[First report in the Liege province (Belgium) of a concomitant aortic and mitral valve surgery via a minimally invasive right latero-thoracic approach]. / Double chirurgie mitrale et aortique par abord mini-invasif latéral thoracique droit : à propos d'une première liégeoise.

Compared to median sternotomy, the potential benefits of minimally invasive single aortic or mitral valve surgery include reduction of blood loss, lower morbidity, and shorter intensive care unit and hospital length of stay. However, there are few reports regarding concomitant aortic and mitral valves minimally invasive surgery via mini-thoracotomy. To the authors knowledge, this is the first report in the Liege area, of a successful minimally invasive right latero-thoracic approach for aortic and mitral valve surgery in a 78-year old woman who presented severe and symptomatic aortic stenosis and mitral insufficiency. In addition to the description of the surgical approach, the authors will summarize the current literature on this approach, as well as the clinical evolution of the patient.

La chirurgie valvulaire isolée, aortique ou mitrale par voie mini-invasive offre de nombreux avantages par rapport à la sternotomie médiane en termes de réduction des pertes sanguines, de diminution de la morbidité et de réduction des durées de séjour aux soins intensifs et hospitalier global. Toutefois, il existe très peu de données dans la littérature sur la chirurgie combinée mitrale et aortique par mini-thoracotomie. à notre connaissance, nous présentons le premier cas de double chirurgie mitrale et aortique réalisée avec succès par abord latéral thoracique droit dans la région liégeoise chez une patiente de 78 ans qui présentait une sténose aortique et une insuffisance mitrale sévères et symptomatiques. En plus d'une description de notre technique chirurgicale, nous résumerons les grandes séries cliniques publiées dans la littérature sur le sujet, ainsi que l'évolution clinique de notre patiente.

[The opportunities of the minimally invasive approach for the cardiovascular and thoracic surgery]. / Apport de l'approche moins invasive en chirurgie cardiovasculaire et thoracique.

There is a continuous growth in the incidence of cardiovascular and thoracic diseases, especially related to the increased life expectancy. Moreover, the quality and efficacy of care for these pathologies are progressing constantly. The evolution of surgery prompts us to develop less aggressive (minimally invasive), although technically more complex, treatment or diagnostic techniques. Pathologies, which until now required heavy surgeries, are managed today in a less invasive way and become therefore accessible to patients even if they are older or in a poor general condition. In this article, we present our experience in the development of the minimal invasive procedures in cardiovascular and thoracic surgery.

Les pathologies cardiovasculaires et thoraciques, au sens large, sont de plus en plus fréquentes, vu l'augmentation de l'espérance de vie, mais elles sont aussi de mieux en mieux prises en charge. En effet, l'évolution de la chirurgie nous incite à développer des techniques de traitement ou de diagnostic moins agressives (mini-invasives) quoique techniquement plus complexes. Des pathologies qui nécessitaient, jusqu'à présent, des chirurgies lourdes se prennent en charge, aujourd'hui, de manière moins invasive et deviennent donc accessibles à des patients en moins bon état général ou de plus en plus âgés. Nous présentons ici notre expérience dans le développement de l'approche mini-invasive en chirurgie cardiovasculaire et thoracique.

[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.

[Transcatheter aortic valve replacement : from a concept to a medical revolution]. / Remplacement valvulaire aortique par voie transcathéter : du concept au changement de paradigme dans le traitement des sténoses aortiques.

Since the first transcatheter aortic valve implantation (TAVI) in 2002, the paradigm for the treatment of severe aortic stenosis has changed. In the recent past, medical therapy with or without balloon aortic valvuloplasty was the only option for inoperable patients but now, TAVI has become the treatment of choice for these patients and the preferred alternative for high-risk operable patients. Surgical aortic valve replacement (SAVR) currently remains the gold standard for patients at low operative risk. As randomized trials have demonstrated comparable (or better results with TAVI) between TAVI and SAVR in the high-risk population, there is now a clear trend towards performing TAVI even in intermediate-risk. Nevertheless, there are still questions regarding TAVI involving paravalvular leak, stroke, pacemaker requirements, and durability, which remain to be more definitively answered before TAVI can routinely be performed in lower risk and younger population. Improvements in patient selection, multimodal imaging, and third generation devices have significantly decreased the incidence of TAVI complications. A role for post-procedure antithrombotic or anticoagulant management remains unanswered. Waiting for current studies to provide us with clear answers to these questions, it is the Heart Team's task to determine the optimal treatment for each patient based on risk scores, frailty metrics, comorbidities, patient's preference, and potential for improvement in quality of life.

Depuis la première implantation chez l'homme d'une prothèse aortique via un cathéter percutané en 2002 (TAVI, «Transcatheter Aortic Valve Implantation¼), nous avons assisté à un changement de paradigme en ce qui concerne le traitement des sténoses aortiques. Dans un passé récent, le traitement médical, avec ou sans valvuloplastie au ballonnet, était la seule option thérapeutique pour les patients inopérables, mais, actuellement, le TAVI s'est imposé comme le traitement de choix pour ces patients et ceux à haut risque chirurgical. Le remplacement valvulaire aortique chirurgical classique reste le traitement de choix pour les patients symptomatiques à faible risque opératoire. Des études randomisées ont démontré des résultats équivalents, voire supérieurs, du TAVI comparé à la chirurgie chez les patients à haut risque et il y a actuellement de solides arguments en faveur de l'approche transcathéter chez les patients à risque intermédiaire. Cependant, avant d'élargir les indications du TAVI aux patients plus jeunes ou à faible risque, certaines questions relatives aux points faibles de cette technique telles les insuffisances paravalvulaires, les complications neurologiques, les implantations de pacemakers et la longévité des prothèses sont en attente de réponses plus précises. L'amélioration de la sélection des patients, de l'imagerie multimodale, les troisièmes générations de prothèses ont permis de réduire considérablement l'incidence des complications liées au TAVI. Il reste encore à définir un protocole efficace de traitement antithrombotique ou anticoagulant en post-procédure. En attendant que les études en cours nous apportent des réponses claires à ces questions, c'est le rôle du «Heart Team¼ de déterminer, au travers d'une discussion collégiale entre experts de différentes disciplines, le traitement de choix pour chaque patient, en tenant compte des scores de risque, de l'évaluation des fonctions cognitives, des comorbidités, des préférences du patient et de l'impact du traitement sur la qualité de vie.

[How I manage... Malignant pleural mesothelioma in 2019]. / Comment je traite Le mésothéliome pleural malin en 2019.

Malignant pleural mesothelioma is a rare disease originating from mesothelial cells of the pleura and is related to asbestos exposure. The tumor is generally extended at the time of diagnosis and the treatment consists of a systemic palliative therapy. Radical approach is limited to very selected patients and is performed in expert centers but without validated schema. Radiotherapy alone is mainly used in palliative intent. Platinum-based chemotherapy in association with pemetrexed is the frontline standard of care and provides a 12-month overall survival. The addition of bevacizumab, an antiangiogenic drug, shows an improvement in median survival. To date, there is no second-line treatment approved for this disease and therefore inclusion in trials is recommended. Currently, various studies are investigating target therapy, immunotherapy and intrapleural perioperative treatment.

Le mésothéliome pleural malin est une tumeur rare, issue des cellules mésothéliales de la plèvre et liée à un contact avec l'amiante. Au moment du diagnostic, la maladie est souvent de stade avancé et est prise en charge par un traitement systémique palliatif. Un traitement radical est réservé pour de rares cas très sélectionnés, au sein de centres experts et ce, sans qu'aucun schéma de prise en charge ne soit validé. La radiothérapie seule est essentiellement utilisée à titre palliatif antalgique. Le traitement systémique de référence consiste en une chimiothérapie à base de cisplatine et pemetrexed permettant une survie globale de 12 mois. L'ajout à la chimiothérapie d'une thérapie ciblée anti-angiogénique, le bévacizumab, a permis une amélioration significative de la survie. A ce jour, il n'y a pas de traitement de 2ème ligne validé et il est donc recommandé d'inclure les patients dans des études cliniques. Actuellement, de multiples études évaluent des thérapies ciblées, des immunothérapies et des traitements intrapleuraux peropératoires.

[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.

[Giant pulmonary artery aneurysms. Case report and proposal of management algorithm]. / Anévrysmes géants de l'artère pulmonaire : cas clinique et proposition d'un algorithme de diagnostic et de prise en charge.

Pulmonary artery aneurysm is a rare and multiform pathology related to multiple etiologies and therefore different pathophysiological mechanisms. Delineating homogenous sub-groups is a pre-requisite to refine medico-surgical management. The case of a giant PAA without pulmonary hypertension but associated to a dysplastic pulmonary valve is reported. This association could be in some instances the result of a congenital anomaly in the development of both the pulmonary valve and the root creating the conditions for further development of a pulmonary artery aneurysm. Whilst minor forms are usually asymptomatic, they can lead to lethal complications in huge sizes and are frequently associated via pulmonary valve insufficiency to right ventricular dysfunction. This specific association is discussed and a diagnostic algorithm for nosologic classification and management is proposed.

L'anévrysme de l'artère pulmonaire est une pathologie rare, qui répond à de multiples étiologies et autant de physiopathologies différentes. L'identification de sous-groupes constituant des entités cliniques homogènes est un prérequis pour préciser la prise en charge médico-chirurgicale optimale. Nous rapportons un cas d'anévrysme géant de l'artère pulmonaire principale, sans hypertension artérielle pulmonaire, mais associé à une dysplasie/dysfonction de la valve pulmonaire. Cette association pourrait être, dans certains cas, congénitale et liée à une anomalie de la morphogénèse de la valve et de la racine pulmonaire, association qui crée les conditions pour le développement d'un anévrysme. Asymptomatiques dans les formes mineures, les anévrysmes pulmonaires peuvent être causes de symptômes ou de complications gravissimes dans les formes très développées et entraînent souvent, par insuffisance pulmonaire, une dysfonction ventriculaire droite. Nous suggérons une classification claire de cette pathologie mal connue et, sur base de la littérature et de notre expérience personnelle, nous proposons un algorithme de prise en charge médico-chirurgicale.

Surgical aortic valve replacement for stenosis of TAVI device.

We here report the case of a stenosis of the CoreValve® system due to reduced mobility of prosthesis cusps for which a surgical replacement of the aortic valve was proposed. The exact mechanism leading to this impaired mobility of the leaflets is yet to be determined. We also underline the fact a transcatheter aortic valve implantation (TAVI) device can be replaced by a surgical replacement without excessive operative risks despite the patient being initially considered as high-risk.

[The ideal valvular prosthesis is still to come. Which factors can help decide between mechanical and bioprosthetic heart valve replacement?]. / La prothèse valvulaire idéale n'existe toujours pas. quels facteurs entrent en compte pour orienter les choix d'une valve mécanique ou biologique?

The prevalence of valvular heart diseases reaches 2.5% in the overall population. Aortic valve replacement is one of the most common surgical procedures. We report the story of a female patient whose aortic mechanical valve, implanted at the age of 54 years at the time of a mitral valve repair surgery, had to be replaced 14 years later, due to the development of a subvalvular pannus narrowing the valvular orifice. We use this clinical story to compare the advantages and disadvantages of repair surgery and valve replacement with a biological or mechanical prosthesis, and summarize the latest evidence for the choice of the most adequate prosthesis for a particular patient's profile.

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.

Cardiac paraganglioma: diagnostic work up and review of the literature.

Paraganglioma of the heart are potentially invasive, highly vascularized tumors for which complete resection may be curative. Derived from the cardiac wall in most instances, resectability can be assessed after integration of the data provided by MRI in T2 sequence, and coronarography. A fully documented case of a large cardiac pheochromocytoma of the left atrium and AV groove is reported and the pertinent literature on the subject is here presented.

[Constrictive pericarditis: case report and review]. / Le cas clinique du mois. Péricardite constrictive.

Constrictive pericarditis (CP) is a common disease with difficult diagnosis. We report a well-documented case of CP with extended pericardial calcification treated by total pericardiectomy. A brief review of symptoms and signs of CP is presented, as well as additional examination allowing the diagnosis to be confirmed. The differential diagnosis with restictive cardiomyopathy is also discussed.

[Interventional options in modern treatment of hypertrophic obstructive cardiomyopathy]. / Options interventionnelles en matière de traitement moderne de la cardiomyopathie hypertrophique obstructive.

Obstructive hypertrophic cardiomyopathy is a complex pathology. The understanding of its physiopathology and, notably, of the SAM phenomenon (Systolic Anterior Motion), is crucial for all available treatments. Amongst the most efficient therapies, one can cite the septal myectomy and its most recent technical updates, as well as the alcohol septal ablation. The choice between these two methods depends on the general state of the patient, the thickness of the interventricular septum and the coronary anatomy of the patients.

[Clinical case of the month. Intrapulmonary lung sequestration diagnosed in an adult]. / Le cas clinique du mois. A propos d'un cas de séquestration pulmonaire intralobaire diagnostiqué à l'âge adulte.

Pulmonary sequestration is a rare congenital lung malformation characterized by an abnormal segment of bronchopulmonary tissue supplied by aberrant systemic arteries. Due to the non-specific symptomatology, the diagnosis can be missed. Imaging is the cornerstone of the diagnosis. Complete surgical resection provides the definitive treatment. We report a case of pulmonary sequestration associated with an asymptomatic aspergillosis presenting during adulthood and describe briefly the epidemiology, embryology, histology, imaging and surgical treatment of this congenital abnormality.

[Cardiac metastasis from malignant melanoma]. / Métastase cardiaque d'un mélanome.

The authors describe a case of cardiac metastasis associated with a malignant melanoma, which was removed in its totality. Malignant melanoma is a tumour which metastases frequently at the cardiac level. The mechanism of implantation and the symptomatology of this metastatic localisation are discussed.

Extended transsternal thymectomy for myasthenia gravis: a report of 19 consecutive cases.

BACKGROUND: Thymectomy is considered as an effective therapeutic option for patients with myasthenia gravis (MG). This study reports the experience of our centre's investigation into the efficacy and the safety of the procedure and the influence of different pre-operative factors on the surgical outcome. METHODS: A retrospective chart review/interview was made of 19 consecutive patients who underwent extended transsternal thymectomy for MG from 1992 to 2003. The severity of the disease was determined according to the Osserman Classification. Efficacy was measured by determining the change in clinical status, the rate of remission during follow-up, and the reduction in medication requirements after thymectomy. Complete remission (CR) was defined as asymptomatic off medication for 6 months. The CR rate was calculated using the Kaplan-Meyer method. RESULTS: The mean age of the patients at surgery was 34 years (range, 9-63) and 78.9% were female. Mean length of follow up was 86 months (range, 24-163). The overall complication rate was 10.6% (1 episode of atrial fibrillation and a left recurrent laryngeal nerve palsy that resolved after the first postoperative month). There was no operative mortality. The mean hospital stay was 9.4 days (range, 5-23). The crude CR rate was 32% (n = 6). The Kaplan-Meier estimate of CR was 42% at 6 years. Age, gender, duration of symptoms, thymic histology, Osserman stage and the presence of thymoma were not identified as prognostic variables. The average daily dose of Medrol and Mestinon decreased significantly between the pre-operative period and the last follow-up (Medrol, p = 0.0081; Mestinon, p = 0.0013). CONCLUSIONS: Transsternal thymectomy for MG is safe and effective. It benefits patients with MG at all stages. Patients with thymoma are not associated with poorer remission rates. Complete responses are durable, as the CR rate remains stable over time.

[Myxomatous mitral valve degeneration: biochemical aspects and physiopathological considerations]. / L'insuffisance mitrale par dégénerescence myxoïde: aspect biochimique et considérations physiopathologiques.

Mitral valve is a complex structure which is submitted to repeated mechanical constraints. In clinical practice, an increasing incidence of mitral insufficiency resulting from myxomatous degeneration is observed. Since myxomatous degeneration is also observed in defined genetic diseases of connective tissues, we propose the hypothesis that idiopathic mitral insufficiency might result from a minor alteration of the interstitial valvular cells and/or their interactions with their support. After a brief review of the role of the extracellular matrix in the heart, some histopathological and biochemical aspects of myxomatous degeneration are presented. Our data and those of the literature will be summarized and a physiopathological hypothesis proposed for myxomatous mitral valve degeneration.

Description and evaluation of a simplified technique for replacement of the ascending aorta and proximal arch in degenerative aneurysmal disease.

The distal extension of ascending aorta pathology often requires prosthetic grafting into the proximal arch. In order to perform optimal distal anastomosis, an open technique under a short period of circulatory arrest (CA) was adopted. For this purpose we evaluated prospectively a simplified technique for surgery and perfusion. The aneurysmal aorta was directly cannulated to cool down the patient to 26 degrees C. Under CA and retrograde cerebral perfusion, the diseased aorta and aortic cannulation site were resected. After completion of the distal anastomosis, antegrade rewarming was performed via recannulation of the AAo graft (side branch graft) whilst surgery was proceeded on the root and/or aortic valve. This technique clearly addresses the safety of cannulation into the aneurismal aorta. The issues of cerebral and visceral protection during CA and antegrade reperfusion and rewarming have been analysed prospectively in eight patients operated on over a period of 6 months. Our preliminary results indicate that this technique of arterial cannulation and CA at 26 degrees C for the management of degenerative AAo disease involving the proximal arch appears safe both in terms of cerebral and systemic (visceral, muscular) protection. By this way, the complications related to deep hypothermia and prolonged cardiopulmonary bypass are avoided. This assumption may be only valid for a CA period less than 30 min. This preliminary study is limited by its small size and heterogeneity of the pathologies. However, the simplicity, surgical ease, rapidity and efficacy conveyed by this technique warrant further consideration and evaluation.

[The ostium primum or partial atrioventricular septal defect]. / La CIA, de type ostium primum ou canal atrio-ventriculaire partiel.

Often assimilated to simple inter-atrial communication, the ostium primum, or partial atrio-ventricular septal defect, is an entity that is characterized by a different embryological mechanism and requires some specific surgical expertise. Basically, knowledge of the morphology of the common atrioventricular valve with 5 components, the topography of the A-V node and His bundle, and the ventricular consequences of the absence of atrio-ventricular septal structures must be taken into account.

[Ground-glass opacity and mixed pulmonary nodules: a new computed tomography semiology of the pulmonary adenocarcinoma]. / Comment j'explore... les nodules pulmonaires de types verre dépoli et mixte: une nouvelle sémiologie tomodensitométrique de l'adénocarcinome pulmonaire.

Recently a new computed tomography semiology of the pulmonary adenocarcinoma was highlighted. Studies on ground-glass nodule and on mixed nodule showed the relation between these radiological images and the different anatomopathological forms of lung adenocarcinoma. Ground-glass opacity can correspond to precancerous lesions and morphological characteristics of nodules are correlated with the prognosis. The presence of spiculation, pleural retraction and air bronchogram is significantly more important in neoplasic lesions. The presence or the apparition of a solid component inside the nodule or the presence of indentation is highly suggestive of adenocarcinoma. A lesion smaller than 20 mm and persistant after 1 month must be, either followed up, or removed by a limited surgical resection. Lesions larger than 20 mm or associated with a solid component must be treated by conventional surgery.