Anomalous sub aortic left brachiocephalic vein: a case report

The left brachiocephalic vein occasionally follows an aberrant course. It is usually associated with congenital cardiac anomaly. We present a case of anomalous left brachiocephalic vein which followed a sub aortic course, with no cardiac abnormality. Multi detector computed tomography is very useful in accurate diagnosis of this condition and prevents any further investigation in cases of isolated abnormalities.

Implantation de valve aortique par voie transcatheter (TAVI): update sur les indications [Transcatheter aortic valve implantation (TAVI): update on the indications].

Although surgical aortic valve replacement has been the standard of care for patient with severe aortic stenosis, transcatheter aortic valve implantation (TAVI) is now a fair standard of care for patients not eligible or high risk for surgical treatment. The decision of therapeutic choice between TAVI and surgery considers surgical risk (estimated by the Euro-SCORE and STS-PROM) as well as many parameters that go beyond the assessment of the valvular disease's severity by echocardiography: a multidisciplinary assessment in "Heart Team" is needed to assess each case in all its complexity.

Ventricularisation of the left atrium: a rare cause of left ventricular dysfunction in a patient with mitral valve prolapse

Case: A 11 yo girl with Marfan syndrome was referred to cardiac MR (CMR) to measure the size of her thoracic aorta. She had a typical phenotype with arachnodactyly, abnormally long arms, and was tall and slim (156 cm, 28 kg, body mass index 11,5 kg/m2). She complained of no symptoms. Cardiac auscultation revealed a prominent mid-systolic click and an end-systolic murmur at the apex. A recent echocardiogram showed a moderately dilated left ventricle with normal function and a mitral valve prolapse with moderate mitral valve regurgitation. CMR showed a dilatation of the aortic root (38 mm, Z-score 8.9) and a severe prolapse of the mitral valve with regurgitation. The ventricular cavity was moderately dilated (116 ml/m2) and its contraction was hyperdynamic (stroke volume (SV): 97 ml; LVEF 72%, with the LV volumes measured by modified Simpson method from the apex to the mitral annulus). In this patient however, the mitral prolapse was characterized by a severe backward movement of the valve toward the left atrium (LA) in systole and the dyskinetic movement of the atrioventricular plane caused a ventricularisation of a part of the LA in systole (Figure). This resulted in a significant reduction of LVEF: more than ¼ of the apparent SV was displaced backwards into the ventricularized LA volume, reducing the effective LVEF to 51% (effective SV 69ml). Moreover, by flow measurement, the SV across the ascending aorta was 30 ml (cardiac index 2.0 l/min/m2) allowing the calculation of a regurgitant fraction across the mitral valve of 56%, which was diagnostic for a severe mitral valve insufficiency. Conclusion: This case illustrates the phenomenon of a ventricularisation of the LA where the severe prolapse gives the illusion of a higher attachement of the mitral leaflets within the atrial wall. Besides the severe mitral regurgitation, this paradoxical backwards movement of the valve causes an intraventricular unloading during systole reducing the apparent LVEF of 72% to an effective LVEF of only 51%. In addition, forward flow fraction is only 22% after accounting for the regurgitant volume, as well. This combined involvement of the mitral valve could explain the discrepancy between a low output state and an apparently hyperdynamic LV contraction. Due to its ability to precisely measure flows and volumes, CMR is particularly suited to detect this phenomenon and to quantify its impact on the LV pump function.

Use of a ventricular septal defect occluder for apical closure in transapical aortic valve replacement.

During transapical transcatheter aortic valve replacement (TA-TAVR), the apical closure remains a challenge for the surgeon, having the risk for ventricular tear and massive bleeding. Apical closure devices are already under clinical evaluation, but only a few can lead to a full percutaneous TA-TAVR. We describe the successful use of a 9-mm myocardial occluder (ventricular septal defect occluder) that was used to seal the apex after a standard TA-TAVR (using the Sapien XT 23-mm transcatheter valve and the Ascendra + delivery system). The placement of the nonmodified myocardial occluder was performed through the Ascendra + delivery system, with a very small amount of blood loss and an acceptable sealing of the apical tear. This approach is feasible and represents a further step toward true-percutaneous transapical heart valve procedures. Modified apical occluders are under evaluation in animal models.

'Fast-implantable' aortic valve implantation and concomitant mitral procedures.

Concomitant aortic and mitral valve replacement or concomitant aortic valve replacement and mitral repair can be a challenge for the cardiac surgeon: in particular, because of their structure and design, two bioprosthetic heart valves or an aortic valve prosthesis and a rigid mitral ring can interfere at the level of the mitroaortic junction. Therefore, when a mitral bioprosthesis or a rigid mitral ring is already in place and a surgical aortic valve replacement becomes necessary, or when older high-risk patients require concomitant mitral and aortic procedures, the new 'fast-implantable' aortic valve system (Intuity valve, Edwards Lifesciences, Irvine, CA, USA) can represent a smart alternative to standard aortic bioprosthesis. Unfortunately, this is still controversial (risk of interference). However, transcatheter aortic valve replacements have been performed in patients with previously implanted mitral valves or mitral rings. Interestingly, we learned that there is no interference (or not significant interference) among the standard valve and the stent valve. Consequently, we can assume that a fast-implantable valve can also be safely placed next to a biological mitral valve or next to a rigid mitral ring without risks of distortion, malpositioning, high gradient or paravalvular leak. This paper describes two cases: a concomitant Intuity aortic valve and bioprosthetic mitral valve implantation and a concomitant Intuity aortic valve and mitral ring implantation.

Impact of body tilt on the central aortic pressure pulse.

The present work was undertaken to investigate, in young healthy volunteers, the relationships between the forward propagation times of arterial pressure waves and the timing of reflected waves observable on the aortic pulse, in the course of rapid changes in body position. 20 young healthy subjects, 10 men, and 10 women, were examined on a tilt table at two different tilt angles, -10° (Head-down) and + 45° (Head-up). In each position, carotid-femoral (Tcf) and carotid-tibial forward propagation times (Tct) were measured with the Complior device. In each position also, the central aortic pressure pulse was recorded with radial tonometry, using the SphygmoCor device and a generalized transfer function, so as to evaluate the timing of reflected waves reaching the aorta in systole (onset of systolic reflected wave, sT1r) and diastole (mean transit time of diastolic reflected wave, dMTT). The position shift from Head-up to Head-down caused a massive increase in both Tct (women from 130 ± 10 to 185 ± 18 msec P < 0.001, men from 136 ± 9 to 204 ± 18 msec P < 0.001) and dMTT (women from 364 ± 35 to 499 ± 33 msec P < 0.001, men from 406 ± 22 to 553 ± 21 msec P < 0.001). Mixed model regression showed that the changes in Tct and dMTT observed between Head-up and Head-down were tightly coupled (regression coefficient 2.1, 95% confidence interval 1.9-2.3, P < 0.001). These results strongly suggest that the diastolic waves observed on central aortic pulses reconstructed from radial tonometric correspond at least in part to reflections generated in the lower limbs.

Aortic root morphology: a paradigm for successful reconstruction.

Aortic root (AoR) components provide synchronous and precise 3D deformation of the aortic root during the cardiac cycle in order to ensure closure and opening of the three leaflets over a lifetime. Any deviation from the natural 3D morphology, such as with AoR annulus dilatation, enlarged sinuses and/or dilatation of the sinotubular junction, as in the case of ascending aortic dilatation, may result in disruption of the natural AoR function. Surgical treatment of AoR pathology has two modalities: the replacement of the aortic valve by artificial prosthesis or by preservation of the three leaflets and reconstruction of the aortic root components. Currently, there are two basic aortic root reconstruction procedures: aortic root sparing and aortic valve reimplantation techniques. Regardless of the technique used, the restoration of adequate cusp coaptation, is from a technical point of view, the most important element to consider. To achieve this, there are two requirements that need to be met: (i) the valve coaptation should be superior to the level of the aortic root base by at least 8 mm and (ii) the coaptation height per se has to be ≥5 mm. Successful restoration of the aortic root requires adequate technical skills, detailed knowledge of aortic root anatomy and topography, and also knowledge of the spatial pattern of AoR elements. Recently, there has been growing interest in aortic root reconstructive procedures as well their modifications. As such, the aim of this review is to analyse aortic root topography and 3D anatomy from a surgical point of view. The review also focuses on potential risk regions that one should be aware of before the surgical journey into the 'deep waters area' of the AoR begins.

Evaluation of preoperative computed tomography angiography in association with conventional angiography versus computed tomography angiography only, in the endovascular treatment of aortic diseases

Objective To evaluate the association of conventional angiography (AG) with computed tomography angiography (CTA) as compared with CTA only, preoperatively, in the treatment of aortic diseases. Materials and Methods Retrospective study involving patients submitted to endovascular treatment of aortic diseases, in the period from January 2009 to July 2010, with use of preoperative CTA + conventional AG or CTA only. The patients were divided into two groups, namely: G1 – thoracic aortic diseases; and G2 – abdominal aortic diseases. G1 was subdivided into 1A (preoperative AG + CTA) and 1B (preoperative CTA). G2 was subdivided into 2C (CTA + AG) and 2D (CTA only). Results The authors evaluated 156 patients. In subgroups 1A and 1B, the rate of technical success was, respectively, 100% and 94.7% (p = 1.0); and the rate of therapeutic success was, respectively, 81% and 58% (p = 0.13). A higher number of complications were observed in subgroup 1B (p = 0.057). The accuracy in the calculation of the prosthesis was higher in subgroup 1A (p = 0.065). In their turn, the rate of technical success in subgroups 2C and 2D was, respectively, 92.3% and 98.6% (p = 0.17). The rate of therapeutic success was 73% and 98.6% (p = 0.79). Conclusion Preoperative conventional AG should be reserved for cases where CTA cannot provide all the information in the planning of a therapeutic intervention.

Hybrid treatment of penetrating aortic ulcer

AbstractPenetrating atherosclerotic aortic ulcer is a rare entity with poor prognosis in the setting of acute aortic syndrome. In the literature, cases like the present one, located in the aortic arch, starting with chest pain and evolving with dysphonia, are even rarer. The present report emphasizes the role played by computed tomography in the diagnosis of penetrating atherosclerotic ulcer as well as in the differentiation of this condition from other acute aortic syndromes. Additionally, the authors describe a new therapeutic approach represented by a hybrid endovascular surgical procedure for treatment of the disease.

Mycoplasma hominis mediastinitis after acute aortic dissection repair.

We report a case of ascending aortic graft infection by an atypical bacteria, Mycoplasma hominis, with mediastinitis, a dreaded complication after cardiac surgery. A 55-year-old patient underwent ascending aorta replacement for acute type A dissection. He developed sternal instability and purulent discharge, requiring sternal wire removal and debridement. Cultures were initially sterile, but showed M. hominis infection after a significant delay and in specific culture media. The patient was treated with doxycycline and moxifloxacine. Cultures became negative and the sternum was closed on the 28th postoperative day after the first debridement. Recovery was favorable, with no signs of infection. Antibiotics were continued for one year. The patient is still asymptomatic 16 months after antibiotic interruption. Atypical organisms should be considered in the differential diagnosis of acute mediastinitis of unknown etiology after routine microbiological investigations.

Percutaneous access versus standard femoral exposure for endovascular abdominal aortic aneurysm repair: a randomized, controlled trial

The treatment of abdominal aortic aneurysm (AAA) has shifted from the exposure of the aorta artery in an open repair technique to a small groin cut in an endovascular repair. Recently, a percutaneous access for endovascular repair has appeared. This new technique aims to minimize the complications of the common femoral artery exposure, the patient discomfort and the length of hospitalizationObjectives: To compare the proportion of discharged patients within the first 48 postoperative hours of two common femoral artery accesses for endovascular repair of AAA: the open exposure technique and the percutaneous technique. Secondary objectives include to evaluate the total procedure time, the femoral access complications, the need for extra analgesia and the patient satisfaction and groin discomfort of the two techniquesDesign: Randomized controlled trial conducted between 2014 and 2017Participants: Patients diagnosed with abdominal aortic aneurysm with elective endovascular repair indication

Vasopressor mechanisms in acute aortic coarctation hypertension

Angiotensin II (ANG II) and vasopressin (AVP) act together with the mechanical effect of aortic constriction in the onset of acute aortic coarctation hypertension. Blockade of ANG II and AVP V1 receptors demonstrated that ANG II acts on the prompt (5 min) rise in pressure whereas AVP is responsible for the maintenance (30-45 min) of the arterial pressure elevation during aortic coarctation. Hormone assays carried out on blood collected from conscious rats submitted to aortic constriction supported a role for ANG II in the early stage and a combined role for both ANG II and AVP in the maintenance of proximal hypertension. As expected, a role for catecholamines was ruled out in this model of hypertension, presumably due to the inhibitory effect of the sinoaortic baroreceptors. The lack of afferent feedback from the kidneys for AVP release from the central nervous system in rats with previous renal denervation allowed ANG II to play the major role in the onset of the hypertensive response. Median eminence-lesioned rats exhibited a prompt increase in proximal pressure followed by a progressive decline to lower hypertensive levels, revealing a significant role for the integrity of the neuroaxis in the maintenance of the aortic coarctation hypertension through the release of AVP. In conclusion, the important issue raised by this model of hypertension is the likelihood of a link between some vascular territory - probably renal - below the coarctation triggering the release of AVP, with this vasoconstrictor hormone participating with Ang II and the mechanical effect of aortic constriction in the acute aortic coarctation hypertension

Heart rate changes during the Valsalva maneuver in patients with isolated aortic insufficiency

To determine the possible relationship between left ventricular dilatation and heart rate changes provoked by the Valsalva maneuver (Valsalva ratio), we studied 9 patients with isolated chronic aortic insufficiency. Left ventricular systolic function was assessed by two-dimensional echocardiography and cardiac catheterization. All patients were asymptomatic (functional class I of the New York Heart Association). The left ventricular internal diameters and volumes were significantly increased in all patients. The asymptomatic patients had either normal or slightly depressed ejection fraction (EF>0.40). The Valsalva ratio of these asymptomatic patients showed no significant correlation with the left ventricular volumes or with the left ventricular ejection fraction. In other words, parasympathetic heart rate control, as expressed by the Valsalva ratio, was normal in the asymptomatic patients with left ventricular dilatation and preserved left ventricular ejection fraction. Therefore, left ventricular dilatation may not be the major mechanism responsible for the abnormal parasympathetic heart rate control of patients with acquired heart disease