Fabrice Vanhuyse

Experts’ recommendations for the management of adult patients with cardiogenic shock

Unlike for septic shock, there are no specific international recommendations regarding the management of cardiogenic shock (CS) in critically ill patients. We present herein recommendations for the management of cardiogenic shock in adults, developed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system by an expert group of the French-Language Society of Intensive Care (Société de Réanimation de Langue Française (SRLF)), with the participation the French Society of Anesthesia and Intensive Care (SFAR), the French Cardiology Society (SFC), the French Emergency Medicine Society (SFMU), and the French Society of Thoracic and Cardiovascular Surgery (SFCTCV). The recommendations cover 15 fields of application such as: epidemiology, myocardial infarction, monitoring, vasoactive drugs, prehospital care, cardiac arrest, mechanical assistance, general treatments, cardiac surgery, poisoning, cardiogenic shock complicating end-stage cardiac failure, post-shock treatment, various etiologies, and medical care pathway. The experts highlight the fact that CS is a rare disease, the management of which requires a multidisciplinary technical platform as well as specialized and experienced medical teams. In particular, each expert center must be able to provide, at the same site, skills in a variety of disciplines, including medical and interventional cardiology, anesthesia, thoracic and vascular surgery, intensive care, cardiac assistance, radiology including for interventional vascular procedures, and a circulatory support mobile unit.

Cardiac surgery in cirrhotic patients: results and evaluation of risk factors

OBJECTIVES Liver cirrhosis increases mortality and morbidity following cardiac surgery. This study evaluated the results of cardiac surgery in cirrhotic patients and the relevance of EuroSCORE, Child-Turcotte-Pugh (CTP) class and model for end-stage liver disease (MELD) score in terms of prediction of surgical mortality and survival. METHODS The study involved 34 patients with hepatic cirrhosis who underwent cardiac surgery between January 1996 and January 2010. RESULTS The in-hospital mortality was 26%. Postoperative mortality of patients with CTP class A, B or C was 18, 40 and 100%, respectively. In univariate analysis, a history of cerebrovascular disease and hypoalbuminaemia was predictive of operative mortality. Multivariate exact logistic regression revealed that hypoalbuminaemia was an independent factor. Long-term survival was 63 ± 0.08% at 1 year and 40.2 ± 0.12% at 5 years. The 1-year survival for CTP A, B and C was 76.7 ± 0.09, 60 ± 15.4 and 0%, respectively, and the 5-year survival was 60 ± 15.4, 25 ± 0.19 and 0%, respectively. The EuroSCORE was not a discriminant [area under the curve (AUC): 0.57 ± 0.15]. The performance of CTP class and MELD score was better, but neither provided optimal discrimination: AUC was 0.691 ± 0.110 for MELD and 0.658 ± 0.10 for CTP class. CONCLUSIONS Cardiac surgery can be performed safely in CTP class A patients. In CTP C patients, surgery is hazardous, and an alternative treatment must be considered. In CTP B, the MELD score could be helpful in deciding whether surgical intervention is a reasonable option.

Prone positioning use to hasten veno-venous ECMO weaning in ARDS

Dear Editor, A 41-year-old overweight (body mass index 35 kg/m) woman was admitted from home to the intensive care unit (ICU) for acute respiratory distress with fever. Her medical history mainly included a neurosarcoidosis treated with corticosteroids, methotrexate and six courses of cyclophosphamide. The computed tomography scan revealed a diffuse alveolar–interstitial syndrome without any mediastinal adenopathy. She received an initial antibiotherapy (cephalosporine, rovamycin) after an examination for infectious diseases. No infectious process or cause for an acute exacerbation of pulmonary sarcoidosis was found in the bronchoalveolar lavage fluid, and antibiotherapy was stopped after 5 days. There was no acute cardiac dysfunction on echocardiography. No diagnosis was made and her respiratory state worsened. She required, after 6 days of evolution, invasive mechanical ventilation to treat an acute respiratory distress syndrome (ARDS). After 3 days of lung protective ventilation [normal tidal volume (Vt) 5 ml/kg, respiratory rate (RR) 30/min, positive end expiratory pressure (PEEP) 12 cmH2O, plateau pressure (PP) 30 cmH2O, static compliance (SC) 20 ml/cmH2O) with neuromuscular blockade, she remained with a severe ARDS [partial pressure of oxygen in the blood (PaO2)/fraction of inspired oxygen (FiO2) 85 mmHg]. Two 24-h sessions of prone positioning failed to improve the PaO2/FiO2. No evolutive infectious process was found, and corticosteroids were maintained at 1 mg/kg/day to treat the ARDS inflammatory process. Her respiratory function worsened (Vt 5 ml/kg, RR 35/min, PEEP 10 cmH2O, PP 30 cmH2O, SC 20 ml/cmH2O) with refractory hypoxia on arterial gasometry [FiO2 100 %, pH 7.45; partial pressure oxygen (PO2) 75 mmHg; PCO2 40 mmHg; HCO3 -

Modified Bentall Procedure Using Two Short Grafts for Coronary Reimplantation: Long-Term Results

BACKGROUND The modified Bentall procedure remains a gold standard of aortic root surgery. We present in this study the early and late outcomes of a particular modification using 2 separated grafts for the coronary reimplantation. METHODS From 1995 to 2009, 153 patients aged 57±12 (mean±standard deviation [SD]) underwent elective (n=113) or urgent (n=40) aortic root replacement with a composite mechanical valve conduit reconstruction using 2 short, separated 8-mm Dacron grafts for the coronary reimplantation and were retrospectively reviewed. RESULTS Aortic disease etiologies were annuloaortic ectasia (n=108), type A aortic dissection (n=38), aortic false aneurysm, or Valsalva aneurysm evolution after previous cardiac surgery (n=7). The overall early mortality was 8.5% (20% for urgent procedure and 4.4% for elective procedure). For the whole group, actuarial survival at 5 and 10 years was 86.3%±2.78 and 73.7%±4.23, respectively. Among the 23 late deaths, 9 were valve-related deaths (stroke, n=3; endocarditis, n=1; unknown, n=5). During the follow-up, linearized rates of major bleeding, thromboembolism, and endocarditic evolution were, respectively, 1.3 %/patient-years, 0.42 %/patient-years, and 0.22 %/patient-years. One patient presented a nonseptic false aneurysm of the right coronary anastomosis and no structural valve dysfunction has been diagnosed. In total, only 2 patients required an aortic root reoperation. CONCLUSIONS The modified Bentall procedure using 2 separated grafts for the coronary reimplantation is a feasible, safe, easy, and reproducible operative technique for aortic root surgery.

Improving blood oxygenation during venovenous ECMO for ARDS

Dear Editor, Schmidt et al. [1] elegantly demonstrated that pump blood flow is a major determinant of oxygenation in patients treated with venovenous ECMO for ARDS. In this report, the authors proposed certain tools to improve oxygenation in such patients. Their proposals were mainly based on optimization of tissue oxygen delivery using large cannula size and transfusion. Based on the fact that an ECMO flow/cardiac output ratio of greater than 60 is constantly associated with adequate blood oxygenation and oxygen transport and delivery, we propose another means to improve oxygenation in patients treated with VV ECMO with inadequate oxygenation due to an imbalance between ECMO blood flow/cardiac output. The first is the use of moderate hypothermia which is very easy to obtain in such patients since blood temperature is controlled during ECMO. Table 1 represents the evolution of oxygen saturation in a patient treated with ECMO for ARDS secondary to H1N1 influenza complicated by severe septic shock requiring very high norepinephrine doses. The patient was severely vasoplegic with a subsequent highly elevated cardiac output. Decreasing body temperature from 37 C to 34 C markedly improved oxygen saturation. Meanwhile, as suggested by Schortgen et al. [2] norepinephrine doses were reduced. In this case, oxygen saturation improvement is likely due to both an increase in ECMO flow/cardiac output due to cardiac output decrease and a decrease in pulmonary shunt secondary to high blood flow. The second approach to improve ECMO flow/cardiac output is to reduce cardiac output using esmolol, a short-acting selective beta-1 blocking agent. The reduction in cardiac output is parallel to the decrease in heart rate. Table 2 represents the theoretical evolution of ECMO flow/ cardiac output in using esmolol to reduce heart rate. We hypothesize that stroke volume remains constant during esmolol infusion and that the reduction in cardiac output does not interfere with venous return. These two hypotheses require clinical confirmation however. The use of esmolol could be considered even in patients treated with norepinephrine as recently demonstrated [3]. To conclude, in some patients treated with VV-ECMO and high cardiac output, oxygen saturation could be improved by increasing pump blood flow as high as possible and in reducing cardiac output through the use of moderate hypothermia and/or esmolol.

Beneficial Effects of Norepinephrine Alone on Cardiovascular Function and Tissue Oxygenation in a Pig Model of Cardiogenic Shock.

ABSTRACT Introduction: The present study was developed to investigate the effects of norepinephrine alone on hemodynamics and intrinsic cardiac function in a pig model of cardiogenic shock mimicking the clinical setting. Methods: Cardiogenic shock was induced by 1-h ligation of the left anterior descending (LAD) artery followed by reperfusion. Pigs were monitored with a Swan-Ganz catheter, a transpulmonary thermodilution catheter, and a conductance catheter placed in the left ventricle for pressure-loop measurements. Measurements were performed before LAD occlusion, 1 h after LAD occlusion, and 4 h after myocardial reperfusion. Results: Myocardial infarction and reperfusion was followed by cardiogenic shock characterized by a significant increase in heart rate and significant decreases in mean arterial pressure (MAP), mixed venous oxygen saturation (SVO2), left ventricular end-diastolic pressure (LVEDP), prerecruitable stroke work (PRSW), and cardiac power index (CPI). Lactate levels were significantly increased. The systemic vascular resistance index (SVRI) and global end-diastolic volume index (GEDVI) remained unchanged. When compared with the control group (n = 6), norepinephrine infusion (n = 6) was associated with no changes in heart rate, a significant increase in MAP, SVO2, left ventricular ejection fraction, pressure development during isovolumic contraction, SVRI, and CPI and a decrease in lactate level. Cardiac index tended to increase (P = 0.059), whereas PRSW did not change in the norepinephrine group. LVEDP and GEDVI remained unchanged. Conclusions: Norepinephrine alone is able to improve hemodynamics, cardiac function, and tissue oxygenation in a pig model of ischemic cardiogenic shock.

Use of the model for end-stage liver disease score for guiding clinical decision-making in the selection of patients for emergency cardiac transplantation

OBJECTIVES The outcomes of emergency cardiac transplantation remain controversial, but recipient selection is essential for success. With a shortage of organs, it is essential to determine an objective method, such as a risk score, for choosing patients who are at too great a risk to undergo cardiac transplantation. In this study, we analysed the model for end-stage liver disease in terms of predicting operative mortality after emergency cardiac transplantation. METHODS We analysed the Nancy University database of heart transplantation and selected all patients who underwent emergency heart transplantation between January 2005 and January 2012. The calibration and discriminatory power were evaluated to determine the model for end-stage liver disease (MELD) score. Preoperative and peri-operative variables regarding the prediction of operative mortality were analysed by univariate and multivariate logistic regression models. RESULTS Forty-three patients underwent emergency cardiac transplantation. The operative mortality was 20.9% (n = 9). The Hosmer-Lemeshow test demonstrated a calibrated model for predicting operative mortality (P = 0.15), and the MELD score presented an excellent discrimination between survivors and non-survivors (AUC: 0.89 ± 0.05; 95% CI: 0.79-0.99). In the univariate analysis, an MELD score of ≥ 16 and bilirubin concentration were predictive markers of operative mortality. Multivariate logistic regression tested the contribution of the univariate risk predictors (P < 0.15) and confirmed that an MELD score of ≥ 16 was predictive of operative mortality. CONCLUSIONS The MELD score appears to be adequate for predicting operative mortality among patients who undergo heart transplantation. The MELD score could therefore be used to guide clinical decision-making for emergency transplantation.

Diagnostic and prognostic value of MRI T2 quantification in heart transplant patients

This study was designed retrospectively to assess the value of myocardial T2 to detect or predict ongoing acute heart rejection, in heart transplant patients, with a 1.5‐T MRI magnet. One hundred and ninety‐six myocardial T2 quantifications were performed on sixty consecutive heart transplant patients during routine follow‐up. T2 values were assessed (i) with regard to the results of concomitant biopsies and (ii) with a Cox multivariate model for the prediction of subsequent rejections, defined by a ≥ grade 2 at biopsy or highly suspected in the absence of biopsy (>10% drop in ejection fraction with subsequent reversibility under treatment). T2 values were proposed as main covariate, after logit transformation and adjustment for other confounding parameters such as delay since graft surgery and delay before biopsy. T2 values were strongly linked (i) to the presence of rejection on concomitant biopsy (P < 0.0001) and (ii) to the risk of subsequent rejection on Cox multivariate model (P < 0.001). T2 values above 60 ms were associated with relative risk of rejection higher than 2.0 and rapidly increasing. In conclusion, myocardial T2 yields a high diagnostic and prognostic value for graft rejection in heart transplant patients.

Surgery for Acute Type A Aortic Dissection in Octogenarians

Abstract  Background and aim: Emergency surgery for type A aortic dissection (AAD) is associated with high mortality rates. The published outcomes of such surgery in aging patients are controversial and the optimal management for elderly patients has not been established. Our study aimed to evaluate the outcomes of surgery for AAD in patients over the age of 80 years. Materials and Methods: Between January 1996 and January 2010, 236 patients underwent surgery for AAD, of which 15 patients were older than 80 years. We evaluated the operative mortality in the whole cohort compared to the outcomes in the elderly subgroup. We assessed the preoperative risks factors and quality of life after surgery by performance status and the patients’ ability to return home. Results: Operative mortality was higher in patients aged >80 years (40% vs. 18%, p = 0.04). The survival rate for patients >80 years at one, three, and five years was 53.3%± 0.12%, 42.6%± 0.14%, and 42.6%± 0.12%, respectively. Of the survivors, six patients were able to return home (40%) and the postoperative performance status was “3” in one patient, “2” in six patients, and “1” in two patients. A preoperative level of 2 or greater was found to be a significant risk factor (p = 0.04). Conclusion: Survival in octogenarians undergoing surgery for AAD is possible, and some patients were able to return home with a reasonable level of autonomy. Larger series will be needed to define the optimal management for octogenarians presenting with AAD.
(J Card Surg 2012;27:65–69)

Bilateral internal mammary artery bypass grafting: long-term clinical benefits in a series of 1000 patients

Objective Bilateral internal mammary arteries (BIMA) remain widely underused in coronary artery bypass grafting (CABG). In this study, we aim to investigate the early and long-term outcomes of BIMA grafts in isolated CABGs. Design Single-centre retrospective observational study. Setting University Hospital, Nancy. Patients 1000 consecutive patients undergoing elective, isolated, primary, multiple CABGs using BIMA grafts and supplemental venous grafts for multi-vessel coronary disease. Main outcome measures In-hospital mortality and major morbidity, and long-term all-cause mortality. Results Mean age of the overall population was 60±15 years. A left ventricular ejection fraction (LVEF) ≤45% was found in 28% of the patients and 27.1% of the patients were diabetics. Comorbidities were represented by chronic renal failure, chronic obstructive pulmonary disease and peripheral artery disease in 11, 11.7 and 27.3% of the cases, respectively. The in-hospital mortality rate was 2.8%. Early postoperative morbidity included myocardial infarction (2.2%), stroke (0.9%), mesenteric ischaemia (0.7%) and mediastinitis (2.2%). The Kaplan–Meier 8-year survival rates for patients less than 65 and between 65 and 74 years of age were 88% and 66%, respectively (p<0.01). Multiple regression analysis showed that patients’ age 65 years or greater at baseline (OR 2.3; 95% CI 1.3 to 4, p<0.001), acute coronary syndrome (OR 1.9; 95% CI 1.1 to 3.4, p=0.02), chronic renal failure (OR 2.7; 95% CI 1.4 to 5.2, p<0.001), peripheral artery disease (OR 3.1; 95% CI 1.8 to 5.5, p<0.001) and LVEF ≤45% (OR 2.6; 95% CI 1.4 to 4.5, p<0.001) were independent predictors of long-term cardiovascular mortality. Conclusions Our longitudinal analysis presents encouraging data concerning operative risk of BIMA grafting and provides excellent long-term survival in appropriately selected patients.