Search

Background The modified Bentall procedure remains a gold standard of aortic root surgery. We present in this study the early and late outcomes of a particular modification using 2 separated grafts for the coronary reimplantation. Methods From 1995 to 2009, 153 patients aged 57 ± 12 (mean ± standard deviation [SD]) underwent elective (n = 113) or urgent (n = 40) aortic root replacement with a composite mechanical valve conduit reconstruction using 2 short, separated 8-mm Dacron grafts for the coronary reimplantation and were retrospectively reviewed. Results Aortic disease etiologies were annuloaortic ectasia (n = 108), type A aortic dissection (n = 38), aortic false aneurysm, or Valsalva aneurysm evolution after previous cardiac surgery (n = 7). The overall early mortality was 8.5% (20% for urgent procedure and 4.4% for elective procedure). For the whole group, actuarial survival at 5 and 10 years was 86.3% ± 2.78 and 73.7% ± 4.23, respectively. Among the 23 late deaths, 9 were valve-related deaths (stroke, n=3; endocarditis, n=1; unknown, n=5). During the follow-up, linearized rates of major bleeding, thromboembolism, and endocarditic evolution were, respectively, 1.3 %/patient-years, 0.42 %/patient-years, and 0.22 %/patient-years. One patient presented a nonseptic false aneurysm of the right coronary anastomosis and no structural valve dysfunction has been diagnosed. In total, only 2 patients required an aortic root reoperation. Conclusions The modified Bentall procedure using 2 separated grafts for the coronary reimplantation is a feasible, safe, easy, and reproducible operative technique for aortic root surgery.

Background Left main coronary artery (LMCA) disease is currently treated by coronary artery bypass grafting or, more recently, by percutaneous coronary intervention. Occasionally, direct surgical patch angioplasty of the LMCA can be proposed as an alternative treatment. The aim of this study was to analyze, on a long-term basis, the safety and efficacy of this technique. Methods This retrospective analysis was obtained from clinical data between April 1995 and December 2008: 91 consecutive patients (67 men, 24 women; mean age: 58 ± 10 years) underwent surgical angioplasty of the LMCA with an autologous pericardial patch. Among them, 80 (87.9%) presented an isolated LMCA disease. Mean logistic European system for cardiac operative risk evaluation of this series was 3.9 ± 2.9. Concomitant surgical procedures included coronary artery bypass grafting (n = 11; 12%), valve procedure (n = 5; 5.5%), and carotid endarterectomy (n = 1; 1.1%). We analyzed the early and late mortality, major adverse cardiac or cerebral event rate, and repeat revascularization rate. Results The mean follow-up was 7.22 ± 3.60 years (maximum 13.8 years, minimum 180 days). Perioperative mortality was 1.1%. Five and ten-year global survival was 95 ± 4.5% and 80 ± 8.3%, respectively. Major adverse cardiac or cerebral event rates at five and ten years were, respectively, 21 ± 8.4% and 31 ± 9.6%. First repeat postoperative revascularization rate was 12 ± 6.8% at five and 17 ± 7.8% at ten years (n = 10 patients). Among them, repeat target lesion revascularization concerned four patients. Conclusions Similar to other series, our study shows satisfactory long-term outcomes with the surgical patch-plasty of LMCA. This technique can be proposed as an efficient and safe alternative to selected patients, particularly in case of isolated LMCA disease without extended calcification.

Refractory shock from anaphylaxis can occur after induction of general anesthesia. We report two cases of fatal cardiac arrest with increased blood tryptase and immunoglobulin E values after succinylcholine administration. Tryptase and immunoglobulin E assays may help to identify anaphylactic reactions when cardiac arrest occurs at induction of anesthesia.

Anti-GPIIb/IIIa associated thrombocytopenia has been reported in most large trials, but very little data is available regarding tirofiban. We report three cases of thrombocytopenia, most likely attributed to tirofiban (two moderate and one severe). For each patient, laboratory investigation has allowed us to exclude another cause of thrombocytopenia, particularly heparin-induced thrombocytopenia. Platelet count recovery could be earlier with tirofiban than with abciximab. Some suggestions are proposed for practical management of these patients with persistent thrombotic risk, who are sometimes candidates for cardiopulmonary bypass surgery.

AF is frequent after cardiac surgery. However, ventricular arrhythmias are less known. The purpose of the study was to evaluate the causes and the prognostic significance of severe ventricular arrhythmias occurring after cardiac surgery. For 10 years, among 2,100 cardiac surgeries, 16 (0.8%) patients (13 men, 3 women; age 49-71 years, mean 62 +/- 9 years) without previous ventricular arrhythmias, with preserved left ventricular ejection fraction, and without acute cause of ventricular arrhythmias, developed VF (n = 4) or a sustained VT between 3 days and 3 weeks after cardiac surgery (coronary artery bypass grafting [n = 6], valve replacement [n = 10]). Rapid AF (n = 5) or slow AF (n = 1) were present at the time of VT/VF. Programmed ventricular stimulation occurred after up to three extrastimuli in the basal state and after infusion of 20-30 micrograms of isoproterenol. An echocardiogram, coronary angiography, Holter monitoring with heart rate variability (HRV) study were performed. Ventricular stimulation was negative in six patients (with AF); sustained and clinical VT was induced in 10 patients with a left ventricular ejection fraction > 0.40, except in one patient. Valvular prothesis and coronary bypass graftings were normal. In all patients, HRV was normal before surgery and decreased after cardiac surgery; before versus after surgery, respectively, HR 69 +/- 9 and 89 +/- 30 beats/min (P < 0.01), SDNN 117 +/- 31 and 50 +/- 11 ms (P < 0.001), low frequency (LF) 474 +/- 658 and 51 +/- 40 ms2 (P < 0.05), high frequency (HF) 115 +/- 23 and 33 +/- 32 ms2 (P < 0.05), LF:HF 4 +/- 3 and 1 +/- 0.6 (P < 0.01). Follow-up lasted from 6 months to 10 years (mean 3 +/- 2 years). In patients without induced VT, 1 patient died from asystole, 1 had an ICD but no subsequent events, and the other 4 untreated patients are free of events. Patients with induced VT were treated with amiodarone and beta-blockers except in one patient who died from extracardiac complications. Six of nine patients had no inducible VT with this treatment and are alive; 3 patients had inducible VT, 1 died suddenly before implantation of ICD, and 2 patients are alive with an ICD; recurrent VTs were noted in one patient and received an ICD. In conclusion, recent heart surgery may increase the risk of ventricular arrhythmias. The reduction of indexes reflecting sympathetic and parasympathetic tone could facilitate the occurrence of atrial arrhythmias (and then VT) in patients without ventricular arrhythmogenic substrate or the development of VT/VF in patients with a latent previous ventricular arrhythmogenic substrate. In patients without inducible VT, the prognosis is excellent and an ICD is not recommended in these patients. In those with inducible VT, there is a high incidence of responders to antiarrhythmic drugs with a favorable prognosis.

Some cases of heparin-induced thrombocytopenia (HIT) have been reported to be associated with antibodies against interleukin-8 (IL-8), a chemokine related to platelet factor 4. We found that sera from 5 HIT patients containing immunoglobulin G (IgG) or IgM antibodies to IL-8, as evidenced using surface plasmon resonance spectroscopy, were able to trigger IL-8–dependent activation of washed platelets, leading to procoagulant activity. This activation occurred at IL-8 concentrations achievable in vivo and was facilitated by heparin (0.1 U/mL). Activation was also induced by affinity-purified anti–IL-8 IgG and involved FcγRIIa. In the 2 patients who could be followed up, antibodies were no longer detectable 4 months after heparin withdrawal. One additional patient with paraneoplastic recurrent thrombosis without thrombocytopenia was found to have platelet-activating anti–IL-8 IgM, but in this case heparin was inhibitory. This is another example of potentially pathogenic platelet activation by antibodies.

Background Bleeding remains a potentially lethal complication of cardio-pulmonary bypass (CPB) surgery. The purpose of this study was to obtain a better insight into in vitro thrombin generation in the context of CPB. Methods We used Calibrated Automated Thrombography to assess blood coagulation of 10 low-risk patients operated for valve replacement with CPB, under 2 experimental conditions, one implicating platelets as platelet dysfunction has been described to occur during CPB. Results Our main finding was that CPB-induced coagulopathy was differently appreciated depending on the presence or absence of platelets: the decrease in thrombin generation was much less pronounced in their presence (mean endogenous thrombin potential change values before and after CPB were -3.9% in the presence of platelets and -39.6% in their absence). Conclusion Our results show that experimental conditions have a profound effect in the study of in vitro thrombin generation in the context of CPB.

OBJECTIVES: Liver cirrhosis increases mortality and morbidity following cardiac surgery. This study evaluated the results of cardiac surgery in cirrhotic patients and the relevance of EuroSCORE, Child–Turcotte–Pugh (CTP) class and model for end-stage liver disease (MELD) score in terms of prediction of surgical mortality and survival. METHODS: The study involved 34 patients with hepatic cirrhosis who underwent cardiac surgery between January 1996 and January 2010. RESULTS: The in-hospital mortality was 26%. Postoperative mortality of patients with CTP class A, B or C was 18, 40 and 100%, respectively. In univariate analysis, a history of cerebrovascular disease and hypoalbuminaemia was predictive of operative mortality. Multivariate exact logistic regression revealed that hypoalbuminaemia was an independent factor. Long-term survival was 63 ± 0.08% at 1 year and 40.2 ± 0.12% at 5 years. The 1-year survival for CTP A, B and C was 76.7 ± 0.09, 60 ± 15.4 and 0%, respectively, and the 5-year survival was 60 ± 15.4, 25 ± 0.19 and 0%, respectively. The EuroSCORE was not a discriminant [area under the curve (AUC): 0.57 ± 0.15]. The performance of CTP class and MELD score was better, but neither provided optimal discrimination: AUC was 0.691 ± 0.110 for MELD and 0.658 ± 0.10 for CTP class. CONCLUSIONS: Cardiac surgery can be performed safely in CTP class A patients. In CTP C patients, surgery is hazardous, and an alternative treatment must be considered. In CTP B, the MELD score could be helpful in deciding whether surgical intervention is a reasonable option.

The study aimed to describe French off-label use of rFVIIa for intractable bleeding in major cardiovascular surgery.Retrospective observational analysis of data from 2005 to October 2007 (no formal guidelines were available) was employed. The collect request form was elaborated by a multidisciplinary committee.Data on 109 patients--37 mechanical cardiac assist devices--were collected, with repeated injection for 24%. Bleeding stopped, decreased or continued in 43%, 37% and 20% of the cases, respectively. For patients treated in the intensive care unit (ICU), hourly bleeding decreased from 365 ± 212 to 115 ± 106 ml h(-1) (p0.001). The median number of transfused products was 25 (2-90) before and 6 (0-48) after rFVIIa (p0.001). Most patients had been well compensated with fibrinogen (1g.l(-1)) and platelets (50 G.l(-1)) before rFVIIa. The bleeding outcome (cessation, decrease or no change) was associated with the infused dose (81 ± 31, 71 ± 24, 64 ± 23 μg.kg(-1); p = 0.044) and did not differ whether rFVIIa was administered in the operating room (49%) or ICU (51%). Thrombotic events occurred in 13% of patients without assist devices and in 27% of those with them (but without obvious intra-device clotting). The overall 28-day survival rate was 60% and associated with bleeding outcome (p = 0.002).rFVIIa rescue therapy was followed by control of bleeding in a substantial number of the patients with seemingly acceptable safety; however, thrombotic risk remains a matter of concern. Our observational study suggests that the dose to be tested prospectively is at least 80 μg.kg(-1).

The present study was aimed at evaluating telomere length in blood and in different vascular tissues with or without atheroma, in 3 groups of subjects: a group of atherosclerotic subjects who underwent surgery (Atherosclerosis-Surgery), a second group of subjects with asymptomatic atherosclerotic carotid plaques but who did not undergo cardiovascular surgery (Atherosclerosis-No surgery), and a third group of subjects without atherosclerotic disease (Controls). The main objective was to determine if there is in vivo regulation of telomere length in situ by atherosclerotic lesions.A total of 84 subjects (mean age 69 ± 8 years) were studied. Blood and arterial tissue telomere lengths were determined by Southern blotting. Personal medical history (diabetes, hypertension, cardiovascular disease, dyslipidemia), family medical history, drug intake, and lifestyle were evaluated in the entire population through the use of a questionnaire.Arterial segments which did not develop atherosclerosis such as the saphenous vein and internal mammary artery, had longer telomere length than aortic segments. On the other hand, telomere length was shorter in aortic tissues which presented atherosclerotic lesions compared to corresponding tissues without atherosclerotic lesions. These results also suggest tissue regulation of telomere size by local factors likely related to oxidative stress responses.

Multivalvular endocarditis accounts for 15% of all endocarditis. The mechanisms of spread of the infection differs whether endocarditis is only left-sided (involving both the mitral and aortic valves) or bilateral. In left-sided bivalvular endocarditis, it is often a secondary mitral lesion following a primary aortic endocarditis. Multivalvular endocarditis often results in severe and extensive cardiac lesions, well described at echocardiography and frequently responsible for severe heart failure. Patients often need surgery, which consists of radical debridement of all the infected tissue with reconstruction using different types of prostheses; therefore, the surgery may be very complex. The goal should be an early diagnosis of endocarditis to avoid spread of the infection to more than one valve, to improve the prognosis for those patients.

BACKGROUND AND OBJECTIVE Recombinant activated factor VII (rFVIIa), which is used off-label as an adjuvant therapy for uncontrolled and life-threatening bleeding, might also attenuate intractable bleeding related to macrovascular arterial lesions. Here we evaluated the efficacy of rFVIIa in sealing a large arterial wound in haemostatically competent rabbits. METHODS Sixty male New Zealand rabbits were randomly divided into vehicle control and 80 and 200 μg kg⁻¹ rFVIIa groups (n = 20 animals each). A standardized wound of the isolated right carotid artery was made in all rabbits with an 18-G catheter. Bleeding, which was limited by mild compression, was assessed every minute. At 5 min, an intravenous bolus of vehicle or human rFVIIa was given and the animals were further observed for 1 h. Efficacy was assessed from the bleeding duration and blood mass lost. Statistical significance was defined as P less than 0.05. All investigators were blinded to the treatment the animals received. RESULTS The bleeding duration and blood mass lost were significantly reduced in both rFVIIa dosage groups as compared with the vehicle control group. For the vehicle, 80 and 200 μg kg⁻¹ rFVIIa groups, the median bleeding durations were 56 min (range 7-60 min), 15 min (range 5-60 min) and 10 min (range 5-60 min), respectively; and the median blood mass losses were 22.5 g (range 1-58 g), 12 g (range 0-36 g) and 5 g (range 0-31 g), respectively. The prothrombin time was shorter in the rFVIIa groups. Visual inspection of the carotid artery and microscopic analysis of the liver and kidney revealed neither gross thrombi nor entrapped microthrombi in any rabbit. CONCLUSION Recombinant FVIIa at 80 or 200 μg kg⁻¹ promoted the sealing of a large and slightly compressed arterial wound in rabbits. These results suggest a potential role for the drug in the management of massive bleeds due to an arterial lesion when surgical intervention is not immediately and readily available. Safety should remain a matter of concern.

International audience; BACKGROUND: Randomized studies evaluating left atrial radiofrequency ablation (RFA) in patients with persistent atrial fibrillation undergoing mitral valve surgery are scarce and monocentric. AIM: To evaluate the efficacy of left atrial RFA concomitant with mitral valve surgery to restore and maintain sinus rhythm. METHODS: The SAFIR is a multicentre, double-blinded, centrally randomized study involving four university hospitals. Between December 2002 and September 2005, 43 patients with mitral valve disease and long-standing, persistent atrial fibrillation (duration>6 months) were included. We compared valvular surgery alone (n=22) or with left atrial RFA (n=21). The main endpoint was sinus rhythm at 12 months without recurrence of arrhythmia during follow-up. Secondary endpoints were surgical adverse events, atrial fibrillation relapses, stroke and echocardiographic measurements after three and 12 months' follow-up. Analyses of the efficacy criteria were performed on an intention-to-treat basis. RESULTS: The primary endpoint occurred significantly more often in the RFA group than in the control group (respectively, 12/21 patients [57%] vs 1/22 patients [4%]; p=0.004). There were more patients with sinus rhythm in the RFA group than in the control group at discharge (72.7% vs 4.8%; p

We aimed to evaluate the long-term clinical outcomes among patients with peripheral arterial disease (PAD) after coronary artery bypass grafting. We studied 589 consecutive patients who had undergone isolated coronary artery bypass grafting from January 2003 to June 2005 at our university hospital. The effect of PAD was assessed by comparing the 2-year follow-up data from 2 groups of patients: 243 patients with and 346 without PAD. A large systematic atherosclerosis screening was performed, including cerebrovascular disease, lower extremity artery disease, and abdominal aorta disease and its branches. PAD was defined as a history of treated atherosclerotic disease and significant atherosclerotic stenosis on screening. Patients with PAD were significantly older (70 +/- 9 vs 64 +/- 11 years, p0.001) and were more often men (p = 0.04) than those without PAD. They had a greater incidence of hypertension (p = 0.002), chronic renal dysfunction (p0.01), chronic pulmonary disease (p = 0.005), and a history of coronary artery disease (p = 0.03). No significant difference was noted between the 2 groups with regard to the left ventricular ejection fraction. The 2-year cumulative survival rate was 76.6% for patients with PAD and 94.1% for those with isolated coronary disease (p0.001). In conclusion, after adjusting all significant variables, the presence of PAD appeared as an independent predictive factor for all-cause mortality (adjusted hazard ratio 3.2, 95% confidence interval 1.8 to 5.7, p = 0.001).

Le raccourcissement des telomeres est un determinant majeur du vieillissement cellulaire. Des etudes in vitro montrent qu’un stress oxydant accru serait responsable d’une attrition plus marquee des telomeres. Par ailleurs, des etudes cliniques portant sur l’association atherothrombose – longueur des telomeres ont montre que les sujets atheromateux avaient des telomeres leucocytaires plus courts. Le but de cette etude est d’etudier la dynamique des telomeres sur des tissus atteints ou non par l’atherosclerose. Differents parametres arteriels (PAS et PAD) et metaboliques (diabete, dyslipidemie, BMI, tabagisme) ont ete evalues au sein de 28 hommes et de 9 femmes (âge moyen : 70 ± 7,8 ans) presentant differentes pathologies cardiovasculaires. La longueur moyenne des telomeres a ete mesuree par Southernblotting sur des tissus arteriels atteints de l’atherome, des tissus arteriels non atherogenes, du tissus graisseux et du sang. Les tissus atherogenes de l’arbre aortique constitue par la valve aortique, l’aorte ascendante, l’aorte abdominale, l’artere iliaque et l’artere femorale, presentent des telomeres plus courts que ceux retrouves dans les vaisseaux non atherogenes (artere mammaire et veine saphene). En presence de facteurs de risque cardiovasculaire (HTA, diabete type 2, tabagisme), seuls les tissus atherogenes presentent des TRF plus courts, les TRF des tissus non atherogenes etant essentiellement influences par l’âge. Notre etude montre aussi qu’il existe, uniquement dans l’arbre aortique, une relation inverse entre la pression pulsee, indice de rigidite aortique, et la longueur des telomeres. Les differences de TRF observees entre tissus sains et tissus atheromateux pourraient suggerer l’existence d’une regulation locale de la taille des telomeres pouvant etre due a la presence du processus inflammatoire caracteristique de l’atherosclerose, et d’un stress oxydant accru, ces deux processus etant frequemment rencontres chez les patients presentant des facteurs de risque cardiovasculaires tels que l’HTA, le diabete, et une augmentation de la rigidite arterielle.

The study aim was to update the authors' experience with aortic valve replacement (AVR) using the ATS mechanical prosthesis in terms of early and long-term outcome in routine practice.This retrospective analysis was extracted from clinical data available between April 1996 and February 2005, of AVR with the ATS Medical prosthesis in 510 consecutive patients (345 men, 165 women; mean age 62 +/- 12 years), of whom 296 underwent isolated AVR (iAVR). Concomitant surgical procedures included coronary artery bypass grafting (AVR+CABG, n = 47), mitral valve procedure (AVR+MVP, n = 59), ascending aortic replacement (AVR+AAR, n = 74) and other procedures (AVR+Miscellaneous, n = 34). Early and late morbidity/mortality were analyzed for the entire group in case of emergency surgery, preoperative low left ventricular ejection fraction (LVEF50%) and in elderly people (ageor = 70 years).The overall 30-day mortality was 7.2% (iAVR 4.7%; AVR+CABG 4%; AVR+MVP 8.5%; AVR+AAR 2.9%; AVR+Miscellaneous 14.7%). The five- and nine-year global survival rates were respectively 81.14 +/- 2.4% and 67.02 +/- 10.4%. Long-term survival was lower in case of emergency surgery (p = 0.001), when the preoperative LVEF was50% (p = 0.03), and when patients were agedor = 70 years (p = 0.0005). Linearized postoperative valve-related death was 1.1% per patient-year (pt-yr). However, nine years' freedom from valve-related death and valve-related morbidity were not significantly different when the patient age wasor = 70 years. The linearized rate for postoperative thromboembolism complication was 0.4% per pt-yr, and that for postoperative bleeding complication 0.63% per pt-yr. There were two perivalvular leaks (0.05%/pt-yr). Neither valve thrombosis, structural dysfunction nor endocarditis were observed.The findings of this retrospective study point to a globally very good performance of the ATS valve, and essentially similar to previously reported results with these and other available mechanical valves.

Heparin-induced thrombocytopenia was diagnosed in a 50-year-old man on day 5 after cardiac surgery (aorto-coronary bypass and mitral valve replacement). He required redo (para-prosthesis leak) on day 13. The cardiopulmonary bypass (CPB) was performed with unfractionated heparin (UFH) and the platelet glycoprotein (GP) IIb/IIIa inhibitor tirofiban. Post-protamine bleeding likely due to documented persistent platelet blockade by tirofiban was successfully treated with one dose of recombinant activated factor VII (rFVIIa, 60 microg/kg). No thrombotic complications were detected. The management of CPB with UHF and tirofiban is a convenient option and rFVIIa seems appropriate to handle bleeding issues.

Radiofrequency (RF) ablation is a new technique used to destroy locally malignant hepatic tumors. The RF current is a high frequency sinusoidal current (400–500 kHz) that produces ionic agitation and results in frictional heat, distributed by conduction into the tissue about the electrode.1 At a temperatures near 60°C, the intracellular proteins and collagen are denatured, lipids are dissolved, and cellular death becomes irreversible. Coagulation starts at 70°C and tissue desiccation at 100°C, thus causing coagulation necrosis of the tumor tissue and the surrounding parenchyma.2–4 The morbidity rate of this technique varies according to the studies from 3% to 14%.1,5–9 The bile ducts cannot withstand the heating effect, leading to either ductal stenosis with dilation of the upper bile duct or abscess formation.10,11 Most authors recommend a minimal distance of 1.5 to 2 cm, from a proximal intrahepatic bile duct, to perform RF ablation without any risk.1,12–14 An experimental model was designed for secondary biliary lesions in pig.15 RF ablation in proximity to the bile duct consistently induced radiologic and histologic lesions. The radiologic lesions observed were either biliary stenosis with upstream dilation or complete interruption of the bile duct, or destruction of the bile duct with extravasation of contrast. Histologic examination showed desquamation of the biliary epithelium associated with destruction of the biliary duct wall. The aim of this study was to evaluate the role of bile ducts cold 5% glucose perfusion during RF ablation on secondary post-RF biliary lesions.

In chronic pulmonary vascular thrombotic disease, pulmonary thromboendarterectomy lure proved to be effective in reducing pulmonary hypertension and improving gas exchange. However, persistent pulmonary hypertension and unrelenting reperfusion edema are the main causes of death. We report a case of pulmonary thromboendarterectomy followed by an immediate unfavorable postoperative course with acute and persistent pulmonary hypertension, gas exchange impairment, and heart dysfunction. In this particular case, inhaled nitric oxide was successfully administered.

The promising concept of cell transplantation and cardiac tissue engineering has been developed in the last few years and focused on strategies attempting to replace dysfunctional, necrotic, and/or apoptotic cardiomyocytes with new cells of mesodermal origin. Transplantation of autologous cells minimizes the risk of neoplasia and avoids immune rejection associated with allogenic or xenogenic cells and recent data hold enormous hopes for short term clinical practices. Tissue engineering represents another promising approach that makes possible the creation of new functional tissues to replace the lost or failing one. Three-dimensional polymeric scaffolds provide the mechanical support for the candidate cells until the formation of cardiac-like tissue prior to surgical repair of the infarcted myocardium. For ultimate clinical applications, further investigations have to select the appropriate cell types, to determine the sufficient number of grafted cells and to provide the long term evaluation of these strategies in the global improvements of cardiac function (neoangiogenesis, synchronous contraction and extracellular matrix remodelling).

Plaques from the coronary arteries of explanted hearts showed massive calcification (15-fold increase) with a loss of scleroproteins (-36%), an increase in the collagen to elastin ratio (twofold) and activation (+15%) of matrix metalloproteinase-2 (MMP-2). Plaque-free portions of the coronary artery gave results similar to those obtained with the internal mammary artery. There was a significant correlation between plaque calcification and MMP-2 activation, suggesting that the two processes may be linked.

International audience; Abstract: OBJECTIVES This study aimed to determine whether the myocardial T-2 relaxation time, determined using a black-blood magnetic resonance imaging (MRI) sequence, could predict acute heart transplant rejection. BACKGROUND The use of black-blood MRI sequences allows suppression of the confusing influence of blood signal when myocardial T-2 is calculated to detect myocardial edema. METHODS A total of 123 investigations, including cardiac MRI and myocardial biopsy, were performed 8 +/- 11 months after heart transplantation. Myocardial T-2 was determined using an original inversion-recovery/spin-echo sequence. RESULTS A higher than normal T-2 (greater than or equal to 56 ms) allowed an accurate detection of the moderate acute rejections evidenced at baseline biopsy (greater than or equal to International Society for Heart and Lung Transplantation grade 2): sensitivity, 89% and specificity, 70% (p < 0.0001). T-2 was increased in grade 2 (n = 11) compared with grade 0 (n = 49, p < 0.05), grade 1A (n = 34, p < 0.05) and grade 1B (n = 21, p < 0.05); T-2 was further increased in grade 3 (n = 8) compared with grade 2 (p < 0.05). In addition, in patients without rejection equal to or greater than grade 2 at baseline, a T-2 higher than normal (56 ms) was correlated with the subsequent occurrence of equal or greater than grade 2 rejection within the next three months: sensitivity 63% (12/19) and specificity 78% (64/82) (p = 0.001). CONCLUSIONS Myocardial T-2 determined using a black-blood MRI sequence, is sufficiently sensitive to identify most; of the moderate acute rejections documented with biopsy at the same time, but is also a predictor of the subsequent occurrence of such biopsy-defined rejections.

Adenosine is a potent vasodilator whose concentration has been shown to increase in cardiac tissue in response to hypoxia. However, the time-dependent relationship between the levels of myocardial interstitial adenosine and tissue oxygenation has not yet been completely established. Therefore, the purpose of this study was to investigate the complex relationship between tissue myocardial oxygen tension (PtiO(2)) and interstitial myocardial adenosine and lactate concentrations by developing a new technique which combines a cardiac microdialysis probe and a Clark-type P O(2)electrode. The combined and the single microdialysis probes were implanted in the left ventricular myocardium of anesthetized pigs. The consequences of the combined use of microdialysis and P O(2)probes on myocardial PtiO(2)and microdialysis performances against glucose were evaluated. A moderate but significant reduction in the relative recovery against glucose of the combined probe was observed when compared to that of the single microdialysis probe (42+/-2 v 32+/-1%, mean+/-S.E. M.n=5 P

Background: Acute pulmonary hypertension occurring after cardiopulmonary bypass can be a cause of post-operative morbidity and mortality. The purpose of this study was to investigate whether bosentan, a non-peptidic mixed endothelin antagonist affected the pulmonary hypertension induced by experimental cardiopulmonary bypass. Methods: Pigs were anesthetized and instrumented to determine hemodynamic measurements. Pigs were randomized to receive either 3 mg/kg bolus + 7 mg/kg per h bosentan (n = 8) or saline (n = 7). All pigs underwent 90 min of cardiopulmonary bypass and were further observed for a 120-min period. Results: In the control group, cardiopulmonary bypass induced a dramatic pulmonary hypertension (+78 ∠ 13%, P , 0.005) and accompanied an increase of pulmonary vascular resistance (+228 ∠ 50%, P , 0.005), whereas, in the treated group, bosentan completely prevented these deleterious effects of cardiopulmonary bypass with only a moderate decrease of systemic vascular resistance (-19 ∠ 14.6%, P , 0.05). Conclusions: The present findings support the hypothesis that endogenous endothelin is a mediator of acute pulmonary hypertension occurring after cardiopulmonary bypass. Bosentan, a mixed endothelin antagonist completely prevented pulmonary hypertension after cardiopulmonary bypass and may, therefore, have therapeutic applications in the management of patients following cardiac surgery. © 1999 Elsevier Science B.V. All rights reserved.

Prosthetic mechanical valves differ from one another in regard to several characteristics including mainly thrombogenicity and hemodynamic profile. The ATS heart valve prosthesis is a bileaflet Pyrolite carbon heart valve that is nearly identical to the St. Jude prosthesis (SJM). ATS is different from the SJM prosthesis in some ways including valve pivot design and absence of pivot guards. It is, thus, a second generation bileaflet prosthesis and as such merits it to be compared with the SJM in terms of hemodynamic performance. The aim of the study was to compare at the 10th post operative day and 180th post operative day the echocardiographic assessment of implanted aortic valve prosthesis (ATS versus SJM).

An attempt to determine the consequences of prolonged ischemia on simultaneous regional changes in norepinephrine (NE) and neuropeptide Y (NPY) interstitial myocardial concentrations in a pig model in vivo was made. The aim of the authors was to investigate further the mechanism of the major NE release previously observed in perfused hearts preserved using a Langendorff technique. Regional myocardial ischemia was induced by ligation of the left anterior descending coronary artery (LAD) in ten anesthetized pigs. NE and NPY release was studied using interstitial microdialysis, a technique initially used to monitor neurotransmitter kinetics in brain dialysate samples. Four dialysis probes were implanted into the left ventricular wall of the beating heart. Two were implanted into the ischemic region (LAD) (for NE and NPY determinations, respectively) and the remaining two into the non-ischemic left circumflex coronary artery region (LCX). Dialysate NE and NPY concentrations, as indices of interstitial myocardial NE and NPY concentrations, were measured by HPLC and RLA, respectively. A slight but significant increase in NPY levels was observed in both territories (LAD: from 190 +/- 27 to 349 +/- 62 pmol/l, LCX: 146 +/- 30 to 257 +/- 52 pmol/l) suggesting moderate stimulation of cardiac sympathetic nerve activity following LAD occlusion. On the contrary, a marked but progressive increase in NE release was observed in the ischemic region (from 8.8 +/- 1.0 to 251.4 +/- 44.8 nmol/l), when NE levels in the non-ischemic region remained stable (from 10.3 +/- 2.1 to 11.0 +/- 1.9 nmol/l). These results demonstrate the utility of regional in-vivo myocardial NE and NPY monitoring using microdialysis. The strong and sustained NE accumulation occurring in the ischemic region is consistent with the hypothesis of a local non-exocytotic metabolic NE release in case of prolonged myocardial ischemia, when exocytotic release remain only minimal as attested by the slight increase in NPY observed.

Background. Because of problems concerning the functional quality of heart transplants, more and more interest has been focused on the physiologic changes occurring during brain death, one of the major possible contributing factors to the myocardial alterations. Methods. The aim of this study was to describe the link between acute experimental brain death and myocardial metabolism. This was achieved by in vivo 3-hour hemodynamic and biological (myocardial lactate production) studies and then in vitro 6-hour phosphorus-31 nuclear magnetic resonance spectroscopy. Two groups of pigs were involved in the study: group I (n = 10) as control and group II (n = 10) as brain-dead animals. Results. Within the first hour, we observed a strong increase in myocardial activity associated with the onset of myocardial lactate production, lasting 2 hours and corresponding to a myocardial anaerobic metabolism period. Despite the apparent normalization before excision of the hearts, phosphorus-31 nuclear magentic resonance spectroscopy revealed to significant decrease in adenosine triphosphate levels in group II when compared with group I. Conclusions. We conclude that, in our study, acute experimental brain death is associated with an early and transient period of myocardial anaerobic metabolism and adenosine triphosphate consumption. These myocardial consequences of brain death could partially explain some observations of hear graft dysfunction.

Background Specific thrombin inhibitors are considered to be more potent antithrombotics than heparin. However, the relation between the systemic anticoagulation generated by thrombin inhibitors and their antithrombotic effect is not well defined. In a guinea pig carotid thrombosis model, the activated clotting time (ACT), the activated partial thromboplastin time (aPTT), and thrombin-generation tests were evaluated for their ability to predict the arterial antithrombotic effect of direct thrombin inhibitors such as hirudin and Ro 46-6240 compared with heparin. Methods and Results Thrombosis of the carotid artery was induced by subendothelial damage in guinea pigs, and the subsequent cyclic flow variations were monitored. The effects of pretreatment with intravenous heparin, hirudin, and Ro 46-6240 were tested. After doubling the baseline aPTT, 1 IU · kg −1 · min −1 heparin was inactive, whereas either hirudin or Ro 46-6240 (30 μg · kg −1 · min −1 ) prevented thrombus formation by 80%. Heparin (10 IU · kg −1 · min −1 ) induced the same antithrombotic effect but with indefinite aPTT prolongation. However, for similar prolongation of the ACT, the three compounds had equivalent antithrombotic effects. Thrombin generation was predictive of the antithrombotic effect of the thrombin inhibitors but not of heparin. Conclusions The arterial antithrombotic effect of direct thrombin inhibitors, when compared with those of heparin, should be evaluated by the ACT and not the aPTT or thrombin-generation assays. For a “therapeutic” aPTT prolongation, thrombin inhibitors induce higher systemic anticoagulation than does heparin and thus might unduly have higher bleeding liability.

The concept of global vascular risk is recognized as an important predictor of major events in patients with coronary artery disease.We aimed to evaluate long term clinical outcome among patients with peripheral vascular disease (PVD) following coronary artery bypass grafting.We studied 589 consecutive patients who underwent isolated coronary artery bypass grafting between January 2003 and June 2005. The impact of peripheral artery disease was assessed by comparing a two year follow-up of 2 groups of patients: patients with (n=243) and without (n=346) PVD.Patients with PVD were significantly older (70±9 vs 64±11 years p

Après mi rappel concernant les circuits de CEC pré-hépzrinés et la genèse destroubles des fonctions plaquettaires au cours des circulations extra corporelles, nousprésentons le PFA- 100[marque déposée] analyseur de petite taille des fonctions plaquettaires, a taux de cisaillement élevés (4000 à 5000 s [exposant -1]) du fiux sanguin. Cette étude basée sur 26 patients a un double objectif : celui d'étudier dans un premier temps les avaritages des circuits de CEC pré-liéparinés par rapport aux circuits standards, et d'étudier le PFA- 100[marque déposée] dans le cadre desCEC. L'originalité de cette étude réside dans le fait que cet appareil "de paillasse" qui évalue la fonction plaquettaire a été très peu utilisé durant les CEC. Les principales limites de notre étude ont été : le faible effectif des patients, l'absence de standardisation des protocoles anesthésiques, des solutés de remplissage et des critères de transfusion ainsi que l'absence de modification du protocole d'héparinisation en fonction du type cle circuit. Lors de l'interprétation des résultats du PFA- 100[marque déposée], nous avons été confrontés à une grandedispersion des valeurs du temps d'occlusion en pré CEC. Les temps de recueil et detraitement ne sont pas connus dans la plupart des cas.Au décours de notre étude, nous ne trouvons aucune différence significative sur la survenue de troubles du rythme ainsi que sur lesaignement post - opératoire extériorisé par les drains en fonction du type de circuit. A la différence de certaines études, notre analyse concernant l'utilisation du PFA- 100[marque déposée] enchirurgie cardiaque n'a trouvé aucune valeur prédictive de celui-ci sur le saignement post opératoire des 24 ° heures, ainsi que sur les pertes sanguines moyennes totales. Ceci indépendamment du type de cartouche, des valeurs de pré CEC ou de post CEC, et malgré des valeurs d'hématocrite et de plaquettes compatibles avec un bon fonctionnernent de l'appareil.