Roland G. Demaria

Preoperative Evaluation in Aortic Endocarditis: Findings on Cardiac CT

OBJECTIVE The purpose of this study was to study the feasibility and diagnostic capability of preoperative cardiac CT for depicting aortic valvular pseudoaneurysms and vegetations in patients referred for aortic endocarditis requiring surgical intervention. MATERIALS AND METHODS Consecutive patients presenting with active aortic endocarditis requiring surgical intervention were included. CT scan examinations were performed for assessing coronary artery status. Aortic valves were retrospectively analyzed. Contrast-enhanced CT scans were retrospectively gated to the ECG and obtained without the administration of a beta-blocker. The CT and intraoperative findings were systematically compared. RESULTS During a 4-year period, 19 consecutive patients (18 men and one woman) were included (mean age +/- SD, 55 +/- 13 years). Results are expressed on a per-patient basis. The sensitivity, specificity, positive predictive value, and negative predictive value of MDCT in depicting aortic valve pseudoaneurysms were 100%, 87.5%, 91.7%, and 100%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of the MDCT in depicting the extension of the aortic valve pseudoaneurysms into the intervalvular fibrous body were each 100%. The sensitivity, specificity, positive predictive value, and negative predictive value of MDCT in depicting aortic valve vegetations were 71.4%, 100%, 100%, and 55.5%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of MDCT for depicting aortic valve vegetations larger than 1 cm were all 100%. CONCLUSION Our study shows the feasibility of preoperative CT in aortic infective endocarditis for providing relevant data about the presence and relationships of aortic valvular pseudoaneurysms. A larger prospective study including a systematic comparison with transesophageal echocardiography should be performed to determine the respective value of each technique.

Reconstructive surgery of postinfarction left ventricular aneurysms: techniques and unsolved problems

The progress in the surgical treatment of postinfarction left ventricular (LV) aneurysm surgery has reduced the operative mortality considerably, while the selection of the optimal LV repair technique remains unclear. Any of the surgical techniques presented in this review has its own advantages and disadvantages. The main goal of this study was to perform a selective literature review of LV aneurysm repair techniques, the most widespread being the linear repair and patch ventriculoplasty.

Acute changes in aortic wall mechanical properties after stent placement in rabbits.

PURPOSE To evaluate mechanical property changes after endovascular stent placement in small-diameter arteries. MATERIALS AND METHODS Self-expanding stents (Wallstent) were placed in the infrarenal aorta of five New Zealand White rabbits via a surgical right femoral approach. Blood pressure changes (deltaP) were monitored in the aorta. Blood flow velocity was measured with a 20-MHz, pulsed Doppler probe (n = 4) to calculate the pulsatility index. Aortic diameter (dA) and diameter changes (delta(d)) were measured with a 20-MHz probe in echo-tracking mode. Diameter compliance (Cd) and distensibility coefficient (DC) were calculated as Cd = 2(delta)d/(delta)P and DC = 2delta(d)/delta(P)/dA. RESULTS Aortic diameter increased from 3.360 +/- 0.4033 mm to 4.020 +/- 0.3033 mm after stent placement at the stent level only. Compliance decreased from 77.644 +/- 24.306 mm kPa(-1) to 31.150 +/-8.245 x 10(-3) mm kPa(-1) at the stent level, and was then significantly lower than upstream (98.500 +/- 53.196 mm kPa(-1)) and down-stream (59.047 +/- 13.833 mm kPa(-1)). There was no significant change in pulsatility index. CONCLUSIONS Endovascular stent placement produces a significant decrease in arterial wall compliance of the rabbit abdominal aorta.

Factors favoring retrograde aortic dissection after endovascular aortic arch repair

OBJECTIVE To assess factors predisposing patients to retrograde type A aortic dissection (RTAD) who have undergone hybrid aortic arch repair. METHODS From 2001 to 2013, 32 patients underwent hybrid aortic arch repair in our department: 19 in zone 1 and 13 in zone 0. Among these patients, 6 experienced RTAD (18.7%): 3 in zone 0 (23%), 3 in zone 1 (15.8%). Preoperative computed tomography scans of these 32 patients were evaluated. A morphologic assessment of the aortic arch, ascending aorta, and aortic root was performed. Other potential risk factors were investigated. Binary logistic regression was performed to test for possible associations with RTAD. RESULTS Five patients were successfully converted to open repair. Patients who had RTAD were similar to those who did not, across pertinent variables, including age, type of device, diameter of the ascending aorta, and presence of a bicuspid aortic valve (all P > .1). Incidence of RTAD was observed to be higher among women (P = .034), patients with stent-graft oversizing ≥10% (P = .018), and patients treated with a stent-graft of diameter >42 mm (P = .01). Aortic morphology analysis showed that an indexed aortic diameter of ≥20 mm/m(2) (P = .003); aortic root morphology, specifically loss of the sinotubular junction (P = .004); and presence of an aortic arch malformation (P = .03) were correlated with risk of RTAD. Two patients in the zone-0 group with severe angulation (>120°) between the ascending and the transverse aorta suffered RTAD. CONCLUSIONS The occurrence of RTAD after hybrid aortic arch repair is common. To prevent this complication, preoperative screening of the aortic arch, ascending aorta, and aortic root morphology is critical.

Long-term outcomes after cryoablation for ventricular tachycardia during surgical treatment of anterior ventricular aneurysms

Intraoperative map‐guided procedures have been widely advocated as the best surgical strategy for the treatment of ventricular tachycardia (VT), though favorable results have been reported with subendocardial resection without mapping. This study examined the very long‐term results of encircling cryoablation without mapping during surgery for anterior left ventricular aneurysm complicated by VT. Between 1985 and 2003, this procedure was performed in 52 patients, 7 of whom (13.7%) were operated within 1 month of anterior myocardial infarction. Their mean age was 64.4 ± 8.3 years and mean left ventricular ejection fraction was 31.7%± 9.5%. The overall hospital mortality was 1.9%. At 14 years, 86% of patients (95% CI: 75.4–96.6) were free from VT or sudden death. An implantable defibrillator was implanted in five patients (9.6%) during follow‐up. The 14‐year overall survival was 51.4% (95% CI: 33.8–72.4), and two patients (3.8%) underwent cardiac transplantation during follow‐up. The main cause of late death was congestive heart failure in eight patients (40.0%). Favorable long‐term results can be achieved with encircling cryoablation without mapping in patients undergoing surgery for anterior left ventricular aneurysm complicated by VT.

Early Postoperative Assessment of Coronary Artery Bypass Graft Patency and Anatomy: Value of Contrast-Enhanced 16-MDCT with Retrospectively ECG-Gated Reconstructions

OBJECTIVE The objective of our study was to assess early postoperative patency and anatomy of off-pump coronary artery bypass grafts (CABGs) using retrospectively ECG-gated MDCT. CONCLUSION Retrospectively ECG-gated MDCT is a promising noninvasive technique with which to assess early postoperative patency and anatomy of CABGs.

Wall mechanics of the stented rabbit aorta: long-term study and correlation with histological findings.

Purpose: To evaluate long-term changes in arterial wall mechanics induced by stenting of the rabbit aorta. Methods: Eighteen New Zealand white rabbits had initial stent deployment (3×8 mm Multilink) at 110% of the pre-stenting abdominal aortic diameter. Group A (n=10) had no post-deployment stent expansion and group B (n=8) had 30% overdilation of the stent. A noninvasive B-mode ultrasound examination coupled with image processing allowed measurement of diameters at systole and diastole and the calculation of diameter compliance. Measurements were performed before stenting and compared to those recorded immediately after stenting and at 3 months at 3 locations: upstream from the stent, at the stent level, and downstream from the stent. Measurements were also compared among measurement sites. The pathological study included measurement of intimal thickening and calculation of an injury score. Results: At the stent level, diameter compliance was significantly lower after initial stenting and at 3 months than before stenting (group A: p<0.005; group B: p<0.001) and than downstream or upstream from the stent (group A: p<0.0001, group B: p<0.005). No significant difference in diameter compliance was found between groups A and B. In group B, intimal thickening and the injury score were greater than in group A (p<0.05 and p<0.0001, respectively). Conclusions: Endovascular stenting of the rabbit aorta impairs wall mechanics. Performing 30% overdilation of the stent does not worsen this impairment but induces greater in-stent intimal hyperplasia.

Validation of a newly developed B-mode image-processing technique versus wall-tracking ultrasound for the study of wall mechanics in small-calibre arteries

Purpose: To validate a newly developed image‐processing technique for the assessment of arterial wall compliance and distensibility from non‐invasive B‐mode ultrasound compared with the invasive wall‐tracking technique.

Should the mind be a matter? The impact of depression and anxiety on cardiac surgery outcomes

We read with great interest the article by Dr Kustrzycki et al. [1] about depression and anxiety symptoms 8 years following coronary surgery. This paper discusses an important part of a larger clinical problem: the interaction between psychological or psychiatric disorders and the results of cardiac surgery. This major issue is rarely taken into consideration by cardiac surgeons in their presurgical evaluation. When we wrote our paper cited in this article, depression and anxiety had only recently been identified as important risk factors for ischaemic heart disease, and were, for the first time, considered as similar in importance to smoking, hypercholesterolemia and arterial hypertension [2]. Furthermore, studies have confirmed that symptoms of depression and anxiety are associated with worse outcomes after coronary surgery. Behavioural factors, in particular hostility and anger, have also been shown to be important independent predictors of adverse outcome after myocardial infarction and myocardial revascularization. All these points emphasize the need for cooperation among surgeons, cardiologists and psychiatrists in the careful preoperative evaluation of these symptoms. This will allow identification of these high-risk patients who may benefit from psychological support tailored to their specific needs with the aim being an improvement of long-term psychiatric and cardiac prognosis. However, a simple question still remains unsolved: does the effective treatment of theses psychiatric symptoms and pathologies really improve the results of coronary surgery or not? The paper by Dr Kustrzycki in our opinion does not provide any response. It is obvious that coronary surgery itself, even a complete success from a cardiac point of view, will not reduce depressive symptoms. Depression is a separate disease that needs specific treatment and psychiatric follow-up. Coronary surgery is certainly not designed to treat depression, but each patient recognized as depressive by a psychiatrist must have the benefit of a specific treatment and careful specialized follow-up. The fact that during the 8 years of follow-up not one patient was treated by a psychiatrist but 22% took psychiatric drugs prescribed by a general practitioner creates a major bias in this study. The differentiation of presurgical anxiety that is considered as normal and anxiety as a real psychiatric pathology is also important. Finally, the most important message for cardiac surgeons is that the interactions between the mind and the heart are probably more complex than we recognize, and a psychiatric disorder such as depression can clearly be detrimental to the results of cardiac surgery. Close collaboration between cardiologists, surgeons and psychiatrists is mandatory before and after cardiac surgery in order to optimize as much as possible the treatment of these difficult patients.

Experimental model for comparative evaluation of pharmacologically induced vasodilation of arterial wall mechanical properties.

&NA; Arterial wall compliance (C) and distensibility coefficient (DC) are key factors of pathologic physiology, especially in arteries less than 2 mm in diameter. The aim of this study was to design an experimental model allowing comparative measurement of C and DC during pharmacologically induced vasodilation on small‐diameter arteries. Both femoral arteries were exposed in eight New Zealand White rabbits. Diameter (d) and systolic/diastolic diameter changes (&dgr;d) were measured simultaneously, and C and DC were calculated before and after topical application of 1 mL of 4% papaverine on the right side and topical application of 1 mL of 1% lidocaine on the left side. Diameter measurements were performed by echo tracking with 20‐MHz implanted microprobes. After papaverine and lidocaine application, respectively, d increased from 1.36 mm to 2.23 mm (P < 0.0001) and from 1.45 mm to 2.4 mm (P < 0.0001), &dgr;d increased from 0.0568 mm to 0.0571 mm (P = 0.34) and from 0.064 mm to 0.077 mm (P < 0.01), C increased from 5.7 × 10‐3 mm/mm Hg to 6 × 10‐3 mm/mm Hg (P < 0.02) and from 6.23 × 10‐3 mm/mm Hg to 8.49 × 10‐3 mm/mm Hg (P < 0.01), and DC decreased from 4.22 × 10‐3 mm Hg‐1 to 2.61 × 10‐3 mm Hg ‐1 (P < 0.0004) and from 4.36 × 10‐3 mm/mm Hg to 3.46 × 10‐3 mm/mm Hg (P < 0.005). Papaverine‐ and lidocaine‐induced changes were significantly different for &dgr;d, C, and DC (P < 0.01). These results suggest that, unlike that with papaverine, lidocaine‐induced vasodilation leads the artery up to the nonlinear part of its pressure/diameter relationship, with decreased distensibility contrasting with increased diameter and compliance. Our experimental model may be useful to compare the effects of different vasoactive drugs at different concentrations on the mechanical properties of the arterial wall.