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1.
J Card Surg ; 35(10): 2550-2558, 2020 Oct.
Article in English | MEDLINE | ID: mdl-32840928

ABSTRACT

BACKGROUND/OBJECTIVES: Chronic kidney disease (CKD) is a risk factor for long-term survival in cardiac surgery. The Cockcroft-Gault, Modification of Diet in Renal Disease (MDRD) study, CKD Epidemiology Collaboration (CKD-EPI), revised Lund-Malmö (LM), and full age spectrum equations are used to estimate glomerular filtration rates (eGFR), but each have advantages and disadvantages. Our objective was to determine which equation better predicts long-term survival. METHODS: Data on 1492 consecutive patients who underwent isolated off-pump coronary artery bypass surgery between September 1996 and December 2008 were prospectively collected. Preoperative and postoperative eGFR were calculated using the five equations and compared using Cox regression analyses and time-dependent receiver operating characteristic (ROC) curves at 10 years. RESULTS: In a Cox regression model after correction for significant predictors of long-term mortality, adjusted hazard ratios (HR) for one standard deviation increase in preoperative eGFR were 0.661 (P < .0001), 0.844 (P = .0166), 0.787 (P = .0002), 0.746 (P < .0001), and 0.717 (P < .0001) for the CG, MDRD, CKD-EPI, LM, and FAS equations, respectively. The areas under the time-dependent ROC curve at 10 years also showed that the CG formula has a better predictive value. Postoperative eGFR at discharge were also significant predictors of long-term mortality (HR = 0.603, P < .0001; HR = 0.725, P < .0001; HR = 0.688, P < .0001; HR = 0.673, P < .0001; HR = 0.632, P < .0001 for the CG, MDRD, CKD-EPI, LM, and FAS equations, respectively). CONCLUSIONS: The CG formula was shown to better predict survival in cardiac surgery, though the FAS equation has a comparable prognostic value. Additionally, postoperative eGFR at discharge also predicted long-term survival.


Subject(s)
Coronary Artery Bypass, Off-Pump , Coronary Artery Disease/surgery , Glomerular Filtration Rate , Renal Insufficiency, Chronic , Risk Assessment/methods , Aged , Coronary Artery Bypass, Off-Pump/mortality , Coronary Artery Disease/mortality , Female , Humans , Male , Middle Aged , Predictive Value of Tests , Proportional Hazards Models , ROC Curve , Renal Insufficiency, Chronic/diagnosis , Risk Factors , Survival Rate
2.
Ann Thorac Surg ; 108(4): 1257-1264, 2019 10.
Article in English | MEDLINE | ID: mdl-31185202

ABSTRACT

BACKGROUND: There is uncertainty whether venoarterial extracorporeal membrane oxygenation (VA-ECMO) should be used in older patients with cardiopulmonary failure after cardiac surgery. METHODS: This was a retrospective multicenter study of 781 patients who required postcardiotomy VA-ECMO for cardiopulmonary failure after adult cardiac surgery from 2010 to 2018 at 19 cardiac surgery centers. A parallel systematic review with meta-analysis of the literature was performed. RESULTS: The hospital mortality in the overall Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation (PC-ECMO) series was 64.4%. A total of 255 patients were 70 years old or older (32.7%), and their hospital mortality was significantly higher than in younger patients (76.1% vs 58.7%; adjusted odds ratio, 2.199; 95% confidence interval [CI], 1.536 to 3.149). Arterial lactate level greater than 6 mmol/L before starting VA-ECMO was the only predictor of hospital mortality among patients 70 years old or older in univariate analysis (82.6% vs 70.4%; P = .029). Meta-analysis of current and previous studies showed that early mortality after postcardiotomy VA-ECMO was significantly higher in patients aged 70 years or older compared with younger patients (odds ratio, 2.09; 95% CI, 1.59 to 2.75; 5 studies including 1547 patients; I2, 5.9%). The pooled early mortality rate among patients aged 70 years or older was 78.8% (95% CI, 74.1 to 83.5; 6 studies including 617 patients; I2, 41.8%). Two studies reported 1-year mortality (including hospital mortality) of 79.9% and 75.6%, respectively, in patients 70 years old or older. CONCLUSIONS: Advanced age should not be considered a contraindication for postcardiotomy VA-ECMO. However, in view of the high risk of early mortality, meaningful scrutiny is needed before using VA-ECMO after cardiac surgery in older patients.


Subject(s)
Cardiac Surgical Procedures/adverse effects , Extracorporeal Membrane Oxygenation , Heart Arrest/therapy , Postoperative Complications/therapy , Respiratory Insufficiency/therapy , Age Factors , Aged , Female , Heart Arrest/etiology , Heart Arrest/mortality , Hospital Mortality , Humans , Male , Middle Aged , Patient Selection , Postoperative Complications/etiology , Postoperative Complications/mortality , Respiratory Insufficiency/etiology , Respiratory Insufficiency/mortality , Retrospective Studies
5.
J Stroke Cerebrovasc Dis ; 25(5): 1280-1283, 2016 May.
Article in English | MEDLINE | ID: mdl-26965469

ABSTRACT

BACKGROUND AND PURPOSE: Acute stroke in the setting of acute type A aortic dissection is not rare and may contraindicate immediate surgery. Evaluating irreversible brain damage is critical in this setting and magnetic resonance imaging is a key determinant in the decision of selecting surgical over medical treatment for these patients. SUMMARY OF CASES: We report herein 2 cases assessed at a tertiary care center for acute stroke. The initial diagnosis workup revealed cerebral hemispheric severe hypoperfusion without any brain infarction. The absence of ischemic lesions prompted surgical repair, despite the severity of clinical symptoms. Both patients demonstrated complete neurological recovery and neuroimaging showed no persistent sequel. CONCLUSION: Acute type A aortic dissection is an important differential diagnosis in the causative workup for stroke. Brain hypoperfusion alone should not be a contraindication for urgent surgical treatment, regardless of initial clinical neurological severity.


Subject(s)
Aortic Aneurysm/diagnostic imaging , Aortic Dissection/diagnostic imaging , Brain Ischemia/diagnostic imaging , Carotid Stenosis/diagnostic imaging , Cerebrovascular Circulation , Diffusion Magnetic Resonance Imaging , Stroke/diagnostic imaging , Acute Disease , Aged , Aortic Dissection/complications , Aortic Dissection/physiopathology , Aortic Dissection/surgery , Aortic Aneurysm/complications , Aortic Aneurysm/physiopathology , Aortic Aneurysm/surgery , Aortography/methods , Blood Vessel Prosthesis Implantation , Brain Ischemia/etiology , Brain Ischemia/physiopathology , Carotid Stenosis/etiology , Carotid Stenosis/physiopathology , Computed Tomography Angiography , Diagnosis, Differential , Female , Humans , Predictive Value of Tests , Stroke/physiopathology , Treatment Outcome
6.
JACC Cardiovasc Interv ; 9(5): 472-80, 2016 Mar 14.
Article in English | MEDLINE | ID: mdl-26965937

ABSTRACT

OBJECTIVES: The purpose of this study was to assess the feasibility and safety of transcarotid transcatheter aortic valve replacement (TAVR). BACKGROUND: Many candidates for TAVR have challenging vascular anatomy that precludes transfemoral access. Transcarotid arterial access may be an option for such patients. METHODS: The French Transcarotid TAVR Registry is a voluntary database that prospectively collected patient demographics, procedural characteristics, and clinical outcomes among patients undergoing transcarotid TAVR. Outcomes are reported according to the updated Valve Academic Research Consortium criteria. RESULTS: Among 96 patients undergoing transcarotid TAVR at 3 French sites (2009 to 2013), the mean age and Society of Thoracic Surgeons predicted risk of mortality were 79.4 ± 9.2 years and 7.1 ± 4.1%, respectively. Successful carotid artery access was achieved in all patients. The Medtronic CoreValve (Medtronic, Inc., Minneapolis, Minnesota) (n = 89; 92.7%) and Edwards SAPIEN valves (Edwards Lifesciences, Irvine, California) (n = 7; 7.3%) were used. Procedural complications included: valve embolization (3.1%), requirement for a second valve (3.1%), and tamponade (4.2%). There were no major bleeds or major vascular complications related to the access site. There were 3 (3.1%) procedural deaths and 6 (6.3%) deaths at 30 days. The 1-year mortality rate was 16.7%. There were 3 (3.1%) cases of Valve Academic Research Consortium-defined in-hospital stroke (n = 0) or transient ischemic attack (TIA) (n = 3). None of these patients achieved the criteria for stroke and none manifested new ischemic lesions on cerebral computed tomography or magnetic resonance imaging. At 30 days, a further 3 TIAs were observed, giving an overall stroke/TIA rate of 6.3%. CONCLUSIONS: Transcarotid vascular access for TAVR is feasible and is associated with encouraging short- and medium-term clinical outcomes. Prospective studies are required to ascertain if transcarotid TAVR yields equivalent results to other nonfemoral vascular access routes.


Subject(s)
Aortic Valve Stenosis/therapy , Aortic Valve , Cardiac Catheterization/methods , Carotid Artery, Common , Heart Valve Prosthesis Implantation/methods , Aged , Aged, 80 and over , Aortic Valve/diagnostic imaging , Aortic Valve/physiopathology , Aortic Valve Stenosis/diagnostic imaging , Aortic Valve Stenosis/mortality , Aortic Valve Stenosis/physiopathology , Cardiac Catheterization/adverse effects , Cardiac Catheterization/instrumentation , Cardiac Catheterization/mortality , Carotid Artery, Common/diagnostic imaging , Cerebral Angiography , Coronary Angiography , Feasibility Studies , Female , France , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis Implantation/mortality , Humans , Ischemic Attack, Transient/etiology , Male , Middle Aged , Multidetector Computed Tomography , Predictive Value of Tests , Prospective Studies , Registries , Risk Factors , Stroke/etiology , Time Factors , Treatment Outcome , Ultrasonography, Doppler , Ultrasonography, Doppler, Transcranial
7.
Vascul Pharmacol ; 80: 59-66, 2016 May.
Article in English | MEDLINE | ID: mdl-26779598

ABSTRACT

Inflammatory injury and hypoperfusion following cardiopulmonary bypass (CPB) are associated with potential brain injury in relationship between CPB, memory impairment, changes in cerebral vascular reactivity and both systemic and cerebral inflammatory reaction. The objective of this study was to assess the preventive effect of a pretreatment with simvastatin or fenofibrate on neurovascular and cognitive consequences of CPB. Male Sprague-Dawley rats were treated by control diet, simvastatin 10 mg/kg/day or fenofibrate 200 mg/kg/day for 14 days before CPB surgery and were sacrificed immediately after surgery or 24h later. Cognitive function, vascular reactivity, neuronal counts in CA1 and CA3 hippocampal regions, and inflammatory markers were assessed. CPB induced memory impairment and endothelial dysfunction 24h after surgery associated with neuronal loss. Neuronal loss was reduced by simvastatin or fenofibrate treatment in parallel to memory alteration prevention. Pretreatment by simvastatin and fenofibrate prevented CPB-induced endothelial dysfunction. CPB led to early and marked release of TNFα and overexpression of ICAM-1. Both inflammatory marker expression was decreased in the pretreated groups by lipid-lowering drugs. In a rat model of CPB, we demonstrated that simvastatin and fenofibrate protected against CPB-induced endothelial dysfunction, cerebral and systemic inflammation in parallel to memory impairment prevention.


Subject(s)
Cardiopulmonary Bypass/adverse effects , Cerebrovascular Disorders/prevention & control , Cognition Disorders/prevention & control , Hypolipidemic Agents/therapeutic use , Neuroprotective Agents/therapeutic use , Animals , Avoidance Learning/drug effects , Cerebrovascular Disorders/immunology , Cerebrovascular Disorders/metabolism , Cerebrovascular Disorders/pathology , Cognition Disorders/immunology , Cognition Disorders/metabolism , Cognition Disorders/pathology , Endothelium, Vascular/drug effects , Fenofibrate/administration & dosage , Fenofibrate/therapeutic use , Hemodynamics/drug effects , Hypolipidemic Agents/administration & dosage , Lipids/blood , Male , Maze Learning/drug effects , Neurons/drug effects , Neurons/immunology , Neurons/pathology , Neuroprotective Agents/administration & dosage , Rats, Sprague-Dawley , Simvastatin/administration & dosage , Simvastatin/therapeutic use , Tumor Necrosis Factor-alpha/blood , Vasodilation/drug effects
8.
Catheter Cardiovasc Interv ; 87(4): 797-804, 2016 Mar.
Article in English | MEDLINE | ID: mdl-26424679

ABSTRACT

OBJECTIVES: We compared the outcomes of transcatheter aortic valve implantation (TAVI) in three different aortic stenosis syndromes: paradoxical low-flow low-gradient aortic stenosis (PLFLG), high-gradient aortic stenosis (HGAS), and low ejection fraction low-gradient severe aortic stenosis (LEF-LG). BACKGROUND: Outcomes for PLFLG patients after TAVI procedure are not well known. METHODS: Between 2010 and 2013, patients with severe (indexed aortic valve area iAVA≤0.6 cm(2)/m(2)) symptomatic aortic stenosis were consecutively referred to our institution for TAVI because of multiple comorbidities and excessive surgical risk. About 262 patients were split into three groups as following, PLFLG: mean gradient MG≤40 mm Hg, stroke volume index SVI≤35 mL/m(2), ejection fraction EF≥55%, valvuloarterial impedance Zva>4.5 mm Hg/mL/m(2), maximal aortic jet velocity MaxV<4 m/s; LEF-LG: MG≤40 mm Hg, MaxV<4 m/s, EF≤50%, SVI≤35 mL/m(2); and HGAS: MaxV>4 m/s, MG>40 mm Hg, EF>55%. The primary endpoint of our study was to evaluate mid-term global and cardiovascular mortalities; secondary endpoints included recommended VARC-2 variables. RESULTS: PLFLG (n = 31) mid-term survival was similar to HGAS (n = 172) (mean follow-up = 13.2 months [4.6-26]). Conversely LEF-LG patients (n = 59) displayed significant higher rates of all-cause (P = 0.01) and cardiovascular mortalities (P = 0.05). Postprocedural outcomes (VARC-2 criteria) were similar in the PLFLG and HGAS groups except regarding major bleeding (P = 0.02), while the LEF-LG group had more congestive heart failure and a higher BNP before discharge (both P < 0.001) than the other groups. 30-days deaths were significantly more frequent in LEF-LG and PLFLG in comparison to HGAS (P = 0.03). CONCLUSION: As opposed to LEF-LG patients, mid-term prognosis after TAVI procedure in PLFLG patients is similar to HGAS patients despite higher perioperative mortality.


Subject(s)
Aortic Valve Stenosis/therapy , Aortic Valve/physiopathology , Cardiac Catheterization/methods , Heart Valve Prosthesis Implantation/methods , Hemodynamics , Aged , Aged, 80 and over , Aortic Valve Stenosis/diagnosis , Aortic Valve Stenosis/mortality , Aortic Valve Stenosis/physiopathology , Cardiac Catheterization/adverse effects , Cardiac Catheterization/instrumentation , Cardiac Catheterization/mortality , Female , Heart Valve Prosthesis , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis Implantation/mortality , Hospital Mortality , Humans , Male , Prosthesis Design , Risk Factors , Severity of Illness Index , Stroke Volume , Time Factors , Treatment Outcome , Ventricular Function, Left
9.
J Card Surg ; 29(3): 337-9, 2014 May.
Article in English | MEDLINE | ID: mdl-24417339

ABSTRACT

Transcatheter aortic valve implantation (TAVI) is still under active investigation. When the femoral route is impossible for anatomic reasons, the transapical, transaxillary and direct aortic approaches have demonstrated their effectiveness. We report the successful implantation of a Sapien XT bioprosthesis with the NovaFlex catheter through a left carotid approach.


Subject(s)
Aortic Valve Stenosis/surgery , Aortic Valve/surgery , Bioprosthesis , Cardiac Catheterization/instrumentation , Cardiac Catheters , Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis Implantation/methods , Aged, 80 and over , Cardiac Catheterization/methods , Carotid Arteries , Humans , Male , Severity of Illness Index , Treatment Outcome
10.
J Thorac Cardiovasc Surg ; 147(1): 254-8, 2014 Jan.
Article in English | MEDLINE | ID: mdl-23141030

ABSTRACT

OBJECTIVES: We examined the characteristics and outcomes of patients requiring valve surgery during active infective endocarditis (IE), focusing on the impact of antimicrobial therapy. METHODS: In this retrospective study, medical charts of all consecutive patients admitted to our cardiovascular surgery department from January 1998 to December 2010, with a diagnosis of IE requiring surgical management, were reviewed. Adult patients were enrolled in the study if they had definite or possible active IE and if the antimicrobial treatment was evaluable. RESULTS: After initial screening of medical records, we selected 173 surgically treated patients (135 men; mean age, 55.8 years). Native valves were involved in 150 (87%) patients. IE mainly involved the aortic valve (n = 113) and then mitral (n = 83), tricuspid (n = 13), and pulmonary (n = 3) valves. The most common causative pathogens were streptococci (n = 70), staphylococci (n = 60), and enterococci (n = 29). Operative mortality was 15%. Multivariate logistic regression analysis demonstrated that adequacy of the overall antimicrobial treatment (adjusted odds ratio, 0.292; 95% confidence interval, 0.117-0.726; P = .008) and temperature greater than 38°C at the time of diagnosis (adjusted odds ratio, 0.288; 95% confidence interval, 0.115-0.724; P = .008) were independently associated with a lower risk of mortality. Conversely, age greater than 60 years (adjusted odds ratio, 4.42; 95% confidence interval, 1.57-12.4; P = .005) was associated with a greater risk of operative mortality. CONCLUSIONS: Surgery for active IE is still associated with a high mortality rate, but its prognosis is significantly improved by adequate antimicrobial therapy.


Subject(s)
Anti-Infective Agents/therapeutic use , Cardiac Surgical Procedures , Endocarditis, Bacterial/therapy , Heart Valve Diseases/therapy , Heart Valves/drug effects , Heart Valves/surgery , Adult , Aged , Cardiac Surgical Procedures/adverse effects , Cardiac Surgical Procedures/mortality , Chi-Square Distribution , Endocarditis, Bacterial/diagnosis , Endocarditis, Bacterial/drug therapy , Endocarditis, Bacterial/microbiology , Endocarditis, Bacterial/mortality , Endocarditis, Bacterial/surgery , Female , Heart Valve Diseases/diagnosis , Heart Valve Diseases/drug therapy , Heart Valve Diseases/microbiology , Heart Valve Diseases/mortality , Heart Valve Diseases/surgery , Heart Valves/microbiology , Hospital Mortality , Humans , Logistic Models , Male , Middle Aged , Multivariate Analysis , Odds Ratio , Retrospective Studies , Risk Factors , Time Factors , Treatment Outcome
11.
J Vasc Surg ; 57(6): 1671-3, 2013 Jun.
Article in English | MEDLINE | ID: mdl-23332237

ABSTRACT

Surgical management of extensive thoracoabdominal aortic aneurysms is associated with high rates of mortality and morbidity, including spinal cord ischemia. We report a successful three-stage repair combining open and endovascular surgery in a patient presenting with an ascending, arch, and thoracoabdominal aneurysm. Spinal cord protective measures included a staged approach, preserved antegrade flow to the left subclavian and hypogastric arteries, absence of aortic cross-clamping, and aggressive perioperative hemodynamic monitoring.


Subject(s)
Aortic Aneurysm, Thoracic/surgery , Humans , Ischemia/etiology , Ischemia/prevention & control , Male , Middle Aged , Spinal Cord/blood supply , Stents , Vascular Surgical Procedures/adverse effects , Vascular Surgical Procedures/methods
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