Predictive performance of surgical mortality risk scores in infective endocarditis.

OBJECTIVES: This observational study aimed to evaluate Association pour l'Etude et la Prévention de l'Endocardite Infectieuse (AEPEI) surgery score predictive performance in comparison to general (EuroSCORE I, II) and specific (De Feo, PALSUSE) surgical risk scores for infective endocarditis (IE). METHODS: The study included patients who underwent surgery for IE during the acute phase at Bichat University Hospital (Paris, France) between 1 January 2006 and 31 December 2016 and at Nancy University Hospital (Nancy, France) between 1 January 2009 and 31 December 2019. Patients with IE complicating percutaneous aortic valve implantations or implantable intra-cardiac devices were excluded. Discrimination and calibration were assessed using receiver operating characteristic curve analysis, calibration curves and the Hosmer-Lemeshow test. RESULTS: In-hospital mortality rates were 18% at Bichat and 16% at Nancy. Discrimination was high for all risk scores at Bichat (area under the receiver operating characteristic curve = 0.77 for EuroSCORE I, 0.78 for EuroSCORE II, 0.76 for De Feo score, 0.72 for PALSUSE and 0.73 for AEPEI with 95% confidence interval ranging from 0.67 to 0.83), but lower at Nancy (0.56 for EuroSCORE I, 0.65 for EuroSCORE II, 0.63 for De Feo score, 0.67 for PALSUSE and 0.66 for AEPEI score with 95% confidence interval ranging from 0.47 to 0.75). With Brier score, all scores were adequately calibrated in both populations between 0.129 (De Feo) and 0.135 (PALSUSE) for Bichat and between 0.128 (De Feo) and 0.135 (EuroSCORE I) for Nancy. With the Hosmer-Lemeshow test, the AEPEI score exhibited the best calibration (observed/predicted ratio 1.058 in Bichat, 1.087 in Nancy). CONCLUSIONS: This surgical score external validation in 2 large independent populations demonstrated that the AEPEI surgical score had the best predictive performance compared to other prognosis scores. It could be helpful in clinical practice to assist the endocarditis team in decision-making.

Prognostic influence of acute decompensated heart failure in patients planned for transcatheter aortic valve implantation.

OBJECTIVE: The aim of our study was to evaluate the outcome of patients with severe aortic stenosis presenting with acute decompensated heart failure (ADHF) and planned for transcatheter aortic valve implantation (TAVI) and to study the variables influencing their prognosis. METHODS: Our retrospective study included 801 patients planned for TAVI in our center. Seven hundred and fifty-six underwent TAVI and were categorized according to ADHF as the initial clinical presentation into two groups: ADHF group (n = 261) and no-ADHF group (n = 495). Pre as well as periprocedural outcomes and 1 year mortality were analyzed. RESULTS: Among the patients planned for the TAVI procedure, 45 patients remained untreated: 35 patients died while waiting to undergo TAVI which represented 20% of all deaths in our study, ADHF was observed in 23 of 45 (51%) these untreated patients. The 1-year all-cause mortality rate was significantly higher in the ADHF group versus the no-ADHF group (27% vs. 15%, p < .0001). In multivariate analysis, male gender (odds ratio [OR] =2.5, 95% confidence interval [CI]: 1.37-4.57, p = .03), body mass index <25 kg/m2 (OR = 2.76, 95% CI: 1.51-5.04, p = .0009), and logistic EuroSCORE II ≥20% (OR = 3.04, 95% CI: 1.56-5.94, p = .001) were associated with a higher 1-year mortality in the ADHF group. CONCLUSION: The patients eligible for TAVI presenting with ADHF were associated with a higher mortality for both: while on the waiting list for TAVI as well as at 1-year follow-up and thus asking for clearer criteria to prioritize action in this high-risk TAVI patients.

[Treatment of infectious endocarditis]. / Traitement de l'endocardite infectieuse.

Antibiotic treatment of infective endocarditis is part of a multidisciplinary patient management that should be conducted within an "Endocarditis team". Initial antibiotic treatment of infective endocarditis should be parenteral and comply with current international guidelines. A switch to an oral antibiotic regimen may be considered after 2weeks of successful parenteral antibiotic treatment. Aminoglycosides should no longer be used for the initial treatment of native valve Staphylococcus aureus endocarditis. Valve surgery is required in almost half of the patients.

Transcarotid transcatheter aortic valve implantation: multicentre experience in France.

OBJECTIVES: Transcatheter aortic valve implantation is a well-recognized treatment option for high-risk patients with aortic stenosis. The femoral approach is possible in 80% of cases and remains the access of choice. When this approach is not feasible, other alternative routes have been proposed such as transapical, transaortic and subclavian. Transcarotid aortic valve implantation has been proposed as another direct vascular access. Its use is relatively new and still under evaluation. METHODS: We successfully performed transcarotid aortic valve implantation in 145 consecutive patients through the left or right carotid artery in 3 different French sites over a 2-year period. Data were prospectively entered in the French transcatheter aortic valve implantation database. RESULTS: The mean age was 79.8 ± 8.7 years, with a mean logistic EuroSCORE of 20.7 ± 12.6%. The procedure was successful in all patients, and no conversion was necessary. Thirty-day survival was 93.7%, 8 (5.5%) patients presented either minor or major strokes and 1 patient had a localized asymptomatic carotid dissection. All patients were immediately extubated, and none presented respiratory complications. CONCLUSIONS: Transcarotid aortic valve implantation is a safe alternative to transfemoral transcatheter aortic valve implantation, with direct access to the aortic valve, which can be performed with limited incision.

Ventricular Dysfunction in Patients with Acute Coronary Syndrome Undergoing Coronary Surgical Revascularization: Prognostic Impact on Long-Term Outcomes.

BACKGROUND: Patients with non-ST elevation acute coronary syndrome complicated by left ventricular dysfunction (LVEF) are a poor prognosis group. The aim of our study was to assess the short and long term LEVF prognostic value in a cohort of NSTE-ACS patients undergoing surgical revascularization. METHODS: We performed elective and isolated CABG on a cohort of 206 consecutive patients with LVEF≤0.40 complicating acute coronary syndrome. The case cohort was compared with a cohort of controls (LVEF>0.40) randomly selected (2:1) among patients who underwent the procedure during this period. RESULTS: The Kaplan-Meier 5-year estimated survival rates for patients in the low and normal LVEF groups were 70.8% (95% confidence interval CI: 64.2-77.4) and 81.7% (95%CI: 77.8-85.6), respectively. A low LVEF was associated with both a higher all-cause (HR [95%CI] = 1.84[1.18-2.86]) and a higher cardiovascular mortality (HR = 2.07 [1.27-3.38]) during the first 12 months of follow-up. After adjustment for potential confounders, a low LVEF remained associated with a higher cardiovascular mortality only (1.87[1.03-3.38]) during the first 12 months of follow-up. After 12 months of follow-up, a low LVEF was no more associated with all-cause, nor cardiovascular mortality. CONCLUSION: Patients with low LVEF might require more intensive care than patients with normal LVEF during the year after the surgical procedure, but once the first postoperative year over, the initial low LVEF was no more associated with long term mortality.

Transcarotid transcatheter aortic valve implantation.

Transcatheter aortic valve implantation is a well-recognized treatment option for high-risk patients with aortic stenosis. The femoral approach is possible in 80% of cases. Initially, only the transcarotid and subclavian approaches were performed as alternative routes. Both approaches have advantages and disadvantages. The carotid approach is a new approach that offers direct vascular access to the aortic valve. The technique of access is very simple and well known to all cardiovascular surgeons, and the morbidity is minimal. It avoids a thoracotomy with all its complications. We present here our technique and results of our initial experience.

Challenge for perceval: aortic valve replacement with small sutureless valves--a multicenter study.

BACKGROUND: There is controversy concerning the performance of small aortic prostheses (size < 21). These have been associated with morbidity and mortality after aortic valve replacement (AVR) due to their increased gradient. Sutureless technology is now available but the performance of the smallest of these prostheses needs to be assessed. METHODS: The registries of 4 European centers, including 276 consecutive patients (mean age 79.7 ± 5.2 years, 69.9% females), were reviewed in order to compare data on the smallest model of the Sorin-Perceval sutureless prosthesis (Sorin Group, Saluggia, Italy) compared with larger models. The small valve ("S" size) was inserted (S group) in 47 patients, while 229 patients had a larger one (labeled "M" and "L" by manufacturer, herein L group). Except for body surface area (1.60 ± 0.16 vs 1.78 ± 0.19 m(2), p < 0.001), there were no other relevant preoperative differences. The European system for cardiac operative risk evaluation log was 11.4 ± 6.1 versus 12.6 ± 9.6 (p = 0.28). RESULTS: Median sternotomy was the most frequent approach (S group 87.2% vs L group 79.5%, p = 0.31). The associated procedures were similar for both groups (31.9% vs 34.5%, p = 0.87). For isolated AVR, cardiopulmonary bypass and cross-clamp times were, respectively, 49.1 ± 16.0 and 30.7 ± 9.2 minutes (S group) versus 52.6 ± 23.1 and 32.3 ± 13.6 minutes (L group) (p = 0.33 and 0.45). Hospital mortality was nil (S group) versus 2.6% (L group) (p = 0.62). At discharge, the peak-pressure-gradients were 22.7 ± 7.9 and 20.9 ± 8.4 mm Hg (p = 0.24) while indexed effective orifice areas were 0.84 ± 0.16 and 0.86 ± 0.25 cm(2)/m(2) (p = 0.76). At follow-up (1.5 ± 1.3 years), echo data and survival did not differ (p = 0.17). CONCLUSIONS: This multicenter study confirms the safety, efficacy, and ease of insertion of Perceval valves in elderly patients with small annulus. The performance of the smaller prosthesis was satisfying and prosthesis size did not affect patient outcome.

Treatment of arterial lesions in drug addicts.

BACKGROUND: Arterial complications among drug addicts are rare. Their appearance can engage the vital prognosis of the patient and present a major risk of amputation. The injection of products with high cellular toxicity induces septic necrosis of the arterial wall and adjacent tissues. It is frequently responsible for acute hemorrhage. The data in the literature concerning surgical treatment are discussed. The goal of our study was to analyze the immediate and midterm results of the surgical management of these arterial lesions. METHODS: Between January 2005 and April 2012, 31 drug addicts (4 women; 31.4 ± 7.2 years) presenting with 33 arterial lesions were treated. They presented with a humeral (n = 15), femoral (n = 13), or axillar (n = 3) false aneurysm. Two patients had an arterial thrombosis. The clinical manifestations were an acute hemorrhage (n = 16), a septic syndrome (n = 7), a pulsatile mass (n = 6), and an acute ischemia (n = 4). In situ revascularization was carried out in 20 cases, in 15 patients with a bypass (9 venous and 6 prosthetic), in 2 with a venous patch, in 2 by direct suture, and in 1 by transposition of the superficial femoral artery in the deep femoral artery. Extra-anatomic bypass revascularization was performed in 6 cases (4 venous and 2 prosthetic). The other techniques used were ligature (n = 5) and medical care (n = 2). Two patients had an additional procedure with a musculocutaneous epigastric pedicled flap in order to fill the loss of substance. RESULTS: The early rate of reinterventions was 38.7% at 30 days (12 patients), because of a suture line hemorrhage related to sepsis (n = 6), a bypass thrombosis (n = 5), and of acute ischemia after a arterial ligature. These complications occurred mainly on extremities, having had an anatomic revascularization (n = 9). Six extra-anatomic revascularizations had to be performed in second intention. The average follow-up was 8.6 months (range: 1-73.5 months), and 15 patients were lost to follow-up at 6 months. The patients were followed by duplex ultrasonography and/or angioscanner. Primary and secondary actuarial patencies at 1, 3, and 6 months were 61%, 46%, 46%, and 91%, 81%, and 71%, respectively. The rate of salvage of extremities was 100%. CONCLUSION: Our study reveals the difficulty of the management of these arterial lesions. The local and general septic process is primarily responsible for early complications. Arterial restoration with extra-anatomic bypass makes it possible to be distant from the infection. This technique can be associated with a covering flap.

Off-pump axillo-coronary artery bypass: a simple approach for high-risk myocardial revascularization.

We report the case of a 66-year-old male with increasing angina occurring after two previous coronary artery surgery procedures. The second operation had been complicated by severe mediastinitis necessitating surgical drainage, and sternal stabilization. Angiography revealed an occlusion of the LAD bypass with a patent LAD associated with a stenotic circumflex coronary artery. The ascending aorta was severely calcified. An off-pump axillo-LAD coronary artery bypass was safely performed in conjunction with stenting of the circumflex artery. This approach dramatically simplified the procedure and reduced the operative risk. At the 52-month follow-up, the patient is free of any angina symptoms.

Femoral pseudoaneurysms and current cardiac catheterization: evaluation of risk factors and treatment.

OBJECTIVES: We sought to determine the incidence of femoral pseudoaneurysm (FPA) following cardiac catheterization, identify the risk factors for FPA and factors influencing therapeutic strategy. METHODS: 11,992 consecutive patients who underwent cardiac catheterization via femoral artery were studied over a period of four years in one University Hospital. Our prospective case control group analysis registered patients who developed FPA after the procedure. Patient-related factors, procedure related factors and peri-procedure treatment were compared between the two groups. RESULTS: 76 FPA were diagnosed over the study period accounting for a global incidence of 0.6% procedures. By univariate analysis, interventional procedure (p<0.01), rhythmologic procedure (p=0.03), sheath>or=6F (p=0.04) and left groin puncture (p<0.001) were FPA risk factors. By multivariate analysis, interventional procedure (adjusted odds ratio [OR]=1.99; 95% confidence interval [CI]1.14-3.44 p=0.01) and left groin puncture (OR=4.65; 95% CI, 1.78-12.1 p=0.001) are independent predictive factors of FPA. FPA thrombosis was obtained by ultrasound guided compression (UGC) in 71% of the cases. By univariate analysis, PFA diameter larger than 4 cm (p<0.001), the use of anticoagulation (p<0.01) or GPIIbIIIa inhibitors (p=0.001) and UGC under anticoagulation (p=0.01) are predictive factors of need for FPA surgical repair. By multivariate analysis, FPA diameter>4 cm and use of GPIIbIIIa inhibitors are independent predictive factors of FPA's surgical treatment. Superficial femoral puncture was predictive of successful UGC both by uni and multivariate analysis. CONCLUSIONS: Our study shows that FPA occurrence is mainly due to by procedure-related factors. FPA size, level of puncture and the use of GPIIbIIIa inhibitors are independent predictive factors of need for surgical therapy.

Abdominal aortic aneurysm infected by Yersinia pseudotuberculosis.

Infected aneurysms caused by Yersinia are very uncommon and are principally due to Yersinia enterocolitica. We describe the first case of an infected aneurysm caused by Yersinia pseudotuberculosis in an elderly patient with a history of atherosclerotic cardiovascular disease.