Jean-Benoît Le Polain De Waroux

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

OBJECTIVESnThe 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.nnnBACKGROUNDnSurgical valve repair for AR has significant advantages over valve replacement, but little is known about the predictors and mechanisms of its failure.nnnMETHODSnWe 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.nnnRESULTSnPre-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.nnnCONCLUSIONSnOur results demonstrate that intraoperative transesophageal echocardiography can be used to identify patients undergoing AR repair who are at increased risk for late repair failure.

Evaluation of a new semiautomated external defibrillator technology: a live cases video recording study

Aim To determine the effect of a new automated external defibrillator (AED) system connected by General Packet Radio Service (GPRS) to an external call centre in assisting novices in a sudden cardiac arrest situation. Method Prospective, interventional study. Layperson volunteers were first asked to complete a survey about their knowledge and ability to give cardiopulmonary resuscitation (CPR) and use an AED. A simulated cardiac arrest scenario using a CPR manikin was then presented to volunteers. A telephone and semi-AED were available in the same room. The AED was linked to a call centre, which provided real-time information to ‘bystanders’ and emergency services via GPRS/GPS technology. The scene was videotaped to avoid any interaction with examiners. A standardised check list was used to record correct actions. Results 85 volunteers completed questionnaires and were recorded. Mean age was 44±16, and 49% were male; 38 (45%) had prior CPR training or felt comfortable intervening in a sudden cardiac arrest victim; 40% felt they could deliver a shock using an AED. During the scenarios, 56 (66%) of the participants used the AED and 53 (62%) successfully delivered an electrical shock. Mean time to defibrillation was 2u2005min 29u2005s. Only 24 (28%) participants dialled the correct emergency response number (112); the live-assisted GPRS AED allowed alerted emergency services in 38 other cases. CPR was initiated in 63 (74%) cases, 26 (31%) times without prompting and 37 (44%) times after prompting by the AED. Conclusions Although knowledge of the general population appears to be inadequate with regard to AED locations and recognition, live-assisted devices with GPS-location may improve emergency care.

An atypical cause of malignant syncope and sudden cardiac arrest.

Coronary spasm (CS) or Prinzmetals angina is an important cause of pectoral angina but remains difficult to diagnose. Historical descriptions presented the syndrome as a benign affection, but recent reports showed that CS could trigger ventricular arrhythmias and …

Giant venous aneurysm jeopardising internal mammary arterial graft patency

The authors report a 79-year old man with a history of coronary bypass surgery, presenting with acute heart failure and elevated troponin. Coronarography revealed a giant saphenous vein graft aneurysm, which was compressing the left internal mammary artery bypass graft. This was confirmed by a multislice enhanced-ECG gated cardiac CT, showing the venous aneurysm responsible for external compression of the arterial graft and its functional occlusion. Myocardial ischaemia, the mechanism leading to cardiac failure, was confirmed by hypoperfusion of the sub-endocardial area shown by the CT. The aneurysm was surgically removed without complications. The patient recovered and his cardiac function improved. This is the first recorded case of compression of the left internal mammary artery by an giant saphenous vein graft aneurysm having triggered severe myocardial ischaemia and heart failure. The authors review the incidence and complications of giant venous bypass graft aneurysms reported in the literature.

Defibrillation testing is mandatory in patients with subcutaneous implantable cardioverter–defibrillator to confirm appropriate ventricular fibrillation detection

BACKGROUNDnThe subcutaneous implantable cardioverter-defibrillator (S-ICD) remains a new technology requiring accurate assessment of the various aspects of its functioning. Isolated cases of delayed sensing of ventricular arrhythmia have been described.nnnOBJECTIVEnThe purpose of this multicenter study was to assess the quality of sensing during induced ventricular fibrillation (VF).nnnMETHODSnOne hundred thirty-seven patients underwent induction of VF at the end of the S-ICD implantation.nnnRESULTSnVF induction was successful in 133 patients (97%). Mean time to first therapy was 16.2 ± 3.1 seconds, with a substantial range from 12.5 to 27.0 seconds. Four different detection profiles were arbitrarily defined: (1) optimal detection (n = 39 [29%]); (2) undersensing with moderate prolongation of time to therapy (<18 seconds; n = 68 [51%]); (3) undersensing with significant prolongation of the time to therapy (>18 seconds; n = 19 [14%]); and (4) absence of therapy or prolonged time to therapy related to noise oversensing (n = 7 [6%]). In some of the patients in the last group, despite induction of VF the initial counter was never filled, the device did not charge the capacitors, and the shock was not delivered because of a sustained diagnosis of noise (n = 5). A manual shock by the device or an external shock had to be delivered to restore the sinus rhythm.nnnCONCLUSIONnOur study demonstrated a marked sensing delay leading to prolonged time to therapy in a large number of S-ICD patients. A few worrisome cases of noise oversensing inhibiting the therapies were detected. These results support the need for systematic intraoperative defibrillation testing.

Giant right atrial thrombus associated with ICD lead externalized conductors: a case report

Abstract Introduction Narrow calibre ICD leads are prone to present insulation defects and conductor externalization. Close follow-up of these leads is recommended but as long as their electrical function is maintained, no prophyllactic replacement or extraction is advised. Although the risk of thrombus formation involving externalized conductors has been described, this risk seems considered as negligible compared with the risk of a prophylactic lead extraction. However, when an intracavitar thrombus is identified, the safest therapeutic approach remains undetermined. Case presentation In the present clinical vignette, we describe the case of a giant thrombus developed along the externalized portion of an electrically functional ICD lead. In this case, the thrombus was successfully treated with a systemic oral anticoagulation. Discussion This case report supports the concept of a prolonged anticoagulation for both the diagnosis and the long-term treatment of thrombus developed along externalized ICD leads, in particular when the patient prefers to avoid or postpone the risk of a trans-venous lead extraction.