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THE INTERNAL MAMMARY ARTERY (IMA) is used as the conduit of choice in coronary artery bypass grafting (CABG) due to its superior long-term outcomes compared to venous grafts. The IMA collateralizes to the external iliac artery by anastomosis with the inferior epigastric artery. In patients with chronic aortoiliac occlusion, arterial perfusion of the lower limbs may be supplied mostly by this collateral pathway. In this case report, the authors describe the occurrence of acute bilateral lower limb ischemia following CABG using bilateral IMA grafts in a patient with severe aortoiliac occlusive disease.

E-learning is considered in present as an important research area in the domain of education's sciences, as it has opened new ways of learning for many people. E-assessment has been widely used since the development of e-learning exist. However, what most electronic exercises and test do, is to transform the paper exercises and exams into electronic format. This is clear from the types of questions used by most e-learning and e-assessment platforms. In order to overcome such limitations and gain more control over types of questions, we have developed a model of classifying, indexing and selecting the topics for multiple choice questions. Our model was inspired from the graph theoretical knowledge model of Kasyanov and uses a graduate hierarchical representation of knowledge, from basic definitions of simple notions, concepts or principia until the relationship understanding. We used the following four grades which divide all students on novices, beginners, advanced students and expert. The novice are possess only knowledge of basic notions; the beginners can define composite concepts and exemplify them, eventually to identify connection relationship between concepts related at distance

International audience; Aims: Serial invasive endomyocardial biopsies (EMB) remain the gold standard for acute cellular rejection (ACR) diagnosis. However histological grading has several limitations. We aimed to explore the value of myocardial Gene Expression Profiling (GEP) for diagnosing and identifying predictive biomarkers of ACR.Methods: A case-control study nested within a retrospective heart transplant patients cohort included 126 patients with median (IQR) age 50 (41-57) years and 111 (88%) males. Among 1157 EMB performed, 467 were eligible (i.e, corresponding to either ISHLT grade 0 or ≥3A), among which 36 were selected for GEP according to the grading: 0 (CISHLT, n = 13); rejection ≥3A (RISHLT, n = 13); 0 one month before ACR (BRISHLT, n = 10).Results: We found 294 genes differentially expressed between CISHLT and RISHLT, mainly involved in immune activation, and inflammation. Hierarchical clustering showed a clear segregation of CISHLT and RISHLT groups and heterogeneity of GEP within RISHLT. All EMB presented immune activation, but some RISHLT EMB were strongly subject to inflammation, whereas others, closer to CISHLT, were characterized by structural modifications with lower inflammation level. We identified 15 probes significantly different between BRISHLT and CISHLT, including the gene of the muscular protein TTN. This result suggests that structural alterations precede inflammation in ACR. Linear Discriminant Analysis based on these 15 probes was able to identify the histological status of every 36 samples.Conclusion: Myocardial GEP is a helpful method to accurately diagnose ACR, and predicts rejection one month before its histological occurrence. These results should be considered in cardiac allograft recipients' care.

We report and examine the outcomes of emergency venoarterial extracorporeal membrane oxygenation (ECMO) support initiated via percutaneous cannulation of the femoral vessels.Fifteen patients undergoing percutaneous venoarterial ECMO under emergency circumstances between January 2009 and July 2011 were identified. The implantation technique employed the Seldinger's technique for both arterial and venous cannulae. Whenever possible antegrade perfusion of the ipsilateral lower limb was performed through percutaneous catheterization of the superficial femoral artery (SFA).ECMO support was indicated mainly for cardiac arrest (n=9, 60%) or cardiogenic shock (n=4, 27%), while two (13%) patients required ECMO support for acute respiratory failure. In five (33%) patients, ECMO was implanted during cardiopulmonary resuscitation manoeuvres. ECMO support was maintained for a mean of 4.9 days. Eight patients (53%) were successfully weaned from the device. Thirty-day mortality was 53%. Seven patients (47%) suffered early complications, namely two wound infections, one thrombosis of the venous cannula, one erroneous implantation of the arterial cannula into the femoral vein, one local dissection of the femoral artery, one retroperitoneal bleeding and one acute limb ischaemia. No long-term vascular complications were noted.Percutaneous femoral cannulation for ECMO support remains a prompt approach for establishing extracorporeal circulatory support in acute cardiopulmonary failure when conditions for performing femoral vessel cut down are not optimal. However, vascular complications are frequent and carry a significant morbidity and mortality.

Objectives The singularity of the ascending aorta regarding mechanisms driving aneurysm formation requires the development of specific animal models. We investigated if adventitial elastase application results in ascending aorta aneurysms in rats. Methods Adult Lewis rats (n = 26) were anesthetized, their ascending aortas measured by transthoracic ultrasound, and exposed via median sternotomy. Elastase or saline was applied on the ascending aortic adventitia. Ascending aorta diameters were monitored by ultrasound at 10 and 30 days, when the animals were killed. Wall area was measured on orcein stained sections. Matrix metalloproteinase-2 and matrix metalloproteinase-9 levels were quantified on gelatin zymography. Results Following elastase application, ascending aortic diameter increased at 10 and 30 days follow-up by 38% and 44%, respectively ( P = .004). Despite thinning of the media secondary to vascular dilation, standardized medial area was not different between elastase-treated aortas and controls. Standardized total wall area had a significant increase in treated aortas compared with controls. Active matrix metalloproteinase-2 was significantly increased at 30 days in treated aortas, whereas active matrix metalloproteinase-9 was no different from controls. Conclusions Elastase application on rat ascending aortic adventitia produced aneurysms, creating a reproducible model. Aortic wall remodeling evolved toward an increase in total wall area, reproducing the main structural features of this disease in human beings.

Aims We describe the first report of an Edwards SAPIEN valve implanted in a tricuspid bioprosthesis from the femoral vein. We highlight the feasibility of this previously avoided approach and the techniques involved. Methods and results A 61-year-old woman with multiple valve replacements for rheumatic heart disease presented with NHYA IV dyspnoea secondary to a severely stenosed tricuspid bioprosthesis. After failed aggressive medical therapy and surgical turn down, an Edwards SAPIEN XT valve was deployed in the tricuspid bioprosthesis via the right femoral vein. Adaptations to the standard transfemoral transcatheter aortic valve implantation (TAVI) technique included: (1) crossing the tricuspid bioprosthesis with a balloon floatation catheter; (2) temporary pacing wire in the coronary sinus rather than the right ventricle; (3) mounting of the SAPIEN XT valve in the reverse orientation to transfemoral TAVI; and (4) fine positioning of the final valve position pre-deployment by 3D transoesophageal echocardiography (3D TOE) alone due to complete radiolucency of the tricuspid bioprosthesis. The procedure was completed without complication and resulted in significant symptomatic improvement. Conclusions Deployment of an Edwards SAPIEN valve in a tricuspid bioprosthesis via the femoral vein is feasible and, with careful adaptations to established TAVI techniques, can be performed without complications and with good clinical response.

A 56-year-old woman was admitted for recurrent, refractory congestive heart failure. When she was aged 17 years, she had a Hodgkin lymphoma treated by chest radiation. She then developed postradiation heart disease, which required surgery in 2004, combining mitral valve repair using a Physio semirigid ring sized 28 mm (Edwards Lifesciences Inc; Irvine, CA) and tricuspid annuloplasty. In March 2009, the patient experienced recurrent congestive heart failure due to mitral valve stenosis. Percutaneous mitral commissurotomy achieved transient symptom relief, but her clinical status severely worsened in the past year. On admission, the patient was in New York Heart Association class IV heart failure. Physical examination showed worrying skin sequelae of chest radiation and severe congestive heart failure. Echocardiography demonstrated severe mitral valve stenosis (mean gradient, 11 mm Hg), regurgitation (grade 3+), dilatation of the right atrium and ventricle, moderate tricuspid regurgitation, and estimated systolic pulmonary artery pressure >60 mm Hg (Move 1). On multislice CT, the anteroposterior diameter of the mitral ring was calculated at 16 mm and the intercommissural diameter at 27 mm. Because repeated surgery carried a prohibitive risk, a transcatheter option was considered. Because of the cutaneous lesions and postradiation cardiomyopathy, the transapical approach was deemed inadequate; thus, it was decided to intervene through the right femoral vein and a transseptal route. After transseptal catheterization and septal dilation with a 10-mm balloon, crossing the mitral valve …

Objective To describe differences in intra- and postoperative care between general (GA) and local/regional anesthesia (LRA) in consecutive high-risk patients with aortic stenosis who underwent transfemoral transcatheter aortic valve implantation (TAVI). Design A retrospective review of data collected in an institutional registry. Setting An academic hospital. Participants One hundred twenty-five consecutive patients with severe aortic stenosis who underwent transfemoral TAVI. Interventions GA versus LRA followed by postoperative care. Complications were defined by pre-established criteria. Material and Methods Consecutive patients referred for transfemoral TAVI between October 2006 and October 2010 initially underwent GA (n = 91) followed by LRA after March 2010 (n= 34). Results are presented as mean ± standard deviation or median (25-75 percentiles) as appropriate. GA and LRA TAVI patients had similar preoperative characteristics. LRA was associated with a significantly shorter procedure duration (LRA: 80 [67-102]; GA: 120 [90-140 minutes]; p < 0.001), hospital stay (LRA: 8.5 [7-14.5]; GA: 15.5 [10-24] days; p < 0.001), intraoperative requirements of catecholamines (LRA 23%; GA: 90% of patients; p < 0.001), and volume expansion (LRA: 11 [8-16]; GA: 22 [15-36] mL/kg; p < 0.001). There were significant differences in delta creatinine (day 1, preoperative creatinine values; LRA: 0 [−12 to 9]; GA: −15 (−25 to 2.9) μmol, p < 0.004). The frequency of any postoperative complications was 38% (LRA) and 77% (GA) (p = 0.11). Thirty-day mortality was 7% (GA) and 9% (LRA) (p = 0.9). Conclusions This observational study suggests that LRA was associated with less intraoperative hemodynamic instability and significant shortening of the procedure and hospital stay. Changes in the anesthetic technique adapted to changes in TAVI interventional techniques and did not increase the rate of postoperative complications.

This paper presents two ultra-discrete versions (discrete time, space, and values) of an important reaction-diffusion system arising from the biomathematical domain, the so-called predator-prey interaction system.

Although video-assisted metastasectomy has been proposed for some solitary metastases, its value has not been investigated in patients with pulmonary metastases from sarcoma for which open resection remains the usual approach.In all, 113 consecutive patients underwent curatively intended lung resection for metastases from sarcomas. Of these 113 patients, 31 were selected for a thoracoscopic wedge resection (group TS). These patients were compared with 29 patients operated on by thoracotomy but whose features could have made them possible candidates for a thoracoscopic resection (group TT). Follow-up was complete for all patients (mean follow-up, 34 months).No mortality occurred. No morbidity was observed in group TT, and 1 complication occurred in group TS. The mean postoperative hospital stay was 3.7 days for group TS and 6.2 days for group TT (p0.0001). Overall survival rates at 1, 3, and 5 years were, respectively, 87.4%, 70.9%, and 52.5% in group TS, and 82.3%, 63.6%, and 34% in group TT (p = 0.20). Disease-free survival rates at 1 and 3 years were, respectively, 50.5% and 26.4% in group TS and 60% and 24.8% in group TT (p = 0.74). Local recurrence occurred in 1 patient in each group. Survival without a homolateral recurrence (i.e., in the operated lung) at 1 and 3 years was 66.7% and 44.4% in group TS and 83.5% and 45% in group TT, respectively (p = 0.54).In selected patients with a maximum of two pulmonary nodules, thoracoscopic resections yield survival rates similar to open resections while being less invasive and preserving the patient's ability to undergo possible repeat operations.

The majority of ascending aortic aneurysms cannot be related to any specific etiology and should be qualified as idiopathic. The incidence of this disease is increasing in the population of the developed countries but its pathobiology is poorly understood.This article is reviewing the publications concerning the pathobiology of idiopathic ascending aortic aneurysms.A PubMed search on articles published in English or French, between January 1965 and December 2007, on key-wordsaortic root,ascending aorta,aortic arch,thoracic aorta,aneurysm,dilatationanddissectionwas undertaken. Articles on aneurysms related to inflammatory and infectious diseases, congenital or genetic syndromes were excluded.The presented data suggests that destructive remodeling of the aortic wall, inflammation and angiogenesis, biomechanical wall stress, and molecular genetics are relevant mechanisms of idiopathic ascending aortic aneurysm formation and progression.Sparse data available from few direct studies offer limited knowledge on pathobiology of idiopathic ascending aortic aneurysms.A more intimate knowledge of the triggers and perpetrating factors of this disease might offer new diagnostic and treatment options.

Although some series of video-assisted major pulmonary resections have been reported, very few series of totally endoscopic lobectomies have been published and - to our knowledge - none of totally endoscopic anatomic segmentectomies. We have recently performed five anatomic segmentectomies using this approach. The video demonstrates the main steps of the procedure, based on the recordings of three different operations: a lingulectomy, a left basilar segmentectomy and a resection of the right lower lobe superior segment.

The use of staplers during thoracoscopic pulmonary resections has entailed several incidents. This study aimed to evaluate the rate of adverse events related to the use of an endostapler during video-assisted thoracic surgery (VATS). All thoracoscopic procedures involving the use of an endostapler were prospectively studied. The study was based on the analysis of data prospectively entered into a database and the review of videotapes recorded during the procedure. The video clip of each incident was included into the database. The following events were recorded: oozing or hemorrhage on the staple line, partial or total disruption of the staple line, and any other technical issue. A total of 434 firings were made during 130 thoracoscopic operations. The operations involved 77 wedge resections of lung nodules, 11 pulmonary biopsies, 34 bullectomies, and 8 thoracoscopic lobectomies. Although firing was uneventful for most patients, a minor or major problem was encountered during 34 firings (7.6%). Two technical malfunctions of the device occurred, both of them noticed by the scrub nurse before introduction of the stapler into the trocar. The other pitfalls were oozing (13 cases) and active hemorrhages (5 cases) on the staple line and disruption of the staple line, either partial (13 cases) or total (1 case). Conversion to thoracotomy was never necessary. Whereas no specific action was imposed by the pitfall in 12 cases, the incident led to a repair in 22 cases. None of the incidents had a clinical consequence in the postoperative course. The video tapes were reviewed to check whether the accident was unpredictable or due the surgeon’s misuse or misjudgment. In 14 cases, no cause was found. In 5 cases, the lung parenchyma probably was too thick for the staples chosen, whereas no technical error was found in the remaining 15 cases. Although some adverse events are attributable to surgical errors, many are linked to the device. This underscores the need for improving staplers and evaluating new technologies.

Objectives The study addresses mechanisms driving the formation of ascending aortic aneurysms by comparing the maximal dilatation area with the transition area immediately adjacent to the normal aortic tissue left in place during surgical repair. Methods Aortic wall specimens were taken from the maximal dilatation area and transition area in 10 patients undergoing surgery for ascending aortic aneurysms and fixed for histology and immunohistochemistry for vascular smooth muscle cells (alpha-actin), endothelial cells (CD31), and macrophages (CD68). Tissue concentrations of vascular endothelial growth factor, matrix metalloproteinase-2, and matrix metalloproteinase-9 were determined by enzyme-linked immunosorbent assay. The results are expressed as medians with their 25th and 75th centiles. Results Vascular smooth muscle cells were significantly more abundant in the maximal dilatation area than in the transition area (20.3 [14.8-24.4]/10 −2 mm 2 vs 8.0 [6.4-9.3]/10 −2 mm 2 , respectively, P = .002). In the maximal dilatation area, vascular smooth muscle cells had lost their typical lamellar organization, whereas it was preserved in the transition area. Microvessels were significantly more abundant in the media of transition area than in the maximal dilatation area (7.5 [2.9-10.1]/mm 2 vs 1.75 [1.5-2.0]/mm 2 , respectively, P = .008) and were associated with an inflammatory cell infiltration that predominated in their immediate vicinity. There were no significant differences in vascular endothelial growth factor, matrix metalloproteinase-2, and matrix metalloproteinase-9 between both areas. Conclusions The transition area appears as a disease progression front characterized by microvessel formation and inflammatory cell infiltration. In contrast, increased vascular smooth muscle cell density in the maximal dilatation area suggests a healing process, although inefficient to prevent aortic dilatation.

The majority of ascending aortic aneurysms cannot be related to any specific etiology and should be qualified as idiopathic. The pathobiology of ascending aortic aneurysms remains incompletely understood. Data from direct study are still scarce and often limited because of patient heterogenicity. Currently available information suggests that destructive remodeling of the aortic wall, inflammation and angiogenesis, biomechanical wall stress, and molecular genetics are relevant mechanisms of idiopathic ascending aortic aneurysm formation and progression. Further understanding of these mechanisms will likely provide novel diagnostic, prognostic, and therapeutical tools for the clinician.

ObjectivesWhat influence do patient selection and learning curve have on the results of transapical aortic valve implantation (TAVI)?MethodsFrom September 2007 to January 2009, 33 patients treated with TAVI for severe symptomatic aortic stenosis were included in a prospective registry. According to their risk profile, 2 patient groups were distinguished. In Group 1 (n=25) the high surgical risk was related to technical difficulties for conventional aortic valve replacement (porcelain aorta, redo surgery with patent coronary artery bypass grafts, hi-dose mediastinal radiotherapy). In Group 2 (n=8) the high risk was due to severe comorbidities.ResultsTAVI was successfully performed in all patients without per-procedural death or stroke. “Valve in valve” reimplantation was necessary in 2 patients due to persistent leaks. Mean follow-up was 10.8 months (1-17). Overall mortality was 16% in Group 1and 37.5% in Group 2 (p=0.03). Predictive factors of hospital mortality were: NYHA class (p=0.03), LV dysfunction (p=0.009) and pulmonary hypertension (p

Background Aortic root replacement after a previous operation on the aortic valve, aortic root, or ascending aorta remains a major challenge. Methods Records of 56 consecutive patients (44 men; mean age, 56.4 ± 13.6 years) undergoing reoperative aortic root replacement between June 1994 and June 2005 were reviewed retrospectively. Results Reoperation was performed 9.4 ± 6.7 years after the last cardiac operation. Indications for reoperation were true aneurysm (n = 14 [25%]), false aneurysm (n = 10 [18%]), dissection or redissection (n = 9 [16%]), structural or nonstructural valve dysfunction (n = 10 [18%]), prosthetic valve-graft infection (n = 12 [21%]), and miscellaneous (n = 1 [2%]). Procedures performed were aortic root replacement (n = 47 [84%]), aortic root replacement plus mitral valve procedure (n = 5 [9%]), and aortic root replacement plus arch replacement (n = 4 [7%]). In 14 (25%) patients coronary artery bypass grafting had to be performed unexpectedly during the same procedure or immediately after the procedure to re-establish coronary perfusion. Hospital mortality reached 17.9% (n = 10). Multivariate logistic regression analysis revealed the need for unplanned perioperative coronary artery bypass grafting as the sole independent risk factor for hospital death ( P = .005). Actuarial survival was 83.8% ± 4.9% at 1 month, 73.0% ± 6.3% at 1 year, and 65.7% ± 9.0% at 5 years after the operation. One patient had recurrence of endocarditis 6.7 months after the operation and required repeated homograft aortic root replacement. Conclusion Reoperative aortic root replacement remains associated with a high postoperative mortality. The need to perform unplanned coronary artery bypass grafting during reoperative aortic root replacement is a major risk factor for hospital death. The optimal technique for coronary reconstruction in this setting remains to be debated.