[Management of Stent-graft migration with obstruction of supra-aortic vessel during an endovascular procedure for aortic isthmus rupture]. / Migration d'endoprothèse thoracique avec occlusion des troncs supra-aortiques en per-procédure pour rupture isthmique ; prise en charge.

The endovascular approach is widely used in the management of aortic isthmic rupture. Even if it remains less invasive than conventional surgery, a life-threatening complications are possible. We report the case of a young female patient presenting a stent-graft migration during the deployment with total obstruction of the supra-aortic vessels. We describe the therapeutic management with a cerebral rescue procedure followed by a delayed surgical repair.

[Constrictive pericarditis and disseminated nocardiosis]. / Péricardite constrictive et la nocardiose disséminée.

Human nocardiosis usually involves the respiratory tract or the skin but may disseminate to virtually any organ, it occurs in immunocompromised hosts as well as individuals with no apparent predisposition. Involvement of the pericardium is uncommon, having been reported infrequently in the past, but mandates a special management. This report describes the first case in Europe of a patient with chronic constrictive pericarditis from nocardia brasiliens, successfully treated with pericardiectomy and appropriate antibiotic therapy.

[ECMO for post cardiotomy refractory cardiogenic shock: Experience of the cardiac surgery department of the Grenoble Alpes University Hospital]. / ECMO pour choc cardiogénique réfractaire post cardiotomie : expérience du service de chirurgie cardiaque du CHU de Grenoble Alpes.

OBJECTIVE: The objective of our study is to detail our experience relating to ECMO implantations for post-cardiotomy refractory shock, by analyzing the pre-ECMO factors (history, type of surgery, LVEF), factors relating to ECMO (implantation time, duration) and post-ECMO factors (weaning, complications) in order to highlight those possibly associated with high mortality. METHODS: This is a univariate and multivariate retrospective study of ECMO data implemented between 2011 and 2019 at the Grenoble Alpes University Hospital Center following cardiac surgery. The time to implantation of ECMO was less than 3hours (intraoperative) between 3 and 24hours (early postoperative) and between 24 and 48hours after aortic unclamping (late postoperative). Preoperative or postoperative intra-aortic balloon counterpulsation (CPBIA) could be associated. RESULTS: 114 veino-arterial ECMOs were implanted for refractory cardiogenic shock after 5702 cardiac surgeries (1.9%) with a survival rate of 30.7%. The mean age of the patients was 68.6+- 10.5 years. The implantation of ECMO was performed intraoperatively in 71 patients (62.2%), early postoperatively in 22 patients (19.2%) and late postoperatively in 21 patients (18.4%). The duration of assistance was less than 48hours in 27 patients (23.6%), between 48hours and one week in 58 patients (50.9%) and more than one week in 29 patients (25.5%). Univariate analysis revealed a statistically significant association between mortality rate and male sex (P=0.002), association absent with other preoperative characteristics, delay in implantation of ECMO, installation of CPBIA, post-operative characteristics and resuscitation suites. Multivariate analysis of the entire study population demonstrated that the use of ECMO for cardio-respiratory arrest was the only independent risk factor for mortality (OR=7.57 [1.41-40, 62]). After multivariate reanalysis excluding patients with ECMO placement for cardio respiratory arrest, age, preoperative renal failure, type of procedure and EuroSCORE II were risk factors for mortality. CONCLUSION: In this study, male gender, type of intervention, occurrence of cardiac arrest were significantly associated with the death rate. A study of greater power, multicentric, and with a larger sample, will have to be carried out to reach significance.

Early postoperative bleeding after isolated coronary bypasses: Changes over a period of 20 years - An observational study.

OBJECTIVES: The objectives were to analyze the evolution of the postoperative bleeding after coronary artery bypass grafting and to determine which factors impacted on this evolution. METHODS: This is a single-center retrospective study including 4590 patients undergoing coronary bypass surgery between 1995 and 2017. The study period was divided into 3 same-sized periods. We analyzed the evolution of the bleeding according to: the chest volume bleeding over the first 24hours, the severity and the rate of transfusion during the hospital stay. Intrahospital outcomes were compared between "minor" and "major" bleedings. The risk factors of major bleeding were analyzed by multiple logistic regression. RESULTS: The chest volume decreased particularly during the first years of the study period. Major bleedings decreased over the periods (7.3%, 4.9% and 3.8% respectively, P<0.0001), as did the rate of transfusion (26.4%, 23.5% and 19.6% respectively, P<0.0001). Major bleedings were correlated with hospital mortality (8.2% versus 1.1%, P<0.0001). The risk factors of major bleeding were the period 1 (1995 to 2003), a renal failure, a resternotomy, the EuroSCORE, the hematocrit prior to cardiopulmonary bypass and the duration of cardiopulmonary bypass. CONCLUSIONS: Postoperative bleeding decreased mainly in the 1990s. Progressive changes in bleeding prevention and blood recovery, surgical techniques, haemoglobin threshold for transfusion decision and practitioners' experience have contributed to these results and must be continued to optimize the postoperative outcomes.

[Type A acute aortic syndromes: Assessment of the management delays in an emergency medicine network]. / Syndromes aortiques aigus de type A : évaluation des délais de prise en charge dans un réseau de médecine d'urgence.

OBJECTIVE: To assess the diagnostic delay (between first hospital medical contact and diagnosis) and the surgical delay (between diagnosis and incision) of type A acute aortic syndromes (AAAS) within the RENAU (REseau Nord Alpin des Urgences), organizing the management of emergency medicine care in the French North Alpine Arc. PROCEDURE: Multicenter retrospective study between 2012 and 2016 on the AAAS operated in the RENAU heart surgical centers (Annecy, Grenoble). Post-traumatic, iatrogenic or chronic lesions, incidental discoveries and deaths before surgery were excluded. RESULTS: One hundred and ninety-seven patients were included with a median age [IQR] of 65 years [58; 73] of which 67% were men. The median diagnosis delay was 88min [46;241] and the median surgical delay was 193min [146;249]. Initial management was performed by the SMUR for 102 patients (52%), 7% of whom received a pre-hospital transthoracic ultrasound. 52 patients (26%) presented themselves spontaneously to the emergency department. Patients were initially admitted in a center without cardiac surgery in 65% of cases. The CT scan was the diagnostic test in 81% of cases. The postoperative hospital mortality was 16%. CONCLUSION: Referring to IRAD data reporting a median diagnostic and surgical delay of 258min each, our study suggests that the RENAU organization may be associated with reduced diagnostic and surgical delays for patients with SAAA.

Extracorporeal life support for massive pulmonary embolism during pregnancy.

Massive pulmonary embolism is a leading cause of death during pregnancy. While the prevention of thromboembolic disease during the peripartum period is codified, there is no consensus regarding its treatment. We report two cases of pregnant women who had massive pulmonary embolisms (PE) and shock treated with veno-arterial extracorporeal life support (ECLS) and heparin therapy.Haemodynamic and oxygenation parameters were rapidly restored. The patients completely recovered and the pregnancies continued. The patients did not develop pulmonary hypertension. ECLS can be considered as a successful treatment option of massive pulmonary embolism during pregnancy.

Is intra-aortic balloon pump absolutely contraindicated in type A aortic dissection?

AIM: Circulatory failure following surgery for type A aortic dissection is frequent and associated with a high mortality rate. The intra-aortic balloon pump (IABP) is used to treat postcardiotomy cardiogenic shock but aortic dissection is traditionally a contraindication. In 10 patients we used IABP for severe cardiogenic shock following aortic dissection surgery, here we report on the short and midterm results. METHODS: From January 2000 to April 2008, among 151 patients with type A aortic dissection 10 received a postoperative IABP. False lumen extension was limited to the ascending aorta for 3 patients, reached the arch for 1 and the descending aorta for 6. RESULTS: The device was placed in the operative room (7 patients), intensive care unit (2) and preoperatively (1). IABP was introduced percutaneously except for one who required surgical placement. The mean duration of IABP therapy was 3.8 days. Four patients died, but no death was directly related to IABP. Improvement in hemodynamics allowed 8 patients to be weaned off IABP. None suffered extension of the dissection. Two patients developed IABP-related complications. Six required extrarenal purification. Among the survivors, one died of a stroke at 38 months, 2 recovered the same quality of life and 3 had neurological sequelae without loss of autonomy. CONCLUSION: IABP should only be used as a salvage option in cases of severe cardiogenic shock following type A aortic dissection. No patient suffered device-related aortic rupture or extension of the dissection. High mortality and morbidity underline the gravity of cardiogenic shock in this setting.

[Aortic dissection spread to the renal arteries: role of renal volumetry after angioplasty]. / Dissection aortique étendue aux artères rénales : intérêt de la volumétrie rénale après angioplastie.

OBJECTIVE: Type A or B aortic dissection can extend to renal arteries, causing a renal ischemia which treatment is usually endovascular. The aim of our study is to show the interest of the renal volumetry in the follow-up of these patients. PATIENTS AND METHODS: Twenty-two patients (16 men, mean age 63.4±11.8years, BMI 25.2±3.4kg/m(2)) with a type A or B aortic dissection spread to one or to both renal arteries and followed at Grenoble university hospital were consecutively included. All patients underwent renal angiography with aorto-renal pressure gradients measurements and follow-up by renal volumetry (scanner Siemens(®)). A renal ischemia was defined by a decrease of 20% or more of the volumetry. RESULTS: Sixteen patients (73%) were hypertensive before the aortic dissection among which ten (62%) were treated. Eight patients (36%) have a significant renal pressure gradient among which five (62%) underwent renal endovascular therapy. The renal volumetry of these five patients remained unchanged while six of 17 patients (36%) without angioplasty have a decreasing volumetry. CONCLUSION: Renal volumetry appeared an effective and attractive option for the follow-up of the patients with aortic dissection spread to the renal arteries. These results should be taken into account to put the indication of an endovascular treatment.

[Paraplegia after prolonged cardiac arrest and extracorporeal life support]. / Paraplégie après arrêt cardiaque prolongé et circulation extracorporelle.

Paraplegia by medullar ischaemia after cardiac arrest is rarely reported, especially without an oxo-ischaemic cerebral lesions. We report the case of a 17-year-old woman who underwent a 70 minute cardiac arrest with recovery of consciousness, but a symptomatic medullar ischaemia (paraplegia under T4).

[The association of VAC® therapy, titanium plates osteosynthesis and bilateral pectoral muscle flaps in the management of postoperative mediastinitis in an obese and diabetic patient]. / Intérêt de l'association VAC®-thérapie, ostéosynthèse sternale et lambeaux pectoraux d'avancement dans la prise en charge d'une médiastinite postopératoire après chirurgie cardiaque chez une obèse diabétique.

Postoperative mediastinitis is one of the most worrisome complications after heart surgery. Until now there is no universally accepted strategy in the management of this infectious complication. Recently, various novel techniques like negative pressure therapy and titanium plates sternal reconstruction have allowed a dramatic decrease of mortality and morbidity after mediastinitis. We report the case of a diabetic patient suffering from morbid obesity who developed a severe postoperative mediastinitis after a coronary artery bypass; she was successfully treated by combining negative pressure therapy, titanium plates osteosynthesis and bilateral pectoral muscle flaps.

Dramatic improvement in survival after lung transplantation over time: a single center experience.

Lung transplantation (LT) is a recognized procedure for selected patients with end-stage respiratory failure. We performed 123 LT, including 32 single lung, 84 double lung, and 7 heart-lung transplantations in 48 patients with chronic obstructive pulmonary disease (COPD), 13 patients with pulmonary hypertension (PH), 33 with cystic fibrosis (CF), and 29 with interstitial lung disease (ILD) between July 1990 and January 2008. Survival was compared for periods before and after December 2001. The mean age of patients was 44.4 years (range 16-66.5 years); 84 (69%) were men. Before LT, 1 second forced expiratory volume was 28.7% +/- 18.1% and PaCO(2) = 6.3 kPa. Fifty-five patients were on noninvasive ventilation. Cold ischemia time was 320 +/- 91 minutes. Cardiopulmonary bypass (CPB) was used in 77 patients (64%). There were 18 early surgical reinterventions, 8 extracorporeal membrane oxygenations, and 38 bronchial stent insertions among 206 at-risk bronchial sutures. Crude survivals were 69%, 58%, 41%, and 18% at 1, 2, 5, and 10 years, respectively. Comparing before (n = 70 with 15 CF) vs after December 2001 (n = 53 with 17 CF), survivals were 63% vs 78%, 51% vs 71%, and 33% vs 60% at 1, 2, and 5 years, respectively (P = .01) and for CF patients, 52% vs 100%, 52% vs 94%, and 25% vs 94% at 1, 2, and 5 years, respectively (P = .005). There was significant improvement in survival before and after 2001 in 123 LT and particularly among CF patients. Improvement in survival after LT may be related to the sum of numerous changes in our practice since December 2001, including the use of pulmonary rehabilitation pre-LT, extracellular pneumoplegia, statins, macrolides for chronic rejection, monitoring of Epstein-Barr blood load, changes in maintenance immunosuppressants, as well as position movement up the coordinator nurse and learning curve.

[Kidney allograft harvesting on a donor patient under cardiopulmonary bypass]. / Prélèvements de reins chez une patiente en mort encéphalique sous circulation extracorporelle.

We report the case of a kidney allograft harvesting on a donor patient under cardiopulmonary bypass (CPB) after a cardiac arrest. The two kidneys were successfully transplanted with immediate graft function. CPB may provide an option to expand the number of harvested grafts.

Effect of aprotinin on postoperative blood loss in off-pump coronary artery bypass surgery.

BACKGROUND AND AIM OF THE STUDY: Off-pump coronary artery bypass (OPCAB) enables a reduction in postoperative complications, particularly bleeding and transfusion. Nevertheless, a significant percentage of patients still needs transfusion. The effect of antifibrinolytic therapy on postoperative bleeding as part of OPCAB is still not widely described. The purpose of this study was to investigate the potential benefit of aprotinin in OPCAB. METHODS: We conducted a retrospective comparative study with a historical control group. Consecutive patients undergoing off-pump coronary bypass were divided in two groups: 40 patients were operated without any antifibinolytic drug (group C); 40 patients received aprotinin (group A) during surgery. Patients in group A received a bolus of 2 x 10(6) KIU during 30 minutes, followed by a continuous infusion of 0.5 x 10(6) KIU per hour until the end of surgery. The same protocol was used during the whole study period. RESULTS: Preoperative data of the two groups did not differ except for the number of grafts performed, which was higher in group A. Prothrombin time and activated clotting time increased in both groups after surgery. The use of packed red blood cells or fresh frozen plasma was not significantly different between both groups. Postoperative blood loss was significantly reduced in the aprotinin group (540 mL +/- 320 vs. 770 mL +/- 390, p = 0.006). No increase in postoperative troponin values was found in group A. CONCLUSIONS: Aprotinin significantly reduced postoperative blood loss without reducing the transfusion rate. Aprotinin was not associated with any increase in postoperative complications.

Atypical primary epithelioid hemangioendothelioma of the heart.

We report an unusual case of primary cardiac epithelioid hemangioendothelioma (EHE) with atypical features, which was treated by orthoptic transplantation with a good outcome for 10 years despite recurrent pulmonary and nodal metastases. EHE is a rare vascular tumor that belongs to the group of malignant proliferations from the new World Health Organization classification of soft tissue tumors. EHE may harbor atypical features that confer a more aggressive course, albeit better than that of conventional angiosarcomas. Histological examination of the primary cardiac tumor revealed a proliferation of large epithelioid tumor cells presenting atypical features and a mitotic index of 3 mitoses per 10 high power fields. In contrast, pulmonary metastases exhibited typical features of EHE, and CD 34 and CD 31 immunostainings strongly stained cytoplasmic vascular lumen. In this report, we illustrate the potential aggressiveness of the atypical variant of EHE and suggest that transplantation might be considered as an alternative therapy in the treatment of EHE of the heart.

Disseminated toxoplasmosis with pulmonary involvement after heart transplantation.

We report a case of pulmonary toxoplasmosis after heart transplant despite the prophylactic anti-toxoplasmic treatment that was given but was not sufficient to prevent toxoplasmosis. However, the patient survived thanks to early diagnosis confirmed by polymerase chain reaction on blood and by serological techniques, and early treatment.

[Continuous infusion of remifentanil and target-controlled infusion of propofol for coronary surgery in elderly patients: comparison with continuous infusion of remifentanil and propofol]. / Perfusion continue de rémifentanil et propofol en anesthésie intraveineuse à objectif de concentration au cours de la chirurgie coronaire du sujet âgé: comparaison avec l'alfentanil et le propofol en perfusion continue.

OBJECTIVES: Comparison of the length of mechanical ventilation and postoperative complications after coronary surgery in elderly patients anaesthetised with propofol associated with either alfentanil or remifentanil. STUDY DESIGN: Retrospective study with an historic control group. PATIENTS: Three hundred thirty-eight consecutive patients (75-year-old or more) undergoing isolated coronary surgery. One hundred and fifty seven patients operated between January 1998 and June 2000 received alfentanil (1 microg/kg/minute) with a manually control infusion of propofol, 181 operated between July 2000 and 2002, remifentanil 0.25 microg/kg/minute with target controlled infusion of propofol (target blood concentration: 1.5 to 2 microg/ml). METHODS: The two groups were compared for preoperative and surgical data. The length of mechanical ventilation, stay in ICU and the main postoperative complications were compared between the two groups. RESULTS: Length of mechanical ventilation was significantly reduced in the remifentanil group (6 +/- 9 h vs. 13 +/- 63 h ; p <0.0001), 70% of the patients were extubated before the 6th postoperative hours against 53% in the alfentanil group (p =0.0023). This was not associated with a reduction of stay in ICU or postoperative complications. During surgery, an increased used of vasopressor was observed in the remifentanil group (40.2% vs 2.4% ; p <0.0001) with a postoperative elevation of blood concentration of CKMb (35.7 +/- 38.2 microg/l, vs. 27.7 +/- 31.9 microg/l, p =0.02). CONCLUSION: Elderly patients undergoing coronary surgery were extubated earlier with remifentanil. However, this had no effect on duration of ICU stay but was associated with an increased used of vasopressor.

[Pulmonary embolism with right intra-auricular thrombus. Fatal outcome during fibrinolysis]. / Embolie pulmonaire avec thrombus intra-auriculaire droit. Décès au cours d'une fibrinolyse.

INTRODUCTION: The spontaneous prognosis of pulmonary embolism associated with mobile intra-cardiac thrombus is most severe, and the choice of a therapeutic strategy is often difficult. OBSERVATION: The treatment of a patient with intravenous fibrinolytics for massive pulmonary embolism and right atrium thrombus was complicated by his early death. We attributed his death to the migration of the intra-cardiac thrombus. Indeed, the cardiac ultrasound, performed when the patient's hemodynamic state had worsened, revealed the complete disappearance of the thrombus too early to correspond to its complete lysis (30th minute of fibrinolysis). COMMENTS: In this pathology, several therapeutic approaches are possible. Surgical removal of the embolus has been validated, but cannot be proposed to all patients since it is a high-risk intervention. Fibrinolysis is generally efficient but exposes the patient to the risk of migration of the intra-cavity thrombus with occasionally deleterious evolution (as in our patient). Heparin treatment alone has been proposed as an alternative when the other two techniques are contraindicated. These techniques currently require assessment in a randomized study, in order to define the appropriate therapeutic strategy.

[Does the time between preoperative interruption of aspirin intake and operation influence postoperative blood loss and transfusion requirement in coronary artery bypass graft?]. / L'intervalle entre l'arrêt préopératoire de l'aspirine et l'intervention chirurgicale a-t-il une influence sur le saignement et la transfusion en chirurgie coronaire?

OBJECTIVE: Impact of the interval between interruption of aspirin intake and surgery on postoperative bleeding and transfusion in coronary artery bypass graft (CABG), with extracorporeal circulation (ECC). STUDY DESIGN: Retrospective study. PATIENTS AND METHODS: Four hundred and twelve patients having undergone CABG were retrospectively reviewed. Three groups were evaluated according to the length of the interval defined above: Group I (< 3 days), Group II (3-7 days), Group III (> 7 days or without aspirin intake). Postoperative blood loss at 3rd, 6th, 12th, and 24th hour and transfusion requirements were assessed for the 3 groups. Aprotinin (low dose, 2 M KIU) was systematically included in the priming of the ECC circuit. RESULTS: There were no significant differences among groups for weight, size, duration of ECC, and number of bypasses. No significant correlation was noted among the 3 groups for postoperative blood loss and transfusion. Multivariate analysis showed that factors associated to a higher risk of excessive bleeding were ECC duration and number of arterial grafts. Factors associated with a higher risk of transfusion were: emergency, minimum patient temperature during ECC, weight and preoperative haemoglobin level. Aspirine intake was not associated with an increase of bleeding or transfusion. CONCLUSION: Our study showed that in our practice using systematic low dose of aprotinin when priming the ECC circuit, aspirin did not significantly increase bleeding or transfusion requirements in CABG with ECC, whatever the interval between interruption of aspirin intake and surgery. Consequently, in our practice, aspirin intake is interrupted on hospitalisation, one day before surgery.