Fonction rénale et chirurgie cardiaque (évaluation de la cinétique de l'index de résistance au cours de la défaillance rénale aiguë)

INTRODUCTION: L'insuffisance rénale est un problème quotidien en chirurgie cardiaque sous CEC avec une morbi-mortalité élevée. La comparaison de la toxicité rénale des différents types de colloïdes entre eux reste à établir. Nous avons évalué la néphrotoxicité des HEA et des gélatines par la cinétiques de l'index de résistance rénale chez les patients de chirurgie cardiaque. MATERIELS et METHODE: Les patients soumis à une chirurgie cardiaque réglée ont été observées prospectivement, après recueil de leur consentement éclairé pour la réalisation de dopllers rénaux. Deux groupes ont été séparés selon les pratiques des anesthésistes, des patients recevant des gélatines et des cristolloïdes et d'autres recevant des HEA et des cristalloïdes. Un doppler a été réalisé à l'induction anesthésiques, 1 heure après la sortie du bloc opératoire et à la 48ème heure, de façon parallèle la créatinine était relevée. RESULTATS: Durant la période de mai 2013 à novembre 2014, 60 patients ont été inclus. Les valeurs de créatinine et de doppler rénaux préoppératoires étaient identiques dans les 2 groupes. Le doppler rénal de H1 était plus élevé chez les patients du groupe HEA (0,64 vs 0,586 p=0,008), les patients ont présentés au cours d'hospitalisation un nombre plus important d'insuffisance rénale (13 contre 6 p=0,041), alors que le doppler de H48 ne mettait pas en évidence de différence statistiquement significative entre les 2 groupes. L'analyse de la courbe ROC de notre série retrouve une AUC à 0,847 pour la prédiction de l'IRA par le doppler rénal de 48H. CONCLUSION: Le doppler rénal est un outil fiable pour la prédicion de la toxicité rénale des HEA à la phase post opératoire de chirurgie cardiaque mais la valeur seuil diagnostique de l'IR n'est à notre sens par définie clairement par cette étudeAIX-MARSEILLE2-BU Méd/Odontol. (130552103) / SudocSudocFranceF

Peri-operative oral caffeine does not prevent postoperative atrial fibrillation after heart valve surgery with cardiopulmonary bypass: A randomised controlled clinical trial

International audienceBACKGROUND:Raised plasma levels of endogenous adenosine after cardiac surgery using cardiopulmonary bypass (CPB) have been related to the incidence of postoperative atrial fibrillation (POAF).OBJECTIVE:We wished to assess if caffeine, an adenosine receptor antagonist could have a beneficial effect on the incidence of POAF.DESIGN:A randomised controlled study.SETTING:Single University Hospital.PATIENTS:One hundred and ten patients scheduled for heart valve surgery with CPB.INTERVENTIONS:We randomly assigned patients to receive peri-operative oral caffeine (400 mg every 8 h for 2 days) or placebo. Adenosine plasma concentrations and caffeine pharmacokinetic profile were evaluated in a subgroup of 50 patients.MAIN OUTCOME MEASURES:The primary endpoint was the rate of atrial fibrillation during postoperative hospital stay.RESULTS:The current study was stopped for futility by the data monitoring board after an interim analysis. The incidence of atrial fibrillation was similar in the caffeine and in the placebo group during hospital stay (33 vs. 29%, P = 0.67) and the first 3 postoperative days (18 vs. 15%; P = 0.60). Basal and postoperative adenosine plasma levels were significantly associated with the primary outcome. Adenosine plasma levels were similar in the two treatment groups. Caffeine administration was associated with a higher incidence of postoperative nausea and vomiting (27 vs. 7%, P = 0.005).CONCLUSION:Oral caffeine does not prevent POAF after heart valve surgery with CPB but increased the incidence of postoperative nausea and vomiting.CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov, no.: NCT01999829

Severe right ventricular dysfunction is an independent predictor of pre- and post-transplant mortality among candidates for heart transplantation

International audienceBackground. Heart transplantation is the gold-standard treatment for end-stage heart failure. However, the shortage of grafts has led to longer waiting times and increased mortality for candidates without priority. Aims. To study waiting-list and post-transplant mortality, and their risk factors among patients registered for heart transplantation without initial high emergency procedure. Methods. All patients registered on the heart transplantation waiting list (2004-2015) without initial high emergency procedure were included. Clinical, biological, echocardiographic and haemodynamic data were collected. Waiting list and 1-year post-transplant survival were analysed with a Kaplan-Meier model. Results. Of 221 patients enrolled, 168 (76.0%) were men. Mean age was 50.0 +/- 12.0 years. Forty-seven patients died on the waiting list, resulting in mortality rates of 11.2 +/- 2.7% at 1 year, 31.9 +/- 5.4% at 2 years and 49.4 +/- 7.1% at 3 years. Median survival was 36.0 +/- 4.6 months. In the multivariable analysis, left ventricular ejection fraction 50 years were strong predictors of death after transplantation (HR: 5.38, 95% CI: 1.38-10.24 [P=0.020] and HR: 6.16, 95% CI: 1.62-9.32 [P=0.0130], respectively). Conclusions. Mortality among candidates for heart transplantation remains high. Patients at highest risk of waiting-list mortality have to be promoted, but without compromising post transplant outcomes. For this reason, candidates with severe right ventricular dysfunction are of concern, because, for them, transplantation is hazardous. (C) 2016 Elsevier Masson SAS. All rights reserved

Effect of Moderate Hypothermia vs Normothermia on 30-Day Mortality in Patients With Cardiogenic Shock Receiving Venoarterial Extracorporeal Membrane Oxygenation: A Randomized Clinical Trial

IMPORTANCE: The optimal approach to the use of venoarterial extracorporeal membrane oxygenation (ECMO) during cardiogenic shock is uncertain. OBJECTIVE: To determine whether early use of moderate hypothermia (33-34 °C) compared with strict normothermia (36-37 °C) improves mortality in patients with cardiogenic shock receiving venoarterial ECMO. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial of patients (who were eligible if they had been endotracheally intubated and were receiving venoarterial ECMO for cardiogenic shock for <6 hours) conducted in the intensive care units at 20 French cardiac shock care centers between October 2016 and July 2019. Of 786 eligible patients, 374 were randomized. Final follow-up occurred in November 2019. INTERVENTIONS: Early moderate hypothermia (33-34 °C; n = 168) for 24 hours or strict normothermia (36-37 °C; n = 166). MAIN OUTCOMES AND MEASURES: The primary outcome was mortality at 30 days. There were 31 secondary outcomes including mortality at days 7, 60, and 180; a composite outcome of death, heart transplant, escalation to left ventricular assist device implantation, or stroke at days 30, 60, and 180; and days without requiring a ventilator or kidney replacement therapy at days 30, 60, and 180. Adverse events included rates of severe bleeding, sepsis, and number of units of packed red blood cells transfused during venoarterial ECMO. RESULTS: Among the 374 patients who were randomized, 334 completed the trial (mean age, 58 [SD, 12] years; 24% women) and were included in the primary analysis. At 30 days, 71 patients (42%) in the moderate hypothermia group had died vs 84 patients (51%) in the normothermia group (adjusted odds ratio, 0.71 [95% CI, 0.45 to 1.13], P = .15; risk difference, -8.3% [95% CI, -16.3% to -0.3%]). For the composite outcome of death, heart transplant, escalation to left ventricular assist device implantation, or stroke at day 30, the adjusted odds ratio was 0.61 (95% CI, 0.39 to 0.96; P = .03) for the moderate hypothermia group compared with the normothermia group and the risk difference was -11.5% (95% CI, -23.2% to 0.2%). Of the 31 secondary outcomes, 30 were inconclusive. The incidence of moderate or severe bleeding was 41% in the moderate hypothermia group vs 42% in the normothermia group. The incidence of infections was 52% in both groups. The incidence of bacteremia was 20% in the moderate hypothermia group vs 30% in the normothermia group. CONCLUSIONS AND RELEVANCE: In this randomized clinical trial involving patients with refractory cardiogenic shock treated with venoarterial ECMO, early application of moderate hypothermia for 24 hours did not significantly increase survival compared with normothermia. However, because the 95% CI was wide and included a potentially important effect size, these findings should be considered inconclusive. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02754193

Prevalence and outcome of heparin-induced thrombocytopenia diagnosed under veno-arterial extracorporeal membrane oxygenation a retrospective nationwide study

International audiencePurpose - Thrombocytopenia is a frequent and serious adverse event in patients treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock. Similarly to postcardiac surgery patients, heparin-induced thrombocytopenia (HIT) could represent the causative underlying mechanism. However, the epidemiology as well as related mortality regarding HIT and VA-ECMO remains largely unknown. We aimed to define the prevalence and associated 90-day mortality of HIT diagnosed under VA-ECMO. Methods - This retrospective study included patients under VA-ECMO from 20 French centers between 2012 and 2016. Selected patients were hospitalized for more than 3 days with high clinical suspicion of HIT and positive anti-PF4/heparin antibodies. Patients were classified according to results of functional tests as having either Confirmed or Excluded HIT. Results - A total of 5797 patients under VA-ECMO were screened; 39/5797 met the inclusion criteria, with HIT confirmed in 21/5797 patients (0.36% [95% CI] [0.21-0.52]). Fourteen of 39 patients (35.9% [20.8-50.9]) with suspected HIT were ultimately excluded because of negative functional assays. Drug-induced thrombocytopenia tended to be more frequent in Excluded HIT at the time of HIT suspicion (p = 0.073). The platelet course was similar between Confirmed and Excluded HIT (p = 0.65). Mortality rate was 33.3% [13.2-53.5] in Confirmed and 50% [23.8-76.2] in Excluded HIT (p = 0.48). Conclusions - Prevalence of HIT among patients under VA-ECMO is extremely low at 0.36% with an associated mortality rate of 33.3%, which appears to be in the same range as that observed in patients treated with VA-ECMO without HIT. In addition, HIT was ultimately ruled out in one-third of patients with clinical suspicion of HIT and positive anti-PF4/heparin antibodies