Aims:Cardiac surgery may induce abrupt changes in pre-load, afterload, and right ventricular contractility. The ability of the right ventricle to maintain systolic performance in the presence of increased afterload is referred to as right ventricular-pulmonary artery (RV-PA) coupling. To assess RV-PA coupling in patients undergoing surgery for severe mitral regurgitation (MR), to identify a tricuspid annular plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP) threshold for RV-PA uncoupling, and to evaluate its prognostic value for early mortality, right heart failure (RHF), post-operative course, and late mortality. Methods and results:This retrospective single-centre observational study included 277 patients who underwent surgery for severe MR between January 2018 and March 2023. RV-PA coupling was assessed using the ratio of TAPSE/PASP derived from pre-operative transthoracic echocardiography. The primary endpoint was early all-cause mortality within 30 days. Secondary endpoints included mortality from RHF, length of intensive care unit (ICU) stay, length of hospital stay, and late all-cause mortality.Receiver operating characteristic analysis identified an optimal TAPSE/PASP cut-off of 0.30 mm/mmHg to define RV-PA uncoupling. Patients with TAPSE/PASP ≤0.30 mm/mmHg had significantly higher early mortality and worse post-operative outcomes. In multivariable logistic regression, TAPSE/PASP remained an independent predictor of early mortality together with EuroSCORE II, cardiopulmonary bypass time, and weaning from bypass requiring ECMO or inotropic support. In a sensitivity analysis restricted to isolated mitral valve (MV) surgery, TAPSE/PASP remained the only independent predictor of early mortality. RV-PA uncoupling was also associated with excess early mortality from RHF and longer ICU and hospital stay, but not with late mortality. Conclusion:Pre-operative RV-PA uncoupling assessed by TAPSE/PASP is strongly associated with early mortality and post-operative RHF after MV surgery for severe MR and may help refine perioperative risk stratification.

BACKGROUND:Right ventricular (RV) systolic parameters are difficult to assess in heart transplant recipients (HTRs) compared to healthy people because of discordant data, and their impact on exercise capacity remains undefined. We sought to retrospectively assess the impact of RV systolic function on exercise capacity after heart transplantation.METHODS:We analyzed data from 61 HTRs who underwent transthoracic echocardiography (TTE), cardiac magnetic resonance imaging (CMR), and exercise capacity assessment by 6-minute walking test (6MWT) and cardiopulmonary exercise testing (CPET) at 1- and 2-year follow-ups.RESULTS:Transthoracic echocardiography RV longitudinal systolic function including tricuspid annular plan systolic excursion (TAPSE), peak systolic S' wave tricuspid annular velocity (PSVtdi) and RV free wall longitudinal strain was decreased at 1 year (respectively, 15 ± 3 mm, 10 ± 3 cm/s, and -19 ± 5%) and at 2 years (respectively, 15 ± 3 mm, 10 ± 2 cm/s, and -20 ± 5%) with no significant difference between both evaluations; meanwhile, RV ejection fraction (RVEF) measured by CMR was preserved. Mean percentage of predicted peak oxygen consumption was altered, but improved between the first and second year (55 ± 18 vs 60 ± 18%, P = .038). PSVtdi was weakly correlated with 6MWT distance (r = .426, P = .017) and RVEF with the predicted distance at 6MWT (r = .410, P = .027) at the 1-year follow-up.CONCLUSIONS:Despite decreasing values, RV longitudinal systolic function has a weak impact on exercise capacity of HTRs. PSVtdi and RVEF are the most pertinent parameters to assess the impact of RV systolic function on exercise capacity after heart transplantation. These results should lead to redefine normal RV systolic function thresholds for HTRs.

Objective: Residual False Lumen (FL) patency after chronic type A or type B Aortic Dissection (AD) treatment is an independent factor of poor longterm outcome. The aim of this study was to evaluate ancillary endovascular procedures in progressive AD, to improve false lumen thrombosis and aortic remodeling. Methods: Between August 2005 and December 2017, 59 ancillary endovascular procedures were performed in 35 consecutive patients for aneurysmal expansion, aortic rupture or malperfusion syndrome. Sixteen patients (45.7%) presented an initial type A AD treated by open aortic surgery, and 19 (54.3%) presented a type B AD, previously treated by TEVAR. Aortic remodeling was evaluated on the preprocedural and on the most recent computed tomography angiography followup for each patient. Results: At a median follow-up time of 60.7 months [44.4-76.8], 59 ancillary endovascular procedures were performed. At the end of the follow-up, positive remodeling was obtained in 85.7% of cases with a complete false lumen thrombosis in 9 patients (25.7%), and a diameter reduction or stability (<5 mm increase) in 21 patients (60.0%). The mean total false lumen thrombosis score before the first ancillary procedure was 0.97 (± 0.90) vs. 2.54 (± 0.98) at the end of the follow-up, p<0.0001. One patient died of a retrograde dissection, 2 days after a proximal aortic stent graft extension. Conclusion: Ancillary endovascular procedures are effective and safe to promote aortic remodeling in progressive chronic AD.

Objective: Participating in either competitive or leisure sports is restrictive after surgical mitral valve repair (MVR). In this study, we examine the impact of sports on outcomes after MVR. Design: Retrospective cohort study. Setting: Patients aged 18 to 65 years who underwent a first-time MVR for primary mitral regurgitation (MR) in a tertiary care center. Patients: One hundred twenty-one consecutive patients were included in the study. The exclusion criteria were as follows: other concomitant procedures, early perioperative death or repeat intervention, noncardiac death or endocarditis during follow-up, and general contraindications for normal physical activity. Assessment of Risk Factors: Participation in sports was quantified by the number of hours per week during the past 6 months, classified according to the Mitchell classification and assessed with the International Physical Activity Questionnaire (IPAQ) short form. Main Outcome Measures: The primary composite endpoint was MVR failure defined as MR grade ≥2 or mean transmitral gradient ≥8 mm Hg, signs and symptoms of heart failure, or late-onset postoperative AF (>3 months). Results: The mean age was 50 ± 11 years, and there were 85 (71%) men. The median follow-up was 34 months [interquartile range (IQR): 20-50]. Fifty-six (46%) patients participated in sports regularly (median of 3 h/wk; IQR: 2-5). Twenty (17%) patients reached the primary composite endpoint with no correlation with participation in sports (P = 0.537), IPAQ categories (P = 0.849), in any of the Mitchell classification subgroups and a high level of participation in sports ≥6 hours (P = 0.679). Conclusions: Sports seem to be unrelated to the worst outcome after MVR.

It is well known that a heavily calcified mitral valve significantly increases the perioperative and postoperative risks of mitral valve surgery. A 71-year-old woman was referred to our department with severe mitral valve disease. Cardiac imaging revealed extremely severe calcification of the entire left heart. Surgery was performed through a median sternotomy with standard cardiopulmonary bypass. After dilating the mitral orifice with a balloon, we replaced the valve with a transcatheter Edwards Sapiens 3 aortic valve under direct vision. Seven months after the procedure, the patient was doing well and no longer suffered from dyspnea.

•Coronary artery perforation was related to angiosarcoma with prior radiation therapy.•Pericardial effusion must make a neoplastic origin suspicious, even from coronary arteries.•Angiosarcomas are rare complications of radiotherapy that must be considered in case of complex situations.

To report the results of the elephant trunk surgery with the Thoraflex Hybrid prosthesis in the treatment of extensive pathologies of the horizontal aorta.

The Epicor system ® is based on high intensity focused ultrasound (HIFU) energy used for creating a wide circumferential linear left atrial lesion encircling both left atrial posterior wall and pulmonary veins (box lesion) and provides long-term cure in patients with atrial fibrillation undergoing heart surgery. Whether if acute complete disconnection of the box lesion is achieved by application of HIFU is unknown. bipolar pacing and detection into the box lesion was studied in 9 pts (5 men, 77 ± 18 yo) undergoing heart surgery (5 aortic valve replacement, 3 mitral valve repair or replacement and one coronary by-pass) using bipolar electrophysiological catheter and a real time telemetry (Medtronic CareLink® programmer), just after completion of the ablation process on the beating heart prior to initiation of extracorporeal circulation. Sinus rhythm was present or obtained using internal cardioversion in each before the ablation process. Entrance block was absent in 7 (1 to 1 conduction from sinus rhythm inside the box lesion), undetermined in one and present in one (dissociated slow local rhythm). Exit block was lacking in 6 (capture of the cardiac rate by pacing inside the box lesion) and present in 3 (dissociated sinus rhythm from the paced area). Acute complete block of the Epicor ® HIFU induced box lesion is lacking in the vast majority of pts despite completion of the energy deliverance according to the automated ablation process. Whether block later happens, or whether supplementary applications would increase the electrophysiological and clinical success rate is unknown.

Stent graft has resulted in major advances in the treatment of trauma patients with blunt traumatic aortic injury (TAI) and has become the preferred method of treatment at many trauma centers. In this review, we provide an overview of the place of stent grafts for the management of this disease. As a whole, TEVAR repair of TAIs offers a survival advantage and reduction in major morbidity, including paraplegia, compared with open surgery. However, endovascular procedures in trauma require a sophisticated multidisciplinary and experienced team approach. More research and development of TAI-specific endograft devices is needed and large, multicenter studies will help to clarify the role of TEVAR compared with open repair of TAI.

Acute aortic syndrome (AAS) describes several life threatening aortic pathologies.Acute aortic syndrome include intramural haematoma, penetrating aortic ulcer and acute aortic dissection.Advances in both imaging and endovascular treatment has led to an increase in diagnosis and improved management of these often catastrophic pathologies.The current place of stent-grafts for the AAS management is defined on the basis of the most recent literature.

Les syndromes aortiques aigus regroupent trois entites : la dissection aortique, l’hematome intramural et l’ulcere atherosclereux penetrant. En raison du risque vital, le diagnostic et la prise en charge doivent etre realises rapidement avec la technique la plus fiable et la moins invasive possible. Une imagerie complementaire est indispensable, elle aura plusieurs objectifs : une description precise des lesions, une classification topographique, une recherche d’extension aux troncs supra-aortiques et aux arteres viscerales, ou une atteinte des structures voisines (pericarde, plevre, mediastin). Ce bilan exhaustif permet d’evaluer la severite et le potentiel evolutif des lesions et ainsi guider la strategie therapeutique. Le scanner permet actuellement au mieux le bilan des lesions en urgence, en revanche, il n’apporte pas d’information sur l’etat de la valve aortique. L’echocardiographie a l’avantage d’etre disponible et realisable au lit du patient, dans les unites de soins intensifs, mais elle n’est pas toujours contributive. Cet examen permet en revanche l’evaluation de la fonction ventriculaire, la recherche d’une insuffisance aortique ou d’un epanchement. En fait, ces deux examens sont souvent complementaires. Un traitement medical et une surveillance en reanimation sont indispensables dans tous les cas. En dehors du traitement medical, schematiquement, pour les atteintes de l’aorte ascendante, une intervention chirurgicale en urgence reste la regle, parfois associee a un geste endovasculaire, en particulier en cas de malperfusion viscerale. Pour les dissections de type B, les traitements chirurgicaux ou endovasculaires sont reserves aux complications, dominees par la rupture et les ischemies viscerales. Dans ce cas, les techniques endovasculaires se sont developpees du fait de leur meilleure tolerance. 1) L’exclusion des portes d’entrees par un stent-graft permet la depressurisation du faux chenal et la thrombose de celui-ci. Un remodelage avec une diminution des diametres aortiques est ainsi observe avec une reperfusion des arteres distales. 2) La fenestration par voie endovasculaire est reservee aux malperfusions liees a un mecanisme dynamique. Le principe est de creer un orifice de communication large entre le vrai et le faux chenal pour faire baisser la pression dans le faux chenal. 3) La mise en place de stents non couverts dans les arteres d’organes concernes par la malperfusion peut etre utile pour les ischemies d’origine statique. Au total, les dissections aortiques peuvent beneficier de therapeutiques endovasculaires efficaces, soit isolement, soit en complement d’une chirurgie de l’aorte ascendante.

OBJECTIVE:The endovascular management of aortic traumatic ruptures has been proposed as an alternative to classical surgical procedures. The aim of this work was to report the midterm results of the endovascular treatment of traumatic ruptures of the isthmic aorta.METHODS:Between January 1996 and July 2005, endovascular repair of blunt traumatic aortic ruptures was performed in 33 patients (mean age, 40 +/- 17 years). The stent grafts used were either Talent Medtronic (n = 27), Gore Excluder (n = 4), or Boston Vanguard (n = 2) grafts. Follow-up was 94.9% complete and averaged 32.4 +/- 28.8 months (maximum, 8 years).RESULTS:Stent graft deployment was successful in all cases without need for surgical conversion. Except for one iliac rupture, which was treated with an iliofemoral bypass during the same procedure, there was no major perioperative complication. The early complications consisted of 3 primary endoleaks (1 type I and 2 type IV), 1 transient paraparesis, 1 occlusion of the main left bronchus, 1 thrombosis, and 2 pseudoaneurysms of the brachial artery. All the primary endoleaks healed within the first month. No patient died, and no aortic reinterventions were performed. The midterm complications were a mild circumferential thrombus at the distal part of the stent graft and a fracture of the nitinol stent. Both complications were asymptomatic and were discovered on systematic computed tomographic scan examination. Actuarial freedom from complication at 1 year was 96.1% +/- 3.8% and 85.5% +/- 10.6% at 3 and 5 years, respectively.CONCLUSION:This study demonstrates that the endovascular treatment of blunt thoracic aortic traumatisms is a safe and effective therapeutic method without increased midterm morbidity and mortality rates.

Objective: We sought to determine the midterm results of endovascular repair of atherosclerotic aneurysms of the thoracic descending aorta by using second-generation, commercially available stent grafts.Methods: Between 1996 and 2005, 45 patients (mean age, 68 +/- 11 years) with aneurysms of the descending thoracic aorta underwent endovascular repair. Aortic dissections, penetrating ulcers, and traumatisms were excluded. The mean follow-up was 24.7 +/- 21.6 months (maximum, 6.7 years).Results: No patients died, and no conversion to surgical intervention was required during the procedures. Three (6.7%) patients died during the first month, and 6 (14.7%) died later on. The main complications were strokes (13.3%), vascular access complications (8.9%), aortic complications (6.6%), paraplegia (4.4%), and sudden deaths (4.4%). Nineteen (42%) primary endoleaks were encountered: 3 required reinterventions, 15 spontaneously thrombosed, and 1 patient died. Except for 2 sudden unexplained deaths, no aortic complications were observed after 1 month. Actuarial survival estimates at 1, 3, and 5 years were 87.6% +/- 5.3%, 76.9% +/- 7.4%, and 70.6% +/- 9.2%, respectively. Actuarial freedom from death related to the treated aortic disease was 94.3% +/- 4.0%, 94.3% +/- 4.0%, and 86.4% +/- 8.4% at 1, 3, and 5 years, respectively. Aspirin status of greater than 3 (P = .005), high aortic diameter (P = .007), and long covered lengths (P = .02) were determinant for mortality. Actuarial freedom from complication was 62.6% +/- 7.7%, 58.9% +/- 8.1%, and 58.9% +/- 8.1% at 1, 3, and 5 years, respectively. The location of the aneurysm (P = .05) and a high aortic diameter (P = .04) were both determinants for endoleaks.Conclusions: Stent grafting of atherosclerotic aneurysm of the thoracic descending aorta is safe and effective. Further studies are mandatory to determine the most relevant indications and the long-term efficacy of such treatment.

Background: There is a need for a validated rapid procedure for the evaluation of posture, defined as lateral balance/imbalance at the pelvic, shoulder, and neck levels. This would enable clinicians to determine the importance of symmetry in the pathophysiology of musculoskeletal disorders and to assess the efficacy of devices and treatments claiming to normalize or improve posture. In this investigation, the efficacy of such a device, a set of insoles with a hypothesized proprioceptive-like action, was evaluated through use of the described procedure. Objectives: To develop a new scoring system to evaluate body posture on the basis of symmetry and to use this scoring system to investigate the efficacy of insoles containing a combination of mineral derivatives designed to balance posture through a neurophysiological effect. Methods: The posture score was based on the evaluation of 4 postural parameters: pelvic and shoulder lateral balance/imbalance, static shoulder rotation, and amplitude of head rotation. In the placebo-controlled study, 32 patients were tested in a double-blind fashion, either with placebo insoles or with insoles containing mineral derivatives. The same study was repeated in unblind conditions in 137 patients selected from 2 chiropractic clinics in an open-label protocol. Study Designs: A crossover placebo-controlled, double-blind study and a multicenter, large-scale, open-label study in patients selected from chiropractic clinics. Results: A basal postural evaluation in 137 patients revealed that no patient had a perfect symmetry—ie, a perfectly or nearly perfectly balanced posture. The insoles with mineral derivatives induced a highly significant and similar improvement in the postural score in both the crossover double-blind study (32 patients; 56.7% improvement) and the open-label study (137 patients; 60.7% improvement, P <.001). Conclusions: All patients tested and selected in chiropractic clinics exhibited asymmetries and postural imbalances according to the newly developed scoring method, and this method was successful in assessing the efficacy of insoles exerting a profound and immediate postural effect through a hypothesized neurophysiological mode of action. (J Manipulative Physiol Ther 2000;23:596-600)

Aortomyoplasty consists of wrapping the latissimus dorsi muscle (LDM) around the ascending aorta and electrostimulating it during diastole. The ascending aorta will act as an ectopic neo-ventricle compressed during diastole, thus reproducing the effects of long-term diastolic counterpulsation. In 5 goats, the right LDM was transferred to the thoracic cavity after removal of the second rib. The ascending aorta was enlarged by a pericardial patch and wrapped with the LDM. Postoperative electrostimulation was delivered in a counterpulsating manner. Hemodynamic studies were performed at 12 and 24 months postoperatively. Percent increase in the subendocardial viability index (diastolic pressure-time index/systolic tension-time index) was calculated using unassisted and assisted cardiac cycles with the stimulator off versus the stimulator on at a 1:1 ratio in the basal state and after acute heart failure was induced by the administration of high doses of propranolol hydrochloride. Diastolic counterpulsation of the ascending aorta resulted in significant improvement in the subendocardial viability index long term, both in basal state conditions and after induced cardiac failure. During heart failure, aortomyoplasty increased the cardiac output and decreased systemic vascular resistance. Histopathologic studies up to 24 months showed preservation of the histologic structure of the aortic wall and no evidence of thromboembolism. Tight adhesions developed between the aortic wall (including the pericardial patch) and the LDM. The diameters of the enlarged aortas showed no significant differences compared with diameters immediately postoperatively. In conclusion, aortomyoplasty produces chronic diastolic augmentation with preservation of aortic structure. After induction of heart failure, aortomyoplasty offers efficient circulatory support.