Bernard Albat

Chronic left main coronary artery occlusion: a complication of radiofrequency ablation of idiopathic left ventricular tachycardia.

We describe in this report the development of chronic left main coronary artery (LMCA) occlusion in a young patient 2 years after an uncomplicated, successful ablation of idiophic left ventricular tachycardia. This complication appears to be a late consequence of trauma to the LMCA during the procedure rather than an acute or subacute embolic event.

Preoperative Evaluation in Aortic Endocarditis: Findings on Cardiac CT

OBJECTIVE The purpose of this study was to study the feasibility and diagnostic capability of preoperative cardiac CT for depicting aortic valvular pseudoaneurysms and vegetations in patients referred for aortic endocarditis requiring surgical intervention. MATERIALS AND METHODS Consecutive patients presenting with active aortic endocarditis requiring surgical intervention were included. CT scan examinations were performed for assessing coronary artery status. Aortic valves were retrospectively analyzed. Contrast-enhanced CT scans were retrospectively gated to the ECG and obtained without the administration of a beta-blocker. The CT and intraoperative findings were systematically compared. RESULTS During a 4-year period, 19 consecutive patients (18 men and one woman) were included (mean age +/- SD, 55 +/- 13 years). Results are expressed on a per-patient basis. The sensitivity, specificity, positive predictive value, and negative predictive value of MDCT in depicting aortic valve pseudoaneurysms were 100%, 87.5%, 91.7%, and 100%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of the MDCT in depicting the extension of the aortic valve pseudoaneurysms into the intervalvular fibrous body were each 100%. The sensitivity, specificity, positive predictive value, and negative predictive value of MDCT in depicting aortic valve vegetations were 71.4%, 100%, 100%, and 55.5%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of MDCT for depicting aortic valve vegetations larger than 1 cm were all 100%. CONCLUSION Our study shows the feasibility of preoperative CT in aortic infective endocarditis for providing relevant data about the presence and relationships of aortic valvular pseudoaneurysms. A larger prospective study including a systematic comparison with transesophageal echocardiography should be performed to determine the respective value of each technique.

An aortic ring: From physiologic reconstruction of the root to a standardized approach for aortic valve repair

OBJECTIVE We suggest standardizing aortic valve repair using a physiologic approach by associating root remodeling with resuspension of the cusp effective height and external subvalvular aortic ring annuloplasty. METHODS A total of 187 patients underwent remodeling associated with subvalvular aortic ring annuloplasty (14 centers, 24 surgeons). Three strategies for cusp repair were evaluated: group 1, gross visual estimation (74 patients); group 2, alignment of cusp free edges (62 patients); and group 3, 2-step approach, alignment of the cusp free edges and effective height resuspension (51 patients). The composite outcome was defined as recurrence of aortic insufficiency of grade 2 or greater and/or reoperation. RESULTS The operative mortality rate was 3.2% (n = 6). Treatment of a cusp lesion was most frequently performed in group 3 (70.6% vs 20.3% in group 1 and 30.6% in group 2, P < .001). Nine patients required reoperation during a follow-up period of 24 months (range, 12-45), 6 patients in group 1 and 3 patients in group 2. At 1 year, no patients in group 3 presented with composite outcome events compared with 28.1% in group 1 and 15% in group 2 (P < .001). Residual aortic insufficiency and tricuspid anatomy were independent risk factors for the composite outcome in groups 1 and 2. The annulus diameter, the presence of Marfan syndrome, and cusp repair had no effect on aortic insufficiency recurrence or reoperation. CONCLUSIONS A standardized and physiologic approach to aortic valve repair, considering both the aorta (root remodeling) and the valve (resuspension of the cusp effective height and subvalvular ring annuloplasty) improved the preliminary results and might affect their long-term durability. The ongoing Conservative Aortic Valve Surgery for Aortic Insufficiency and Aneurysm of the Aortic Root (CAVIAAR) trial will compare this strategy to mechanical valve replacement.

Surgical conversion after thoracic endovascular aortic repair

OBJECTIVE Improved early and late outcomes of thoracic endovascular aortic repair compared with open repair have changed the therapeutic paradigm of thoracic aortic lesions. However, rare but serious complications due to device failure or adverse events may occur, requiring conversion to open repair. METHODS In our experience, 186 patients underwent thoracic endovascular aortic repair. Seven of these patients (3.7%) required open repair because of 3 retrograde type A dissections, 1 thoracic stent-graft collapse, 1 aneurysm enlargement without endoleak, 1 aortoesophageal fistula, and 1 stent-graft infection. All patients but 1 underwent surgical repair using cardiopulmonary bypass. Four stent-grafts were totally removed, and 3 endografts were left in situ. Three patients underwent supracoronary ascending aorta replacement via a sternotomy. Three patients underwent a descending aortic replacement via a left thoracotomy. One patient was treated by ligation of the aortic arch, ascending to supraceliac abdominal aorta bypass, and stent-graft explantation. RESULTS Thirty-day mortality was 28%. Four patients had an uneventful postoperative course. One patient was treated for postoperative sternitis. Two patients with stent-graft infections died of multiorgan failure in the early postoperative course. No stroke, paraplegia, or renal failure occurred. With a mean follow-up of 21.4 months (range, 2-60 months), 5 patients had no adverse events. CONCLUSIONS Complications due to device failure or adverse events may occur after thoracic endovascular aortic repair, requiring conversion to open repair. Our experience suggests that in some clinical or anatomic situations, caution should be recommended when offering endovascular procedures to patients with thoracic aortic diseases. Open conversion can be performed with encouraging results by a team experienced in the management of thoracic aortic diseases. With the increasing use of thoracic endovascular aortic repair, more patients will present with indications of surgical conversion.

Clinical outcome after repair of acute type A dissection in patients over 70 years-old

BACKGROUND Despite current aging of patients proposed for cardiac surgery, published results of type A dissection repair in the elderly are sparse and controversial though an increased operative risk when compared to younger patients is well-documented. Whether any patient of an advanced aged suffering from acute dissection of the proximal aorta should be referred for surgery deserves specific clinical studies. OBJECTIVE To define factors of poor outcome after repair of type A dissection in the elderly by focusing on both early and late results. METHOD A retrospective study including a consecutive series of 83 patients operated on in two neighboring French university centers between 1988 and 1999 with similar outstanding methods. Complete follow-up was achieved in March 2000. Results were compared according to: (i) the presence or the absence of complications at admission; and (ii) the use of hypothermic circulatory arrest (HCA) for completion of the distal suture. RESULTS Mean age was 75.2+/-3.6 years (70-85). Overall operative mortality (OM) was 37.3%. OM was significantly higher (51.2 versus 23.8%, P=0.01) for patients who presented at admission any one of the following complications: tamponade, shock, endotracheal intubation upon arrival or evidence of brain, myocardial, mesenteric, renal or limb malperfusion. OM was not significantly affected by age or by the use of HCA during repair. Overall Kaplan-Meier survival was 50% at 1 year, 30% at 5 years and 13% at 10 years and was significantly lower (P=0.004) for patients who presented at least one complication at admission. Kaplan-Meier survival (excluding OM) was respectively 81, 48 and 21% and was significantly lower in case of prolonged stay in ICU (P=0.014) and for patients operated on without HCA (P=0.02). CONCLUSIONS Results of repair of acute type A dissections in the elderly are acceptable for uncomplicated cases at admission. Using HCA in elderly patients whenever required for appropriate repair does not worsen early or late survival.

Reconstructive surgery of postinfarction left ventricular aneurysms: techniques and unsolved problems

The progress in the surgical treatment of postinfarction left ventricular (LV) aneurysm surgery has reduced the operative mortality considerably, while the selection of the optimal LV repair technique remains unclear. Any of the surgical techniques presented in this review has its own advantages and disadvantages. The main goal of this study was to perform a selective literature review of LV aneurysm repair techniques, the most widespread being the linear repair and patch ventriculoplasty.

Local carotid atherosclerotic plaque proteins for the identification of circulating biomarkers in coronary patients.

OBJECTIVE To identify circulating biomarkers that originate from atherosclerotic vulnerable plaques and that could predict future cardiovascular events. METHODS After a protein enrichment step (combinatorial peptide ligand library approach), we performed a two-dimensional electrophoresis comparative analysis on human carotid plaque protein extracts (fibrotic and hemorrhagic atherosclerotic plaques). In silico analysis of the biological processes was applied on proteomic data. Luminex xMAP assays were used to quantify inflammatory components in carotid plaques. The systemic quantification of proteins originating from vulnerable plaques in blood samples from patients with stable and unstable coronary disease was evaluated. RESULTS A total of 118 proteins are differentially expressed in fibrotic and hemorrhagic plaques, and allowed the identification of three biological processes related to atherosclerosis (platelet degranulation, vascular autophagy and negative regulation of fibrinolysis). The multiplex assays revealed an increasing expression of VEGF, IL-6, IL-8, IP-10 and RANTES in hemorrhagic as compared to fibrotic plaques (p<0.05). Measurement of protein expressions in plasmas from patients with stable and unstable coronary disease identified a combination of biomarkers, including proteins of the smooth muscle cell integrity (Calponin-1), oxidative stress (DJ-1) and inflammation (IL-8), that allows the accurate classification of patients at risk (p=0.0006). CONCLUSION Using tissue protein enrichment technology, we validated proteins that are differentially expressed in hemorrhagic plaques as potential circulating biomarkers of coronary patients. Combinations of such circulating biomarkers could be used to stratify coronary patients.

Post cardiac surgery vasoplegia is associated with high preoperative copeptin plasma concentration

IntroductionPost cardiac surgery vasodilatation (PCSV) is possibly related to a vasopressin deficiency that could relate to chronic stimulation of adeno-hypophysis. To assess vasopressin system activation, a perioperative course of copeptin and vasopressin plasma concentrations were studied in consecutive patients operated on for cardiac surgery.MethodsSixty-four consecutive patients scheduled for elective cardiac surgery with cardiopulmonary bypass were studied. Hemodynamic, laboratory and clinical data were recorded before and during cardiopulmonary bypass, and at the eighth postoperative hour (H8). At the same time, blood was withdrawn to determine plasma concentrations of arginine vasopressin (AVP, radioimmunoassay) and copeptin (immunoluminometric assay). PCSV was defined as mean arterial blood pressure < 60 mmHg with cardiac index ≥ 2.2 l/min/m2, and was treated with norepinephrine to restore mean blood pressure > 60 mmHg. Patients with PCSV were compared with the other patients (controls). Students t test, Fishers exact test, or nonparametric tests (Mann-Whitney, Wilcoxon) were used when appropriate. Correlation between AVP and copeptin was evaluated and receiver-operator characteristic analysis assessed the utility of preoperative copeptin to distinguish between controls and PCSV patients.ResultsPatients who experienced PCSV had significantly higher copeptin plasma concentration before cardiopulmonary bypass (P < 0.001) but lower AVP concentrations at H8 (P < 0.01) than controls. PCSV patients had preoperative hyponatremia and decreased left ventricle ejection fraction, and experienced more complex surgery (redo). The area under the receiver-operator characteristic curve of preoperative copeptin concentration was 0.86 ± 0.04 (95% confidence interval = 0.78 to 0.94; P < 0.001). The best predictive value for preoperative copeptin plasma concentration was 9.43 pmol/l with a sensitivity of 90% and a specificity of 77%.ConclusionsHigh preoperative copeptin plasma concentration is predictive of PSCV and suggests an activation of the AVP system before surgery that may facilitate depletion of endogenous AVP stores and a relative AVP deficit after surgery.

Factors favoring retrograde aortic dissection after endovascular aortic arch repair

OBJECTIVE To assess factors predisposing patients to retrograde type A aortic dissection (RTAD) who have undergone hybrid aortic arch repair. METHODS From 2001 to 2013, 32 patients underwent hybrid aortic arch repair in our department: 19 in zone 1 and 13 in zone 0. Among these patients, 6 experienced RTAD (18.7%): 3 in zone 0 (23%), 3 in zone 1 (15.8%). Preoperative computed tomography scans of these 32 patients were evaluated. A morphologic assessment of the aortic arch, ascending aorta, and aortic root was performed. Other potential risk factors were investigated. Binary logistic regression was performed to test for possible associations with RTAD. RESULTS Five patients were successfully converted to open repair. Patients who had RTAD were similar to those who did not, across pertinent variables, including age, type of device, diameter of the ascending aorta, and presence of a bicuspid aortic valve (all P > .1). Incidence of RTAD was observed to be higher among women (P = .034), patients with stent-graft oversizing ≥10% (P = .018), and patients treated with a stent-graft of diameter >42 mm (P = .01). Aortic morphology analysis showed that an indexed aortic diameter of ≥20 mm/m(2) (P = .003); aortic root morphology, specifically loss of the sinotubular junction (P = .004); and presence of an aortic arch malformation (P = .03) were correlated with risk of RTAD. Two patients in the zone-0 group with severe angulation (>120°) between the ascending and the transverse aorta suffered RTAD. CONCLUSIONS The occurrence of RTAD after hybrid aortic arch repair is common. To prevent this complication, preoperative screening of the aortic arch, ascending aorta, and aortic root morphology is critical.

Carotid atherosclerotic plaques: Proteomics study after a low-abundance protein enrichment step

Atherosclerosis is one of the most important causes of cardiovascular and cerebrovascular events. Although phenotypic differentiation between stable and unstable plaques is currently possible, proteomic analysis of the atherosclerotic plaque could offer a global view of the atherosclerosis pathology. With the objective to highlight the detection of low‐abundance proteins, we reduced the dynamic range of proteins by combinatorial peptide ligand library treatment of human carotid artery atherosclerotic plaques. After enrichment step, abundance of major proteins was decreased, revealing different protein profiles as assessed by both SDS‐polyacrylamide gel electrophoresis and two‐dimensional electrophoresis comparative analyses. Identification of proteins that were contained in a spot allowed finding large differences between noncomplicated and complicated plaques from carotid atherosclerotic lesions. Novel low‐abundance proteins were detected correlating very well with biological alterations related to atherosclerosis (heat shock protein 27 (HSP27) isoforms, aldehyde dehydrogenase, moesin, Protein kinase C delta‐binding protein, and inter‐α trypsin inhibitor family heavy chain‐related protein (ITIH4)). At the same time, the differential expression of known proteins of interest such as hemoglobin β‐chain and heat shock protein 27 between noncomplicated and hemorrhagic complicated plaques was maintained after enrichment step. The detection of different isoforms of a low‐abundance protein such as heat shock protein 27 species was actually improved after enrichment of tissue protein extracts. All of these findings clearly support further investigations in view to confirm the role of these proteins as possible biomarkers.