J. Guihaire

Comparison of cardiac allograft vasculopathy in heart and heart–lung transplantations: A 15-year retrospective study

BACKGROUND Cardiac allograft vasculopathy (CAV) is a major factor limiting long-term survival after heart transplantation (HTx). Specific determinants of CAV and long-term outcome after CAV occurrence have been poorly investigated after heart-lung transplantation (HLTx). METHODS Between January 1996 and December 2006, 79 patients underwent HLTx (36.3 ± 12.2 years old; 47% men) and 141 patients underwent HTx (49.2 ± 12.3 years old; 77% men) at two different institutions. CAV grading was reviewed in both groups according to the 2010 standardized nomenclature of the International Society for Heart and Lung Transplantation. The mean post-transplant follow-up was 94 (1 to 181) months. RESULTS Overall 10-year survival rate was 58% after HTx and 43% after HLTx (p = 0.11). The Grade 1 (or higher) CAV-free survival rate was 95% at 4 years and 69% at 10 years after HLTx, and 77% and 39%, respectively, after HTx (p < 0.01). Mean cyclosporine blood levels were similar between the groups at 3, 6, 12, 24 and 36 months. The main causes of mortality beyond 5 years after HTx and HLTx were malignancies and bronchiolitis obliterans, respectively. By multivariate analysis, recipients who developed >3 acute myocardial rejections during the first year post-transplant were exposed to a higher risk of CAV (95% CI 1.065 to 2.33, p = 0.02). Episodes of acute pulmonary rejection and bronchiolitis obliterans were not associated with an increased risk of CAV (p = 0.52 and p = 0.30). CONCLUSION HLTx recipients appeared protected from CAV compared with HTx patients in this retrospective study. Repeated acute cardiac rejections were independent predictors of CAV. Unlike bronchiolitis obliterans, CAV had a very low impact on long-term survival after HLTx.

Impact of donor comorbidities on heart transplant outcomes in the modern era

OBJECTIVES The use of marginal donors with cardiovascular risk factors is increasing due to organ shortage but remains controversial in heart transplantation (HTx). We sought to investigate post-transplant outcomes in the recent era taking into account donor characteristics. METHODS We reviewed 261 HTx performed in our hospital between January 1996 and March 2013. Donor characteristics were obtained from the national database. The incidence of primary graft dysfunction (PGD) and cardiac allograft vasculopathy (CAV) and overall survival were compared in 2 groups of HTx recipients: those receiving transplants from 1996 to 2004 (Group A, n =  120) and from 2005 to 2013 (Group B, n =  141). RESULTS The mean age of the donors was 34 ± 12 years in Group A vs 42 ± 13 years in Group B ( P  < 0.001). Donors in Group B had a higher body mass index (23 ± 2 vs 26 ± 5 kg/m 2 , P  < 0.001), were more likely to be smokers (29.6% vs 52.9%, P  < 0.001) and were more likely to have hypertension (5% vs 13.5%, P  = 0.030). There was no difference in survival at 1 and 5 years (79% and 63% in Group A vs 80% and 62% in Group B, respectively; P  = 0.551). The rate of PGD was 36% in Group A vs 40% in Group B ( P  = 0.092). Freedom from CAV at 5 years was 64% and 61%, respectively ( P  = 0.367). Among the characteristics of the donors, only hypertension was associated with reduced survival. CONCLUSIONS The use of older cardiac donors with more cardiovascular comorbidities in the recent era did not impair the post-transplant outcomes. Donor hypertension was the only determinant of worse survival.

Traumatic false aneurysms of the left ventricle after an attempt at video-thoracoscopic surgery.

OBJECTIVES Video-thoracoscopic surgery (VTS) has been accepted as a safe and credible technique since 1990. Lung injury is one of the main perioperative complications. Few data are available about cardiac trauma and VTS-related false aneurysm of the left ventricular (LV) wall has not yet been reported. METHODS A 62-year old woman presented with a left thoracic empyema. Video-thoracoscopy was attempted for bacterial sampling and surgical drain of the pleura. A rapid conversion to open thoracotomy was necessary to control massive bleeding after the first thoracic port intrusion. An apical systolic murmur was found 2 weeks later during a systematic clinical examination. The patient was asymptomatic and had no personal history of cardiac disease. RESULTS Colour Doppler imaging showed two spurious aneurysms on the LV wall without any haemopericardium. Pericardial enhancement around the left ventricle was observed on the chest computerized tomography scan with the injection of contrast. After the careful excision of the two false aneurysms, a surgical repair was strengthened with a suture under a cardiopulmonary bypass. The postoperative course was uneventful and the patient was safe at 3 years. CONCLUSIONS This is the first report of LV traumatic false aneurysms secondary to an attempt of a video-thoracoscopic procedure. This is a rare but life-threatening complication because of the risk of spontaneous rupture. Left persistent thoracic empyemas associated with the ipsilateral mediastinum deviation carry a high risk of myocardial damage related to the trocar port intrusion.

Rest and Exercise Adaptation of the Right Ventricular Function in Long-Term Left Ventricular Assist Device Patients: A Prospective, Pilot Study.

HAL is a multi-disciplinary open access archive for the deposit and dissemination of scientific research documents, whether they are published or not. The documents may come from teaching and research institutions in France or abroad, or from public or private research centers. L’archive ouverte pluridisciplinaire HAL, est destinée au dépôt et à la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des établissements d’enseignement et de recherche français ou étrangers, des laboratoires publics ou privés. Rest and Exercise Adaptation of the Right Ventricular Function in Long-Term Left Ventricular Assist Device Patients: a Prospective, Pilot Study Marie Aymami, Erwan Donal, Julien Guihaire, Alain Le Helloco, Marie Federspiel, Elena Galli, François Carré, Bernard Lelong, Céline Chabanne, Hervé Corbineau, et al.

Exérèse chirurgicale des métastases pulmonaires de cancer colorectal : quelle stratégie en 2014 ?

RésuméLa résection pulmonaire en cas de cancer colorectal métastatique est possible si la maladie est stable et sous contrôle. Les patients sont admissibles après une évaluation stricte et une longue période de rémission. Nous avons effectué une revue de la littérature récente portant sur la résection pulmonaire en cas de cancer colorectal métastatique en comparant particulièrement le rôle de la chirurgie conventionnelle face à la thoracotomie et à la vidéothoracoscopie. La survie à cinq ans de ces patients varie entre 35 et 61,4 % selon les séries. La chirurgie vidéothoracoscopique permet une résection complète de la maladie (R0), mais seule la chirurgie conventionnelle semble offrir un bon curage ganglionnaire. Il est établi que la vidéothoracoscopie peut être une alternative pour les patients fragiles et difficilement opérables. La chirurgie ouverte reste aujourd’hui la référence ; cependant, et à notre connaissance, elle est controversée, car il n’existe pas d’études randomisées solides pour démontrer son efficacité. La chirurgie est plus susceptible de détecter une petite tumeur via palpation bidigitale du reste du poumon. Elle reste aujourd’hui la meilleure stratégie possible pour les patients atteints de cancers métastatiques dont la fonction pulmonaire permet une résection du poumon. Dans ce contexte, la médiastinoscopie garde clairement une place prépondérante dans la stratégie thérapeutique, car elle définit le staging ganglionnaire. L’ablation par radiofréquence (RF) et la radiothérapie stéréotaxique ablative sont aussi des alternatives appropriées pour le contrôle local. Pour les patients fragiles, elles représentent une thérapeutique acceptable.AbstractPulmonary resection of metastatic colorectal cancer is reasonable if the disease is stable and hallmark. Patients are eligible after highly selected assessment and long disease-free interval. We reviewed the recent literature about pulmonary resection of metastatic colorectal cancer, especially comparing the role of conventional surgery through thoracotomy with videothoracoscopy. The survival (5 years) rate of these patients ranges from 35 to 61.4% depending on the series. Videothoracic surgery allows a complete resection of the disease (R0); however, only conventional surgery seems to provide good lymphatic nodes removal. It is well known that videothoracoscopy may be an alternative in fragile and poor condition patients. Open surgery remains today the gold standard although, and according to our knowledge, there is no solid randomized study to demonstrate so and the subject remains controversial. Surgery is more sensitive to detect small tumor through bidigital palpation of the remaining lung. It remains today the best strategy for metastatic patients with pulmonary function suitable for lung resection. In that field, mediastinoscopy clearly plays a key role in the therapeutic strategy by specifying the node staging. Radiofrequency ablation and stereotactic ablative radiotherapy are also suitable alternatives for local control. For fragile patients, this treatment is acceptable.

Cardiac Allograft Vasculopathy after Heart and Heart-Lung Transplantations: Is There Any Protective Role from the Lung?

Purpose Cardiac allograft vasculopathy (CAV) is a major factor limiting long-term survival after heart transplantation (HTx). CAV has been reported to be delayed in heart-lung transplant (HLTx) recipients. However specific determinants of CAV development and long-term outcome after CAV occurrence have been poorly investigated after HLTx. Methods and Materials Between January 1996 and December 2006, 79 patients underwent HLTx (36.3±12.2 y−o; 47.2% men) and 141 patients underwent HTx (49.2±12.3 y-o; 76.7% men) in two different institutions. CAV grading was registered in both groups according to the International Society of Heart and Lung Transplantation 2010 standardized nomenclature for CAV. The mean post-Tx follow-up was 94 months [1-181]. Kaplan-Meyer analysis was used to calculate actuarial survival. Results Freedom from CAV (grade 1 or more) survival was 65% at 5 years and 53.9% at 10 years after HLTx and 62.5% and 42.5% respectively after HTx ( P =0.21). There were 81% of CAV grade 0, 10% of CAV grade 1, 6% of CAV grade 2 and 3% of CAV grade 3 at 5 years after HLTx whereas there were 58%, 21%, 12% and 9% respectively after HTx. Overall 5 and 10-year survival were 49.4% and 41.2% after HLTx and 66.6% and 54.5% after HTx ( P =0.04) and 41,2% in HLT recipients at 10 years ( P =0.04). The main mortality risk factors were CAV and bronchiolitis obliterans for HTx and HLTx respectively. Transplantation type has not been found as a protective factor for CAV development at univariate and multivariate analysis. By multivariate analysis, only HTx recipients who developed more than 3 acute myocardial rejections during the first post-HTx year had a higher risk factor of CAV occurrence ( P =0.02, CI[1.065-2.33]). Bronchiolitis obliterans was not associated with an increased risk of CAV after HLTx ( P =0.30). Conclusions We report an original 15-year comparative study. Combined HLTx did not protect from CAV development compared to isolated HTx. However CAV severity seems to be higher in HTx recipients.

Utilisation de l’Extra corporeal membrane ox ygenation (ECMO) dans l’embolie pulmonaire et l’hypertension artérielle pulmonaire

L’utilisation de l’ECMO dans l’HTAP peut etre envisagee dans deux contextes menacants differents: l’EP massive et le stade terminal de l’HTAP chronique. Dans ces deux situations graves mais potentiellement reversibles, l’ECMO se pose comme moyen de ressucitation en attente ou au decours d’un traitement specifi que (thrombolyse in situ, embolectomie, thromboendarterectomie, transplantation pulmonaire). Elle doit toujours venir en association et non en rupture avec les therapeutiques conventionnelles prealablement initiees. Il n’existe a ce jour aucun procede d’assistance de moyenne ou longue duree pour les patients au stade terminal d’insuffi sance respiratoire chronique. Le developpement du poumon artificiel de longue duree reste un challenge pour la communaute scientifique dans un contexte preoccupant de penurie des greffons.