Frédéric Vanden Eynden

Endoscopic Drainage of Pyogenic Liver Abscesses With Suspected Biliary Origin

OBJECTIVES:Pyogenic liver abscesses remain an important and life-threatening clinical problem but their causes and management have changed over the last two decades. The aim of this study was to assess the feasibility and the impact of an endoscopic approach in the management of liver abscesses with suspected biliary origin.METHODS:We reviewed the records of 16 patients suffering from pyogenic liver abscess, who underwent endoscopic retrograde cholangiopancreatography (ERCP) in the setting of biliary diseases between January 1995 and December 2004. Nine patients had an underlying neoplastic disease; 13 had a history of biliary endoscopic maneuvers. When the collections were communicating with the biliary tree, an endoscopic drainage of the abscess was performed either by sphincterotomy, dilation, insertion of a nasobiliary catheter, or stenting. In noncommunicating liver abscesses associated with bile duct abnormalities, biliary decompression was obtained by insertion or replacement of biliary stents.RESULTS:Fourteen patients had liver abscesses communicating with the biliary system and underwent an endoscopic drainage of the cavity. Ten of these patients had an exclusive endoscopic drainage of the abscess, while four cases required additional percutaneous drainage. The two noncommunicating abscesses were associated with previous insertion of biliary stents; these were cured percutaneously after endoscopic stent replacement. Among the 16 patients, 13 had a rapid resolution of symptoms (81%).CONCLUSION:This initial clinical experience suggests that ERCP can demonstrate communications between the biliary tract and liver abscesses, and that an internal drainage of the cavity is feasible and safe.

How to cope with a temporarily aborted transplant program: solutions for a prolonged waiting period

BACKGROUND Due to budgetary restrictions our university heart transplant program came to a standstill to be gradually restarted early 2011. Consequently waiting-times for transplantation increased dramatically beyond the usual 10-15 months. We reviewed the clinical results of this peculiar transplant program over the past 4 years. METHODS Since March 2011 until February 2015, 65 patients (age 48±23 years) were listed for heart transplantation. Eight patients (11%) of whom three in high emergency were transplanted without any form of mechanical assistance. Fifty-one patients required a left ventricular assist device (LVAD) Heartware (Heartware Inc., Miami Lakes, FL, USA) as a bridge-to-transplant due to terminal heart failure. Merely 5 listed patients remain without assistance. RESULTS One patient without assistance and 11 LVAD patients (22%) died on the waiting-list. Meanwhile 10 LVAD patients were transplanted after a 2-year waiting time (770±717 days). Four transplanted patients died of early graft failure none after LVAD explantation. Survival at 1 and 3 years was respectively 78 (72%) and 83 (78%) for transplanted and assisted patients (log-rank P=0.056). Cox multivariable regression analysis identified crash-to-burn patients (P=0.002) and waiting-times over 2 years (P=0.044) as risk factors for early death, while age above 60 (P=0.008) and ischemic aetiology (P=0.029) and pulmonary hypertension (P=0.092) were risk factors for survival. CONCLUSIONS In times of donor shortage mechanical assistance proves very effective as bridge-to-transplant in patients for whom candidacy follows the standard inclusion procedures. In our settings, a steep increase in LVAD implantation served to salvage patients for whom transplantation became jeopardized due to an ever increasing waiting-time. Circulatory LVAD support could be considered as primary therapy in the future.

Unusual 30-year durability of Hancock II porcine bioprosthesis in tricuspid position.

Highlights • Bioprosthesis durability.• Hancock II valve.• Tricuspid position.

Gonococcal ascending aortic aneurysm with penetrating ulcer and bovine arch.

We describe a patient with ascending aorta aneurysm and bovine aortic arch who initially presented with fever. A 65-year-old man with a 2-month history of intermittent fever was referred to our hospital and diagnosed as having a gonococcal ascending aorta aneurysm with penetrating ulcers. He was successfully treated by resection of the ascending aorta and ulcers, replacement of the aortic valve, and prolonged postoperative antibiotic therapy.

Measuring pulmonary arterial compliance: mission impossible? Insights from a novel in vivo continuous-flow based experimental model

Arterial compliance (C) is related to the elasticity, size, and geometrical distribution of arteries. Compliance is a determinant of the load that impedes ventricular ejection. Measuring compliance is difficult, particularly in the pulmonary circulation in which resistive and compliant vessels overlap. Comparing different methods for quantification of compliance to a method that involves a continuous flow might help to identify the optimal method. Pulmonary arterial compliance was computed in six pigs based on the stroke volume to pulse pressure ratio, diastolic decay exponential fitting, area method, and the pulse pressure method (PPM). Compliance measurements were compared to those obtained under continuous flow conditions through a right ventricular bypass (Heartware Inc., Miami Lakes, FL, USA). Compliance was computed for various flows using diastolic decay exponential fitting after an abrupt interruption of the pump. Under the continuous flow conditions, resistance (R) was a decreasing function of the flow, and the fitting to P = e-t/RC yielded a pulmonary time constant (RC) of 2.06 s ( ± 0.48). Compliance was an increasing function of flow. Steady flow inter-method comparisons of compliance under pulsatile flow conditions showed large discrepancies and values (7.23 ± 4.47 mL/mmHg) which were lower than those obtained under continuous flow conditions (10.19 ± 1 0.31 mL/mmHg). Best agreement with steady flow measurements is obtained with the diastolic decay method. Resistance and compliance are both flow-dependent and are inversely related in the pulmonary circulation. The dynamic nature of the pulsatile flow may induce a non-uniformly distributed compliance, with an influence on the methods of measurement.

A bullet through the aortic arch

A 45-year-old male was admitted in shock at the emergency department with a gunshot wound to the chest. The entry wound was located in the middle of the sternum at the level of the 3rd intercostal space. Surprisingly, emergency echocardiography detected no pericardial effusion. The aortic CT-angiography revealed two separate perforations of the aortic arch: one at the base of the brachio-cephalic trunk (Panels A, B, C, D, arrow), another at the origin of the left subclavian artery (Panels A, B, C, D, arrowhead) and a rupture of the superior thoracic artery and a pulmonary contusion of the right upper lobe. The bullet fragments were found lodged in the body of the 4th thoracic vertebra after having perforated the oesophagus (Panel C, curved arrow). The patient was rushed to the operating room and the aortic arch was successfully repaired under deep hypothermia and circulatory arrest without major blood loss. A stent was placed in the oesophagus. The patient recovered completely and was discharged after 10 days. Aortic arch gunshot wounds are almost always lethal. In our patient’s case, his miraculous survival might be due to the bleeding containment from the aorta by the surrounding fatty tissues. After initial resuscitation, patients with thoracic gunshot wounds should be transferred to trauma centres. The extent of internal lesions caused by thoracic gunshot wounds is difficult to precisely evaluate with the physical examination only and the threshold for ordering chest computed tomography should be low.

Chronic kidney disease as major determinant of the renal risk related to on-pump cardiac surgery: a single-center cohort study

Abstract Background: Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common complication and is associated with the poorest outcomes. Therefore, early prediction of CSA-AKI remains a major issue. Severity scores such as the STS score could estimate the risk of AKI preoperatively. The main objective of this study was to evaluate the risk factors of on-pump CSA-AKI and to assess the performance of the STS score in order to predict CSA-AKI. Patients: We identified 252 patients with on-pump cardiac surgery, and the STS score was defined retrospectively. Results: AKI occurred in 14.6% (n = 37/252) of patients and renal replacement therapy was required in 21.6% of AKI (n = 8/37). CSA-AKI was associated with 35.1% in-hospital mortality (vs. 1.4%) and nearly doubled length of stay (14.5 vs. 8.0 d). The risk of CSA-AKI was mainly determined by preoperative morbidities such as chronic kidney disease, peripheral vascular disease, and severe congestive heart failure. Long cardio-pulmonary bypass time was also a determinant. CSA-AKI + patients exhibited higher STS renal risk (5.6% vs. 2.0%; p < 0.0001), resulting in a good discrimination between AKI + and AKI − patients (area under curve [AUC] 0.80). Interestingly, a basal renal function ≤55 ml/min/1.73m2 was as good as the STS score to predict CSA-AKI (AUC 0.75; P 0.26). Conclusions: On-pump CSA-AKI was observed in nearly 15% of cases and was associated with poorer outcomes. Interestingly, the risk of CSA-AKI could be estimated preoperatively, thanks to the basal renal function, which exhibited an equal performance to the STS score.

Composite indices of upstream pulmonary vascular impedance and capacitance do not help in identifying patients who should undergo pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension

Background Chronic thromboembolic pulmonary hypertension (CTEPH) is potentially curable by surgical pulmonary endarterectomy (PEA). Patient selection for PEA is crucial and depends mainly on discriminating between those with proximal accessible disease and distal disease. In this study we evaluated the value of composite indices such as upstream resistance (Zup) and capacitance (Cp) for partitioning of pulmonary vascular resistance and surgical outcome. Methods We retrospectively reviewed data from 30 patients who underwent PEA between 2007 and 2012. Zup, defined as the ratio between the mean pulmonary artery pressure (PAPm) minus diastolic pulmonary artery pressure (PAPd) and PAPm minus pulmonary artery occlusion pressure (POAP), was computed preoperatively as was the Cp, defined as the ratio of stroke volume over pulse pressure. We assessed the use of these indices to predict pulmonary haemodynamics after PEA. Results Postoperatively, total pulmonary vascular resistance (tPVR) was > 400 dynes·s·cm-5 in 11 patients (37%); nine patients were treated with an endothelin receptor antagonist (ERA) and had unsatisfactory surgical results. Preoperative Cp was identical in both groups (0.9945 ± 0.06867 vs. 1.348 ± 0.1961, P = 0.14). Zup was higher in the group with better haemodynamic outcomes (50.29% ± 3.266) than in the ERA group (38.59% ± 2.86) (P