Philippe Deleuze

Transcatheter aortic valve implantation through carotid artery access under local anaesthesia

OBJECTIVES Trans-femoral and transapical are the most commonly used accesses for transcatheter aortic valve implantation (TAVI). However, when these approaches are unsuitable, alternative accesses are needed. We report a series of 19 patients undergoing TAVI through common carotid artery (CCA) access under local anaesthesia in order to assess its feasibility and safety. METHODS From November 2008 to September 2013, 361 patients underwent TAVI at our institution. Nineteen of them (14 men) with mean age 82.2 ± 6.2 years, EuroSCORE 25.2 ± 15.7, Society of Thoracic Surgeons score 11.9 ± 5.1 and with severe peripheral arteriopathy were unsuitable for usual approaches and underwent TAVI through CCA access under local anaesthesia. Preoperative computed tomography assessed suitable carotid artery anatomy. Common carotid cross-clamping test allowed verifying patients neurological status stability. An 18-Fr or 20-Fr sheath inserted into the CCA down into the ascending aorta was used for the delivery catheter. Valve implantation procedures were as usual. After sheath removal, the CCA was surgically purged and repaired. Feasibility and safety end points (VARC-2) were collected up to 30 days. RESULTS Transcarotid insertion of the delivery sheath was successful in all cases (8 right, 11 left) and accurate deployment of the device was achieved in 18 patients (4 Edwards SAPIEN XT and 14 Medtronic CoreValve). There was 1 intraoperative death by annulus rupture during preimplant balloon valvuloplasty, and 1 in-hospital death due to multisystem organ failure. There was no myocardial infarction, stroke or major bleeding. Third-degree atrioventricular block requiring pacemaker implantation occurred in 3 patients. No vascular access-site, access-related or other TAVI-related complication occurred. Echocardiography revealed good prosthesis functioning with none, mild and moderate paravalvular leak in, respectively, 8, 9 and 1 patients. Patient ambulation was immediate after TAVI and hospital stay was 4.6 ± 2.3 days. CONCLUSIONS TAVI through the CCA approach under local anaesthesia is feasible and safe. It allows continuous clinical neurological status monitoring with low risk of stroke, bleeding events, vascular access-site and access-related complications and immediate patient ambulation. It appears to be a valuable alternative access for patients who cannot undergo trans-femoral TAVI.

Clinical implantation of the wearable Baxter Novacor ventricular assist system.

Implantation of the wearable Novacor electrically powered left ventricular assist system was performed on March 16, 1993, in a 44-year-old man hospitalized for an acute episode of myocardial decompensation after a 6-year history of dilated cardiomyopathy. He was rehabilitated fully and became ambulatory, awaiting a suitable cardiac graft for 59 days. He is now back to work, enjoying a normal life. This case illustrates the progress made by miniaturization of the external components of the system. General acceptance of the system and psychological adaptation to the new way of life were remarkable.

Bacterial translocation and plasma cytokines during transcatheter and open-heart aortic valve implantation.

ABSTRACT Objective: To determine whether the good safety profile of transarterial aortic valve implantation (TAVI) is related to lower levels of systemic bacterial translocation and systemic inflammation compared with open-heart surgery. Background: Transcatheter aortic valve implantation via the transfemoral approach is increasingly used in very high-risk patients with aortic stenosis. The outcomes seem similar to those after open-heart aortic valve replacement (OHAVR). Methods: Each of 26 consecutive high-risk patients (EuroSCORE >20% for risk of operative death) who underwent TAVI (cases) was matched to the first low-risk patient treated next in our department using elective OHAVR without coronary artery bypass (control subjects). We collected severity, outcome, and echocardiography indicators before and after surgery; complications; proinflammatory cytokine levels; and markers for microbial translocation. Results: Despite greater illness severity, the TAVI patients had significantly lower vasopressor agent requirements, lower delirium rates, shorter hospital stays, and better hemodynamic findings compared with OHAVR patients. Vascular complications were more common after TAVI than after OHAVR (12, with seven requiring interventional therapy vs. 0, P = 0.006). Patients who underwent TAVI had lower blood transfusion requirements. Two TAVI patients died: one from iliac artery injury and the other from intracardiac prosthesis migration. Patients who underwent TAVI had lower plasma levels of endotoxin and bacterial peptidoglycan, as well as lower proinflammatory cytokine levels, suggesting less gastrointestinal bacterial translocation compared with OHAVR. Conclusions: Compared with OHAVR, TAVI was associated with decreases in bacterial translocation and inflammation. These differences may explain the lower delirium rate and better hemodynamic stability observed, despite the greater disease severity in TAVI patients.

Long-term results of Freestyle stentless bioprosthesis in the aortic position: A single-center prospective cohort of 500 patients

OBJECTIVE Stentless xenograft bioprostheses may be the future valve of choice for aortic valve replacement. The study aim was to investigate the long-term clinical outcome after aortic valve replacement with the Medtronic Freestyle bioprosthesis (Medtronic Inc, Minneapolis, Minn). METHODS Between April 1997 and November 2004, a total of 500 patients (mean age, 74.5±9.6 years; 52% were male) underwent aortic valve replacement with a Freestyle bioprosthesis, without population selection. The surgical procedure used a modified subcoronary technique in 479 patients and a complete root replacement in 21 patients, conducted with mini-extracorporeal circulation. Concomitant procedures included coronary artery bypass grafting in 122 patients (24%) and mitral valve repair/replacement in 11 patients. RESULTS The mean cardiopulmonary bypass time was 98±26 minutes, and total aortic crossclamp time was 77±19 minutes. Operative mortality was 5.2%. The median follow-up time was 104.8±5.7 months. During this period, there were 224 deaths (n=122 cardiovascular and n=102 noncardiovascular deaths). The actuarial survivals from cardiovascular and valve-related mortality were 67%±3% and 70%±4%, respectively, at 10 years. Freedom from structural valve deterioration at 10 years was 94%±2%. The linearized structural valve deterioration incidence was 0.6% per patient/year. Multivariate Cox regression analysis revealed that older age, impaired renal function, and coronary artery disease were independent predictors of cardiovascular death. In the subgroup of patients aged less than 65 years at implantation (n=45), the actuarial cardiovascular survival was 83%±8% and freedom from structural valve deterioration was 89%±6% at 10 years. CONCLUSIONS The use of the Freestyle bioprosthesis for aortic valve replacement resulted in good long-term cardiovascular survival and freedom from structural valve deterioration in this cohort regardless of age at implantation.

Aortic Wrapping for Stanford Type A Acute Aortic Dissection: Short and Midterm Outcome

BACKGROUND Conventional surgical treatment of Stanford type A acute aortic dissection (AAD) is associated with considerable in-hospital mortality. As regards very elderly or high-risk patients with type A AAD, some may meet the criteria for less invasive surgery likely to prevent the complications associated with aortic replacement. METHODS We have retrospectively analyzed a cohort of patients admitted to our center for Stanford type A AAD and having undergone surgery between 2008 and 2012. The outcomes of the patients having had an aortic replacement under cardiopulmonary bypass (group A) have been compared with the outcomes of the patients who underwent off-pump wrapping of the ascending aorta (group B). RESULTS Among the 54 patients admitted for Stanford type A AAD, 15 with a mean age of 77 years [46 to 94] underwent wrapping of the aorta. Regarding the new standard European system for cardiac operative risk evaluation (EuroSCORE II), the median result in our group B patients was 10.47 [5.02 to 30.07]. In-hospital mortality was 12.80% in group A and 6.6% in group B (p=0.66). For patients who underwent external wrapping of the ascending aorta, follow-up mortality rate was 13.3% with a median follow-up of 15 months [range 0 to 47]. CONCLUSIONS The gold standard in cases of Stanford type A AAD consists of emergency surgical replacement of the dissected ascending aorta. In some cases in which the aortic root is not affected a less invasive surgical approach consisting of wrapping the dissected ascending aorta can be suggested as an alternative.

Assessment of a percutaneous hemopump in high risk coronary angioplasty patients

This study assessed the safety and efficacy of a new 14 Fr Hemopump device. Ten high risk patients requiring percutaneous transluminal coronary angioplasty (PTCA) (last remaining patent vessel or low left ventricular ejection fraction) underwent PTCA with the prophylactic use of the Hemopump. This device was inserted percutaneously through the femoral artery using a 16 Fr sheath and placed into the left ventricle. Hemodynamic parameters (pulmonary capillary wedge pressure, cardiac output, mean aortic pressure) were recorded before, during, and after PTCA when the Hemopump was on and off. Adequate placement of the Hemopump was obtained in all patients with moderate temporary rhythm instability, and PTCA was performed in all patients. Under assist, pulmonary capillary wedge pressure was 22 +/- 8 mmHg, compared with 29 +/- 7 mmHg (P < 0.05), whereas no significant change in other hemodynamic parameters was observed. One patient experienced ventricular fibrillation twice during PTCA, which was correlated by electrical cardioversion. During this temporary cardiac arrest, the aortic blood pressure was maintained at 50 mmHg with the Hemopump. For all patients, the Hemopump was withdrawn 15 min after the end of PTCA, and the sheath was removed 4-6 hr later. However, two patients required surgical sheath removal. One patient died of cardiogenic shock in the intensive care unit. Other patients were discharged 3 days after the procedure. Long-term follow-up shows eight surviving patients. These data show that 1) the 14 Fr percutaneous Hemopump is safe, and 2) can unload the left ventricle during PTCA while maintaining mean aortic pressure and cardiac output.

The Total Artificial Heart: Indications and Preliminary Results

The development of the total artificial heart (TAH) has reached a level where it is now available for clinical applications. The TAH has demonstrated distinct advantages over other forms of mechanical circulatory assistance. As of December 1, 50 TAHs have been implanted: 5 as permanent devices, and 45 as a temporary mechanical bridge to cardiac transplantation. The use of the TAH has increased in the last several months, leading to a growing interest in defining the indications and contraindications to its use. End‐stage cardiomyopathy (either idiopathic, ischemic, viral, or postpartum) has been the underlying disease in 80% of the TAH procedures to date. The TAH has also been applied in 5 cases of acute cardiac graft rejection, 2 cases of congenital heart diseases, and in one case after acute myocardial infarction. The indications for the use of the TAH in these and other potential patient groups is discussed in light of the current clinical results.

Isolated Huge Aneurysm of the Left Main Coronary Artery in a 22-Year-Old Patient With Type 1 Neurofibromatosis

A 22-year-old patient with neurofibromatosis type 1 presented with acute chest pain. A computed tomography scan and coronary angiography revealed a partially thrombosed huge aneurysm of the left main coronary artery. Despite medical treatment, the patients angina recurred. The patient underwent a coronary bypass grafting operation and surgical exclusion of the aneurysm. Postoperative imaging disclosed good permeability of the 3 coronary artery bypass grafts and complete thrombosis of the excluded aneurysm.

Donor/Recipient Aorta Size Mismatch in Heart Transplantation: A Technical Alternative

A technical alternative is proposed to enable transplantation in cases of considerable size mismatch between donor and recipient aorta: interposition of a Dacron graft of intermediate diameter. This procedure was performed in a 56‐year‐old patient weighing 75 kg in whom a heart from a 40‐kg donor was implanted. (J Card Surg 7994;9:70–73)

Ascending Aorta Stenting After Off-Pump Aortic Wrapping in Stanford A Retrograde Aortic Dissection

We report 4 cases of off-pump ascending aorta wrapping combined with ascending aorta stenting in retrograde Stanford A acute aortic dissection (SAAD). Since 2008, 18 patients have undergone wrapping of the ascending aorta at our institution. Four patients had a persistent circulating false lumen in the ascending aorta after wrapping, with a threat to the aortic root. We chose an endovascular approach with ascending aorta stenting. Follow-up computed tomography showed a reapplication of the intimal flap in the reinforced aorta. Ascending aorta stenting after aortic wrapping for retrograde SAAD is a safe and efficient technique to prevent proximal progression of the dissection.