Philippe Demers

Stent-graft repair of penetrating atherosclerotic ulcers in the descending thoracic aorta: mid-term results.

BACKGROUNDnLocalized aortic pathoanatomic abnormalities are good targets for endovascular stent-grafting but only short-term results have been reported. Our objective was to determine the effectiveness of endovascular stent-graft treatment of patients with descending thoracic atherosclerotic penetrating atherosclerotic ulcers (PAU) and to identify risk factors for treatment failure.nnnMETHODSnBetween 1993 and 2000 endovascular repair of PAU with first-generation (custom-fabricated) and second-generation (commercial) stent-grafts was performed in 26 patients (mean age, 70 years), 6 (23%) of whom had rupture. Fourteen patients (54%) were not candidates for open surgical repair. Follow-up was 100% complete (average, 51 months; maximum, 114 months). Outcome variables considered in the multivariable analysis included death and treatment failure (composite end-point comprising early death, endoleak, stent-graft mechanical fault, late aortic event, reintervention, and aortic-related or sudden death).nnnRESULTSnThree patients (12% +/- 7% [+/-70% confidence limits]) died within 30 days and 2 had an early type I endoleak. Primary success rate was 92%. Actuarial survival estimates at 1, 3, and 5 years were 85% +/- 8%, 76% +/- 8% and 70% +/- 10% respectively and actuarial freedom from treatment failure was 81% +/- 8%, 71% +/- 9% and 65% +/- 10%. Multivariable analyses identified previous cerebrovascular accident (hazard ratio [HR] 17.1, p = 0.02) and female sex (HR 7.4, p = 0.08) as independent risk factors for death. For treatment failure the predictors were increasing aortic diameter (HR 1.1 [per mm above the mean value], p = 0.01) and female sex (HR 5.5, p = 0.09).nnnCONCLUSIONSnEndovascular stent-graft repair is effective but not curative treatment for selected, high surgical risk, elderly patients with a descending aortic PAU over the medium term. Assiduous serial follow-up imaging after stent-grafting is mandatory to detect late complications especially in those with a large aorta.

Long-term results of heart transplantation in patients older than 60 years

BACKGROUNDnAdvanced age has been traditionally considered a relative contraindication for heart transplantation. Older patients are now considered as potential candidates for heart transplantation. The objective of this study was to evaluate the long-term results of heart transplantation in patients older than 60 years.nnnMETHODSnBetween 1986 and 2001, 81 patients aged between 60 and 70 years (mean, 63 +/- 2 years) underwent heart transplantation. These patients were compared with 403 adult recipients younger than 60 years (mean, 47 +/- 11 years) who underwent transplantation during the same period.nnnRESULTSnThirty-day mortality was 6% (5/81) and 6% (25/403) in the older and younger patients, respectively (P = NS). Actuarial survival at 1, 5, and 10 years was 88% +/- 4% versus 83% +/- 2%, 75% +/- 5% versus 69% +/- 2%, and 50% +/- 9% versus 51% +/- 3% in the older and younger patients, respectively (P = NS). Older patients had significantly fewer rejection episodes (P =.003). Freedom from allograft coronary artery disease at 1, 5, and 10 years was 98% +/- 2% versus 92% +/- 2%, 85% +/- 6% versus 76% +/- 3%, and 81% +/- 7% versus 68% +/- 3% (P =.1). The incidences of infectious complication, cytomegalovirus infection, and posttransplant lymphoproliferative disorder were similar between the 2 groups, but older recipients were more likely to have a nonposttransplant lymphoproliferative disorder cancer (P =.002). Age at transplantation was not identified as an independent risk factor for early and late death.nnnCONCLUSIONnHeart transplantation in selected patients aged 60 years and older results in survival comparable with that of younger patients. Older patients have a lower risk of rejection but an increased risk of development of a nonposttransplant lymphoproliferative disorder cancer. Advanced age per se should not be considered as an exclusion criterion for transplantation.

Long-Term Results After Systematic Off-Pump Coronary Artery Bypass Graft Surgery in 1000 Consecutive Patients

Background— Off-pump coronary artery bypass surgery (OPCAB) is currently used as an alternative to conventional “on-pump” surgery, but there are very little data available on long-term follow-up. The aim of this study was to review our long-term experience with the use of systematic OPCAB. Methods and Results— 1000 consecutive OPCAB surgeries were systematically performed between 1996 and 2004, representing 95% of all coronary revascularization during that same time frame, with a 97% complete follow-up. Average age of the patients was 64±10 years (778 men and 222 women). Seventy-three percent had triple-vessel disease. Operative 30-day mortality was 1.6%. Overall survival at 96 months was 74±3.5% and cardiac survival was 94±1.3%. By Cox regression analysis, age (odds ratio [OR], 1.07), congestive heart failure (CHF) (OR, 1.90), peripheral vascular disease (OR, 1.74), chronic renal insufficiency (OR, 2.04), previous myocardial infarction (MI) (OR, 1.60), and New York Heart Association functional class (OR, 1.60) were risk factors for long- term mortality. Survival free of any cardiac events (cardiac death, MI, unstable angina, heart failure, or reintervention) was 80±3.4%. Survival free of any type of reintervention alone was 90±3%. By Cox regression analysis, mitral regurgitation (OR, 2.3), peripheral vascular disease (OR, 2.1), and diffuse coronary disease (OR, 2.3) were significant predictors of recurrent cardiac events. Conversion to “on-pump” (OR, 14.3) was predictor of long-term need for repeat revascularization. Conclusion— In this series, systematic OPCAB surgery was shown to be an acceptable alternative to conventional “on-pump” coronary artery bypass graft for the treatment of coronary artery disease.

Excellent outcomes for transcatheter aortic valve replacement within 1 year of opening a low-volume centre and consideration of requirements.

BACKGROUNDnAfter the approval of transcatheter aortic valve replacement (TAVR) for high-risk or inoperable patients with severe aortic stenosis (AS), many low- and moderate-volume TAVR programs were initiated. Contemporary outcomes from these newly initiated centres remain unknown.nnnMETHODSnIn March 2013, our institution was authorized by the Québec Ministry of Health to perform 30 TAVR procedures. After thorough clinical screening and imaging evaluation, suitable patients underwent transfemoral TAVR with the balloon-expandable SAPIEN XT (Edwards Lifesciences, Irvine, CA) transcatheter heart valve (THV). In-hospital and 30-day outcomes were prospectively collected and reported according to Valve Academic Research Consortium 2 guidelines.nnnRESULTSnFrom April 2013 to January 2014, 30 consecutive high-risk (n = 16 [53.3%]) or inoperable (n = 14 [46.7%]) patients (mean age, 84.6 years; mean Society of Thoracic Surgery score, 7) with symptomatic severe AS underwent transfemoral TAVR. No catastrophic intraprocedural complications such as annulus rupture, valve embolization, aortic dissection, or coronary occlusion occurred, and there were no deaths at 30 days. Disabling stroke occurred in 1 (3.3%) patient 48 hours after THV implantation. Major vascular complications and major bleeding occurred in 1 (3.3%) patient. No moderate or severe paravalvular leak was observed. The median length of stay was 2 (1-3) days, with 8 (26.7%) patients discharged within 24 hours after the procedure.nnnCONCLUSIONSnExcellent outcomes can be achieved in newly initiated relatively low-volume centres, which compares favorably to previously published large series. Important considerations include appropriate team training, rigorous patient screening, use of multimodality imaging techniques, a heart team approach, constant integration of lessons learned from larger published experiences, and maintaining a recommended minimum volume of 25 cases per year.

Results following implantation of mechanical circulatory support systems: The Montreal Heart Institute experience

BACKGROUNDnMechanical circulatory support systems (MCSS) have been available in Canada since 1986. Accepted indications include bridging to transplantation or recovery. The present study reviewed the results following MCSS implantation at the Montreal Heart Institute (Montreal, Quebec).nnnMETHODSnFrom September 1987 to September 2006, 43 MCSS were implanted (32 Thoratec [Thoratec Corporation, USA], nine CardioWest TAH [SynCardia Systems Inc, USA], two Novacor [WorldHeart Corporation, Canada]) in 43 patients (mean [+/- SD] age 44+/-13 years; range 19 to 64 years). Indications for implantation included cardiogenic shock due to ischemic (n=19), viral (n=10) or other types of cardiomyopathies (n=14).nnnRESULTSnThe mean ejection fraction before implantation was 17.6+/-6.5% (range 10% to 45%). Before MCSS implantation, most patients showed signs of end-organ failure, including mechanical ventilation (77%), central venous pressure higher than 16 mmHg (44%), oliguria (35%) and hepatic dysfunction (19%). The mean duration of MCSS support was 22.8+/-32.8 days (range one to 158 days). Survival to transplantation or recovery was 74%. Only one patient was successfully bridged to recovery. Complications were common during MCSS support. They included reexploration for bleeding (47%), respiratory failure (44%), renal failure requiring temporary dialysis (40%), infection (33%) and neurological events (16%). Only one patient had device failure. In patients successfully bridged to transplantation, early actuarial survival (one month) following transplantation averaged 71+/-8% and was 57+/-9% at one year.nnnCONCLUSIONnMCSS support with a left ventricular assist device or a total artificial heart provides an effective means of bridging terminally ill patients to transplantation or recovery. Early survival after transplantation shows satisfactory results. However, these results come at the expense of frequent device-related complications, and device failure remains a constant threat.

Outcomes of Traumatic Aortic Injury in a Primary Open Surgical Approach Paradigm

Background: Multiple classifications can be used to define the magnitude of aortic injury. The Vancouver Classification (VC) is a new and simplified computed tomography-based Blunt Aortic Injury (BAI) grading system correlating with clinical outcomes. Objectives: The objectives of this study are: 1) to describe the severity of aortic injury in a center with a predominantly surgical approach to BAI; 2) to correlate the severity of aortic trauma to hospital survival rate and rate of adverse events according to the type of interventions performed during the hospital stay; and 3) to evaluate VC. Patients and Methods: All patients referring to the Sacre-Coeur Hospital of Montreal between August 1998 and April 2011 for management of BAI were studied. Two radiologists reviewed all CT scan images individually and classified the aortic injuries using VC. Results: Among the 112 patients presenting with BAI, 39 cases had local CT scans available for reconstruction. Seven patients were identified as suffering from grade I injuries (flap or thrombus of less than 1 cm), 6 from grade II injuries (flap or thrombus of more than 1 cm), and 26 from grade III injuries (pseudoaneurysm). Among the patients with grade I injuries, 57% were treated surgically and 43% medically with a survival rate of 100%. Among the patients with grade II injuries (67% treated surgically and 33% treated medically) survival was also 100%. Among patients with grade III injuries (85% treated surgically, 7% had Thoracic Endovascular Aortic Repair (TEVAR) and 8% treated medically) survival was 95%, 95% and 50%, respectively. There were no significant differences between groups as to clinical outcome. Inter-rater reliability was 0.81. Conclusions: VC is easy to use and has low inter-observer variability. Low grades of injury were associated with low mortality related to medical treatment.

Knowledge, attitudes, and practice preferences of Canadian cardiac surgeons toward the management of acute type A aortic dissection

OBJECTIVESnThe complexity of surgical treatment for acute type A dissection contributes to the variability in patient management. This study was designed to elucidate the contemporary practice preferences of cardiac surgeons regarding different phases of management of acute type A aortic dissection.nnnMETHODSnA 34-item questionnaire was distributed to all Canadian adult cardiac surgeons addressing the preoperative, intraoperative, and postoperative management of acute type A dissection. A total of 100 responses were obtained (82% of active surgeons in Canada). Outcomes were compared between high- and low-volume aortic surgeons.nnnRESULTSnSeventy-six percent of respondents favored axillary artery cannulation. High-volume surgeons (>150 cases) were more likely to indicate a target lowest nasopharyngeal temperature more than 20 °C (53% vs 25%, P = .02). The majority of surgeons (65%) recommended using selective antegrade cerebral perfusion, with a significantly greater proportion for higher-volume aortic surgeons (P = .03). In addition, high-volume aortic surgeons were more likely to recommend aortic root replacement at smaller diameters (73% vs 55%, P = .02), to recommend more extensive distal aortic resection with routine open hemiarch anastomosis (85% vs 65%, P = .04), and to more commonly perform total arch reconstruction when needed (93% vs 77%, P = .04). In the follow-up period, frequency of serial imaging of the residual aorta was significantly higher for high-volume aortic surgeons (P = .04).nnnCONCLUSIONSnThis study identified some commonalities in practice preferences among Canadian cardiac surgeons for the management of acute type A aortic dissection. However, it also highlighted significant differences in temperature management, cerebral protection strategies, and extent of resection between high-volume and low-volume aortic surgeons.

Two decades of cardiac transplantation at the Montreal Heart Institute.

BACKGROUNDnThe first heart transplantation in Canada was performed in 1968 at the Montreal Heart Institute (Montreal, Quebec). After nine patients transplanted in the precyclosporine era, the program was stopped. With the advent of cyclosporine, the program was reactivated in 1983.nnnOBJECTIVEnTo review the experience of the Montreal Heart Institute with heart transplantation between 1983 and 2005.nnnMETHODSnThree hundred patients underwent heart transplantation and were followed at the transplant clinic. Patients were divided into two groups: group 1--first decade (1983 to 1993, n=145) and group 2--second decade (1994 to 2005, n=155).nnnRESULTSnThere were 125 men (86%) and 20 women (14%) with a mean age of 45+/-10 years in group 1 compared with 118 men (76%) and 37 women (24%) with a mean age of 48+/-12 years in group 2 (P=0.03 and P=0.02, respectively). Indications for transplantation included congestive heart failure and/or ischemic heart disease in the majority of patients of both groups, with 83% in group 1 and 73% in group 2, respectively. In group 1, 30 patients (21%) required preoperative pharmacological support and 13 patients (9%) were on mechanical support compared with 16 (10%) and 34 (22%) patients in group 2 (P<0.01). The mean age of donors was 27+/-10 years and 34+/-13 years in groups 1 and 2, respectively (P<0.01). Major causes of mortality for donors included a motor vehicle accident in 65 cases (45%) and brain hemorrhage in 43 cases (30%) in group 1 compared with 34 cases (22%) and 68 cases (44%) in group 2 donors (P<0.01). The one-, five- and 10-year actuarial survival rates were 86%, 77% and 71%, respectively, in group 1 compared with 84%, 80% and 68%, respectively, in group 2 (P=0.95). The one-, five- and 10-year freedom from rejection rates were 35%, 28% and 25%, respectively, in group 1 compared with 41%, 36% and 33%, respectively, in group 2 (P=0.13). The one-, five- and 10-year freedom from infection rates were 38%, 24% and 17%, respectively, in group 1 compared with 37%, 23% and 19%, respectively, in group 2 (P=0.72). The one- and five-year freedom from graft coronary artery disease rates were 93% and 67%, respectively, in group 1 compared with 88% and 81%, respectively, in group 2 (P<0.01). The one-, five- and 10-year cancer-free survival rates were 98%, 91% and 73%, respectively, in group 1 compared with 98%, 90% and 77%, respectively, in group 2 (P=0.76).nnnCONCLUSIONSnPatients who underwent heart transplantation in the second decade of the investigators experience were older and in worse preoperative clinical condition; the donors were also older. However, survival and event-free survival rates remained similar throughout both periods.

Simultaneous “Tirone David–V” Valve-Sparing Aortic Root Replacement and Radical Mitral Valve Repair for the Marfan Syndrome With Barlow Syndrome

Aortic root dilatation and aortic regurgitation (AR) are the most prominent cardiovascular manifestations of the Marfan syndrome (MFS), but mitral valve regurgitation (MR) requiring operative correction develops in 15% to 20%. The mitral pathology usually represents an advanced form of the Barlow syndrome. Aortic root aneurysm and severe mitral regurgitation require simultaneous surgical correction. Historically, replacement of the aortic root and valve with a composite valve graft using a mechanical prosthesis has been the standard operation for patients with the MFS. Recently, valve-sparing aortic root replacement has become popular in selected patients because indefinite anticoagulation is not necessary.nnA 26-year-old man with the MFS and progressive fatigue and dyspnea was referred from another state …

Successful explantation of a left ventricular assist device following acute fulminant myocarditis

A left ventricular (LV) assist device was implanted in a 53-year-old woman in cardiogenic shock secondary to fulminant myocarditis. LV function recovered to normal after one week of support from an LV assist device. The device was explanted and the patient is showing a good outcome with a normalized LV function.