[Show abstract][Hide abstract] ABSTRACT: Background
Bleeding originating in the gastrointestinal (GI) tract is one of the most common adverse events after left ventricular assist device (LVAD) implantation. In these patients, GI bleeding appears to be the consequence of altered hemostasis on the one hand and alterations of the GI microvasculature on the other.Case ReportWe report the case of a patient who suffered repeated, severe GI bleeding early after implantation of a HeartMate II continuous-flow LVAD.ResultsAfter failure of conventional treatment strategies, GI bleeding was controlled using repeated transfusions of a purified von Willebrand factor (VWF) concentrate, almost devoid of Factor VIII (Wilfactin, LFB). No episodes of pump thrombosis were noted. Subsequent to VWF transfusions, we observed a progressive normalization of circulating vascular endothelial growth factor levels.Conclusions
Our data raise the possibility that, in addition to its hemostatic properties, transfusions of VWF might have acted as an antiangiogenic factor.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: The Logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) and the Society of Thoracic Surgeons (STS) score are routinely used to identify patients at high surgical risk as potential candidates for transcatheter aortic valve implantation (TAVI).
AIMS: To compare the new EuroSCORE II with the Logistic EuroSCORE and the STS score.
METHODS: From October 2006 to June 2011, patients with severe symptomatic aortic stenosis who underwent a TAVI were enrolled prospectively.
RESULTS: Among 272 patients, the EuroSCORE II was significantly lower and moderately correlated with the Logistic EuroSCORE (9±8% vs. 23±14%, P<0.01; r=0.61, P<0.001), but similar to and poorly correlated with the STS (10±9%, P=0.10; r=0.25, P<0.001). Based on recommended high-risk thresholds (Logistic EuroSCORE≥20%; STS≥10%), a EuroSCORE II≥7% provided the best diagnostic value. However, using the EuroSCORE II, Logistic EuroSCORE or STS score, only 51%, 58% and 37% of patients, respectively, reached these thresholds. Contingency analyses showed that agreements between the EuroSCORE II and the Logistic EuroSCORE or the STS score were modest or poor, respectively, with a risk assessment different in 28% and 36% of patients, respectively.
CONCLUSIONS: A EuroSCORE II≥7% corresponded to a Logistic EuroSCORE≥20% or STS score≥10%, but correlations and agreements were at best modest and only approximately half of the patients reached these thresholds. Our results highlight the limits of current scoring systems and reinforce the European guidelines stressing the importance of clinical judgment in addition to risk scores.
Archives of cardiovascular diseases 07/2014; 107(6-7):353-360. · 0.66 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Mitral insufficiency is a frequently occurring valvular disease for which surgery is the reference treatment. A large number of patients are at high risk or even contraindicated for surgery due to comorbidities. The MitraClip procedure reproduces a surgical technique for mitral valve repair. Global experience includes over 12,000 patients and has been mainly reported in registries with limited follow-up. The degree of reduction of mitral insufficiency is less with the MitraClip than with surgery. Safety of the procedure is good in experienced centres. Most patients have functional improvement in the mid-term. The procedure may be considered in patients who are at high risk for surgery and remain symptomatic despite optimal medical treatment. In the future, more data are needed from longer follow-up and randomised trials. Both the technique and the equipment used in the procedure need to improve. In addition, it is hoped that combined percutaneous procedures will be available in the near future.
[Show abstract][Hide abstract] ABSTRACT: Mitral insufficiency is a frequently occurring valvular disease for which surgery is the reference treatment.
A large number of patients are at high risk or even contraindicated for surgery due to comorbidities.
The MitraClip procedure reproduces a surgical technique for mitral valve repair.
Global experience includes over 12,000 patients and has been mainly reported in registries with limited follow-up.
The degree of reduction of mitral insufficiency is less with the MitraClip than with surgery.
Safety of the procedure is good in experienced centres. Most patients have functional improvement in the mid-term.
The procedure may be considered in patients who are at high risk for surgery and remain symptomatic despite optimal medical treatment.
In the future, more data are needed from longer follow-up and randomised trials. Both the technique and the equipment used in the procedure need to improve. In addition, it is hoped that combined percutaneous procedures will be available in the near future.
[Show abstract][Hide abstract] ABSTRACT: Aims: We report a case of emergency transcatheter heart valve implantation in a failing mitral bioprosthesis via a transseptal access complicated by the atrial migration of a prosthesis. Methods and results: A 42-year-old woman was referred for stenotic failure of a mitral bioprosthesis. A transapical valve-in-valve implantation was initially planned. However, due to sudden haemodynamic deterioration, an emergency transseptal implantation via a femoral venous access was undertaken. Following cardiac arrest, the procedure was performed with extracorporeal membrane oxygenation (ECMO), and was complicated by the migration of a valve, which was left moving freely in the left atrium. A second valve was successfully implanted in the mitral bioprosthesis. Following initial clinical recovery, there was a sudden recurrence of heart failure due to entrapment of the migrated valve in the implanted valve in a "reverse position", which was dislodged percutaneously in an emergency procedure. The valve later migrated into the left atrial appendage. Immediate outcome was uneventful, but the patient suddenly died six months later. Conclusions: Transseptal transcatheter mitral valve-in-valve implantation is feasible, even in an emergency setting with ECMO. Valve migration in the left atrium may occur and lead to late entrapment in a "reverse position", with significant haemodynamic consequences.
EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology 09/2013; 9(5):636-42. · 3.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In selected high-risk patients with aortic stenosis, transcatheter aortic valve implantation (TAVI) can provide comparable functional improvement and early survival after surgical aortic valve replacement. However, the long-term outcome after TAVI is still to be determined and the occurrence of aortic dissection has not been systematically reported. Herein, a case is presented of delayed aortic dissection and rupture several months after an uneventful TAVI in a patient with bicuspid aortic valve stenosis.
The Journal of heart valve disease 09/2013; 22(5):701-3. · 1.07 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Peripheral venoarterial extracorporeal membrane oxygenation support provides prolonged support in the event of acute or acute-on-chronic cardiac and/or respiratory failure. This support serves as a bridge to recovery, decision-making, heart transplantation or ventricular-assist device implantation. It can be implanted either through a percutaneous approach using Seldinger's technique or via an open approach via the common femoral artery or the axillary artery. Early and late arterial vascular complications remain an important issue, with rates of up to 28% with femoral and axillary cannulation sites. Among them, limb ischemia requires prompt diagnosis and management to avoid limb amputation. In the case of peripheral artery cannulation, ipsilateral distal limb perfusion to prevent acute limb ischemia can be performed via a single lumen catheter through the artery or via the 'chimney graft' technique during extracorporeal membrane oxygenation implantation.
[Show abstract][Hide abstract] ABSTRACT: Tissue activation of proteolysis is involved in acute intramural rupture (dissections, acute ascending aortic dissection) and in progressive dilation (aneurysms, thoracic aneurysm of the ascending aorta) of human ascending aorta. The translational aim of this study was to characterize the regulation of antiproteolytic serpin expression in normal, aneurysmal, and dissecting aorta.
We explored expression of protease nexin-1 (PN-1) and plasminogen activator inhibitor-1 and their regulation by the Smad2 signaling pathway in human tissue and cultured vascular smooth muscle cells (VSMCs) of aneurysms (thoracic aneurysm of the ascending aorta; n=46) and acute dissections (acute ascending aortic dissection; n=10) of the ascending aorta compared with healthy aortas (n=10). Both PN-1 and plasminogen activator inhibitor-1 mRNA and proteins were overexpressed in medial tissue extracts and primary VSMC cultures from thoracic aneurysm of the ascending aorta compared with acute ascending aortic dissection and controls. Transforming growth factor-β induced increased PN-1 expression in control but not in aneurysmal VSMCs. PN-1 and plasminogen activator inhibitor-1 overexpression by aneurysmal VSMCs was associated with increased Smad2 binding on their promoters and, functionally, resulted in VSMC self-protection from plasmin-induced detachment and death. This phenomenon was restricted to aneurysms and not observed in acute dissections.
These results demonstrate that epigenetically regulated PN-1 overexpression promotes development of an antiproteolytic VSMC phenotype and might favor progressive aneurysmal dilation, whereas absence of this counter-regulation in dissections would lead to acute wall rupture.
Arteriosclerosis Thrombosis and Vascular Biology 06/2013; · 6.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: AIMS: In patients with a suspicion of prosthetic valve endocarditis (PVE), detection of perivalvular infection can be difficult based only on echocardiography. The aim of this retrospective study was to test the interest of radiolabelled leucocyte scintigraphy (LS) for the detection of perivalvular infection in patients with a suspicion of PVE and inconclusive transoesophageal echocardiography (TEE). METHODS AND RESULTS: LS was performed in 42 patients. The results of LS were classified as positive in the cardiac area (intense or mild), or negative. Macroscopical aspects and bacteriology were obtained from patients who underwent cardiac surgery (n = 10). Clinical outcome was collected in patients treated medically (n = 32).Among patients with intense signal with LS who underwent surgery (n = 6), five had an abscess confirmed during intervention and one, post-operatively. Patients with intense accumulation of radiolabelled leucocytes with scintigraphy and treated medically (n = 3) had a poor outcome: death (n = 1); prosthetic valve dehiscence (n = 1); and recurrent endocarditis (n = 1). Among patients with mild activity with LS (n = 5), one patient developed a large prosthetic valve dehiscence during the follow-up. The remaining four patients were treated medically and did not present any recurrent endocarditis after a median follow-up of 14 months. No abscess was detected in patients with negative LS who underwent surgery (n = 4). Among the patients with negative LS treated medically (n = 24), none presented recurrent endocarditis after a mean follow-up of 15 ± 16 months. Patient management was influenced by the results of LS in 12 out of 42 patients (29%). CONCLUSION: This study suggests that LS is useful for the identification of perivalvular infection in patients with a suspicion of PVE and inconclusive TEE.
European heart journal cardiovascular Imaging. 03/2013;
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES
Sternal wound infections occurring after cardiac surgery have a critical impact on morbidity, mortality and hospital costs. This study evaluated the efficacy of a gentamicin-collagen sponge in decreasing deep sternal-wound infections in high-risk cardiac surgery patients.METHODS
We conducted a quasi-experimental single-centre prospective cohort study in diabetic and/or overweight patients undergoing coronary-artery bypass surgery with bilateral internal mammary artery grafts. The end-point was the rate of reoperation for deep sternal wound infection. The period from January 2006 to October 2008, before the introduction of the gentamicin sponge, was compared with the period from November 2008 to December 2010.RESULTSOf 552 patients (median body mass index, 31.5; 37.7% with diabetes requiring insulin), 68 (12.3%) had deep sternal wound infections. Reoperation for deep sternal wound infections occurred in 40/289 (13.8%) preintervention patients and 22/175 (12.6%) patients managed with the sponge. Independent risk factors were female sex and longer time on mechanical ventilation, but not use of the sponge (adjusted odds ratio, 0.95; 95% confidence interval, 0.52-1.73; P = 0.88). The group managed with the sponge had a higher proportion of gentamicin-resistant micro-organisms (21/27, 77.8%) compared with the other patients (23/56, 41.1%; P < 0.01). The median time to reoperation for wound infection was higher with the sponge (21 vs 17 days, P < 0.01).CONCLUSIONSA gentamicin-collagen sponge was not effective in preventing deep sternal wound infections in high-risk patients. Our results suggest that a substantial proportion of wound contaminations occur after bypass surgery with bilateral internal mammary artery grafts.
Interactive Cardiovascular and Thoracic Surgery 10/2012; · 1.11 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Little is known about transcatheter aortic valve implantation (TAVI) in patients with bicuspid aortic valve stenosis, which usually represents a contraindication. The aim of this study was to assess the feasibility and the results of TAVI in this patient subset. Of 316 high-risk patients with severe aortic stenosis who underwent TAVI from January 2009 to January 2012, 15 (5%) had documented bicuspid aortic valves. They were treated using a transarterial approach, using the Medtronic CoreValve system. Patients were aged 80 ± 10 years, in New York Heart Association functional classes III and IV. The mean aortic valve area was 0.8 ± 0.3 cm(2), and the mean gradient was 60 ± 19 mm Hg. The mean calcium score, calculated using multislice computed tomography, was 4,553 ± 1,872 arbitrary units. The procedure was successful in all but 1 patient. Major adverse events, according to Valvular Academic Research Consortium definitions, were encountered in 1 patient (death). The mean postimplantation prosthetic gradient was 11 ± 4 mm Hg, and ≤1+ periprosthetic leaks were observed in all but 2 patients. The mean prosthetic ellipticity index was 0.7 ± 0.2 at the level of the native annulus and 0.8 ± 0.2 at the level of the prosthetic leaflets. After a mean follow-up period of 8 ± 7 months, 1 patient had died from aortic dissection; there were no additional adverse events. All but 2 hospital survivors were in New York Heart Association class I or II. In conclusion, the present series suggests that transarterial Medtronic CoreValve implantation is feasible in selected patients with bicuspid aortic valve and may lead to short-term hemodynamic and clinical improvement.
The American journal of cardiology 06/2012; 110(6):877-83. · 3.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We report and examine the outcomes of emergency venoarterial extracorporeal membrane oxygenation (ECMO) support initiated via percutaneous cannulation of the femoral vessels.
Fifteen patients undergoing percutaneous venoarterial ECMO under emergency circumstances between January 2009 and July 2011 were identified. The implantation technique employed the Seldinger's technique for both arterial and venous cannulae. Whenever possible antegrade perfusion of the ipsilateral lower limb was performed through percutaneous catheterization of the superficial femoral artery (SFA).
ECMO support was indicated mainly for cardiac arrest (n=9, 60%) or cardiogenic shock (n=4, 27%), while two (13%) patients required ECMO support for acute respiratory failure. In five (33%) patients, ECMO was implanted during cardiopulmonary resuscitation manoeuvres. ECMO support was maintained for a mean of 4.9 days. Eight patients (53%) were successfully weaned from the device. Thirty-day mortality was 53%. Seven patients (47%) suffered early complications, namely two wound infections, one thrombosis of the venous cannula, one erroneous implantation of the arterial cannula into the femoral vein, one local dissection of the femoral artery, one retroperitoneal bleeding and one acute limb ischaemia. No long-term vascular complications were noted.
Percutaneous femoral cannulation for ECMO support remains a prompt approach for establishing extracorporeal circulatory support in acute cardiopulmonary failure when conditions for performing femoral vessel cut down are not optimal. However, vascular complications are frequent and carry a significant morbidity and mortality.
European heart journal. Acute cardiovascular care. 06/2012; 1(2):111-4.
[Show abstract][Hide abstract] ABSTRACT: Transcatheter aortic valve implantation (TAVI), introduced 10 years ago by Alain Cribier, has now been performed in more than 50,000 patients worldwide. Our vision of the main directions for the future are fourfold. Firstly, the 'Heart Team' is and will remain, essential for patient selection and the performance of the procedure. Careful training and controlled diffusion of the technique to medico-surgical centres are also keys to success. Secondly, patient selection must be refined, in order to predict the risk of surgery and that of TAVI. The technique is currently limited to very high-risk patients or those with contraindications to surgery. It will be extended to include lower risk patients once there are adequate trial data, the safety of the procedure has been improved and better knowledge of long-term outcomes from the procedure has been obtained. Thirdly, the procedure will be simplified, and should also be safer with an expected decrease in the occurrence of strokes, vascular complications and perivalvular regurgitation. Fourthly, the devices will also improve, with the addition of the potential for repositioning and improvement in durability. The role of imaging with the use of multimodality techniques will no doubt increase and ease the efficacy and safety of the procedure. Overall, the use of TAVI will undoubtedly increase over time, enabling a larger number of patients with severe aortic stenosis to be treated in an effective and safe way, in complement to surgical aortic valve replacement.
Archives of cardiovascular diseases 03/2012; 105(3):181-6. · 0.66 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Surgical aortic valve replacement in patients with previous coronary artery bypass grafting (CABG) carries a high mortality. Transcatheter aortic valve implantation (TAVI) has been shown to be successful in high risk subgroups of patients. Our goal is therefore to evaluate the impact of a history of CABG on the outcome of patients who undergo TAVI.
From October 2006 to June 2010, among the 201 patients selected to undergo TAVI, 54 (27%) had a history of CABG. Outcomes were prospectively collected.
The 30-day outcome was not different between patients with previous CABG vs. those without, in particular as regards mortality (respectively, 5.6% vs. 10.9%; P = 0.25). Mid-term survival (mean FU: 7 ± 9 months) was not different at 2 years between patients with previous CABG vs. patients without (65.7 ± 6.2% vs. 80.0 ± 7.7% respectively; P = 0.12). In multivariate analysis, CABG was not associated with an excess mid-term mortality after TAVI.
Previous CABG does not adversely affect outcome in patients undergoing TAVI. If confirmed by larger prospective series and ideally by a randomized trial comparing CABG vs. redo surgery, this observation might lead the heart team to consider TAVI as an attractive option in the population of high risk patients with aortic stenosis and previous CABG.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 03/2012; 41(3):499-504. · 2.40 Impact Factor