Search

Purpose: To prospectively investigate the coronary artery status using coronary CT angiography (CCTA) in patients with Hodgkin lymphoma treated with combined modalities and mediastinal irradiation., Methods and Materials: All consecutive asymptomatic patients with Hodgkin lymphoma entered the study during follow-up, from August 2007 to May 2012. Coronary CT angiography was performed, and risk factors were recorded along with leukocyte telomere length (LTL) measurements., Results: One hundred seventy-nine patients entered the 5-year study. The median follow-up was 11.6 years (range, 2.1-40.2 years), and the median interval between treatment and the CCTA was 9.5 years (range, 0.5-40 years). Coronary artery abnormalities were demonstrated in 46 patients (26%). Coronary CT angiography abnormalities were detected in nearly 15% of the patients within the first 5 years after treatment. A significant increase (34%) occurred 10 years after treatment (P=.05). Stenoses were mostly nonostial. Severe stenoses were observed in 12 (6.7%) of the patients, entailing surgery with either angioplasty with stent placement or bypass grafting in 10 of them (5.5%). A multivariate analysis demonstrated that age at treatment, hypertension, and hypercholesterolemia, as well as radiation dose to the coronary artery origins, were prognostic factors. In the group of patients with LTL measurements, hypertension and LTL were the only independent risk factors., Conclusions: The findings suggest that CCTA can identify asymptomatic individuals at risk of acute coronary artery disease who might require either preventive or curative measures. Conventional risk factors and the radiation dose to coronary artery origins were independent prognostic factors. The prognostic value of LTL needs further investigation., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Conventional surgical treatment of Stanford type A acute aortic dissection (AAD) is associated with considerable in-hospital mortality. As regards very elderly or high-risk patients with type A AAD, some may meet the criteria for less invasive surgery likely to prevent the complications associated with aortic replacement., Methods: We have retrospectively analyzed a cohort of patients admitted to our center for Stanford type A AAD and having undergone surgery between 2008 and 2012. The outcomes of the patients having had an aortic replacement under cardiopulmonary bypass (group A) have been compared with the outcomes of the patients who underwent off-pump wrapping of the ascending aorta (group B)., Results: Among the 54 patients admitted for Stanford type A AAD, 15 with a mean age of 77 years [46 to 94] underwent wrapping of the aorta. Regarding the new standard European system for cardiac operative risk evaluation (EuroSCORE II), the median result in our group B patients was 10.47 [5.02 to 30.07]. In-hospital mortality was 12.80% in group A and 6.6% in group B (p=0.66). For patients who underwent external wrapping of the ascending aorta, follow-up mortality rate was 13.3% with a median follow-up of 15 months [range 0 to 47]., Conclusions: The gold standard in cases of Stanford type A AAD consists of emergency surgical replacement of the dissected ascending aorta. In some cases in which the aortic root is not affected a less invasive surgical approach consisting of wrapping the dissected ascending aorta can be suggested as an alternative., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

None of the animal models have been able to reproduce all aspects of CTEPH because of the rapid resolution of the thrombi in the pulmonary vasculature. The aim of this study was to develop an easily reproducible large-animal model of chronic pulmonary hypertension (PH) related to the development of a postobstructive and overflow vasculopathy. Chronic PH was induced in 5 piglets by ligation of the left pulmonary artery (PA) through a midline sternotomy followed by weekly transcatheter embolization of the right lower-lobe arteries. Sham-operated piglets (n = 5) served as controls. Hemodynamics, RV function, lung morphometry, and endothelin-1 (ET-1) pathway gene expression (ET-1 and its receptors ETA and ETB) were assessed after 5 weeks in the obstructed (left lung and right lower lobe) and unobstructed (right upper lobe) territories. All animals developed chronic PH within 5 weeks. Compared to controls, chronic-PH animals had higher mean PA pressure (28.5 ± 1.7 vs. 11.6 ± 1.8 mmHg, P = 0.0001) and total pulmonary resistance (784 ± 160 vs. 378 ± 51 dyn s(-1) cm(-5), P = 0.05). Echocardiography showed RV enlargement, RV wall thickening (56 ± 5 vs. 30 ± 4 mm, P = 0.0003), decreased tricuspid annular plane systolic excursion (11.3 ± 0.9 vs. 14.4 ± 0.4 mm, P = 0.01), and paradoxical septal motion. In obstructed territories, morphometry demonstrated increases in the number of bronchial arteries per bronchus (8.7 ± 0.9 vs. 2 ± 0.17, P < 0.0001) and in distal PA media thickness (60% ± 2.8% vs. 29% ± 0.9%, P < 0.0001), consistent with postobstructive vasculopathy. Distal PA media thickness was increased in unobstructed territories (70% ± 2.4% vs. 29% ± 0.9%, P < 0.0001). ET-1 was overexpressed in unobstructed territories, compared to controls and obstructed territories. In conclusion, the large-animal model described here is reproducible and led to the development of PH in a relatively short time frame.

Background: TAVI is an alternative solution for patients with aortic valve stenosis (AS) who are refused for conventional surgery. We sought to evaluate the incidence, characteristics, predictors and prognosis impact of serious hemorrhagic complications following transcatheter aortic valve implantation (TAVI)., Methods: One hundred and seventy one consecutive patients with symptomatic severe AS (83.5 ± 6.1 y; 53% women; mean EuroSCORE=22.1 ± 12.3) underwent transapical (TA) or transfemoral (TF) TAVI in our institution using Edwards SAPIEN© and Medtronic CoreValve© devices. The primary evaluated criterion was the incidence of any bleeding complication, according to the Valve Academic Research Consortium (VARC) criteria., Results: VARC serious hemorrhagic complications occurred in 34.5% of patients (n=23 life-threatening/disabling (LT/D) and n=36 major bleedings). Most of these complications were related to access site complications (69%). Multivariable analysis revealed that TA access, low weight and underlying coronary artery diseases were independent predictors for development of serious bleeding. The mortality was significantly higher in patients with serious events compared to patients without bleeding (p=0.008, log-rank analysis). Although the survival didn't significantly differ in patients with major hemorrhagic events, subjects with LT/D bleeding events had a higher mortality than the subjects with no hemorrhagic complications (p<0.001, log-rank analysis). Occurrence of VARC LT/D event independently predicted all-cause mortality (HR=5.35 [2.51-11.43], p<0.001) during the first year following TAVI in multivariate Cox regression analysis., Conclusion: Severe bleeding is frequent following TAVI procedure and is mainly related to local hemorrhage. VARC LT/D events are associated with decreased survival after AS correction., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: To assess the relation of aortic transvalvular gradient with outcomes following transcatheter aortic valve implantation (TAVI)., Background: Relatively little is known about the predictors of adverse outcomes in patients with severe aortic stenosis following TAVI., Methods: We studied 126 consecutive patients (mean age 83.2 ± 6.3 years; 59% women) who underwent TAVI (23% transapical; 77% transfemoral) at our institution. All patients were followed for the incidence of major adverse cardiovascular events (MACE), including myocardial infarction, heart failure, stroke, and cardiovascular death., Results: The acute procedural success rate was 98%; at 1 year, the cumulative incidence of MACE and cardiovascular death was 29% and 10%, respectively. In multivariable analyses adjusting for clinical and echocardiographic risk factors, presence of a baseline mean transvalvular gradient (MTG) <40 mmHg was a significant predictor of 30-day MACE in the total sample (OR 4.4, 95% CI 1.7-11.4; P=0.003) as well as in patients with an ejection fraction ≥ 50% (OR 10.3, 95% CI 3.0-33.4; P<0.001). In multivariable analyses, low MTG was also associated with 2-fold and 4-fold increased hazards for MACE (HR 4.2, 95% CI 2.0-8.9; P<0.001) and cardiovascular death (HR 4.2 95% CI 1.2-14.9; P=0.03), respectively, within 1 year following TAVI., Conclusion: Presence of a low MTG (<40 mmHg) prior to TAVI was associated with a greater risk of major adverse events, including cardiovascular death, up to 1 year following the procedure. Pre-procedural MTG could be used to identify patients at a high risk for adverse outcomes following TAVI., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: During postprandial state, TG concentration is increasing and HDL cholesterol decreasing, leading to a transitory pro-atherosclerotic profile. Previous studies have reported that bicarbonate water improve postprandial lipemia. The objective of this study was to analyze the effect of a strongly bicarbonated mineral water on lipoprotein levels during fasting and postprandial state., Methods: A controlled, randomised, double-blind cross-over design was conducted in 12 moderately hypercholesterolemic subjects after a daily ingestion of 1.25 L of mineral (SY) or low mineral water during eight weeks separated by a one week wash-out period. Blood samples were collected in first visit to the hospital (V1) before water consumption (referent or SY) and in a second visit (V2) after eight week water consumption period. The effect of the consumed water was studied in fasting and in postprandial state during ingestion of a meal and 0.5 L of water., Results: Comparison of data between V1 and V2 after SY consumption showed a significant decrease in triglyceridemia (23%), VLDL TG (31%) and tendency to a decrease of VLDL cholesterol (p = 0.066) at fasting state. Whatever the consumed water during postprandial state, the measurement of total areas under curves did not show a significant difference. No difference was observed between SY and referent water consumption for measured parameters at fasting and postprandial state., Conclusion: When subjects consumed SY we showed a decrease of their basal TG and VLDLTG. The unexpected absence of effect of high mineralized water on postprandial lipemia, probably related to experimental conditions, is discussed in the discussion section.

Aim: To evaluate the evolution of surgical management in a large population of patients with Marfan syndrome., Methods: This is a retrospective study of patients fulfilling the Ghent criteria for Marfan syndrome, who visited the Centre de référence national pour le syndrome de Marfan et apparentés and underwent a surgical event before or during follow-up in the centre., Results: One thousand and ninety-seven patients with Marfan syndrome, according to international criteria, came to the clinic between 1996 and 2010. Aortic surgery was performed in 249 patients (22.7%; 20 children and 229 adults), including the Bentall procedure in 140 patients (56%) and valve-sparing surgery in 88 patients (35%); a supracoronary graft was performed in 19 patients (7.6%), usually for aortic dissection. During the past 20 years, the predominant reason for aortic surgery has switched from aortic dissection to aortic dilatation, while age at surgery has tended to increase (from 32.4 ± 11.9 years to 35.2 ± 12.4 years; P=0.075). Mitral valve surgery was performed in 61 patients (5.6%; six children and 55 adults), including 37 valvuloplasties (60.6%) and 18 mitral valve replacements (29.5%). No significant difference was observed when comparing mitral valve surgery before and after 2000., Conclusion: Surgery performed in patients with Marfan syndrome has switched from emergency surgery for aortic dissection to elective surgery for aortic dilatation; this is associated with surgery performed at an older age despite the indication for surgery having decreased from 60mm to 50mm. No significant evolution was observed for mitral valve surgery., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Aims: To better characterize patients with Marfan syndrome who have survived an acute aortic dissection and to estimate the risks of events in the descending aorta. Up until now, this portion of the aorta has not been well studied but is gaining importance due to improved patient survival., Methods and Results: We report a retrospective cohort of 100 Marfan patients who survived an aortic dissection. Dissection occurred in either the ascending aorta (AscAo) (n = 37), the descending aorta (DescAo) (n = 20), or both (As + DescAo, n = 43). During a mean follow-up of 9.8 ± 6.0 years (complete for 88% of the patients), 17 patients died and 52 had a clinical event (new aortic dissection, surgery, ischaemia, haemorrhage), 60% of which involved the descending aorta. Event-free survival was similar whatever the location of the aortic dissection. However, a better event-free survival was observed when no dissected portion of the aorta remained after surgery, which was the case in 62% (23/37) of the AscAo patients (30% incurred an event vs. 86%; P = 0.008 by log-rank test). Interestingly, the diameter of the ascending aorta was below the surgical threshold in 60% of the patients who incurred a dissection of the descending aorta, and within the normal range in 25%., Conclusion: The descending aorta may dissect whatever the diameter of the ascending aorta. The descending aorta is the location of most late clinical events after any dissection of the aorta. The rate of clinical events is much lower when all the dissected aorta has been removed in patients with AscAo dissection.

The evaluation of aortic root dilation is of major importance for the diagnosis and follow-up of patients with diverse diseases, including the Marfan syndrome. However, we noted that the available nomograms suggested a lower aortic root dilation rate in adults (75%) than in children (90%), when the opposite would have been expected. To establish new nomograms, we selected a population of 353 normal children. We took transthoracic echocardiographic measurements of the aortic root diameters at the level of the aortic annulus, sinuses of Valsalva, sinotubular junction, and ascending aorta according to the American Society of Echocardiography recommendations. All diameters correlated well with the height, weight, body surface area, and age (r = 0.75 to 0.84, p <0.0001). Covariance analysis adjusting for body surface area showed slightly larger diameters at the level of the sinuses of Valsalva in male children than in female children (+1 mm, p = 0.0002). Equations and derived nomograms were developed, giving the upper limit of normal (allowing simple recognition of aortic dilation) and the Z score (allowing fine quantification of dilation and differentiation of normal growth from pathologic dilation) for all 4 aortic root diameters (ie, aortic annulus, sinuses of Valsalva, sinotubular junction, and proximal ascending aorta) according to body surface area and gender. We applied the nomograms to 282 children with confirmed Marfan syndrome, of whom 65.2% presented with dilation of the sinuses of Valsalva. In conclusion, we propose equations to calculate the upper limit of normal and Z-score for aortic root diameters measured by 2-dimensional echocardiography, which should be useful tools for the diagnosis and follow-up of aortic root aneurysms in children., (Copyright 2010 Elsevier Inc. All rights reserved.)

Objective: Dystrophic aortic insufficiency is characterized by dilation of the aortic annular base and sinotubular junction diameters preventing coaptation of thin and pliable cusps amenable to valve repair. An expansible aortic ring was designed to reduce dilated aortic root diameters to increase valvular coaptation height while maintaining root dynamics. The properties of the device were tested in vitro and in vivo in an ovine model., Methods: Expansible rings were composed of an elastomer core covered by polyester fabric. After in vitro analysis of their mechanical properties, the rings were implanted in 6 sheep at both the level of the annular base and sinotubular junction (double subvalvular and supravalvular external aortic annuloplasty). Root dynamics were assessed by using intracardiac ultrasonography before surgical intervention and at 6 months. Histologic, scanning electron microscopic, and mechanical studies were then performed on explanted samples., Results: The expansible ring produced a significant reduction of the aortic annular base and sinotubular junction diameters. Coaptation height was increased from 2.5 +/- 0.7 mm to 6.2 +/- 1.1 mm (P < .001). Mechanical testing on 6-month explanted samples revealed no significant differences in elastic modulus. Dynamics of the root were well preserved. Histomorphologic studies showed incorporation of the material without degradation., Conclusions: Expansible aortic ring implantation produces a significant annuloplasty that increases coaptation height while preserving the dynamics of the aortic root. The effectiveness of the device in treating aortic insufficiency is currently being evaluated in the prospective Conservative Aortic Valve surgery for aortic Insufficiency and Aneurysm of the Aortic Root trial comparing conservative aortic valve surgery versus mechanical valve replacement.

Objective: Aortic valve repair is an alternative to valve replacement for treatment of chronic aortic insufficiency (AI). In order to standardize surgical management, we suggest a classification based on echocardiographic and operative analysis of valvular lesions., Methods: Classification was based on the retrospective analysis of chronic AI mechanisms of 781 adults operated on electively between 1997 and 2003., Results: AI was isolated (406 patients (52%)), associated with supra-coronary aneurysm (97 cases (12.4%)), or with aortic root aneurysm (278 patients (35.6%)). Etiologies of valvular or aortic lesions were respectively rheumatic, dystrophic and atheromatous in 17%, 73.6% and 9.4% of cases. Lesional classification is based on the analysis of chronic AI mechanisms defining type I with central jet (354 cases, 45.3%) and type II with eccentric jet (54.7%). Type Ia is defined as isolated dilation of sino-tubular junction (47 supra-coronary aneurysms), and type Ib as dilation of both sino-tubular junction and aortic annular base (233 root aneurysms, 74 isolated AI). The type II associates dilation of sino-tubular junction and annular base to a valvular lesion: IIa cusp prolapse (95 aneurysms, 200 isolated AI); IIb cusp retraction (132 rheumatic AI), IIc cusp tear (endocarditis, traumatic)., Conclusion: A lesional classification aims to standardize the surgical management of aortic valve repair: type Ia, by supra-coronary graft; type Ib, by subvalvular aortic annuloplasty associated with the aortic root replacement with a remodelling technique (root aneurysm) or double sub- and supravalvular annuloplasty (isolated AI). For chronic AI type II, aortic annuloplasty associated a remodelling technique or double sub- and supravalvular annuloplasty is combined with the treatment of the cusp lesion (cusp resuspension, cusp reconstruction with autologous pericardium).

Dystrophy represents the most common etiology of aortic insufficiency and aortic root aneurysms in Western countries. Main characteristic lesions of dystrophic aortic roots are the constant dilation of the aortic annular base and sinotubular junction diameters, preventing coaptation of otherwise pliable bicuspid or tricuspid valves. Although these lesions are amenable to conservative aortic valve surgery, mechanical valve replacement remains the surgical standard. The multiplicity of current surgical techniques for conservative aortic valve repair substantiates the need for standardization. Analysis of the literature emphasizes two basic surgical objectives: the treatment of the lesions (dilation of aortic annular base and sinotubular junction) as well as the preservation of aortic root dynamics. From these findings, we suggest a standardized approach for conservative aortic valve surgery meeting both of these principles, based on the implantation of an expansible aortic ring. In the case of aortic root aneurysm, the remodeling technique is combined with a subvalvular external aortic annuloplasty. In the case of isolated aortic insufficiency, a double aortic annuloplasty (sub- and supravalvular) is performed.

Atherosclerosis is a ubiquitous inflammatory disease. Patients presenting an acute atherothrombotic event (acute coronary syndrom, stroke, aortic aneurysm, ...) have an increased risk of events in remote arterial territories affected by atherosclerosis. These patients could benefit from systematic screening of asymptomatic atherosclerotic lesions to avoid these complications. For each atherosclerotic territory (coronary artery, carotid artery, aorta, peripheral arteries including renal arteries), we review the methods for screening asymptomatic atherothrombotic lesions which could justify specific treatments: coronary artery stenosis > or = 50%, carotid artery stenosis > or = 60%, renal artery stenosis > or = 50%, and abdominal aortic aneurysm > or = 30 mm. This review shows that non invasive methods (ie, echography, tomodensitometry) are widely available for diagnosis of asymptomatic lesions in carotid and renal arteries, and in the aorta. Despite its invasive caracteristic, coronarory angiography remains the gold-standard for the diagnosis of coronary artery disease. However, cardiac multi-slices CT-scan appears a promising technique for asymptomatic patients.

Coronary arteries are the most frequent location of atherosclerosis. Coronary artery disease is the first cause of death related to atherothrombosis. In addition, patients with a prior history of acute coronary syndromes exhibit a 10% annual risk of recurrence. Although there seems to be a close correlation between the extension of CAD and the severity of atherosclerotic lesions in extra coronary arterial beds, the prevalence of these extracoronary asymptomatic lesions depends on their location. Hence, the prevalence of renal artery disease defined as stenosis > or = 50% or of peripheral artery disease defined as an ABI < 0.9 is estimated to be 20% up to 30%, whereas the prevalence of both carotid artery disease defined as stenosis > or = 70% or aortic aneurysm is estimated to be 5%. Conversely, the annual absolute risk of stroke among CAD patients is estimated at 1% while it remains unknown for vascular events related to PAD or aortic lesions. These data suggest that a systematic screening for asymptomatic extracoronary atherosclerotic lesions among CAD patients cannot be justified without a better knowledge of the prevalence of these lesions. In addition, the identification of the predicting factors for the presence and the development of these asymptomatic lesions is warranted. Finally, the potential benefit in terms of therapeutic intervention of such screening needs to be evaluated. These important issues warrant further clinical studies with appropriate design.

Background: this study aimed to assess the hypothesis that essential hypertension (EH) may increase coronary microcirculation dysfunction in patients with type 2 diabetes mellitus (DM). Microvascular dysfunction has been reported in patients with DM or EH. Discordant results have been reported on cumulative adverse effects of the simultaneous presence of DM and EH on coronary flow velocity reserve (CFR)., Methods: CFR were compared in 13 hypertensive diabetics (group 1), 12 normotensive diabetics (group 2), 11 hypertensive non diabetics (group 3) and 29 normotensive non diabetic patients (group 4). CFR was calculated using an intracoronary Doppler-tipped flow wire., Results: CFR was significantly lower in patients with both DM and EH (2.2 +/- 0.4 in group 1 vs 2.8 +/- 0.5, 2.8 +/- 0.6 and 2.9 +/- 0.7 in groups 2, 3 and 4 respectively, p<0.01). The presence of hypertension reduced CFR in diabetic patients with angiographically abnormal but unobstructed coronary arteries (2.1 +/- 0.3 in hypertensive vs 3.1 +/- 0.2 in normotensive diabetic patients, p<0.02). No cumulative adverse effect was observed in diabetics with angiographically normal coronary arteries (2.3 +/- 0.6 in hypertensive vs 2.6 +/- 0.5 in normotensive diabetic patients, NS). Multivariate analysis revealed that combination of DM and EH (p<0.007) was independently related to CFR., Conclusions: the presence of hypertension appears to worsen coronary microangiopathy in diabetic patients with unobstructed coronary artery disease. The cumulative effect of EH and DM on CFR impairment has consequences for decision-making during coronary angioplasty and could identify patients at risk for cardiomyopathy.

We report the case history of a patient aged 68 years presenting with a recurrence of anterior myocardial infarction complicated by cardiogenic shock with a thrombosis of an active rapamycin stent 77 days following the angioplasty procedure. This was provoked by stopping platelet anti-aggregant treatment, a diabetic background and in the context of scheduled surgery for cancer recurrence. Recent data in the literature combined with our observations prompt the continuation of anti-aggregant bi therapy for at least 9 months after endoprosthesis insertion even if an active stent is used. In the case where surgery is envisaged, it is necessary to wait at least 6 months after the rapamycin stent revascularisation procedure. If an extra-cardiac procedure is envisaged during the angioplasty, it would be preferable to not use an active stent.

We describe the case of a patient showing bilateral disk edema linked to amiodarone intake and discuss the controversial physiopathology of this condition. The clinical investigation as well as the follow-up of this case established the diagnosis of amiodarone-induced papillary disease. Pseudotumor cerebri and alteration of optic disk vascularization were also involved in the optic neuropathy displayed by this patient. This case illustrates the multifactorial character of this entity whose heterogeneous clinical expression is linked both to the direct toxic effect of amiodarone and the likely occurrence of pseudotumor cerebri, as well as to the disorders for which this type of medication is frequently used. Amiodarone is widely used and its implication as a cause of disk swelling should be systematically investigated.

We report the case of a patient with a past history of coronary atherosclerosis treated with primary angioplasty 5 hours following an inferior myocardial infarction. Echocardiography performed during the procedure revealed a mediastinal tumour invading the tricuspid, responsible for the occlusion of the right coronary. Infarction due to tumour compression is a rare presentation of mediastinal tumour. Diagnosis relies on echocardiographic, CT or magnetic resonance imaging. The prognosis is linked to the tumour pathology.