Jean-Pol Depoix

Contemporary surgical or percutaneous management of severe aortic stenosis in the elderly

AIMS To assess patient characteristics, therapeutic options, and their results in patients referred to a tertiary centre with on-site capabilities for surgical and percutaneous valvular interventions for the management of severe symptomatic aortic stenosis (AS). METHODS AND RESULTS Sixty-six consecutive patients >70 years (83 +/- 6 years) were referred for severe AS. Their mortality risk predicted by the logistic European System for Cardiac Operative Risk Evaluation and the Society of Thoracic Surgeons-Predicted Risk of Mortality scores were on average 20 +/- 14% and 17 +/- 7%, respectively. Thirty-nine patients (59%) were considered at high-risk for surgery or inoperable after multidisciplinary evaluation: 12 (31%) underwent a transfemoral aortic valve implantation and 27 were considered unsuitable and treated medically (n = 16) or with valvuloplasty (n = 7), or were re-directed towards surgery (n = 4). The 27 other patients underwent valve replacement. In-hospital mortality was 9% (6 of 66). There were three hospital deaths in patients treated percutaneously, two in those treated medically, and one after surgery. At 6 months, 10% (6 of 60) of the survivors died: two after valvuloplasty and four after medical treatment. CONCLUSION A large proportion of elderly patients referred for management of severe AS have a high-risk profile. The availability of percutaneous valvular interventions increases the number of those who are offered interventions.

Transfemoral Implantation of Transcatheter Heart Valves After Deterioration of Mitral Bioprosthesis or Previous Ring Annuloplasty

OBJECTIVES This study sought to evaluate the feasibility of transfemoral transcatheter heart valve (THV) implantation in failed mitral bioprostheses and ring annuloplasties. BACKGROUND Redo mitral surgery may be high risk or contraindicated due to comorbidity. THV implantation has been recently reported in this setting. METHODS Transfemoral implantation of Edwards Sapien prosthesis was performed in 17 patients for degenerated mitral bioprosthesis or previous ring annuloplasty (6 bioprostheses, 11 ring annuloplasties). The procedure was elective for 14 patients and attempted as a rescue in 3 patients. Mean age was 61 ± 24 years. All patients were in New York Heart Association class ≥III, and the surgical risk was high (EuroSCORE [European System for Cardiac Operative Risk Evaluation]: 37 ± 29%, Society of Thoracic Surgeons score: 18 ± 22%). RESULTS Procedure was successful in 14 patients (82%). Two complications occurred during rescue procedures: 1 procedural death and 1 THV migration. One patient had moderate paraprosthetic regurgitation following the procedure, whereas residual regurgitation was trace or less in 11 patients (69%) and mild in 4 patients (25%). Mean gradient decreased from 12 ± 6 mm Hg to 8 ± 3 mm Hg. During a mean follow-up of 22 months, 4 patients died, 3 from cardiac cause. The 18-month survival was 68 ± 14% in the overall population and 78 ± 14% for patients with elective procedure. One patient underwent mitral valve replacement due to periprosthetic mitral regurgitation. At last follow-up, 12 patients were in New York Heart Association class ≤II (75%) and 4 in class III (25%). CONCLUSIONS This single-center series suggests that transfemoral THV implantation for deterioration of mitral bioprosthesis or surgical repair is feasible in selected patients and improves early hemodynamic and midterm functional status.

Comparison of minithoracotomy and conventional sternotomy approaches for valve surgery

OBJECTIVE To compare patients undergoing valve surgery through a minithoracotomy approach with a matched group undergoing conventional valve surgery. DESIGN Control study. SETTING University hospital, single center. PARTICIPANTS Forty-one consecutive patients scheduled for valve surgery by minithoracotomy approach were matched with a similar group of patients operated on by the sternotomy approach. INTERVENTIONS Criteria for matching included type of valve procedure (aortic valve replacement or mitral valve repair), age, surgeons, and left ventricular function. Two surgeons performed the surgical procedures. Perioperative care was standardized for all patients. Operative and postoperative data were recorded. MEASUREMENTS AND MAIN RESULTS The 41 pairs of patients were correctly matched, except for left ventricular function (n = 1). Twenty patients underwent mitral valve repair and 62 aortic valve replacement. Preoperative demographic data and clinical characteristics were similar in both groups. Cardiopulmonary bypass, aortic clamping, and surgery times were longer in the minithoracotomy group (p < 0.05). In 3 patients, the minithoracotomy approach had to be converted into a sternotomy during the surgical procedure for better visualization. Minithoracotomy patients had significantly increased postoperative total blood loss (p < 0.05). No difference was found between the groups for extubation time and intensive care or in-hospital lengths of stay. CONCLUSION These results suggest that valve surgery is feasible in many cases through minithoracotomy. Nevertheless, this approach increases surgical complexity and in this comparative study no significant benefit was shown.

Transfemoral Tricuspid Valve-in-Ring Implantation Using the Edwards Sapien XT Valve One-Year Follow-Up

Between November 2012 and August 2013, after multidisciplinary evaluation, 3 high-risk patients underwent transfemoral tricuspid valve-in-ring implantation (TVIRI) for refractory congestive heart failure because of deterioration of their tricuspid surgery, using Sapien XT valves (Edwards Lifesciences Inc, Irvine, CA). Patient 1: 44-year-old man, drug abuse, 4 episodes of tricuspid endocarditis, 2 previous cardiac surgeries for mitral homograft in tricuspid position with 30-mm Classic Carpentier Edwards annuloplasty ring (2001), presenting with massive central tricuspid regurgitation (TR; Figure 1A). Figure 1. Color transesophageal echocardiography (TEE) image of tricuspid regurgitation (TR) before implantation on the left panels. A , Patient 1: severe TR with 2 jets, one emanating from the center of the homograft and the second from the medial part of the prosthetic annulus. B , Patient 2: severe central intraprosthetic jet. C , Patient 3: severe central intraprosthetic jet. Color TEE image of TR after valve-in-ring implantation on the right panels: A′ , Patient 1: mild residual TR with an excentric jet coming from the medial part of the prosthetic annulus. Mid-esophageal two-dimensional (2D) TEE view at 0°, compare black and white and color Doppler. B′ , Patient 2: trace TR coming from the medial part of the prosthetic annulus. Mid-esophageal 2D TEE view at 90°, compare black and white and color Doppler. C′ , Patient 3: moderate-to-severe residual paravalvular TR with a jet coming from …

Successful Endovascular Stroke Rescue With Retrieval of an Embolized Calcium Fragment After Transcatheter Aortic Valve Replacement

A 90-year-old symptomatic woman with a critical aortic stenosis was referred for transcatheter aortic valve replacement (TAVR). The procedure was performed under locoregional anesthesia from a right femoral approach, with the successful implantation of a 23-mm CoreValve (Medtronic Inc, Minneapolis, MN). Echocardiographic assessment after TAVR showed a mean transprosthetic gradient of 16 mm Hg and trace paravalvular regurgitation. After percutaneous closure of the right femoral artery, the patient suddenly became unresponsive. After prompt intubation, emergency cerebral MRI was performed to assess the presence of reversible ischemia and exclude parenchymal hemorrhage, showing partial occlusion of the right middle cerebral artery with ischemia in the corresponding territory (Figure 1). Conventional cerebral angiography confirmed partial M1-M2 occlusion of the right middle cerebral artery (Figure 2A; Movie I in the Data Supplement). Complete revascularization …

Implantation valvulaire aortique percutanée : prise en charge par l’anesthésiste-réanimateur

OBJECTIVE To describe the perioperative management, from the point of view of the anesthesia-intensive care unit specialist, of patients with aortic stenosis who undergo transcatheter aortic valve implantation (femoral or apical TAVI). DATA SOURCE The PubMed database (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi) was queried, using the following keywords: aortic stenosis, transcatheter aortic valve implantation TAVI, outcome, complications, anesthesia. DATA SYNTHESIS TAVI is performed in patients suffering from aortic stenosis and presenting with numerous comorbidities, high-predicted perioperative mortality and/or contraindications to conventional cardiac surgery. TAVI is performed either by percutaneous transfemoral or transapical puncture of the left ventricle (LV) apex. These patients are older, have more comorbidities than those undergoing aortic valve replacement surgery and perioperative mortality predicted by risk scores is higher. While transapical TAVI is performed with general anaesthesia, transfemoral TAVI can be performed with either general or locoregional anaesthesia and/or sedation. The choice of the anaesthetic technique for transfemoral TAVI depends on the patients medical history, the technique chosen for valve implantation, the type of monitoring and the anticipated hemodynamic problems. The incidence of complications following TAVI is high, some are common to surgical aortic valve replacement, and others are specific to this technique. Because of the prevalence of comorbidities, the hemodynamic-specific constraints of this technique and the incidence of complications, anaesthetic and perioperative management (evaluation, anaesthetic technique, monitoring, post-surgery care) requires the same level of expertise as in cardiac surgery anaesthesia. CONCLUSION TAVI expands treatment options for patients with aortic valve stenosis. The anaesthesia team must be involved in the care of these patients with the same level of expertise and care as in heart surgery on critical patients.

A comparison of bilateral with single internal mammary artery grafts on postoperative mediastinal drainage and transfusion requirement.

The superiority of the left internal mammary artery (LIMA) graft over autogenous saphenous vein as a bypass conduit in coronary artery bypass surgery has been well established. Early and late patency rates of bilateral internal mammary artery (BIMA) grafts exceed those of vein grafts, and patients who receive BIMA have improved long-term survival rates and more freedom from reoperations and other cardiac events. But because of other concerns, particularly the question of increased risk of postoperative bleeding, controversy still surrounds the perioperative period. In the present study we sought to determine whether BIMA grafting was an independent risk factor of postoperative bleeding and of blood product use in patients undergoing primary elective coronary artery revascularization. For this purpose, 33 consecutive patients scheduled for BIMA grafting were matched with 66 patients operated on by single LIMA grafting. Patients in the LIMA group had significantly less postoperative mediastinal drainage than those in the BIMA group (median: 722 vs 920 mL, P = 0.0001). Fifty-six patients received blood products (56% vs 51% in LIMA and BIMA groups, respectively; P = 0.67). In multivariate analysis, BIMA and operative duration were independent predictors of increased postoperative drainage. Nevertheless, in logistic regression, BIMA was not significantly associated with blood product use, unlike precardiopulmonary bypass hematocrit and duration of surgery (OR and 95% CI: 0.89 [0.80–0.96] P = 0.01; 1.009 [1.001–1.019] P = 0.04, for an increase of 1% in hematocrit and 1 min in duration of surgery, respectively). In conclusion, these data support the idea that BIMA graft slightly increases postoperative drainage but not transfusion requirement.

How should I treat prosthetic tricuspid stenosis in an extreme surgical risk patient

BACKGROUND A 64-year-old female with rheumatic heart disease and multiple prior valve replacements presented with progressive oedema, ascites and dyspnoea on exertion. INVESTIGATION Physical examination, transthoracic echocardiography, intracardiac echocardiography, transoesophageal echocardiography, right heart cathetherisation, computed tomography. DIAGNOSIS She had a mitral homograft and Physio ring in the tricuspid position, and presented with severe bioprosthetic tricuspid valve stenosis (mean gradient 16 mmHg) and right-sided heart failure. TREATMENT A transcatheter 26 mm Edwards SAPIEN valve was placed in the tricuspid position, resulting in near normalisation of tricuspid valve gradient. This represents the first report of a combined valve-in-ring (VIR) and valve in a homograft valve (VIV) SAPIEN implantation.

Understanding Risk Assessment in Cardiac Surgery Patients

Understanding the risk of surgery in valvular disease is of interest because aging of the population renders decision making more difficult and the magnitude of risk will influence not only the decision to intervene but also the choice of intervention and its timing. To assist clinicians in assessing the risk of cardiac surgery, multivariate risk scores are increasingly used to estimate operative mortality. Overall, the currently available scores, mostly U.S. Society of Thoracic Surgeons score and European System for Cardiac operative Risk Evaluation, achieve acceptable discrimination but suboptimal calibration in estimating the operative mortality of heart valve surgery. The intrinsic limitations of scoring systems highlight the fact that risk scores should be integrated into clinical judgment but should not be a substitute for it. A multidisciplinary approach involving cardiologists, cardiac surgeons, and anesthesiologists is required for this purpose, especially in high-risk patients.

Pregnancy in a Patient With Severe Aortic Stenosis Requiring Unusual Management.

IN DEVELOPED COUNTRIES, congenital heart disease is the most common cardiovascular disease reported during pregnancy, with the majority of the cases of aortic stenosis in pregnant women being caused by congenital bicuspid aortic valve. While patients with asymptomatic mild, moderate, or even severe aortic stenosis usually can continue pregnancy to term, all symptomatic patients with severe aortic stenosis or asymptomatic patients with impaired left ventricular function are at high risk for cardiac complications. Aortic valve replacement is indicated before pregnancy in these women. Percutaneous aortic valvuloplasty also can be considered during pregnancy. More invasive techniques, such as aortic valve replacement under normothermic cardiopulmonary bypass during pregnancy, are associated with a high risk of mortality and morbidity for both the mother and the fetus The authors report here a case in which the global management of a pregnant patient with severe aortic stenosis was reconsidered in light of an unexpected echocardiographic report of calcified valves with a high risk of emboli.