Charles Mve Mvondo

Left atrial radiofrequency ablation associated with valve surgery: midterm outcomes.

BACKGROUND Left atrial ablation is a surgical standard technique for the treatment of persistent or chronic atrial fibrillation (p-AF and c-AF, respectively).Objective The aim of the study is to evaluate midterm results of left atrial ablation according to modified Maze procedure in patients affected by p-AF or c-AF and concomitant mitral or aortic valve disease requiring surgical treatment. METHODS A total of 108 patients (age, mean ± standard deviation [SD]: 66 ± 8.5 years) underwent left atrial ablation by means of unipolar (n = 62) or bipolar (n = 66) radiofrequency for p-AF (n = 28) or c-AF (n = 100) in association with mitral (n = 93) or mitral and aortic valve (n = 35) surgery. RESULTS In-hospital mortality was 0.8%. Patients with preoperative c-AF had preoperative greater value of left atrial diameter (56.7 ± 7.4 vs. 52 ± 9 mm, p = 0.05) than those with p-AF. At 9 years after Maze procedure, 86% (n = 24/28) of patients with preoperative p-AF were in sinus rhythm versus 28% (n = 27/95) with c-AF (p < 0.0001). Preoperative c-AF and left atrial diameter of 75 mm or more predicted atrial fibrillation recurrence. In patients in sinus rhythm compared with those in residual atrial fibrillation, survival was 100 versus 86% ± 6.4%, New York Heart Association class was 1.3 ± 0.5 versus 1.7 ± 0.6, and need of lifelong anticoagulation therapy was 43 versus 91% (p < 0.05, for all comparisons). CONCLUSIONS Left atrial Maze procedure for p-AF offers better chances to conversion in sinus rhythm as compared with long-standing c-AF. Survival, functional status, and quality of life are superior in patients who benefit from sinus rhythm.

Surgical Treatment of Aortic Valve Regurgitation Secondary to Ascending Aorta Aneurysm: Is Adjunctive Subcommissural Annuloplasty Necessary?

BACKGROUND Subcommissural aortic annuloplasty (SCA) has been recommended for treatment of functional aortic regurgitation (AR), but its association with sinotubular junction adjustment is still controversial. METHODS Sixty patients with moderate or severe functional AR secondary to proximal ascending aorta aneurysm operated on between May 2004 and December 2010 were reviewed. Forty patients underwent SCA and ascending aorta repair (SCA group; mean age, 65 ± 9 years) and 20 underwent ascending aorta repair alone (non-SCA group; mean age, 69 ± 8 years). Preoperative AR grades were comparable between groups (p = 0.9). Echocardiographic data at discharge and during follow-up (SCA group, 41 ± 13 months; non-SCA group, 46 ± 13 months) were analyzed. RESULTS Improvement of mean AR grade was better in the SCA group than in the non-SCA group at discharge (0.78 ± 0.9 vs 1.8 ± 0.1/4+, p = 0.0001) and at follow-up (0.44 ± 0.8 vs 2.4 ± 0.7/4+, p = 0.0001). Cox-regression analysis (odds ratio [95% confidence interval]) identified a higher residual AR at discharge (0.14 [0.012-0.37], p = 0.02) and the surgical technique, SCA or not (0.5 [0.03-0.899], p = 0.04), as predictors of more than grade 2/4+ AR at follow-up. Five-year freedom from more than grade 2/4+ AR was 94.4% ± 5.4% vs 58% ± 16% in SCA vs non-SCA (p = 0.02), respectively, and the survival rate was 95% ± 5% vs 89% ± 7.5% (p = 0.7). No valve stenosis was observed in the SCA group. CONCLUSIONS SCA is effective for treatment of functional AR, providing stable results even for significant AR. Our results suggest that it should be possibly associated to sinotubular junction adjustment. SCA seems to not impair normal aortic valve opening.

Candida parapsilosis endocarditis on a prosthetic aortic valve with unclear echocardiographic features.

Fungal endocarditis is rare in comparison with bacterial endocarditis and is associated with a poor prognosis. Despite the proven reliability of echocardiography, false negatives are not uncommon and may influence the therapeutic strategy, as some reports have supported the efficacy of antifungal treatment alone. We report on a case of bioprosthetic aortic valve Candida parapsilosis endocarditis without typical echocardiograhy findings, which we treated with both antifungal and surgical therapy.

Mechanical Heart Valve Replacement in a Low-Middle Income Region in the Modern Era: Midterm Results from a Sub-Saharan Center

BACKGROUND  The management of patients with mechanical heart valves remains a major concern in populations with limited resources and medical facilities. This study reports the clinical outcomes of patients who underwent mechanical valve implantation in a sub-Saharan center over an 8-year period. METHODS  A total of 291 mechanical valves were implanted in 233 patients in our institution between February 2008 and June 2016. A total of 117 patients underwent mitral valve replacement (MVR, 50.2%), 57 had aortic valve replacement (AVR, 24.4%), and 59 underwent both AVR and MVR (double valve replacement [DVR], 25.7%). The mean age at surgery was 27.6 ± 13.4 years (range, 7-62 years). Rheumatic etiology was found in 80.6% of the patients. Hospital mortality, late deaths, and valve-related events were reviewed at follow-up (839 patient-years, range: 1-9.4 years, complete in 93%). RESULTS  The 30-day mortality was 4.7% (11/233). The overall survival at 1 and 6 years for the whole cohort was 88.8 ± 2.1% and 78.7 ± 3.3%, respectively. The 6-year survival for AVR, MVR, and DVR was 89.3 ± 4.8%, 73.2 ± 5.4%, and 79.3 ± 5.8%, respectively (p = 0.15). The freedom from neurologic events and anticoagulation-related bleeding at 6 years was 93.1 ± 2.1% and 78.9 ± 3.7%, respectively. No patient had reoperation at follow-up. No case of prosthetic valve thrombosis was identified. Eight full-term pregnancies were reported. CONCLUSION  This preliminary experience reports acceptable midterm results after mechanical heart valve implantation in our region. Both accurate surgical evaluation and strategies, either financial or social, facilitating patients education and medical assistance are crucial to ensure good results. Long-term follow-up and further studies comparing current nonthrombogenic options are warranted to draw reliable conclusions.

The Shisong Cardiac Center in Cameroon: An Example of a Long-Term Collaboration/Cooperation Toward Autonomy

Congenital heart diseases (CHD) are present in nearly 1% of live births; according to WHO, there are 1. 5 million newborns affected by CHD per year and more than 4 million children waiting for cardiac surgery treatment worldwide. The majority of these children (~90%) could be treated, saved and subsequently have a good quality of life but unfortunately, in developing countries with a suboptimal care or no access to care, they are destined to die. Cameroon, one of the 40 poorest countries in the world, is a typical example of this dramatic scenario and this is why we started a collaboration project with a local religious partner (Tertiary Sisters of Saint Francis) in 2001 with the aim of establishing the first cardiac surgery center in this country. There are various well-known organizational models to start a cooperation project in pediatric cardiac surgery in a developing country. In our case, the project included a long-term collaboration with a stable local partner, a big financial investment and a long period of development (10 years or more). It is probably the most difficult model but it is the only one with the greatest guarantee of success in terms of sustainability and autonomy. The aim of this study is to analyze the constructive and problematic aspects of the 17-year collaboration in this project, and to assess possible solutions regarding its critical issues. Although much has been done during this 17-year we are aware that there is still a lot that needs to be done.

Acute type A aortic dissection involving the iliac and left renal arteries, misdiagnosed as myocardial infarction

Summary Acute aortic dissection is the most frequent and deadly presentation of acute aortic syndromes. Its incidence is estimated at three to four cases per 100 000 persons per year. Its clinical presentation may be misleading, with misdiagnosis ranging between 14.1 and 38% in many series. A late diagnosis or absence of early and appropriate management is associated with mortality rates as high as 50 and 80% by the third day and second week, respectively, especially in proximal lesions. We report on the case of a 53-year-old man who presented with type A aortic dissection, misdiagnosed as acute myocardial infarction, who later died on day 12 of hospitalisation. Although a relatively rare condition, poor awareness in Africa probably accounted for the initial misdiagnosis. Thorough investigation of acute chest pain and initiation of clinical registries are potential avenues to curb related morbidity and mortality.Acute aortic dissection is the most frequent and deadly presentation of acute aortic syndromes. Its incidence is estimated at three to four cases per 100 000 persons per year. Its clinical presentation may be misleading, with misdiagnosis ranging between 14.1 and 38% in many series. A late diagnosis or absence of early and appropriate management is associated with mortality rates as high as 50 and 80% by the third day and second week, respectively, especially in proximal lesions. We report on the case of a 53-year-old man who presented with type A aortic dissection, misdiagnosed as acute myocardial infarction, who later died on day 12 of hospitalisation. Although a relatively rare condition, poor awareness in Africa probably accounted for the initial misdiagnosis. Thorough investigation of acute chest pain and initiation of clinical registries are potential avenues to curb related morbidity and mortality.

Sternal bone erosion by a giant chronic aortic pseudoaneurysm in a patient with previous surgery for type A aortic dissection.

Pseudoaneurysm may be defined as a tear through the arterial wall with persistent flow outside the vessel into a space contained by the surrounding tissue. Aortic pseudoaneurysm may occur after surgery for acute aortic dissection and commonly occurs at sites of aortic wall disruption. The arterial site cannulation and anastomosis lines are the main locations. It could develop subclinically, leading to chronic and complex pathological patterns, which make surgical management challenging. Therefore, accurate postsurgical imaging is essential in order to avoid later complications, often associated with fatal consequences. Surgical treatment is complex and often associated with a high morbidity and mortality. Therefore, the therapeutic strategy

Bilateral cerebral perfusion via right axillary artery cannulation alone in aortic arch surgery.

Several methods have been proposed to avoid cerebral damage during aortic arch surgery. Antegrade, bilateral, selective cerebral perfusion is probably the most efficient one, although it has some drawbacks, such as air or particulate embolism risk, limitation in operative field visibility, and interactions with surgical maneuvers. We describe a surgical technique that provides bilateral antegrade perfusion to the brain, via the right axillary artery, with no need of additional arterial lines or shunting devices.

Hybrid approach to treat total thoracic aortic aneurysm in a patient undergoing emergency surgery for descending aortic rupture.

Rupture of the descending aorta is a life-threatening complication requiring emergency intervention. The endovascular approach (TEVAR) has been recently introduced to treat the descending aorta in the emergency setting, resulting in better early postoperative outcome as compared with traditional surgery. However, when the pathology involves the aortic arch and ascending aorta, TEVAR alone cannot be performed, requiring an alternative approach. We describe a one-stage hybrid repair via midline sternotomy to treat rupture of the descending thoracic aortic segment in toto.