Optimal Timing of Coronary Artery Bypass Grafting in Haemodynamically Stable Patients after Myocardial Infarction.

During the acute phase of myocardial infarction, the culprit artery must be revascularized quickly with angioplasty. Surgery then completes the procedure in a second stage. If emergency surgery is performed, the resulting death rate is high; 15-20% of patients are operated on within the first 48 h after the myocardial infarction. The timing of surgical revascularization and the patient's preoperative state influence the mortality rate. We aimed to evaluate the impact of surgery delay on morbimortality. Between 2007 and 2017, a retrospective monocentric study was conducted including 477 haemodynamically stable patients after myocardial infarction who underwent an urgent coronary bypass. Three groups were described, depending on the timing of the surgery: during the first 4 days (Group 1, n = 111, 23%), 5 to 10 days (Group 2, n = 242, 51%) and after 11 days (Group 3, n = 124, 26%). The overall thirty-day mortality was 7.1% (n = 34). The death rate was significantly higher in Group 1 (n = 16; 14% vs. n = 10; 4.0% vs. n = 8; 6%, p < 0.01). The mortality risk factors identified were age (OR: 1.08; CI 95%: 1.04-1.12; p < 0.001), peripheral arteriopathy (OR: 3.31; CI 95%: 1.16-9.43; p = 0.024), preoperative renal failure (OR: 6.39; CI 95%: 2.49-15.6; p < 0.001) and preoperative ischemic recurrence (OR: 3.47; CI 95%: 1.59-7.48; p < 0.01). Ninety-two patients presented with preoperative ischemic recurrence (19%), with no difference between the groups. The optimal timing for the surgical revascularization of MI seems to be after Day 4 in stable patients. However, timing is not the only factor influencing the death rate: the patient's health condition and disease severity must be considered in the individual management strategy.

Concomitant Cardiac Surgery and Radiofrequency Ablation of Atrial Fibrillation: A Retrospective Single Center Study.

OBJECTIVES: Concomitant cardiac surgery and radiofrequency atrial fibrillation (AF) ablation is an established procedure recommended in guidelines. However, the results have not been as good as expected. The authors therefore searched for predictive factors of success of the ablation procedure. DESIGN: The authors carried out a retrospective cohort study. SETTING: All the included patients had cardiac surgery in the Dijon University Hospital. PARTICIPANTS: One hundred sixty-three patients with AF underwent a concomitant radiofrequency ablation between January 2009 and December 2016. INTERVENTIONS: A radiofrequency device was used to isolate the pulmonary veins creating a "Box lesion." MEASUREMENTS AND MAIN RESULTS: The primary endpoint of the study was freedom from AF at 12 months with follow-up assessed by an electrocardiogram or a 24-hour recording electrocardiogram Holter. The patient's mean age was 71 ± 9 years with a sex ratio of 1.4. Sixty-six percent of patients had paroxysmal AF and 34% nonparoxysmal AF, which includes persistent and long-standing persistent AF. Sixty-one percent of patients had an AF history for more than 1 year. The mean left atrial diameter was 47 ± 10 mm. No major ablation complications related to the procedure occurred. Overall freedom from AF rate after 1-year follow-up was 60% (n = 98). Six patients (4%) received an additional catheter-based ablation, and 10 patients (6%) had an electrical cardioversion during the follow-up period. The authors identified preoperative paroxysmal AF (odds ratio [OR] 2.54 [1.27-5.14] p = 0.008) and recent history of AF, less than 1 year, (OR 1.99 [1-4.06] p = 0.05) as statistically significant predictors for sinus rhythm maintenance at the 12-month follow-up. At the 12-month follow-up, 64% of patients who had concomitant epicardial treatment were in sinus rhythm and 57% of patients were in sinus rhythm after endocardial treatment. There were no significant differences in rhythm outcome between epicardial and endocardial radiofrequency approach, or between surgical procedures (mitral valve replacement versus coronary artery bypass grafting). The authors could not identify in a univariate analysis a significant left atrium size cutoff upon which ablation was less likely to be successful at 12 months follow-up. CONCLUSIONS: Concomitant cardiac surgery and radiofrequency AF ablation provided freedom from AF for 60% of patients after 1-year follow-up. The authors have shown that paroxysmal AF and recent AF are predictive factors of success. Nevertheless, thorough postoperative care is necessary to improve long-term results, including the use of additional catheter ablation or cardioversion.

Comparison of automated fastener device Cor-Knot versus manually-tied knot in minimally-invasive isolated aortic valve replacement surgery.

BACKGROUND: The aim of our prospective study was to evaluate the efficacy and the safety of the Cor-Knot device in isolated aortic valve replacement by right anterior minithoracotomy. METHODS: A single-center, prospective study was conducted between September 2009 and June 2018. Four hundred and forty patients were operated on for aortic valve replacement by right anterior minithoracotomy. Of these patients, 221 underwent isolated AVR surgery with stented prosthesis. Sutures were secured using the Cor-Knot titanium fastener in 63 patients (28.5%) and knots were hand-tied in 158 (71.5%). Statistical analyses were done using a propensity score with 1:1 matching for the automatically tied (AT) and manually tied (MT) patients. RESULTS: The aortic cross-clamping and cardiopulmonary bypass times were significantly decreased in the AT group (74±13.8 minutes vs. 90.4±23.7 minutes, P<0.0001, and 100.8±20.6 minutes vs. 117.6±33.1 minutes, P<0.0001), compared with the MT group. Clinical outcomes were similar in the two groups, whether in the analysis of non-matched or matched groups. There was no difference in 30 day-mortality (1.2% vs. 0%, P=0.37), and the stroke and transient ischemic attack rates were comparable (2.5% vs. 1.6%; P=0.67). There was no significant increase in pacemaker implantation in the AT group (1.3% vs. 0%, P=0.36), and the rate of aortic regurgitation ≥ 2 was lower (3.9% vs. 0%; P=0.11) but not statistically significant. CONCLUSIONS: The automated Cor-Knot fastener is an easy-to-use, time-saving device which does not increase perioperative morbidity and mortality in patients undergoing aortic valve replacement by right anterior minithoracotomy.

Usefulness and limitations of contractile reserve evaluation in patients with low-flow, low-gradient aortic stenosis eligible for cardiac resynchronization therapy.

AIMS: In low-flow, low-gradient aortic stenosis (LF/LG AS), the assessment of contractile reserve (CR) by dobutamine stress echocardiography (DSE) is recommended for risk stratification and treatment strategy. However, DSE may show limitations in cases of left ventricular dyssynchrony (LVD). The impact of LVD in LF/LG AS, and the feasibility of CRT in this setting have never been evaluated. We aimed to assess: (i) the proportion of LF/LG AS patients with LVD; (ii) the influence of LVD on CR at DSE; and (iii) the effects of CRT in these patients. METHODS AND RESULTS: Thirty consecutive patients with LF/LG AS underwent DSE with study of CR. The operative risk for aortic valve replacement (AVR) was assessed using the logistic EuroSCORE. Twenty-one of the 30 patients had LVD. They were significantly older, more symptomatic, had a higher EuroSCORE, and a lower prevalence of CR than those with a narrow QRS (47% vs. 100%, P = 0.009). A CRT pacemaker was implanted in 19 of the 21 patients with LVD. All 19 (except for one patient who died suddenly) experienced significant clinical and echocardiographic improvement. Fourteen CRT patients underwent subsequent AVR with a low event rate. Four CRT patients refused AVR; two of them worsened again 1-2 years post-CRT. CONCLUSION: LVD is common in LF/LG AS patients and may be a major mechanism of afterload mismatch, as well as a cause of underdetection of CR. CRT in this population is feasible and may be proposed as a bridge to surgery.

Clinical experience and Doppler echocardiographic assessment of the first one hundred ATS AP (advanced performance) prosthetic valve in the aortic position.

BACKGROUND AND AIM OF THE STUDY: The ATS Medical mechanical bileaflet valve is composed of pyrolitic carbon and is available in two forms: Standard and Advanced Performance. The study aim was to evaluate the clinical results and define, in blinded manner, the Doppler echocardiographic characteristics of normally functioning ATS AP prostheses with respect to their size. METHODS: One hundred patients (63 men, 37 women; mean age 63.6 +/- 10.6 years) were studied between January 1996 and February 1999. Doppler echocardiography was performed at least three months after valve replacement (mean 1.68 +/- 0.86 months; range: 3 months to 3 years). RESULTS: The in-hospital mortality was 3%, and there were four late deaths. None of the deaths was valve-related. Thromboembolic and anticoagulant-related hemorrhagic rates were 0.55% per patient-year (pt-yr) and 1.1% per pt-yr, respectively. Maximum and mean gradients were calculated using the simplified Bernoulli equation. Functional valve surface area was assessed using the continuity equation and time-velocity integrals using echographic measurements to calculate the subaortic surface. The Doppler velocity index was obtained from the ratio of subaortic and transaortic velocities. For the most frequently used aortic valve (22 mm), the maximum pressure gradient was 18.67 +/- 8.31 mmHg, the mean gradient 9.97 +/- 3.84 mmHg, functional surface area 1.50 +/- 0.35 cm2, and Doppler velocity index 0.41 +/- 0.08. CONCLUSION: Based on Doppler echocardiographic characteristics, the new ATS Medical AP prosthesis, when implanted in the aortic position, has an excellent hemodynamic profile which compares favorably with that of similarly designed prostheses. The clinical results show a very low rate of thromboembolic and anticoagulant-related hemorrhagic events, perhaps due to the new design of the pivoting area.

Combined treatment of aortic type A dissection: ascending aorta repair and placement of a stent in the descending aorta.

BACKGROUND: The established treatment modality of acute Stanford type A dissection includes repairing the ascending aorta and a variable part of the aortic arch and leaving the descending aorta untreated. We report a simultaneous approach of open repair of the ascending aorta with the transluminal placement of a stent in the descending aorta to minimize the consequences of an untreated descending aorta. METHODS: Two cases of type A aortic dissection are described, one case with the entry port in the descending aorta and the second case with the entry port in the aortic arch. Both patients were treated by the replacement of the ascending aorta (and the aortic arch in the second case) and the placement of a stent in the descending aorta with a new device as the patients were under circulatory arrest and deep hypothermia. The device consists of a Djumbodis stent mounted on a compliant balloon. This stent is made of 316L stainless steel and can be adapted to the shape of the aortic arch or descending aorta. Three different lengths are available: 4 cm, 9 cm, and 14 cm. The device used in these patients has a diameter of 9 mm. RESULTS: The early results were satisfactory with a completely thrombosed false lumen in one case and a partially thrombosed false lumen in the other, according to immediate postoperative transesophageal echocardiography control. A follow-up computed tomographic chest scan was done at 12 months in the first case and at 7 months in the second case and confirmed the good surgical results. CONCLUSIONS: This preliminary study shows that combined surgical and endovascular treatment of acute type A dissection is feasible and that at least partial thrombosis of the false lumen can be achieved, potentially minimizing the risk of further dilatation or rupture. The early results are encouraging, but more cases and long-term results are required to demonstrate the effectiveness of this new combined treatment modality.

A spontaneous rupture of the external iliac vein revealed as a phlegmasia cerulea dolens with acute lower limb ischemia: Case report and review of the literature.

We reported a case in a previously healthy 45-year-old woman of spontaneous rupture of the left external iliac vein, which was revealed as a phlegmasia cerulea dolens with acute lower limb ischemia. A tear on the anterior surface of the vein was discovered during an emergency laparotomy, and the rent was repaired successfully. Twenty-four hours later, the leg swelling increased, and at the reexploration, the common iliac vein was found to be occluded by an organized thrombus as the result of a well-endothelialized membranous band (Cockett or May-Turner syndrome). A Palma-Dale operation (crossover saphenous bypass grafting) was performed secondarily. The swelling in the leg diminished slowly, and the patient was discharged 10 days later with an oral anticoagulant therapy and elastic stockings.

Systemic free radical activation is a major event involved in myocardial oxidative stress related to cardiopulmonary bypass.

BACKGROUND: Cardiopulmonary bypass (CPB) can induce deleterious effects that could be triggered in part by radical oxygen species; however, their involvement in the course of surgery has been elusive. The aim of this study was to evaluate the time course and origin of radical oxygen species release, myocardial or not, in patients undergoing coronary artery surgery involving CPB. METHODS: Blood samples were taken from periphery and coronary sinus of patients during CPB, and oxidative stress was evaluated by direct and indirect approaches. Direct detection of alkyl and alkoxyl radicals was assessed by electron spin resonance spectroscopy associated with the spin-trapping technique using alpha-phenyl-N-tert-butylnitrone. RESULTS: The authors showed that the spin adduct concentration was not influenced by anesthesia and pre-CPB surgery. A rapid systemic increase of plasma spin adduct concentration occurred after starting CPB, and it stayed at a high concentration until the end of CPB. At the beginning of reperfusion period, radical oxygen species release was accelerated in the coronary sinus; however, it was not significant. A positive correlation was found between alpha-phenyl-N-tert-butylnitrone adduct concentrations and (1) the duration of CPB and (2) concentration of postoperative creatine phosphokinase of muscle band (CPK MB). Plasma vitamin E and C, ascorbyl radical, uric acid, thiol, plasma antioxidant status, and thiobarbituric acid reacting substances were also measured but did not give relevant indications, except for uric acid, which seemed to be consumed by the heart during reperfusion. CONCLUSION: The results indicate that a systemic production of free radicals occurs during CPB that may overwhelm the production related to reperfusion of the ischemic heart. This systemic oxidative stress is likely to participate in secondary myocardial damage.