[Tricuspid regurgitation: transcatheter treatment by TriClip®]. / Insuffisance tricuspide. Traitement transcathéter par TriClip®.

Tricuspid regurgitation (TR) is not rare and has been associated with poor clinical outcomes when severe. The etiology of TR is functional in most cases and is usually associated with left-sided valvular heart disease. Severe TR is responsible for right heart failure and may evolve to global heart failure. Current echocardiographic classification includes several grades (trivial, moderate, severe, massive, torrential TR) which influence patients' prognosis in an incremental manner. Management of patients with severe TR is discussed in Heart Team after evaluation of surgical risk. The TRI-SCORE may be used to evaluate the intra-hospital mortality risk in case of isolated tricuspid surgery. Isolated TR surgery is rarely performed as surgical risk outweighs expected clinical benefits. Transcatheter treatment of severe TR may be considered in highly selected cases. Transcatheter edge-to-edge repair (TEER) restores leaflets coaptation. First tricuspid TEER procedures were performed with the MitraClip® (Abbott, Santa Clara, CA, USA) device, but a specific device has been developed: the TriClip® (Abbott). The prospective multicenter TRILUMINATE trial evaluated the TriClip® procedure in patients with symptomatic moderate to severe TR and high surgical risk. The results show a good efficacy with reduction of post-procedural TR grade and increase in NYHA functional class, 6-minute walking test distance, right ventricular function, and quality of life at 1 year. Other devices are currently being evaluated or in development (i.e., transcatheter tricuspid implantation). Non-surgical TR management is likely to evolve and improve significantly soon.

L'insuffisance tricuspide (IT) est une valvulopathie assez fréquente dans la population et qui est associée à un mauvais pronostic lorsqu'elle est modérée à sévère. Elle est le plus souvent fonctionnelle et liée à une valvulopathie du cœur gauche. Cliniquement, elle se marque par le développement de signes d'insuffisance cardiaque droite avec évolution vers une décompensation cardiaque globale. La classification échocardiographique actuelle distingue plusieurs stades (IT minime, modérée, sévère, massive et torrentielle) qui influencent le pronostic de façon incrémentielle. La prise en charge est discutée de manière collégiale après stratification du risque opératoire, dont l'évaluation est facilitée par le TRI-SCORE (risque de mortalité intra-hospitalière post-opératoire de chirurgie isolée de la valve tricuspide). La prise en charge chirurgicale d'une IT isolée est rarement pratiquée en raison d'un risque opératoire souvent élevé. Une prise en charge percutanée peut être envisagée dans certains cas, selon les limitations anatomiques. La technique de réparation bord à bord au niveau tricuspidien permet de restaurer une coaptation valvulaire par accolement des feuillets. Initialement réalisée à l'aide du système MitraClip® (Abbott, Santa Clara, CA, USA), il existe maintenant un système dédié spécifiquement à la tricuspide : le TriClip® (Abbott), dont la dernière génération existe en quatre tailles. Le TriClip® a été évalué dans l'étude prospective multicentrique TRILUMINATE chez des patients avec IT modérée à sévère symptomatique à haut risque chirurgical. La procédure a montré une efficacité avec réduction rapide du grade d'IT et amélioration de la classe fonctionnelle NYHA, de la distance de marche à 6 minutes, de la fonction ventriculaire droite et de la qualité de vie à un an. D'autres dispositifs sont en cours d'étude ou en développement (implantation tricuspide percutanée). La prise en charge non chirurgicale de l'IT devrait se développer de manière significative dans le futur.

[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.

[Minimally invasive aortic valve replacement through right anterior minithoracotomy: early experience at the University Hospital of Liege]. / Chirurgie valvulaire aortique mini-invasive vidéo-assistée par thoracotomie. Expérience initiale liégeoise.

Aortic valve replacement is nowadays a safe procedure with low morbidity and mortality. However, the evolution of surgery requires the development of less invasive techniques. Aortic valve replacement through a right mini-thoracotomy, technically more complicated, offers a lower rate of complications including less postoperative pain and less blood loss and transfusion, with a faster recovery. We report our early experience of aortic valve replacement through a right anterior mini-thoracotomy.

La chirurgie de remplacement valvulaire aortique offre toujours d'excellents résultats avec une morbidité et une mortalité faibles. Cependant, l'évolution de la chirurgie nous incite à développer des techniques mini-invasives. La mini-thoracotomie antérieure droite, pour la chirurgie de remplacement de la valve aortique, techniquement plus complexe, offre de nombreux avantages. Cette technique assure une réduction des pertes sanguines et des douleurs postopératoires, une meilleure fonction respiratoire, un rétablissement plus rapide (durée de séjour hospitalier plus court) et un bénéfice esthétique. Nous rapportons ici notre expérience initiale de remplacement valvulaire aortique par mini-thoracotomie antérieure droite.

[Minimally invasive aortic valve surgery. Experience of the academic hospital of Liege and review of the literature]. / Chirurgie «mini-invasive¼ de la valvule aortique. Expérience du CHU de Liège et revue de la littérature.

Minimally invasive aortic valve surgery aims at reducing surgical invasiveness whilst preserving the high efficacy of surgical aortic valve replacement. As such it increases the value of the overall procedure. The surgical experience at the ULg is reported and replaced in the context of the pertinent related litterature.

La réalisation de la chirurgie de la valve aortique par une voie d'abord réduite atténue le traumatisme chirurgical subi par le patient, mais doit garantir un geste de qualité équivalente. Au travers de la présentation d'une histoire clinique inscrite dans la routine, nous rapportons l'expérience du service dans ce domaine et nous la confrontons aux données de la littérature. L'approche mini-invasive apporte des avantages supplémentaires par rapport à la chirurgie conventionnelle et s'inscrit dans l'évolution actuelle des procédures interventionnelles.

[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).

Timing of carotid endarterectomy: a comprehensive review.

UNLABELLED: Some controversy exists on the best moment to treat symptomatic carotid artery disease. This controversy concerns mainly neurologically unstable patients and patients who suffered a minor stroke. The authors discuss recent literature data on the feasibility and the safety of performing urgent (within 24 to 72 hours) carotid endarterectomy (CEA) in patients presenting repetitive transient ischaemic attacks or progressing stroke. Neurologically unstable patients, suffering ischemic brain deficit caused by carotid artery stenosis, are defined according to the following criteria: two or more transient ischaemic attacks (crescendo TIAs) or a fluctuating neurological deficit evolving no longer than 24 hours (progressing stroke), no impairment of consciousness, cerebral infarct of limited size on diffusion-weighted magnetic resonance imaging of the brain and a carotid artery stenosis of 70% or more on the appropriate side. In the past, these patients were often considered at too high risk to undergo immediate carotid surgery. Many neurologists remain reluctant to confine these neurologically unstable patients for urgent carotid endarterectomy and prefer to stabilise the neurological status, arguing the increased stroke morbidity in the urgent setting. Nevertheless, the natural history of stroke- in-evolution or repetitive transient ischemic attacks is far from benign, exposing the patient to a high risk of subsequent spontaneous stroke, even under best medical treatment. Another controversy exists on the timing of surgery in patients who suffered a minor, non-disabling stroke. Is a waiting period of 6 weeks safe? Once more, the operative risk should be balanced against the anticipated natural history. Published series, and sub-analysis of the recent carotid surgery trials (NASCET, ECST) plaid for carotid surgery within two weeks of a minor stroke. CONCLUSIONS: Contemporary literature argues that neurologically unstable patients, presenting repetitive transient ischaemic attacks or progressing stroke, should be managed by urgent (within 24 to 72 hours) carotid endarterectomy, even if the peri-operative stroke-death rate is slightly higher than in the elective setting. Despite an inherent increased operative morbidity-mortality, urgent carotid endarterectomy seems to us justified by the fact that waiting for the surgery may lead to the development of a more profound stroke in these neurologically unstable patients. Their only chance for neurological recovery (partial or complete) is in the early phase (12 to 60 hours after the acute onset of the neurological syndrome of crescendo-TIAs or stroke-in-evolution). For patients presenting a minor stroke, with limited brain infarction, carotid endarterectomy should preferentially be done in a semi-urgent fashion, within two weeks.

Comparison of laparoscopic and open aortobifemoral bypass in the treatment of aortoiliac disease. Results of a contemporary series (2003-2009).

OBJECTIVES: The study objective was to describe and evaluate our single center (University Hospital Liège) experience with totally laparoscopic bypass surgery compared with conventional open surgery to treat aortoiliac occlusive disease. MATERIAL AND METHODS: A retrospective database review of all patients undergoing aortobifemoral bypass for aortoiliac occlusive disease in our center, between 2003 and 2009, was performed. During this period, a total of 251 consecutive patients were identified. Among these patients, 95 underwent totally laparoscopic aortobifemoral bypass (group I) and 156 conventional open surgery (group II). Demographic data, operative data, postoperative recovery data, complications, two-year follow-up, morbidity and mortality were analysed according to the laparoscopic and conventional open group. RESULTS: Patients included 160 men and 91 women. The mean age was 61 years (range, 40 to 88 years) in both groups. Indications for surgery were invalidating claudication in 87%, rest pain in 7%, trophic disorders in 5%, impotence in 1.6% and digestive claudication in 1.2%. Prior to bypass surgery, 11 (11.6%) for the group I and 41 (26.3%) for the group II had undergone one or more abdominal surgical procedures. A transperitoneal and retrocolic approach was preferred in all laparoscopic procedures. Laparoscopic aortobifemoral bypass (LABF) required an operative time of 242 minutes (range, 129 to 465) and open aortobifemoral bypass (OABF), 200 minutes (range, 105 to 430). The mean aortic cross clamping time was 62 minutes in group I and 33 minutes in group II. Mean blood loss was more important in group II (1010 ml) than in group I (682 ml). The average length of hospital stay was 8.1 days for LABF compared with an average of 12 days for OABF. In 21 cases (20%) conversion to open surgery was necessary in the laparoscopic group. Systemic morbidity was significantly higher in the OABF group. Thirty-day postoperative mortality was 2% for group II. There was no hospital mortality in the laparoscopic group. Twenty nine patients were lost to follow-up and the mean follow-up was 23.5 months. CONCLUSION: Analysis of the results shows that laparoscopic aortobifemoral bypass for aortoiliac occlusive disease is a safe procedure. The statistically significant advantages observed in the majority of our patients were decreased blood loss, faster post-operative recovery and shorter hospital stay. In the two groups, late morbidity attributable to the bypass prosthesis was minimal compared with other causes.

Surgical treatment of cardiovascular complications in patients with Marfan syndrome: a report of two cases and literature review.

Cardiovascular disease is the main cause of morbidity and mortality in patients with Marfan syndrome. The most life threatening complication is aortic root aneurysms leading to aortic dissection or rupture. It can be prevented by regular aortic follow-up and prophylactic aortic surgery. Modern aortic surgery has led to a substantial increase in the life expectancy of these patients. We report two cases of Marfan syndrome with cardiovascular complications. Their management is discussed according to the most recent literature.

[Bronchial artery ligation for the management of hemoptysis]. / Prise en charge radiologique de l'hémoptysie.

Hemoptysis is defined by the expectoration of blood from infra-glottal airway. Massive hemoptysis can be a life-threatening intrathoracic disease that requires urgent investigations and management. The chest radiography and the computed tomography (CT) are useful to localize the bleeding site and to identify the cause of hemoptysis. Bronchial artery embolization is the most effective nonsurgical treatment in the management of massive and recurrent hemoptysis. This article reviews the role of radiology in the diagnosis and treatment of hemoptysis.

[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.

[Endoleak, a specific complication of the endovascular treatment of aortic aneurysms]. / Le cas clinique du mois. Les endofuites, une complication spécifique du traitement endovasculaire des pathologies aortiques.

Endoleaks represent the most common complication of endovascular aortic aneurysm repair. With the increasing use of endovascular techniques for aortic aneurysm repair, the prevalence of endoleaks has risen. While maintaining pressurization of the aneurysm sac, endoleaks expose to persistent risks of an evolution towards rupture. Long-term surveillance with imaging studies is necessary to reduce the incidence of these specific complications that may require intervention. The objective of this article is to draw the attention to the possible occurrence of these complications and to report the elements of diagnosis and treatment.

[Aortic pseudo-aneurysm after coarctation repair]. / Pseudo-anévrysme de l'isthme aortique après correction chirurgicale de la coarctation aortique.

Aortic pseudo-aneurysm is a well-known late complication after surgical repair of aortic coarctation. We report two cases of pseudo-aneurysm of the aortic isthmus evidenced after previous surgical repair of congenital aortic coarctation. These clinical observations give us the opportunity to underline the importance of a specific lifelong medical follow-up for patients who have undergone such surgery.

Ruptured hepatocellular carcinoma following transcatheter arterial chemoembolization.

Transcatheter arterial chemoembolization (TACE) is known to be an effective palliative treatment in unresectable hepatocellular carcinoma (HCC). Although TACE can control tumour growth and palliate the patients, complications of TACE with significant morbidity are well known and adversely affect the outcome of patients. Necrotic tumor rupture is a serious complication of TACE and has a high mortality rate. We report a case of ruptured HCC followingTACE in a 78-year-old male patient who subsequently developed peritonitis and pneumoperitoneum. This case gives us the opportunity to underline the importance of such complications and demonstrates the utility of CT imaging for diagnosis and management of patients with ruptured HCC.