Alessandro Piccardo

Outcomes After Surgical Treatment for Type A Acute Aortic Dissection in Octogenarians: A Multicenter Study

BACKGROUND Management of octogenarian patients with acute type A acute aortic dissection is controversial. This study analyzed the surgical outcomes to identify patients who should undergo operations. METHODS Beginning January 2000, we established a registry including all octogenarian patients operated on for type A acute aortic dissection. We evaluated 57 consecutive patients enrolled up to December 2006. Their median age was 82 (range, 80 to 89 years). Compassionate indication operations were attempted in 2 moribund patients and in 5 presenting with shock associated with neurologic symptoms or renal failure, or both. Operations followed the standard procedure recommended in younger patients. Follow-up was 100% complete (mean, 3.9 +/- 2 years; range, 5 months to 8 years). RESULTS There were 26 (45.6%) in-hospital and 6 late deaths. Multivariate analysis identified compassionate indication (p < or = 0.0001) and total arch replacement (p = 0.0060) as risk factors for in-hospital mortality. Postoperative complications occurred in 36 patients (69.2%) and were associated with a higher mortality (p = 0.0001). Overall survival was 51% at 1 year and 44% at 5 years. Excluding patients with compassionate indication and those who underwent total arch replacement, or both, overall survival was 66% at 1 year and 57% at 5 years. CONCLUSIONS Surgical treatment for type A acute aortic dissection in octogenarians shows satisfactory midterm results among survivors. However, the high mortality rate imposes a requirement for better perioperative management. Compassionate cases should be managed medically. A less aggressive approach should improve outcomes of surgical treatment.

Thrombocytopenia After Aortic Valve Replacement With Freedom Solo Bioprosthesis: A Propensity Study

BACKGROUND The incidence of postoperative thrombocytopenia after aortic valve replacement with the Freedom Solo bioprosthesis remains unclear. This propensity-matched study was carried out to evaluate the incidence and clinical impact of thrombocytopenia in patients receiving the Freedom Solo bioprosthesis. METHODS Patients who underwent aortic valve replacement with a Freedom Solo or Carpentier-Edwards Perimount pericardial prosthesis at our institution between 2006 and 2008 were screened retrospectively. Exclusion criteria included double valve replacement, redo surgery, and active endocarditis. Two hundred six patients were considered eligible for this analysis. Using propensity scores 36 matched pairs of patients with a Freedom Solo or Perimount bioprosthesis were obtained. The primary end point was the occurrence of postoperative thrombocytopenia. Secondary end points were postoperative thromboembolic or hemorrhagic events and 30-day mortality. RESULTS Before matching, severe thrombocytopenia (<30 x 10(9) platelets/L) occurred in 22% of patients with a Freedom Solo bioprosthesis and 1% with a Perimount bioprosthesis (p < 0.0001), thromboembolic or hemorrhagic events occurred in 3% and 2%, respectively (p = 0.37), and 30-day mortality was 4% and 6%, respectively (p = 0.48). Multivariate analysis identified preoperative platelet count (p = 0.01) and Freedom Solo (p < 0.0001) as independent risk factors for severe postoperative thrombocytopenia. After matching, severe thrombocytopenia occurred in 25% and 3% of patients with Freedom Solo and Perimount bioprostheses, respectively (p < 0.0001), thromboembolic or hemorrhagic events occurred in 0%, and 30-day mortality was 3% and 6%, respectively (p = 0.99). CONCLUSIONS The risk of thrombocytopenia was high after Freedom Solo implantation. However, this complication was not related to any deleterious events in our study population.

Octogenarians With Uncomplicated Acute Type A Aortic Dissection Benefit From Emergency Operation

BACKGROUND The management of acute type A aortic dissection (aTAAD) in octogenarian patients is controversial. This study analyzed the surgical outcomes to identify patients who should undergo operations. METHODS Beginning in January 2000, we established a registry including all octogenarian patients operated on for type A acute aortic dissection. We evaluated 79 consecutive patients enrolled up to December 2010. Their median age was 81.6 years (range, 80 to 89 years). Sixteen patients (20%) presented a complicated type because of a neurologic deficit, mesenteric ischemia, a requirement for cardiopulmonary resuscitation, or some combination of those features. Operations followed the standard procedure recommended for younger patients. Follow-up was 95% complete (mean, 4.6±2.8 years). RESULTS The overall in-hospital mortality was 44.3%. The in-hospital mortality among patients with uncomplicated aTAAD was 33.3%. Multivariate analysis identified complicated aTAAD as the only risk factors for in-hospital mortality (p<0.0001). Postoperative complications occurred in 50 patients (68.5%) and were associated with a higher mortality (p<0.0001). The overall survival was 53% at 1 year and 32% at 5 years. In uncomplicated aTAAD, the overall survival was 63% at 1 year and 38% at 5 years. CONCLUSIONS Octogenarians with uncomplicated aTAAD benefit from emergency surgical repair. In those patients, early and midterm outcomes are good and are similar to those in published series of younger patients. Complicated aTAAD should be medically managed.

Aortic Valve Replacement with Smaller Prostheses in Elderly Patients: Does Patient Prosthetic Mismatch Affect Outcomes?

To evaluate the influence of patient‐prosthesis mismatch (PPM) on survival, and quality of life (QOL) after aortic valve replacement (AVR) in elderly patients with small prosthesis size.

Uterus tolerance to extended cold ischemic storage after auto-transplantation in ewes

OBJECTIVE To assess how the uterus tolerates extended cold ischemic storage before auto-transplantation in ewes. STUDY DESIGN Fourteen uterine auto-transplantations were performed in ewes from November 2014 to June 2015 at the Analysis and Research Laboratory of Limoges, France. The animals were divided into 2 groups: 7 after 3h of cold ischemia timeand 7 after 24h. Transplant was assessed ≥8days after transplantation. Histology and apoptosis analyses (TUNEL method and indirect immunohistochemistry of cleaved Caspase 3) were performed before uterus retrieval (control), after 90min following reperfusion and ≥8days after transplantation. RESULTS Twelve uterine auto-transplantations were successfully performed. The histological analysis at 90min following reperfusion revealed a moderate inflammation of the endometrium and serosa in the 3-h group and severe inflammation in the 24-h group, but no significant apoptotic signal was found in either group. Seven ewes were alive at ≥8days after transplantation: the macroscopic and histological analyses revealed two viable uteri in the 3-h group and three in the 24-h group. In each group one uterus was necrotic. CONCLUSION These first results in ewes suggest that the uterus is an organ with a good tolerance to extended cold ischemic storage before transplantation.

Usefulness of Electrocardiographic Strain to Predict Survival After Surgical Aortic Valve Replacement for Aortic Stenosis

Electrocardiographic (ECG) strain has been reported as a specific marker of midwall left ventricular (LV) myocardial fibrosis, predictive of adverse clinical outcomes in aortic stenosis (AS), but its prognostic impact after aortic valve replacement (AVR) is unknown. We aimed to assess the impact of ECG strain on long-term mortality after surgical AVR for AS. From January 2005 to January 2014, patients with interpretable preoperative ECG who underwent isolated AVR for AS were included. ECG strain was defined as ≥1-mm concave downslopping ST-segment depression with asymmetrical T-wave inversion in lateral leads. Mortality was assessed over a follow-up period of 4.8 ± 2.7 years. Among the 390 patients included, 110 had ECG strain (28%). They had significantly lower body mass index, higher mean transaortic pressure gradient and Cornell-product ECG LV hypertrophy than in those without ECG strain. There was also a trend for lower LV ejection fraction in patients with ECG strain as compared with those without. Patients with ECG strain had significantly lower 8-year survival than those without. ECG strain remained associated with reduced survival both in patients with and without LV hypertrophy (p <0.0001 for both). After adjustment, ECG strain remained a strong and independent determinant of long-term survival (hazard ratio 4.4, p <0.0001). Similar results were found in patients with LV hypertrophy or without LV hypertrophy. In the multivariate model, the addition of ECG strain provided incremental prognostic value (p <0.0001). In conclusion, in patients with AS, ECG strain is associated with 4-fold increased risk of long-term mortality after isolated AVR, regardless of preoperative LV hypertrophy.

Medical and Economic Interest of the Use of Cryosurgery in the Instrumental Treatment of Atrial Fibrillation

Introduction: In order to definitively integrate cryosurgery for the surgical treatment of atrial fibrillation (AF) into the therapeutic armamentarium, the medical and economic impact of its use on a population of patients with a high risk of recurrence of postoperative AF must be evaluated. Method: An observational study of patients who benefited from cryosurgery between July 2006 and December 2008 was performed. The cost of consumables and hospitalization was determined and compared to that of a control group of 27 patients with preoperative AF that had not benefited from cryosurgery. Results: Twenty-nine patients benefited from cryosurgery during a mitral (65.5%) or aortic intervention (37.9%) to treat a paroxystic (44.8%) or permanent AF (55.2%). More than half of them (58.6%) had a 12-month follow-up; 82.4% of these patients showed a permanent sinus rhythm and 32.6% had stopped their antiarrhythmic medication. There was no significant difference between the duration and cost of hospitalization for the 2 groups. Conclusion: Cryosurgery provides a clear clinical and economic advantage with no recurrence of AF, and it reduces antiarrhythmic medication treatment.

Which echocardiographic parameters improve the risk prediction for peri-operative outcomes in patients undergoing coronary bypass surgery: a prospective study:

Objective: To assess the performance of transthoracic echocardiographic parameters to predict operative mortality and morbidity in patients undergoing coronary artery bypass grafting, and to assess its incremental prognostic value as compared to the Society of Thoracic Surgeons (STS) score. Materials and methods: We prospectively collected the clinical and biological data required to calculate the STS score in patients hospitalised for coronary artery bypass grafting. Preoperative transthoracic echocardiography was performed for each patient. The primary endpoint was 30-day mortality or major morbidity (i.e. stroke, renal failure, prolonged ventilation, deep sternal wound infection, reoperation) as defined by the STS. The secondary endpoint was prolonged hospitalisation for over 14 days. Results: A total of 172 patients was included (mean age 66.1±10.2 years, 12.2% were women). The primary endpoint occurred in 33 patients (19.2%), and 28 patients (16.3%) had a prolonged hospital stay. Independent predictive factors for the primary endpoint were an increased left atrial volume (>31 mL/m²; odds ratio (OR) 3.55, 95% confidence interval (CI) 1.38–9.12; P=0.004) and a decreased tricuspid annular plane systolic excursion (<20 mm; OR 3.45, 95% CI 1.47–8.21; P=0.008). The predictive value of the multivariate model increased when the two echocardiographic parameters were added to the STS score (area under the curve 0.598 vs. 0.695, P=0.001; integrated discrimination improvement 7.44%). Conclusion: In patients undergoing coronary artery bypass grafting, preoperative assessment of left atrial size and tricuspid annular plane systolic excursion should be performed systematically, as it provides additional prognostic information to the STS score.

Immature Granulocytes: A Risk Factor of Infection after Cardiac Surgery: FLOW CYTOMETRY PREDICTION OF INFECTION RISK

Similarly, to sepsis, cardiac surgery with cardiopulmonary bypass (CPB) induces major changes in leukocyte subsets. Immature granulocytes (IGs) increase both in sepsis and after open‐heart surgery. Secondary infections are a major complication of cardiac surgery with CPB. We hypothesized that the assessment of leukocyte subsets with multicolor flow cytometry (FCM) could help the front‐line clinician to better identify patients at high risk of infectious complications in this clinical setting.

IMPACT OF RENIN-ANGIOTENSIN SYSTEM BLOCKERS ON LONG TERM SURVIVAL FOLLOWING ISOLATED AORTIC VALVE REPLACEMENT FOR AORTIC STENOSIS

Background: Angiotensin receptors blockers (ARB) and angiotensin conversion enzyme inhibitors (ACEi) are effective for cardiac remodeling, but their clinical interest after isolated aortic valve replacement (AVR) for aortic stenosis (AS) is unclear. We studied the impact of renin-angiotensin