Does severe hyperlactatemia during cardiopulmonary bypass predict a worse outcome?

INTRODUCTION: The aim of the current study was to evaluate the impact of increased blood lactate levels during cardiopulmonary bypass (CPB) on immediate results in patients who underwent open heart surgery. MATERIALS AND METHODS: We performed a retrospective single-center study on 1290 patients. Adult cardiac surgical patients who underwent valve surgery, coronary artery bypass graft, combined procedure, adult congenital anomalies and aortic surgery were enrolled. Patients with associated comorbidities such as liver dysfunction, hemodynamic instability before surgery were excluded. Arterial blood lactate concentration was measured immediately after weaning from CPB and evaluated together with clinical data and outcomes including in hospital mortality. Patients were classified into 3 groups according to their peak arterial lactate level: group I [normal lactatemia, lactate ˂ 2 mmol/l (n = 749)], group II [mild hyperlactatemia, lactate 2-5 mmol/l (n = 489)], group III [severe hyperlactatemia, lactate ˃ 5 mmol/l (n = 52)]. RESULTS: When comparing outcomes across the 3 groups, severe hyperlactatemia was correlated with worse outcomes including higher in-hospital mortality, low output cardiac syndrome, postoperative renal insufficiency, myocardial infarction, red blood cell transfusion (RBC) transfusion, prolonged mechanical ventilation and longer intensive care unit (ICU) stay hours. CONCLUSION: Blood lactate level above 5 mmol/l and more during CPB is associated with higher in-hospital mortality rate and postoperative complications. More attention must be given to correct the common abnormalities conditions inherent of CPB in order to conduct adequate tissue perfusion and reduce the risk of hyperlactatemia.

Surgical aspects of thoracic aortic aneurysms: A case series from a real-world setting.

BACKGROUND: The objective of the present study is to review different surgical features and treatment modalities of thoracic aortic aneurysms. METHODS: This was a retrospective study of 17 patients operated on for thoracic aortic aneurysm in the Department of Cardiovascular Surgery of the Military Hospital of Rabat (Morocco) over a 10-year period, from January 2007 to December 2016. All patients with aneurysms located in the thoracic aorta or extended to the abdominal aorta were included in the study. RESULTS: The mean age of the patients was 49 ± 6 years. 58% of the patients were symptomatic. 10 patients (62%) had an aneurysm of the ascending thoracic aorta and 2 patients had an aneurysm of the ascending aorta extended to the arch. In 2 patients, the aneurysm was located in the descending thoracic aorta. Three patients (18%) had a post-traumatic false aneurysm of the aortic isthmus. Six patients underwent a Bentall procedure. One patient underwent the Yacoub technique. Two patients underwent ascending aorta replacement using the Wheat technique. In addition, two patients underwent ascending aorta and arch replacement and five patients (29%) underwent descending thoracic aorta replacement. In-hospital mortality was 12%. Two patients (12%) developed paraplegia and two developed renal failure (12%). CONCLUSION: Thoracic aortic aneurysms are a serious pathology requiring surgical treatment before complications arise. Replacement of the arch and the descending thoracic aorta still remain a challenge for cardiovascular surgeons because of neurological complications.

Unexpected normal left ventricular systolic function after total chronic occlusion of left main coronary artery and stenosis of right coronary artery: a case report and review of the literature.

INTRODUCTION: Total occlusion of the left main coronary artery is a very rare finding in coronary angiography because of its highly lethal nature. Right coronary artery dominance and extensive collateral circulation are the principal determinant factors of survival after total occlusion of the left main coronary artery. The impact on the left ventricle is often significant with a profound alteration of its systolic function. CASE PRESENTATION: We describe a 52-year-old North African man, a tobacco smoker, who presented symptoms of unstable angina related to a total chronic occlusion of his left main coronary artery with a right coronary artery stenosis. Unexpectedly, the impact on his left ventricle was absent with normal dimensions and systolic function. He underwent a successful on-pump coronary artery bypass grafting with uneventful postoperative course and good recovery. CONCLUSIONS: Total occlusion of the left main coronary artery is a rare condition, the fact that the left ventricle retains a normal size and systolic function makes it exceptional, which must be kept in mind to avoid dangerous examinations and delayed treatment. Coronary artery bypass surgery should be considered the main treatment of total chronic occlusion of the left main coronary artery.

Reoperation for isolated rheumatic tricuspid regurgitation.

BACKGROUND: The reoperation for isolated tricuspid regurgitation in rheumatic population is rare and still unclear and controversial because of the rarity of publications. The aim of this study was to analyze short and long-term results and outcome of tricuspid valve surgery after left-sided valve surgery in rheumatic patients. METHODS: Twenty six consecutive rheumatic patients who underwent isolated tricuspid valve surgery after left-sided valve surgery between January 2000 and January2017 were retrospectively registered in the study. The mean age was 48.2 ± 8.6 years with 8.3% as sex-ratio (M/F). EuroSCORE was 6.1 ± 5 (range 2.5 to 24.1). The mechanism of tricuspid regurgitation was functional and organic in respectively 14 (53.8%) and 12 cases (46.2%). Ten patients (38.5%) had previous tricuspid valve repair. Surgery consisted of 15 ring annuloplasty and 11 tricuspid valve replacement (5 bioprostheses and 6 mechanical prostheses). Follow-up was 96.1% complete, with a mean follow-up of 55.6 ± 38.8 months (range 1 to 165). RESULTS: The operative mortality rate was 15.4% (n = 4) and the cumulative survival at 1, 5 and 10 years was respectively 80% ± 8%, 75.6% ± 8.7% and 67.2% ± 11.1% with no significant difference at 8 years between tricuspid valve replacement (80% ± 12.6%) and repair (57.6% ± 16.1%) (p = 0.5). Multivariable Cox regression analysis revealed that ascites (HR, 5.8; p = 0.01), and right ventricular dysfunction (HR, 0.94; p = 0.001) were predictors of major adverse cardiac events. There were no recurrence of tricuspid regurgitation and no structural or non-structural deterioration of valvular prostheses. CONCLUSION: The reoperation of rheumatic tricuspid regurgitation should be considered before the installation of complications such as right ventricular dysfunction and major signs of right heart failure. Despite the superiority of repair techniques, tricuspid valve replacement should not be banished.

[Cardiac pseudotumor revealing Behçet's disease]. / Pseudotumeur cardiaque révélant une maladie de Behçet.

Intracardiac thrombosis is a rare complication of Behçet's disease (BD), which may manifest as intracardiac tumor. In half of cases, its detection precedes the diagnosis of MB. High mortality rates may be related to post-surgical complications and/or pulmonary arteries involvement. We report the case of a 29-year old young patient, with a previous history of bipolar aphthosis, who underwent surgery after the detection of right atrium and ventricle tumor. Anatomo-pathological examination showed thrombus and MB was diagnosed in the postoperative period. Patient's evolution was favorable under medical treatment based on corticosteroids, colchicine and vitamin K antagonists (AVK). The detection of intracardiac mass in a young subject should suggest the diagnosis of cardiac thrombus and Behçet's disease, even in the absence of ethnic or geographical risk factors.

[Myxoma involving posterolateral leaflet: about a case]. / Myxome de la petite valve mitrale: à propos d'un cas.

Cardiac myxomas are the most common type of primary cardiac tumors. They mainly affect the interatrial septum and exceptionally the heart valves. Surgical excision remains the only therapeutic alternative. We here report the case of a 69-year old patient with no significant pathological history suffering from NYHA class II-III dyspnea associated with lipothymia. Transthoracic echocardiography showed a tight calcified aortic narrowing with aortic valve gradient of 58 mmHg. A sessile mass of 15mm diameter inserted into the posterolateral leaflet, without stenosis or mitral regurgitation evoking an atypical localization of myxomaor or fibroelastoma was detected at the level of the mitral valve. The examination was supplemented by ETO which confirmed the diagnosis of a mass involving the posterolateral leaflet. The patient underwent surgery via median sternotomy, under conventional extracorporeal circulation. Left atriotomy allowed to objectify a sessile mass of 15mm of diameter involving the auricular wall of the friable and easily cleavable posterolateral leaflet. Cauterization of the implant base via electric scalpel was then performed without any additional gesture on the posterolateral leaflet. Anatomopathologic analysis of the surgical specimen confirmed the diagnosis of myxoma. The patient also underwent aortic valve replacement with mechanical prosthesis. The postoperative course was uneventful. The patient was discharged on postoperative day 8. Cardiac myxoma involving the mitral leaflet is very rare. Surgical procedure attempting to resect the widest possible surgical margins remains the only therapeutic option to avoid the risk of recurrence.

A giant aneurysm of ascending aorta revealed by superior vena cava syndrome.

We report a 72 year-old man who presented symptoms of right heart failure and patent superior vena cava syndrome related to a huge ascending aortic aneurysm with a maximal diameter at 11 cm. The patient underwent a successful surgical repair by a modified Bentall operation with good recovery.