Fiona Ecarnot

Is Endocan a Diagnostic Marker for Pneumonia After Cardiac Surgery? The ENDOLUNG Study

BACKGROUND Postoperative pneumonia is frequent after cardiac surgery and is associated with increased morbidity and mortality. We tested the hypothesis that endocan is an early biomarker for the detection of pneumonia after cardiac surgery. METHODS Between January and May 2016, 155 patients scheduled to undergo elective cardiac surgery with cardiopulmonary bypass were prospectively included in the study. Serum level of endocan was measured at five timepoints (preoperative, and at 6, 24, 48, and 72 hours after the end of surgery). Procalcitonin and C-reactive protein were measured at 24 and 72 hours. The preoperative and postoperative characteristics of the patients were recorded. Independent predictors of postoperative pneumonia were identified by logistic regression. Threshold values of endocan predictive of postoperative pneumonia were determined using receiver-operating characteristics curve analysis. RESULTS Seventeen patients (11%) had pneumonia after surgery. Endocan greater than 3.7 ng/mL before induction of anesthesia, or greater than 12.1 ng/mL at 6 hours after surgery, as well body mass index higher than 27 kg/m2 and duration of surgery were independent predictors of postoperative pneumonia. At induction of anesthesia, an endocan cutoff value of 3.7 ng/mL had 65% sensitivity and 72% specificity for the prediction of postoperative pneumonia; whereas at 6 hours, with a cutoff value of 12.1 ng/mL, these values were 71% and 75%, respectively. The time saved by endocan dosage compared with clinical diagnosis of postoperative pneumonia was 96 hours. CONCLUSIONS This study shows that endocan is an early marker of postoperative pneumonia in patients after cardiac surgery.

Relevance of Endothelial Cell-Specific Molecule 1 (Endocan) Plasma Levels for Predicting Pulmonary Infection after Cardiac Surgery in Chronic Kidney Disease Patients: The Endolung Pilot Study

Objectives: This pilot study aimed to evaluate the relevance of endocan plasma levels for predicting pulmonary infection after cardiac surgery in patients with chronic kidney disease (CKD). Methods: Serum collected in a previous prospective cohort study (from 166 patients with preoperative CKD who underwent cardiac surgery) was used. Five patients with postoperative pulmonary infection were compared with 15 randomly selected CKD patients with an uneventful outcome. Blood samples were tested at 4 time points (preoperatively and 6, 12, and 24 h after the end of surgery). Endocan, procalcitonin, and C-reactive protein plasma levels were compared between the two groups. Results: At 6 h, the patients with pulmonary infection had significantly higher levels of endocan than the patients without pulmonary infection (24.2 ± 15.6 vs. 6.4 ± 3.2 ng/mL; p = 0.03). A receiver operating characteristic curve analysis showed 80% sensitivity and 100% specificity for endocan to predict pulmonary infection (area under the curve 0.84), with a cutoff value of 15.9 ng/mL. The time saved by assessment of the endocan dosage compared to a clinical diagnosis of pulmonary infection was 47 h. Conclusion: This pilot study showed that a specific study to assess the link between endocan plasma levels and pulmonary infection after cardiac surgery in CKD patients is of potential utility.

Relationship between Two Depression Scales and Quality of Life in Patients Undergoing Surgical Coronary Revascularization: A MOTIV-CABG Substudy

Objective: The MOTIV-CABG trial evaluated the efficacy of antidepressant therapy (Escitalopram) in patients undergoing coronary artery bypass grafting (CABG). Quality of life was assessed using the 36-Item Short Form health survey (SF-36). Depression was assessed using the Beck Depression Inventory short-form (BDI-SF) and the Center for Epidemiological Studies Depression scale (CES-D). We compared the relation between each of these scales, and quality of life. Methods: We analyzed 1674/1805 questionnaires (93%). Respondents were classified into 4 groups: D+both corresponds to patients classed as depressive by both BDI-SF and CES-D, D-both to patients classed as nondepressive by both BDI-SF and CES-D, D+BDI to patients classed as depressive by BDI-SF and non-depressive by CES-D, D+CES to patients classed as non-depressive by BDI-SF and depressive by CES-D. Results: The values of Group D+BDI and D+CES were within the range of values of groups D+both and D-both for all SF-36 items. The difference between D+both and D-both was significant for all SF-36 items, including the mental (MCS) and physical component scores (PCS). The PCS was significantly lower in Group D+BDI vs Group D+CES, while the MCS was significantly lower in Group D+CES vs Group D+BDI. There was agreement between BDI and CES-D findings in 1522 questionnaires (83%) and discordance in 318 (17%) (kappa 0.52 (95% CI 0.47-0.57)). Conclusions: BDI and CES-D are sensitive to different aspects of the effect of depression on quality of life. The integrated use of these scales can be helpful in identifying areas that require specific treatments in patients undergoing CABG

Intensive care unit strain should not rush physicians into making inappropriate decisions, but merely reduce the time to the right decisions being made

Deaths in the intensive care unit (ICU) are preceded in 53% to 90% of cases by a decision to withhold or withdraw life-sustaining therapies (1-3). The most common reasons justifying this decision include the patient’s age, previous autonomy, comorbidities, expected future quality of life, diagnosis at admission, non-response to maximal therapy and multi-organ failure (1,3,4).

Outcomes after extracorporeal membrane oxygenation for the treatment of high-risk pulmonary embolism: a multicentre series of 52 cases

Aims The role of extracorporeal membrane oxygenation (ECMO) remains ill defined in pulmonary embolism (PE). We investigated outcomes in patients with high-risk PE undergoing ECMO according to initial therapeutic strategy. Methods and results From 01 January 2014 to 31 December 2015, 180 patients from 13 Departments in nine centres with high-risk PE were retrospectively included. Among those undergoing ECMO, we compared characteristics and outcomes according to adjunctive treatment strategy (systemic thrombolysis, surgical embolectomy, or no reperfusion therapy). Primary outcome was all-cause 30-day mortality. Secondary outcome was 90-day major bleeding. One hundred and twenty-eight patients were treated without ECMO; 52 (mean age 47.6 years) underwent ECMO. Overall 30-day mortality was 48.3% [95% confidence interval (CI) 41-56] (87/180); 43% (95% CI 34-52) (55/128) in those treated without ECMO vs. 61.5% (95% CI 52-78) (32/52) in those with ECMO (P = 0.008). In patients undergoing ECMO, 30-day mortality was 76.5% (95% CI 57-97) (13/17) for ECMO + fibrinolysis, 29.4% (95% CI 51-89) (5/17) for ECMO + surgical embolectomy, and 77.7% (95% CI 59-97) (14/18) for ECMO alone (P = 0.004). Among patients with ECMO, 20 (38.5%, 95% CI 25-52) had a major bleeding event in-hospital; without significant difference across groups. Conclusion In patients with high-risk PE, those with ECMO have a more severe presentation and worse prognosis. Extracorporeal membrane oxygenation in patients with failed fibrinolysis and in those with no reperfusion seems to be associated with particularly unfavourable prognosis compared with ECMO performed in addition to surgical embolectomy. Our findings suggest that ECMO does not appear justified as a stand-alone treatment strategy in PE patients, but shows promise as a complement to surgical embolectomy.

Kinetics of endocan in patients undergoing cardiac surgery with and without cardiopulmonary bypass

HighlightsEndocan plays a major role in inflammation and infection.We describe kinetics of endocan in cardiac surgery with and without CPB.Kinetics of endocan release differs according to whether surgery is on‐ or off‐pump.In patients with CPB, endocan peaks and is significantly higher at 6 h after surgery.In off‐pump surgery, endocan peaks at 24 h after surgery, then declines gradually. Background: Endocan plays an important role in the processes of inflammation and infection. The use of cardiopulmonary bypass (CPB) during cardiac surgery can induce an inflammatory response. We aimed to describe the kinetics of endocan in patients undergoing cardiac surgery with and without the use of CPB. Methods: Single‐centre, observational study with retrospective analysis of prospectively collected data, to compare the kinetics of endocan in patients undergoing isolated coronary artery bypass graft (CABG) surgery. Endocan was measured at induction of general anesthesia (baseline), and at 6, 24, 48 and 72 h after the end of surgery. Patients were classified into two groups, namely those undergoing CPB (CPB group) and those without CPB (off‐pump group). Results: In total, 91 patients were included in this analysis: 61 patients in the CPB group and 30 in the off‐pump group. There were no major significant differences between groups. Patients with CPB had a significantly higher level of endocan at 6 h (9.7 ± 6.7 ng/ml vs 6.9 ± 3.3 ng/ml, p = 0.03), but the difference was no longer statistically significant at subsequent timepoints. Endocan values were not significantly correlated with the duration of CPB (p = 0.53). Conclusion: Endocan levels in patients undergoing isolated CABG surgery with CPB are significantly higher at 6 h than in patients with off‐pump surgery, and peaks earlier in those with CPB (6 h) than in those undergoing off‐pump surgery (24 h).

Response by Meneveau and Ecarnot to Letter Regarding Article, “Optical Coherence Tomography to Optimize Results of Percutaneous Coronary Intervention in Patients With Non-ST-Elevation Acute Coronary Syndrome: Results of the Multicenter, Randomized DOCTORS Study (Does Optical Coherence Tomography Optimize Results of Stenting)”

We read with interest the letters by Vallurupalli and Uretsky and also Dr Nadir relating to the results of the DOCTORS study (Does Optical Coherence Tomography Optimize Results of Stenting).1 We thank the authors for their insightful remarks. Vallurupalli and Uretsky raise an interesting point when they underline that a prolonged inflation time is superior to a rapid inflation/deflation technique in terms of both stent expansion and apposition. We acknowledge that we did not take stent inflation time into account in the case report form of the DOCTORS study. The arguments put forward by Vallurupalli and Uretsky suggest that this variable should be systematically recorded and reported. However, we cannot state with certainty that the failure to take this parameter into account in any way impacted the results of the DOCTORS study. Indeed, the randomized design, by its nature, partially compensates …

Non-readmission decisions in the intensive care unit under French rules: A nationwide survey of practices

Purpose We investigated, using a multicentre survey of practices in France, the practices of ICU physicians concerning the decision not to readmit to the ICU, in light of current legislation. Materials and methods Multicentre survey of practices among French ICU physicians via electronic questionnaire in January 2016. Questions related to respondents’ practices regarding re-admission of patients to the ICU and how these decisions were made. Criteria were evaluated by the health care professionals as regards importance for non-readmission. Results In total, 167 physicians agreed to participate, of whom 165 (99%) actually returned a completed questionnaire from 58 ICUs. Forty-five percent were aged <35 years, 74% were full-time physicians. The findings show that decisions for non-readmission are taken at the end of the patient’s stay (87%), using a collegial decision-making procedure (89% of cases); 93% reported that this decision was noted in the patient’s medical file. While 73% indicated that the family/relatives were informed of non-readmission decisions, only 29% reported informing the patient, and 91% considered that non-readmission decisions are an integral part of the French legislative framework. Conclusion This study shows that decisions not to re-admit a patient to the ICU need to be formally materialized, and anticipated by involving the patient and family in the discussions, as well as the other healthcare providers that usually care for the patient. The optimal time to undertake these conversations is likely best decided on a case-by-case basis according to each patient’s individual characteristics.

Deep Sternal Infection Following Bilateral Internal Thoracic Artery Grafting

Deep sternal wound infection (DSWI) is a serious complication after cardiac surgery. Risk factors include patient-related conditions (obesity, female sex, age, chronic obstructive pulmonary disease, diabetes, carriage of Staphylococcus aureus on the skin) and surgical aspects (paramedian sternotomy, re-exploration for bleeding, prolonged ventilation). Patients receiving bilateral internal thoracic artery (BITA) grafts have better long-term outcomes but also a higher risk of sternal wound complications, as consequence of a complete sternal devascularization. This problem may be prevented by skeletonization of BITA grafts. Other useful precautions are presurgical bathing with chlorhexidine, as well as the identification and prevention of all preoperative and perioperative risk factors, including surgical techniques, rapid extubation, and early removal of catheters. Surgical treatment for DSWI includes many different techniques, depending on wound degree and institutional policy.

Incidence, Predictors, and Impact on Six-Month Mortality of Three Different Definitions of Contrast-Induced Acute Kidney Injury After Coronary Angiography

We assessed incidence, predictors, and impact on 6-month mortality of contrast-induced acute kidney injury (CI-AKI) after coronary angiography with or without percutaneous coronary intervention in patients with acute coronary syndrome (ACS), according to 3 different CI-AKI definitions. Serum creatinine (sCr) was assessed at baseline and 48 to 72 hours after procedure to classify patients into 3 CI-AKI groups: Group 1: increase in sCR ≥25% over baseline but absolute increase <0.5 mg/dl; Group 2: absolute increase ≥0.5 mg/dl; Group 3: absolute increase ≥0.3 mg/dl or ≥50% over baseline. The association between CI-AKI and all-cause 6-month mortality was assessed using multivariate Cox regression. Among 1,002 patients included, median age was 68 [57 to 79] years. The sample had the following characteristics: 70% men, 25% diabetics, 22% had a history of myocardial infarction, 21% had baseline estimated glomerular filtration rate (as calculated by the Modification of Diet in Renal Disease)  <60 ml/min/1.72 m2, 34% had ST-segment elevation myocardial infarction, 61% underwent percutaneous coronary intervention, and 43% had multivessel disease. Based on changes in sCr, 89 patients (8.9%) were classified in Group 1; 69 (6.9%) in Group 2; and 157 (15.7%) in Group 3, whereas sCr did not increase >25% in the remaining 844 (84.2%). CI-AKI was significantly associated with 6-month all-cause mortality using the definitions for Group 2 (hazard ratio 3.1, 95% confidence interval [CI] 1.5 to 6.6, p = 0.002) and Group 3 (hazard ratio 2.03, 95% CI 1.03 to 4.0, p = 0.04), but not Group 1. In conclusion, based on the definition used for CI-AKI, CI-AKI is observed in 6% to 15.7% of patients. An increase of 25% over baseline sCr does not identify high-risk patients. CI-AKI defined as an increase in sCr >0.3 mg/dl identifies 15.7% of the population at 2-fold higher risk of mortality.