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The aim of this study was to establish the relationship between the occurrence of a surgical site infection (SSI) and the presence of a central venous catheter-related infection (CVCRI). The Department of Thoracic and Cardiovascular Surgery, University Hospital, Rouen, has carried out a prospective epidemiological survey of all nosocomial infections (pneumonia, SSI and CVCRI) since 1997. The study group included all consecutive patients who underwent cardiac surgery over a 10-year period from 1997 to 2007. A nested case-control study was conducted to identify the risk factors for SSI after CVCRI. Cases were patients with SSI after CVCRI and controls were randomized from patients who presented with CVCRI not followed by SSI. In total, 7557 patients were included and 133 SSIs (1.7%) were identified. The rate of superficial SSI was 0.7% [95% confidence interval (CI): 0.5-0.9] and of mediastinitis was 1.0% (95% CI: 0.8-1.2). Among the 133 cases of SSI, 12 (9.0%; 95% CI: 5.0-14.8) occurred after a CVCRI with identical micro-organisms. CVCRI [adjusted odds ratio (aOR): 5.2; 95% CI: 3.2-8.5], coronary artery bypass grafting (aOR: 2.9; 95% CI: 1.6-5.2), and obesity (aOR: 11.4; 95% CI: 1.0-130.1) were independent factors associated with SSI. The new finding of this study is that patients with CVCRI were 5.2 times more likely to develop SSI compared to patients without CVCRI. [ABSTRACT FROM AUTHOR]

The patient, who had undergone a complete cure of a tetralogy of Fallot 25 years previously, was discovered to have an ascending aorta aneurysm on echography. Bentall's procedure was carried-out, using a modified indirect coronary artery transplantation based on the Cabrol technique. As reported in the literature complications are mainly right sided and less frequently occur on the left side in this disease. Including the hypothesis of the overload volume which may provoke aortic root dilation, there is also an intrinsic pathology of the media which could often be related to embryogenesis abnormalities, i.e., abnormal migration of cardiac neural crest cells which may explain this condition. [ABSTRACT FROM AUTHOR]

Background: Older age and the use of bilateral internal thoracic artery (ITA) grafting are both considered risk factors for surgical wound infection (SWI) after coronary artery bypass grafting (CABG). The 2014 European Guidelines recommend that bilateral ITA grafting should be considered in patients aged younger than 70 years. Our aim was to investigate interaction between age and the number of ITA grafts., Methods: All patients aged 18 years and older who had undergone CABG with at least 1 ITA at Rouen University Hospital between 2001 and 2012 were selected. Data regarding surgical procedure (single/bilateral ITA grafting) were extracted from the medical information system. SWI was identified from prospective surveillance of patients according to Centers for Disease Control and Prevention criteria. Independent factors associated with SWI were assessed by logistic regression, and an interaction test between age (≤69 or ≥70 years) and the number of ITA grafts was performed., Results: SWI occurred in 71 of 2,726 patients (2.6%). Bilateral ITA grafting was associated with SWI (adjusted odds ratio [aOR], 2.55; 95% confidence interval, 1.51 to 4.30). After fitting an interaction term between age and number of ITA grafts, the aORs for SWI after bilateral ITA grafting substantially differed between patients aged 69 years and younger (aOR, 1.88; 95% confidence interval, 0.94 to 3.75) and 70 years and older (aOR, 3.52; 95% confidence interval, 1.69 to 7.33). However, this interaction failed to reach statistical significance (p = 0.2213), possibly because of insufficient statistical power (23.5%) despite the large sample size., Conclusions: Age 70 years and older compared with age 69 years and younger was associated with higher occurrence of SWI after bilateral ITA grafting, but this interaction was not statistically significant. Larger studies are needed to test this interaction., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Left ventricular assist devices (LVADs) are used as a bridge to heart transplantation. During the preimplantation or pretransplantation screening, malignant tumours can be discovered. Owing to the lack of guidelines, the management is difficult. We describe our perioperative approach and the patients' outcomes., Methods: Between 2006 and 2014, 55 patients underwent implantation of HeartMate II LVAD. Five were diagnosed with malignant tumours: 2 renal, 2 lung and 1 breast tumours. The renal tumours were diagnosed during the preimplantation screening. An LVAD was implanted in both followed by partial nephrectomies 8 and 9 months later. The lung cancers were diagnosed after device implantation, a left pulmonary segmentectomy and a right upper sleeve lobectomy were performed. The breast cancer was diagnosed few months after support and a tumourectomy with lymphadenectomy was performed., Results: Tumour resection was performed successfully in all patients. Prior to surgery haemostasis, device and heart function were evaluated. During surgery, haemodynamics and anticoagulation were monitored. Reoperations were necessary to evacuate haemothorax after lobectomy and an abdominal haematoma post-nephrectomy. After discussion with oncologists, 3 patients were relisted for heart transplantation. Two were successfully transplanted 2 and 3 years after partial nephrectomy with an actual survival of 56 and 59 months after the cancer diagnosis. The follow-up revealed no cancer recurrences., Conclusions: Malignant tumours during support with LVAD can be successfully resected. A multidisciplinary evaluation in these high-risk patients is mandatory. After careful evaluation, regaining the patient's heart transplant candidacy is possible., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: The study objective was to compare the 30-day outcomes of a standardized aortic valve repair technique (REPAIR group) associating root remodeling with an expansible aortic ring annuloplasty versus mechanical composite valve and graft (CVG group) replacement in treating aortic root aneurysms., Methods: A total of 261 consecutive patients with aortic root aneurysm were enrolled in this multicentric prospective cohort (131 in the CVG group, 130 in the REPAIR group) in 20 centers. The main end point is a composite criterion including mortality; reoperation; thromboembolic, hemorrhagic, or infectious events; and heart failure. Secondary end points were major adverse valve-related events. Crude and propensity score adjusted estimates are provided., Results: The mean age was 56.1 years, and the valve was bicuspid in 115 patients (44.7%). The median (interquartile range) preoperative aortic insufficiency grade was 2.0 (1.0-3.0) in the REPAIR group and 3.0 (2.0-3.0) in the CVG group (P = .0002). Thirty-day mortality was 3.8% (n = 5) in both groups (P = 1.00). Despite a learning curve and longer crossclamp times for valve repair (147.7 vs 99.8 minutes, P < .0001), the 2 groups did not differ significantly for the main criterion (odds ratio, 1.31; 95% confidence interval, 0.72-2.40; P = .38) or 30-day mortality (odds ratio, 0.99; 95% confidence interval, 0.28-3053; P = .99), with a trend toward more frequent major adverse valve-related events in the CVG group (odds ratio, 2.52; 95% confidence interval, 0.86-7.40; P = .09). At discharge, 121 patients (96.8%) in the REPAIR group had grade 0 or 1 aortic insufficiency., Conclusions: A new standardized approach to valve repair, combining an expansible aortic annuloplasty ring with the remodeling technique, presented similar 30-day results to mechanical CVG with a trend toward reducing major adverse valve-related events. Analysis of late outcomes is in process for 3- and 10-year follow-ups., (Copyright © 2015. Published by Elsevier Inc.)

Objectives: Extracorporeal membrane oxygenation (ECMO) for respiratory support is increasingly used in intensive care units (ICU), but rarely during thoracic surgical procedures outside the transplantation setting. ECMO can be an alternative to cardiopulmonary bypass for major trachea-bronchial surgery and single-lung procedures without in-field ventilation. Our aim was to evaluate the intraoperative use of ECMO as respiratory support in thoracic surgery: benefits, indications and complications., Methods: This was a multicentre retrospective study (questionnaire) of use of ECMO as respiratory support during the thoracic surgical procedure. Lung transplantation and lung resection for tumour invading the great vessels and/or the left atrium were excluded, because they concern respiratory and circulatory support., Results: From March 2009 to September 2012, 17 of the 34 centres in France applied ECMO within veno-venous (VV) (n=20) or veno-arterial (VA) (n=16) indications in 36 patients. Ten VA ECMO were performed with peripheral cannulation and 6 with central cannulation; all VV ECMO were achieved through peripheral cannulation. Group 1 (total respiratory support) was composed of 28 patients without mechanical ventilation, involving 23 tracheo-bronchial and 5 single-lung procedures. Group 2 (partial respiratory support) was made up of 5 patients with respiratory insufficiency. Group 3 was made up of 3 patients who underwent thoracic surgery in a setting of acute respiratory distress syndrome (ARDS) with preoperative ECMO. Mortality at 30 days in Groups 1, 2 and 3 was 7, 40 and 67%, respectively (P<0.05). In Group 1, ECMO was weaned intraoperatively or within 24 h in 75% of patients. In Group 2, ECMO was weaned in ICU over several days. In Group 1, 2 patients with VA support were converted to VV support for chronic respiratory indications. Bleeding was the major complication with 17% of patients requiring return to theatre for haemostasis. There were two cannulation-related complications (6%)., Conclusions: VV or VA ECMO is a satisfactory alternative to in-field ventilation in complex tracheo-bronchial surgery or in single-lung surgery. ECMO should be considered and used in precarious postoperative respiratory conditions. Full respiratory support can be achieved with VV ECMO. Indications for and results of ECMO during surgery in patients with ARDS warrant further careful investigation., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Dual antiplatelet therapy is commonly used in patients undergoing transcatheter aortic valve implantation (TAVI), but the optimal antiplatelet regimen is uncertain and remains to be determined. The objective of this study was to compare 2 strategies of antiplatelet therapy in patients undergoing TAVI. A strategy using monoantiplatelet therapy (group A, n = 164) was prospectively compared with a strategy using dual antiplatelet therapy (group B, n = 128) in 292 consecutive patients undergoing TAVI. The primary end point was a combination of mortality, major stroke, life-threatening bleeding (LTB), myocardial infarction, and major vascular complications at 30 days. All adverse events were adjudicated according to the Valve Academic Research Consortium. The primary end point occurred in 22 patients (13.4%) in the group A and in 30 patients (23.4%) in the group B (hazard ratio 0.51, 95% confidence interval 0.28 to 0.94, p = 0.026). LTB (3.7% vs 12.5%, p = 0.005) and major bleedings (2.4% vs 13.3%, p <0.0001) occurred less frequently in the group A, whereas the incidence of stroke (1.2% vs 4.7%, p = 0.14) and myocardial infarction (1.2% vs 0.8%, p = 1.0) was not significantly different between the 2 groups. The benefit of a strategy using mono versus dual antiplatelet therapy persisted after multivariate adjustment and propensity score analysis (hazard ratio 0.53, 95% confidence interval 0.28 to 0.95, p = 0.033). In conclusion, a strategy using mono versus dual antiplatelet therapy in patients undergoing TAVI reduces LTB and major bleedings without increasing the risk of stroke and myocardial infarction. The results of our study question the justification of dual antiplatelet therapy and require confirmation in a randomized trial., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objectives: The Ross procedure has received increasing interest as an attractive alternative to a prosthetic aortic valve. Given its presumably greater resistance to infection, the pulmonary autograft is theoretically preferable for active endocarditis. The objective of this retrospective study was to present our experience in aortic valve endocarditis treated using the Ross procedure., Methods: Between May 1997 and February 2011, the Ross procedure was performed on 142 patients in our institution. Twenty-eight patients had aortic valve endocarditis at the time of operation. Fourteen patients had urgent or emergency procedures, and 13 had active disease at the time of surgery. Twelve patients were alcoholics and/or drug addicts. Eight patients had an abscess of the aortic annulus. Clinical follow-up was complete., Results: Hospital mortality was 10.7%. Overall patient survival (± standard deviation) was 47 ± 13% at 10 years with no cardiac-related death during the mean follow-up of 6.4 ± 4.2 years. There were 3 cases of recurrent endocarditis including anterior mitral leaflets endocarditis and right-sided endocarditis to another germ in a drug addict. Four patients required further surgery, 2 on the pulmonary autograft; 18 of the 19 survivors were in New York Heart Association class I. At the final investigation, all patients had no or grade I autograft regurgitation. The mean pressure gradient across the homograft was 9 ± 7.5, 11 ± 9.5 and 15 ± 9.5 mmHg, respectively, for patients between 0-3, 4-9 and >9 years., Conclusions: Endocarditis can be treated with good results using the Ross procedure, with a very low rate of recurrence of endocarditis.

Objectives: We report our 5-year experience of continuous flow left ventricular assist device (LVAD) implantation without the use of anti-platelet therapy., Methods: Between February 2006 and September 2011, 27 patients (26 men; 1 woman) were implanted with a continuous flow LVAD (HeartMate II, Thoratec Corporation, Pleasanton, CA, USA). The mean age was 55.7 ± 9.9 years. The mean duration of support was 479 ± 436 (1-1555) days with 35.4 patient-years on support. Twenty-one patients were implanted as a bridge to transplantation and 6 for destination therapy. The anticoagulation regimen was fluindione for all patients, with aspirin for only 4 patients. At the beginning of our experience, aspirin was administered to 4 patients for 6, 15, 60 and 460 days. Due to gastrointestinal (GI) bleeding and epistaxis, aspirin was discontinued, and since August 2006, no patients have received anti-platelet therapy., Results: At 3 years, the survival rate during support was 76%. The most common postoperative adverse event was GI bleeding (19%) and epistaxis (30%) (median time: 26 days) for patients receiving fluindione and aspirin. The mean International Normalized Ratio (INR) was 2.58 ± 0.74 during support. Fifteen patients have been tested for acquired Von Willebrand disease. A diminished ratio of collagen-binding capacity and ristocetin cofactor activity to Von Willebrand factor antigen was observed in 7 patients. In the postoperative period, 2 patients presented with ischaemic stroke at 1 and 8 months. One of these 2 patients had a previous history of carotid stenosis with ischaemic stroke. There were no patients with haemorrhagic stroke, transient ischaemic attack or pump thrombosis. The event rate of stroke (ischaemic and haemorrhagic) per patient-year was 0.059 among the patients without aspirin with fluindione regimen only., Conclusions: A fluindione regimen without aspirin in long-duration LVAD support appears to not increase thromboembolic events and could lead to a diminished risk of haemorrhagic stroke.

Tako-tsubo syndrome is a rare cardiomyopathy secondary to catecholamine toxicity responsible of myocardial stunning. Severe complications such as cardiogenic shock or ventricular arrhythmia can occur. We presented the case of a 32-year-old woman victim of a tako-tsubo syndrome with severe cardiogenic shock during surgical procedure for urgent caesarean section. After refractory haemodynamic failure, the patient benefits from extracorporeal membrane oxygenation support device with success., (Copyright © 2013 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

Background: Only 50% of patients with aortic stenosis (AS) and low ejection fraction (EF) improve their contractility after surgical aortic valve replacement (AVR). Long-term prognosis of these patients is strongly correlated to EF recovery after the surgery. The aim of this study was to compare the postoperative left ventricular function recovery in patients with severe AS and reduced EF after AVR and transcatheter aortic valve implantation (TAVI)., Methods and Results: Twenty-one patients undergoing AVR for severe AS (<1 cm²) and reduced EF (<45%) were echocardiographically compared with 31 patients treated with TAVI by conventional and two-dimensional (2D) strain method. TAVI patients were older (83 ± 6 vs. 74 ± 13 years, P < 0.001), had more comorbidities (Euroscore 26 ± 15% vs. 16 ± 12%, P < 0.001) and no differences in ischemic heart disease (16.1% vs. 9.5%, P = 0.39). EF was similar in both groups at baseline. Aortic valve area significantly increased (P = 0.01) while pressure gradient decreased (P = 0.009) after both procedures but TAVI was associated with a better EF recovery compared with AVR at day 7. Regional function assessed by radial 2D strain increased in TAVI group but was transiently deteriorated in AVR patients (P < 0.05). Longitudinal as well as circumferential 2D strain progressively increased at follow-up in both groups (P < 0.05). EF was similar in both groups at 3-month follow-up., Conclusion: In patients with severe AS and reduced EF, TAVI is associated with faster and better recovery of LV function compared with AVR., (© 2013, Wiley Periodicals, Inc.)

Objectives: To evaluate the incidence, predictors and impact of bleeding after transcatheter aortic valve implantation (TAVI)., Design: Single-centre prospective observational study., Setting: Charles Nicolle University Hospital, Rouen, France., Interventions: We included 250 consecutive patients who underwent TAVI between May 2006 and October 2011. All procedures were performed using Edwards SAPIEN and SAPIEN XT valves via transfemoral (TF) and transapical (TA) routes. Surgical cutdown was used for TF access when implanting the SAPIEN valve, while percutaneous access was used for SAPIEN XT implantation. Life-threatening bleeding (LTB), major and minor bleeding and other complications were defined using Valve Academic Research Consortium criteria., Results: TAVI was performed via TF access in 190 cases (76%) and the SAPIEN XT valve was used in 123 cases (49.2%). Bleeding after TAVI was noted in 68 patients (27.2%): LTB in 33 (13.2%), major bleeding in 23 (9.2%) and minor bleeding in 12 (4.8%). By multivariate analysis, only TA access was an independent predictor of LTB (OR 3.7, 95% CI 1.73 to 7.9, p = 0.001). Patients presenting with LTB after TAVI had a higher 30-day mortality (33.3% vs 3.7%, p < 0.001) and 1-year mortality (54% vs 18%, p < 0.001). LTB was an independent predictive factor of 1-year mortality (HR 2.54, 95% CI 1.3 to 4.9, p = 0.002)., Conclusions: Bleeding is a frequent complication of TAVI, occurring in 27% of cases. LTB is associated with higher 30-day and 1-year mortality.

The original European System for Cardiac Operative Risk Evaluation (EuroSCORE) has been recently updated as EuroSCORE II to optimize its efficacy in cardiac surgery, but its performance has been poorly evaluated for predicting 30-day mortality in patients who undergo transcatheter aortic valve replacement (TAVR). Consecutive patients (n = 250) treated with TAVR were included in this analysis. Transapical access was used in 60 patients, while 190 procedures were performed using a transfemoral approach. Calibration (risk-adjusted mortality ratio) and discrimination (C-statistic and U-statistic) were calculated for the logistic EuroSCORE, EuroSCORE II, and Society of Thoracic Surgeons (STS) scores for predicting 30-day mortality. Observed mortality was 7.6% in the overall population (6.3% and 11.7% for the transfemoral and transapical cohorts, respectively). Predicted mortality was 22.6 ± 12.8% by logistic EuroSCORE, 7.7 ± 5.8% by EuroSCORE II, and 7.3 ± 4.1% by STS score. The risk-adjusted mortality ratio was 0.34 (95% confidence interval [CI] 0.10 to 0.58) for logistic EuroSCORE, 0.99 (95% CI 0.29 to 1.69) for EuroSCORE II, and 1.05 (95% CI 0.30 to 1.79) for STS score. Moderate discrimination was observed with EuroSCORE II (C-index 0.66, 95% CI 0.52 to 0.79, p = 0.02) compared to the logistic EuroSCORE (C-index 0.63, 95% CI 0.51 to 0.76, p = 0.06) and STS (C-index 0.58, 95% CI 0.43 to 0.73, p = 0.23) score, without a significant difference among the 3 risk scores. Discrimination was slightly better in the transfemoral cohort compared to the transapical cohort with the 3 risk scores. In conclusion, EuroSCORE II and the STS score are better calibrated than the logistic EuroSCORE but have moderate discrimination for predicting 30-day mortality after TAVR., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The aim of this work is to reflect on different teaching methods can be used in a surgical teaching and its assessment methods. TWO sessions of Multiple Choice Questions (MCQ) have been proposed, the first before all education, the second after education in order to assess its impact on knowledge. Script Concordance Test (SCT) will replace the traditional interactive case report. Eighteen participants (Group 1) completed both sessions of MCQ: 9 residents (R), 2 equivalent resident (ER), 4 Clinical Fellow (CF), 1 Professor (Pr) and 2 senior surgeons (SS). Sixteen participants (group 2) were present at the first session of MCQ: 6 R, 1 ER, 4 CF, 2 Pr, 2 SS and 1 indeterminate status. Finally, 12 participants (group 3) were present at the second session: 6 R, 1 ER, 1 CF, 1 SS and 3 indeterminate status. The results of"seniors" in Group 1 were higher than those of "juniors" at the first session. MCQ results for the second session were higher in the subgroup CF. A more marked progression in knowledge was observed in resident and Clinical Fellow. Finally, the score obtained by the group 3 was lower than in group 1. The format of the MCQ was particularly heterogeneous. The SCT will help to assess the capacity of decision making in a context of uncertainty (as unexpected surgery requiring quick decisions with immediate effect, surgical strategy in an unusual clinical situation). The different tools available would allow the establishment of an evaluation of teaching, but also to assess the development of thinking skills in situations of uncertainty. Their implementation will take place with the participation and support of the largest number of teachers in our specialty.

Objective: Cardiopulmonary bypass (CPB) is responsible for an inflammatory response that can lead to postoperative organ dysfunction. Undernutrition increases the risk of organ failure. We investigated the effect of undernutrition on the inflammatory response and mesenteric vascular reactivity induced by CPB in rats., Methods: CPB was performed in Wistar rats given normal nutrition or protein undernutrition. Mesenteric artery contractility was determined in the presence of increasing concentrations of phenylephrine with or without nitric oxide synthase blockade. Relaxation was assessed in the presence of acetylcholine or sodium nitroprusside. The inflammatory response was evaluated by the measurement of systemic tumor necrosis factor-α at cannulation and after 150 min and by a histologic study of pulmonary and gut leukocyte infiltration., Results: CPB and protein undernutrition induced hypercontractility to phenylephrine and early relaxation defects in the mesenteric arteries. CPB caused endothelial dysfunction with early impairment of endothelium-dependent relaxation. Protein undernutrition led to an impaired relaxation of the mesenteric arteries, which was in part endothelium independent. Concomitantly, a significant inflammatory response was observed., Conclusion: CPB and undernutrition induce mesenteric hypercontractility to α1-adrenergics and impair vascular relaxation, without any additive effect of CPB on undernutrition. Undernutrition causes inflammation and a lack of vascular relaxation, probably involving smooth muscle contractile mechanisms., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The aim of this study was to investigate the potential anti-inflammatory and endothelial protective properties of albumin during cardiopulmonary bypass (CPB) in an experimental porcine model. Two groups underwent CPB for 90 min (n = 7 in each group), and a baseline (BL) control group did not undergo CPB (n = 7). Priming consisted of a gelatin solution (4% gelofusine, CPBG group) or colloid solution (5% albumin, CPBA group). Mesenteric arterial segments were isolated and exposed in vitro to phenylephrine (with or without nitric oxide synthase inhibition) to assess contractility, and exposed to acetylcholine and sodium nitroprusside to assess relaxation. Plasma tumor necrosis factor (TNF)-α levels, intestinal and pulmonary TNF-α and heme oxygenase (HO)-1 mRNA expression, and organ injury were studied. Upon sacrifice, TNF-α levels were significantly higher in the CPBG group than in the CPBA and BL groups. The contractile response was significantly higher in the CPBG group, whereas the response to acetylcholine was significantly lower in the CPBG group than in the other groups. HO-1 mRNA expression was significantly higher in intestine samples in the CPBA group than in the CPBG and BL groups. HO-1 mRNA expression was significantly higher in lung samples in the CPBA group than in the CPBG group. Leukocyte infiltration was significantly higher in intestine and lung samples in the CPBG group than in the CPBA and BL groups. Albumin priming reduced CPB-induced mesenteric vascular dysfunction and prevented the development of a systemic inflammatory response by modeling HO-1 expression in target organs., (© 2012, Copyright the Authors. Artificial Organs © 2012, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Background: Diabetes is a risk factor for perioperative complications after cardiac surgery. We studied its effects on mesenteric endothelial function in a cardiopulmonary bypass (CPB) model., Methods: Forty Wistar rats were divided into four groups: sham (D-CPB-), cardiopulmonary bypass (D-CPB+), diabetic (D+CPB-) and diabetic that have undergone CPB (D+CPB+). Two samples of mesenteric artery were used for nitric oxide synthase (NOS) Western blot analysis, and two others for assessing contractile response and endothelium relaxations. Nitrite products and tumour necrosis factor-alpha (TNF-α) were assessed as markers of inflammatory response., Results: We observed an enhanced contractile response to the α-adrenergic agonist associated with impairment of mesenteric vasorelaxation in D+CPB+ rats. Western immunoblot analysis of D+CPB+ highlighted an additive effect of hyper-expression of inducible NOS. A significantly increased inflammatory response was observed after CPB in diabetic animals., Conclusions: This work confirms the potential deleterious impact of diabetes on the mesenteric endothelium during CPB in cardiac surgery.

The durability of a Starr-Edwards valve implanted in the tricuspid position in 1967 to treat Ebstein's disease with tricuspid valve regurgitation. At surgery, cardiac permanent pacing for postoperative complete atrioventricular block was achieved using a nuclear-powered pacemaker (NP). Although the 43rd year of cardiologic follow up was free from complications, the patient--a 74-year-old woman--suffered symptomatic mitral regurgitation and underwent a redo mitral valve replacement, during which the Starr-Edwards valve and NP were left in place.

Background: During aortic surgery, the long-term patency of reimplanted intercostal arteries is unknown, limiting the relevance to preserve spinal cord vascularization., Methods: Between January 2001 and January 2007, 40 patients were operated for either thoracic aortic aneurysm (TAA) or thoracoabdominal aortic aneurysm (TAAA). Twenty cases of aneurysms limited to the proximal descending thoracic aorta were treated using endovascular repair, without preoperative spinal cord artery identification. Twenty patients--seven with extensive TAA, seven with type I TAAA, two with type II TAAA, and four with type III TAAA--underwent open surgery. Before open surgery, preoperative angiography was performed to identify spinal cord vascularization; in one case, the angiography failed to identify it. The segmental artery destined to the spinal cord artery was identified as originating from outside the aneurysm in 7 patients and inside the aneurysm in 12 patients: T6 R (1), T8 L (2), T9 L (3), T10 L (3), T11 L (3), L1 L (1). During the surgery, normothermic and femorofemoral bypass was used for visceral protection. All segmental arteries identified as critical before surgery were reattached in the graft. Twenty-four months later, computed tomography scans were performed to assess the patency of the reattached segmental arteries., Results: Three patients died, including one with paraplegia (T9 L). No other cases of paraplegia were reported. Computed tomography scans were performed in 10 patients. Segmental artery reattachment was patent in nine patients., Conclusion: Our experience indicates the long-term patency of reimplanted segmental artery, without any convincing evidence of its utility in preventing neurologic events during TAA and TAAA direct repair., (Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

A good selection of patients is a crucial step before transcatheter aortic valve implantation (TAVI) in order to select the good indications and choose the access route. TAVI should be considered only in patients with symptomatic severe aortic stenosis and either contraindication or high surgical risk. Indication for TAVI should be discussed in a multidisciplinary team meeting. Echocardiography and/or CT scan are mandatory to evaluate the aortic annulus size and select the good prosthesis size. The possibility of transfemoral implantation is evaluated by angiography and CT scan, and based on the arterial diameters, but also on the presence of tortuosities and arterial calcifications., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Numerous cardiopulmonary bypass (CPB) models in the rat have already been described, but these models often have an important mortality and differ a lot from human clinical conditions thus making them hardly usable. The CPB model in the rat we describe allows a femoro-femoral support CPB with a low priming volume, minimal surgical approach and excellent peroperative survival. This CPB model in the rat allows evaluating extracorporeal circulation effects.

Objectives: The authors report the feasibility and 30-day outcomes of transfemoral aortic valve replacement (TAVR), using the Edwards SAPIEN (Edwards Lifesciences, Irvine, California) and Edwards SAPIEN XT (Edwards Lifesciences) prosthesis, implanted using exclusively local anesthesia and fluoroscopic guidance., Background: Transfemoral TAVR is often managed with general anesthesia. However, a simplified percutaneous approach using local anesthesia has become more popular because it offers multiple advantages in an elderly and fragile population., Methods: Between May 2006 and January 2011, the authors prospectively evaluated 151 consecutive patients (logistic EuroSCORE: 22.8 ± 11.8%) who underwent TAVR (SAPIEN: n = 78, SAPIEN XT: n = 73) using only local anesthesia and fluoroscopic guidance. The primary endpoint was a combination of all-cause mortality, major stroke, life-threatening bleeding, stage 3 acute kidney injury (AKI), periprocedural myocardial infarction (MI), major vascular complication, and repeat procedure for valve-related dysfunction at 30 days., Results: Transarterial femoral approach was surgical in all SAPIEN procedures and percutaneous in 97.3% of SAPIEN XT, using the ProStar vascular closure device, and was well tolerated in all cases. Conversion to general anesthesia was required in 3.3% (SAPIEN cases) and was related to complications. Vasopressors were required in 5.5%. Procedural success was 95.4%. The combined-safety endpoint was reached in 15.9%, including overall mortality (6.6%), major stroke (2.0%), life-threatening bleeding (7.9%), stage 3 AKI (0.7%), periprocedural MI (1.3%), major vascular complication (7.9%), and repeat procedure for valve-related dysfunction (2.0%) at 30 days. A permanent pacemaker was required in 5.3%., Conclusions: This single-center, prospective registry demonstrated the feasibility and safety of a simplified transfemoral TAVR performed using only local anesthesia and fluoroscopic guidance in high surgical risk patients with severe aortic stenosis., (Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The first French transapical transcatheter aortic valve implantation (TAVI) was performed in July 2007 in our department., Aims: To report 4-year outcomes of transapical implantation with the Edwards transcatheter bioprosthesis., Methods: We prospectively evaluated consecutive patients who underwent transapical implantation with an Edwards transcatheter bioprosthesis between July 2007 and October 2011. Patients were not suitable for conventional surgery (due to severe comorbidities) or transfemoral implantation (due to poor femoral access)., Results: Among 61 patients (59.0% men), mean logistic EuroSCORE was 27.5 ± 14.9% and mean age was 81.0 ± 6.8 years. Successful valve implantation was achieved in 59/61 patients (96.7%) of patients. The other two patients required conversion to conventional surgery due to prosthesis embolization and died. Six additional patients died in the postoperative period. Causes of perioperative death were two septic shocks (one of peritonitis), two multi-organ failure, one ventricular fibrillation and one respiratory insufficiency. Intraprocedural stroke was not observed in any patient. The actuarial survival rates at 1, 2 and 4 years were 73.8%, 67.2% and 41.0%. During this 4-year period, four patients died of cardiovascular events, but no impairment of transprosthesis gradient was observed., Conclusion: Our series of 61 patients who underwent transapical implantation of the Edwards transcatheter bioprosthesis shows satisfactory results, similar to other reports, considering the high level of severity of patients referred for this method. Transapical access is a reliable alternative method for patients that cannot benefit from a transfemoral approach., (Copyright © 2012. Published by Elsevier Masson SAS.)

Background: A new generation of balloon-expandable valves (e.g. Edwards SAPIEN XT) enables the use of a decreased sheath size using the NovaFlex™ delivery system for transfemoral transcatheter aortic valve implantation (TAVI). However, there are few data analysing the efficacy and safety of this new prosthesis., Aims: To evaluate periprocedural and 30-day clinical outcomes using the Edwards SAPIEN XT compared with the first-generation Edwards SAPIEN prosthesis., Methods: Between May 2006 and October 2011, consecutive high-risk or non-operable patients with severe aortic stenosis had TAVI using an Edwards SAPIEN or SAPIEN XT prosthesis. Valve Academic Research Consortium endpoints were used., Results: Of 250 patients who underwent TAVI, 190 were performed transfemorally (78 SAPIEN and 112 SAPIEN XT). Transfemoral access was possible more often using SAPIEN XT (112/123 [91.1%] vs 78/127 [61.4%]; P<0.001). Mean logistic EuroSCORE was significantly lower in the SAPIEN XT group (18.1±11.0% vs 27.3±11.1%; P<0.0001), and the iliofemoral artery minimal lumen diameter was smaller (6.7±1.2 vs 8.5±1.3mm; P<0.0001). Device success was similar in both groups (95.5% for SAPIEN XT and 93.6% for SAPIEN), as was the 30-day combined safety endpoint (15.2% and 17.9%, respectively). At 30days, prosthesis performance was similar in both groups., Conclusions: Short-term safety and performance analysis of the latest generation of balloon-expandable valve, the SAPIEN XT, seem similar to the previous generation. However, transfemoral implantation is more often possible, related to sheath size reduction., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Currently, imaging assessment of patients who undergo transcatheter aortic valve implantation is based mainly on echocardiography and angiography, both limited to provide a 3-dimensional evaluation of the prosthesis within the native valve. This study involved 34 patients who underwent multislice computed tomography (MSCT) after transcatheter aortic valve implantation. Prosthesis expansion and circularity, depth of implantation, apposition degree at the ventriculoaortic junction, and positioning in relation to coronary artery ostia were evaluated. Early clinical events such as aortic regurgitation and periprocedural conduction abnormalities were recorded and correlated with multislice computed tomographic findings. MSCT provided comprehensive 3-dimensional assessments of the prostheses in 31 of 34 of patients (91%). Expansion was excellent (mean expansion ratio 100.0 ± 10.4%) and increased significantly from the ventricular side to the aortic side of the prosthesis. Circular deployment was achieved in most patients and increased from the ventricular to the aortic side. Mean implantation depth was -2.4 ± 2.5 mm, associated with a low rate (12%) of permanent pacemaker implantation. Patients with a new conduction abnormalities had the deepest prosthesis implantation, associated with lesser expansion and circularity. Perfect apposition on MSCT was associated with a low rate of significant aortic regurgitation. In conclusion, MSCT is able to provide an accurate 3-dimensional evaluation of prosthesis deployment and positioning after transcatheter aortic valve implantation. Moreover, these anatomic findings correlate with the most frequent early complications (i.e., the occurrence of aortic regurgitation and conduction abnormalities)., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Thoracoabdominal aortic aneurysms (TAAA) and extensive thoracic descending aortic aneurysms (TDA) are not accessible through standard endovascular treatment. Fenestrated and branched endograft technology was developed rapidly without widespread application. The aim of this study was to review our open repair (OR) experience of TAAA and TDA. A total of 28 patients who underwent elective OR of TAAA or TDA between January 2001 and January 2009 were analyzed retrospectively. The mean age of the patients was 65.5 years (three women). The anatomic locations of the aneurysms were as follows: six in thoracic descending aorta and 22 in thoracoabdominal aorta (14 TAAA I, two TAAA II, six TAAA III). TDA (40 patients) available for ordinary endovascular treatment and TAAA IV (35 patients) were excluded from this study. To focus on spinal cord vascularization, 25 patients were submitted for angiography. Three patients suffering from back pain required quick treatment and were excluded from angiographic investigations. Angiography procedures were contributive in 23 patients (92%). Surgical repairs were driven through left thoraco-phreno-laparotomy, with the adjunct of distal aortic perfusion (femorofemoral bypass) including the use of an oxygenator and sequential aortic cross-clamping. Cerebrospinal fluid drainage was not used in this experience. The 30-day mortality rate was 14.3% (four of 28 patients): one multiorgan failure and three pulmonary sepsis. An immediate postoperative paraplegia occurred, affecting a patient with TDA who was previously submitted for infrarenal aorta replacement, despite angiographic identification and revascularization of intercostal artery destined to spinal artery. The 1-year survival rate was 82.1% (23 of 28 patients). In the preliminary experience of this study, OR of extensive TAAA and TDA with distal aortic perfusion and an oxygenator without use of cerebrospinal fluid drainage was associated with a significant perioperative mortality rate (14.2%), a reasonable rate of paraplegia (3%), and 1-year survival rate of 82.1%., (Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Background: Transplant arteriosclerosis is characterized by intraluminal obstructive proliferation occurring in response to immune-mediated arterial wall injury. Cell therapy with vascular progenitor cells have been suggested to repair intimal lesions following endothelial injury. The aim of the current study was to assess the effects of autologous bone marrow cell direct transfer and of Fucan-mobilization bone marrow-derived progenitor cells on intimal thickening in vascular grafts., Methods: Aortic allografts were performed in Brown Norway (BN) and Lewis (LEW) rats. Cell therapy was performed by injection of two doses of 10 million LEW bone marrow mononuclear cells to recipient LEW following aortic grafting. Fucan, a low molecular weight sulfated polysaccharide (LMWF) was used to mobilize bone marrow-derived progenitor cells. Five groups of 10 rats included: untreated isografts (BN to BN), untreated allografts, and three allografted groups, respectively, treated by fucan therapy, cell therapy, or cell and fucan therapy. Aorta were studied by morphometric analysis at 30 d., Results: In the absence of treatment, intimal thickening was greater in allograft than in isograft groups (299±50 versus 3.5±1.7 μm, P<0.001). Cell therapy alone, fucan therapy alone, and the combined treatment were shown to prevent intimal thickening in allografts (5.1±1.7, 6.1±2.3, 4.1±2.5, versus 299±50 μm respectively, P<0.001). In the three treated groups, the intimal lining was a single layer of endothelial cells expressing CD34 positive, endothelial nitric oxide synthase (eNOS) positive, and Ox3 specific-recipient monoclonal antibody positive., Conclusion: These results provide the proof of concept of recipient syngenic bone-marrow cell therapy for the prevention of chronic vasculopathy., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Intraoperative aortic dissection is a rare but potentially fatal complication of cardiac surgery. In this report, we present a case of intraoperative aortic dissection that was complicated by intestinal ischaemia. The aorta was successfully repaired using both open and endovascular techniques., (© 2010 Wiley Periodicals, Inc.)

Objective: We suggest standardizing aortic valve repair using a physiologic approach by associating root remodeling with resuspension of the cusp effective height and external subvalvular aortic ring annuloplasty., Methods: A total of 187 patients underwent remodeling associated with subvalvular aortic ring annuloplasty (14 centers, 24 surgeons). Three strategies for cusp repair were evaluated: group 1, gross visual estimation (74 patients); group 2, alignment of cusp free edges (62 patients); and group 3, 2-step approach, alignment of the cusp free edges and effective height resuspension (51 patients). The composite outcome was defined as recurrence of aortic insufficiency of grade 2 or greater and/or reoperation., Results: The operative mortality rate was 3.2% (n = 6). Treatment of a cusp lesion was most frequently performed in group 3 (70.6% vs 20.3% in group 1 and 30.6% in group 2, P < .001). Nine patients required reoperation during a follow-up period of 24 months (range, 12-45), 6 patients in group 1 and 3 patients in group 2. At 1 year, no patients in group 3 presented with composite outcome events compared with 28.1% in group 1 and 15% in group 2 (P < .001). Residual aortic insufficiency and tricuspid anatomy were independent risk factors for the composite outcome in groups 1 and 2. The annulus diameter, the presence of Marfan syndrome, and cusp repair had no effect on aortic insufficiency recurrence or reoperation., Conclusions: A standardized and physiologic approach to aortic valve repair, considering both the aorta (root remodeling) and the valve (resuspension of the cusp effective height and subvalvular ring annuloplasty) improved the preliminary results and might affect their long-term durability. The ongoing Conservative Aortic Valve Surgery for Aortic Insufficiency and Aneurysm of the Aortic Root (CAVIAAR) trial will compare this strategy to mechanical valve replacement., (Copyright © 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Coronary artery dissection (CAD) is a rare but serious complication of type A aortic dissection (AD) which may be discovered preoperatively in the presence of clinical or ECG signs of ischemia, or intraoperatively after dissection of the coronary ostium. Treatment of CAD consists of surgical repair with glue and, if necessary, coronary artery bypass graft. No case of AD with CAD complicated by major arrhythmias treated by assisted circulation has been reported in the literature. We report the first case of AD with implementation of extracorporeal membranous oxygenation following cardiotomy with a favorable outcome.

Objectives: Cardiac surgery can relieve symptoms and improve the prognosis of patients with aortic stenosis. However, surgery-related morbidity and mortality are high when severe cardiac or extracardiac factors co-exist. We report the outcome of percutaneous balloon aortic valvuloplasty (BAV) as a bridge to aortic valve replacement (AVR) in temporarily inoperable patients in our institution., Methods: All patients who, between January 2002 and December 2006, underwent a bridging percutaneous BAV and had an AVR performed 8-14 weeks later, were included in the study. Clinical and investigational data were collected retrospectively from the patients' files. Follow-up was performed by telephonic interview., Results: Twenty-five patients were included in the analysis (median age 71.9 years). Operative risk decreased from 18.6% before BAV to less than 13% before AVR, according to the logistical European System for Cardiac Operative Risk Evaluation (EuroSCORE). Median ejection fraction (EF) was 40% before dilation compared with 44% after BAV. The necessity for BAV included acute pulmonary oedema (8%), cardiac failure (64%), cardiogenic shock (16%), syncope (8%) and EF<10% (4%). Complications included low output (28%), renal failure (20%), septic shock (4%) and cerebrovascular accident (8%). One postoperative hospital death was observed. The median length of stay in the intensive care unit (ICU) was 44 days, and the median total hospital stay was 10 days., Conclusions: BAV used as a bridging procedure to improve cardiovascular function prior to AVR is an interesting therapeutic approach in patients with aortic stenosis and haemodynamic failure. The postoperative course after AVR was also improved in our patients., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

We evaluated the incidence of conduction abnormalities and requirement for permanent pacemaker in patients undergoing transcatheter aortic valve implantation (TAVI) with the Edwards Sapien prosthesis. In 2009, >8,000 patients were treated with TAVI using 1 of the 2 commercialized models of bioprosthesis (Edwards Sapien, Edwards Lifesciences, Irvine, California; and CoreValve, Medtronic, Irvine, California). Occurrence of conduction abnormalities including complete atrioventricular block requiring permanent pacemaker has been reported after TAVI with the 2 models of valve, more frequently with the CoreValve. We analyzed standard 12-lead electrocardiograms of 69 consecutive patients in whom an Edwards Sapien prosthesis was successfully implanted. Electrocardiograms were examined before treatment, at day 1, and at 1-month follow-up. Heart rate, PR and QT intervals and QRS duration were measured and the presence of a first-, second-, or third-degree atrioventricular block was documented. There was a slight increase in heart rate and a discrete decrease in QT interval at day 1. These values had returned to baseline values at 1 month. There was no change in PR interval but a transitory increase in QRS duration was noted. Frequency of left bundle branch block increased from 14.5% at baseline to 27.5% at day 1 with a decreased incidence at day 30 (21.3%). Permanent pacemaker was required in only 3 patients (4.3%). In conclusion, in our experience, conductive disorders and requirement of a definitive pacemaker after implantation of an Edwards Sapien aortic bioprosthesis are infrequent. The physical properties of this prosthesis may explain this observation., (2010. Published by Elsevier Inc.)

Acute aortic syndrome (AAS) (aortic dissection, intramural aortic haematoma, or penetrating atherosclerotic ulcer) is a surgical emergency. Computed tomography (CT) is the reference technique for the diagnosis of this critical situation. However, a few reports of false-positive images leading to unnecessary interventions have been published. It is important to recognize and understand the pitfalls in the CT diagnosis of AAS. We describe the case of a 76-year-old man with clinical signs of AAS and a CT-scan compatible with a diagnosis of aortic intra-mural haematoma, leading to emergency surgery. The peroperative findings revealed a normal aortic wall with the presence of an unusual pericardial recess at the right side of the aorta.

Unlabelled: We report our experience with using integrated molecular and anatomic hybrid imaging to assess infection in patients who have a left-ventricular-assist device (LVAD)., Methods: Thirteen (99m)Tc-exametazime-leukocyte planar and SPECT/CT scans were obtained for 8 consecutive patients who had an implanted LVAD. SPECT/CT was used to assess suspected device-related infections (n = 8) and to evaluate the efficiency of current antibiotic therapy (n = 5)., Results: Device-related infection was seen on 8 of the 13 scans. SPECT/CT was positive for infection in all 8 patients, whereas planar scans were positive in 6 of 8. SPECT/CT provided relevant information on the extent of infection and its exact location in all patients. Additional distant infectious foci were demonstrated in 3 of 13 patients., Conclusion: SPECT/CT led to an accurate diagnosis of LVAD-related infection, revealing both anatomic location and extent. This noninvasive approach could lead to improved therapeutic strategies.

Background: Cardiac allograft vasculopathy (CAV) limits long-term survival after heart transplantation. Diagnostic and prognostic value of gated single photon emission computed tomography (gated SPECT) has not been documented in this setting., Methods and Results: We identified 110 consecutive heart transplant recipients (with transplantation >18 months) who underwent stress-rest gated SPECT and coronary angiography within 1 month, and were clinically monitored in a single heart transplantation center. Visual scoring of perfusion and wall motion images used a 16-segment model. Left ventricular function was automatically calculated. Coronary angiography was normal in 64 patients (58%) and abnormal in 46 (any CAV, 42%), of whom 19 had severe stenoses. Sensitivity and negative predictive (NPV) value were .63 and .75 for identification of any CAV, and .84 and .96 for severe CAV. Cox regression analysis showed that independent predictors of cardiac death and retransplantation were the presence of any angiographic CAV lesions (RR = 8.816, P = .043) and a stress perfusion defect >3 segments (RR = 5.607, P = .0053). A stress perfusion defect >3 segments predicted the need for late coronary revascularization >2 months (RR = 6.11, P = .0002)., Conclusions: We conclude that perfusion gated SPECT is a useful noninvasive screening test and may be proposed to help identify heart transplant recipients with a high risk of poor clinical outcome. A normal gated SPECT was associated with a low risk of cardiac hard event and might alleviate the need for coronary angiography.

Transcatheter aortic valve implantation (TAVI) using a balloon-expandable valve has been developed by the authors' group 7 years ago to offer a therapeutic solution to nonoperable or surgical high-risk patients with degenerative aortic stenosis. The technique and the devices used have rapidly evolved thereafter and TAVI has become a clinical reality with more than 3,500 patients implanted worldwide with this device. The currently used Edwards-Sapien Transcatheter Heart Valve (THV) consists of a balloon-expandable stent with an integrated bovine pericardial valve. It can be implanted within the diseased native aortic valve using either the retrograde transfemoral or antegrade transapical routes. This article is aimed at describing the updated transfemoral technique. Appropriate patient selection is crucial for a successful procedure including close evaluation of the arterial characteristics. After predilatation of the native valve with a balloon catheter, the THV with its delivery system is introduced within the femoral artery, advanced to the native aortic valve under X-ray control, positioned across the aortic annulus, and delivered by balloon inflation under rapid heart pacing. The acute procedural success is 96% and the technique leads to an immediate and lasting improvement of hemodynamics and clinical status. Complications are rare and the mortality rate is 6.3% at 1 month in this cohort of very sick patients. Procedural complications are headed by vascular injury related to the large size of the arterial introducers. An upcoming lower- profile Edwards THV should improve this issue and increase the indication for this less invasive approach in the near future. At the present time, the indications should be restricted to nonoperable or surgical high-risk patients and the procedure performed by experienced and formally trained physicians working in an optimal multidisciplinary environment.

Cryoablation can be used to treat atrial fibrillation (AF) surgically. We describe a 71-year-old woman who underwent cryoablation after 6 months of AF. Four hours post-surgery, electrocardiographic changes were observed in the circumflex artery territory associated with hemodynamic instability, which responded to inotropic agents. Angiography revealed a diffuse circumflex artery spasm with a heterogeneous aspect of the posterior branch evoking a dissection. Platelet anti-aggregant and trinitrine therapy were started. Recovery was uneventful and the patient was discharged on day 13. Cryoablation-associated circumflex artery dissection is rare. Caution is required when locating the ablation lines to avoid coronary artery injury.

Background: In a pressure overloaded left ventricle, regional systolic function has often deteriorated despite normal ejection fraction., Objective: To correlate regional systolic function obtained by tissue Doppler imaging (TDI) with improvement in functional status after aortic valve replacement in patients with aortic stenosis (AS)., Methods and Results: 24 hours before aortic valve replacement, 32 patients with severe AS underwent conventional and TDI echocardiography for systolic peak velocity, peak strain and peak strain rate measurement in the short-axis posterior wall. At follow-up, a composite end point of cardiovascular death, worsening of heart failure and limited exercise capacity was recorded. Before surgery, mean (SD) aortic valve area and pressure gradient were 0.69 (0.22) cm(2) and 50 (14) mm Hg, respectively. Ejection fraction was 61 (10)% and septal thickness was 15 (3) mm. Fourteen events were recorded but no cardiac death. By using the multivariate regression analysis, systolic peak strain rate (p = 0.003) was the strongest predictor of limited recovery after aortic valve replacement. The peak strain rate cut-off point was 2/s by receiver operating characteristic analysis., Conclusion: Irrespective of ejection fraction and thickness, strain rate is a determinant which predicts recovery after aortic valve replacement in patients with severe AS.

Objective: We report the first case description of surgical aortic valve replacement after percutaneous valve implantation., Methods: An 87-year-old man with severe aortic stenosis who was rejected for surgical intervention underwent percutaneous valve implantation through a retrograde femoral approach. The procedure was complicated by cardiogenic shock caused by severe aortic insufficiency, leading to emergency surgical aortic valve replacement., Results: The operative findings revealed the presence of commissural paravalvular leaks and centrally malapposed leaflets. Surgical replacement was uneventful, and the patient was discharged on day 30, despite a challenging postoperative course. His follow-up at 1 year has been uneventful. This case illustrates that overdilatation of the stent is not recommended because it might worsen central aortic insufficiency. Moreover, the transapical route should be considered when the appropriately sized prosthesis is unable to be inserted because of inappropriate vascular access. However, despite an initial "prohibitive" surgical risk, surgical aortic valvular replacement after percutaneous valve implantation could be easily performed., Conclusion: Percutaneous heart valve implantation, which provides a larger surface area than balloon valvotomy, can be offered to patients with cardiogenic shock and severe comorbidities to improve their hemodynamic state and reduce their surgical risk.

The most common aortic valve congenital abnormality is observed in bicuspid aortic valve. Only a few cases of aortic valve quadricuspidy have been reported in the literature. We report a new case of endocarditis complicating a congenital quadricuspid aortic valve.