Guillaume Lebreton

Out-of-hospital extra-corporeal life support implantation during refractory cardiac arrest in a half-marathon runner

For patients who present with an out-of-hospital refractory cardiac arrest, in-hospital extracorporeal life-support (ECLS) initiation represents an alternative therapy which allows significant survival. We describe here the first case of out-of-hospital ECLS implantation in a patient presenting with a refractory cardiac arrest during a road race. ECLS was initiated within the MICU ambulance 60 min after cardiac arrest and enabled restoration of cardiac output to 4.5 l min⁻¹. Coronarography revealed a severe isolated stenosis of the right coronary artery, which was treated by angioplasty. The cardiogenic shock resolved progressively, enabling ECLS weaning within 48h, while renal, hepatic, and respiratory functions recovered simultaneously.

Limitations in the inter-observer reliability of EuroSCORE: what should change in EuroSCORE II?

OBJECTIVES To carry out an in-depth single-centre analysis of the inter-observer reliability of the EuroSCORE (European System for Cardiac Operative Risk Evaluation) to propose changes for the EuroSCORE II. METHODS Data for the EuroSCORE additive and logistic models were prospectively collected by surgeons (computer-assisted calculation) (SurgAE and SurgLE) and perfusionists (on A4 data collection forms; PerfAE) for 1719 consecutive adult heart operations. The performance of the EuroSCORE was first analysed, then inter-observer discrepancies in the score were assessed globally and for any of its 17 risk factors. RESULTS Hospital mortality was 4.3% (SurgAE and SurgLE: 5.3 and 7.3, respectively). The predictive ability and the calibration of the score were acceptable (area under the receiver operating characteristics curve: 0.75 for SurgAE and 0.753 for SurgLE, p = 0.98, Hosmer and Lemeshow goodness-of-fit test). Overall inter-observer concordance was satisfactory (Kappa coefficient: 0.71) but SurgAE and PerfAE were different in 26.3% of cases (SurgAE>PerfAE in 18.6%, and PerfAE>SurgAE in 7.7%). Five of the 17 risk factors accounted for most of the variability: left-ventricular ejection fraction, extracardiac arteriopathy, surgery other than isolated coronary artery bypass graft, recent myocardial infarction and pulmonary hypertension (with discrepancies respectively noticed in 7.6%, 5.3%, 5%, 3.9% and 3% of cases). Encoding mismatches for EuroSCORE items have been either assigned to human errors related to interpretation or conflicting information in the charts. Both situations may reflect structural weaknesses of the EuroSCORE. CONCLUSIONS The EuroSCORE is a widely used score, but its predictive power and reliability are declining due to changes in cardiac surgery case mix and outcomes in recent years. The present work highlights the fact that the encoding system in the EuroSCORE still gives room for interpretation. Along with other possible modifications described elsewhere, it is suggested that reliability and predicting ability of the score might be increased by changes in some definitions of risk factors and by the use of numeric values instead of intervals of values.

Life-threatening massive pulmonary embolism rescued by venoarterial-extracorporeal membrane oxygenation

BackgroundDespite quick implementation of reperfusion therapies, a few patients with high-risk, acute, massive, pulmonary embolism (PE) remain highly hemodynamically unstable. Others have absolute contraindication to receive reperfusion therapies. Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) might lower their right ventricular overload, improve hemodynamic status, and restore tissue oxygenation.MethodsECMO-related complications and 90-day mortality were analyzed for 17 highly unstable, ECMO-treated, massive PE patients admitted to a tertiary-care center (2006–2015). Hospital- discharge survivors were assessed for long-term health-related quality of life. A systematic review of this topic was also conducted.ResultsSeventeen high-risk PE patients [median age 51 (range 18–70) years, Simplified Acute Physiology Score II (SAPS II) 78 (45–95)] were placed on VA-ECMO for 4 (1–12) days. Among 15 (82%) patients with pre-ECMO cardiac arrest, seven (41%) were cannulated during cardiopulmonary resuscitation, and eight (47%) underwent pre-ECMO thrombolysis. Pre-ECMO median blood pressure, pH, and blood lactate were, respectively: 42 (0–106) mmHg, 6.99 (6.54–7.37) and 13 (4–19) mmol/L. Ninety-day survival was 47%. Fifteen (88%) patients suffered in-ICU severe hemorrhages with no impact on survival. Like other ECMO-treated patients, ours reported limitations of all physical domains but preserved mental health 19 (4–69) months post-ICU discharge.ConclusionsVA-ECMO could be a lifesaving rescue therapy for patients with high-risk, acute, massive PE when thrombolytic therapy fails or the patient is too sick to benefit from surgical thrombectomy. Because heparin-induced clot dissolution and spontaneous fibrinolysis allows ECMO weaning within several days, future studies should investigate whether VA-ECMO should be the sole therapy or completed by additional mechanical clot-removal therapies in this setting.

Short-term mechanical circulatory support with the Impella 5.0 device for cardiogenic shock at La Pitié-Salpêtrière

Introduction: Cardiogenic shock carries a high mortality rate despite aggressive medical treatment. The Impella® Recover® LP 5.0 Support System is a microaxial minimally invasive ventricular assist device designed for short-term mechanical circulatory support in low cardiac output states. The aim of this study is to assess the safety of the Impella 5.0 device, using the right axillary artery approach, in cardiogenic shock managed at La Pitié-Salpêtrière Hospital. Methods: Since December 2010 and during a period of 14 months, 14 highly selected patients underwent surgical implantation of an Impella 5.0 device for cardiogenic shock. Demographics, preoperative and postoperative data were retrospectively collected from La Pitié-Salpêtrière computerized medical charts. Responders to Impella support were defined as patients with rapid improvement in haemodynamic condition and biological profile. Patients who had no signs of cardiac recovery after two weeks of mechanical support were considered for heart transplantation or long-term left ventricular assist device implantation. Results: Patients were predominantly male (78.5%) with a mean age of 64±15. Short-term circulatory support was indicated for cardiogenic shock in the setting of acute coronary syndromes (n=7; 50%), postcardiotomy cardiac dysfunctions (n=6; 43%) and anthracycline-induced dilated cardiomyopathy (n=1; 7%). After a mean support time of 8.5 days, six patients (42.8%) were successfully weaned and four (28.5%) were switched to a long-term left ventricular assist device. No major bleeding, arm ischaemia, ventricular arrhythmia or severe haemolysis was noted. We report two cases (14%) of pump thrombosis, four cases of device displacement with the need of pump repositioning and one case (7%) of infection at the insertion site. Thirty-day mortality was 35.7%. Long-term overall mortality rate at six months, one year and two years was 42.8, 42.8 and 42.8%, respectively. Conclusions: The Impella 5.0 device surgically inserted through the axillary artery is a valuable minimally invasive short-term circulatory support in cardiogenic shock of various aetiologies.

Short-term mechanical circulatory support for cardiogenic shock in severe peripartum cardiomyopathy: La Pitié-Salpêtrière experience

OBJECTIVES Mechanical circulatory support (MCS) is a valuable option in the setting of cardiogenic shock (CS), although MCS use in severe forms of peripartum cardiomyopathy (PPCM) is underreported. We aimed to investigate maternal outcomes under MCS for refractory CS complicating PPCM. METHODS We retrospectively reviewed 10 consecutive patients (2010-2015) meeting diagnosis criteria of PPCM that were managed with peripheral veno-arterial extracorporeal membrane oxygenation (pVA-ECMO) for severe CS. RESULTS Median age was 29 years (range 20-36), and median left ventricular (LV) ejection fraction was 10% (range 5-30). All patients received femoro-femoral cannulation. All patients were implanted after delivery. Central rescue cannulation was considered in 5 patients in the setting of peripheral ECMO-related complications. Median peripheral support duration was 4 days (range 2-25), median central support duration was 51 days (range 9-180). Five patients died under central support. Three patients were successfully explanted after LV recovery, and 2 were successfully transplanted. CONCLUSIONS Peripheral VA-ECMO, and prompt conversion to central rescue cannulation when necessary have to be considered in the management of severe cases of PPCM. Nevertheless, refractory CS in this specific population remains a life-threatening condition despite aggressive management.

Management of cardiogenic shock complicating myocardial infarction

Up to 10% of acute coronary syndromes are complicated by cardiogenic shock (CS) with contemporary mortality rates of 40–50%. The extent of ischemic myocardium has a profound impact on the initial, in-hospital, and post-discharge management and prognosis in this patient population. Individualized patient risk assessment plays an important role in determining appropriate revascularization, drug treatment with inotropes and vasopressors, mechanical circulatory support, intensive care support of other organ systems, hospital level of care triage, and allocation of clinical resources. This review will outline the underlying causes and diagnostic criteria, pathophysiology, and treatment of CS complicating acute coronary syndromes with a focus on (a) potential therapeutic issues from the perspective an interventional cardiologist, an emergency physician, and an intensive care physician, (b) the type of revascularization, and (c) new therapeutic advancements in pharmacologic and mechanical percutaneous circulatory support.

Fungal native pulmonary valve endocarditis: facing both medical and surgical challenges

Fungal isolated native pulmonary valve endocarditis is extremely uncommon. Data are scarce and report high mortality and recurrence rates. Recommended management combines both medical and surgical approaches. We report herein a rare case of isolated pulmonary valve endocarditis caused by Candida albicans The patient did not display prior heart disease. Medical management was unsuccessful. Pulmonary valve replacement allowed rapid improvement.

Heart Transplantation for Peripartum Cardiomyopathy: A Single-Center Experience

Background Peripartum cardiomyopathy is an idiopathic disorder defined by the occurrence of acute heart failure during late pregnancy or post-partum period in the absence of any other definable cause. Its clinical course is variable and severe cases might require heart transplantation. Objective To investigate long-term outcomes after heart transplantation (HT) for peripartum cardiomyopathy (PPCM). Methods Out of a single-center series of 1938 HT, 14 HT were performed for PPCM. We evaluated clinical characteristics, transplant-related complications, and long-term outcomes, in comparison with 28 sex-matched controls. Primary endpoint was death from any cause; secondary endpoints were transplant-related complications (rejection, infection, cardiac allograft vasculopathy). A value of p < 0.05 was considered of statistical significance. Results PPCM patients and matched controls were comparable for most variables (all p values > 0.05), except for a higher use of inotropes at the time of HT in PPCM group (p = 0.03). During a median follow-up of 7.7 years, 16 patients died, 3 (21.5%) in PPCM group and 13 (46.5%) in control group. Mortality was significantly lower in PPCM group (p = 0.03). No significant difference was found in terms of transplant-related complications (p > 0.05). Conclusions Long-term outcomes following HT for PPCM are favorable. Heart transplantation is a valuable option for PPCM patients who did not recover significantly under medical treatment.

Monitoring of left ventricular assist device implantation and set-up with miniaturized transoesophageal echocardiography: Initial experience at La Pitié-Salpêtrière Hospital and possible application fields

Background: Left ventricular assist devices are valuable options for mechanical circulatory support in patients with severe heart failure as a bridge to cardiac transplantation, to recovery, or as destination therapy. Transoesophageal echocardiography plays a key role in the management of left ventricular assist device patients; either in guiding the device implantation or in post-operative haemodynamic assessment. The aim of this observational study is to investigate the usefulness of a miniaturized transoesophageal echocardiography probe designed for continuous haemodynamic monitoring (haemodynamic transoesophageal echocardiography; ImaCor, Garden City, NY) in the haemodynamic assessment of patients undergoing left ventricular assist device implantation. Methods: Between June 2014 and September 2014, seven consecutive patients underwent left ventricular assist device implantation for severe heart failure. A haemodynamic transoesophageal echocardiography probe was used for continuous haemodynamic monitoring in the pre-, intra- and post-operative periods. All procedures were performed by haemodynamic transoesophageal echocardiography-trained physicians. Results: All data were recorded and used without need of a further haemodynamic device. The average number of haemodynamic assessments in each patient was 5.3. The average number of haemodynamic assessments leading to therapeutic changes in each patient was 2.6. The mean duration of haemodynamic transoesophageal echocardiography probe insertion was approximately 20 hours (9 hours – 72 hours). No device complications were noticed during this period. Conclusions: This observation suggests that haemodynamic monitoring using the haemodynamic transoesophageal echocardiography system in left ventricular assist device patients is feasible after a brief training period. The overall impact of haemodynamic transoesophageal echocardiography use in these patients is yet to be determined and further studies are still required.

High-urgency waiting list for cardiac recipients in France: single-centre 8-year experience

OBJECTIVES: The ‘Special Urgency1’ (SU1) offers a 48-h national priority for critically ill cardiac recipients in France. We evaluated our experience of high-urgency cardiac transplantation. METHODS: Between January 2005 and December 2012, 265 patients met the criteria for SU1 waiting list enrolment at our Institution: 212 patients were transplanted during the SU1 priority period, whereas 53 patients missed SU1 priority donor allocation and were downgraded to the standard waiting list. We compared baseline characteristics and outcomes of SU1 priority patients (SU1 group) with 297 recipients, who underwent transplantation according to standard donor allocation (SL group). A propensity score analysis was performed. RESULTS: Overall occurrence of severe primary graft failure, 1and 5-year survivals in groups SU1 and SL were 27% vs 26% (P = 0.72), 75% vs 71% (P = 0.36) and 69% vs 59% (P = 0.16). A subgroup analysis was carried out on SU1 patients only: independent risk factors for 1-year mortality were recipient insulin-dependent diabetes (OR 3.83, P = 0.04), recipient history of vascular disease (OR 7.67, P = 0.02), recipient creatinine (OR 1.01, P < 0.01) and unfavourable sex mismatch (male recipient/female donor, OR 2.62, P < 0.01). Period analysis of SU1 patients showed a reduction trend in 1-year mortality over time: 29% (Era I, 2005–08) vs 22% (Era II, 2009–12), P = 0.23. Oneand 5-year survivals of patients who missed SU1 donor allocation were 36% and 29%. CONCLUSIONS: Special Urgency1 waiting list allows allocating cardiac donors for critically ill patients without increasing early and midterm mortality. Careful selection of recipients is mandatory in order to improve outcomes.