Annie Robert

Mechanisms of Recurrent Aortic Regurgitation After Aortic Valve Repair: Predictive Value of Intraoperative Transesophageal Echocardiography

OBJECTIVES The aim of the present study was to examine the intraoperative echocardiographic features associated with recurrent severe aortic regurgitation (AR) after an aortic valve repair surgery. BACKGROUND Surgical valve repair for AR has significant advantages over valve replacement, but little is known about the predictors and mechanisms of its failure. METHODS We blindly reviewed all clinical, pre-operative, intraoperative, and follow-up transesophageal echocardiographic data of 186 consecutive patients who underwent valve repair for AR during a 10-year period and in whom intraoperative and follow-up echo data were available. After a median follow-up duration of 18 months, 41 patients had recurrent 3+ AR, 23 patients presented with residual 1+ to 2+ AR, and 122 had no or trivial AR. In patients with recurrent 3+ AR, the cause of recurrent AR was the rupture of a pericardial patch in 3 patients, a residual cusp prolapse in 26 patients, a restrictive cusp motion in 9 patients, an aortic dissection in 2 patients, and an infective endocarditis in 1 patient. RESULTS Pre-operatively, all 3 groups were similar for aortic root dimensions and prevalence of bicuspid valve (overall 37%). Patients with recurrent AR were more likely to display Marfan syndrome or type 3 dysfunction pre-operatively. At the opposite end, patients with continent AR repair at follow-up were more likely to have type 2 dysfunction pre-operatively. After cardiopulmonary bypass, a shorter coaptation length, the degree of cusp billowing, a lower level of coaptation (relative to the annulus), a larger diameter of the aortic annulus and the sino-tubular junction, the presence of a residual AR, and the width of its vena contracta were associated with the presence of AR at follow-up. Multivariate Cox analysis identified a shorter coaptation length (odds ratio [OR]: 0.8, p = 0.05), a coaptation occurring below the level of the aortic annulus (OR: 7.9, p < 0.01), a larger aortic annulus (OR: 1.2, p = 0.01), and residual aortic regurgitation (OR: 5.3, p = 0.01) as risk factors of repair failure. CONCLUSIONS Our results demonstrate that intraoperative transesophageal echocardiography can be used to identify patients undergoing AR repair who are at increased risk for late repair failure.

Endocrine and metabolic disorders in young adult survivors of childhood acute lymphoblastic leukaemia (ALL) or non‐Hodgkin lymphoma (NHL)

Background  Treatments of acute lymphoblastic leukaemia (ALL) and non‐Hodgkin lymphoma (NHL), involving various combinations of chemotherapy (chemo), cranial irradiation (CI) and/or bone marrow transplantation after total body irradiation (BMT/TBI), are often successful but may have several long‐term harmful effects.

Dispersion of ventricular repolarization in hypertrophic cardiomyopathy

On an averaged QRS-T cycle from a 15-lead record (12-lead electrocardiogram + XYZ leads) and through interactive editing, four electrocardiographic indices of the dispersion of ventricular repolarization (DVR) are automatically computed and represent the maximal interlead difference of QT and JTend and QT and JTapex. The values of these indices were then examined in three clinical groups matched for age and sex: normal subjects (control), patients with left ventricular hypertrophy (LVH group), and patients with hypertrophic cardiomyopathy (HCM group) without ventricular arrhythmias and without interacting drugs. The mean values of all four DVR indices were significantly increased in the HCM group compared with the control group and the LVH group of another origin (ie, for the QTe dispersion index, the mean values and the 97.5th percentiles were, respectively, 65 +/- 18 ms and 97 ms in the HCM group, 41 +/- 25 ms and 79 ms in the LVH group, and 31 +/- 15 ms and 58 ms in the control group). The maximal QT interval was also significantly longer in the HCM group (464 +/- 30 ms) than in the LVH group (436 +/- 32 ms) and the control group (428 +/- 25 ms).

Does right ventricular outflow tract damage play a role in the genesis of late right ventricular dilatation after tetralogy of Fallot repair

BACKGROUND The aim of this study was to determine the relative role of pulmonary insufficiency and right ventricular outflow tract damage in the genesis of late symptoms related to right ventricular dilatation. METHODS In a retrospective study we compared the late outcomes of patients who had undergone operations known to generate pulmonary insufficiency, namely, transventricular repair of tetralogy of Fallot and pulmonary commissurotomy for isolated pulmonary stenosis. RESULTS In our institution, between 1964 and 1984, a total of 44 patients were found to have had an isolated pulmonary commissurotomy and 189 survived a transventricular repair of tetralogy of Fallot. Of these patients, 134 had patching of the right ventricle and 55 direct closure of a right ventriculotomy. Follow-up was 94% complete after a mean of 22 +/- 7 years. On echocardiography, patients with isolated commissurotomy had similar degrees of moderate and severe pulmonary insufficiency as tetralogy of Fallot patients who had a right ventricular patch (p > 0.2). However, freedom from adverse events related to right ventricular dilatation was far better (log rank p < 0.001) in patients with isolated commisurotomy. CONCLUSIONS Pulmonary insufficiency is not the only determinant of late symptomatic right ventricular dilatation after repair of tetralogy of Fallot. Pulmonary insufficiency seems much more deleterious in patients who have had right ventricular outflow tract patching. Long-term pulmonary insufficiency alone is responsible for a slight degree of right ventricular dilatation, but symptoms may develop much later if the contractility of the pulmonary infundibulum is preserved. The pulmonary infundibulum may be essential for right ventricular ejection, and for maintaining pulmonary valve competence.

Bone marrow micrometastasis might not be a short-term predictor of survival in early stages non-small cell lung carcinoma

OBJECTIVE To determine the presence of occult micrometastasis (OM) in a selected population of surgically resectable patients presenting with non-small cell lung carcinoma (NSCLC) and to evaluate its prognostic value on relapses and survival. METHODS From February 1996 to December 1999, 99 patients undergoing surgical treatment for NSCLC were prospectively investigated for the presence of occult bone marrow micrometastasis. Tumor cells were detected with monoclonal primary antibodies directed against low molecular weight cytokeratins. RESULTS Median follow-up time was 14.3 months (range 0.2-45.6 months). Overall prevalence of OM was 22.2% (22 out of 99). The presence of OM was not correlated to pathology, T status, or N status. In survival analysis, the only independent predictors of overall survival were N0 status and Stage I (P=0.016 and 0.004, respectively), while T1 was a predictor of disease-free survival (P=0.044). Metastasis and loco-regional recurrence were observed at follow-up in 18.2 (four out of 22) and 9% (two out of 22) of patients OM(+) and in 14.3 (11 out of 77) and 7.8% (six out of 77) of patients OM(-), respectively (P=not significant). OM was a predictor neither of overall survival nor of disease-free survival (P=0.52 and 0.97, respectively). In Stage I patients, 1-year overall survival and 1-year disease-free survival were 89 and 98% for OM(-) patients and 88 and 90% for OM(+) patients, respectively (P=0.57 and P=0.75). CONCLUSIONS OM was present in >20% of surgically treated NSCLC patients and did not correlate to pathological variables. In contrast to previous published data, in this study the presence of OM had no influence on overall or disease-free survival.

Stable hepatitis C virus RNA detection by RT-PCR during four days storage

BackgroundSuboptimal specimen processing and storage conditions of samples which contain hepatitis C virus (HCV) RNA may result in a decline of HCV RNA concentration or false-negative results in the detection of HCV RNA in serum. We evaluated the stability of HCV RNA in serum and clotted blood samples stored at room temperature or at 4°C for 4 days with the aim of optimizing the standard procedures of processing and storage of samples.MethodsBlood from five HCV RNA positive patients was collected in tubes with and without separator gel, centrifuged 1 or 6 hours after collection. Samples were then left 6, 24, 48, 72 or 96 h at room temperature (21.5 – 25.4°C) or at 4°C before determining their HCV RNA level using the COBAS AMPLICOR HCV MONITOR Test, vs 2.0 (Roche Diagnostic Systems).ResultsThe logarithm of the HCV RNA level measurements remained within a 0.3 value of the means for 4 days at both temperatures (room temperature or 4°C).ConclusionsWe conclude that blood samples may be collected and aliquoted within 6 h of collection and can be stored at 4°C for 72 hours as proposed by the manufacturer without significant differences in measured HCV RNA level. Our results indicate that lapses in this scheme may still yield reliable results.

Etude prospective du rendement des biopsies endoscopiques dans le diagnostic différentiel des ulcérations gastriques

RésuméAucune étude prospective n’a, jusqu’à présent, évalué les taux de biopsies inutilisables par le pathologiste et positives pour le cancer dans une série comparative d’ulcérations bénignes et malignes.Dans la présente étude, un nombre fixe de biopsies (n = 10) a été prélevé selon un programme systématique au niveau d’ulcérations larges (diamètre ≥ 8 mm). Ces biopsies ont été recueillies en flacons séparés et analysées par le pathologiste selon la séquence des prélèvements.Sur 65 ulcérations étudiées, la proportion de biopsies non interprétables par le pathologiste est de 11,5 %, soit environ la moitié de celle obtenue dans les séries rétrospectives. Elle est respectivement de 14 % sur les ulcères bénins et 5,7 % sur les ulcérocancers.Dans la séquence des prélèvements, les biopsies non utilisables se répartissent au hasard. Dans les ulcérations bénignes, leur proportion s’élève progressivement dès la 6e biopsie, mais cette augmentation n’est pas significative.Sur 120 biopsies d’ulcérations malignes (21 cancers invasifs), 67,6 % des prélèvements sont positifs, taux supérieur à celui relaté dans la littérature (49 à 56 %).La répartition des biopsies positives dans la série des prélèvements séparés s’effectue également selon le hasard.Les nombres de biopsies nécessaires pour obtenir avec une haute probabilité (p = 0,999) des prélèvements positifs pour le cancer, sont dans un ordre croissant: 6 biopsies pour en obtenir une, 8 pour deux et 11 pour trois.Les auteurs recommandent par sécurité, un nombre de prélèvements situé entre 8 et 11.SummaryNo prospective study has evaluated the proportion of biopsies unusable by the pathologist and of biopsies positive for cancer in a comparative series of benign and malignant ulcerations.In the present study, a constant number of biopsies (n = 10) has been sampled following a systematic program from large gastric ulcers (> 8 mm). They have been kept in separate bottles and analysed by the pathologist according to the sampling sequence.Among 65 ulcerations, 11.5 % of the biopsies are non interpretable by the pathologist, that is half the proportion obtained in retrospective series. With regards to the benign and to the malignant lesions, the percentage of non interpretable biopsies are 14 % and 5.7 % respectively.In the sequence of sampling, the non usable biopsies are randomly distributed although in benign ulcers, a non significant increase in unusable biopsies is observed after 5 biopsies.67.5 % of the 210 biopsies from 21 invasive cancers are positive, a proportion superior to results from the literature (49-56 %). No particular distribution of positive biopsies in the order of sampling is observed.In order to obtain a high probability (p = 0.999) of biopsies positive for cancer, the number of biopsies is 6 for one positive biopsy, 8 for 2 and 11 for 3.We recommend that endoscopists obtain between 8 and 11 biopsies in gastric ulcerations.ResumenHasta el momento ningun estudio prospectivo ha evaluado la tasa de biopsias no utilizables por el patólogo y las que son positivas para cancer, en una serie comparativa de úlceras benignas y malignas.En este estudio hemos obtenido un número constante de biopsias (n = 10), de acuerdo con un programa sislemático, en ulceraciones de diámetro superior o igual a 8 mm. Dichas biopsias fueron recogidas en frascos separados y analizadas por el patólogo según la secuencia de las tomas.En 65 úlceras estudiadas, la proporción de biopsias no interpretables por el patólogo fué de 11.5 %, es decir aproximadamente la mitad de la proporción obtenida en series retrospectivas. Fué, respectivamenle, del 14 % en las biopsias sobre úlceras benignas y del 5.7 % en las úlceras cancerosas.En relación con la secuencia de obtención, las biopsias no utilizables se reparten al azar. En las úlceras benignas se eleva progresivamente a partir de la sexta toma si bien úste aumento no es estadisticamente significativo.De 120 biopsies sobre úlceras malignas (21 cánceres invasivos) un 67.6 % fueron positivas, tasa superior a la recogida en la literatura.El reparto de biopsias positivas en las series de tomas separadas se produce también al azar.El número de biopsies necesarias para obtenir con probabilidad elevada (p = 0.999) tomas positivas para cancer son, en orden creciente: 6 biopsias para obtener una positiva para cancer, 8 para obtener, 2 y 11 para obtener tres.Para conseguir la mayor seguridad, los autores recomiendan un número de biopsias entre 8 y 11.

Early calcific stenosis of the aortic sorin pericarbon valve implanted in the elderly.

BACKGROUND We reviewed our experience with the Sorin Pericarbon (Sorin, Saluggia, Italy) valve implanted in the aortic position. METHODS From January 1990 to January 1996, 143 consecutive patients had a Pericarbon valve implanted in the aortic position. The mean age was 75+/-5 years. Seventy-eight patients (55%) were in New York Heart Association (NYHA) class III or IV. Sixty patients (42%) had one or more concomitant procedures (51 coronary artery bypass grafting [CABG], 7 carotid endarterectomies, 9 others). RESULTS The hospital mortality rate was 12% (17 of 143 patients). The follow-up was 100% complete and the median time was 42 months (range, 2 to 79 months). There were 36 late deaths, 20 being cardiac-related: 5 non-valve-related, 11 valve-related, and 4 sudden unexpected deaths. The 5-year actuarial survival was 57%+/-5%. There were 6 early valve failures related to a calcific stenosis at a median time of 36 months (range, 5 to 66 months). Three patients had to undergo another operation and one of these patients died. One patient died the day before the planned reoperation and 2 patients are followed with a symptomatic aortic stenosis but refuse reoperation. Freedom from structural deterioration was 93%+/-3% at 4 years. Echocardiographic examination was obtained in 73 patients at a median time of 42 months (range, 4 to 79 months). Four additional asymptomatic patients were found to have calcifications of their prosthesis. The 5-year freedom from thromboembolic events and from endocarditis were, respectively, 87%+/-5% and 92%+/-3%. CONCLUSION The surprisingly high rate of early failure due to calcific stenosis and of thromboembolic events of the Pericarbon valve implanted in the aortic position in the elderly made us discontinue its use in our institution.