Transfemoral versus transcarotid access for transcatheter aortic valve replacement.

Objectives: To compare the outcomes after transcatheter aortic valve replacement (TAVR) through a transfemoral (TF) and transcarotid (TC) access at our institution. Methods: From January 2014 to January 2020, 62 TC-TAVR and 449 TF-TAVR were performed using 2 prosthesis devices (Edwards SAPIEN 3, n = 369; Medtronic Evolut R, n = 142). Propensity score matching was used to adjust for imbalance in the baseline characteristics of the study groups. Results: Propensity score matching provided 62 matched pairs with comparable operative risk (mean European System for Cardiac Operative Risk Evaluation II, TC-TAVR 7.6% vs TF-TAVR 6.6%, P = .17). Thirty-day mortality (4.8% vs 3.2%, P = 1.00) and 2-year mortality (11.3% vs 12.9%, P = .64) after TC-TAVR were comparable with TF-TAVR. Strokes were numerically more frequent after TC-TAVR compared with TF-TAVR (3.2% vs 0%, P = .23), but the difference did not reach statistical significance. TF-TAVR was associated with a significantly greater risk of permanent pacemaker implantation (29.0% vs 12.9%, P = .04) compared with TC-TAVR. Other complications were not frequent and were similarly distributed between the matched groups. Conclusions: TC access for TAVR was associated with satisfactory results compared to the femoral access. TC-TAVR could be considered a valid and safe alternative to TF-TAVR when femoral access is contraindicated.

Obesity and Preoperative Anaemia as Independent Risk Factors for Sternal Wound Infection After Coronary Artery Bypass Graft Surgery with Pedicled (Non-Skeletonized) Internal Mammary Arteries: The Role of Thoracic Wall Ischemia?

PURPOSE: Obesity remains statistically associated with coronary artery disease, for which coronary artery bypass graft surgery (CABG) remains the standard of care. However, obesity is also associated with sternal wound infection (SWI) which is a severe complication of CABG despite advances in surgery and in infection prevention and control. Strategies to reduce the incidence of SWI are still being investigated, and we therefore conducted a retrospective study to revisit factors other than obesity associated with SWI after CABG. PATIENTS AND METHODS: Data were extracted from the medical records of 182 patients who underwent elective on-pump CABG using one or both pedicled internal mammary artery grafts in Reims University Hospital between May 2015 and May 2016. All preoperative or perioperative variables with a p value<0.10 in univariate analysis were entered into a stepwise logistic regression model. RESULTS: Among the 182 patients (145 male (79.6%), median age 68.0 [45.0-87.0] years), 138 (75.8%) underwent CABG using bilateral internal mammary artery grafts. Median BMI was 27.7 [18.7-50.5] kg/m2, and there were 51 (28.0%) and 79 (43.4%) patients with obesity and overweight, respectively. Twenty-three out of the 182 patients (12.6%) developed SWI. In-hospital mortality was not statistically different between patients with and without SWI but the median length of stay was (6.0 [2.0-38.0] versus 5.0[3.0-21.0] days in the intensive care unit, p=0.03, and 26.0 [9.0-134.0] versus 9.0 [7.0-51.0] days in hospital, p<0.0001). Obesity and preoperative anaemia were independently associated with SWI, as was the number of red blood cell (RBC) units transfused (OR 14.61 [2.64-80.75], OR 4.64 [1.61-13.34] and OR 1.27 [1.02-1.58], respectively). CONCLUSION: The independent association of SWI with the number of RBC units transfused and the existence of preoperative anaemia and obesity suggests a mechanism of thoracic wall ischemia in SWI after CABG, thus leaving insufficient perfusion of the thoracic wall in patients with obesity. Medical strategies are warranted to try to prevent this costly complication.

Comparison of clinical outcomes after transcarotid and transsubclavian versus transfemoral transcatheter aortic valve implantation: A propensity-matched analysis.

BACKGROUND: Transcarotid and trans-subclavian access routes are increasingly used as alternative approaches for transcatheter aortic valve implantation (TAVI) when transfemoral access is not suitable. However, concerns remain about the risk of periprocedural stroke and long-term outcomes following transcarotid/trans-subclavian TAVI. AIMS: The present study sought to compare early and long-term outcomes of transcarotid/trans-subclavian TAVI versus transfemoral TAVI after propensity-score matching. METHODS: The 260 patients who underwent TAVI through a transfemoral (n=220), transcarotid (n=32) or trans-subclavian (n=8) approach at our institution over a 4-year period were identified. A 1:1 matching based on propensity score was performed, and led to a study population of 80 patients (40 transfemoral and 40 transcarotid/trans-subclavian). Primary endpoints were early complications; secondary endpoints were long-term outcomes. RESULTS: There were no differences in the baseline characteristics of the two groups. At 30 days after TAVI there were no significant differences between transfemoral and transcarotid/trans-subclavian TAVI in terms of death rates (5% vs 5%, respectively; P=1.00) and stroke rates (5% vs 2.5%, respectively; P=1.00). After a median follow-up of 21 months, the risk of death (P=0.95), stroke (P=0.82) and myocardial infarction (P=0.16) did not differ between the two groups. CONCLUSIONS: After propensity-score matching, no significant differences in early and long-term outcomes were observed between transfemoral and transcarotid/trans-subclavian TAVI. These findings should encourage heart teams to consider a transcarotid or trans-subclavian approach when transfemoral access is unavailable.

Abdominal aorta tortuosity on computed tomography identifies patients at risk of complications during transfemoral transcatheter aortic valve replacement.

BACKGROUND: Transcatheter aortic valve replacement is now indicated in patients at intermediate surgical risk and will probably soon be indicated in patients at low surgical risk, for whom the occurrence of serious procedural complications is not acceptable. AIMS: We aimed to investigate whether simple arterial variables from computed tomography scanning can predict the occurrence of severe early complications in patients undergoing transfemoral TAVR. METHODS: All patients with symptomatic severe aortic stenosis treated by transfemoral transcatheter aortic valve replacement in our centre, and for whom computed tomography images were available, were included. An exhaustive analysis of preprocedural computed tomography scans was performed retrospectively, in search of arterial tortuosity and vascular calcifications. The primary endpoint was a composite 30-day safety endpoint. RESULTS: Overall, 175 patients were included. The primary endpoint was observed in 60 patients (35%). Abdominal aorta tortuosity was identified in 28 patients (16%) and was strongly associated with the occurrence of a complication (adjusted odds ratio 2.7, 95% confidence interval 1.1-6.6; P=0.03). There was no significant association between iliofemoral tortuosity or vascular calcification and the occurrence of complications. CONCLUSIONS: A tortuous abdominal aorta was found to be a predictor of the occurrence of a complication in patients undergoing transfemoral transcatheter aortic valve replacement. This computed tomography variable should therefore be taken into account when choosing the approach, especially for patients at intermediate and low surgical risk.

Negative Pressure versus Conventional Sternal Wound Dressing in Coronary Surgery Using Bilateral Internal Mammary Artery Grafts.

BACKGROUND: Sternal wound infection (SWI) is a major complication occurring often after coronary artery bypass grafting (CABG) using bilateral internal mammary artery (BIMA) grafts. The aim of this study is to assess whether such a risk may be reduced by using incision negative pressure wound therapy (INPWT). METHODS: Data on patients undergoing isolated CABG using BIMA grafts at the Reims University Hospital, France, from 2013 to 2016 without or with INPWT was prospectively collected.  Results: INPWT was used in 161 patients and conventional sterile wound dressing was used in 266 patients. Propensity score matching resulted in 128 pairs with similar characteristics. SWIs were similarly distributed between the conventional sterile wound dressing (10.9%) and the INPWT cohorts (10.2%) (P = 1.00). Patients treated with INPWT had a lower rate of deep SWI/mediastinitis than patients who had conventional sterile dressing (5.5% versus 10.2%, P = .210), but the difference did not reach statistical significance. Tests for interaction confirmed these findings in different patient subgroups. CONCLUSION: The routine use of INPWT may not significantly reduce the risk of SWI in patients undergoing BIMA grafting. In view of previous reports showing a benefit with the use of this method, a large randomized study is justified to assess the efficacy of INPWT in patients undergoing cardiac surgery.

[Hyperamylasemia after cardiac surgery: which significance?]. / Augmentation de l'amylasémie après chirurgie cardiaque : quelle signification ?

We report the case of an 82-year-old woman, suffering of aortic valve stenosis, hospitalized for an aortic valve replacement surgery. This woman presented a hyperamylasemia during the early postoperative period. This raised the question of issue and explanation of this hyperamylasemia. A review of the literature showed that hyperamylasemia was reported in a large number of patients undergoing cardiac surgery, with various serum amylase levels and time courses. Mechanisms of this hyperamylasemia remain poorly understood and the interest of amylasemia measurement after cardiothoracic surgery is not clearly defined. Since postoperative hyperamylasemia can result from a tissular hypoxia, blood lactate measurement could be a more effective biochemical marker.

How to perform a haemodialysis using the arterial and venous lines of an extracorporeal life support.

Continuous renal replacement therapy is particularly suited in the setting of acute renal failure, occurring after cardiac surgery, in patients requiring extracorporeal life support (ECLS) or membrane oxygenation. In such patients, temporary catheters are not necessary since the circuit of haemodialysis or haemofiltration may be connected on the ECLS cannulae. We report how to modify a classical ECLS circuit to connect directly the haemodialysis (Prismaflex device, Gambro-Hospal, Lyon, France) to the ECLS. We also detail parameters used to initiate the haemodialysis. Actually, we modify all our ECLS circuits as described here, at implantation time, allowing rapid haemodialysis initiations. Since 2004, 21 patients have been treated, as described here, without supplemental mortality or related complication.

Endovascular treatment of an acute subdiaphragmatic aortic rupture.

We report the case of a 23-year-old man presenting an acute rupture of the subdiaphragmatic aorta in front of a T12 vertebral fracture after a road accident. Because of the location of this lesion, the operative risk and a cardiac instability, we opted for an endovascular treatment with a new and original approach in covering a small part of the aorta using commercial devices. We also describe the probable mechanism of this uncommon aortic rupture. The surgical outcome was uneventful and the 3 month computed tomographic scan confirmed the complete exclusion of the aortic disruption.

Traumatic aorto-right atrial fistula and tricuspid valve rupture. Post-operative cardiac and respiratory support with extracorporeal membrane oxygenation.

We report the case of a 30-year-old man admitted for a crushed chest trauma. The echocardiography found an aorto-right atrial fistula, a tricuspid valve rupture and a myocardial contusion. The fistula was closed using an autologous pericardial patch and a bioprosthetic tricuspid valve replacement was performed because the lesions did not allow for any valvular sparing. Because of the proximity between the right coronary ostium and the rupture, a venous aorto-right coronary bypass was performed. The ostium was also closed by the pericardial patch. A peripheral ECMO was implanted at the end of the surgical repair because of a right ventricle dysfunction and a respiratory failure related to severe bilateral pulmonary contusions. A few days later, renal, hepatic and coagulation failures were also noticed, justifying hemodialysis and transfusions. Despite an initial worsening of these five organ failures, the outcome was finally favorable and the patient was discharged 108 days after surgery. A 3-year follow-up revealed a complete recovery of all organ failures. To conclude, we firmly believe that the ECMO can be successfully applied in selected cases of severe right ventricular dysfunction and respiratory failure after cardiac surgery.

Retrograde aortic dissection after a stent graft repair of a type B dissection: how to improve the endovascular technique.

To date, endovascular repair of thoracic dissections is a reality, associated with acceptable morbidity and mortality. We present the case of a 72-year-old woman presenting a retrograde aortic dissection at the postoperative day 12, after an endovascular repair for a 60-mm thoracic dissecting aneurysm. Two years earlier, she had presented an uncomplicated thoracoabdominal type B aortic dissection between the isthmic aorta and the iliac bifurcation. Despite an acceptable blood pressure control, a 62-mm thoracic dissecting aneurysm was observed on the 24-month CT-scan. Due to a chronic obstructive pulmonary disease, we chose the endovascular approach to exclude the thoracic entry tear leading to the complete false lumen thrombosis around the endoprosthesis. However, the inferior part of the false lumen remained patent due to a second abdominal entry tear. The initial outcome was uneventful but the patient presented a sudden death syndrome twelve days after the endovascular repair. During the autopsy, we discovered an intrapericardial rupture of a retrograde dissection, starting at the level of the proximal bare spring of the endoprosthesis. We discuss some important technical details to improve the safety, and to reduce the risk of immediate or delayed complications.

Endovascular control of patent internal thoracic artery graft in aortic valve surgery.

Aortic valve replacement in patients who underwent previous coronary artery bypass with a patent internal thoracic artery is often a challenge because of the risk of graft injury during dissection or difficulties to obtain optimum myocardial protection. Different approaches to myocardial protection or internal thoracic graft dissection and control have been described. Endovascular control of the internal thoracic graft by an angioplasty balloon catheter positioned in the operating room before the operation can be a safe and simple alternative. We report the case of a patient who underwent this technique for aortic valve replacement.