Background: The impact of prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR) for aortic stenosis on exercise capacity remains controversial. The aim of this study was to analyze the long-term impact of PPM after mechanical AVR on maximal oxygen uptake (VO2max).Methods: The study included 75 patients who had undergone isolated mechanical AVR for aortic stenosis with normal left ventricular (LV) function between 1994 and 2012. Their functional capacity was evaluated on average 4.6 years after AVR by exercise testing, including measurement of their VO2max, and by determining their New York Heart Association functional class and Short Form-36 score. Two groups were defined by measuring the patients' indexed effective orifice area (iEOA) by transthoracic echocardiography: a PPM group (iEOA < 0.85 cm(2)/m(2)) and a no-PPM group (iEOA >= 0.85 cm(2)/m(2)).Results: PPM was present in 37.0% of the patients. The percentage of the predicted VO2max achieved was significantly lower in the PPM group (86.7 +/- 19.5% vs 97.5 +/- 23.0% in the no-PPM group; P = 0.04). Compared with the no-PPM group, the PPM group contained fewer patients in New York Heart Association functional class I and their mean Short Form-36 physical component summary score was significantly lower. The mean transvalvular gradient was significantly higher in the PPM group than in the no-PPM group (P < 0.001). Systolic and diastolic function and LV mass had normalized in both groups.Conclusions: PPM is associated in the long term with moderate but significant impairment of functional capacity, despite optimal LV reverse remodelling and normalization of LV systolic and diastolic function.

Diagnostic value of circulating D-Dimer (DD) in acute aortic dissection (AAD) has been shown recently. However, there is no data concerning the kinetics of DD in AAD and few is known about prognostic value of DD in AAD. to describe the kinetics of circulating DD during the in-hospital period of AAD in patients and to analyse its prognostic value. consecutive patients presenting with AAD in our institution were included. Follow-up was obtained to determine the total mortality and major events related to AAD i.e. : re-intervention, aneurismal evolution, persistence of a circulating false lumen). DD were assessed by immunoturbidimetric method (Stago®, France). 109 patients (mean age 62 ± 14 years) were included. 76 patients were Stanford A (70%, surgery in 97%), and 33 Stanford B (30%, surgery in 9%). DD levels at admission were 10032 ± 7955 ng/ml. The kinetic of DD followed a “V” curve with a significant decrease until day 2 (nadir) and a slow increase thereafter up to day 8 without difference between the type of dissection or whether the patients were operated or not. Cumulative mortality was 16% in-hospital and 28% at a mean of follow up 3.4 ± 3 years. In-hospital mortality was associated with DD level at admission and at day2 (nadir). Cumulative long-term mortality was only associated with DD level at day 2 (nadir) at the cut off of 2000ng/ml. DD were not associated with re-intervention, aneurismal evolution or persistence of a circulating false lumen. DD kinetic in AAD follows a biphasic “V” curve, with a nadir at day 2. In hospital mortality is associated with DD at admission and at day2, whereas cumulative long-term mortality is only associated with DD levels at day 2. These results suggest that a DD dosage at admission and at day 2 in AAD might be of help for the patient prognosis evaluation.

A 49-year-old male patient presented with a paravalvular leakage 18 years after aortic valve replacement. The patient received a mechanical valve and was weaned uneventfully from cardiopulmonary bypass. After a drop in the pressure curve of the left radial artery an additional line was placed in the proximal ascending aorta showing normal systemic pressure. Transesophageal echocardiography showed a massive circular thrombosis of the distal aortic arch. The patient received a covered stent to expand the residual aortic lumen and left the hospital in good health. doi: 10.1111/j.1540-8191.2008.00750.x (J Card Surg 2009;24:470-472)

Objective: To compare the diagnostic value of circulating Sta-Liatest D-Di levels in classic acute aortic dissection (AAD) and in aortic intramural hematoma (AIH), a variant of AAD without a patent false lumen.Design: Single-center retrospective case-control study.Setting. University Hospital of Strasbourg, France.Patients. Ninety-four consecutive patients with both confirmed AAD and d-dimer measurements at entry were included. d-dimer levels were assayed by the immunoturbidimetric method Sta-Liatest D-Di (Diagnostica Stago, Asnieres sur Seine, France).Intervention: Patient characteristics and clinical evolution were analyzed.Measurements and Main Results. Eighty-four patients (89%) presented a classic AAD with patent false lumen and ten (11%) presented an AIH. Clinical presentation did not differ between the two groups. The mortality rate was 0% in AIH and 26% in classic AAD. d-dimer levels were significantly lower in patients with AIH (median, 1230 ng/mL; interquartile range, 685-2645 ng/mL than in patients with AAD with patent false lumen (median value, 9290 ng/mL; interquartile range, 3890-20,000 ng/mL; p = 0.008). All patients with AAD and patent false lumen had d-dimer levels above the threshold of 400 ng/mL (sensitivity 100%). However, one patient with AIH presented d-dimer levels below the threshold. Therefore, the sensitivity of the d-dimer test in detecting AIH was 90%.Conclusions: Sta-Liatest D-Di levels are lower in AIH than in AAD with patent false lumen. This test can quite possibly be negative in the case of intramural hematoma. This feature must be considered when interpreting d-dimer levels in patients with acute aortic syndrome. (Crit Care Med 2009; 37:899-901)

Cardiac intracavitary metastasis is very uncommon. In a 55-year-old man presenting with a massive pulmonary embolism pattern, transthoracic echocardiography (TTE) allowed us to visualize an isolated right ventricular metastasis extended into the pulmonary trunk. It led to the discovery of a primary testis embryonal carcinoma. No intracaval and right atrial localization was observed. Despite an urgent complete cardiac metastasis resection and concomitant orchidectomy, TTE showed on postoperative day 6 an uncommon total intracardiac regrowth spreading again to the pulmonary trunk. Combination chemotherapy (etoposide, cisplatin, and bleomycin) was immediately undertaken. This is the first well-documented case of an isolated right ventricular germ-cell cancer metastasis extended into the pulmonary trunk, without intracaval and right atrial involvement, where the outcome was marked with immediate regrowth despite cardiac surgery and orchidectomy. In conclusion, TTE should be considered alongside germ-cell cancer standard staging procedures.

Abdominal aortic aneurysm (AAA) is very frequently accompanied by coronary artery disease. Myocardial ischemia is the leading cause of mortality and morbidity in AAA repair. Therapeutic strategy, in presence of ischemic heart failure and AAA, is not well established. Actually, AAA is considered as a contraindication to ventricular assist device (VAD) support. We report a unique case of concomitant open AAA repair and biVAD implantation in a patient with severe ischemic heart failure. This case argues that AAA should no longer be considered a contraindication for VAD implantation, provided the AAA repair is made before or simultaneously with device placement.

We read with great interest the article by Sodeck et al. 1 reporting the negative predictive value of D-Dimer in acute aortic dissection (AAD). Based on a meta-analysis and on a personal series of 65 patients, the authors conclude that current evidence supports a routine measurement of D-Dimer for excluding AAD. Furthermore, a D-Dimer threshold <0.1 µg/mL would exclude AAD in all cases. We previously reported on a 94-case series of patients2 and believe for several reasons that Sodeck's conclusion could …

Background and aim of the study: The study aim was to assess early and late outcome in patients undergoing composite valve graft replacement (CVGR) of the aortic root by means of the Bentall procedure, and to identify predictors of early and late death associated with this surgical approach.Methods: Between August 1975 and July 2002, 162 consecutive patients underwent a Bentall procedure for CVGR. Demographic, treatment and clinical outcome data from these patients were gathered, reviewed, and analyzed. Potential predictors of early and late mortality were analyzed.Results: The study population was predominantly male (n = 132; 81.5%) and middle-aged (mean age 51.3 +/- 15.8 years; range: 10-79 years). The main indications for surgery were annuloaortic ectasia (n = 75; 46.3%), aortic dissection (n = 44; 27.2%) and Marfan syndrome (n = 34; 21%). Reoperation was required in 37 cases (22.8%). The mean follow up was 74 months. Early (in-hospital) mortality was 1.9% (n = 3). The only independent determinant of early mortality was cardiopulmonary bypass time (p = 0.025). Late mortality was 27.7% (n = 44). On multivariate analysis, the only independent risk factors for late mortality were age >60 years (p = 0.044) and left ventricular ejection fraction <50% (p = 0.037). Actuarial survival rates were 92.9%, 77%, 56.2%, and 47.1% at one, five, 10, and 15 years, respectively. Rates of freedom from reoperation on the aortic root and ascending aorta were 90.6% and 72.5% at five and 15 years, respectively. No false aneurysms were observed at any coronary reimplantation sites.Conclusion: In this series, the Bentall procedure was associated with low operative mortality and good early and late results. This suggests that the procedure may be considered as a reference to other operations on the aortic root, at least in adult patients.

A 65-year-old patient with a past medical history of hypertension, alcoholism, micronodular cirrhosis, and coronary artery bypass grafting 10 years ago developed a hepatocellular carcinoma, treated by chemoembolization. One month after treatment, thoracoabdominal CT scan showed no residual hepatic tumor, but tumoral aspect in the right atrium with extension into the inferior vena cava. The patient being asymptomatic, cardiac ultrasound confirmed the presence of a free, mobile, pediculated tumor in the right atrium. Surgical exploration found a well-circumscribed mass, attached to the atrial wall by a 1.5-cm diameter pedicle implanted near the inferior vena cava ostium, moving freely in the right atrial cavity. The tumor was easily resected by section of the pedicle and its surrounding parietal implantation zone. No complications occurred postoperatively, and the patient was discharged on the 10th postoperative day. Three years after, the patient is in good health and is asymptomatic; cardiac ultrasound showed no tumor recurrence.

Biventricular assist device (BVAD) has been shown to be effective for bridge to heart transplantation with an acceptability low incidence of adverse effects in critically ill heart failure patients. We report the case of a 44-year-old man with severe acute ischemic heart failure who was supported with the Thoratec paracorporeal biventricular assist system. After an initial uneventful postoperative course the patient experienced a splenic rupture which required a splenectomy. The pathological mechanism of this outcome remains unclear. Two months after discharge, the patient underwent heart transplantation and had no postsplenectomy sepsis or thrombotic complications at the last follow-up.

The outcome of conventional elective open repair for infrarenal abdominal aortic aneurysm (AAA) has improved mainly as a result of screening to detect coronary artery disease, the main risk factor for morbidity and mortality. Our group’s policy is to perform routine coronary angiography in patients scheduled to undergo elective AAA repair. The purpose of this study was to evaluate morbidity and mortality in our department using this work-up strategy. From January 1990 to December 2000 we performed elective open repair on 632 patients, including 580 men (92%) and 52 women (8%). Preoperative coronary angiography performed in 607 cases (96%) revealed significant coronary disease in 53% of patients and led to the decision to propose prior myocardial revascularization in 12.5% of cases. Mortality and morbidity in the first 30 days after AAA repair were 1.4% and 15%, respectively. Analysis with the Cox model showed that the only risk factor for mortality was chronic renal insufficiency. Our data support routine use of coronary angiography prior to AAA repair. Screening and, if necessary, treatment of coronary artery disease that is commonly associated with AAA enhances the outcome of open AAA repair.

The study of heart rate variability allows analysis of modulations of heart rate by the sympathetic vagal system. The authors studied the course of sinus variability by 24-hour Holter monitoring preoperatively, and on the 6th and 42nd postoperative day, in 25 patients undergoing coronary bypass graft (group I) and 10 patients undergoing aortic valve replacement (group II). Surgery was performed under cardiopulmonary bypass with selective antegrade cold crystalloid cardioplegia. The preoperative ejection fraction of these patients was 62% with a mean age of 59.5 years in group I and 61.5 years in group II. All temporal or spectral parameters were significantly decreased in the two groups on the sixth day (p<0.05). Parameters which remain altered on D42 compared to baseline values were temporal parameters: pNN50 and rMSSD for group I and ASDNN for group II, with a tendency to return to baseline values, but with a higher mean heart rate in group II on D6 and D42 (p<0.05). In the spectral domain, TP (total power of the spectrum) and LF (Low frequencies) remained decreased in both groups. A reversible alteration of sinus variability parameters was therefore observed in the two groups of patients. Other studies are necessary to define the mechanisms of these alterations, which are most probably related to catecholaminergic flooding related to CPB or partial vagal denervation by ischaemic or surgical damage to nerve structures.

Objective: It is a common statement that every mitral repair should be stabilized by some type of prosthetic mitral ring. In the very specific situation of isolated prolapse of the posterior leaflet (PPL), this statement may be enhanced by the possible anatomically discontinuity of the mitral annulus. This article concerns 96 patients with 'isolated' PPL (IPPL) who were operated upon without ring insertion. Long-term follow-up was obtained in order to ascertain the survival, stability of the repair and the need fur reoperation, thus justifying or not the lack of use of a ring. Methods: A total of 96 patients, 70 male and 26 female, underwent mitral repair for mitral insufficiency (MI) almost exclusively caused by PPL. Age ranged from 33 to 81 years (mean 60.7 +/- 11.3). All underwent quadrangular resection of the prolapsed portion and plication of the annulus. In 69 cases local stabilization was achieved by four U stiches, two on each side of the plication, passed through and sutured on some flexible material, 2-3 cm in length. Twenty seven patients had no such local reinforcement. Results: There was one case of early death (1%) caused by refractory hypoxemia in a patient with long lasting pre-operative pulmonary edema. Two patients were lost for follow-up after 2 months. Follow-up was from 0.2 to 14.7 years (mean 4.5, for a total of 422.7 patient-years. There were four late deaths at a mean of 6-year follow-up (0.9-10 years). Actuarial survival was 95.5 and 90.5% at 5 and 8 years, respectively. Event-free for recurrence of significant mitral insufficiency (MI) was 96 and 92% at 5 and 8 years. Event-free of thromboembolic or hemorrhagic events was 84.3 and 72.3% at 5 and 8 years. Event-Free from reoperation was 97.8 and 94% at 5 and 8 years. Conclusion: One can conclude that (a) IPPL repair without insertion of a ring is safe and long-lasting (b) the incidence of late death, recurrence of MI, thromboembolic/hemorrhagic events, need for reoperation, is not higher in this subset of patients than in conventional repair (c) such repair might work better and for a longer time, as reaction and sclerosis resulting from ring insertion are avoided (d) minor advantages could be due to an easier surgical procedure, especially through a minimally invasive approach. (C) 1998 Elsevier Science B.V. All rights reserved.

The study of heart rate variability allows analysis of modulations of heart rate by the sympathetic vagal system. The authors studied the course of sinus variability by 24-hour Holter monitoring preoperatively, and on the 6th and 42nd postoperative day, in 25 patients undergoing coronary bypass graft (group I) and 10 patients undergoing aortic valve replacement (group II). Surgery was performed under cardiopulmonary bypass with selective antegrade cold crystalloid cardioplegia. The preoperative ejection fraction of these patients was 62% with a mean age of 59.5 years in group I and 61.5 years in group II. All temporal or spectral parameters were significantly decreased in the two groups on the sixth day (p < 0.05). Parameters which remain altered on D42 compared to baseline values were temporal parameters: pNN50 and rMSSD for group I and ASDNN for group II, with a tendency to return to baseline values, but with a higher mean heart rate in group II on D6 and D42 (p < 0.05). In the spectral domain, TP (total power of the spectrum) and LF (Low frequencies) remained decreased in both groups. A reversible alteration of sinus variability parameters was therefore observed in the two groups of patients. Other studies are necessary to define the mechanisms of these alterations, which are most probably related to catecholaminergic flooding related to CPB or partial vagal denervation by ischaemic or surgical damage to nerve structures.

Background Contrast echocardiography is a useful tool for assessing repeatedly patients with coronary artery disease. Nevertheless, elevated pulmonary artery and systemic blood pressures likely to be associated with cardiac ischemia may limit the left ventricular opacification (LVO) because of the microspheres' sensitivity to pressure. Objective To determine the effects of systemic and pulmonary artery blood pressures on LVO. Methods We performed 55 intravenous injections (0.08 and 0.22 ml/kg) of a new transpulmonary contrast agent (Albunex), during two separated exposures, into 20 cardiac ischemic patients while monitoring invasively their cardiac indexes, and intracardiac, systemic, and pulmonary artery blood pressures. LVO was graded qualitatively from faint to full. Results A logistic model with the grade of LVO as the dependent variable and a selection from among the dose, exposure, right and left atrial blood pressures, systolic systemic and pulmonary artery blood pressures (ranges 94–208 and 14–45 mmHg, respectively), cardiac index, stroke index, and pulmonary and systemic vascular resistances as the explanatory variables demonstrated that increasing the dose gives an increasing probability of LVO (P=0.02) and that increasing the pulmonary artery pressure reduces that probability (P= 0.006). A decreased cardiac index tended also to be associated with decreased LVO. The systemic blood pressure and the pulmonary and systemic vascular resistances had no statistically significant effect on the grade of LVO. Conclusions LVO after intravenous administration of Albunex is dose-dependent and limited by an elevated pulmonary artery pressure. These data suggest that one should use higher doses for cardiac ischemic patients with elevated pulmonary artery pressures and that use of Albunex has the potential to detect pulmonary hypertension in patients.

The standard approach (right ventriculotomy and atriotomy) for surgical repair of double-outlet right ventricle with subaortic ventricular septal defect and pulmonary stenosis may not give an adequate view of the intracardiac defect due-to the presence of anomalous coronary artery anatomy or unusual cavity spacial relationship. Thus, a transverse aortotomy was performed and the left ventricular outflow tract was well visualized through the aortic valve and could be reconstructed precisely. Therefore, the transaortic approach also should be considered for systemic route reconstruction in this group.

Exercise tolerance of heart transplant patients is often limited. Central and peripheral factors have been proposed to explain such exercise limitation but, to date, the leading factors remain to be determined. We examined how a short-term endurance exercise training programme may improve exercise capacity after heart transplantation, and whether atrial natriuretic peptide (ANP) release may contribute to the beneficial effects of exercise training by minimizing ischaemia and/or cardiac and circulatory congestion through its vasodilatation and haemoconcentration properties. Seven heart transplant recipients performed a square-wave endurance exercise test before and after 6 weeks of supervised training, while monitoring haemodynamic parameters, ANP and catecholamine concentrations. After training, the maximal tolerated power and the total mechanical work load increased from 130.4 (SEM 6.5) to 150.0 (SEM 6.0) W (P < 0.05) and from 2.05 (SEM 0.1) to 3.58 (SEM 0.14) kJ . kg(-1) (P < 0.001). Resting heart rate decreased from 100.0 (SEM 3.4) to 92.4 (SEM 3.5) beats . min(-1) (P < 0.05) but resting and exercise induced increases in cardiac output, stroke volume, right atrial, pulmonary capillary wedge, systemic and pulmonary artery pressures were not significantly changed by training. Exercise-induced decrease of systemic vascular resistance was similar before and after training. After training arterio-venous differences in oxygen content were similar but maximal lactate concentrations decreased from 6.20 (SEM 0.55) to 4.88 (SEM 0.6) mmol . l(-1) (P < 0.05) during exercise. Similarly, maximal exercise noradrenaline concentration tended to decrease from 2060 (SEM 327) to 1168 (SEM 227) pg . ml(-1). A significant correlation was observed between lactate and catecholamines concentrations. The ANP concentration at rest and the exercise-induced ANP concentration did not change throughout the experiment [104.8 (SEM 13.1) pg . ml(-1) vs 116.0 (SEM 13.5) pg . ml(-1) and 200.0 (SEM 23.0) pg . ml(-1) vs 206.5 (SEM: 25.9) pg . ml(-1), respectively]. The results of this study suggested that the significant improvement in exercise capacity observed after this short-term endurance training period may have arisen mainly through peripheral mechanisms, associated with the possible decrease in plasma catecholamine concentrations and reversal of muscle deconditioning and/or prednisone-induced myopathy.