When cheating turns into a stabilizing mechanism of plant-pollinator communities.

Mutualistic interactions, such as plant-mycorrhizal or plant-pollinator interactions, are widespread in ecological communities and frequently exploited by cheaters, species that profit from interactions without providing benefits in return. Cheating usually negatively affects the fitness of the individuals that are cheated on, but the effects of cheating at the community level remains poorly understood. Here, we describe 2 different kinds of cheating in mutualistic networks and use a generalized Lotka-Volterra model to show that they have very different consequences for the persistence of the community. Conservative cheating, where a species cheats on its mutualistic partners to escape the cost of mutualistic interactions, negatively affects community persistence. In contrast, innovative cheating occurs with species with whom legitimate interactions are not possible, because of a physiological or morphological barrier. Innovative cheating can enhance community persistence under some conditions: when cheaters have few mutualistic partners, cheat at low or intermediate frequency and the cost associated with mutualism is not too high. Under these conditions, the negative effects of cheating on partner persistence are overcompensated at the community level by the positive feedback loops that arise in diverse mutualistic communities. Using an empirical dataset of plant-bird interactions (hummingbirds and flowerpiercers), we found that observed cheating patterns are highly consistent with theoretical cheating patterns found to increase community persistence. This result suggests that the cheating patterns observed in nature could contribute to promote species coexistence in mutualistic communities, instead of necessarily destabilizing them.

Efficacy of maintaining low-tidal volume mechanical ventilation as compared to resting lung strategy during coronary artery bypass graft cardiopulmonary bypass surgery: A post-hoc analysis of the MECANO trial.

STUDY OBJECTIVE: To compare a low-tidal-volume with positive end-expiratory pressure strategy (VENT strategy) to a resting-lung-strategy (i.e., no-ventilation (noV) strategy) during cardiopulmonary bypass for coronary artery bypass graft surgery on the incidence of postoperative pulmonary complications. DESIGN: Post-hoc analysis of the MECANO trial which was a prospective single-center, blind, randomized, parallel-group controlled trial. SETTING: Tertiary care cardiac surgery center. PATIENTS: Patients who underwent isolated on-pump coronary bypass surgery were randomized either to VENT or noV group. INTERVENTION: During the cardiopulmonary bypass phase of the cardiac surgery procedure, mechanical ventilation in the VENT group consisted of a tidal volume of 3 mL/kg, a respiratory rate of 5 per minute and a positive end-expiratory pressure of 5 cmH2O. Patients in the noV group received no ventilation during this phase. MEASUREMENTS: Primary composite outcome combining death, early respiratory failure, ventilation support beyond day 2 and reintubation. MAIN RESULTS: In this post-hoc analysis, we retained 725 patients who underwent isolated CABG surgery, from the 1501 patients included in the original study. There were 352 in the VENT group and 373 patients in the noV group. Post-hoc comparison yielded no differences in baseline characteristics between these two groups. The primary outcome occurred less frequently in the VENT group than in the noV group, with 44 (12.5%) and 76 (20.4%) respectively (odds-ratio (OR) = 0.56 (0.37-0.84), p = 0.004). There were fewer early respiratory dysfunctions and prolonged respiratory support in the VENT group (respectively, OR = 0.34 (0.12-0.96) p = 0.033 and OR = 0.51 (0.27-0.94) p = 0.029). Complications related to mechanical ventilation were similar in the two groups. CONCLUSIONS: In this post-hoc analysis, maintaining low-tidal ventilation compared to a resting-lung strategy was associated with fewer pulmonary postoperative complications in patients who underwent isolated CABG procedures.

First experimental use of magnets in cardiac valve repair.

BACKGROUND AND AIM OF THE STUDY: Valve repair is currently performed to treat mitral regurgitation, but aortic valve repair remains a surgical challenge. In contrast, aortic valve replacement leads to complications and constraints on the patients' quality of life and valve durability. The mechanisms that produce malcoaptation of the aortic leaflets, with resultant insufficiency, are mainly due to prolapse or retraction of the leaflets. Thus, a new strategy has been proposed to correct valvular insufficiency, using magnetic force. METHODS: Low-profile permanent magnets were implanted in seven sheep, under cardiopulmonary bypass (CPB), through a transverse aortotomy, and maintained in place for three months. No aortic insufficiency was created in these first experiments. Two-dimensional color Doppler echocardiography was used to assess the function and safeguarding of the aortic valve. Blood samples were withdrawn to assess hemolysis, and histopathologic examinations performed at necropsy. RESULTS: Direct implantation of the three permanent magnets was possible in all seven animals, but the surgical procedure resulted in major complications in three cases. Only five animals could be weaned from CPB, and only four survived the procedure at three months. One magnet was also shown to have migrated postoperatively. Echocardiography confirmed the stability of the aortic leaflet contours. The biocompatibility of the implanted magnets (i.e., absence of hemolytic reaction) was found to be satisfactory, without a need for postoperative anticoagulation. CONCLUSION: The use of magnetic force to correct valvular insufficiency has not previously been reported, and is an interesting field of investigation. Whilst these experiments are at an early stage of development, future changes in magnet design and surgical approach are indicated.

Low Tidal Volume Mechanical Ventilation Against No Ventilation During Cardiopulmonary Bypass in Heart Surgery (MECANO): A Randomized Controlled Trial.

BACKGROUND: Postoperative pulmonary complications are common after cardiac surgery and have been related to lung collapse during cardiopulmonary bypass (CPB). No consensus exists regarding the effects of maintaining mechanical ventilation during CPB to decrease these complications. RESEARCH QUESTION: To determine whether maintaining low-tidal ventilation (3 mL/kg 5 times/min, with positive end expiratory pressure of 5 cm H2O) during CPB (ventilation strategy) was superior to a resting-lung strategy with no ventilation (no ventilation strategy) regarding postoperative pulmonary complications, including mortality. STUDY DESIGN AND METHODS: In a randomized controlled trial, patients undergoing cardiac surgery at a single center from May 2017 through August 2019 were randomized to the ventilation or no ventilation strategy during CPB (1:1 ratio). Apart from the CPB phase, perioperative ventilation procedures were standardized. RESULTS: The study included 1,501 patients (mean age, 68.8 ± 10.3 years; 1,152 (76.7%) men; mean EuroSCORE II, 2.3 ± 2.7). Seven hundred fifty-six patients were in the ventilation strategy group, and no differences existed in baseline characteristics and types of procedures between the two groups. An intention-to-treat analysis yielded no significant difference between the ventilation and no ventilation groups regarding incidence of the primary composite outcome combining death, early respiratory failure, ventilation support beyond day 2, and reintubation, with 112 of 756 patients (14.8%) in the ventilation group vs 133 of 745 patients (17.9%) in the no ventilation group (OR, 0.80; 95% CI, 0.61-1.05; P = .11). Strict per-protocol analyses of 1,338 patients (89.1%) with equally distributed preoperative characteristics yielded similar results (OR, 0.81; 95% CI, 0.60-1.09; P = .16). Post hoc analysis of the subgroup who underwent isolated coronary artery bypass graft procedures (n = 725) showed that the ventilation strategy was superior to the no ventilation strategy regarding the primary outcome (OR, 0.56; 95% CI, 0.37-0.84; P = .005). INTERPRETATION: Among patients undergoing cardiac surgery with CPB, continuation of low tidal volume ventilation was not superior to no ventilation during CPB with respect to postoperative complications, including death, early respiratory failure, ventilation support beyond day 2, and reintubation. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03098524; URL: www.clinicaltrials.gov.

Efficacy of parasternal block to decrease intraoperative opioid use in coronary artery bypass surgery via sternotomy: a randomized controlled trial.

OBJECTIVE: This study aims to assess the effect of a preoperative parasternal plane block (PSB) on opioid consumption required to maintain hemodynamic stability during sternotomy for coronary artery bypass graft surgery. METHODS: This double-blind, randomized, placebo-controlled trial prospectively enrolled 35 patients scheduled for coronary artery bypass graft surgery under general anesthesia with propofol and remifentanil. Patients were randomized to receive preoperative PSB using either ropivacaine (PSB group) or saline solution (placebo group) (1:1 ratio). The primary endpoint was the maximal effect-site concentration of remifentanil required to maintain heart rate and blood pressure within the recommended ranges during sternotomy. RESULTS: Median maximum concentration of remifentanil necessary to maintain adequate hemodynamic status during sternotomy was significantly reduced in PSB group (4.2 (2.5-6.0) ng/mL) compared with placebo group (7.0 (5.2-8.0) ng/mL) (p=0.02). Mean maximum concentration of propofol used to control depth of anesthesia was also reduced (3.9±1.1 µg/mL vs 5.0±1.5 µg/mL, PSB vs placebo, respectively; p=0.02). This reduction in propofol consumption during sternotomy enabled a more adequate level of sedation to be maintained in patients (minimum patient state index was 11.7±8.7 in placebo group and 18.3±6.8 in PSB group; p=0.02). PSB reduced postoperative inflammatory response by limiting concentrations of proinflammatory cytokines IL-8, IL-18, IL-23, IL-33 and MCP-1 measured in the first 7-day after surgery (p<0.05). CONCLUSIONS: Preoperative PSB reduced the maximum concentrations of remifentanil and propofol required to maintain hemodynamic stability and depth of anesthesia during sternotomy. TRIAL REGISTRATION NUMBER: NCT03734159.Sébastien Bloc, M.D.1,2; Brieuc P. Pérot, Ph.D.3; Hadrien Gibert, M.D.1; Jean-Dominique Law Koune, M.D.1; Yannick Burg, M.D.1; Didier Leclerc, M.D.1; Anne-Sophie Vuitton, M.D.1; Christophe De La Jonquière, M.D.1; Marine Luka, L.S.3; Thierry Waldmann, M.D.4; Nicolas Vistarini, M.D.4; Stéphane Aubert, M.D.4; Mickaël M. Ménager, Ph.D.3; Messaouda Merzoug, Ph.D.2; Cécile Naudin, Ph.D.2; Pierre Squara, M.D.2,5.

Gaping cleft or commissure--an under-rated cause of residual mitral insufficiency following valve repair: case reports.

Naturally occurring clefts in the posterior leaflet of the mitral valve and/or the mitral commissures themselves may become the foci of residual mitral regurgitation when distorted by an adjacent rigid suture line. Herein are reported the details of three cases in which cleft/commissure closure resolved such leaks. The anatomical substrate which predisposed to this problem is also discussed.

A safe option to perform an apparent difficult redo surgery.

A 50-year-old female operated of Bentall five years before was referred to our hospital for an aneurysm of both right subclavian artery and brachiocephalic trunk associated with a false anastomotic aneurysm on the insertion of the left coronary artery. The procedure was performed under moderate hypothermic circulatory arrest; the false aneurysm was repaired, the brachiocephalic trunk and the subclavian aneurysm were resected, an aorto-carotid and axillary bypass were finally performed. The postoperative course was uneventful. She was discharged to home on postoperative day 7. At six-month follow-up, she was still asymptomatic.

Successful repair of late left ventricular rupture after mitral valve replacement.

Ventricular rupture is a dreaded complication of mitral valve replacement. Herein are reported two cases of late left ventricular rupture following mitral valve replacement at 10 and 48 days, respectively, after the initial surgery. Both ventricular ruptures were successfully repaired, one through an internal and one an external approach.

Valve repair for mitral insufficiency secondary to idiopathic juvenile polyarthritis.

A female patient in whom idiopathic rheumatoid polyarthritis was diagnosed at the age of 8 years required surgery for severe mitral valve insufficiency 16 years later. Intraoperative analysis revealed a fibrotic endocarditis involving mainly the posterior leaflet. Granulomatous vegetations as well as a large thrombus which filled the left ventricular apex and simulated endomyocardial fibrosis were noted. Valve repair was achieved using an anterior leaflet augmentation with a patch of mitral homograft associated with a prosthetic ring annuloplasty. Postoperatively, a severe pericardial effusion required surgical drainage. Eight years later, the patient had no cardiac symptoms and echocardiography confirmed a normally functioning mitral valve.

Surgery for infective endocarditis on mitral annulus calcification.

BACKGROUND AND AIM OF THE STUDY: The study aim was to assess the characteristics of bacterial endocarditis complicating mitral annulus calcification, and to evaluate the surgical results. METHODS: Twenty-four patients (mean age 64 years) underwent surgery for mitral insufficiency secondary to mitral endocarditis with annulus calcification (acute, n = 18; healed, n = 6). Surgery was performed as an emergency in seven cases for septic (n = 3) or cardiogenic (n = 4) shock. An aortic prosthesis had previously been placed in three cases. Comorbidities noted included chronic renal insufficiency/dialysis (n = 8), cancer (n = 6), coronary disease (n = 6), and obstructive cardiomyopathy (n = 1). Nine patients suffered an embolic complication, such as stroke (n = 7, of which three had coma), splenic (n = 3), or lower limb (n = 1). The microorganism present was identified as Staphylococcus aureus (n = 9), Streptococcus/ Enterococcus sp. (n = 12), or others (n = 3). The left atrial diameter was 48 mm, the ejection fraction 63%, and the septal thickness 13 mm. RESULTS: The mean severity score of annulus calcifications (range: 1 to 5) was 1.9. The anatomical lesions included: vegetations (n = 16, of which eight were > 10 mm), leaflet perforation (n = 9), chordae rupture (n = 9), aortic abscess (n = 2) and mitral annular abscess (n = 9), and one fistulation into the pericardium. The valve was repaired in 15 cases, and replaced in nine (seven bioprostheses, two mechanical). Associated procedures included aortic valve replacement (n = 7) and coronary artery bypass (n = 3). The in-hospital mortality was 29% (n = 7); all patients who died were operated on during the acute phase. All patients who presented with septic shock or coma died. After a mean follow up of 46 months, six patients had died (overall survival was 46% at 33 months), and 11 were in NYHA class I/II. One recurrence of endocarditis was treated medically. CONCLUSION: Bacterial endocarditis complicating mitral annulus calcification has a poor prognosis due to the frequent comorbidity and severity of the infectious complications. Patients in septic shock or coma do not appear to be suitable candidates for surgery. Valve repair was possible in two-thirds of the present patients; otherwise, a bioprosthetic replacement was the option of choice.

Surgical treatment of a pulmonary artery aneurysm.

We would like to report a rare case of post-stenotic aneurysm of the pulmonary trunk and its left branch in a 51-year-old man. His cardiac disease, which was first diagnosed at the age of 4, was left untreated because of absence of symptoms and normal physical development. A CT scan, recently performed because of decrease in exercise tolerance and worsening dyspnea, showed a pulmonary artery aneurysm (52 mm x 79 mm). The echocardiography revealed a severe pulmonary commissural stenosis. Through a surgical approach the pulmonary trunk and its left branch were excised and reconstructed using a 30 mm Dacron graft; the right pulmonary branch was then reimplanted on the right side of the tube. The patient's postoperative course was uneventful. He was discharged on the seventh postoperative day and there were no adverse events or complications at 1- and 3-month follow-up.

Mitral annulus calcification: determinants of repair feasibility, early and late surgical outcome.

OBJECTIVE: The aim of this study was to determine the factors influencing the feasibility of valve repair and the surgical outcome in patients with mitral annulus calcification. METHODS: In 124 patients with mitral annulus calcification undergoing surgery, two entities were distinguished: Barlow disease (myxomatous leaflets, n=60) and fibroelastic deficiency (FED) (normal leaflets, n=64). The calcification score was lower (1.9 vs 2.8); the annulus was more dilated (ring 35 vs 32 mm) and ruptured chordae were more frequent (77% vs 37%) in Barlow than in FED (p<0.001). The clinical profile was different: age (60+/-14 vs 73+/-8 years, p<0.001), systemic hypertension (22% vs 70%, p<0.001), chronic renal insufficiency (5% vs 22%, p<0.01), cancer (7% vs 25%, p<0.01). Multifocal atherosclerosis was less frequent in Barlow than in FED: carotid disease (17% vs 54%, p<0.001), aortic atheroma (21% vs 51%, p<0.001) and coronary disease (22% vs 56%, p<0.01). Echocardiography showed two different patterns in Barlow and FED: aortic valve stenosis (1.7% vs 31%), left atrial diameter (54 vs 49 mm), left ventricular end-diastolic diameter (62 vs 54 mm), interventricular septal thickness (11 vs 13 mm), and systolic pulmonary pressure (40 vs 56 mmHg), respectively (p<0.001). Bacterial endocarditis was observed in 24 cases (19%). RESULTS: The surgical technique was a valve repair in 68% and a replacement in 32%. The repair rate depended upon the extent of annulus calcifications (p<0.001) and the type of degenerative disease (95% vs 44% in Barlow and FED p<0.001). In-hospital mortality was 14% (Barlow: 5% vs FED: 23%, p<0.01). The mean follow-up was 50+/-41 months. Overall 5-year year survival was 76% (Barlow: 90% vs FED: 64%, p<0.001) and survival free from cardiac event was 69% at 5 years (Barlow: 87% vs FED: 52%, p<0.001). Five-year survival was higher following repair than replacement (84% vs 64% p<0.001). Chronic renal insufficiency and bacterial endocarditis were two predictors of early and late death (p<0.01). CONCLUSIONS: The aetiopathogeny of the degenerative mitral disease responsible for annulus calcifications corresponded to distinct anatomical, clinical and echographic patterns. It was a main determinant of repair feasibility, early and late surgical outcome.

Low tidal volume mechanical ventilation against no ventilation during cardiopulmonary bypass heart surgery (MECANO): study protocol for a randomized controlled trial.

BACKGROUND: Postoperative pulmonary complications are a leading cause of morbidity and mortality after cardiac surgery. There are no recommendations on mechanical ventilation associated with cardiopulmonary bypass (CPB) during surgery and anesthesiologists perform either no ventilation (noV) at all during CPB or maintain low tidal volume (LTV) ventilation. Indirect evidence points towards better pulmonary outcomes when LTV is performed but no large-scale prospective trial has yet been published in cardiac surgery. DESIGN: The MECANO trial is a single-center, double-blind, randomized, controlled trial comparing two mechanical ventilation strategies, noV and LTV, during cardiac surgery with CPB. In total, 1500 patients are expected to be included, without any restrictions. They will be randomized between noV and LTV on a 1:1 ratio. The noV group will receive no ventilation during CPB. The LTV group will receive 5 breaths/minute with a tidal volume of 3 mL/kg and positive end-expiratory pressure of 5 cmH2O. The primary endpoint will be a composite of all-cause mortality, early respiratory failure defined as a ratio of partial pressure of oxygen/fraction of inspired oxygen <200 mmHg at 1 hour after arrival in the ICU, heavy oxygenation support (defined as a patient requiring either non-invasive ventilation, mechanical ventilation or high-flow oxygen) at 2 days after arrival in the ICU or ventilator-acquired pneumonia defined by the Center of Disease Control. Lung recruitment maneuvers will be performed in the noV and LTV groups at the end of surgery and at arrival in ICU with an insufflation at +30 cmH20 for 5 seconds. Secondary endpoints are those composing the primary endpoint with the addition of pneumothorax, CPB duration, quantity of postoperative bleeding, red blood cell transfusions, revision surgery requirements, length of stay in the ICU and in the hospital and total hospitalization costs. Patients will be followed until hospital discharge. DISCUSSION: The MECANO trial is the first of its kind to compare in a double-blind design, a no-ventilation to a low-tidal volume strategy for mechanical ventilation during cardiac surgery with CPB, with a primary composite outcome including death, respiratory failure and postoperative pneumonia. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03098524 . Registered on 27 February 2017.

Cardiac tamponade in Hashimoto's disease.

Myxedematous pericardial effusions, occurring in about one-third of patients with hypothyroidism, usually do not cause symptoms and regress slowly with hormonal treatment. We report a cardiac tamponade inaugural of a Hashimoto's disease.

Posterior leaflet preservation in mitral valve prolapse: a new approach to mitral repair.

The most common repair technique for P2 prolapse is quadrangular resection of the posterior leaflet associated with a plication of the mitral annulus or with a sliding plasty. Although effective, these techniques do not respect the anatomy of the mitral valve, especially the physiological role of the posterior leaflet. Herein is described another technique which does not include P2 removal, thus preserving the posterior leaflet mobility. This technique represents a new approach to mitral valve repair that respects the motion of the two leaflets, allowing a more physiological opening of the mitral valve.

A new ultrasonic process for a renewal of aortic valve decalcification.

BACKGROUND: Aortic valve decalcification by ultrasound was given up. We evaluated a new ultrasound microhandpiece (Dissectron Penstyle) to rehabilitate this alternative treatment. METHODS: We used under magnifying lenses the ultrasound microhandpiece to decalcify 30 explanted aortic valves. In the cases with embedded calcifications the thin top of the probe could be introduced into the thickness of the leaflet preserving covering layers. RESULTS: The leaflets were totally decalcified and flexible, and surrounding structures were preserved as assessed by histological examination. CONCLUSION: This new approach of ultrasonic aortic valve decalcification gives good in vitro results which allow to consider a clinical evaluation of this procedure.

Mitral valve repair for commissural prolapse: surgical techniques and long term results.

OBJECTIVE: The aim of this study was to describe the pattern of lesions responsible for commissural prolapse, the techniques of valve repair and their long-term results. METHODS: Between 1992 and 2004, 128 mitral valve repairs were consecutively performed for commissural prolapse. There were 86 males and 42 females, the median age was 57.5 years (range 14-84 years). Forty-six percent of patients were in NYHA III or IV, mean ejection fraction was 61+/-9.4%. The diagnosis of commissural prolapse was recognized by preoperative echocardiography in 32% of the patients and was revealed by intraoperative inspection of the valve in the other cases. The site of the prolapse was the posteriomedial commissure (n=94), the anterior commissure (n=30) or both (n=4). The aetiologies were: infective endocarditis (n=56), degenerative (n=46), ischemic (n=25), congenital mitral regurgitation (n=1). The commissural prolapse was associated with another mitral valvular lesion requiring a specific treatment in 61 cases (47.7%). An associated procedure was carried out in 45 patients. RESULTS: The operative treatment of the commissural prolapse included: commissural closure 65 (50.8%), leaflet resection 31 (24.2%), transposition or shortening of chordae 19 (14.8%), reimplantation or shortening of papillary muscles 3 (2.3%), and replacement of the commissural area by a partial mitral homograft 10 (8%). In-hospital mortality included three deaths (2.3%) and four patients (3.1%) were reoperated: three pericardial drainages for hemopericardium and one for mediastinitis. During the follow-up, one patient died (0.8%) from myocardial infarction and eight patients (6.3%) were reoperated including six (4.7%) for recurrent mitral regurgitation. After a median follow-up time of 76.9 months (range from 15 days to 160 months), 116 patients (90.1%) were in NYHA I. Echocardiographs showed no or minimal insufficiency in 112 patients (87.5%) and mild or moderate insufficiency in 10 patients (7.8%). CONCLUSIONS: The diagnosis of commissural prolapse is difficult by preoperative echocardiography. The aetiology of the mitral disease is variable (endocarditis, degenerative or ischemic mitral regurgitation). Using a variety of techniques, commissural prolapse can be repaired with excellent clinical and echographic long-term results.

Atypical forms of isolated partial atrioventricular septal defect increase the risk of initial valve replacement and reoperation.

OBJECTIVE: We consider the short- and long-term outcomes of the repair of the isolated partial atrioventricular (AV) septal defect to determine the role played by the atypical forms on the initial AV valve replacement and on the risk of reoperation. METHODS: Two hundred and eight patients underwent an operation for this malformation between 1974 and 2001. Clinical and echocardiographic examinations were performed on all patients, the AV valve regurgitation was graded from 1 to 4 and a residual interatrial shunt was sought. Median age at the intervention was 5.8 years (3 months to 67 years). RESULTS: Median follow-up time was 7.5 years (range 0-22.6 years). The cumulative 30-day, 5- and 20-year survival rates were 96.5, 95.4 and 94.6%, respectively. AV valve replacement was associated with a high mortality (P<0.001). A reoperation was performed on 12 patients (5.7%) including six patients within less than a 30-day period, especially to repair residual AV valve regurgitation. We performed four AV valve repairs by annuloplasty and six AV valve replacements. Two patients who had initially undergone an AV valve replacement underwent a reoperation for valve thrombosis. The cumulative 30-day, 5- and 20-year rates of freedom from reoperation were 96.5, 93.6 and 83%, respectively. An atypical form was present in 24 patients (11.5%) and was a risk factor for initial AV valve replacement (P<0.001) and for reoperation (P<0.001). A complete AV block occurred in 13 patients (6.2%), all of them within a 30-day period. The AV valve replacement was a high risk factor for a complete AV block (P<0.001). At the end of our study 180 patients (96%) were in NYHA I and 8 in NYHA II. CONCLUSIONS: The morbi-mortality of the isolated partial AV septal defect is primarily perioperative and is linked with the presence of an atypical form of the lesion. This atypical form was the main reason for reoperation for AV valve regurgitation. The AV valve replacement was associated with a high mortality and with the occurrence of complete AV block. Using a standardized technique, the AV septal defect can be repaired with excellent long-term clinical and echographic results.

Totally endoscopic off-pump bilateral internal thoracic artery bypass grafting.

The introduction of robotic assistance has enabled totally endoscopic closed chest procedures, most often by left internal thoracic artery to left (LITA) anterior descending. Endoscopic stabilizers have made off-pump surgery feasible. We report the first case of a totally endoscopic off-pump bilateral ITA grafting in a 58-year-old patient.