[Cardiac surgery in the time of COVID19 - A narrative of three very unusual cases and lessons learned]. / Chirurgie cardiaque au temps du Covid-19 - Récit de trois cas très inhabituels et leçons retenues.

COVID19 altered and impacted medical and surgical practice around the world. Standard of care and routine procedures are disrupted. Majors shift in personnel, and ad hoc new team as well as delocalization and working with new infrastructures are further challenges to be dealt with. This review of three very unusual scenarios illustrates pitfalls and dangers harbored in the re-shaped landscape of COVID19 exemplifying the narrow path bridging from the medical and surgical comfort zone to uncharted territory and eventually leading to collateral damage.

Le Covid-19 a profondément modifié et sévèrement impacté les pratiques médicales et chirurgicales à long terme. Les standards de prise en charge et les procédures de routine sont altérés, voire perturbés. Des mutations majeures au niveau du personnel et des équipes de même que la délocalisation ou le travail avec de nouvelles infrastructures sont autant de défis à relever, encore aujourd'hui. Trois scénarios inhabituels illustrent les pièges et les dangers qui se cachent dans le paysage marqué par le Covid-19. Ces exemples démontrent la marge étroite entre la zone de confort médicale et chirurgicale classique et l'appréhension d'une situation inhabituelle qui risque d'entraîner des dommages collatéraux pour les patients.

Cardiac Neural Crest Cells: Their Rhombomeric Specification, Migration, and Association with Heart and Great Vessel Anomalies.

Outflow tract abnormalities are the most frequent congenital heart defects. These are due to the absence or dysfunction of the two main cell types, i.e., neural crest cells and secondary heart field cells that migrate in opposite directions at the same stage of development. These cells directly govern aortic arch patterning and development, ascending aorta dilatation, semi-valvular and coronary artery development, aortopulmonary septation abnormalities, persistence of the ductus arteriosus, trunk and proximal pulmonary arteries, sub-valvular conal ventricular septal/rotational defects, and non-compaction of the left ventricle. In some cases, depending on the functional defects of these cells, additional malformations are found in the expected spatial migratory area of the cells, namely in the pharyngeal arch derivatives and cervico-facial structures. Associated non-cardiovascular anomalies are often underestimated, since the multipotency and functional alteration of these cells can result in the modification of multiple neural, epidermal, and cervical structures at different levels. In most cases, patients do not display the full phenotype of abnormalities, but congenital cardiac defects involving the ventricular outflow tract, ascending aorta, aortic arch and supra-aortic trunks should be considered as markers for possible impaired function of these cells. Neural crest cells should not be considered as a unique cell population but on the basis of their cervical rhombomere origins R3-R5 or R6-R7-R8 and specific migration patterns: R3-R4 towards arch II, R5-R6 arch III and R7-R8 arch IV and VI. A better understanding of their development may lead to the discovery of unknown associated abnormalities, thereby enabling potential improvements to be made to the therapeutic approach.

External Iliac Artery Endofibrosis in a Female Cyclist: A Case Report.

External iliac artery endofibrosis is a rare disease described mainly in male endurance athletes. It presents as claudication of the lower limb during near-maximum effort. The patients lack the usual risk factors for atherosclerosis, which makes diagnosis challenging. We present a case of external iliac artery endofibrosis in a female competitive cyclist. The initial surgical management was complicated by early recurrence due to intimal hyperplasia. After secondary drug-eluting balloon angioplasty, the patient was able to resume competition. As such, it is important to maintain a high index of suspicion when evaluating a patient presenting with claudication symptoms in this setting. Primary treatment is surgical, and in cases of early recurrence angioplasty may be indicated. Most patients can return to full activity after healing is complete.

Rescue of a Failing Endovascular Infrarenal Aortic Repair Using an Off-The-Shelf Branched Endograft.

BACKGROUND: Proximal aortic dilation following open and endovascular aortic repair (EVAR) is a well-known phenomenon. If severe enough, it may lead to late onset of type Ia endoleak that jeopardizes the proximal seal. METHODS: We report the case of a patient previously treated by EVAR for an infrarenal aneurysm who developed a type Ia endoleak after proximal aortic dilation. His aneurysms enlarged to 10 cm mandating a rapid repair without the delay for a custom-made device. RESULTS: We successfully used the off-the-shelf thoracic t-Branch graft (Cook, Bloomington, IN) with its 4 branches to treat the dilated aorta and seal the endoleak. CONCLUSION: The off-the-shelf t-Branch is a useful option in patient with previous EVAR presenting with proximal aortic dilation and endoleak who cannot wait for a custom-made device.

[Management of carotid artery stenosis]. / Prise en charge de la sténose carotidienne.

Carotid artery atherosclerosis remains one of the major causes of stroke. The efficacy of carotid artery recanalization has already been established and is considered significant for symptomatic stenosis >70% and moderate for stenosis between 50-69 %. Regarding asymptomatic stenosis, carotid artery recanalization should be reserved for carefully selected patients with a stenosis between 70-90 % and an estimated procedural risk at less than 3 %. Two therapeutic options are currently available : angioplasty with stent placement and endarterectomy. While the endovascular approach may be associated with a higher periprocedural complication rate of stroke, there remains a significant decrease in the rate of myocardial infarction and peripheral nerve palsy compared to surgery. As a result, each case should be reviewed with a multidisciplinary approach in order to propose the best therapeutic strategy.

L'athérosclérose des artères carotides est une des causes majeures d'infarctus cérébral. Le bénéfice de la revascularisation carotidienne est très important pour les sténoses symptomatiques de 70 % ou plus, et modéré pour celles de 50 à 69 %. Pour les sténoses asymptomatiques, la revascularisation carotidienne devrait être proposée chez des patients bien sélectionnés, avec une sténose entre 70 et 90 %, si le risque de la procédure peut être estimé à moins de 3 %. Deux approches sont possibles : le stenting et la chirurgie. Le stenting semble être associé à un nombre plus important d'AVC périprocéduraux, mais à un risque moindre d'infarctus du myocarde et de paralysie des nerfs crâniens par rapport à la chirurgie. Chaque cas devrait être discuté dans le cadre d'un colloque multidisciplinaire pour proposer la meilleure stratégie thérapeutique au patient.

Embolization of a Large Rapidly Growing Aortic Pseudo-Aneurysm Not Amenable to Open or Endovascular Repair.

BACKGROUND: To report the case of a rapidly growing aortic false aneurysm because of Q fever infection that was managed by embolization. CASE REPORT: An 80-year-old man was admitted to our unit for an aortic false aneurysm from a chronic Q fever infection. During his stay, the aneurysm showed rapid progression necessitating urgent treatment. The patient was unfit for surgical repair; moreover, the location of the aneurysm at the level of the superior mesenteric artery prohibited the use of an endovascular graft. He was managed by coiling of the aneurysmal cavity with multiple detachable coils after positioning of a bare aortic stent to lock the coils and prevent their migration into the aortic lumen. The false aneurysm was successfully thrombosed with no complications. The patient was then put on doxycycline and hydroxychloroquine to target Coxiella burnetii. CONCLUSIONS: Aortic false aneurysm coiling is feasible in cases where an endograft is not possible or an open repair is contraindicated. The use of a bare metal stent may help as a barrier to prevent the coils from migrating into the aneurysm and thus avoiding embolization into the systemic circulation.

Ascending aorto-superior mesenteric artery bypass as a surgical option for revascularization in mesenteric ischemia associated with type B aortic dissection.

We report the case of an acute ischemia of the superior mesenteric artery (SMA) after endovascular fenestration of a complicated acute type B aortic dissection. An initial attempt for endovascular revascularization of the SMA failed, and an ascending aorto-superior mesenteric artery bypass was urgently performed to salvage the small bowel. Surgery of patients in these specific settings is more complex because an adequate, more distal inflow vessel is often not present due to the dissected aorta and iliac arteries. This surgical option could be lifesaving and should be part of the vascular surgeon's armamentarium.

Off-label use of a reversed flared endurant iliac limb stengraft for the management of a life-threatening internal iliac artery aneurysm rupture.

We report a case of a life-threatening internal iliac artery aneurysm rupture managed successfully with an on-table reversed flared iliac limb stentgraft and embolization. This easily off-the-shelf reproducible technique avoids using a more complex and expensive bifurcated aorto-iliac graft and could be a good solution in emergency situation where a custom graft is not available.

Aortic Dilatation on the Edge of Dissection-Do We Operate Too Late? The Ratio between Ascending and Descending Aorta DiameteR (RADAR).

(1) Background: There is a need for a novel surrogate marker to ease decision making when facing ascending aortic dilatation. In this article, we study the ratio between ascending and descending aorta diameters as a potential one. (2) Methods: Retrospective observational cohort study, including all the patients who underwent surgery for acute type A aorta dissection (aTAAD) between January 2014 and September 2020 at our center. A total of 50 patients were included. Clinical and demographic data were collected. The anatomical measurements were made including orthogonal maximal diameters of the ascending and descending aorta, post-dissection whole circumference length (post-wCL), post-dissection true lumen circumference length (post-tCL), and surface and sphericity indices of the ascending and descending aorta. Pre-dissection ascending aorta diameter (pre-AAD) and pre-dissection descending aorta diameter (pre-DAD) were calculated as well as the ratio between them and compared with reference values. (3) Results: Of the pre-AAD patients, 96% had smaller than the recommended 55 mm. The ratio between the descending and ascending aorta pre-dissection diameters was significantly smaller compared to the reference value (0.657 ± 0.125 versus 0.745 ± 0.016 with a mean difference of -0.088 and a p < 0.001). (4) Conclusions: The 55 mm threshold for aorta maximal diameter is an insufficient criterion when assessing the risk of dissection. The ratio between DAD and AAD is a parameter worthy of analysis as a tool to stratify the risk of dissection.

Iliac occlusion due to covered stent deformation following abdominal massages.

Extrinsic compression is a potential cause of stent failure. We have described the case of a 65-year-old paraplegic patient with acute right leg ischemia. His medical history was relevant for aortobifemoral bypass, followed by kissing covered stent reconstruction of a proximal anastomotic false aneurysm. The computed tomography scan showed collapse of the right iliac covered stent with ipsilateral iliofemoral graft thrombosis and partial collapse of the left iliac covered stent. He underwent emergent right iliac limb open thrombectomy and redo covered stent relining. The cause of compression was found to be daily deep abdominal massages for intestinal evacuation. The endovascular device should be tailored to the patient's particularities.

Treatment of HeartMate III-LVAD driveline infection by negative pressure wound therapy: Result of our case series.

Driveline infection is one of the most frequent complications following left ventricular assist device (LVAD) treatment and there is no consensus for its management. The standard approach to treat foreign-body infection is complete device ablation, which is not always feasible and therefore not an elected method for LVAD driveline infections. Here we share the results from a series of cases successfully treated for driveline infection by negative pressure wound therapy (NPWT) therapy. Between 2016 and 2020, five male patients were hospitalized in our unit with a driveline infection of HeartMate III-LVAD®. Ultrasonography and/or thoraco-abdominal CT confirmed the diagnosis, infection localization, and abscess formation. Following an antibiotic treatment, an urgent surgical abscess drainage and debridement of the infected tissues were performed. At the end of the procedure, NPWT was applied. NPWT re-dressing and debridement of wound was performed every 3-4 days. The wound was closed surgically after obtaining negative culture results and good healing. The patients were discharged in good condition, without signs of infection. Two patients underwent successful heart transplantation after 1 and 13 months. Other patients did not show any residual or recurrent infection during the follow-up within 25 months. Driveline infection following LVAD implantation is a significant complication and a challenging in terms of management for both; the surgical team and the patient. These results from our case series report a successful and less invasive approach by using NPWT for the treatment of LVAD driveline infections.

To Balloon or Not to Balloon? The Effects of an Intra-Aortic Balloon-Pump on Coronary Artery Flow during Extracorporeal Circulation Simulating Normal and Low Cardiac Output Syndromes.

ECMO is the most frequently used mechanical support for patients suffering from low cardiac output syndrome. Combining IABP with ECMO is believed to increase coronary artery blood flow, decrease high afterload, and restore systemic pulsatile flow conditions. This study evaluates that combined effect on coronary artery flow during various load conditions using an in vitro circuit. In doing so, different clinical scenarios were simulated, such as normal cardiac output and moderate-to-severe heart failure. In the heart failure scenarios, we used peripheral ECMO support to compensate for the lowered cardiac output value and reach a default normal value. The increase in coronary blood flow using the combined IABP-ECMO setup was more noticeable in low heart rate conditions. At baseline, intermediate and severe LV failure levels, adding IABP increased coronary mean flow by 16%, 7.5%, and 3.4% (HR 60 bpm) and by 6%, 4.5%, and 2.5% (HR 100 bpm) respectively. Based on our in vitro study results, combining ECMO and IABP in a heart failure setup further improves coronary blood flow. This effect was more pronounced at a lower heart rate and decreased with heart failure, which might positively impact recovery from cardiac failure.

Short-term outcomes of aortic valve neocuspidization for various aortic valve diseases.

Objectives: Bioprosthetic valve deterioration remains a major limitation following aortic valve replacement. Favorable results have been reported with an autologous pericardium aortic valve neocuspidization. Methods: Seventy patients (31 women and 39 men) (mean age, 62 ± 12 years) with aortic stenosis (n = 52 [74%]) or aortic regurgitation (n = 18 [26%]) underwent the aortic valve neocuspidization procedure. Thirty-four patients (49%) had a tricuspid valve, 35 (50%) had a bicuspid valve, and 1 (1%) had a monocuspid valve. European System for Cardiac Operative Risk Evaluation and Society of Thoracic Surgeons scores were, respectively, 2.2% ± 2% and 2.0% ± 1.8%. Four patients (6%) had active endocarditis and 2 (3%) had endocarditis sequelae. One patient (1%) had fibroelastoma. A combined procedure was performed in 33 patients (46%). Results: The follow-up period was 24 ± 12 months. One patient (1%) died in hospital and 1 patient (1%) underwent conventional valve replacement for significant aortic regurgitation. Postoperative peak and mean pressure gradients were respectively 14 ± 5 and 8 ± 3 mm Hg. Aortic valve area was 2.5 ± 0.6 cm2. During follow-up, no patients died. Reintervention occurred in 2 patients (3%). At last follow-up, peak pressure gradient was 13 ± 7 mm Hg, mean pressure gradient was 7 ± 4 mm Hg, and aortic valve area was 2.3 ± 0.7 cm2. There was 1 recurrence of moderate aortic stenosis (1%). All patients were in New York Heart Association functional class I (90%) or II (10%). Freedom from major valve-related events was 92.1%, (98.5% for death, 95.2% for reintervention, and 95.2% for endocarditis). Conclusions: In our experience, the midterm outcomes of the aortic valve neocuspidization procedure with autologous glutaraldehyde fixed pericardium were acceptable for survival, operative risk and valve-related complications, for our all-comer patient population with various aortic valve diseases.

Isolated bilateral profunda femoris artery aneurysm.

BACKGROUND: Isolated bilateral profunda femoris artery aneurysm (PFAA) is a very rare entity. Most of the cases are unilateral and occur with synchronous aneurysms elsewhere. Symptoms range from none to limb ischemia or hemorrhage because of rupture. METHODS: We present a rare case of PFAA. In contrast to the general rule, the patient had a bilateral PFAA which was isolated to the deep femoral artery. The aneurysm was discovered after signs of acute limb ischemia caused by distal embolization. The patient was treated surgically with open aneurysmectomy and ligation of a branch of the deep femoral artery. CONCLUSION: PFAA are asymptomatic most of the time. Surgical repair is always recommended to prevent such life-threatening complications. Different treatment modalities are offered, including endovascular options. The presence of a PFAA should prompt screening for concomitant aneurysms.

Incidental diagnosis of a silent brachiocephalic vein aneurysm and its surgical treatment.

Brachiocephalic vein aneurysm is an extremely rare clinical entity, with a limited number of case reports in the literature. We report the case of a 74-year-old woman with a left brachiocephalic vein aneurysm (3 × 3 × 6.5 cm) that was discovered fortuitously by contrast-enhanced chest computed tomography. Surgical intervention was performed simultaneously during tricuspid valve surgery with coronary artery bypass grafting. This paper discusses the details of our case, the surgical treatment of brachiocephalic vein aneurysms, and the different treatment options.

Incidence, risk factors and prognosis of changes in serum creatinine early after aortic abdominal surgery.

OBJECTIVE: To determine the incidence, risk factors, and prognostic implications of serum creatinine changes following major vascular surgery. DESIGN: Observational study. SETTINGS: University hospital. PATIENTS: Cohort of 599 consecutive patients undergoing elective abdominal aortic surgery. INTERVENTIONS: Review of prospectively collected data from 1993 to 2004. MEASUREMENTS AND RESULTS: The receiver-operator characteristic (ROC) curve analysis was used to detect the best threshold for postoperative elevation in serum creatinine (Delta Creat) in relation to major complications. A cut-off value of +0.5 mg/dl was selected to define renal dysfunction (RD(0.5) group, n=91; no RD(0.5), n=508) that was associated with higher mortality (7.7% in RD(0.5) group vs 1.4% in no RD(0.5) group, P<0.05), rate of admission to the ICU (34% vs 13%, P<0.05), and incidence of cardiovascular (9% vs 4%, P<0.05), respiratory (21% vs 7%, P<0.05), surgical (24% vs 10%, P<0.05), and septic complications (9% vs 3%, P<0.05). After multivariate analysis with logistic regression, renal dysfunction was independently related to low preoperative creatinine clearance [<40 ml/min; odds ratio (OR) 1.5, 95% confidence interval (CI) 1.1-3.9], prolonged renal ischemic time (>40 min; OR, 3.8, 95% CI, 1.9-7.2), blood transfusion (>5 units; OR, 1.9, 95% CI 1.2-6.1), and rhabdomyolysis (OR, 3.6, 95% CI 1.7-7.9). CONCLUSIONS: Postoperative RD(0.5) (Delta Creat >0.5 mg/dl) occurs in 15% of vascular patients and carries a bad prognosis. Preoperative renal insufficiency and factors related to the complexity of surgery are the main predictors of renal dysfunction.

Axillary cerebral perfusion for arch surgery in acute type A dissection under moderate hypothermia.

BACKGROUND: Aortic arch surgery is still associated with increased mortality and morbidity especially in acute type A aortic dissection. Adequate brain protection is essential and commonly performed by either antegrade selective perfusion of the brachiocephalic arteries or an interval of profound hypothermic circulatory arrest. We present our experience for open aortic arch repair with continuous antegrade brain perfusion by means of direct cannulation of the right axillary artery, under moderate hypothermia in patients with acute type A aortic dissection. METHODS: In, 25 consecutive patients (17 men) with a mean age of 62.6+/-14.8 years, aortic repair extended to the arch, for acute type A aortic dissection, was performed through a midline sternotomy. The right axillary artery was used for arterial systemic and brain perfusion at a rectal temperature of 25-27 degrees C. RESULTS: Mean duration of CPB and aortic cross-clamping was 241+/-55 and 155+/-72 min, respectively. The mean duration of circulatory arrest of the lower body and brain perfusion was 39.7 (range, 24-55 min). All the patients survived the procedure and all but one were discharged from hospital. One patient had left arm paralysis which he recovered the first postoperative month. There were no other transient or permanent neurologic deficits. A CT scan was performed at discharge for routine postoperative evaluation. There were no local neurovascular complications related to the cannulation site except for one local re-exploration for bleeding. CONCLUSIONS: The absence of any major permanent neurologic deficit or any visceral damages in our patients suggests that continuous moderate hypothermic cerebral perfusion, with an interval of circulatory arrest of the lower body, is adequate for acute type A aortic dissection surgery, allowing safe open repair of the distal aortic arch.

Veno-arterial extracorporeal membrane oxygenation: an overview of different cannulation techniques.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has known a widespread application over the last decade and is now an effective and valuable therapeutic option in refractory cardiogenic shock of various etiologies. In this subgroup of critically ill and unstable patients in cardiogenic shock, VA-ECMO allows, on the one hand, temporary hemodynamic stabilization with improvement of end-organ function and, on the other hand, gives the time to perform complementary diagnostic exams and to decide the therapeutic strategy in these high-risk candidates for immediate long-term mechanical circulatory support (MCS) implantation. VA-ECMO could also be suggested as a rescue therapeutic option for refractory cardiac arrest. It showed promising results in the specific setting of in-hospital cardiac arrest and survival rates with good neurological outcome are reported between 20% and 40%. Conversely, there are contrasting data in the literature about survival after VA-ECMO for out-of-hospital cardiac arrest, as results are highly dependent on low-flow time. The aim of the present report is to offer an overview of different cannulation techniques of VA-ECMO.