Three-dimensional computed tomography angiography of the pulmonary veins and their anatomical variations: involvement in video-assisted thoracoscopic surgery-lobectomy for lung cancer.

BACKGROUND: Identification and section of pulmonary veins are an essential part of anatomical pulmonary resections. Intraoperative misunderstandings of pulmonary venous anatomy can lead to serious complications such as bleeding and delayed lung infarction or necrosis. We evaluated principally the rate of pulmonary veno-us anatomical variations, and secondarily the reliability and clinical outcomes of a preoperative morphological analysis. MATERIALS AND METHODS: Between November 2012 and October 2013, we studied 100 consecutive patients with highly suspected or diagnosed stage I-II primitive lung cancer lesion. The surgical procedure initially retained was video-assisted thoracoscopic surgery (VATS) pulmonary resections and we studied preoperatively the proximal pulmonary venous anatomy using 64 channels multi- -detector computed tomography (CT)-scan angiography to describe the venous anatomical variations. RESULTS: There were 65 men and 35 women with a mean age of 63 years. A pulmonary venous anatomical variation was present in 36 (36%) patients, and right-sided anatomical variations were more frequent than on left-sided ones (25% vs. 11%). The most frequent variation encountered on the right side was the existence of three separate pulmonary veins (16%), and on the left side a single pulmonary vein (8%). Surgical conversion occurred in 21% and we didn't experience a pulmonary venous lesion (0%) or a post-operative lung infarction (0%). CONCLUSIONS: We described pulmonary venous anatomical variations and their frequency. Anatomical variations exist and preoperative assessment of pulmo-nary venous anatomy using CT scan is a useful tool in VATS lobectomy to avoid unnecessary extension of pulmonary resections or iatrogenic complications in lung cancer surgery.

Remote patient monitoring for chronic heart failure in France: When an innovative funding program (ETAPES) meets an innovative solution (Satelia® Cardio).

Introduction: Remote patient monitoring (RPM) is a telehealth activity to collect and analyze patient health or medical data. Its use has expanded in the past decade and has improved medical outcomes and care management of non-communicable chronic diseases. However, implementation of RPM into routine clinical activities has been limited. The objective of this study was to describe the French funding program for RPM (known as ETAPES) and one of the RPM solution providers (Satelia®) dedicated to chronic heart failure (CHF). Methods: A descriptive assessment of both the ETAPES funding program and Satelia® RPM solution was conducted. Data were collected from official legal documents and information that was publicly available online from the French Ministry of Health. Results and Discussion: ETAPES was formally created in 2016 based on previous legislation pertaining to the national health insurance funding strategy. However, it only started to operate in 2018. Patients with CHF were only eligible if they were at medium or high risk of re-hospitalization with a New York Heart Association (NYHA) score superior or equal to two and a BNP>100 pg/ml or NT pro BNP>1000 pg/ml. Medical monitoring was supported through the therapeutic education of a patient on the RPM model of care with a minimum of three training sessions during the first six months. The use of Satelia® Cardio is noteworthy since it relies only on symptomatic monitoring through which the patient manually reports their information by answering a simple questionnaire on a regular basis and does not rely on any connected devices. Conclusion: Innovative funding programs and solutions for RPM need real-world evaluation in the future.

A role for CD4+ and CD8+ cells and not for CD25+ cells in the control of Plasmodium berghei Anka blood stage parasites in rats.

In previous studies of the infection of rats by P. berghei Anka, we have shown that primary blood stage infection induced the expansion of CD4+ T cells and CD8+ T cells in adult resistant rats while the number of CD4+CD25+ cells was found to be higher in young susceptible rats. In this work, the respective contribution of each cell population was determined in young and adult rats treated with monoclonal antibodies. Down-regulation of surface CD25 molecules, including those expressed by CD4+ cells did not significantly enhance the capacity of young rats to control the development of erythrocytic stages or modify the course of infection in adult infected rats. However, we observed a significant loss of protection when adult rats were treated with anti-CD4 mAb (W3/25) with higher blood parasitemia levels and approximately 50% of rats succumbed to infection. More importantly and in contrast to earlier studies performed in mice, we found a significant increase in blood parasite levels and a significant delay in parasite clearance in adult rats treated with anti-CD8 mAb OX8, known to deplete CD8+ cells. These results suggest that CD8+ cells play a critical role in the development of immune responses in rats to control the replication of blood stage parasites.

[Echocardiography and resynchronization in 2007]. / Echocardiographie et resynchronisation en 2007.

Biventricular resynchronisation is accepted as an effective alternative treatment for patients with refractory dilated cardiomyopathy. Based on the presence of ventricular asynchrony, the objective of this technique is to restore homogenous contraction of the myocardial walls. The electrocardiographic criteria for selecting patients only generates a response rate in the order of 70%. Echocardiography has been suggested as another tool for evaluating asynchrony, but there is much confusion in the application of the different criteria. Here we propose an approach based on an understanding of the complexity of myocardial contraction in order to integrate the different echocardiographic parameters in a logical overall evaluation of asynchrony. However, the role of echography does not end with pre-implantation evaluation alone. The follow up of resynchronised patients can effectively benefit from all the opportunities of functional, morphological and hemodynamic investigation, that ultrasound provides. From confirmation of the efficacy of resynchronisation to optimising the pacemaker, the applications of echographic investigation in this field are widespread.

[The best of echocardiography in 2006]. / L'essentiel de 2006 en échocardiographie.

In recent years, Doppler echocardiography has undergone significant technological advances, resulting in spectacular improvements in diagnosis and quantification. This review summarises the advances made in 2006 in fields as varied as cardiac resynchronisation, cardiac failure with preserved systolic function, contrast echocardiography, 3D echocardiography and echocardiographic evaluation of valvular heart disease. Despite growing competition, but mostly complementarity with CT scan and MRI, Doppler echocardiography remains the keystone of cardiological rationale based on non-intensive investigations.

[Thrombosis of valvular prostheses: the role of medical treatment]. / Thrombose de prothèses valvulaires: place du traitement médical.

Thromboses of valvular prostheses represent a rare but serious complication for mechanical valves, and are sometimes fatal. Obstructive thromboses present an immediate threat to life, while the more common, more insidious, non-obstructive thromboses are essentially manifested by thrombo-embolic events. These thromboses often occur at times of insufficient anticoagulation, especially during the first post-operative year and during treatment breaks for non-cardiac surgery, an increasingly common situation. The therapeutic management of an 'obstructive' thrombosis is above all surgical. However, fibrinolysis represents an effective alternative, although it does present a not insignificant risk of systemic embolism (in the order of 10 to 15%). The main indications for fibrinolysis are thromboses of right heart valves, and for left heart prostheses, patients in a very unstable haemodynamic state, remoteness from a cardiac surgery centre, any surgical contraindications, and cases where a large thrombus has been excluded by trans-oesophageal ultrasound. In cases of contraindications to both surgery and fibrinolysis, treatment with heparin might be proposed, but without any great hopes of completely unblocking the prosthesis. Treatment of a 'non-obstructive' thrombosis is primarily medical: optimising anticoagulation with intravenous heparin, or even the addition of aspirin. When the thrombus is large and mobile, surgery should be envisaged if medical treatment fails.

[Identification of candidates for multisite pacing: results and presumed mechanisms of action after five years experience]. / Identification des patients candidats a la stimulation multisite. Résultats et mécanismes d'action supposés a l'issue d'une expérience monocentrique de 5 ans.

Biventricular resynchronisation is an additional therapeutic option in the management of refractory heart failure, with a functional and haemodynamic benefit as well as an improved morbidity and mortality. However, the rate of non-responsive patients has prompted a re-think about the presumed mechanisms of action for this procedure. This study aims to identify candidates more successfully. Based on five years experience in this centre, our work confirmed a medium and long term clinical benefit with multisite pacing. Nevertheless, there was evidence of a relative discordance between the functional benefit and the haemodynamic impact in terms of ejection fraction achieved with resynchronisation. While QRS narrowing appears to be a predictive factor for a successful procedure, the ECG alone is not sufficient to select 'unsynchronised' candidates. Statistical analysis reveals that before implantation the independent predictive factors to identify non-responsive patients include the presence of a complication of myocardial infarction and a low grade mitral leak. The limits of the ECG suggest a more mechanical than electrical approach to understanding the mechanisms of action for resynchronisation. Its effectiveness in cases of right bundle branch block confirm the hypothesis of left intra-ventricular conduction defects, not apparent on the surface ECG but accessible through new imaging techniques. Based on the hypothesis of delayed movement of the ventricular walls, the principle of resynchronisation aims to restore homogenous contraction. Echocardiography allows observation of electromechanical delay and opens new perspectives in the future for selecting patients for pacing. Ar

[Outpatient thoracic surgery: Evolution of the indications, current applications and limits]. / Chirurgie thoracique ambulatoire : évolution des indications, applications actuelles et limites.

The objectives of outpatient surgery are to reduce the risks connected to hospitalization, to improve postoperative recovery and to decrease the health costs. Few studies have been performed in the field of thoracic surgery and there remains great scope for progress in outpatient lung surgery. The purpose of this article is to present a revue of the current situation and the prospects for the development of out patient thoracic surgery.

Comparison of real-time and intermittent triggered myocardial contrast echocardiography for quantification of coronary stenosis severity and transmural perfusion gradient.

BACKGROUND: Both intermittent triggered and real-time myocardial contrast echocardiography (MCE) have been proposed to detect impaired myocardial perfusion. We compared the ability of these 2 methods to quantify altered myocardial blood flow (MBF) and transmural distribution of MBF produced by graded coronary stenoses. METHODS AND RESULTS: In 8 open-chest dogs, we created 4 graded left anterior descending coronary artery (LAD) stenoses: 3 levels of reduced adenosine hyperemia (non-flow-limiting at rest) and 1 grade of flow-limiting at rest. Real-time MCE was performed with SonoVue infusion using low-energy power pulse inversion (ATL) imaging, whereas ECG-gated intermittent triggered imaging used high energy at pulsing intervals from 1:1 to 1:10. LAD signal intensity (SI) was plotted versus time by real-time MCE and versus pulsing intervals by triggered MCE and was fitted to a 1-exponential function to obtain plateau SI (A) and the rate of SI rise (b). Visual detection of decreased opacification was equivalent by triggered and real-time MCE. Fluorescent microsphere-derived MBF ratio in LAD/left circumflex artery beds demonstrated close correlation with both real-time imaging (b, r=0.79; Axb, r=0.81) and triggered imaging (b, r=0.78; Axb, r=0.80). The endocardial/epicardial ratio of MBF in the LAD bed demonstrated closer correlation with the endocardial/epicardial ratios of b (r=0.71) and Axb (r=0.67) obtained by real-time than triggered imaging (b, r=0.42; Axb, r=0.52). CONCLUSIONS: Real-time and triggered MCE are equivalent in their ability to identify coronary stenosis and quantify altered MBF.

Comparative value of dobutamine and adenosine stress in the detection of coronary stenosis with myocardial contrast echocardiography.

BACKGROUND: Controversy continues as to whether adenosine or dobutamine is the superior pharmacological stress agent for myocardial contrast echocardiography (MCE). METHODS AND RESULTS: We compared real-time MCE refilling curves and wall thickening during adenosine and dobutamine stress in 14 open-chest dogs with left anterior descending and left circumflex coronary artery stenoses that reduced hyperemia by 40% to 60% and 70% to 90% (mild and severe non-flow-limiting stenosis, NFLS) and resting flow by 10% to 30% and 35% to 50% (mild and severe flow-limiting stenosis, FLS). MCE was performed with low-energy imaging during Optison infusion. After high-energy bubble destruction, time-intensity data from risk beds were fitted for an exponential function as y=A(1-e(-)(bt)), from which the rate of intensity increase (b) and maximal plateau intensity (A) were derived. Although severe NFLS and greater stenoses decreased b with both dobutamine and adenosine, with mild NFLS it was reduced in 58% of animals with dobutamine versus 8% with adenosine. The absolute decrease in b, however, was greater for adenosine than dobutamine with FLS. The A parameter was decreased with both adenosine and dobutamine only with the most severe FLS. Wall thickening was decreased with dobutamine in 33% of animals with severe NFLS and in all animals with any FLS; with adenosine, in all with severe FLS. CONCLUSIONS: Both dobutamine and adenosine significantly reduce MCE refilling rates in the setting of severe stenosis and in the absence of contractile abnormalities. Dobutamine decreases refilling rate and wall thickening at a less reduced flow grade than adenosine, but adenosine produces a greater magnitude of change than dobutamine.

Quantitative assessment of myocardial perfusion during graded coronary stenosis by real-time myocardial contrast echo refilling curves.

OBJECTIVES: The present study examined the ability of real-time myocardial contrast echocardiography (MCE) to delineate abnormalities produced by graded coronary stenoses and to correlate signal intensity (SI) parameters derived from destruction/refilling curves with regional myocardial blood flow (MBF) and contractile function. BACKGROUND: Recent technological advances have enabled myocardial opacification by MCE to be achieved during real-time imaging. METHODS: In eight open-chest dogs, we created LAD occlusion and graded stenoses that were either flow-limiting at rest (FLS) or reduced adenosine hyperemia (non-flow-limiting at rest = NFLS). Myocardial contrast echo used Optison infusion and low-energy real-time power pulse inversion imaging. High-energy FLASH frames destroyed bubbles every 15 cardiac cycles. Myocardial SI-versus-time plots were fitted to a one-exponential function to obtain the rate of SI rise (b) and peak SI in the last frame. RESULTS: Dyssynergy was not observed during any NFLS, but perfusion abnormalities were. Visual detection of decreased opacification was possible with severe NFLS and FLS. b demonstrated a significant reduction with severe NFLS and near significant with moderate NFLS; peak SI did not. All exponential parameters were significantly decreased with FL stenosis and occlusion. The MBF ratio in LAD/LCx beds (fluorescent microspheres) correlated with b (r = 0.79) and the product of the peak SI and b (r = 0.80). CONCLUSIONS: In an open-chest dog model, parameters derived from microbubble refilling of the imaging field by real-time MCE correlate well with myocardial blood flow and can identify coronary stenosis.

Early and long-term (one-year) effects of the association of aspirin and oral anticoagulant on thrombi and morbidity after replacement of the mitral valve with the St. Jude medical prosthesis: a clinical and transesophageal echocardiographic study.

OBJECTIVES: The aim of the study was to test the value of low dose aspirin associated with standard oral anticoagulants (OAC) after mechanical mitral valve replacement (MMRV) to reduce strands, thrombi and thromboembolic events. BACKGROUND: Strands and thrombi are thought to increase the risk of embolic events after MMVR, particularly in the immediate postoperative period. METHODS: Two hundred twenty-nine patients were prospectively recruited: 109 patients (group A+) were randomly assigned to aspirin (200 mg per day) with OAC and 120 patients (group A-) to OAC alone (international normalized ratio 2.5 to 3.5). All patients were subjected to multiplane transesophageal echocardiography at nine days and five months and were followed up for one year. RESULTS: At nine days and five months, there was a high and comparable incidence of strands in the two groups (group A+: 44%, 58%; group A-: 49%, 63%). However, the incidence of nonobstructive periprosthetic valve thrombi was significantly lower in group A+ at 9 days: 5% versus 13%, p = 0.03. Total thromboembolic events were reduced in group A+ (9% vs. 25%, p = 0.004) although there was an increased incidence of gastrointestinal hemorrhage (7% vs. 0%). Overall mortality was 9% in group A+ and 4% in group A-. Valve-related events were similar in both groups. Early thrombi, but not strands, were associated with higher morbidity, especially thromboembolic events (30% vs. 13%, p = 0.003). CONCLUSIONS: One year after MMVR, the association of aspirin with OAC reduced thrombi and thromboembolic events, but not morbidity, due to an increase in hemorrhagic complications.

[Myocardial perfusion and contrast echocardiography. Application to acute coronary syndrome]. / Perfusion myocardique et échocardiographie de contraste. Application au syndrome coronaire aigu.

After mastering epicardial revascularisation, the therapeutic management of acute coronary syndrome has progressively turned towards the preservation of the capillary microcirculation. In this respect, contrast echocardiography provides all the answers to the main questions which arise, and is available within a timeframe and place compatible with the management of such patients. The techniques for microbubble detection, quantification tools, and contrast agents are well optimised for routine use both for initial diagnosis as well as monitoring the therapeutic effectiveness. It is only the administrative authorisation which is currently lacking treatment.

[Diagnosis difficulty in occult constrictive pericarditis]. / Difficulté diagnostique de la péricardite constrictive occulte. A propos d'un cas.

We report the case of a 42 years woman known to have a cardiac heart failure attributed to restrictive cardiomyopathy for want of any other plausible diagnosis. Evolution and repeted investigations finally permitted to rectify the diagnosis by revealing a constrictive pericarditis, remained occult 9 years during. The differentiation of restrictive cardiomyopathy and constrictive pericarditis has been a perennial problem in clinical cardiology. Diagnosis of constrictive pericarditis is based on associated signs sometimes too poor to go straight to thoracotomy. We discuss the mean to approach more precisely this uncommon pattern named occult constrictive pericarditis.

[Echocardiography and biventricular resynchronisation]. / Echocardiographie et resynchronisation biventriculaire.

Biventricular resynchronisation has been recently shown to be an effective therapeutic option in patients with refractory dilated cardiomyopathy. Based on the finding of ventricular asynchrony, the aim of the method is to restore uniform contraction of the ventricular walls. However, the initial electrocardiographic criteria for selection of patients were only associated with a 70% rate of response. Consequently, it became necessary to refocus this method in patients with true ventricular asynchrony. Echocardiography is one of the non-invasive techniques which provides morphological and functional analysis of the myocardium with a high degree of accessibility. The multiplication of tools for echocardiographic quantification has been very valuable from a theoretical point of view for assessing ventricular asynchrony. In practice, techniques such as Doppler tissue imaging are being validated, but already offer the possibility of a multi-directional approach to this pathology. The diagnosis of asynchrony is based on a range of echocardiographic findings which not only improve the selection of patients but also optimise the programming of multisite stimulation.

[Asynchronism and right ventricular pacing]. / Asynchronisme et stimulation ventriculaire droite. Démonstration de l'effet délétère d'une stimulation apicale dans une population d'adultes appareillés pour BAV congénital.

UNLABELLED: In patients with congenital heart block (CHB), dual-chamber pacing restores physiological heart rate and atrio-ventricular synchronization. However, patients with narrow QRS junctional escape rhythm may be deleteriously affected by long-term, permanent, apical ventricular pacing. We assessed the impact of apical ventricular pacing on echocardiographic ventricular dyssynchrony and hemodynamic parameters. METHODS: Fourteen CHB adults (23 +/- years, 58% male), with a DDD transvenous pacemaker and a junctional escape rhythm (QRS<120 ms) before implantation, were studied. Echocardiography coupled with tissue Doppler imaging (TDI) and Strain rate was performed in spontaneous rhythm (VVI mode 30/mn) and during atrio-synchronized ventricular pacing. RESULTS: The heart rate (43 +/- 09 vs 68 +/- 07: p<0.01), cardiac output (2.9 +/- 0.7 vs 3.7 +/- 0.6 L/min) and left ventricular filling time (325 +/- 38 vs 412 +/- 51 ms; p<0.01) were significantly less in the escape spontaneous rhythm compared with atrio-ventricular synchronized apical pacing. However, interventricular dyssynchrony (28 +/- 12 vs 59 +/- 25 ms, p<0.05), intra-left ventricular dyssynchrony (36 +/- 11 vs 57 +/- 29 ms; p<0.05), extent of left ventricular myocardium displaying delayed longitudinal contraction (26 +/- 10 vs 39 +/- 17%: p<0.05) were significantly less in the escape rhythm compared with paced rhythm. CONCLUSION: Once implanted with a DDD pacemaker, CHB patients present with increased cardiac output secondary to the restoration of physiological heart rate and improved diastolic function. However, the apical site is not optimal, as it creates detrimental ventricular dyssynchrony in patients with previous nearly physiological ventricular activation. Alternative pacing sites should be investigated.

Improved reliability for echocardiographic measurement of left ventricular volume using harmonic power imaging mode combined with contrast agent.

Harmonic power imaging (HPI) is a new echocardiographic modality that enhances the detection of contrast agents in the left ventricle. The endocardium can be delineated by conventional echocardiography using ultrasound contrast agents, although the images tend to be faint. The present study was designed to assess left ventricular volume using HPI after intravenous injection of the contrast agent Levovist (Schering SA, Berlin, Germany) in 25 unselected patients. End-diastolic volume, end-systolic volume, and ejection fraction were determined for each patient with angiography and with 4 different ultrasound modalities: (1) conventional mode without contrast, (2) contrast conventional mode, (3) contrast harmonic intermittent imaging mode, and (4) contrast triggered HPI. The use of HPI improved correlations between the echographic and angiographic measurements for all parameters as well as precision and bias determined by Bland and Altman analysis. The relative errors for interobserver variability were also lower with HPI. This study demonstrates that echocardiographic determination of left ventricular volumes and ejection fraction is more accurate and reproducible using HPI combined with Levovist.

Echocardiographic demonstration of rupture of intraseptal hydatid cyst.

We report a case of an intracardiac hydatid cyst observed before and after rupture complicated by a pulmonary embolus. The echocardiographic findings are analyzed and discussed. This dramatic course underscores the surgical emergency of cardiac hydatidosis.

Can power motion imaging mode combined with contrast agent assess myocardial contraction and perfusion? In vitro and in vivo studies.

Power motion imaging (PMI) is a new Doppler imaging technology that can enhance contrast agent visualization. We hypothesized that PMI combined with Albunex injection (CPMI) could provide new insights into myocardial contractility and perfusion. In a first step, PMI signal was studied with an in vitro phantom. In a second step, PMI signal was studied in 10 rabbits at different workloads. In a third step, 10 rabbits were studied before and after ischemia produced by coronary ligation and finally during reperfusion. During the latter protocol, epicardial echocardiography analyzed by PMI and fundamental mode was performed before and after Albunex injection. PMI signal was well correlated with phantom velocity. PMI signal and myocardial wall thickening were well correlated, particularly in the septal area. On the coronary occlusion model, ischemia was associated with a significant decrease in PMI and CPMI signals, whereas reperfusion was associated with a significant decrease in PMI signals only, indicating stunning. We conclude that PMI combined with CPMI is a powerful tool to assess myocardial contractility and perfusion.

Accuracy and reproducibility of coronary flow rate assessment by real-time contrast echocardiography: in vitro and in vivo studies.

Real-time myocardial contrast echo (MCE) provides the potential to assess myocardial blood flow from time-intensity refilling curves after high-energy bubble destruction. This study validated the accuracy of this approach and the effect of specific examination variables and instrument settings on results. The effects of examination depth and angle as well as dynamic range, pulse repetition frequency, and line density were assessed with the use of in vitro incremental flow rates produced in an in vitro tissue phantom. In vivo recordings of real-time imaging with an infusion of a contrast agent (Optison) were obtained in 7 open-chest dogs with graded left anterior descending artery stenosis at baseline and during adenosine hyperemia, and were compared with flow probe measurements. After bubble destruction, time-intensity data were fitted to an exponential function, and the rate of intensity increase (b) and peak plateau intensity (A) were derived from refilling curves. In vivo real-time values for b, but not A, correlated closely with flow probe measures (r = 0.93). A similar correlation for b was observed in vitro (r = 0.98). The correlation between flow rate and b was influenced by several examination variables, including depth, angle, and instrument settings. Real-time MCE provides accurate quantification of coronary flow by assessing the rate of microbubble refilling. However, this parameter may be affected by several examination and instrument variables. Therefore, real-time MCE refilling measures are best applied by comparing baseline values with those of stress studies.