Surgical treatment of a floating thrombus of the ascending aorta causing repeated arterial embolisms.

Floating thrombus of the ascending aorta is a rare and often ignored cause of peripheral embolic events. We report the observation of a patient presenting recurrent peripheral embolic demonstrations: acute ischemia of the right lower limb complicated of a thigh amputation and transient cerebrovascular accident. The assessment by angioscanner highlighted a 40-mm thrombus of the ascending aorta. The thrombus was removed surgically. This diagnosis should not be ignored in the assessment of an embolic pathology with the risk of severe functional after-effects caused by an important diagnostic delay.

[Analysis of 2000 heart transplant, procedures at la Pitié Hospital]. / Réflexions sur 2 000 transplantations cardiaques, expérience de La Pitié.

Since the first procedure carried out at La Pitié Hospital, on 27 April 1968, we have performed 1918 heart transplants. We analyzed outcomes in four successive periods: initial experience from 1968 to 1981 (53 patients), using early immunosuppressive regimens; an expansion phase (839 patients) from 1982 to 1992, with the introduction of cyclosporine; a stabilisation phase (522 patients) from 1993 to 2003; and the most recent phase (504 patients) from 2004 to 2010. We focused particularly on the most recent period. National super-emergency "rules were created, and grafts from older," "borderline" donors were used. Hyperimmune recipients started to be grafted, and ECMO was frequently used during the preoperative and postoperative periods. Due to limited organ availability, we have gradually placed more and more patients on mechanical cardiac support as a bridge to transplantation. Their quality of life is improved.

Papillary muscle approximation for ischemic mitral valve regurgitation.

In patients with ischemic left ventricular dysfunction and functional mitral regurgitation, the surgical treatment of the mitral insufficiency remains a challenging issue. Several procedures were described to restore a more normal alignment between the mitral annulus and the laterally displaced papillary muscles. We report a new approach to relocate the displaced papillary toward the mitral annulus and to reduce tethering. This procedure is believed to be technically easy and beneficial in terms of mitral repair.

Chronic dissection of the ascending aorta: surgical results during a 20-year period (previous surgery excluded).

OBJECTIVE: We study here the surgical results of chronic dissection involving the ascending aorta over the last 20 years. Patients with previous cardiac surgery, or proximal aortic repair, were excluded. The patients survived an acute dissection, undiagnosed as pauci- or asymptomatic. The aorta was normal or pathological (atheromatous aneurysm in 15 cases, Marfan's disease in 12 cases, and annuloectasic disease in 18 cases). Two patients had a bicuspid aortic valve. METHODS: Between January 1981 and December 2001, 77 patients (mean age 48+/-15) underwent surgery for chronic dissection of the ascending aorta; 60 patients had severe aortic regurgitation, 12 had Marfan syndrome, and 18 had annuloaortic ectasia. Only the ascending aorta was dissected in 37 patients, the ascending aorta and arch in 26, and the whole aorta in 14. Coronary artery disease occurred in five patients. Statistical analysis was performed using SAS software. Different surgical procedures were used. The aortic arch was repaired in 40 cases; selective antegrade cerebral perfusion and partial circulatory arrest were used. Total aortic replacement was performed on four patients. RESULTS: In-hospital mortality was 10%. The only risk factor was the extent of the dissection. The rate of neurologic stroke was 2.5%. Late survival rate was 42+/-7.5% at 12 years for all the patients; it was 71+/-10% when only the ascending aorta was dissected, 44+/-11% when the ascending aorta and arch were dissected, and 33+/-15% when the whole aorta was dissected (p = 0.0329). The extent of the dissection was the only risk factor for late mortality. Reoperation was required for one proximal and five distal problems. CONCLUSION: In chronic aortic dissection, in-hospital and late mortality were related to the extent of the dissection; in-hospital mortality remained unchanged during the operative period.

Aortobronchial fistula in the presence of a midgraft hole after endovascular repair of thoracic aortic aneurysms.

Aortobronchial fistulas (ABF) are infrequent and require urgent diagnosis, often relying on a bundle of arguments. Thoracic endovascular aortic repair (TEVAR) is a possible therapeutic approach that needs close surveillance because its durability in such situations remains uncertain. We report a case of haemoptysis related to an aortobronchial fistula recurring 6 years after TEVAR, with an intraoperative finding of a midgraft hole. The patient underwent open repair with in situ aortic replacement with an aortic cryopreserved homograft.

Congenital bilateral coronary artery to pulmonary artery fistulas associated with left main trunk stenosis.

A rare case of a 57-year-old patient who presented with an acute coronary syndrome with incidental discovery of bilateral coronary arteriovenous fistulas originating from both coronary arteries to the pulmonary artery trunk and coronary artery atherosclerosis.

New technique of aortic root reconstruction with aortic valve annuloplasty in ascending aortic aneurysm.

We describe a new technique of aortic valve conservation for ascending aortic aneurysm with aortic valvular insufficiency. This technique allows a total anatomic aortic root reconstruction associated with an aortic annuloplasty preventing late annulus dilation and reoperation. Preliminary results demonstrate the feasibility and the safety of this new original procedure.

Papillary muscle approximation for functional ischemic mitral regurgitation.

In patients with ischemic left ventricular dysfunction and functional mitral regurgitation, surgical treatment of mitral insufficiency remains a challenging issue. Several procedures have been described to restore a near to natural alignment between the mitral annulus and the laterally displaced papillary muscles. We report a new approach to relocate the displaced papillary muscles toward the mitral annulus and to reduce tethering in 8 patients, providing satisfactory initial results. Echocardiography showed mild or no mitral regurgitation at the follow-up (mean, 11.4 +/- 3.6 months; range = 7 to 14 months). This procedure is believed to be technically easy and beneficial in terms of mitral repair.

Cardiac surgery in nonagenarians: hospital mortality and long-term follow-up.

Nonagenarians represent a growing part of the population. However, it is assumed that they present a poorer functional class to cope with the stress inferred by surgical interventions. The aim of this study was to review our experience with nonagenarians concerning postoperative morbidities, mortality, and long-term survival status. Retrospective data from 30 consecutive nonagenarians who underwent cardiac surgery between January 1990 and December 2002, and their long-term follow-up was analysed. There were 18 women (60%) and 11 men. Left ventricle ejection fraction (LVEF) was 50.3+/-10.5%. Fifty percent of the patients were in NYHA functional class III or IV. There were nine coronary artery bypass grafting (CABG) procedures (30%), 16 aortic valve replacements (AVR), (53%), one double valve procedure and one replacement of infected intracavitary pace-maker leads. In-hospital mortality rate was 20% (6/30). Mean follow-up was 21.5+/-19 months (r: 2.2 to 68). Actuarial survival rate at 12, 24 and 60 months was 67%, 43% and 30%, respectively. Surviving patients referred quality of life as good, all but one were in NYHA functional class I. Nonagenarians undergoing cardiac surgery have higher mortality and morbidity rates than younger patients. However, in a carefully selected group of patients, the operative risk remains acceptable.

Reoperation for false aneurysm of the ascending aorta after its prosthetic replacement: surgical strategy.

BACKGROUND: This study analyzes surgical approaches of 29 operations carried out for false aneurysms of the ascending aorta after prosthetic replacement (FAA) from January 1979 to April 2003, in 28 patients. METHODS: Initial operations consisted of a composite valve graft with reimplantation of coronary arteries (n = 14) or a supracoronary tube (n = 14) with 7 aortic valve replacements. Initial pathology included acute aortic dissection (n = 20), aortic annuloectasia (n = 6), and aortic valvulopathies with concomitant aneurysm of the ascending aorta (n = 2). Resternotomy was performed under the following conditions: femoral artery cannulation in 7, femoral artery and vein cannulation in 6, femoral artery, vein, and carotid artery cannulation in 16 patients of whom 6 patients underwent partial circulatory arrest. The FAA ruptured during sternotomy in 9 cases. Operative intervention consisted of direct simple suture repair (n = 7), complete revision (n = 21), and one isolated reimplantation of the coronary artery. RESULTS: No patients died after FAA rupture during resternotomy. Among the 6 patients who underwent partial circulatory arrest before sternotomy, the FAA ruptured 5 times. Carotid artery cannulation was always justifiable: 2 cases of FAA rupture, 9 cases of aortic arch replacement, and 5 cases with both. The operative mortality was 17.2% (n = 5). Mortality was influenced by the emergent nature of operations (p < 0.05). CONCLUSIONS: The FAA can be surgically managed with acceptable results through a sternotomy using prior femoro-femoral and carotid cannulation. The latter allows for cerebral perfusion in cases of FAA rupture during resternotomy and is of value for the surgical treatment of these complex lesions.