Search

AIMS: Stenting of the popliteal artery (PA) is generally considered inappropriate due to the high mechanical stress and bending of the artery during knee flexion. Nevertheless, vessel recoil remains problematic following angioplasty procedure for chronic total occlusions (CTOs) and adjunctive stenting may be required. The purpose of this study is to compare balloon angioplasty alone versus bailout stenting for isolated CTO of the PA. MATERIALS AND METHODS: Between March 2012 and October 2016, 43 patients were treated with percutaneous transluminal angioplasty with balloon alone (PTA, n = 16) or bailout stenting percutaneous transluminal angioplasty and stenting (PTAS, n = 27) for de novo CTO of PA. There was no statistically significant difference between both groups with regard to patient demographics and lesions characteristics (calcification severity and lesion length). The median lesion lengths were 67 mm (39.5-78.5) in the PTA group and 94 mm (50-114) in the PTAS group ( p = 0.14). The primary outcome measure was primary patency; secondary outcomes were technical success, primary assisted patency, major amputation, and increased Rutherford classification. RESULTS: Technical success rate was 37% and 96.3% in the PTA and PTAS groups, respectively. There was no statistical difference in 12-month primary patency rate (65.8% versus 58.7%; p = 0.15) and primary assisted patency at 12 months (75.2 versus 69.2; p = 0.47) between the 2 groups. Freedom from target lesion revascularization at 12 months was not significantly different, with 85.7% and 81.6% ( p = 0.2) in the PTA and PTAS groups, respectively. One amputation occurred in the PTA group. CONCLUSION: This small cohort suggests that stenting as a bailout procedure in CTO of the PA provides similar results to successful balloon angioplasty. Stenting should only be performed after suboptimal balloon angioplasty with vessel recoil. Due to the large lost to follow-up, strong evidence of a therapy over the other canno

OBJECTIVES: Aortic cusp free margins are a central target in most aortic valve repair operations to optimize valve coaptation. The objective of this anatomical study was to analyse the normal dimensions of free margin length (FML) and coaptation surface and to analyse their relationship with other valve and root dimensions in normal tricuspid aortic valves. METHODS: We analysed 25 aortic root homografts. Eight valve and root measurements were obtained from fresh specimens including the length of the free margin while applying appropriate tension on the structures. The valves were then fixed with formalin in the diastolic position under pressure to allow measurement of the coaptation surface. In addition to normal values, we analysed the correlations and ratios between the different measures. RESULTS: The mean FML was 34.3 ± 3.1 mm. The FML was similar between the 3 cusps and correlated with all other valve and root measures. The ratio of the FML to the geometric height was 1.81, and the free edge length/sinotubular junction was 1.29. The mean coaptation surface was 122 ± 21 mm2 per cusp and corresponded to 41% of the cusp surface. The central coaptation length was 3.3 ± 0.8 mm, and the lateral coaptation length was 5.9 ± 0.6 mm. The total coaptation surface per specimen was 184 ± 32 mm2. CONCLUSIONS: We described the normal dimensions of the FML and coaptation surface in the tricuspid aortic valve. These measurements will serve in the further development of an objective method of free margin shortening based on intraoperative measurements of the FML to treat cusp prolapse and low coaptation after valve-sparing surgery.

Fibromuscular dysplasia (FMD) is an idiopathic, segmental, non-atherosclerotic and non-inflammatory disease of the musculature of arterial walls, leading to stenosis of small and medium-sized arteries, mostly involving renal and cervical arteries. As a result of better and more systematic screening, it appears that involvement of the splanchnic vascular bed is more frequent than originally assumed. We review epidemiology, pathogenesis, clinical picture as well as diagnosis and treatment of visceral artery (VA) FMD. The clinical picture is very diverse and diagnosis is based on CT-, MR- or conventional catheter-based angiography. Involvement of VAs generally occurs among patients with multi-vessel FMD. Therefore, screening for VA FMD is advised especially in renal artery (RA) FMD and in case of aneurysms and/or dissections. Treatment depends on the clinical picture. However, the level of evidence is low and much of the common practice is extrapolated from visceral atherosclerotic disease. This article is protected by copyright. All rights reserved.

Ce papier se situe dans le cadre de la conception d'un dispositif chirurgical en cardiologie destiné à la découpe circulaire de la valve aortique. Ici, les conséquences d'une mauvaise utilisabilité du dispositif peuvent être graves mais il est impossible de réaliser des tests utilisateurs pour chaque itération de conception. Les auteurs présentent les méthodes qu'ils ont appliquées pour contourner l’évaluation en situation réelle et pour aménager l'utilisabilité d'un prototype. L’intérêt des méthodes (inspection heuristique, modélisation de la tâche et test en situation artificielle) relève de leurs utilisations combinées. Globalement, les résultats tendent à montrer que la triangulation de méthode est vraiment intéressante si elle croise des méthodes de collecte de données artificielles et réelles, avec l’utilisateur et sans l’utilisateur.

A device (100) is presented for excision of a heart valve comprising a first (120) and second (140) clamping element in mutual sliding relation, each having an annular clamping surface (122, 142) which annular clamping surfaces (122, 142) mutually co-operate to form an annular clamping region (166) configured for clamping a heart valve annularly, and a slidable cutting element (160) slidable and rotatable with respect to the annular clamping region (166) configured to circularly excise the heart valve, wherein the slidable cutting element (160) is displaceable within an annulus of the annular clamping zone region (166).

The Perceval S (Liva Nova PLC, London, United Kingdom)sutureless bioprosthesis is a self-expanding bovinepericardial valve. Because of a simple and fast implantationtechnique, this valve allows a short crossclamp time withexcellent hemodynamics and almost no paravalvularleak.1,2The supplied sizers determine the best-suitedprosthesis by measuring the aortic annulus after native valveresection.3We report the case of 4 patients in whomincomplete deployment led to severe dysfunction andexplantation of the Perceval S bioprosthesis [...]

BACKGROUND: Inflammation and intraplaque neovascularization are acknowledged to be 2 features of plaque vulnerability, although their temporal expression and their respective value in predicting clinical events are poorly understood. To determine their respective temporal associations, we conducted a comprehensive assessment of inflammation and intraplaque neovascularization in the carotid plaque of symptomatic and asymptomatic patients. METHODS AND RESULTS: Thirty patients with severe carotid stenosis underwent 18F-fluorodeoxyglucose-positron emission tomography/computed tomographic imaging. Plaque 18F-fluorodeoxyglucose-uptake, indicative of inflammation, was measured by calculating the target:background ratio. The presence of intraplaque neovascularization during contrast-enhanced ultrasound was judged semiquantitatively; low-grade contrast enhancement (CE) suggested its absence, and high-grade CE, the presence of neovascularization. Carotid surgery was performed 1.6±1.8 days after completing both imaging modalities in all patients, and the presence of macrophages and neovessels was quantified by immunohistochemistry. We identified a significant correlation between the target:background ratio and macrophage quantification (R=0.78; P<0.001). The number of vessels was also significantly higher in carotid plaque with high-CE (P<0.001). Surprisingly, immunohistochemistry showed that high-CE and vessel number were neither associated with an elevated target:background ratio (P=0.28 and P=0.60, respectively) nor macrophage infiltration (P=0.59 and P=0.40, respectively). Finally, macrophage infiltration and target:background ratio were higher in the carotid plaque of symptomatic patients (P=0.021 and P=0.05, respectively), whereas CE grade and the presence of neovessels were not. CONCLUSIONS: Inflammation and intraplaque neovascularization are not systematically associated in carotid plaques, suggesting a temporal separation between the 2 processes. Inflammation seems mo

Infective endocarditis (IE) is a rare but serious illness associated with a high mortality. Staphylococcus spp and Streptococcus spp are the most frequent causative pathogens. In this study, we compared the epidemiology, clinical characteristics and outcomes of patients with Staphylococcal and Streptococcal IE in a tertiary hospital. Using our institutional database 'Medical Explorer', we collected all cases of IE retrospectively between January 2005 and December 2010 at the Cliniques Universitaires Saint Luc and then focused on Staphylococcal and Streptococcal IE. Of the 212 patients with IE included in our study, Staphylococcus spp accounted for 35.9% (76/212) of the cases, Streptococcus spp for 35.4% (75/212) and the remainder 18% (61/212) of cases were caused by other pathogens. Negative blood culture IE accounted for 10.4% of all cases. Demographic and clinical characteristics such as age, gender, fever, presence of a heart murmur, heart failure, nature of the affected valve, location of the endocarditis, duration of antibiotics, length of stay and complication were not different when comparing Staphylococcal and Streptococcal IE; only mortality differed. The mortality rate was 21.4 and 6.6% (p = 0.02) for Staphylococcal and Streptococcal IE, respectively. In the multivariate analysis, age >60 years, Staphylococcal IE, presence of complications and absence of surgery were independent risk factors for mortality.

Comment on Head-to-Head Comparison of Inflammation and Neovascularization in Human Carotid Plaques: Implications for the Imaging of Vulnerable Plaques. [Circ Cardiovasc Imaging. 2017]

The aim of this study was to independently evaluate the real-world performances of Eluvia paclitaxel drug-eluting stents (DES) (Boston Scientific, Marlborough, Massachusetts) for the treatment of external iliac and femoropopliteal artery lesions. We prospectively collected, and retrospectively reviewed, data for all patients who underwent an endovascular treatment with an Eluvia™ DES for the treatment of an external iliac or femoropopliteal lesion. Patient demographics, concomitant procedures, arterial lesions characteristics, procedural details, and follow-up were reviewed. Between April and October 2016, 15 Eluvia™ DES were placed in 15 consecutive adult patients with a technical success of 100%. The treated lesions had a mean length of 93.9 ±58 mm. Sixty percent of the lesions were total occlusions and 13% were restenosis of previous stents. An additional inflow treatment was performed in 40% of the cases. At six months, two patients were lost at follow-up and one had an occluded stent. We had a primary patency rate and freedom from TLR of 92%. All remaining patients had an improved Rutherford class, improved quality of life and wound healing, and an increase in walking distance. Survival and limb salvage rates were 100%. This study confirms the good result of DES, in general, and of the Eluvia™ stent, in particular, in the treatment of external iliac and femoropopliteal arterial lesions, with a primary patency rate and a freedom from TLR of 92% at six months. A larger number of patients and longer follow-up will be required to determine the true real-world efficacy of the Eluvia™ DES, but short-term experience is encouraging.

OBJECTIVES: The aim of this study was to evaluate the long-term outcomes following the Ross procedure in young adults in our institution. METHODS: All adult patients who received a Ross operation between 1991 and 2014 were included in the study. Survival analysis and regression analysis were performed. Survival of the Ross cohort was compared with the age-, gender- and calendar year-matched general population. RESULTS: Three hundred-and-six patients (mean age: 41.7 ± 9.7, male: 74.8%, bicuspid aortic valve: 58.5%, valve stenosis: 68%) were included in the analysis. There were 7 perioperative deaths (2.3%). Nine patients were lost to follow-up from hospital and completeness of the follow-up was 94%. The median follow-up of the remaining 290 patients was 10.6 years. There were 21 late deaths of which only 3 were valve-related. The overall survival at 15 years since surgery is 88 ± 3% that is comparable with the matched population. Freedom from valve-related deaths was 96.8 ± 2% at 16 years. Freedom from autograft and pulmonary homograft reoperation was 74.5 ± 4.3% at 16 years. Preoperative aortic regurgitation was the only significant predictor of autograft failure over time. Freedom from the combined end point of bleeding/thromboembolism/endocarditis/reoperation was 69.2 ± 4% at 16 years. Perioperative mortality following reoperation was 2.6% and the autograft could be spared in 72% of reinterventions. CONCLUSIONS: The Ross operation in young adults is associated with an excellent survival in the long term that is comparable with the general population. Although there is a risk of reoperation, incidence of other valve-related events is very low. The use of pulmonary autograft should be considered in any young adult patient requiring aortic valve replacement.

OBJECTIVES: Valve sparing reimplantation can improve the durability of bicuspid aortic valve repair compared with subcommissural annuloplasty, especially in patients with a large basal ring. This study analyses the effect of basal ring size and annuloplasty on valve repair in the setting of a tricuspid aortic valve. METHODS: From 1995 to 2013, 382 patients underwent elective tricuspid aortic valve repair. We included only those undergoing subcommissural annuloplasty, valve sparing reimplantation or no annuloplasty and in whom intraoperative transoesophageal echocardiography images were available for retrospective pre- and post-repair basal ring measurements (n = 323, subcommissural annuloplasty: 146, valve sparing reimplantation: 154, no annuloplasty: 23). In a subgroup of patients with available echocardiographic images, basal ring was retrospectively measured at the latest follow-up or prior to reoperation. subcommissural annuloplasty and valve sparing reimplantation were compared after matching for degree of aortic regurgitation and root size. RESULTS: All three groups differed significantly for most of preoperative characteristics. Hospital mortality was 0.9%. The median follow-up was 4.7 years. At 8 years, overall survival was 80 ± 5%. Freedom from reoperation and freedom from aortic regurgitation >1+ were 92 ± 5% and 71 ± 8%, respectively. In multivariate analysis, predictors of aortic regurgitation >1+ were left ventricular end-diastolic diameter (P = 0.003), cusp repair (P = 0.006), body surface area (P = 0.01) and subcommissural annuloplasty (P = 0.05). In subcommissural annuloplasty, freedom from aortic regurgitation >1+ was lower for patients with basal ring ≥28 mm compared with patients with basal ring <28 mm (P = 0.0001). In valve sparing reimplantation, freedom from aortic regurgitation >1+ was independent of basal ring size (P = 0.38). In matched comparison between subcommissural annuloplasty and valve sparing reimplantation, freedom from aortic regur

The increase of life expectancy in Western countries over the past 30 years has resulted in an exponential increase of elderly patients presenting for cardiac surgery. In this population, aortic stenosis is the most important acquired heart disease, with a prevalence of 4.8% in patients aged over 75 years. Despite the good results with conventional aortic valve replacement in elderly patients, many patients are denied surgery because of the high operative risk. In this frail population, transcatheter aortic valve implantation (TAVI) can be a good compromise to achieve good results and minimize morbidity and mortality. This technique allows the implantation of an expandable bioprosthesis without the resection of the native aortic valve. Several complications have been described as a consequence of the residual highly calcified valve being squeezed between the aortic wall and the stent of the implant. To avoid those complications, it is necessary to resect the aortic valve before TAVI. Starting from the initial need asked by the surgeon – design a device for minimally invasive aortic valve resection – this thesis firstly focuses on a detailed study of the heart, the pathology of calcific aortic stenosis and its different current medical treatments. The clarification of the task starts with the analysis of the need and the functional analysis of the need leading to the establishment of the functional specifications. Then, the choices for the different function from the functional specifications are performed. The conception of the different subsets of the solution follows a traditional design method, until the realization of demonstrators. A clinical trial on patients undergoing open heart surgery ends this work and validates the concept of the final solution. Finally, some prospects are given to improve the device before its marketing thanks to the results achieved throughout this work., (FSA - Sciences de l'ingénieur) -- UCL, 2016

Transcatheter aortic valve implantation was introduced into clinical practice in 2002 as a rescue approach in patients presenting with symptomatic severe aortic stenosis but not eligible for conventional aortic valve replacement. This technique allows implantation of a balloon expandable bioprosthesis without resection of the native aortic valve. Several complications are described as a consequence of the residual highly calcified valve being squeezed against the aortic wall by the stent of the implant. This can result in deformation of the metal stent and paravalvular leakage, risk of occlusion of the coronary ostia, or central and peripheral embolization of valvular debris. To avoid these complications, many authors suggest the possibility to resect and remove the native aortic valve before transcatheter aortic valve implantation. In this field, different authors have described possible techniques and different sources of energy to resect the calcified valve. In this article, we review the development of these experimental techniques and discuss future prospects in this field.

OBJECTIVES: Despite the controversy, the aortic homograft is supposedly the best option in acute infective endocarditis (AIE), due to its resistance to reinfection. However, the technical complexity and the risk of structural deterioration over time have limited its utilization. The aim of this study was to evaluate the long-term results of aortic homograft for the treatment of infective endocarditis in our institution with particular attention to predictors of survival and homograft reoperation. METHODS: The cohort includes 112 patients who underwent aortic valve replacement with an aortic homograft for AIE between January 1990 and December 2014. RESULTS: Fifteen patients (13.4%) died during the first 30 days after the operation. Two patients were lost to follow-up after discharge from the hospital; therefore, 95 patients were available for long-term analysis. The median duration of follow-up was 7.8 years (IQR 4.7-17.6). Five patients (5.3%) suffered a recurrence of infective endocarditis (1 relapse and 4 new episodes). Sixteen patients (16.8%) were reoperated for structural valve degeneration (SVD; n = 14, 87.5%) or for infection recurrence (n = 2, 12.5%). Freedom from homograft reoperation for infective endocarditis or structural homograft degeneration at 10 and 15 years postoperatively was 86.3 ± 5.5 and 47.3 ± 11.0%, respectively. For patients requiring homograft reoperation, the median interval to reintervention was 11.6 years (IQR 8.3-14.5). Long-term survival was 63.6% (95% CI 52.4-72.8%) and 53.8% (95% CI 40.6-65.3%) at 10 and 15 years, respectively. CONCLUSIONS: The use of aortic homograft in acute aortic valve endocarditis is associated with a remarkably low risk of relapsing infection and very acceptable long-term survival. The risk of reoperation due to SVD is significant after one decade especially in young patients. The aortic homograft seems to be ideally suited for reconstruction of the aortic valve and cardiac structures damaged by the infective p

BACKGROUND: Bilateral internal thoracic arteries (BITA) have demonstrated superior patency and improved survival in patients undergoing coronary artery bypass grafting. However, the optimal configuration for BITA utilization and its effect on long-term outcome remains uncertain. METHODS AND RESULTS: We randomly assigned 304 patients undergoing coronary artery bypass grafting using BITA to either in situ or Y grafting configurations. The primary end point was 3-year angiographic patency. Secondary end points included major adverse cardiac and cerebrovascular events (ie, death from any cause, stroke, myocardial infarction, or repeat revascularization) at 7 years. More coronary targets were able to be revascularized using internal thoracic arteries in patients randomized to Y grafting versus in situ group (3.2±0.8 versus 2.4±0.5 arteries/patient; P<0.01). The primary end point did not show significant differences in graft patency between groups. Secondary end points occurred more frequently in the in situ group (P=0.03), with 7-year rates of 34±10% in the in situ and 25±12% in the Y grafting groups, driven largely by a higher incidence of repeat revascularization in the in situ group (14±4.5% versus 7.4±3.2% at 7 years; P=0.009). There were no significant differences in hospital mortality or morbidity or in late survival, myocardial infarction, or stroke between groups. CONCLUSIONS: Three-year systematic angiographic follow-up revealed no significant difference in graft patency between the 2 BITA configurations. However, compared with in situ configuration, the use of BITA in a Y grafting configuration results in lower rates of major adverse cardiovascular and cerebrovascular events at 7 years. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01666366.

BACKGROUND: To enhance the reproducibility of aortic valve-sparing reimplantation and annuloplasty, we analyzed the topographic relationship between the ventriculoaortic junction (VAJ), basal ring (BR), and sinotubular junction (STJ). The root base thickness is also quantified. METHOD: Fifty-eight fresh human aortic valves were analyzed. The root was dissected to the limit where the aortic wall terminates into the cardiac structures (VAJ). Root height was measured externally from the STJ to the VAJ and internally from the STJ to the BR defined as the plane passing through the cusps nadir. The root base thickness was measured at the BR and orthogonal to the internal wall; except at the right coronary sinus, where it was measured between the BR internally and the VAJ externally. Measurements were taken at the middle of the 3 sinuses and commissures. RESULTS: The VAJ is at the same level as the BR from the noncoronary sinus (-0.1 ± 0.9 mm) to the left coronary sinus (0.5 ± 1.3 mm); it is above the BR from the left/right commissure (4.6 ± 1.4 mm) to the right/non commissure (2.5 ± 1.6 mm). The external root height was highest at the non/left commissure (21.5 ± 2.6 mm) followed by the right/non commissure (19.2 ± 2.3 mm) then the left/right commissure (15.7 ± 2.2 mm) (P < .05). The mean root base thickness was 3.2 mm, ranging from 1 ± 0 mm at the left/non commissure to 6.2 ± 1.2 mm at the right coronary sinus (P < .001). CONCLUSIONS: The VAJ is not planar; it is above the level of the BR from the left/right to the right/non commissure. As a consequence, the external height of the non/left commissure is greater than the other 2 commissures. These findings should be taken into consideration when performing aortic valve-sparing reimplantation or external annuloplasty.

CONTEXT: Several studies have analyzed the long-term survival after transcatheter aortic valve implantation (TAVI). However, no previous studies have looked at survival beyond 1-year with respect to the type of anesthesia. AIMS: The aim was to evaluate the mid-term survival after TAVI with respect to the type of anesthesia (general anesthesia [GA] vs. local anesthesia ± sedation [LASedation]) or the type of procedure (transfemoral [transfem] vs. transapical TAVI) performed. SETTINGS AND DESIGN: Retrospective cohort study. SUBJECTS AND METHODS: This retrospective study included TAVI's between January 2009 and June 2013. Patients were divided into three groups: transfem TAVI under GA, transfem TAVI under LASedation and transapical TAVI. A total of 176 patients were eligible. The following clinical outcomes were evaluated: (1) Mortality, (2) Major cardiovascular complications, (3) Conduction abnormalities and arrhythmias, (4) Acute kidney injury, (5) Aortic regurgitation, (6) Neurologic events, (7) Vascular complications, (8) Pulmonary complications, (9) Bleeding, (10) Infectious complications, (11) Delirium. STATISTICAL ANALYSIS USED: A Kruskal-Wallis test was performed to test significance between the three groups for quantitative variables. Categorical variables were compared using a Chi-square test. Survival was estimated using Kaplan-Meier method. RESULTS: There was no statistically significant difference between the survival of both transfem TAVI's (P = 0.46). The short-term outcome of the transfem TAVI groups was better than the transapical arm, but their mid-term survival did not show any significant difference (P = 0.69 transapical vs. transfem GA; P = 0.07 transapical vs. transfem LASedation). CONCLUSIONS: Our results demonstrate that the type of anesthesia and the access route do not influence mid-term survival after TAVI.