et al.. Percutaneous repair or medical treatment for secondary mitral regurgitation: outcomes at 2 years Methods and results. AimsThe MITRA-FR trial showed that among symptomatic patients with severe secondary mitral regurgitation, percutaneous repair did not reduce the risk of death or hospitalization for heart failure at 12 months compared with guideline-directed medical treatment alone.At 37 centres, we randomly assigned 304 symptomatic heart failure patients with severe secondary mitral regurgitation (effective regurgitant orifice area >20 mm 2 or regurgitant volume >30 mL), and left ventricular ejection fraction between 15% and 40% to undergo percutaneous valve repair plus medical treatment (intervention group, n = 152) or medical treatment alone (control group, n = 152). The primary efficacy outcome was the composite of all-cause death and unplanned hospitalization for heart failure at 12 months. At 24 months, all-cause death and unplanned hospitalization for heart failure occurred in 63.8% of patients (97/152) in the intervention group and 67.1% (102/152) in the control group [hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.77-1.34]. All-cause *Corresponding author. Hôpital Cardiovasculaire Louis Pradel, Chirurgie Cardio-Vasculaire et Transplantation Cardiaque, mortality occurred in 34.9% of patients (53/152) in the intervention group and 34.2% (52/152) in the control group (HR 1.02, 95% CI 0.70-1.50). Unplanned hospitalization for heart failure occurred in 55.9% of patients (85/152) in the intervention group and 61.8% (94/152) in the control group (HR 0.97, 95% CI 0.72-1.

Mitral valve surgery can be performed safely by means of less invasive techniques, but with increased technical difficulty. A low asymmetric median sternotomy seems preferable to an anterior thoracotomy.

Mitral valve repair is frequently feasible and gives good results in patients with infective endocarditis. Patients operated on for acute endocarditis experience more events during follow-up than those operated on after healed endocarditis but have excellent late survival.

The scarcity of small donors has significantly limited lung transplantation for pediatric and small adult patients. Use of single lobes procured from size-unmatched donors has overcome this difficulty, but only in a few selected cases and, in addition, it represents a waste of lung tissue. In an animal model we have shown that it is possible to divide one lung with careful partitioning of the vascular and bronchial structures and thus obtain two viable lobar grafts suitable for bilateral implantation in a smaller animal. We have now applied this procedure clinically in seven patients operated on between May 1993 and November 1994. The indications were cystic fibrosis in three children, primary pulmonary hypertension in two adults, bronchiectasis in one, and idiopathic pulmonary fibrosis in one. There were three children aged 13 to 17 years (median 14) and four adults aged 40 to 53 years (median 45). There was a 46% to 50% discrepancy for weight between recipient and donor and a 12% to 17% discrepancy for height. The surgical technique consisted of careful partitioning of the left donor lung, bilateral anterior thoracotomy in the recipient, and, with the use of cardiopulmonary bypass, implantation of the lower lobe in the left hemithorax and the upper lobe in the right hemithorax. Vascular and bronchial connections were facilitated by leaving a long pedicle on the recipient side. The pulmonary artery anastomosis for the donor left upper lobe was done with the "fissure" side of the artery to ensure an anastomosis without tension. An end-to-end bronchial anastomosis overcame the problem of size discrepancy. Six patients are alive and well 10 to 27 months (median 19) after operation. One patient with cystic fibrosis died of systemic aspergillosis infection. All were discharged from the hospital within the first or second postoperative month. No technical problems were identified: repeated bronchoscopy has demonstrated satisfactory healing without early stricture formation. All patients remain well subjectively with good exercise tolerance and all patients achieve greater than 70% of predicted values of forced expiratory volume in 1 second. Perfect adaptation of the transplanted lobes to the recipient pleural space has been demonstrated by postoperative computed tomographic scan. In conclusion, bilateral lobar transplantation from a single donor lung is possible in small adults or children when there is a large size discrepancy with the donor. This may help resolve the problem of donor availability in the pediatric population.

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Pulmonary artery dissection was diagnosed in a 32-year-old man who was admitted to the emergency department with intense chest pain. He had a history of pulmonary balloon valvuloplasty for congenital pulmonary stenosis at the age of 7 and no pulmonary hypertension. The operation was performed with cardiopulmonary bypass. The dissected pulmonary arterial trunk was removed with the distorted valve, and replaced with a pulmonary artery homograft. The postoperative course was uneventful. Histologic examination revealed medionecrosis. Pulmonary artery dissection is a rare but highly lethal pathology. In the absence of pulmonary hypertension, surgical treatment with homograft replacement can lead to excellent results.

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We read with interest the article by Pothula et al. (1) investigating effects had by preoperative ADP antagonists with or without heparin on postoperative blood loss after cardiac surgery. This is an important issue because anesthesiologists are increasingly confronted with patients on platelet-active drugs. The authors found that patients receiving ADP antagonists and additional low-dose heparin exhibited a significantly minor blood loss as compared with the control group and the group receiving only ADP antagonists. This result was explained by a possible beneficial effect of heparin in preventing formation of microemboli and thus preserving coagulation factors until the postoperative period. This assumption is interesting, since exogenous heparin or endogenous heparinoids are usually associated with increased bleeding and all patients were on full heparin dosage during CBP. Furthermore, with the exception of fibrinogen, no coagulation factor was measured pre-or postoperatively. In addition, the authors made no attempt to measure platelet function preoperatively, which seems necessary to guarantee that groups are comparable. Clopidogrel is six times more potent than ticlopidine and shows linear pharmacokinetics, while ticlopidine does not (2). However, clopidogrel-induced platelet inhibition exhibits considerable individual heterogeneity (3). Furthermore, it is not clear how many patients in each group received clopidogrel or ticlopidine or whether patients received one single or repeated doses, which influences half-life, especially for ticlopidine. Why did 13% of patients in the treatment groups receive aprotinin and 4.3% the combination of aprotinin and ⑀-aminocaproic acid, while this was true for 9% and 0% of control patients, respectively? Data from animal experiments show that aprotinin partially reverses effects of thienopyridines in a dose-dependent manner (4). Lastly, concentrations of fibrinogen already varied considerably between groups at baseline. Although differences in aortic cross-clamping time and extracorporeal circulation time were investigated as possible confounders, the obvious difference in preoperative fibrinogen concentrations did not correlate with the amount of blood loss. Since intraoperative blood loss was equal in all groups, it was to be expected that postoperative concentrations of fibrinogen would correlate well with preoperative values in all groups (5), provided that fluid therapy, which itself influences hemostasis, was also comparable between groups.Consequently, the causal relationship between platelet antagonists with or without heparin therapy and the reported postoperative blood loss seems quite questionable. Moreover, since several confounders cannot be excluded, results should be interpreted with caution. Dietmar Fries, MD References 1. Pothula S, Sanchala VT, Nagappala B, Inchiosa MA Jr. The effect of preoperative antiplatelet/anticoagulant prophylaxis on postoperative blood loss in cardiac surgery. Anesth Analg 2004;98:4 -10. 2. Jaremo P, Lindhal TL, Fransson SG, Ric...