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Summary Background Optimal treatment of type B dissections is open to debate. The use of endoprostheses is an option that requires evaluation. Aim To report our experience with endoprostheses in type B aortic dissections. Methods We report our short- and medium-term results with covered prostheses for the treatment of acute (n = 7) and chronic (n = 28) type B aortic dissections. The criteria used to indicate treatment were the same as those usually used for surgery: acute complications or dilated aneurysm. Cover of the main intimal tear was obtained in all cases with an improvement in symptoms in patients with acute dissections. Results Early mortality was 14.3% (five patients), linked in three cases to the occurrence of a retrograde dissection of the ascending aorta. No neurological complications were observed. Four patients required an additional endovascular and/or surgical procedure. On early control scans, complete thrombosis of the false lumen at the thoracic level was observed in 40% of cases, partial thrombosis in 42.8% and an absence of thrombosis in 11.4%. After a mean follow-up of 20.8 months, one patient died of a pneumopathy. No secondary aneurysm expansion was noted at the thoracic stage whereas three patients presented with dilation of the abdominal aorta. Conclusion The results of treatment of type B dissections with covered endoprostheses are encouraging. However, the morbimortality associated with treatment and the uncertainty of long-term results do not allow the use of this therapeutic option outside the criteria usually recognized to indicate surgery.

Objective: The aim of this study was to determine the factors influencing the feasibility of valve repair and the surgical outcome in patients with mitral annulus calcification. Methods: In 124 patients with mitral annulus calcification undergoing surgery, two entities were distinguished: Barlow disease (myxomatous leaflets, n = 60) and fibroelastic deficiency (FED) (normal leaflets, n = 64). The calcification score was lower (1.9 vs 2.8); the annulus was more dilated (ring 35 vs 32 mm) and ruptured chordae were more frequent (77% vs 37%) in Barlow than in FED (p < 0.001). The clinical profile was different: age (60 14 vs 73 8 years, p < 0.001), systemic hypertension (22% vs 70%, p < 0.001), chronic renal insufficiency (5% vs 22%, p < 0.01), cancer (7% vs 25%, p < 0.01). Multifocal atherosclerosis was less frequent in Barlow than in FED: carotid disease (17% vs 54%, p < 0.001), aortic atheroma (21% vs 51%, p < 0.001) and coronary disease (22% vs 56%, p < 0.01). Echocardiography showed two different patterns in Barlow and FED: aortic valve stenosis (1.7% vs 31%), left atrial diameter (54 vs 49 mm), left ventricular end-diastolic diameter (62 vs 54 mm), interventricular septal thickness (11 vs 13 mm), and systolic pulmonary pressure (40 vs 56 mmHg), respectively (p < 0.001). Bacterialendocarditis wasobservedin24 cases (19%).Results:Thesurgicaltechniquewas a valverepairin 68%anda replacement in 32%. The repair rate depended upon the extent of annulus calcifications (p < 0.001) and the type of degenerative disease (95% vs 44% in Barlow and FED p < 0.001). In-hospital mortality was 14% (Barlow: 5% vs FED: 23%, p < 0.01). The mean follow-up was 50 41 months. Overall 5-year year survival was 76% (Barlow: 90% vs FED: 64%, p < 0.001) and survival free from cardiac event was 69% at 5 years (Barlow: 87% vs FED: 52%, p < 0.001). Five-year survival was higher following repair than replacement (84% vs 64% p < 0.001). Chronic renal insufficiency and bacterial endocarditis were two predictors of early and late death (p < 0.01). Conclusions: The aetiopathogeny of the degenerative mitral disease responsible for annulus calcifications corresponded to distinct anatomical, clinical and echographic patterns. It was a main determinant of repair feasibility, early and late surgical outcome. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Objective: We study here the surgical results of chronic dissection involving the ascending aorta over the last 20 years. Patients with previous cardiac surgery, or proximal aortic repair, were excluded. The patients survived an acute dissection, undiagnosed as pauci- or asymptomatic. Theaortawasnormalorpathological (atheromatousaneurysmin15cases,Marfan’sdiseasein12 cases,andannuloectasicdiseasein18cases). Two patients had a bicuspid aortic valve. Methods: Between January 1981 and December 2001, 77 patients (mean age 48 15) underwent surgery for chronic dissection of the ascending aorta; 60 patients had severe aortic regurgitation, 12 had Marfan syndrome, and 18 had annuloaortic ectasia. Only the ascending aorta was dissected in 37 patients, the ascending aorta and arch in 26, and the whole aorta in 14. Coronary artery disease occurred in five patients. Statistical analysis was performed using SAS software. Different surgical procedures were used. The aortic arch was repaired in 40 cases; selective antegrade cerebral perfusion and partial circulatory arrest were used. Total aortic replacement was performed on four patients.Results: In-hospital mortality was 10%. The only risk factor was the extent of the dissection. The rate of neurologic stroke was 2.5%. Late survival rate was 42 7.5% at 12 years for all the patients; it was 71 10% when only the ascending aorta was dissected, 44 11% when the ascending aorta and arch were dissected, and 33 15% when the whole aorta was dissected (p = 0.0329). The extent of the dissection was the only risk factor for late mortality. Reoperation was required for one proximal and five distal problems. Conclusion: In chronic aortic dissection, in-hospital and late mortality were related to the extent of the dissection; in-hospital mortality remained unchanged during the operative period.

In December 2009, a 79-year-old white man was admitted to the Department of Cardiology for a moderate dyspnea (New York Heart Association II) with breath. His past medical history included a cardiac surgery with double coronary arteries bypass grafting in 1996 and thyroid cancer treated with surgery and radiotherapy. On admission, the physical examination revealed regular heart sounds at 60 bpm, and blood pressure was 100/60 mm Hg. No cardiac murmur was heard. Chest x-ray showed a mild cardiomegaly with a retrocardiac mass without pulmonary edema or pleural effusion. The left ventricular (LV) ejection fraction on echocardiography was at 67%. No LV hypertrophy and no LV dilation (LV end-diastolic diameter, 46 mm; index LV end-diastolic diameter, 40 mm/m2 …

Objective: Clinical experience with a video-assisted coronary artery bypass grafting procedure using the internal mammary artery is reported. The technique consists of a videoscopic harvesting of the left internal mammary artery (LIMA) to revascularise the left anterior descending artery (LAD) through a 4-cm left thoracotomy. Methods: Between September 1995 and July 1996, we performed this procedure on 30 patients (29 males, 1 female; aged 38-71) with an isolated proximal LAD stenosis (n = 21) or occlusion (n=9). All patients were symptomatic despite appropriate medication. A history of non-transmural myocardial infarction with myocardial viability was found in nine patients. Fourteen patients had a restenosis after previous percutaneous transluminal coronary angioplasty (PTCA). Mean left ventricular ejection fraction was 0.61 (

Between January 1979 and December 1991, we operated on 339 patients for chronic disease of the ascending aorta. The operation was elective in all. Endocarditis and its sequelae have been excluded. Thirty-one patients had a previous operation on the ascending aorta or the aortic valve; 268 patients had aneurysms of the ascending aorta without dissection; 72 had chronic aortic dissections, of whom 33 had a preexistent aneurysm. The patients included 272 men and 67 women. Mean age was 53.58 +/- 7 years. Eight percent of the patients had clinical stigmata of Marfan's disease. A tubular graft replacement was used in 7 patients, a tubular graft and valve replacement in 72 patients, and a composite valve graft replacement with reattachment of the coronary arteries using a 8 mm Dacron graft was performed in 260 patients. Concomitant procedures were used in 74 patients: coronary artery bypass grafts in 25, mitral valve replacement in 9, and aortic arch reconstruction in 40. The 30-day mortality rate was 7.6% (n = 26). For the whole group, multivariate analysis using stepwise logistic regression showed that operative risk factors were concomitant coronary artery bypass grafting, age (increased), aortic valve regurgitation, and previous cardiac surgery. Follow-up was conducted in 303 patients, and risk factors for late mortality were studied. Long-term survival was 59.6% +/- 3.7% at 9 years. It was 67% +/- 3.5% at 9 years for patients without aortic arch reconstruction and 56% +/- 4.5% for patients with aortic arch reconstruction (p = 0.0018). Reoperation was needed in 14 patients. Actuarial freedom from reoperation was 90% +/- 0.2% at 9 years for all the patients. Only one patient with composite valve graft replacement and reattachment of the coronary arteries had required reoperation for problems related to this procedure. This technique is used routinely by our team, especially in patients with large chronic aneurysms, dissected or not, and in those who had previous operations. The long-term results are good.

From January 1978 to December 1988, 71 patients underwent surgical intervention at our institution for prosthetic valve endocarditis with ring abscesses. These procedures involved 59 aortic prostheses and 12 mitral prostheses. No causative agent could be identified in 19 patients (26.7%). The operation was performed during antibiotic therapy in 63 patients and after a planned course of antibiotic therapy in 8 patients. At the aortic level, abscesses were remedied by suturing in 3 cases, by pericardial patches in 34 cases, and by complex procedures in 22 cases (subcoronary valved conduit in 11 cases, supracoronary valved conduit with coronary bypass grafts in 10 cases, apicoaortic valved conduit in 1 case). At the mitral level, ring abscesses were cured in 10 cases by intraatrial implantation of the prosthesis. In one case, the prosthesis was anchored inside the left ventricle; and in one case the valve could be seated on the anulus. The overall operative mortality rate was 17%. Long-term survival was 54% +/- 8% at 6 years. Fifteen (26%) of the survivors needed a third valve replacement (four operative deaths); a complex reconstruction was performed in seven patients. Better detection of ring abscesses and earlier surgical intervention before annular destruction and hemodynamic failure can improve the operative mortality rate for prosthetic valve endocarditis. When it is necessary, complex reconstruction, in spite of a high mortality rate, seems to eradicate the infectious seat, and the outlook for the patient's condition appears good.