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Background Pre-operative myocardial fibrosis and remodeling impact on outcomes after aortic valve replacement (AVR). We aimed at investigating the prognostic impact of preoperative electrocardiographic (ECG) markers of left ventricular (LV) myocardial damage, i.e. bundle branch block (BBB) and ECG strain pattern after (surgical or transcatheter) AVR for severe aortic stenosis (AS). Methods Between April 2008 and October 2017, we explored consecutive patients referred to our Heart Valve Clinic for first AVR for severe AS. Detailed pre-operative phenotyping and ECG analysis were performed. Patients were followed-up after AVR for major cardiac events (ME), i.e. cardiovascular death, cardiac hospitalization for acute heart failure and stroke. Results BBB and ECG strain were respectively observed in 13.5 and 21% of the 1122 patients included. These ECG markers identified a subgroup of older patients, with higher NYHA class and more advanced myocardial disease as detected by echocardiography, i.e. higher LV mass and lower LV ejection fraction, global longitudinal strain and integrated backscatter, than patients without ECG strain or BBB. ME occurred in 212 (18.6%) patients during a mean follow-up of 4.4 ± 1.5 years with higher incidence in case of ECG strain or BBB (HR 1.56, 95%CI 1.13–2.14, p = 0.006; HR 1.47, 95%CI 1.02–2.13, p = 0.04 respectively). The prognostic value of ECG strain remained significant after adjustment for age, diabetes and pre-operative LVEF. Conclusions Pre-operative ECG markers of myocardial damage identify a subgroup of AS patients at high risk of post-AVR cardiovascular complications irrespective of other prognostic factors and should help the multiparametric staging of cardiac damage to guide AVR.

Objectifs L’objectif de cette video est de decrire les differentes etapes chirurgicales d’une nephrectomie droite avec thrombectomie cave (niveau 2) par voie coelio-robotisee. Methodes Expliquer les differentes etapes chirurgicales en robotique et en particulier le controle vasculaire de la veine cave (en toute securite). Resultats La duree d’intervention est de 90 min avec 14 min de clampage cave. Les pertes sanguines sont de 300 ml. Suites simples et sortie a J4. Conclusion La nephrectomie droite avec thrombectomie cave de niveau 2 est realisable par voie coelio-robotisee en toute securite dans un centre expert de chirurgie renale. Le benefice de la voie coelio -robotisee sont les pertes sanguines faibles, sortie precoce et recuperation amelioree.

Background and Purpose Acute stroke in the setting of acute type A aortic dissection is not rare and may contraindicate immediate surgery. Evaluating irreversible brain damage is critical in this setting and magnetic resonance imaging is a key determinant in the decision of selecting surgical over medical treatment for these patients. Summary of Cases We report herein 2 cases assessed at a tertiary care center for acute stroke. The initial diagnosis workup revealed cerebral hemispheric severe hypoperfusion without any brain infarction. The absence of ischemic lesions prompted surgical repair, despite the severity of clinical symptoms. Both patients demonstrated complete neurological recovery and neuroimaging showed no persistent sequel. Conclusion Acute type A aortic dissection is an important differential diagnosis in the causative workup for stroke. Brain hypoperfusion alone should not be a contraindication for urgent surgical treatment, regardless of initial clinical neurological severity.

Objectives The purpose of this study was to assess the feasibility and safety of transcarotid transcatheter aortic valve replacement (TAVR). Background Many candidates for TAVR have challenging vascular anatomy that precludes transfemoral access. Transcarotid arterial access may be an option for such patients. Methods The French Transcarotid TAVR Registry is a voluntary database that prospectively collected patient demographics, procedural characteristics, and clinical outcomes among patients undergoing transcarotid TAVR. Outcomes are reported according to the updated Valve Academic Research Consortium criteria. Results Among 96 patients undergoing transcarotid TAVR at 3 French sites (2009 to 2013), the mean age and Society of Thoracic Surgeons predicted risk of mortality were 79.4 ± 9.2 years and 7.1 ± 4.1%, respectively. Successful carotid artery access was achieved in all patients. The Medtronic CoreValve (Medtronic, Inc., Minneapolis, Minnesota) (n = 89; 92.7%) and Edwards SAPIEN valves (Edwards Lifesciences, Irvine, California) (n = 7; 7.3%) were used. Procedural complications included: valve embolization (3.1%), requirement for a second valve (3.1%), and tamponade (4.2%). There were no major bleeds or major vascular complications related to the access site. There were 3 (3.1%) procedural deaths and 6 (6.3%) deaths at 30 days. The 1-year mortality rate was 16.7%. There were 3 (3.1%) cases of Valve Academic Research Consortium–defined in-hospital stroke (n = 0) or transient ischemic attack (TIA) (n = 3). None of these patients achieved the criteria for stroke and none manifested new ischemic lesions on cerebral computed tomography or magnetic resonance imaging. At 30 days, a further 3 TIAs were observed, giving an overall stroke/TIA rate of 6.3%. Conclusions Transcarotid vascular access for TAVR is feasible and is associated with encouraging short- and medium-term clinical outcomes. Prospective studies are required to ascertain if transcarotid TAVR yields equivalent results to other nonfemoral vascular access routes.

Changes in parameters of longitudinal systolic function after cardiac surgery (i.e., tricuspid annular plane systolic excursion [TAPSE] and peak systolic velocity [PSV] of tricuspid annulus obtained by M-mode or Doppler tissue imaging) have been described for many years, with almost no data on their

Background In some patients, transfemoral, transaxillary, or transapical aortic valve implantation is not possible. Thus, carotid artery access may represent a safe alternative to those accesses, and even offers certain advantages. In this article, we describe aortic valve implantation using the left carotid arterial approach and report our initial experience. Methods Using a self-expandable nitinol based device (CoreValve ReValving system, Medtronic Ltd, Luxembourg), we exposed the left carotid artery through a small incision. Arterial puncture and initial 6F sheath introduction were achieved through a contraincision. The same implantation technique as for transaxillary implantation was used. Progressive artery dilatation was achieved using sheaths of increasing diameter. Rapid ventricular pacing was used to reduce cardiac output while performing a routine aortic balloon valvuloplasty. Only then, an 18F sheath was inserted into the carotid artery and pushed down into the ascending aorta. The patients were monitored using cerebral oxymetry to assess cerebral perfusion. Results Twelve consecutive patients, at high surgical risk, were implanted and studied prospectively. Transfemoral and subclavian catheterization were considered unfeasible or at risk of severe complications. Carotid arterial injury did not occur in any patient. A transient ischemic attack occurred in 1 patient, contralateral to the carotid access. There were no deaths in either intraprocedural or during the 30-day follow-up period. Conclusions This initial experience suggests that left carotid transarterial aortic valve implantation, in selected high-risk patients, is feasible and safe with satisfactory short-term outcomes.

Summary Aim To assess the feasibility and safety of a hybrid myocardial revascularization strategy combining “exclusive arterial” conventional coronary artery bypass grafting (CABG) followed by early drug-eluting stent (DES) implantation in multivessel coronary artery disease (CAD). Methods Eighteen consecutive patients with multivessel CAD were enrolled prospectively. Within 48 hours of CABG using left internal mammary artery (IMA) to left anterior descending (LAD) coronary artery with or without right IMA to non-LAD vessel in an open chest approach, DESs were implanted systematically in an additional vessel after a clopidogrel 300-mg preloading dose. This group was compared with 18 matched patients who underwent standard CABG alone using left IMA to LAD and at least one additional graft. Results Baseline clinical characteristics were similar in both groups. There were 46 grafts in the CABG group and 28 in the hybrid group. In the hybrid group, 27.8% of patients were treated off-pump versus none in the CABG group; a median of 2 (interquartile range: 1–2) stents was implanted per patient. The hybrid procedure was associated with shorter durations of cardiopulmonary bypass (77 [67–100] min versus 97 [90–105] min, P = 0.049). Major bleeding rates were higher in the CABG group, but the difference was not statistically significant (44.4% versus 11.1%, P = 0.06). Re-intervention for bleeding was not needed in either group. One (5.6%) myocardial infarction occurred in hospital in each group following CABG. At 1 year, the cumulative rates of major adverse cardiac events (death, myocardial infarction, target vessel revascularization) were similar (11.2% in hybrid group versus 5.6% in CABG group, P = 0.99). One death occurred in the CABG group and one target vessel revascularization in the hybrid group. Conclusion A hybrid revascularization strategy, combining conventional CABG with exclusive arterial conduits followed by early DES implantation, is feasible. One-year event rates compare favourably to those with traditional CABG alone.

Objectives To evaluate the early outcomes following thoracoabdominal aortic aneurysm (TAAA) repair utilising fenestrated and branched endografts. Design and materials and methods A prospective analysis of all patients undergoing endovascular repair of TAAA in a single academic centre. All patients were deemed unfit for open surgical repair. Customised endografts were designed using CT data reconstructed on 3D workstations. Post-operatively all patients were evaluated radiologically at hospital discharge, at 6, 12, 18 and 24 months, and annually thereafter. Results Thirty-three consecutive patients (30 males) were treated over 33 months (August 2006 to April 2009). Median age and aneurysm size were 70 years (range 50–83 years) and 64 mm (range 55–100 mm) respectively. 114/116 (98%) of the targeted visceral vessels were successfully catheterised and perfused. The in-hospital mortality rate was 9% (3/33). Transient spinal cord ischaemia was diagnosed in 4/33 (12%) patients, and permanent paraplegia in one (3%). The median follow-up period was 11 months (range 1–33 months). Endoleaks were identified in 5/33 (15%) patients: type II in four patients and a type III endoleak in one patient which required the only secondary intervention. During follow-up, two patients died: one from stroke and the other from myocardial infarction 9 and 29 months respectively after the procedure. Conclusion This preliminary study, which includes our learning curve, confirms the feasibility and safety of the endovascular repair of TAAA in high-risk patients. Meticulous follow-up to assess sac behaviour and visceral perfusion is critical in order to ensure optimal results of these complex endovascular repairs requiring numerous mating components.

Resume Le traitement endovasculaire des anevrismes thoracoabdominaux (ATA) est une nouvelle option therapeutique chez les patients a haut risque chirurgical selon les criteres de l’AFSSAPS. Quelques equipes ont evalue les resultats initiaux de ces reparations endovasculaires complexes effectuees avec des endoprotheses fenetrees et/ou multibranches. Le taux de succes technique varie de 88 a 100 %. Les complications peri operatoires, notamment les taux de mortalite et d’ischemie medullaire, sont comparables a ceux de la chirurgie ouverte. L’evaluation a moyen et long terme de cette nouvelle generation d’endoprotheses est indispensable avant d’elargir les indications du traitement endovasculaire des ATA a tous les patients.

Il trattamento endovascolare degli aneurismi dell’aorta toracoaddominale e un’alternativa terapeutica al trattamento chirurgico convenzionale nei pazienti ad «alto rischio chirurgico». La selezione dei pazienti per una chirurgia convenzionale si effettua sulla base di criteri fisiologici, mentre vi sono criteri anatomici che stabiliscono quali pazienti possono essere sottoposti a un trattamento endovascolare. Le endoprotesi sono fenestrate e/o multibranche per perfondere le arterie viscerali che originano dalla sacca aneurismatica. Vengono confezionate su misura a partire dall’angio-TC preoperatorio. Per limitare i rischi del trattamento (paraplegia, insufficienza renale) e indispensabile una rianimazione aggressiva durante il periodo perioperatorio. E necessario un controllo mediante angio-TC ed ecodoppler.

Purpose. To evaluate a novel approach to preserve pelvic perfusion during endovascular AAA repair in patients with common iliac aneurysms extending to the iliac bifurcation. Materials and methods. A multicenter prospective analysis of patients undergoing implantation of a branched endograft designed to perfuse the internal iliac artery was conducted. All patients enrolled were considered high risk for open surgical repair and presented with common iliac artery aneurysms greater than 20 mm and anatomy amenable to implant the branched device. Preoperative high resolution spiral CT, and follow-up CT studies in addition to abdominal radiographs were obtained at discharge, 1, 6, 12, and 24 months. Results. Between 2003 and 2006, 52 patients (53 internal iliacs) were implanted with an investigational device. Mean common iliac aneurysm maximal diameter was 38 mm. The branch graft was combined with a proximal standard bifurcated component (61%), a fenestrated or a visceral branch component (33%), an aortouni-iliac component (2%), and alone in 2 patients (4%, following prior aortobi-iliac repair). Technical success was achieved in 94% of patients. Within the first month, 6 (11%) internal iliac branches occluded. No occlusions were noted after 1 month. The mean follow-up was 14.2 months. Common iliac aneurysm shrinkage was noted in 42% and 81% of patients at 6 and 12 months. There were no rupture, aneurysm related deaths or conversions, but there were 7 deaths during follow-up. Conclusions. The placement of endovascular prostheses that maintain antegrade perfusion of one or both internal iliac arteries is feasible, and early results provide evidence for optimism with regard to safety and efficacy.

The aim of the study was to assess the prognosis of three different aortic stenosis populations operated by TAVI: Severe aortic stenosis (SAS), lowflow low-gradient aortic stenosis (LFLG) and paradoxical low-flow low-gradient aortic stenosis (PLFLG).Between January 2010 and August 2013, patients with severe symptomatic aortic stenosis were consecutively referred to our institution, for TAVI because of multiple comorbidities and excessive surgical risk. We defined and split patients into 3 populations as followed: PLFLG (iAVA≤0.6cm2, MG≤40mmHg, SVI≤35mL/m2, LVEF≥50%, Zva>4.5mmHg/mL/m2, MaxV4m/s, MG>40mmHg, LVEF>50%). The primary endpoint of our study was to evaluate global and cardiovascular mortalities; secondary endpoints included VARC 2 variables. A significant decrease in survival rate regarding the all-cause mortality (p=0.02) and cardiovascular mortality (p=0.05) was observed in the LFLG group (n=59) in comparison to the PLFLG (n=31) and SAS (n=172) groups, which had similar survival rates. Regarding the immediate post-procedural outcomes, the LFLG group had more CHF (p

Culture of a mitral valve prosthesis excised for streptococcal endocarditis yielded Aspergillus fumigatus. The patient had undergone valve replacement 20 years earlier for A fumigatus endocarditis. Data suggest that quiescent A fumigatus may have survived in a biofilm on the surface of the prosthesis. An antifungal therapy was initiated for 6 months.

Oversizing strategies to avoid post-procedural aortic leak following TAVI are developing. The purpose of the study was to investigate if the oversizing strategy compared with normal sizing was deleterious on the immediate and late post-procedural outcomes. From January 2010 to August 2013, consecutive severe symptomatic aortic stenosis patients were referred for TAVI. They all underwent preoperative MultiSlice- angio CT scan (MSCT) and the procedures were achieved using Edwards Sapien® or Corevalve devices®. Early and late follow-up were completed. Retrospectively, according to pre-procedural MSCT and the valve size, patients were classified into three continuous groups: normal sizing, moderate and severe oversizing; depending on the ratio between the prosthesis area and the annulus area indexed and calculated on MSCT. Main endpoint was the all-cause and cardiovascular mortality and secondary endpoints corresponded to the VARC2 endpoints. 268 patients had a MSCT and underwent TAVI procedure, with mainly Corevalve ®. While all-cause and cardiovascular mortality rates were similar in all groups, post-procedural new pace-maker implantation rate was significantly higher in the severe oversizing group (p=0.03), while we observed more in-hospital congestive heart-failure (p=0.02) and tamponade (p=0.02) in the normal sizing group. There was also a trend toward more moderate to severe AR in the normal sizing group (p=0.12). At 1 month there was significantly more MACCE in the normal sizing group (p=0.03). Oversizing based on this ratio is a safe and feasible strategy to reduce aortic leak with lower rates of immediate post-procedural complications and a similar long-term survival. Download : Download full-size image Abstract 0050 – Figure: All-cause mortality Survival curve

Background Aortic dissection is a well rare disease with pour mid and long term prognosis. The treatment of initial phase of acute aortic syndrom (AAS) affecting the descending aorta is essentially based on lowering blood pressure and on relieving pain. The emergence of endovascular therapy offers new perspectives in the management of this old disease. Few data exist on the long term prognosis of patients who discharge alive after a medical treatment of a type B AAS. The aim of our study was to determine factors of the acute phase associated with adverse long term survival. Methods and Results We study the long term outcome of 77 patients, hospitalized in our center from 1996 to 2008, who discharge alive after type B AAS. All patients received a medical treatment and an endovascular therapy if needed. The mean follow-up period was 50.8 month, with a survival rate of 78%. Kaplan-Meier survival curves were constructed, and Cox proportional hazards analysis was performed to identify independent predictors of follow-up mortality from any cause. Factors that influence the mortality (p Conclusion Patients who discharge alive after medically treated type B acute aortic disease keep a worse mid and long term prognosis. Our study identifies new risk factors of mortality after discharge, and a population at very high risk. The treatment of the acute phase needs further study to better understand and optimize care of this patients.

Objectifs Evaluer les resultats de la fenestration dans les dissections aortiques avec syndrome de malperfusion aigu. Materiels et methodes Entre 1999 et 2007, 36 patients (32 hommes ; 57+/-11 ans) avec dissection aortique (type A 21 ; type B 15) etaient traites par fenestration pour syndrome de malperfusion (renal 28 ; digestif 27 ; membres inferieurs 14) lie a une compression dynamique. La fenestration etait realisee avec 2 guides rigides introduits dans un introducteur 8F. Le delai entre la dissection et la fenestration etait de 5 jours (28 patients Resultats La fenestration (succes technique 100 %) associee a des gestes complementaires (stents peripheriques 26, stent graft thoracique 1, chirurgie digestive 5) permettait un succes angiographique dans 97 %. La mortalite dans le premier mois (11/36) etait liee aux complications digestives (5), neurologiques (2), post-chirurgicales (type A, 2) et multiviscerales (2). Au cours du suivi (moyenne 45 mois), 5/25 patients etaient decedes. Le diametre aortique (thoracique 45 mm+/-11, abdominal 34 mm+/-10), mesure par TDM/IRM, restait stable chez 20/25 et augmentait chez 5/25 (1 Marfan, 2 patients avec ectasies arterielles multiples). Conclusion La fenestration permettait une survie chez 69 % des patients. Au cours du suivi, le diametre aortique restait stable chez la majorite des patients survivants.

Objectifs Rapporter les resultats sur 5 ans d’une etude monocentrique concernant les indications, les taux de morbi-mortalite de l’implantation d’endoprotheses dans l’aorte thoracique descendante. Materiels et methodes Quatre vingt trois patients presentant une contre-indication chirurgicale, porteurs d’une lesion de l’aorte thoracique descendante (dissection aortique (n = 28), anevrisme thoracique (n = 16), faux anevrisme (n = 15), hematome dissequant (n = 5), rupture isthmique (n = 11) ulcere penetrant (n = 7), rupture aortique post chirurgicale (n = 1)) etaient traites par mise en place d’endoprotheses (endoprothese Medtronic (n = 77), Cook (n = 5), Gore (n = 1)) apres consensus multidisciplinaire. Resultats Le succes technique etait de 100 %. Un geste associe etait effectue dans 5 cas (stenting renal, embolisation, pontage carotido-sous-clavier). Au suivi precoce, une intervention complementaire etait necessaire dans 5 cas avec implantation d’une autre endoprothese pour persistance d’une rupture aortique. Les complications immediates etaient une rupture iliaque (n = 3), une dissection retrograde (n = 1), un hematome intra-musculaire (n = 1), et une paraplegie pour 1 patient beneficiant d’une reparation concomitante d’un anevrisme abdominal. Les complications tardives etaient une migration d’endoprothese (n = 2) et une fuite (n = 7). Le taux de mortalite precoce etait de 8 % (n = 7) pour un total de 16 % (n = 13) sur une periode d’un an. Conclusion La mise en place d’endoprotheses aortiques thoraciques apparait efficace et prometteuse pour le traitement de diverses lesions de l’aorte descendante.