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Background The electro-hydraulically actuated Carmat total artificial heart (C-TAH) is designed to replace the heart in patients with end-stage heart failure, either as bridge to transplant or destination therapy. It provides pulsatile flow and contains bio-prosthetic blood contacting materials. A clinical feasibility study was conducted to evaluate the C-TAH safety and performance. Methods Hospitalized patients, at imminent risk of death from irreversible biventricular failure despite optimal medical management, and not eligible for transplant or eligible but on extracorporeal life support, were enrolled. The primary endpoint was 30-days survival. Results Four patients were implanted with the C-TAH, three as destination therapy (ages 76, 68, 74) and one as bridge to transplant (age 58). They had implant times of 74, 270, 254 and 20 days respectively. All patients were free from hemolysis, clinical neurologic events, clinical evidence of thrombus and device-related infections. Hemodynamic and physical recovery allowed two patients to be discharged home for a cumulative duration of 7 months. The anticoagulation management strategy comprised initial unfractionated heparin, from postoperative day 2, followed by low molecular weight heparin and aspirin. An increased D-dimer level was observed in all patients during months 1 to 4. Temporary suspension of heparin anticoagulation resulted in thrombocytopenia and increased fibrin monomer, reversed by resuming anticoagulation with heparin. Causes of death were device-related (2 cases), respiratory failure and multi-organ failure. Conclusions Preliminary clinical results with the C-TAH demonstrated good safety and performance profiles in patients suffering from biventricular failure, which need to be confirmed in a pivotal study. [ABSTRACT FROM AUTHOR]

Objectives To determine hemostasis perturbations, including von Willebrand factor (VWF) multimers, after implantation of a new bioprosthetic and pulsatile total artificial heart (TAH). Design Preclinical study Setting Single-center biosurgical research laboratory. Participants Female Charolais calves, 2-to-6 months old, weighing 102-to-122 kg. Interventions Surgical implantation of TAH through a mid-sternotomy approach. Measurements and Main Results Four of 12 calves had a support duration of several days (4, 4, 8, and 10 days), allowing for the exploration of early steps of hemostasis parameters, including prothrombin time; coagulation factor levels (II, V, VII+X, and fibrinogen); and platelet count. Multimeric analysis of VWF was performed to detect a potential loss of high-molecular weight (HMW) multimers, as previously described for continuous flow rotary blood pumps. Despite the absence of anticoagulant treatment administered in the postoperative phase, no signs of coagulation activation were detected. Indeed, after an immediate postsurgery decrease of prothrombin time, platelet count, and coagulation factor levels, most parameters returned to baseline values. HMW multimers of VWF remained stable either after initiation or during days of support. Conclusions Coagulation parameters and platelet count recovery in the postoperative phase of the Carmat TAH (Camat SA, Velizy Villacoublay Cedex, France) implantation in calves, in the absence of anticoagulant treatment and associated with the absence of decrease in HMW multimers of VWF, is in line with early hemocompatibility that is currently being validated in human clinical studies. [ABSTRACT FROM AUTHOR]

Whether Barlow disease (BD) and fibroelastic deficiency (FED), the main causes of mitral valve prolapse (MVP), should be considered 2 distinct diseases remains unknown. Mitral valves from patients who required surgery for severe mitral regurgitation due to degenerative nonsyndromic MVP were analyzed. Intraoperative diagnosis of BD or FED was based on leaflet redundancy and thickness, number of segments involved, and annular dimension. The removed medial scallop of the posterior leaflet and attached chordae were used for histopathological and immunohistological assessment. Histologically, compared to normal controls (n = 3), BD (n = 14), and FED (n = 9) leaflets demonstrated an altered architecture and increased thickness. Leaflet thickness was greater and chordae thickness lower in BD than FED (P < 0.0001). In BD, increased thickness was owing to spongiosa expansion (proteoglycan accumulation) and intimal thickening on fibrosa and atrialis; in FED, local thickening was predominant on the fibrosa side, with accumulation of proteoglycan-like material around the chordae. Collagen accumulation was observed in FED leaflets and chords and decreased in BD. Fragmented elastin fibers were present in BD and FED; elastin decreased in BD but increased in FED leaflets and around chordae. Activated myofibroblasts accumulate in both diseased leaflets and chords, but more abundantly in FED chordae (P < 0.0001), independently of age, suggesting a role of these cells in chordal rupture. There were more CD34-positive cells in BD leaflets and in FED chordae (P < 0.01). In BD leaflets (but not chordae) proliferative Ki67-positive cells were more abundant (P < 0.01) and matrix metalloproteinase 2 levels were increased (P < 0.01) indicating tissue remodeling. Upregulation of transforming growth factor beta and pERK signaling pathways was evident in both diseases but more prominent in FED leaflets (continued on next page)(P < 0.001), with pERK upregulation in FED chordae (P < 0.0001). Most cellular and signaling markers were negligible in control valves. Quantitative immunohistopathological analyses demonstrated distinct changes between BD and FED valves: predominant matrix degradation in BD and increased profibrotic signaling pathways in FED, indicating that BD and FED are 2 different entities. These results may pave the way for genetic studies of MVP and development of preventive drug therapies. [ABSTRACT FROM AUTHOR]

Objective Tricuspid valve repair has been recently advocated in patients undergoing mitral valve surgery who have mild to moderate secondary tricuspid regurgitation. However, the incidence of heart conduction disorders after combined mitral valve and tricuspid valve interventions has not been evaluated. We sought to analyze the incidence of permanent pacemaker implantations and heart conduction disorders in patients undergoing mitral valve surgery with and without tricuspid valve annuloplasty. Methods In 2011 and 2012, among 201 consecutive patients referred to the Hôpital Européen Georges Pompidou for isolated nonischemic mitral valve disease, 113 underwent an isolated mitral valve procedure (group 1) and 88 had a concomitant tricuspid valve ring annuloplasty (group 2). Results Patients' mean age was 59.7 ± 16.5 years in group 1 and 60.7 ± 14.9 years in group 2 ( P = .5). Mean crossclamp time and bypass time were 78 ± 35 minutes and 105 ± 47 minutes in group 1 and 92 ± 36 minutes and 128 ± 50 minutes in group 2, respectively ( P = .001 and .005, respectively). Operative mortality was 3% (2.7% in group 1 and 3.2% in group 2, P = .4). Incidence of high-grade heart conduction disorders lasting more than 3 days postoperatively was 14.5% in group 1 and 41.2% in group 2 ( P = .001). At 3 years, freedom from permanent pacemaker implantation was 99% ± 2% in group 1 and 94.1% ± 5% in group 2 ( P = .02). For the entire cohort, longer crossclamp time ( P = .02) and tricuspid ring annuloplasty (hazard ratio, 3.8; P = .001) were independent predictors of heart conduction disorders. Conclusions The need for permanent pacemaker implantation is increased after concomitant tricuspid ring annuloplasty in the setting of mitral valve surgery. A clinical period of observation up to 14 days after postoperative heart conduction disorders should be observed before recommending permanent pacemaker placement. [ABSTRACT FROM AUTHOR]

Background: Pneumonectomies for lung cancer are associated with a high postoperative mortality, especially when right-sided, after neoadjuvant radiochemotherapy, and in patients over 70 years of age. Preliminary studies in our laboratory have shown that aortic grafts could be valuable airway substitutes. We report the first human bronchial transplantation of a cryopreserved aortic allograft used as a biologic airway substitute to prevent a pneumonectomy for lung cancer. Methods: The procedure was performed in a high-risk 78-year old patient with an extensive right bronchopulmonary malignant tumor pretreated with chemotherapy. After a complete resection of the lung cancer using an upper bilobectomy with lymph node removal, mobilization procedures did not allow for a primary end-to-end bronchial anastomosis. A stent-supported cryopreserved aortic allograft from a certified tissue bank was interposed to restore the bronchial continuity with sparing of the lower lobe. Results: The postoperative course was eventful for a supraventricular arrhythmia leading to mild pulmonary edema that resolved using standard medical therapy, and a right lower lobe atelectasis with bacterial colonization that required fiberoptic bronchoscopies in addition to antibiotic treatment. A 1-year postoperative evaluation found a well-functioning reimplanted lower lobe with no complications related to the cryopreserved aortic allograft or the stent. The patient recovered to his baseline activity with a satisfying health-related quality of life. Conclusions: We demonstrate the feasibility of this surgical innovation to prevent the high-risk procedure of pneumonectomy in a single case. If confirmed in larger series of selected patients, it could bring new perspectives in conservative lung cancer surgery. [ABSTRACT FROM AUTHOR]

Objectives: Human subjects and Old World primates have high levels of antibody to galactose-α-1,3 galactose β-1,4-N-acetylglucosamine (α-Gal). Commercially available bioprosthetic heart valves of porcine and bovine origin retain the Gal antigen despite current processing techniques. Gal-deficient pigs eliminate this xenoantigen. This study tests whether binding of human anti-Gal antibody effects calcification of wild-type and Gal-deficient glutaraldehyde-fixed porcine pericardium by using a standard subcutaneous implant model. Methods: Expression of α-Gal was characterized by lectin Griffonia simplicifolia–IB4 staining. Glutaraldehyde-fixed pericardial disks from Gal-positive and Gal-deficient pigs were implanted into 12-day-old Wistar rats and 1.5-kg rabbits with and without prelabeling with affinity-purified human anti-Gal antibody. Calcification of the implants was determined after 3 weeks by using inductively coupled plasma spectroscopy. Results: The α-Gal antigen was detected in wild-type but not Gal-deficient porcine pericardium. Wild-type disks prelabeled with human anti-Gal antibody exhibited significantly greater calcification compared with that seen in antibody-free wild-type samples (mean ± standard error of the mean: 111 ± 8.4 and 74 ± 9.6 mg/g, respectively; P = .01). In the presence of anti-Gal antibody, a significantly greater level of calcification was detected in wild-type compared with GTKO porcine pericardium (111 ± 8.4 and 55 ± 11.8 mg/g, respectively; P = .005). Calcification of Gal-deficient pericardium was not affected by the presence of anti-Gal antibody (51 ± 9.1 and 55 ± 11.8 mg/g). Conclusions: In this model anti-Gal antibody accelerates calcification of wild-type but not Gal-deficient glutaraldehyde-fixed pericardium. This study suggests that preformed anti-Gal antibody present in all patients might contribute to calcification of currently used bioprosthetic heart valves. Gal-deficient pigs might become the preferred source for new, potentially calcium-resistant bioprosthetic heart valves. [Copyright &y& Elsevier]

Background: This study was designed to investigate the incidence of and early and midterm outcomes after major complications in cardiac surgery patients. We determined independent predictors of operative mortality to create a model for prediction of outcome. A particular focus was the fate of patients after the occurrence of these complications. Methods: Prospectively collected data of 6,641 patients (mean age, 64 ± 14 years; n = 2,499 female [38%]) undergoing cardiac surgery between January 1998 and December 2006 were retrospectively analyzed. Outcome measures were six index complications: respiratory failure, sepsis, dialysis-dependent renal failure, mediastinitis, gastrointestinal complication, and stroke; and their impact on operative mortality, hospital length of stay, and midterm survival using multivariate regression models. The discriminatory power was evaluated by calculating the area under the receiver operating characteristic curves (C statistic). Results: A total of 1,354 complications were observed in 826 (12.4%) patients: respiratory failure (n = 634; 9.5%), sepsis (n = 202; 3%), stroke (n = 163; 2.5%), dialysis-dependent renal failure (n = 145; 2.2%), mediastinitis (n = 111; 1.7%), and gastrointestinal complication (n = 99; 1.5%). Overall operative mortality was 20% and correlated with the number of complications (single, 12.0%; n = 58 of 485; double, 25.5%; n = 52 of 204; ≥3, 40.1%; n = 55 of 137). Ten preoperative and five postoperative predictors of operative mortality were identified and included in the logistic model, which accurately predicted outcome (C statistic, 0.866). One-year survival was less than 50% in patients with three or more complications and a length of stay greater than 60 days. Conclusions: With a worsening in the risk profile of patients undergoing cardiac surgery, an increasing number of patients develop major complications leading to increased length of stay and mortality, which is correlated to the number and severity of these complications. Our predictive model based on preoperative and postoperative variables allowed us to determine with accuracy the operative mortality in critically ill patients after cardiac surgery. One-year survival after multiple complications and prolonged length of stay remains marginal. [Copyright &y& Elsevier]

Background: Pneumonectomy is well known for a high risk of postoperative death. The alternative, sleeve lobectomy, is sometimes technically inaccessible, and is associated with locoregional recurrence. In certain situations, the use of a bronchial substitute would allow longer bronchial resections with better security margins. Previous experiments demonstrated that aortic grafts are valuable tracheal and carinal substitutes. The present study evaluated bronchial replacement with arterial allografts. Methods: Fifteen female sheep underwent a left bilobectomy with replacement of the bronchus intermedius with arterial allografts: 5 received a fresh graft (group 1) and 10 received cryopreserved (group 2). A bronchial silicone stent was used to confer rigidity. Evaluation was conducted on clinical and histologic criteria at regular intervals up to 18 months. Results: There were no perioperative deaths. Atelectasis, the only early postoperative complication (n = 2), was successfully treated by fiberscopic aspiration. The late postoperative period was uneventful in 12 sheep. Complications included 1 bronchopneumonia, 1 pulmonary abscess, and 1 distortion of the bronchial stent. Fiberscopic examination revealed 3 sheep with granuloma formation. The bronchial stent was removed in 3 sheep, 1 at 9 months and 2 at 12 months, without clinical complications or stenosis of the graft. Histologic analysis showed regeneration of new bronchial tissue, comprising epithelium and cartilage. Conclusions: This study confirmed that an arterial allograft could be a valuable bronchial substitute. The use of a bronchial substitute offers new perspectives in surgical resection of lung cancer because it would avoid pneumonectomy in some patients. [Copyright &y& Elsevier]

Objectives: The aim of this study was to investigate the incidence and predictors of deep sternal wound infection (DSWI) in a contemporary cohort of patients undergoing cardiac surgery. The early and late outcomes of patients with this complication also were analyzed. Design: A retrospective study of consecutive patients undergoing cardiac surgery using a computerized database based on the New York State Department of Health registry. Data collection was performed prospectively. Setting: A university hospital (single institution). Participants: Five thousand seven hundred ninety-eight patients who underwent cardiac surgery between January 1998 and December 2005 including isolated coronary artery bypass graft (CABG) (n = 2,749, 47%), single- or multiple-valve surgery (n = 1,280, 22%), combined valve and CABG procedures (n = 934, 16%), and surgery involving the ascending aorta or the aortic arch (n = 835, 15%). Interventions: None. Measurements and Main Results: The overall incidence of DSWI was 1.8% (n = 106). The highest rate of DSWI occurred after combined valve/CABG surgery (2.4%, n = 22) and aortic procedures (2.4%, n = 19). Multivariate analysis revealed 11 predictors of DSWI: obesity (odds ratio [OR] = 2.2), previous myocardial infarction (OR = 2.1), diabetes (OR = 1.7), chronic obstructive pulmonary disease (OR = 2.3), preoperative length of stay >3 days (OR = 1.9), aortic calcification (OR = 2.7), aortic surgery (OR = 2.4), combined valve/CABG procedures (OR = 1.9), cardiopulmonary bypass time (OR = 1.8), re-exploration for bleeding (OR = 6.3), and respiratory failure (OR = 3.2). The mortality rate was 14.2% (n = 15) versus 3.6% (n = 205) in the control group (p < 0.001). One- and 5-year survival after DSWI were significantly decreased (72.4% ± 4.4% and 55.8% ± 5.6% v 93.8% ± 0.3% and 82.0% ± 0.6%, p < 0.001). Conclusion: DSWI remains a rare but devastating complication and is associated with significant comorbidity, increased hospital mortality, and reduced long-term survival. [Copyright &y& Elsevier]

Background: Seven years of experimental research provided a valuable tracheal substitute, the aortic allograft, which can promote the regeneration of epithelium and cartilage. In human application, both fresh and preserved aortic allografts could be used. The optimal method of aortic allograft preservation remains to be evaluated. This study assessed the use of cryopreserved, decellularized, or glutaraldehyde-treated aortic allografts as tracheal substitutes. Methods: Twenty-two sheep underwent tracheal replacement using cryopreserved (n = 10), decellularized (n = 7) or glutaraldehyde-treated (n = 5) allografts, supported by a temporary stent to prevent airway collapse. Aortic segments were retrieved at regular intervals up to 12 months after implantation to analyze the regenerative process. Results: All animals survived the operation. Major complications such as infection, stent migration, or obstruction were predominantly encountered in the decellularized group. The lack of major inflammatory response within the aortic graft observed in the glutaraldehyde group was associated with the absence of tracheal regeneration. Histologic examinations showed a progressive transformation of the aorta into a tracheal tissue comprising respiratory epithelium and cartilage only in the cryopreserved group. Conclusions: This study demonstrated that regeneration of a functional tissue could be obtained after tracheal replacement with a cryopreserved aortic allograft. The regenerative process followed the same pattern as previously described for fresh allografts. Cryopreserved aortic allografts present major advantages: availability in tissue banks, permanent storage, and no need for immunosuppression. This offers a new field of perspectives for clinical application in patients with extensive tracheal cancer. [Copyright &y& Elsevier]

Background: The purpose of this study was to report our 19-year experience in redo surgery for failure of mitral valve repair (MVRep) in degenerative disease. Methods: From 1987 to 2006, 43 consecutive patients (32 males) underwent either redo MVRep (n = 21) or redo mitral valve replacement (n = 22) for failure of MVRep. Age ranged from 10 to 78 years (median, 59 years). Forty-one patients (95%) had grade 3+ or greater mitral regurgitation, and 3 patients had chronic systolic anterior motion of the anterior leaflet of the mitral valve. Repair was mainly performed using Carpentier''s techniques. Results: There was no perioperative death in the MVRep group and 2 deaths in the redo mitral valve replacement group. In univariate analysis, long-term survival was significantly superior in the MVRep group compared with redo mitral valve replacement (p = 0.011). There were three reoperations (14%) in the MVRep group for recurrent severe mitral regurgitation. One patient (5%) in the redo mitral valve replacement group underwent reoperation for prosthetic endocarditis. The 7-year freedom from reoperation rate was 95% (95% confidence interval, 84% to 99%) in both groups. At the latest follow-up, 16 (94%) patients in the MVRep group were in New York Heart Association I or II functional status. Fifteen (88%) had no or mild mitral regurgitation on echocardiography. Two patients (12%) presented with moderate (2+) mitral regurgitation. Conclusions: In case of failure of MVRep for severe degenerative mitral valve disease, re-repair is feasible in about 50% of the patients with encouraging results at 7 years. [Copyright &y& Elsevier]

Copyright of Archives of Cardiovascular Diseases is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Archives of Cardiovascular Diseases is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objectives: The aim of the study was to investigate the incidence and predictors of renal failure requiring dialysis (RF-D) in a contemporary cohort of patients undergoing cardiac surgery. The authors also analyzed early and late outcome of patients with this complication. Design: A retrospective study of consecutive patients undergoing cardiac surgery using a computerized database based on the New York State Department of Health registry. Data collection was performed prospectively. Setting: A university hospital (single institution). Participants: Six thousand four hundred forty-nine patients who underwent cardiac surgery between January 1998 and December 2006 including isolated coronary artery bypass graft (CABG) surgery (n = 2,819, 44%), single- or multiple-valve surgery (n = 1,378, 21%), combined valve and CABG procedures (n = 1,032, 16%), and surgery involving the ascending aorta or the aortic arch (n = 1,220, 19%). Interventions: None. Measurements and Main Results: The incidence of RF-D was 2.2% (n = 139). The incidence per type of procedure was as follows: CABG surgery (0.8%), valve/CABG surgery (2.7%), valve surgery (2.9%), and aortic surgery (4%) (p = 0.001). Multivariate analysis revealed preoperative renal dysfunction (odds ratio [OR] = 5.5), hemodynamic instability (OR = 5.2), diabetes (OR = 2.6), aortic surgery (OR = 2.2), congestive heart failure (CHF) (OR = 2.1), peripheral vascular disease (PVD) (OR = 1.9), and reoperation (OR = 1.8) as independent predictors of RF-D. The hospital mortality after RF-D was 36.7% (n = 51) compared with 2.9% (n = 180) in the control group (p < 0.001). Long-term survival after RF-D was significantly decreased (1-year and 5-year survival 48.5% ± 6.1% and 28.7% ± 7.2% v 94.5% ± 0.3% and 83.5% ± 0.6% in the control group, p < 0.001). Hypertension, CHF, and PVD were independent predictors of late mortality. Conclusion: The authors observed an increase in the overall incidence of RF-D compared with previous studies, probably related to an increased prevalence of patients undergoing more complex procedures with a worsening risk profile. Postoperative RF-D was not only associated with increased hospital mortality and morbidity, but also with a significant reduction of long-term survival in discharged patients. Seven independent predictors of RF-D were identified. Future research efforts should focus on a more precise identification of patients at risk and the development of new treatment modalities, which would potentially prevent the occurrence of this complication. [Copyright &y& Elsevier]

Background: Cell transplantation for the regeneration of ischemic myocardium is limited by poor graft viability and low cell retention. In ischemic cardiomyopathy, the extracellular matrix is deeply altered; therefore, it could be important to associate a procedure aiming at regenerating myocardial cells and restoring the extracellular matrix function. We evaluated the feasibility and safety of intrainfarct cell therapy associated with a cell-seeded collagen scaffold grafted onto infarcted ventricles. Methods: In 20 consecutive patients presenting with left ventricular postischemic myocardial scars and indication for coronary artery bypass graft surgery, bone marrow cells were implanted during surgery. In the last 10 patients, we added a collagen matrix seeded with bone marrow cells, placed onto the scar. Results: There was no mortality and any related adverse events (follow-up 10 ± 3.5 months). New York Heart Association functional class improved in both groups from 2.3 ± 0.5 to 1.3 ± 0.5 (matrix, p = 0.0002) versus 2.4 ± 0.5 to 1.5 ± 0.5 (no matrix, p = 0.001). Left ventricular end-diastolic volume evolved from 142.4 ± 24.5 mL to 112.9 ± 27.3 mL (matrix, p = 0.02) versus 138.9 ± 36.1 mL to 148.7 ± 41 mL (no matrix, p = 0.57), left ventricular filling deceleration time improved significantly in the matrix group from 162 ± 7 ms to 198 ± 9 ms (p = 0.01) versus the no-matrix group (from 159 ± 5 ms to 167 ± 8 ms, p = 0.07). Scar area thickness progressed from 6 ± 1.4 to 9 mm ± 1.1 mm (matrix, p = 0.005) versus 5 ± 1.5 mm to 6 ± 0.8 mm (no matrix, p = 0.09). Ejection fraction improved in both groups, from 25.3% ± 7.3% to 32% ± 5.4% (matrix, p = 0.03) versus 27.2% ± 6.9% to 34.6% ± 7.3% (no matrix, p = 0.031). Conclusions: This tissue-engineered approach is feasible and safe and appears to improve the efficiency of cellular cardiomyoplasty. The cell-seeded collagen matrix increases the thickness of the infarct scar with viable tissue and helps to normalize cardiac wall stress in injured regions, thus limiting ventricular remodeling and improving diastolic function. [Copyright &y& Elsevier]

Copyright of Revista Española de Cardiología (18855857) is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Degenerative mitral valve disease is the most common cause of mitral regurgitation (MR) in developed countries. The most common etiologies of valvular regurgitation are Barlow’s disease and fibroelastic deficiency. The mechanism of MR is type II dysfunction (leaflet prolapse) due to chordae elongation or rupture in most patients. Associated annular dilation is a common lesion in almost all patients with chronic MR. By means of segmental valve analysis, isolated posterior leaflet prolapse (P2 segment) is often observed in patients with fibroelastic deficiency, whereas the prolapse of multiple segments or bileaflet prolapse is typically seen in patients with Barlow’s disease. In patients with degenerative mitral valve disease and severe MR, reconstructive surgery should be performed before the occurrence of clinical symptoms, atrial fibrillation, pulmonary hypertension, and left ventricular dysfunction or enlargement. The goals of reconstructive surgery are preservation or restoration of normal leaflet motion, creation of a large surface of coaptation, and stabilization of the entire annulus with a remodeling annuloplasty. Today, reconstructive techniques are standardized, reliable, and reproducible, and therefore should be applied systematically to all patients with degenerative valvular disease. [Copyright &y& Elsevier]

Background: Carinal replacement after extensive resection remains a tremendous challenge in thoracic surgery. In previous studies, we demonstrated that an aortic graft could be a valuable tracheal substitute. The goal of this new study was to evaluate the reconstruction of the carina using a stent supported bifurcated aortic allograft. Methods: In 15 sheep the replacement of the tracheobronchial bifurcation with an aortic allograft was performed under cardiopulmonary bypass. A temporary stent prevented airway collapse. No immunosuppression was used. Aortic segments were retrieved at regular intervals up to 24 months after implantation. Results: All animals survived the initial aortic allograft operation. Six animals died postoperatively (1 of graft necrosis, 2 of pneumonia, and 3 of bronchial fistula). The remaining 9 animals were in good condition until they were euthanized. Stent removal was tolerated after 9 months in 3 animals. Progressive transformation of the arterial graft initially into extensive inflammatory tissue, and after 3 to 6 months into a tracheal tissue comprising a well-differentiated epithelium and cartilage was confirmed by histology. Conclusions: This study showed that regeneration of a functional tissue can be obtained after replacement of the carina with an aortic allograft. The origin and mechanisms of this regenerative process remains to be discovered. These results represent an important hope for the reconstruction of the carina after extensive resection, especially for cancer lesions. In human application, the systemic use of omentoplasty or myoplasty should further reduce its risk of complication. [Copyright &y& Elsevier]

Background: Nesiritide is a recombinant brain-type natriuretic peptide (BNP), which decreases pulmonary arterial (PA) pressures and myocardial oxygen consumption while increasing coronary flow and urine output. Mitral valve (MV) surgery in patients with severe mitral regurgitation (MR), impaired left ventricular function, and pulmonary hypertension is associated with a high operative mortality. We hypothesized that the perioperative use of Nesiritide is safe, and may improve surgical outcomes. Methods: From May 2003 to August 2004, 14 patients (11 male, 3 female; mean age, 64 years [23–87 years]; mean systolic PA, 63 mm Hg [48–94 mm Hg]; mean ejection fraction, 36% [10–50%]), undergoing MV surgery (10 repairs, 2 replacements, and 2 rereplacements) for severe MR, were treated for a median of 24 hours (13–55 hours) preoperatively with intravenous Nesiritide. Expected mortality by EuroSCORE was 26% (7.8–59%) (5 reoperations). Concomitant procedures included tricuspid valve repair (n = 7), coronary artery bypass grafting (n = 5), and left atrial maze procedure (n = 3). Eleven patients received Nesiritide postoperatively during a mean duration of 22 hours (2–80 hours). Results: Operative mortality was 0%. Prior to surgery after BNP treatment, mean systolic PA pressure dropped to 39 mm Hg (p = 0.0003), pulmonary capillary wedge pressure to 15 mm Hg (p = 0.001), central venous pressure to 6 mm Hg (p = 0.002), and weight by 3.7 kg (p = 0.006). Postoperative median ventilation time was 14 hours (4–48 hours). All other major hemodynamic parameters (systemic blood pressure, heart rate, and cardiac output) remained constant. The treatment was well-tolerated in all patients. Conclusions: Perioperative use of Nesiritide is safe, and may contribute to improved early outcomes in high-risk patients undergoing MV surgery. This may be due to improved ventricular loading conditions (decreased PA pressures, more effective diuresis) and/or a direct myocardial effect of BNP. Further prospective evaluation of the role of BNP in cardiac surgery is warranted. [Copyright &y& Elsevier]

Background: Tracheal replacement remains an unsolved surgical problem. Attempts to use tracheal substitutes have failed to achieve reliable results. In this study, tracheal regeneration was obtained after tracheal replacement with an allogenic aorta. Methods: Twenty female sheep underwent a 8-cm tracheal replacement with a fresh aortic allograft. In the six last animals, aortic grafts came from male sheep. A stent prevented airway collapse. No immunosuppressive therapy was used. Aortic segments were retrieved at regular intervals up to 16 months. A polymerase chain reaction for the SRY gene was performed in specimens with aortic grafts from male sheep. Results: All animals but one survived the operation without complications. Clearly identified between the suture lines, the aortic segments were completely transformed into a tracheal structure. Histology showed initially an inflammatory reaction with proliferation of a squamous epithelium followed by mucociliary epithelium and newly formed cartilage rings. SRY gene was not found in newly formed cartilage rings showing that the regeneration originated from recipient cells. Conclusions: This study presents a new type of tissue regeneration and brings hopes to the treatment of extensive tracheal lesions. [Copyright &y& Elsevier]

Myocardial regeneration can be induced with the implantation of a variety of myogenic and angiogenic cell types. More than 150 patients have been treated with cellular cardiomyoplasty worldwide, 18 patients have been treated by our group. Cellular cardiomyoplasty seems to reduce the size and fibrosis of infarct scars, limit postischemic remodelling, and restore regional myocardial contractility. Techniques for skeletal myoblasts culture and ex vivo expansion using autologous patient serum (obtained from plasmapheresis) have been developed by our group. In this article we propose (1) a total autologous cell culture technique and procedures for cell delivery and (2) a clinical trial with appropriate endpoints structured to determine the efficacy of cellular cardiomyoplasty. [Copyright &y& Elsevier]

: BackgroundTracheal reconstruction after extensive resection remains a challenge in thoracic surgery. The goal of this experimental study was to analyze the long-term evolution of tracheal replacement using an autologous aortic graft.: MethodsIn 21 sheep, a 5-cm segment of the cervical trachea was replaced by a segment of the descending thoracic aorta that was reconstructed to a prosthetic graft. Because of the airway collapse reported in a previous series, a permanent (n = 13) or temporary (n = 8) stent was systematically placed in the lumen of the graft. Clinical, bronchoscopic, and histologic examinations were performed up to 3 years after implantation.: ResultsAll animals survived the operation with no paraplegia. In the group with a permanent stent, three complications occurred: one stent displacement, one laryngeal edema, and one infection. Stent removal was tolerated after 6 months in the group with a temporary stent. Histologic examination showed a progressive transformation of the arterial segment into first extensive inflammatory tissue with a squamous epithelium, and after 6 to 36 months well-differentiated tracheal tissue including a continuous mucociliary epithelium and regular rings of newly formed cartilage.: ConclusionsAn autologous aortic graft used as a substitute for extensive tracheal replacement in sheep remained functional for periods up to 3 years. The progressive transformation of the graft into a structure resembling tracheal tissue seems to be a key factor in long-term patency. The mechanism of this regenerative process and the possibility of using arterial homografts, which would make clinical application easier, remain to be evaluated. [Copyright &y& Elsevier]

: BackgroundChronically depressed right ventricular (RV) function presents an unsolved therapeutic challenge in cardiac surgery. Despite recent advances in medical and surgical therapies, prognosis remains poor and patient’s quality of life and mortality are frequently unacceptable. The aim of this study is to present the first clinical report and long-term results of RV dynamic cardiomyoplasty applied in patients with RV failure caused by isolated RV cardiomyopathies.: MethodsSeven consecutive patients (5 males, 2 females; mean age, 40 ± 9 years; range, 15 to 63 years) from a series of 113 cardiomyoplasty procedures performed at Broussais and Pompidou Hospitals were evaluated. The mean duration of follow-up was 10 ± 3.5 years. All patients had predominant RV dysfunction, associated with tricuspid regurgitation in 6 patients. The cause of RV failure was arrhythmogenic cardiomyopathy (4 patients), ischemic (2 patients), and Uhl’s disease (1 patient), and endomyocardial fibrosis (1 patient). Six patients were in preoperative New York Heart Association functional class III and 1 was in intermittent class III/IV. The mean preoperative ejection fraction (measured by isotopic technique) was 18% ± 5.7% for the right ventricle and 40% ± 13% for the left ventricle. Right ventricular dynamic cardiomyoplasty consists of wrapping the RV free walls with the left latissimus dorsi muscle flap. The distal part of the latissimus dorsi muscle is fixed to the diaphragm and then electrostimulated. Six patients required associated tricuspid valve surgery.: ResultsThere were no perioperative deaths. The mean duration of follow-up was 10 ± 3.5 years. Six patients are alive with a remarkable quality of life, 4 are in New York Heart Association functional class I and 2 are in class II. One patient who was in New York Heart Association functional class II died in postoperative year 7 caused by stroke. At last follow-up, mean RV ejection fraction was 33% ± 11.8% and left ventricular ejection fraction was 52% ± 12.6%.: ConclusionsThe results of this long-term study demonstrate hemodynamic and functional improvements after RV cardiomyoplasty without perioperative mortality, no long-term malignant arrhythmias, and RV dysfunction related deaths. We believe that RV cardiomyoplasty, associated with tricuspid valve surgery when required, could be an effective treatment for severe RV failure. [Copyright &y& Elsevier]

Abstract: This paper presents STARS (Simulation and Transfer Architecture for Robotic Surgery), a versatile system that aims at enhancing minimally invasive robotic surgery through patient-dependent optimized planning, realistic simulation, safe supervision, and augmented reality. The underlying architecture of the proposed approach is presented, then each component is detailed. An experimental validation is conducted on a dog for a coronary bypass intervention using the Da VinciTM surgical system focusing on planing, registration, and augmented reality trials. © 2003 Elsevier Inc. All rights reserved. [Copyright &y& Elsevier]

: BackgroundDynamic cardiomyoplasty consists of wrapping the electrostimulated latissimus dorsi muscle (LDM) around the failed heart. Partial ischemia followed by atrophy of the middle and distal part of the LDM were observed in 30% of clinical cases after LDM flap elevation from its origin. In the current study, we hypothesized that local administration of growth factors at the LDM/epicardial interface could improve muscle vascularization and trophicity.: MethodsIn 24 sheep, dynamic cardiomyoplasty was performed using the left LDM. A multiperforated catheter was positioned at the LDM/epicardial interface for a weekly administration, during a 1-month period, of the following factors: basic fibroblast growth factor (bFGF, n = 6), vascular endothelial growth factor (VEGF, n = 6), and regenerating agent (RGTA, n = 6). Six sheep injected with phosphate-buffered saline (used for dilution of the growth factors) were used as a control group. At 3 months, angiographic, histologic, and histomorphometric studies were performed.: ResultsAngiographic studies of the animals treated with growth factors demonstrated hypervascularization due to the development of new vessels. Histomorphometric and histologic studies showed a significant increase in the number of capillaries and arterioles (100 fields/muscle) in the groups treated with bFGF (443.0 ± 101.2, p < 0.01), RGTA (293.2 ± 29.3, p < 0.05), and VEGF (246.5 ± 45.9, p < 0.05), as compared with the control group (81.5 ± 11.4). A significantly lower atrophy score was observed in the groups treated with bFGF (1.4 ± 0.18, p < 0.05), RGTA (1.59 ± 0.17, p < 0.05), and VEGF (1.96 ± 0.14, NS), as compared with the control group (2.48 ± 0.16).: ConclusionsLocal administration at the heart/muscle interface of growth factors increases muscle vascularization and avoids muscle atrophy in an experimental cardiomyoplasty model, both of which are advantageous to the contracting LDM. The local growth factors delivery system used in this study appears efficient, easy to implant, and manipulate and safe. [Copyright &y& Elsevier]

Background. The surgical management of rheumatic aortic insufficiency in the young remains problematic owing to the drawbacks of prosthetic valve replacement at this age. In young foreign patients, for whom long-term anticoagulation therapy is unavailable, we have used a glutaraldehyde preserved autologous pericardium cusp extension technique to repair rheumatic aortic valve insufficiencies resulting from cusp retractions.Methods. From September 1992 to December 2000, 89 consecutive patients with a mean age of 16 ± 5 years underwent triple pericardial aortic cusp extension valvuloplasty. Eighty patients had pure aortic insufficiency, 9 had mixed aortic disease. Twenty-nine patients (33%) had isolated aortic valve disease and 60 patients (69%) had combined aortic and mitral valve disease with significant tricuspid valve disease in 21 (24%). Aortic repair consisted of free edge aortic cusp extension using three rectangular strips of glutaraldehyde stabilized autolologous pericardium. Twenty-nine patients (33%) underwent an isolated aortic repair, 39 patients (44%) underwent combined aortic and mitral procedures (34 mitral repairs, 3 mitral homografts, and 2 prothesis replacements), and 21 patients (23%) underwent a triple valve repair.Results. The hospital mortality was 2.2%. Primary failure of the aortic repair requiring immediate reoperation occurred in 2 patients. During follow-up (mean of 62 ± 22 months) 1 patient died and 7 underwent redo valvular surgery. At 5 years the actuarial survival rate was 96.4%, and 92.1% of the patients were free from redo valvular surgery. At 7 years 90% of the patients were free from valve-related complications. Among the 76 patients free from redo valvular surgery at follow-up, 6 had deterioration of the repair resulting in grade II aortic and mitral insufficiencies.Conclusions. Our midterm results of glutaraldehyde stabilized autologous pericardial aortic cusp extension are encouraging and suggest that this technique should be considered as a viable alternative palliative procedure in a young rheumatic population, allowing for growth of the annulus and delaying to a less critical period the need for the lifelong anticoagulation therapy required for a prosthetic mechanical valve. [Copyright &y& Elsevier]

Background. Seven patients with acute tricuspid endocarditis underwent partial replacement of the tricuspid valve using mitral homograft tissue. Valve function was evaluated at midterm.Methods. Operative indications were uncontrolled sepsis in all cases associated with heart failure symptoms in 3 patients and septic pulmonary emboli in 2 patients. These patients were referred to our institution after a course of antibiotic treatment ranging from 7 to 12 weeks. Lesions found at the level of the anterior leaflet of the tricuspid valve were vegetations and rupture of more than half of the marginal cords in all patients. Vegetations were also found on the posterior leaflet in 5 patients. In all instances the septal leaflet was free of lesions. The aortic valve was involved in 4 patients and the pulmonary valve in 1 patient. All patients underwent resection of the anterior and posterior leaflets of the tricuspid valve with their corresponding papillary muscles leaving the septal leaflet in place. Replacement of the tricuspid valve was performed through a right longitudinal atrial access, using the anterior leaflet of a mitral homograft alone in 3 patients and the anterior leaflet with part of posterior leaflet in 4 patients. Associated procedures included aortic valve replacement by a homograft (n = 4) and pulmonary valve reconstruction (n = 1).Results. No hospital deaths are reported. One late death, at 16 months, is reported after reoperation due to recurrent aortic valve endocarditis. At midterm (mean follow-up, 30 months) patients had excellent functional status and normal valvular function during echocardiographic studies.Conclusions. We conclude that when the degree of tricuspid valve destruction prevents repair, partial homograft replacement can be used as an extension of the already existing reconstructive techniques, with excellent functional results. [Copyright &y& Elsevier]

Tricuspid valve surgery in the presence of severe right ventricular dysfunction and pulmonary hypertension secondary to mitral valve stenosis is associated with poor early outcomes. We report the case of a young patient, presenting with severe chronic mitral-tricuspid disease responsible for long-lasting pulmonary hypertension and altered right ventricular function, who initially underwent mitral valve replacement and 7 days later the correction of her tricuspid insufficiency. This 2-staged approach permitted progressive reduction of pulmonary pressure and partial right ventricular remodeling before closing the systolic release valve of the right ventricle represented by tricuspid regurgitation. [Copyright &y& Elsevier]

Objectives: Recent advances in airway transplantation have shown the ability of ex vivo or in vivo tracheal regeneration with bioengineered conduits or biological substitutes, respectively. Previously, we established a process of in vivo–guided tracheal regeneration using vascular allografts as a biological scaffold. We theorized that tracheal healing was the consequence of a mixed phenomenon associating tracheal contraction and regeneration. The aim of the present study was to determine the role that bone marrow stem cells play in that regenerative process. Methods: Three groups of 12 rabbits underwent a gender-mismatched aortic graft transplantation after tracheal resection. The first group received no cells (control group), the second group had previously received autologous green fluorescent protein–labeled mesenchymal stem cell transplantation, and the third group received 3 labeled mesenchymal stem cell injections on postoperative days 0, 10, and 21. Results: The clinical results were impaired by stent complications (obstruction or migration), but no anastomotic leakage, dehiscence, or stenosis was observed. The rabbits were killed, and the trachea was excised for analysis at 1 to 18 months after tracheal replacement. In all 3 groups, microscopic examination showed an integrated aortic graft lined by metaplastic epithelium. By 12 months, immature cartilage was detected among disorganized elastic fibers. Positive SRY gene detection served as evidence for engraftment of cells derived from the male recipient. EF-green fluorescent protein detection showed bone marrow–derived mesenchymal stem cell involvement. Conclusions: The results of the present study imply a role for bone marrow stem cells in tracheal regeneration after aortic allografting. Studies are necessary to identify the local and systemic factors stimulating that regenerative process. [Copyright &y& Elsevier]

Objective: Owing to the complexity of the underlying lesions, Barlow disease remains a challenge for surgeons performing mitral valve repair. We aimed to assess whether our most recent results involving several surgeons were comparable with those of a previous experience in which mitral valve repair was performed by a more limited group of surgeons. Methods: From September 2000 to January 2007, 200 patients with Barlow disease (135 men and 65 women; mean age, 56 ± 13 years) were referred to our institution for surgical treatment of their mitral regurgitation. We retrospectively analysed the mitral lesions characteristics, the surgical techniques used, and clinical outcomes. Follow-up echocardiograms were biannually reviewed. Results: Lesions comprised annular dilatation, excess tissue, and leaflet prolapse in all cases. The most frequent prolapsed segments were P2 (88.5%; n = 177) and A2 (55.5%; n = 111). Annular calcifications and restrictive valvular motion were associated in 20% (n = 40). Repair was feasible in 94.7% (n = 179/189) of non-redo interventions. Immediate postoperative echocardiography showed residual mitral regurgitation greater than 1+ in 6 cases; these patients were all reoperated on within the next months. Operative mortality was 1.5% (n = 3). Mean follow-up was 77.5 ± 25.6 months. At 8 years postoperatively, overall survival was 88.6% ± 3.1%, freedom from reintervention was 95.3% ± 1.7%, and freedom from late recurrent moderate mitral regurgitation (>2+) was 90.2% ± 3.1% Conclusions: Provided that the fundamental principles of mitral valve reconstruction are respected, the surgical techniques are highly reproducible with good long-term results, similar to those published during the pioneering phase of this surgery. [ABSTRACT FROM AUTHOR]

Background: In ischemic mitral regurgitation (IMR), leaflet tethering is caused by post-MI LV and annular remodeling. Severing second-order mitral chordae significantly decreases tethering and MR. We tested whether undersized ring annuloplasty can improve chordal cutting efficacy by reducing annulus-related tethering. Methods: Posterolateral MI created chronic remodeling and MR in 28 sheep. At 3 months, sheep were randomized to sham surgery vs isolated annuloplasty undersized by 2 sizes vs isolated bileaflet chordal cutting vs at the combined therapy (n=7 each). At baseline, chronic MI (3 months) and sacrifice (6.6 months) we measured LV volumes and ejection fraction (EF), wall motion score index (WMSi), MR Regurgitation fraction (MRRF) and vena contracta (VC), Mitral annulus area (MAA) and posterior leaflet (PL) restriction angle (PL to MAA) by 2D and 3D echo. Results: All groups were comparable at baseline and chronic MI, with mild- moderate MR (MRVC 4.6±1.0mm, MRRF 24±2.6%) and MA dilatation (p<0.01). At sacrifice, LV end-systolic volume (ESV) increased by 108% in controls vs 28% with ring + chordal cutting, less than with each intervention alone (p<0.01). Also, MR progressed to moderate-severe in controls but decreased to trace with ring + chordal cutting vs mild-moderate with ring alone and trace-mild with chordal cutting alone (MRVC 5.9±1.1mm in controls, 2.0±0.7 with ring, 1.0±0.9 with chordal cutting, 0.5±0.08 with both, p<0.01). Ring alone did not improve PL mobility, but chordal cutting did alone or with ring (PL restriction angle 54±5° vs. 45±2.3° with ring, p=NS). In multivariate analysis, LVESV and MAA most strongly predicted MR (r2=0.82, p<0.01). Conclusions: Comprehensive annular and subvalvular repair provides the most effective long-term reduction of both chronic ischemic MR and LV remodeling. [Copyright &y& Elsevier]