The peak of blood lactate during the first 24h predicts mortality in acute coronary syndrome patients under extracorporeal membrane oxygenation.

BACKGROUND: Parameters allowing for outcome discrimination of extracorporeal membrane oxygenation (ECMO) therapy in acute coronary syndromes (ACS) complicated by refractory cardiogenic shock (CS) and/or cardio-respiratory arrest (CA) remain elusive. We aimed at evaluating the potential prognostic roles of blood and procedural parameters associated with 30-day mortality following ECMO. METHODS AND RESULTS: A group of 29 patients with ACS complicated by CS and/or CA, who underwent ECMO at a single center, was retrospectively analyzed. Eighteen patients (62%) died at 30-day follow up. "Survivors" and "non-survivors" had similar demographics, clinical and biochemical characteristics at admission, except for blood lactate peak in the first 24h that was increased in non-survivors. Procedural characteristics of percutaneous coronary intervention (PCI) and ECMO were comparable in either group. The peak of blood lactate concentration predicted 30-day mortality independently of age, sex and ECMO duration. The cutoff value, determined by receiver operating characteristic (ROC) curve analysis, was found at 11mmol/l. CONCLUSIONS: The peak of serum lactate under ECMO in the first 24h predicted 30-day mortality in patients with ACS complicated with CS and CA.

Measurement of left and right atrial volume in patients undergoing ablation for atrial arrhythmias: comparison of a manual versus semiautomatic algorithm of real time 3D echocardiography.

AIMS: Real time full-volume 3D echocardiography (3DE) allows rapid and noninvasive measurement of left (LA) and right atrial (RA) volume without geometric assumptions. Different algorithms from different commercial providers are available. Older software requires manual tracing of endocardial contours. Recently, software with semiautomatic endocardial contour-finding algorithms has become available, which considerably speeds up the procedure. Our aim was to compare, in the same dataset, both LA and RA volumes determined by an algorithm involving manual tracing to the corresponding volumes obtained by an algorithm with semiautomatic contour detection. METHODS: Maximal atrial volumes were measured in 88 patients using a multiplane interpolation method algorithm based on manual planimetry of 8 slices. These volumes were compared with volumes determined by the QLAB 8.1 software using semiautomatic border detection. RESULTS: Linear regression showed excellent correlation between volumes determined by manual and by semiautomatic software for both LA and RA (r(2) = 0.90 and 0.89, respectively, P < 0.001). Bland-Altman analysis of manual versus semiautomatic volume determination showed narrow 95% limits of agreement (-15.9 to +12.0 mL for LA volume and -13.9 to +12.2 mL for RA volume) with a minimal bias of -1.9 ± 7.0 mL and -0.8 ± 6.5 mL, respectively, by the semiautomatic method. CONCLUSION: The semiautomatic border detection method shows excellent correlation for maximal LA and RA volume determination compared to the more time-consuming, multiplane interpolation method, with only slight underestimation. The results indicate that values of LA and RA volumes obtained by either algorithm can be compared, for example, during follow-up examinations.

Thyrotoxicosis-facilitated bridge to recovery with a continuous-flow left ventricular assist device.

The HeartMate II is a continuous-flow left ventricular assist device that can be explanted from patients after cardiac recovery. We implanted a HeartMate II in a 21-year-old man who had idiopathic cardiomyopathy. A year later, he developed thyrotoxicosis, presumably secondary to amiodarone administered for ventricular fibrillation. Four months after the diagnosis of thyrotoxicosis, thyroid hormone levels had returned to normal, and native cardiac function had improved remarkably. After a support period of 24 months, the HeartMate II was explanted. Six years later, the patient continues to be in New York Heart Association functional Class I. Amiodarone-induced thyrotoxicosis may have contributed to myocardial recovery.

Implementation of an INR self-testing and self-management programme in common ambulatory private practice: our experience with 90 patients.

QUESTIONS UNDER STUDY: INR self-testing devices allow patients on vitamin K antagonists (VKA) to determine their INR and then have their VKA dose adapted by a physician (INR self-testing, ST) or adapt it themselves according to pre-established guidelines (INR self-management, SM). The safety, efficacy and advantages of ST and SM have been demonstrated, but their use remains limited. In an effort to improve the availability of ST and SM, we tested the hypothesis that implementing a teaching programme for ST and SM in a small structure in common ambulatory private practice is feasible, safe and can lead to high patient satisfaction. METHODS: Patients on long-term anticoagulation were assigned to a specific training programme. Patients used the CoaguChek (S then XS) INR testing system. Technical problems, adverse events and INR values were then recorded during the first year of follow-up and analysed. Patient satisfaction data were obtained via a specific questionnaire. RESULTS: 169 patients were referred and 90 included in the teaching programme. 80 performed SM and 10 performed ST. 54 patients (60%) returned the 1-year questionnaire with complete INR data available for 35 patients. The percentage of INR in the target range (target ± 0.5) was 60.6%. The rate of major adverse clinical events (MACE) was 3.7 per 100 patient-years. The main reported advantages were a reduction in visits to the INR testing facility and increased autonomy. There was better venous to capillary INR correlation with the CoaguChek XS than with the S (p <0.025). CONCLUSIONS: The development in a small structure in common ambulatory practice of a specific teaching programme made ST and SM available to a new patient population. It led to high patient satisfaction, significantly reducing the burden of VKA monitoring. These results were obtained while preserving the safety and efficacy standards of VKA treatment and favour greater expansion of ST and SM programmes.

Successful cardiac transplantation in a patient with elevated pulmonary vascular resistance: a relative contraindication to transplantation.

Elevated pulmonary vascular resistance in a transplantation candidate should be viewed as potentially reversible, and there are several options for therapy. We describe a young patient with congenital restrictive cardiomyopathy and a markedly elevated pulmonary artery pressure. The patient underwent successful orthotopic heart transplantation after pharmacologic lowering of the pulmonary artery pressure with a new drug combination of milrinone and nesiritide. The length of therapy can be extended to 3 days to allow for determining the pulmonary vascular responsiveness.

Bridge to transplantation with the TandemHeart: bending the indications in a chronic aortic dissection patient with postcardiotomy shock.

Herein, we report a successful bridge to heart transplantation by use of the TandemHeart percutaneous ventricular assist device (pVAD) in a chronic aortic dissection patient who was experiencing postcardiotomy shock. The patient had undergone an aortocoronary bypass to treat an acute, extensive myocardial infarction that had resulted from severe stenosis of a Cabrol-like graft to the left main coronary artery. The TandemHeart was used successfully, despite classic contraindications for pVAD support. The outcome shows that, in critically ill cardiogenic shock patients, a permissive approach to pVAD use is valuable in screening candidates for long-term ventricular assist device support or for heart transplantation. This case also reveals the validity of direct bridging to transplantation from a pVAD in carefully selected patients.

Management of air embolism during HeartMate XVE exchange.

Air embolism is a rare and usually fatal complication of major cardiac surgery. We present a case in which a 45-year-old man supported by a HeartMate(R) XVE left ventricular assist device required a pump exchange due to failure of the device motor. During pump dissection, a massive amount of air entered the systemic circulation. Urgent cannulation for cardiopulmonary bypass was performed, and cardiopulmonary bypass was initiated, followed by profound hypothermia, circulatory arrest, retrograde cerebral perfusion, retrograde coronary sinus perfusion, and then barbiturate coma and steroid therapy. The HeartMate XVE left ventricular assist device was removed, and a HeartMate II was implanted. After 5 days, the patient awoke with left hemiparesis, which nearly resolved with aggressive physical therapy. Forty-four days after the pump exchange operation, the patient was discharged from the hospital with only mild left hemiparesis. Exposure of the left ventricular assist device or its external components requires careful monitoring, because air can enter the pump-particularly in a hypovolemic patient. Rapid response after massive air entry into the left ventricular assist device system, as in our patient, can result in a successful outcome.

Intraoperative TandemHeart implantation as an adjunct to high-risk valve surgery.

Newer generations of assist devices for postcardiotomy support in patients with ventricular failure have eliminated bearings and incorporated suspended impellers, smaller cannulae and hardware, and simplified insertion techniques. We describe the use of a surgically implanted, percutaneous, continuous-flow centrifugal pump (the TandemHeart percutaneous ventricular assist device) as part of a planned, pre-emptive approach for postcardiotomy support in a patient with severe mitral regurgitation, moderate tricuspid regurgitation, and biventricular failure. To our knowledge, this report documents the 1st use of a percutaneous ventricular assist device as an elective support device in a patient undergoing high-risk mitral or tricuspid valve surgery.

Cavo-pulmonary shunt for left ventricular outflow tract obstruction after senning.

We report a case of Senning procedure in a 32-month-old girl with transposition of the great arteries and dynamic left ventricular outflow tract obstruction (LVOTO). After discontinuation of cardio-pulmonary bypass, the persisting, worsened LVOTO caused hemodynamical instability. A cavo-pulmonary shunt (CPS) was performed, with considerable subsequent improvement. We consider the use of CPS as a valuable option in patients with persisting, significant dynamic LVOTO after atrial switch.

[Management of end-stage heart failure]. / Prise en charge de l'insuffisance cardiaque terminale.

Non-medical approaches to end-stage heart failure (ESHF) include heart transplantation, but also implantable cardioverter-defibrillators, cardiac resynchronization therapy and ventricular assist devices. These techniques might be used as a bridge to transplant, as a bridge to recovery or as destination therapy. Optimal medical therapy of ESHF should include an angiotensin-converting enzyme inhibitor, a beta-blocker and spironolactone. Risk stratification in ESHF allows to determine the individual prognosis of each patient with parameters such as echocardiographic criteria, peak exercise oxygen consumption, or plasma BNP levels. Heart transplantation is to be considered if the individual prognosis obtained after stratification is worse than the expected survival of transplant recipients.