Michel Redonnet

Coarctation of the aorta in adults: surgical results and long-term follow-up

BACKGROUND The aim of this retrospective study was to determine the impact of coarctation surgical repair on arterial blood pressure in adults more than 20 years of age. METHODS Thirty-five adults (23 men), mean age 28.1 +/- 5.7 years (range, 21 to 52 years), underwent coarctation surgical repair between 1977 and 1997. All patients had preoperative hypertension. Mean systolic blood pressure was 178 +/- 37 mm Hg (range, 110 to 230 mm Hg). Thirty-three patients were taking at least one hypertension medication at the time of operation. All patients had preoperative catheterization and angiography (mean gradient across the coarctation was 62 +/- 27 mm Hg [range, 32 to 130 mm Hg]). Operative technique was resection and end-to-end anastomosis for 30 patients, resection with Dacron (C. R. Bard, Haverhill, MA) graft for 4 patients, and a prosthetic bypass graft for 1 patient. There were no hospital deaths and no late morbidity. RESULTS All patients were reviewed. Follow-up was 165 +/- 56 months (range, 25 to 240 months). Of the 35 patients with preoperative hypertension, 23 were normotensive (systolic blood pressure < or = 140 mm Hg, diastolic blood pressure < or = 90 mm Hg) with no medication. Twelve patients were receiving medication: 6 required single-drug therapy and 6 patients required two drugs. Exercise testing was performed at an average of 6 +/- 4 months after repair and revealed hypertensive response to exercise in 8 of the 23 patients who were normotensive at rest and without medication. There were no recoarctation or repeat operations. Six aortic valve diseases were observed: three aortic incompetences (two bicuspid valves) treated by two valve replacements and one Bentall procedure, and three aortic stenoses (two valve replacements). No patient had evidence of a cerebrovascular accident. CONCLUSIONS Surgical repair of coarctation in adults has proved to be an effective procedure and significantly reduces arterial hypertension. However, long-term surveillance is mandatory and should include exercise testing to identify patients with potential hypertension.

Dobutamine stress echocardiography in orthotopic heart transplant recipients

Abstract Objectives. This study sought to determine whether dobutamine stress echocardiography could accurately identify coronary artery disease after heart transplantation. Background. After heart transplantation, coronary artery disease is related to either diffuse concentric intimal thickening or focal stenosis and may be underdiagnosed by coronary angiography. Methods. We enrolled 41 patients, a mean (±SD) of 40 ± 20 months after heart transplantation, at the time of their routine control coronary angiogram. Three patients were excluded because of poor echogenicity on the angiogram and one because of ventricular premature beats. Standard echocardiographic views were acquired at baseline and at incremental dobutamine infusion levels (from 5 to a maximal dose of 40 μg/kg body weight per min at 3-min intervals). Regional wall motion score was calculated from a 16-segment model, and each segment was graded from 1 (normal) to 4 (dyskinesia). Coronary angiography was performed 24 h after dobutamine stress echocardiography, and angiograms were analyzed in blinded manner. Results. Twenty-three (62%) of 37 patients had normal coronary angiographic findings. Dobutamine stress echocardiography showed abnormalities in only 2 of 23 patients. Fourteen patients (38%) had abnormal angiographic findings, seven of whom had stenoses >50%. Dobutamine stress echocardiography correctly identified the corresponding hypoperfused segments in these seven patients. More of interest were the other seven patients, of whom three had angiographic nonsignificant stenoses ( Conclusions. Dobutamine stress echocardiography is a useful technique for the diagnosis of coronary artery disease after heart transplantation. These preliminary results indicate that dobutamine stress echocardiography may have a predictive value for further ischemic events in heart transplant recipients.

Catheter ablation of atrioatrial conduction as a cure for atrial arrhythmia after orthotopic heart transplantation

OBJECTIVES We present three patients in whom atrial arrhythmia was treated by ablation of electrical conduction across a surgical suture line. BACKGROUND Conduction across the suture line separating the donor and native right atria has recently been described after orthotopic heart transplantation. METHODS Mapping and pacing of both grafted and recipient right atrium was performed to assess the relation between both atria and its relevance to clinical arrhythmia, prior to successful radiofrequency at the site of electrical communication. RESULTS In cases 1 and 3, atrioatrial conduction was bidirectional. In both, two types of P waves were observed during sinus rhythm. In case 2, conduction from the recipient to the grafted atrium yielded a very particular surface ECG pattern of atrial extrasystole. The block being unidirectional, the recipient atrial sinus rhythm was not perturbed and behaved like an atrial parasystole. Ablation was performed during sinus rhythm in case 1, recipient right atrial pacing in case 2 and grafted right atrial pacing in case 3 at the site with the shortest conduction time to the other tissue. At the successful ablation site multiple component potentials were recorded. Respectively, 1, 4 and 2 radiofrequency pulses were followed by total atrioatrial conduction interruption. No tachycardia could be induced at the end of the procedure and late follow-up was event free. CONCLUSIONS The existence of arrhythmogenic atrioatrial conduction should be taken into account when evaluating atrial arrhythmias in the transplanted heart because it is potentially curable by radiofrequency catheter ablation.

Pseudomonas aeruginosa coronary stent infection

Stent infection is a rare complication of coronary angioplasty. We report a case of a coronary stent bacterial infection due to Pseudomonas aeruginosa, shortly after implantation of the stent in the left circumflex artery, which presented as an acute pericarditis. Surgical treatment consisted of stent removal and partial excision of the circumflex artery without coronary artery bypass grafting.

Atrioatrial conduction after orthotopic heart transplantation

OBJECTIVES In two patients with orthotopic heart transplantation, the surface electrocardiogram suggested interaction between the donor right atrium and the recipient right atrium. An electrophysiologic investigation was performed to assess possible atrioatrial conduction. BACKGROUND After orthotopic heart transplantation, both recipient and donor atrial activities are usually independent, but in humans they may synchronize for short periods during exercise. METHODS Electrophysiologic recordings were made using standard techniques. The atrial electrode locations (anterior for the donor and posterior for the recipient right atria) were confirmed by fluoroscopy. Incremental and programmed donor and recipient right atrial pacing protocols were performed. RESULTS Unidirectional conduction between native and graft atria occurred in both patients. This phenomenon was evident at rest, during normal sinus rhythm and at various pacing rates, resulting in frequent atrial bigeminy and trigeminy. CONCLUSIONS Possible atrioatrial conduction after orthotopic heart transplantation may potentially be arrhythmogenic for the chamber where extrasystoles occur. This should be taken into account in attempting to devise new pacing modes if both atria are rendered electrically common.

Heart transplantation in systemic (AL) amyloidosis: a retrospective study of eight French patients.

BACKGROUND Immunoglobulinic (AL) amyloidosis is a complication of plasma cell dyscrasia, characterized by widespread deposition of amyloid fibrils derived from monoclonal light chains. Cardiac amyloid is the main prognostic factor, with a median survival of six months. Cardiac transplantation in AL amyloidosis is associated with high mortality, due to disease recurrence in the allograft and systemic progression. Suppression of light chain (LC) production with chemotherapy by melphalan plus dexamethasone (MD) or high dose melphalan followed by autologous stem cell transplantation (HDM/ASCT) improves survival. However, both the indications and results of chemotherapy in patients transplanted for cardiac AL amyloidosis remain unclear. AIMS To assess the outcome of cardiac transplantation and haematological therapy in patients with cardiac AL amyloidosis. METHODS Eight French patients, who underwent heart transplantation for cardiac AL amyloidosis between 2001 and 2006 were studied retrospectively. RESULTS Before transplantation, six patients received MD (n=5) or HDM/ASCT (n=1). Haematological remission was obtained in three patients treated with MD. In the three remaining patients, postoperative HDM/ASCT (n=2) or allogeneic bone marrow transplantation (n=1) resulted in haematological remission in one patient. In 2 patients not treated before transplantation, post-operative treatment with MD resulted in complete hematological remission in one. After a median follow-up of 26 months from cardiac transplantation, six patients were alive and four had sustained haematological remission, as indicated by normal serum free LC levels. CONCLUSION Appropriate haematological therapy, including MD, may result in a survival benefit in AL amyloidosis patients with advanced heart failure requiring transplantation.

Combined endovascular and video-assisted thoracoscopic procedure for treatment of a ruptured pulmonary arteriovenous fistula: case report and review of the literature

A35-year-old woman with a medical history of hereditary and recurrent epistaxis and lip telangiectasia was admitted with sudden left thoracic pain and dyspnea. There was no recent history of fever or thoracic trauma. Biologic data were as follows: hemoglobin level, 8.8 g/L; hematocrit level, 28%; oxygen saturation, 97%; and fraction of inspired oxygen, 10 L/min. Chest radiography and computed tomographic (CT) scanning revealed a left hemothorax with a suspicion of a vascular malformation in the left lower lobe (Figure 1). There were no aortic or pericardial abnormalities. An intercostal drain was placed in the left pleural cavity, and 2000 mL of blood was drained, leading to a significant clinical improvement. Pulmonary angiography confirmed the presence of 2 arteriovenous fistulas in the upper part of the left lower lung and in the lingula (Figure 2). Rendu-Osler-Weber syndrome (ROW) was diagnosed on the basis of the patient’s history and clinical and radiologic data. Embolization of the lower lobe fistula was performed during general anesthesia with 3 Guglielmi Detachable Coils (Boston Scientific, Target Therapeutics, Fremont, Calif). One 3-dimensional shaped coil of 8 20 mm and 2 fibered coils of 6 20 mm and 4 20 mm, respectively, were placed with a 0.018-inch microcatheter (Boston Scientific, Target Therapeutics) in the feeding artery. Occlusion was completed with the injection of 0.3 mL of enbucrilate (Histoacryl; Braun Aesculap, Tuttlingen, Germany) emulsified with iodized oil (Lipiodol; Guerbet, Aulnay-sous-Bois, France). Catheterization of the lingula fistula was technically more difficult, and occlusion was achieved with a 4 20–mm fibered spiral placed with a 0.018-inch microcatheter (Boston Scientific; Figure 3). Immediately after the endovascular procedure, video-assisted thoracoscopic surgery was performed to remove any residual clot and exclude further bleeding. The patient was placed in the right decubitus position. A single-lumen endotracheal tube was inserted, and ventilation was performed with reduced tidal volume throughout the procedure. A 10-mm trocar was introduced through a skin incision into the fifth intercostal space in the midaxillary line for insertion of a 0° endoscope (Karl Storz, Tuttlingen, Germany). Numerous clots and a large hemothorax in the left thoracic cavity were observed. Two additional ports were then inserted under direct vision. After the entire thoracic cavity had been rinsed with saline and clots had been removed, pulmonary arteriovenous fistulas were visible on the surface of the lung (Figure 4). No active bleeding was observed, and no further operations were required. Two 28F chest drains were introduced through the trocar incisions, one in the eighth and one in the anterior fifth intercostal spaces. The tubes were connected to an underwater seal suction device (Pleurevac; Genzime, Cergy-Pontoise, France) with a negative pressure of 20 cm H2O. The patient was extubated 3 hours after the operation, and pain was managed with a patient-controlled analgesia pump. Intercostal drainage was continued for 4 days, with a total volume of 975 mL. No air leak was observed, and the postoperative hospital stay was 6 days. Follow-up angiography at 1 month and CT scanning at 3 months revealed recurrent limited flow in the lingula fistula (Figure 5). Repeat embolization was performed with 2 coils (1 fibered coil of 2 50 mm and 1 coil of 2 30 mm) placed with a 0.018-inch microcatheter (Boston Scientific). The occlusion was completed without injection of enbucrilate. Follow-up CT scans at 3 months and 2 years showed no recurrence.

Impact of the reduction of calcineurin inhibitors on renal function in heart transplant patients: a systematic review and meta‐analysis

Calcineurin inhibitors (CNIs) taken after heart transplantation lead to excellent short‐term outcomes, but long‐term use may cause chronic nephrotoxicity. Our aim was to identify, appraise, select and analyse all high‐quality research evidence relevant to the question of the clinical impact of CNI‐sparing strategies in heart transplant patients.

Impact of the early reduction of cyclosporine on renal function in heart transplant patients: a French randomised controlled trial

BackgroundUsing reduced doses of Cyclosporine A immediately after heart transplantation in clinical trials may suggest benefits for renal function by reducing serum creatinine levels without a significant change in clinical endpoints. However, these trials were not sufficiently powered to prove clinical outcomes.MethodsIn a prospective, multicentre, open-label, parallel-group controlled trial, 95 patients aged 18 to 65 years old, undergoing de novo heart transplantation were centrally randomised to receive either a low (130 < trough CsA concentrations <200 μg/L, n = 47) or a standard dose of Cyclosporine A (200 < trough CsA concentrations<300 μg/L, n = 48) for the three first post-transplant months along with mycophenolate mofetil and corticosteroids. Participants had a stable haemodynamic status, a serum creatinine level <250 μmol/L and the donors’ cold ischemia time was under six hours; multiorgan transplants were excluded. The change in serum creatinine level over 12 months was used as the main criterion for renal function. Intention-to-treat analysis was performed on the 95 randomised patients and a mixed generalised linear model of covariance was applied.ResultsAt 12 months, the mean (± SD) creatinine value was 120.7 μmol/L (± 35.8) in the low-dose group and 132.3 μmol/L (± 49.1) in the standard-dose group (P = 0.162). Post hoc analyses suggested that patients with higher creatinine levels at baseline benefited significantly from the lower Cyclosporine A target. The number of patients with at least one rejection episode was not significantly different but one patient in the low-dose group and six in the standard-dose group required dialysis.ConclusionsIn patients with de novo cardiac transplantation, early Cyclosporine A dose reduction was not associated with renal benefit at 12 months. However, the strategy may benefit patients with high creatinine levels before transplantation.Trial registrationClinicalTrials.gov NCT00159159

Assessment of endothelial function and myocardial flow reserve using 15 O-water PET without attenuation correction

PurposeMyocardial blood flow (MBF) measurement using positron emission tomography (PET) from the washout rate of 15O-water is theoretically independent of tissue attenuation. The aim of this study was to evaluate the impact of not using attenuation correction in the assessment of coronary endothelial function and myocardial flow reserve (MFR) using 15O-water PET.MethodsWe retrospectively processed 70 consecutive 15O-water PET examinations obtained at rest and during cold pressor testing (CPT) in patients with dilated cardiomyopathy (n = 58), or at rest and during adenosine infusion in heart transplant recipients (n = 12). Data were reconstructed with attenuation correction (AC) and without attenuation correction (NAC) using filtered backprojection, and MBF was quantified using a single compartmental model. The agreement between AC and NAC data was assessed using Lin’s concordance correlation coefficient followed by Bland-Altman plot analysis.ResultsRegarding endothelial function, NAC PET showed poor reproducibility and poor agreement with AC PET data. Conversely, NAC PET demonstrated high reproducibility and a strong agreement with AC PET for the assessment of MFR.ConclusionNon-attenuation-corrected 15O-water PET provided an accurate measurement of MFR compared to attenuation-corrected PET. However, non-attenuation-corrected PET data were less effective for the assessment of endothelial function using CPT in this population.