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Objectives: To present the results of a 15-year follow-up of the Sorin Bicarbon prosthesis (SBP) from a European multicentre study. Methods: From 1990 to 1996, a total of 1900 SBPs were implanted in 1704 patients, with a mean age of 59 13 years, as aortic (AVR, 922 patients), mitral (MVR, 586) or mitro-aortic (DVR, 196) valve replacement. Most patients received an SBP for rheumatic or degenerative valve disease. Concomitant procedures were performed in 25% of cases, mainly coronary artery bypass grafting (14%) or tricuspid annuloplasty (7%). Results: There were 70 (4.1%) early deaths. Actuarial survival at 15 years is 61.4% (95% confidence interval (CI): 56.4—66.0) for AVR, 63.4% (59.1—67.5) for MVR, 56.4% (47.3—64.6) for DVR. Late valve-related deaths were 260 with an actuarial freedom from valve-related deaths at 15 years of 76.4% (81.5—83.7). There were 27 cases of SBP thrombosis with an actuarial freedom from this complication at 15 years of 99.6% (98.6—99.9) after AVR, 95.8% (93.0—97.5) after MVR and 97.0% (92.8—98.7) after DVR. Thrombo-embolic episodes were 159; actuarial freedom from thrombo-embolism at 15 years is 88.8% (86.8—90.5). Haemorrhages related to anticoagulant treatment occurred in 293 cases with 39 fatal episodes; actuarial freedom at 15 years is 77.5% (74.2—80.4). There were 45 episodes of endocarditis, 21 required re-operation; actuarial freedom from endocarditis at 15 years is 96.8% (95.6—97.7). Re-operation was performed in 71 patients (non-structural valve deterioration in 28, endocarditis in 21, SBP thrombosis in 15 and non-valve-related causes in seven patients). No cases of structural failure were observed. Actuarial freedom from reoperation at 15 years is 97.6% (96.3—98.5) after AVR, 92.8% (90.1—94.8) after MVR and 90.7% (85.2—94.2) after DVR. Conclusions: The SBP continues to perform satisfactorily even in the long term with low incidence of valve-related mortality and morbidity confirming to be an extremely reliable and durable mechanical valve substitute. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Summary Introduction Thromboembolic accidents and haemorrhage are the main complications observed during long-term follow-up of mechanical heart valve patients. Several suggestions for improving anticoagulation quality have been made, including international normalised ratio (INR) self-monitoring. Objectives We report the preliminary results of a single-centre, open, randomised study (scheduled population of 200 patients), which compares monthly laboratory monitoring (group A) versus weekly self-monitoring of INR (group B). The primary aim is INR stability improvement within the target range, and the secondary aim is adverse events reduction. Patients and methods Between May 2004 and June 2005, 67 patients with an average age of 56.6 years (± 9.6), were enrolled in the study (group A: 34 patients, group B: 33 patients). The mean follow-up was 47 weeks (± 11.5). The two groups differed only in the sex ratio (44.1 and 21.2% of women in groups A and B respectively, p = 0.0459). Mechanical heart valves were aortic in 73% of patients, mitral in 13.5%, and multiple in 13.5%. Sixty-five patients (97%) were treated with fluindione, the others with acenocoumarol. The intraclass correlation coefficient between the self- and laboratory-monitored INR was 0.75. Results The time spent in the INR target range (group A: 53 ± 19%, group B: 57 ± −19%, p = 0.45) and the time spent in the INR therapeutic range, between 2 and 4.5, (group A: 86 ± 14%, group B: 91 ± 7%, p = 0.07) are longer in group B, but not significantly so. For patients outside the range, the absolute mean deviation of INR from the target or therapeutic range (range standardized between 0 and 100) is lower for the self-monitoring group (41.1 ± 39.3 and 11.27 ± 11.2) than for the control group (62.4 ± 72.6 and 39.2 ± 52.8). This difference is significant ( p = 0.0004 and p = 0.0005). Eighteen adverse events were reported: 17 haemorrhages, 13 in group A (9 mild, 4 serious) and four in group B (all mild), and one sudden death in group B, two days after the patient's discharge. No thromboembolic events were reported. Six patients (8.8 %), 3 in each group, dropped out of the study. Conclusion This first study evaluating INR self-monitoring in France shows that this method leads to better stability of the INR within the target range. On the basis of these preliminary data, this appears to be related to a decrease in serious haemorrhages (11.8% serious haemorrhage cases in group A versus 0% in group B, p = 0.06, NS).

We present the case of a 57-year-old woman with severe aortic regurgitation and ventricular dysfunction (ejection fraction 34%) requiring surgical intervention. In pre-operative period, no left ventricular (LV) asynchrony was detected by QRS duration and current echocardiographic techniques, including tissue Doppler imaging. A new echocardiographic technology, the timing of regional volumetric changes by three-dimensional echocardiography (3DEcho), demonstrated an intraventricular mechanical asynchrony. Indeed, during surgery, epicardial leads were attached to the right atrium and the right ventricle as part of the standard management. Two additional epicardial leads were attached to the left ventricle on the most delayed wall localized precisely by 3DEcho on the inferolateral wall. In post-operative period, biventricular (BiV) pacing showed improvement in the LV mechanical synchronization, resulting in improvement in the LV systolic function compared with right ventricular pacing or no pacing. This case shows the potential utility of 3DEcho in prediction of favourable response of the BiV pacing in patients with depressed LV systolic function ongoing cardiac surgery.

Background . Stabilization of the posterior annulus seems to be a critical factor to achieve a stable mitral valve repair. To assess the benefit of softer mural annuloplasty, we analyzed results obtained with the flexible linear reducer. Methods . From 1985 to 1993, 120 patients, with pure mitral regurgitation, mainly degenerative, had a mitral reconstruction. Mean age was 64 ± 11 years and 74% of the patients were in New York Heart Association functional class III or IV. Results . Hospital mortality was 3.3%. Mean follow-up was 56 ± 24 months. There were 23 late deaths; 10 valve-related including 7 sudden deaths. Two patients (1.7%) required a reoperation. Doppler echocardiographic studies revealed excellent valve function; 5-year freedom from significant regurgitation was 85.8% ± 5.4%. Mean mitral valve area was 2.76 ± 0.77 cm 2 . Although 105 patients were in class I or II, 23 patients were not functionally improved. Previous myocardial infarction and shorter deceleration time of early filling were risk factors for worsening functional disability. Conclusions . This support provides stable repair with excellent clinical and echographic results. Previous myocardial infarction and noncompliant left ventricle negatively influence outcome.

A 13-year-old boy with tetralogy of Fallot and pulmonary atresia after a Waterston and Blalock-Taussig shunt underwent successful repair using a cryopreserved pulmonary homograft as a valved extracardiac conduit. Aortic transection gave a good operative field for pulmonary angioplasty and closure of the Waterston anastomosis. The cryopreserved pulmonary homograft provided excellent handling characteristics. The postoperative course was good, and postoperative echocardiography showed good function of the valved conduit.

In this single-center French study, the conventional management of patients receiving vitamin K antagonists (VKAs) was compared with an International Normalized Ratio (INR) self-testing program. The aim was to determine the reliability of self-testing devices, and to estimate the variability of the self-measured INR within the therapeutic and target range.A total of 206 patients who had undergone valve replacement with a mechanical prosthesis, with or without myocardial revascularization, between May 2004 and September 2007 was randomized into two groups. Group 1 patients (n = 103) underwent INR monitoring at a laboratory, while Group 2 patients (n = 103) underwent self-testing INR using either the CoaguChek (Roche) (Group 2A; n = 55) or INRatio (Hemosense) (Group 2B; n = 48) system. Patients in Group 1 underwent at least once-monthly INR measurement, while those in Group 2 carried out once-weekly self-testing, and also underwent once-monthly INR measurement at the laboratory. The large majority of patients (97.9%) were treated with fluindione.The mean follow up period was 49.0 +/- 10.3 weeks. Self-testing was reliable, with a correlation coefficient between device- and laboratory-measured INRs of 0.80 [CI: 0.78, 0.82] (p0.0001). The proportion of time spent within the INR target range was significantly higher for Group 2 (61.5 +/- 19.3% versus 55.5 +/- 19.9%; p0.05), while the absolute mean deviation of INR from the target range was higher in Group 1 (60.1 +/- 70.2% versus 47.4 +/- 51.5%). Adverse events were reported by seven patients in Group 1, but by no patients in Group 2 (p0.01).INR self-testing devices are reliable and beneficial. Moreover, INR self-monitoring allows an enhanced stability within a target range, and also helps to prevent serious postoperative complications.

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Several surveys showed that cardiopulmonary bypass (CPB) is associated with incidents that negatively affect outcome and suggested that improved monitoring and safety could be associated with a decreased rate of incidents. In 2004, the French "Haute Autorité de Santé" (an independent French government advisory agency) and the French College of Perfusion issued recommendations concerning safety and monitoring devices for CPB. The aims of this study were to investigate the difference between the recommendations and the clinical practice of CPB shortly after publication of the recommendations and compare the 2005 situation with the results of a previous survey performed in France and to investigate the rate of perfusion incidents and their outcome. A 62-item questionnaire was sent in January 2006 to all 66 centers performing cardiac surgery and CPB in France. The survey investigated the use of safety and monitoring devices as well as perfusion incidents for 2005. Fifty-seven centers (response rate, 86%) returned the questionnaire, totaling 34,496 CPB procedures. There was a wide difference between the recommendations and the reported use of safety and monitoring devices with no clinically relevant change from the previous French survey concerning 2001. An incident was reported for every 198 CPB procedures with death at a frequency of 1:4864 and permanent sequelae of 1:11,349, respectively (a permanent injury or death in 1:3220 procedures). The three most frequent perfusion incidents were adverse effects to protamine (1:1702), dissection at the arterial cannulation site (1:1792), and coagulation of the circuit (1:4864). In conclusion, this survey showed that an important effort must be made in France to implement into clinical practice the recommendations concerning CPB monitoring and safety devices. The analysis of CPB-related incidents suggest that, with the exception of protamine adverse effects, the majority of deaths and severe permanent injuries in this survey could probably be avoided by improved use of the monitoring and safety devices.

and regained normal immunity to ensure success. In agreement with other authors, ~ we never found that cervicothoracic access was not needed for simple repair of a TEF. Thus the risks of postoperative assisted ventilation (which constitute the main cause of relapse) are greatly reduced, resulting in an acceptable rate of mortality (about 10% according to Marzelle and associates1). A left lateral cervical incision gives very satisfactory access for simple closure of a TEF, with better visibility and adequate operative space compared with the median approach, and has the advantage of being able to be transformed to a cervical incision at the neck if necessary. Placement of a muscular flap between the two viscera is another indispensable element for success. The partial relapse in our second patient was due, in our opinion, to the insertion of a muscular flap that was too thin (omohyoidal muscle). In cases of associated tracheal stenosis, which occurs in about 22% of patients with a TEF, 1 the possible anastomotic resection of even a small segment (a rare event) greatly increases the surgical risk. For this reason, in two of our patients with associated tracheal lesions, we opted for t reatment with a dilating endoprosthesis.

Aim: To report palliative embolization of a false aneurysm over the distal suture line of an ascending aorta graft replacement. Material and Method: A 78-year-old male patient was admitted for increasing bleeding of a chronic Manubrium ulceration, 20 months after coronary artery bypass complicated by perioperative ascending aorta dissection requiring prosthetic graft replacement. One month later, he underwent epiploplasty for a mediastinitis followed by long-term antibiotic therapy. Five months later, he presented with a Manubrium ulceration of the sternotomy. Spiral computerized tomography (CT) and aortography revealed a 20 mm anterior peri-prosthetic false aneurysm with a wide neck. Advanced age, active mediastinitis and patient’s objection led us to perform percutaneous occlusion according to the Moret remodeling technique while protecting the coils release with balloon catheter inflation. Results: No post-operative complication was observed and at 1-year follow-up the patient was doing well with no recurrent bleeding. Magnetic resonance imaging (MRI) and spiral CT controls confirmed coils stability without any internal flow. Conclusion: Percutaneous coils embolization of a large false aneurysm in the ascending aorta can be a palliative treatment in a surgically unsuited patient.

Although the ideal technique is still controversial, mitral valve reconstruction for mitral insufficiency usually includes an annuloplasty. From August 1985 to June 1993, 126 cases of pure, acquired mitral insufficiency were repaired by means of a posterior annuloplasty. Whatever the etiology, all types of mitral insufficiency allowing a mitral reconstruction were included. The annuloplasty, performed with a flexible linear reducer, was associated with valvular (62%) and subvalvular (11%) repairs. An associated surgical procedure was necessary in 62% of the patients. Operative mortality was 2.4%, and follow-up (mean 29 months) was complete for all survivors. Five-year survival was 90%. Five-year complication-free rate for emboli was 91%. Only one patient at 12 months underwent reoperation to treat recurrent mitral insufficiency. Ninety-seven patients were in New York Heart Association Class I or II. Follow-up echocardiographic studies on 75% of eligible patients showed a free rate for significant regurgitation of 99%. Mean valve area was estimated at 2.88 +/- 0.85 cm2. These findings suggest that the flexible linear reducer seems to be a reliable device and a valid alternative for annuloplasty.

A 19-day-old child suffering from cyanosis due to tetralogy of Fallot was palliated by using his right retroesophageal subclavian artery. It was anastomosed side-to-side onto the ascending aorta and end-to-side onto the right pulmonary artery. The palliation obtained with this systemic-pulmonary shunt was satisfying. The right brachial vascular flow was normal.

The myocardial uptake of rest-injected technetium 99m sestamibi on single-photon-emission computed tomographic images was assessed in 25 patients. All had an area of myocardial dysfunction that could be related to a coronary artery stenosis. None of the patients had clinical evidence of a myocardial infarction. Three months after revascularization, viability was demonstrated by contrast angiography and center-line analysis in 21 (78%) of the 27 formerly hibernating territories. Among these, none had a transmural defect, and 38% had a normal technetium 99m-sestamibi uptake. The four transmural preoperative defects were located in territories without viability. Eight of the 9 territories that were normal at scintigraphy proved to be viable postoperatively. It is concluded that as long as some residual technetium 99m-sestamibi uptake is present, viable myocardium is also present.

A 70-year man, with chest pain history, was referred for thoracic aortic aneurysm diagnosed by CT scan. A CT scan (Fig. 1a) was repeated for stent-graft selection, completed by MR due to diagnosis doubt (Fig. 1b). Radiological findings were consistent with a peri-aortic tumor and revealed a groin mass, whose histology was nonHodgkin lymphoma. Chemotherapy was effective (Fig. 2). European Journal of Cardio-thoracic Surgery 25 (2004) 1126 www.elsevier.com/locate/ejcts

SummaryWe describe two cases of thrombosis after mitral valvuloplasty (MV). Antithrombotic therapy after MV in patients with no thromboembolic risk factors is essentially based on treatment with a platelet aggregation inhibitor. This strategy may not be sufficient in some cases and the introduction of oral anticoagulant therapy may be necessary.

The aim of this work was to develop a human cell therapy program in our local university hospital. The work begun with 4 myocardial celle therapy protocols in rat heart, each published a pubmed indexed, international journal : 1) Can cold or heat shock improve skeletal myoblast engraftment in infarcted myocardium? (Transplantation. 2005 Sep 15;80(5):660-5) ; 2) Enhancement of the functional benefits of skeletal myoblast transplantation by means of coadministration of hypoxia-inducible factor 1α (J Thorac Cardiovasc Surg. 2005 Jul;130(1):173-9) ; 3) Can bone marrow-derived multipotent adult progenitor cells regenerate infarcted myocardium? (Cardiovasc Res. 2006 Oct 1;72(1):175-83) ; 4) Can erythropoietin improve skeletal myoblast engraftment in infarcted muocardium? (J Interact Cardiovasc Thorac Surg. 2007 Jun;6(3):293-7). The human myocardial cell therapy protocol was accepted in 2006-2007. Purified autologous bone marrow cells are injected after infarction to a damaged myocardium area, after myocardial revascularization. Patient inclusions will end in December 2010., Objectif : à partir d'un sujet de DEA, avec le soutien de toute l'équipe INSERM U633, élaborer une stratégie de recherche et progresser sur un thème pour permettre le développement de la thérapie cellulaire. Ce travail de recherche fondamentale permettant l'écriture et l'application d'un protocole de recherche chez l'homme. Quatre protocoles différents ont été réalisés : 1) Améliorer la résistance du greffon cellulaire en appliquant un choc thermique ; 2) Améliorer la survie des myoblastes squelettiques à l'aide d'un gène de survie cellulaire ; 3) Etudier la survie et l'efficacité des cellules progénitrices adultes multipotentes dérivées de la moelle osseuse en greffon myocardique ; 4) Améliorer les résultats de la transplantation de myoblastes squelettiques par l'apport d'érythropoïétine. Un PHRC local sur la thérapie cellulaire par des cellules mononuclées médullaires autologues lors de la revascularisation myocardique a été élaboré et accepté. Actuellement un tiers de l'effectif a été inclus. Une modification des critères d'inclusion permet actuellement un recrutement plus important de patients.