Search

Background Sutureless valves have recently enabled closed chest aortic valve replacement. This paper evaluates the feasibility of a robotic telemanipulation during thoracoscopic sutureless aortic valve implantation in cadavers. Methods Cadavers were prepared with a five thoracosopic trocar setting, with a transthoracic clamp inserted in the first right intercostal space and the optics inserted in the second. Seven sutureless valve implantations were scheduled using 5 Sorin Perceval and 2 Medtronic 3f Enable valves. Results In all cases performance of pericardial suspension, aortotomy and root exposure required less than 20 min. Native valve excision and sutureless bioprosthesis implantation was technically feasible in all cases. A satisfactory prosthesis sealing was ascertained visually and the absence of paravalvular leakages was assessed with a nerve hook test around the prosthetic flange. Conclusions Closed chest and robot assisted sutureless valve implantation is feasible in cadavers. Robotic technology can enhance reproducibility of the technique. Copyright © 2015 John Wiley & Sons, Ltd.

We report the case of a 61-year-old man who underwent a Bentall procedure with a BioValsalva conduit for an acute type A aortic dissection. Two years later the patient presented at our institution with severe aortic regurgitation caused by the rupture of one cusp of the bioprosthesis (Elan valve) included in the conduit. A transcatheter valve-in-valve option was discussed by the heart team but was dismissed in favor of a sutureless 3f Enable valve implantation into the failing bioprosthesis after leaflet removal. This strategy simplified the surgical procedure and provided excellent postoperative hemodynamics at follow-up.

Background— The clinical impact of prior percutaneous coronary intervention (PCI) in patients requiring coronary artery bypass grafting (CABG) remains unsettled. We sought to determine whether prior PCI is associated with adverse outcome after CABG. Methods and Results— Data from the prospective E-CABG (European Multicenter Study on Coronary Artery Bypass Grafting) conducted between January 2015 and March 2016 at 16 European centres were analyzed using propensity weighted methodology to adjust for confounding. A parallel systematic review/meta-analysis (MEDLINE, Embase, SCOPUS, and Cochrane Library) through September 2017 was accomplished. Of a total of 3641 adult patients included in the E-CABG study, 685 (19%) patients had a history of PCI. At multivariable level, prior PCI was not associated with an increased hospital mortality in both unweighted and weighted patient groups (odds ratio, 0.73; 95% confidence interval, 0.29–1.38; P =0.33 and odds ratio, 0.90; 95% confidence interval, 0.39–2.08; P =0.81, respectively). Subgroup analyses confirmed that prior PCI had no impact on hospital mortality and morbidity, including reexploration for bleeding, blood transfusion, hospital resource use, and neurological, renal, and cardiac complications. The systematic review provided a total of 71 366 individuals and showed a trend toward higher in-hospital/30-day mortality (adjusted odds ratio, 1.30; 95% confidence interval, 0.99–1.70; I 2 =43.1%) in patients with prior PCI. Conclusions— Our prospective multicenter study showed that prior PCI was not associated with an increased risk of mortality or other adverse outcomes in patients undergoing CABG. In light of a trend toward increased mortality observed in the meta-analysis, further studies are needed to ascertain the prognostic impact of prior PCI in the outcome after CABG. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT02319083.

Background: The evidence of the benefits of using venoarterial extracorporeal membrane oxygenation (VA-ECMO) after coronary artery bypass grafting (CABG) is scarce. Methods: We analyzed the outcomes of patients who received VA-ECMO therapy due to cardiac or respiratory failure after isolated CABG in 12 centers between 2005 and 2016. Patients treated preoperatively with ECMO were excluded from this study. Results: VA-ECMO was employed in 148 patients after CABG for median of 5.0 days (mean, 6.4, SD 5.6 days). Inhospital mortality was 64.2%. Pooled in-hospital mortality was 65.9% without significant heterogeneity between the centers (I-2 8.6%). The proportion of VA-ECMO in each center did not affect in-hospital mortality (p = 0.861). No patients underwent heart transplantation and six patients received a left ventricular assist device. Logistic regression showed that creatinine clearance (p = 0.004, OR 0.98, 95% CI 0.97-0.99), pulmonary disease (p = 0.018, OR 4.42, 95% CI 1.29-15.15) and pre-VA-ECMO blood lactate (p = 0.015, OR 1.10, 95% CI 1.02-1.18) were independent baseline predictors of in-hospital mortality. One-, 2-, and 3-year survival was 31.0%, 27.9%, and 26.1%, respectively. Conclusions: One third of patients with need for VA-ECMO after CABG survive to discharge. In view of the burden of resources associated with VA-ECMO treatment and the limited number of patients surviving to discharge, further studies are needed to identify patients who may benefit the most from this treatment. (C) 2017 Elsevier B.V. All rights reserved.

Perioperative bleeding is a determinant of poor outcome in patients undergoing coronary artery bypass grafting (CABG), but there is a lack of adequate stratification of its severity. The ability of the European registry of Coronary Artery Bypass Grafting (E-CABG), Universal Definition of Perioperative Bleeding (UDPB), Study of Platelet Inhibition and Patient Outcomes (PLATO), Clopidogrel and Aspirin Optimal Dose Usage to Reduce Recurrent,Events Seventh Organization to Assess Strategies in Ischemic Syndromes (CURRENT-OASIS 7), Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q Wave Coronary Events (ESSENCE), and SafeTy and Efficacy of Enoxaparin in Percutaneous coronary intervention patients, an internationaL randomized Evaluation (STEEPLE) bleeding classifications to predict early mortality, stroke, acute kidney injury (AKI) stage 3, and deep sternal wound infection/mediastinitis was investigated in 3,730.patients from the prospective, multicentre E-CABG registry. Increasing grades of the E-CABG, UDPB, PLATO, and CURRENT-OASIS 7 classifications were associated with increasing risks of early mortality, had similar receiver-operating characteristic area under the curves (>0.7), and were predictive also when adjusted for EuroSCORE II. The E-CABG and UDPB classifications had satisfactory area under the curves (>0.6) in pre,dicting stroke, AKI stage 3, and deep sternal wound infection/mediastinitis even when adjusted for EuroSCORE II. The PLATO and CURRENT-OASIS 7 classifications had similar predictive ability for stroke and AKI stage 3 as confirmed by multivariate analysis adjusted for EuroSCORE II but showed inferior ability in predicting severe wound infection compared to the E-CABG and UDPB classifications. The STEEPLE and ESSENCE classifications had a poor ability of predicting all these adverse events. Decision curve analysis showed a benefit of the ECABG bleeding classification over the other classifications in predicting all adverse events. In conclusion, the E-CABG, UDPB, PLATO, and CURRENT-OASIS 7 bleeding classifications have a satisfactory ability in predicting adverse events after CABG. Decision curve analysis showed that the E-CABG bleeding classification had the best predictive performance. (C) 2016 Elsevier Inc. All rights reserved.

International audience; Objective To clarify the mid-term durability of the Trifecta bioprosthesis for aortic valve replacement (AVR). Methods We retrospectively analyzed the prospectively collected data of 824 consecutive implants of the Trifecta valve at a single institution. A 100% complete follow-up was available (average duration, 2.2 ± 1.3 years; range, 0.03-6.9 years; 1747.6 patient-years). Echocardiography data at discharge were recorded prospectively. Results Operative mortality was 3.8%; 2.7% in patients receiving isolated AVR. There were 5 valve-related early reoperations, including 1 for infective prosthetic endocarditis and 4 for nonstructural valve dysfunction. The global rate of severe patient–prosthesis mismatch was 1.26%. Overall 5-year survival was 74.9%, and freedom from valve-related death was 97.8%. The majority of deaths attributed to the valve were due to unknown causes. We observed 6 SVD events at 3.4 ± 1.6 years after surgery. At 5 years, the actuarial freedom from SVD was 98% ± 0.9% (n = 6), freedom from reintervention for SVD was 98% ± 0.9% (n = 5, including 2 transcatheter valve-in-valve), and freedom from open reoperation for SVD was 98.9% ± 0.6%. The 5-year freedom from prosthetic endocarditis was 97.7% ± 0.7% (n = 12, 6 requiring reoperation). There was 1 case of late NSVD (5-year freedom, 99.8% ± 0.2%). Freedom from hemorrhagic events was 98.6% ± 0.5% (86% occurring in patients on anticoagulants); there were no thromboembolic events at follow-up. Conclusions The Trifecta bioprosthesis is a reliable device for AVR. We confirm excellent immediate hemodynamic properties and a very low rate of patient–prosthesis mismatch. The absolute number of SVD cases observed remains limited; nevertheless, their timing, pathological characteristics, and clinical presentation mandate continued follow-up.

BACKGROUND Excessive bleeding and blood transfusion are associated with adverse outcome after cardiac surgery, but their mechanistic effects are difficult to disentangle in patients with increased operative risk. This study aimed to evaluate the incidence and prognostic impact of bleeding and transfusion of blood products in low-risk patients undergoing coronary artery bypass grafting (CABG). STUDY DESIGN AND METHODS Sixteen tertiary European centers of cardiac surgery contributed to the prospective European registry of CABG (E-CABG). The severity of bleeding was defined by the E-CABG bleeding severity classification and universal definition of perioperative bleeding (UDPB) classification. RESULTS Of 1213 patients with EuroSCORE II of less than 2% (mean, 1.1 ± 0.4%), 18.5% suffered from mild bleeding (E-CABG bleeding Grade 1) and 3.4% experienced severe bleeding (E-CABG bleeding Grade 2-3). Similarly, 19.7% had UDPB Class 2 and 5.9% had UDPB Classes 3 and 4. Mild and severe bleeding defined by the E-CABG and UDPB classifications were associated with an increased risk of several adverse events as adjusted by multiple covariates. The risk of death, stroke, and acute kidney injury was particularly increased in patients with severe bleeding. CONCLUSION Severe bleeding is rather uncommon in low-risk patients undergoing CABG, but it is associated with an increased risk of major adverse events. Prevention of excessive perioperative bleeding and patient blood management may improve the outcome of cardiac surgery also in low-risk patients.

To investigate the impact of minor perioperative bleeding requiring transfusion of 1-2 red blood cell (RBC) units on the outcome after coronary artery bypass grafting (CABG). Purpose: To investigate the impact of minor perioperative bleeding requiring transfusion of 1-2 red blood cell (RBC) units on the outcome after coronary artery bypass grafting (CABG).Methods: Sixteen cardiac surgical centers contributed to the prospective European CABG registry (E-CABG). 1014 patients receiving 1-2 RBC units during or after isolated CABG were compared to 2264 patients not receiving RBCs.Results: In 827 propensity score matched pairs, transfusion of 1-2 RBC units did not affect the risk of in-hospital/30-day death (p = 0.523) or stroke (p = 0.804). However, RBC transfusion was associated with an increased risk of acute kidney injury (p = 0.008), sternal wound infection (p = 0.001), postoperative use of antibiotics (p = 0.001), prolonged use of inotropes (p < 0.0001), use of intra-aortic balloon pump (p = 0.012), length of intensive care unit stay (p < 0.0001) and length of in-hospital stay (p < 0.0001). Matched paired analysis excluding pre- and postoperative critical hemodynamic conditions showed that RBC transfusion was associated with an increased risk of major complications except in-hospital/30-day death.Conclusion: Minor perioperative bleeding and subsequent transfusion of 1-2 RBC units did not affect the risk of early death, but increased the risk of other major adverse events. Minimizing perioperative bleeding and prevention of even low-volume RBC transfusion may improve the outcome after CABG. (C) 2017 Elsevier Inc. All rights reserved.

Glycated hemoglobin (HbA1c) is a suspected risk factor for sternal wound infection (SWI) after CABG.Methods and Results:Data on preoperative HbA1c and SWI were available in 2,130 patients undergoing isolated CABG from the prospective E-CABG registry. SWI occurred in 114 (5.4%). Baseline HbA1c was significantly higher in patients with SWI (mean, 54±17 vs. 45±13 mmol/mol, P0.0001). This difference was also observed in patients without a diagnosis of diabetes (P=0.027), in insulin-dependent diabetic (P=0.023) and non-insulin-dependent diabetic patients (P=0.034). In the overall series, HbA1c70 mmol/mol (NGSP units, 8.6%) was associated with the highest risk of SWI (20.6% vs. 4.6%; adjusted OR, 5.01; 95% CI: 2.47-10.15). When dichotomized according to the cut-off 53 mmol/mol (NGSP units, 7.0%) as suggested both for diagnosis and optimal glycemic control of diabetes, HbA1c was associated with increased risk of SWI in the overall series (10.6% vs. 3.9%; adjusted OR, 2.09; 95% CI: 1.24-3.52), in diabetic patients (11.7% vs. 5.1%; adjusted OR, 2.69; 95% CI: 1.38-5.25), in patients undergoing elective surgery (9.9% vs. 2.7%; adjusted OR, 2.09; 95% CI: 1.24-3.52) and in patients with bilateral mammary artery grafts (13.7% vs. 4.8%; adjusted OR, 2.35; 95% CI: 1.17-4.69).Screening for HbA1c before CABG may identify untreated diabetic patients, as well as diabetic patients with suboptimal glycemic control, at high risk of SWI.

Aim We describe a series of 3f Enable sutureless prostheses implanted in bicuspid valves. Methods Between March 2011 and April 2014, five patients with Sievers type 0 bicuspid valves were selected to receive the sutureless 3f Enable prosthesis . Exclusion criteria were: intraoperative calibration of the aortic annulus >27 mm, left ventricle ejection fraction

Transcatheter aortic valve implantation could represent an alternative option to conventional surgery in high risk patients with degeneration of aortic bioprosthesis. Herein we report the performance of a valve-in-valve procedure in urgent conditions and via the left axillary artery in a patient with patent left internal mammary artery coronary graft. A 23 mm Edwards Sapien(®) transcatheter valve was deployed within a 23 mm Edwards Magna Ease bioprosthesis through the novel Edwards 16 French expandable introducer. In this non-elective case the expandable introducer allowed a safe procedure, reduced the risk of subclavian injury and preserved the LIMA graft flow. © 2012 Wiley Periodicals, Inc.

Orthotopic heart transplantation (OHT) is a well established and commonly utilized procedure for end-stage heart failure patients. Heterotopic heart transplantation (HHT) is a surgical procedure that allows the graft to be connected to the native heart in a parallel fashion. The main advantage of HHT is to assist the patient's native heart and to maintain circulation in the cases of severe acute rejection. HHT has also been proposed to overcome pulmonary hypertension, to increase the size of the donor pool and to decrease waiting times without increasing morbidity caused by the procedure. However, only a few papers have reported the short- or long-term results of HHT, and most of these studies have included

SummarySevere perioperative bleeding after coronary artery bypass grafting (CABG) is associated with poor outcome. An additive score for prediction of severe bleeding was derived (n=2494) and validated (n=1250) in patients from the E-CABG registry. Severe bleeding was defined as E-CABG bleeding grades 2–3 (transfusion of >4 units of red blood cells or reoperation for bleeding). The overall incidence of severe bleeding was 6.4 %. Preoperative anaemia (3 points), female gender (2 points), eGFR 6: 24.6 % vs 24.2 %, both pClinical Trial Registration: NCT02319083 (https://clinicaltrials.gov/ct2/show/NCT02319083)

To address the long-term durability of bioprostheses used for aortic valve replacement (AVR) in adult patients aged ≤60 years at the time of surgery.Through a retrospective review of a prospectively collected database, we identified 416 bioprosthetic AVRs performed between 1977 and 2013. A prospective follow-up of valve-related and non-valve-related events was performed.Follow-up was 98.5% complete (2423.1 patient-years; average, 6 ± 5.5 years). At 15 years, overall survival was 62.1 ± 4.4%; freedom from valve-related death was 97.1 ± 1.6%. There were 68 SVD events (11.9 ± 28.8 years after surgery). Freedom from SVD at 15 years was 48.7 ± 5.5% for Kaplan-Meier analysis and 61.4 ± 4.3% for competing-risks analysis. After stratification into age subgroups (40 years, ≥40 and 50 years, and ≥50 and ≤60 years), we observed no significant difference in freedom from SVD (P = .50). The average delay to SVD was not statistically different among subgroups (P = .30). There were 57 reoperations for SVD (11.8 ± 5.2 years after implantation). The 15 year freedom from reoperation for SVD was 55.4 ± 5.6% by Kaplan-Meier analysis and 67.1 ± 4.2% by competing-risks analysis. After stratification by age, freedom from reoperation for SVD was comparable (P = .13). Freedom from any valve-related complication or death was 42 ± 5% by Kaplan-Meier analysis and 54.4 ± 4.1% by competing-risks analysis.The lifetime risk of SVD is considerable in patients aged ≤60 years at the time of bioprosthesis implantation. Nonetheless, durability remains consistent during the first decade; additional data are required for the second decade. Patients' information is pivotal for valve choice (competing-risks method).

International audience; INTRODUCTION: This study was planned to investigate the impact of severe bleeding and blood transfusion on the development of stroke after coronary surgery.METHODS: This cohort study includes 2357 patients undergoing isolated CABG from the prospective European Coronary Artery Bypass Grafting (E-CABG) registry. Severity of bleeding was categorized according to the Universal Definition of Perioperative Bleeding (UDPB), E-CABG and PLATO definitions.RESULTS: Thirty patients (1.3%) suffered postoperative stroke. The amount of transfused red blood cell (RBC) (OR 1.10, 95%CI 1.03-1.18), preoperative use of unfractioned heparin (OR 4.49, 95%CI 1.91-10.60), emergency operation (OR 3.97, 95%CI 1.47-10.74), diseased ascending aorta (OR 4.62, 95%CI 1.37-15.65) and use of cardiopulmonary bypass (p = 0.043, OR 4.85, 95%CI 1.05-22.36) were independent predictors of postoperative stroke. Adjusted analysis showed that UDPB classes 3-4 (crude rate: 3.6% vs. 1.0%; adjusted OR 2.66, 95%CI 1.05-6.73), E-CABG bleeding grades 2-3 (crudes rate: 6.3% vs. 0.9%; adjusted OR 5.91, 95%CI 2.43-14.36), and PLATO life-threatening bleeding (crude rate: 2.5% vs. 0.6%, adjusted OR 3.70, 95%CI 1.59-8.64) were associated with an increased risk of stroke compared with no or moderate bleeding.CONCLUSIONS: Bleeding and blood transfusion are associated with an increased risk of stroke after CABG, which is highest in patients with severe bleeding.

Objective This study aimed to assess the long-term outcome of combined coronary revascularization. Methods Between January 2000 and September 2010, 106 consecutive patients underwent combined coronary revascularization, either the same day or staged within 90 days. Percutaneous coronary intervention was always performed before coronary artery bypass grafting. We identified three groups as follows: one-stop combined coronary revascularization (n = 20), percutaneous coronary intervention for acute coronary syndrome before subsequent surgery (n = 39), and percutaneous coronary intervention for stable coronary artery disease before subsequent surgery (n = 47). Off-pump technique was used in all cases. Results A total of 107 angioplasties were realized (drug-eluting stents, 21; bare metal stents, 114; balloon angioplasty, 4). Percutaneous coronary intervention was mostly performed in the right coronary artery or branches (85%). The mean (SD) number of grafts was 1.9 (0.6), among them 1.8 (0.7) with arterial grafts. A total of 87.7% of the patients underwent exclusive arterial revascularization. There was one reexploration for bleeding and no in-hospital death. Eleven patients died in the follow-up. Repeat percutaneous coronary intervention was necessary for six patients and repeat surgery for one patient. The mean (SD) follow-up was 6.1 (2.7) years. Complete follow-up was obtained in 96.2% of the patients. Freedom from ischemic events (all-cause deaths, angina, acute coronary syndrome, myocardial infarction) was 86.3% (3.7%) at 5 years and 79.7% (5.2%) at 8 years (no difference between groups). Freedom from major adverse cardiac or cerebrovascular events was 88.8% (3.4%) at 5 years and 75.7% (5.2%) at 8 years (no difference between groups). Conclusions Combined coronary revascularization increases the use of arterial grafts, with good long-term outcome.

International audience; OBJECTIVES: To address the safety (rate of thromboembolic events and circuit complications) and efficacy (rate of bleeding control) of recombinant activated coagulation factor VII (rFVIIa) to treat severe bleeding refractory to all surgical and medical treatments in patients under veno-arterial (VA) or veno-venous (VV) extracorporeal membrane oxygenation (ECMO) support. METHODS: In a tertiary referral University Cardiothoracic Surgery Centre including three intensive care units, 30 patients received the rFVIIa during ongoing VA or VV ECMO support (8.6% of ECMO activity from 2005 to 2014; N = 347). Early and late clinical results were analysed (retrospective analysis of prospectively collected data). In a substudy, a case-matching procedure was performed among ECMO patients who received (Group A) or did not receive (Group B) rFVIIa treatment. RESULTS: The mediastinum was the most common site of refractory bleeding (after heart transplantation or other cardiac surgery; 90%); 90% (n = 27) of patients were on VA ECMO and the remainder on VV ECMO. The survival rate at ECMO explantation and at the 30th post-implantation day was 67 and 50%, respectively. The final efficacy rate of rFVIIa in stopping bleeding was 93.3%. The rate of thromboembolic events was 3.3% (1 case) and the rate of circuit change was 16.7% (without instances of overt circuit clotting). After case-matching, Group A comprised 23 patients and Group B included 43 patients. No statistically significant differences were observed among groups in terms of thromboembolic events (P = 0.99), circuit change, ventilation time (P = 0.71), infectious complications (P = 06) and survival at both ECMO explantation and the 30th post-implantation day. Late survival was comparable (Kaplan-Meier analysis; P = 0.42). CONCLUSIONS: In case of life-threatening bleeding refractory to all conventional therapies, rFVIIa presents an acceptable safety profile in patients under ECMO support. No circuit dysfunctions and limited rates of thromboembolism are observed.

International audience; OBJECTIVES To examine the haemodynamic performance of the St Jude Trifecta valve for aortic valve replacement (AVR) at 3 years after implantation. METHODS In a single-centre, prospective, observational, independent study, we enrolled 122 patients who had AVR using a Trifecta bioprosthesis in the July 2010–June 2011 period. A clinical and echocardiographic in-house follow-up was scheduled. RESULTS In our series, 14.7% of patients received a 19-mm, 28.7% had a 21-mm, 35.2% had a 23-mm and 21.3% had a greater-size prosthesis. There were no cases of operative mortality or of valve-related complications both early and at follow-up (except one sudden unexplained death). Completeness of the 3-year echocardiographic follow-up was 80% among survivors. The average mean transvalvular gradient (mTVG) at 3 years was 14.2, 10.8, 8.6, 7.1 and 6.8 mmHg (sizes 19 to 27/29, respectively). There was no statistically significant difference between average mTVGs measured immediately after implantation versus at the 3-year follow-up in the overall population. The average peak transvalvular gradient (pTVG) at 3 years was 25, 20, 16.8, 13.9 and 14.4 mmHg (sizes 19 to 27/29, respectively). The average indexed effective orifice area (iEOA) at 3 years was 0.8, 0.9, 1, 1.3 and 1.3 cm2/m2 (sizes 19–27, respectively). The rate of moderate patient–prosthesis mismatch (PPM) at 3 years was 15.7%; there were two instances of severe PPM (2.2%). All cases of PPM occurred in the 19, 21 and 23 mm size subgroups. CONCLUSIONS The Trifecta valve retains its excellent haemodynamic properties at the 3-year follow-up. The rate of PPM is considerably low

The optimal timing of discontinuation of ticagrelor before cardiac surgery is controversial. Importance: The optimal timing of discontinuation of ticagrelor before cardiac surgery is controversial.Objective: To evaluate the safety of preoperative use of ticagrelor with or without aspirin in patients with acute coronary syndromes (ACS) undergoing isolated coronary artery bypass grafting (CABG) compared with aspirin alone.Design, Setting, and Participants: This prospective, multicenter clinical trial was performed at 15 European centers of cardiac surgery. Participants were patients with ACS undergoing isolated CABG from the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) registry between January and September 2015.Exposures: Before surgery, patients received ticagrelor with or without aspirin or aspirin alone.Main Outcomes and Measures: Severe bleeding as defined by the Universal Definition of Perioperative Bleeding (UDPB) and E-CABG bleeding classification criteria. A propensity score-matched analysis was performed to adjust for differences in baseline and operative covariates.Results: Of 2482 patients from the E-CABG registry, the study cohort included 786 (31.7%) consecutive patients with ACS (mean [SD] age, 67.1 [9.3] years; range, 32-88 years), and 132 (16.8%) were female. One-to-one propensity score matching provided 215 pairs, whose baseline and operative covariates had a standardized difference of less than 10%. Preoperative use of ticagrelor was associated with a similar risk of bleeding according to the UDPB and E-CABG bleeding classifications, but the incidence of platelet transfusion was higher in the ticagrelor group (13.5% [29 of 215] vs 6.0% [13 of 215]). Compared with those receiving aspirin alone, continuing ticagrelor up to the time of surgery or discontinuing its use less than 2 days before surgery was associated with a higher risk of platelet transfusion (22.7% [5 of 22] vs 6.4% [12 of 187]) and E-CABG bleeding grades 2 and 3 (18.2% [4 of 22] vs 5.9% [11 of 187]) and tended to have an increased risk of UDPB grades 3 and 4 (22.7% [5 of 22] vs 9.6% [18 of 187]). Among patients in whom antiplatelet drug use was discontinued at least 2 days before surgery, the incidence of platelet transfusion was 12.4% (24 of 193) in the ticagrelor group and 3.6% (1 of 28) in the aspirin-alone group.Conclusions and Relevance: In propensity score-matched analyses among patients with ACS undergoing CABG, the use of preoperative ticagrelor with or without aspirin compared with aspirin alone was associated with more platelet transfusion but similar degree of bleeding; in patients receiving ticagrelor 1 day before or up until surgery, there was an increased rate of severe bleeding.

International audience; Background We address the differential long-term results of tricuspid valve replacement and late valve-related events among bioprostheses versus mechanical prostheses. Methods In a single-institution investigation, we reviewed the patients’ prospectively collected data and performed a clinical follow-up. Both the Kaplan-Meier (actuarial) and the competing risks (actual) methodologies were used. Results Overall, 188 tricuspid valve replacements were performed during 1971 to 2012. In this complex population (reoperations, 48.1%; associated procedures in 71.3%), operative mortality was 27.6% (significantly declining in recent years). A bioprosthesis was used in 82.4%. Follow-up was 10.2 ± 9.1 years (as long as 37.3 years, or 1,270 patient-years; 91.2% complete). At 15 years, freedom from structural valve deterioration was 93.3% ± 6.4% (competing risks 94.7 ± 5.1%) in the mechanical group and 85.2% ± 5.4% (competing risks 92% ± 2.9%) in the bioprostheses group (p = 0.19). Freedom from any valve-related adverse events was lower among mechanical valves versus bioprostheses (although not statistically significant). Mechanical valves showed significantly lower freedom from thromboembolic events (actuarial 62.3% ± 14.3% versus 97.7% ± 1.6%; competing risks 74.1% ± 10% versus 98% ± 1.4%; p < 0.001) and earlier adverse events (4.9 ± 4.5 versus 11.1 ± 9.4 years) than bioprostheses. There were 11 reoperations for bioprosthetic structural valve deterioration (89.8% and 94.3% actuarial and actual freedom, respectively). Conclusions Bioprostheses for tricuspid valve replacement have a very good long-term durability. Mechanical valves display earlier and more severe morbidity at follow-up

Referred to by : Joseph M. Bednarczyk, Rohit K. SingalFunctional outcomes after resuscitative extracorporeal membrane oxygenation for cardiac arrest: The patients speak for themselvesThe Journal of Thoracic and Cardiovascular Surgery, Volume 150, Issue 4, October 2015, Pages 955-956; International audience; OBJECTIVES: Extracorporeal life support (ECLS) is an emerging option to treat selected patients with cardiac arrest refractory to cardiopulmonary resuscitation (CPR). Our primary objective was to determine the mortality at 30 days and at hospital discharge among adult patients receiving veno-arterial ECLS for refractory cardiac arrest. Our secondary objectives were to determine the 1-year survival and the health-related quality of life, and to examine factors associated with 30-day mortality. METHODS: In a retrospective, single-center investigation within a tertiary referral center, we analyzed the prospectively collected data of 49 patients rescued from refractory cardiac arrest through emergent implantation of ECLS (E-CPR) (18.1% of our overall ECLS activity, 2005-2013), implanted in-hospital and during ongoing external cardiac massage in all cases. A prospective follow-up with administration of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) questionnaire was performed. RESULTS: The mean age was 47.6 ± 1.6 years; out-of-hospital cardiac arrest occurred in 12% of cases; average low-flow time was 47.2 ± 33 minutes; causes of cardiac arrest were heart disease (61.2%), trauma (14.3%), respiratory disease (4.1%), sepsis (2%), and miscellaneous (18.4%). PRIMARY OBJECTIVE: Rates of survival at E-CPR explantation and at 30 days were 42.9% and 36.7%, respectively; brain death occurred in 24.5% of cases. SECONDARY OBJECTIVES: Increased simplified acute physiology score; higher serum lactate levels and lower body temperature at the time of implantation were associated with 30-day mortality. Bridge to heart transplantation or implantation of a long-term ventricular assist device was performed in 8.2%. No deaths occurred during the follow-up after discharge (36.7% survival; average follow-up was 15.6 ± 19.2 months). The average Physical Component Summary and Mental Component Summary scores (SF-36 questionnaire) were, respectively, 45.2 ± 6.8 and 48.3 ± 7.7 among survivors. CONCLUSIONS: Extracorporeal cardiopulmonary resuscitation is a viable treatment for selected patients with cardiac arrest refractory to CPR. In our series, approximately one third of rescued patients were alive at 6 months and presented quality-of-life scores comparable to those previously observed in patients treated with ECLS

Adult respiratory distress syndrome (ARDS) may pose specific challenges in pregnant women, including the need for prone decubitus ventilation and extracorporeal membrane oxygenation (ECMO). We present our experience with ECMO during pregnancy and review the literature on this topic.We performed a systematic literature review using the MEDLINE-NIH database. Papers describing single cases or clinical series of pregnant women treated with veno-venous ECMO for ARDS were retrieved; the clinical features and maternal and infant outcomes were presented in aggregate form.We describe the case of a 32-year-old primigravida who received ECMO starting at the 28th gestation week due to A/H1N1 influenza-related ARDS. This strategy allowed saving both mother and child; normal recovery without sequelae was evident at one year. The systematic review included 29 reported cases of ECMO employment during pregnancy; A/H1N1 influenza was the etiology of ARDS in 79% of cases. Maternal and infant mortality may reach 28%, while the rate of complications during ECMO support reaches 57%.ECMO is a viable treatment for severe ARDS during pregnancy, after failure of other therapeutic strategies; the risk of spontaneous gynecological bleeding is limited. Issues remain about the timing of ECMO implantation and the management of gestation. Close fetal assessment and multidisciplinary discussion are pivotal for decision-making.

Background We describe a 1-step treatment of extensive arch and descending aortic aneurysm by combination of frozen elephant trunk (FET) (hybrid endoprosthesis) and of conventional endoprosthesis deployment. Methods In a single-center, prospective, treatment-only study, the clinical data of 4 patients receiving combined FET and distal endoprosthesis deployment in the descending aorta were prospectively collected. Thoracic endoprostheses were deployed either retrogradely (off-pump from the femoral arterial access) or antegradely (from the aortic arch during hypothermic arrest). A distal-first approach was used (“trombone” mechanism). Spinal cord protection was achieved by transposition of the left subclavian artery to the left common carotid artery and selective antegrade cerebral perfusion. Preoperative computed tomography scan was performed to identify the collateral circulation. Preoperative planning was assisted by a sizing software (Endosize, Therenva Inc.). Results The aortic coverage was extended down to the orifice of the celiac trunk in one case and to the T8 level in the remainders. There was no operative mortality, 1 transient paraparesis, and 1 case of renal insufficiency. Follow-up results were satisfying (no device migration, no endoleak, no endotension, and no late neurologic complications). Conclusions The present strategy may abolish the risks connected with the waiting time between the surgical first step and the later completion (aortic-related adverse events and drop-out) and deserves further investigations to determine its safety and feasibility profile.

International audience; Background - Operative risk prediction systems (logistic EuroSCORE I, EuroSCORE II and STS Score) are employed together with multidisciplinary discussion to contraindicate conventional surgery in patients with valvular heart disease and propose the employment of alternative transcatheter procedures. The EuroSCORE I has been reported to underperform in these circumstances; we hypothesize that the EuroSCORE II is best suited for the stratification of risk in patients with structural deterioration (SVD) of valvular bioprostheses and potential candidates to the Valve-in-Valve procedure (deployment of a transcatheter valve within a failing valvular bioprosthesis). Methods and evaluation of the hypothesis - A multi-institutional collaboration is required to fully address such hypothesis. Therefore, we performed a preliminary validation study by retrieval of the complete records of 81 patients undergoing reoperative aortic valve replacement for preoperative diagnosis of bioprosthetic SVD at our Institution. Logistic EuroSCORE I, EuroSCORE II and STS Score were calculated by preoperatively available data. Faced to an observed reoperative mortality of 4.9%, average EuroSCORE I was 15.8%±13.4, EuroSCORE II was 7.3%±7.4 and the STS Score was 15%±9.8. The three systems provided sufficient adequacy (Hosmer-Lemeshow p=0.847, p=0.999 and p=0.9948, respectively). Yet, the area under the ROC curve was significantly higher for the EuroSCORE II (0.9903) vs. the EuroSCORE I (0.8994) (p=0.044). The STS Score yielded an intermediate figure (0.9643). The odds ratios (logistic regression) were 1.079 for EuroSCORE I, 1.223 for the STS Score and 1.474 for EuroSCORE II. Conclusions - The three investigated algorithms showed reasonable calibration in the prediction of mortality for reoperative aortic valve replacement, but they evenly overestimated the observed mortality. The hypothesis that the EuroSCORE II is better suited for the selection of candidates to Valve-in-Valve implantation is worth of further multi-institutional investigations on the basis of our preliminary findings and due to the expanding role of transcatheter techniques.

OBJECTIVE Interest in aortic sutureless bioprostheses is growing. Here, we evaluate the feasibility of performing aortic sutureless valve replacement concomitant with mitral valve surgery using the 3f Enable prosthesis. METHODS Of the 198 3f Enable® valve implantation procedures carried out in our unit between March 2011 and October 2014, 15 were performed concomitant with mitral valve surgery (8 bioprosthetic replacements and 7 annuloplasties). RESULTS The mean age and logistic EuroSCORE were 76 ± 6 years and 10.2 ± 4.8, respectively. The procedural success rate of aortic sutureless valve implantation was 100%. Mean cross-clamping and cardiopulmonary bypass times were 113.9 ± 35 and 150- ± 43 min, respectively. No reclamping in response to a sutureless paravalvular leakage (PVL) was needed. One grade 1 leak was observed at the time of discharge. There was no perioperative mortality. Pacemaker implantation was required in 1 case (6.6%). Initial follow-up (median = 8 months, range 1-6) showed no new aortic PVL; mean and peak transprosthetic gradients and the orifice area were 11.1 ± 2.5 and 18.4 ± 4.9 mmHg and 1.7 ± 0.4 cm(2), respectively. One grade 2 and two grade 1 mitral valve leaks were detected following annuloplasty. CONCLUSIONS 3f Enable® sutureless valve implantation combined with mitral valve surgery appears feasible and the results presented here are encouraging. This procedure has the potential to simplify surgery in a cohort of high-risk patients for whom transcatheter aortic valve replacement is not an effective option. Larger studies should be conducted to confirm these observations.

Objective: The authors aimed to validate the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) classification of postoperative Complications in patients undergoing coronary artery bypass grafting (CABG).Design: Retrospective, observational study.Setting: University hospital.Participants: A total of 2,764 patients with severe coronary artery disease. Complete baseline, operative, and postoperative data were available for patients who underwent isolated CABG.Interventions: Isolated CABG.Measurements and Main Results: The E-CABG complication classification was used to stratify the severity and prognostic impact of adverse postoperative events. Primary outcome endpoints were 30-day, 90-day, and long-term all cause mortality. The secondary outcome endpoints was the length of intensive care unit stay. Both the E-CABG complication grades and additive score were predictive of 30-day (area under the receiver operating characteristics curve 0.866, 95% confidence interval [CI] 0.829-0.903; and 0.876; 95% CI 0.844-0.908, respectively) and 90-day (area under the receiver operating characteristics curve 0.850, 95% CI 0.812-0.887; and 0.863, 95% CI 0.829-0.897, respectively) all-cause mortality. The complication grades were independent predictors of increased mortality at actuarial (log-rank: p < 0.0001) and adjusted analysis (p < 0.0001; grade 1: hazard ratio [HR] 1.757, 95% CI 1.111-2.778; grade 2: HR 2.704, 95% CI 1.664-4.394; grade 3: HR 5.081, 95% CI 3.148-8.201). When patients who died within 30 days were excluded from the analysis, this grading method still was associated with late mortality (p < 0.0001). The grading method (p < 0.0001) and the additive score (rho, 0.514; p < 0.0001) were predictive of the length of intensive care unit stay.Conclusions: The E-CABG postoperative complication classification seems to be a promising tool for stratifying the severity and prognostic impact of postoperative complications in patients undergoing cardiac surgery. (C) 2016 Elsevier Inc. All rights reserved.

National audience; Points essentiels Les procédures de remplacement valvulaire aortique percutané (TAVI) doivent être proposées à des patients porteurs d’un rétrécissement aortique serré symptomatique présentant une contre-indication au remplacement valvulaire chirurgical ou ayant un risque opératoire jugé élevé en réunion de concertation pluridisciplinaire. On note une diminution de l’EuroSCORE moyen depuis janvier 2010, diminution qui traduit déjà une évolution progressive dans la sélection des patients. S’agissant d’une population âgée (moyenne d’âge : 83,4 ± 7,3 ans), l’expertise des gérontologues peut être importante et l’évaluation de la « fragilité » fait partie du bilan. La voie fémorale est utilisée dans 80 % des cas avec un taux de succès procédural supérieur à 95 %. Le taux de mortalité hospitalière est de 5,9 %. Les complications sont essentiellement représentées par le risque de rupture d’anneau (0,9 % dans FRANCE TAVI), le risque de tamponnade (2,3 %), le risque d’accident vasculaire cérébral (2,2 %), le risque de fuite péri-prothétique importante (1,2 %), le risque d’implantation de pacemaker (14,4 %). Les résultats attendus de la cohorte A de PARTNER II et de SURTAVI pourront conduire à élargir les indications à des patients à moindre risque s’il est montré que le TAVI fait aussi bien que la chirurgie dans cette population ce que le récent essai randomisé NOTION suggère alors que le CoreValve Pivotal Trial va même dans le sens d’une possible supériorité de la technique percutanée. Key points Transcatheter aortic valve implantation (TAVI) is indicated in patients with severe symptomatic aortic stenosis who are not suitable for surgery or should be considered when there is a high surgical risk as assessed by a heart team. There is a decrease in mean logistic EuroSCORE since January 2010, which translates a gradual evolution in patients’ selection. Expertise of geriatricians to further assess frailty is a key step in the risk stratification process of this elderly population (mean age: 83.4 ± 7.3 years). Femoral access is used in 80% of cases with a procedural success rate higher than 95%. In-hospital mortality rate is 5.9%. The main complications of the procedure are aortic annulus rupture (0.9% in FRANCE TAVI), tamponade (2.3%), stroke (2.2%), severe paravalvular leak (1.3%) and permanent pacemaker implantation (15%). The awaited results of PARTNER II and SURTAVI may lead to expand the indications to lower-risk patients if it is shown that TAVI is non-inferior to surgery in this population which has been suggested by the recent randomized NOTION Trial while the CoreValve Pivotal Trial even points in the direction of a possible superiority of the percutaneous technique over surgery

International audience; BACKGROUND: Clinical evidence in coronary surgery is usually derived from retrospective, single institutional series. This may introduce significant biases in the analysis of critical issues in the treatment of these patients. In order to avoid such methodological limitations, we planned a European multicenter, prospective study on coronary artery bypass grafting, the E-CABG registry. DESIGN: The E-CABG registry is a multicenter study and its data are prospectively collected from 13 centers of cardiac surgery in university and community hospitals located in six European countries (England, Italy, Finland, France, Germany, Sweden). Data on major and minor immediate postoperative adverse events will be collected. Data on late all-cause mortality, stroke, myocardial infarction and repeat revascularization will be collected during a 10-year follow-up period. These investigators provided a score from 0 to 10 for any major postoperative adverse events and their rounded medians were used to stratify the severity of these complications in four grades. The sum of these scores for each complication/intervention occurring after coronary artery bypass grafting will be used as an additive score for further stratification of the prognostic importance of these events. DISCUSSION: The E-CABG registry is expected to provide valuable data for identification of risk factors and treatment strategies associated with suboptimal outcome. These information may improve the safety and durability of coronary artery bypass grafting. The proposed classification of postoperative complications may become a valuable research tool to stratify the impact of such complications on the outcome of these patients and evaluate the burden of resources needed for their treatment. CLINICAL TRIALS NUMBER: NCT02319083

Extension to the right heart chambers can cause valve obstruction, leading to cardiac insufficiency and death. Magnetic resonance and computed tomographic angiography are the most sensitive methods to diagnose this pathology and to enable planning of the most appropriate therapeutic strategy. Treatment consists in a total hysterectomy and bilateral salpingo-oophorectomy, along with removal of as much of the extrauterine tumor as possible. Recurrence can result from incomplete excision and may necessitate further surgical treatment. Because of the presence of estrogen receptors, antiestrogens such as tamoxifen may be given when the tumor is unresectable or to control for incomplete resection or recurrence of the tumor.

International audience; The visualization of bioprosthesis leaflet morphology might help to better understand the underlying mechanism of dysfunction in degenerated aortic bioprosthesis. Because today such visualization of bioprosthesis leaflet morphology is intricate to impossible with other imaging techniques, we hypothesized that the processing of multi-detector CT images would allow better visualization of the prosthetic valve leaflets after biological aortic valve replacement. The purpose of our study was to prospectively evaluate patients with a degenerated aortic bioprosthesis, waiting for reoperation, by using 64-slice CT to evaluate prosthetic leaflets morphology. A semi-automatic segmentation of pre-operative tomodensitometric images was conducted, using 2 different implementations of the region growing algorithm. Here we report all segmentation steps (selection of the region of interest, filtering, segmentation). Studied degenerated aortic bioprostheses were represented by two Carpentier-Edwards Supra Annular Valve (porcine leaflets), one Edwards Perimount (pericardial leaflets) and one Medtronic Mosaic (porcine leaflets). Both segmentation methods (Isotropic Region Growing and Stick Region Growing) allowed a semi-automatic segmentation with 3D reconstruction of all bioprosthetic components (stent, leaflets, degeneration/calcifications). Explanted bioprosthesis CT images were also processed and used as reference. Segmentation results were compared by means of quantitative criteria. Semi-automatic segmentation using region growing algorithm seems to provide an interesting approach for the morphological characterization of degenerated aortic bioprostheses. We believe that in the next future CT scan images segmentation may play an important role to better understand the mechanism of dysfunction in failing aortic bioprostheses. Moreover, bioprostheses 3D reconstructions could be integrated into preoperative planning tools to optimize valve-in-valve procedure.

Ascending aortic pseudoaneurysm following prior cardiac or aortic surgery is a rare entity that requires reoperation. Surgical repair is a complex procedure associated with high operative mortality. We report the case of a 76-year-old male patient with an ascending aortic pseudoaneurysm developing from distal anastomosis of a Dacron aorto-aortic prosthesis. This high-risk patient had previously undergone multiple cardiovascular operations and was treated by performing an extra-anatomic bypass between the descending thoracic aorta and supra-aortic vessels, followed by endovascular stent graft placement, avoiding median re-sternotomy.

Acute pulmonary embolism is the third most common cardiovascular disease in Italy with approximately 65 000 new cases a year. Appropriate medical therapy does not necessarily prevent evolution of acute pulmonary embolism into chronic thromboembolic pulmonary hypertension (CTEPH), which occurs in 0.1-4.0% of cases. In our country, there are approximately up to 2600 new CTEPH patients a year. CTEPH is a progressive and potentially lethal disease. Medical therapy is palliative and only surgery can modify its natural history. Pulmonary endarterectomy (PEA) is the treatment of choice and lung transplantation should be considered only when PEA is contraindicated. Currently, nearly 4000 PEAs have been performed worldwide. Approximately ten centers are able to carry out this intervention with excellent and permanent results. Solid experience and close multidisciplinary collaboration allow appropriate patient selection, rigorous surgical technique, and adequate postoperative management. All these aspects represent the key to the success in the treatment of CTEPH. After PEA, quality and expected length of life are similar to the age-matched general population and the only therapy required is oral anticoagulation.

ObjectiveWe addressed the long-term results of the Medtronic Mosaic porcine prosthesis in the aortic position.MethodsFrom 1994 to 2004, 1007 Mosaic valves were used for aortic valve replacement. The data were prospectively collected, retrospectively analyzed, and stratified according to patient age at surgery (group 1, 80 years), using both actual (cumulative risks) and actuarial methods.ResultsOperative mortality was 5% (valve related in 14%). Globally, 8122.17 patient-years were available (average follow-up, 8.5 ± 3.9 years; 99.8% complete). Overall, survival at 15 years was lower among the elderly strata (P

BackgroundFew data are currently available about patients characteristics and procedural features associated with AKI after TAVI using the new recommended VARC definition.Methods99 patients underwent TAVI (1 procedural death, 78.8% transfemoral, 12.1% trans-apical/aortic and 9.1% subclavian access) between February 2009 and September 2011 at Rennes university hospital. Creatinine level was assessed daily at least up to 72 hours after TAVI. Patients’ characteristics, procedural features and outcomes according to VARC definitions were studied to evaluate determinants and prognostic impact of AKI.ResultsAKI occurred in 22 patients (22.2%). Among them, 5 were AKI 2 (5.1%), 8 were AKI 3 (9.1%) including 4 who needed dialysis (4%). At baseline, compared to no AKI or AKI 1, AKI 2 or 3 patients had a higher prevalence of moderate or severe chronic kidney disease (p=0.046) and ≥ grade 2 mitral regurgitation (p=0.03). During the post TAVI hospitalization, AKI 2 or 3 was associated to a higher rate of death from any cause (p=0.0009), major bleeding, acute heart failure (both p=0.002), infectious complications (p=0.0008) and longer total and ICU hospitalization duration (p=0.0004 and