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Background: Transcatheter aortic valve implantation (TAVI) is the preferred treatment for symptomatic severe aortic stenosis (AS) in a majority of patients across all surgical risks. Patients and methods: Paravalvular leak (PVL) and patient–prosthesis mismatch (PPM) are two frequent complications of TAVI. Therefore, based on the large France-TAVI registry, we planned to report the incidence of both complications following TAVI, evaluate their respective risk factors, and study their respective impacts on long-term clinical outcomes, including mortality. Results: We identified 47,494 patients in the database who underwent a TAVI in France between 1 January 2010 and 31 December 2019. Within this population, 17,742 patients had information regarding PPM status (5138 with moderate-to-severe PPM, 29.0%) and 20,878 had information regarding PVL (4056 with PVL ≥ 2, 19.4%). After adjustment, the risk factors for PVL ≥ 2 were a lower body mass index (BMI), a high baseline mean aortic gradient, a higher body surface area, a lower ejection fraction, a smaller diameter of TAVI, and a self-expandable TAVI device, while for moderate-to-severe PPM we identified a younger age, a lower BMI, a larger body surface area, a low aortic annulus area, a low ejection fraction, and a smaller diameter TAVI device (OR 0.85; 95% CI, 0.83–0.86) as predictors. At 6.5 years, PVL ≥ 2 was an independent predictor of mortality and was associated with higher mortality risk. PPM was not associated with increased risk of mortality. Conclusions: Our analysis from the France-TAVI registry showed that both moderate-to-severe PPM and PVL ≥ 2 continue to be frequently observed after the TAVI procedure. Different risk factors, mostly related to the patient’s anatomy and TAVI device selection, for both complications have been identified. Only PVL ≥ 2 was associated with higher mortality during follow-up.

Objectives Using French transcatheter aortic valve replacement (TAVR) registries linked with the nationwide administrative databases, the study compared the rates of long-term mortality, bleeding, and ischemic events after TAVR in patients requiring oral anticoagulation with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs). Background The choice of optimal drug for anticoagulation after TAVR remains debated. Methods Data from the France-TAVI and FRANCE-2 registries were linked to the French national health single-payer claims database, from 2010 to 2017. Propensity score matching was used to reduce treatment-selection bias. Two primary endpoints were death from any cause (efficacy) and major bleeding (safety). Results A total of 24,581 patients who underwent TAVR were included and 8,962 (36.4%) were treated with OAC. Among anticoagulated patients, 2,180 (24.3%) were on DOACs. After propensity matching, at 3 years, mortality (hazard ratio [HR]: 1.37; 95% confidence interval [CI]: 1.12-1.67; P Conclusions In these large multicenter French TAVR registries with an exhaustive clinical follow-up, the long-term mortality and major bleeding were lower with DOACs than VKAs at discharge. The present study supports preferential use of DOACs rather than VKAs in patients requiring oral anticoagulation therapy after TAVR.

International audience; BACKGROUND:Femoral access is the gold standard for transcatheter aortic valve replacement (TAVR). Guidelines recommend reconsidering surgery when this access is not feasible. However, alternative peripheral accesses exist, although they have not been accurately compared with femoral access.OBJECTIVES:This study compared nonfemoral peripheral (n-FP) TAVR with femoral TAVR.METHODS:Using the data from the national prospective French registry (FRANCE TAVI [French Transcatheter Aortic Valve Implantation]), this study compared the characteristics and outcomes of TAVR procedures according to whether they were performed through a femoral or a n-FP access, using a pre-specified propensity score-based matching between groups. Subanalysis during 2 study periods (2013 to 2015 and 2016 to 2017) and among low/intermediate-low and intermediate-high/high volume centers were performed. RESULTS:Among 21,611 patients, 19,995 (92.5%) underwent femoral TAVR and 1,616 (7.5%) underwent n-FP TAVR (transcarotid, n = 914 or trans-subclavian, n = 702). Patients in the n-FP access group had more severe disease (mean logistic EuroSCORE 19.95 vs. 16.95; p < 0.001), with a higher rate of peripheral vascular disease, known coronary artery disease, chronic pulmonary disease, and renal failure. After matching, there was no difference in the rate of post-procedural death and complications according to access site, except for a 2-fold lower rate of major vascular complications (odds ratio: 0.45; 95% confidence interval: 0.21 to 0.93; p = 0.032) and unplanned vascular repairs (odds ratio: 0.41; 95% confidence interval: 0.29 to 0.59; p < 0.001) in those who underwent n-FP access. The comparison of outcomes provided similar results during the second study period and in intermediate-high/high volume centers.CONCLUSIONS:n-FP TAVR is associated with similar outcomes compared with femoral peripheral TAVR, except for a 2-fold lower rate of major vascular complications and unplanned vascular repairs. n-FP TAVR may be favored over surgery in patients who are deemed ineligible for femoral TAVR and may be a safe alternative when femoral access risk is considered too high.

Background The use of intracardiac electrograms to guide atrial fibrillation (AF) ablation has yielded conflicting results. Objectives The authors evaluated the usefulness of spatiotemporal dispersion, a visually recognizable electric footprint of AF drivers, for the ablation of all forms of AF. Methods The authors prospectively enrolled 105 patients admitted for AF ablation. AF was sequentially mapped in both atria with a 20-pole PentaRay catheter. The authors tagged and ablated only regions displaying electrogram dispersion during AF. Results were compared to a validation set in which a conventional ablation approach was used (pulmonary vein isolation/stepwise approach). To establish the mechanism underlying spatiotemporal dispersion of AF electrograms, the authors conducted realistic numerical simulations of AF drivers in a 2-dimensional model and optical mapping of ovine atrial scar-related AF. Results Ablation at dispersion areas terminated AF in 95% of the 105 patients. After ablation of 17 ± 10% of the left atrial surface and 18 months of follow-up, the atrial arrhythmia recurrence rate was 15% after 1.4 ± 0.5 procedures per patient versus 41% in the validation set after 1.5 ± 0.5 procedures per patient (arrhythmia free-survival: 85% vs. 59%; log-rank p Conclusions The clustering of intracardiac electrograms exhibiting spatiotemporal dispersion is indicative of AF drivers. Their ablation allows for a nonextensive and patient-tailored approach to AF ablation. (Substrate Ablation Guided by High Density Mapping in Atrial Fibrillation [SUBSTRATE HD]; NCT02093949)

Objectives This study sought to evaluate the impact of a complex fractionated atrial electrogram (CFAE)–guided ablation strategy on atrial fibrillation (AF) dynamics in patients with persistent AF. Background It is still unclear whether complete pulmonary vein isolation (PVI) is required or if the ablation of well-delineated pulmonary vein (PV) subregions could achieve similar outcomes in persistent AF. Methods CFAE-guided ablations were performed in 76 patients (65.2 ± 10 years of age) with persistent AF. In 47 patients, we measured mean PVs and left atrial appendage (LAA) cycle length (CL) values (PV-CL and LAA-CL), before ablation and before AF termination. We defined “active” PVs as PV-CL ≤ LAA-CL, “rapid fires” as PV-CL ≤80% of LAA-CL, and “PV-LAA CL gradient” as a significant CL difference between the 2 regions. Results AF termination (sinus rhythm [SR] or atrial tachycardia [AT] conversion) occurred in 92% and SR conversion in 75%. The radiofrequency time for AF termination and total radiofrequency time were 26 ± 25 min and 61.1 ± 21.6 min, respectively. Thirty of 47 patients had active PV (with 19 PV “rapid fires”). Ablation significantly increased median CL, both at PVs and LAA from 188 ms (interquartile range [IQR]: 161 to 210 ms) to 227.5 ms (IQR: 200 to 256 ms) (p Conclusions CFAE-guided ablation leads to a large decrease in PV frequency of activation, preceding AF termination. A PV modulation approach, rather than complete PVI, may be preferable for persistent AF.

OBJECTIVES The transcarotid (TC) approach for transcatheter aortic valve implantation (TAVI) is potentially an optimal alternative to the transfemoral (TF) approach. Our goal was to compare the safety and efficacy of TC- and TF-TAVI. METHODS Patients who underwent TF-TAVI or TC-TAVI in the prospectively collected FRANCE TAVI registry between January 2013 and December 2015 were compared. Propensity score inverse probability weighting methods were employed to minimize the impact of bias related to non-random treatment assignment. RESULTS Of the 11 033 patients included in the current study, 10 598 (96%) underwent a TF-TAVI and 435 (4.1%) had a TC-TAVI. Patients in the TC-TAVI access group presented with a higher risk profile but were significantly younger. There were no differences in the perioperative and 2-year mortality rates after adjustment [odds ratio (OR) 1.02, 95% confidence interval (CI) 0.62–1.68; P = 0.99 and hazard ratio 1.03, 95% CI 0.7–1.35; P = 0.83). TC-TAVI was associated with a significant risk of stroke (OR 2.42, 95% CI 2.01–2.92; P CONCLUSIONS TC-TAVI is a safe procedure compared to TF-TAVI, although it holds an increased risk of perioperative complications. It should be considered in case of non-femoral peripheral access as the second access choice, to increase the overall safety of TAVI procedures.

Objective Advances in early management of congenital heart disease (CHD) have led to an exponential growth in adults with CHD (ACHD). Many of these patients require cardiac surgery. This study sought to examine outcome and its predictors for ACHD cardiac surgery. Methods This is an observational cohort study of prospectively collected data on 1090 consecutive adult patients with CHD, undergoing 1130 cardiac operations for CHD at the Royal Brompton Hospital between 2002 and 2011. Early mortality was the primary outcome measure. Midterm to longer-term survival, cumulative incidence of reoperation, other interventions and/or new-onset arrhythmia were secondary outcome measures. Predictors of early/total mortality were identified. Results Age at surgery was 35±15 years, 53% male, 52.3% were in New York Heart Association (NYHA) class I, 37.2% in class II and 10.4% in class III/IV. Early mortality was 1.77% with independent predictors NYHA class ≥ III, tricuspid annular plane systolic excursion (TAPSE)

The role of pulmonary veins (PVs) in persistent atrial fibrillation (AF) perpetuation appears less important than in paroxysmal AF. Electrogram-based substrate ablation is not widely performed as a stand-alone strategy.To evaluate PV activity in AF perpetuation and efficacy of our patient-tailored ablation strategy (electrogram-based substrate ablation with or without pulmonary vein isolation [PVI]).One hundred twenty-one patients with paroxysmal (n = 19; 15.7%), persistent (n = 77; 63.6%), or long-standing persistent (n = 25; 20.7%) AF underwent electrogram-based substrate ablation with AF termination end point: sinus rhythm or atrial tachycardia conversion. Before ablation, we classified PVs as "passive" if silent PV or if PV cycle length is greater than left atrial appendage cycle length. No PVI was performed in such cases.Passive PVs were observed in 52 of 121 patients (paroxysmal AF = 0%, persistent AF = 40%, and long-standing persistent AF = 76%; P.0001]). Substrate ablation terminated AF in 95.6% (sinus rhythm conversion in 80.2%). Compared with patients with active PVs, patients with passive PVs had longer AF sustained duration (19.1 ± 29.7 months vs 4.9 ± 11.1 months; P.0001), larger left atrial diameter (46.9 ± 7.3 mm vs 41.9 ± 6.0 mm; P = .0014), lower left ventricular ejection fraction (45.4% ± 13.5% vs 55.1% ± 9.4%; P.0001), and more often structural heart disease (57% vs 33%; P = .02). After a follow-up of 20.39 ± 11.23 months (1.6 procedures per patient), 82% were arrhythmia free with this strategy.PV activity during AF decreases with AF chronicity, left atrial dilatation, and left ventricular ejection fraction. Our patient-tailored ablation strategy without systematic PVI provides good results.

Although the high prevalence of aortic root dilatation in adults with repaired tetralogy of Fallot (rTOF) is well established [(1,2)][1], evidence to guide clinical follow-up and decision making remains sparse. We sought to define the features, determinants, and rate of progression of aortic

Le choc cardiogenique peut compliquer l’insuffisance cardiaque chronique ou avoir une presentation aigue. La premiere cause en est le syndrome coronarien aigu. La prise en charge comporte deux volets : le traitement symptomatique et le traitement etiologique. L’amelioration de la perfusion peripherique peut etre obtenue a l’aide d’un remplissage vasculaire prudent, en cas de presentation aigue et donc de volemie normale ; des catecholamines (inotropes et/ou vasoconstricteurs) ; et de la ventilation mecanique (invasive ou non-invasive). Le traitement de la cause, notamment la revascularisation coronaire dans le cas des syndromes coronariens, est indispensable. De recents progres technologiques ont permis l’essor de l’assistance circulatoire (partielle ou totale), seule technique pouvant eviter le recours a la transplantation cardiaque en cas de choc cardiogenique refractaire au traitement classique.

Aims Temporary circulatory support with extracorporeal membrane oxygenation (ECMO) is often the only alternative for supporting patients with refractory cardiogenic shock (RCS). In practice, this strategy is limited to a small minority of patients hospitalized in tertiary-care centres with ECMO programs. The cardiac-RESCUE program was designed to test the feasibility of providing circulatory support distant from specialized ECMO centres, for RCS patients in remote locations. Methods and results From January 2005 to December 2009, hospitals without ECMO facilities throughout the Greater Paris area were invited to participate. One hundred and four RCS cases were assessed and 87 consecutively eligible patients (mean age 46 ± 15 years, 41% following cardiac arrest) had ECMO support instituted locally and were enrolled into the program. Local initiation of ECMO support allowed successful transfer to the tertiary-care centre in 75 patients. Of these, 32 patients survived to hospital discharge [overall survival rate 36.8%, 95% confidence interval (CI) 27.4–46.2]. Independent predictors for in-hospital mortality included initiation of ECMO during cardiopulmonary resuscitation [hazard ratio (HR) = 4.81, 95% CI 2.25–10.30, P < 0.001] and oligo-anuria (HR = 2.48, 95% CI 1.29–4.76, P = 0.006). After adjusting for other confounding factors, in-hospital mortality was not statistically different from that of 123 consecutive patients who received ECMO at our institution during the same period (odds ratio 1.48, 95% CI 0.72–3.00, P = 0.29). Conclusion Offering local ECMO support appears feasible in a majority of RCS patients hospitalized in remote hospitals. In this otherwise lethal situation, our pilot experience suggests that over one-third of such patients can survive to hospital discharge.

We appreciate the interest of Dr. Gianni and colleagues in our paper [(1)][1] and their invitation to a careful consideration of history. Classic anatomy-based approach may be insufficient for treating persistent atrial fibrillation (AF) (reference #1 in our article [[1]][1]). Gianni and colleagues

Melanotic Xp11 translocation renal cancer is a recently recognized aggressive epithelioid neoplasm with features overlapping between PEComa, carcinoma, and melanoma, in which TFE3 gene fusions coexist with melanin synthesis. These findings support the idea that melanotic Xp11 translocation renal cancer is a distinct variant of the MiT/TFE3 family neoplasms. The authors describe a pigmented renal tumor occurring in a 30-year-old woman with distinct morphology and immunohistochemical characteristics as Xp11 translocation renal cancer.

Background Femoral access is currently the preferred approach for TAVI procedures. However, it is not feasible in all cases and alternative access sites, peripheral and transthoracic have emerged. Purpose To compare femoral to non-femoral peripheral vascular access site in propensity matched group. Methods Using data from the national prospective French registry in France – the France TAVI registry – we compared the characteristics and outcomes of TAVI procedures according to whether they were performed through a femoral or a non-femoral peripheral (transcarotid or transaxillary), with a propensity score-based matching of patients with femoral and non-femoral peripheral interventions. Results Among 13.157 patients included in the France TAVI registry, 83.9% underwent a femoral TAVI, 6.7% a non-femoral peripheral vascular TAVI, and 9.4% transthoracic TAVI. Patients in non-femoral peripheral access were more severe (mean logistic Euroscore 17.3 vs. 19.7, P Conclusion Compared to femoral approach, non-femoral peripheral TAVI is associated with a similar outcome except for a twice-lower rate to access site-related complications. It should be considered more routinely as an alternative to femoral approach.

Aims To determine whether the timing of surgery could influence mortality and morbidity in adults with complicated infective endocarditis (IE). Methods and results In 291 consecutive adults with definite IE who underwent surgery during the active phase, we compared those operated on within the first week of antimicrobial therapy ( n = 95) to those operated on later ( n = 191). The impact of the timing of surgery on 6-month mortality, relapses, and postoperative valvular dysfunctions (PVD) was analysed using propensity score (PS) analyses. After stratification of the cohort into quintiles based on the PS, ≤1st week surgery was associated with a trend of decrease in 6-month mortality in the quintile of patients with the most likelihood of undergoing this early surgical management [quintile 5: 11% vs. 33%, odds ratio (OR) = 0.18, 95% CI (confidence interval) 0.04–0.83, P = 0.03]. Patients of this subgroup were younger, were more likely to have Staphylococcus aureus infections, congestive heart failure, and larger vegetations. Besides, ≤1st week surgery was associated with an increased number of relapses or PVD (16% vs. 4%, adjusted OR = 2.9, 95% CI 0.99–8.40, P = 0.05). Conclusion Surgery performed very early may improve survival in patients with the most severe complicated IE. However, a greater risk of relapses and PVD should be expected when surgery is performed very early.

This study sought to evaluate the impact of a complex fractionated atrial electrogram (CFAE)-guided ablation strategy on atrial fibrillation (AF) dynamics in patients with persistent AF.It is still unclear whether complete pulmonary vein isolation (PVI) is required or if the ablation of well-delineated pulmonary vein (PV) subregions could achieve similar outcomes in persistent AF.CFAE-guided ablations were performed in 76 patients (65.2 ± 10 years of age) with persistent AF. In 47 patients, we measured mean PVs and left atrial appendage (LAA) cycle length (CL) values (PV-CL and LAA-CL), before ablation and before AF termination. We defined "active" PVs as PV-CL ≤ LAA-CL, "rapid fires" as PV-CL ≤80% of LAA-CL, and "PV-LAA CL gradient" as a significant CL difference between the 2 regions.AF termination (sinus rhythm [SR] or atrial tachycardia [AT] conversion) occurred in 92% and SR conversion in 75%. The radiofrequency time for AF termination and total radiofrequency time were 26 ± 25 min and 61.1 ± 21.6 min, respectively. Thirty of 47 patients had active PV (with 19 PV "rapid fires"). Ablation significantly increased median CL, both at PVs and LAA from 188 ms (interquartile range [IQR]: 161 to 210 ms) to 227.5 ms (IQR: 200 to 256 ms) (p 0.0001) and from 197 ms (IQR: 168 to 220 ms) to 224 ms (IQR: 193 to 250 ms) (p 0001), respectively. After ablation, PV-LAA CL gradients were withdrawn and all PV "rapid fires" were extinguished (without PVI). After 17.2 ± 10 months of follow-up and 1.61 ± 0.75 procedures, 86.3% and 73% of the patients were free from AF and from any arrhythmia (AF/AT), respectively.CFAE-guided ablation leads to a large decrease in PV frequency of activation, preceding AF termination. A PV modulation approach, rather than complete PVI, may be preferable for persistent AF.

Introduction: Multi-electrode electrogram temporal activation and fractionation have been used to localize atrial fibrillation (AF) drivers. Yet, the feasibility of a simplified “online” analysis and its usefulness to ablate AF remain to be investigated. Hypothesis: Evaluating a simplified “online” electrogram analysis approach designed to localize and ablate AF drivers. Methods: 105 patients undergoing AF ablation (77% with persistent AF, 3 centres) were prospectively enrolled. AF was first mapped in both atria with the 20-pole contact electrode catheter PentaRay® (Biosense Webster, Inc.) in order to identify regions with a temporal activation pattern compatible with the presence of rapidly rotating rotors. Specifically, regions with consecutive activations spanning the majority of the AF cycle length (including examples of rapid and continuously fractionated electrograms) were visually selected (“hot zone”).The endpoints were AF termination acutely, and freedom from long-term AF (single procedure). Off-line, electrogram cycle length values were compared between “hot” and “non-hot” regions and a numerical simulation of PentaRay-enabled unipolar recordings of a stable rotor driving AF was conducted Results: Visually selected “hot” regions located mostly in the left atrium (6.5 ±4.2/patient; ~70% of ”hot” regions). “Hot” regions were activated at a significantly shorter cycle length than “non-hot” regions (171.8 ± 4.8 vs. 193.0 ± 6.3 ms, p=0.01, N=20). 95.6% of the “hot regions” were automatically labelled CFAEs (automated analysis, Carto). However, 4.5±3.4 distinct CFAEs regions/patient were also labelled in “non-hot” regions. Ablation at “hot” regions terminated AF in 99/104 patients (95.2%), 46 [21-72] min after the 1st radiofrequency application within 20 [10-37] min of RF. Also, numerical simulations show that a simplified PentaRay®-enabled activation analysis is sufficient to distinguish rotor and non-rotor regions. After 9+3 [6-11], months of median [Q1-Q3] follow-up, 87 % were free from AF after 1 procedure and 53 % still under antiarrhythmic drugs. Conclusions: With this simplified “online” analysis, we could successfully localize rotor regions and perform efficient AF ablation. Clinical trial.gov: NCT02093949

According to PARTNER 2 (2016), Transcatheter Aortic Valve Replacement (TAVR) is non inferior to surgery in intermediate risk patient. Furthermore, TAVR through a transfemoral access might be superior to surgery (second cohort, not designed for superiority) while TAVR through other access sites

Marijon and colleagues1 studied the different causes of death in patients with atrial fibrillation (AF) in a very interesting post hoc analysis of the Randomized Evaluation of Long-Term Anticoagulant Therapy (RE-LY) trial. They showed in a contemporary anticoagulated AF population that the majority of deaths were not related to stroke but to cardiac deaths (9.8% versus 37.4%), more specifically sudden cardiac death and progressive heart failure (HF). From their analyses HF emerged as the strongest independent predictor …

We report the case of a 34-year-old woman admitted in our institution for cardiogenic shock related to acute myocarditis. Initial hemodynamic instability required mechanical ventilation and peripheral venoarterial extracorporeal membrane oxygenation (ECMO). Secondary acute pulmonary edema after ECMO implantation required emergency left ventricular decompression with a percutaneous Impella Recover LP 5.0. After a short period of improvement, an unexpected technical problem led to the Impella Recover LP 5.0 arrest. The clinical situation quickly worsened, and the patient finally died. This case highlights the usefulness of Impella pump to unload left cardiac chambers but also its technical challenge when used in a patient on ECMO.

During 2009, pandemic influenza A (H1N1) affected France and several patients developed influenza A (H1N1)-associated acute respiratory distress syndrome. The use of extracorporeal membrane oxygenation (ECMO) could be advocated as therapeutic solution. We present our experience with ECMO utilized in patients with influenza A (H1N1)-associated respiratory failure.We conducted a retrospective observational analysis of our experience with veno-venous ECMO for 2009 influenza A (H1N1)-associated respiratory failure. We have excluded from our study all not confirmed cases of influenza A (H1N1). Veno-venous ECMO was always instituted using a percutaneous cannulation technique. Mechanical circulatory support was maintained until respiratory function recovery.Between October 2009 and February 2010, we performed veno-venous ECMO support in 12 patients with influenza A (H1N1)-associated respiratory failure. Mean age was 33 ± 12 years (14-63 years) and there was a prevalence of female sex. Median time from influenza A (H1N1) onset to mechanical ventilation (MV) initiation was 6 days (1-17 days); median time from MV to veno-venous ECMO support was 3 days (1-20 days). Six patients (50%) suffered ventilator-associated pneumonia during ECMO support. Eight patients (66.6%) suffered significant haemorrhage requiring transfusion of more than 2 packed red cells. In two patients (16.6%), there was a thrombosis of the inferior vena cava and one of them experienced pulmonary embolism. Mean duration of ECMO support was 23 ± 14 days (3-47 days); mean duration of mechanical ventilatory support was 24 ± 21 days (6-70 days). ECMO was weaned in 10 patients (83.3%) and all these patients are still alive after a period of follow-up of 13.8 ± 1.12 months (11.03-14.83 months). Two patients (in-hospital mortality of 16.6%) died under ECMO support for refractory septic shock.Veno-venous ECMO for 2009 H1N1-associated respiratory failure gives good results with a very low mortality rate. The use of a mobile unit is a safe procedure and may improve survival of patients who might not be otherwise eligible for transfer to our institution. Larger studies are however required in order to optimize and refine the best treatment strategy in this subgroup of patients.

We report the case of a patient stabilized under extra-corporeal membrane oxygenation after a refractory cardiogenic shock following myocardial infarction. Persistent left ventricular failure required secondary implantation of the left ventricular assist device (LVAD) HeartMate II. LVAD succeeded in the gradual recovery of myocardial contractility, allowing weaning of the device five months after implantation. Simultaneously, the patient beneficiated from coronary revascularization and resumed normal activity. This case emphasizes potential late recoveries after myocardial infarction complicated by left ventricular failure.

The new-generation bioprostheses are associated with a longer lifespan, and therefore tend to be implanted in younger patients. However, with the increase in life expectancy, the trend is towards a higher rate of repeat valve replacement. Hence, the study aim was to evaluate the present mortality and risk factors for repeat valvular surgery.A total of 183 consecutive patients (87 males, 96 females; mean age 62 years; range: 28-88 years) who underwent repeat valve replacement at the authors' institution between 2001 and 2004 was reviewed. Reoperations in these patients were required due to structural degeneration of the bioprosthesis (50%), to paravalvular leak (20%), and to prosthetic endocarditis (14%), valve thrombosis (9%), and plasty failure (9%). In total, 105 patients (57%) had received at least one bioprosthesis during the previous operation, 58 (31%) had a mechanical valve, 15 (8%) had an isolated mitral plasty, and five (2%) hybrid procedures. All preoperative and operative risk factors were studied.The overall operative mortality rate was 6.6% (n = 12), but only 3.9% (n = 4) for the bioprosthesis reoperation. The risk factors for mortality included pulmonary hypertension (60 mmHg; p = 0.03), renal insufficiency (p = 0.02), more than one repeat valve replacement (p = 0.004), previous mechanical prosthesis (p = 0.02), previous mitral surgery (p = 0.019), and associated tricuspid surgery (p = 0.03).The data acquired tended to show that repeat valve replacement of bioprostheses may be carried out with an acceptable operative risk, in connection with the majority of operations on bioprostheses being secondary to structural degeneration of the implant. Hence, in most cases a well-controlled, programmed operation would lead to very low mortality (4%), despite a significant morbidity rate.

Background We examined the features, determinants and rate of progression related to aortic dilatation in adults with repaired tetralogy of Fallot (rTOF). Methods and Results One-hundred-and-ten adults with rTOF and native aorta, baseline median age 30.9 (IQR22.9–39.4) years were assessed by serial cardiovascular magnetic resonance (CMR), and over a median follow-up of 6.3 (IQR5.1–7.6) years. Aortic dimensions were measured at sinus, sinotubular junction (STJ) and mid-ascending aortic level. Dilatation was defined as diameter >2 standard deviations larger than normal for the age. Seventy-six patients (69%) had aortic dilatation, of which 27% at sinus, 66% at STJ, and 21% had ascending aortic level (figure 1). Baseline predictors of aortic dilatation were male gender and previous history of palliation. Forty-seven percent had increase in aortic diameters, 25% at sinus, 21% at STJ and 35% at ascending aortic level, at a rate of 0.05 ± 0.1, 0.06 ± 0.14 and 0.12 ± 0.26 mm/year respectively. Predictors of aortic diameter increase at STJ level were older age, later repair and right aortic arch. No predictors of aortic diameter increase at other levels were ascertained. Conclusions Aortic dilatation was observed in two thirds of our adult with rTOF patients, affecting not only the aortic root but the ascending aorta as well. However, the rates of progression were very low. These data do not support frequent aortic assessment in follow-up and aggressive prophylactic aortic root replacement.

Summary Background An increasing number of patients with infective endocarditis (IE) are operated on before the end of the first week of antimicrobial therapy. The mortality and morbidity of this specific group are unknown. Aims To evaluate the outcome of patients with IE requiring cardiac surgery performed within the first week of antimicrobial therapy. Methods All consecutive patients with a definite diagnosis of IE operated on within the first week of antimicrobial therapy were followed prospectively. Endpoints were in-hospital mortality and a combined endpoint of long-term cardiovascular death, recurrence and non-infective postoperative valvular dysfunction (PVD). The three main conditions requiring surgery, namely haemodynamic impairment, high embolic risk and periannular extension, were tested as potential predictors of outcome after adjustment for relevant variables. Results Among the 95 patients included, surgery was performed a median time of 3 days after starting antimicrobial therapy. In-hospital mortality was 15%. The 3-year cumulative rates of the combined endpoint and of cardiovascular death were 38 ± 7% and 27 ± 7%, respectively. Recurrence occurred in 12% and PVD in 7%. Periannular extension was the main predictor of in-hospital death and the combined endpoint. Conclusion Despite the short time between starting antimicrobial therapy and performing surgery, the risk of death, recurrence and PVD does not appear excessively high. In the presence of periannular extension, however, surgery is associated with a greater risk of postoperative events.

Materials and methods Retrospective study of 110 rtoF adults with native aorta, median age 30.9 (22.9-39.4) years were studied by cardiovascular magnetic resonance (CMR) at baseline, and at follow-up (median 6.3 [IQR:5.1-7.6] years). Aortic measurements were performed at sinus, sinotubular junction (STJ), and mid-ascending aorta level. AD was defined as diameter > 2 standard deviations larger than published normal Z-Scores, according to the age and body surface area.