Revascularisation myocardique chirurgicale des patients diabétiques insuffisants rénaux chroniques sévères à dialysés (68 patients consécutifs à l'île de La Réunion, survie à long terme)

PROBLEMATIQUE : La prévalence de la néphropathie diabétique et de la coronaropathie qui lui est très souvent associée ne cesse d'augmenter dans le monde. Cependant les résultats des pontages coronaires du patient diabétique insuffisant rénal (DIR) stade 4 ou 5 effectués selon les indications recommandées dans la population générale sont très peu rapportés. OBJECTIF : Caractériser cette popoulation dans ce contexte de revascularisation et étudier la mortalité opératoire et la survie à long terme. TYPE D'ETUDE : Etude rétrospective de cas suivis à long terme. LIEUX : Seul centre de chirurgie cardiaque de l'Ile de La Réunion, à Saint Denis. METHODE : En Janvier 2011, tous les cas de patients DIR stades 4 ou 5 revascularisés isolément entre Octobre 2001 et Décembre 2010 ont été revus. Les données étaient collectées dans le dossier médical et au travers d'enquêtes téléphoniques. RESULTATS : 68 patients dont 37 dyalisés chroniques étaient revascularisés. L'âge moyen était de 62,1 (+/- 9,1) ans ; 91 % étaient traités par insuline et 82 % étaient tritronculaires. La mortalité opératoire était de 10 % (3 % chez les non dialysés, 16 % chez les dialysés, 16 % chez les dialysés). Nous n'avions pas perdu de vue, et la durée de suivi était de 38.2 (+/- 31,1) mois. La survie actuarielle était de 74 %, 66 %, 60 % et 54 % à respectivement 1, 2, 3, 4 et 5 ans. CONCLUSION : A notre connaissance nous rapportons la plus importante série de patients revascularisés DIR stade 4 ou 5 essentiellement diabétiques de type 2. La mortalité opératoire était faible pour les DIR stade 4. La mortalité dans le groupe dialysé ne semble pas devoir être rédhibitoire et l'optimisation de la réanimation post opératoire devrait améliorer ce résultat. La survie à long terme semble meilleure que celle atttendue chez des patients DIR stades 4 et 5 porteurs d'une coronaropathie sévère. Au total la revascularisation myocardique chirurgicale semble donc bénéfique chez les patients DIR stades 4 ou 5.BACKGROUND : There is a global incrrease of patients with diabetic nephropathy and associated coronaropathy. The outcome of coronary artery bypass grafting (CABG), as indicated in published guidelines, in diabetiic patients with chronic kidney disease (CKD) stage 4 and 5 is unknown. OBJECTIVES : Determine the characteristics of diabetic CKD stage 4 and 5 patients requiring CABG, perioperative outcome and survival time after CABG. STUDY TYPE : Case study and long term follow up. LOCATION : In the only cardiac surgery center of Reunion Island, a French oversea territory in the Indian Ocean. METHOD : In January 2011 we reviewed all cases of diabetic CKD stage 4 or 5 patients that were operated by isolated CABG from October 2001 till December 2010. RESULTS : 68 including 37 dialysed patients underwent CABG. Mean Age was 62.1 (+/- 9.1) years, 91 % needed long term insulin therapy and 82 % had a three vessels disease. Operative Mortality rate was 10 % (3 % in the non dialysed patients and 16 % in the dialysed patients). We had no lost to follow up. Mean follow up time was 38.2 (+/- 31.1) years. Actuarial survival rate was 74 %, 66 %, 66 %, 60 % and 54 % at 1, 2, 3, 4, and 5 years respectively. CONCLUSION : To our knowledge this is the largest case series of diabetic patients with CKD stage 4 and 5 (mainly type 2 diabetes) after CABG. Operative mortality was low in the non dialysed group, and could be decreased in the dialysed group by optimised post operative intensive care. Long term survival seems to be better than expected in diabetic patient with severe or end stage CKD having extensive coronary artery disease. CABG seems to be beneficial in diabetic stage 4 and 5BORDEAUX2-BU Santé (330632101) / SudocSudocFranceF

Right ventricular infarction and mitral stenosis: a resuscitation challenge

International audienceWe report the case of a 49-year-old woman who experienced an inferior myocardial infarction with right ventricular extension, poorly tolerated, partly due to a severe rheumatic mitral stenosis discovered during the hospitalization. Following an initial emergent mechanical circulatory support with femoro-femoral extracorporeal life support (ECLS), the patient had the mitral valve replaced, and the arterio-venous ECLS was removed for a right ventricular assistance device. After seven weeks, she was discharged and fully recovered

Case series of 12 Bartonella quintana endocarditis from the Southwest Indian Ocean

International audienceBackground Bartonella spp. are fastidious bacteria frequently identified as the cause of blood culture-negative (BCN) endocarditis. However, Bartonella infections are difficult to diagnose in routine laboratory testing and their incidence is probably underestimated. We investigated the epidemiological and clinical features of Bartonella endocarditis cases diagnosed between 2009 and 2021 on Reunion Island (Southwest Indian Ocean). Method We retrospectively included all patients diagnosed with Bartonella endocarditis at Reunion Island University Hospital during this period. Endocarditis was diagnosed on the basis of microbiological findings, including serological tests (IFA) and PCR on cardiac valves, and the modified Duke criteria. We used then the multispacer typing (MST) method to genotype the available Bartonella strains. Findings We report 12 cases of B . quintana endocarditis on Reunion Island (83.3% in men, median patient age: 32 years). All the patients originated from the Comoros archipelago. The traditional risk factors for B . quintana infection (homelessness, alcoholism, exposure to body lice) were absent in all but two of the patients, who reported head louse infestations in childhood. Previous heart disease leading to valve dysfunction was recorded in 50% of patients. All patients underwent cardiac valve surgery and antimicrobial therapy with a regimen including doxycycline. All patients presented high C-reactive protein concentrations, anemia and negative blood cultures. The titer of IgG antibodies against Bartonella sp. exceeded 1:800 in 42% of patients. Specific PCR on cardiac valves confirmed the diagnosis of B . quintana endocarditis in all patients. Genotyping by the MST method was performed on four strains detected in preserved excised valves and was contributive for three, which displayed the MST6 genotype. Conclusions Bartonella quintana is an important cause of infective endocarditis in the Comoros archipelago and should be suspected in patients with mitral valve dysfunction and BCN from this area

Clinical and Epidemiological Aspects of Acute Q Fever in Reunion Island over Fourteen Years: A Retrospective Cohort Study

International audienceThe clinical characteristics and epidemiology of Q fever in the Tropics are poorly described. We performed a retrospective cohort study of hospitalized cases between 2004 and 2017 in Reunion Island. Acute Q fever was defined in presence of a positive serology (phase II IgG ≥ 200 and phase II IgM ≥ 50), or a seroconversion (4-fold increase in phase II IgG between paired samples), or a positive PCR (blood or serum). Forty-two cases matched the diagnostic criteria. The most common clinical manifestations were fever (85.7%) and pulmonary symptoms (61.9%), including pneumonia (45.2%). Ninety percent of the patients were living in a farming area. Cumulative incidence was estimated at 9.3 per 100,000 inhabitants (95%CI: 6.4–12.1) with cases diagnosed yearly all throughout the study period except in 2006. Together with the seroprevalence figures, these data suggest that Q fever reaches low to moderate endemic levels on Reunion Island. As previously reported, pulmonary symptoms are in the foreground

Impact of levosimendan on weaning from peripheral venoarterial extracorporeal membrane oxygenation in intensive care unit

Abstract Background Few data are available on the impact of levosimendan in refractory cardiogenic shock patients undergoing peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO). The aim of this study was to evaluate the impact of levosimendan on VA-ECMO weaning in patients hospitalized in intensive care unit (ICU). Methods This retrospective cohort study was conducted in a French university hospital from 2010 to 2017. All patients hospitalized in ICU undergoing VA-ECMO were consecutively evaluated. Results A total of 150 patients undergoing VA-ECMO were eligible for the study. Thirty-eight propensity-matched patients were evaluated in the levosimendan group and 65 in the non-levosimendan group. In patients treated with levosimendan, left ventricular ejection fraction had increased from 21.5 ± 9.1% to 30.7 ± 13.5% (P < 0.0001) and aortic velocity–time integral from 8.9 ± 4 cm to 12.5 ± 3.8 cm (P = 0.002) 24 h after drug infusion. After propensity score matching, levosimendan was the only factor associated with a significant reduction in VA-ECMO weaning failure rates (hazard ratio = 0.16; 95% confidence interval 0.04–0.7; P = 0.01). Kaplan–Meier survival curves showed that survival rates at 30 days were 78.4% for the levosimendan group and 49.5% for the non-levosimendan group (P = 0.02). After propensity score matching analysis, the difference in 30-day mortality between the two groups was not significant (hazard ratio = 0.55; 95% confidence interval 0.27–1.10; P = 0.09). Conclusions Our results suggest that levosimendan was associated with a beneficial effect on VA-ECMO weaning in ICU patients

Human herpesvirus 8-negative effusion-based large B-cell lymphoma: a distinct entity with unique clinicopathologic characteristics

Rare cases of human herpesvirus 8 (HHV8)-negative effusion-based large B-cell lymphoma (EB-LBCL) occur in body cavities without antecedent or concurrent solid mass formation. In contrast to HHV8 + primary effusion lymphoma (PEL), EB-LBCL has no known association with HIV or HHV8 infection. However, the small sample sizes of case reports and series worldwide, especially from non-Japanese regions, have precluded diagnostic uniformity. Therefore, we conducted a retrospective, multi-institutional study of 55 cases of EB-LBCL and performed a comprehensive review of an additional 147 cases from the literature to identify distinct clinicopathologic characteristics. In our study, EB-LBCL primarily affected elderly (median age 80 years), immunocompetent patients and manifested as lymphomatous effusion without a solid component. The lymphomatous effusions mostly occurred in the pleural cavity (40/55, 73%), followed by the pericardial cavity (17/55, 31%). EB-LBCL expressed CD20 (53/54, 98%) and PAX5 (23/23, 100%). Most cases (30/36, 83%) were of non-germinal center B-cell subtype per the Hans algorithm. HHV8 infection was absent (0/55, 0%), while Epstein-Barr virus was detected in 6% (3/47). Clinically, some patients were managed with drainage alone (15/34, 44%), while others received rituximab alone (4/34, 12%) or chemotherapy (15/34, 44%). Eventually, 56% (22/39) died with a median overall survival (OS) of 14.9 months. Our findings were similar to those from the literature; however, compared to the non-Japanese cases, the Japanese cases had a significantly higher incidence of pericardial involvement, a higher rate of chemotherapy administration, and longer median OS. Particularly, we have found that Japanese residence, presence of pericardial effusion, and absence of MYC rearrangement are all favorable prognostic factors. Our data suggest that EB-LBCL portends a worse prognosis than previously reported, although select patients may be managed conservatively. Overall, EB-LBCL has distinct clinicopathologic characteristics, necessitating the establishment of separate diagnostic criteria and consensus nomenclature