Thoracic splenosis: Case report of a symptomatic case.

Thoracic splenosis is the autotransplantation of splenic tissue in the left thoracic cavity as a result of a splenic injury. This rare pathology is usually asymptomatic and may be discovered on incidental imaging, but the diagnosis often requires invasive procedures such as surgery in order to eliminate a neoplasic origin. We report a rare symptomatic case of a 39-year-old man presenting with chest pain and multiple nodules revealed on a computed tomography scan. The patient underwent a surgical exploration and the pathological studies concluded to a thoracic splenosis. Indeed, the previous medical history of the patient revealed a left thoraco-abdominal traumatism during childhood. The aim of this paper is to emphasize that the diagnosis can now be performed using only imaging techniques such as technetium-99 sulfur colloid or labelled heat-denatured red blood cell scintigraphy to avoid unnecessary invasive procedures including thoracotomy.

Hemodynamic Results and Mid-term Follow-up of 850 19 to 23 mm Perimount Magna Ease Valves.

BACKGROUND: Aortic valve replacement (AVR) in small aortic roots remains a surgical dilemma with a higher risk of patient-prosthesis mismatch (PPM). The Perimount Magna Ease aortic valve (PMEAV) represents an attractive device in such cases. We examined the early hemodynamic performance, the mid-term outcomes of the PMEAV, and the impact of PPM on outcome and functional class. METHODS: We performed a retrospective analysis of prospectively collected in-hospital data, and a prospective single-center follow-up of 849 patients who received a 19 to 23 mm PMEAV (2008-2014). Concomitant mitral or tricuspid replacement was the exclusion criterion. Early hemodynamic features were prospectively collected; mid-term follow-up was conducted according to current guidelines. RESULTS: Size of implanted prosthesis was 19 mm in 11.5% of patients, 21 mm in 36.9%, and 23 mm in 51.5%. Operative mortality was 4.5% (3.1% for isolated AVR). The rate of severe and moderate PPMs was significantly higher in the 19 mm group. Follow-up was 99.9% complete (3.7 ± 2 years). Actuarial freedom from structural valve deterioration (SVD) at 5 years was 99.1%. At stratified Kaplan-Meier's analysis, PPM and age <70 years were associated with SVD. PPM was not associated with worse functional status (New York Heart Association class) or mortality at follow-up. CONCLUSION: This series shows satisfactory clinical outcomes of the PMEAV implanted in small aortic annuli at mid-term follow-up. Although PPM may occur in smaller sizes, it has limited clinical impact, and it is not associated with mid-term mortality or worse functional class. Few SVD events are evidenced; nonetheless, limited follow-up duration and its methodology need to be considered.

Left ventricular function after correction of mitral regurgitation: Impact of the clipping approach.

AIMS: Functional mitral regurgitation (FMR) is associated with poor outcome in systolic heart failure (HF) patients. Percutaneous edge-to-edge mitral valve repair (PMVR) in Mitra-Fr study failed to prove any beneficial effect over optimal medical treatment (OMT) but win in COAPT study. Nevertheless, little is known about the effect of PMVR on LV performance and mechanics in HF patients with severe secondary MR. METHOD AND RESULTS: Thirty-seven patients with severe FMR undergoing PMVR were included and compared (according to indices of LV myocardial function and the relationship between LV-size and the degree of regurgitation) to nineteen patients with FMR treated by OMT. Both groups were clinically comparable. At 6-month follow-up, cardiac index such as LV global constructive work (GCW) improved significantly in both groups (1.86 vs 2.13 L/min/m2 , P = .02, 1.73 vs 2.28 L/min/m2 P = .002 and 977 vs 1101 mm Hg.%, P = .003, 967 vs 1110 mm Hg.%, P = .002 for PMVR and OMT groups, respectively) whereas left ventricular (LV) end-systolic volume index, LV ejection fraction, and global longitudinal strain were not different. Receiver operating characteristics in PMVR with LVEF ≤ 35% subgroup analysis demonstrated that global work index (GWI) had the best ability to identify patients with worse evolution (AUC = 0.882; P = .009), confirmed by univariable logistic regression, particularly for patients with GWI < 482 mm Hg.%. CONCLUSION: Echocardiographic characteristics at 6-month follow-up are not different when compare PMVR and OMT for HF patients with severe FMR. A low global work index might be a tool for discouraging the implantation of clips for this indication.

Prognostic impact of blood product transfusion in VA and VV ECMO.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is an accepted and reliable technique to provide temporary circulatory and/or respiratory support. Our objective was to describe the transfusion requirements in ECMO recipients. Secondarily, we addressed the effect of indications for ECMO on transfusion requirements and the baseline factors associated with worse survival. METHODS: We reviewed the prospectively collected data of 509 patients receiving venoarterial (VA) or venovenous (VV) ECMO therapy (2005-2016). Follow-up was prospectively conducted. Data were prospectively entered in the Rennes ECMO database. RESULTS: VA ECMO was employed in 81% of cases; indications were post-cardiotomy myocardial failure in 28% of cases, post-heart transplantation (early graft failure) in 13.2% and cardiogenic shock in 149 (36.4%). VV ECMO was employed in the remaining patients. Average follow-up was 80.25 ± 85.13 days and was 100% complete. In the VA and VV groups, survival at the 30th post-implantation day was 58.3% and 71.1%, respectively, and survival at 6 months was 40.5% and 50.5%, respectively. Platelets and prothrombin time (PT) levels were significantly lower in the VA ECMO group at implantation (p<0.001). VA ECMO patients had a higher rate of thrombotic/haemorrhagic complications (p<0.001) and received both fresh frozen plasma (FFP) (60.5% vs. 31.8% p<0.001) and platelet units (Plt) (61.7% vs. 34.1% p<0.001) more frequently than VV ECMO patients. Post-cardiotomy and post-transplantation patients had significantly higher rates of transfusion of packed red blood cells (pRBC), FFP and Plt than other VA ECMO cases (p<0.001, all). Mortality was equal or greater than 80% among patient subgroups who received more than 19 pRBC, 5 Plt and/or 12 FFP. CONCLUSIONS: An ECMO program is associated with important consumption of blood products. VA ECMO patients have a greater transfusion burden than VV ECMO patients. Mortality is greater in the case of extreme transfusion requirements.

Late clinical and echocardiographic results with the Magna Ease© pericardial aortic bioprosthesis.

OBJECTIVES: The population of candidates to surgical aortic valve replacement (SAVR) is evolving. The Perimount Magna Ease© bioprosthesis has been introduced relatively recently in the practice. We aimed at evaluating its long-term results. METHODS: This article describes a single-centre cohort of 1016 consecutive SAVRs with the Magna Ease© valve (2008-2014), consisting of an all-comers population. We performed a prospective collection of in-hospital data, systematic clinical and echocardiographic follow-up. Valve-related events were as follows: structural valve deterioration (SVD; according to modified definition criteria), nonstructural valve dysfunction, patient-prosthesis mismatch (PPM). RESULTS: Age at SAVR was 73.4 ± 9.5 years; calcified aortic stenosis was the indication to surgery in 59.6%. A total of 974 patients entered the follow-up; 564 were alive at the last follow-up (median duration: 9.8 years) (up to 13.4 years). New York Heart Association class was I or II in 92.1%. Overall survival at 10 years was 56.8 ± 1.8%. Freedom from SVD at 10 was 96.5 ± 0.8% (Kaplan-Meier) and 97.4 ± 0.6% (competing risks) (28 SVD events after 6.9 ± 3.3 years). There were 15 reinterventions for SVD (redo-SAVR and Transcatheter Aortic Valve Implantation (TAVI)); 10-year freedom from reintervention was 97.8 ± 0.6%. Moderate and severe PPM occurred in 26.8% and 5.4%, respectively, without association with late mortality (P = 0.12 for moderate and P = 0.70 for severe PPM). Freedom from valve-related mortality was 97.8 ± 0.5% at 10 years. CONCLUSIONS: In this follow-up of the Magna Ease bioprosthesis for SAVR, data indicate good late outcomes (30-day outcomes are excluded). Continued follow-up is required to further support its use in patients with life expectancy >10-12 years.

Posterior leaflet P2-P1 transposition for mitral repair in a case of infective endocarditis.

Infective endocarditis represents a pathological process associated with a high mortality. The dysfunction of cardiac valves and its consequent hemodynamic deterioration often requires urgent surgery. Tissue preservation and valve repair without a substitute material may be extremely difficult. Herein, the details are reported of a safe technique used to repair a mitral valve presenting with P1 destruction caused by pneumococcal endocarditis vegetation, associated with severe mitral regurgitation. A safe repair was achieved by performing a P2 to P1 transposition, after a subvalvular apparatus analysis, followed by annular plication and ring annuloplasty. The postoperative course was uneventful, and echocardiography at discharge showed excellent mitral valve competence. Sufficient evidence was provided to demonstrate that, in these cases, it is better to repair than to replace. Hence, the present technique should be considered, whenever possible, for mitral valve surgical repair in order to avoid substitute interposition in cases of infective endocarditis.

Logistic EuroSCORE I risk analysis in aortic valve reoperations after bioprosthetic replacement.

BACKGROUND AND AIM OF THE STUDY: The aim was to evaluate the early and long-term results of redo-aortic valve replacement (AVR) for dysfunctioning bioprostheses, according to the type of bioprosthesis failure. The performance of the EuroSCORE in predicting operative mortality was addressed. METHODS: A retrospective analysis was performed of 164 patients who had undergone redo-AVR at the authors' institution. All data were collected prospectively. The type of bioprosthesis failure was categorized as either structural valve dysfunction (SVD), non-structural vale dysfunction (NSVD), or infective endocarditis (IE). The logistic EuroSCORE I was obtained, and a formal analysis of its predictive performance was conducted. RESULTS: The mean logistic EuroSCORE was 26.3 +/- 20.6%, while the observed operative mortality was 10.6%. The EuroSCORE overestimated mortality in all subgroups of indication; operative mortality was higher among the NSVD (14.7%) and IE (13.9%) groups, and lower among SVD patients (8.5%). The performance of the EuroSCORE in predicting mortality was better in SVD patients, and worse in NSVD patients (areas under the ROC curve of 0.857 and 0.751, respectively). Only patient-related factors independently predicted the operative mortality (logistic regression). The SVD patients displayed a significantly better long-term survival compared to NSVD and IE patients. Patient-related factors were seen to be the determinants of long-term survival. CONCLUSION: Redo-AVR can be performed with good early and long-term results, despite a high predicted risk. The logistic EuroSCORE I globally overestimates the risk, and its performance varies considerably according to the indication for redo-AVR. Therefore, it should not be used to determine the application of valve-in-valve procedures. The type of indication for redo-AVR (SVD, NSVD, IE) defines three different profiles of patients having distinctive early and long-term behaviors.

Early diffuse coronary artery spasm after heart valve surgery in the carcinoid syndrome.

BACKGROUND: Coronary spasm has been described in the context of carcinoid heart disease, but few information are available over perioperative coronary spasm. METHODS: We describe the case of a patient developing severe spasm of the entire coronary tree immediately after tricuspid valve surgery for carcinoid heart disease, leading to severe myocardial failure. RESULTS: The spasm was diagnosed by coronary angiography and resolved by intracoronary injection of trinitrine. We present the angiographic features of simultaneous spasm of all coronary arteries and of its evolution. CONCLUSION: The present case illustrates the likelihood of perioperative spasm of the entire coronary tree in carcinoid heart disease, and the usefulness of coronary angiography for both diagnosis and treatment.

Durability of Mitral Valve Replacement With a Third-generation Bioprosthesis.

BACKGROUND: Our aim was to evaluate the durability of a third-generation porcine bioprosthesis (Epic porcine xenograft; Abbott Cardiovascular Inc, St Paul, MN) in the mitral position, according to patients' age at surgery. METHODS: Four hundred eighty-two mitral valve replacements using the Epic valve at a single center were included (2009-2018). Perioperative and early postoperative data were prospectively collected. A systematic follow-up was performed (99% complete, 1609.5 patient-years; average, 3.8 ± 2.5). Standardized definitions of valve-related events were adopted. Mean patient age at mitral valve replacement was 68.1 ± 10.4 years. RESULTS: Operative mortality was 9.3%. There were 5 early valve-related reoperations, mainly due to recurrent infectious endocarditis. Global survival at 8.8 years was 69.5% ± 5%. Nine structural valve deterioration (SVD) events occurred during follow-up (3 receiving reoperations, 4 transcatheter mitral valve replacement valve-in-valve, and 2 medical treatment only). The freedom from SVD at 5 and 10 years was 97.4% ± 1.2% and 89.6% ± 4.4% (actuarial) and 97.8% ± 1% and 91.9% ± 3.3%, respectively (competing risks). After stratification into subgroups by age at surgery (≤59 years, 50.8%; 60-69, 32.8%; ≥70, 16.4%) there was no significant intergroup difference in freedom from SVD (log-rank P = .24). The overall freedom from any reintervention for SVD at 10 years was 90.5% ± 4.4% (actuarial) and 92.7% ± 3.3% (competing risks), with no intergroup difference (log-rank P = .14). The freedom from any valve-related complication at 8.4 years was 83.2% ± 4.5% (actuarial). CONCLUSIONS: The Epic bioprosthesis shows good durability at 5 to 10 years in the mitral position.

Delayed hospitalisation for heart failure after transcatheter repair or medical treatment for secondary mitral regurgitation: a landmark analysis of the MITRA-FR trial.

BACKGROUND: In the MITRA-FR trial, transcatheter mitral valve repair (TMVR) was not associated with a 2-year clinical benefit in patients with secondary mitral regurgitation (SMR). AIMS: This landmark analysis aimed at investigating a potential reduction of the hospitalisation rate for heart failure (HF) between 12 and 24 months after inclusion in the MITRA-FR trial in patients randomised to the intervention group (TMVR with the MitraClip device), as compared with patients randomised to the control group (guideline-directed medical therapy [GDMT]). METHODS: The MITRA-FR trial randomised 307 patients with SMR for TMVR on top of GDMT (TMVR group; n=152) or for GDMT alone (control group; n=155). We conducted a 12-month landmark analysis in surviving patients who were not hospitalised for HF within the first 12 months of follow-up. The primary endpoint was the 1-year cumulative number of HF hospitalisations. RESULTS: A total of 140 patients (TMVR group: 67; GDMT group: 73) were selected for this landmark analysis with similar characteristics at inclusion in the trial. The primary endpoint was 28 events per 100 patient-years in the TMVR group, as compared with 60 events per 100 patient-years in the GDMT group (hazard ratio [HR] 0.46, 95% confidence interval [CI]: 0.20-1.02; p=0.057). CONCLUSIONS: In this landmark analysis of the MITRA-FR trial, the cumulative rate of HF hospitalisation between 12 and 24 months among patients treated with TMVR on top of GDMT was approximately half as many as those of patients treated with GDMT alone, a difference which did not reach statistical significance in the setting of a low number of events.

Transcatheter edge-to-edge repair following surgical valve repair with ring implantation: Results from the multicentre "Clip-in-Ring" registry.

BACKGROUND: Management of mitral regurgitation recurrence after failed surgical valve repair with ring implantation is controversial. AIM: To describe the French experience regarding midterm safety and efficacy of transcatheter edge-to-edge mitral valve repair (TEER) in patients with failed surgical valve repair with ring implantation. METHODS: The "Clip-in-Ring" registry is a multicentre registry conducted in 11 centres in France, approved by local institutional review boards, of consecutive TEER following surgical valve repair with ring implantation. Outcomes were Mitral Valve Academic Research Consortium (MVARC) technical success, modified 30-day device and procedural success (where 10mmHg is considered as a cut-off for significant mitral stenosis) and MVARC complications. RESULTS: Twenty-three patients were studied: mean age, 69±10years; male sex, 74%; EuroSCORE II, 16±17; left ventricular ejection fraction, 53±12%; mitral regurgitation grade 3+/4+, 17%/78%; New York Heart Association class III/IV, 47%/22%; median surgery to TEER delay, 23 (6-94) months. Technical success was 100%. At discharge, residual mitral regurgitation grade was≤2+ in 87% and median transmitral gradient was 4 (3-5) mmHg. Thirty-day modified MVARC device and procedural success was 82%: four patients (17%) had residual mitral regurgitation grade>2+, including two patients who needed complementary surgery. No patient had a 30-day transmitral gradient>7mmHg. No patient died or had a stroke or any life-threatening complications. One patient presented a vascular access complication requiring transfusion. No other MVARC-2 adverse event was reported. CONCLUSIONS: TEER in patients with failed mitral ring is feasible and safe. Further studies should delineate its exact role in the therapeutic armamentarium for this medical issue.

Improved diagnosis of post-operative myocardial infarction by contrast echocardiography after coronary artery bypass graft surgery.

OBJECTIVE: Contrast echocardiography is a more accurate means of assessment of left ventricular (LV) regional motion compared with non-enhanced echocardiography. Despite new tests, the diagnosis of post-operative myocardial infarction (MI) remains difficult. The aim of this study was to determine whether contrast echocardiography can facilitate this diagnosis. METHODS: We performed standard and contrast echocardiography in 79 consecutive patients before and up to 10 days after they underwent isolated coronary artery bypass graft (CABG) surgery. RESULTS: The post-operative intra- and interobserver reproducibility of echocardiographic measurements of the LV ejection fraction and wall motion score was significantly higher with than without contrast enhancement. The proportion of non-visualized LV myocardial segments was significantly greater with non-enhanced (6.6%) than with contrast (0.3%) echocardiography (P< 0.0001). The mean peak serum cardiac troponin (cTnI) concentration was significantly higher in the group of patients with new wall motion abnormalities detected with contrast-enhanced echocardiography. A correlation was found (r = -0.43, P< 0.01) between peak cTnI and changes in wall motion score only when a contrast agent was used. CONCLUSION: Contrast echocardiography facilitated the detection of new LV wall motion abnormalities after CABG. This observation, added to other markers, might facilitate the diagnosis of post-operative MI.

Early and long-term results of hypothermic circulatory arrest in aortic surgery: a 20-year single-centre experience.

AIMS: The aim of this study was to document the postoperative outcomes of patients who underwent hypothermic circulatory arrest (HCA), the evolution of HCA management over time and to identify the risks factor for early mortality and postoperative stroke. METHODS: Four hundred and twenty-four patients who underwent aortic surgery with HCA at our institution between January 1995 and June 2016 were consecutively included. RESULTS: The main indications were degenerative aneurysm (254; 59.9%) and acute type A aortic dissection (146; 34.4%). Interventions were performed under deep (18.4 ±â€Š0.9°C; n = 350; 82.5%) or moderate (23.9 ±â€Š1.9°C; n = 74; 17.5%) hypothermia. Antegrade cerebral perfusion (ACP) was employed in 86 (20.3%) cases. The use of moderate hypothermia significantly increased from 2011, to become the preferred strategy in 2016. The in-hospital mortality was 12.5% and the postoperative stroke rate was 7.1%. Kaplan--Meier 5-year survival was 65.7%. Nonelective timing [odds ratio (OR) 4.05; P < 0.001], stroke (OR 3.77' P = 0.032), renal failure (OR 2.49; P = 0.023), redo surgery (2.42; P = 0.049) and CPB time (OR 1.05; P = 0.03) were independent risk factors for in-hospital mortality in multivariate analysis. Femoral cannulation was the only independent risk factor for stroke (OR 3.97; P = 0.002). The level of hypothermia and the use of ACP were not associated with either in-hospital mortality or postoperative stroke. CONCLUSION: HCA might be widely considered to achieve a radical treatment of the aortic disease, provided that hypothermia is maintained below the 24°C safety threshold and ACP is used for HCA exceeding 30 min, to ensure optimal brain, spinal cord and visceral organs protection.

Adult cardiac surgery during COVID-19 lockdown: Impact on activity and outcomes in a high-volume centre.

BACKGROUND: The coronavirus disease 2019 (COVID-19) outbreak had a direct impact on adult cardiac surgery activity, which systematically necessitates a postoperative stay in intensive care. AIM: To study the effect of the COVID-19 lockdown on cardiac surgery activity and outcomes, by making a comparison with the corresponding period in 2019. METHODS: This prospective observational cohort study compared adult cardiac surgery activity in our high-volume referral university hospital from 9 March to 10 May 2020 versus 9 March to 10 May 2019. Data were collected in our local certified database and a national database sponsored by the French society of thoracic and cardiovascular surgery. The primary study endpoints were operative mortality and postoperative complications. RESULTS: With 105 interventions in 2020, our activity dropped by 57% compared with the same period in 2019. Patients were at higher risk, with a significantly higher EuroSCORE II score (3.8±4.5% vs. 2.0±1.8%; P<0.001) and higher rates of active endocarditis (7.6% vs. 2.9%; P=0.047) and recent myocardial infarction (9.5% vs. 0%; P<0.001). The weight and priority of the interventions were significantly different in 2020 (P=0.019 and P<0.001, respectively). The rate of acute aortic syndromes was also significantly higher in 2020 (P<0.001). Operative mortality was higher during the lockdown period (5.7% vs. 1.7%; P=0.038). The postoperative course was more complicated in 2020, with more postoperative bleeding (P=0.003), mechanical circulatory support (P=0.032) and prolonged mechanical ventilation (P=0.005). Only two patients (1.8%) developed a positive status for severe acute respiratory syndrome coronavirus 2 after discharge. CONCLUSIONS: Adult cardiac surgery was heavily affected by the COVID-19 lockdown. A further modulation plan is necessary to improve outcomes and reduce postponed operations to decrease operative mortality and morbidity.

Predictors of post-operative cardiovascular events, focused on atrial fibrillation, after valve surgery for primary mitral regurgitation.

Aims: Primary mitral regurgitation (PMR) can be considered as a heterogeneous clinical disease. The optimal timing of valve surgery for severe PMR remains unknown. To determine whether unbiased clustering analysis using dense phenotypic data (phenomapping) could identify phenotypically distinct PMR categories of patients. Methods and results: One hundred and twenty-two patients who underwent surgery were analysed, excluding patients with pre-operative permanent atrial fibrillation (AF), were prospectively included before surgery. They were given an extensive echocardiographic evaluation before surgery, and clinical data were collected. These phenotypic variables were grouped in clusters using hierarchical clustering analysis. Then, different groups were created using a dedicated phenomapping algorithm. Post-operative outcomes were compared between the groups. The primary endpoint was post-operative cardiovascular events (PCE), defined as a composite of: deaths, AF, stroke, and rehospitalization. The secondary endpoint was post-operative AF. Data from three phenogroups with different characteristics and prognoses were identified. Phenogroup-1 (67 patients) was the reference group. Phenogroup-2 (33 patients) included intermediate-risk male and smoker patients with heart remodelling. Phenogroup-3 (22 patients) included older female patients with comorbidities (chronic renal failure, paroxysmal AF) and diastolic dysfunction. They had a higher risk of developing both PCE [(hazard ratio) HR = 3.57(1.72-7.44), P < 0.001] and post-operative AF [HR = 4.75(2.03-11.10), P < 0.001]. Pre-operative paroxysmal AF was identified as an independent risk factor for PCE. Conclusion: Classification of PMR can be improved using statistical learning algorithms to define therapeutically homogeneous patient subclasses. High-risk patients can be identified, and these patients should be carefully monitored and may even be treated earlier.

Right ventricular exercise contractile reserve and outcomes after early surgery for primary mitral regurgitation.

OBJECTIVE: To assess if the lack of development of right ventricular (RV) contractile reserve during exercise echocardiography (ex-echo) might be a predictor of postoperative major adverse cardiovascular events (MACEs) in patients with primary mitral regurgitation (pMR) undergoing early surgery. METHODS: Comprehensive resting and ex-echo were performed in 142 asymptomatic patients (58±21 years, 68% men, New York Heart Association functional class ≤2) with isolated severe pMR and preserved left ventricular (LV) function (LV ejection >60%, LV end-systolic diameter <45 mm) undergoing mitral valve replacement (n=20) or repair. Postoperative MACEs were defined as occurrence of atrial fibrillation, stroke, cardiac-related hospitalisation or death. RV function was evaluated at rest in every patient during ex-echo by measuring their tricuspid annular plane systolic excursion (TAPSE) value. RESULTS: After median follow-up of 30 months (IQR 16-60 months), MACEs occurred in 48 (34%) patients. Using Bayesian model averaging, among all the characteristics including the type of surgery, exercise TAPSE (ex-TAPSE) emerged as the most likely predictor of prognosis (HR 0.91, 95% CI 0.86 to 0.96). Other probable predictors were exercise fractional area change (HR 0.02, 95% CI 0.00 to 0.80), male gender (HR 0.40, 95% CI 0.21 to 0.75) and RV basal diameter (HR 1.06, 95% CI 0.98 to 1.14). In the receiver operating characteristic curve analysis, an ex-TAPSE value of <26 mm (sensitivity 73% (95% CI 61 to 84) and specificity of 86% (95% CI 77% to 93%)) defined RV dysfunction. Event-free survival at 5 years was significantly lower in the patient group that exhibited no development of RV contractile reserve during exercise: 43.9% (95% CI 31.3 to 61.4) vs 75.8% (95% CI 64.8 to 88.7). CONCLUSION: Lack of development of exercise-induced RV contractile reserve is a prognostic predictor in patients with severe pMR undergoing early mitral valve surgery.

Conventional aortic valve replacement in 2005 elderly patients: a 32-year experience.

OBJECTIVES: Considering the good immediate results reported for transcatheter aortic valve implantation in high-risk patients, the role of conventional aortic valve replacement (AVR) is being questioned, especially in elderly patients. The aim of this study was to evaluate our long-term results of conventional AVR in octogenarians. METHODS: A total of 2005 patients aged ≥80 years underwent AVR for aortic stenosis in our institution between 1978 and 2011. Of these, 1009 (50%) patients had an associated extracardiac comorbidity and 650 (32%) patients had coronary lesions. Valve replacement was the sole procedure in 1515 (76%) patients, and 396 (19%) patients had concomitant coronary artery bypass grafting. Data were collected at the time of surgery in our database, and regularly updated by mailed questionnaires and telephone contact. RESULTS: Early mortality of isolated AVR was 5.5% for the last 10 years of the series. Significant risk factors were chronic obstructive pulmonary disease, chronic renal failure, advanced cardiac disease [left or right ventricular failure, New York Heart Association (NYHA) Class IV and atrial fibrillation] and coronary disease. Long-term follow-up was 99.5% complete (9 patients lost to follow-up), totalling 8849 patient-years. Nine hundred and one patients died at late follow-up with a median survival of 7.1 years, with 7 patients becoming centenarian. Apart from older age, main late causes of death were cardiovascular (20.5%), neurological deficit (10.2%) and cancer (10.2%). Actuarial survival was 83%, 62.5% and 25% at 2, 5 and 10 years, respectively. This survival compares favourably with that of a French-matched population. Above all, 90% of late survivors reported functional improvement. Univariable and multivariable analysis identified risk factors of late death as male gender, associated comorbidity, renal failure, advanced cardiac disease, atrial fibrillation and impaired ventricular function. Coronary lesions, associated cardiac surgery and small diameter prostheses (19 or 21 mm) did not impair long-term survival. CONCLUSIONS: AVR is effective for all age groups to treat aortic stenosis. Elderly people should not be denied surgery only because of their old age as conventional AVR provides an excellent quality of life and restores life expectancy. Percutaneous valve implantation is to be considered, in cases of non-operable or high-risk patients. However, to date, open-heart surgery remains the treatment of choice for aortic stenosis for the majority of patients.

Collateral blood flow between left coronary artery bypass grafts and chronically occluded right coronary circulation in patients with triple vessel disease. Observations during complete revascularisation of beating hearts.

OBJECTIVE: Preoperative measurements of collateral blood flow in patients with triple vessel disease and chronic occlusions of the right coronary artery do not, currently, ascertain the need to revascularise an occluded right coronary artery. We performed direct measurements of flow across left coronary bypass grafts to determine their contributions to collateral blood flow. METHODS: Collateral blood flow was scored preoperatively according to Rentrop in 13 patients with triple vessel disease and chronic occlusions of the right coronary artery who underwent complete, off-pump, surgical revascularisation. The transit-time flow through the left coronary grafts was measured before and after unclamping of the right coronary artery bypass graft. RESULTS: Unclamping of the right coronary artery bypass graft was associated with a 5.9+/-6.9ml/min (mean+/-SD) decrease in flow across the left circumflex territory (P=0.009), which was proportional to the preoperative Rentrop score (P=0.007). No significant change was observed in flow across the graft to the left anterior descending artery. CONCLUSIONS: Grafts to the left circumflex system are the only grafts that supply a significant, albeit modest amount of collateral blood flow to chronically occluded right coronary artery. These observations confirm that (1) most collateral flow after revascularisation is supplied by the native network, and (2) revascularisation of an occluded right coronary artery is fully justified.