-transplant was 20.7 months. Median time on ECMO before HTx was 9 days (IQR = 5-15). Post-transplant survival in ECMO-patients was not significantly different from non-ECMO patients (see figure, p=0.12). In the overall cohort, only recipient age (HR = 1.22 per 10-year increment), recipient BMI (HR = 3.93 for BMI < 18.5 compared to BMI 18.5 to 25 kg/m2), creatinine clearance (HR = 2.35 for clearance between 30 and 60 ml/min; HR = 3.73 for clearance < 30 ml/min compared to clearance ≥ 90 ml/min) and cold ischemia time (HR = 1.03 per 1-hour increment) were independent predictors of all-cause mortality. Death-censored rejection-free survival was similar between groups. Infection of the ECMO site was the most prevalent complication of ECMO (37% of patients). Conclusion A direct heart transplantation strategy in selected patients on ECMO support achieved favorable post-transplant outcomes. [ABSTRACT FROM AUTHOR]