Impact of cardiac arrest resuscitated donors on heart transplant recipients' outcome.

OBJECTIVE: To evaluate the influence of cardiac arrest-resuscitated donors (CARDs) on the outcome of heart recipients. METHODS: Patients transplanted between July 2004 and December 2012 were divided into 2 groups according to the history of cardiac arrest in donors and their clinical records were retrospectively reviewed. RESULTS: A total of 584 heart transplantations were performed during the study period, and 117 recipients received an organ from a CARD. There were no differences between the 2 groups with regards to recipient age, sex, cardiomyopathy, preoperative extracorporeal membrane oxygenation, national high emergency waiting list, and redo surgery. Donors who sustained a cardiac arrest were significantly younger (44 [32-51] vs 49 [41-56] years; P < .001), their main cause of death was anoxia (57% vs 1%; P < .001), and they had significantly greater troponin T peak levels (0.51 [0.128-3.108] vs 0.11 [0.04-0.43] ng/mL; P < .001). Median cardiac arrest duration was 15 minutes (5-25). No difference was noted in donors with regards to left ventricular ejection fraction at time of organ procurement (62% ± 8% vs 63% ± 8%; P = .2). There were no differences between the 2 groups with regards to ischemic time (179 ± 60 vs 183 ± 59 minutes; P = .43), need for postoperative extracorporeal membrane oxygenation for primary graft failure (31% vs 30%; P = .993) and 30-days mortality. Recipients receiving an organ from a CARD had a significantly better 10 year survival (69.4% vs 50.4%; P = .017). CONCLUSIONS: History of cardiac arrest in donors with a preserved left ventricular ejection fraction at time of organ procurement doesn't affect outcome of heart recipients.

Extracorporeal life support as a bridge to bridge: a strategy to optimize ventricular assist device results.

OBJECTIVES: Extracorporeal life support (ECLS) devices provide temporary mechanical circulatory assistance and are usually implanted under emergency conditions in critical patients. If weaning off ECLS is not possible, heart transplantation or implantation of long-term mechanical circulatory support (LTMCS) is required. The purpose of our study was to evaluate the bridge-to-bridge (BTB) concept. METHODS: Between 1 January 2004 and 1 August 2010, 97 patients were assisted by LTMCS. The implantation was the first-line intervention in 48 patients (the bridge group), and was performed after a period of ECLS support in 49 others (the BTB group). RESULTS: The long-term survival rate was 51.6%, with a mean follow-up of 30.7 months, and there were no differences for biological parameters between the two groups. Patients in the BTB group whose condition was initially more severe, improved under ECLS support, and those in whom biological parameters did not revert to normal died after LTMCS. Risk factors for mortality in the BTB group were total bilirubin and lactate before LTMCS, and alkaline phosphatase before ECLS support. CONCLUSIONS: The BTB concept allows the implementation of LTMCS in severe patients, for whom it was not originally envisaged, with the same long-term survival as in first-line settings. ECLS in the evolution of patients is predictive of survival after LTMCS.

[Not Available].

Coronary revascularization in patients with diabetes mellitus. Macrovascular complications of diabetes mellitus and particularly difuse coronary artery atherosclerosis, confer a high risk of morbidity and mortality to this population. Percutaneous coronary intervention (PCI) is the preferred mode of coronary revasculari- zation in acute coronary syndromes withlwithout ST elevation, due to the availability of this procedure in emergency situations and to the fact that the benefit is similar in patients with or without diabetes. In symptomatic stable coronary artery disease, large clinical trials including BARI-2D and FREEDOM have clarified the respective role of PCI and of Coronary Artery By-Pass Surgery (CABG) in patients with multiple vessel disease. The superiority of CABG over PCI is clearly demonstrated in multivessel disease, particu- larly with a high SYNTAX score related to complex lesions. The optimal surgical approach should use the two internal mammary arteries in order to ensure a complete revascularization and to reduce delayed scar healing and infection. The surgical approach in this context improves mortality, reduces the risk of repeat revascularization and preserves cardiac function. The decision of the type of procedure should be taken as recommended by the Haute Autorité de Santé (HAS) by a heart team including an interventional cardiologist, a cardiac surgeon anda diabetologist, and shouldfollow international recommendations such as those of the European Society of Cardiology (Class 1A).

Renal insufficiency, mortality, and drug management in heart transplant. Results of the CARIN study.

Renal insufficiency (RI) is a frequent complication in heart transplant (HT) patients. The main objectives of the Cardiac trAnsplantation and Renal INsufficiency (CARIN) study were to follow the evolution of renal function after heart transplantation (HTx), to identify the factors associated with the decline of renal function, to describe the impact of RI on mortality during 3 years after the HT, and to observe the renal profile of the prescriptions. CARIN was a French retrospective, multicentric, study. Data were collected for patients who received a HT between 2000 and 2005. Data collection was performed at five time points: before HTx (T0), 1(T1), 6(T6), 12 (T12), and 36 (T36) months after HTx. Glomerular filtration rate (GFR) was estimated with aMDRD formula. RI was defined as GFR < 60 ml/min/1.73 m². Four hundred and forty-one patients from five HT centers were included. The prevalences of RI were 28.8% (T0), 54.0% (T1), 50.4% (T6), 51.6% (T12), and 59.6% (T36). Age and cyclosporine were independently linked to the decline of renal function. Hypertension and GFR < 60 at T0 were independent risk factors of mortality. 48.7-64.7% of the nonimmunosuppressive prescriptions were drugs that required dosage adjustment in RI patients or for which no data were available concerning administration in RI patients. RI is highly frequent after HTx. Because RI is a risk factor of mortality, any sparing renal strategies have to be undertaken.

Severe mitral stenosis as the first manifestation of systemic lupus erythematosus in a 20-year-old woman: the value of magnetic resonance imaging in the diagnosis of Libman-Sacks endocarditis.

We report a case of severe mitral stenosis caused by Libman-Sacks endocarditis, as an initial manifestation of systemic lupus erythematosus (SLE) in a 20-year-old woman. Cardiac magnetic resonance imaging (MRI) demonstrated a thickening of the mitral valve with basal endocardial thickening exhibiting defect on first-pass perfusion short-axis acquisition and delayed enhancement in keeping with extensive fibrous endocarditis. The patient underwent successful mechanical mitral valve replacement. This case illustrates that MRI is useful in diagnosing this recognised but uncommon cardiac complication of SLE and excluding differential diagnosis such as valve tumour and infective endocarditis with perivalvular abscesses.

Temporary right ventricular support following left ventricle assist device implantation: a comparison of two techniques.

OBJECTIVES: Right ventricular failure (RVF) after implantation of left ventricular assist device (LVAD) is a dramatic complication. We compared retrospectively two techniques of temporary right ventricular support after LVAD (HeartMate II, Thoratec Corp, Pleasonton, CA, USA) implantation. METHODS: From 1 January 2006 to 31 December 2012, 78 patients [mean age 52 ± 1.34 years; 15 women (19%)] received a HeartMate II at our institution. Among these, 18 patients (23%) suffered postimplant RVF treated by peripheral temporary right ventricular support. Aetiology of heart failure was ischaemic in 12 (67%) and dilated cardiomyopathy in 6 (33%) patients. The preimplant RV risk score averaged 5.1 ± 0.59. Ten patients were treated using a femorofemoral venoarterial extracorporeal life support (ECLS) and 8 patients were treated using extracorporeal membrane oxygenation as a right ventricular assist device (RVAD) established between a femoral vein and the pulmonary artery via a Dacron prosthesis (RVAD). RESULTS: Duration of RV support was 7.12 ± 5.4 days and 9.57 ± 3.5 days in venoarterial ECLS and vein and the pulmonary artery RVAD groups, respectively (P = 0.32). Three patients (17%) died while under RV support (venoarterial ECLS, n = 2; and vein and the pulmonary artery RVAD, n = 1, P = 0.58). In the venoarterial ECLS group, 6 (60%) patients suffered major thromboembolic complications including thrombosis of the ECLS arterial line (n = 2), ischaemic stroke (n = 2) and thrombosis of the ascending aorta (n = 2). No major complication was observed in the vein and the pulmonary artery RVAD group (P = 0.01). RV support was successfully weaned in 8 (80%) patients of the venoarterial ECLS group and in 7 (87.5%) of the vein and the pulmonary artery RVAD group (P = 0.58). The duration of postimplant intensive care unit stay was not different (respectively, 27.5 ± 18.7 days and 20.0 ± 12.0 days; P = 0.38) between both groups. CONCLUSIONS: Temporary support of the failing RV after LVAD implantation using temporary vein and the pulmonary artery RVAD is a promising therapeutic option. This approach provides adequate LVAD pre- and afterload and is associated with significantly less thromboembolic complications.

Clinical outcome and quality of life of patients surviving 20 years or longer after heart transplantation.

To evaluate outcome and quality of life (QoL) in ≥ 20 years survivors after heart transplantation. Patients surviving ≥ 20 years with a single graft were retrospectively reviewed. Heterotopic, multiorgan and retransplantations were excluded. QoL was evaluated using the SF-36 survey. Eight hundred and twenty-seven heart transplants were performed from 1981 to 1993, and among these, 131 (16%) patients survived ≥ 20 years; 98 (75%) were male and mean age at transplant was 43 ± 13 years. Conditional survival in these 20 years survivors was 74.1 ± 4.3% at 23 years and 60.9 ± 5.3% at 25 years (45 deaths, 34%). Forty-four (34%) patients suffered rejection ≥ 2R. Conditional survival free from rejection ≥ 2R was 68 ± 4.1% at 5 years and 66.4 ± 4.2% at 10 years. Thirty-five (27%) patients had cardiac allograft vasculopathy (CAV) grade 2-3. Conditional CAV-free survival was 76 ± 3.8% at 20 years and 72.1 ± 4% at 25. Sixty-nine (53%) patients developed malignancy, mostly skin cancers. Conditional malignancy-free survival was 53.5 ± 4.4% at 20 years and 45.2 ± 4.6% at 25 years. At latest follow-up, 24.0 ± 3.0 years after transplantation, mean left ventricular ejection fraction was 62 ± 11% and mean physical and mental scores were 57 ± 23 and 58 ± 21, respectively. Sixteen per cent of heart recipients survived ≥ 20 years with good ventricular performance and QoL. CAV and malignancies account for late morbidity and mortality.

Predictors of 30-day mortality and outcome in cases of myocardial infarction with cardiogenic shock treated by extracorporeal life support.

OBJECTIVES: The twin aims of this study were to identify the independent predictors of 30-day mortality and to analyse the outcomes of patients with cardiogenic shock (CS) associated with acute myocardial infarction (AMI) and necessitating extracorporeal life support (ECLS). METHODS: The investigation was a single-centre, retrospective study of 77 patients who required ECLS for AMI with CS. A logistic regression analysis was performed to identify the independent variables associated with 30-day mortality. RESULTS: Between February 2006 and November 2009, 745 patients in our establishment received ECLS. In the single-centre cohort, we retrospectively reviewed 77 patients who had required ECLS support for AMI with CS. The delay between AMI and CS ECLS was 15 ± 4 h. PCI was performed in 58 patients (75.3%) and isolated emergency CABG in 12 (15.6%). The remaining 7 patients (9.1%) did not undergo revascularization. ECLS duration averaged 9.8 ± 7.1 days. Nineteen patients were successfully weaned from ECLS (24%). Fifty-eight patients did not undergo or did not tolerate the weaning trial (76%). Forty patients died during ECLS support, 13 were implanted with a mono-ventricular (n = 9) or biventricular assist device (n = 4) and 5 were bridged to heart transplantation. Complications consisted primarily in pneumonia (51.3%) and acute renal failure requiring haemofiltration (46.1%). Pulmonary oedema occurred in 24 patients (31.6%) and major bleeding in 16 (21.33%). 30-day and in-hospital survival rates were, respectively, 38.9 and 33.8%. Multivariable analysis identified preimplantation lactate serum level, preimplantation creatinine serum level and previous cardiopulmonary resuscitation as independent predictors of 30-day mortality. CONCLUSIONS: Prompt ECLS support is an effective strategy and provides a reasonable chance of survival in patients with AMI associated with profound CS. As shown in our results pertaining to predictive risk factors for 30-day mortality, reducing the duration of end-organ ischaemia is the keystone to management of this patient population. A major remaining challenge will consist in preventing pulmonary oedema following peripheral ECLS.

SynCardia temporary total artificial heart as bridge to transplantation: current results at la pitié hospital.

BACKGROUND: The SynCardia temporary total artificial heart (t-TAH) provides complete circulatory support by replacing both native cardiac ventricles and all cardiac valves. METHODS: We performed a retrospective analysis of demographics, clinical characteristics and survival of patients bridged to transplantation using the SynCardia t-TAH (SynCardia Systems Inc, Tucson, AZ). RESULTS: From 2000 to 2010, the SynCardia t-TAH was implanted in 90 consecutive patients (80 males; mean age, 46 ± 13 years) suffering cardiogenic shock secondary to idiopathic (n = 40, 46%) or ischemic (n = 24, 27%) cardiomyopathy or other causes. Before implantation, 7 (9%) patients had cardiac arrest, 27 (33%) were on ventilator, and 18 (22%) were on extracorporeal life support. Pre-implant creatinine values were 1.7 ± 0.97 mg/dL and total bilirubin levels were 45 ± 32 µmol/L; mean duration of support was 84 ± 102 days. Thirty-five (39%) patients died while on support after a mean of 62 ± 107 days. Actuarial survival on device was 74% ± 5%, 63% ± 6%, and 47% ± 8% at 30, 60, and 180 days after implantation. While on support, 9 (10%) patients suffered stroke, 13 (14%) had mediastinitis, and 35 (39%) required surgical reexploration for bleeding, hematoma, or infection. Multivariate analysis revealed that older recipient age and preoperative mechanical ventilation were risk factors for death while on support. Fifty-five (61%) patients were transplanted after a mean of 97 ± 98 days of support. Actuarial survival rates were 78% ± 6%, 71% ± 6%, and 63% ± 8% at 1, 5, and 8 years after transplantation. CONCLUSIONS: The SynCardia t-TAH provided acceptable survival to transplantation rates with a remarkably low incidence of neurologic events. Posttransplant survival was similar to that of patients undergoing primary heart transplantation in France.

The challenge of home discharge with a total artificial heart: the La Pitie Salpetriere experience.

OBJECTIVES: The total artificial heart (TAH) helps to counteract the current decrease in heart donors and is likely to bridge patients to transplant under favourable conditions. Today's mobile consoles facilitate home discharge. The aim of this study was to report on the La Pitie Hospital experience with CardioWest TAH recipients, and more particularly, on generally successful outpatient' management. METHODS: A retrospective analysis was performed on clinical and biological data from patients implanted with a TAH between December 2006 and July 2010 in a single institution. Morbi-mortality during hospital stay, number and causes of rehospitalizations, quality of life during home discharge, bridge to transplant results and survival have all been analysed. RESULTS: Twenty-seven patients were implanted with the CardioWest. Fifteen patients (55.5%) died during support. Prior to home discharge, the most frequent cause of death was multi-organ failure (46.6%). Twelve patients were discharged home from hospital within a median of 88 days [range 35-152, interquartile range 57] postimplantation. Mean rehospitalization rate was 1.2 by patient, on account of device infection (n = 7), technical problems with the console (n = 3) and other causes (n = 4). Between discharge and transplant, patients spent 87% of their support time out of hospital. All patients who returned home with the TAH were subsequently transplanted, and 1 died in post-transplant. CONCLUSION: Despite the morbidity and mortality occurring during the postimplantation period, home discharge with a TAH is possible. Portables drivers allow for a safe return home. Aside from some remaining weak points such as infectious complications or noise, CardioWest TAH allows for successful rehabilitation of graft candidates, and assures highly satisfactory transplant results.

Unusual heart transplantation for iterative disinsertion of mitral prosthesis.

Heart transplantation is the gold standard of care for end-stage heart failure, usually associated with an impairment of left ventricular systolic function. We describe a case of heart transplantation in a 58-year-old man with normal left ventricular systolic function, because of recurrent mitral prosthesis disinsertion after multiple reoperations for infective endocarditis.

Hybrid access to atria via the Guiraudon Universal Cardiac Introducer for arrhythmia ablation after total cavopulmonary derivation.

We report the first use of a new platform, the Guiraudon Universal Cardiac Introducer (GUCI), in humans for accessing the left atrium for catheter-based ablations in patients with resistant atrial arrhythmias after total cavopulmonary derivation. The GUCI was originally designed for intracardiac access for closed, beating instrumental intracardiac surgery.The patient was a 29-year-old man with problematic atrial arrhythmias resistant to antiarrhythmic drugs because of severe uncontrolled bradycardia and because his pacemaker was explanted for infection.The GUCI was attached to the left atrial appendage via an anterior left thoracotomy. The GUCI was modified to accommodate introduction and manipulation of multiple catheters. This allowed electrophysiologists to perform catheter-based exploration and ablation. A DDD pacemaker was implanted, with an atrial endocardial lead introduced via the GUCI cuff and a ventricular epicardial lead.Postoperative atrial arrhythmias were controlled using amiodarone and atrial pacing. At the 12-month follow-up, the patient was arrhythmia- and drug-free and returned to full employment.This new access offers an additional new alternative atrial access to treat resistant arrhythmia after total cavopulmonary derivation. The current state-of-the-art makes patient selection difficult and uncomfortable for the surgeons because of incomplete preoperative electrophysiological data, such as a return to the beginning of surgery for arrhythmia; however, more cumulative experience with intraoperative electrophysiological data and new mapping technologies should address these limitations.

[Surgery for infective endocarditis]. / Indication opératoire des endocardites infectieuses.

Surgical treatment is a cornerstone in the management of infective endocarditis, approximately 50% of patients should be operated in the acute phase. Surgery is indicated in heart failure by acute valvular insufficiency refractory to medica treatment, persistent sepsis despite adequate antibiotic therapy, infections by microorganisms with low response to antibiotics, paravalvular abscess or cardiac fistulas, and for prevention of cerebral embolism when large vegetations are present. Other indication in prosthetic valve endocarditis is prosthesis dysfunction including significant perivalvular leaks or obstruction. In infection of leads of electrophysiological cardiac devices material should always be removed, preferably percutaneously, surgery is indicated when it is not technically possible.

Extracorporeal membrane oxygenation for 2009 influenza A (H1N1) acute respiratory distress syndrome: single-centre experience with 1-year follow-up.

OBJECTIVES: During 2009, pandemic influenza A (H1N1) affected France and several patients developed influenza A (H1N1)-associated acute respiratory distress syndrome. The use of extracorporeal membrane oxygenation (ECMO) could be advocated as therapeutic solution. We present our experience with ECMO utilized in patients with influenza A (H1N1)-associated respiratory failure. METHODS: We conducted a retrospective observational analysis of our experience with veno-venous ECMO for 2009 influenza A (H1N1)-associated respiratory failure. We have excluded from our study all not confirmed cases of influenza A (H1N1). Veno-venous ECMO was always instituted using a percutaneous cannulation technique. Mechanical circulatory support was maintained until respiratory function recovery. RESULTS: Between October 2009 and February 2010, we performed veno-venous ECMO support in 12 patients with influenza A (H1N1)-associated respiratory failure. Mean age was 33 ± 12 years (14-63 years) and there was a prevalence of female sex. Median time from influenza A (H1N1) onset to mechanical ventilation (MV) initiation was 6 days (1-17 days); median time from MV to veno-venous ECMO support was 3 days (1-20 days). Six patients (50%) suffered ventilator-associated pneumonia during ECMO support. Eight patients (66.6%) suffered significant haemorrhage requiring transfusion of more than 2 packed red cells. In two patients (16.6%), there was a thrombosis of the inferior vena cava and one of them experienced pulmonary embolism. Mean duration of ECMO support was 23 ± 14 days (3-47 days); mean duration of mechanical ventilatory support was 24 ± 21 days (6-70 days). ECMO was weaned in 10 patients (83.3%) and all these patients are still alive after a period of follow-up of 13.8 ± 1.12 months (11.03-14.83 months). Two patients (in-hospital mortality of 16.6%) died under ECMO support for refractory septic shock. CONCLUSIONS: Veno-venous ECMO for 2009 H1N1-associated respiratory failure gives good results with a very low mortality rate. The use of a mobile unit is a safe procedure and may improve survival of patients who might not be otherwise eligible for transfer to our institution. Larger studies are however required in order to optimize and refine the best treatment strategy in this subgroup of patients.

Predictive risk factors for primary graft failure requiring temporary extra-corporeal membrane oxygenation support after cardiac transplantation in adults.

OBJECTIVE: Primary graft failure (PGF) is a major risk factor for death after heart transplantation. We investigated the predictive risk factors for severe PGF that require extra-corporeal membrane oxygenation (ECMO) circulatory support after cardiac transplantation. METHODS: Between January 2003 and December 2008, 402 adult patients underwent isolated cardiac transplantation at our institution. PGF was defined as the need for ECMO support in the immediate postoperative period. Thirty-three recipient and 37 donor variables were analyzed for the risk of PGF occurrence. RESULTS: PGF occurred in 91 (23%) patients. Predictive risk factors for PGF occurrence were, in the recipient, being aged >60 years (odds ratio (OR) 2.11, p=0.01) and preoperative mechanical circulatory support (MCS) (OR 2.65, p=0.01); in the donor, they were mean norepinephrine dose (OR 2.02, p<0.01), trauma as the cause of death (OR 2.45, p<0.01), left-ventricle ejection fraction (LVEF) <55% (OR 2.72, p=0.02), and the ischemic time (OR 1.01, p<0.01). Weaning and discharge rates after ECMO support for PGF were, respectively, 60% (55/91 patients) and 46% (42/91 patients). The absence of PGF was correlated with improved long-term survival: 78% at 1 year and 71% at 5 years without PGF versus 39% at 1 year and 34% at 5 years with PGF (p<0.01). Surviving patients treated with ECMO for PGF have similar conditional 1-year survival rates as non-PGF patients: 93% at 3 years and 91% at 5 years without PGF versus 93% at 3 years and 84% at 5 years with PGF (p=0.46, NS). CONCLUSIONS: Occurrence of PGF is a multifactorial event that depends on both donor and recipient profiles. ECMO support is a reliable treatment for severe PGF; furthermore, surviving patients treated with ECMO have the same 1-year conditional survival rates as patients not having suffered a PGF.

Early percutaneous tracheotomy versus prolonged intubation of mechanically ventilated patients after cardiac surgery: a randomized trial.

BACKGROUND: Whether early percutaneous tracheotomy in patients who require prolonged mechanical ventilation can shorten mechanical ventilation duration and lower mortality remains controversial. OBJECTIVE: To compare the outcomes of severely ill patients who require prolonged mechanical ventilation randomly assigned to early percutaneous tracheotomy or prolonged intubation. DESIGN: Prospective, randomized, controlled, single-center trial (ClinicalTrials.gov registration number: NCT00347321). SETTING: Academic center. PATIENTS: 216 adults requiring mechanical ventilation 4 or more days after cardiac surgery. INTERVENTION: Immediate early percutaneous tracheotomy or prolonged intubation with tracheotomy 15 days after randomization. MEASUREMENTS: The primary end point was the number of ventilator-free days during the first 60 days after randomization. Secondary outcomes included 28-, 60-, or 90-day mortality rates; durations of mechanical ventilation, intensive care unit stay, and hospitalization; sedative, analgesic, and neuroleptic use; ventilator-associated pneumonia rate; unscheduled extubations; comfort and ease of care; and long-term health-related quality of life (HRQoL) and psychosocial evaluations. RESULTS: There was no difference in ventilator-free days during the first 60 days after randomization between early percutaneous tracheotomy and prolonged intubation groups (mean, 30.4 days [SD, 22.4] vs. 28.3 days [SD, 23.7], respectively; absolute difference, 2.1 days [95% CI, -4.1 to 8.3 days]) nor in 28-, 60-, or 90-day mortality rates (16% vs. 21%, 26% vs. 28%, and 30% vs. 30%, respectively). The durations of mechanical ventilation and hospitalization, as well as frequencies of ventilator-associated pneumonia and other severe infections, were also similar. However, early percutaneous tracheotomy was associated with less intravenous sedation; less time of heavy sedation; less haloperidol use for agitation, delirium, or both; fewer unscheduled extubations; better comfort and ease of care; and earlier resumption of oral nutrition. After a median follow-up of 873 days, between-group survival, psychosocial evaluations, and HRQoL were similar. LIMITATION: The prolonged intubation group had more ventilator-free days during days 1 to 60 than what was hypothesized (mean, 23.0 days [SD, 17.0]). CONCLUSION: Early tracheotomy provided no benefit in terms of mechanical ventilation and length of hospital stay, rates of mortality or infectious complications, and long-term HRQoL for patients who require prolonged mechanical ventilation after cardiac surgery. However, the well-tolerated procedure was associated with less sedation, better comfort, and earlier resumption of autonomy. PRIMARY FUNDING SOURCE: French Ministry of Health.

Transcatheter aortic valve implantation: early results of the FRANCE (FRench Aortic National CoreValve and Edwards) registry.

AIMS: Transcatheter aortic valve implantation is a therapeutic alternative for high-surgical-risk patients with severe symptomatic aortic stenosis. Two models of prosthesis are currently commercialized in France, which can be implanted either via a transarterial or a transapical approach. The aim of the study was to evaluate in a national French registry the early safety and efficacy of transcatheter aortic valve replacement (AVR) using either the Edwards SAPIEN™ or CoreValve™ in high-surgical-risk patients with severe aortic stenosis. METHODS AND RESULTS: The multicentre national registry was conducted in 16 centres between February 2009 and June 2009, under the authority of the French Societies of Cardiology and Thoracic and Cardio-Vascular Surgery. The primary endpoint was mortality at 1 month. Two hundred and forty-four high-surgical-risk patients (logistic EuroSCORE ≥20%, STS ≥10%, or contra-indication to AVR) were enrolled. Mean age was 82 ± 7 years and 43.9% were female. Edwards SAPIEN and CoreValve were implanted in 68 and 32% of patients, respectively. The approaches used were transarterial (transfemoral: 66%; subclavian: 5%) or transapical in 29%. Device success rate was 98.3% and 30-day mortality was 12.7%. Severe complications included stroke (3.6%), tamponade (2%), acute coronary occlusion (1.2%), and vascular complications (7.3%). Pacemaker was required in 11.8%. At 1 month, 88% of patients were in NYHA class II or less. CONCLUSION: This prospective registry reflects the real-life experience of transcatheter aortic valve implantation in high-risk elderly patients in France. The early results are satisfactory in terms of feasibility, short-term haemodynamic and functional improvement, and safety. Longer term follow-up will be further assessed.

Successful weaning of a left ventricular assist device implanted for ischemic heart failure.

We report the case of a patient stabilized under extra-corporeal membrane oxygenation after a refractory cardiogenic shock following myocardial infarction. Persistent left ventricular failure required secondary implantation of the left ventricular assist device (LVAD) HeartMate II. LVAD succeeded in the gradual recovery of myocardial contractility, allowing weaning of the device five months after implantation. Simultaneously, the patient beneficiated from coronary revascularization and resumed normal activity. This case emphasizes potential late recoveries after myocardial infarction complicated by left ventricular failure.