ESC Joint Working Groups on Cardiovascular Surgery and the Cellular Biology of the Heart Position Paper: Perioperative myocardial injury and infarction in patients undergoing coronary artery bypass graft surgery

International audienc

Perception des risques liés au voyage par les consultants du centre de vaccinations internationales et de conseils aux voyageurs de Clermont-Ferrand (étude prospective portant sur 574 fiches d'autoévaluation)

L'objectif de l'étude prospective menée de novembre 2005 à janvier 2006 auprès de 574 consultants du centre de vaccination antiamarile de Clermont-Ferrand était d'obtenir des données sur les voyages et sur les connaissances des voyageurs sur les risques encourus lors de leur séjour. La majorité des voyages sont des séjours touristiques courts sur le continent africain, surtout au Sénégal. Les consultants partent plutôt accompagnés, en voyage organisé, à l'hôtel et préfèrent la cuisine internationale et locale au restaurant. 94% ont un contrat de rapatriement sanitaire. Plus de la moitié estiment être à jour pour le DTPolio, 38% pour l'hépatite B. 67% pensent utile lavaccination fièvre jaune, 16% l'hépatite A, 7,5% la typhoïde. Les voyageurs connaissent bien les maladies transmises par piqûres d'insectes, en particulier le paludisme et appréhendent mieux les risques liés à l'eau de boisson et au soleil que ceux liés à l'alimentation et à la baignade. Cette fiche avait également un objectif pragmatique : celui de faciliter la communication au cours de la consultation de conseils aux voyageurs notamment les risques peu abordés tels les MST.CLERMONT FD-BCIU-Santé (631132104) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Esmolol Corrects Severe Hypoxemia in Patients with Femoro-Femoral Venoarterial Extracorporeal Life Support for Lung Transplantation

Competitive flows syndrome result in severe regional hypoxemia when the deoxygenated flow from the native left ventricle (LV) competes with oxygenated flow from extracorporeal life support (ECLS) pump with potentially severe consequences for the cerebral and coronary circulations. Fast correction of hypoxemia could be obtained by decreasing native LV flow by infusion of a short-acting beta-blocker (esmolol). Our purpose was to retrospectively review the efficacy of esmolol in this situation and hypothesize on the potential mechanisms of action and the associated risks. This is a retrospective analysis of five clinical cases, who underwent lung transplantation and a femoro-femoral venoarterial (VA) ECLS. The patients presented severe hypoxemia (SpO2 < 85%) measured through photoplethysmography on a right hand finger. From the patients' medical records and anesthesia flowcharts, hemodynamic, right heart catheterization, echocardiography variables, and arterial blood gas results were noted before and after injection of esmolol. Mechanical ventilation and VA ECLS function variables were optimized and unchanged before and after esmolol injection. All patients had terminal respiratory failure with pulmonary hypertension and conserved LV systolic function. Immediately following esmolol injection (1.3 ± .7 mg/kg; mean ± 1 SD), SpO2 increased from 73% ± 12 to 95% ± 6; blood to arterial partial pressure in CO2 (PaCO2) decreased from 52 ± 18 to 35 ± 7 mmHg systolic pulmonary artery pressure decreased from 61 ± 8 to 50 ± 12 mmHg; the pulmonary artery oxygen saturation (SvO2); increased from 51% ± 24 to 77% ± 12; systemic arterial pressure or catecholamine requirements were unchanged. In conclusion, these results suggest that injection of esmolol allowed rapid correction of regional hypoxemia occurring during lung transplantation despite femoro-femoral VA ECLS. The mechanism is probably a decreased cardiac output of the native LV due to esmolol-induced negative inotropic and chronotropic effects without significant adverse effects on systemic tissue perfusion

Impact of Antibiotic Prophylaxis on Surgical Site Infections in Cardiac Surgery

(1) Background: Cephalosporins (CA) are the first-line antibiotic prophylaxis recommended to prevent surgical site infection (SSI) after cardiac surgery. The combination of vancomycin/gentamicin (VGA) might represent a good alternative, but few studies have evaluated its efficacy in SSI prevention. (2) Methods: A single-centre retrospective study was conducted over a 13-year period in all consecutive adult patients undergoing elective cardiac surgery. Patients were stratified according to the type of antibiotic prophylaxis. CA served as the first-line prophylaxis, and VGA was used as the second-line prophylaxis. The primary endpoint was SSI occurrence at 90 days, which was defined as the need for reoperation due to SSI. (3) Results: In total, 14,960 adult patients treated consecutively from 2006 to 2019 were included in this study, of whom 1774 (12%) received VGA and 540 (3.7%) developed SSI. VGA patients had higher severity with increased 90-day mortality. Nevertheless, the frequency of SSI was similar between CA and VGA patients. However, the microbiological aetiologies were different, with more Gram-negative bacteria noted in the VGA group. (4) Conclusions: VGA seems to be as effective as CA in preventing SSI

The impact of the development of transcatheter aortic valve implantation on the management of severe aortic stenosis in high-risk patients: treatment strategies and outcome

International audienceObjectives: Transcatheter aortic valve implantation (TAVI) has reoriented the treatment of aortic stenosis (AS) for high-risk patients. Little is known about late outcome after TAVI, surgical aortic valve replacement (AVR) or medical treatment in a single centre. We report patients' characteristics, early and 6-year survival rates after the three therapeutic strategies, and the evolution over time. We also analysed predictive factors of mortality after TAVI or surgical AVR.Methods: Between October 2006 and December 2010, 478 high-risk consecutive patients were referred for severe symptomatic AS. After Heart Team evaluation, 253 underwent a TAVI, 102 a surgical AVR and 123 medical treatment including 33 compassionate percutaneous balloon aortic valvuloplasties (PBAVs). Follow-up was complete in 98% of patients.Results: Medically treated patients had higher risk scores than the other two groups. They presented a significantly worse survival (P < 0.001), with a 1-year rate of only 30%. The 33 patients who underwent compassionate PBAV presented the lowest survival rate, even lower than patients receiving drug therapy alone. In the TAVI group, patients had more comorbidities than those in the surgical group. There was no difference in 30-day survival rates [91 ± 2% for TAVI and 88 ± 3% for surgical AVR, hazard ratio (HR) for TAVI: 1.37; 95% CI: 0.73-2.58, P = 0.32]. Predictive factors of 30-day mortality were mainly postintervention complications illustrated by higher troponin levels and infection. The 6-year survival rates were 32 ± 4 and 40 ± 6% for TAVI and surgical AVR, respectively (HR for TAVI: 0.71; 95% CI: 0.53-0.97, P = 0.03), but the difference was no longer significant after adjustment on the Charlson comorbidity index (HR: 0.94; 95% CI: 0.68-1.29, P = 0.68). Predictive factors of late mortality were patients' comorbidities for both groups and paraprosthetic aortic regurgitation ≥2/4 for the TAVI group. The number of interventions (TAVI or surgery) increases over years, driven by the number of TAVI procedures without any decrease in surgical AVR.Conclusions: In this single-centre study, medically treated patients with severe AS have a higher risk profile than those undergoing surgery or TAVI. Their survival is particularly poor and not improved by compassionate PBAV. When comparing TAVI and surgical AVR, there was no difference in 30-day and 6-year survival rates after adjusting for comorbidities

A Comparison of a Machine Learning Model with EuroSCORE II in Predicting Mortality after Elective Cardiac Surgery: A Decision Curve Analysis

<div><p>Background</p><p>The benefits of cardiac surgery are sometimes difficult to predict and the decision to operate on a given individual is complex. Machine Learning and Decision Curve Analysis (DCA) are recent methods developed to create and evaluate prediction models.</p><p>Methods and finding</p><p>We conducted a retrospective cohort study using a prospective collected database from December 2005 to December 2012, from a cardiac surgical center at University Hospital. The different models of prediction of mortality in-hospital after elective cardiac surgery, including EuroSCORE II, a logistic regression model and a machine learning model, were compared by ROC and DCA. Of the 6,520 patients having elective cardiac surgery with cardiopulmonary bypass, 6.3% died. Mean age was 63.4 years old (standard deviation 14.4), and mean EuroSCORE II was 3.7 (4.8) %. The area under ROC curve (IC95%) for the machine learning model (0.795 (0.755–0.834)) was significantly higher than EuroSCORE II or the logistic regression model (respectively, 0.737 (0.691–0.783) and 0.742 (0.698–0.785), p < 0.0001). Decision Curve Analysis showed that the machine learning model, in this monocentric study, has a greater benefit whatever the probability threshold.</p><p>Conclusions</p><p>According to ROC and DCA, machine learning model is more accurate in predicting mortality after elective cardiac surgery than EuroSCORE II. These results confirm the use of machine learning methods in the field of medical prediction.</p></div

Decision curves showing the clinical usefulness of EuroSCORE I, EuroSCORE II, and the ML model in predicting post-operative mortality.

<p>The blue line represents the net benefit of providing surgery for all patients, assuming that all patients would survive. The red line represents the net benefit of surgery to none patients, assuming that all would die after surgery. The green, purple and turquoise lines represent the net benefit of applying surgery to patients according to EuroSCORE I, EuroSCORE II, and ML model, respectively. The selected probability threshold (<i>i</i>.<i>e</i>., the degree of certitude of postoperative mortality over which the patient's decision is not to operate) is plotted on the abscissa.</p