Percutaneous mitral annuloplasty through the coronary sinus: An anatomic point of view

ObjectiveWe assessed the anatomic relationships among the mitral annulus, coronary sinus, and circumflex artery in human cadaver hearts.MethodsPercutaneous posterior mitral annuloplasty has been proposed to treat functional mitral regurgitation on the basis of the proximity of the coronary sinus to the mitral annulus. However, concern remains about the ability to perform a trigone-to-trigone posterior annuloplasty and the potential for compromise of the circumflex coronary artery. Ten hearts were studied after injection of expansible foam into the coronary sinus and circumflex artery. The mitral annulus perimeter, posterior intertrigonal (T1–T2) and intercommissural (C1–C2) distance, and coronary sinus projection on the native annulus (S1–S2) were measured. The spatial geometry of the coronary sinus was correlated with the circumflex artery route and the distance with the native mitral annulus.ResultsThe projection of coronary sinus annuloplasty achieves at best a commissure-to-commissure annuloplasty 14.5 (6–24) mm behind each trigone: T1–T2: 74 (56–114) mm, C1–C2: 62.2 (48–80) mm, S1–S2: 59.5 (40–80) mm. The coronary sinus was distant from the native annulus (8–14 mm at the coronary sinus ostium, 13.7–20.4 mm at the middle of the coronary sinus, 6.9–14 mm at the level of the great coronary vein). The circumflex artery was located between the coronary sinus and the mitral annulus in 45.5% of cases.ConclusionsThis anatomic study highlights the 3-dimensional structure of the coronary sinus and its distance from the native mitral annulus and fibrous trigones. Human anatomic studies are mandatory for the further development of percutaneous mitral repair technology

Echocardiography practice, training and accreditation in the intensive care: document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS)

Echocardiography is increasingly used in the management of the critically ill patient as a non-invasive diagnostic and monitoring tool. Whilst in few countries specialized national training schemes for intensive care unit (ICU) echocardiography have been developed, specific guidelines for ICU physicians wishing to incorporate echocardiography into their clinical practice are lacking. Further, existing echocardiography accreditation does not reflect the requirements of the ICU practitioner. The WINFOCUS (World Interactive Network Focused On Critical UltraSound) ECHO-ICU Group drew up a document aimed at providing guidance to individual physicians, trainers and the relevant societies of the requirements for the development of skills in echocardiography in the ICU setting. The document is based on recommendations published by the Royal College of Radiologists, British Society of Echocardiography, European Association of Echocardiography and American Society of Echocardiography, together with international input from established practitioners of ICU echocardiography. The recommendations contained in this document are concerned with theoretical basis of ultrasonography, the practical aspects of building an ICU-based echocardiography service as well as the key components of standard adult TTE and TEE studies to be performed on the ICU. Specific issues regarding echocardiography in different ICU clinical scenarios are then described

Optimising Aortic Endovascular Repair in Patients with Marfan Syndrome

International audienc

Sternal Wound Infection after Cardiac Surgery: Management and Outcome.

Sternal Wound Infection (SWI) is a severe complication after cardiac surgery. Debridement associated with primary closure using Redon drains (RD) is an effective treatment, but data on RD management and antibiotic treatment are scarce.We performed a single-center analysis of consecutive patients who were re-operated for SWI between 01/2009 and 12/2012. All patients underwent a closed drainage with RD (CDRD). Patients with endocarditis or those who died within the first 45 days were excluded from management analysis. RD fluid was cultured twice weekly. Variables recorded were clinical and biological data at SWI diagnosis, severity of SWI based on criteria for mediastinitis as defined by the Centers for Disease Control (CDC), antibiotic therapy, RD management and patient's outcome.160 patients developed SWI, 102 (64%) fulfilled CDC criteria (CDC+) and 58 (36%) did not (CDC- SWI). Initial antibiotic treatment and surgical management were similar in CDC+ and CDC- SWI. Patients with CDC+ SWI had a longer duration of antibiotic therapy and a mortality rate of 17% as compared to 3% in patients with CDC- SWI (p = 0.025). Rates of superinfection (10% and 9%) and need for second reoperation (12% and 17%) were similar. Failure (death or need for another reoperation) was associated with female gender, higher EuroScore for prediction of operative mortality, and stay in the ICU.In patients with SWI, initial one-stage surgical debridement with CDRD is associated with favorable outcomes. CDC+ and CDC- SWI received essentially the same management, but CDC+ SWI has a more severe outcome

Pathogenic FBN1 Genetic Variation and Aortic Dissection in Patients With Marfan Syndrome

International audienceBackgroundAortic risk has not been evaluated in patients with Marfan syndrome and documented pathogenic variants in the FBN1 gene.ObjectivesThis study sought to describe aortic risk in a population with Marfan syndrome with pathogenic variants in the FBN1 gene as a function of aortic root diameter.MethodsPatients carrying an FBN1 pathogenic variant who visited our reference center at least twice were included, provided they had not undergone aortic surgery or had an aortic dissection before their first visit. Aortic events (aortic surgery or aortic dissection) and deaths were evaluated during the 2 years following each patient visit. The risk was calculated as the number of events divided by the number of years of follow-up.ResultsA total of 954 patients were included (54% women; mean age 23 years). During follow-up (9.1 years), 142 patients underwent prophylactic aortic root surgery, 5 experienced type A aortic dissection, and 12 died (noncardiovascular causes in 3, unknown etiology in 3, post-operative in 6). When aortic root diameter was <50 mm, risk for proven type A dissection (0.4 events/1,000 patient-years) and risk for possible aortic dissection (proven aortic dissection plus death of unknown cause, 0.7 events/1,000 patients-years) remained low in this population that was treated according to guidelines. Three type A aortic dissections occurred in this population during the 8,594 years of follow-up, including 1 in a patient with a tubular aortic diameter of 50 mm, but none in patients with a family history of aortic dissection. The risk for type B aortic dissection in the same population was 0.5 events/1,000 patient-years.ConclusionsIn patients with FBN1 pathogenic variants who receive beta-blocker therapy and who limit strenuous exercise, aortic risk remains low when maximal aortic diameter is <50 mm. The risk of type B aortic dissection is close to the remaining risk of type A aortic dissection in this population, which underlines the global aortic risk