Fifteen-year experience with the Tirone David procedure in bicuspid aortic valve: A safe option.

BACKGROUND: We evaluated short and midterm outcomes with use of aortic valve-sparing root replacement to treat bicuspid aortic valves (BAVs). METHODS: From December 2007 to January 2022, all patients with BAVs who underwent aortic root replacement using Tirone's procedure were included. This study based on department database information for retrospective and follow-up data. RESULTS: Among 51 adults undergoing aortic root replacement using Tirone's procedure, the mean age was 47.4 ± 12.5 years, and most were men (92.2%). Three presented with a dysmorphic syndrome and one had Marfan's syndrome. All patients were alive at 30 days, and as of January 2022, 45 were alive, two were lost to follow-up, and there were four noncardiac deaths. Two patients had infectious endocarditis and needed a Bentall's procedure. One patient had a double biologic valve replacement in the context of severe mitral insufficiency with moderate aortic stenosis at 4.5 years postprocedure. Echocardiographic follow-up showed a left ventricular ejection fraction of 63 ± 7% (n = 36), Vmax 2 ± 0.6 m/s (n = 17), and a mean gradient of 9.4 ± 5.4 mmHg (n = 27). No patients had grade 3 or 4 aortic regurgitation, one patient had grade 2, and four had grade 1. CONCLUSION: Tirone's procedure is an option for BAV surgery, with good safety and outcomes, especially in younger patients.

Eligibility for minithoracotomy aortic valve replacement: from Van Praet classification to complex scanner measurements.

Van Praet proposed a classification to predict the ease of minithoracotomy aortic valve replacement (MT-AVR) based on the position of the aorta in the thorax. We have evaluated the relevance of complex computed tomography (CT) scan measurements to predict the ease of performing a MT-AVR. The first 57 patients who underwent MT-AVR from February 2018 to June 2020 were selected prior to surgery using Van Praet's IA and IB classes. We made additional measurements on aorta position related to the chest and the incision on the preoperative CT scan. The main objective was to correlate complex CT measurements with different operating durations. Van Praet criteria were significantly related to the distance from the center of the aorta to the midline (p value < 0.001), the distance from the center of the aortic ring to the midline (p value = 0.013) and aorto-sternal angle (p < 0.001). We did not find a correlation between CT criteria and the different surgical steps durations in patients belonging to Van Praet classes IA and IB. Our cohort of Van Praet class Ia and Ib patients were able to benefit from a MT-AVR without the need for conversion. Complex CT measurements do not provide additional information to predict surgical difficulties. This classification appears to be sufficient to determine a patient's eligibility for MT-AVR, even for a surgeon experienced in sternotomy in his first MT-AVR.

Bilateral sternal infusion of ropivacaine and length of stay in ICU after cardiac surgery with increased respiratory risk: A randomised controlled trial.

BACKGROUND: The continuous bilateral infusion of a local anaesthetic solution around the sternotomy wound (bilateral sternal) is an innovative technique for reducing pain after sternotomy. OBJECTIVE: To assess the effects of the technique on the need for intensive care in cardiac patients at increased risk of respiratory complications. DESIGN: Randomised, observer-blind controlled trial. SETTING: Single centre, French University Hospital. PATIENTS: In total, 120 adults scheduled for open-heart surgery, with one of the following conditions: age more than 75 years, BMI >30 kg m, chronic obstructive pulmonary disease, active smoking habit. INTERVENTION: Either a bilateral sternal infusion of 0.2% ropivacaine (3 ml h through each catheter; 'intervention' group), or standardised care only ('control' group). Analgesia was provided with paracetamol and self-administered intravenous morphine. MAIN OUTCOME MEASURES: The length of time to readiness for discharge from ICU, blindly assessed by a committee of experts. RESULTS: No effect was found between groups for the primary outcome (P = 0.680, intention to treat); the median values were 42.4 and 37.7 h, respectively for the control and intervention groups (P = 0.873). Similar nonsignificant trends were noted for other postoperative delays. Significant effects favouring the intervention were noted for dynamic pain, patient satisfaction, occurrence of nausea and vomiting, occurrence of delirium or mental confusion and occurrence of pulmonary complications. In 12 patients, although no symptoms actually occurred, the total ropivacaine plasma level exceeded the lowest value for which neurological symptoms have been observed in healthy volunteers. CONCLUSION: Because of a small size effect, and despite significant analgesic effects, this strategy failed to reduce the time spent in ICU. TRIAL REGISTRATION: EudraCT (N°: 2012-005225-69); ClinicalTrials.gov (NCT01828788).

New-Onset Left Bundle Branch Block Induced by Transcutaneous Aortic Valve Implantation.

New-onset left bundle branch block (LBBB) is a specific concern of transcutaneous aortic valve implantation (TAVI) given its estimated incidence ranging from 5% to 65%. This high rate of occurrence is dependent on the type of device used (size and shape), implantation methods, and patient co-morbidities. The appearance of an LBBB after TAVI reflects a very proximal lesion of the left bundle branch as it exits the bundle of His. At times transient, its persistence can lead to permanent pacemaker implantation in 15% to 20% of cases, most often for high-degree atrioventricular block. The management of LBBB after TAVI is currently not defined by international societies resulting in individual centers developing their own management strategy. The potential consequences of LBBB are dysrhythmias (atrioventricular block, syncope, and sudden death) and functional (heart failure) complications. Prompt postprocedural recognition and management (permanent pacemaker implantation) of patients prevents the occurrence of potential complications and may constitute the preferred approach in this frail and elderly population despite additional costs and complications of cardiac pacing. Moreover, the expansion of future indications for TAVI necessitates better identification of the predictive factors for the development of LBBB. Indeed, long-term right ventricular pacing may potentially increase the risk of developing heart failure in this population. In conclusion, it is thus imperative to not only develop new aortic prostheses with a less-deleterious impact on the conduction system but also to prescribe appropriate pacing modes in this frail population.

Tracheoplasty With Use of an Intercostal Muscle Flap for Caustic Necrosis.

We report a case of intercostal muscle flap used in tracheobronchial reconstruction for extensive necrosis after burn lesions of the posterior wall. A 32-year-old man attempted suicide by ingestion of caustic material. He underwent emergency total esogastrectomy, tracheostomy, and feeding jejunostomy. Ten days later, endoscopy showed complete destruction of the membranous trachea, extending from the tracheostomy to the carina. Reconstruction was conducted with the patient under venovenous extracorporeal membrane oxygenation by use of a pedicled intercostal muscle flap. The patient was weaned from respiratory support on the 14th postoperative day. Examination of a biopsy specimen from the flap 7 months after tracheoplasty showed ciliated neoepithelium.

Comparison between three types of stented pericardial aortic valves (Trivalve trial): study protocol for a randomized controlled trial.

BACKGROUND: Aortic valve stenosis is one of the most common heart diseases in older patients. Nowadays, surgical aortic valve replacement is the 'gold standard' treatment for this pathology and the most implanted prostheses are biological ones. The three most implanted bovine bioprostheses are the Trifecta valve (St. Jude Medical, Minneapolis, MN, USA), the Mitroflow valve (Sorin Group, Saluggia, Italy), and the Carpentier-Edwards Magna Ease valve (Edwards Lifesciences, Irvine, CA, USA). We propose a randomized trial to objectively assess the hemodynamic performances of these bioprostheses. METHODS AND DESIGN: First, we will measure the aortic annulus diameter using CT-scan, echocardiography and by direct sizing in the operating room after native aortic valve resection. The accuracy of information, in terms of size and spatial dimensions of each bioprosthesis provided by manufacturers, will be checked. Their hemodynamic performances will be assessed postoperatively at the seventh day and the sixth month after surgery. DISCUSSION: This prospective controlled randomized trial aims to verify and compare the hemodynamic performances and the sizing of these three bioprostheses. The data obtained may help surgeons to choose the best suitable bioprosthesis according to each patient's morphological characteristics. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01522352.