OBJECTIVE:To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay. DESIGN:A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence. METHODS:Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method. RESULTS:The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions. CONCLUSIONS:Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.

OBJECTIVES: Despite growing evidence that aortic valve repair improves long-term patient outcomes and quality of life, aortic valves are mostly replaced. We evaluate the effect of aortic valve repair versus replacement in patients with dystrophic aortic root aneurysm up to 4 years. METHODS: The multicentric CAVIAAR (Conservation Aortique Valvulaire dans les Insuffisances Aortiques et les Anevrismes de la Racine aortique) prospective cohort study enrolled 261 patients: 130 underwent standardized aortic valve repair (REPAIR) consisting of remodelling root repair with expansible aortic ring annuloplasty, and 131 received mechanical composite valve and graft replacement (REPLACE). Primary outcome was a composite criterion of mortality, reoperation, thromboembolic or major bleeding events, endocarditis or operating site infections, pacemaker implantation and heart failure, analysed with propensity score-weighted Cox model analysis. Secondary outcomes included major adverse valve-related events and components of primary outcome. RESULTS: The mean age was 56.1 years, and valve was bicuspid in 115 patients (44.7%). Up to 4years, REPAIR did not significantly differ from REPLACE in terms of primary outcome [Hazard Ratio (HR) 0.66 (0.39; 1.12)] but showed significantly less valve-related deaths (HR 0.09 [0.02; 0.34]) and major bleeding events (HR 0.37 [0.16; 0.85]) without an increased risk of valve-related reoperation (HR 2.10 [0.64; 6.96]). When accounting for the occurrence of multiple events in a single patient, the REPAIR group had half the occurrence of major adverse valve-related events (HR 0.51 [0.31; 0.86]). CONCLUSIONS: Although the primary outcome did not significantly differ between the REPAIR and REPLACE groups, the trend is in favour of REPAIR by a significant reduction of valve-related deaths and major bleeding events. Long-term follow-up beyond 4 years is needed to confirm these findings.

Objective > To provide recommendations for Enhanced Recovery After Cardiac Surgery (ERACS) based on a multimodal approach of perioperative medicine of adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity and reducing length of hospital stays.Design > A consensus committee of 20 experts from the French society of anaesthesiology and critical care medicine (Societe francaise d'anesthesie-reanimation, SFAR) and the French society of thoracic and cardio-vascular surgery (Societe francaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assess-ment of quality of evidence.Methods > Six fields were defined: 1) selection of the patient pathway and their information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for cardiac surgery; 4) surgical strategy for cardiac surgery and bypass management; 5) Patient Blood Management; and 6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analysed using the GRADE approach. The recommendations were formulated according to the GRADE methodology, and then voted by all the experts according to the GRADE grid method.Results > The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing pulmonary lobectomy. After three rounds of voting and several amend-ments, a strong agreement was reached for 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert judgments. Finally, no recommenda-tion was provided for 3 questions. Conclusions > Strong agreement exists among the experts to provide recommendations to opti-mize the whole perioperative management of patients undergoing cardiac surgery.

Éditer des recommandations pour un programme de Réhabilitation améliorée après chirurgie cardiaque (RAACC), reposant sur une approche multimodale de la médecine périopératoire des patients adultes opérés d'une chirurgie cardiaque, ayant pour objectifs d'améliorer la satisfaction du patient, de réduire la morbidité et la mortalité postopératoires et les durées de séjour. Un groupe composé de 20 experts des Sociétés françaises d'anesthésie-réanimation (SFAR) et de la Société française de chirurgie thoracique et cardiovasculaire (SFCTCV) a été réuni. D'éventuels conflits d'intérêts ont été officiellement déclarés dès le début du processus d'élaboration des recommandations et ce dernier a été conduit indépendamment de tout financement de l'industrie. Les auteurs ont suivi la méthode GRADE (Grading of Recommendations Assessment, Development and Evaluation) pour évaluer le niveau de preuve de la littérature. Six champs ont été définis : 1) la sélection du parcours patient et son information ; 2) la gestion et la réhabilitation préopératoire ; 3) l'anesthésie et analgésie pour chirurgie cardiaque ; 4) la stratégie chirurgicale et la gestion de la circulation extracorporelle (CEC) ; 5) la gestion personnalisée du capital sanguin, et 6) la réhabilitation postopératoire. Pour chaque champ, l'objectif des recommandations était de répondre à un certain nombre de questions formulées selon le modèle PICO (Population, Intervention, Comparison, Outcome). À partir de ces questions, une recherche bibliographique extensive a été réalisée, et analysée selon la méthode GRADE. Les recommandations ont été formulées selon la méthode GRADE, puis votées par tous les experts selon la méthode GRADE grid. Trente-trois recommandations sur la prise en charge des patients opérés d'une chirurgie cardiaque sous CEC ou à cœur battant ont été formulées par le panel d'experts SFAR/SFCTCV. Après trois tours de votes et plusieurs amendements, un accord fort a été obtenu pour 33 recommandations. Parmi ces recommandations, 10 ont un niveau de preuve élevé (7 GRADE 1+ et 3 GRADE 1-), 19 ont un niveau de preuve faible (15 GRADE 2+ et 4 GRADE 2-) et 4 sont des avis d'experts. Enfin, pour 3 questions, aucune recommandation n'a pu être formulée. Un accord fort a été obtenu parmi les experts afin de fournir des recommandations visant à optimiser la prise en charge périopératoire des patients opérés d'une chirurgie cardiaque sous CEC ou à cœur battant. To provide recommendations for Enhanced Recovery After Cardiac Surgery (ERACS) based on a multimodal approach of perioperative medicine of adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity and reducing length of hospital stays. A consensus committee of 20 experts from the French society of anaesthesiology and critical care medicine (Société française d'anesthésie-réanimation, SFAR) and the French society of thoracic and cardio-vascular surgery (Société française de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. Six fields were defined: 1) selection of the patient pathway and their information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for cardiac surgery; 4) surgical strategy for cardiac surgery and bypass management; 5) Patient Blood Management; and 6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analysed using the GRADE approach. The recommendations were formulated according to the GRADE methodology, and then voted by all the experts according to the GRADE grid method. The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing pulmonary lobectomy. After three rounds of voting and several amendments, a strong agreement was reached for 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert judgments. Finally, no recommendation was provided for 3 questions. Strong agreement exists among the experts to provide recommendations to optimize the whole perioperative management of patients undergoing cardiac surgery.

HomeCirculation: Cardiovascular ImagingVol. 13, No. 10Rare Case of an Intrapericardial Ectopic Thyroid (Struma Cordis) on the Ascending Aorta Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessCase ReportPDF/EPUBRare Case of an Intrapericardial Ectopic Thyroid (Struma Cordis) on the Ascending Aorta Hicham Mesrar, MD Didier Chatel, MD Christophe Barbey, MD Jean-Paul Biny, MD Marc-Antoine Arnould, MD Guillaume Gouffran, MD Olivier Bar, MD Stéphan ChassaingMD Hicham MesrarHicham Mesrar Hicham Mesrar, MD, Department of Interventional Cardiology and Cardiac Imaging, Institut du Cœur St-Gatien, Nouvelle Clinique Tours Plus, Tours, France. Email E-mail Address: [email protected] https://orcid.org/0000-0001-5707-6995 Department of Interventional Cardiology and Cardiac Imaging (H.M., C.B., M.-A.A., G.G., O.B., S.C.), Institut du Cœur Saint-Gatien, Nouvelle Clinique Tours Plus, France. , Didier ChatelDidier Chatel Department of Cardiac Surgery (D.C.), Institut du Cœur Saint-Gatien, Nouvelle Clinique Tours Plus, France. , Christophe BarbeyChristophe Barbey Department of Interventional Cardiology and Cardiac Imaging (H.M., C.B., M.-A.A., G.G., O.B., S.C.), Institut du Cœur Saint-Gatien, Nouvelle Clinique Tours Plus, France. , Jean-Paul BinyJean-Paul Biny Laboratory of Pathology Origet, Pôle Equa Santé, Tours, France (J.-P.B.). , Marc-Antoine ArnouldMarc-Antoine Arnould Department of Interventional Cardiology and Cardiac Imaging (H.M., C.B., M.-A.A., G.G., O.B., S.C.), Institut du Cœur Saint-Gatien, Nouvelle Clinique Tours Plus, France. , Guillaume GouffranGuillaume Gouffran Department of Interventional Cardiology and Cardiac Imaging (H.M., C.B., M.-A.A., G.G., O.B., S.C.), Institut du Cœur Saint-Gatien, Nouvelle Clinique Tours Plus, France. , Olivier BarOlivier Bar Department of Interventional Cardiology and Cardiac Imaging (H.M., C.B., M.-A.A., G.G., O.B., S.C.), Institut du Cœur Saint-Gatien, Nouvelle Clinique Tours Plus, France. , Stéphan ChassaingStéphan Chassaing Department of Interventional Cardiology and Cardiac Imaging (H.M., C.B., M.-A.A., G.G., O.B., S.C.), Institut du Cœur Saint-Gatien, Nouvelle Clinique Tours Plus, France. Originally published23 Sep 2020https://doi.org/10.1161/CIRCIMAGING.120.010508Circulation: Cardiovascular Imaging. 2020;13:e010508Cardiac ectopic thyroid gland, also called Struma cordis (SC), is a rare finding. Ectopic thyroid tissue occurs because of embryological malformation, and its prevalence is ≈1 in 300 000 to 400 000 individuals. In 1941, Dotsch discovered SC during routine chest autopsy.1 We report about an unexpected asymptomatic cardiac mass detected using multimodal imaging. Surgical resection and histological analysis revealed ectopic thyroid tissue on the ascending aorta (AA).A right cardiac mass was discovered by chance in a 67-year-old White male during chest computed tomography (CT) for recurrent infectious pneumonitis. He had a history of ischemic heart disease related to many cardiovascular risk factors, including smoking. He was clinically asymptomatic; physical examination was normal, as were chest X-ray, ECG, and biological examinations. Preoperative thyrotropin-releasing hormone and free thyroxine (FT4) levels were normal at 0.76 mIU/L and 12.9 pmol/L, respectively.Two-dimensional transthoracic echocardiography revealed preserved heart function with no pericardial effusion evident; however, the cardiac mass was not visible. Gated cardiac CT (Figure 1) confirmed an ovoid mass with moderate contrast enhancement, measuring 45×35×28 mm, in close contact with the anterolateral AA wall, anterior pericardium, right auricle, and superior vena cava. However, clearly determining whether the mass was intracavitary (within the right auricle) or extracavitary (in the pericardium) using CT was difficult. Cardiac CT after 3 months confirmed the mass had not evolved. Additional imaging with ECG-gated cardiac magnetic resonance imaging at 1.5 T demonstrated a regular and heterogeneous noninfiltrating tissue mass, with moderate gadolinium enhancement (Figure 2, Movies I and II in the Data Supplement). The immobile mass appeared close to the anterolateral AA wall, was nonpediculated, and did not invade the pericardium. Cine-cardiac magnetic resonance sequences finally confirmed the mass was located in the pericardium. The signal intensity of the mass was isointense on T1-weighted images (with and without fat-saturation) and high on T2-weighted images. 18-fluorodeoxyglucose positron emission tomography-CT was performed to examine possible hypermetabolic activity of the cardiac mass that was comparable with neoplasia; however, results were negative. Similarly, thoraco-abdominopelvic CT scanning did not reveal any secondary neoplasms. Without confirmed diagnosis, surgical exploration was performed.Download figureDownload PowerPointFigure 1. Cardiac computed tomography. Axial (A) and coronal (B) planes showing the right juxta-aortic ovoid mass.Download figureDownload PowerPointFigure 2. Cardiac magnetic resonance imaging. Axial (A), sagittal (B), and coronal (C) cine-cardiac magnetic resonance sequences demonstrating the intrapericardial location of the cardiac mass arising from the ascending aorta.Complete excision of the intrapericardial mass appended to the aorta was achieved by median sternotomy without the need for extracorporeal circulation (Figure 3, Movie III in the Data Supplement). The operation was deemed successful, and postoperative echocardiogram was normal. Pathological examination confirmed a diagnosis of cardiac ectopic thyroid tissue growing from the AA adventitia without histological malignancy (Figure 4). In the first weeks after surgery, the patient showed no clinical signs of secondary hypothyroidism, thyroid hormone levels were normal (postoperative thyrotropin-releasing hormone and FT4 were 0.81 mIU/L and 13.5 pmol/L, respectively), and thyroid ultrasonography showed a pretracheal thyroid with no morphological abnormality.Download figureDownload PowerPointFigure 3. Intraoperative macroscopic view. Revealing the intrapericardial mass appended to the ascending aorta wall.Download figureDownload PowerPointFigure 4. Histological examination. Highlighting thyroid tissue comprising thyroid vesicles of variable sizes with colloid content, free of cytonuclear atypia. Hematoxylin eosin saffron, magnification ×4.SC is a rare entity that affects mostly middle-aged women (90% cases). Cardiac SC may result from aberrant craniocaudal migration of the primitive heart and thyroid during embryogenesis.1 The most common cardiac locations for SC are intracavitary, mainly in the interventricular groove and the right ventricular outflow tract. Intrapericardial ectopic thyroid arising from the AA, as described here, is extremely rare, and to our knowledge, only 5 similar cases have been previously reported.2 Initial presentation is often an incidental finding during imaging in asymptomatic patients; however, in some cases, the mass can lead to dyspnea, atypical chest pain, syncope, pulmonary embolism, ventricular arrhythmia, or sudden death owing to possible cavitary compression or obstruction in the heart.The main differential diagnoses of SC are cardiac tumors, which largely affect the right side of the heart, and cardiac thrombi.3 These diagnoses should be excluded before considering exceptional alternative diagnoses, including cardiac ectopic thyroid, intrapericardial hematoma, teratoma, pleuropericardial or hydatid cysts, and paraganglioma. Secondary tumors (metastases) from the lung, breast, thyroid, esophagus, lymphoma, melanoma, and leukemia are the most common cardiac masses detected. Primary tumors are predominately benign (myxoma, lipoma, fibroma, rhabdomyoma, fibroelastoma, hemangioma) but are sometimes malignant, including sarcoma, lymphoma, or mesothelioma.Multimodal imaging using echocardiography, cardiac magnetic resonance, and CT is essential to completely characterize heart masses. Cardiac CT and cardiac magnetic resonance can define anatomic relationships between the mass, myocardium, and pericardium owing to their significant spatial and temporal resolution.In SC cases, thyroid hormone levels are often normal and usually do not contribute to diagnosis. A normal thyroid position is also typically observed. Treatment can be surgical for symptomatic patients or if diagnosis is uncertain. Prognosis is generally favorable, similar to benign cardiac tumors, and no SC recurrence case has ever been described.4This case is interesting because it highlights the importance of performing multimodal imaging to confirm the rare diagnosis of cardiac ectopic thyroid tissue.Sources of FundingNone.DisclosuresNone.FootnotesThe Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCIMAGING.120.010508.Hicham Mesrar, MD, Department of Interventional Cardiology and Cardiac Imaging, Institut du Cœur St-Gatien, Nouvelle Clinique Tours Plus, Tours, France. Email hicham.[email protected]comReferences1. Gackowski A, Pietrucha A, Miszalski-Jamka T, Rostoff P, Sadowski J, Nessler J. Intrapericardial ectopic thyroid gland mimicking cardiac tumor.Int J Cardiol2012; 158:e55–e56. doi: 10.1016/j.ijcard.2011.10.109CrossrefMedlineGoogle Scholar2. Williams RJ, Lindop G, Butler J. Ectopic thyroid tissue on the ascending aorta: an operative finding.Ann Thorac Surg2002; 73:1642–1643. doi: 10.1016/s0003-4975(01)03439-7CrossrefMedlineGoogle Scholar3. Ozpolat B, Dogan OV, Gökaslan G, Erekul S, Yücel E. Ectopic thyroid gland on the ascending aorta with a partial pericardial defect: report of a case.Surg Today2007; 37:486–488. doi: 10.1007/s00595-006-3439-7CrossrefMedlineGoogle Scholar4. Taylor MA, Bray M, Roberts WC. Aberrant thyroid gland attached to ascending aorta.Am J Cardiol1986; 57:708. doi: 10.1016/0002-9149(86)90871-4CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails October 2020Vol 13, Issue 10Article InformationMetrics Download: 39 © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.120.010508PMID: 32967443 Originally publishedSeptember 23, 2020 Keywordsmagnetic resonance imagingthyroid glandcardiac tumorPDF download SubjectsComputerized Tomography (CT)Magnetic Resonance Imaging (MRI)

Aortic valve surgery in non-elderly patients represents a very challenging patient population. The younger the patient is at the point of aortic valve intervention, the longer their anticipated life expectancy will be, with longer exposure to valve-related complications and risk for re-operation. Although the latest international guidelines recommend aortic valve repair in patients with aortic valve insufficiency, what we see in the real world is that the vast majority of these aortic valves are replaced. However, current prosthetic valves has now been shown to lead to significant loss of life expectancy for non-elderly patients up to 50% for patients in their 40s undergoing mechanical aortic valve replacement. Bioprostheses carry an even worse long-term survival, with higher rates of re-intervention. The promise of trans-catheter valve-in-valve technology is accentuating the trend of bioprosthetic implantation in younger patients, without yet the appropriate evidence. In contrast, aortic valve repair has shown excellent outcomes in terms of quality of life, freedom from re-operation and freedom from major adverse valve-related events with similar life expectancy to general population as it is also found for the Ross procedure, the only available living valve substitute. We are at a time when the paradigm of aortic valve surgery needs to change for the better. To better serve our patients, we must acquire high quality real-world evidence from multiple centers globally - this is the vision of the AVIATOR registry and our common responsibility.

Objective: Despite growing evidence that aortic valve repair improves long term patient outcomes and quality of life, like mitral valve repair, the aortic valve remained mostly replaced. Main reasons are the lack of multicentric comparative evaluation and the common opinion that replacement reduces the risk of reoperation. Methods: The multicentric CAVIAAR trial enrolled 261 consecutive unselected patients with dystrophic aortic root aneurysm as a prospective cohort comparing 130 patients who underwent a standardized aortic valve repair (REPAIR) associating root remodeling with an expansible aortic ring annuloplasty versus 131 patients with mechanical composite valve and graft replacement (REPLACE). Results: Mean age was 56.1 years, valve was bicuspid in 115 patients (44.7%). Thirty-day mortality was 4.6% (n=6) in both groups (p=1.00). At 4 years, crude and propensity matched analysis confirmed that freedom from valve related death and hemorrhagic events are significantly higher after valve repair than replacement respectively 99.1% vs 94.3% (p < 0.001) and 89.2% vs 78.3% (p=0.02), whereas freedom from valve related reoperation was similar (p=0.223). Furthermore, binomial analysis confirmed that risk of major adverse valve related events is significantly higher after valve replacement (RR=1.94 [1.16-3.24]; p=0.011) with the highest risk of bleeding complications (RR=2.9 (1.37-6.17);p=0.005). Conclusions: A multicentric evaluation of a standardized approach aortic valve repair associating root remodeling with an expansible aortic ring shows a significant reduction of valve related death and complications compared to mechanical valve replacement, without increasing the risk of reoperation.

Objectives: Current national registries are lacking detailed pathology-driven analysis and long-term patients outcomes. The Heart Valve Society (HVS) aortic valve (AV) repair research network started the Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (AVIATOR) to evaluate long-term patient outcomes of AV repair and replacement. The purpose of the current report is to describe the AVIATOR initiative and report in a descriptive manner the patients included. Methods: The AV repair research network includes surgeons, cardiologists, and scientists and established an online database compliant with the guidelines for reporting valve-related events. Prospective inclusion started from January 2013. Adult patients (18 years or older) who were operated on between 1995 and 2017 with complete procedural specification of the type of repair/replacement were selected for descriptive analysis. Results: Currently 58 centers from 17 countries include 4896 patients with 89% AV repair (n = 4379) versus 11% AV replacement (n = 517). AV repair was either isolated (28%), or associated with tubular/partial root replacement (22%) or valve-sparing root replacement (49%) with an in-hospital mortality of 0.5%, 1.7%, and 1.2%, respectively. AV replacement was either isolated (24%), associated with tubular/partial root replacement (17%) or root replacement (59%) with an in-hospital mortality of 1%, 2.6%, and 2.0%, respectively. Conclusions: The multicenter surgical AVIATOR registry, by applying uniform definitions, should provide a solid evidence base to evaluate the place of repair versus replacement on the basis of long-term patient outcomes. Obtaining data completeness and adequate representation of all surgery types remain challenging. Toward the near future AVIATOR-medical will start to study natural history, as will AVIATOR-kids, with a focus on pediatric disease.

Objective: The study objective was to compare the 30-day outcomes of a standardized aortic valve repair technique (REPAIR group) associating root remodeling with an expansible aortic ring annuloplasty versus mechanical composite valve and graft (CVG group) replacement in treating aortic root aneurysms.Methods: A total of 261 consecutive patients with aortic root aneurysm were enrolled in this multicentric prospective cohort (131 in the CVG group, 130 in the REPAIR group) in 20 centers. The main end point is a composite criterion including mortality; reoperation; thromboembolic, hemorrhagic, or infectious events; and heart failure. Secondary end points were major adverse valve-related events. Crude and propensity score adjusted estimates are provided.Results: The mean age was 56.1 years, and the valve was bicuspid in 115 patients (44.7%). The median (interquartile range) preoperative aortic insufficiency grade was 2.0 (1.0-3.0) in the REPAIR group and 3.0 (2.0-3.0) in the CVG group (P = .0002). Thirty-day mortality was 3.8% (n = 5) in both groups (P = 1.00). Despite a learning curve and longer crossclamp times for valve repair (147.7 vs 99.8 minutes, P<.0001), the 2 groups did not differ significantly for the main criterion (odds ratio, 1.31; 95% confidence interval, 0.72-2.40; P = .38) or 30-day mortality (odds ratio, 0.99; 95% confidence interval, 0.28-3053; P = .99), with a trend toward more frequent major adverse valve-related events in the CVG group (odds ratio, 2.52; 95% confidence interval, 0.86-7.40; P = .09). At discharge, 121 patients (96.8%) in the REPAIR group had grade 0 or 1 aortic insufficiency.Conclusions: A new standardized approach to valve repair, combining an expansible aortic annuloplasty ring with the remodeling technique, presented similar 30-day results to mechanical CVG with a trend toward reducing major adverse valve-related events. Analysis of late outcomes is in process for 3- and 10-year follow-ups.

Dual antiplatelet therapy is commonly used in patients undergoing transcatheter aortic valve implantation (TAVI), but the optimal antiplatelet regimen is uncertain and remains to be determined. The objective of this study was to compare 2 strategies of antiplatelet therapy in patients undergoing TAVI. A strategy using monoantiplatelet therapy (group A, n = 164) was prospectively compared with a strategy using dual antiplatelet therapy (group B, n = 128) in 292 consecutive patients undergoing TAVI. The primary end point was a combination of mortality, major stroke, life-threatening bleeding (LTB), myocardial infarction, and major vascular complications at 30 days. All adverse events were adjudicated according to the Valve Academic Research Consortium. The primary end point occurred in 22 patients (13.4%) in the group A and in 30 patients (23.4%) in the group B (hazard ratio 0.51, 95% confidence interval 0.28 to 0.94, p = 0.026). LTB (3.7% vs 12.5%, p = 0.005) and major bleedings (2.4% vs 13.3%, p <0.0001) occurred less frequently in the group A, whereas the incidence of stroke (1.2% vs 4.7%, p = 0.14) and myocardial infarction (1.2% vs 0.8%, p = 1.0) was not significantly different between the 2 groups. The benefit of a strategy using mono versus dual antiplatelet therapy persisted after multivariate adjustment and propensity score analysis (hazard ratio 0.53, 95% confidence interval 0.28 to 0.95, p = 0.033). In conclusion, a strategy using mono versus dual antiplatelet therapy in patients undergoing TAVI reduces LTB and major bleedings without increasing the risk of stroke and myocardial infarction. The results of our study question the justification of dual antiplatelet therapy and require confirmation in a randomized trial.

Aortic root aneurysms are characterized by dilation of both functional aortic annulus diameters (aortic annular base and sino-tubular junction), preventing coaptation of otherwise pliable valves often associated with cusp prolapse. Multiple techniques of aortic valve sparing procedures try to restore the complex interplay of aortic valve and root function in order to improve durability of the repair. Ideally, procedures should treat dilatation of the aortic annular base, while preserving dynamics of the aortic root with vortices (neosinuses of Valsalva) and root expansibility (interleaflet triangles). We describe a standardized approach, combining the advantages of both the remodeling and reimplantation technique by adding an external subvalvular ring annuloplasty to the physiological remodeling of the aortic root. To address the need for a dedicated aortic annuloplasty device, a new expansible aortic ring was designed in order to achieve a complete and calibrated annuloplasty in diastole, while maintaining systolic expansibility of the aortic root.

Objective: We suggest standardizing aortic valve repair using a physiologic approach by associating root remodeling with resuspension of the cusp effective height and external subvalvular aortic ring annuloplasty.Methods: A total of 187 patients underwent remodeling associated with subvalvular aortic ring annuloplasty (14 centers, 24 surgeons). Three strategies for cusp repair were evaluated: group 1, gross visual estimation (74 patients); group 2, alignment of cusp free edges (62 patients); and group 3, 2-step approach, alignment of the cusp free edges and effective height resuspension (51 patients). The composite outcome was defined as recurrence of aortic insufficiency of grade 2 or greater and/or reoperation.Results: The operative mortality rate was 3.2% (n = 6). Treatment of a cusp lesion was most frequently performed in group 3 (70.6% vs 20.3% in group 1 and 30.6% in group 2, P < .001). Nine patients required reoperation during a follow-up period of 24 months (range, 12-45), 6 patients in group 1 and 3 patients in group 2. At 1 year, no patients in group 3 presented with composite outcome events compared with 28.1% in group 1 and 15% in group 2 (P < .001). Residual aortic insufficiency and tricuspid anatomy were independent risk factors for the composite outcome in groups 1 and 2. The annulus diameter, the presence of Marfan syndrome, and cusp repair had no effect on aortic insufficiency recurrence or reoperation.Conclusions: A standardized and physiologic approach to aortic valve repair, considering both the aorta (root remodeling) and the valve (resuspension of the cusp effective height and subvalvular ring annuloplasty) improved the preliminary results and might affect their long-term durability. The ongoing Conservative Aortic Valve Surgery for Aortic Insufficiency and Aneurysm of the Aortic Root (CAVIAAR) trial will compare this strategy to mechanical valve replacement. (J Thorac Cardiovasc Surg 2010;140:S28-35)

Aortic valve sparing is gaining increasing acceptance, however association with cusp repair may jeopardize its results. We studied patients operated electively with a standardized valve sparing approach with or without additional cusp repair. 125 patients with aortic root aneurysms underwent the Remodeling technique combined with a subvalvular annuloplasty in 10 centers (16 surgeons). Patients were analysed prospectively in 2 groups: without cusp repair (group 1, n=80) and with cusp repair (group 2, n=45) using plicating stitches (33), and/or running suture (10), and/or median raphe resection (12). Despite more severe preoperative aortic insufficiency (AI) in group 2, reoperation rate was not significantly higher (table). Five over 6 reoperations occurred during early experience. Cusp repair rate increased from 22.3% (15) in early period to 53.4% (27, p<0.01) since 2007, when aggressive management of cusp prolapse was started combining cusp free edges alignment with effective height measurement.Empty CellGroup 1 without cusp repairGroup 2 with cusp repairMarfan16 (20%)2 (4.4%)*Bicuspid valves7 (8.8%)19 (42.2%)*Preoperative AI grade1.66±1.2 (0-4)2.42±1.2 (0-4)*Preoperative annulus diameter (mm)27.5±1.6 (23-30)28.6±2.1 (24-36)*Operative mortality4 (5%)1 (2.2%)Postoperative annulus diameter (mm)20.1±2.1 (17-25)21.3±1.1 (16-25)*Post-operative AI grade0.3±0.4 (0-1)0.2±0.4 (0-1)Mean follow-up (months)36.1±21 (1-69)17.5±16.9 (1-66)*Freedom from AI≥grade 264 (94.1%)37 (92.5%)Reoperation for valve replacement4 (5%)2 (4.4%)Survival72 (97.3%)42 (95.5%)*p<0.05 p<0.05 Additional cusp repair does not affect early results of aortic valve sparing. Standardized management of root remodeling, cusp repair and aortic annuloplasty may improve feasibility and long term outcomes. This approach is currently evaluated versus mechanical valve replacement by CAVIAAR trial (Conservative Aortic Valve surgery for aortic Insufficiency and Aneurysms of the Aortic Root).

Background. - The use of the internal thoracic artery for coronary artery bypass has improved the results of such surgery. However, bypass using only the internal thoracic arteries sometimes requires a T-graft. This purely internal thoracic artery T-graft technique has progressively become part of our surgical protocol for coronary artery bypass surgery.Aims. - The aim of the study was to analyse the impact of this surgical technique on the degree and quality of coronary revascularization using early postoperative angiography.Methods. - Between January 2004 and December 2006, 148 patients underwent coronary artery bypass surgery exclusively using both internal thoracic arteries in a T-graft configuration. Systematic postoperative angiography was offered to all 148 patients; it was accepted by 108 patients and refused by 40 patients.Results. - There were no statistically significant differences between the two groups. Inpatient mortality was 2.02% (n = 3) for the whole population studied, and 1.49% (n = 2) for the 134 patients who received only coronary artery bypass grafts. The revascutarization rate was 89% and 3.46 coronary anastomoses were constructed per patient (range 2-6). Angiography was performed on 108 right internal thoracic artery to left internal thoracic artery anastomoses, 374 anastomoses of internal thoracic arteries to coronary arteries and 382 inter-anastomosis segments: 98% of the anastomoses and segments were patent.Conclusion. - The exclusive recourse to the purely internal thoracic artery T-graft technique meant that it has been possible to dispense with other types of graft while achieving complete and effective revascularization of the coronary artery. (C) 2009 Elsevier Masson SAS. All rights reserved.

For the CryoLife-O'Brien valve (CryoLife Inc, Kennesaw, GA, USA), implanted with a single suture line, we aimed to analyze the surgical requests and the hemodynamic results compared to stented bioprostheses. Two groups of patients requiring isolated aortic valve replacement from this population were compared retrospectively: 84 patients receiving the stentless CryoLife-O'Brien valve (Group A) and 94 patients receiving stented bioprostheses (Group B). Preoperative characteristics of patients were statistically equivalent for both groups. Statistically significant differences were observed only for operative durations and post-operative transprosthetic gradients: Aorta cross-clamp and cardio-pulmonary bypass durations were statistically longer for Group A than for Group B (45.9+/-5.7 min vs. 41.1+/-6.8 min; P<0.0001; and 64.3+/-11.6 min vs. 59.3+/-11.9 min, respectively; P=0.0053); maximal gradients and mean gradients were 19.9+/-10.9 mmHg vs. 25.6+/-10.4 mmHg (P=0.0008) and 10.8+/-5.3 mmHg vs. 14.8+/-6.4 mmHg (P<0.0001). Few surgical constraints and early post-operative hemodynamic efficiency of the stentless CryoLife-O'Brien valve means that this bioprosthesis can be intented in current practice for the aortic valve replacement in elderly patients.

The aim of this study was to report two cases of rupture of the right hemidiaphragm with intra-thoracic liver hernia, associated with a traumatic aortic disruption. These two lesions followed traffic accidents, and were both treated separately. Both patients had a long-term favourable progression. Association of these two lesions is particularly rare: fewer than 50 cases have been previously described in an extensive review of the literature. CT-scan seems to be particularly efficient in diagnosis, even if less efficient than other more specific explorations. The order of surgical management is guided by the physical examination, and especially by abdominal emergency.

For original ovoid shaped artificial ventricles, a biomechanical double sac consisting of a biological sac (porcine pericardium) as the blood contact interface and a synthetic sac (Pebax 3533) as the mechanical support to assume systolic-diastolic dynamic constraints was conceived. The volumetric and mechanical properties were assessed with a three-dimensional modeling of Pebax sacs and computerized simulations of their systolic distortions for both right and left ventricular configurations. The stresses and strains of these sacs were represented as quantitative mappings for a maximum end-systolic state and were below the respective threshold values above which the Pebax material is jeopardized for permanent structure impairment. After fatigue tests applied on Pebax strips under the alleged working conditions of Pebax sacs, the material structure was unchanged and maintained its intrinsic mechanical properties. The theoretical maximum stroke volumes were 74.4 cm3 and 62.4 cm3 for the left and right ventricular configurations, respectively. With these mechanical and volumetric features, the biomechanical double sac concept was considered valid and could be provided for a consequent specific total artificial heart.

The need for improvement of artificial heart biocompatibility led to the design of new artificial ventricles with biological internal coating and new shapes and sizes. The internal coating of these artificial ventricles is made of a molded single-piece, glutaraldehyde-preserved pericardial sac. The pericardial sac was obtained from the entire intact pericardium of Yucatan pigs. The pericardium was molded and fixed in a 0.6% glutaraldehyde buffered solution and specifically cut to obtain a truncated egg shaped sac with specific dimensions and 110 cm(3) total volume. Two pericardial sacs associated with one another form a biventricular device to create a new orthotopic total artificial heart. The compliance of this device to rules pertaining to total artificial heart concept and implantation makes plausible a new total artificial heart which given its biomaterials, shape, and dimensions can provide optimal anatomical, biological, and hemodynamic conditions.