In this paper, the authors report the case of a 28 year old man with pulmonary vein leiomyosarcoma presenting subacute respiratory distress Thoracic computed tomography and transoesophagal ultrasonographic examination of the heart suggested the diagnosis of a heart tumour revealed by the obstruction of the mitral valve and pulmonary oedema Emergency cardiac surgery revealed the mass to be a leiomyosarcoma, probably extending from the right inferior pulmonary vein and extending into the left atrium The clinical evoluton was complicated because of a sudden local relapse The patient underwent a second cardiac intervention involving lower right lobectomy followed by adjuvant chemotherapy with an ifosfamide-adriamycin combination This treatment failed to control the disease and a third cardiac intervention was necessary with second line gemcitabine paclitaxel adjuvant chemo therapy Further recurrences were observed with metastases first in the scalp and then in the spine and adrenal glands leading to the death of the patient 2 years after the diagnosis (C) 2010 Elsevier Masson SAS All rights reserved

Background: informed consent is a fundamental and legal obligation for each interventional cardiologist. The effect of consent form describing risks of invasive procedure on anxiety is controversial. This trial was aimed to assess the added value of video information to the standard informed consent process.Methods: 200 consecutive patients undergoing coronary angiography were enrolled. The first one hundred were assigned to conventional education conducted by the physician (no video group) and the second one hundred had consent obtained in the conventional manner assisted by video information (video group). The outcome variables for this comparison consisted of a standard anxiety score (Spielberger Statement Anxiety Inventory questionnary) plus hemodynamics measurements of heart rate, systolic and diastolic blood pressure obtained at baseline and immediately after written informed consent In addition, before discharge, patients graded the tolerability and satisfaction on a 4-point scale.Results: The groups were similar with regard to their baseline characteristics and anxity score (37+23 vs 37+23). Patients who had not had prior experience of catheterization had higher baseline anxiety than those who had prior angiography (45+22 vs 31+20; p=0.027). Patients who watched the video were significantly less anxious after informed consent (28+21 vs 34+22; p=0.048) and had a significantly lower heart rate (65+10 vs 71 + 12; p=0,03). The benefits of video information were especially prominent in those with higher anxiety scores at baseline (score after 45+24 vs; 57+26: p=0.046). Tolerability were higher in the video group compared with no video group (98% vs 86%; p=0.003). Finally, satisfaction of information for informed consent process was higher in video group than in no video group (99% VS 76%; p=0,001).Conclusion: a video information decreased anxiety level after written informed consent and improved tolerability and satisfaction scales in patients undergoing coronary angiography. The most likely to benefit from video information are patients with higher anxiety level at baseline. Beneficial effect on informed refusal should be investigated in larger population.

Objective: Robotically assisted mitral valve repair were compared with sternotomy mitral valve repair. Prospectively we evaluated safety and efficacy in performing simple mitral repairs. Methods: Between February 2004 and September 2005, 25 patients with posterior leaflet insufficiency underwent mitral valve repair using the da Vinci system. They were matched retrospectively with 25 patients who underwent the same repair via a median sternotomy. The minimal invasive repairs were performed with peripheral cardiopulmonary bypass, transthoracic aortic cross-clamp, and antegrade cardioplegia. Repair was performed with two ports and a 4-cm intercostals lateral incision in the right chest for access. All patients had posterior leaflet resection and placement of a ring annuloptasty. Results: All patients had successful valve repairs. There were no deaths. There was one conversion to an extended thoracotomy in the minimal. invasive group due to a bleeder on the left atrial. appendage. Overall mean study times showed a longer aortic cross-clamp (range, 96.1 min vs 69.6 min) and cardiopulmonary bypass (range, 122.1 min vs 85.7 min) for the minimal invasive group. Length of stay was Less for the minimal group (7 days vs 9 days). At postoperative echocardiography two patients in both group developed 2+ mitral regurgitations. All other patients had a competent mitral valve repair with no insufficiency. Conclusions: Simple mitral valve repair can be successfully performed with the da Vinci robotic system. This approach is as safe as a sternotomy and long-term follow-up is needed to determine the durability of the mini invasive repair. (c) 2005 Elsevier B.V. All rights reserved.

This study was undertaken to develop a dilatable valved conduit for reconstruction of the right ventricular outflow tract in the animal.The conduits were made by sewing a valved tube (Medtronic Inc) inside a vascular stent (Numed Inc). After preparation, they were inserted surgically in five lambs. The conduits were then dilated 6 weeks and 3 months after their implantation. Before sacrificing the animals at 3 months, a 22 mm valved stent was implanted percutaneously inside the surgical conduits.One animal died suddenly due to kinking of the conduit. Balloon dilatation was performed in the surviving animals. The first dilatation only had a modest impact on valvular function but it was much aggravated after the second dilatation. A valved stent was successfully inserted percutaneously. At sacrifice, all the conduits were completely engulfed in an intense fibrosis.In conclusion, a valved biological conduit for reconstruction of the right ventricular ejection tract has been developed and can be dilated sequentially to follow growth. The new product could have an important role to play in the management of congenital malformations involving the right ventricular outflow tract.

UNLABELLED:The GRACE registry provides the opportunity to analyse management of acute coronary syndromes in the real word and the impact of hospital characteristics. In this setting, we compare the activity of a new coronary intensive care unit with regional data. METHODS:From January 2000 to December 2003, 376 eligible patients were involved (22% of regional inclusion). GRACE standard diagnosis were the following, for our centrer (for the cluster): ST elevation myocardial infarction 28% (37%), non-ST elevation myocardial infarction 32% (31%), unstable angina 33% (24%). Demographic characteristics were similar with a median age of 64 (vs 66) and a large majority of male (74 vs 81%). Medical history and cardiovascular risk factors were comparable. Predictors of hospital mortality were observed at the same rate: cardiogenic shock (3 vs 3%), congestive heart failure > Killip 2 (4 vs 4%), left ventricular ejection fraction (LVEF) lower than 40% (17 vs 16%), recurrent ischemic symptoms (8 vs 8%). Coronary artery bypass grafts were required in 5% (vs 2%). RESULTS:Drugs prescription rates were similar: aspirin at admission (95%) and at discharge (95%), betablocker at admission (70%) and at discharge (85%), statin at admission (< 30% in 2000, > 60% in 2003) and at discharge (< 60% in 2000 and > 80% in 2003), ticlopidin-clopidogrel at admission (< 20% in 2000 and > 40% in 2003), ACE inhibitor for LVEF < 40%, intravenous GPIIblIIa, and low molecular weight heparin (90%). Cardiac catheterisation (90%) and percutaneous coronary interventions (80%) were performed at the same rates in our center and in the cluster. Hospital death was similar (2 vs 4%). Discharge status was home for a large majority of patients (63 vs 76%). The median length of stay was five days and shorter than three days for patients with unstable angina. CONCLUSION:Based on GRACE registry data, the present evaluation revealed that our new center offered evidence-based medical and interventional therapy in patients with acute coronary syndromes at the same level than experienced institutions with similar results for hospital death and length of stay.

Le registre international GRACE permet d'évaluer la prise en charge des syndromes coronaires aigus dans le monde réel. L'expérience des quatre premières années d'activité d'une unité de soins intensifs est comparée aux données régionales françaises de ce registre.

Les stents à élution de médicament ont été développés pour éviter la resténose intrastent survenant dans 20 à 40 % des cas après implantation d'un stent nu. La mise en évidence du rôle clé de la prolifération néo-intimale de cellules musculaires lisses dans la resténose intrastent a conduit à tester l'intérêt de différents agents antimitotiques et/ou anti-inflammatoires déposés sur le stent et capables ainsi de bloquer in situ le phénomène prolifératif. Un stent actif associe trois éléments, le stent métallique, le médicament actif et son système de délivrance, le plus souvent un polymère. Le stent à élution de sirolimus et le stent à élution de paclitaxel ont récemment obtenu le marquage de conformité européenne sur la base des preuves acquises dans des études randomisées. Leurs résultats sont concordants et cohérents en faveur d'une réduction significative de la resténose intrastent dont l'incidence moyenne semble désormais comprise entre 5 et 7 %. Le suivi à long terme devra apporter des réponses à deux incertitudes persistantes : quelle est l'incidence de la thrombose de stent actif et quelle est la signification des mal-appositions de stents actifs apparues après quelques semaines ? L'incidence de la thrombose de stent évaluée à moins de 1 % dans le monde réel des stents nus semble effectivement un peu plus élevée avec les stents actifs, notamment en raison de thromboses tardives observées jusqu'à plusieurs mois après l'implantation. Ce risque particulier justifie le prolongement du traitement antiagrégant par aspirine et clopidogrel pendant deux à six mois selon le modèle utilisé. La mal-apposition de stent, définie sur des critères échographiques endocoronaires, pourrait être liée au développement d'une réaction d'hypersensibilité au polymère du système de délivrance et la question est posée de son association avec le risque de thrombose tardive. La pratique actuelle de l'implantation des stents à élution de médicaments doit intégrer ces preuves et ces incertitudes dans le respect de l'utilisation des matériels marqués CE et de leurs indications officielles définies par le Journal officiel et les recommandations de la Société française de cardiologie. Le surcoût initial important des stents actifs par rapport aux stents inactifs semble compensé dans le temps avec la réduction des réinterventions pour les patients à haut risque de resténose. Cette approche médicoéconomique sera sans doute à reconsidérer après la mise en place progressive de la tarification à l'activité qui devrait égaliser les pratiques des secteurs publics et privés français vis-à-vis du coût des matériaux prothétiques.

BACKGROUND:Coronary artery bypass grafting with cardioplegia in patients with a low ejection fraction carries a risk of myocardial ischemia. Beating heart surgery is associated with hemodynamic changes when the heart is manipulated. We assessed an alternative: minimal extracorporeal circulation for coronary artery bypass grafting on a beating heart in patients with a poor ejection fraction.METHODS:From January 2000 to January 2002, 50 patients with an ejection fraction of less than 35%, who represented 10% of all patients undergoing coronary artery procedures, underwent revascularization on a beating heart with assistance. We used a closed cardiopulmonary bypass system with a centrifugal pump without reservoir, and the surgical strategy was modified to avoid aortic cross-clamping and to decrease bypass time.RESULTS:The main preoperative characteristics were: age (mean +/- SD) of 64 +/- 11.2 years (range, 41-87 years), 35 male patients (70%), mean left ejection fraction of 24.8% +/- 11.2%, and a mean EuroSCORE of 5.8 +/- 2.7. Revascularizations of 146 distal anastomoses (2.9 +/- 0.7 grafts/patient) were completed. Twelve percent were double bypass, 86% were triple bypasses, and 2% were quadruple bypasses; the mean bypass time was 64.2 +/- 26.2 minutes. The mean graft number was 2.9, and the hospital mortality was 2%. Perioperative hematocrit levels were 30.1%, and 26% of patients received transfusions. Postoperative data showed a median extubation time of 9 hours, a median intensive care unit stay of 48 hours, and a hospital stay of 8 +/- 2 days. Postoperative complications included inotropic support (14%), cerebrovascular events (2%), reoperation for homeostasis (4%), delayed sternal closure (2%), and mediastinitis (2%). Peak troponin Ic level remained a low 2.4 +/- 1.9 g/mL. Follow-up at 6 months was complete with 1 late mortality and with a mean ejection fraction of 30.5% +/- 10.8% for the survivors.CONCLUSIONS:Coronary revascularization on a beating heart with extracorporeal assistance can be done in patients with a low ejection fraction. It avoids the myocardial injury associated with aortic cross-clamping and allows safe and complete coronary revascularization.

X-ray exposure during radiologically guided interventional procedures may have some deleterious effects. The aim of our study was to analyse the factors affecting patient dose during percutaneous coronary angioplasty (PTCA). We evaluated radiation dose during coronary angiography followed by one-vessel PTCA in 402 consecutive patients who were treated by three experienced physicians using both femoral and radial techniques. Fluoroscopy time (t) and patient dose measured by a dose-area product (DAP) meter were recorded. A good correlation was observed between t and the DAP (r=0.78, p<0.001). To assess the factors affecting radiation exposure, we studied the differences between operators, arterial catheterization access and stenting strategy. Median (25th to 75th percentiles) values for t were 19 (13 to 26) min and for DAP were 191 (145 to 256) Gy cm(2) for operator 3 compared with t=12 (9 to 18) min and DAP=137 (91 to 208) Gy cm(2) for operator 2 (p<0.005 versus operator 3) and t=13 (9 to 17) min, and DAP=134 (93 to 190) Gy cm(2) for operator 1 (p<0.001 versus operator 3). Differences between the radial and the femoral techniques were: t=17 (13 to 24) min versus 12 (8 to 17) min, (p<0.001) and DAP=175 (128 to 246) Gy cm(2) versus 138 (93 to 197) Gy cm(2), (p<0.001). In comparison with stenting without pre-dilation, direct stenting significantly reduced t and DAP [t=12 (9 to 16) min versus 16 (11 to 22) min, (p<0.001) and DAP=130 (95 to 186) Gy cm(2) versus 163 (119 to 230) Gy cm(2), respectively, (p<0.01)]. Radiation exposure to patients and staff are strongly dependent on operators, stenting strategy and the arterial access chosen for ad hoc one-vessel PTCA.

Between September 1999 and June 2001, 591 patients required ad hoc coronary angioplasty. The authors compared the group of patients in whom the approach of first intent was radial (n = 328, 55%) with those in whom the femoral approach had been used (n = 263), in terms of immediate local (haematoma or thrombosis requiring surgical intervention or transfusion) and general complications (myocardial infarction, cerebrovascular accident), and major adverse cardiovascular events (infarction, angioplasty, bypass and death) at 1 year. The dose of ionising radiation during the procedures was also compared prospectively. The conversion rate from the radial (R) to the humeral or femoral (F) approach was 10%. The angioplasty, stenting, and stenting without dilatation failure rates were identical in the two groups (5% versus 5%, 0.6% versus 1.9%, 3% versus 4%, respectively). The average irradiation time was greater in the R group than in the F group (23 +/- 12 min vs 17 +/- 4 min, p < 0.001) as was the irradiation per surface unit (242 +/- 137 Gy.cm2 vs 185 +/- 117 Gy.cm2, p < 0.001). The immediate complication rate was comparable in the two groups (2.5% in group R vs 3.6% in group F) as was the major adverse cardiovascular event rate at 1 year (13% in both groups). The authors observed the same rate of immediate complications and late adverse cardiac events in patients undergoing coronary angioplasty followed by immediate angioplasty by the radial or femoral approaches with an acceptable conversion rate from the radial to the femoral approach. The procedures by the radial approach seem to be associated with a greater time and dosage of ionising radiation.

Cardiac surgery in the octogenarians is increasing in the industrialized countries and therefore represents a growing population. In order to better define the benefits of cardiac surgery in this population, we reviewed all consecutive octogenarians patients operated during the last 10 years. Out of 3 409 patients operated between January 1990 and December 1999, we identified 215 patients (6.3%) aged 80 years or more. Median age was 82.4+/-2.45 years, and 52.6% were males. Preoperatively, 52% were in New York Heart Association functional class 11, 19.3% in class 111, and 28.3% in class IV, with a mean Euroscore score of 7.5+/-2.6. Among them, 113 patients (52.5%) had isolated aortic valve replacement, 66 patients (30.6%) had isolated coronary artery bypass graft, 22 patients (10.2%) had aortic valve replacement combined with CABG, and 14 patients (6.5%) had mitral valve operation.The overall hospital mortality was 8%, and multivariate analysis revealed as risk factor for mortality aortic valve replacement combined with coronary artery bypass graft. Median follow up was 36,7 months, with 86% survival at 1 year, 59% at 5 years, and 40% at 7 years. Survival was reduced when aortic valve was combined with revascularisation. Quality of life was improved in 72% of patients.We conclude that for selected octogenarians cardiac surgery can be performed with an acceptable mortality and improves both survival and quality of life.

Cardiac surgery in the octogenarians is increasing in the industrialized countries and therefore represents a growing population. In order to better define the benefits of cardiac surgery in this population, we reviewed all consecutive octogenarians patients operated during the last 10 years. Out of 3,409 patients operated between January 1990 and December 1999, we identified 215 patients (6.3%) aged 80 years or more. Median age was 82.4 +/- 2.45 years, and 52.6% were males. Preoperatively, 52% were in New York Heart Association functional class II, 19.3% in class III, and 28.3% in class IV, with a mean Euroscore score of 7.5 +/- 2.6. Among them, 113 patients (52.5%) had isolated aortic valve replacement, 66 patients (30.6%) had isolated coronary artery bypass graft, 22 patients (10.2%) had aortic valve replacement combined with CABG, and 14 patients (6.5%) had mitral valve operation. The overall hospital mortality was 8%, and multivariate analysis revealed as risk factor for mortality aortic valve replacement combined with coronary artery bypass graft. Median follow up was 36.7 months, with 86% survival at 1 year, 59% at 5 years, and 40% at 7 years. Survival was reduced when aortic valve was combined with revascularisation. Quality of life was improved in 72% of patients. We conclude that for selected octogenarians cardiac surgery can be performed with an acceptable mortality and improves both survival and quality of life.

Background: To evaluate the advantages and benefits of a minimized extracorporeal circulation system in the performance of coronary artery bypass grafts.Methods: From September 2000 to February 2003, 279 consecutive patients underwent isolated coronary artery bypass grafting with minimal extracorporeal circulation. A group of 243 patients at good risk as defined by a EuroSCORE of 3 underwent complete bypass and blood cardioplegia, and a high-risk group of 45 patients (EuroSCORE, 6) underwent operations with partial assistance and a beating heart. In a prospective substudy analysis of thrombocyte and platelet counts, transfusion requirements, PaO2/FIO2, leukocyte count, C-reactive protein level, postoperative bleeding, intensive care unit stay, and ventilation, 40 patients from the good-risk group were matched and compared with 40 patients who underwent operations with a conventional extracorporeal system.Results: Revascularization was complete with a mean of 2.8 distal anastomoses in the good-risk group and 2.4 in the high-risk group. Mortality rates were 1.2% and 4%, respectively. The system provided either complete or partial bypass assistance and depended on preload and afterload. The system also allowed easy access to all territories with perfect hemodynamic stability. Priming was reduced to 400 mL, and arterial and venous saturation monitoring revealed excellent maintenance of pH values. No complications or failure of the system occurred. Hemodilution, inflammatory response, and transfusion requirements were reduced in the minimal extracorporeal circulation group.Conclusions: Minimal extracorporeal circulation allows minimal hemodilution and reduces transfusion requirements. The method allows safe and complete revascularization of either an arrested or a beating heart.