[Right aortic arch with mirror image branching : a rare cause of dysphagia]. / L'image du mois. Arc aortique droit avec image en miroir : une cause rare de dysphagie.

We report the case of a 36-year-old female whose dysphagia revealed a congenital anomaly of the thoracic aorta: the right aortic arch with mirror image branching. This is a rare embryonic developmental anomaly where the aorta wraps around the right bronchus and the supra-aortic trunks emerge from the arch in the opposite order to normal. Most of the patients are asymptomatic unless there is a significant compression of mediastinal structures. Major compression of the esophagus or trachea, aneurysmal disease, dissection of the thoracic aorta, or the presence of a Kommerell diverticulum larger than 2 cm may require a surgical repair. There is no standard treatment and it must be adapted to the clinical presentation and the anatomic configuration of each patient. Our patient did not receive any treatment for her condition.

Nous rapportons le cas d'une patiente de 36 ans dont le tableau de dysphagie a permis de mettre en évidence une anomalie congénitale de l'aorte thoracique : l'arc aortique droit avec image en miroir. Il s'agit d'une anomalie de développement embryonnaire rare où l'aorte s'enroule autour de la bronche souche droite et où les troncs supra-aortiques émergent de la crosse dans l'ordre inverse et opposé à la normale. La grande majorité des patients est asymptomatique, à moins qu'il existe une compression des structures médiastinales. Une compression majeure de l'oesophage ou de la trachée, une maladie anévrismale, une dissection de l'aorte thoracique ou la présence d'un diverticule de Kommerell de plus de 2 cm peuvent justifier une sanction chirurgicale. Il n'y a pas de traitement standard et celui-ci doit être adapté à la présentation clinique et à la configuration anatomique du patient. Notre patiente n'a bénéficié d'aucun traitement pour son affection.

Off-Label Use of COR-KNOT Automated Fastener for Manual Bronchial Closure Through a Video-Assisted Thoracoscopic Surgery Approach.

Manual closure of the bronchial stump can be challenging during minimally invasive thoracic surgery. An automated fastener has been used for more than a decade in minimally invasive heart valve surgery to eliminate the need for manual knot tying during the suturing of prosthetic valves. Herein, we describe the use of the COR-KNOT automated fastener (LSI SOLUTIONS®, Victor, NY, USA) in a case of video-assisted left upper lobectomy with open section of the bronchus and manual closure with interrupted resorbable sutures for a malignant bronchial tumor located on the proximal part of the left upper lobe bronchus. This case represents, to our knowledge, the first case using the COR-KNOT device for minimally invasive pulmonary surgery.

[Aortic valve repair surgery : state of the art and clinical experience of the university hospital center of Liege]. / Chirurgie de réparation de la valve aortique : statut actuel de la technique et expérience clinique du CHU de Liège.

In the past 20 years, there has been a real development of aortic valve repair techniques with an increasing number of publications describing the long-term benefits of aortic valve repair in terms of survival, freedom from major adverse valve related-events and reoperations. Aortic valve repair can now be considered as a valuable alternative to prosthetic valve replacement in patients with dystrophic ascending aorta pathology associated or not to aortic insufficiency with pliable leaflets. In this paper, the authors describe the state of the art of aortic valve repair and present their clinical experience with aortic valve repair surgery in the university hospital center of Liege from April 2021 to September 2022.

Les techniques de réparation de la valve aortique se sont considérablement développées ces 20 dernières années. Plusieurs publications confirment les bénéfices à long terme de ces techniques en termes de survie, d'absence de complications majeures et de réinterventions pour récidive d'insuffisance aortique. La réparation de la valve aortique apparaît ainsi comme une véritable alternative au remplacement valvulaire aortique prothétique chez certains patients qui présentent une pathologie dystrophique de l'aorte ascendante associée ou non à une insuffisance aortique sur valve souple. Dans cet article, les auteurs parcourent la littérature actuelle sur le sujet et décrivent leur expérience clinique avec la chirurgie de réparation de la valve aortique au sein du centre hospitalier universitaire de Liège d'avril 2021 à septembre 2022.

Cardiac Biomarkers and Prediction of Early Outcome After Heart Valve Surgery: A Prospective Observational Study.

OBJECTIVES: Circulating cardiac biomarkers may improve the prediction of long-term outcomes after cardiac surgery. The authors sought to assess if cardiac biomarkers also help better predict short-term morbidity. DESIGN: Prospective observational study. SETTING: Single academic hospital. PARTICIPANTS: A total of 250 patients undergoing aortic or mitral valve surgery with or without associated coronary artery bypass grafts. INTERVENTION: None MEASUREMENT AND MAIN RESULTS: Relationships between preoperative plasma concentrations of four cardiac biomarkers (sST2, Galectin-3, GDF-15, and NT-proBNP) and postoperative outcome were assessed using logistic regressions and Cox proportional hazards models. The primary outcome was a composite of 30-day mortality, an inotropic support longer than 48 hours and an initial length of stay in the intensive care >five days. Secondary outcome measures were postoperative acute kidney injury, inotropic support duration, lengths of intensive care unit and hospital stays, and 30-day and one-year mortality. No association was observed between any of the four cardiac biomarkers and the primary outcome. The preoperative levels of Galectin-3 (hazard ratio = 1.2; p < 0.001) and sST2 (hazard ratio = 1.01, p < 0.001) were significantly associated with one-year survival, and their addition to the EuroSCORE II significantly improved the prediction of one-year mortality (p < 0.001). Similarly, Galectin-3 was associated with postoperative acute kidney injury (odds ratio = 1.15, p = 0.001) and improved the prediction of this complication when added to the EuroSCORE II (p = 0.002). CONCLUSIONS: These results suggested that the ability of cardiac biomarkers to predict short-term outcome after cardiac surgery, though of interest, appears limited. Conversely, cardiac biomarkers may have the potential to refine the prediction of long-term outcome. Admittedly, all positive results were obtained on secondary outcomes and must be regarded with caution.

Mycotic aneurysm of the ascending aorta due to Escherichia coli: a case report.

Ascending aorta mycotic aneurysm is a rare entity. It is a life-threatening condition because of the possibility of aortic dissection, or rupture. Escherichia coli is recognised as an uncommon cause of aortic mycotic aneurysm. An 81-year-old woman with a history of Escherichia coli pyelonephritis 4 months previously, was admitted to our centre for a mycotic aneurysm of the ascending aorta caused by Escherichia coli. She was successfully treated by urgent in situ replacement of the ascending aorta with a cryopreserved homograft, combined with antibiotics. Although infrequent, Escherichia coli mycotic aneurysm should be suspected in older patients with atherosclerosis and who developed septicaemia. Prompt treatment with a combination of appropriate antibiotics and surgery is required.

Early Conduction Disorders After Aortic Valve Replacement With the Sutureless Perceval Prosthesis.

BACKGROUND: This study was conducted to determine the incidence of postoperative conduction disorders and need for pacemaker (PM) implantation after aortic valve replacement (AVR) with the Perceval prosthesis (Livanova, Saluggia, Italy). METHODS: From January 2007 to December 2017, 908 patients underwent AVR with Perceval S in 5 participating centers. Study end points focused on electrocardiographic changes after AVR and the incidence of new PM implantation in 801 patients after exclusion of patients with previous PM (n = 48) or patients undergoing tricuspid (n = 28) and/or atrial fibrillation ablation (n = 31) surgery. Logistic regression analysis was performed to determine risk factors for PM need. RESULTS: Mean age was 79.7 ± 5.2 years, and 476 (59.4%) were women. Median logistic European System for Cardiac Operative Risk Evaluation (2011 revision) score was 4.1% (interquartile range, 2.6%-6.0%). Isolated AVR was performed in 441 patients (55.1%). Associated procedures were coronary artery bypass grafting in 309 (38.6%) and mitral valve surgery in 51 (6.4%). Overall 30-day mortality was 3.9% and was 2.8% for isolated AVR. Electrocardiographic changes included a significant increase of left bundle branch block from 7.4% to 23.7% (P < .001) and development of complete atrioventricular block requiring PM implantation in 9.5%. Multivariable analysis revealed independent of a learning period (odds ratio [OR], 1.91; 95% confidence limits (CL), 1.16-3.13; P = .011), preexisting right-bundle branch block (OR, 2.77; 95% CL, 1.40-5.48; P = .003), intraoperative prosthesis repositioning (OR, 6.70; 95% CL, 1.89-24.40; P = .003), and size extra large (OR, 6.81; 95% CL, 1.55-29.96; P = .011) as significant predictors of PM implantation. CONCLUSIONS: In a challenging elderly population, use of the Perceval S for AVR provides low operative mortality but at the risk of an increased PM implantation rate. Besides preexisting right bundle branch block, the significant effect of size extra large, an increased valve size/body surface area ratio, and need for intraoperative repositioning on PM rate are underscoring the reappraisal of the annular sizing policy.

Pregnancy and delivery in a patient with a Fontan circulation and primary ciliary dyskinesia: A case report.

A patient had primary ciliary dyskinesia with a complex cardiac malformation. As a child, she had benefited from a Fontan surgery to maintain a proper cardiac function. In such patients, whether it is safe to become pregnant is controversial. This case illustrates the possibility of carrying a pregnancy to term and providing a vaginal birth if a rigorous preconception consultation is performed to ensure care by a multidisciplinary specialized team, and the patient is properly informed of the risks.

Recurrent cardiac intimal sarcoma misdiagnosed as a myxoma or malignant transformation of a cardiac myxoma?

Cardiac intimal sarcoma is extremely rare and aggressive primary malignant cardiac tumors. Here, we reported the case of a young man initially operated for a tumor of the left atrium, causing a dynamic obstruction of the mitral valve and (mis-)diagnosed as a myxoma at the histopathological analysis. Patient presented a local recurrence at 3 months and was reoperated. Pathology revealed this time the presence of an intimal sarcoma. Patient received adjuvant chemotherapy. Despite a good local control, the 1-year follow-up positron emission tomography scan revealed the presence of a metastasis in the left adrenal gland that was surgically resected. This article aims to highlight the risk of misdiagnosis in case of cardiac tumors, the hypothetical concept of malignant transformation of a cardiac myxoma, the aggressive course of the extremely rare cardiac intimal sarcoma, and the therapeutic modalities available to treat this pathology.

Mechanical strain induces a pro-fibrotic phenotype in human mitral valvular interstitial cells through RhoC/ROCK/MRTF-A and Erk1/2 signaling pathways.

The mitral valve is a complex multilayered structure populated by fibroblast-like cells, valvular interstitial cells (VIC) which are embedded in an extracellular matrix (ECM) scaffold and are submitted to the mechanical deformations affecting valve at each heartbeat, for an average of 40 million times per year. Myxomatous mitral valve (MMV) is the most frequent heart valve disease characterized by disruption of several valvular structures due to alterations of their ECM preventing the complete closure of the valve resulting in symptoms of prolapse and regurgitation. VIC and their ECM exhibit reciprocal dynamic processes between the mechanical signals issued from the ECM and the modulation of VIC phenotype responsible for ECM homeostasis of the valve. Abnormal perception and responsiveness of VIC to mechanical stress may induce an inappropriate adaptative remodeling of the valve progressively leading to MMV. To investigate the response of human VIC to mechanical strain and identify the molecular mechanisms of mechano-transduction in these cells, a cyclic equibiaxial elongation of 14% at the cardiac frequency of 1.16 Hz was applied to VIC by using a Flexercell-4000 T™ apparatus for increasing time (from 1 h to 8 h). We showed that cyclic stretch induces an early (1 h) and transient over-expression of TGFß2 and αSMA. CTGF, a profibrotic growth factor promoting the synthesis of ECM components, was strongly induced after 1 and 2 h of stretching and still upregulated at 8 h. The mechanical stress-induced CTGF up-regulation was dependent on RhoC, but not RhoA, as demonstrated by siRNA-mediated silencing approaches, and further supported by evidencing RhoC activation upon cell stretching and suppression of cell response by pharmacological inhibition of the effector ROCK1/2. It was also dependent on the MEK/Erk1/2 pathway which was activated by mechanical stress independently of RhoC and ROCK. Finally, mechanical stretching induced the nuclear translocation of myocardin related transcription factor-A (MRTF-A) which forms a transcriptional complex with SRF to promote the expression of target genes, notably CTGF. Treatment of stretched cultures with inhibitors of the identified pathways (ROCK1/2, MEK/Erk1/2, MRTF-A translocation) blocked CTGF overexpression and abrogated the increased MRTF-A nuclear translocation. CTGF is up-regulated in many pathological processes involving mechanically challenged organs, promotes ECM accumulation and is considered as a hallmark of fibrotic diseases. Pharmacological targeting of MRTF-A by newly developed inhibitors may represent a relevant therapy for MMV.

Outcomes of Patients With Asymptomatic Aortic Stenosis Followed Up in Heart Valve Clinics.

Importance: The natural history and the management of patients with asymptomatic aortic stenosis (AS) have not been fully examined in the current era. Objective: To determine the clinical outcomes of patients with asymptomatic AS using data from the Heart Valve Clinic International Database. Design, Setting, and Participants: This registry was assembled by merging data from prospectively gathered institutional databases from 10 heart valve clinics in Europe, Canada, and the United States. Asymptomatic patients with an aortic valve area of 1.5 cm2 or less and preserved left ventricular ejection fraction (LVEF) greater than 50% at entry were considered for the present analysis. Data were collected from January 2001 to December 2014, and data were analyzed from January 2017 to July 2018. Main Outcomes and Measures: Natural history, need for aortic valve replacement (AVR), and survival of asymptomatic patients with moderate or severe AS at entry followed up in a heart valve clinic. Indications for AVR were based on current guideline recommendations. Results: Of the 1375 patients included in this analysis, 834 (60.7%) were male, and the mean (SD) age was 71 (13) years. A total of 861 patients (62.6%) had severe AS (aortic valve area less than 1.0 cm2). The mean (SD) overall survival during medical management (mean [SD] follow up, 27 [24] months) was 93% (1%), 86% (2%), and 75% (4%) at 2, 4, and 8 years, respectively. A total of 104 patients (7.6%) died under observation, including 57 patients (54.8%) from cardiovascular causes. The crude rate of sudden death was 0.65% over the duration of the study. A total of 542 patients (39.4%) underwent AVR, including 388 patients (71.6%) with severe AS at study entry and 154 (28.4%) with moderate AS at entry who progressed to severe AS. Those with severe AS at entry who underwent AVR did so at a mean (SD) of 14.4 (16.6) months and a median of 8.7 months. The mean (SD) 2-year and 4-year AVR-free survival rates for asymptomatic patients with severe AS at baseline were 54% (2%) and 32% (3%), respectively. In those undergoing AVR, the 30-day postprocedural mortality was 0.9%. In patients with severe AS at entry, peak aortic jet velocity (greater than 5 m/s) and LVEF (less than 60%) were associated with all-cause and cardiovascular mortality without AVR; these factors were also associated with postprocedural mortality in those patients with severe AS at baseline who underwent AVR (surgical AVR in 310 patients; transcatheter AVR in 78 patients). Conclusions and Relevance: In patients with asymptomatic AS followed up in heart valve centers, the risk of sudden death is low, and rates of overall survival are similar to those reported from previous series. Patients with severe AS at baseline and peak aortic jet velocity of 5.0 m/s or greater or LVEF less than 60% have increased risks of all-cause and cardiovascular mortality even after AVR. The potential benefit of early intervention should be considered in these high-risk patients.

Lung-resident eosinophils represent a distinct regulatory eosinophil subset.

Increases in eosinophil numbers are associated with infection and allergic diseases, including asthma, but there is also evidence that eosinophils contribute to homeostatic immune processes. In mice, the normal lung contains resident eosinophils (rEos), but their function has not been characterized. Here, we have reported that steady-state pulmonary rEos are IL-5-independent parenchymal Siglec-FintCD62L+CD101lo cells with a ring-shaped nucleus. During house dust mite-induced airway allergy, rEos features remained unchanged, and rEos were accompanied by recruited inflammatory eosinophils (iEos), which were defined as IL-5-dependent peribronchial Siglec-FhiCD62L-CD101hi cells with a segmented nucleus. Gene expression analyses revealed a more regulatory profile for rEos than for iEos, and correspondingly, mice lacking lung rEos showed an increase in Th2 cell responses to inhaled allergens. Such elevation of Th2 responses was linked to the ability of rEos, but not iEos, to inhibit the maturation, and therefore the pro-Th2 function, of allergen-loaded DCs. Finally, we determined that the parenchymal rEos found in nonasthmatic human lungs (Siglec-8+CD62L+IL-3Rlo cells) were phenotypically distinct from the iEos isolated from the sputa of eosinophilic asthmatic patients (Siglec-8+CD62LloIL-3Rhi cells), suggesting that our findings in mice are relevant to humans. In conclusion, our data define lung rEos as a distinct eosinophil subset with key homeostatic functions.

New biomarkers for primary mitral regurgitation.

BACKGROUND: Mitral regurgitation is a frequent valvular heart disease affecting around 2.5 % of the population with prevalence directly related to aging. Degeneration of mitral valve is broadly considered as a passive ongoing pathophysiological process and little is known about its physiological deregulation. The purpose of this study was to highlight new biomarkers of mitral regurgitation in order to decipher the underlying pathological mechanism as well as to allow the diagnosis and the monitoring of the disease. RESULTS: Modulation of various blood proteins expression was examined in patients suffering from different grades of mitral regurgitation (mild, moderate and severe) compared to healthy controls. To this end, several routine clinical assays and the multi analyte profile technology targeting 184 proteins were used. High-density lipoprotein, apolipoprotein-A1, haptoglobin and haptoglobin-α2 chain levels significantly decreased proportionally to the degree of mitral regurgitation when compared to controls. High-density lipoprotein and apolipoprotein-A1 levels were associated with effective regurgitant orifice area and regurgitant volume. Apolipoprotein-A1 was an independent predictor of severe mitral regurgitation. Moreover, with ordinal logistic regression, apolipoprotein-A1 remained the only independent factor associated with mitral regurgitation. In addition, myxomatous mitral valves were studied by immunocytochemistry. We observed an increase of LC3, the marker of autophagy, in myxomatous mitral valves compared with healthy mitral valves. CONCLUSION: These potential biomarkers of mitral regurgitation highlighted different cellular processes that could be modified in myxomatous degenerescence: reverse cholesterol transport, antioxidant properties and autophagy.