Louis Labrousse

Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial.

Background— Thoracic endovascular aortic repair (TEVAR) represents a novel concept for type B aortic dissection. Although life-saving in acute emergencies, outcomes and survival of TEVAR in stable dissection are unknown. Methods and Results— One hundred forty patients in stable clinical condition at least 2 weeks after index dissection were randomly subjected to elective stent-graft placement in addition to optimal medical therapy (n=72) or to optimal medical therapy alone (n=68) with surveillance (arterial pressure according to World Health Organization guidelines ≤120/80 mm Hg). The primary end point was all-cause death at 2 years, whereas aorta-related death, progression (with need for conversion or additional endovascular or open surgery), and aortic remodeling were secondary end points. There was no difference in all-cause deaths, with a 2-year cumulative survival rate of 95.6±2.5% with optimal medical therapy versus 88.9±3.7% with TEVAR (P=0.15); the trial, however, turned out to be underpowered. Moreover, the aorta-related death rate was not different (P=0.44), and the risk for the combined end point of aorta-related death (rupture) and progression (including conversion or additional endovascular or open surgery) was similar (P=0.65). Three neurological adverse events occurred in the TEVAR group (1 paraplegia, 1 stroke, and 1 transient paraparesis), versus 1 case of paraparesis with medical treatment. Finally, aortic remodeling (with true-lumen recovery and thoracic false-lumen thrombosis) occurred in 91.3% of patients with TEVAR versus 19.4% of those who received medical treatment (P<0.001), which suggests ongoing aortic remodeling. Conclusions— In the first randomized study on elective stent-graft placement in survivors of uncomplicated type B aortic dissection, TEVAR failed to improve 2-year survival and adverse event rates despite favorable aortic remodeling. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00525356.

Experimental Validation of Circumferential, Longitudinal, and Radial 2-Dimensional Strain During Dobutamine Stress Echocardiography in Ischemic Conditions

OBJECTIVES The aim of this study was to assess and validate 2-dimensional (2D) strain for the detection of ischemia during dobutamine stress echocardiography (DSE). BACKGROUND Evaluation of abnormalities of left ventricular (LV) function from wall thickening during DSE is unsatisfactory and requires a high level of expertise. METHODS In 10 open-chest anesthetized pigs, myocardial deformation was studied before and during dobutamine infusion, under control and ischemic conditions produced by various degrees of coronary artery constriction: 2 of nonflow-limiting stenoses (NFLS) of increasing severity reducing left anterior descending artery hyperemic flow by 40% and 70% and 2 flow-limiting stenoses (FLS) reducing resting coronary flow by 25% and 50%. Agreement between 2D strain echocardiography and sonomicrometry (reference method) was evaluated by linear regression and Bland-Altman analysis. RESULTS Good correlation and agreement were observed between 2-dimensional strain and sonomicrometry at rest and during dobutamine infusion; longitudinal strain: r = 0.77, p < 0.001 and r = 0.80, p < 0.001; radial strain: r = 0.57, p < 0.05 and r = 0.63, p < 0.05; and circumferential strain: r = 0.74, p < 0.001 and r = 0.58, p < 0.001. Circumferential and longitudinal strains in the risk area were significantly decreased at rest in the presence of FLS and during dobutamine infusion in the presence of NFLS. By contrast, radial strain was significantly decreased in the presence of severe FLS only during dobutamine infusion. CONCLUSIONS The 2D strain provides accurate assessment of LV regional function. Evaluation of circumferential and longitudinal strains during DSE has real potential for quantitative evaluation of LV deformation in the routine assessment of ischemia.

Strategies for subacute/chronic type B aortic dissection: the Investigation Of Stent Grafts in Patients with type B Aortic Dissection (INSTEAD) trial 1-year outcome.

OBJECTIVE Endovascular stent grafting represents a novel concept for type B aortic dissection both in the acute and subacute/chronic setting, with an unknown effect on outcomes. METHODS In a prospective trial 140 patients with stable type B dissection were randomly subjected to elective stent-graft placement in addition to optimal medical therapy (n = 72) or to optimal medical therapy (n = 68) with surveillance (arterial pressure according to World Health Organization guidelines ≤ 120/80 mm Hg). The primary end point was 1-year all-cause mortality, whereas aorta-related mortality, progression (with need for conversion or additional endovascular or open surgical intervention), and aortic remodeling were secondary end points. RESULTS There was no difference in all-cause mortality: cumulative survival was 97.0% ± 3.4% with optimal medical therapy versus 91.3% ± 2.1% with thoracic endovascular aortic repair (P = .16). Moreover, aorta-related mortality was not different (P = .42), and the risk for the combined end point of aorta-related death (rupture) and progression (including conversion or additional endovascular or open surgical intervention) was similar (P = .86). Three neurologic adverse events occurred in the thoracic endovascular aortic repair group (1 paraplegia, 1 stroke, and 1 transient paraparesis) versus 1 episode of paraparesis with medical treatment. Finally, aortic remodeling (with true-lumen recovery and thoracic false-lumen thrombosis) occurred in 91.3% with thoracic endovascular aortic repair versus 19.4% with medical treatment (P < .001), which is suggestive of continued remodeling. CONCLUSIONS In survivors of uncomplicated type B aortic dissection, elective stent-graft placement does not improve 1-year survival and adverse events, despite favorable aortic remodeling.

Biventricular pacing in patients with Tetralogy of Fallot: non-invasive epicardial mapping and clinical impact.

INTRODUCTION Patients who have undergone repair of Tetralogy of Fallot (TOF) often present with right bundle branch block. Cardiac resynchronization therapy (CRT) with right ventricular (RV) or biventricular (BiV) stimulation has been proposed as a modality to correct electrical abnormalities and improve cardiac contractility in patients with repaired TOF. We aimed to 1) compare ventricular electrical activation in adults with repaired TOF during RV versus BiV stimulation, using a non-invasive epicardial mapping system, and 2) examine the clinical mid-term effects of BiV resynchronization. METHODS 9 adults with repaired TOF were implanted with a CRT system and underwent 1) a non-invasive epicardial mapping (n=9) during sinus intrinsic rhythm, RV and BiV pacing 2) a clinical evaluation (n=7) before and after 6 months CRT with assessment of NYHA class and exercise capacity. RESULTS During intrinsic rhythm, non-invasive mapping demonstrated delayed activation of the right compared with the left ventricle in all patients, with the greatest activation delay noted near the infundibulum. However, we observed important differences among patients, in the severity of activation delays. Global activation time and an index of dyssynchrony were improved (p<0.05) during BiV pacing compared with RV pacing and spontaneous rhythm. BiV pacing increased (p<0.05) exercise tolerance and lowered the mean NYHA functional class at 6 months of follow up. CONCLUSION Patients with corrected TOF present with different patterns of ventricular activation. RV stimulation modestly improved RV activation sequence and was associated with a delayed LV activation. Biventricular stimulation significantly decreased right and left ventricular dyssynchrony.

Pathophysiology, clinical course, and management of congenital complete atrioventricular block

The incidence of congenital atrioventricular (AV) block is between 1 in 15,000 and 1 in 20,000 births. It may occur in isolation or as a consequence of anomalous development of the conduction tissue in the context of a cardiac malformation. In this review, we use the term congenital AV bock to describe complete heart block when it is diagnosed in utero or at birth. The pathophysiological process is believed to be due to immune-mediated injury of the conduction system, which occurs as a result of transplacental passage of maternal anti-SSA/Ro-SSB/La antibodies. Many mothers are asymptomatic carriers, and less than one-third have a preexisting diagnosis of a rheumatological disorder. The AV block that develops months or years after birth probably occurs as a result of a different disease process that is poorly understood. The diagnosis of congenital AV block is usually confirmed by fetal echocardiography before birth and by electrocardiography after birth. The implantation of a pacemaker is recommended for symptomatic patients and for asymptomatic patients presenting with profound bradycardia, left ventricular dysfunction, a wide QRS interval, or a prolonged QT interval. It is now recognized that a subset of paced patients develop dilated cardiomyopathy and heart failure, and therefore regular follow-up is important. They are also at high risk of developing complications related to the presence of intracardiac material as a result of prolonged exposure to pacing materials. Future areas of research to minimize these risks include assessing the impact of alternative stimulation sites and the development of new cardiac stimulation techniques.

Transcatheter Aortic Valve Replacement Using Transaortic Access: Experience From the Multicenter, Multinational, Prospective ROUTE Registry

OBJECTIVES The Registry of the Utilization of the TAo-TAVR approach using the Edwards SAPIEN Valve (ROUTE) was established to assess the effectiveness and safety of the use of transaortic (TAo) access for transcatheter aortic valve replacement (TAVR) procedures (NCT01991431). BACKGROUND TAVR represents an alternative to surgical valve replacement in high-risk patients. Whereas the transfemoral access route is used commonly as the first-line approach, transapical access is an option for patients not suitable for transfemoral treatment mainly due to anatomic conditions. TAo-TAVR has been shown to be a viable alternative surgical access route; however, only limited data on its effectiveness and safety has been published. METHODS ROUTE is a multicenter, international, prospective, observational registry; data were collected from 18 centers across Europe starting in February 2013. Patients having severe calcific aortic stenosis were documented if they were scheduled to undergo TAo-TAVR using an Edwards SAPIEN XT or a SAPIEN 3 valve. The primary endpoint was 30-day mortality. Secondary endpoints were intraprocedural or in hospital and 30-day complication rates. RESULTS A total of 301 patients with a mean age of 81.7 ± 5.9 years and an Society of Thoracic Surgeons score of 9.0 ± 7.6% were included. Valve success was documented in 96.7%. The 30-day mortality was 6.1% (18/293) (procedure-related mortality: 3.1%; 9 of 293). The Valve Academic Research Consortium-2 defined complications included myocardial infarction (1.0%), stroke (1.0%), transient ischemic attack (0.3%), major vascular complications (3.4%), life-threatening bleeding (3.4%), and acute kidney injury (9.5%). In 3.3% of patients, paravalvular regurgitation was classified as moderate or severe (10 of 300). Twenty-six patients (8.8%) required permanent pacemaker implantation. CONCLUSIONS TAo access for TAVR seems to be a safe alternative to the transapical procedure.

Single surgical procedure combining epicardial pacemaker implantation and subsequent extraction of the infected pacing system for pacemaker-dependent patients

OBJECTIVES Management of pacemaker infection in pacing-dependent patients is often challenging. Typically, temporary pacing is used while antibiotic therapy is given for a number of days before reimplantation of a new endocardial system. This results in a prolonged hospital stay and complications associated with temporary pacing. In this study, we examine the feasibility of performing a single combined procedure of epicardial pacemaker implantation followed by system extraction. METHODS One hundred consecutive infected pacemaker-dependent patients underwent implantation of 2 epicardial ventricular leads and were converted to a ventricular demand pacing system. The infected pacing system was then extracted during the same procedure. Patients were followed up for 12 months. RESULTS Significant pericardial bleeding developed during the procedure in 3 patients. The presence of the pericardial drain positioned during the implantation of the epicardial pacing system meant that cardiac tamponade did not occur, allowing surgical repair with sternotomy to be carried out under stable hemodynamic conditions. Two of these 100 patients died in the 30-day postoperative period; 1 death was due to septic shock and 1 to pulmonary distress. Median 1-year epicardial pacing thresholds were stable and excellent (1.4 ± 0.9 volts). However, 1 of the 2 leads developed increased thresholds in 6 patients, which led to the exclusive use of other ventricular lead. CONCLUSIONS A single combined procedure of surgical epicardial pacemaker implantation and pacemaker system extraction appears to be a safe and effective method for managing pacemaker-dependent patients with infected pacemakers.

Preoperative hepatic insufficiency and type III endoleak: a confirmed potential fatal association following endovascular treatment

Consumptive coagulopathy is known to occur in patients with aneurysm, especially in the thoracic localization. Compared to open chest surgery, the endovascular treatment leaves in place a large thrombosed aneurysmal sac, which might induce and/or exacerbate the coagulopathy. Although exceptional, some recent reports have raised the potential disastrous issue related to this complication. We report the case of a 74-year-old patient treated for an asymptomatic thoracic aorta aneurysm by endoprosthesis who developed a fatal disseminated intravascular coagulopathy. This complication has been related to a type III endoleak associated with a preoperative hepatic insufficiency.

Lethal Aorto-Right Ventricular Defect After Transcatheter Aortic Valve Implantation in a Patient With Radiation-Induced Porcelain Aorta: Notes of Caution

A 47-year-old man with severe radiation-induced aortic stenosis was rejected for cardiac surgery because of porcelain aorta. We successfully implanted an Edwards SAPIEN valve (Edwards Lifesciences, Irvine, CA), but the patient was readmitted 3 weeks later for heart failure with a continuous murmur on auscultation. Echocardiography showed a small defect between the aorta and the infundibulum of the right ventricle, which was also confirmed with aortography and computed tomography. Medical therapy was optimized; however, he died unexpectedly a few weeks later. We concluded that irradiated tissues are particularly fragile and require specific attention during transcatheter aortic valve implantation. Furthermore, this case suggests that a more aggressive closure should have been applied.

Surgery for post-infarction ventricular septal defect (VSD): double patch and glue technique for early repair

Repair of post-infarction ventricular septal defect (VSD) remains a challenging procedure with a high risk of VSD recurrence. In order to reduce this risk, a double patch and glue technique was introduced in the department in 1986. This surgical technique is hereunder presented. Since 1971, ninety-three patients have been operated on early (≪15 days) after the occurrence of a post-infarction VSD. This retrospective study allows to compare the results of this double patch and glue technique to those obtained with the conventional one, in terms of hospital death and VSD recurrence. The double patch and glue technique avoids recurrence of VSD and plays a part in reducing hospital mortality.