International normalized ratio self-testing and self-management: improving patient outcomes

Matteo Pozzi,1 Julia Mitchell,2 Anna Maria Henaine,3 Najib Hanna,4 Ola Safi,4 Roland Henaine2 1Department of Adult Cardiac Surgery, “Louis Pradel” Cardiologic Hospital, Lyon, France; 2Department of Congenital Cardiac Surgery, “Louis Pradel” Cardiologic Hospital, Lyon, France; 3Clinical Pharmacology Unit, Lebanese University, Beirut, Lebanon; 4Pediatric Unit, “Hotel Dieu de France” Hospital, Saint Joseph University, Beirut, Lebanon Abstract: Long term oral anti-coagulation with vitamin K antagonists is a risk factor of hemorrhagic or thromebomlic complications. Periodic laboratory testing of international normalized ratio (INR) and a subsequent dose adjustment are therefore mandatory. The use of home testing devices to measure INR has been suggested as a potential way to improve the comfort and compliance of the patients and their families, the frequency of monitoring and, finally, the management and safety of long-term oral anticoagulation. In pediatric patients, increased doses to obtain and maintain the therapeutic target INR, more frequent adjustments and INR testing, multiple medication, inconstant nutritional intake, difficult venepunctures, and the need to go to the laboratory for testing (interruption of school and parents’ work attendance) highlight those difficulties. After reviewing the most relevant published studies of self-testing and self-management of INR for adult patients and children on oral anticoagulation, it seems that these are valuable and effective strategies of INR control. Despite an unclear relationship between INR control and clinical effects, these self-strategies provide a better control of the anticoagulant effect, improve patients and their family quality of life, and are an appealing solution in term of cost-effectiveness. Structured education and knowledge evaluation by trained health care professionals is required for children, to be able to adjust their dose treatment safely and accurately. However, further data are necessary in order to best define those patients who might better benefit from this multidisciplinary approach. Keywords: oral anticoagulation, vitamin K antagonists, international normalized ratio, INR self-management, INR self-testin

The \u201cPAC-MAN\u201d sign: an insidious complication after transcatheter aortic valve deployment

Transcatheter aortic valve implantation (TAVI) is now a viable and effective alternative to conventional surgical aortic valve replacement for high-risk patients with severe aortic stenosis. Despite its percutaneous and less invasive nature, TAVI is associated with the potential for several intraprocedural complications, which have been recently updated and standardized. Some of them, such as those relating to valve deployment and/or positioning, occur less frequently but they could however represent very serious and life-threatening complications. We report the case of an insidious TAVI complication that required a combined fluoroscopic/echocardiographic approach in order to allow a correct deployment of the transcatheter prosthesis. Our case report highlights this potentially specific under-deployment of large CoreValve prosthesis. Medico-surgical community involved in TAVI must be nowaware of this newtype of complication allowing its successful management

Impact of sugammadex on neuromuscular blocking agents use: A multicentric, pharmaco-epidemiologic study in French university hospitals and military hospitals

International audienceIntroduction. - Seven Neuromuscular Blocking Agents (NMBA) are commercialized in France. Four of them have an intermediate duration of action. Sugammadex required the use of NMBA slightly employed in clinical practice in France. Its introduction in routine practice could have an impact on NMBA use in clinical practice. This study was then conducted to assess and compare NMBA use before and after the commercialization of sugammadex. Materials and methods. - A longitudinal, retrospective, observational study was conducted between 2008 and 2011 in French university hospitals and military hospitals. The consumption data for sugammadex and NMBA were collected using a collection grid which was filled by pharmacists or anesthesiologists. Drug use was measured by the number of vials used divided by the annual number of hospitalizations in surgery and obstetrics (MO). An overall analysis of the annual frequency of NMBA use was firstly performed, then individual data of each hospital were analyzed. Descriptive statistical analysis including mean, standard deviation, median, minimum and maximum was achieved. Results. - Thirty-four out of 39 hospitals participated in the study (87%) and analysis was performed on 26 of them (7%). The data of eight institutions were exluded due to missing values or because of the non-admission of sugammadex in their formulary. The NMBA mostly used were non-steroidal NMBA (75% of market share) with an increased use between 2008 and 2011 concerning atracurium (from 41 to 51 vials of 50 mg atracurium used per 100 HSO). The overall analysis revealed an increase of the occurrence of rocuronium (between 2008 and 2011: from 1 to 4.8 vials of 50 mg rocuronium used per 100 HSO). Individual analyses on each hospital showed a possible effect of sugammadex introduction on NMBA use in nine hospitals. Discussion and conclusions. - The commercialization of sugammadex seems to have induced a discrete increase of steroidal NMBA but non-steroidal NMBA remain the leading agent in France. A long-term follow-up is deserved. (C) 2013 Societe francaise d'anesthesie et de reanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved

Total percutaneous femoral vessels cannulation for minimally invasive mitral valve surgery

BACKGROUND: Minimally invasive mitral valve surgery (MIMVS) has experienced several technological changes in the last two decades. Our aim was to describe one of the most recent improvements, the utilization of a total percutaneous femoral vessels cannulation technique during MIMVS. METHODS: We performed a retrospective observational analysis of this technique among 300 consecutive MIMVS patients, with particular focus on cannulation aspects of MIMVS, its success rate and potential complications. RESULTS: From October 2008 to December 2012, 300 patients (60% males) were operated on. Mean age was 62.9\ub116.4 years. Indications for operation included mitral valve repair (93%) and mitral valve replacement (7%). Two femoral arterial catheterizations failed and required conversion to sternotomy. The complications on the arterial side were: 5 (1.6%) cases of bleeding during the introduction of Prostar leading to a preoperative surgical hemostasis; 2 (0.6%) retroperitoneal bleeds during cardiopulmonary bypass requiring difficult surgical control but with an uneventful follow-up; 6 (2%) bleeding episodes after removal of the arterial cannula easily controlled by direct surgical revision; 1 (0.3%) arterio-venous fistula requiring a surgical correction on postoperative day 32; 1 (0.3%) patient had a transitory claudication due to a superficial femoral artery thrombosis progressively compensated by the collateral circulation. There were no postoperative bleeding complications. There were no other complications linked to the femoral cannulations or to the groin occurred during the follow-up. The percentage of uneventful arterial cannulations was 80% among the first 50 patients (N=10 out of 50) and 98.8% thereafter (N=3 out of 250). CONCLUSIONS: Total percutaneous femoral vessels cannulation technique is particularly suitable for MIMVS with a high success rate and few complications after a short learning curve. With the advent of the percutaneous approach, the traditional complications of the groin incision have completely disappeared in modern operations with no groin infection, hematoma or lymphocele

Current patterns of infective endocarditis in congenital heart disease

OBJECTIVE: To assess the changing profile of infective endocarditis in patients with congenital heart disease. METHODS: All cases diagnosed from 1966 to 2001 (revised Duke criteria) were retrospectively reviewed and categorised in periods I (< 1990) and II (⩾ 1990). RESULTS: 153 episodes occurred, 81 in period I and 72 in period II. Mean age of affected patients was higher in period II. Non‐operated ventricular septal defect, Rastelli correction and palliated cyanotic heart disease increased. Infective endocarditis in corrective surgery changed to patients with prosthetic material. Post‐surgical cases decreased. Dental problems were the leading cause (period I 20% v II 33% of cases) with a large variety of pathological organisms (multiple species of Streptococcus). Cutaneous causative infections increased (5% to 17%) with different species of Staphylococcus. Negative blood cultures lessened (20% to 7%, p  =  0.03). Streptococci were the most common causative organisms in both periods. Severe heart failure and cardiac complications lessened (20% to 4% and 31% to 18% during periods I and II, respectively). Early surgery was more frequent in period II (32% v 18.5%, p  =  0.02). One‐ and 10‐year survival was 91% v 97% in period I and 89% v 97% in period II, respectively (NS). CONCLUSION: Current targets include complex cyanotic disease, congenital heart disease corrected with prosthetic material and small ventricular septal defect. Postoperative cases lessened; dental and cutaneous causes increased. Survival was unchanged. Prophylactic measures targeted at dental and cutaneous sources should be emphasised