105 research outputs found

    Determination of the threshold of cardiac troponin I associated with an adverse postoperative outcome after cardiac surgery: a comparative study between coronary artery bypass graft, valve surgery, and combined cardiac surgery

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    ABSTRACT: BACKGROUND: To compare postoperative cardiac troponin I (cTnI) release and the thresholds of cTnI that predict adverse outcome after elective coronary artery bypass graft (CABG), valve, and combined cardiac surgery. METHODS: Six hundred and seventy five adult patients undergoing conventional cardiac surgery with cardiopulmonary bypass were retrospectively analyzed. Patients in the CABG (n=225) and valve surgery groups (n=225) were selected after matching (age, sex) with those in the combined surgery group (n=225). cTnI was measured preoperatively and 24 h after the end of surgery. The main endpoint was a severe postoperative cardiac event (sustained ventricular arrhythmias requiring treatment, need for inotropic support or intra-aortic balloon pump for at least 24 h, postoperative myocardial infarction) and/or death. Data are medians and odds ratio [95% confidence interval]. RESULTS: Postoperative cTnI levels were significantly different among the three groups (Combined 11.0 [9.5-13.1] vs. CABG 5.2 [4.7-5.7] and Valve 7.8 [7.6-8.0] ng.mL-1, respectively, P<0.05). The thresholds of cTnI predicting severe cardiac event and/or death were also significantly different among the three groups (Combined 11.8 [11.5-14.8] vs. CABG 7.8 [6.7-8.8] and Valve 9.3 [8.0-14.0] ng.mL-1 respectively, P<0.05 level). An elevated cTnI above the threshold in each group was significantly associated with severe cardiac event and/or death (odds ratio, 4.33 [2.82-6.64]). CONCLUSIONS: The magnitude of postoperative cTnI release is related to the type of cardiac surgical procedure. Different thresholds of cTnI must be considered according to the procedure type to predict early an adverse postoperative outcom

    Extracorporeal life support for primary graft dysfunction after heart transplantation

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    OBJECTIVES Survival after heart transplantation is steadily improving but primary graft dysfunction (PGD) is still a leading cause of death. Medical management seems useful in mild or moderate PGD, whereas extracorporeal life support (ECLS) could be suggested for severe PGD refractory to conventional treatment. Our aim is to present the results of ECLS for PGD after heart transplantation at a single-centre experience. METHODS We performed an observational analysis of our local database. According to the International Society for Heart and Lung Transplantation classification, patients were divided into a left and biventricular failure (PGD-LV) or isolated right ventricular failure (PGD-RV) group. The primary end point was survival to hospital discharge. RESULTS Between January 2010 and December 2016, 38 patients presented with PGD (PGD-LV n = 22, 58%; PGD-RV n = 16, 42%) requiring ECLS support. The mean age was 50.8 ± 12.4 years and 79% were males. Baseline characteristics were comparable between the 2 groups. PGD-LV patients displayed a significantly higher mortality rate on ECLS support as opposed to PGD-RV patients (46% vs 13%, P = 0.033). The rate of complications during ECLS support was comparable between the 2 groups. Twenty-three (61%) patients were successfully weaned from ECLS (PGD-LV = 50% vs PGD-RV = 75%, P = 0.111) after a mean support of 9.0 ± 6.4 days. Seventeen (45%) patients survived to hospital discharge (PGD-LV = 41% vs PGD-RV = 50%, P = 0.410). CONCLUSIONS In case of severe PGD with various manifestations of ventricular failure refractory to conventional treatment, ECLS can be considered as a feasible option with satisfactory survival in this critically ill population

    Ann Intensive Care

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    Despite a large body of evidence, the implementation of guidelines on hemodynamic optimization and goal-directed therapy remains limited in daily routine practice. To facilitate/accelerate this implementation, a panel of experts in the field proposes an approach based on six relevant questions/answers that are frequently mentioned by clinicians, using a critical appraisal of the literature and a modified Delphi process. The mean arterial pressure is a major determinant of organ perfusion, so that the authors unanimously recommend not to tolerate absolute values below 65 mmHg during surgery to reduce the risk of postoperative organ dysfunction. Despite well-identified limitations, the authors unanimously propose the use of dynamic indices to rationalize fluid therapy in a large number of patients undergoing non-cardiac surgery, pending the implementation of a "validity criteria checklist" before applying volume expansion. The authors recommend with a good agreement mini- or non-invasive stroke volume/cardiac output monitoring in moderate to high-risk surgical patients to optimize fluid therapy on an individual basis and avoid volume overload. The authors propose to use fluids and vasoconstrictors in combination to achieve optimal blood flow and maintain perfusion pressure above the thresholds considered at risk. Although purchase of disposable sensors and stand-alone monitors will result in additional costs, the authors unanimously acknowledge that there are data strongly suggesting this may be counterbalanced by a sustained reduction in postoperative morbidity and hospital lengths of stay. Beside existing guidelines, knowledge and explicit clinical reasoning tools followed by decision algorithms are mandatory to implement individualized hemodynamic optimization strategies and reduce postoperative morbidity and duration of hospital stay in high-risk surgical patients

    Overview of the current use of levosimendan in France: a prospective observational cohort study

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    Abstract Background Following the results of randomized controlled trials on levosimendan, French health authorities requested an update of the current use and side-effects of this medication on a national scale. Method The France-LEVO registry was a prospective observational cohort study reflecting the indications, dosing regimens, and side-effects of levosimendan, as well as patient outcomes over a year. Results The patients included ( n = 602) represented 29.6% of the national yearly use of levosimendan in France. They were treated for cardiogenic shock ( n = 250, 41.5%), decompensated heart failure ( n = 127, 21.1%), cardiac surgery-related low cardiac output prophylaxis and/or treatment ( n = 86, 14.3%), and weaning from veno-arterial extracorporeal membrane oxygenation ( n = 82, 13.6%). They received 0.18 ± 0.07 ”g/kg/min levosimendan over 26 ± 8 h. An initial bolus was administered in 45 patients (7.5%), 103 (17.1%) received repeated infusions, and 461 (76.6%) received inotropes and or vasoactive agents concomitantly. Hypotension was reported in 218 patients (36.2%), atrial fibrillation in 85 (14.1%), and serious adverse events in 17 (2.8%). 136 patients (22.6%) died in hospital, and 26 (4.3%) during the 90-day follow-up. Conclusions We observed that levosimendan was used in accordance with recent recommendations by French physicians. Hypotension and atrial fibrillation remained the most frequent side-effects, while serious adverse event potentially attributable to levosimendan were infrequent. The results suggest that this medication was safe and potentially associated with some benefit in the population studied

    ECMO for COVID-19 patients in Europe and Israel

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    Since March 15th, 2020, 177 centres from Europe and Israel have joined the study, routinely reporting on the ECMO support they provide to COVID-19 patients. The mean annual number of cases treated with ECMO in the participating centres before the pandemic (2019) was 55. The number of COVID-19 patients has increased rapidly each week reaching 1531 treated patients as of September 14th. The greatest number of cases has been reported from France (n = 385), UK (n = 193), Germany (n = 176), Spain (n = 166), and Italy (n = 136) .The mean age of treated patients was 52.6 years (range 16–80), 79% were male. The ECMO configuration used was VV in 91% of cases, VA in 5% and other in 4%. The mean PaO2 before ECMO implantation was 65 mmHg. The mean duration of ECMO support thus far has been 18 days and the mean ICU length of stay of these patients was 33 days. As of the 14th September, overall 841 patients have been weaned from ECMO support, 601 died during ECMO support, 71 died after withdrawal of ECMO, 79 are still receiving ECMO support and for 10 patients status n.a. . Our preliminary data suggest that patients placed on ECMO with severe refractory respiratory or cardiac failure secondary to COVID-19 have a reasonable (55%) chance of survival. Further extensive data analysis is expected to provide invaluable information on the demographics, severity of illness, indications and different ECMO management strategies in these patients

    Evaluation de la bioimpédancemétrie endotrachéale en réanimation chirurgicale cardiaque

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    CAEN-BU MĂ©decine pharmacie (141182102) / SudocSudocFranceF

    Apports de la troponine I cardiaque dans l Ă©valuation du dommage myocardique aprĂšs chirurgie cardiaque avec circulation extracorporelle chez l homme

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    La physiopathologie du dommage myocardique en chirurgie cardiaque associe des causes traumatiques, ischĂ©miques et inflammatoires. La circulation extracorporelle reprĂ©sente en outre un modĂšle global d ischĂ©mie-reperfusion myocardique. L Ă©valuation biologique du dommage myocardique Ă  l aide des biomarqueurs traditionnels manque de sensibilitĂ© et de spĂ©cificitĂ© et si des dosages fiables de troponine Ic ont permis de rĂ©soudre les problĂšmes rencontrĂ©s en chirurgie gĂ©nĂ©rale, il n en va pas de mĂȘme en chirurgie cardiaque. En dĂ©pit de concentrations pĂ©ricardiques postopĂ©ratoires Ă©levĂ©es, les dosages pĂ©ricardiques de troponine Ic n ont pas de valeur diagnostique pertinente pour la pratique. La libĂ©ration plasmatique postopĂ©ratoire de troponine Ic et les valeurs seuils prĂ©disant la survenue d un mauvais pronostic dĂ©pendent de l intervention chirurgicale rĂ©alisĂ©e. La grande sensibilitĂ© diagnostique de la troponine Ic permet une mesure prĂ©cise des dĂ©gĂąts tissulaires myocardiques et l Ă©valuation de stratĂ©gies de protection myocardique. La troponine Ic est Ă©galement un facteur prĂ©dictif fort et indĂ©pendant de morbi-mortalitĂ© postopĂ©ratoire prĂ©coce et tardive en chirurgie cardiaque et un prĂ©lĂšvement sanguin unique vers la 24Ăšme heure postopĂ©ratoire prĂ©sente le meilleur rapport coĂ»t/bĂ©nĂ©fices pour la dĂ©tection des patients Ă  risque. Les dosages plasmatiques de BNP pourraient, en association avec la troponine Ic, s avĂ©rer utiles pour une dĂ©tection accrue des malades Ă  risque en chirurgie cardiaque. De nouveaux biomarqueurs sont Ă  l Ă©tude et l essor de la pathobiologie risque de bouleverser les pratiques dans les annĂ©es Ă  venir.PARIS-BIUSJ-ThĂšses (751052125) / SudocPARIS-BIUSJ-Physique recherche (751052113) / SudocSudocFranceF
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