[The opportunities of the minimally invasive approach for the cardiovascular and thoracic surgery]. / Apport de l'approche moins invasive en chirurgie cardiovasculaire et thoracique.

There is a continuous growth in the incidence of cardiovascular and thoracic diseases, especially related to the increased life expectancy. Moreover, the quality and efficacy of care for these pathologies are progressing constantly. The evolution of surgery prompts us to develop less aggressive (minimally invasive), although technically more complex, treatment or diagnostic techniques. Pathologies, which until now required heavy surgeries, are managed today in a less invasive way and become therefore accessible to patients even if they are older or in a poor general condition. In this article, we present our experience in the development of the minimal invasive procedures in cardiovascular and thoracic surgery.

Les pathologies cardiovasculaires et thoraciques, au sens large, sont de plus en plus fréquentes, vu l'augmentation de l'espérance de vie, mais elles sont aussi de mieux en mieux prises en charge. En effet, l'évolution de la chirurgie nous incite à développer des techniques de traitement ou de diagnostic moins agressives (mini-invasives) quoique techniquement plus complexes. Des pathologies qui nécessitaient, jusqu'à présent, des chirurgies lourdes se prennent en charge, aujourd'hui, de manière moins invasive et deviennent donc accessibles à des patients en moins bon état général ou de plus en plus âgés. Nous présentons ici notre expérience dans le développement de l'approche mini-invasive en chirurgie cardiovasculaire et thoracique.

[Heart transplantation, indications and results at the University Hospital of Liege]. / La transplantation cardiaque : indications actuelles et résultats de l'expérience liégeoise.

Heart transplantation remains undoubtedly the most effective treatment for end-stage heart failure, whatever its cause. Last decade has witnessed significant improvements in terms of morbidity and mortality following heart transplant. The 5-year survival rate is now beyond 70 %. However, the shortage of potential donors limits its use and requires strict criteria before listing a candidate for heart transplantation. Herein, we present a review of current indications and results of the heart transplantation program at the University hospital of Liège.

La transplantation cardiaque demeure, à ce jour sans conteste, le traitement de choix de l'insuffisance cardiaque terminale, quelle qu'en soit l'origine. La dernière décennie a été marquée par une amélioration significative des résultats de la transplantation cardiaque tant en termes de mortalité que de morbidité. La survie globale à 5 ans dépasse maintenant 70 %. Cependant, la pénurie d'organes limite malheureusement son emploi et impose des critères de sélection rigoureux des potentiels candidats. Une revue des indications actuelles ainsi qu'un aperçu des résultats de la transplantation cardiaque au CHU de Liège sont présentés.

[Giant pulmonary artery aneurysms. Case report and proposal of management algorithm]. / Anévrysmes géants de l'artère pulmonaire : cas clinique et proposition d'un algorithme de diagnostic et de prise en charge.

Pulmonary artery aneurysm is a rare and multiform pathology related to multiple etiologies and therefore different pathophysiological mechanisms. Delineating homogenous sub-groups is a pre-requisite to refine medico-surgical management. The case of a giant PAA without pulmonary hypertension but associated to a dysplastic pulmonary valve is reported. This association could be in some instances the result of a congenital anomaly in the development of both the pulmonary valve and the root creating the conditions for further development of a pulmonary artery aneurysm. Whilst minor forms are usually asymptomatic, they can lead to lethal complications in huge sizes and are frequently associated via pulmonary valve insufficiency to right ventricular dysfunction. This specific association is discussed and a diagnostic algorithm for nosologic classification and management is proposed.

L'anévrysme de l'artère pulmonaire est une pathologie rare, qui répond à de multiples étiologies et autant de physiopathologies différentes. L'identification de sous-groupes constituant des entités cliniques homogènes est un prérequis pour préciser la prise en charge médico-chirurgicale optimale. Nous rapportons un cas d'anévrysme géant de l'artère pulmonaire principale, sans hypertension artérielle pulmonaire, mais associé à une dysplasie/dysfonction de la valve pulmonaire. Cette association pourrait être, dans certains cas, congénitale et liée à une anomalie de la morphogénèse de la valve et de la racine pulmonaire, association qui crée les conditions pour le développement d'un anévrysme. Asymptomatiques dans les formes mineures, les anévrysmes pulmonaires peuvent être causes de symptômes ou de complications gravissimes dans les formes très développées et entraînent souvent, par insuffisance pulmonaire, une dysfonction ventriculaire droite. Nous suggérons une classification claire de cette pathologie mal connue et, sur base de la littérature et de notre expérience personnelle, nous proposons un algorithme de prise en charge médico-chirurgicale.

[Ruptured abdominal aortic aneurysm]. / L'anévrisme rompu de l'aorte abdominale.

Ruptured abdominal aortic aneurysm is a cardiovascular emergency associated with a 30 day mortality as high as 70 %. However, recent progresses in the management of these patients have improved the results. From a surgical point of view, endovascular methods such as balloon occlusion and endovascular repair (EVAR) in patients with suitable anatomy are recommended in order to reduce mortality.

isme rompu de l'aorte abdominale constitue une urgence cardiovasculaire qui s'accompagne d'un taux de mortalité globale pouvant atteindre 70 % à 30 jours. Cependant, les progrès récents dans la prise en charge de ces patients ont permis d'améliorer les résultats. Du point de vue chirurgical, des techniques endovasculaires telles que l'endoclampage et la mise en place d'endoprothèses en cas d'anatomie favorable, sont de plus en plus recommandées afin de diminuer la mortalité.

[Aortic dissection]. / La dissection aortique.

Aortic dissection is a life-threatening condition due to a tear in the intimal layer of the aorta or bleeding within the aortic wall, resulting in the separation of the different layers of the aortic wall. Among the risk factors, age, hypertension, dyslipidemia and genetic disorders of the connective tissue have been identified. A prompt diagnosis and an adequate treatment are important in the management of affected patients. The type of treatment depends on the location and extension of the dissection. Open surgical repair is most commonly used for dissections involving the ascending aorta and the aortic arch, whereas endovascular intervention is indicated for descending aorta dissections that are complicated. In this paper, we will review the epidemiology, and physiopathology of aortic dissection and describe the appropriate management for each type of dissection (open surgery, endovascular or medical treatment).

La dissection aortique est une pathologie grave et potentiellement mortelle. Elle résulte d'une déchirure intimale ou d'un saignement dans la paroi aortique, qui entraîne une séparation au sein des différentes couches de cette dernière. Parmi les facteurs de risque de cette pathologie, citons l'âge, l'hypertension artérielle, la dyslipidémie, et les atteintes génétiques du tissu conjonctif. Un diagnostic précis et une prise en charge adéquate et rapide sont déterminants dans le management des patients. Le type de traitement est conditionné par la localisation et l'extension de la dissection. La chirurgie ouverte est généralement indiquée dans les atteintes de l'aorte ascendante et de l'arche aortique, tandis que l'approche endovasculaire sera privilégiée dans les dissections de l'aorte thoracique descendante compliquées. Dans cet article, nous ferons un rappel succinct de l'épidémiologie et de la physiopathologie des dissections aortiques, puis nous décrirons la prise en charge médicale, chirurgicale ouverte et endovasculaire.

[Isolated spontaneous dissection of the superior mesenteric artery]. / Le cas clinique du mois. Dissection isolée de l'artère mésentérique supérieure.

We report the case of a 57-year old man suffering from acute abdominal cramps. Abdominal computed tomography (CT) scanner revealed an isolated dissection of the superior mesenteric artery. The pain decreased within a few days under conservative treatment and monitoring by angioscans showed a stabilization of the dissection. This clinical case report is accompanied by a literature review on this rare pathology.

Ce cas clinique est celui d'un patient de 57 ans souffrant de douleurs abdominales aiguës. La tomodensitométrie abdominale a permis de mettre en évidence une dissection isolée de l'artère mésentérique supérieure. Les douleurs abdominales ont fortement régressé en quelques jours sous traitement conservateur et les angioscanners de suivi ont montré une stabilisation de la dissection. Ce cas clinique permet une revue de la littérature concernant cette pathologie rare.

[Marfan syndrome in childhood and adolescence]. / Le syndrome de Marfan chez l'enfant et l'adolescent : cas clinique.

The Marfan syndrome is a systemic connective tissue disorder with autosomal dominant inheritance. A mutation of the fibrillin-1 gene, a glycoprotein which is the main constituent of the extracellular matrix, is the cause of the disease. The cardinal features involve the skeletal, ocular and cardiovascular systems. The expression of the Marfan syndrome varies from the severe neonatal presentation to the classical manifestations of the child and young adult, but also comprises isolated features. In children, phenotypical manifestations are age dependent. For these reasons, the diagnosis of Marfan syndrome might be lately revealed by its cardiovascular complications. We report the case of 2 siblings: it illustrates the phenotypic variability that might be observed in a same family, the phenotype evolution with age and the diagnosis challenge in childhood.

Le syndrome de Marfan est une maladie systémique du tissu conjonctif qui se transmet de façon autosomale dominante. Elle est due à une mutation du gène codant pour la fibrilline-1, une glycoprotéine, constituant principal des microfibrilles de la matrice extra-cellullaire. La maladie touche principalement le squelette, les yeux et le système cardiovasculaire. Son expression phénotypique est variable avec des formes néonatales sévères, un tableau classique chez l'enfant ou le jeune adulte ou des lésions isolées d'un seul organe. Chez l'enfant, le phénotype évolue avec l'âge. Ainsi, le syndrome de Marfan peut n'être reconnu que tardivement, par exemple à l'occasion de manifestations de ses complications cardiovasculaires. Le cas d'un adolescent et de sa jeune sœur que nous rapportons ici illustre la variabilité phénotypique au sein d'une même famille, l'évolution des manifestations cliniques et la difficulté diagnostique chez l'enfant.

[TRAUMATIC RUPTURE OF THE AORTIC ISTHMUS: MODERN PERSPECTIVES]. / Rupture post-traumatique de l'isthme aortique: perspectives modernes de prise en charge.

Traumatic aortic rupture of the thoracic aorta (usually at the isthmus) is frequently associated with concomitant life-threatening injuries. Historically, the conventional care consisted of surgical repair of the lesion performed as soon as possible. However, in spite of constant technical improvements the morbi-mortality remains high because of these associated lesions. In addition, their management can have priority and delay aortic surgery. The endovascular approach has been shown to be a feasible and efficient technique and currently represents a valuable alternative to open surgery for patients with multiple traumas. We report a patient presenting with a traumatic aortic rupture of the aortic isthmus, which was successfully treated by delayed combined endovascular (thoracic aortic stentgrafting) and open approach (hemiaortic arch debranching).

A novel strategy to translate the biomechanical rupture risk of abdominal aortic aneurysms to their equivalent diameter risk: method and retrospective validation.

OBJECTIVE: To translate the individual abdominal aortic aneurysm (AAA) patient's biomechanical rupture risk profile to risk-equivalent diameters, and to retrospectively test their predictability in ruptured and non-ruptured aneurysms. METHODS: Biomechanical parameters of ruptured and non-ruptured AAAs were retrospectively evaluated in a multicenter study. General patient data and high resolution computer tomography angiography (CTA) images from 203 non-ruptured and 40 ruptured aneurysmal infrarenal aortas. Three-dimensional AAA geometries were semi-automatically derived from CTA images. Finite element (FE) models were used to predict peak wall stress (PWS) and peak wall rupture index (PWRI) according to the individual anatomy, gender, blood pressure, intra-luminal thrombus (ILT) morphology, and relative aneurysm expansion. Average PWS diameter and PWRI diameter responses were evaluated, which allowed for the PWS equivalent and PWRI equivalent diameters for any individual aneurysm to be defined. RESULTS: PWS increased linearly and PWRI exponentially with respect to maximum AAA diameter. A size-adjusted analysis showed that PWS equivalent and PWRI equivalent diameters were increased by 7.5 mm (p = .013) and 14.0 mm (p < .001) in ruptured cases when compared to non-ruptured controls, respectively. In non-ruptured cases the PWRI equivalent diameters were increased by 13.2 mm (p < .001) in females when compared with males. CONCLUSIONS: Biomechanical parameters like PWS and PWRI allow for a highly individualized analysis by integrating factors that influence the risk of AAA rupture like geometry (degree of asymmetry, ILT morphology, etc.) and patient characteristics (gender, family history, blood pressure, etc.). PWRI and the reported annual risk of rupture increase similarly with the diameter. PWRI equivalent diameter expresses the PWRI through the diameter of the average AAA that has the same PWRI, i.e. is at the same biomechanical risk of rupture. Consequently, PWRI equivalent diameter facilitates a straightforward interpretation of biomechanical analysis and connects to diameter-based guidelines for AAA repair indication. PWRI equivalent diameter reflects an additional diagnostic parameter that may provide more accurate clinical data for AAA repair indication.

High prevalence of abdominal aortic aneurysm in patients with three-vessel coronary artery disease.

OBJECTIVES: Currently, the prevalence of abdominal aortic aneurysm (AAA) in patients with coronary artery disease (CAD) and the correlation between CAD severity and AAA prevalence are not clearly known. We conducted a prospective study to determine the prevalence of AAA in patients undergoing coronary angiography and to determine the risk factors and a coronary profile associated with AAA. METHODS: Over an 18-month period, abdominal aortic ultrasound was performed on 1,000 patients undergoing coronary angiography for suspected or known CAD, or prior to valve surgery. Clinical characteristics and coronary profile were collected from the patients. RESULTS: The overall number of previously repaired, already diagnosed, and new cases of AAA in the study population was 42, yielding a prevalence of 4.2%. Among the patients with newly detected AAAs, only two had an AAA diameter of >54 mm and were therefore treated surgically. In men aged ≥ 65 years, the prevalence reached 8.6%, while in men with three-vessel CAD it was 14.4%. Multivariate analysis showed that age ≥ 65 years (p = .003), male gender (p = .003), family history of AAA (p = .01), current smoking (p = .002), and three-vessel CAD (p < .001) were significantly associated with a higher prevalence of AAA. CONCLUSION: The prevalence of AAA was high in men aged ≥ 65 years and in those with three-vessel CAD regardless of age. While our findings do not prove the cost-effectiveness of screening for AAA in these high risk patients, they do support the usefulness of a quick ultrasound examination of the abdominal aorta during routine transthoracic echocardiography in such patients.

[Benefits of positron emission tomography in the management and prognosis of abdominal aortic aneurysms]. / Intérêts de la tomographie à éimission de positons dans le suivi et le pronostic des anévrysmes de l'aorte abdominale.

Rupture of abdominal aortic aneurysm (AAA) remains a major cause of death in the elderly. Its prediction is a serious challenge for public health. Despite its regular use to identify patients requiring surgical treatment, the diameter of AAA is not a sufficiently precise and reliable parameter for discriminating aneurysms at high risk of rupture. A better targeting of high risk patients needs understanding in deep the processes and mechanisms directing wall rupture. Inflammation is a significant element in the progression ofAAA and can be visualized using medical imaging techniques such as positron emission tomography (PET) using a glucose derivative (FDG) as radiotracer. Studies conducted in our department have established a relationship between PET positivity and the presence of symptoms such as accelerated growth of the aneurysm or pain, signs generally considered as predictive of rupture. Moreover, activation of leukocytes coupled to cellular and molecular alterations of the aneurysmal wall in the sites of FDG uptake may lead to its instability and incompetence to resist blood pressure and rupture. PET therefore represents a new original exploration method to characterize the severity of AAA progression allowing to assess the need for a surgical treatment much better than does the AAA diameter.

[Endovascular treatment of descending aortic dissection (type B)]. / Traitement endovasculaire des dissections de l'aorte descendante (type B).

Aortic dissection is one of the most serious aortic diseases by its potential for rupture, but also for other complications, such as cerebral or splanchnic ischemia, which may be fatal. If open surgery is the rule for lesions of the ascending aorta (type A), type B (not concerning the ascending aorta) is first a matter of medical treatment except when complications are present. In this case the placement of a stentgraft is a valuable alternative to open surgery. We report a patient presenting with a type B aortic dissection, characterized by rapid expansion and complicated by peri-aortic leakage, who was successfully treated by thoracic aortic stentgraft placement. This was done in a hybrid operating room associating the characteristics of a classical operating room for cardio-vascular surgery with those of an interventional radiology suite.

[Opportunistic screening for abdominal aortic aneurysm during echocardiography in patients with coronary artery disease: Utility or futility?] / Dépistage opportuniste de l'anévrysme de l'aorte abdominale lors de l'échocardiographie chez le patient coronarien : utile ou futile ?

Abdominal aortic aneurysm is a chronic degenerative disease that is usually silent until rupture occurs and this complication is still associated in contemporary era with a high rate of mortality. Screening programmes for abdominal aortic aneurysm have been shown to be effective in reducing global mortality in the screened population but these programmes are poorly implemented in the Western countries. As coronary artery disease and abdominal aorta aneurysmal disease share many risk factors, the cardiologist is centrally positioned in the screening strategy, not only to identify patients with higher risk of developing abdominal aortic aneurysm, but also to perform an opportunistic screening during echocardiography. This paper summarises evidence about the feasibility, indications, modalities, benefits and risks related to the opportunistic screening for abdominal aortic aneurysm during echocardiography with a particular emphasis on the population of patients with coronary artery disease.

High levels of 18F-FDG uptake in aortic aneurysm wall are associated with high wall stress.

BACKGROUND: Functional imaging using positron emission tomography (PET) showed increased metabolic activities in the aneurysm wall prior to rupture, whereas separate studies using finite element analysis techniques found the presence of high wall stresses in aneurysms that subsequently ruptured. This case series aimed to evaluate the association between wall stress and levels of metabolic activities in aneurysms of the descending thoracic and abdominal aorta. METHODS: Five patients with aneurysms in the descending thoracic aorta or abdominal aorta were examined using positron emission tomography-computed tomography (PET-CT). Patient-specific models of the aortic aneurysms were reconstructed from CT scans, and wall tensile stresses at peak blood pressure were calculated using the finite element method. Predicted wall stresses were qualitatively compared with measured levels of 18F-fluoro-2-deoxy-glucose (18F-FDG) uptakes in the aneurysm wall. RESULTS: The distribution of wall stress in the aneurysm wall was highly non-uniform depending on the individual geometry. Predicted high wall stress regions co-localised with areas of positive 18F-FDG uptake in all five patients examined. In the two ruptured cases, the locations of rupture corresponded well with regions of elevated metabolic activity and high wall stress. CONCLUSIONS: These preliminary observations point to a potential link between high wall stress and accelerated metabolism in aortic aneurysm wall and warrant further large population-based studies.

Functional imaging of atherosclerosis to advance vascular biology.

Preliminary events leading to the rupture of atherosclerotic plaques or aneurysmal wall expansion undoubtedly are linked to altered and increased metabolism of cells in the vascular wall. To allow in vivo identification of this local activity, imaging techniques such as positron emission tomography (PET) and contrast ultrasonography may be used. However, the use of complementary multimodal imaging methods, such as computed tomography (CT), magnetic resonance imaging (MRI), single photon emission computed tomography (SPECT), etc., can inform about other processes, including vascular wall calcification, haemosiderin deposits, apoptosis and accumulation of activated platelets in the arterial wall. Such techniques may be used as an adjunct in following the evolution of the disease, as well as having crucial roles as molecular and cellular probes of arterial disease. Therefore, functional imaging techniques may be able to help us take more reliable decisions on the need for medical or surgical treatment of arterial disease.

Abdominal aortic aneurysm.

Abdominal aortic aneurysms cause 1.3% of all deaths among men aged 65-85 years in developed countries. These aneurysms are typically asymptomatic until the catastrophic event of rupture. Repair of large or symptomatic aneurysms by open surgery or endovascular repair is recommended, whereas repair of small abdominal aortic aneurysms does not provide a significant benefit. Abdominal aortic aneurysm is linked to the degradation of the elastic media of the atheromatous aorta. An inflammatory cell infiltrate, neovascularisation, and production and activation of various proteases and cytokines contribute to the development of this disorder, although the underlying mechanisms are unknown. In this Seminar, we aim to provide an updated review of the pathophysiology, current and new diagnostic procedures, assessment, and treatment of abdominal aortic aneurysm to provide family practitioners with a working knowledge of this disorder.

Factors promoting rupture of abdominal aortic aneurysms.

The risk for rupture of an abdominal aortic aneurysm is widely believed to be related to its maximum diameter. Rupture occurs at the site of maximum wall stress, when it exceeds the tensile strength of the aortic wall. Basic research confirmed that peak wall stress and aortic wall biodegradation contribute to the mechanism of aneurysm rupture. In order to highlight the role of loss in wall strength and increase in focal peak stress, the authors reviewed recent literature. The clinical relevance of these recent insights in the etiopathogenesis of aneurysm rupture is analysed.

[Clinical case of the month. Twiddler's syndrome: report of a case]. / Le cas clinique du mois. Le Twiddler's syndrome.

The Twiddler's syndrome is characterized by the migration of pacemaker's leads due to rotation of the pulse generator. In our case, ventricular leads coiled in the upper side of the right atrium with stimulation of pectoralis major muscle during left decubitus lateralis position.

Analysis of coding sequences for tissue inhibitor of metalloproteinases 1 (TIMP1) and 2 (TIMP2) in patients with aneurysms.

Aneurysms are characterized by dilation, i.e. expansion and thinning of all the arterial wall layers, which is accompanied by remodeling of the connective tissue. Genes involved in the regulation of tissue remodeling are therefore candidate genes. We analyzed TIMP1 and TIMP2 coding sequences in 12 individuals with abdominal aortic aneurysms (AAA), one individual with AAA and intracranial aneurysms (IA), four individuals with IA and two clinically unaffected individuals. We identified two nucleotide variants in both the TIMP1 and the TIMP2 coding sequences. All differences occurred in the third base positions of codons and were neutral polymorphisms. A significant difference was observed in the frequency of TIMP2 nt 573 polymorphism between 168 alleles from AAA patients and 102 control alleles.

[Mechanism of the growth and rupture of abdominal aortic aneurysm]. / Mécanisme de croissance et de rupture des anévrysmes de l'aorte abdominale.

The relationship between atherosclerosis and abdominal aortic aneurysm development is well known. Atherosclerosis cannot explain the whole mechanism. Genetic characters of mechanisms leading to abdominal aortic development is obvious from this study and others. Our study evidences an increased metalloproteases activity in aortic wall proportionally to the size of the abdominal aortic aneurysm. A decrease of aortic wall elastin is evidenced proportionally to the AAA size. Extractable collagen is significantly increased in the aortic wall of patients operated on for aortic rupture.