New estimate of valvuloarterial impedance in aortic valve stenosis: A cardiac magnetic resonance study.

PURPOSE: Valvuloarterial impedance (ZVA ), estimating left ventricle (LV) afterload, has been proposed in transthoracic echocardiography (TTE) as a predictor of mortality in aortic valve stenosis (AVS). However, its calculation differs from arterial characteristic impedance (ZC ). Our aim was to apply the concept of ZC calculation to estimate ZVA from MR with carotid tonometry and to evaluate these indices through their associations with symptoms, LV diastolic function and aortic stiffness. MATERIALS AND METHODS: In 40 patients with AVS (76 ± 13 years), ZVA-TI derived from velocity time integral and E/Ea were estimated by TTE. ZVA-INS , based on ZC formula, calculated as the instantaneous pressure gradient to peak flow ratio and aortic compliance were estimated by using MRI at 1.5 Tesla. RESULTS: Both ZVA estimates were higher in symptomatic than asymptomatic patients (707 ± 22 versus 579 ± 53 dyne.s/cm5 , P = 0.031 for ZVA-INS and 4.35 ± 0.16 versus 3.33 ± 0.38 mmHg.m2 /mL, P = 0.018 for ZVA-TI ). Although they were both associated with aortic compliance (r = -0.45; P = 0.006 for ZVA-INS and r = -0.43; P = 0.008 for ZVA-TI ) only ZVA-INS was associated with E/Ea (r = 0.50; P < 0.001). In multivariate analysis to identify determinants of E/Ea, a model including age, mean blood pressure, LV ejection fraction, LV mass, and aortic valve area was performed (R2 = 0.41; P < 0.01). When ZVA-INS was added to the model, its overall significance was higher R2 = 0.56 (P < 0.01) and ZVA-INS and LV mass were the only significant determinants. CONCLUSION: ZVA-INS was more strongly associated with diastolic dysfunction than usual parameters quantifying AVS severity. This new ZVA estimate could improve LV afterload evaluation. LEVEL OF EVIDENCE: 1 J. Magn. Reson. Imaging 2017;45:795-803.

Technical Aspects of Open Repair for Degenerative Aneurysmal Evolution Despite Early Thoracic Endovascular Repair of Type B Aortic Dissection.

BACKGROUND: Closure of the proximal tear by thoracic endovascular aortic repair (TEVAR) at the acute phase appears to be a safe effective treatment to prevent aneurysmal degeneration type B dissection. However, it appears to be inefficient in up to a third of the patient. We report the technical aspects of our experience with patients undergoing secondary open repair after TEVAR for dissecting thoracoabdominal aneurysm despite early closure proximal tear by TEVAR. METHODS: During a period of 5 years, 96 patients presenting acute type B aortic dissections were treated by TEVAR and followed-up in our institution. Among them, 5 patients experienced an evolution to a dissecting thoracoabdominal aortic aneurysm. Their demographic data and initial medical conditions, delay to reintervention, operative technical details, perioperative and mid-term outcomes were collected and analyzed. RESULTS: All 5 patients (4 male, mean age 58 ± 9) were operated under peripheral normothermic bypass without deep circulatory arrest using the thoracic stent graft as an elephant trunk for completion of the proximal anastomosis. In cases of patency, the false lumen was reapproximated in the anastomosis, 6 visceral arteries were revascularized selectively. One patient died at day 1 of perioperative ventricular fibrillation due to an acute myocardial infarction. The 4 others are alive without complication after a median of 30 months, range (13-22). CONCLUSIONS: In our experience, TEVAR was not only efficient at the acute phase to deal with complications, but in cases of subsequent aneurysmal evolution, it made open repair even easier by avoiding very proximal cross-clamping/anastomosis and circulatory arrest.

First clinical use of a bioprosthetic total artificial heart: report of two cases.

BACKGROUND: The development of artificial hearts in patients with end-stage heart disease have been confronted with the major issues of thromboembolism or haemorrhage. Since valvular bioprostheses are associated with a low incidence of these complications, we decided to use bioprosthetic materials in the construction of a novel artificial heart (C-TAH). We report here the device characteristics and its first clinical applications in two patients with end-stage dilated cardiomyopathy. The aim of the study was to evaluate safety and feasibility of the CARMAT TAH for patients at imminent risk of death from biventricular heart failure and not eligible for transplant. METHODS: The C-TAH is an implantable electro-hydraulically actuated pulsatile biventricular pump. All components, batteries excepted, are embodied in a single device positioned in the pericardial sac after excision of the native ventricles. We selected patients admitted to hospital who were at imminent risk of death, having irreversible biventricular failure, and not eligible for heart transplantation, from three cardiac surgery centres in France. FINDINGS: The C-TAH was implanted in two male patients. Patient 1, aged 76 years, had the C-TAH implantation on Dec 18, 2013; patient 2, aged 68 years, had the implantation on Aug 5, 2014. The cardiopulmonary bypass times for C-TAH implantation were 170 min for patient 1 and 157 min for patient 2. Both patients were extubated within the first 12 postoperative hours and had a rapid recovery of their respiratory and circulatory functions as well as a normal mental status. Patient 1 presented with a tamponade on day 23 requiring re-intervention. Postoperative bleeding disorders prompted anticoagulant discontinuation. The C-TAH functioned well with a cardiac output of 4·8-5·8 L/min. On day 74, the patient died due to a device failure. Autopsy did not detect any relevant thrombus formation within the bioprosthesis nor the different organs, despite a 50-day anticoagulant-free period. Patient 2 experienced a transient period of renal failure and a pericardial effusion requiring drainage, but otherwise uneventful postoperative course. He was discharged from the hospital on day 150 after surgery with a wearable system without technical assistance. After 4 months at home, the patient suffered low cardiac output. A change of C-TAH was attempted but the patient died of multiorgan failure. INTERPRETATION: This preliminary experience could represent an important contribution to the development of total artificial hearts using bioprosthetic materials. FUNDING: CARMAT SA.

Three-Year Outcomes With the Multilayer Flow Modulator for Repair of Thoracoabdominal Aneurysms: A Follow-up Report From the STRATO Trial.

PURPOSE: To evaluate midterm outcomes of endovascular repair of types II and III thoracoabdominal aortic aneurysms (TAAA) using the Multilayer Flow Modulator (MFM) in patients unsuitable for open surgery or fenestrated stent-grafts. METHODS: In the prospective, multicenter, nonrandomized STRATO trial (EudraCT registration: 2009-013678-42; ClinicalTrials.gov identifier NCT01756911), 23 patients (mean age 75.8 years; 19 men) with Crawford type II and III TAAA (mean diameter 6.5 cm) were implanted between April 2010 and February 2011. Outcomes included all-cause mortality and stable aneurysm thrombosis with associated branch vessel patency. RESULTS: Through 36 months, there were 7 deaths (none confirmed as aneurysm-related), and no cases of spinal cord injury, device migration or fracture, or respiratory, renal, or peripheral complications. Three patients were lost to follow-up and 2 devices were explanted. The device was patent in the 11 remaining patients at 3 years. Stable aneurysm thrombosis was achieved for 15 of 20 patients at 12 months, 12 of 13 at 24 months, and 10 of 11 at 36 months. The rate of branch patency was 96% at 12 months (primary patency), 100% at 24 months, and 97% at 36 months. Nine patients suffered from endoleaks (attachment site or device overlap); 9 patients underwent 11 reinterventions (3 surgical). Maximum aneurysm diameter was stable for 18 of 20 patients at 12 months, 11 of 13 at 24 months, and 9 of 11 at 36 months. For 10 patients with computed tomography at 36 months, the mean ratio of aneurysm flow volume to total volume had decreased by 83%; the mean ratio of thrombus volume to total volume increased by 159%. CONCLUSION: Through 3 years, endovascular repair with the MFM appears to be safe and effective while successfully maintaining branch vessel patency.

Atrial fibrillation at mid-term after bioprosthetic aortic valve replacement ­ implications for anti-thrombotic therapy.

BACKGROUND: Little is known about mid-term (3-month) postoperative atrial fibrillation (MT-POAF) in patients treated with bioprosthetic aortic valve replacement (BAVR). The aim of this study was to describe the natural history, identify the predictors and investigate the potential consequences in terms of anti-thrombotic therapy. METHODS AND RESULTS: During a longitudinal, prospective study, 219 patients were treated with BAVR early (7 days) and at mid-term postoperatively (30 and 90 days). POAF was monitored and risk factors were identified on logistic regression analysis. History of previous AF (OR, 3.08; 95% CI: 1.35-6.98), early POAF (OR, 5.93; 95% CI: 2.96-11.8), and BMI (per 5 kg/m(2): OR, 1.46; 95% CI: 1.03-2.09), were independent predictors for MT-POAF whereas sex, age and Euroscore were not. Results were identical when restricted to the 176 patients free from preoperative AF. In this subgroup, 36 patients (20.4%) had MT-POAF; 33 out of 174 (18.7%) would have required anticoagulation (CHA2DS2VASc score ≥ 1). Conversely, patients with BMI <27.7 and sinus rhythm at early follow-up had a very low risk of MT-POAF (OR, 0.16; 95% CI: 0.06-0.42). CONCLUSIONS: There was a higher than expected occurrence of MT-POAF in patients treated with BAVR, particularly in overweight patients with early POAF. This raises the question of implementing an anti-thrombotic therapy in these patients at higher risk of delayed atrial arrhythmia.

Determinants of Transcutaneous Ear Lobe CO2 Tension (PtCO2) at 37°C During On-Pump Cardiac Surgery.

OBJECTIVE: There are no available criteria for determining the optimal flow rate and mean arterial pressure level in patients undergoing cardiopulmonary bypass (CPB). Transcutaneous carbon dioxide tension (PtCO2) has been proposed for microcirculation monitoring and it could be useful for guiding hemodynamic optimization under CPB. The goal of this exploratory study was to determine the factors that influence PtCO2 variations during CPB. DESIGN: Cutaneous ear lobe CO2 tension was monitored along with hemodynamic parameters every 10 minutes during CPB, until aortic unclamping. SETTING: French university teaching hospital. PARTICIPANTS: Patients scheduled for cardiac surgery requiring CPB were prospectively included. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: A total of 41 patients were included (520 observations). There was a statistically significant association between PaCO2 and PtCO2 (beta = 0.493 [0.154-0.832], p = 0.043), mostly when PaCO2 was outside the normal range. When PaCO2 was normal, PtCO2 was inversely correlated with mean arterial pressure (after adjustment for PaCO2 and body temperature: Beta -0.245, SE = 0.037, p<0.001) but not with CPB flow rate (p = 0.11). CONCLUSION: The factors that influence PtCO2 during CPB cardiac surgery are PaCO2, body temperature, and mean arterial pressure. When PaCO2 is normal, a PtCO2 elevation might be explained by insufficient mean arterial pressure. Whether low PtCO2 values during CPB should trigger the administration of vasoconstrictors remains to be evaluated.

Experience of the Zenith Dissection Endovascular System in the emergency setting of malperfusion in acute type B dissections.

OBJECTIVE: This study evaluated the safety and effectiveness of the Zenith Dissection Endovascular System (Cook Medical, Bloomington, Ind) in the urgent treatment of acute type B aortic dissections complicated by organ malperfusion. METHODS: Between June 2011 and June 2013, we prospectively enrolled all patients with acute type B dissection (<14 days) complicated by visceral malperfusion and treated by the Zenith Dissection Endovascular System, including a proximal covered stent and a distal noncovered stent. Organ malperfusion was diagnosed during the clinical, biological, and morphologic follow-up of patients admitted to a dedicated intensive care unit (SOS Aorta). End points were 30-day mortality and morbidity, and reoperation rate, survival, and remodelling of the dissected aorta during follow-up. RESULTS: Fifteen patients (11 men; mean age, 60 ± 12 years) were treated in emergency procedures with a median delay of 36 hours. Malperfusions included renal ischemia in all patients, intestinal ischemia in nine, and lower limb ischemia in six. The proximal entry tear in each patient was covered by a stent Zenith TX2 graft (mean diameter, 36 mm; mean length, 170 mm; Cook Medical), supplemented by a noncovered aortic stent (diameter, 36 or 46 mm; length, 164 mm) with a technical success rate of 100%. The left subclavian artery in 10 patients was covered without revascularization. One chimney was necessary to revascularize the left common carotid artery. Six patients required complementary arterial branch stenting for persistent static malperfusion, using eight peripheral stents (five iliacs, three renals). No deaths were recorded during the 30-day postoperative period. Major adverse events were reported in three patients (20%): 1 paraparesis with complete recovery, 1 colonic resection, 1 stroke, and 2 transient renal failures. The mean hospital stay was 14 ± 6 days. During a mean follow-up of 8 ± 3 months, one sudden death, no aortic-related complications, and no reoperations or conversions were recorded. Remodelling with healing of the thoracic false lumen was obtained in 10 patients (67%), and five others had a partially thrombosed false lumen without remodelling. CONCLUSIONS: Used as a treatment for organ malperfusion complicating acute type B dissections, the Zenith Dissection Endovascular System achieved safely and effectively satisfactory clinical results in the short term. The long-term effect of this composite treatment on aortic remodelling remains to be determined.

One-year outcomes following repair of thoracoabdominal aneurysms with the multilayer flow modulator: report from the STRATO trial.

PURPOSE: To evaluate endovascular repair of type II and III thoracoabdominal aortic aneurysms (TAAA) using the Multilayer Flow Modulator (MFM) in patients with contraindications for open surgery and fenestrated stent-grafts. METHODS: In this prospective, multicenter, nonrandomized trial (EudraCT registration: 2009-013678-42; ClinicalTrials.gov identifier NCT01756911), 23 patients (19 men; mean age 75.8 years) with Crawford type II (43.5%) and III (56.5%) TAAA (mean diameter 6.5 cm) were treated with the MFM between April 2010 and February 2011. The primary efficacy outcome measure was stable aneurysm thrombosis with associated branch vessel patency at 12 months; the primary safety endpoint was 30-day and 12-month all-cause mortality. RESULTS: The rate of technical success was 100%. In 20 patients with computed tomography scans at 12 months, the primary efficacy outcome was met in 15 patients. The rate of primary patency of covered branch vessels was 96% (53/55); 1 patient with 2 occluded visceral branches underwent successful surgical reintervention. Endoleaks were identified in 5 patients (3 attachment site and 2 at device overlap), 4 of whom underwent reintervention (3 additional MFMs and 1 stent-graft implanted). At 12 months, aneurysm diameter was stable in 18 of 20 patients; the mean ratio of residual aneurysm flow volume to total volume had decreased by 28.9%, and the mean ratio of thrombus volume to total lumen volume had increased by 21.3% (n=17). There were no cases of device migration, loss of device integrity, spinal cord ischemia, or aneurysm rupture. CONCLUSION: At 1 year, endovascular repair with the MFM appears to be safe and effective while successfully maintaining branch vessel patency. Follow-up is ongoing.

Chimney stent graft for endovascular sealing of a pararenal aortic aneurysm.

Chimney endovascular aneurysm repair is still a controversial treatment of complex aortic aneurysms. Stent-graft patency and type-I endoleaks are the main challenges that temper this bailout technique. Endovascular aneurysm sealing (EVAS) consists of anchoring and sealing the device within the aneurysm sac. The first results are promising, even for adverse anatomy. We describe a case of EVAS for a pararenal aortic aneurysm associated with a chimney stent graft for the right renal artery. Wrapping the chimney stent graft inside endobags filled with polymer is expected to prevent gutters and stent compressions.

Elective treatment of abdominal aortic aneurysm is reasonable in patients >85 years of age.

BACKGROUND: The numbers of patients >85 years of age referred for abdominal aortic aneurysm (AAA) repair have increased in recent decades. With the population aging, increased screening of AAA, and introduction of less invasive surgical techniques, vascular surgeons will be treating more elderly patients. Few data are available for estimating the risks and benefits of prophylactic repair among those with such an advanced age. The aim of this single-center study was to evaluate the short-term to midterm results after AAA repair in patients >85 years of age. METHODS: Between 2004 and 2012, data of patients >85 years old who required an elective AAA repair at our institution were collected prospectively. According to the current guidelines, patients underwent endovascular aneurysm repair (EVAR) each time the aortic anatomy was suitable. Open repair (OR) was performed in those patients with hostile proximal neck anatomy and/or severe iliac tortuosity. Type of repair (EVAR or OR) and perioperative and midterm outcomes were analyzed. Primary end points were 30-day mortality and midterm survival. RESULTS: Among 1016 patients undergoing elective AAA repair during the study period, 59 (5.8%) were ≥85 years of age (54 men, mean age 87 ± 2 years), with a mean aneurysm diameter of 61.5 ± 20.3 mm. Thirty-three patients (56%) underwent EVAR and 26 (44%) had an OR. Thirty-day mortality was 6.7% (6% with EVAR and 7.6% with OR, P <0.05). Mean follow-up was 24.7 ± 18 months. Kaplan‒Meier analyses for survival were 85.5%, 64.5%, and 50% at 1, 3, and 5 years, respectively. No aneurysm-related death was observed during follow-up. CONCLUSION: Elective repair may be proposed in patients >85 years of age in cases of threatening AAA, showing acceptable perioperative mortality and reasonable midterm survival results. Even if EVAR did not seem to offer significant benefits in perioperative mortality in our study, it appears reasonable to suggest this less invasive technique as first-line treatment in cases of suitable anatomy in such an advanced-age population.

Reinterventions for type 2 endoleaks with enlargement of the aneurismal sac after endovascular treatment of abdominal aortic aneurysms.

BACKGROUND: Type 2 endoleaks after the endovascular treatment (EVAR) of abdominal aorta aneurysms (AAAs) remain a concern for vascular surgeons, especially when they are associated with an enlargement of the persistent aneurysmal sac. The purpose of this study is to evaluate the effectiveness of secondary reinterventions for type 2 endoleaks associated with enlargement of the aneurysmal sac after EVAR. METHODS: The incidence of endoleaks, aneurysmal sac diameters, and reinterventions were collected from the clinical and radiologic data of the patients treated by EVAR for AAA with >1 year of follow-up. Patients with a type II endoleak associated with an enlargement of the aneurysmal sac were identified; their operative data and the results of the secondary procedures were recorded. The principal criterion of evaluation was the effectiveness of these reinterventions on the evolution of the diameter of the AAA. The secondary criteria were death rate related to aneurysm and the average costs of these additional procedures. RESULTS: In 232 patients treated by EVAR with an average of 2 years of follow-up (23 ± 30 months), 15 type I (6.5%), 94 type II (40.5%), and 8 type III (3.5%) endoleaks were identified. Among the 94 AAAs with a type II endoleak, 21 had a regression of the aneurysmal sac (22.5%), 46 were stable (49.5%), and 27 continued to grow (28%), including 9 because of another type of endoleak. Among the 18 patients presenting with a type II endoleak linked with an enlargement of the aneurysmal sac, 14 were treated with endovascular embolization, 1 was treated by conventional aneurysmectomy, and 3 patients were followed-up only. Among 14 patients treated by embolization, 9 (60%) presented with persistent enlargement of the aneurysmal sac after embolization, of which 5 were finally treated by conventional treatment with 1 postoperative death. The average cost per patient that required a reintervention for a type II endoleaks was €28,096 ± €30,490 ($37,530 ± $40,728). CONCLUSION: Endovascular reinterventions for type II endoleaks associated with an enlargement of the aneurysmal sac after EVAR have a poor effectiveness on the stabilization of the diameter of the AAA. These procedures involve an high cost and high rates of morbidity, which should be taken into account in their use.

Endoluminal gingival fibroblast transfer reduces the size of rabbit carotid aneurisms via elastin repair.

OBJECTIVE: Matrix metalloproteinase-9 is considered to play a pivotal role in aneurismal formation. We showed that gingival fibroblasts (GF) in vitro reduced matrix metalloproteinase-9 activity via increased secretion of tissue inhibitor of metalloproteinase 1. We aimed to evaluate in vivo the efficacy of GF transplantation to reduce aneurism development in a rabbit model. METHODS AND RESULTS: Seventy rabbit carotid aneurisms were induced by elastase infusion. Four weeks later, GF, dermal fibroblast, or culture medium (DMEM) were infused into established aneurisms. Viable GF were abundantly detected in the transplanted arteries 3 months after seeding. GF engraftment resulted in a significant reduction of carotid aneurisms (decrease of 23.3% [P<0.001] and 17.6% [P=0.01] of vessel diameter in GF-treated arteries, 1 and 3 months after cell therapy, respectively), whereas vessel diameter of control DMEM and dermal fibroblast-treated arteries increased. GF inhibited matrix metalloproteinase-9 activity by tissue inhibitor of metalloproteinase 1 overexpression and matrix metalloproteinase-9/tissue inhibitor of metalloproteinase 1 complex formation, induced elastin repair, and increased elastin density in the media compared with DMEM-treated arteries (38.2 versus 18.0%; P=0.02). Elastin network GF-induced repair was inhibited by tissue inhibitor of metalloproteinase 1 blocking peptide. CONCLUSIONS: Our results demonstrate that GF transplantation results in significant aneurism reduction and elastin repair. This strategy may be attractive because GF are accessible and remain viable within the grafted tissue.

Incidence, risk factors and prediction of post-operative acute kidney injury following cardiac surgery for active infective endocarditis: an observational study.

INTRODUCTION: Cardiac surgery is frequently needed in patients with infective endocarditis (IE). Acute kidney injury (AKI) often complicates IE and is associated with poor outcomes. The purpose of the study was to determine the risk factors for post-operative AKI in patients operated on for IE. METHODS: A retrospective, non-interventional study of prospectively collected data (2000-2010) included patients with IE and cardiac surgery with cardio-pulmonary bypass. The primary outcome was post-operative AKI, defined as the development of AKI or progression of AKI based on the acute kidney injury network (AKIN) definition. We used ensemble machine learning ("Super Learning") to develop a predictor of AKI based on potential risk factors, and evaluated its performance using V-fold cross validation. We identified clinically important predictors among a set of risk factors using Targeted Maximum Likelihood Estimation. RESULTS: 202 patients were included, of which 120 (59%) experienced a post-operative AKI. 65 (32.2%) patients presented an AKI before surgery while 91 (45%) presented a progression of AKI in the post-operative period. 20 patients (9.9%) required a renal replacement therapy during the post-operative ICU stay and 30 (14.8%) died during their hospital stay. The following variables were found to be significantly associated with renal function impairment, after adjustment for other risk factors: multiple surgery (OR: 4.16, 95% CI: 2.98-5.80, p<0.001), pre-operative anemia (OR: 1.89, 95% CI: 1.34-2.66, p<0.001), transfusion requirement during surgery (OR: 2.38, 95% CI: 1.55-3.63, p<0.001), and the use of vancomycin (OR: 2.63, 95% CI: 2.07-3.34, p<0.001), aminoglycosides (OR: 1.44, 95% CI: 1.13-1.83, p=0.004) or contrast iodine (OR: 1.70, 95% CI: 1.37-2.12, p<0.001). Post-operative but not pre-operative AKI was associated with hospital mortality. CONCLUSIONS: Post-operative AKI following cardiopulmonary bypass for IE results from additive hits to the kidney. We identified several potentially modifiable risk factors such as treatment with vancomycin or aminoglycosides or pre-operative anemia.

Spot stenting of the tear in type B aortic dissection.

BACKGROUND: In selected type B acute aortic dissection with aortic growth and patent false lumen, an intervention may be required to prevent aortic rupture. Apart from stent grafting of the thoracic aorta, aimed at occluding the primary intimal tear, some have advocated closure of reentry tears by stent grafting of the aortic true lumen after hybrid revascularization of the excluded viscera or by branched aortic endografts. METHODS: We describe a simple technique for occluding a major reentry tear in the visceral abdominal aorta, using on-the-shelf covered stent grafts, arising from the aortic true lumen, crossing the dissection septum tear and aortic false lumen, and being distally anchored in the visceral branch vessel, acting as a rivet on the dissection septum tear, achieving aortic false lumen thrombosis. RESULTS: In selected cases, we achieved aortic false lumen thrombosis by spot stenting of the tear. CONCLUSIONS: This spot stenting technique may be a useful way of achieving complete false lumen thrombosis or lowering the false lumen pressure of degenerating dissecting aneurysms.

Applicability and mid-term results of endovascular treatment for descending thoracic acute aortic syndromes.

BACKGROUND: Descending thoracic acute aortic syndromes (DTAASs) are life-threatening pathologies in which thoracic endovascular aortic repair (TEVAR) is an attractive therapeutic option. There are few data in the literature on the survival and morbidity rates of TEVAR in such indications. We provide the results of TEVAR from our single-center cohort of DTAASs: ruptured aneurysms (RAs), acute symptomatic dissections (ADs), and traumatic ruptures (TRs). METHODS: Between 2004 and 2011, data from all patients treated by TEVAR for DTAAS in our university center were collected prospectively. Primary end points were rates of 30-day mortality and morbidity. Secondary end points were mid-term outcomes and reinterventions. RESULTS: Forty-eight patients underwent TEVAR for DTAASs: 19 RAs (39.6%), 12 ADs (25.0%), and 17 TRs (35.4%). The cumulative 30-day mortality and morbidity rate was 33%. There were 10 deaths (6 RAs, 1 AD, and 3 TRs), 2 cases of paraplegia (0 postoperative and 2 preoperative cases (2 TRs), and no major reinterventions and 4 minor reinterventions (embolization for endoleak exclusion). Long-term outcomes were known in 33 patients (5 patients were lost to follow-up), with a mean duration follow-up of 27 months. The cumulative mortality and morbidity rate was 9%: no deaths were reported, and 2 major reinterventions (open aneurysm repair) and 1 minor reintervention (endoleak exclusion) were required. CONCLUSIONS: Our results confirm that TEVAR, as an emergency therapeutic option, is suited to DTAASs. The 21% perioperative mortality rate for such dramatic lesions remains high but is lower than medical or open repair therapeutic options previously reported. No additional deaths occurred during the 2-year follow-up period, and a low incidence of endograft-related reinterventions was observed. Nevertheless, scheduled follow-up visits with computed tomodensitometry scans on a regular basis are mandatory.

Transfemorally or transapically deployed Sapien Edwards bioprosthesis is always deformed.

OBJECTIVE: To study the impact of femoral compared to apical access on the Sapien-Edwards (SE) prosthesis deployment and geometry in patients treated with transcatheter aortic valve implantation (TAVI) for aortic stenosis. BACKGROUND: SE prosthesis deformation exists after its deployment through transfemoral (TF-TAVI) approach. However, no study comparing the deformation between TF-TAVI and transapical (TA-TAVI) approaches has yet been published. METHODS: Forty consecutive patients received TAVI with the SE prosthesis (TF-TAVI n = 25; TA-TAVI n = 15). A fluoroscopic analysis of the prosthesis was then performed. The stent frame geometry was assessed during deployment in the profile view, and after implantation in the profile and frontal views. RESULTS: Expansion kinetics revealed a triphasic stent deployment with both approaches; the aortic extremity being the first to open. After implantation, on the profile view, the stent shape was never rectangular (therefore never cylindrical) in both groups. It had a biconic shape in most of the patients (76% vs. 93.3% for TF-TAVI and TA-TAVI patients, respectively, P = 0.224) with a wider aortic extremity relative to the ventricular one. The frontal view analysis showed that circular deployment of the stent was never achieved. A greater leaflet to stent mismatch was noted in TA-TAVI patients, however, the difference was not statistically significant (12% vs. 33.3%, P = 0.126). CONCLUSION: Fluoroscopically assessed, the geometry of SE prosthesis was never cylindrical after deployment, whatever the access for implantation was. Longitudinal deformation was greater after TF-TAVI whereas leaflet to stent mismatch tended to be more pronounced after TA-TAVI.

Elliptical shape of a SAPIEN XT prosthesis deployed in a patient with bicuspid aortic valve stenosis.

Transcatheter aortic valve implantation (TAVI) has been shown as an effective procedure in patients considered at high risk for surgery. Aortic valve bicuspidy, as encountered in up of 50% of patients with severe aortic stenosis, has been considered a contraindication to TAVI. One reason for this is that stent deformation is likely to occur after prosthesis deployment, but this has been refuted by recent observations with the SAPIEN prosthesis. Herein is reported the first case of a severely deformed SAPIEN XT prosthesis after TAVI in a patient with severe symptomatic aortic stenosis, and known to have a bicuspid native aortic valve.

Antegrade, covered, self-expanding stent as an iliac extension in a bifurcated endograft: a feasible technical maneuver for challenging aortoiliac aneurysmal anatomy.

BACKGROUND: Aneurysmal and occlusive aortoiliac disease can make the process of introducing large delivery catheters for endovascular repair challenging. We describe the case of a patient who could be treated by a bifurcated stent-graft despite having a unilateral external iliac occlusion. METHODS AND RESULTS: From a brachial access, a covered self-expanding stent was deployed antegradely through the distal gate of the stent-graft into the common iliac artery. This technical choice helped to overcome the problem of an external iliac occlusion, so as to maintain an antegrade flow into the internal iliac and avoid the need for an interfemoral bypass. CONCLUSION: Auto-expandable covered stent-graft with a thinner shaft can be used through a brachial access as an iliac extension of a bifurcated aortic endograft. However, a longer follow-up duration and more cases are necessary to warrant the safety and the durability of such an "off-label" endovascular material assemblage.

The significance of endoleaks in thoracic endovascular aneurysm repair.

BACKGROUND: Endoleak is one of the rare complications that occur after thoracic endovascular aneurysm repair (TEVAR). The aim of this study was to assess the incidence of endoleaks and the predictive factors for their occurrence, as well as their effect on secondary interventions after TEVAR. METHODS: Medical and radiological data of all TEVAR procedures performed between 2004 and 2008 were entered prospectively into our database and reviewed retrospectively. Primary endpoints included were the incidence and the type of endoleak, aneurysmal sac expansion, and secondary interventions. RESULTS: In all, 67 patients (18 women and 49 men; mean age, 67 ± 14 years) were treated consecutively for descending thoracic aortic aneurysms (mean diameter: 69 ± 18 mm) by TEVAR during the observed period, using 83 stent-grafts (11 Cook TX2, 31 Gore TAG, and 41 Medtronic Valiant), with a median follow-up of 27 months (range: 2-64). In 13 of 67 patients, 14 (19.4%) endoleaks were diagnosed, of which 71% (10 of 14) were type I, 29% (4 of 14) were type II, and none were type III. Ten endoleaks (71%) were diagnosed on the first postoperative computed tomographic angiography at 1 month, and the other four (29%) developed later on. Predictive factors for endoleaks on univariate analysis included age (p = 0.04), length of the proximal neck immediately after the left subclavian artery (p = 0.04), the fusiform morphology of the descending thoracic aortic aneurysms (p = 0.04), and the type of stent-graft used (p = 0.02). Eight of the 10 type I endoleaks (80%) were successfully treated by endovascular means, using proximal cuffs (n = 5) or distal extensions (n = 3). None of type II endoleaks were treated by secondary intervention. The six endoleaks treated conservatively were all associated with a significant mean increase of their aneurysmal sac (+3.2 ± 2.6 mm) during follow-up. No secondary conversion to open surgery was performed to treat an endoleak. CONCLUSIONS: On the basis of the study, it seems as if endoleaks are detected in one of the five patients treated with TEVAR during follow-up period, particularly if they are old with a proximal and fusiform aneurysm. Short- and mid-term follow-up suggest that most type I endoleaks can successfully be treated by endovascular techniques and that type II endoleaks treated conservatively require a close radiological monitoring.

Complications of the access during aortic valve implantation through transfemoral access.

BACKGROUND: Aortic valve implantation (AVI) is a booming therapeutic option in high-risk patients with calcific aortic stenosis. Retrograde femoral approach drawbacks include vascular complications owing to the size of the introduction system (22- and 24-F).The aim of this study was to retrospectively analyze the incidence and the treatment of vascular complications in the first 2 years of transfemoral AVI experience with the first generation of Edwards SAPIEN transcatheter heart valves. METHODS: Since December 2007, AVI has been performed in 71 patients, 21 times by the transapical route and 50 times by the transfemoral route through an inguinal approach with the first generation of Edwards SAPIEN transcatheter heart valves (23 and 26 mm). The incidence and the treatment of vascular complications were evaluated as main criteria for transfemoral AVI. RESULTS: All the procedures could be successfully performed by a femoral route, except for three cases when the introducing device could not be fixed on the thoracic aorta because of vascular access problems. Vascular access-related complications occurred in nine patients (18%), including three iliac dissections, two aortic dissections, three femoral lesions, and one thoracic aorta rupture. These complications were treated either in a conservative way (n = 2), or in an endovascular way using a contralateral approach (n = 3), or surgically through an inguinal approach (n = 3). A traumatic rupture of the thoracic aorta resulted in the death of a female patient. CONCLUSION: In our experience, transfemoral AVI gives a satisfying technical success rate in the selected patients. The incidence of complications involving the vascular access remains an important limitation of this new technique. Although a conservative or endovascular treatment can be applied in most cases, improving the introduction devices is highly expected because it would reduce the complications rate of vascular access.