Nadir Tafer

Early to Midterm Results of Total Cavopulmonary Connection in Adult Patients

BACKGROUND Total cavopulmonary connection (TCPC) has not been studied in adults. We investigated early and midterm morbidity and mortality in adults undergoing TCPC and assessed risk factors for mortality. METHODS Between June 1994 and October 2010, 30 adults (21.3 ± 5.5 years) underwent TCPC (extracardiac conduit). Twenty-two patients who had palliated single ventricles underwent TCPC completions and 8 patients underwent TCPC conversions. Preoperative and perioperative data were reviewed retrospectively. RESULTS Six of 9 patients with preoperative atrial flutter or fibrillation or intraatrial reentry tachycardia were treated in the catheterization room. An aortic cross-clamp was necessary in 12 patients, and 16 TCPCs were fenestrated. Mean follow-up was 51 months (range, 4-198 months). Early mortality was 10%: 2 of 8 conversions and 1 of 22 completions. There was 1 late conversion death (at 56 months postoperatively). Postoperatively, 4 patients required pacemakers and 1 patient required long-term antiarrhythmic medication, but no heart transplantations were necessary. Risk factors for early mortality were arrhythmia (p = 0.02), aortic cross-clamp (p = 0.054), and extracorporeal circulation in hypothermia (p = 0.03). Risk factors for overall mortality were conversion (p = 0.047), absence of fenestration (p = 0.036), surgery before January 2006 (p = 0.036), aortic cross-clamp (p = 0.018), extracorporeal circulation in hypothermia (p = 0.008), and arrhythmia (p = 0.005). New York Heart Association functional class had improved at the last follow-up: preoperatively, 17 patients were in class II and 12 patients were in class III versus 18 patients in class I and 9 patients in class II postoperatively (p < 0.001). At the last clinical visit, systemic ventricular function was maintained, and no late supraventricular arrhythmia was found. CONCLUSIONS Early and midterm TCPC results for adults are encouraging for completion but are disappointing for conversion. Identified risk factors for mortality should improve patient selection for TCPC.

Single-centred experience with levosimendan in paediatric decompensated dilated cardiomyopathy.

BACKGROUND Children with dilated cardiomyopathy in advanced heart failure may spend a long time awaiting heart transplantation. Consequently, mechanical circulatory support is sometimes required as a bridge to transplantation. Levosimendan, a positive inotropic agent, has been reported to be safe and efficient for the treatment of paediatric heart failure. AIMS To report our experience with levosimendan in children with decompensated dilated cardiomyopathy. METHODS Paediatric patients with dilated cardiomyopathy on the transplant waiting list and with criteria for mechanical support were included in this single-centred retrospective study. Each patient received at least one 24-hour infusion of levosimendan before mechanical circulatory support was considered. Biological and echocardiographic data were analysed. RESULTS Six patients were included over a 24-month period. The median age was 25.5months (7.7-34.2months); 82 infusions were performed. Median B-type natriuretic peptide concentration decreased significantly between days 0 and 2 (2443ng/L [1458-3819ng/L] vs 1358ng/L [1025-2534ng/L]; P=0.003). While only a trend was noted in left ventricular ejection fraction improvement (P=0.054 by Simpsons method and P=0.068 by the Teicholz method), the subaortic velocity time integral rose significantly between days 0 and 8 (12.8cm/s [10-14.5cm/s] vs 15.3cm/s [14.3-16.9cm/s]; P=0.041). CONCLUSIONS Levosimendan seems to improve haemodynamics in children with decompensated dilated cardiomyopathy; repeated infusions may delay the need for mechanical circulatory support while awaiting heart transplantation. This therapeutic agent should be systematically considered in this setting, in addition to conventional inotropic drugs.

Extending percutaneous left atrial appendage closure indications using the AMPLATZER™ Cardiac Plug device in patients with persistent left atrial appendage thrombus: The thrombus trapping technique

BACKGROUND Percutaneous left atrial appendage (LAA) closure has emerged as an alternative therapeutic option for the prevention of embolic stroke in high-risk patients with non-valvular atrial fibrillation. The presence of thrombus in the LAA is currently a contraindication to the procedure. AIM To describe a modified LAA closure technique that allows a safe procedure in patients with LAA thrombus. METHODS Between May 2013 and October 2014, LAA closure was performed in three patients with LAA thrombus (mean age 73.6±14 years; two men), using a modified technique that avoids manipulation of catheters or angiography in the LAA. RESULTS Two patients had persistent thrombus despite appropriate antithrombotic therapy, while the other patient had a contraindication to systemic anticoagulation. The procedure was successful using the modified implantation technique in all patients. The implanted device was the AMPLATZER™ Cardiac Plug (St. Jude Medical, Minneapolis, MN, USA) in one patient and the Amulet™ (St. Jude Medical, Minneapolis, MN, USA) in two patients. No periprocedural complications occurred. After a mean follow-up of 8±2 months, no deaths or late complications were observed. CONCLUSIONS Thrombus trapping is a feasible and effective technique for performing LAA occlusion in patients with thrombus within the LAA. This modification of the implantation technique may allow LAA closure indications to be extended to include patients with LAA thrombus, who were formerly considered unsuitable.

Acquired von Willebrand disease in a child with a ventricular assist device.

function. Furthermore, an exercise stress test showed increased left VAD flow even at a fixed pump speed. Frazier et al used a calf model in which both native ventricles were excised and replaced with 2 continuous-flow VADs. An exercise test demonstrated increased flow in both VADs. Our results have confirmed their experimental findings, suggesting that even without native ventricular contraction, biventricular VADs can adjust their flow according to the flow

Mechanical circulatory assistance in children

For the past two decades, circulatory assistance in paediatrics has much improved and is evolving from classical extracorporeal membrane oxygenation (ECMO) to pulsatile assistance. ECMO is still widely used for short-term assistance, mostly after cardiac surgery, whereas pulsatile support is for the most part indicated as a bridge to transplantation. Both techniques are within the realm of current strategies to treat cardiac failure.

0229: Intra-aortic balloon pump in children: single-centre experience and overview of practices

Background Intra-aortic balloon pump (IABP) is a commonly used method of temporary circulatory support in adults. Despite the availability of paediatric size balloons, the use of IABP in children is currently not widespread. Aims To describe our practice of IABP in children and to review its indications. Methods Single-centre retrospective study. We reviewed the medical records of all paediatric patients ( Results During this period 7 patients (6 boys) had a circulatory support with IABP. Mean age was 12.1 years (10-14) and mean weight was 46.1kg (30-61). All were mechanically ventilated and received inotropic support at the time of IABP deployment. 2 IABP were started before surgery to treat acute heart failure (1 myocarditis and 1 ischemic condition). The major indication for IABP was postoperative hemodynamic deterioration (n=5). 4 of them were related to suboptimal cardioplegia in a context of left ventricular hypertrophy. Mean duration of IABP support was 7.1 days (2-13). All IABP catheters were inserted through the common femoral artery. No local complication was reported. All IABP were inserted by an intensivist without surgical help. Conclusion IABP is a feasible method in children with acute left ventricular failure. By improving diastolic perfusion of the coronary arteries, IABP is effective especially in case of myocardial ischemia. This life-saving technique has to be associated to conventional medical treatment of refractory low cardiac output. Sometimes, IABP may be an alternative for effective mechanical circulatory support.

0240: Percutaneous left atrial appendage closure for stroke patients with nonvalvular atrial fibrillation and contraindication for oral anticoagulation

Background The PROTECT AF trial previously demonstrated that left atrial appendage closure (LAAC) was non inferior to warfarin in patients with nonvalvular atrial fibrillation (NVAF). However, this trial included patients eligible for anticoagulation therapy who received warfarin for 6 weeks after device implantation. The purpose of the present study was to assess the safety and efficacy of LAAC for stroke patients with NVAF and contraindication for anticoagulation. Methods Consecutive patients with a previous ischemic or hemorrhagic stroke, NVAF and contraindication for anticoagulation underwent LAAC with the Amplatzer Cardiac Plug device between July 2010 and July 2013 in a French university hospital. Follow-up included clinical evaluation at 3 and 12 months, and a cardiac computed tomography (CT) at 3 months. Single-antiplatelet therapy was prescribed after the procedure for a minimum of 3 months and stopped if the control cardiac CT demonstrated complete LAA exclusion. RESULTS: 26 patients (age 73±8 years) were included. The mean CHA 2 DS 2 -VASc and HAS-BLED scores were 4±1.5 and 4±0.8, respectively. The main contraindications for anticoagulation were: intracerebral hemorrhage while receiving anticoagulation (62%), ischemic stroke with large hemorrhagic transformation (15%) and probable cerebral amyloid angiopathy (8%). The procedure was successful in 100%. Procedure-related complications were serious pericardial effusion (3.8%) and femoral bleeding (7.7%). During a mean follow-up of 8.6 (3-16) months, ischemic stroke occurred in 2 patients (7.7%), after antiplatelet therapy was stopped for one of them. One patient died of an intracranial hemorrhage. Conclusion LAAC followed by a single antiplatelet therapy could be a reasonable alternative for stroke patients with NVAF and contraindication for anticoagulation. Lifelong rather than short-term single antiplatelet therapy should be prescribed after the procedure for patients at high cardio-vascular risk.

0344: Why levosimendan should be considered for the treatment of viral myocarditis in children

Background Animal studies showed that levosimendan protects cardiomyocytes against apoptotic cell death in acute viral myocarditis. In addition to its inotropic properties, levosimendan seems to prevent the detrimental effects of oxidative stress and to limit cardiomyocyte loss. Aim To analyze the outcome of children who received levosimendan for acute or fulminant viral myocarditis. Patients and methods Retrospective single center study covering the period 2007- 2013. All children ( Results Between 2007 and 2013, 18 successive children were treated, 9 for acute myocarditis and 9 for fulminant myocarditis (according to the international clinicopathological classification). Median age was 4 years (1.1-11) and median weight was 15kg (10-40). BNP level significantly decreased 48 hours after the beginning of the infusion (4599ng/L [2698-9266] vs 1928ng/L [848-4557], p=0.05). No dialysis was necessary. Among the fulminant myocarditis group, 1 patient (11%) required early mechanical circulatory support with a limitation of care due to severe neurologic complications. 13 patients (72%) recovered a LVEF >55% (100% for the acute myocarditis group). 1 patient had heart transplantation 18 months later. Conlusion In our experience, levosimendan was efficient for the inotropic support of acute and fulminant viral myocarditis. We believe that its cardioprotective effect enabled us to limit the use of mechanical assistance (only 11% of the fulminant forms) and allowed a recovering of the cardiac function for the majority of the patients. Although further clinical studies are needed to confirm these data, levosimendan should be systematically considered for the treatment of these critical patients.

Congenital isolated cleft of the tricuspid valve

An asymptomatic 8-year-old boy was addressed to our echolab for the exploration of a systolic cardiac murmur. ECG demonstrated a right heart volume overload and a right bundle branch block. Chest X-ray showed a slight enlargement of right-sided heart chambers. TTE and TEE showed a prolapse of the anterior leaflet of the tricuspid valve (TV; Panels A and B ; see Supplementary data online, Video S1 ). Because of a lack of coaptation, this prolapse was responsible for a severe tricuspid insufficiency ( Panels C and D ). The width of the vena contracta was estimated at …

248 Conscious sedation instead of general anesthesia for epicardial VT ablation

Philippe Maury [Orateur] (1), Anne Rollin (2), Frederic Sacher (3), Frank Raczka (4), Jean Luc Pasquié (4), Vanina Bongard (2), Alexandre Duparc (2), Pierre Mondoly (2), Cristelle Cardin (2), Marc Delay (2), Jean-Marc Davy (4), Meleze Hocini (3), Pierre Jaïs (3), Didier Carrie (2), Michel Galinier (1), Michel Haïssaguerre (3) (1) CHU Rangueil Toulouse, Cardiologie, Toulouse, France – (2) CHU Rangueil, Toulouse, France – (3) CHU Haut Lévêque, Pessac, France – (4) CHU Arnaud-de-Villeneuve, Montpellier, France