Hybrid surgical ablation for persistent or long standing persistent atrial fibrillation: A French single centre experience.

BACKGROUND: Hybrid ablation for the treatment of atrial fibrillation is a single combined procedure consisting in a minimally thoracoscopic surgical ablation followed by a catheter ablation. This promising technique is recommended in persistent atrial fibrillation according to the current guidelines but is not routinely performed in France, mainly due to the absence of reimbursement by the French National Health Insurance. AIMS: The aim of this prospective and single-centre study was to analyse, for the first time in France, the feasibility, efficacy and complication rates of hybrid ablation in patients with persistent atrial fibrillation. METHODS: Hybrid ablation was performed in 15 consecutive patients (13 men, mean age 61±6 years) with persistent (7 patients) or long standing persistent (8 patients) atrial fibrillation. RESULTS: Hybrid ablation was completed in 14/15 patients. Eleven patients returned in sinus rhythm during the procedure. Two patients (13%) had major per-procedural complications and 2 had minor complications. During an average follow-up of 25±6 months, 6 patients (40%) underwent a redo catheter ablation because of atrial tachycardia, mainly peri-mitral atrial flutter. At 1 year follow up, 14/15 patients were in sinus rhythm, including 11 free of antiarrhythmic drugs.

Surgical site infection after valvular or coronary artery bypass surgery: 2008-2011 French SSI national ISO-RAISIN surveillance.

BACKGROUND: Multisite information regarding surgical site infection (SSI) rates for cardiac surgery programmes is not widely available. Ward characteristics that may affect outcomes have not been analysed previously. AIM: To determine individual- and ward-level factors associated with SSI occurrence after coronary artery bypass grafting (CABG) and valvular surgery. METHODS: A dataset from the French national SSI database ISO-RAISIN 2008-2011 was used. Only adult patients were included. A standardized questionnaire was completed for each patient who underwent surgery, and patients with and without SSI were characterized. Patients and ward risk factors for SSI were analysed using a multilevel logistic regression model with SSI as binary outcome (two levels: patient and ward). RESULTS: Out of 8569 patients from 39 wards, the SSI rate was 2.2%. Micro-organisms were isolated in 144 patients (74%): 35% coagulase-negative staphylococci (N = 51), 23% Staphylococcus aureus (N = 33), 6% Escherichia coli (N = 8). Higher probability of SSI was associated with the duration of preoperative hospitalization, the duration of follow-up, the duration of surgery >75th percentile and the SSI rate in the surgery ward. The residual heterogeneity between wards (median odds ratio: 1.53) was as relevant as duration of preoperative hospitalization (odds ratio: 1.57). CONCLUSION: Although patient risk factors were more strongly associated with SSI occurrence, this study provided evidence for the existence of a ward-level effect. This should be taken into account when considering possible corrective interventions.

[Cavernous haemangioma of the right atrium]. / Hémangiome caverneux de l'oreillette droite.

Cardiac haemangiomas are rare benign primitive tumors. We are reporting the case of a 67-year-old woman presenting with a haemangioma of the right atrium. This tumor was discovered by echocardiography because of cerebral strokes. The magnetic resonance imaging determined the characteristics of the tumor. It was completely resected through a right atrial approach. This was a round mobile mass, pediculed and implanted at the inferior area of the interatrial septum. The histopathological analysis revealed a cavernous haemangioma.

[Left ventricular assist devices in cardiogenic shock]. / Assistances circulatoires dans les chocs cardiogéniques.

Cardiogenic shock is the leading cause of in-hospital death for myocardial infarction. Despite therapeutic improvements, such as medical treatment with inotropes, myocardial revascularization, circulatory assistance can be an option. Intra-aortic balloon pumping is highly recommended in the presence of haemodynamic impairment. If the patient continues to deteriorate and cardiac function cannot maintain adequate circulation to prevent end-organ failure, several mechanical circulatory assist devices can be considered: extracorporeal membrane oxygenator (ECMO), Impella(®)… These devices should be used at tertiary centres either as bridge to recovery or as bridge to transplantation or as bridge to long-term left ventricle assist device.

Prognosis of perioperative myocardial infarction after off-pump coronary artery bypass surgery.

AIM: Perioperative myocardial infarction (PMI) is associated with long-term morbidity and mortality. CKMB cut-off level and importance of Q-wave MI have not been specifically studied after off-pump coronary artery bypass (OPCAB) surgery. The aim of this paper was to study the impact of PMI (CKMB >/= 20 times the upper normal limit [UNL] 100 mg/L) and CKMB rise (5-20 UNL) on survival and recurrent major adverse cardiac event (MACE) after OPCAB surgery. METHODS: One thousand consecutive prospectively followed OPCAB patients operated between September 1996 and March 2004 were analyzed. Follow-up was complete in 97% of the cohort. Average follow-up was 66 +/- 28 months. RESULTS: Overall and cardiac survival at 10 years was 70 +/- 2.6% and 88 + 2.3%, respectively. Evolving MI (EMI) occurred in 1.8%, postoperative non-Q MI (NQMI) in 1.3%, and Q-wave MI (QMI) in 2.0%. Operative mortality was higher in PMI patients (P < 0.001). After adjusting for risk factors, survivors of EMI (HR: 2.0) and QMI (HR: 2.3) but not NQMI had a lower life expectancy and a higher long-term cardiac mortality (EMI: HR: 3.5; QMI: HR: 4.3) compare to non-PMI patients. EMI and QMI were associated with a decrease MACE-free survival. CKMB 5-10 UNL did not affect overall and cardiac mortality. CKMB 10-20 UNL was associated to lower cardiac survival. CONCLUSIONS: PMI (CKMB > 20 UNL) was a strong predictor of operative mortality. QMI and EMI were predictors of long-term mortality and cardiac morbidity after OPCAB surgery. CKMB 10-20 UNL affected long-term cardiac survival but not overall survival.

[Mitral regurgitation associated with Wegener's granulomatosis]. / Insuffisance mitrale et maladie de Wegener.

BACKGROUND: Wegener's granulomatosis (WG) is a granulomatous disease that can affect many organ systems. The most frequently involved organs include the upper and lower respiratory tract as well as the kidney. Cardiac involvement is rare. METHODS: We report the case of a patient with grade 4 mitral insufficiency associated with severe WG. RESULTS: Surgical analysis of the mitral valve revealed perforation of the anterior leaflet without evidence of endocarditis. Pathological examination of the anterior mitral leaflet revealed myxoid degeneration nodules and bacteriological examination was negative. As the perforated lesion was very close to the free margin of the anterior leaflet, valve replacement appeared a reasonable surgical option in a poor surgical candidate. Six months after the operation, the patient is doing well. CONCLUSION: Wegener's granulomatosis is an autoimmune necrotizing vasculitis that can affect many organ systems. Cardiac involvement is rare. Heart in his globality can be affected by WG in many different ways. Cardiac valvular involvement in WG is rare. The aortic valve seems to be more frequently affected. Cardiologic investigations should have an important place at diagnosis and supervision.

Aorto-enteric fistula after endovascular abdominal aortic aneurysm repair: case report and review.

OBJECTIVE: To report a case and to review previous publications regarding the rare complication of aorto-enteric fistula following endovascular aortic aneurysm repair. METHODS: We report the case of a stent-graft infection secondary to an aorto-enteric fistula 14 months after uncomplicated endovascular treatment of an infra-renal aortic aneurysm. RESULTS: The surgical treatment involved the removal of the infected graft and in situ aortic replacement by cryopreserved allograft. There have been no major complications noted during the 2-month follow-up after surgery. CONCLUSIONS: An aortojejunal fistula is a possible long-term complication of endovascular treatment of abdominal aortic aneurysm. An explantation of the infected graft and aortic replacement by a cryopreserved allograft is a valuable surgical treatment.

[Late complications of a pseudo aneurysm of the left ventricle: thrombus infection and purulent pericarditis]. / Complications tardives d'un faux anévrisme du ventricule gauche: infection du thrombus et péricardite purulente.

Pseudoaneurysm is a rare complication of left ventricle myocardial infarction. Rupture with tamponade and sudden death is the usual outcome. Surgical intervention remains the treatment of choice. Long term survival cases without surgery are rare. Infection of the thrombus is also a possible event. We report the case of a patient with postinfarction left ventricular pseudoaneurysm complicated by infection of the thrombus and purulent pericarditis involving a peptostreptococcus. Infection must be considered a potential complication of left ventricular pseudoaneurysms.

Endovascular treatment of thoracic dissection.

Type A aortic dissection remains fatal if untreated. Although classical medical therapy for type B dissection is considered the therapy of choice in uncomplicated cases, the paradigm is changing as greater experience is accrued with endovascular treatments and technical advances improve the long-term outlook. Diagnosis is also becoming more sophisticated, allowing greater appreciation of the anatomy of dissections and improving the knowledge base as their natural history is assessed.

[Endografts (or stent-grafts) and diseases of the descending thoracic aorta]. / Endoprothèses (ou stent-grafts) et pathologies de l'aorte thoracique descendante.

The endovascular treatment of aorta diseases with S-Graft is considered as an alternative to surgery, especially interesting in patients with severe comorbidities. Indeed, the mid-term morbidity and mortality are comparable to surgery in relatively large series, and S-Graft implantation appeared as a safe, less invasive and efficient treatment for different affections of the thoracic aorta. This article reviews technical aspects, indications and results of endovascular repairs of thoracic aorta lesions. We will also assess the advantages and limitations of S-Graft therapy.

Chronic vascular rejection: histologic comparison between two murine experimental models.

BACKGROUND: We previously developed an experimental model to study chronic vascular rejection (CVR) in mice, the orthotopic aortic allograft. More recently we performed human arterial grafts into SCID/Beige mice reconstituted with human spleen cells. We report herein the differences in CVR lesions. MATERIAL AND METHODS: In the first model, recipient mice were C57BL/6 (H-2b), and donor mice were DBA/2 (H-2d). In the second model, terminal branches of the human superior mesenteric artery were transplanted into SCID/Beige mice in the infrarenal aorta. Human immune reconstitution was achieved by a single intraperitoneal injection of 30 x 10(6) human spleen cells. The presence of human lymphocytes and IgG was verified weekly. In both models, the vascular grafts were inserted in the infrarenal aortic position using the sleeve technique. The transplanted mice were sacrificed at 35 days after the operation. The grafts were analyzed by histology and morphometry. The mean intimal thickening was calculated based on transverse sections at 0.1-mm intervals. RESULTS: Typical CVR lesions developed with neointimal thickening, T-cell infiltration, and smooth muscle cell (SMC) proliferation in both models. In the mouse aortic model, disappearance of SMC in the media was noted in contrast to human arterial transplants, where the media remained intact. CONCLUSION: Other groups have noted that arteries conserve their media in clinical organ transplants. From this point of view, the lesions in the second experimental model (human arteries) better reflect the pathology of CVR in clinical transplantation than the murine aortic transplant model.

Human immune reconstitution with spleen cells in SCID/Beige mice.

BACKGROUND: We developed an original experimental model to study chronic vascular rejection (CVR) consisting of a graft of human mesenteric artery followed by human immune reconstitution into CB.17 SCID/Beige mice. Human immune reconstitution achieved after human PBMC injection has often been variable and incomplete. The aim of this work was to develop an alternative method to achieve a complete, functional human immune reconstitution. METHOD: After institutional authorizations, spleen cells were recovered from cadaveric organ donors. Single intraperitoneal injections of various doses of spleen cells were made into 70 CB.17 SCID/Beige mice. Reconstitution of the human immune system was monitored by flow cytometry (circulating human cells) and ELISA (human IgG). Colonization of murine lymphoid organs by human cells was studied by immunohistochemistry and flow cytometry. Evaluation of the immune function consisted of examination of CVR lesions in human arterial grafts. The animals were humanely killed at day 28. RESULTS: After injection of 30 to 40 x 10(6) spleen cells, the mice showed significant human CD3(+), CD19(+), and CD56(+) populations in peripheral blood. The mean human cells levels were, respectively, 8.2% +/- 5.4%, 2.9% +/- 1.2%, and 5.3% +/- 5.1%. Murine spleen and mesenteric lymph nodes were colonized by human T and B cells, while the murine thymus was only colonized by human T cells. Human IgG was detected in murine serum (65.9 +/- 63.3 mg/L) and typical CVR lesions were observed within the allogeneic grafts. CONCLUSION: Intraperitoneal injection of 30 to 40 x 10(6) human spleen cells into CB.17 SCID/Beige mice induces complete and functional human immune reconstitution allowing the study of CVR under human allogeneic conditions.

Stent-graft repair of thoracic aortic aneurysms.

Endovascular treatment of aortic disease has emerged as an alternative mode of treatment that is particularly attractive for patients with severe comorbidities who would not be ideal candidates for open surgery. Actually, short-term morbidity and mortality rates, of large series, compare favorably with those from surgery, and stent-graft placement is proving to be a safe, minimally invasive, and effective treatment for thoracic aortic diseases. However, although endoluminal interventions are minimally invasive, they are associated with complications, as are surgical methods. In this article, indications, technical aspects, and results of endovascular TAA repairs will be reviewed. We will also examine the advantages and limitations of stent-graft treatment. Finally, we will discuss the management of complications following aortic stent-graft implantation. We intentionally do not cover the topic of thoracic dissection, as it is being covered in another article in this volume.

Reconstitution of a human immune system in immunodeficient mice: models of human alloreaction in vivo.

Rodents have been widely used for studies in transplantation immunology because of their short reproduction period and the relative ease of generating inbred mutant or transgenic strains. However, although many biological mechanisms are similar between rodents and humans, several features clearly distinguish the immune system in these species. Consequently, it is rarely possible to extrapolate observations from rodent models directly into clinical practice. In vitro studies with human cells are useful for elucidation of basic mechanisms, but in order to study complex biological phenomena, in vivo studies are indispensable. In later years, a number of interesting models have been described where immunodeficient mice have been reconstituted with human cells, so-called humanized mice, in order to study human immune responses in vivo. This has opened a new field of experimental immunology that has been applied to areas such as cancer, autoimmunity, allergy, infections, and transplantation biology. In this review, we shall concentrate on the use of severe combined immunodeficient mice reconstituted with human immune or stem cells for studies of human alloreaction in vivo.

Acute traumatic aortic rupture: a comparison of surgical and stent-graft repair.

OBJECTIVE: The study's objective was to comparatively evaluate surgery and stent-graft repair of acute or subacute traumatic aortic rupture. METHODS: A total of 76 patients (14-76 years old; mean, 37 years; male/female ratio, 63/11) with a traumatic aortic injury were admitted to our hospital between 1981 and 2003. Six patients died within 1 to 9 days of another associated severe traumatic lesion. The 70 remaining patients were divided according to the type of rupture repair. In group 1, 35 patients were treated surgically: 28 with immediate repair and 7 with delayed repair (average time interval 66 days, 5-257 days). In group 2, 29 patients were treated with stent grafting of the aortic isthmus. In group 3, 6 patients with minor aortic lesions were treated medically with a close follow-up. RESULTS: In the 28 patients treated surgically in the emergency department, the mortality and paraplegia rates were 21% and 7%, respectively. No death or paraplegia was observed in the group with delayed surgical repair. With stent grafting, complete exclusion of the pseudoaneurysmal sac was observed in all patients. Except for 1 iliac rupture treated during the same procedure, there was no major morbidity or mortality during the mean follow-up of 46 months (13-90 months). No major complication was observed in group 3. CONCLUSIONS: In stable rupture of the aorta, initial conservative treatment is safe and allows management of the major associated lesions. Stent grafting of the aortic isthmus is a valuable therapeutic alternative to surgical repair, especially in patients considered high risk for conventional thoracotomy.

Use of human mesenteric arteries to study chronic vascular rejection in SCID/beige mice reconstituted with human spleen cells.

We wanted to establish a preclinical model of chronic vascular rejection (CVR) by transplanting small arteries from the mesentery of cadaveric organ donors by the rapid "sleeve" technique into SCID/beige mice reconstituted with human allogeneic spleen cells. After institutional authorization and with informed consent from relatives, we obtained tissues and cells from cadaveric organ donors. A piece of mesentery was recovered from the donor and kept in buffered solution at 4 degrees C until use. After dissection of the mesentery, small arteries of suitable size were transplanted in place of the infrarenal aorta of the mice. Cells for the immunological reconstitution of the mice were spleen cells from the same or other organ donors. Twenty-three suitable arterial segments were obtained from the mesentery of three cadaveric donors. Ten of the mice received 3 x 10(7) human spleen cells intraperitoneally 1 week after the arterial graft and they all showed circulating human CD3+ and CD19+ cells 2 weeks after injection. The mice were sacrificed 5 weeks after the arterial graft. SCID/beige mice reconstituted with allogeneic spleen cells showed a typical CVR, whereas mice that received no cells had a normal vascular anatomy. We believe our model is well suited for the study of treatment of CVR under human allograft conditions.

[Transhepatic percutaneous embolisation of a post-traumatic pseudoaneurysm of hepatic artery]. / Embolisation transhépatique percutanée d'un pseudoanévrisme post-traumatique de l'artère hépatique.

Pseudoaneurysm of the hepatic artery is a rare complication of blunt abdominal trauma. We report a case of post-traumatic pseudoaneurysm diagnosed several months after the initial traumatism in a 18-year-old man who presented recurrent abdominal pain. This pseudoaneurysm was successfully treated by association of both classical endovascular treatment and transhepatic percutaneous embolization.

[Towards a new management of acute traumatic aortic ruptures]. / Vers une nouvelle prise en charge des ruptures traumatiques aiguës de l'isthme aortique.

PURPOSE: The aim of this study was to evaluate the feasibility and safety of endovascular repair in acute traumatic aortic rupture on the basis of our experience with 16 patients. MATERIALS AND METHODS: From January 1996 to December 2001,16 patients, with a mean age 36 years, underwent repair of traumatic rupture of the aorta with the use of stent-grafts. All patients presented with coexisting injuries and 9 of 16 patients were hemodynamically unstable because of other injury. After a delay ranging from 9 to 245 days (mean 78 days), aortic stent-grafting was performed by a multidisciplinary team. All patients had regular follow-up with spiral CT and transesophageal echocardiogram. RESULTS: Stent-graft placement was successful in all patients with exclusion of false aneurysm. The duration of the procedure was about 120 min and mechanical respiratory assistance could be removed immediately in 80% of patients. Mean stay in the intensive care unit was 24 hours. One complication was noted: compression of the left main stem bronchus successfully treated with endoprosthesis. Maximum follow-up was 7 years. CONCLUSION: Endovascular stent-graft repair is a valuable technique and is emerging as an alternative technique for treating thoracic aortic injury in patients in whom coexisting injury increases the surgical risk.

[Leiomyosarcoma of the inferior vena cava]. / Léiomyosarcome de la veine cave inférieure.

Leiomyosarcoma of the inferior vena cava is a rare tumor of mesenchymal origin most commonly found in women. Clinical signs are non-specific. Imagery with ultrasound, CT, or MRI may strongly suggest the diagnosis, but it can only be confirmed by histologic examination of tissue obtained pre or intra-operatively. The tumor is slow growing but nonetheless carries a bad prognosis; it may grow to a large size before directly invading adjacent structures. Systemic spread is a late occurrence. Radical surgical resection is the only treatment which offers any hope for prolonged survival. Standard vascular surgical techniques are usually sufficient. Progress in the techniques of hepatectomy and liver transplantation have allowed the experienced surgeon to undertake the removal of retrohepatic lesions once considered unresectable. High-lying lesions adjacent to the hepatic veins or with thrombus extending into the proximal vena cava may require extracorporeal circulation with or without profound hypothermic circulatory arrest. The efficacy of chemotherapy, whether pre-operative for inaccessible tumors or post-operative for incompletely resected or recurrent tumor, is poorly defined and very limited.