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Isolated exclusion of the non-coronary sinus (NCS) is an attractive strategy in valve-sparing aortic root surgery, which avoids the mobilisation and re-implantation of coronary ostia. However, the long-term durability of aortic valve repair and the fate of remnant sinuses of Valsalva remain unclear.From January 2006 to December 2013, 29 patients underwent replacement of the ascending aorta extending to the NCS (group NCS) and 56 patients underwent a modified Yacoub procedure (group MY) in our centre by a single surgeon. Significant difference of preoperative parameters was observed between two groups in the presence of bicuspid aortic valve (41.4% vs 12.5%, p=0.002) and the diameter of the sinus of Valsalva (47.3±4.7 mm vs 51.5±4.9 mm, p=0.01).The group NCS, as compared to the group MY, was associated with significantly shorter cardiopulmonary bypass time (106.6±40.5 min vs 138.4±37.5 min, p=0.001) and aortic cross clamping time (69.0±21.8 min vs 105.4±27.8 min, p0.01). The mean follow-up was 11.5±2.8 years. No surgical re-intervention was performed for aortopathies of the aortic root; the neo-sinus were not dilated in either groups (38.2±4.2 mm vs 34.0±4.0 mm, p0.01). The 10-year freedom from aortic valve-related re-operation was estimated to be 96.6±3.4% and 94.5±3.1% (p=0.58), and the cumulative 10-year survival rates were 95.2±4.6% and 85.6±4.7% (p=0.61) in the group NCS and the group MY, respectively.Aortic valve-sparing isolated NCS replacement can be safely performed in selected patients; its early outcomes, overall survival and long-term freedom from aortic valve-related or aortopathy-related re-intervention were comparable to those obtained with the Yacoub procedure.

Valve-sparing aortic root replacement (VSRR) techniques have several advantages such as preservation of physiological haemodynamics of the native aortic valve and avoidance of prosthetic valve-related complications. However, VSRR procedures are generally performed in young patients and the long-term results in elderly patients (≥65 years) are scarce.Fifty-six (56) consecutive patients underwent VSRR surgery by a single surgeon at the current centre between January 2006 and December 2013; a modified "remodelling technique" was typically performed. The mean age was 58.86±12.5 years; Marfan syndrome and bicuspid aortic valve were both present in six patients (10.7%); 38 patients (67.8%) presented with greater than moderate aortic regurgitation; and 17 patients (30.4%) were in New York Heart Association (NYHA) class III before surgery. They were divided into two groups according to their ages receiving VSRR surgery: Group E (elderly patients aged ≥65 years, n=24) and Group Y (young patients aged65 years, n=32). The primary outcomes were aortic valve-related reoperation, cardiovascular reoperation, all-cause mortality, and functional status.One (1) patient in Group E was converted to aortic valve replacement as a result of a failed aortic valve repair. No perioperative mortality was observed. The mean follow-up was 11.5±2.9 years. Aortic valve-related reoperation was noted in two patients of each group (one with endocarditis, one with severe aortic regurgitation). Cardiovascular reoperations were observed in three and six patients, and all-cause deaths in seven and two patients in Group E and Group Y, respectively. The 10-year freedom from aortic valve-related reoperation was estimated to be 91.7±5.6% and 92.7±5.0% (p=0.594), the 10-year freedom from cardiovascular reoperation was 86.4±7.3% and 81.1±7.7% (p=0.781), and the cumulative 10-year survival rates were 74.0±9.2% and 93.8±4.3% (p=0.018) in Group E and Group Y, respectively. During follow-up, 6.7% of patients were in NYHA class III and 6.4% of patients developed moderate-to-severe aortic regurgitation. Cox regression analysis failed to identify predictors for primary outcomes.Valve-sparing aortic root replacement can safely be performed in elderly patients with low early mortality and satisfactory long-term freedom from aortic valve-related and cardiovascular re-intervention.

BACKGROUND: Left heart involvement might be a differential factor in the physiopathology and prognosis of severe tricuspid regurgitation (TR) following cardiac surgery. We aimed to compare the outcomes of isolated tricuspid valve surgery (ITVS) after congenital versus left heart-disease surgery. METHODS: We retrospectively studied and followed up 58 patients who underwent ITVS for TR following cardiac surgery in our center from January 2012 to December 2017. According to the different etiologies of TR, the participants were divided into one group of TR following surgery for congenital heart diseases (CHD) (pCHD group, n=24), and another group of TR following surgery for left heart disease (pVHD group, n=34). RESULTS: Compared to the pCHD group, the pVHD group presented with a more advanced age (P

AIM To investigate the survival benefit of bilateral internal mammary artery (BIMA) grafts in patients with left ventricular dysfunction. METHODS Between 1996 and 2009, we performed elective, isolated, primary, multiple cardiac arterial bypass grafting in 430 consecutive patients with left ventricular ejection fraction ≤ 40%. The early and long-term results were compared between 167 patients undergoing BIMA grafting and 263 patients using left internal mammary artery (LIMA)-saphenous venous grafting (SVG). RESULTS The mean age of the overall population was 60.1 ± 15 years. In-hospital mortality was not different between the two groups (7.8% vs 10.3%, P = 0.49). Early postoperative morbidity included myocardial infarction (4.2% vs 3.8%, P = 0.80), stroke (1.2% vs 3.8%, P = 0.14), and mediastinitis (5.3% vs 2.3%, P = 0.11). At 8-year follow-up, Kaplan-Meier-estimated survival (74.2% vs 58.9%, P = 0.02) and Kaplan-Meier-estimated event-free survival (all cause deaths, myocardial infarction, stroke, target vessel revascularization, heart failure) (61.7% and 41.1%, P < 0.01) were significantly higher in the BIMA group compared with the LIMA-SVG group in univariate analysis. The propensity score matching analysis confirmed that BIMA grafting is a safe revascularization procedure but there was no long term survival (P = 0.40) and event-free survival (P = 0.13) in comparison with LIMA-SVG use. CONCLUSION Our longitudinal analysis suggests that BIMA grafting can be performed with acceptable perioperative mortality in patients with left ventricular dysfunction.

Aims Little data on very long-term survival and associated prognostic factors in heart failure (HF) are available. The aim was to describe 15-year survival and to identify the baseline prognostic factors associated with mortality in a community-based sample of patients hospitalized for systolic HF. Methods Vital status was collected 15years after inclusion of 352 patients hospitalized for systolic HF born in France from the prospective cohort EPICAL. The prognostic value of baseline socioeconomic, clinical and biological characteristics on 15-year mortality was assessed using Cox models. Results The mean (±SD) age was 63.9 (±10.8)years, 76% of the patients were male, median left ventricular ejection fraction (LVEF) was 23% IR [18–27]. Overall, the mean (±SD) follow-up was 1826 (±111)days. A total of 290 (82.4%) deaths and 22 heart transplantations occurred during the follow-up. The 15-year survival rate was 13.2% (95% CI [9.0–16.3]), i.e. 4.7 times lower than the one observed in the general population. Baseline characteristics associated with 15-year mortality were: age older than 65years (HR=1.48, CI 95% [1.15–1.90]), diabetes mellitus (1.31 [1.00–1.72]), chronic kidney disease (1.73 [1.23–2.43]), serious comorbidity (1.29 [1.02–1.64]), time from first HF diagnosis exceeding 1year at inclusion (1.68 [1.26–2.24]), HF hospitalization during the previous 12months (1.36 [1.04–1.78]), heart rate higher than 110 beats per minute (1.87 [1.26–2.76]), LVEF % (0.88 per quartile increase [0.80–1.98]), and serum sodium below 130mmol/L (3.14 [1.76–5.61]. Conclusions Only 13% of patients hospitalized for HF survived at 15years. The usual mid-term prognostic factors are also predictive of very long-term survival.

PURPOSE To evaluate endovascular repair of type II and III thoracoabdominal aortic aneurysms (TAAA) using the Multilayer Flow Modulator (MFM) in patients with contraindications for open surgery and fenestrated stent-grafts. METHODS In this prospective, multicenter, nonrandomized trial (EudraCT registration: 2009-013678-42; ClinicalTrials.gov identifier NCT01756911), 23 patients (19 men; mean age 75.8 years) with Crawford type II (43.5%) and III (56.5%) TAAA (mean diameter 6.5 cm) were treated with the MFM between April 2010 and February 2011. The primary efficacy outcome measure was stable aneurysm thrombosis with associated branch vessel patency at 12 months; the primary safety endpoint was 30-day and 12-month all-cause mortality. RESULTS The rate of technical success was 100%. In 20 patients with computed tomography scans at 12 months, the primary efficacy outcome was met in 15 patients. The rate of primary patency of covered branch vessels was 96% (53/55); 1 patient with 2 occluded visceral branches underwent successful surgical reintervention. Endoleaks were identified in 5 patients (3 attachment site and 2 at device overlap), 4 of whom underwent reintervention (3 additional MFMs and 1 stent-graft implanted). At 12 months, aneurysm diameter was stable in 18 of 20 patients; the mean ratio of residual aneurysm flow volume to total volume had decreased by 28.9%, and the mean ratio of thrombus volume to total lumen volume had increased by 21.3% (n=17). There were no cases of device migration, loss of device integrity, spinal cord ischemia, or aneurysm rupture. CONCLUSION At 1 year, endovascular repair with the MFM appears to be safe and effective while successfully maintaining branch vessel patency. Follow-up is ongoing.

Annuloplasty constitutes a major operative step in the surgical treatment of degenerative mitral valve regurgitation (MR). The choice of ring structure to obtain an adequate remodeling of the mitral orifice and to respect the motion of the mitral apparatus remains the subject of debate. The study aim was to determine the clinical and echocardiographic outcome when using an open rigid ring to treat MR.A total of 129 patients (94 men, 35 women; mean age 64.5 ± 11.7 years) was referred to the authors' institution between 1997 and 2011 for the surgical management of severe MR. Patients were implanted with a modified open rigid annuloplasty ring, and also underwent anterior and/or posterior leaflet repair. The occurrence of any major adverse cardiac and cerebrovascular event (MACCE) was considered as the primary end-point and was retrospectively collected along with echocardiographic data.The perioperative mortality was 1.6%. The cardiopulmonary bypass and cross-clamp times were 73.3 ± 17.1 min and 51.6 ± 13.0 min, respectively. There was one case (0.7%) of postoperative mitral systolic anterior motion. During a mean follow up period of 6.0 ± 3.1 years, 25 patients (19%) presented a MACCE. MACCE-free survival at one, five and 10 years was respectively 96.8%, 91.3%, and 61.4%. Preoperative determinants of MACCE were paroxysmal/persistent atrial fibrillation (HR 2.53; 95% CI: 1.06-6.01; p = 0.035) and age (HR 1.05; 95% CI: 1-1.09; p = 0.035).Mitral valve repair with an open-rigid ring offers satisfactory long-term results with a low rate of subsequent MR recurrence and reintervention. Preoperative AF is the main determinant of long-term adverse outcome.

Resume Objectif Decrire l’utilisation de facteur VII active recombinant (rFVIIa) chez des patients sous ECMO centrale veino-arterielle avec une attention particuliere sur les complications thrombotiques associees. Conception de l’etude Etude retrospective monocentrique. Patients et methodes Nous avons etudie les dossiers des 91 patients mis sous ECMO entre 2005 et 2010. Durant cette periode, huit patients ont presente une hemorragie refractaire et ont recu du rFVIIa comme therapeutique de sauvetage. Resultats Chez six patients, l’hemorragie a ete jugulee. Une diminution du saignement a ete mise en evidence apres l’administration de rFVIIa (pre-rFVIIa : 40,1 ± 33,1 mL/kg par trois heures versus 5,4 ± 3,2 mL/kg par trois heures ( p = 0,01). Les besoins transfusionnels ont ete diminues apres administration de rFVIIa. Aucun evenement thrombotique n’a ete detecte. Le fibrinogene, les d -dimeres, la numeration des plaquettes et les lactates n’ont pas ete modifies par le traitement. Deux patients ont ete sevres de l’ECMO. Un est decede 17 jours apres le sevrage. L’autre patient a survecu sans sequelles neurologiques. Conclusion Le rFVIIa est un traitement d’exception chez le patient traite avec une ECMO centrale veino-arterielle. Il ne doit pas etre administre avant que toutes les therapeutiques conventionnelles n’aient ete tentees, mais peut etre une solution de sauvetage en presence d’une hemorragie massive.

Bilateral internal mammary arteries (BIMA) remain widely underused in coronary artery bypass grafting (CABG). In this study, we aim to investigate the early and long-term outcomes of BIMA grafts in isolated CABGs.Single-centre retrospective observational study.University Hospital, Nancy.1000 consecutive patients undergoing elective, isolated, primary, multiple CABGs using BIMA grafts and supplemental venous grafts for multi-vessel coronary disease.In-hospital mortality and major morbidity, and long-term all-cause mortality.Mean age of the overall population was 60 ± 15 years. A left ventricular ejection fraction (LVEF) ≤ 45% was found in 28% of the patients and 27.1% of the patients were diabetics. Comorbidities were represented by chronic renal failure, chronic obstructive pulmonary disease and peripheral artery disease in 11, 11.7 and 27.3% of the cases, respectively. The in-hospital mortality rate was 2.8%. Early postoperative morbidity included myocardial infarction (2.2%), stroke (0.9%), mesenteric ischaemia (0.7%) and mediastinitis (2.2%). The Kaplan-Meier 8-year survival rates for patients less than 65 and between 65 and 74 years of age were 88% and 66%, respectively (p0.01). Multiple regression analysis showed that patients' age 65 years or greater at baseline (OR 2.3; 95% CI 1.3 to 4, p0.001), acute coronary syndrome (OR 1.9; 95% CI 1.1 to 3.4, p = 0.02), chronic renal failure (OR 2.7; 95% CI 1.4 to 5.2, p0.001), peripheral artery disease (OR 3.1; 95% CI 1.8 to 5.5, p0.001) and LVEF ≤ 45% (OR 2.6; 95% CI 1.4 to 4.5, p0.001) were independent predictors of long-term cardiovascular mortality.Our longitudinal analysis presents encouraging data concerning operative risk of BIMA grafting and provides excellent long-term survival in appropriately selected patients.

Background Patients with non-ST elevation acute coronary syndrome complicated by left ventricular dysfunction (LVEF) are a poor prognosis group. The aim of our study was to assess the short and long term LEVF prognostic value in a cohort of NSTE-ACS patients undergoing surgical revascularization. Methods We performed elective and isolated CABG on a cohort of 206 consecutive patients with LVEF≤0.40 complicating acute coronary syndrome. The case cohort was compared with a cohort of controls (LVEF>0.40) randomly selected (2:1) among patients who underwent the procedure during this period. Results The Kaplan-Meier 5-year estimated survival rates for patients in the low and normal LVEF groups were 70.8% (95% confidence interval CI: 64.2–77.4) and 81.7% (95%CI: 77.8–85.6), respectively. A low LVEF was associated with both a higher all-cause (HR [95%CI] = 1.84[1.18–2.86]) and a higher cardiovascular mortality (HR = 2.07 [1.27–3.38]) during the first 12 months of follow-up. After adjustment for potential confounders, a low LVEF remained associated with a higher cardiovascular mortality only (1.87[1.03–3.38]) during the first 12 months of follow-up. After 12 months of follow-up, a low LVEF was no more associated with all-cause, nor cardiovascular mortality. Conclusion Patients with low LVEF might require more intensive care than patients with normal LVEF during the year after the surgical procedure, but once the first postoperative year over, the initial low LVEF was no more associated with long term mortality.

Purpose: To evaluate midterm outcomes of endovascular repair of types II and III thoracoabdominal aortic aneurysms (TAAA) using the Multilayer Flow Modulator (MFM) in patients unsuitable for open surgery or fenestrated stent-grafts. Methods: In the prospective, multicenter, nonrandomized STRATO trial (EudraCT registration: 2009-013678-42; ClinicalTrials.gov identifier NCT01756911), 23 patients (mean age 75.8 years; 19 men) with Crawford type II and III TAAA (mean diameter 6.5 cm) were implanted between April 2010 and February 2011. Outcomes included all-cause mortality and stable aneurysm thrombosis with associated branch vessel patency. Results: Through 36 months, there were 7 deaths (none confirmed as aneurysm-related), and no cases of spinal cord injury, device migration or fracture, or respiratory, renal, or peripheral complications. Three patients were lost to follow-up and 2 devices were explanted. The device was patent in the 11 remaining patients at 3 years. Stable aneurysm thrombosis was achieved for 15 of 20 patients at 12 months, 12 of 13 at 24 months, and 10 of 11 at 36 months. The rate of branch patency was 96% at 12 months (primary patency), 100% at 24 months, and 97% at 36 months. Nine patients suffered from endoleaks (attachment site or device overlap); 9 patients underwent 11 reinterventions (3 surgical). Maximum aneurysm diameter was stable for 18 of 20 patients at 12 months, 11 of 13 at 24 months, and 9 of 11 at 36 months. For 10 patients with computed tomography at 36 months, the mean ratio of aneurysm flow volume to total volume had decreased by 83%; the mean ratio of thrombus volume to total volume increased by 159%. Conclusion: Through 3 years, endovascular repair with the MFM appears to be safe and effective while successfully maintaining branch vessel patency.

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.

Patients with Turner syndrome are prompt to develop spontaneous acute aortic dissection following insidious aortic dilatation, with abnormal cardiovascular anatomy and consequently require specific guidelines for regular surveillance since they represent a subset of high-risk young patients. We report a rare and uncommon case of spontaneous acute aortic dissection in a 48-year old female patient with Turner syndrome who was not apparently eligible for a prophylactic surgery. A CT scan showed a Stanford type A aortic dissection and was urgently referred for surgical management. We operated on the patient under deep hypothermia (18°C) and circulatory arrest with a retrograde cerebroplegia as the primary entry tear was located in the arch. The postoperative course was uneventful and the patient was discharged at the eighth postoperative day. Following description of this case, special attention was paid to determine predisposing risk factors for aortic dissection to be specifically adjusted to TS patients.

Pulmonary artery aneurysm is a rare pathology and the optimal treatment approach remains unclear in the absence of clear guidelines. We report a case of pulmonary aneurysm and discuss the treatment options.

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.

Arterial blood gas assessment is still routinely performed in candidates for a cardiovascular surgery. Whether sampling arterial blood is useful in an elderly patient with a near normal lung function and who meets all other criteria for operability, is unknown. Therefore, it was our purpose to provide reference values for arterial blood gases in these patients and to examine how the level of arterial oxygen partial pressure (PaO(2)) might influence postoperative outcome. We retrospectively studied arterial blood gases in 201 patients, aged 70-92 years with normal or near normal ventilatory function awaiting a planned cardiovascular surgery. PaO(2) averaged 81.6+/-7.6 mmHg and PaCO(2) averaged 37.7+/-3.2 mmHg. Both were independent of age. Factors associated with mortality according to bivariate analysis were: gender (female), type of surgery (valve replacement), and a low PaO(2) with strictly no ventilatory abnormality. In conclusion, PaO(2) values in elderly patients with cardiac disease and normal ventilatory function are greater than those obtained by extrapolation from healthy younger subjects. PaO(2) measurement should be recommended prior to cardiovascular surgery in elderly patients since a low PaO(2) with strictly normal ventilatory function is significantly associated with an increased risk for postoperative mortality.

Postinfarction ventricular septal defect (PIVSD) is a devastating mechanical complication following acute myocardial infarction. The management of this pathology is quite challenging, especially in case of complicated cardiogenic shock. The difficulties lie in the timing and type of intervention. Debates exist with regard to immediate versus deferring repair, as well as open repair versus percutaneous closure. The anatomic characteristics and hemodynamic consequence of PIVSD are important elements determining which strategy to adopt, since large septal defect (>15 mm) cannot be appropriately treated by percutaneous occluder devices limiting by their available size, while compromised hemodynamics usually require emergent repair or mechanical support “bridging to surgery”. Herein, we report our experience of successful management of a case of cardiogenic shock complicating large PIVSD (38 mm) by delayed surgical repair bridged with Extracorporeal Membrane Oxygenation (ECMO) during 7 days. We emphasize the importance of 3-dimensional transesophageal echocardiography as a decision-making tool.

Telerobotic-assisted laparoscopic attempts to provide technological solutions to the inherent limitations of traditional laparoscopic surgery. The aim of this study is to report the first experience of two teams concerning telerobotic-assisted laparoscopic hysterectomy for benign and malignant pathologies. This study included 14 patients at the University Hospital Saint Pierre of Brussels (Belgium) and 16 patients at the Cancer Center of Nancy (France) from September 1999 to July 2003. The indications for surgery were uterine malignant diseases in 12 cases (stade I) (41%), and benign pathologies of the uterus in 18 cases (59%). Five postoperative complications (17%) occurred, none related to the robotic system. Robotic surgery can be safely performed in gynecologic and gynecologic–oncologic surgery with no increase in complication rates. A significant advance is represented by the surgeon’s ergonomic improvement.

We report the case of a 66-year-old male with increasing angina occurring after two previous coronary artery surgery procedures. The second operation had been complicated by severe mediastinitis necessitating surgical drainage, and sternal stabilization. Angiography revealed an occlusion of the LAD bypass with a patent LAD associated with a stenotic circumflex coronary artery. The ascending aorta was severely calcified. An off-pump axillo-LAD coronary artery bypass was safely performed in conjunction with stenting of the circumflex artery. This approach dramatically simplified the procedure and reduced the operative risk. At the 52-month follow-up, the patient is free of any angina symptoms. doi: 10.1111/jocs.12113 (J Card Surg 2013;28:388–390)

International audience; A small cardiac tumor in the left ventricle was discovered incidentally in a 53-year-old patient by echocardiography and was further confirmed by magnetic resonance imaging. A clinical diagnosis of "fibroelastoma or myxoma with an atypical location?" was made, and an uneventful surgical resection was carried out in consideration of the potential embolic risk. The histologic analysis revealed a capillary hemangioma. A posteriori, we reviewed the coronary angiography performed 2 years earlier and found a typical "tumor blush" sign. We discuss the diagnostic features of this case and the alternative approaches that could have been chosen, including a conservative approach with close follow-up.

OBJECTIVESCharacterize the incidence, clinical and etiologic features and outcomes of advanced congestive heart failure.BACKGROUNDThis condition is frequent, severe and costly, yet no population-based epidemiological data are available that take into account modern advances in diagnosis and therapy.METHODSThe EPICAL (EPidémiologie de l’Insuffisance Cardiaque Avancée en Lorraine) study was based on a comprehensive registration of patients with ACHF (defined as hospital admission for presence of NYHA class III or IV symptoms, radiological and/or clinical signs of pulmonary congestion and/or signs of peripheral edema, left ventricular ejection fraction 60%) in patients aged 20–80 years during year 1994, in the community of the Lorraine region in France (n = 1,592,263). Average follow-up for readmission to hospital and mortality was 18 months (12–24 months).RESULTSFrom 2,576 registered patients, 499 were enrolled into the study among which, 358 were new presentations. This represents a crude incidence rate of 225 per million. 46.3% had a coronary heart disease. One-year mortality rate was 35.4% and the rate of mortality and/or readmission to hospital was 81%. Patients were admitted to hospital 2.05 times per year (64% of these for worsening heart failure), spending 27.6 days per year in hospital. Twenty received a heart transplant (4%). On discharge, 74.8% were using ACE inhibitors and 49.6% digitalis.CONCLUSIONSMortality and hospitalization rate of advanced CHF remain very high despite recent therapeutic progress. Major therapeutic and managed-care research is required.

BackgroundPatients with non-ST elevation acute coronary syndrome complicated by left ventricular dysfunction are a poor prognosis. The aims of our study were to describe the use of surgical revascularization in these high risk patients and to assess the impact of left ventricular dysfunction on long term outcomes.MethodsBetween 1996 and 2008, we performed elective, isolated, primary CABG in 206 consecutive patients with LVEF≤0.40 complicating acute coronary syndrome. The case group was compared with a group of controls randomly selected (2:1) among the patients who underwent the procedure during this period.ResultsThe analysis of in-hospital course showed a significantly greater all-cause mortality (14.1% vs 7.3%, p

Background. Brain death-related cardiovascular dysfunction has been documented; however, its mechanisms remain poorly understood. We investigated changes in myocardial function and metabolism in brain-dead and control pigs. Methods. Heart rate, systolic (SAP) and mean (MAP) arterial pressure, left ventricular (LV) dP/dt max , ratepressure product, cardiac output (CO), left anterior descending coronary artery blood flow, lactate metabolism, and interstitial myocardial purine metabolite concentrations, monitored by cardiac microdialysis, were studied. A volume expansion protocol was performed at the end of the study. Results. After brain death, a transient increase in heart rate (from 90 [67-120] to 158 [120-200] beats/min) (median, with range in brackets), MAP (82 [74-103] to 117 [85-142] mmHg), LV dP/dt max (1750 [1100-2100] to 5150 [4000-62,000] mmHg.sec -1 ), rate-pressure product (9100 [7700-9700] beats mmHg/min to 22,750 [20,000-26,000] beats mmHg/min), CO (2.2 [2.0-4.0] to 3.3 [3.0-6.0] L/min), and a limited increase in left anterior descending coronary artery blood flow (40 [30-60] to 72 [50-85] ml/min) were observed. Net myocardial lactate production occurred (27 [4-40] to -22 [-28, -11] mg/L, P

Operative risk is assessed preoperatively through the use of predictive scores. The study aim was to evaluate the validity of five different scoring systems, including the Society of Thoracic Surgeons (STS) score, additive and logistic European systems (EuroSCORE 1) for cardiac operative risk evaluation, EuroSCORE 2, and the Ambler score in octogenarian patients undergoing aortic valve replacement (AVR).A total of 225 patients agedor = 80 years with aortic stenosis underwent isolated AVR between January 1996 and September 2010. All five scores were evaluated with regards to their accuracy in predicting operative mortality, mortality at one year, and the capacity to identify those patients most likely to die during long-term follow up.The observed operative mortality rate was 7.6%. The observed/expected ratios calculated for perioperative mortality were 0.42, 0.87, 1.16 and 1.16 for the logistic EuroSCORE, Ambler score, STS score and EuroSCORE 2 cohorts, respectively. The Hosmer-Lemeshow statistical test showed that all five scores were well calibrated. The STS score was a good test for predicting operative mortality (AUC 0.81) and the EuroSCORE 2 was fair (AUC 0.72). In terms of predicting the one-year mortality rate, the STS score was ranked as fair (AUC0.7). It was noted that patients with a STS scoreor = 75th percentile were more likely to die during the follow up period.The STS score appeared to be more adequate for predicting operative mortality among patients agedor = 80 years. STS scores were predictive of both one-year and long-term survival rates. These results indicated that the STS score could be used to guide clinical decision-making for performing AVR in elderly patients.

We report the case of a 66-year-old male with increasing angina occurring after two previous coronary artery surgery procedures. The second operation had been complicated by severe mediastinitis necessitating surgical drainage, and sternal stabilization. Angiography revealed an occlusion of the LAD bypass with a patent LAD associated with a stenotic circumflex coronary artery. The ascending aorta was severely calcified. An off-pump axillo-LAD coronary artery bypass was safely performed in conjunction with stenting of the circumflex artery. This approach dramatically simplified the procedure and reduced the operative risk. At the 52-month follow-up, the patient is free of any angina symptoms.

OBJECTIVES: The outcomes of emergency cardiac transplantation remain controversial, but recipient selection is essential for success. With a shortage of organs, it is essential to determine an objective method, such as a risk score, for choosing patients who are at too great a risk to undergo cardiac transplantation. In this study, we analysed the model for end-stage liver disease in terms of predicting operative mortality after emergency cardiac transplantation. METHODS: We analysed the Nancy University database of heart transplantation and selected all patients who underwent emergency heart transplantation between January 2005 and January 2012. The calibration and discriminatory power were evaluated to determine the model for end-stage liver disease (MELD) score. Preoperative and peri-operative variables regarding the prediction of operative mortality were analysed by univariate and multivariate logistic regression models. RESULTS: Forty-three patients underwent emergency cardiac transplantation. The operative mortality was 20.9% (n= 9). The Hosmer– Lemeshow test demonstrated a calibrated model for predicting operative mortality (P= 0.15), and the MELD score presented an excellent discrimination between survivors and non-survivors (AUC: 0.89 ± 0.05; 95% CI: 0.79–0.99). In the univariate analysis, an MELD score of ≥16 and bilirubin concentration were predictive markers of operative mortality. Multivariate logistic regression tested the contribution of the univariate risk predictors (P< 0.15) and confirmed that an MELD score of ≥16 was predictive of operative mortality. CONCLUSIONS: The MELD score appears to be adequate for predicting operative mortality among patients who undergo heart transplantation. The MELD score could therefore be used to guide clinical decision-making for emergency transplantation.

Purpose: Up to now, there has been limited investigation into cell therapy in the chronic phase of severe myocardial infarction (MI), and many questions remain concerning the contribution of the engrafted cells and especially their impact on the reperfusion of MI areas, when assessed by objective quantitative imaging techniques. This randomized pilot SPECT, PET, and MRI study was aimed at assessing the effects of bone marrow mononuclear cells (BMNCs) when implanted in areas of severe and chronic MI. Materials and Methods: Fourteen patients, who were referred for coronary artery bypass grafting (CABG) and in whom a screening MIBI-SPECT revealed severely damaged myocardium (G50% uptake under nitrate), were randomized between a cell therapy group (n = 7; CABG and injection of BMNCs within MI areas) and a control group (n = 7; CABG alone). Results: The MI areas exhibited a posttherapeutic enhancement in the restuptake of MIBI in the cell therapy group [difference between 6-month control and baseline: +6.8% (5.4%), P = 0.03] but not in the control group [+1.0% (4.3%)]. However, in a per-patient analysis, this improvement was significant (9 +9%) in only 3 cell therapy patients, whose MI areas before therapy had a higher FDG uptake [59% (9%) vs 38% (8%), P = 0.03] and a lower transmural extent at MRI [40% (6%) vs 73% (18%), P = 0.03] when compared with the other cell therapy patients. Conclusions: Perfusion enhancement, obtained with BMNCs in areas of chronic MI, might require an intermediate level of viability documented with FDG-PET and MRI and that totally necrotic MI seems refractory to this cell therapy technique.

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.

In heart surgery departments, patients follow a specific route, from the initial appointment through to the post-operative outpatient appointment. A study was carried out in 2009 in order to compare the caregivers' experience with the needs expressed by patients during this journey. It forms part of a global quality of care improvement approach.

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.

To assess long-term outcome of coronary artery diseased patients undergone the surgical angioplasty of left main coronary artery.From September 1983 to December 2004, 162 patients were operated on for left main coronary artery stenosis with surgical angioplasty. The data were retrospectively analyzed. Operative death associated factors were evaluated with univariate analysis, and long-term survival was estimated by Kaplan-Meier analysis.The in-hospital mortality was 8% for all the patients but only 5.1% for the patients with simple left main coronary artery stenosis. A significant drop of operative mortality was noted in the later era of treatment (1983 to 1994 vs. 1994 to 2004). The operative death was more likely associated with no-isolated left main coronary artery pathologic feature and the urgency of surgery. An average of 102 (8 to 264) months' follow-up was completed in 95% of discharged patients. Coronary event occurred in 42 patients in the follow-up period and it was mortal for 9 cases. The overall long-term survival was 81% at 10 years and 52% at 20 years. The coronary event-free survival was 77% at 10 years and 41% at 20 years.Surgical angioplasty of left main coronary artery could produce excellent long-term outcome with acceptable per-operative mortality in left main coronary artery stenosis patients. This technique should deserve an important place in therapeutic options for this cohort of patients.

This prospective multicentre study assessed the midterm clinical and haemodynamic results of the Edwards Mira curved bileaflet prosthesis in aortic position. From June 1998 to October 2000, 117 patients, mean age 64 years (31-78 years) underwent aortic valve replacement with the Edwards Mira valve in three institutions. Clinical status, haemodynamic performance and valve related complications were assessed. Serial echocardiographic examinations were performed at discharge and at least two years follow-up. Operative mortality was 1.7% (n=2). Follow-up was 100% complete (594.1 patient-years). Actuarial survival at one, three and five years was 96.5+/-1.7%, 93.9+/-2.2% and 88.4+/-3.0%, respectively. Freedom from thrombosis was 99.1+/-0.9%, from embolic events: 96.2+/-1.9%, from bleeding events: 96.4+/-1.7%, and from non-structural dysfunction 97.2+/-1.6%. There was no structural dysfunction. The peak gradient at discharge was 22.13+/-8.1 mmHg down to 20.8+/-8 mmHg at 28 months. The mean gradient at discharge was 12.7+/-4.5 mmHg at discharge down to 10.8+/-4.2 mmHg at 28 months. The permeability index was 53.3+/-10% at 28 months. The Edwards Mira aortic valve showed excellent midterm haemodynamic performance, good midterm survival and low valve related complications rate. Long term follow-up remains to be assessed.

1010-7940/$ — see front matter # 2007 European Association for Cardio-Thoracic doi:10.1016/j.ejcts.2007.09.034 clavicle luxation. The patient was operated and we realized a bypass between proximal undamaged brachiocephalic artery trunk and the right subclavian carotid bifurcation. A 49-year-old woman was admitted after a fall in the staircases. Chest CT scan (Figs. 1 and 2) shows a pseudoaneurysm of the brachiocephalic artery caused by posterior

Cell therapy-induced changes in the perfusion of areas of myocardial infarction (MI) remain unclear. This study investigated whether an original pinhole SPECT technique could be applied to a rat MI model to analyze local improvement in myocardial perfusion relating to engraftment sites of bone marrow-derived stem cells (BMSCs).Four-month-old MI rats were either untreated (n = 8) or treated (n = 10) by intramyocardial injection of (111)In-labeled BMSCs. Early distribution of (111)In-BMSCs within the MI target was evidenced by dual (111)In/(99m)Tc pinhole SPECT 48 h later. Myocardial perfusion was serially monitored by (99m)Tc-sestamibi pinhole gated SPECT up to 3 mo after transplantation.Forty-eight hours after transplantation, (111)In-BMSCs were observed in all treated rats and in 18 of their 32 underperfused MI segments (70% sestamibi uptake before transplantation). During the subsequent 3-mo follow-up, the perfusion of MI segments worsened in untreated rats (absolute change in sestamibi uptake, -3% +/- 3%; P0.05) but improved in treated rats (+4% +/- 7%; P0.05). This perfusion improvement was unrelated to the initial detection of (111)In-BMSCs (+2% +/- 6% in segments with (111)In-BMSCs vs. +5% +/- 7% in those without; not statistically significant) but was strongly associated with less severe perfusion defects before transplantation (+6% +/- 6% in segments with 60%-70% sestamibi uptake [n = 19] vs. -1% +/- 6% in those with60% uptake [n = 13]; P = 0.003).When BMSCs are injected within chronic MI, perfusion enhancement predominates in the MI areas showing a high enough residual perfusion before treatment but not in those of the initial cell engraftment, giving evidence of dependency on the perfusion and metabolic environment at implantation sites.

International audience; OBJECTIVE: This study was designed to assess the ability of an ultrasound-guided radiofrequency (RF)-driven procedure to induce complete and irreversible cord occlusion using a 90 days fetal sheep model. STUDY DESIGN: Twenty 90 days gestation sheep underwent general anesthesia. The first ten fetuses were exposed under hysterotomy, and RF electrode was inserted visually in the middle of the umbilical cord and deployed. Fetuses were then replaced into the amniotic fluid and RF procedure (average target temperature of 100 degrees C during 10 minutes) was applied. For the next ten fetuses, RF electrode was inserted into the cords under trans-parietal ultrasound guidance and the same RF procedure was applied. Cord occlusion was assessed by Doppler examination (absence of cordonal flows at the end of the procedure and until fetal heart failure occurred) and by subsequent histopathological analysis. RESULTS: Cord occlusion was always complete at Doppler examination at the end of RF procedure for the ten experiments realized under hysterotomy. No cordonal reperfusion was observed until fetal heart failure. Histopathological analysis confirmed cordonal occlusion at the site of impact. Neither cordonal rupture nor cordonal bleeding was observed for any of the ten experiments. When RF electrode was inserted under ultrasound guidance, complete occlusion could be obtained only for 6 of the ten experiments. CONCLUSION: Our results suggest that RF might be an appropriate method for selective termination of pregnancy. Yet, optimal insertion of the electrode is required to engender a complete and irreversible cord occlusion, and ultrasound-guidance training seems necessary before current human application.

Cell therapy with bone marrow mesenchymal stem cells (BMSCs) is a new strategy for treating ischemic heart failure, but data concerning the distribution and retention of transplanted cells remain poor. We investigated the short-term myocardial retention of BMSCs when these cells are directly injected within necrotic or intact myocardium. 111Indium-oxine-labeled autologous BMSCs were injected within either 1-month-old infarction (n = 6) or normal myocardium (n = 6) from rats. Serial in vivo pinhole scintigraphy was scheduled during 1 week in order to track the implanted cells. The myocardial retention of BMSCs was definitely higher in myocardial infarction than in normal myocardial area (estimated percent retention at 2 h: 63 ± 3% vs. 25 ± 4%, p < 0.001) and the estimated cardiac retention values were unchanged in both groups along the 7 days of follow-up. On heart sections at day 7, labeled BMSCs were still around the injection site and appeared confined to the scarred tissue corresponding either to the infarct area or to the myocardium damaged by needle insertion. BMSCs have a higher retention when they are injected in necrotic than in normal myocardial areas and these cells appear to stay around the injection site for at least a 7-day period.

Recent experimental and clinical studies have shown that autologous cell based therapy using skeletal myoblasts or bone marrow-derived stem cells might have beneficial effects in chronic ischemic heart disease. The underlying concept is based on the repopulation of necrotic tissue by either readily contractile myoblasts or by bone marrow-derived stem cells. However, there is a need to resolve a number of issues for determining the better way to perform these treatments and, moreover, for assessing the real beneficial functional effect of each of these cell therapies. In this mini-review, we will discuss (i) the issues of the selection of chronic infarct animal to truly determine the impact of cell therapy on cardiac function recovery, and (ii) the evaluation of the bio-availability and the bio-distribution of transplanted cells. Some new investigational methodologies based on clinical end-points are also proposed.

Cell therapy using bone marrow mesenchymal stem cells (BMSCs) shows promise in the treatment of myocardial infarction (MI) but accurate cell delivery within MI areas remains critical. In the present study, we tested the feasibility of in vivo pinhole SPECT imaging for monitoring the sites of intramyocardial implanted BMSCs in relation to targeted MI areas in rats.BMSCs were labelled with (111)In-oxine and injected within the fibrotic areas of 3-month-old MI in ten rats. Two days later, dual (111)In/(99m)Tc-sestamibi pinhole SPECT was recorded for localisation of (111)In-BMSCs on a 15-segment left ventricular (LV) division. Additional (99m)Tc-sestamibi pinhole SPECT had been performed 1 month earlier and on the day before transplantation. In vitro counting on histological sections was used to validate the pinhole SPECT determination of (111)In-BMSC activity within LV segments.The underperfused MI area (segments with70% uptake) was stable between the (99m)Tc-sestamibi SPECT study recorded at 1 month (4.6+/-1.9 segments) and at 1 day (4.7+/-2.3 segments) before transplantation. (111)In-BMSCs were detected by dual-energy SPECT in 56 segments: 33 (59%) were underperfused MI segments but 23 (41%) were not (14 adjacent and nine remote segments). Finally, (111)In-labelled BMSCs were not detected in 14 out of the 47 (30%) underperfused MI segments.When BMSCs are injected within MI areas in rats, sites of early cell retention do not always match the targeted MI areas. The dual-energy pinhole SPECT technique may be used for monitoring the sites of early retention of implanted BMSCs and the data obtained may have critical importance when analysing the effects of cardiac cell therapy.

Background. The purpose of this prospective, randomized, open-label, phase II, multicenter study was to optimize the initial oral dose of tacrolimus. Methods. A total of 113 patients were randomly assigned to initial low-dose (0.075 mg/kg/day, n=55) or high-dose (0.15 mg/kg/day, n=58) oral tacrolimus and followed for 3 months. Target whole-blood trough levels were 10 to 20 ng/mL. Prophylactic use of corticosteroids and azathioprine was identical in both groups, and antibody induction was mandatory. The primary endpoint was the time to and incidence of the initial oral tacrolimus dose adjustment because of toxicity or rejection, or withdrawal before initial dose change. Efficacy was assessed by the occurrence of biopsy-proven rejection (International Society for Heart and Lung Transplantation grade ≥ 1B). Results. In the primary endpoint, no significant difference was observed between the low- and high-dose groups. After 3 months, there was no difference in freedom from initial oral tacrolimus dose change because of rejection, toxicity, or withdrawal (89.0% vs. 87.6%; not significant [NS] ). In both groups, dose adjustments were mainly required to achieve and maintain target blood levels (80.0% vs. 82.8%; NS). Patient survival was 92.7% and 98.3% (NS). There was no significant difference between groups regarding freedom from biopsy-proven acute rejection (57.1% vs. 66.3%; NS). The overall safety profiles indicated a tendency toward better tolerability in the low-dose group. Conclusions. Although low-dose and high-dose tacrolimus had similar efficacy, low-dose tacrolimus was associated with a more favorable safety profile. Therefore we recommend starting tacrolimus therapy after antibody induction at 0.075 mg/kg and adjust dose according to whole-blood trough levels.

Bilateral internal mammary arteries (BIMA) remain still widely underutilized in coronary artery bypass grafting (CABG). This historical cohort study evaluated the early and long term outcomes of BIMA grafts in isolated CABG in a single institution.MethodsBetween 1996 and 2008, we performed elective, isolated, primary, multiple CABG using bilateral internal mammary artery (IMA) grafts and supplemental venous grafts for multivessel coronary disease in 1000 consecutive patients.ResultsThe mean age of the overall population was 64±15 years. 20% of patients were diabetics with a left ventricular ejection fraction (LVEF) ≤45% in 28% of patients. Comorbidities were represented by chronic renal failure, chronic obstructive pulmonary disease and peripheral artery disease in 11%, 11,5% and 26,9% of cases respectively. Acute coronary syndrome represented the initial clinical presentation in 41% of cases.The 30-day mortality rate was 2.8%. Early postoperative morbidity included myocardial infarction (2,2%), stroke (0,9%), mesenteric ischemia (0,7%), sternitis requiring reintervention (6,7%) and supraventricular arrhythmia (23,1%).The follow-up (between 3 and 14,8 years; mean follow up: 6,4±5 years) revealed 103 deaths. Kaplan-Meier 8-year survival rates for patients