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We report 4 cases of off-pump ascending aorta wrapping combined with ascending aorta stenting in retrograde Stanford A acute aortic dissection (SAAD). Since 2008, 18 patients have undergone wrapping of the ascending aorta at our institution. Four patients had a persistent circulating false lumen in the ascending aorta after wrapping, with a threat to the aortic root. We chose an endovascular approach with ascending aorta stenting. Follow-up computed tomography showed a reapplication of the intimal flap in the reinforced aorta. Ascending aorta stenting after aortic wrapping for retrograde SAAD is a safe and efficient technique to prevent proximal progression of the dissection.

TAVI is an alternative solution for patients with aortic valve stenosis (AS) who are refused for conventional surgery. We sought to evaluate the incidence, characteristics, predictors and prognosis impact of serious hemorrhagic complications following transcatheter aortic valve implantation (TAVI).One hundred and seventy one consecutive patients with symptomatic severe AS (83.5 ± 6.1 y; 53% women; mean EuroSCORE=22.1 ± 12.3) underwent transapical (TA) or transfemoral (TF) TAVI in our institution using Edwards SAPIEN© and Medtronic CoreValve© devices. The primary evaluated criterion was the incidence of any bleeding complication, according to the Valve Academic Research Consortium (VARC) criteria.VARC serious hemorrhagic complications occurred in 34.5% of patients (n=23 life-threatening/disabling (LT/D) and n=36 major bleedings). Most of these complications were related to access site complications (69%). Multivariable analysis revealed that TA access, low weight and underlying coronary artery diseases were independent predictors for development of serious bleeding. The mortality was significantly higher in patients with serious events compared to patients without bleeding (p=0.008, log-rank analysis). Although the survival didn't significantly differ in patients with major hemorrhagic events, subjects with LT/D bleeding events had a higher mortality than the subjects with no hemorrhagic complications (p0.001, log-rank analysis). Occurrence of VARC LT/D event independently predicted all-cause mortality (HR=5.35 [2.51-11.43], p0.001) during the first year following TAVI in multivariate Cox regression analysis.Severe bleeding is frequent following TAVI procedure and is mainly related to local hemorrhage. VARC LT/D events are associated with decreased survival after AS correction.

Background Surgical management of ventriculo-aortic disconnection and aortic root abscesses after prosthetic aortic valve endocarditis carries high mortality and morbidity. Initial experience with translocation of the aortic valve and distal coronary artery bypass grafting was disappointing in terms of short-term and long-term success in the few published reports. We describe a technique of translocation of the aortic valve into the ascending aorta with direct antegrade myocardial revascularization. Methods Between 1980 and 1992, we included 21 patients and evaluated their long-term outcome. The surgical technique included extracting the aortic valve prosthesis, resecting all infected tissue, restoring the left ventricular outflow tract, and translocating the aortic valve into the ascending aorta, associated with myocardial revascularization of the left main trunk and the proximal right coronary artery. Results All patients required emergency surgery: 15 patients were in severe congestive heart failure, 3 patients were in cardiogenic shock, and 3 patients had multiple neurologic and peripheral signs of distal embolization. Fifteen patients had active prosthetic valve endocarditis. Intraoperative findings dictated the translocation. The overall hospital mortality was 14%. None of the 18 hospital survivors had prosthetic aortic valve endocarditis recurrence. All patients were observed from 12 to 22 years, are alive, and have resumed normal activities. Conclusions In severe forms of prosthetic valve endocarditis, this technique provides a safe and reliable alternative to homograft replacement. The long-term results are satisfactory.

Trans-femoral and transapical are the most commonly used accesses for transcatheter aortic valve implantation (TAVI). However, when these approaches are unsuitable, alternative accesses are needed. We report a series of 19 patients undergoing TAVI through common carotid artery (CCA) access under local anaesthesia in order to assess its feasibility and safety.From November 2008 to September 2013, 361 patients underwent TAVI at our institution. Nineteen of them (14 men) with mean age 82.2 ± 6.2 years, EuroSCORE 25.2 ± 15.7, Society of Thoracic Surgeons score 11.9 ± 5.1 and with severe peripheral arteriopathy were unsuitable for usual approaches and underwent TAVI through CCA access under local anaesthesia. Preoperative computed tomography assessed suitable carotid artery anatomy. Common carotid cross-clamping test allowed verifying patient's neurological status stability. An 18-Fr or 20-Fr sheath inserted into the CCA down into the ascending aorta was used for the delivery catheter. Valve implantation procedures were as usual. After sheath removal, the CCA was surgically purged and repaired. Feasibility and safety end points (VARC-2) were collected up to 30 days.Transcarotid insertion of the delivery sheath was successful in all cases (8 right, 11 left) and accurate deployment of the device was achieved in 18 patients (4 Edwards SAPIEN XT and 14 Medtronic CoreValve). There was 1 intraoperative death by annulus rupture during preimplant balloon valvuloplasty, and 1 in-hospital death due to multisystem organ failure. There was no myocardial infarction, stroke or major bleeding. Third-degree atrioventricular block requiring pacemaker implantation occurred in 3 patients. No vascular access-site, access-related or other TAVI-related complication occurred. Echocardiography revealed good prosthesis functioning with none, mild and moderate paravalvular leak in, respectively, 8, 9 and 1 patients. Patient ambulation was immediate after TAVI and hospital stay was 4.6 ± 2.3 days.TAVI through the CCA approach under local anaesthesia is feasible and safe. It allows continuous clinical neurological status monitoring with low risk of stroke, bleeding events, vascular access-site and access-related complications and immediate patient ambulation. It appears to be a valuable alternative access for patients who cannot undergo trans-femoral TAVI.

To assess the relation of aortic transvalvular gradient with outcomes following transcatheter aortic valve implantation (TAVI).Relatively little is known about the predictors of adverse outcomes in patients with severe aortic stenosis following TAVI.We studied 126 consecutive patients (mean age 83.2 ± 6.3 years; 59% women) who underwent TAVI (23% transapical; 77% transfemoral) at our institution. All patients were followed for the incidence of major adverse cardiovascular events (MACE), including myocardial infarction, heart failure, stroke, and cardiovascular death.The acute procedural success rate was 98%; at 1 year, the cumulative incidence of MACE and cardiovascular death was 29% and 10%, respectively. In multivariable analyses adjusting for clinical and echocardiographic risk factors, presence of a baseline mean transvalvular gradient (MTG)40 mmHg was a significant predictor of 30-day MACE in the total sample (OR 4.4, 95% CI 1.7-11.4; P=0.003) as well as in patients with an ejection fraction ≥ 50% (OR 10.3, 95% CI 3.0-33.4; P0.001). In multivariable analyses, low MTG was also associated with 2-fold and 4-fold increased hazards for MACE (HR 4.2, 95% CI 2.0-8.9; P0.001) and cardiovascular death (HR 4.2 95% CI 1.2-14.9; P=0.03), respectively, within 1 year following TAVI.Presence of a low MTG (40 mmHg) prior to TAVI was associated with a greater risk of major adverse events, including cardiovascular death, up to 1 year following the procedure. Pre-procedural MTG could be used to identify patients at a high risk for adverse outcomes following TAVI.

Background The internal thoracic artery (ITA) is considered to be the conduit of choice for coronary artery bypass grafting surgery (CABG). In triple-vessel–disease patients, CABG can be performed exclusively using both ITAs in a Y fashion with multiple sequential side-to-side coronary anastomoses. The aim of this prospective study was to evaluate by early postoperative angiographic control, the patency and particularly the quality of ITA grafts and coronary anastomoses in this configuration. Methods Between October 2002 and October 2003, 92 triple-vessel–disease patients underwent CABG with this technique and consented to immediate postoperative angiographic control. The right ITA was divided at its origin and connected to the in-situ left ITA (ITA-Y anastomosis). The left ITA was anastomosed to anterior coronary arteries and the right ITA was anastomosed to lateral and inferior coronary arteries, for a total of 374 coronary anastomoses (4.1 anastomoses per patient; range, 3 to 6). Results There was 1 hospital death by septic shock. Two patients were reoperated on for superficial wound infection. There was no postoperative myocardial infarction or stroke. On postoperative angiograms, all ITA-Y (92) and ITA-coronary anastomoses (374) were patent. Competition of flow in right ITA to the moderately stenosed right coronary artery was observed in 9 patients, and there were 4 distal ITA-coronary stenoses, both without clinical consequences. Conclusions In triple-vessel–disease patients, this procedure allows CABG without increasing operative risk. ITA-Y anastomoses and multiple sequential side-to-side ITA-coronary anastomoses are safe to perform and demonstrate excellent patency and quality in early postoperative angiographic control, particularly when coronary artery stenoses are significant (>70%).

Chronic ischemic mitral regurgitation (IMR) is characterized by restricted leaflet closure with increased leaflet tethering caused by displaced attachment of the papillary muscle (PM). Generally, the posterior PM is displaced by ventricular remodeling after posterolateral myocardial infarction. IMR carries a significantly negative prognostic effect for cardiac mortality within 5 years, even in patients without signs of established heart failure. A variety of surgical techniques of repairing or replacing the mitral valve have been advocated. These techniques are generally technically demanding and necessitate opening the left side of the heart. Experimental work on ventricular remodeling through reduction of the left ventricular circumference by plication of the left ventricle (LV) can restore mitral geometry toward a normal level. Recently, an external device that repositions the PM has been shown to reduce IMR without compromising LV function. We report the first 3 cases in human subjects of chronic IMR treated by means of plication of the fibrotic infarct in the posterolateral wall of the LV simultaneously with a coronary revascularization procedure without mitral annuloplasty.

We describe off-pump wrapping of the ascending aorta in 3 high-risk patients with acute type A aortic dissection when the primary intimal tear was not located in the ascending aorta and in the absence of aortic insufficiency. A Teflon plaque (Bard Inc, Murray Hill, NJ) was tailored to tightly wrap the aorta from the coronary ostia to the innominate artery. The mean age of the patients was 80.3 years. All patients were at high risk for conventional surgery. A postoperative computed tomographic scan showed a reapplication of the intimal flap and containment of the false lumen in the reinforced ascending aorta in all patients.

Background Although trans aortic valve implantation (TAVI) is a promising alternative solution for patients who could not undergo conventional surgery, few data are available regarding post-procedure complications among these fragile subjects. Objectives We sought to evaluate the factors associated with adverse outcome in patients with TAVI. Methods Clinical, biological and echocardiographic characteristics of the patients were assessed before implantation. Patients were followed up to 30 days after procedure. Our main primary end-point was the composite of death+stroke+acute pulmonary edema at day 30. Results Between November 2008 and March 2010, n = 55 patients underwent TAVI in our institution (mean age = 84.4 ± 0.7 y; 40% men; mean STS score = 25.2 ± 1.3; 65% transfemoral). Primary endpoint occured in n = 9 subjects (n = 2 deaths; n = 1 stroke; n = 6 pulmonary edema), who presented a longer inhospital stay (14.4 ± 3.2 vs. 9.2 ± 0.6 days, p = 0.008). Patients experiencing the primary endpoint were comparable to the others in terms of age, gender, renal function, comorbidities, type of percutaneous approach and STS score. The pre-implantation aortic gradient was lower in patients with adverse outcome (35.9 ± 4.0 vs. 55.0 ± 2.9 mmHg, p = 0.007), yet the left ventricle ejection fraction (LVEF/56.4 ± 1.9 vs. 58.4 ± 6.0%, p = 0.7) and effective orifice area (0.43 ± 0.03 vs. 0.37 ± 0.02 cm2/m2, p = 0.12) did not significantly differ between the e groups. Among these patients, n = 7 had LVEF>50%. Receiver operating curve analysis showed a significant relationship between aortic gradient and primary end-point (AUC = 0.82 ± 0.07, p = 0.002). Multivariate analysis identified presence of a low trans-aortic gradient ( Conclusion Patients with baseline low trans aortic gradient, as a result of either altered LVEF or paradoxical low flow aortic stenosis syndrome, have a higher incidence of major complications after TAVI and should be identified before procedure.