Position paper of French Interventional Group (GACI) for TAVI in France in 2018

Aortic stenosis is a frequent disease in the elderly. Its prevalence is 0.4% with a sharp increase after the age of 65, and its outcome is very poor when the patient becomes symptomatic. The interventional procedure known as TAVI (trans-catheter aortic valve implantation), which was developed in France and carried out for the first time in Rouen by Prof. Alain Cribier and his team in 2002, has proven to be a valid alternative to surgical aortic valve replacement. At first, this technique was shown to be efficient in patients with contra-indications to surgical treatment or deemed to be at high surgical risk. Given the very promising outcomes achieved as a result of close heart team collaboration, appropriate patient selection, simplified procedures and reduced complication rates, transfemoral (TF) TAVI is now preferred in symptomatic intermediate risk patients>75 years old according to the latest ESC guidelines. In 2017, in France, TAVI is currently performed in 50 centers with on-site cardiac surgery. The 2016 TAVI outcomes recorded in the French national TAVI registry (France TAVI) are very encouraging and show that for 7133 patients treated (age 83.4±7 years, logistic Euroscore 14%), 87% of whom via the TF approach, cross-over to surgery was very low (0.5%) with a 3.0% in-hospital mortality rate. The substantial increase in TAVI indications and the improvement of its outcomes may in the near future call for a reconsideration of the number of high volume centers authorized to carry out this technique.

[Severe infective endocarditis through the history]

The history of infective endocarditis (IE) is a good example of medical progress. Initially incurable, endocarditis, when diagnosed, was synonym of death. After significant diagnostic progress, thanks to Osler's contribution especially, the first surgeries and antibacterial drugs obtained very few successful cures. We had to wait until Flamming's discovery to observe frequent cures thanks to antibiotics. Surgery manages to push possibilities of cure a bit further. However, paravalvular extensions, described since the first surgical case of IE, was a real technical matter. Thus, the second half of 20th century was devoted to overcoming this surgical challenge. In this historical review, we describe the story of severe IE, especially with paravalvular involvement, by highlighting major progress - clinical and surgical, that allows its current management.

Intraoperative tracking of aortic valve plane

The main objective of this work is to track the aortic valve plane in intra-operative fluoroscopic images in order to optimize and secure Transcatheter Aortic Valve Implantation (TAVI) procedure. This paper is focused on the issue of aortic valve calcifications tracking in fluoroscopic images. We propose a new method based on the Tracking-Learning-Detection approach, applied to the aortic valve calcifications in order to determine the position of the aortic valve plane in intra-operative TAVI images. This main contribution concerns the improvement of object detection by updating the recursive tracker in which all features are tracked jointly. The approach has been evaluated on four patient databases, providing an absolute mean displacement error less than 10 pixels (≈2mm). Its suitability for the TAVI procedure has been analyzed.

[Tracheal adenoid cystic carcinoma treated by complete carinal reconstruction with the help of an ECMO: about a case]

Primitive tumors of the trachea are rare, accounting for 0.1% of the airway tumors. Cystic adenoid carcinoma (or cylindroma) represents the second most frequent type of tracheal cancers. Histologically speaking, this tumor type is divided in three patterns: cribriform, tubular and solid; it presents a slow growth, perineural invasion and potential local recurrence and metastasis. We presented herein the case of a 56-year-old female suffering from a cystic adenoid carcinoma of the low trachea. She has been treated by carinal resection with negative airway margin and complete reconstruction, with the help of an extra corporeal membrane oxygenation (ECMO).

[Heart transplantation for patients on high emergency list with or without extracorporeal membrane oxygenation support]

OBJECTIVE

Severely impaired patients may wait in France on a special and temporary high emergency national list (called SU). Some of these patients need mechanical circulatory support with ECMO. In order to compare two groups of patients on SU, who acceeded to heart transplantation (HT) with or without ECMO, we reviewed retrospectively 20 consecutive patients transplanted on SU between January 2004 and September 2007 in Rennes.

PATIENTS AND METHODS

Among them, 10 were transplanted without ECMO and 10 others were implanted with a femoro-femoral ECMO before HT.

RESULTS

(1) Considering the group SU without pretransplantation ECMO: 2 years survival rate was 70%. Mean hospital stay was 26.4 days. Three patients were implanted with ECMO for graft dysfunction during postoperative course, without inherent complication. None graft dysfunction occurred after initial hospitalization; (2) considering the group SU with pretransplantation ECMO: 2 years survival rate was 90% (one early death). Mean hospital stay was 45 days with multiple complications due to the ECMO (leg's ischemia: n = 2; lung oedema: n = 1; lymphorrhea: n = 3, low flow requiring change of canulae: n = 1). None graft dysfunction occurred after initial hospitalization.

CONCLUSION

Although we didn't reach statistical significance, it seems that ECMO for patients in SU may be useful as bridge to transplant but with a higher morbidity than for similar patients transplanted without ECMO. Additional data from other transplant centers are needed to confirm our findings.

[Early non-obstructive thrombosis of mechanical mitral valve prostheses]

Transoesophageal echocardiography has shown a high incidence on non-obstructive thrombosis after mitral valve replacement with a mechanical prosthesis. The unpredictable outcome and the period during which the complication arises make treatment difficult. The aim of this study was to assess the tolerance and efficacy of the association of long-term heparin and oral anticoagulation, as recommended in this indication. All patients undergoing mitral valve replacement with a mechanical prosthesis between June 1999 and July 2001 were systematically included and studied by transoesophageal echocardiography in the immediate postoperative period. Those with non-obstructive thrombosis at least 5 mm in size were treated by heparin and oral coagulation until the thrombus disappeared on transoesophageal echocardiography. One hundred and fourteen patients undergoing 120 mitral valve replacements (6 reoperations) underwent transoesophageal echocardiography and non-obstructive thrombi measuring at least 5 mm were found on 26 occasions (21.7%). The association of heparin and oral coagulation was maintained for 7 to 115 days (average 20 days). No thromboembolic or haemorrhagic complications and no deaths were observed during this period. Two patients were treated with danaparoid and oral anticoagulation because of heparin-induced thrombocytopenia before the diagnosis. None of the patients died during follow-up (average 49 months); there were 4 recurrent non-obstructive thromboses, three of which were complicated by thromboembolic events with no sequellae in the first 8 months, again treated effectively with the association of heparin and oral anticoagulants; two cerebral embolic events without sequellae were observed without a demonstrable non-obstructive thrombus on transoesophageal echocardiography. The authors conclude that the association of heparin and oral anticoagulants seems well tolerated and effective in this small population and this would justify a large scale clinical trial.

Two cases of 'asthma' revealing a diverticulum of Kommerell

Among embryonic aortic vascular malformations, persistence of a right aortic arch and aberrant left subclavian artery associated with a diverticulum of Kommerell is rare, and is estimated to occur in 0.1% of the general population. We report two cases of diverticulum of Kommerell in which tracheal compression due to the vascular ring induced respiratory symptoms such as asthmatic dyspnoea. This reminds us that at least a chest X-ray should be performed in newly diagnosed asthmatic patients, focusing on the trachea and upper mediastinum. In case of vascular abnormality, angiography and magnetic resonance are the best investigations to define the abnormal anatomy and guide surgery.

[Results of surgical treatment of calcified aortic valve stenosis: report of a series of 4,129 interventions]

Aortic stenosis (AS) is the most common lesion currently encountered among valvular heart disease, particularly in elderly people. Severe functional impairment and risk of sudden death explain that surgical treatment is largely accepted. We report a retrospective analysis of institutional experience with aortic valve replacement (AVR) for AS from 1971-1997 in 4,129 patients. Age ranged from 13 to 91 years (mean 68 +/- 10) and degenerative disease was largely predominant (86%). For AVR, mechanical prostheses were used in 2,054 patients (50.2%) and bioprostheses in 2,075 (48.8%) in elderly group. Coronary artery revascularization was associated in 670 patients (16%). Operative mortality was 7% (303 pts) and main cause was left ventricular failure (52%). Late results were studied with a maximum follow-up of 26 years. Total follow-up represents 21,533 pt-years. Late death occurred in 1,108 patients between 1 month and 24 years after operation (mean 6.6 years). Reoperation was necessary in 136 cases. Actuarial survival--including operative mortality--was 77% and 56% at 5 and 10 years. A large functional improvement was observed in the vast majority of patients, 73% being I or II subgroups of the NYHA classification. Incremental risk factors for death (immediate as well as late) were older age, preoperative functional status, emergency, presence of cardiac failure, coronary artery lesions and associated morbidity. The choice of valvular prosthesis remains controversial, but the results show that AVR is the procedure of choice for the vast majority of patients wtih significant aortic valve disease.

Feasibility of the utilisation of the right internal thoracic artery in the transverse sinus in off pump coronary revascularisation: early angiographic results

OBJECTIVE

The objective of this study was to analyze the feasibility of beating heart coronary surgery and to angiographically assess complete revascularisations with routine use of the two internal thoracic arteries (ITA), with the right ITA pedicled and placed through the transverse sinus. The authors report the results of their initial experience of coronary surgery without CPB, which began in December 1998.

METHODS

From December 1998 to October 1999, 50 patients underwent non-urgent beating heart coronary revascularisation via a median sternotomy with the 2 ITA. Stabilization of the anastomotic site was ensured by the Octopus stabilizer 1 then 2. A troponin Ic assay was systematically performed in the initial postoperative period. With the patient's consent, postoperative angiography was performed before discharge.

RESULTS

The mean number of anastomoses was 2.5+/-0.6 per patient (range: 2-4). Distal anastomoses by arterial grafts were performed in 87% of cases. In one case, the right ITA could not be kept pedicled and tunnelled in the transverse sinus and a Y graft onto the left ITA had to be performed. Left anterior descending-diagonal sequential bypass with the left ITA was performed in seven patients (14%). There was no operative mortality. One patient developed postoperative myocardial infarction. Follow-up angiography was performed in 42 cases (84%), with 104 anastomoses reviewed (85%). The patency rate for all anastomoses was 98.1%, with 90.4% of excellent results. The patency rate of the right ITA was 100%, with 90.5% of excellent results.

CONCLUSIONS

Beating heart coronary surgery allows revascularisation of all coronary territories. This technique is not an obstacle to the use of the pedicled right ITA tunnelled in the transverse sinus. It is not associated with an increased postoperative morbidity and mortality, and the early follow-up angiographic results are excellent.

Structural durability in Carpentier Edwards Standard bioprosthesis in the mitral position: a 20-year experience

BACKGROUND AND AIM OF THE STUDY

Few long-term data are available on the Carpentier-Edwards Standard bioprosthesis in the mitral position. As for other bioprostheses, patient age at the time of implant is the main risk factor for structural deterioration, but no published report has analyzed the life-span of these bioprostheses with respect to this parameter.

METHODS

A series of 139 patients who underwent mitral valve replacement with the Carpentier-Edwards Standard bioprosthesis between 1978 and 1987 was reviewed. Mean age at implant was 59.6+/-14.7 years (range: 17-79 years). Follow up was 98.4% complete; total follow up was 1,078.7 patient-years (pt-yr) (mean 8.4+/-4.1 years). Mean follow up in the subgroup of patients alive at the time of the survey was 10.4+/-3.4 years.

RESULTS

Structural valve deterioration (SVD) occurred in 30 patients, with mean time to onset of deterioration 9.0+/-2.7 years (median 8.7 years). This time was independent of age at the time of implantation. Analysis by age group (< or =35, 36-50, 51-60, 61-65, 66-70, >70 years) showed deterioration to be more frequent in younger subjects (linear rates 7.9, 6.0, 3.3, 2.4, 0.6 and 0.4% pt-yr, respectively). Over the age of 65 years, the risk of SVD no longer varied with age, and was a rare complication.

CONCLUSION

The mean time to onset of SVD was independent of patient age at the time of implant. After 65 years, the risk of SVD was low, without any significant variation. The Carpentier-Edwards Standard bioprosthesis may be used in the mitral position in subjects aged over 65 years, and with a low risk of deterioration.

Carpentier-Edwards supraannular porcine bioprosthesis in aortic position: 16-year experience

BACKGROUND

The aim of the study was to evaluate the long-term results of aortic valve replacement with the Carpentier-Edwards supraannular porcine bioprosthesis.

METHODS

A total of 278 patients who underwent aortic valve replacement between January 1983 and December 1986 were reviewed. Mean age was 69.4+/-11.0 years (range 24 to 90 years).

RESULTS

The operative mortality was 8.6% (24 patients). The total follow-up was 2367.1 years (mean 9.3+/-4.3 years, maximum 15.5). The late mortality rate was 6.8%/patient-year (162 patients) and the overall survival at 15 years was 26.5%+/-3.6%. Structural valve deterioration (SVD) occurred in 19 patients (linearized rate 0.8%/ patient-year). The mean time to onset of deterioration was 10.9+/-2.9 years. This time was independent of the age at the time of implantation. The freedom from SVD at 10, 12, and 15 years for patients aged less than 60 was respectively 87.6%+/-6.8%, 77.8%+/-8.9%, and 44.2%+/-12.9% (linearized rate 3.3%/patient-year). For patients aged 61 to 70 years, freedom from SVD was, respectively, 100%, 97.3%+/-2.1%, and 80.8%+/-8.3% (linearized rate 0.63% patient-year). For patients older than 70 years, it was respectively 99.1%+/-0.9%, 95.6%+/-2.6%, and 93.3%+/-3.3% (linearized rate 0.31%/patient-year). No significant difference was observed below the age of 60 years (< or =50 vs 51 to 60 years) or in the older subgroups (61 to 70 years, vs >70 years).

CONCLUSIONS

The Carpentier-Edwards supraannular bioprosthesis in aortic position provides low rate of structural valve deterioration at 15 years in patients aged more than 60 years at the time of implantation. The mean time to onset of SVD is independent of the subject's age at the time of implantation. After 60 years, the risk of deterioration is low and does not present any significant variation. The Carpentier-Edwards supraannular bioprosthesis can reliably be used for aortic valve replacement in patients over the age of 60 years because, beyond this age, SVD is observed much more rarely.

Echocardiographic assessment and preliminary clinical results after aortic valve replacement with the Medtronic Mosaic bioprosthesis

BACKGROUND AND AIM OF THE STUDY

The study aim was to examine prospectively the clinical performance and durability of the Medtronic Mosaic bioprosthesis, a stented porcine aortic valve that combines improvements in tissue preservation, notably net zero differential pressure fixation of the leaflets, with antimineralization treatment using 2-amino-oleic acid (AOA).

METHODS

A total of 158 Mosaic valves was implanted; 152 in patients aged over 70 years, and six in patients aged <70 years with contraindications to anticoagulant therapy. Mean age was 73.7 years. All valves were implanted in the supraannular position. Thirty-two patients (20%) required concomitant procedures, including coronary revascularization, ascending aorta replacement and/or mitral annuloplasty. Postoperative anticoagulation (heparin) was prescribed for ten days, followed by antiplatelet therapy. No long-term oral anticoagulants were prescribed, except in some patients with atrial fibrillation. The follow up included routine clinical and blood work-up, and echocardiography at six months and one year after surgery.

RESULTS

There were seven early (0-30 days) and five late deaths (>30 days). One death was caused by a hemorrhagic stroke at three months in a patient without anticoagulant or antiplatelet therapy. No thromboembolic complications or structural valve deterioration were observed during follow up. At two years, freedom from endocarditis and reoperation was each 99.6%. NYHA class was excellent, with 98% of patients in class I or II at one year. Patient survival was 92% at two years. Hemodynamically, the valve was performing well, with mean systolic gradients of 13.6, 13.2, 12.6 and 9.6 mmHg for the 21, 23, 25 and 27 mm valves, respectively. There was no evidence of structural valve deterioration.

CONCLUSION

Long-term evaluations are mandatory to confirm the durability of any new bioprosthetic valve. Satisfactory early clinical and hemodynamic results with the new Mosaic bioprosthesis warrant its continued implantation in the aortic position for patients over the age of 70 years.

Partial cricoidectomy with primary thyrotracheal anastomosis for postintubation subglottic stenosis

OBJECTIVE

We describe a Pearson-type technique and evaluate its results for postintubation subglottic stenosis.

METHODS

Forty-five patients underwent a partial cricoidectomy with primary thyrotracheal anastomosis, and 5 underwent simultaneous repair of a tracheoesophageal fistula as well. Twenty-four (53%) patients were referred to us after initial conservative (n = 21) or operative (n = 3) management. There were 27 cuff lesions, 7 stomal lesions, and 11 at both levels. The upper limit of the stenosis was 1.5 cm (range, 1-2.5 cm) below the cords, and the subglottic diameter was reduced by 60% in 38 (84%) of the patients. The length of airway resection ranged from 2 to 6 cm (median, 3 cm). Despite 23 thyrohyoid or suprahyoid releases, 8 anastomoses were under tension.

RESULTS

Thirty-seven (82%) patients were extubated after the operation (n = 30) or within 24 hours (n = 7). Six patients required postoperative airway stenting (median, 5.5 days). Early (<30 days) complications occurred in 18 (41%) patients, mainly as transient airway and voice complaints, aspiration, and dysphagia. One (2%) patient died of myocardial infarction. Late morbidities were 2 failures occurring as bilateral recurrent nerve paralysis and restenosis requiring definitive tracheostomy. Patients had excellent or good anatomic (n = 42 [96%]), functional (n = 41 [93%]), or both types of long-lasting results, with no stenotic relapse.

CONCLUSIONS

Partial cricoidectomy with primary thyrotracheal anastomosis can be applied in patients with postintubation stenosis extending up to 1 cm below the cords and measuring up to 6 cm in length with excellent-to-good definitive results. The association with a tracheoesophageal fistula does not contraindicate surgical repair.

Endothelial nitric oxide synthase function in pig lung after chronic pulmonary artery obstruction

Because long-term pulmonary artery (PA) obstruction is associated with expansion of the systemic blood supply to the lung, chronic ischemia may not occur, and endothelium nitric oxide synthase (eNOS) function may be preserved in postobstructive pulmonary arteries. To test this hypothesis, we studied piglets 2 d or 5 wk after left PA ligation or a sham operation. We measured left lung ATP and lactate lung concentrations; calcium-dependent and calcium-independent NOS activities and eNOS protein; and left PA relaxations in response to acetylcholine, calcium ionophore, and sodium nitroprusside. Decreases in ATP and increases in lactate concentrations were significantly attenuated after 5 wk PA occlusion (p < 0.05 versus sham and 2-d ligation). Compared with sham and 2-d PA occlusion, calcium-dependent NOS activity and eNOS protein were lower in the long-term PA occlusion group. Calcium-independent NOS activity was unchanged. Acetylcholine and calcium ionophore relaxations were impaired after 5 wk, whereas only acetylcholine relaxation was impaired after 2-d PA occlusion. Relaxation to sodium nitroprusside remained unchanged. In conclusion, despite relative conservation of lung energy metabolism, prolonged PA occlusion decreased eNOS function and protein in postobstructive pulmonary arteries.

Evaluation and outcome of different surgical techniques for postintubation tracheoesophageal fistulas

OBJECTIVE

We evaluated the outcome of different surgical techniques for postintubation tracheoesophageal fistula.

METHODS

Thirty-two consecutive patients aged 51 +/- 23 years had tracheoesophageal fistulas resulting from a median of 30 days of mechanical ventilation via endotracheal (n = 12) or tracheostomy (n = 20) tubes. Tracheoesophageal fistulas were 2.5 +/- 1.2 cm long and were associated with a tracheal (n = 10) or subglottic (n = 3) stenosis in 13 patients.

RESULTS

All but 3 patients were weaned from respirators before repair. All operations were done through cervical incisions and included direct division and closure (n = 9), esophageal diversion (n = 3), muscle interposition (n = 6), or, more recently, tracheal or laryngotracheal resection and anastomosis with primary esophageal closure (n = 14). Nine thyrohyoid and two supralaryngeal releases reduced anastomotic tension. Twenty-three patients (74%) were extubated after the operation (n = 16) or within 24 hours (n = 7), and 7 required a temporary tracheotomy tube. One postoperative death (3%) was associated with recurrent tracheoesophageal fistula. Seven complications (22%) included recurrent tracheoesophageal fistula (n = 1), delayed tracheal stenosis (n = 2), dysphagia (n = 2), and recurrent nerve palsy (n = 2). Complications necessitated reoperation (n = 1), dilation (n = 2), definitive tracheostomy (n = 1), Montgomery T tubes (n = 1), and Teflon injection of the vocal cords (n = 1). Twenty-nine patients (93%) had excellent (n = 24) or good (n = 5) anatomic and functional long-term results. Complications have been less common (7% vs 38%) and long-term results better (93% vs 65%) recently with tracheal or laryngotracheal resection and anastomosis with primary esophageal closure as compared with previous procedures.

CONCLUSIONS

Postintubation tracheoesophageal fistula is usually best treated with tracheal or laryngotracheal resection and anastomosis with primary esophageal closure even in the absence of tracheal damage.

[Long-term results of valve replacement using the Cobomedics prosthesis]

The Carbomedics valve prosthesis is a second generation mechanical prosthesis with a double hemi-disc. This study analysed long-term morbidity and mortality associated with this prosthesis. Between 1987 and 1996, 397 prostheses were implanted, 306 aortic, 42 mitral and 26 double replacements (3 combining a Carbomedics aortic prothesis with a mitral valve from another type) in 370 patients with a mean age of 62 (range 4 to 88 years). The global operative mortality was 7.4%. A questionnaire sent to treating cardiologists, general practitioners and patients updated the prospective data base of the cardiac surgical department. The follow-up was 99%, representing a total of 1244 patient-years with an average of 41 months (range 1.1 month to 9.9 years). The 1, 3, 5 and 7 year survival (operative mortality included) was 88%, 80%, 76% and 69.6% respectively. Haemorrhagic complications were the most common (17 cases, 1.36% per patient-year) and 11 thromboembolic episodes were observed (0.88% per patient-year) with a higher incidence (p < 10-4) in mitral valve replacement (3.8% in patient-year). The other complications observed were: 5 aseptic paravalvular leaks (0.4% per patient-year) and 5 prosthetic valve infections; no structural alterations were observed. In all, ten reoperations (0.8% per patient-year) were required for prosthetic valve complications. This study shows the reliability of Carbomedics valve prostheses with a low complication rate comparable to that of other modern mechanical valve prostheses.

[Hibernoma of the axilla]

Hibernomas are benign tumors derived from brown fat that most often present as painless, slowly enlarging masses in the interscapular region, the neck, the inguinal region and the mediastinum. We report one case of hibernoma of the axillary region and we review the clinical presentation, diagnostic and therapeutic of this kind of soft tissue neoplasm.

[Coronary artery disease in patients with aortic abdominal aneurysm. Apropos of a consecutive series of 172 cases]

Coronary artery disease is common in patients with abdominal aortic aneurysms (AAA). It is responsible for half the operative deaths explaining the necessity of diagnosing asymptomatic coronary patients. Between 1980 and 1993, 172 patients aged 47 to 92 years (average 69 years) were operated for AAA. Fifty-four of them (31%) were known to have coronary artery disease; 30 preoperative coronary angiograms and 16 prophylactic coronary revascularisation procedures were performed before operating the AAA. In cases with ruptured AAA (42 cases) the operative mortality was 31% (13 patients) compared with 6% (8 patients) in those without rupture (130 cases). Myocardial disease was responsible for 25% of all deaths (2 out of 8) and for 40% of deaths (2 out of 5) in the subgroup of 54 coronary patients. The majority of non-lethal cardiac complications also occurred in this subgroup. On the other hand, no deaths were observed in the group of 16 patients who underwent myocardial revascularisation beforehand. Follow-up of the 151 patients discharged from hospital was complete (100%). With an average follow-up period of 3.5 years (range 5 months to 13 years), 39 secondary deaths have been observed (26%) including 6 (15%) of cardiac causes. In addition, 3 patients in the coronary subgroup and 1 patient from the non-coronary group underwent myocardial revascularisation after surgical cure of their AAA. Coronary artery disease may be totally asymptomatic and severe lesions go unrecognised; the main problem is therefore to detect silent myocardial ischaemia in the absence of totally reliable non-invasive techniques, in order to perform preventive coronary revascularisation in high risk patients before their surgery. Coronary angiography is essential in all documented cases of severe coronary artery disease; exercise testing and thallium scintigraphy should be proposed in cases with clinical or electrocardiographic presumption of angina. However, systematic investigation is not required in the absence of suggestive symptoms.