Composite graft replacement is an established surgical procedure that radically treats pathologies of the aortic root, especially when the aortic valve cannot be spared. We analyzed the intraoperative details and the short-term outcome of a large consecutive series of patients operated in a teaching tertiary institution.
Out of 877 patients that received a composite graft during a 13-years period, we excluded all those patients who were operated as an emergency because of a type A acute aortic dissection, those who received this procedure as a redo-surgery and those who presented with a destructive endocarditis of the aortic root. Finally 622 patients with a mean age of was 59.5 ± 12.5 years (range between 16 and 85 years) were analyzed. 423 patients (68%) were male, mean body mass index was 27.8 ± 4.3 (18.4 to 37.3). Anulo-aortic dilatation with or without aortic valve dysfunction was the most frequent indication (n=448), bicuspid valve with aortic root and/or ascending aortic dilatation was found in 107 patients and typical aortic root dilatation in the presence of Marfan/Loeys-Dietz syndrome was found in 33 patients. A large majority of patients presented with moderate or severe aortic regurgitation (n=409, 65%), while aortic stenosis was present in 164 patients (26.5%).
Early mortality occurred in 9 patients (1.4%). Causes of death were: low output syndrome in 3, severe cerebrovascular complication in 4 patients and respiratory, respectively multiorgan failure in one patient each. Multivariate logistic regression analysis showed that a severly reduced LV function (LV-EF < 0.35) (OR 4.9, 95% CI 1.7-12.2), aortic regurgitation grade IV (OR 6.35, 95% CI 1.8-17.8), NYHA functional class III or IV (OR 2.94 (95% CI 1.5-7.4) and need for additional CABG surgery (OR 4,25, 95% CI 1.6-11.3) were the independent risk factors for mortality as well as for early morbidity.
Composite graft replacement is a standard procedure to treat different pathologies of the aortic root and is associated with a low perioperative risk. This justify liberal indications in case of moderately dilated aortic root (4.5 to 5 cm) in younger patients (<60 years) and in those with a particular cardiovascular risk profile.
Survival and quality of life improved significantly with the dramatic changes of heart failure (HF) treatment in the last decades (1). An unanticipated consequence of this favorable development is the emergence of a patient population increasingly refractory to standard HF treatment. This paradox relates to the fact that none of the currently available drugs or devices completely silences HF disease or protects from the occurrence of new episodes of myocardial damage, the development of cardiorenal syndrom or right heart failure.
La dissection coronaire spontanée (SCAD) est une cause particulièrement sous-estimée du syndrome coronarien aigu (SCA), de l’infarctus du myocarde et de la mort subite. Selon plusieurs études on suppose que la SCAD est la cause sous-jacente de 1,7% à 4,0% des SCA et serait responsable de 0,5% des morts subites. Cette entité clinique est plus courante chez les jeunes femmes et les patients sans facteurs de risque cardiovasculaires classiques. Bien que largement sous-diagnostiquée durant les dernières décennies, le diagnostic de SCAD s’est considérablement amélioré grâce à l’utilisation facilitée de la tomographie par cohérence optique (OCT) et de l’échographie intravasculaire (IVUS). Les recommandations de prise en charge sont basées uniquement sur des avis d’experts, principalement issus d’études rétrospectives et observationnelles. Cette revue résume dans le détail l’épidémiologie, l’étiopathogenèse, les caractéristiques cliniques ainsi que la démarche diagnostique et la prise en charge de la SCAD dans l’état actuel de la littérature médicale. Deux cas cliniques avec une sémiologie classique illustreront finalement ces différentes notions théoriques.
Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annular calcification, which can be difficult to diagnose and can be misdiagnosed as a cardiac tumour or abscess. Multimodality imaging is important for the diagnosis of this entity and to avoid unnecessary surgical treatment.
We present the case of a 77-year-old female patient with initially asymptomatic CCMA who later developed a third degree atrio-ventricular heart block. Four years after the initial diagnosis, she was admitted to the hospital for acute heart failure due to mitral stenosis. Multimodality imaging including transthoracic, transoesophageal echocardiography and CT scan showed an increase in the CCMA’s size with symptomatic mitral stenosis.
Background: Flecainide, a class IC antiarrhythmic drug, is used frequently in patients with supraventricular arrhythmias, mostly atrial fibrillation and less commonly for ventricular arrhythmias. With its strong affinity to sodium channels in the cardiac cells it affects phase 0 of the action potential leading to conduction slowing which is reflected in widening of the QRS and it can also prolong the PR interval. (1) These unspecific electrocardiogram (ECG) changes may mimic myocardial ischemia in patients undergoing myocardial stress testing. The current case report reflects the diagnostic difficulties arising from this phenomenon.
Case summary: A 66-year-old patient who had been treated with flecainide for a decade for atrial fibrillation showed significant QRS widening and ST segment depression during exercise testing. The patient did not exhibit symptoms of myocardial ischemia. A subsequent single photon emission computed tomography (SPECT) revealed a 10-15 % cardiac ischemic area. Invasive coronary angiogram showed a chronic, complete obstruction of the left circumflex artery, which was percutaneously revascularized.
Discussion: This case demonstrates how pharmacological effects of flecainide and other class IC antiarrhythmic drugs may lead to suspicion of cardiac ischemia due to QRS widening and unspecific ST-segment changes. In these patients, accurate ECG interpretation is important to avoid unnecessary invasive procedures like coronary angiography. On the other hand, significant underlying coronary artery disease may nonetheless be present, warranting invasive diagnostic testing. Non-invasive cardiac imaging may facilitate the process of distinguishing real ischemia from flecainide induced ECG changes.