Jérôme Jouan

A Pre-Hospital Extracorporeal Cardio Pulmonary Resuscitation (ECPR) strategy for treatment of refractory out hospital cardiac arrest: an observational study and propensity analysis.

BACKGROUNDnOut of hospital cardiac arrest (OHCA) mortality rates remain very high with poor neurological outcome in survivors. Extracorporeal cardiopulmonary resuscitation (ECPR) is one of the treatments of refractory OHCA. This study used data from the mobile intensive care unit (MOICU) as part of the emergency medical system of Paris, and included all consecutive patients treated with ECPR (including pre-hospital ECPR) from 2011 to 2015 for the treatment of refractory OHCA, comparing two historical ECPR management strategies.nnnMETHODSnWe consecutively included refractory OHCA patients. In Period 1, ECPR was indicated in selected patients after 30min of advanced life support; in- or pre-hospital implementation depended on estimated transportation time and ECPR team availability. In Period 2, patient care relied on early ECPR initiation after 20min of resuscitation, stringent patient selection, epinephrine dose limitation and deployment of ECPR team with initial response team. Primary outcome was survival with good neurological function Cerebral Performance Category score (CPC score) 1 and 2 at ICU discharge or day 28.nnnFINDINGSnA total of 156 patients were included. (114 in Period 1 and 42 in Period 2). Baseline characteristics were similar. Mean low-flow duration was shorter by 20min (p<0.001) in Period 2. Survival was significantly higher in Period 2: 29% vs 8% (P<0.001), as confirmed by the multivariate analysis and propensity score. When combining stringent patient selection with an aggressive strategy, the survival rate increased to 38%. Pre-hospital ECPR implementation in itself was not an independent predictor of improved survival, but it was part of the strategy in Period 2.nnnINTERPRETATIONnOur data suggest that ECPR in specific settings in the management of refractory OHCA is feasible and can lead to a significant increase in neurological intact survivors. These data, however, need to be confirmed by a large RCT.

Mitral valve reconstruction in Barlow disease: Long-term echographic results and implications for surgical management

OBJECTIVEnOwing to the complexity of the underlying lesions, Barlow disease remains a challenge for surgeons performing mitral valve repair. We aimed to assess whether our most recent results involving several surgeons were comparable with those of a previous experience in which mitral valve repair was performed by a more limited group of surgeons.nnnMETHODSnFrom September 2000 to January 2007, 200 patients with Barlow disease (135 men and 65 women; mean age, 56 ± 13 years) were referred to our institution for surgical treatment of their mitral regurgitation. We retrospectively analysed the mitral lesions characteristics, the surgical techniques used, and clinical outcomes. Follow-up echocardiograms were biannually reviewed.nnnRESULTSnLesions comprised annular dilatation, excess tissue, and leaflet prolapse in all cases. The most frequent prolapsed segments were P2 (88.5%; n = 177) and A2 (55.5%; n = 111). Annular calcifications and restrictive valvular motion were associated in 20% (n = 40). Repair was feasible in 94.7% (n = 179/189) of non-redo interventions. Immediate postoperative echocardiography showed residual mitral regurgitation greater than 1+ in 6 cases; these patients were all reoperated on within the next months. Operative mortality was 1.5% (n = 3). Mean follow-up was 77.5 ± 25.6 months. At 8 years postoperatively, overall survival was 88.6% ± 3.1%, freedom from reintervention was 95.3% ± 1.7%, and freedom from late recurrent moderate mitral regurgitation (>2+) was 90.2% ± 3.1%nnnCONCLUSIONSnProvided that the fundamental principles of mitral valve reconstruction are respected, the surgical techniques are highly reproducible with good long-term results, similar to those published during the pioneering phase of this surgery.

Standardized approach to valve repair using an expansible aortic ring versus mechanical Bentall: Early outcomes of the CAVIAAR multicentric prospective cohort study

OBJECTIVEnThe study objective was to compare the 30-day outcomes of a standardized aortic valve repair technique (REPAIR group) associating root remodeling with an expansible aortic ring annuloplasty versus mechanical composite valve and graft (CVG group) replacement in treating aortic root aneurysms.nnnMETHODSnA total of 261 consecutive patients with aortic root aneurysm were enrolled in this multicentric prospective cohort (131 in the CVG group, 130 in the REPAIR group) in 20 centers. The main end point is a composite criterion including mortality; reoperation; thromboembolic, hemorrhagic, or infectious events; and heart failure. Secondary end points were major adverse valve-related events. Crude and propensity score adjusted estimates are provided.nnnRESULTSnThe mean age was 56.1 years, and the valve was bicuspid in 115 patients (44.7%). The median (interquartile range) preoperative aortic insufficiency grade was 2.0 (1.0-3.0) in the REPAIR group and 3.0xa0(2.0-3.0) in the CVG group (Pxa0=xa0.0002). Thirty-day mortality was 3.8% (nxa0=xa05) in both groups (Pxa0=xa01.00). Despite a learning curve and longer crossclamp times for valve repair (147.7 vs 99.8 minutes, Pxa0<xa0.0001), the 2 groups did not differ significantly for the main criterion (odds ratio, 1.31; 95% confidence interval, 0.72-2.40; Pxa0=xa0.38) or 30-day mortality (odds ratio, 0.99; 95% confidence interval, 0.28-3053; Pxa0=xa0.99), with a trend toward more frequent major adverse valve-related events in the CVG group (odds ratio, 2.52; 95% confidence interval, 0.86-7.40; Pxa0=xa0.09). At discharge, 121 patients (96.8%) in the REPAIR group had grade 0 or 1 aortic insufficiency.nnnCONCLUSIONSnA new standardized approach to valve repair, combining an expansible aortic annuloplasty ring with the remodeling technique, presented similar 30-day results to mechanical CVG with a trend toward reducing major adverse valve-related events. Analysis of late outcomes is in process for 3- and 10-year follow-ups.

Conduction disorders after tricuspid annuloplasty with mitral valve surgery: Implications for earlier tricuspid intervention

OBJECTIVEnTricuspid valve repair has been recently advocated in patients undergoing mitral valve surgery who have mild to moderate secondary tricuspid regurgitation. However, the incidence of heart conduction disorders after combined mitral valve and tricuspid valve interventions has not been evaluated. We sought to analyze the incidence of permanent pacemaker implantations and heart conduction disorders in patients undergoing mitral valve surgery with and without tricuspid valve annuloplasty.nnnMETHODSnIn 2011 and 2012, among 201 consecutive patients referred to the Hôpital Européen Georges Pompidou for isolated nonischemic mitral valve disease, 113 underwent an isolated mitral valve procedure (group 1) and 88 had a concomitant tricuspid valve ring annuloplasty (group 2).nnnRESULTSnPatients mean age was 59.7 ± 16.5 years in group 1 and 60.7 ± 14.9 years in group 2 (P = .5). Mean crossclamp time and bypass time were 78 ± 35 minutes and 105 ± 47 minutes in group 1 and 92 ± 36 minutes and 128 ± 50 minutes in group 2, respectively (P = .001 and .005, respectively). Operative mortality was 3% (2.7% in group 1 and 3.2% in group 2, P = .4). Incidence of high-grade heart conduction disorders lasting more than 3 days postoperatively was 14.5% in group 1 and 41.2% in group 2 (P = .001). At 3 years, freedom from permanent pacemaker implantation was 99% ± 2% in group 1 and 94.1% ± 5% in group 2 (P = .02). For the entire cohort, longer crossclamp time (P = .02) and tricuspid ring annuloplasty (hazard ratio, 3.8; P = .001) were independent predictors of heart conduction disorders.nnnCONCLUSIONSnThe need for permanent pacemaker implantation is increased after concomitant tricuspid ring annuloplasty in the setting of mitral valve surgery. A clinical period of observation up to 14 days after postoperative heart conduction disorders should be observed before recommending permanent pacemaker placement.

Gene polymorphisms and cytokine plasma levels as predictive factors of complications after cardiopulmonary bypass

OBJECTIVEnCardiopulmonary bypass remains associated with significant morbidity and mortality, in part caused by a systemic inflammatory response that is unpredictable and variable among patients. Several limited studies have suggested associations of cytokine plasma levels or gene polymorphisms with outcome after cardiopulmonary bypass. The present study was to determine the relationships between several circulating cytokines and their polymorphisms (single nucleotide polymorphisms), and the occurrence of postoperative clinical events in patients who underwent coronary artery bypass grafting under cardiopulmonary bypass.nnnMETHODSnPatients were genotyped for single nucleotide polymorphisms of LTA (Cys13Arg, +252A>G), TNF (-308G>A), IL6 (-597G>A, -572G>C, -174G>C), IL10 (-592C>A, c.∗117C>T), and APOE (Cys112Arg, Arg158Cys). Serum samples were collected preoperatively, immediately after cardiopulmonary bypass, and at different postoperative time points to measure cytokine serum levels by enzyme-linked immunosorbent assay. The clinical end point was the composite of postoperative death, low cardiac output syndrome, myocardial infarction, sepsis, and acute renal insufficiency.nnnRESULTSnSingle nucleotide polymorphisms IL6-572GC+CC/IL10-592CC were associated with the clinical end point (P=.032 and P=.009, respectively). In addition to preoperative clinical conditions, the other factor associated with the clinical end point was interleukin-10 plasma levels 24 hours after surgery (P=.017). On the basis of these results, a predictive model of postoperative complications after coronary artery bypass grafting was created.nnnCONCLUSIONSnOur data suggest that focused genetic testing of the IL6-572G>C and IL10-592C>A single nucleotide polymorphisms might be a tool for identifying patients at the highest risk of poor tolerance to the inflammatory response to cardiopulmonary bypass and for implementing strategies to mitigate it, provided the generalization of these tests makes them reasonably affordable and thus favorably shifts their cost-to-benefit ratio.

Congenital mitral valve regurgitation in adult patients. A rare, often misdiagnosed but repairable, valve disease

OBJECTIVEnCongenital mitral valve regurgitation (MVR) is a rare disease occurring in infancy or childhood. Although congenital MVR has been described in adults, no surgical series has been reported so far. We describe here a 6-year surgical experience of congenital MVR in adults at a single institution.nnnMETHODSnWe reviewed the data of 15 consecutive patients (8 men), aged more than 16 years (median: 38 years; range: 16-70 years) operated on for severe congenital MVR from June 2000 to March 2006. Congenital MVR represented 2.1% of mitral valve surgery performed in adults during the same period. Patients with atrio-ventricular septal defect or atrio-ventricular discordance were excluded.nnnRESULTSnThe congenital MVR was preoperatively diagnosed in six (40%) cases. Two (13%) patients had a Williams-Beuren syndrome. The lesions consisted in annular dilation (100%), prolapsed leaflet (87%), chordal abnormalities (80%), papillary muscle abnormalities (40%) or valvular cleft (33%). Mitral valve repair was performed in all cases using Carpentiers techniques. There was no hospital death or late mortality. At last follow-up (median: 60 months; range: 6-83 months), all patients were in NYHA functional class I or II and in a sinus rhythm. On transthoracic echocardiography, 11 (73%) patients had no or trivial MVR. Mild MVR was present in four (27%) patients. No patient was reoperated and endocarditis did not occur.nnnCONCLUSIONnCongenital MVR is rare in adults, often misdiagnosed and accessible to valve repair with excellent mid-term results.

Results and predictors of early and late outcome of coronary artery bypass graft surgery in patients with ejection fraction less than 20

BACKGROUNDnSeverely depressed left ventricular ejection fraction (EF</=20%) has historically been a major risk factor for morbidity and mortality in medically and surgically managed coronary artery disease. Recent studies have suggested that outcomes in patients with EF less or equal to 20% undergoing coronary artery bypass graft (CABG) surgery are improving, but the trend in the outcomes remains unclear.nnnMETHODSnWe retrospectively analysed prospectively collected data from 2909 consecutive patients undergoing isolated CABG between January 1998 and August 2006. One hundred and eighty five patients (6.4%) had an ejection fraction less or equal to 20%. Primary outcome measures for this study included hospital mortality, major postoperative complications, and long-term survival.nnnRESULTSnThe median age in the overall patient population was 65 years (interquartile range 58-73) and 69% (n=2015) of patients were male. The overall hospital mortality among our study population was 2.3% (n=67). The mortality among patients with EF less or equal to 20 was 5% (n=11) compared to 2% (n=56) in patients with EF above 20% (p=0.001). The proportion of patients with a high EuroSCORE (>9%) was significantly greater in the group with EF less or equal to 20% (49%) than in the group with EF above 20% (20%). EF less or equal to 20% was not shown by multivariable logistic regression analysis to be an independent predictor of operative mortality. Survival rates at one year were 85+/-2.8%, 93+/-0.9%, and 98%+/-0.3% for patients with EF less or equal to 20%, over 20-40% and greater than 40% respectively; and at five years: 72+/-0.4%, 81+/-0.2% and 89+/-0.1%, respectively (p<0.001).nnnCONCLUSIONnWe demonstrate acceptable mortality rates in patients with an EF less or equal to 20%, and show that EF less or equal to 20% does not appear to be an independent predictor of hospital mortality in our practice. Incremental changes in practice including improved patient selection and peroperative management may have reduced the impact of EF less or equal to 20% on mortality following CABG.

Septic Pulmonary Thromboemboli in an Adolescent With Tetralogy of Fallot

A 14-year-old adolescent man from the Republic of Congo, with no personal medical history, presented with progressive shortness of breath and exercise limitation. On clinical examination, he had a 3/6 systolic murmur and regular cardiac rhythm, and cyanotic fingers and clubbing, as well. Pulmonary auscultation was normal. No recent episode of fever or shivering or peripheral sign of endocarditis were reported. Pulse oxymetry showed oxygen saturation at 64%. The diagnosis of Tetralogy of Fallot was subsequently established. Laboratory results showed a normal white blood cell count with no abnormalities.nnThe initial echocardiogram showed a large perimembranous septal defect of 1.5-cm diameter, an aortic override, a predominant right-to-left ventricular shunt, a severe infundibular pulmonary stenosis, and right ventricular hypertrophy. Left ventricular diameter was 39 mm at end-diastole, and the left ventricular ejection fraction was normal. A 4-mm mobile element was unexpectedly visualized at the level of the pulmonary valve.nnAn ECG-gated multidetector pulmonary computed tomography angiogram with iodinated contrast injection was then performed to explore this unusual finding. Preoperative transesophageal echocardiography was not …

Peritoneoatrial Shunting for Intractable Chylous Ascites Complicating Thoracic Duct Ligation

Thoracic duct ligation for chylothorax is considered a safe and efficient procedure. However, we observed two cases that were complicated by intractable chylous ascites. Refractory chylous ascites are usually cured by surgical peritoneovenous shunting, but in both patients successful treatment required peritoneoatrial shunting. Actually, a peritoneovenous shunt was impossible because of extensive venous thrombosis in jugular and superior vena cava in one patient and failed because of constrictive pericarditis requiring pericardectomy in the other, both underlying diseases also accounting for the thoracic duct ligation complications.

Deep hypothermia and low flow for surgery for abdominal or extraperitoneal tumors with cavoatrial extension.

BACKGROUNDnSurgical treatment of retroperitoneal tumors with cavoatrial involvement can be challenging. Completeness of resection of the cava tumor extension is crucial for the patients survival. We report a monocentric experience with the use of cardiopulmonary bypass and deep hypothermic low flow for the surgical resection of caval and atrial involvement of retroperitoneal tumors.nnnMETHODSnBetween 2006 and 2011, 9 patients were admitted in our cardiovascular surgery department for retroperitoneal tumors with cavoatrial extension. Every case was performed with cardiopulmonary bypass under deep hypothermia (18°C) with a continuous low-flow perfusion (1 to 1.5 L/min). Cardiopulmonary bypass output was tuned to obtain a nearly bloodless field. Reconstruction of the atriohepatic confluent was carried out with a pericardium patch without inferior vena cava reconstruction.nnnRESULTSnThere was no perioperative death. Mean duration of deep hypothermic low flow was 52.2 ± 18.2 minutes. The lowest mean esophageal temperature obtained during procedure was 18.2° ± 1.4°C. No neurologic event was noted postoperatively. Three patients had early complications: one reintervention for bleeding, one reintervention for mediastinitis, and one transient moderate renal failure. After a year, all patients were alive with patent atriohepatic reconstruction.nnnCONCLUSIONSnCardiopulmonary bypass with deep hypothermic low flow facilitates tumor resection and reconstruction of the atriohepatic confluent. It provides satisfactory postoperative results. It should be considered as an option in the management of these retroperitoneal tumors with cavoatrial involvement.