The high-intensity focused ultrasound (HIFU) based EpicorH system is used for creating a linear left atrial lesion encircling both left atrial posterior wall and pulmonary veins (box lesion) for providing a long-term cure in patients with atrial fibrillation (AF) undergoing heart surgery. Whether acute complete disconnection of the box lesion is achieved by application of HIFU is poorly known. Thirteen patients (9 men, median 73 years) with AF undergoing heart surgery (8 aortic valve replacements, 4 mitral valve surgery, and 1 coronary by-pass) were concomitantly treated with HIFU. AF was paroxysmal in eight patients and persistent in five. Entrance and exit blocks into/from the box lesion were assessed using bipolar electrophysiological catheter during sinus rhythm after completion of the ablation process. Entrance block was absent in nine patients, undetermined in one and present in three. Exit block was lacking in nine patients and present in four. Entrance and exit block were both present in only two patients, while they were both lacking in eight patients. At 1 year, nine out of 12 patients were in sinus rhythm (8 on antiarrhythmic drugs) while AF was documented in three out of 12 (2 off drugs). Acute complete block of the box lesion was lacking in the vast majority of patients despite completion of the energy deliverance according to the automated ablation process. However, this did not translate into a high long-term recurrence rate. Whether block later happens, or whether supplementary applications would increase the electrophysiological and clinical success rate is unknown.

Sixteen symptomatic iliac artery stenoses and three occlusions in 16 patients were treated by the percutaneous implantation of Wallstent endoprostheses (Medinvent SA, Lausanne, Switzerland). The endoprosthesis consists of stainless steel monofilaments braided into a self-expanding cylinder. The indications for placement were restenosis after angioplasty (10 cases), failed arterial dilations (eight cases), and restenosis after endarterectomy (one case). The prostheses used had a mean diameter of 8 mm (range, 6-10 mm) and were placed in the external iliac (14 cases) and common iliac (five cases) arteries. The 16 stenoses were greater than 80%, and the three occlusions were longer than 7 cm. Mean length of the lesions treated was 7 cm (range, 4-14 cm). Three of the arteries thrombosed after treatment, one 2 days later and two in the month after implantation of the stent. On clinical and angiographic follow-up (mean, 16 months; range, 1-24 months) no symptoms or stenoses reappeared in the remaining 16 cases. Our experience in these cases suggests that implantation of a Wallstent endovascular prosthesis is a valuable technique for the treatment of external and common iliac artery stenoses.

BACKGROUND We studied whether mitral valvuloplasty (MVP) was superior to mitral valve replacement (MVR) in patients with degenerative mitral regurgitation (MR), and analyzed the independent risk factors for survival and reoperation. METHODS 326 patients with degenerative MR underwent MVP (n = 241), mitral valve replacement (MVR) (n = 78) or emergent MVR due to failure of repair (EMVR). Clinical data were analyzed retrospectively. RESULTS Thirty-day mortality was lower after MVP (2.5 %) compared to MVR (9.0 %) ( P < 0.05). Late survival at 1 and 5 years in the MVP group was 94.4 % and 84.3 % versus 80.4 % and 64.6 % in the MVR group ( P < 0.05), respectively. After adjusting the baseline characteristics by the propensity score method, a significant survival benefit was found for patients who underwent MVP. Multivariable analysis showed that MVR was an independent predictor of thirty-day mortality and survival. There was no significant difference in thirty-day mortality and survival between the EMVR and MVR groups. The need for reoperation was not significantly different between the MVP and MVR groups. In the MVP group, the risk factors for survival and reoperation were identified. CONCLUSIONS MVP is superior to MVR for the treatment of degenerative MR despite the impact of repair failure. Age less than 60 years, ring size to body surface area greater than 19.0, absence of a prosthetic ring and residual MR at the end of surgery (≥ 1/4) reduce the durability of MVP.

Les anévrismes de l’aorte ascendante impliquent un risque élevé de dissection aortique ou de rupture en l’absence de traitement chirurgical.Les anévrismes de l’aorte ascendante sont divisés en 2 entités distinctes selon l’étiologie et la prise en charge chirurgicale : l’anévrisme de la racine de l’aorte, concernant la première partie qui comprend les sinus de Valsalva et l’anévrisme aortique supravalvulaire, commençant au-dessus du sinus de Valsalva jusqu’au tronc brachiocéphalique.L’échocardiographie et la tomodensitométrie thoracique spiralée sont les examens clés pour évaluer le diamètre de l’aorte ascendante et sa progression dans le temps.Le traitement médical par ß-bloquants et un suivi par échocardiographie une ou deux fois par an sont recommandés pour les patients asymptomatiques. Les ß-bloquants ont démontré un effet freinateur sur la dilatation de la racine aortique et améliorent la survie surtout dans le syndrome de Marfan.Au delà de 50 mm, un anévrisme présente des risques de complications. Alors que les anévrismes supravalvulaires peuvent être traités par un simple tube supracoronaire, les anévrismes de la racine de l’aorte peuvent nécessiter en plus un geste sur la valve aortique.Un dépistage familial est essentiel chez les patients ayant un anévrisme de l’aorte thoracique.Aneurysms of the ascending aorta carry a high risk of aortic dissection or rupture in the absence of surgical treatment.Aneurysms of the ascending aorta are classified into 2 distinct types according to their etiology and surgical treatment: aortic root aneurysms, in which the dilatation of the aorta involves the initial portion of the aorta and includes the sinuses of Valsalva and supravalvular aortic aneurysms, which involve the ascending thoracic aorta above the sinuses of Valsalva.Echocardiography and CT scan are the main exams in the evaluation of the diameter of the ascending aorta and its follow up.Conservative treatment by par ß-blockers and follow up by echocardiography once or twice a year is recommended for asymptomatic patients. ß-blockers have demonstrated a slowing effect on dilatation of the aortic root and improve survival especially in patients with Marfan's syndrome.Beyond 50 mm, an aneurysm is at risk for complications. Supravalvular aortic aneurysms can be treated by a simple supracoronary tube graft unlike aortic root aneurysms in which replacement or repair of the aortic valve is often necessary.A family history and investigation of other members is essential in patients with aortic aneurysms.

UNLABELLED Aim. After surgical treatment of type A aortic dissections a long segment of these aortas often remain dissected. Our goal was to analyse feasibility and first clinical and pathophysiological results of a combined treatment by ascending aorta replacement and stenting of the arch or descending aorta with Djumbodis(R) bare stents. PATIENTS AND METHODS Twenty two cases from two centres were analyzed (Universitary Hospital of Parma and Rangueil Universitary Hospital of Toulouse). RESULTS All the stents have been implanted with short times of circulatory arrest. Average follow-up was 278 days (0-2005). There were two peroperative deaths (9.1%). One year cumulate survival rate was 72.7%. Postoperative complications were mainly respiratory and renal. We have shown a reduction in number of perfused false lumen for aortic arches, more often stented, than for descending aortas (p=0.0104), and for dissected and stented segments versus dissected unstented segments (p=0.0083). CONCLUSION Our study demonstrates feasibility of this combined procedure and its positive effect on pathophysiologic evolution. Long term results have to be evaluated, but we think promising to extend this treatment to the whole dissected aorta.

An infant with a congenital auriculoventricular block (CAVB) of immunological origin was diagnosed prenatally. The mother had Gougerot‐Sjögren disease with positive anti‐Sjogren's Syndrome A (SSA) and Sjogren's Syndrome B (SSB) serologies. Cardiac pacing was necessary and the epicardial route was chosen. Considering the left ventricular (LV) dilatation, biventricular (BiV) stimulation was preferred to the usual DDD mode, presumed to have a deleterious long‐term effect. Echographic parameters were better with BiV stimulation: the asynchronism induced by mono‐RV stimulation was corrected and the QRS complexes were narrower. BiV pacing of a CAVB with LV dilation looks clinically and echographically attractive but needs to be validated in the long term.

Acute type A aortic dissection is a surgical emergency. After replacement of the ascending aorta, the arch and descending aorta often remain dissected, with a 40% risk of aneurysmal evolution at 5 years. Procedural dissections of arteries (coronary, renal, iliac) are treated with uncovered stents. Experimental studies on aortic dissections report suppression of false lumen and histologic cicatrization of stented aortas after 6 weeks.1,2 On the basis of these facts, our strategy was to support aortic cicatrization and prevent aortic dilatation.

OBJECTIVE:The study's objective was to comparatively evaluate surgery and stent-graft repair of acute or subacute traumatic aortic rupture. METHODS:A total of 76 patients (14-76 years old; mean, 37 years; male/female ratio, 63/11) with a traumatic aortic injury were admitted to our hospital between 1981 and 2003. Six patients died within 1 to 9 days of another associated severe traumatic lesion. The 70 remaining patients were divided according to the type of rupture repair. In group 1, 35 patients were treated surgically: 28 with immediate repair and 7 with delayed repair (average time interval 66 days, 5-257 days). In group 2, 29 patients were treated with stent grafting of the aortic isthmus. In group 3, 6 patients with minor aortic lesions were treated medically with a close follow-up. RESULTS:In the 28 patients treated surgically in the emergency department, the mortality and paraplegia rates were 21% and 7%, respectively. No death or paraplegia was observed in the group with delayed surgical repair. With stent grafting, complete exclusion of the pseudoaneurysmal sac was observed in all patients. Except for 1 iliac rupture treated during the same procedure, there was no major morbidity or mortality during the mean follow-up of 46 months (13-90 months). No major complication was observed in group 3. CONCLUSIONS:In stable rupture of the aorta, initial conservative treatment is safe and allows management of the major associated lesions. Stent grafting of the aortic isthmus is a valuable therapeutic alternative to surgical repair, especially in patients considered high risk for conventional thoracotomy.

Ebstein's anomaly affects the tricuspid valve with a large range of anatomical forms. Successful tricuspid valvuloplasty depends mainly on the ability to mobilise the leaflets. Evaluation of the leaflet surface is difficult with 2D echocardiography whereas 3D echocardiography provides intracardiac views of the valve. The authors used this method in 10 patients with 3 modes of imaging: biplane, real time and total volume.The study population (age: 1 day to 30 years) included: 1 prenatal diagnosis, 1 neonate with refractory cyanosis, 5 patients with mild tricuspid regurgitation, 3 patients with severe tricuspid regurgitation, 2 of whom underwent valvuloplasty. 3D echocardiography was disappointing in the foetus and neonate because of poor spatial resolution. The ventricular view of the tricuspid valve in older children and adults allowed analysis of tricuspid leaflet coaptation and of the mechanism of regurgitation. The commissures and leaflet surfaces were assessed. The results of surgical valvuloplasty could be evaluated by 3D echocardiography.3D echocardiography is now transthoracic and a real time investigation. Technical advances are required before it comes into routine usage: a more manoeuvrable matricial probe (integrating pulsed and continuous wave Doppler) and larger volume real time 3D imaging with better resolution. Its role in the assessment of Ebstein's anomaly should be evaluated in a larger series of patients.

Le traitement des complications ischémiques secondaires à une dissection aortique a bénéficié ces dernières années d'une meilleure prise en charge du fait des progrès des techniques chirurgicales, de l'anesthésie-réanimation, d'une meilleure connaissance de la vascularisation médullaire et des progrès de l'imagerie par tomodensitométrie multibarrette ; en effet, l'évaluation et la reconnaissance très précoce de malperfusions viscérales permettent de proposer des stratégies thérapeutiques offensives combinant la chirurgie et la radiologie interventionnelle vasculaire. L'approche multidisciplinaire radiologique, chirurgicale, cardiologique et anesthésique doit permettre d'améliorer le pronostic immédiat et tardif des dissections de l'aorte.

IntroductionRedo surgery of the aortic arch in elderly patients inpoor health is associated with a high mortality. Thisregion of the aorta cannot always be treated usingendovascular stents. We report our experience with asurgical case of a false anastomotic aneurysm of theaortic arch, treated by open surgery and subsequentendovascular surgery.Case ReportA 74-year-old patient with a persistent hiccoughunderwent a routine medical examination. He hadundergone an aortic valve replacement in 1982followed by a Bentall procedure and an aortic archreplacement in 1986 due to a dissection. Radiographyand the thoracic computerized tomography revealed afalse aneurysm of the distal anastomosis of the aorticarch, fed by a localized leak at the origin of thebrachiocephalic trunk (Fig. 1). The neck between theleak and the brachiocephalic trunk was 0.7 cm. Anendovascular procedure as the first option wasconsidered because of the patient’s medical historyand his precarious coronary condition.First, via a cervical approach, the left subclavianartery was reimplanted into the left common carotidartery, a carotid–carotid bypass graft and exclusion ofthe left common carotid artery were achieved. Apostoperative surgical haemostasis and a bloodtransfusion were both required. Postoperative com-plications included a left recurrent laryngeal nerveparalysis,pneumonia,and theonsetof atrialfibrillation.Because of these complications we waited 6 monthsbefore carrying out the endovascular procedure.At the second procedure an occlusion balloon wasfirst placed in the left subclavian artery to preventretrograde perfusion from the collaterals from feeding

A 25-year-old Marfan patient was operated on for an acute type A aortic dissection that was complicated twice by false aneurysms at the distal suture line. At the third episode a covered endoprosthesis was inserted in the ascending aorta between the coronary ostia and the inominate artery. The postoperative course was uneventful and a control computed tomographic scan showed complete occlusion of the false aneurysm. This attractive technique should be considered versus an open-heart operation in selected patients.

When the port of entry of acute type-A aortic dissection is at the level of the horizontal portion of the aortic arch, the latter should be replaced by a prosthesis. To avoid performing this difficult procedure in an emergency situation, we place a stent in the aortic arch. Then we replace the ascending aorta by a prosthesis.

Aortoesophageal and aortobronchial fistulas constitute a problem in therapy because of the high rates of morbidity and mortality associated with operation. From May 1996 to March 2000, we treated by an endovascular procedure one aortoesophageal and three aortobronchial fistulas. There was no postoperative death. We noted one peripheral vascular complication that required a surgical procedure, one postoperative confusion, and one inflammatory syndrome. In one case, because of a persistent leakage after 21 months, we had to implant a second endovascular stent graft. A few weeks later the reopening of this patient's esophageal fistula led to his death by mediastinitis 25 months after the first procedure. The few cases published seem to bear out the interest, observed in our 4 patients, of an endovascular approach to treat complex lesions such as fistulas of the thoracic aorta especially in emergency or palliative cases.

The authors present a case of acute ischemia of a limb as a complication of multiple hereditary exostoses. They discuss surgery, complications, and review the literature.