[1] Rose EA, Gelijns AC, Moskowitz AJ, Heitjan DF, Stevenson LW, Dembitsky W et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med 2001;345:1435–43. [2] Sharples L, Buxton M, Caine N, Cafferty F, Demiris N. Evaluation of the ventricular assist device programme in the UK. Health Technol Assess 2006;10:138. [3] Thekkudan J, Rogers CA, Thomas HL, van der Meulen JHP, Bonser RS, Banner NR et al. Trends in adult heart transplantation: a national survey from the United Kingdom Cardiothoracic Transplant Audit 1995–2007. Eur J Cardiothorac Surg 2010;37:80–6. [4] Emin A, Rogers CA, Parameshwar J, Macgowan G, Taylor R, Yonan N et al. Trends in long-term mechanical circulatory support for advanced heart failure in the UK. Eur J Heart Fail 2013;15:1185–93. [5] Clarke A, Pulikottil-Jacob R, Connock M, Suri G, Kandala N-B, Maheswaran H et al. Cost-effectiveness of left ventricular assist devices (LVADs) for patients with advanced heart failure: analysis of the British NHS bridge to transplant (BTT) program. Int J Cardiol 2014;171:338–45. [6] Grady KLK, Jalowiec AA, White-Williams CC, Pifarre RR, Kirklin JKJ, Bourge RCR et al. Predictors of quality of life in patients with advanced heart failure awaiting transplantation. J Heart Lung Transplant 1995;14(1 Pt 1): 2–10. [7] Grady KL, Jalowiec A, White-Williams C. Quality of life 6 months after heart transplantation compared with indicators of illness severity before transplantation. Am J Crit Care 1998;7:106–16. [8] Grady KLK. Quality of life in patients with chronic heart failure. Crit Care Nurs Clin North Am 1993;5:661–70. [9] Hsich EME, Naftel DCD, Myers SLS, Gorodeski EZE, Grady KLK, Schmuhl DD et al. Should women receive left ventricular assist device support? Findings from INTERMACS. Circ Heart Fail 2012;5:234–40. [10] Dew MAM, Kormos RLR, Winowich SS, Harris RCR, Stanford EAE, Carozza LL et al. Quality of life outcomes after heart transplantation in individuals bridged to transplant with ventricular assist devices. J Heart Lung Transplant 2001;20:1199–212. [11] Sharples LD, Dyer M, Cafferty F, Demiris N, Freeman C, Banner NR et al. Cost-effectiveness of ventricular assist device use in the United Kingdom: results from the evaluation of ventricular assist device programme in the UK (EVAD-UK). J Heart Lung Transplant 2006;25:1336–43. [12] Green CP, Porter CB, Bresnahan DR, Spertus JA. Development and evaluation of the Kansas City Cardiomyopathy Questionnaire: a new health status measure for heart failure. J Am Coll Cardiol 2000;35:1245–55. [13] Spertus JA. Evolving applications for patient-centered health status measures. Circulation 2008;118:2103–10. [14] EuroQol Group. EuroQol—a new facility for the measurement of health-related quality of life. Health Policy 1990;16:199–208. [15] Dew MAM, Kormos RLR, Roth LHL, Armitage JMJ, Pristas JMJ, Harris RCR et al. Life quality in the era of bridging to cardiac transplantation. Bridge patients in an outpatient setting. ASAIO J 1993;39:145–52. [16] Jakovljevic DG, McDiarmid A, Hallsworth K, Seferovic PM, Ninkovic VM, Parry G et al. Effect of left ventricular assist device implantation and heart transplantation on habitual physical activity and quality of life. Am J Cardiol 2014;114:88–93.

The excellent report by the Mount Sinai Medical Center Group [1] supports the concept of an immediate primary implantation of a long-term ventricular assist device (VAD), in patients in refractory cardiogenic shock because of an acute myocardial infarction (AMI). This primary implantation is probably preferable to more complex strategies, including the ‘bridge-to-bridge’ approach. It may be quite surprising that, after more than 30 years of experience, we are still wondering about the best option in these patients. The probable reason is that few papers focus on the specific issues of these AMI patients. There is actually still a wide variety of options. The most appealing option is the use of very small intraventricular devices (Tamdem, Impella ... ). They may be implanted with a non-invasive technique, under local anaesthesia, and even by the cardiologists who see the patients first and who try to apply some effective treatment such as percutaneous interventions. The device, ideally, should achieve full left ventricular decompression and deliver a pump output meeting the patient’s needs, so as to allow the recovery of peripheral organ function. The return to an adequate arterial pressure improves the coronary circulation, permitting some improvement of left ventricular function. Good left ventricular decompression enables the limitation of the acute myocardial infarct, by recovery of the borderline ischaemic myocardium. However, we currently lack this tiny pump that permits full left ventricular decompression and a return to normal aortic pressure. The available systems do not meet the requirements, in terms of ventricular decompression and pump flow. Moreover, they are also beset by other problems: difficulty in inserting the pump head into the left ventricle either from a peripheral artery, which is often atherosclerotic, or from a peripheral vein, since trans-septal catheterization may be hazardous in these unstable patients. Few papers have reported good results of this elegant approach. However, good results are usually seen in patients with less severe disease [2]. Finally, until now, we may say that great expectations have not been met. A second approach, totally different in its concept, is the use of extracorporeal membrane oxygenation (ECMO). The main advantages of this option are well known: it may be used almost everywhere, even outside a specialized centre, quite rapidly, without any surgical intervention, and is inexpensive. ECMO can therefore be instituted very early in the course of severe AMI. However, experience has shown that ECMO in AMI patients in cardiogenic shock does not fulfil the objectives as well as expected: the death rate during ECMO is quite high, whereas a low rate is quite seen in patients who can be stabilized or improved and receive a long-term VAD. The cost of ECMO also rises rapidly as the time spent in the intensive care unit increases. These less than satisfactory results are actually not that surprising: during ECMO, left ventricular unloading is less than optimal, making pulmonary recovery very unlikely, and right ventricular unloading is most often less than optimal, leading to persistent high venous pressure, which is unfavourable for the recovery of hepatic and renal function. In addition, activation of the inflammatory cascade, which is already stimulated by AMI, does not facilitate the recovery of pulmonary function. Finally, the lack of pulsatility does not help to improve renal and peripheral function. It is interesting to emphasize that the best results using ECMO support in irreversible cardiogenic shock are obtained in patients in whom cardiogenic shock is linked to reversible myocardial damage related, for example, to a toxic aetiology or acute myocarditis [3]. Results in AMI patients are less favourable: 5 of 16 AMI patients receiving urgent ECMO are discharged from the hospital, compared with a 56% overall success rate. Because of its simplicity and apparent low cost, ECMO is nevertheless still performed routinely, almost as a routine first treatment in patients in cardiogenic shock. However, in AMI patients, ECMO actually minimizes the chances of the patients getting a long-term VAD or a transplant. Our personal findings even show that replacement of ECMO by a pulsatile bi-VAD may reverse a situation, which is deteriorating on ECMO. A third approach is the use of pulsatile, paracorporeal VADs. The advantages of this technique are the quality of ventricular decompression, which is almost always complete and the rapid return to normal pulsatile perfusion. The versatility of the system permits either a left VAD or, in the case of additional right ventricular dysfunction, which is frequent in major AMI, temporary right ventricular support. This right ventricular support may be as short as a few days, permitting the recovery of right ventricular function and, in the meantime, avoiding the pulmonary embolic complications of long-term use. The limitation of this approach is obviously the discomfort of a long-term period of

Purpose: The objective of this investigation was to compare transthoracic ultrasound (US) determinations of ascending aortic diameters in rats with video microscopy (VM), the current standard for measuring aortic diameters in rats.Materials and Methods: The diameter of the ascending aorta was measured in 111 adult Lewis male rats, by VM and US, with a 9MHz probe, before and after intervention for induction of experimental aneurysm of the ascending aorta.Results: The Bland-Altman test showed a high degree of agreement between the two methods, with a bias of only 0.23mm (95% confidence limits -0.86 -0.39 mm). Also, the measurements obtained by US correlated highly (r = 0.83, p < 0.0001) with those obtained by VM. Rat ascending aortic diameters obtained both by VM and US correlated significantly with the weight (r = 0.62 and r = 0.39, respectively), and with the age of the animals (r = 0.74 and r = 0.49, respectively).Conclusion: This study demonstrates that non-invasive US ascending aortic measurements are a reliable supplement to VM for the development of an ascending aortic aneurysm model, and for monitoring the efficiency of novel therapeutic agents.

The da Vinci™ Surgical Robot (Intuitive Surgical Inc., Sunnyvale, CA, USA) is a computer-enhanced surgery device that helps to surpass some of traditional laparoscopic instruments limitations. Our work was performed to assess the safety and feasibility of robotically assisted aorto-femoral bypass grafting (AF) as well as to describe the technique. The aortic dissection is performed laparoscopically, with the patient in a modified right lateral position. The proximal anastomosis is completed with the da Vinci™ system by a remote surgeon, positioned at a distance from the patient. The role of the assistant at the patient’s side is especially to expose, to perform haemostasis and to maintain traction on the running sutures performed by the robot. No robot-related complications were noted. Robotically assisted anastomoses are possible by its unique ability to combine conventional laparoscopic surgery with stereoscopic 3D magnification and ultra-precise suturing techniques due to the flexibility of the robotic wristed instruments using different motion scaling of surgeon hand movements. In addition, prior training in laparoscopic aortic surgery is not necessary for surgeons to obtain the level required for suturing. Further clinical trials are needed to explore the clinical potential and value of robotically assisted AF.

The majority of ascending aortic aneurysms cannot be related to any specific etiology and should be qualified as idiopathic. The pathobiology of ascending aortic aneurysms remains incompletely understood. Data from direct study are still scarce and often limited because of patient heterogenicity. Currently available information suggests that destructive remodeling of the aortic wall, inflammation and angiogenesis, biomechanical wall stress, and molecular genetics are relevant mechanisms of idiopathic ascending aortic aneurysm formation and progression. Further understanding of these mechanisms will likely provide novel diagnostic, prognostic, and therapeutical tools for the clinician.

Increasing patient age and improved durability of latest generation bioprostheses have stimulated the use of bioprosthetic devices in the setting of ascending aortic replacement as an alternative to mechanical valved conduits or aortic valve-sparing procedures. We performed an English literature review to assess different surgical options that have been described for bioprosthetic replacement of the ascending aorta. Reported options include: (1) composite valved conduits using a stented bioprosthesis; (2) composite valved conduits using a stentless bioprosthesis; (3) total xenopericardial valved conduits. Composite valved grafts using stented bioprostheses offer a safe and durable option for bioprosthetic replacement of the ascending aorta. Other options are of more recent use and await medium-term results. (C) 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Esophago-pericardial fistula is a rare complication of benign esophageal pathologies. We present the case report of a patient with Barrett's esophagus complicated by an esophago-pericardial fistula managed by a multi-therapeutic approach to close the fistula using an autologous pericardial patch; placement of a coated, expandable, metallic esophageal stent; and a feeding jejunostomy.

Background: Heart transplantation in patients supported with ventricular assist devices (VADs) entails a high risk of injury at resternotomy. Prior femorofemoral bypass is the preferred approach in these patients, but poor venous drainage may restrict arterial flow rate. Patients and methods: We compared bypass parameters, transfusion requirements and postoperative outcome in 33 consecutive patients (40.4 +/- 12.2 years old, 28 men) assisted with the Thoratec (R) paracorporeal VAD (mean duration, 3.0 +/- 2.96 months) undergoing transplantation using either gravity siphon drainage (GSD, n = 16) or kinetic assisted venous drainage (KAVD, n 17). Results: Cannulation technique, perfusion pressure, temperature and duration were similar between groups. There were no significant differences in arterial re-infusion flow rates (GSD, 3.6 +/- 0.7 vs KAVD, 3.8 +/- 0.6 l/min, p = 0.5). KAVD patients had a lower mean S,07 and a higher desaturation index than GSD patients (69.5 +/- 4.6 vs 76.1 +/- 5.4 mmHg, p = 0.004; and 0.63 +/- 0.23 vs 0.25 +/- 0.63, p = 0.0001, respectively). Perioperative requirements in fresh frozen plasma and platelet transfusions were significantly higher in KAVD patients. However, there were no differences in postoperative patient outcome. Conclusion: Perceived benefits on venous return associated with KAVD do not necessarily translate into improved arterial re-infusion flow rates and should be weighed against the hazards of increased venous air aspiration and blood product requirements. (c) 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Objective: Cardioprotective properties have been shown with halogenated volatile agents. It was hypothesized that low-dose isoflurane administered before aortic cross-clamping may reduce the amount of dobutamine required to improve impaired postoperative cardiac function after various types of cardiac surgery.Design: A prospective, randomized trial.Setting: An anesthesia and intensive care unit, university hospital.Participants: Two hundred eighty cardiac surgery patients.Interventions: All patients allocated to either isoflurane treatment (T) or no treatment (control group [C]) received total intravenous anesthesia. In the treatment group, isoflurane was administered at a 0.5 minimum alveolar concentration (MAC) from tracheal intubation to initiation of cardiopulmonary bypass (CPB). During weaning from CPB, dobutamine was introduced by using a hemodynamically driven decision tree.Measurements and Main Results: The number of patients receiving dobutamine was comparable (66 v 78, p = 0.07, in T and C groups, respectively). The total amount of postoperative dobutamine indexed to patient weight, considered as the primary endpoint, was reduced in the isoflurane-treated group (4.2 +/- 8 v 7.2 +/- 15, p < 0.02, in T and C, respectively). Isoflurane was identified as an independent variable significantly (odds ratio [confidence interval]) influencing the total amount of postoperative dobutamine (0.53 [0.31-0.92], p < 0.02). Postoperative troponin 1 release at 20 hours was not affected by isoflurane treatment.Conclusions: This study revealed that exposure to 0.5 MAC isoflurane before CPB reduced the total amount of dobutamine required to normalize postoperative cardiac dysfunction in various types of cardiac surgical patients. (C) 2007 Elsevier Inc. All rights reserved.

Implantation of definitive left ventricular support is now a therapeutic option for certain patients in refractory heart failure who are not candidates for transplantation. Here we report the case of a patient assisted for more than 4 years with an INCOR axial pump from Berlin Heart. This case shows the feasibility of long term assistance with a continuous flow pump, and an innovative anti-thrombotic strategy relying on the combination of low molecular weight heparin with platelet anti-aggregants.

Le vieillissement progressif de la population entraîne une augmentation du nombre de patients âgés (80 ans ou plus) adressés en chirurgie cardiaque. L’association des effets du vieillissement et des pathologies liées à l’âge fait des octogénaires un groupe de patients à haut risque chirurgical. L’analyse de l’expérience internationale publiée dans la littérature sur la chirurgie coronaire, valvulaire aortique et mitrale chez l’octogénaire suggère une morbidité et une mortalité postopératoire précoce plus importante que chez les sujets plus jeunes. Toutefois, l’introduction de techniques chirurgicales dites « moins invasives » permettra probablement d’améliorer les résultats postopératoires précoces. La probabilité de survie à long terme est similaire à celle d’une population d’octogénaires sans pathologie cardiaque et significativement meilleure qu’après traitement non chirurgical. La qualité de vie est le plus souvent améliorée par l’intervention, comme le suggèrent une diminution significative de la symptomatologie et une amélioration des capacité fonctionnelles.

A 56-year old man developed a cardiogenic shock 24 hours after a postero-inferior myocardial infarction. The coronary angiogram revealed a dominant right coronary artery occluded at …

OBJECTIVES:The study addresses mechanisms driving the formation of ascending aortic aneurysms by comparing the maximal dilatation area with the transition area immediately adjacent to the normal aortic tissue left in place during surgical repair.METHODS:Aortic wall specimens were taken from the maximal dilatation area and transition area in 10 patients undergoing surgery for ascending aortic aneurysms and fixed for histology and immunohistochemistry for vascular smooth muscle cells (alpha-actin), endothelial cells (CD31), and macrophages (CD68). Tissue concentrations of vascular endothelial growth factor, matrix metalloproteinase-2, and matrix metalloproteinase-9 were determined by enzyme-linked immunosorbent assay. The results are expressed as medians with their 25th and 75th centiles.RESULTS:Vascular smooth muscle cells were significantly more abundant in the maximal dilatation area than in the transition area (20.3 [14.8-24.4]/10(-2) mm2 vs 8.0 [6.4-9.3]/10(-2) mm2, respectively, P = .002). In the maximal dilatation area, vascular smooth muscle cells had lost their typical lamellar organization, whereas it was preserved in the transition area. Microvessels were significantly more abundant in the media of transition area than in the maximal dilatation area (7.5 [2.9-10.1]/mm2 vs 1.75 [1.5-2.0]/mm2, respectively, P = .008) and were associated with an inflammatory cell infiltration that predominated in their immediate vicinity. There were no significant differences in vascular endothelial growth factor, matrix metalloproteinase-2, and matrix metalloproteinase-9 between both areas.CONCLUSIONS:The transition area appears as a disease progression front characterized by microvessel formation and inflammatory cell infiltration. In contrast, increased vascular smooth muscle cell density in the maximal dilatation area suggests a healing process, although inefficient to prevent aortic dilatation.

Robotic-enhanced coronary surgery has been performed on sixty consecutive unselected patients (60.8+/-12 years) requiring CABG only. Nine had single-vessel (LAD), 13 double-vessel, and 38 triple-vessel disease. Since the endostabilizer was made available in the autumn of 2002 only, the first 47 patients were proposed to have closed chest LIMA dissection only. This was achieved successfully in all but one patient. In addition, 12 distal anastomosis have been performed after full sternotomy with the robot. Every other anastomosis has been hand sewn. The last 13 patients were TECAB candidates. After successful LIMA harvesting, LIMA to LAD suture has been attempted in totally closed chest on the beating heart: it has been successful in two only, the remaining lesions (a total of three) being dilated and stented the day after surgery. In the other 11 patients, the coronary anastomosis was hand sewn after full sternotomy. This suggests that the difficulties in anastomosing small vessels with a standard suture technique jeopardizes the reproducibility of the technique and that further technological developments are needed, to make robotic surgery safe and attractive for the patients.

BACKGROUND:Platelet function plays a major role in the understanding of thromboembolic events in prolonged mechanical support. We studied the platelet activation, platelet aggregation profile, and efficacy of aspirin in patients in whom an external ventricular assist device had been implanted.PATIENTS AND METHODS:Fifteen patients were studied prospectively up to 6 weeks after implantation of the same type of ventricular assist device. Platelet function was studied weekly before daily aspirin administration. Aspirin efficacy was tested ex vivo by measuring platelet aggregation triggered by arachidonic acid. Flow cytometry was used to quantify the spontaneous and induced (adenosine diphosphate stimulation) expression of glycoproteins alphaIIbbeta3, Ibalpha, and CD62P on platelet membranes. The plasma levels of von Willebrand factor (von Willebrand factor activity and von Willebrand factor antigen) and fibrinogen were also determined.RESULTS:Six of the 15 patients (26%) maintained an arachidonic acid-induced platelet aggregation despite daily aspirin treatment (250 mg). CD62P values remained increased during a 5-week postoperative period. Spontaneous levels of glycoproteins alphaIIbbeta3 and Ibalpha on platelet membranes remained within a normal range with a preserved reactivity. The plasma levels of fibrinogen and von Willebrand factor remained increased during the entire study period.CONCLUSION:In patients with an implanted external ventricular assist device, the platelet activation profile displays a persistent activation with a preserved reactivity associated with a persistent high inflammatory state and endothelial activation.

Background: Right ventricular (RV) dysfunction after LVAD implantation remains a major problem. Leftward septal shift secondary to left ventricular (LV) unloading is believed to be an important mechanism. Axial flow pump devices allow for controlled LV unloading by adjustment of rotational speed. We wished to evaluate the impact of progressively increased LV unloading on RV function.