François Bouchart

Myocardial revascularization in patients with severe ischemic left ventricular dysfunction. Long term follow-up in 141 patients

OBJECTIVES The present study evaluates our experience with coronary bypass grafting in patients with EF < or =25%. Myocardial revascularization in this setting remains controversial because of concerns over operative mortality and morbidity and lack of functional and survival benefit. MATERIALS AND METHODS One hundred and forty-one patients with coronary artery disease and left ventricular ejection fraction < or =25% underwent coronary artery bypass graft between January 1988 and December 1998. Mean age at operation was 63.3 years and 81.4% were male. The major indication for surgery was angina (114 patients, 80.8%). Ejection fraction (EF), left ventricular end diastolic pressure (LVEDP) and cardiac index (CI) were used to assess left ventricular function. The number of graft was 2.7+/-1.6/patient. Internal mammary artery was used in 119 patients (84.3%). Intra aortic balloon pump was placed preoperatively in 25 patients (17.7%). Five operative risk factors were associated with a higher mortality: emergency, female sex, LVEDP, CI and NYHA class IV. RESULTS The operative mortality was 7% (10 patients). Left ventricular ejection fraction (assessed post operatively in 83 patients) improved from 22.2% preoperatively to 33.5% post operatively (P<0.001), mean end diastolic volume index fell from 98 to 83 ml/m(2) following surgery. Survival at 2, 5 and 7 years was respectively 84+/-3%, 70+/-4% and 50+/-5%. Two variables were associated with increased long term survival: congestive heart failure (NYHA class lower than IV (P=0.035) and cardiomegaly (P=0.04) CONCLUSION In patients with left ventricular dysfunction, myocardial revascularization can be performed relatively safely with good medium term survival and improvement in quality of life and in left ventricular function. Coronary artery bypass graft may be offered to patients with impaired ventricular function, but careful patient selection and management when considering these patients for operation should assess potentially reversible dysfunction.

Is anti-platelet therapy needed in continuous flow left ventricular assist device patients? A single-centre experience.

OBJECTIVES We report our 5-year experience of continuous flow left ventricular assist device (LVAD) implantation without the use of anti-platelet therapy. METHODS Between February 2006 and September 2011, 27 patients (26 men; 1 woman) were implanted with a continuous flow LVAD (HeartMate II, Thoratec Corporation, Pleasanton, CA, USA). The mean age was 55.7 ± 9.9 years. The mean duration of support was 479 ± 436 (1-1555) days with 35.4 patient-years on support. Twenty-one patients were implanted as a bridge to transplantation and 6 for destination therapy. The anticoagulation regimen was fluindione for all patients, with aspirin for only 4 patients. At the beginning of our experience, aspirin was administered to 4 patients for 6, 15, 60 and 460 days. Due to gastrointestinal (GI) bleeding and epistaxis, aspirin was discontinued, and since August 2006, no patients have received anti-platelet therapy. RESULTS At 3 years, the survival rate during support was 76%. The most common postoperative adverse event was GI bleeding (19%) and epistaxis (30%) (median time: 26 days) for patients receiving fluindione and aspirin. The mean International Normalized Ratio (INR) was 2.58 ± 0.74 during support. Fifteen patients have been tested for acquired Von Willebrand disease. A diminished ratio of collagen-binding capacity and ristocetin cofactor activity to Von Willebrand factor antigen was observed in 7 patients. In the postoperative period, 2 patients presented with ischaemic stroke at 1 and 8 months. One of these 2 patients had a previous history of carotid stenosis with ischaemic stroke. There were no patients with haemorrhagic stroke, transient ischaemic attack or pump thrombosis. The event rate of stroke (ischaemic and haemorrhagic) per patient-year was 0.059 among the patients without aspirin with fluindione regimen only. CONCLUSIONS A fluindione regimen without aspirin in long-duration LVAD support appears to not increase thromboembolic events and could lead to a diminished risk of haemorrhagic stroke.

Acute traumatic isthmic aortic rupture. Long-term results in 49 patients.

Forty-nine patients who sustained acute traumatic rupture of the aorta at the level of the isthmus were treated in our hospital between 1976 and 1990. Four patients died before surgery and 45 patients were operated upon using a pump oxygenator partial bypass in all but 2 cases (1 clamp and sew and 1 shunt). The tear was circumferential in 33 and partial in 12 cases. Direct suture was used in the 12 partial and in 21 of the circumferential tears. A dacron tube was used in 12 patients. Hospital mortality was 3 resulting from brain damage, prolonged shock before surgery and necrosis of the colon 4 weeks after operation. No paraplegia was observed. There were 2 cases of neurological disturbance (2 spinal cord dysfunction 5 and 8 days, respectively, after surgery). These complications were transient. Among the 42 survivors, 1 was lost to follow-up. The clinical aortic status of the remaining 41 was excellent. Aortic reconstitution as assessed by digital aortic angiography was excellent in the 33 cases examined with 2 exceptions (graft stenosis, false aneurysm). Our experience and review of a large series indicate: the use of a partial bypass with pump oxygenator decreases the probability of medullary ischemia, but the risk of spinal cord ischemia is not eliminated. When intra-abdominal lesions are life-threatening, laparotomy must preceed thoracotomy. Clinical results assessed in long-term survivors are excellent, especially after direct repair.

Aortic valve replacement after aortic valvuloplasty for calcified aortic stenosis

OBJECTIVE This study concerns patients who underwent one or several aortic balloon valvuloplasties at our institution and subsequently required cardiac surgery, either on an emergency basis after aortic valvuloplasty or due to the development of aortic stenosis. METHODS Between February 1987 and December 1993, 137 patients (73 male, 64 female, mean age 72 +/- 9 years) underwent aortic valve replacement for calcified aortic stenosis after several percutaneous balloon aortic valvuloplasties. Thirty-one patients were in NYHA stage II, 70 in stage III and 36 in stage IV. Seventy patients had angina (23 stage I or II, 47 stage III or IV) and 24 patients presented syncope or lipothymia. Twenty-three percent had at least two of these three symptoms. The indications for balloon dilatation were non-definitive surgical contraindication or high surgical risk (73), personal choice (49), refusal of surgery (9) and emergency (5:2 massive aortic regurgitation, 1 left ventricle perforation, 1 cardiogenic shock, 1 endocarditis in cardiogenic shock). Seven patients received preoperative aortic valvuloplasty due to a very high operative risk. The average time between dilatation and surgery was 472 days and there was clinical improvement for an average period of 261 days. The aortic valve replacements consisted of 58 mechanical prostheses and 79 xenografts with 22 concomitant procedures. RESULTS Operative mortality was eight patients (5.8%). During the follow-up (17.4 +/- 9.2 months), four patients died (3.6%), 91.2% of the patients were in class I and II and 95% were without angina. The actuarial survival rate was 90.5 +/- 6.6% including hospital mortality. CONCLUSIONS Both our experience and the literature show that balloon aortic valvuloplasty is followed by an immediate improvement in hemodynamic status with a decrease in valve gradient and an increase in valve area. However, the hemodynamic benefit is typically short-lived with a very high restenosis rate. Balloon aortic valvuloplasty is not an alternative to aortic valve replacement, which remains the best treatment for calcified aortic stenosis; the benefits and long-term results of aortic valve replacement are well established, even in the elderly.

The Ross procedure in endocarditis: a report of 28 cases

OBJECTIVES The Ross procedure has received increasing interest as an attractive alternative to a prosthetic aortic valve. Given its presumably greater resistance to infection, the pulmonary autograft is theoretically preferable for active endocarditis. The objective of this retrospective study was to present our experience in aortic valve endocarditis treated using the Ross procedure. METHODS Between May 1997 and February 2011, the Ross procedure was performed on 142 patients in our institution. Twenty-eight patients had aortic valve endocarditis at the time of operation. Fourteen patients had urgent or emergency procedures, and 13 had active disease at the time of surgery. Twelve patients were alcoholics and/or drug addicts. Eight patients had an abscess of the aortic annulus. Clinical follow-up was complete. RESULTS Hospital mortality was 10.7%. Overall patient survival (± standard deviation) was 47 ± 13% at 10 years with no cardiac-related death during the mean follow-up of 6.4 ± 4.2 years. There were 3 cases of recurrent endocarditis including anterior mitral leaflets endocarditis and right-sided endocarditis to another germ in a drug addict. Four patients required further surgery, 2 on the pulmonary autograft; 18 of the 19 survivors were in New York Heart Association class I. At the final investigation, all patients had no or grade I autograft regurgitation. The mean pressure gradient across the homograft was 9 ± 7.5, 11 ± 9.5 and 15 ± 9.5 mmHg, respectively, for patients between 0-3, 4-9 and >9 years. CONCLUSIONS Endocarditis can be treated with good results using the Ross procedure, with a very low rate of recurrence of endocarditis.

Coronary Artery Dissection After Surgical Cryoablation Procedure

Cryoablation can be used to treat atrial fibrillation (AF) surgically. We describe a 71-year-old woman who underwent cryoablation after 6 months of AF. Four hours post-surgery, electrocardiographic changes were observed in the circumflex artery territory associated with hemodynamic instability, which responded to inotropic agents. Angiography revealed a diffuse circumflex artery spasm with a heterogeneous aspect of the posterior branch evoking a dissection. Platelet anti-aggregant and trinitrine therapy were started. Recovery was uneventful and the patient was discharged on day 13. Cryoablation-associated circumflex artery dissection is rare. Caution is required when locating the ablation lines to avoid coronary artery injury.

Isolated ventricular septal rupture secondary to blunt trauma

A ventricular septal rupture (VSR) is a rare complication of blunt chest trauma. We describe the case of a 25-year-old man who developed a VSR as a result of a high-speed road accident. The rupture was closed by left ventricular remodeling and replacement of the diseased myocardium with a Dacron patch. The patch sutures were reinforced with glue. Redo surgery was necessary at nine months due to patch detachment and embolization of the glue in the right lower lobe. The patient is asymptomatic, at 13-month follow-up.

0360 : Iatrogenic circumflex artery occlusion during mitral valve surgery: a retrospective study on 8 patients and a medical review

Background Circumflex coronary artery (CCA) injury during mitral valve surgery is a rare but serious complication whit difficult diagnosis. The aim of our study was to describe the elements of diagnosis that could allow prevention of this complication. Methods and Results From 2006 to 2013 in Rouen University Hospital, 8 patients (1.03%) among 775 undergoing mitral valve surgery (repair or replacement) presented CCA occlusion confirmed by coronary angiography. Sex ratio was 5 men for 3 women with a mean age of 54.2 years. Left main coronary dominance was present in 75%. Mitral valve repair was performed in 5 patients and valve replacement in 3. The diagnosis was suspected by ECG in 7/8 patients: 6 patients (75%) presented ST segment elevation, 1 had permanent AV block while EKG was normal in one. CCA occlusion led to a significant impairment of left ventricular function, median LVEF: decreased from 58 to 43% (p=0.04) although coronary angiography was performed within one hour in 5 patients (62.5%). Five had complete revascularization (4 of those with immediate coronary angiography), while 3 patients were treated medically. Occlusion, assessed by coronary angiography, was preferentially located on the superolateral quarter of the mitral annulus next to the anterolateral commissure predominantly on its mid portion (75%). As regards to the mechanism of CCA occlusion, 37.5% of patients had a stitch passing through the CCA, 50% had a kinking of the vessel due to a stitch located close to the CCA and one of them had a compressive hematoma Follow-up at day-7 was uneventful in 7 patients with one in-hospital death one day after the surgery (cardiac tamponade). Conclusion CCA injury is a rare but serious complication of mitral valve surgery suspected on ECG, due to a stitch always located at the same point of mitral annulus. An eventual intraoperative angiography in hybrid rooms could be a specific solution for patients at risk (large mitral ring, left main coronary dominance).

0247: Mitral valve surgery complicated by circumflex artery: a rare but serious complication

Background Circumflex coronary artery (CCA) injury during mitral valve surgery is a rare but serious complication whit difficult diagnosis. The aim of our study was to describe the elements of diagnosis that could allow prevention of this complication. Method and results From 2006 to 2013 in Rouen University Hospital, 8 patients (1.03%) among 775 undergoing mitral valve surgery (repair or replacement) presented CCA occlusion confirmed by coronary angiography. Sex ratio was 5 men for 3 women with a mean age of 54.2 years. Left main coronary dominance was present in 75%. Mitral valve repair was performed in 5 patients and valve replacement in 3. The diagnosis was suspected by ECG in 7/8 patients: 6 patients (75%) presented ST segment elevation, 1 had permanent AV block while EKG was normal in one. CCA occlusion led to a significant impairment of left ventricular function, median LVEF: decreased from 58 to 43% (p=0.04) although coronary angiography was performed within one hour in 5 patients (62.5%). Five had complete revascularization (4 of those with immediate coronary angiography), while 3 were treated medically. Occlusion, assessed by coronary angiography, was preferentially located on the superolateral quarter of the mitral annulus next to the anterolateral commissure predominantly on its mid portion (75%). As regards to the mechanism of CCA occlusion, 37.5% of patients had a stitch passing through the CCA, 50% had a kinking of the vessel due to a stitch located close to the CCA and one of them had a compressive hematoma. Follow-up at day-7 was uneventful in 7 patients with one in-hospital death one day after the surgery (cardiac tamponade). Conclusion CCA injury is a rare but serious complication of mitral valve surgery suspected on ECG, due to a stitch always located at the same point of mitral annulus. An eventual intraoperative angiography in hybrid rooms could be a specific solution for patients at risk (large mitral ring, left main coronary dominance).