[Impact of sugammadex on neuromuscular blocking agents use: a multicentric, pharmaco-epidemiologic study in French university hospitals and military hospitals]. / Impact du sugammadex sur les consommations de curares : étude pharmaco-épidémiologique multicentrique dans les centres hospitalo-universitaires et hôpitaux d'instructions des armées français.

INTRODUCTION: Seven Neuromuscular Blocking Agents (NMBA) are commercialized in France. Four of them have an intermediate duration of action. Sugammadex required the use of NMBA slightly employed in clinical practice in France. Its introduction in routine practice could have an impact on NMBA use in clinical practice. This study was then conducted to assess and compare NMBA use before and after the commercialization of sugammadex. MATERIALS AND METHODS: A longitudinal, retrospective, observational study was conducted between 2008 and 2011 in French university hospitals and military hospitals. The consumption data for sugammadex and NMBA were collected using a collection grid which was filled by pharmacists or anesthesiologists. Drug use was measured by the number of vials used divided by the annual number of hospitalizations in surgery and obstetrics (HSO). An overall analysis of the annual frequency of NMBA use was firstly performed, then individual data of each hospital were analyzed. Descriptive statistical analysis including mean, standard deviation, median, minimum and maximum was achieved. RESULTS: Thirty-four out of 39 hospitals participated in the study (87%) and analysis was performed on 26 of them (7%). The data of eight institutions were excluded due to missing values or because of the non-admission of sugammadex in their formulary. The NMBA mostly used were non-steroidal NMBA (75% of market share) with an increased use between 2008 and 2011 concerning atracurium (from 41 to 51 vials of 50mg atracurium used per 100 HSO). The overall analysis revealed an increase of the occurrence of rocuronium (between 2008 and 2011: from 1 to 4.8 vials of 50mg rocuronium used per 100 HSO). Individual analyses on each hospital showed a possible effect of sugammadex introduction on NMBA use in nine hospitals. DISCUSSION AND CONCLUSIONS: The commercialization of sugammadex seems to have induced a discrete increase of steroidal NMBA but non-steroidal NMBA remain the leading agent in France. A long-term follow-up is deserved.

[Interhospital transport with extracorporeal life support: results and perspectives after 5 years experience]. / Transport interhospitalier sous extracorporeal life support : résultats et perspectives après cinq ans d'expérience.

OBJECTIVE: Describing the experience of a referral center for interhospital patients transport treated with extracorporeal circulatory or respiratory support (ECLS), the difficulties encountered and the results obtained. STUDY DESIGN: Retrospective and observational study. PATIENTS AND METHODS: All patients with respiratory or circulatory failure accepted for extracorporeal assistance for which routine medical transport was life threatening. STATISTICAL ANALYSIS: A descriptive analysis was performed (median and interquartile deviation). Comparison of biological data was performed using a non-parametric Wilcoxon test and 5 years overall survival was determined by a Kaplan-Meier analysis. RESULTS: Over a 55-month period, 29 patients were selected for transportation under ECMO or ECLS. Indication was respiratory failure in 38 % of cases, hemodynamic instability in 52 % of cases and combined symptoms in 10 % of cases. Average duration of transportation was 40 km (9-64 km). No complication related to transport was observed. Incidence of intrahospital death was 57 %. There was no correlation between death and indication of ECLS. Five-year survival was 55 % and 39 % for venovenous and arteriovenous ECLS, respectively. CONCLUSION: In our experience, interhospital transport of patients under ECMO is feasible in satisfactory conditions of safety with trained team and standard procedures.

Impact of biventricular and left ventricular pacing on hemodynamics and left ventricular dyssynchrony compared with right ventricular pacing in the early postoperative period following cardiac surgery.

OBJECTIVES: The aims of this study were to test the hypotheses that in the postoperative period following corrective surgery for congenital heart defects: (i) atrio-right ventricular (RA-RV) pacing decreases cardiac output (CO) compared with right atrial (RA) pacing, (ii) atrio-biventricular (RA-BiV) and left ventricular (RA-LV) pacing improves CO compared with RA-RV pacing. STUDY DESIGN: Prospective observational study. PATIENTS: Children 0-2years of age referred for surgery of congenital heart defects were studied during intrinsic rhythm and atrial, atrio-right ventricular, atrio-left ventricular and atrio-biventricular pacing. CO, extrapolated from mean systolic aortic velocity (MSAV), and left ventricular dyssynchrony were assessed using transthoracic echocardiography. RESULTS: RA-RV pacing induced a significant decrease in CO (MSAV 0.52±0.19m/s to 0.46±0.16m/s, p=0.01) and a significant increase in LV dyssynchrony (8.7±7.9ms to 33±21ms, p=0.001). RA-BiV pacing induced a significant increase in CO (MSAV 0.46±0.16m/s to 0.52±0.18m/s, p=0.01) and a significant decrease in LV dyssynchrony (33±21ms to 7±4ms, p=0.0003) compared with RA-RV pacing. RA-LV pacing induced a significant decrease in LV dyssynchrony (33±21ms to 9±7ms, p=0.0007) without a significant improvement of CO compared with RA-RV pacing. CONCLUSIONS: RA-BiV pacing improves CO compared with RA-RV pacing in the early postoperative period following pediatric cardiac surgery. This improvement is related to a reduction in left ventricular dyssynchrony.

[Cardiac tamponade by right atrial laceration due to blunt chest trauma in a 3-year-old child]. / Tamponnade cardiaque par plaie de l'oreillette droite liée à un traumatisme fermé du thorax chez une enfant de trois ans.

The case of 3-year-old girl severely injured, as restrained car passenger in a road crash, is reported. She presented with isolated circulatory failure, without specific clinical signs except skin contusions corresponding to seat belt. Because of mediastinum enlargement on systematic chest X-ray, a pericardial effusion was suspected, which was confirmed by echography, rapidly complicated by an acute tamponade without visible cause on CT-scan. The radiological assessment showed a moderate peritoneal haemorrhage related to a splenic injury. A persistent haemodynamic instability required a pericardial puncture, after rapid sequence tracheal intubation of the child, but without clinical improvement, despite fluid bolus, red-blood cell transfusion and epinephrine infusion. The child was rapidly transferred to the cardiac operating room for sternotomy, which showed a right atrial laceration. The injury was repaired, allowing the child to survive without disability. Tamponade due to traumatic cardiac injury is extremely rare in children. The clinical diagnosis is particularly difficult to establish in the context of polytrauma. The classical symptoms of cardiac tamponade are rarely complete. The association of chest injury, isolated circulatory failure and enlargement of mediastinum at chest X-ray should alert the physician. As the severity of these injuries is high, a rapid and multidisciplinary management is required, as well as specific anaesthetics precautions.

[Comparison of ICG thoracic bioimpedance cardiac output monitoring system in patients undergoing cardiac surgery with pulmonary artery cardiac output measurements]. / Comparaison des valeurs de débit cardiaque obtenues à l'aide d'un nouveau système d'impédancemétrie thoracique avec les données du cathéter artériel pulmonaire en postopératoire de chirurgie cardiaque.

OBJECTIVE: Thoracic bioimpedance has been proposed for cardiac output (CO) determination and monitoring without calibration or thermodilution (ICG Monitor 862146, Philips Medical System, Philips, Suresnes, France). The accuracy and clinical applicability of this technology has not been fully evaluated in the cardiac surgery setting. We designed this prospective study to compare the accuracy of the ICG Monitor (CO(ICG)) versus pulmonary artery catheter standard bolus thermodilution (CO(PAC)) in patients after cardiac surgery or having benefited from cardiac surgery. STUDY DESIGN: Prospective, monocentric. MATERIAL AND METHODS: We studied 13 patients in the postoperative period. CO(ICG) and CO(PAC) were determined at the arrival in the intensive care unit and every four hours. Bland-Altman and Critchley and Critchley's analysis were used to assess the agreement between CO(ICG) and CO(PAC). RESULTS: CO(PAC) ranged from 2.6 to 11.0 l/min and CO(ICG) ranged from 1.8 to 11.7 l/min. There was a significant relationship between CO(PAC) and CO(ICG) (r=0.61 ; p<0.001). Agreement between CO(PAC) and CO(ICG) was -0.5+/-1.3 l/min (Bland-Altman analysis). Percentage error between the two methods was 49% (Critchley and Critchley's analysis). CONCLUSION: We found clinically unacceptable agreement between CO(ICG) and CO(PAC) in this setting. Despite its non invasiveness, this device cannot be recommended for CO monitoring in the postoperative period following cardiac surgery.

[Clinical usefulness of new-generation pulse oximetry in the paediatric cardiac surgery setting]. / Utilisation clinique d'un oxymètre de pouls de nouvelle génération dans le cadre de la chirurgie cardiaque pédiatrique.

OBJECTIVES: Arterial oxygen saturation (SaO(2)) monitoring using pulse oximeter (SpO(2)) is mandatory in the intensive care unit. The aim was to assess bias and precision of new (SpO(2)ng) and old (SpO(2)og) pulse oximeter technologies in the postoperative period following pediatric cardiac surgery in cyanotic children. STUDY DESIGN: Prospective, monocentric. PATIENTS AND METHODS: Ten patients (7 days to 53 months old) were studied in the postoperative period following palliative cardiac surgery. SaO(2), SpO(2)og, and SpO(2)ng were obtained every 4 hours. SaO(2) of arterial blood sample was obtained from an intra-arterial catheter located in the radial artery, on the same side as the oximeters. Bias and precision were assessed using Bland-Altman analysis. RESULTS: We obtained 136 SaO(2) determinations. Mean SaO(2) was 76+/-15%. SpO(2)og was significantly different from SaO(2), while SpO(2)ng was not different from SaO(2). In 21 (15%) cases, SpO(2)og was not available whereas SpO(2)ng was available in 136 (100%) cases. In the remaining 115 cases, SpO(2)ng's precision was significantly better than SpO(2)og's precision. DISCUSSION: SpO(2)ng is more accurate and more reliable than SpO(2)og for SaO(2) monitoring in the postoperative period following pediatric cardiac surgery in cyanotic children.

Choice of echocardiography method for postoperative evaluation of mitral valve replacement with a mechanical prosthesis.

OBJECT: The French Cardiology Society (SFC) systematically recommends (Class I) transesophageal echocardiography (TEE) after any mitral valve replacement with a mechanical prosthesis (MMVR). Taking into account the increasing workload of echocardiography laboratories, our attitude was to propose that only post-operative transthoracic echocardiography (TTE) is performed. The purpose of this study was to evaluate the possible risks of this simplified procedure. METHODS: We performed a precise analysis of one full year of practice of MMVR with exhaustive follow-up for the first 2 years concentrating on thromboembolic complications. RESULTS: From January to December 2003, 84 MMVRs (46 after rheumatic fever, 22 degenerative disease, 11 infective endocarditis (IE) and 5 ischemia) were conducted in 45 women and 39 men of average age 61 years. Early mortality (<30 days) concerned 5 patients (5.9%). A control TTE to determine normal prosthetic function was performed 7+/-2 days after surgery and this revealed 2 cases of nonobstructive thrombosis which were treated medically, 3 cases of paraprosthetic regurgitation, and 1 vegetation due to underlying IE. Actuarial survival was 90.5% at 1 year and 83.3% at 2 years. After a mean follow-up of 179.3 patient-years, 5 patients were reoperated (5.9%): 1 for IE, 1 for paravalvular regurgitation, 1 for mitral valve insufficiency with haemolysis, and 2 for obstructive prosthetic valve thromboses. In addition there were 2 cases of prosthetic valve thrombosis, 8 ischemic strokes (2 ministrokes, 6 sequelar strokes), and 1 peripheral embolism. The global thromboembolic complication rate was therefore 6.1 per 100 patient-years (n=11). There were 4 hemorrhagic events, i.e. a rate of 2.2 events per 100 patient-years. 63% of the 1193 INR conducted were within the target range (3-4.5), 26% were below 3 and 11% were greater than 4.5. 35% of patients with thromboembolic complications had an INR<3. CONCLUSION: Morbidity and mortality during the first 2 years after MMVR were relatively high but equivalent to the values of comparable series in the literature. These complications would not have been reduced by a more precise screening based on early TEE. Despite the increasingly litigious nature of the doctor-patient relationship, it would probably be excessive to oppose that this guideline was not followed in a dispute; in particular as it is difficult to apply this measure as echocardiography departments are overworked.

Current patterns of infective endocarditis in congenital heart disease.

OBJECTIVE: To assess the changing profile of infective endocarditis in patients with congenital heart disease. METHODS: All cases diagnosed from 1966 to 2001 (revised Duke criteria) were retrospectively reviewed and categorised in periods I (< 1990) and II (>or= 1990). RESULTS: 153 episodes occurred, 81 in period I and 72 in period II. Mean age of affected patients was higher in period II. Non-operated ventricular septal defect, Rastelli correction and palliated cyanotic heart disease increased. Infective endocarditis in corrective surgery changed to patients with prosthetic material. Post-surgical cases decreased. Dental problems were the leading cause (period I 20% v II 33% of cases) with a large variety of pathological organisms (multiple species of Streptococcus). Cutaneous causative infections increased (5% to 17%) with different species of Staphylococcus. Negative blood cultures lessened (20% to 7%, p = 0.03). Streptococci were the most common causative organisms in both periods. Severe heart failure and cardiac complications lessened (20% to 4% and 31% to 18% during periods I and II, respectively). Early surgery was more frequent in period II (32% v 18.5%, p = 0.02). One- and 10-year survival was 91% v 97% in period I and 89% v 97% in period II, respectively (NS). CONCLUSION: Current targets include complex cyanotic disease, congenital heart disease corrected with prosthetic material and small ventricular septal defect. Postoperative cases lessened; dental and cutaneous causes increased. Survival was unchanged. Prophylactic measures targeted at dental and cutaneous sources should be emphasised.

[Evolution of the Fontan operation and results in patients with single ventricles or mixed congenital malformations]. / Evolution et résultats des opérations de Fontan dans les cardiopathies congénitales univentriculaires ou assimilées.

STUDY OBJECTIVES: To examine the results of right heart derivations and clinical outcomes according to preoperative characteristics and operative strategy implemented. METHODS: Fontan operations were performed in 65 patients (mean age = 10.3 years, 41 males). The majority of cardiopathies were single ventricles (SV) with (49% of patients) or without (26%) tricuspid atresia. A palliative bidirectional cavo-pulmonary (BCP) anastomosis was performed prior to Fontan in 15 patients. Intra-atrial Fontan tunnelling was performed in 43 patients, Kreutzer-type operations in 10, and extracardiac tubes were used in 8 patients. The mean duration of follow-up was 6.1 +/- 0.3 years. RESULT: The 30-day mortality was 13.8%. Early mortality was higher among patients with SV with than without tricuspid atresia (P < 0.01), and among patients < 4 years old. Early reoperations were required in 5 patients, including dismounting in 1, BCP anastomosis after Kreutzer procedure in 1, and tube thrombosis in 1 patient. A single death occurred past 30 days, and late adverse events included protein-losing enteropathy in 1 patient, complete atrioventricular block in 1, and tube thrombosis treated with heparin in 2 patients. At the end of follow-up, 75% were in New York Heart Association functional class I. CONCLUSION: Our intermediate-term results of Fontan-type operations were satisfactory, and steadily improving. The prognosis was better in patients operated at age 4 or older. A prior BCP anastomosis improved the results. A higher morbidity was observed with intra- than with extra-atrial Fontan procedures. The merit of fenestration procedures with respect to morbidity remains the be evaluated.

[Replacement of the ascending aorta with conservation of the aortic valve. Results of 50 cases using the Tirone David procedure]. / Remplacement de l'aorte ascendante avec conservation valvulaire aortique.

Aortic valve sparing operations are now widely accepted for ascending aortic aneurysm surgery. We herein report our experience of the Tirone David procedure in larger indications. From January 1997 to August 2003, 50 Tirone David procedure have been performed on 36 male and 14 female (mean age: 60 +/- 15). Five patients presented a Marfan disease and 4 acute dissections. Grade III or IV aortic insufficiency was frequent (40%). Aortic diameter was not particularly dilated, ranging from 44 to 78 mm (mean: 57 +/- 10 mm). Mean ejection fraction: 57 +/- 10%. Mean left ventricular end diastolic diameter =63 +/- 7 mm. An associated mitral valve repair and 1 coronary bypass were necessary. Mean cross clamp and bypass times =94 min and 122 +/- 28 min respectively. There was one in-hospital mortality. Secondary mortality affected 2 patients (non-cardiac deaths), for a cumulative follow-up of 946 months. During follow-up continence control was always excellent, only 1 bicuspid valve had an aortic insufficiency >grade II. Tirone David procedure gave satisfactory results as regards both aortic ectasia and aortic regurgitation control. We consider it feasible even in case of aortic dissection but caution is required when facing bicuspid aortic valves.

[Blunt trauma to the infrarenal abdominal aorta with neurologic lesions. Case report and review of the literature]. / Traumatisme fermé de l'aorte abdominale sous-rénale avec lésions neurologiques. Stratégie de prise en charge: à propos d'un cas et d'une revue de la littérature.

We report the case of a 31-year-old female involved in a severe motor vehicle accident. The diagnosis of blunt trauma to the abdominal aorta was not retained initially. The patient was referred to our institution when she developed a delayed paralysis of the lower limbs associated with the disappearance of both femoral pulses. Computed tomography evidenced dissection of the infrarenal aorta and NMR ruled out injury to the spinal cord. An aortoiliac endarteriectomy was then performed. Neurological recovery was partial at 3 months. We reviewed the frequency, the mechanisms and the management of blunt trauma to the abdominal aorta.