Christophe Decoene

Regional capnometry with air-automated tonometry detects circulatory failure earlier than conventional hemodynamics after cardiac surgery.

UNLABELLED Gastrointestinal automated online air tonometry has been proposed for monitoring gastric perfusion in patients at risk of circulatory failure (CF) after cardiopulmonary bypass. In this study, CF was prospectively defined as the requirement for vasoactive support to maintain mean arterial pressure > or = 70 mm Hg after optimization of preload. Hemodynamic variables--oxygen (O2) delivery (DO2), O2 uptake (Vo2), venous-to-arterial [P(v-a)CO2], gastric-to-arterial [P(r-a)CO2], and gastric-to-end-tidal [P(r-et)CO2]Pco2 gap-were retrospectively compared in 14 patients with or without CF during a 12-hr postbypass period (HO-H12). In contrast to patients without CF (n = 7), in patients with CF (n = 7) increased VO2 was not associated with an increase in DO2. P(r-a)CO2 was larger at H0 in CF patients and was the only variable that differed between the two groups. P(v-a)CO2 did not vary significantly in both groups, whereas P(r-a)CO2 increased to a larger extent from H0 to H12 in patients with CF, suggesting selective gastrointestinal hypoperfusion in this group. P(r-et)CO2 provided comparable information to P(r-a)CO2. Hospital length of stay was 4 days longer (P < 0.05) in patients with CF. Increased P(r-a)CO2 and P(r-et)CO2, as monitored with automated air tonometry, were associated with rapid occurrence of CF and prolonged hospital stay after cardiac surgery. IMPLICATIONS Regional and automated capnometry may be used noninvasively to identify patients at risk of circulatory failure after cardiopulmonary bypass earlier than with conventional variables.

A single endotoxin injection in the rabbit causes prolonged blood vessel dysfunction and a procoagulant state

ObjectivesTo determine the duration of vascular blood vessel dysfunction and coagulation abnormalities after administration of endotoxin in a nonlethal septic rabbit model. DesignRandomized, controlled, interventional trial. SettingUniversity animal laboratory. SubjectsA total of 30 male New Zealand White rabbits, randomly assigned to one of two groups. InterventionsMale New Zealand White rabbits were randomly divided into control or lipopolysaccharide (LPS) (0.5 mg/kg iv bolus Escherichia coli endotoxin)-treated groups. Metabolic acidosis and coagulation activation confirmed the presence of septic shock. The abdominal aorta was removed at 24 hrs (day 1), day 5, or day 21 after LPS injection. Immunohistochemical staining for an endothelial cell marker (PECAM-1/CD31) was performed to assess endothelial injury. Endothelium-dependent vascular relaxation was analyzed by in vitro vascular reactivity studies. Responses to acetylcholine, to calcium ionophore (A-23187), and to sodium nitroprusside were studied. In addition, arterial blood samples were collected on day 1, day 5, and day 21 for measurement of clotting factors and tissue factor activity. Measurements and Main ResultsLPS injection resulted in endothelial injury, with loss of ∼25% of the endothelial area on day 5, which disappeared on day 21. LPS injection also caused a significantly reduced relaxation response to acetylcholine (44.9% ± 9.9% vs. 76.5% ± 5.4% for the control group;p < .005), which was restored on day 21. In contrast, vascular relaxation in response to A-23187 and sodium nitroprusside was not altered. A significant decrease in the platelet count was observed on day 1, associated with a decrease in factors II and V. On day 5, platelet count and factors II and V were corrected in conjunction with an elevated monocyte tissue factor activity in LPS-injected rabbits. On day 21, coagulation abnormalities were corrected. ConclusionsA single endotoxin injection in the rabbit was responsible for prolonged aortic endothelial cell dysfunction, as well as a prolonged procoagulant state. The latter is a potential trigger for disseminated intravascular coagulation. Importantly, these features are associated with normalization of conventional biological evidence of septic shock.

TEVAR in Patients with Late Complications of Aortic Coarctation Repair

Purpose: To review the use of thoracic endovascular aortic repair (TEVAR) for late pseudoaneurysm formation after surgical repair of aortic coarctation. Methods: From May 2001 to May 2005, 8 patients (5 men; mean age 47.6 years, range 18–73) with a history of aortic coarctation repairs 17 to 40 years prior were referred to our institution for an anastomotic thoracic pseudoaneurysm. TEVAR was performed successfully in 7 patients; 1 died of suspected aneurysm rupture before the scheduled procedure. A carotid-subclavian bypass was performed in 3 patients. Results: All the procedures were immediately successful. No type I endoleaks were seen on the final control angiogram, but 2 of the patients with carotid-subclavian bypasses required additional left subclavian artery embolization due to type II endoleak. One of these patients died before embolotherapy on the 5th postoperative day from presumed aneurysm rupture (14% 30-day mortality rate). Over a follow-up period ranging from 15 to 72 months (mean 37), all the false aneurysms have remained thrombosed and the mean diameter has decreased from 44 to 23 mm. No endograft-related complications have occurred, and no further interventions have so far been necessary. Conclusion: TEVAR is a feasible alternative treatment for patients who have already undergone surgical repair of aortic coarctation. Technical issues regarding the endovascular strategy should be discussed with a multidisciplinary team to define the correct interventional plan.

Circumflex artery stenosis induced by intraoperative radiofrequency ablation.

We report a case of circumflex artery stenosis after intraoperative radiofrequency ablation for permanent atrial fibrillation in a patient who had a previous mitral valve replacement. The patient presented with acute pulmonary edema and severe angina 1 year after an uneventful recovery. The patient underwent a diagnostic angiography that showed the presence of stenosis of a long segment of the circumflex artery, adjacent to the radiofrequency ablation site, which was reopened successfully by angioplasty. Intraoperative radiofrequency ablation caused circumflex artery stenosis. We believe that this complication could have been avoided by applying the radiofrequency ablation more distally between the left pulmonary veins and the mitral valve.

Total orthotopic heart transplantation for primary cardiac rhabdomyosarcoma: factors influencing long-term survival

BACKGROUND Primary cardiac sarcomas are uncommon and rare, with an unequal distribution in the population. A dismal prognosis is usually admitted that is related to a high propensity to develop distant metastasis with survival rarely exceeding 2 years. We report a case of a patient with a primary cardiac rhabdomyosarcoma characterized by an exceptional long-term survival after surgical treatment by a total orthotopic heart transplantation. From this limited experience, we reviewed factors that may influence survival to optimize therapeutic strategy. METHODS A 33-year-old man was found to have a 10-cm primary cardiac rhabdomyosarcoma located in the right atrium and extending to the atrioventricular groove; therefore, resection was not possible. Since no metastases were detected, the patient was scheduled for urgent cardiac transplantation, which was performed after adjuvant radiotherapy. RESULTS Postoperative outcome was uneventful and the patient is still alive, with regular follow-up, at 102 months. CONCLUSIONS In a case of primary rhabdomyosarcoma, heart transplantation, despite immunosuppressive therapy, can provide long-term survival and can be considered for selected patients after rigorous analysis of predictors of survival.

Comparison of Blood Activation in the Wound, Active Vent, and Cardiopulmonary Bypass Circuit

BACKGROUND During cardiopulmonary bypass, aspirated blood exhibits strong activation features, but the triggering event remains unclear. Contact of blood with the pericardial cavity and surgical wound has been advocated as the main trigger, but suction forces are also considered as a possible contributor. We thus designed a study to identify the possible causes involved in this activation. METHODS In 10 patients, we analyzed hemostasis activation markers and inflammatory mediators in blood collected in the pericardial cavity and in blood actively aspirated from the left ventricle without any contact with the pericardial cavity. In addition, the same variables were determined in blood sampled in the cardiopulmonary bypass circuit. RESULTS Markers of tissue factor pathway activation and of thrombin generation, microparticles, free hemoglobin, interleukin 6, and tumor necrosis factor-alpha were significantly increased in pericardial samples as compared with the left ventricle and cardiopulmonary bypass circuit samples. All measured variables were similar between left ventricle and cardiopulmonary bypass samples, except free hemoglobin, interleukin 6, and microparticle levels, which were significantly higher in the left ventricle. CONCLUSIONS Blood contact with the pericardial cavity induces strong hemolysis, inflammatory mediator release, and coagulation activation, driven by tissue factor pathway activation. By contrast, suction forces applied to left ventricular blood poorly contribute to blood trauma and activation. Comparison of pericardial and left ventricular blood shows that contact with the pericardial cavity, and not suction forces, is the leading cause of blood activation. The specific trigger for blood trauma and activation present in the pericardial cavity remains to be identified.

Ross operation for active culture-positive aortic valve endocarditis with extensive paravalvular involvement

BACKGROUND We evaluated the midterm results of the Ross operation in active advanced endocarditis. METHODS Between June 1994 and June 2000 a pulmonary autograft aortic root replacement was performed in 11 consecutive patients who had urgent or emergent procedures for active endocarditis with extensive involvement of the aortic root (10 native, 1 prosthetic). Patients ranged in age from 26 to 45 years (median, 33 years). Indications for operation were uncontrolled infection (n = 5), hemodynamic deterioration (n = 3), or both (n = 3). Four patients were in the New York Heart Association class III, 6 in class IV, and 1 was operated on while in cardiogenic shock. Four patients (36%) suffered an embolic cerebrovascular accident preoperatively. The endocarditis affected the mitral valve in 2 patients and the tricuspid valve in 1 patient. RESULTS There was no early or late death. Recurrent endocarditis was not detected in any of the patients during the follow-up period ranging up to 72 months (median, 40 months). CONCLUSIONS The autograft may well be the best substitute for aortic root reconstruction in advanced endocarditis.

Results of Endoluminal Occlusion of the Inferior Vena Cava During Radical Nephrectomy and Thrombectomy

BACKGROUND The surgical management of renal tumours with thrombi in the inferior vena cava (IVC) has become the gold standard treatment. OBJECTIVE To evaluate endoluminal occlusion of the IVC during radical nephrectomy with either retrohepatic (level II) or suprahepatic (level III) caval tumour thrombus. DESIGN, SETTING, AND PARTICIPANTS From January 2000 to October 2007, 28 consecutive patients with renal cell carcinoma presenting a thrombus level II or III were treated with endoluminal occlusion of the free IVC cranial. SURGICAL PROCEDURE The occlusion balloon was positioned under transesophageal echography (TEE) control through a cavotomy performed at the level of the renal vein ostium. Thrombectomy and radical nephrectomy were then performed. MEASUREMENTS Operative time, perioperative bleeding, and pre- and postoperative complications were assessed. Overall patient survival time, disease-free survival, and development of metastasis were assessed. RESULTS AND LIMITATIONS Caval thrombectomy was performed successfully in all patients. IVC replacement with an expanded polytetrafluoroethylene graft or patch closure after lateral cavectomy was performed in 10 and 4 patients, respectively. Average operative time was 160 min (range: 120-210). There was no perioperative mortality. The complications were one splenectomy and one early thrombosis of the IVC. Mean length of follow-up was 22.1 mo (range: 3-90). There was no local or IVC tumour recurrence. Cause-specific death and metastasis occurred in six (21.4%) and nine patients (32.1%), respectively. Thirteen patients (46.4%) are disease-free. CONCLUSIONS Endoluminal occlusion of the IVC with TEE monitoring for level II and III thrombus avoided a suprahepatic or subdiaphragmatic approach of the IVC. Segmental resection and reconstruction of the IVC could also be performed in case of adherent thrombi.

Aortic root replacement with a pulmonary autograft in young adults: medium-term results in 70 patients

BACKGROUND Pulmonary autograft aortic valve replacement has been introduced in our institution in selected adult patients in light of the known disadvantages and limitations of conventional prosthetic valves. METHODS We prospectively evaluated the use of the pulmonary autograft in a series of 70 young adults (31.2+/-8.7 years, range 16 to 49 years) operated on from March 1992 to April 1997 with aortic root replacement only. RESULTS There were no in-hospital deaths and two noncardiac-related late deaths during follow-up of up to 62 months (mean 33 months). Thromboembolic complications were not observed. One patient required reoperation for infective endocarditis 4.3 years after surgery. Discharge echo-Doppler studies showed normal autograft and allograft valve function. Serial echo-Doppler studies showed no significant progression of aortic insufficiency and no dilatation of the autograft. A severe stenosis of the pulmonary allograft developed in 1 patient. CONCLUSION Aortic root replacement with a pulmonary autograft, although more complex than conventional prosthetic valve replacement, is a safe, effective, and reproducible procedure in properly selected adult patients. Long-term results remain to be evaluated.

Chordal Cutting VIA Aortotomy in Ischemic Mitral Regurgitation: Surgical and Echocardiographic Study

Abstract  Background: Chordal cutting through atriotomy has been proposed to treat significant resting ischemic mitral regurgitation (MR) due to anterior leaflet tenting. In addition, MR may exacerbate during exercise not only trough exercise‐induced ischemia but also through an increase in tenting area. Accordingly, we aimed to perform chordal cutting through aortotomy in patients with exercise‐induced ischemic worsening of MR. Methods: Five patients with ischemic MR, due to anterior leaflet tenting, whichworsened during exercise echocardiography were enrolled. All patients underwent cutting of the 2 basal chordae attached to the anterior mitral leaflet associated with myocardial revascularization. Three patients had additional mitral valve annuloplasty. Postoperative MR was evaluated using exercise echocardiography. Results: Age ranged from 63 to 78 years and 4 patients were male. Preoperative LV ejection fraction averaged 39 ± 3%. Chordal cutting was performed through aortotomy allowing comfortable access to the anterior mitral valve. Mitral effective regurgitant orifice at rest and at peak exercise was reduced by surgery (10 ± 3 to 0.6 ± 0.5 mm2 at rest and from 20 ± 3 to 6 ± 2 mm2 at peak exercise; p = 0.03). Mitral tenting area at rest and at peak exercise was concomitantly reduced by surgery (1.83 ± 0.21 cm2 to 0.50 ± 0.4 cm2 at rest and from 3.11 ± 0.58 to 1.7 ± 0.5 cm2 at peak exercise; p = 0.03). Left ventricular size and function remained unchanged after surgery. Conclusions: Chordal cutting through aortotomy may be an effective option to treat ischemic MR due to anterior leaflet tenting. Associated with myocardial revascularization, it resulted in a decrease of MR at rest and during exercise through a decrease in tenting area without impairment of LV function.