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Prosthetic replacement of the aortic arch requires a cardiopulmonary bypass and deep hypothermic circulatory arrest. Thus, it is associated with major perioperative risks, and custom-made devices have been developed. However, the time required for this procedure precludes emergency cases, and anatomical prerequisites limit the creation of appropriate devices. Here, we present a totally endovascular approach that allowed an exclusion of the aortic arch with the usual commercial devices. We explain, step by step, the procedure and the materials carefully selected for each step.

OBJECTIVES To investigate the long-term outcomes of concomitant suture bicuspidization to treat mild or moderate tricuspid regurgitation at the time of mitral valve surgery. METHODS Data from patients who underwent mitral valve surgery for degenerative mitral valve regurgitation with mild or moderate tricuspid regurgitation and annular dilatation between January 2009 and December 2017 were analyzed. The cohort was divided into 2 groups: mitral valve surgery alone and mitral valve surgery with concomitant tricuspid valve repair. RESULTS A total of 196 patients were included in the study. Mitral valve surgery alone and mitral valve surgery with concomitant tricuspid valve repair were performed in 91 (46.4%) and 105 (53.6%) patients, respectively. Propensity score matching analysis identified 54 pairs. In the matched cohort, 30-day mortality (0.0% vs 1.9%, P = 1.0) and new permanent pacemaker implantation (11.1% vs 7.4%, P = 0.740) did not differ significantly between groups. After a mean follow-up of 6.0 (2.8) years, mitral valve surgery with concomitant tricuspid valve repair was not associated with increased mortality risk compared to mitral valve surgery alone (hazard ratio 1.04, 95% confidence interval 0.47–2.28, P = 0.927) with 10-year overall survival rates of 69.9% and 77.2%, respectively. Furthermore, mitral valve surgery with concomitant tricuspid valve repair was associated with a significantly reduced progression of tricuspid valve regurgitation (P CONCLUSION Patients undergoing mitral valve surgery with concomitant tricuspid valve repair had similar 30-day and long-term survival, similar permanent pacemaker implantation rate, and reduced progression of tricuspid valve regurgitation compared to those undergoing mitral valve surgery alone.

Objectives Using French transcatheter aortic valve replacement (TAVR) registries linked with the nationwide administrative databases, the study compared the rates of long-term mortality, bleeding, and ischemic events after TAVR in patients requiring oral anticoagulation with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs). Background The choice of optimal drug for anticoagulation after TAVR remains debated. Methods Data from the France-TAVI and FRANCE-2 registries were linked to the French national health single-payer claims database, from 2010 to 2017. Propensity score matching was used to reduce treatment-selection bias. Two primary endpoints were death from any cause (efficacy) and major bleeding (safety). Results A total of 24,581 patients who underwent TAVR were included and 8,962 (36.4%) were treated with OAC. Among anticoagulated patients, 2,180 (24.3%) were on DOACs. After propensity matching, at 3 years, mortality (hazard ratio [HR]: 1.37; 95% confidence interval [CI]: 1.12-1.67; P Conclusions In these large multicenter French TAVR registries with an exhaustive clinical follow-up, the long-term mortality and major bleeding were lower with DOACs than VKAs at discharge. The present study supports preferential use of DOACs rather than VKAs in patients requiring oral anticoagulation therapy after TAVR.

OBJECTIVES The aim of this retrospective multicentre study was to investigate and compare clinical outcomes of unilateral and bilateral antegrade cerebral perfusion (ACP) strategies on cerebral protection during surgery for type A aortic dissection. METHODS Data from 646 patients who underwent surgical repair of thoracic type A aortic dissection using unilateral and bilateral ACP with moderate hypothermic circulatory arrest in 3 cardiac surgical institutions between 2008 and 2018 were analysed. Propensity matching was performed to assess which technique ensured better outcomes. RESULTS Unilateral and bilateral ACP techniques were performed in 250 (39%) and in 396 (61%) patients, respectively. Propensity score analysis identified 189 matched pairs. In the matched cohort, the lowest core temperature was 27.5°C and 28°C in the bilateral and unilateral groups, respectively (P CONCLUSIONS Unilateral and bilateral ACP are both valid brain protection strategies in the landscape of aortic arch surgery. While admitting all the study limitations, unilateral technique could offer some clinical advantages. Clinical registration number 76049

MitraClip (Abbott Laboratories, Abbott Park, IL) is validated in high-risk patients with severe degenerative mitral regurgitation (MR); however, it is not well established for functional MR in hypertrophic cardiomyopathy (HCM). We share a case of a 68-year-old man with HCM hospitalized for multiple incidents of acute pulmonary edema caused by a dynamic MR and successfully treated with the MitraClip device. Novel teaching points emerging from this case are that MRs in HCM can often be explained by mixed mechanisms, and properly identifying the MR mechanism is essential to choose optimal treatment. Furthermore, MitraClip can simultaneously treat MR secondarily to annular dilation and systolic anterior motion.

MitraClip (Abbott Laboratories, Abbott Park, IL) is validated in high-risk patients with severe degenerative mitral regurgitation (MR); however, it is not well established for functional MR in hypertrophic cardiomyopathy (HCM). We share a case of a 68-year-old man with HCM hospitalized for multiple incidents of acute pulmonary edema caused by a dynamic MR and successfully treated with the MitraClip device. Novel teaching points emerging from this case are that MRs in HCM can often be explained by mixed mechanisms, and properly identifying the MR mechanism is essential to choose optimal treatment. Furthermore, MitraClip can simultaneously treat MR secondarily to annular dilation and systolic anterior motion. Résumé: Il a été établi démque Le Mitraclip (Abbott Laboratories, Abbott Park, Il) est une intervention percutanée validée pour la prise en charge des patients à haut risque chirurgical qui présente une régurgitation mitrale (RM) sévère dégénérative. Toutefois, cette technique est moins bien établie dans une RM fonctionnelle dans le cadre d'une cardiomyopathie hypertrophique (CMH). Nous faisons part d'un cas d’un homme de 68 ans atteint d’une CMH et hospitalisé en raison de multiples œdèmes aigus du poumon causés une la RM dynamique dont le traitement par MitraClip s’est avéré une réussite. Les nouveaux d'enseignement à enseigner qui émergent de ce cas portent sur le fait que les RM dans le cadre d’une CMH s’expliquent souvent par des mécanismes mixtes et que la détermination exacte du mécanisme de la RM est essentielle pour choisir le traitement qui convient le mieux au patient. De plus, le MitraClip permet de traiter simultanément les deux mécanismes d'une RM due à une dilatation annulaire et au mouvement systolique antérieur.

Open heart transcatheter mitral valve implantation using the Edwards‐Sapien 3 for mitral annular calcification is a safe procedure, because surgeons do not have to decalcify. And also, surgeons can resect the anterior mitral leaflet to prevent left ventricular outflow tract obstruction and deploy the valve under direct visualization.

Cardiac fiber direction is an important factor determining the propagation of electrical activity, as well as the development of mechanical force. In this article, we imaged the ventricles of several species with special attention to the intraventricular septum to determine the functional consequences of septal fiber organization. First, we identified a dual-layer organization of the fiber orientation in the intraventricular septum of ex vivo sheep hearts using diffusion tensor imaging at high field MRI. To expand the scope of the results, we investigated the presence of a similar fiber organization in five mammalian species (rat, canine, pig, sheep, and human) and highlighted the continuity of the layer with the moderator band in large mammalian species. We implemented the measured septal fiber fields in three-dimensional electromechanical computer models to assess the impact of the fiber orientation. The downward fibers produced a diamond activation pattern superficially in the right ventricle. Electromechanically, there was very little change in pressure volume loops although the stress distribution was altered. In conclusion, we clarified that the right ventricular septum has a downwardly directed superficial layer in larger mammalian species, which can have modest effects on stress distribution.

[This corrects the article DOI: 10.3389/fcvm.2021.827515.].

Background and aim of the study To evaluate whether the release and perfuse technique implies a circulatory arrest time comparable with or shorter than those of standard Frozen Elephant Trunk technique in aortic arch surgery. Methods We retrospectively reviewed the records of patients who had undergone aortic arch repair with Release and Perfuse Technique (RPT) or standard Frozen Elephant Trunk (FET) at our Institution between January 2018 and May 2021. Primary endpoints were the comparison of circulatory arrest time, perioperative variables, and complications between two groups. A propensity score weighting approach was used for data analysis. Results A total of 41 patients underwent aortic arch surgery were analyzed:15 (37%) and 26 (63 %) in RPT and FET group, respectively. The use of RPT showed a significant shorter circulatory arrest times than FET: 9 min vs 58 min (P < 0.001), respectively. The median lactates peak in the first 24h post intervention was 2.6 for RPT group and 5.4 mmol/L for FET group, (P Conclusions Considering the anatomical limitations related to the use of this technique, the RPT appears to be safe, feasible, and effective in reducing the circulatory arrest time during aortic arch surgery. Nevertheless, further studies are required to demonstrate its safety and efficacy.

ispartof: INTERACTIVE CARDIOVASCULAR AND THORACIC SURGERY vol:35 issue:6 ispartof: location:England status: published

The hypothermic circulatory arrest is a major limitation of the frozen elephant trunk (FET) technique, associated with a high incidence of postoperative mobility and mortality. The aim of this study was to evaluate the surgical outcomes of patients suffering from different aortic arch diseases treated with the release and perfuse technique (RPT).We retrospectively reviewed the records of patients who had undergone aortic arch repair with the RPT at our Institution between October 2019 and September 2021. Preoperative, intra-operative, and postoperative data were collected.A total of 18 patients undergoing aortic arch surgery with the use of RPT were analyzed. Twelve of them (67%) were males, and the median age of the entire cohort was 67 (56-73) years. The primary indications for surgery included acute type A aortic dissection (50%), chronic type B aortic dissection (33%), and chronic aneurysms (17%). The median cardiopulmonary bypass-, aortic cross-clamp- and circulatory arrest times were 163 (147-213) min, 69 (51-120) min, and 10 (8-13) min, respectively. The median intensive care unit and hospital stay were 4 (2-7) and 12 (11-16) days, respectively. One patient (6%) died during the first 30 days after surgery.Considering the anatomical limitations related to the use of this technique, the RPT can be safely performed and could represent a promising strategy to reduce the circulatory arrest time during aortic arch surgery. Nevertheless, further studies are required to demonstrate its efficacy.

(1) Background: Although transcatheter technology is rapidly growing and represents a promising strategy, the surgical approach remains the best way to repair a degenerative mitral valve regurgitation. In this context, robotic surgery is technologically the most advanced method of minimally invasive mitral valve repair. The aim of this study is to present the preliminary results of the initial single-center experience with a new robotic mitral valve repair program. (2) Methods: We retrospectively reviewed the records of patients who underwent robotic mitral valve repair at our Institution between January and September 2021. (3) Results: A total of 29 patients underwent mitral valve repair with annuloplasty and chordal implantation to treat degenerative mitral regurgitation. The procedure’s success was achieved in 97% of patients. The 30-day cardiac-related mortality was 0%. The median CPB and cross-clamp times were 189 and 111 min, respectively, with a progressive reduction from the beginning of the robotic program. (4) Conclusions: Considering all the limitations related to the small sample, the presented results of robotic mitral valve repair appear to be encouraging and acceptable. A careful patient selection, a dedicated team, and a robust experience in surgical mitral valve repair are the fundamentals to start a new robotic mitral surgery program.

A comprehensive understanding of the interaction between triggers and electrical substrates leading to ventricular fibrillation (VF) and sudden cardiac arrest is lacking, and electrical substrates are difficult to detect and localize with current clinical tools. Here, we created repolarization time (RT) dispersion by regional drug infusion in perfused explanted human (n = 1) and porcine (n = 6) hearts and in a computational model of the human ventricle. Arrhythmia induction was tested with a single ventricular extrastimulus applied at the early or late RT region. Arrhythmias could only be induced from early RT regions. Vulnerability to VF increased with RT gradient steepness and with larger areas of early RT, but not with markers on the body-surface electrocardiogram. Noninvasive electrocardiographic imaging was performed in survivors of idiopathic VF (n = 11), patients with frequent premature ventricular complexes (PVCs) but no history of sudden cardiac arrest (n = 7), and controls (n = 10). In survivors of idiopathic VF, RT gradients were steeper than in controls, without differences in the clinical electrocardiogram, consistent with the ex vivo results. Patients with idiopathic VF also showed local myocardial regions with distinctly early-versus-late RT that were more balanced in size than in controls. Premature beats originated more often from the early RT regions in idiopathic VF survivors than in patients with frequent PVCs only. Thus, idiopathic VF emerges from the spatiotemporal interaction of a premature beat from an early-repolarization region with critical repolarization dispersion in that region. Electrocardiographic imaging can uncover the co-occurrence of these abnormalities.

Background Cardiovascular magnetic resonance T1ρ mapping may detect myocardial injuries without exogenous contrast agent. However, multiple co-registered acquisitions are required, and the lack of robust motion correction limits its clinical translation. We introduce a single breath-hold myocardial T1ρ mapping method that includes model-based non-rigid motion correction. Methods A single-shot electrocardiogram (ECG)-triggered balanced steady state free precession (bSSFP) 2D adiabatic T1ρ mapping sequence that collects five T1ρ-weighted (T1ρw) images with different spin lock times within a single breath-hold is proposed. To address the problem of residual respiratory motion, a unified optimization framework consisting of a joint T1ρ fitting and model-based non-rigid motion correction algorithm, insensitive to contrast change, was implemented inline for fast (~ 30 s) and direct visualization of T1ρ maps. The proposed reconstruction was optimized on an ex vivo human heart placed on a motion-controlled platform. The technique was then tested in 8 healthy subjects and validated in 30 patients with suspected myocardial injury on a 1.5T CMR scanner. The Dice similarity coefficient (DSC) and maximum perpendicular distance (MPD) were used to quantify motion and evaluate motion correction. The quality of T1ρ maps was scored. In patients, T1ρ mapping was compared to cine imaging, T2 mapping and conventional post-contrast 2D late gadolinium enhancement (LGE). T1ρ values were assessed in remote and injured areas, using LGE as reference. Results Despite breath holds, respiratory motion throughout T1ρw images was much larger in patients than in healthy subjects (5.1 ± 2.7 mm vs. 0.5 ± 0.4 mm, P

Over the last twenty years, we marked significant progresses in the field of tissue engineering and the development of new aortic valve structural and delivery systems. These continuous iterations on the field, have completely changed the surgical indications and approaches for AVR. Nowadays, therapeutic decisions are endorsed by international guidelines; however, new technical advances need a new integrated approach. The clinical scenarios issued from the interaction between the Guidelines and the newest approaches and technologies are regularly on debate by the Heart Team. We will present some of our most encountered situations and the pattern of our therapeutic decisions. To easily navigate through Guidelines and clinical scenarios, we reported in this review a simplified and easy to use Clinical decision-making algorithm that may be a valuable tool in our daily practice.

Although some anecdotal experience concerning the use of modern sutureless aortic valve bioprosthesis for the treatment of endocarditis has been reported, no data is available on the mid-and long-term results. We describe a case of a patient successfully treated with Perceval sutureless bioprosthesis for aortic valve endocarditis and his seven years follow-up.

Mitral valve replacement (MVR) using a prosthesis of transcatheter aortic valve implantation for mitral annular calcification (MAC) is an alternative procedure which is very different from a conventional MVR and is safe. Acceptable results including mortality and morbidity have been reported. We report the case of a male patient treated with this procedure. There was a risk of left ventricular rupture due to extensive decalcification, so we performed transcatheter mitral valve implantation (TMVI). Since he had a history of surgical aortic valve replacement (AVR), we chose open-heart transseptal approach so as not to interfere with the aortic prosthesis. TMVI has a risk of an iatrogenic left ventricular outflow tract (LVOT) obstruction. Using open-heart transseptal approach, we could easily check an anterior commissure of mitral annulus to prevent LVOT obstruction.

Background: Minimally invasive procedures have demonstrated their effectiveness in reducing the recovery times while ensuring optimal results and minimizing complications. Regarding the coronary artery surgical revascularization field, the evolution of techniques and technology is permitting new surgical strategies that are increasingly precise and suitable for each patient. We present an initial single center experience with a case series of patients successfully treated with combined robotic harvesting of the left internal mammary artery (LIMA) and minimally invasive direct coronary artery bypass graft (MIDCAB) for the anastomosis. Methods: We retrospectively reviewed the records of patients who underwent minimally invasive coronary artery revascularization with the use of two combined techniques at our Institution between January 2021 and October 2022. Results: A total of 17 patients underwent coronary artery bypass grafting with the described approach. The median cardiopulmonary bypass (CPB) and cross-clamp times were 83 min (76–115) and 38 min (32–58), respectively. The median intensive care unit (ICU) and hospital stay were 2 days (1–4) and 8 days (6–11), respectively. The procedure’s success was achieved in 100% of patients. The 30-day mortality was 0%. Conclusions: Considering all the limitations related to the small sample, the presented results of a hybrid approach for minimally invasive coronary artery bypass grafting (CABG) appears to be encouraging and acceptable. The main advantage of this approach is related to the reduction of postoperative pain and pulmonary complications.

Aims Mapping data of human ventricular fibrillation (VF) are limited. We performed detailed mapping of the activities underlying the onset of VF and targeted ablation in patients with structural cardiac abnormalities. Methods and results We evaluated 54 patients (50 ± 16 years) with VF in the setting of ischaemic (n = 15), hypertrophic (n = 8) or dilated cardiomyopathy (n = 12), or Brugada syndrome (n = 19). Ventricular fibrillation was mapped using body-surface mapping to identify driver (reentrant and focal) areas and invasive Purkinje mapping. Purkinje drivers were defined as Purkinje activities faster than the local ventricular rate. Structural substrate was delineated by electrogram criteria and by imaging. Catheter ablation was performed in 41 patients with recurrent VF. Sixty-one episodes of spontaneous (n = 10) or induced (n = 51) VF were mapped. Ventricular fibrillation was organized for the initial 5.0 ± 3.4 s, exhibiting large wavefronts with similar cycle lengths (CLs) across both ventricles (197 ± 23 vs. 196 ± 22 ms, P = 0.9). Most drivers (81%) originated from areas associated with the structural substrate. The Purkinje system was implicated as a trigger or driver in 43% of patients with cardiomyopathy. The transition to disorganized VF was associated with the acceleration of initial reentrant activities (CL shortening from 187 ± 17 to 175 ± 20 ms, P Conclusions The onset of human VF is sustained by activities originating from Purkinje and structural substrate, before spreading throughout the ventricles to establish disorganized VF. Targeted ablation results in effective reduction of VF burden. Key question The initial phase of human ventricular fibrillation (VF) is critical as it involves the primary activities leading to sustained VF and arrhythmic sudden death. The origin of such activities is unknown. Key finding Body-surface mapping shows that most drivers (≈80%) during the initial VF phase originate from electrophysiologically defined structural substrates. Repetitive Purkinje activities can be elicited by programmed stimulation and are implicated as drivers in 37% of cardiomyopathy patients. Take-home message The onset of human VF is mostly associated with activities from the Purkinje network and structural substrate, before spreading throughout the ventricles to establish sustained VF. Targeted ablation reduces or eliminates VF recurrence.

Background Dispersion and gradients in repolarization have been associated with life‐threatening arrhythmias, but are difficult to quantify precisely from surface electrocardiography. The objective of this study was to evaluate electrocardiographic imaging (ECGI) to noninvasively detect repolarization‐based abnormalities. Methods and Results Ex vivo data were obtained from Langendorff‐perfused pig hearts (n=8) and a human donor heart. Unipolar electrograms were recorded simultaneously during sinus rhythm from an epicardial sock and the torso‐shaped tank within which the heart was suspended. Regional repolarization heterogeneities were introduced through perfusion of dofetilide and pinacidil into separate perfusion beds. In vivo data included torso and epicardial potentials recorded simultaneously in anesthetized, closed‐chest pigs (n=5), during sinus rhythm, and ventricular pacing. For both data sets, ECGI accurately reconstructed T‐wave electrogram morphologies when compared with those recorded by the sock (ex vivo: correlation coefficient, 0.85 [0.52–0.96], in vivo: correlation coefficient, 0.86 [0.52–0.96]) and repolarization time maps (ex‐vivo: correlation coefficient, 0.73 [0.63–0.83], in vivo: correlation coefficient, 0.76 [0.67–0.82]). ECGI‐reconstructed repolarization time distributions were strongly correlated to those measured by the sock (both data sets, R 2 ≥0.92). Although the position of the gradient was slightly shifted by 8.3 (0–13.9) mm, the mean, max, and SD between ECGI and recorded gradient values were highly correlated ( R 2 =0.87, 0.75, and 0.86 respectively). There was no significant difference in ECGI accuracy between ex vivo and in vivo data. Conclusions ECGI reliably and accurately maps potentially critical repolarization abnormalities. This noninvasive approach allows imaging and quantifying individual parameters of abnormal repolarization‐based substrates in patients with arrhythmogenesis, to improve diagnosis and risk stratification.

Objective: Several recent-generation surgical tissue valves have been found to have bleeding rates exceeding rates recommended by regulatory bodies. We explored bleeding events using data from the Pericardial Surgical Aortic Valve Replacement (PERIGON) Pivotal Trial for the Avalus valve (Medtronic, Minneapolis, Minn) to examine whether this end point remains relevant for the evaluation of bioprostheses. Methods: Patients (n = 1115) underwent aortic valve replacement. Bleeding and thromboembolic event episodes in patients within 3 years postimplant were analyzed for frequency, timing, and severity, focusing on patients taking antiplatelet/anticoagulant medications at the time of the event. Clinical and hemodynamic outcomes are also reported. Results: At 3 years, the Kaplan-Meier cumulative probability estimate of all-cause death was 7.2% (cardiac, 3.6%; valve-related, 1.1%). The Kaplan-Meier cumulative probability estimates of all and major hemorrhage were 8.7% and 5.2%, respectively. Ninety-nine bleeding events occurred in 86 patients: most occurred >30 days postsurgery. Among the 51 late major bleeds, in 5 cases the patients were taking anticoagulant/antiplatelet medication for prophylaxis after surgical aortic valve replacement at the time of the event, whereas the remaining patients were taking medications for other reasons. Age (hazard ratio, 1.035; 95% confidence interval, 1.004-1.068), peripheral vascular disease (hazard ratio, 2.135; 95% confidence interval, 1.106-4.122), renal dysfunction (hazard ratio, 1.920; 95% confidence interval, 1.055-3.494), and antithrombotic medication use at the time of the event (hazard ratio, 1.417; 95% confidence interval, 1.048-1.915) were associated with late bleeds (major and minor). Conclusions: Overall clinical outcomes demonstrated low mortality and few complications except for major bleeding. Most bleeding events occurred >30 days after surgery and in patients taking antiplatelet and/or anticoagulation for indications other than postimplant prophylaxis.

International audience; Objective: The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) initially developed for predicting early postoperative mortality of all types of cardiac surgery, is less able to predict, more specifically, long-term outcomes after aortic valve replacement (AVR). The study authors here evaluated the risk factors for three-year mortality after isolated aortic valve replacement (AVR) for severe calcified tricuspid aortic valve stenosis and compared them with EuroSCORE II to predict long-term outcomes. Design: A retrospective study. Setting: A university teaching hospital. Participants: This study included 1,101 adults who underwent isolated AVR for severe calcified tricuspid aortic valve stenosis between September 2010 to June 2015. Interventions: None. Measurements and Main Results: The primary endpoint was that of three-year all-cause mortality after AVR. By three years, 168 patients (15.3%) had died. Risk factors for all-cause mortality were: male gender (odds ratio [OR] = 1.78; 95% confidence interval [CI] = 1.21-2.62; p < 0.01), peripheral arterial disease (OR = 1.77; 95% CI = 1.08-2.92; p = 0.03), age (OR = 1.06 per year increase; 95% CI =1.04-1.09; p < 0.01), pulmonary artery systolic pressure (OR = 1.02 per mmHg increase; 95% CI = 1.01-1.03; p < 0.01), platelet count (OR = 1.003 per G/L increase; 95% CI = 1.000-1.005; p = 0.04), and valve area (OR = 0.97 per cm 2 /m 2 increase; 95% CI= 0.95-0.99; p < 0.01). The area under the receiver operating characteristic curves were 0.67 (95% CI = 0.60-0.75) and 0.60 (95% CI = 0.56-0.65) for the authors' logistic regression model and EuroSCORE II, respectively (p = 0.11). Conclusions: The study authors identified six independent risk factors for three-year mortality after isolated AVR. The logistic regression model had relatively modest predictive performance for three-year mortality.

Modifications of the myocardial architecture can cause abnormal electrical activity of the heart. Fibro-fatty infiltrations have been implicated in various cardiac pathologies associated with arrhythmias and sudden cardiac death, such as arrhythmogenic right ventricular cardiomyopathy (ARVC). Here, we report the development of an MRI protocol to observe these modifications at 9.4 T. Two fixed ex vivo human hearts, one healthy and one ARVC, were imaged with an Iterative decomposition with echo asymmetry and least-square estimations (IDEAL) and a magnetization transfer (MT) 3D sequences. The resulting fat fraction and MT ratio (MTR) were analyzed and compared to histological analysis of the three regions (“ARVC triangle”) primarily involved in ARVC structural remodeling. In the ARVC heart, high fat content was observed in the “ARVC triangle” and the superimposition of the MTR and fat fraction allowed the identification of fibrotic regions in areas without the presence of fat. The healthy heart exhibited twice less fat than the ARVC heart (31.9%, 28.7% and 1.3% of fat in the same regions, respectively). Localization of fat and fibrosis were confirmed by means of histology. This non-destructive approach allows the investigation of structural remodeling in human pathologies where fibrosis and/or fatty tissue infiltrations are expected to occur.

International audience; BACKGROUND An inverse linear relationship has been reported between pre-operative fibrinogen levels and postoperative blood loss in cardiac surgery. However, recently high pre-operative fibrinogen levels have also been reported to be associated with increased blood transfusion and reoperation. OBJECTIVE We tested the hypothesis that the relationship between pre-operative fibrinogen levels and severe perioperative bleeding is not linear. DESIGN A large-scale (n ¼ 3883) single-centre retrospective study. SETTING A tertiary care teaching hospital. PATIENTS We analysed data from our institutional database which includes all patients above 18 years who underwent on-pump cardiac surgery through a sternotomy between September 2010 and May 2014. MAIN OUTCOME MEASURES Peri-operative severe bleeding adapted from the Universal Definition of Peri-operative Bleeding, class 3 or 4. The relationship between pre-operative fibrinogen levels and peri-operative severe bleeding was analysed by binary logistic regression. A cubic B-spline transformation was used to estimate the relationship between pre-operative fibrinogen level associated with excessive peri-operative bleeding. RESULTS Severe peri-operative bleeding was observed in 957 (24.6%) patients. An L-shaped relationship was observed between pre-operative fibrinogen levels and 24h postoperative blood loss. The relationship between preoperative fibrinogen levels and severe peri-operative bleeding (i.e. Universal Definition of Peri-operative Bleeding class 3 or 4) was U-shaped: the risk of severe peri-operative bleeding bottomed at 3.3 g l À1 when the upward sloping curve started at 5.8 g l À1 with a steeper increase above 8.2 g l À1. CONCLUSION We reported a U-shaped relationship between severe peri-operative bleeding and pre-operative fibrinogen levels. While a low-level of fibrinogen appears to be associated with a high risk of bleeding, a high level does not necessarily protect the patient against such a risk and could even be a risk factor for peri-operative bleeding.

Background Surgical management of aortic valve endocarditis in high risk patients is controversial and the ideal treatment has not been found yet. We describe a selected series of eight patients treated with rapid-deployment aortic valve prosthesis as a therapeutic solution for minimizing the risks associated with annulus manipulation in case of severe aortic infective endocarditis. Methods Eight consecutive patients (five men and three women) with a mean age of 74.3±7.2 years, mean logistic EuroSCORE II of 16.0%±0.1%, affected by aortic native (1 patient), or prosthetic valve endocarditis (7 patients), were treated with Edwards Intuity Elite implantation. Hemodynamic performance and infective data were collected pre-, intra-, and postoperatively with a mean follow-up of 2.7±0.7 years. Results One case of in-hospital mortality was noted. None of the patients had any embolic or infective complication postoperatively. The cardiopulmonary bypass and aortic cross-clamp times were 148.4±41.6 and 90.5±25.3 min, respectively. The postoperative echocardiographic controls indicated a mean transvalvular gradient of 16.7±3.0 mmHg and one case of paravalvular leaks (2 +). Two patients underwent epigastric permanent pacemaker implantation. During the follow-up, seven patients were alive, with no evidence of symptoms or recurrences of endocarditis or embolic episodes. No new paravalvular leaks were noted, and the mean gradient on the valves was 12.4±3.4 mmHg. Conclusions Rapid deployment aortic valve replacement in selected very high-risk patients affected by infective endocarditis could be a reasonable choice with acceptable results. However, further studies are needed to confirm these results.

Objectives Although the impact of prosthesis–patient mismatch (PPM) on survival has been widely studied, there has been little debate about whether the current definition of PPM truly reflects hemodynamic obstruction. This study aimed to validate the categorization of indexed effective orifice area (EOAi) for the classification of PPM. Methods In total, 2171 patients who underwent aortic valve replacement with a surgical stented bioprosthesis in 5 trials (CoreValve US High-Risk, SURTAVI [Surgical Replacement and Transcatheter Aortic Valve Implantation Trial], Evolut Low Risk, PERIGON [PERIcardial SurGical AOrtic Valve ReplacemeNt] Pivotal Trial for the Avalus valve, and PERIGON Japan) were used for this analysis. The echocardiographic images at the 1-year follow-up visit were evaluated to explore the association between EOAi and mean aortic gradient and its interaction with other patient characteristics, including obesity. In addition, different criteria of PPM were compared with reflect elevated mean aortic gradients (≥20 mm Hg). Results A relatively smaller exponential decay in mean aortic gradient was found for increasing EOAi, as the slope on the log scale was –0.83 versus –2.5 in the publication from which the current cut-offs for PPM originate. The accuracy of the American Society of Echocardiography, Valve Academic Research Consortium-2, and European Association of Cardiovascular Imaging definitions of PPM to reflect elevated mean aortic gradients was 49%, 57%, and 57%, respectively. The relation between EOAi and mean aortic gradient was not significantly different between obese and non-obese patients (P = .20). Conclusions The use of EOAi thresholds to classify patients with PPM is undermined by a less-pronounced exponential relationship between EOAi and mean aortic gradient than previously demonstrated. Moreover, recent adjustment for obesity in the definition of PPM is not supported by these data.

Reliable patient-specific ventricular repolarization times (RTs) can identify regions of functional block or afterdepolarizations, indicating arrhythmogenic cardiac tissue and the risk of sudden cardiac death. Unipolar electrograms (UEs) record electric potentials, and the Wyatt method has been shown to be accurate for estimating RT from a UE. High-pass filtering is an important step in processing UEs, however, it is known to distort the T-wave phase of the UE, which may compromise the accuracy of the Wyatt method. The aim of this study was to examine the effects of high-pass filtering, and improve RT estimates derived from filtered UEs. We first generated a comprehensive set of UEs, corresponding to early and late activation and repolarization, that were then high-pass filtered with settings that mimicked the CARTO filter. We trained a deep neural network (DNN) to output a probabilistic estimation of RT and a measure of confidence, using the filtered synthetic UEs and their true RTs. Unfiltered ex-vivo human UEs were also filtered and the trained DNN used to estimate RT. Even a modest 2 Hz high-pass filter imposes a significant error on RT estimation using the Wyatt method. The DNN outperformed the Wyatt method in 62.75% of cases, and produced a significantly lower absolute error (p=8.99E-13), with a median of 16.91 ms, on 102 ex-vivo UEs. We also applied the DNN to patient UEs from CARTO, from which an RT map was computed. In conclusion, DNNs trained on synthetic UEs improve the RT estimation from filtered UEs, which leads to more reliable repolarization maps that help to identify patient-specific repolarization abnormalities.

BACKGROUND Recently, the carotid artery has been used as an alternative approach for transcatheter aortic valve implantation (TAVI). The aim of this study was to prove the safety and feasibility of transcarotid (TC) vs. transfemoral (TF) TAVI. Methods and Results: This retrospective study enrolled 726 consecutive patients with severe symptomatic aortic stenosis. All patients underwent TC-TAVI or TF-TAVI at Hopital Haut-Leveque, Bordeaux Heart University Hospital between September 2012 and October 2017. The TC-TAVI (n=83) and TF-TAVI (n=643) groups were compared statistically. The EuroSCORE II was significantly higher (8.2±6.7 vs. 6.4±5.5; P=0.007) and rates of current smoking, dyslipidemia and peripheral arterial disease were higher in the TC-TAVI than TF-TAVI group. All TC-TAVIs and 9.3% of TF-TAVIs were performed under general anesthesia. Radiation time was significantly shorter in the TC-TAVI than TF-TAVI group (14.5±6.0 vs. 23.0±10.8 min; P

Objectives The authors report the first acute clinical experience of atrial fibrillation ablation with PEF—both epicardial box lesions during cardiac surgery, and catheter-based PV isolation. Background Standard energy sources rely on time-dependent conductive heating/cooling and ablate all tissue types indiscriminately. Pulsed electric field (PEF) energy ablates nonthermally by creating nanoscale pores in cell membranes. Potential advantages for atrial fibrillation ablation include: 1) cardiomyocytes have among the lowest sensitivity of any tissue to PEF—allowing tissue selectivity, thereby minimizing ablation of nontarget collateral tissue; 2) PEF is delivered rapidly over a few seconds; and 3) the absence of coagulative necrosis obviates the risk of pulmonary vein (PV) stenosis. Methods PEF ablation was performed using a custom over-the-wire endocardial catheter for percutaneous transseptal PV isolation, and a linear catheter for encircling the PVs and posterior left atrium during concomitant cardiac surgery. Endocardial voltage maps were created pre- and post-ablation. Continuous and categorical data are summarized and presented as mean ± SD and frequencies. Results At 2 centers, 22 patients underwent ablation under general anesthesia: 15 endocardial and 7 epicardial. Catheter PV isolation was successful in all 57 PVs in 15 patients (100%) using 3.26 ± 0.5 lesions/PV: procedure time 67 ± 10.5 min, catheter time (PEF catheter entry to exit) 19 ± 2.5 min, total PEF energy delivery time Conclusions These data usher in a new era of tissue-specific, ultrarapid ablation of atrial fibrillation.

Summary Percutaneous edge-to-edge repair using MitraClip® (Abbott Laboratories, Abbott Park, IL, USA) can be used to treat mitral regurgitation. However, real-time echocardiographic guidance is vital; and use of 3D transoesophageal echocardiography to guide the procedure has improved reproducibility, reliability and safety. This review describes the MitraClip® device – which is composed of a steerable guide catheter (SGC) and a Clip Delivery System (CDS) – and the MitraClip® procedure. The procedure consists of six steps: (1) transseptal approach and puncture; (2) introduction of the SGC into the left atrium; (3) navigation with the CDS into the left atrium to place the MitraClip® above the mitral valve; (4) crossing the valve and advancing the CDS into the left ventricle; (5) grasping the leaflets and assessment of the quality of the grasping; and (6) final mitral regurgitation assessment. This review also describes which imaging techniques are applicable to each stage of the procedure; and contains examples of the various images obtained during these steps.

OBJECTIVES Transaortic (TAo) access for transcatheter aortic valve implantation (TAVI) is an alternative to the conventional transfemoral or transapical routes. Data comparing the characteristics and outcomes of TAo-TAVI using the SAPIEN XT and SAPIEN 3 heart valves are scarce. The objective of the current analysis was to provide such information. METHODS ROUTE is an international, prospective, observational registry. Patients with severe calcific aortic stenosis scheduled for TAo-TAVI with an Edwards SAPIEN XT or a SAPIEN 3 heart valve were consecutively enrolled at 22 centres across Europe between February 2013 and February 2015. Periprocedural, in-hospital and 30-day complication rates were assessed. RESULTS Of the 301 patients included, 126 (41.9%) received a SAPIEN 3 and 175 (58.1%) a SAPIEN XT. The SAPIEN 3 was associated with shorter procedure time (101 ± 35 vs 111 ± 40 min; P = 0.031) and a lower quantity of contrast agent used (87 ± 43 vs 112 ± 50 ml; P

Background HeartMate 3 is a left ventricular assist device, composed of a centrifugal pump. It can be applied as a myocardial recovery, a bridge to transplant, or a destination therapy, in the treatment of patients with left ventricular heart failure. Methods Herein we describe a technique applied against a giant aneurysmal dilatation, which combines a surgical device implantation and a left ventricular reconstruction using a double patch. Results The patch minimizes thrombotic risk thanks to its internal bovine pericardium layer, which is in contact with blood. Conclusions The outlined technique is relatively reproducible and safe in a selected group of patients, as it employs a high-quality device and enables the restoration of an appropriate ventricular geometry.

Objectives Presently, there is enthusiasm for the Enhanced Recovery After Surgery (ERAS) program. The literature clearly indicates this type of program could shorten hospital length of stay and improve patient outcome. However, most of the studies conducted have encompassed mainly colorectal and orthopedic surgeries. Thus, in an effort to provide more evidence to the literature, the authors prospectively investigated the feasibility and clinical effectiveness of a dedicated ERAS program for mini-invasive aortic valve replacements (MIAVRs). Design Observational before-and-after trial. Setting University hospital. Participants Consecutive patients scheduled for an MIAVR via a mini-sternotomy during 2 time periods—before (MIAVR group) and after implementation of an ERAS program (MIAVR-ERAS group). Interventions Patients in the dedicated MIAVR-ERAS group followed a dedicated pathway specifically designed for this procedure, which encompasses several evidence-based medicine elements for cardiac surgery. Measurements and Main Results Data on patient demographics, patient characteristics, compliance to the ERAS protocol, postoperative morphine consumption, postoperative pain scores, postoperative complications, hospital length of stay, and hospital readmission rate were collected and compared. Twenty-three patients were enrolled in each group. Patients enrolled in the new protocol had significantly lower postoperative pain scores (p = 0.03). The median hospital length of stay was 10 (9-13.5) and 7 (6.5-8) days in the traditional MIAVR group and in the MIAVR-ERAS group, respectively (p Conclusions An ERAS pathway planned for MIAVR seems feasible and was associated with a shorter length of hospital stay with trends toward both less opioid consumption and less postoperative complications.

Background: A high perioperative blood lactate level has been reported to be associated with poor outcomes after cardiac surgery. More than isolated peaks of lactate values, it should be more interesting to take into account changes in intraoperative blood lactate level (∆Lact). This large-scale retrospective study evaluated the relationship between ∆Lact and overall intensive care unit morbidity and 30-day all-cause mortality. Methods: Perioperative data from consecutive patients undergoing on-pump cardiac surgery between September 2010 and June 2016 were retrospectively analysed through our institutional database including clinical, transfusion and laboratory test results implemented prospectively by physicians. Blood lactate levels were initially measured after induction of anaesthesia (baseline) and periodically during the surgery. The ∆Lact was defined as the difference between the highest intraoperative blood lactate and the baseline lactate level and offered the opportunity to stratify patients into four subgroups: ⩽0, 0.1-0.9, 1-1.9 and ⩾2 mmol L−1. Results: From the 7,795 patients found eligible during the study period, 7,447 patients were analysed. The median ∆Lact of our patients was 0.6 (0.3-1) mmol L−1. Most of the studied patients (65.9%) exhibited a ∆Lact between 0.1 and 0.9 mmol L−1. A concentration-dependent relationship was observed between ∆Lact and intensive care unit morbidity and 30-day mortality. After adjustment for co-variables, all ∆Lact > 0 was associated with an increase in overall intensive care unit morbidity. An independent relationship was also found between ∆Lact and 30-day mortality as of a 1 mmol L−1 increase. Conclusion: Our results suggest that ∆Lact is associated with poor short-term outcomes in adult cardiac surgical patients.

To provide a model close to the human heart, and to study intrinsic cardiac function at the same time as electromechanical coupling, we developed a magnetic resonance (MR)-compatible setup of isolated working perfused pig hearts. Hearts from pigs (40 kg, n = 20) and sheep ( n = 1) were blood perfused ex vivo in the working mode with and without loaded right ventricle (RV), for 80 min. Cardiac function was assessed by measuring left intraventricular pressure and left ventricular (LV) ejection fraction (LVEF), aortic and mitral valve dynamics, and native T1 mapping with MR imaging (1.5 Tesla). Potential myocardial alterations were assessed at the end of ex vivo perfusion from late-Gadolinium enhancement T1 mapping. The ex vivo cardiac function was stable across the 80 min of perfusion. Aortic flow and LV-dP/d tmin were significantly higher ( P < 0.05) in hearts perfused with loaded RV, without differences for heart rate, maximal and minimal LV pressure, LV-dP/d tmax, LVEF, and kinetics of aortic and mitral valves. T1 mapping analysis showed a spatially homogeneous distribution over the LV. Simultaneous recording of hemodynamics, LVEF, and local cardiac electrophysiological signals were then successfully performed at baseline and during electrical pacing protocols without inducing alteration of MR images. Finally, 31P nuclear MR spectroscopy (9.4 T) was also performed in two pig hearts, showing phosphocreatine-to-ATP ratio in accordance with data previously reported in vivo. We demonstrate the feasibility to perfuse isolated pig hearts in the working mode, inside an MR environment, allowing simultaneous assessment of cardiac structure, mechanics, and electrophysiology, illustrating examples of potential applications.

The onset of right ventricular dysfunction in patients presenting with congenital heart disease is associated with a dismal long-term outcome and often represents a therapeutic dead end. Our study had several objectives: (1) to analyse the anatomical, functional, histological and cellular characteristics of an animal model of repaired tetralogy of Fallot with right ventricular dysfunction (2) to test the new electrical treatment known as cardiac contractility modulation in this animal model. Seven sheep underwent a first surgery at the age of three weeks aiming to mimic the characteristics of a repaired tetralogy of Fallot. Five controls were sham-operated. Experimental studies were performed 12 months after the initial operation. The hemodynamic, echocardiographic, and mitochondrial function studies were carried out before and after cardiac contractility modulation in closed- and open-chest conditions. In this animal model of right ventricular dysfunction, short-term cardiac contractility modulation was associated with a significant improvement in (a) right ventricular function, as evidenced by a significant increase in right ventricular dP/dt (p

OBJECTIVES There is lack of data regarding the longer-term outcomes of patients undergoing transaortic (TAo) transcatheter aortic valve implantation (TAVI). We aimed to provide a contemporary snapshot of the types and frequencies of events in the year following TAo-TAVI. METHODS The Registry of the Utilization of the TAo-TAVI approach using the Edwards SAPIEN Valve (ROUTE) is a multicentre, European, prospective, observational registry of aortic stenosis patients undergoing TAo-TAVI. Patients were grouped according to the composite end point death, myocardial infarction, stroke/transient ischaemic attack, major vascular complications, life-threatening bleeding, acute kidney injury (AKI) and/or cardiovascular rehospitalization. RESULTS Two hundred and fifty-three patients with a mean age of 81.5 ± 5.8 years were included, of whom 89 (35.2%) patients met the composite end point (the event group) and 164 (64.8%) patients did not (the event-free group). New York Heart Association (NYHA) class III/IV (85.2% vs 71.8%, P = 0.017), Canadian Cardiovascular Society angina class III/IV (22.6% vs 11.4%; P = 0.021), pulmonary disease (32.6% vs 18.9%; P = 0.015) and renal insufficiency (15.7% vs 3.0%; P

Postoperative pain after cardiac surgery, exacerbated by cough and sternal mobilization, limits clearance of bronchopulmonary secretions and may predispose to postoperative pneumonia. In this study, we tested the ability of local anesthetic continuous wound infusion to prevent pneumonia after cardiac surgery with sternotomy and cardiopulmonary bypass (CPB) owing to better analgesia and bronchopulmonary drainage. In this randomized, double-blind, placebo-controlled trial conducted in five academic centers, patients undergoing cardiac surgery with sternotomy and CPB were enrolled from February 2012 until November 2014, and were followed over 30 days. Patients were assigned to a 48-h infusion (10 ml h−1) of l-bupivacaine (12.5 mg h−1) or placebo (saline) via a pre-sternal multiperforated catheter. Anesthesia and analgesia protocols were standardized. The primary end point was the incidence of pneumonia during the study period, i.e., until hospital discharge or 30 days. We hypothesized a 30% reduction in the incidence of pneumonia. Among 1493 randomized patients, 1439 completed the trial. Pneumonia occurred in 36/746 patients (4.9%) in the l-bupivacaine group and in 42/739 patients (5.7%) in the placebo group (absolute risk difference taking into account center and baseline risk of postoperative pneumonia, − 1.3% [95% CI − 3.4; 0.8] P = 0.22). In the predefined subgroup of patients at high risk, l-bupivacaine decreased the incidence of pneumonia (absolute risk difference, − 5.6% [95% CI − 10.0; − 1.1], P = 0.01). After cardiac surgery with sternotomy, continuous wound infusion of l-bupivacaine failed to decrease the incidence of pneumonia. These findings do not support the use of local anesthetic continuous wound infusion in this indication. Further study should investigate its effect in high-risk patients. EudraCT Number: 2011-003292-10; Clinicaltrials.gov Identifier: NCT01648777.

Background: A large Dispersion of Repolarization (DoR) is associated with an increased arrhythmogenic risk. This can be measured clinically by calculating the Activation Recovery Interval (ARI) to estimate Action Potential Duration (APD). However, the ability of ARI to accurately predict APD dispersion in patients with repolarization abnormality has not been determined. Objective: Compare ARI calculated from patients with optical mapping of human hearts to establish the validity of ARI as a surrogate for APD. Methods: Optical mapping (OM) was performed on the left ventricles of 4 explanted human hearts. APD and repolarization times were measured endo- and epicardially on the anterior of the LV. Electroanatomic mapping was performed with CARTO over the entire endo- and epicardial surfaces of 3 patients. Activation and repolarization were calculated, dispersion of ARI was measured. Results: APD and ARI were consistent between mapping methods over most of the sub-regions studied. Epicardium ARI dispersion was consistently higher than that of the endocardium in both OM and CARTO datasets. Conclusion: APD distribution, and consequently DoR, agree between mapping methods. Measuring DoR by ARI accurately assesses the underlying repolarization abnormalities in patients.

Supplemental Digital Content is available in the text., Background: Sudden cardiac death because of ventricular fibrillation (VF) is commonly unexplained in younger victims. Detailed electrophysiological mapping in such patients has not been reported. Methods: We evaluated 24 patients (29±13 years) who survived idiopathic VF. First, we used multielectrode body surface recordings to identify the drivers maintaining VF. Then, we analyzed electrograms in the driver regions using endocardial and epicardial catheter mapping during sinus rhythm. Established electrogram criteria were used to identify the presence of structural alterations. Results: VF occurred spontaneously in 3 patients and was induced in 16, whereas VF was noninducible in 5. VF mapping demonstrated reentrant and focal activities (87% versus 13%, respectively) in all. The activities were dominant in one ventricle in 9 patients, whereas they had biventricular distribution in others. During sinus rhythm areas of abnormal electrograms were identified in 15/24 patients (62.5%) revealing localized structural alterations: in the right ventricle in 11, the left ventricle in 1, and both in 3. They covered a limited surface (13±6 cm2) representing 5±3% of the total surface and were recorded predominantly on the epicardium. Seventy-six percent of these areas were colocated with VF drivers (P

The authors report the first acute clinical experience of atrial fibrillation ablation with PEF-both epicardial box lesions during cardiac surgery, and catheter-based PV isolation.Standard energy sources rely on time-dependent conductive heating/cooling and ablate all tissue types indiscriminately. Pulsed electric field (PEF) energy ablates nonthermally by creating nanoscale pores in cell membranes. Potential advantages for atrial fibrillation ablation include: 1) cardiomyocytes have among the lowest sensitivity of any tissue to PEF-allowing tissue selectivity, thereby minimizing ablation of nontarget collateral tissue; 2) PEF is delivered rapidly over a few seconds; and 3) the absence of coagulative necrosis obviates the risk of pulmonary vein (PV) stenosis.PEF ablation was performed using a custom over-the-wire endocardial catheter for percutaneous transseptal PV isolation, and a linear catheter for encircling the PVs and posterior left atrium during concomitant cardiac surgery. Endocardial voltage maps were created pre- and post-ablation. Continuous and categorical data are summarized and presented as mean ± SD and frequencies.At 2 centers, 22 patients underwent ablation under general anesthesia: 15 endocardial and 7 epicardial. Catheter PV isolation was successful in all 57 PVs in 15 patients (100%) using 3.26 ± 0.5 lesions/PV: procedure time 67 ± 10.5 min, catheter time (PEF catheter entry to exit) 19 ± 2.5 min, total PEF energy delivery time 60 s/patient, and fluoroscopy time 12 ± 4.0 min. Surgical box lesions were successful in 6 of 7 patients (86%) using 2 lesions/patient. The catheter time for epicardial ablation was 50.7 ± 19.5 min. There were no complications.These data usher in a new era of tissue-specific, ultrarapid ablation of atrial fibrillation.