Early to mid-term results after total cavopulmonary connection performed in the second decade of life.

OBJECTIVES: Total cavopulmonary connection (TCPC) performed in the second decade of life has rarely been studied. Thus, we investigated (bicentric study) early and late morbidity and mortality following completion of TCPC in these patients. METHODS: From January 1999 to June 2014, 63 patients (14.5 ± 2.9 years) underwent TCPC (extracardiac conduit). Palliation before completion was an isolated bidirectional cavopulmonary shunt (BCPS) in 3 patients or BCPS associated with additional pulmonary blood flow (APBF) that was either antegrade (Group 1) in 38 (63%) or retrograde (Group 2) in 22 (37%). Preoperative and perioperative data were reviewed retrospectively. RESULTS: Mean pulmonary arterial and ventricular end-diastolic pressures were 12.2 and 9.2 mmHg, respectively. Mean Nakata index was 279 ± 123 and 228 ± 87 mm 2 /m 2 in Groups 1 and 2, respectively ( P = 0.01). Aortic cross-clamping was performed in 22 from Group 1 and 8 from Group 2 ( P = 0.04). Mean follow-up was 4.57 years [0.8-15]. Nine patients had prolonged stays in the intensive care unit (>6 days). There were 1 early and 2 late deaths (non-cardiac related). Actuarial survival was 96% at 4 years. At last follow-up, single-ventricle function remained normal or improved in all patients (Group 1) compared to 82% in Group 2 ( P = 0.02). New York Heart Association (NYHA) class had improved in both groups: 47 patients were NYHA class II and 16 class III preoperatively vs 50 class I and 10 class II postoperatively ( P < 0.001). CONCLUSIONS: Single-ventricle palliation with BCPS and APBF allowed completion of TCPC in the second decade of life, with encouraging mid-term results. However, BCPS with retrograde APBF was associated with single-ventricle dysfunction: thus, this technique needs to be used cautiously as long-lasting palliation.

Tricuspid valve repair and pulmonary valve replacement in adults with repaired tetralogy of Fallot.

BACKGROUND: Pulmonary valve replacement (PVR) often is performed in adults with repaired tetralogy of Fallot (TOF). For patients who have tricuspid regurgitation (TR), tricuspid valve (TV) repair associated to PVR is still debated. OBJECTIVE: We sought to evaluate perioperative factors related to TV repair when performed at the time of PVR in patients with repaired TOF. METHODS: We retrospectively reviewed 104 patients with repaired TOF (or its equivalent) who underwent PVR (2002-2014). RESULTS: Mean age at initial complete correction and at PVR was 20.1 ± 17.2 months and 26.3 ± 9.5 years, respectively. Forty-one patients had significant preoperative TR: 24 were moderate (group M) and 17 were severe (group S). A total of 16 TV repair were performed (8 for each group). Moderate and severe tricuspid regurgitation observed in the first year following the initial complete repair were significantly associated with severe TR at PVR (P < .001). In group M patients, TR was improved regardless of TV repair, whereas, in group S, residual significant TR was reported in 7 patients who did not have TV repair. No cases were observed for patients who underwent concomitant TV repair (P = .002). Among these patients with residual significant TR, 2 needed a tricuspid valve replacement. The functional status (New York Heart Association classification) of group S patients was significantly improved by concomitant TV repair. CONCLUSIONS: In adults with repaired TOF, TV repair is a safe procedure when performed at the time of PVR. If, at mid-term follow-up, there is probably no benefit of TV repair when preoperative TR is moderate, TV repair may improve both tricuspid valve function and functional status of the patients in case of severe preoperative TR.

Scimitar Syndrome Repair in Adults: Intermediate-Term Results Using an Extracardiac Conduit.

BACKGROUND: Scimitar syndrome may be corrected using different techniques. Repair using an extracardiac conduit has rarely been performed. This study assessed the intermediate-term outcomes of this technique in adults. METHODS: From January 2000 to June 2011, 7 adult patients underwent correction with a ringed polytetrafluoroethylene conduit used to connect the scimitar vein (SV) to the left atrium, posterior to the inferior vena cava (IVC). Preoperative and perioperative data were reviewed retrospectively. RESULTS: All patients (32 ± 10.6 years old) were symptomatic (3 patients were New York Heart Association [NYHA] functional class II, 4 had recurrent pneumonia), with a ratio of pulmonary to systemic blood flow greater than 2, without significant pulmonary hypertension. In all patients, the SV drained the entire right lung venous return to the IVC below the diaphragm. Surgical repair was performed by sternotomy, normothermic cardiopulmonary bypass, and aortic cross-clamping. Four patients required additional closure of an atrial septal defect. Mean conduit diameter was 14 mm (range, 12 to 16 mm). Patients received long-term platelet suppression therapy with aspirin. There were no deaths and no reoperations. Mean follow-up time was 9.1 ± 3.6 years. Postoperative morbidity was nil. No evidence of subclinical stroke or embolization was found in postoperative magnetic resonance imaging of the brain. No thrombi on the prosthesis or in the left atria were detected at the latest echocardiogram, with laminar flow from the SV to the left atrium. At last follow-up, all patients were in NYHA class I. CONCLUSIONS: Correction of scimitar syndrome with an extracardiac conduit can be easily and safely performed in adults, with excellent intermediate-term durability, without graft thrombi or stenosis. This technique avoids deep hypothermic circulatory arrest when the SV is short or enters the IVC in an unusually caudad location.

A Methodology for Concomitant Isolation of Intimal and Adventitial Endothelial Cells from the Human Thoracic Aorta.

BACKGROUND: Aortic diseases are diverse and involve a multiplicity of biological systems in the vascular wall. Aortic dissection, which is usually preceded by aortic aneurysm, is a leading cause of morbidity and mortality in modern societies. Although the endothelium is now known to play an important role in vascular diseases, its contribution to aneurysmal aortic lesions remains largely unknown. The aim of this study was to define a reliable methodology for the isolation of aortic intimal and adventitial endothelial cells in order to throw light on issues relevant to endothelial cell biology in aneurysmal diseases. METHODOLOGY/PRINCIPAL FINDINGS: We set up protocols to isolate endothelial cells from both the intima and the adventitia of human aneurysmal aortic vessel segments. Throughout the procedure, analysis of cell morphology and endothelial markers allowed us to select an endothelial fraction which after two rounds of expansion yielded a population of >90% pure endothelial cells. These cells have the features and functionalities of freshly isolated cells and can be used for biochemical studies. The technique was successfully used for aortic vessel segments of 20 patients and 3 healthy donors. CONCLUSIONS/SIGNIFICANCE: This simple and highly reproducible method allows the simultaneous preparation of reasonably pure primary cultures of intimal and adventitial human endothelial cells, thus providing a reliable source for investigating their biology and involvement in both thoracic aneurysms and other aortic diseases.

Pulmonary-Valve Replacement in Adults: Results With the Medtronic Freestyle Valve.

BACKGROUND: We used the Medtronic Freestyle valve (Medtronic, Minneapolis, MN) as an orthotopic conduit in pulmonary valve replacement in repaired tetralogy of Fallot and as part of the Ross procedure. Midterm outcomes and hemodynamic status of this conduit were analyzed and performances in both subgroups were compared. METHODS: From February 2002 to July 2012, 115 Freestyle valves were implanted in 52 patients with tetralogy of Fallot and 63 patients within the Ross procedure. Preoperative and perioperative data were reviewed retrospectively in this bicentric study. RESULTS: Mean age at valve surgery was 37 ± 13 years. Median implanted valve size was 27 mm (21 to 29). Early postoperative mortality was 3.48%. There was 100% follow-up for the survivors at a mean of 4.38 ± 2.52 years. There was 1 case of thromboembolism (0.89%), 6 endocarditis (5.4%), and 9 (7.8%) conduit re-interventions. Echocardiography at discharge and last follow-up showed average peak systolic transvalvular gradients of 12.4 ± 5.1 and 18.7 ± 8.8 mm Hg, respectively. Ten patients had significant proximal anastomotic gradients of greater than 50 mm Hg and 4 moderate conduit regurgitations. Survival was 96.52%. No valve degeneration was seen in 87.82% at 5 years. The only risk factor identified for valve re-intervention was conduit implantation without infundibular hood (p = 0.01 in multivariate analysis). CONCLUSIONS: Mid-term data show that Freestyle valves are well suited for pulmonary valve replacement in adults in both categories. The surgical technique used in valve implantation is important to ensure conduit durability. These results and accessibility to the Freestyle valve make this an acceptable alternative to homografts.

The use of Impella 2.5 in severe refractory cardiogenic shock complicating an acute myocardial infarction.

OBJECTIVES: To investigate the outcome of patients with acute myocardial infarction (AMI) complicated by refractory cardiogenic shock (CS) who underwent mechanical circulatory support with Impella 2.5. BACKGROUND: AMI complicated by CS remains a highly fatal condition. A potent and minimally invasive left ventricular assist device might improve patient outcomes. METHODS: We analyzed the procedural characteristics and outcomes of 22 consecutive patients who underwent, between July 2008 and December 2012, a percutaneous coronary intervention and Impella 2.5 support for AMI complicated by CS refractory to first-line therapy with inotropes and/or Intra-aortic balloon pump. RESULTS: In this analysis, patients were relatively young with a mean age of 57.9 ± 11.6 year old and 59.1% were male. The majority of patients (77.3%) were admitted in CS and 40.9% sustained cardiac arrest prior to admission. Hemodynamics improved significantly upon initiation of support, end-organ and tissue perfusion improved subsequently demonstrated by a significant decrease in lactate levels from 6.37 ± 5.3 mmol/L to 2.41 ± 2.1 mmo/L, (P = 0.008) after 2 days of support. Thirteen (59.1%) patients were successfully weaned-off Impella 2.5 and 4 (18.2%) were transitioned to another device. We observed a functional recovery of the left ventricle when compared to baseline (43 ± 10% vs. 27 ± 9%, P < 0.0001). The survival rate at 6 months and 1 year was 59.1% and 54.5%, respectively. CONCLUSION: Impella 2.5 was initiated as a last resort therapy to support very sick patients with refractory CS after failed conventional therapy. The use of the device yielded favorable short and mid-term survival results with recovery being the most frequently observed outcome.

Electrophysiological study 6 months after Epicor™ high-intensity focused ultrasound atrial fibrillation ablation.

PURPOSE: Little is presently known about the outcome of atrial lesions performed with high-intensity focused ultrasound (HIFU) for atrial fibrillation ablation. We aimed to assess endocardial atrial lesions 6 months after epicardial HIFU ablation (Epicor(™)) and to evaluate the benefit of a combined ablation approach. METHODS: Thirty patients (21 males, mean age 68 ± 12 years old) undergoing HIFU atrial fibrillation ablation during cardiac surgery were enrolled. Electrophysiological study (EPS) was performed 6 months after HIFU ablation, and endovascular radiofrequency was delivered in case of conduction gaps. Patients were followed up for at least 6 months after the EPS. RESULTS: At EPS, ten patients (38 %) had achieved complete or near-complete "box" isolation and four (15 %) had no visible lesion. Using this technology, freedom from symptomatic atrial arrhythmia at 6 months was 60 % (n = 18/30) (64 % for paroxysmal and 56 % for persistent subgroups) improving to 81 % (n = 21/26) (90 % for paroxysmal and 73 % for persistent subgroups) at 12 months after a facultative percutaneous endocardial approach was performed. Using an UltraCinch device sized below 10 improved the rate of complete lesion as assessed 6 months after surgery (58 % of complete or near-complete box isolation with UltraCinch device <10 vs 21 % when ≥11; p = 0.05). CONCLUSION: Six months after HIFU ablation, only 38 % of the patients had complete or near-complete box isolation, and the recurrence rate of symptomatic atrial arrhythmia was 40 %. The latter was reduced to 19 % 6 months after complementary percutaneous approach.

Left posterolateral thoracotomy: an alternative approach for pulmonary valve replacement.

Pulmonary valve replacement in adults who have a repaired tetralogy of Fallot is realized through a redo median sternotomy. A dilated ascending aorta is often present and adherent to the sternum and can be injured during sternum reentry, with dramatic consequences. We report on an adult patient with a corrected tetralogy of Fallot who underwent pulmonary valve replacement, thick transannular patch excision, and left pulmonary artery enlargement. Surgery was performed through a left posterolateral thoracotomy. This surgical approach was safe and efficient and, compared with the left anterior thoracotomy approach, offered many more possibilities.

Early to midterm results of total cavopulmonary connection in adult patients.

BACKGROUND: Total cavopulmonary connection (TCPC) has not been studied in adults. We investigated early and midterm morbidity and mortality in adults undergoing TCPC and assessed risk factors for mortality. METHODS: Between June 1994 and October 2010, 30 adults (21.3 ± 5.5 years) underwent TCPC (extracardiac conduit). Twenty-two patients who had palliated single ventricles underwent TCPC completions and 8 patients underwent TCPC conversions. Preoperative and perioperative data were reviewed retrospectively. RESULTS: Six of 9 patients with preoperative atrial flutter or fibrillation or intraatrial reentry tachycardia were treated in the catheterization room. An aortic cross-clamp was necessary in 12 patients, and 16 TCPCs were fenestrated. Mean follow-up was 51 months (range, 4-198 months). Early mortality was 10%: 2 of 8 conversions and 1 of 22 completions. There was 1 late conversion death (at 56 months postoperatively). Postoperatively, 4 patients required pacemakers and 1 patient required long-term antiarrhythmic medication, but no heart transplantations were necessary. Risk factors for early mortality were arrhythmia (p = 0.02), aortic cross-clamp (p = 0.054), and extracorporeal circulation in hypothermia (p = 0.03). Risk factors for overall mortality were conversion (p = 0.047), absence of fenestration (p = 0.036), surgery before January 2006 (p = 0.036), aortic cross-clamp (p = 0.018), extracorporeal circulation in hypothermia (p = 0.008), and arrhythmia (p = 0.005). New York Heart Association functional class had improved at the last follow-up: preoperatively, 17 patients were in class II and 12 patients were in class III versus 18 patients in class I and 9 patients in class II postoperatively (p < 0.001). At the last clinical visit, systemic ventricular function was maintained, and no late supraventricular arrhythmia was found. CONCLUSIONS: Early and midterm TCPC results for adults are encouraging for completion but are disappointing for conversion. Identified risk factors for mortality should improve patient selection for TCPC.

Mediastinal lymphadenectomy in elderly patients with non-small-cell lung cancer.

OBJECTIVES: The progressive ageing of the population is accompanied by an increasing incidence of cancer. Our objective was to compare mediastinal lymphadenectomy performed in the surgical treatment of non-small-cell lung cancer (NSCLC) patients between ≥ 70 and <70. METHODS: We performed a retrospective single-centre case-control study, including 80 patients ≥ 70 years of age, surgically treated for NSCLC between January 2008 and December 2010, matched 1:1 to 80 younger controls on gender, American Society of Anesthesia score, performance status and histological subtype of the tumour. The number and type of dissected hilar/intrapulmonary and mediastinal lymph node stations as well as the number of resected lymph nodes were compared between the two age groups. RESULTS: The type of pulmonary resection was significantly different between the two groups (P = 0.03): pneumonectomy 6% (n = 5) for patients ≥ 70 vs 12% (n = 10) for patients <70, lobectomy 85 (n = 68) vs 65% (n = 52), bilobectomy 1 (n = 1) vs 2% (n = 2) and sub-lobar resection 7 (n = 6) vs 20% (n = 16). There was no significant difference in type of mediastinal lymphadenectomy (radical vs sampling; P = 0.6). Elderly patients presented a more advanced N status of lymph node invasion than younger controls (P = 0.02). The number and type of dissected lymph node stations and the number of lymph nodes were not significantly different between the two age groups (P = 0.66 and 0.25, respectively). The mean number of metastatic lymph nodes was higher in patients ≥ 70 (2.3 vs 1.3 in patients <70; P = 0.002). Lymph node ratio between metastatic and resected lymph nodes was higher in elderly patients (0.11 vs 0.07 in younger controls; P = 0.009). CONCLUSIONS: Lymph node involvement in surgically treated NSCLC was more significant in elderly patients ≥ 70 than in younger patients presenting comparable clinical and histopathological characteristics, and undergoing a similar lymphadenectomy.

Validation of an animal model of right ventricular dysfunction and right bundle branch block to create close physiology to postoperative tetralogy of Fallot.

BACKGROUND: In the past 5 years a few number of studies and case reports have come out focusing on biventricular (BiV) stimulation for treatment of congenital heart disease related ventricular dysfunction. The few available studies include a diverse group of pathophysiological entities ranging from a previously repaired tetralogy of Fallot (TOF) to a functional single ventricle anatomy. Patient's status is too heterogeneous to build important prospective study. To well understand the implication of prolonged electromechanical dyssynchrony we performed a chronic animal model that mimics essential parameters of postoperative TOF. METHODS: Significant pulmonary regurgitation, mild stenosis, as well as right ventricular outflow tract (RVOT) scars were induced in 15 piglets to mimic repaired TOF. 4 months after hemodynamics and dyssynchrony parameters were compared with a control group and with a population of symptomatic adult with repaired TOF. RESULTS: Comparing the animal model with the animal control group on echocardiography, RV dilatation, RV and LV dysfunction, broad QRS complex and dyssynchrony were observed on the animal model piglets. Moreover, epicardial electrical mapping showed activation consistent with a right bundle branch block. The animal models displayed the same pathophysiological parameters as the post TOF repair patients in terms of QRS duration, pulmonary regurgitation biventricular dysfunction and dyssynchrony. CONCLUSION: This chronic swine model mimics electromechanical ventricular activation delay, RV and LV dysfunction, as in adult population of repair TOF. It does appear to be a very useful and interesting model to study the implication of dyssynchrony and the interest of resynchronization therapy in TOF failing ventricle.

Fast track echo of abdominal aortic aneurysm using a real pocket-ultrasound device at bedside.

BACKGROUND: Ultraminiaturization of echographic systems extraordinarily provides the image "within" the clinical examination. Abdominal aorta aneurysm (AAA) diagnosis based on conventional evaluation with a dedicated operator and ultrasound machine is still controversial due to the lack of evidence of the proposed management and guidelines' cost-effectiveness. We hypothesized that less expensive ultraportable devices could identify AAA with the same level of accuracy as conventional approaches. METHODS: A first step of this study was to validate the VSCAN's image capabilities in patients referred to the vascular Doppler laboratory. Abdominal aorta measurements were performed by an experienced physician using conventional equipment followed by a second blinded physician using the ultraportable device VSCAN. Then, 204 patients hospitalized in our cardiology institute were prospectively included for a systematic screening of AAA at bedside using the VSCAN in order to determine the feasibility and impact of fast track evaluation compared to clinical examination. RESULTS: A strong correlation was obtained between measurements of abdominal aorta diameters using the two ultrasound systems (r = 0.98, CI: 0.97-0.99, P < 0.001) with 100% of agreement for AAA diagnosis. In the second part of the study, visualization and measurement of the transverse diameter of the abdominal aorta was obtained in 199 patients, resulting in a feasibility of 97.5%. Among these patients, 18 AAAs were detected, which corresponds to a prevalence of 9%, whereas clinical evaluation did not detect any of them. Patients with AAA were more likely men (77.77% vs. 57.45%, P < 0.05) and hypertensive (88.8% vs. 56.9%, P < 0.05) as compared to those without AAA. Two patients with large AAA were quickly referred to the surgery department. CONCLUSION: Considering its low cost, diagnostic accuracy, and widespread availability, screening for AAA using an ultraportable ultrasound device such as VSCAN by an experienced physician is promising and should be used as an extension of routine physical examination in vascular patients.

Late outcome of 132 Senning procedures after 20 years of follow-up.

BACKGROUND: Risk factors and rates of reoperation, arrhythmias, systemic right ventricular dysfunction (RVD), and late death after a Senning procedure were investigated. METHODS: One-hundred thirty-two patients underwent a Senning operation between 1977 and 2004 (105 simple and 27 complex transpositions of the great arteries). Mean follow-up time was 19.5 ± 6.6 years. Surviving patients were evaluated by transthoracic echocardiography and electrocardiography. Right ventricular function was assessed in 70 patients by isotopic ventriculography or magnetic resonance imaging. RESULTS: Operative and late mortality were 5.3% (7/132) and 9.6% (12/125), respectively. Nine patients were reoperated for left ventricular outflow tract obstruction or baffle stenosis. Survival rate was 91.5%, 91%, 89%, and 88% at 1, 5, 10, and 20 years, respectively. Probability of maintaining permanent sinus rhythm was 80%, 65%, 55%, and 44%. Twelve patients required pacemaker implantation. Probability of no supraventricular tachycardia, atrial flutter/fibrillation or ventricular tachycardia was 95.5%, 91.5%, 88%, and 75%, respectively. These parameters were similar for simple and complex transposition. Probability of right ventricular ejection fraction >40% was 100% at 5 and 10 years, and 98% at 20 years for simple transposition, and 100%, 92%, and 58% for complex transposition. This difference was statistically significant. Risk factors for RVD were complex transposition (p < 0.001), body weight (p = 0.008), no cardioplegia (p < 0.001), and tricuspid valve regurgitation (p = 0.004). CONCLUSIONS: Senning procedure results in very good long-term survival out to 20 years. Both RVD and baffle stenosis were rare, but there was a concerning incidence of arrhythmia over time suggesting careful long-term surveillance.

Beating-heart coronary artery bypass surgery with the help of mini extracorporeal circulation for very high-risk patients.

BACKGROUND: Left ventricle dysfunction and co-morbidities are responsible for a large number of complications after coronary artery bypass graft (CABG) surgery. The best strategy for these patients, including the use or not and type of extracorporeal circulation (ECC), the use of minimized ECC (MECC), or conventional ECC (CECC), remains unclear. The aim of the present study was to investigate the potential effect of on-pump beating-heart (OPBH) surgery with the help of MECC for CABG in patients with a high-risk EuroSCORE and to compare this strategy to three other different procedures, including OPCAB and MECC or CECC with cardiac arrest. METHODS: Patients were included if their EuroSCORE was strictly >" xbd="1427" xhg="1404" ybd="1477" yhg="1440"/>9. Four groups were retrospectively compared: an OPCAB, an OPBH, a MECC and a CECC group under cardiac arrest. RESULTS: 214 patients, mean age 74.26 ± 8.5 years, 68.7% male, were operated. Mean EuroSCORE was 12.1 ± 2.9, left ventricular (LV) function 37.4 ± 12.3%, recent myocardial infarction (MI) 49.5%, renal failure 48.1%, chronic obstructive pulmonary disease (COPD) 42.2%, and peripheral vascular disease (PVD) 55.6%. Mean number of grafts per patient was 2.4 ± 0.7. Our study showed that it was possible, in very high-risk patients, to carry out revascularisation with OPBH similar to that using MECC or CECC under cardiac arrest (p=NS). This technique reduces troponin release (3.23 vs 6.56, p<0.01), postoperative myocardial complications (2% vs 8%, p<0.01), cardiotonic drug prescription (15.7% vs 31.3%, p<0.01), ventilation time (4.57H vs 6.48H, p<0.01) and length of stay (LOS) in ICU (2.16 vs 2.53, p=0.02). CONCLUSION: The OPBH method seems to be safe, secure and effective in this population of very high-risk patients, reducing early complications and multi-organ failure. OPBH surgery, combining MECC without aortic cross-clamping, makes it possible to perform complete revascularization and is an interesting alternative for CABG in high-risk patients.

Freedom SOLO valve: early- and intermediate-term results of a single centre's first 100 cases.

OBJECTIVE: The Freedom SOLO aortic valve is a bovine pericardial stentless valve, which requires only one suture line. The aim of our single-centre retrospective study was to assess postoperative and intermediate-term haemodynamic results of the first 100 consecutively implanted valves. METHODS: One hundred patients (39 male and 61 female) underwent aortic valve replacement with a Freedom SOLO from November 2006 to January 2008. Their clinical, operative, platelet levels, echocardiography and follow-up data were prospectively recorded. All but two patients were available for follow-up (98% completeness), which averaged 12.6 ± 5.06 months. RESULTS: Associated procedures were performed in 38 patients (38%): 27 coronary artery bypass grafting (CABG), 11 mitral valve replacement, 11 septal myectomy and one ablation for atrial fibrillation. The mean age at the time of surgery was 77.2 ± 6.43 years. The mean European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 8.05 ± 2.07. Mean cross-clamp time of isolated valve replacements was 51.27 ± 4.7 min and 63.18 ± 21.7 min with associated procedures. The mean implanted valve size was 23.5 ± 1.9 mm. One patient was re-operated for bleeding, two for pericardial effusion and 39 were transfused. The overall hospital mortality was 3%. One patient died suddenly postoperatively, and a second due to a fatal atrio-ventricular block. A third patient died following a subdural bleed. Three patients required a pacemaker before hospital discharge. The overall patient survival was 97 ± 2.26% at 1 year. Echocardiographic results preoperative, 8 days postoperative and 12 months after surgery showed mean transvalvular gradients of 50.6 ± 15.3, 15.6 ± 5.2 and 11.5 ± 3.8 mm Hg, respectively, and mean left ventricular ejection fractions of 37.9 ± 10.2%, 44 ± 15.2% and 53.6 ± 10.4%. Effective orifice area index for valve sizes 19, 21, 23, 25 and 27 were 0.91 ± 0.08, 0.97 ± 0.1, 1.08 ± 0.07, 1.53 ± 0.12 and 1.57 ± 0.1cm(2)m(-2), respectively. There were three early non-structural dysfunctions (grade 1) of regurgitation, which remained stable at 12 months. CONCLUSIONS: Freedom SOLO valve has very good early- and intermediate-term results. Short implantation times and its haemodynamic performances, particularly in small diameters, allow us to use it by first intention in older and often sicker patients. These results must be confirmed by long-term outcomes.

Adjustment and characterization of an original model of chronic ischemic heart failure in pig.

We present and characterize an original experimental model to create a chronic ischemic heart failure in pig. Two ameroid constrictors were placed around the LAD and the circumflex artery. Two months after surgery, pigs presented a poor LV function associated with a severe mitral valve insufficiency. Echocardiography analysis showed substantial anomalies in radial and circumferential deformations, both on the anterior and lateral surface of the heart. These anomalies in function were coupled with anomalies of perfusion observed in echocardiography after injection of contrast medium. No demonstration of myocardial infarction was observed with histological analysis. Our findings suggest that we were able to create and to stabilize a chronic ischemic heart failure model in the pig. This model represents a useful tool for the development of new medical or surgical treatment in this field.

Echocardiographic analysis with a two-dimensional strain of chronic myocardial ischemia induced with ameroid constrictor in the pig.

Despite much progress in the medical management of myocardial ischemia, several problems remain and experimental models help to improve our understanding of the pathophysiology involved in this domain. The ameroid constrictor model is the most widely used to create ischemia but evaluation of patent ischemia is still under debate. In the present study, we describe the potential of a two-dimensional (2D) strain for experimentally evaluating myocardial ischemia in the pig. An ameroid constrictor was placed around the circumflex artery in 30 pigs. Angiography showed 90% stenosis at one and two months. Left ventricular function was moderately altered and associated with mitral valve insufficiency in 30% of cases. Longitudinal and circumference strains were dramatically modified in the ischemic inferior-lateral zone compared to the healthy anterior zone (P<0.01) at one and two months. We correlated these results to myocardial ischemia by using contrast echocardiography, which showed a significant reduction in myocardial perfusion in the ischemic zone compared to the uninjured area, and by using histological analysis. We showed that evaluation of the 2D strain could be an interesting approach for assessing myocardial ischemia after ameroid constrictor implantation. The 2D strain represents a useful tool for the evaluation of experimental models of myocardial ischemia.

Biventricular stimulation improves right and left ventricular function after tetralogy of Fallot repair: acute animal and clinical studies.

BACKGROUND: Optimal treatment of right ventricular (RV) dysfunction observed in patients after tetralogy of Fallot (TOF) repair is unclear. Studies of biventricular (BiV) stimulation in patients with congenital heart disease have been retrospective or have included patients with heterogeneous disorders. OBJECTIVE: The purpose of this study was to determine the effects on cardiac function of stimulating at various cardiac sites in an animal model of RV dysfunction and dyssynchrony and in eight symptomatic adults with repaired TOF. METHODS: Pulmonary stenosis and regurgitation as well as RV scars were induced in 15 piglets to mimic repaired TOF. The hemodynamic effects of various configurations of RV and BiV stimulation were compared with sinus rhythm (SR) 4 months after surgery. In eight adults with repaired TOF, RV and left ventricular (LV) dP/dt(max) were measured invasively during SR, apical RV stimulation, and BiV stimulation. RESULTS: At 4 months, RV dilation, dysfunction, and dyssynchrony were present in all piglets. RV stimulation caused a decrease in LV function but no change in RV function. In contrast, BiV stimulation significantly improved LV and RV function (P < .05). Echocardiography and epicardial electrical mapping showed activation consistent with right bundle branch block during SR and marked resynchronization during BiV stimulation. In patients with repaired TOF, BiV stimulation increased significantly RV and LV dP/dt(max) (P < .05). CONCLUSION: In this swine model of RV dysfunction and in adults with repaired TOF, BiV stimulation significantly improved RV and LV function by alleviating electromechanical dyssynchrony.

Intra-diaphragmatic pacemaker implantation in very low weight premature neonate.

Implantation of a pacemaker (PM) in very low weight premature neonates can be a challenging procedure because of the actual dimension of generators. Ideal placement of the PM is still controversial. We describe a technique of intra-diaphragmatic PM implantation in a 1.3 kg neonate.

Management of prosthetic heart valve obstruction: fibrinolysis versus surgery. Early results and long-term follow-up in a single-centre study of 263 cases.

Optimal management of prosthetic heart valve obstruction (PHVO) remains controversial even though surgery is usually recommended. To better define the efficacy and safety of fibrinolysis versus surgery in the pre- and post-transoesophageal echocardiography (TEE) eras. We analysed initial results and follow-up data from a large, retrospective, single-centre series, comparing fibrinolysis and surgery in patients with PHVO treated over 20 years. Two hundred and sixty-three consecutive episodes of PHVO in 210 patients, mainly left sided, were managed in our institution by either fibrinolysis (n=127) or surgery (n=136). Early clinical evolution was assessed in terms of haemodynamic success and complications. Concerning early results, there were no significant differences between the two groups in terms of mortality (10%). However, haemodynamic success was significantly more frequent in the surgical group (89% versus 70.9% p<0.001), embolic episodes were significantly more frequent in the fibrinolysis group (15% versus 0.7%, p<0.001), as were total complications (25.2% versus 11.1%, p=0.005). Long-term follow-up, with a mean duration of 6 years (range: 0-20), was obtained and showed significantly better results in the surgical group in terms of recurrence (p=0.021) and mortality (p=0.002). In univariate and multivariable analyses, NYHA functional class at presentation was a strong predictor of late death (p<0.01). Management of patients during the pre- and post-TEE eras was significantly different, since introduction of TEE surgery has become the preferred therapeutic strategy. Results of this extensive single-centre experience indicate that since the introduction of TEE, surgery is more frequently performed than fibrinolysis due to the improvement of thromboembolic risk assessment. Furthermore, prompt surgical treatment is associated with a better early success rate and a significantly lower incidence of complications than fibrinolysis in left-sided PHVO. However, fibrinolysis may be justified in selected cases. Long-term follow-up showed significantly better results in the surgical group in terms of recurrence and mortality.