Background: Endomyocardial biopsies (EMB) are recommended for the detection of acute cardiac rejection (ACR) despite limited sensitivity. We report the long-term post -transplant results of Doppler echocardiography as a noninvasive alternative of routine EMB. Methods: Two cohorts of heart transplantation (HT) recipients were chronologically defined as follows: Dual Monitoring Cohort (DMC) from January 1990 to December 1997 included patients who underwent routine EMB and Doppler echocardiography within 24 hours for ACR surveillance; and the "Echo -First Cohort" (EFC), including patients transplanted from January 1998 to December 2018 with Doppler echocardiography as first -line approach for ACR surveillance. Echocardiographic measurements of interest were collected: early diastolic (E) wave peak velocity; pressure half time (PHT) and isovolumetric relaxation time (IVRT). Post -transplant outcomes were reviewed and the Kaplan -Meier approach was used for survival estimates. Inter -operator variability for ultrasound measurements was investigated. Data were collected from medical records from January 2019 to December 2020. Results: A total of 228 patients were included, 99 patients in the DMC and 129 in the EFC. Overall, 10- and 15 -year survival rates were 65.4%, 55.5% and 44.1% respectively, without any significant difference between the two cohorts (log rank test, P=0.71). Echocardiography variables and EMB findings were associated with a mean area under the receiver operating characteristic curve (AUC-ROC) of 0.73 confidence interval (CI): 0.54-0.91], 0.74 (95% CI: 0.54-0.94) and 0.75 (95% CI: 0.57-0.94) respectively E wave, PHT and IVRT. IVRT and PHT were significantly decreased, and E wave significantly increased, in case of histologically proven ACR. Inter -operator variability was not significant for E wave and IVRT measurements (P=0.13 and 0.30 respectively).

OBJECTIVES:To assess the feasibility of acute type A dissections treatment with a dedicated aortic root endograft concept and introduce a new aortic classification. BACKGROUND:Acute type A aortic dissection remains a catastrophic aortic condition with perioperative mortality ranging from 12% and 20%. Total Aortic root endovascular repair, the "Endo-Bentall concept," has been explored as an alternative but only documented in the case report. METHODS:An imaging study of all consecutive patients treated in 3 French centers was achieved. The study introduces an adapted aortic classification to report entry tear locations. Measurements included aortic annulus mensuration, coronary height, and several aortic lengths. Two treatment concepts were described "fenestrated Endo-Bentall" (FEB) and "branched Endo-Bentall (BEB)." Patients were eligible for the "FEB" design if their aortic root dimensions fitted the Edwards Sapien and Corevalve Medtronic instructions for use. Eligibility for the "BEB" required meeting the criteria for a "FEB" and having a left coronary main stem length exceeding 5 mm. "BEB" was mandatory when the entry was located in the aortic root. RESULTS:A total of 250 computed tomography scans for acute type A aortic dissection were reviewed, and 116 were finally included for analysis. The primary entry tear was found in the aortic root in 9% of patients, and in 31% of cases, it was located within the first centimeter distal to the sinotubular junction. Of the patients, 63.7% were eligible for an Endo-Bentall procedure, even 73.3% when considering extended criteria. FEB accounted for 2/3 of cases. CONCLUSIONS:In our study, 63.7% of patients with aortic type A dissections are deemed eligible for an "Endo-Bentall repair," increasing to 73.3% when considering extended anatomic criteria.

PURPOSE OF REVIEW:This article explores recent developments in left main revascularization, with a focus on appraising the latest American and European guidelines. RECENT FINDINGS:Recent pooled data analysis from four major randomized controlled trials (RCTs) for left main coronary artery stenosis indicate an advantage for CABG over PCI in regard to freedom from major adverse cardiovascular events, despite no significant difference in mortality observed at 5 years. Additional data support the use of CABG for patients with left ventricular dysfunction, complex left main lesions, diffuse coronary disease, and diabetes. SUMMARY:The data underpinning the guidelines on each revascularization modality (PCI versus CABG) must consider factors such as lesion complexity, diabetes, and left ventricular dysfunction. Additionally, the findings of the four major RCTs upon which the guidelines are based must be ascertained in light of the latest advancements in these revascularization techniques.

Objective: Aortic endografting and antegrade in situ laser fenestration of visceral arteries (LFEVAR) may be considered as an alternative to open surgery for the emergency repair of complex abdominal aortic aneurysms (AAA) in fragile patients. The aim of this article was to evaluate the midterm results of LFEVAR performed with polyester endografts.Methods: From August 2015 to December 2020, all consecutive LFEVAR performed for non-deferrable treatment of complex AAA were analysed. Polyester endografts were deployed and subsequently fenestrated using an atherectomy laser probe; the fenestrations were enlarged using cutting and semicompliant balloons before implantation of balloon expandable bridging stents into the target vessels. Prospectively collected midterm survival, patency, and re-intervention rates were analysed.Results: Forty four procedures were performed for 11 type 1a endoleaks, five thoraco-abdominal aneurysms, 20 pararenal aneurysms, four segmental renal artery (RA) preservations, three anastomotic aneurysms, and one aortic dissection. One hundred and eight laser fenestrations were performed (26 for the superior mesenteric artery [SMA], 13 for the coeliac trunk, 33 and 31 for the right and left RA, respectively). The median ischaemia duration was 7, 48, 48, and 45 minutes, respectively. The technical success rate was 97%, with no open surgical conversions. The 30 day mortality was 4.5% (n 1/4 2). No spinal cord ischaemia events were observed nor early stent related complications. Kaplan -Meier overall survival at two years was 73%, the aortic related re-intervention free survival was 70%, and the stent related re-intervention free survival was 90.6%. Four target vessel thromboses were detected, of which three were rescued. Three type IIIc endoleaks, one RA false aneurysm, and one SMA stenosis, required re-intervention during a median follow up of 24.7 months.Conclusion: Antegrade LFEVAR is feasible, safe, and provides satisfactory early and midterm outcomes for non -deferrable treatment of aortic pathologies involving the visceral segment. Long term data are mandatory to confirm the usefulness of this promising off label technique.

"A Dancing Trapped Intracardiac Thrombus." American Journal of Respiratory and Critical Care Medicine, 206(11), pp. 1405–1407

BACKGROUND: Assessment of myocardial viability during ex situ heart perfusion (ESHP) is based on the measurement of lactate concentrations. As this provides with limited information, we sought to investigate the metabolic signature associated with donation after circulatory death (DCD) and the impact of ESHP on the myocardial metabolome.METHODS: Porcine hearts were retrieved either after warm ischemia (DCD group, N = 6); after brain-stem death (BSD group, N = 6); or without DCD nor BSD (Control group, N = 6). Hearts were perfused using normothermic oxygenated blood for 240 minutes. Plasma and myocardial samples were collected respectively every 30 and 60 minutes, and analyzed by an untargeted metabolomic approach using liquid chromatography coupled to high-resolution mass spectrometry.RESULTS: Median duration of warm ischemia was 23 minutes [19-29] in DCD animals. Lactate level within myocardial biopsies was not significantly different between groups at T0 (p = 0.281), and remained stable over the 4-hour period of ESHP. More than 300 metabolites were detected in plasma and heart biopsy samples. Compared to BSD animals, metabolomics changes involving energy and nucleotide metabolisms were observed in plasma samples of DCD animals before initiation of ESHP, whereas 2 metabolites (inosine monophosphate and methylbu-tyrate) exhibited concentration changes in biopsy samples. Normalization of DCD metabolic pro-file was remarkable after 4 hours of ESHP. CONCLUSION: A specific metabolic profile was observed in DCD hearts, mainly characterized by an increased nucleotide catabolism. DCD and BSD metabolomes proved normalized during ESHP. Complementary investigations are needed to correlate these findings to cardiac performances.

Background. - The number of heart transplantations (HTs) has decreased in France since 2017 (-5%/year) despite a stable rate of patients referred on the waiting list. Ex vivo heart perfusion (EVHP) is an innovative approach for organ preservation, reducing graft ischaemic time and facilitating continuous organ monitoring before transplantation. Aim. - To report our preliminary experience of seven donor hearts preserved with EVHP, including the first heart resuscitated after circulatory-determined death in France. Methods. - Seven hearts were procured from donation after brain death (DBD) for HT or donation after circulatory-determined death (DCD) for research purposes (Protocol PFS20-004, Agence de la Biomedecine, La Plaine Saint-Denis, France). All grafts were preserved using the Organ Care System (R) (TransMedics Inc., Andover, MA, USA) for normothermic EVHP. Perfusion parameters were adjusted to achieve stable or decreasing arterial lactate trend consistent with suitability for organ transplantation. Results. - Indications for EVHP were assessment of a marginal graft in four cases, prolonged preservation in two cases (anticipated duration for retrieval of recipient's heart > 3 hours) and resuscitation after circulatory-determined death in one case. Median duration of EVHP was 270 (interquartile range 216-343) minutes. five were transplanted, with a median ex situ preservation time (ischaemic time + EVHP time) of 334 (interquartile range 326-444) minutes. The two other grafts were discarded for HT. Three recipients had extracorporeal life support after HT, and presented complete cardiac recovery within a week after HT. One patient died at day 11 because of septic shock. The 3-month survival rate was 75% among recipients. Three months after HT, the left ventricular ejection fraction was > 60% in all cases. Conclusions. - EVHP enabled safe prolonged preservation and assessment of marginal grafts. This approach provides an opportunity to expand the donor pool by resuscitating grafts from donors with extended criteria, including controlled DCD. (c) 2021 Elsevier Masson SAS. All rights reserved.

Three-dimensionally (3D) printed models have been increasingly used in medicine. Few reports have focused on prototype experiments, especially in aortic surgery. Although endovascular repairs are routinely performed for thoracoabdominal aortic aneurysms and lesions involving the aortic arch, endovascular treatment of the ascending aorta is still at an early stage of development. Using a 3D model, based on patient computed tomography scans and manufactured by Biomodex (Paris, France), we performed a patient-specific rehearsal of an endovascular Bentall repair to treat an ascending aorta aneurysm involving the aortic root. We achieved a patient-specific proof of concept of a new technique using an in vitro 3D model.

Endovascular treatment of thoracoabdominal aneurysms: what's new? Thoracoabdominal aneurysms (T-AAA) are aortic aneurysms that involve both the thoracic and abdominal segments of the aorta and its associated visceral branches. Although the first successful open repair was reported over 50 years ago, the risks of treatment remain considerable. As the first generations of devices available for endovascular aneurysm repair (EVAR) were relatively simple tubes or bifurcated grafts, initial attempts to extend the benefits of EVAR to patients with T-AAA lead to "hybrid solution". Good results with hybrid repairs have not been universal and the approach does not exploit all of the potential advantages of a "pure" endovascular approach (lesser surgical insult). This unmet need, together with rapid technological advances, has encouraged the development of custom-made endografts with fenestrations and/or branches (F-BEVAR) for extension into the visceral vessel ostia. F-BEVAR requires considerably more complex device design and planning than conventional EVAR. Deployment is more technically demanding and takes longer to complete. Thus, patient, aneurysm anatomy and surgical team selection is paramount. Favorable outcomes have been widely reported following T-AAA repair with F-BEVAR in expert centers; more complex aortic lesions such as T-AAA in the context of chronic dissection or arch aneurysms are thus now also offered endovascular repair with F-BEVAR.

Les anévrysmes thoraco-abdominaux sont des anévrysmes qui englobent l’aorte thoracique et abdominale et donc les vaisseaux à destinée viscérale. Bien que la première réparation chirurgicale ouverte d’un anévrysme thoraco-abdominal ait été réalisée il y a plus de 50 ans, les risques associés à cette chirurgie restent très élevés. Comme la première génération d’endoprothèses disponibles pour le traitement endovasculaire des anévrysmes de l’aorte étaient de « simples » tubes ou des endoprothèses bifurquées (EVAR), les premières utilisations de la technique endovasculaire à l’étage thoraco-abdominal ont été hybrides, associant chirurgie ouverte et endovasculaire. Les résultats de cette technique n’ont pas été satisfaisants car celle-ci reste invasive comparativement à une réparation exclusivement endovasculaire. Ces résultats décevants associés à l’évolution rapide des technologies ont abouti au développement d’endoprothèses sur mesure avec des fenêtres ou des branches (F-BEVAR) pour perfuser les vaisseaux à destinée viscérale. Les F-BEVAR nécessitent un planning préopératoire beaucoup plus précis que les EVAR. Le déploiement de la prothèse est plus complexe et le temps opératoire est donc allongé. Il existe une courbe d’apprentissage pour la sélection des patients et la formation à ces techniques. Les résultats favorables après F-BEVAR ont été publiés par de nombreux centres experts ; cette approche endovasculaire est donc maintenant proposée pour des lésions plus complexes comme les anévrysmes thoraco-abdominaux dans un contexte de dissection chronique ou les anévrysmes de la crosse aortique.

La Presse Medicale - In Press.Proof corrected by the author Available online since samedi 24 fevrier 2018

Neurologic lesions are unusual complications after coronary artery bypass surgery. Among them, paraplegia is one of the rarest, with only a few cases reported in the literature. We report a case of paraplegia after coronary artery bypass following previous thoracic endovascular aortic repair.