Search

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

OBJECTIVES Our goal was to provide a picture of left ventricular assist device (LVAD) activity in France between 2007 and 2016 based on the multicentric ASSIST-ICD registry. METHODS We retrospectively collected 136 variables including in-hospital data, follow-up survival rates and adverse events from 671 LVAD recipients at 20 out of 24 LVAD implant centres in France. The average follow-up time was 1.2 years (standard deviation: 1.4); the total follow-up time was 807.5 patient-years. RESULTS The included devices were the HeartMate II®, HeartWare LVAS® or Jarvik 2000®. The overall likelihood of being alive while on LVAD support or having a transplant (primary end point) at 1, 2, 3 and 5 years postimplantation was 65.2%, 59.7%, 55.9% and 47.7%, respectively, given a cumulative incidence of 29.2% of receiving a transplant at year 5. At implantation, 21.5% of patients were on extracorporeal life support. The overall rate of cardiogenic shock at implantation was 53%. The major complications were driveline infection (26.1%), pump pocket or cannula infection (12.6%), LVAD thrombosis (12.2%), ischaemic (12.8%) or haemorrhagic stroke (5.4%; all strokes 18.2%), non-cerebral haemorrhage (9.1%) and LVAD exchange (5.2%). The primary end point (survival) was stratified by age at surgery and by the type of device used, with inference from baseline profiles. The primary end point combined with an absence of complications (secondary end point) was also stratified by device type. CONCLUSIONS The ASSIST-ICD registry provides a real-life picture of LVAD use in 20 of the 24 implant centres in France. Despite older average age and a higher proportion of patients chosen for destination therapy, survival rates improved compared to those in previous national registry results. This LVAD registry contrasts with other international registries because patients with implants have more severe disease, and the national policy for graft attribution is distinct. We recommend referring patients for LVAD earlier and suggest a discussion of the optimal timing of a transplant for bridged patients (more dismal results after the second year of support?).

Introduction The morbi-mortality related to infective endocarditis (IE) remains high as the epidemiology has changed over the last years: ageing of patients, comorbidity and healthcare-associated infections. To optimize IE management, a weekly endocarditis multidisciplinary meeting (EMM) was set up at our facility. We present the activity report of the EMM. Patients and methods All patients hospitalized for IE who were presented at the weekly EMM between January 2013 and June 2017 were prospectively included. The main objective was to assess the impact of the EMM on the management of community-acquired IE and healthcare-associated IE by analyzing in-hospital case fatality. Results Of the 1139 cases reported during the EMM for suspicion of IE, 493 (86% were definite cases) were selected for the study: 262 patients had community-acquired IE and 231 had healthcare-associated IE; 43% of IEs involved a valvular prosthesis. Following the EMM, infections were documented in 92% of cases: staphylococci in 45% of healthcare-associated IEs and streptococci in 44% of community-acquired IE cases. A septic embolism was diagnosed in 57% of cases. Finally, 49% of patients underwent surgery. The in-hospital case fatality was 12% with no significant difference between community-acquired IEs and healthcare-associated IEs. Case fatality was also significantly higher in elderly patients, in the absence of surgical treatment, initial heart failure, or Staphylococcus aureus IE. Conclusion The weekly EMM allows our facility to follow the European Society of Cardiology guidelines and to adapt the management of each patient to improve IE prognosis.

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 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.

The usage of left-ventricular-assist device (LVAD) is increasing in patients presenting with advanced heart failure. However, device-related infections are a challenge to recognize and to treat, with an important morbidity and mortality rate. The role of nuclear medicine imaging remains not well established for LVAD infections. The present study compared the accuracy of positron emission tomography/computed tomography with 18F-fludeoxyglucose (18F-FDG PET/CT) and radiolabeled leucocyte scintigraphy for the diagnosis of infections in patients supported with a continuous-flow LVAD. From a prospectively maintained database, we retrospectively analyzed the diagnostic performance of radiolabeled leucocyte scintigraphy and 18F-FDG PET/CT in 24 patients who had a LVAD with a suspected device-related infection. Both examinations were routinely performed in all patients. Infection was assessed by the International Society for Heart and Lung Transplantation criteria. Twenty-four patients were included: 15 had a specific VAD infection (5 cardiac-LVAD and 10 driveline), 6 had a VAD-related infection, while 3 patients had a non-VAD-related infection. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 95.2%, 66.7%, 95.2%, 66.7%, and 91.6%, respectively, for 18F-FDG-PET; and 71.4%, 100%, 100%, 33.3%, and 75%, respectively, for leucocyte scintigraphy. 18F-FDG PET/CT showed significantly higher sensitivity (P = 0.01) than leucocyte scintigraphy. 18F-FDG PET/CT and radiolabeled leucocyte scintigraphy single-photon emission computed tomography carry high performance in the diagnostic of LVAD infections. 18F-FDG PET/CT shows significantly higher sensitivity and could be proposed as first-line nuclear medicine procedure.

Summary Background Ventricular arrhythmia is common after left ventricular assist device (LVAD) implantation, especially in the early postoperative phase ( Aim To identify the incidence of and risk factors for electrical storm (ES) occurring within 30 days of HeartMate ® II implantation. Methods We reviewed data from all consecutive patients undergoing HeartMate ® II device implantation at our institution from January 2008 to December 2014. Patient demographic data, pharmacotherapies and outcomes were collected. The primary endpoint was occurrence of early ES (within 30 days of surgery), defined as three or more separate episodes of sustained ventricular arrhythmia within a 24-hour interval, requiring appropriate therapy. Results Forty-three patients (mean age 56.7 ± 11.2 years; 39 men) were included. At HeartMate ® II implantation, mean left ventricular ejection fraction was 20 ± 5%, 32 (74.4%) patients had ischaemic cardiomyopathy and 31 (72.1%) were implanted with an indication of bridge to cardiac transplantation. During follow-up, 12 (27.9%) patients experienced early ES after HeartMate ® II implantation (median delay 9.1 ± 7.8 days). Early ES was more frequent in larger patients (body surface area 1.99 vs 1.81 m 2 ; P P = 0.08), previous implantable cardioverter-defibrillator implantation (66.7% vs 38.7%; P = 0.09), discontinuation of long-term beta-blocker therapy (75.0% vs 45.2%; P = 0.08), weaning of adrenergic drugs after the third day (66.7% vs 35.5%; P = 0.06) and the use of extracorporeal life support (50% vs 22.6%; P = 0.079), but was not associated with the cardiomyopathy aetiology or the indication for assistance. Catheter ventricular tachycardia ablation was performed in six (14.0%) patients. Early ES was associated with a significantly higher all-cause mortality rate at the 30th day (33.3% vs 6.5%; P = 0.02). Conclusion ES is a common and pejorative feature in the early postoperative period.

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.

International audience; Objectives - This study aimed to evaluate incidence, clinical significance, and predictors of early ventricular arrhythmias (VAs) in left ventricular assist device (LVAD) recipients. Background - LVAD implantation is increasingly used in patients with end-stage heart failure. Early VAs may occur during the 30-day post-operative period, but many questions remain unanswered regarding their incidence and clinical impact. Methods - This observational study was conducted in 19 centers between 2006 and 2016. Early VAs were defined as sustained ventricular tachycardia and/or ventricular fibrillation occurring

Left ventricular assist devices (LVADs) are used as an alternative therapy for heart transplantation in patients with advanced heart failure. However, the mortality rate of these patients remains relatively high. A large proportion of deaths after LVAD implantation occur during intensive care unit (ICU) stay. We conducted a retrospective study to identify the risk factors for all-cause ICU mortality in patients with an implanted LVAD. Between January 1, 2008 and December 31, 2016, 70 consecutive patients who had received an LVAD were analyzed. The median ICU length of stay was 14 days (IQR: 8-31) and 16 patients (22.9% [95%CI: 13.1-32.7]) died in the ICU. The 90-day mortality rate was 25.7% (95%CI: 15.5-35.9). The main causes of ICU mortality were: multiple organ failure, stroke, and hemorrhagic events. The univariate analysis identified the following perioperative risk factors for all-cause ICU mortality: hypertension, preoperative platelet count, preoperative white cell count, inotropic support before LVAD implantation, mechanical ventilation before LVAD implantation, renal replacement therapy before LVAD implantation, short-term mechanical support before LVAD implantation, INTERMACS class 1 to 2, low intraoperative platelet count, low early postoperative hemoglobin level, low early postoperative platelet count, low early postoperative pH, and massive perioperative blood transfusion. In the multivariate logistic regression analysis, only mechanical ventilation before LVAD implantation was retained as an independent risk factor for ICU mortality (OR = 11.96 [95%CI: 2.67-53.45], P < .01). These findings confirm that most deaths after LVAD implantation occur in the ICU. Patients that receive mechanical ventilation preoperatively have the highest risk of death. This confirms the need to actively treat respiratory failure and to wean patients from respiratory support before LVAD implantation. Such a strategy offers the best opportunity to initiate active rehabilitation.

Background Sparing Aortic Valve procedure requires to reproduction of the geometry of the physiologic anatomy of the aortic root. Thus, the materials adopted may make a difference. CARDIOROOT is a one-piece collagen-coated woven vascular graft with pseudo-sinuses, which was designed for use in the treatment of aortic root disease. We report the results of a prospective, multicenter, observational post-market surveillance study evaluating the safety and performance of the CARDIOROOT in patients requiring aortic root surgery. Methods Patients with aortic root disease suitable for treatment with a vascular graft with pseudo-sinuses CARDIOROOT graft were eligible for participation. The enrolled patients were assessed intraoperatively, post-operatively, at discharge and at 1-year. Sites assessed complications at each visit, and recorded any reported adverse events. The study endpoint was mortality and complications through 1-year post-procedure. Results Fifty-two patients were enrolled from 6 European centers. All procedures were technically successful. Operative mortality was 1.9%: one patient suffered hemorrhagic shock unrelated to the graft 1 day following surgery. At 1-year follow-up the survival rate was 96.2%, with a late death due to pneumonia 5 months post-procedure. Eleven serious adverse events occurred in 7 patients, which included cardiac complications (pericardial effusion, myocardial infarction and ventricular arrhythmia), infection (pericardial infection, deep sternal infection and superficial sternal infection), vascular disorders, including hemorrhagic shock and pleural effusion requiring drainage. Nine of the 11 events were deemed procedure-related by the local investigator, and all were deemed unrelated to the device. There were no reports of graft-related adverse events, infection, occlusion or graft failure. Conclusions The results of this 1-year follow-up study showed that the CARDIOROOT vascular graft is safe and effective for the treatment of aneurysmal aortic root in immediate and mid-term follow-up. However, longer term follow-up is needed before conclusions can be made on the long-term safety and effectiveness. Trial registration ClinicalTrials.gov Identifier: NCT01609270. Registered 31 May 2012.

International audience; Background - Left ventricular assist device (LVAD)-associated infections may be life-threatening and impact patients' outcome. We aimed to identify the characteristics, risk factors, and prognosis of LVAD-associated infections. Methods - Patients included in the ASSIST-ICD study (19 centers) were enrolled. The main outcome was the occurrence of LVAD-associated infection (driveline infection, pocket infection, or pump/cannula infection) during follow-up. Results - Of the 652 patients enrolled, 201 (30.1%) presented a total of 248 LVAD infections diagnosed 6.5 months after implantation, including 171 (26.2%), 51 (7.8%), and 26 (4.0%) percutaneous driveline infection, pocket infection, or pump/cannula infection, respectively. Patients with infections were aged 58.7 years, and most received HeartMate II (82.1%) or HeartWare (13.4%). Most patients (62%) had implantable cardioverter-defibrillators (ICDs) before LVAD, and 104 (16.0%) had ICD implantation, extraction, or replacement after the LVAD surgery. Main pathogens found among the 248 infections were Staphylococcus aureus (n = 113' 45.4%), Enterobacteriaceae (n = 61; 24.6%), Pseudomonas aeruginosa (n = 34; 13.7%), coagulase-negative staphylococci (n = 13; 5.2%), and Candida species (n = 13; 5.2%). In multivariable analysis, HeartMate II (subhazard ratio, 1.56; 95% CI, 1.03 to 2.36; P = .031) and ICD-related procedures post-LVAD (subhazard ratio, 1.43; 95% CI, 1.03-1.98; P = .031) were significantly associated with LVAD infections. Infections had no detrimental impact on survival. Conclusions - Left ventricular assist device-associated infections affect one-third of LVAD recipients, mostly related to skin pathogens and gram-negative bacilli, with increased risk with HeartMate II as compared with HeartWare, and in patients who required ICD-related procedures post-LVAD. This is a plea to better select patients needing ICD implantation/replacement after LVAD implantation.

Contexte L’utilisation du dispositif d’assistance ventriculaire gauche (DAVG) est en expansion chez les patients en insuffisance cardiaque avancee. Cependant, les infections liees au dispositif sont un defi a reconnaitre et a traiter en raison d’un taux de morbidite et de mortalite important. Le role de l’imagerie de medecine nucleaire n’est pas encore bien etabli pour les infections de DAVG. La presente etude compare les performances diagnostiques de la tomographie par emission de positons/tomodensitometrie au 18F-fluorodeoxyglucose (TEP-TDM au 18F-FDG) et de la scintigraphie aux leucocytes marques (SLM) pour le diagnostic d’infections chez des patients porteurs d’un DAVG a flux continu. Methodes A partir d’une base de donnees completee de maniere prospective, nous avons analyse retrospectivement les performances diagnostiques de la SLM et de la TEP-TDM au 18F-FDG chez 24 patients ayant un DAVG avec une infection suspectee liee au dispositif. Les deux types d’examens ont ete systematiquement realises chez tous les patients. Le diagnostic d’infection fut etabli selon les criteres ISHLT. Resultats Parmi les 24 patients inclus, 15 avaient une infection specifique du DAVG (5 au niveau de la pompe et/ou canule d’insertion myocardique et 10 au niveau de la driveline), 6 avaient une infection liee au DAVG, tandis que 3 patients avaient une infection non liee au DAVG. La sensibilite, la specificite, la valeur predictive positive, la valeur predictive negative et la precision etaient de 95,2 %, 66,7 %, 95,2 %, 66,7 % et 91,6 %, respectivement, pour la TEP-TDM au 18F-FDG et 71,4 %, 100 %, 100 %, 33,3 %, et 75 %, respectivement, pour la SLM. La TEP-TDM au 18F-FDG a montre une sensibilite significativement plus elevee (p = 0,01) que la scintigraphie aux leucocytes marques. Conclusion La TEP-TDM au 18F-FDG et la SLM s’averent tres efficaces pour le diagnostic des infections de DVAG. La TEP-TDM au 18F-FDG montre une sensibilite significativement plus elevee et pourrait etre proposee en tant que procedure de medecine nucleaire de premier choix.

Background— Left ventricular assist devices (LVADs) are increasingly used as a bridge to cardiac transplantation or as destination therapy. Patients with LVADs are at high risk for ventricular arrhythmias. This study describes ventricular arrhythmia characteristics and ablation in patients implanted with a Heart Mate II device. Methods and Results— All patients with a Heart Mate II device who underwent ventricular arrhythmia catheter ablation at 9 tertiary centers were included. Thirty-four patients (30 male, age 58±10 years) underwent 39 ablation procedures. The underlying cardiomyopathy pathogenesis was ischemic in 21 and nonischemic in 13 patients with a mean left ventricular ejection fraction of 17%±5% before LVAD implantation. One hundred and ten ventricular tachycardias (VTs; cycle lengths, 230–740 ms, arrhythmic storm n=28) and 2 ventricular fibrillation triggers were targeted (25 transseptal, 14 retrograde aortic approaches). Nine patients required VT ablation Conclusions— Catheter ablation of VT among LVAD recipients is feasible and reasonably safe even soon after LVAD implantation. Intrinsic myocardial scar, rather than the apical cannula, seems to be the dominant substrate.

Pacemaker infection in pacing-dependent patients is challenging. After extraction, temporary pacing usually is utilized before delayed reimplantation (after an appropriate course of antibiotics), resulting in prolonged hospital stays. A single combined procedure of epicardial (EPI) pacemaker implantation and system extraction may prevent this.The purpose of this study was to evaluate the feasibility and safety of these 2 approaches by comparing clinical outcome for both strategies over 1 year.In center 1, 80 consecutive pacemaker-dependent patients underwent extraction with an externalized pacemaker and delayed implantation on the contralateral side (ENDO group). In center 2, 80 consecutive patients had 2 epicardial ventricular leads surgically implanted with extraction of the infected pacemaker during the same procedure (EPI group). Patients were followed-up for 12 months.One hundred sixty pacing-dependent patients were successfully implanted and extracted (ENDO group 71 ± 13 years vs EPI group 73 ± 14, P = NS). In the EPI group, 2 patients developed significant pericardial bleeding. In-hospital mortality was 0% in the ENDO group and 2.5% in the EPI group. Total hospitalization time was 15 ± 7 days in the ENDO group vs 9 ± 6 days in the EPI group (P.001). At 1 year, no infection recurrences occurred in either group, and mortality was equal (5% in each group). Median 1-year pacing thresholds were lower in the ENDO vs the EPI group (0.8 ± 0.6 V vs 1.1 ± 0.6 V, P = .02).The ENDO and EPI strategies had an excellent success rate and low risk of complications. A single procedure using surgical epicardial lead implantation was associated with a shorter duration of hospital stay.

Objectives To investigate the outcome of patients with acute myocardial infarction (AMI) complicated by refractory cardiogenic shock (CS) who underwent mechanical circulatory support with Impella 2.5. Background AMI complicated by CS remains a highly fatal condition. A potent and minimally invasive left ventricular assist device might improve patient outcomes. Methods We analyzed the procedural characteristics and outcomes of 22 consecutive patients who underwent, between July 2008 and December 2012, a percutaneous coronary intervention and Impella 2.5 support for AMI complicated by CS refractory to first-line therapy with inotropes and/or Intra-aortic balloon pump. Results In this analysis, patients were relatively young with a mean age of 57.9 ± 11.6 year old and 59.1% were male. The majority of patients (77.3%) were admitted in CS and 40.9% sustained cardiac arrest prior to admission. Hemodynamics improved significantly upon initiation of support, end-organ and tissue perfusion improved subsequently demonstrated by a significant decrease in lactate levels from 6.37 ± 5.3 mmol/L to 2.41 ± 2.1 mmo/L, (P = 0.008) after 2 days of support. Thirteen (59.1%) patients were successfully weaned-off Impella 2.5 and 4 (18.2%) were transitioned to another device. We observed a functional recovery of the left ventricle when compared to baseline (43 ± 10% vs. 27 ± 9%, P

Background - Transcatheter aortic valve replacement (TAVR) is standard therapy for patients with severe aortic stenosis who are at high surgical risk. However, national data regarding procedural characteristics and clinical outcomes over time are limited. Objectives - The aim of this study was to assess nationwide performance trends and clinical outcomes of TAVR during a 6-year period. Methods - TAVRs performed in 48 centers across France between January 2013 and December 2015 were prospectively included in the FRANCE TAVI (French Transcatheter Aortic Valve Implantation) registry. Findings were further compared with those reported from the FRANCE 2 (French Aortic National CoreValve and Edwards 2) registry, which captured all TAVRs performed from January 2010 to January 2012 across 34 centers. Results - A total of 12,804 patients from FRANCE TAVI and 4,165 patients from FRANCE 2 were included in this analysis. The median age of patients was 84.6 years, and 49.7% were men. FRANCE TAVI participants were older but at lower surgical risk (median logistic European System for Cardiac Operative Risk Evaluation [EuroSCORE]: 15.0% vs. 18.4%; p < 0.001). More than 80% of patients in FRANCE TAVI underwent transfemoral TAVR. Transesophageal echocardiography guidance decreased from 60.7% to 32.3% of cases, whereas more recent procedures were increasingly performed in hybrid operating rooms (15.8% vs. 35.7%). Rates of Valve Academic Research Consortium-defined device success increased from 95.3% in FRANCE 2 to 96.8% in FRANCE TAVI (p < 0.001). In-hospital and 30-day mortality rates were 4.4% and 5.4%, respectively, in FRANCE TAVI compared with 8.2% and 10.1%, respectively, in FRANCE 2 (p

International audience

Little is presently known about the outcome of atrial lesions performed with high-intensity focused ultrasound (HIFU) for atrial fibrillation ablation. We aimed to assess endocardial atrial lesions 6 months after epicardial HIFU ablation (Epicor™) and to evaluate the benefit of a combined ablation approach. Thirty patients (21 males, mean age 68 ± 12 years old) undergoing HIFU atrial fibrillation ablation during cardiac surgery were enrolled. Electrophysiological study (EPS) was performed 6 months after HIFU ablation, and endovascular radiofrequency was delivered in case of conduction gaps. Patients were followed up for at least 6 months after the EPS. At EPS, ten patients (38 %) had achieved complete or near-complete “box” isolation and four (15 %) had no visible lesion. Using this technology, freedom from symptomatic atrial arrhythmia at 6 months was 60 % (n = 18/30) (64 % for paroxysmal and 56 % for persistent subgroups) improving to 81 % (n = 21/26) (90 % for paroxysmal and 73 % for persistent subgroups) at 12 months after a facultative percutaneous endocardial approach was performed. Using an UltraCinch device sized below 10 improved the rate of complete lesion as assessed 6 months after surgery (58 % of complete or near-complete box isolation with UltraCinch device

Impella for cardiogenic shock Monocentric cohort of 112 patients supported with an Impella device (2011-2017) At implantation, patients were : INTERMACS I 68, INTERMACS II 42 ,INTERMACS III 8 32 patients had ECMO first Mean support: 6,7 days (max 22) ![Figure][1] ![Figure][1] ![

Objectives During sequential double-lung transplantation (DLT), the newly implanted first lung receives the entire cardiac output during the implantation of the second one. This may be responsible for the increased hydrostatic pressure that causes severe interstitial and alveolar edema that can lead to allograft dysfunction. The authors tested the hypothesis that CPB started after first graft implantation and before second recipient lung removal should improve post-transplantation oxygenation and clinical outcomes. Design Observational during 2 consecutive 1-year periods. Setting University hospital. Participants Nine consecutive patients undergoing sequential DLT with CPB started after first graft implantation and before second recipient lung removal were compared to controls, who were 10 consecutive patients who underwent sequential DLT but without CPB the year before. Measurements and Main Results Oxygenation after transplantation was assessed. The use of CPB during the implantation of the second lung was associated with an increased mean postoperative ratio of PaO 2 to the fraction of inspired oxygen at 1 hour (363±51 v 240±113, p = 0.01) and 6 hours (430±111 v 280±103, p = 0.03). The mean duration of CPB was 111±19 min. The occurrence of primary graft dysfunction and the need for extracorporeal membrane oxygenation tended to be lower, but did not reach significance. Similarly, mortality rate was comparable between both groups, as was the rate of blood transfusions. Conclusions The authors' results suggest that the use of CPB started after first graft implantation and before second recipient lung removal appears to benefit oxygenation and reduces the occurrence of severe pulmonary edema in the first transplanted lung.

Background Left ventricular (LV) afterload could be associated with reduced myocardial contractility. The aim of this study was to evaluate the relative impact of increased afterload on LV myocardial deformation indices in chronic aortic constriction, with regard to hypertrophy, myocardial fibrosis, and mitochondrial function, and to differentiate acute versus chronic afterload effect. Methods Young pigs underwent aortic banding ( n = 11) or sham ( n = 7) operations. Nineteen weeks later, LV morphology and systolic function, including myocardial deformation, were assessed by echocardiography before and after banding release or acute aortic constriction (in the sham group). After the animals were euthanized, mitochondrial function and LV interstitial fibrosis were assessed. Results The chronic banding group ( n = 8) presented with significant LV hypertrophy compared with the sham group ( n = 7), and longitudinal strain (LS) was significantly altered (16.9 ± 0.7% vs 20.3 ± 0.7%, P = .001) while circumferential, radial strain, and ejection fraction were not. LS abnormalities were situated mostly on the basal and mid segments and on the septal wall. There was also significantly more myocardial fibrosis in the chronic banding group compared with the sham group, while mitochondrial function was preserved. The relative contributions of hypertrophic and fibrotic remodeling and of afterload to alter global LS were 62%, and 38%, respectively. Acute aortic banding also significantly altered LS. The ratio of LS to septal wall thickness enabled differentiation between chronic and acute afterload increase (1.9 ± 0.2 in the chronic group vs 2.9 ± 0.3 in the acute group, P = .001). Conclusions LS is susceptible to both hypertrophic and fibrotic remodeling and afterload increase, particularly on the basal and mid LV segments of the septum. The ratio of LS to septal wall thickness enables differentiation of acute from chronic afterload LS alteration.

Initially double-lung transplantation (DLT) was performed with airway anastomosis at the tracheal bifurcation requiring a cardiopulmonary bypass (CBP). Complications related to ischemia of the bronchi and trachea around the carina prompted adoption of sequential single lung implantations as the method of choice for DLT. In different studies, CPB was associated with an increase in postoperative morbidity but this was probably due to the selection of more severe patients. Moreover, important progress in the technology of CPB has occurred. Therefore, the systematic use of CPB during sequential lung transplantation might have some interest by limiting the occurrence of ventilation and perfusion injuries. This article discusses the potential beneficial effects of CPB during double-lung transplantation.

Background. Metaboreflex overactivation has been proprosed to explain exaggerated hyperventilation in heart failure population. We investigated the metaboreflex activation after cardiac resynchronization therapy (CRT). Methods. 10 heart failure patients (mean left ventricular ejection fraction (LVEF) 2 7 ± 4 %) schedulded for CRT implantation were prospectively studied. At baseline and after 6 month follow up two maximal cardiopulmonary exercise tests with and without regional circulatory occlusion (RCO) during recovery were performed. RCO was achieved by inflation of bilateral upper thigh tourniquets 30 mmHg above peak systolic blood pressure during 3 minutes after peak exercise. Metaboreflex contribution to the ventilatory response was assessed as the difference in ventilatory data at the third minute during recovery between the two tests (Δ). Results. Patients had enhanced VE/VCO2 slope ( 4 0 ± 9 ) and an evident metaboreflex contribution to the high ventilatory response (ΔVE: 3 ± 4 L/min; 𝑃 = 0 . 0 5 , ΔRR: 4 . 5 ± 4 /min; 𝑃 = 0 . 0 0 3 and ΔVE/VCO2: 5 . 5 ± 4 ; 𝑃 = 0 . 0 0 7 ). 6 months after CRT implantation, NYHA class, LVEF, peak VO2 and VE/VCO2 were significantly improved ( 1 . 4 ± 0 . 5 ; 𝑃 < 0 . 0 0 1 , 4 2 ± 7 %; 𝑃 < 0 . 0 0 1 , 1 6 . 5 ± 3 mL/kg/min; 𝑃 = 0 . 0 0 3 ; 3 3 ± 1 0 ; 𝑃 = 0 . 0 1 ). Metaboreflex contribution to VE, RR, and VE/VCO2 was reduced compared with baseline ( 𝑃 = 0 . 0 8 , 𝑃 = 0 . 0 1 and 𝑃 = 0 . 4 resp.). Conclusion. 6 months after CRT metaboreflex contribution to the ventilatory response is reduced.

Background: Ultraminiaturization of echographic systems extraordinarily provides the image “within” the clinical examination. Abdominal aorta aneurysm (AAA) diagnosis based on conventional evaluation with a dedicated operator and ultrasound machine is still controversial due to the lack of evidence of the proposed management and guidelines’ cost-effectiveness. We hypothesized that less expensive ultraportable devices could identify AAA with the same level of accuracy as conventional approaches. Methods: A first step of this study was to validate the VSCAN’s image capabilities in patients referred to the vascular Doppler laboratory. Abdominal aorta measurements were performed by an experienced physician using conventional equipment followed by a second blinded physician using the ultraportable device VSCAN. Then, 204 patients hospitalized in our cardiology institute were prospectively included for a systematic screening of AAA at bedside using the VSCAN in order to determine the feasibility and impact of fast track evaluation compared to clinical examination. Results: A strong correlation was obtained between measurements of abdominal aorta diameters using the two ultrasound systems (r = 0.98, CI: 0.97‐0.99, P < 0.001) with 100% of agreement for AAA diagnosis. In the second part of the study, visualization and measurement of the transverse diameter of the abdominal aorta was obtained in 199 patients, resulting in a feasibility of 97.5%. Among these patients, 18 AAAs were detected, which corresponds to a prevalence of 9%, whereas clinical evaluation did not detect any of them. Patients with AAA were more likely men (77.77% vs. 57.45%, P < 0.05) and hypertensive (88.8% vs. 56.9%, P < 0.05) as compared to those without AAA. Two patients with large AAA were quickly referred to the surgery department. Conclusion: Considering its low cost, diagnostic accuracy, and widespread availability, screening for AAA using an ultraportable ultrasound device such as VSCAN by an experienced physician is promising and should be used as an extension of routine physical examination in vascular patients. (Echocardiography 2012;29:285-290)

Background The management of infective endocarditis (IE) by an expert medico-surgical team through multidisciplinary consultation meetings is now recommended. While it seems clear that it can improve the short-term prognosis of patients, long-term data are still scarce. Methods All patients hospitalized between 2013 and 2017 in the three teaching hospitals of our center with an IE treated by the multidisciplinary team were followed prospectively at 1, 3, 6, and 12 months. The main objective was to determine the 1-year mortality of the entire cohort treated by the team. Results During the study, 493 patients had a certain or possible IE and the outcome at 1 year was known for 448 of them (4 lost to follow-up and 41 followed for less than 1 year): 254 had native valve IE (57%) and 194 had prosthetic valve IE (43%). The median age of IE patients was 69.3 years (155 patients were over 75 years old) and 329 (73%) were men. Healthcare-associated IE (HAIE) accounted for 47% of cases. A microorganism was isolated in 92% of cases (S. aureus = 24%), 252 patients (56%) had an embolic events and 68 (15%) had heart failure. The Charlson Median Comorbidity Index (ICC) was 5.0. Two hundred sixteen patients (48%) underwent surgery. The mortality rates at 1 month, 3 months, 6 months, and 1 year were, respectively, 14.1%, 19.0%, 23.2%, and 27.7%. The ICC at inclusion of patients who died at 1 year was 6.0 vs. 4.0 for survivors. Mortality at 1 year was significantly higher in case of HAIE (33% vs. 23%), documented S. aureus IE (39% vs. 24%), exclusive medical treatment (40% vs. 15%), and heart failure (43% vs. 25%). Conclusion While the management of IE by an endocarditis team seems to improve the short-term prognosis of IE, 1-year mortality remains high as patients are increasingly older and have severe comorbidities. Our study confirms that early prognostic factors remain in the long term and that the prognosis is better in community-acquired IE with surgery. Disclosures All authors: No reported disclosures.

Introduction: Cardiac pacemakers with preerosion are often reimplanted. Preerosion may be caused by an evolving local infectious process affecting the entire pacing system or by mechanical migration of the device causing ischemic necrosis of the skin tissues. We examined the long-term outcome of 33 patients who underwent pocket or scar revision and submuscular reimplantation of cardiac pacemakers in our institution. Methods: Before undergoing pocket or scar revision and reimplantation, all patients (1) had negative serial blood cultures, (2) had no vegetation on transesophageal echocardiography, (3) had a normal blood C-reactive protein concentrations, (4) were afebrile, (5) had no cutaneous breakthrough, and (6) presented with preerosion of the pulse generator or granulomatous-like scar abnormality. Results: The mean follow-up was 37 ± 12 months. Among 16 patients presenting with preerosion associated with signs of local cutaneous inflammation, 62.5% developed an infection of the pacing system requiring later explantation. Of eight patients presenting initially with migration of the pulse generator and mechanical protrusion, none required subsequent explantation of the system. Among nine patients presenting initially with granulomatous-like scar abnormalities, 55.6% underwent explantation of the pacing system during follow-up for management of documented local infection. Conclusions: The reimplantation of pulse generators with preerosion in the presence of local inflammatory manifestations or granulomatous-like changes of the scar is complicated by documented cardiac pacemaker infection in >50% of cases. In these patients, the explantation of the pacing system is recommended before the development of prognostically much more serious spread of infection to the leads and cardiac tissues. (PACE 2011; 34:150–154)

The development of small-diameter active fixation pacing and implantable cardioverter-defibrillator leads may be associated with increased risk for delayed right ventricular perforation. The management of this unforeseen complication has been poorly described. Eleven successive patients referred for right ventricular subacute or delayed perforation (no evidence of lead perforation at the time of the procedure, perforation of the right ventricle diagnosedor =5 days after implantation) were reviewed. The perforation was related to a pacing (n = 7) or an implantable cardioverter-defibrillator (n = 4) lead. The main symptoms were major dyspnea with pericardial effusion requiring emergency pericardial drainage (n = 3), inappropriate implantable cardioverter-defibrillator shock (n = 1), syncope (n = 2), abdominal pain (n = 1), mammary hematoma (n = 1), diaphragm stimulation (n = 1), and chest pain (n = 1). One patient was strictly asymptomatic. Signs of lead dysfunction were observed in all 11 patients. The diagnosis of lead perforation was confirmed by chest x-ray, echocardiography, or computed tomography. Surgery was directly performed in 1 patient with suspicion of digestive perforation. In the remaining 10 patients, the leads were removed by simple traction under fluoroscopic guidance in the operating room, with surgical backup support. The need for close monitoring was highlighted by the occurrence in 1 patient of tamponade requiring percutaneous pericardiocentesis and urgent surgical revision. The postoperative course of these patients was unremarkable. In conclusion, subacute ventricular perforation is a rare but potentially life threatening complication of lead implantation. In most patients, the leads can safely be removed under fluoroscopic guidance, with surgical backup support and close monitoring.

Summary Introduction Coronary revascularization surgery is a palliative treatment modality which should not preclude efforts to treat atherosclerosis. Aim To assess ongoing cardiovascular risk factors after coronary artery bypass surgery and develop a strategy to attenuate such factors. Methods 108 patients requiring a coronary artery bypass were included: 2 died soon after surgery and 6 were excluded for personal reasons. 100 patients were re-admitted into hospital 7 months after surgery for risk factor assessment. Eight months later, they were re-contacted by telephone (systematic follow-up) for a re-assessment. Results The population consisted of 77 men with an average age of 64±11 years. Prior to the operation, the known risk factors were: smoking 34%; HBP 61%; cholesterol 47%; diabetes 30%; obesity 25%. During their hospital stay six months after the procedure: 91% of the patients had at least one lipid metabolism abnormality. New-onset diabetes was diagnosed in 5%. Blood pressure was uncontrolled in 18% and 10% were still smoking. Patients tended to be putting on weight and 55% engaged in little or no physical activity. Systematic follow-up: lipid metabolism had normalized in 70% of the patients. Blood glucose levels were significantly lower. Blood pressure was uncontrolled in 9% and 4% were still smoking. Their weight had stabilized and 65% were engaging in moderate-to-strenuous physical activity. Conclusion Inadequate attention is paid to risk factors after coronary artery bypass surgery. A short hospital stay including a cardiovascular evaluation and education about risk factors has a positive impact on the management of atherosclerosis in the medium term.

Rhythmic complications seem common after left ventricular (LV) assist device (LVAD), especially in the early phase of implantation (

The incidence of peripheral arterial disease is rising and despite advances in clinical management, many problems remain unsolved. Better knowledge of the mechanisms and consequences associated with chronic muscle ischemia has opened the way for development of new treatment strategies, including therapeutic angiogenesis. Therapeutic angiogenesis is a promising technique based on experimental studies showing that growth factors or genes able to increase capillary density can be used to reduce the impact of muscle ischemia and increase blood flow to ischemic tissue. Enthusiasm for this technique has prompted numerous clinical trials with encouraging results, but data are still inconclusive. Optimal indications for gene therapy must be defined and further experimental progress is needed to respond to ethical issues. Therapeutic angiogenesis should be viewed as an adjunct to rather than as a competitor of current surgical revascularization techniques.

Background Myocardial infarction results in irreversible myocyte loss. In a murine model, we tested the feasibility of a novel repair technique combining bone marrow cell (BMC) transplantation and cardiomyoplasty. Methods Myocardial infarction was induced cryogenically in backcrossed ROSA 26 transgenic × C57BL/6J mice (n = 75). Thirty days later, surviving mice (n = 69) were randomized to sham treatment (rethoracotomy only; n=11), patch only treatment (n = 29), or patch + BMC treatment (n = 29). Abdominal muscle patches were harvested from donor littermates not expressing the β-galactosidase reporter gene and sutured on the epicardium directly above the infarct zone. Patch only–treated mice received uncoated patches. Patch + BMC–treated mice received patches coated with 5 × 10 6 β-galactosidase-expressing BMCs embedded in a collagen-rich three-dimensional matrix. Results Mortality rate was 52% after muscle patch implantation. Bone marrow cells were able to migrate from muscle patch into the infarct zone, as demonstrated by β-galactosidase immunostaining, and ultimately constituted 8% of all cells in scar tissue (mean ± standard deviation, 219 ± 111/mm 2 ). Angiogenesis and cell survival in the scar were improved by patch + BMC treatment. Left ventricular geometry and cardiac function were improved by patch treatment, with or without BMC, although the effects were stronger after patch + BMC treatment. Conclusions Epicardial deposition of a BMC-coated muscle patch is a promising approach to restoring cardiac function after myocardial infarction.

The Impella Recover LP 5.0® is an aortic transvalvular microaxial pump designed to unload the left ventricle and to ensure a systemic flow in severe left ventricular dysfunction. We propose a new suggestion for the Impella 5.0 as a temporary right ventricular assist device after the surgical treatment of a posterior post-infarction ventricular septal defect.

Cardiac support is a new and promising therapy for refractory heart failure. Only a few previous publications focused on technical implantation of such device. We have developed a new technique that facilitates a consistent and safe implant when the procedure is done without extra-corporeal circulation (ECC). Herein, we report our experience of 60 consecutive Corcap ® cardiac support device (Acorn Cardiovascular, USA) implantations off-pump for both isolated and combined implantation.

Infrarenal aortic cross-clamping (ACC) induces hemodynamic disturbances that may affect respiratory-induced variations in stroke volume and, therefore, affect the ability of dynamic parameters such as pulse-pressure variation (PPV) to predict fluid responsiveness. Since this issue has not been investigated yet to authors' knowledge, the hypothesis was tested that ACC may change PPV and impair its ability to predict fluid responsiveness.Prospective laboratory experiment.A university research laboratory.Nineteen anesthetized and mechanically ventilated pigs.Two courses of volume expansion were performed using 500 mL of saline before and during ACC. Animals were monitored using a systemic arterial catheter, and a pulmonary arterial catheter (stroke volume, central venous pressure, pulmonary arterial occlusion pressure). Animals were defined as responders to volume expansion if stroke volume increased ≥ 15%.Before ACC, 13 animals were responders. Fluid responsiveness was predicted by a PPV ≥ 14% with a sensitivity of 77% (95% CI = 46%-95%) and a specificity of 83% (95% CI = 36%-97%). The area under the receiver operating characteristic curve was 0.90(95% CI = 0.67-0.99) and was higher than those generated for central venous pressure and pulmonary arterial occlusion pressure. ACC induced an increase in PPV (p0.0005). During ACC, 8 animals were responders. An 18% PPV threshold discriminated between responders and non-responders to volume expansion, with a sensitivity of 87% (95% CI = 47%-98%) and a specificity of 54% (95% CI = 23%-83%). The area under the receiver operating characteristic curve was 0.72 (95% CI = 0.47-0.90) and was not different from those generated for central venous pressure and pulmonary arterial occlusion pressure.ACC induced a significant increase in PPV and reduced its ability to predict fluid responsiveness.

OBJECTIVES: Cell loss during cardiac injection and hostility of the host-tissue microenvironment have the potential to diminish the overall effect of stem cell therapy. The purposes of this study were to evaluate the effect of a hypoxic preconditioning of mesenchymal stromal cells (MSC), to determine its safety and effectiveness, and to improve the efficacy of cell therapy using MSC in the setting of chronic myocardial ischaemia in swine. METHODS: Myocardial ischaemia was induced by an ameroid constrictor. Human MSC were cultured under normoxic (20% O2 )o r hypoxic conditions (1.5% O2) before transplantation. One month after ischaemia, pigs were randomly assigned to saline injection (sham), and 1 × 10 6 /kg normoxic or hypoxic MSC transplantation into the ischaemic inferior-lateral zone. RESULTS: Twenty-seven pigs were operated on and the mortality rate was 33.3%. The remaining 18 animals were randomly assigned to sham (n= 4), normoxic (n= 8) or hypoxic MSC (n= 6) treatment. Global systolic (left ventricle ejection fraction, P= 0.04) and diastolic (E/ Ea, P= 0.008) functions were increased in the hypoxic group compared with other groups. The peak of 2-dimensional longitudinal strain was less altered in the hypoxic group compared with other groups (P< 0.001). Haemodynamic data showed that dP/dT max was improved in the hypoxic group compared with the other group (P< 0.01). Capillary density was increased in the hypoxic group (P= 0.001). MSC density was significantly higher in the ischaemic zone in the hypoxic group (P< 0.01). CONCLUSION: MSC engraftment with hypoxic preconditioning significantly improves capillary density and cell survival, resulting in improvement in global, regional and diastolic left ventricular functions. This highlights the therapeutic potential of transplanting hypoxicpreconditioned MSC in the setting of chronic ischaemic heart failure.

Objective— The inflammatory response after myocardial infarction plays a crucial role in the healing process. Lately, there is accumulating evidence that the Wnt/Frizzled pathway may play a distinct role in inflammation. We have shown that secreted frizzled-related protein-1 (sFRP-1) overexpression reduced postinfarction scar size, and we noticed a decrease in neutrophil infiltration in the ischemic tissue. We aimed to further elucidate the role of sFRP-1 in the postischemic inflammatory process. Methods and Results— We found that in vitro, sFRP-1 was able to block leukocyte activation and cytokine production. We transplanted bone marrow cells (BMCs) from transgenic mice overexpressing sFRP-1 into wild-type recipient mice and compared myocardial healing with that of mice transplanted with wild-type BMCs. These results were compared with those obtained in transgenic mice overexpressing sFRP-1 specifically in endothelial cells or in cardiomyocytes to better understand the spatiotemporal mechanism of the sFRP-1 effect. Our findings indicate that when overexpressed in the BMCs, but not in endothelial cells or cardiomyocytes, sFRP-1 was able to reduce neutrophil infiltration after ischemia, by switching the balance of pro- and antiinflammatory cytokine expression, leading to a reduction in scar formation and better cardiac hemodynamic parameters. Conclusion— sFRP-1 impaired the loop of cytokine amplification and decreased neutrophil activation and recruitment into the scar, without altering the neutrophil properties. These data support the notion that sFRP-1 may be a novel antiinflammatory factor protecting the heart from damage after myocardial infarction.

Background After an acute coronary syndrome (ACS), pharmacologic therapy and lifestyle intervention (optimal medical therapy, OMT) are efficient in reducing cardiovascular (CV) events. However, even if recommended secondary prevention goals are reached, a subset of patients still present CV events. Aim To identify biological or cardiovascular markers predicting the residual risk of CV events in post-ACS patients receiving OMT. Patients and methods 990 patients benefited from an evaluation of risk factors and atherosclerosis lesions, and optimization of long-term treatment and education. Traditional CV risk factors and atheroma disease markers (intima-media thickness (IMT), carotid atheroma, Ankle Brachial Index (ABI) and number of coronary arteries with >50% stenosis) were evaluated 3 months after ACS. CV events were recorded at follow-up (CV death, ACS, stroke, heart failure, revascularization). Results At a median follow-up of 20 months, more than 80% of the patients reached recommended prevention goals. 116 total CV events were recorded. Diabetes was the only CV risk factor significantly associated with CV events in multivariate analysis (including age, sex, hypertension, LDL cholesterol, smoking, diabetes and hsCRP); HR 1,61 (1,09–2,39), p = 0,017. In multivariate analysis including CV risk factors and atheroma disease markers (peripheral vascular disease (PVD) defined as ABI 50%, IMT >0,7 mm, 3-vessel and/or left main coronary disease), only PVD remained significantly associated with CV events; HR 1,83 (1,02–3,31), p = 0,04. The number of vascular beds involved was associated with poorer prognosis: HR for 3 vascular-beds disease 3,85 (1,72–8,63) p = 0,001, given 1 vascular-bed disease as a reference group. Conclusion In post-ACS patients with OMT, PVD and atheroma burden represent powerful prognostic markers of CV events, while diabetes remains the only independent marker of CV events among traditional CV risk factors.

Background A pacemaker recipient may be hospitalized recurrently with an infection of unknown origin despite detailed investigations. Objective The purpose of this study was to investigate whether 18 F-fluorodeoxyglucose positron emission tomography/computerized tomography (FDG-PET/CT) scanning has a role in identifying pacing material infection in these difficult cases. Methods Ten patients who presented with fever of unknown origin despite detailed investigations including transesophageal echocardiography underwent FDG-PET/CT scanning. Identification of increased FDG uptake along a pacing lead prompted the removal of the entire pacing system, whereas in the absence of increased FDG uptake the pacing material was left in place. Forty control pacemaker recipients underwent FDG-PET/CT scanning as part of investigation of malignancy. Results Among the 40 patients in the control group, FDG-PET/CT scanning was normal in 37 (92.5%) patients. Among the 10 patients who presented with suspected pacing system infections, FDG-PET/CT scanning showed increased FDG uptake along a lead in six patients; as a result of this finding, these patients subsequently underwent complete removal of the implanted material. Cultures of the leads were positive in all six patients, confirming involvement of the leads in the infectious process. In the other four patients, the pacing system was left in place without objective signs of active lead endocarditis during follow-up. Conclusion This study demonstrates the potential value of FDG-PET/CT scanning in the diagnosis of pacing lead endocarditis in difficult cases. Increased FDG uptake along a lead in this clinical context appears to be a reliable sign of active infection.

We present and characterize an original experimental model to create a chronic ischemic heart failure in pig. Two ameroid constrictors were placed around the LAD and the circumflex artery. Two months after surgery, pigs presented a poor LV function associated with a severe mitral valve insufficiency. Echocardiography analysis showed substantial anomalies in radial and circumferential deformations, both on the anterior and lateral surface of the heart. These anomalies in function were coupled with anomalies of perfusion observed in echocardiography after injection of contrast medium. No demonstration of myocardial infarction was observed with histological analysis. Our findings suggest that we were able to create and to stabilize a chronic ischemic heart failure model in the pig. This model represents a useful tool for the development of new medical or surgical treatment in this field.

Background— Some operators routinely extract chronically implanted transvenous leads from a femoral, whereas others prefer a superior approach. This prospective study compared the safety and effectiveness of laser sheaths versus femoral snare extractions. Methods and Results— The single-center study comprised 101 patients referred for unequivocal indications to extract ≥1 transvenous lead(s). Patients were >4 years of age and were randomly assigned to extractions with a laser sheath (group 1: n=50) versus a snare via femoral approach (group 2: n=51). The multicenter study comprised 358 patients who underwent extraction of old transvenous leads using laser sheaths (n=218, group 3) in 3 centers and from a femoral approach (n=138, group 4) in 3 other centers. In the single-center study, the success and complications rates were similar in groups 1 and 2. No patient died of a periprocedural complication. The procedural duration (51±22 versus 86±51 minutes) and duration of total fluoroscopic exposure (7±7 versus 21±17 minutes) were significantly shorter (each P P =NS). The rates of complete, partial, and unsuccessful extractions were similar in groups 3 and 4. Conclusions— Old transvenous leads were extracted with similar success and complication rates by the femoral and laser approaches. However, the femoral approach was associated with longer procedures and a longer duration of fluoroscopic exposure.

Despite much progress in the medical management of myocardial ischemia, several problems remain and experimental models help to improve our understanding of the pathophysiology involved in this domain. The ameroid constrictor model is the most widely used to create ischemia but evaluation of patent ischemia is still under debate. In the present study, we describe the potential of a two-dimensional (2D) strain for experimentally evaluating myocardial ischemia in the pig. An ameroid constrictor was placed around the circumflex artery in 30 pigs. Angiography showed 90% stenosis at one and two months. Left ventricular function was moderately altered and associated with mitral valve insufficiency in 30% of cases. Longitudinal and circumference strains were dramatically modified in the ischemic inferior-lateral zone compared to the healthy anterior zone (P

Purpose: We measured the proportion of intravascular leads, which can be extracted by simple traction versus with newer techniques, and examined the overall safety and success rate of lead extractions. Methods: Between January 2005 and December 2007, 311 consecutive patients (mean age = 70 ± 14 years, 79% men) underwent extractions of 250 atrial, 318 ventricular, and 22 coronary sinus leads, in the surgical facilities of two experienced medical centers, under general anesthesia, at a mean of 7.2 ± 5.1 years (range 0.1–27.0) after lead implantation. Infection was the indication for extraction in 67.5% of cases. Complementary techniques were used when simple extraction with a locking stylet was unsuccessful. Results: Simple traction, with or without a locking stylet, allowed the complete removal in 27.0% (95% confidence interval [CI] 22.1–31.9) of patients. A mechanical sheath, laser sheath, and/or lasso catheter were used in the remaining patients. The overall extraction success rate was 89.7% (95% CI 86.3–93.1). There was one procedure-related death (0.3%; 95% CI 0.0–1.0). Among five other deaths occurring within 10 days after the procedure, four were due to septic shock. Duration of lead implantation was the strongest independent predictor of major adverse events (P = 0.002) and incomplete lead extraction (P = 0.005). Conclusion: In contrast with simple traction, advanced techniques allowed the complete extraction of nearly 90% of leads. In experienced hands and with surgical back-up, these techniques were safe. Patients presenting with infected implanted cardiac devices suffered a high rate of major adverse despite complete extraction of the lead(s).

Background: Cardiogenic dysfunction with acute renal failure (ARF) and diuretic drug resistance increases mortality after cardiac surgery with cardiopulmonary bypass (CPB) in adults. Until few years ago, intermittent renal replacement therapy (IRRT) was the only therapeutical strategy proposed to such patients. Few data are available in the literature regarding the use of continuous veno-venous haemofiltration (CVVH) in this clinical context. The aim of our observational study was to evaluate the impact of CVVH strategy on ARF in conjunction with cardiogenic shock after cardiac surgery and on its well-known associated poor outcome. Methods: During the period 2005—2006, we prospectively collected data from our database as we controlled the renal replacement therapy using CVVH (n = 73). We also retrospectively collected data from our computerised database on patients who were treated with IRRT (n = 68, period 2002—2003). Among CVVH-treated patients, a multivariate analysis of the data aimed to identify risk factors associated with 30-day mortality. Results: In patients who presented with ARF in conjunction with cardiogenic shock after cardiac surgery, 30-day mortality rate was 59% for the IRRT group and 42% for the CVVH group. Within the CVVH group, the logistic regression and multivariate analyses reported that some variables were associated with higher mortality risk: a score F concerning the urinary output criteria of the RIFLE (risk, injury, failure, loss, end-stage kidney disease) classification (for scores R or I: odds ratio (OR): 0.01, 95% confidence interval (95% CI): 0.02—0.59; p = 0.01), plasma bilirubin (OR: 1.44, 95% CI: 1.12—1.84; p = 0.04), total CVVH duration 50 h; OR: 0.009, 95% CI: 0.04—0.93; p = 0.01), the need of catecholamine support (OR: 12.88, 95% CI: 1.95—84.96; p = 0.01), tachycardia in the intensive care unit (ICU; OR: 1.64, 95% CI: 1.02—2.65; p = 0.04), surgery duration (