Angles between the aortic root and the left ventricle assessed by MDCT are associated with the risk of aortic regurgitation after transcatheter aortic valve replacement.

OBJECTIVES: To evaluate the impact of the angles quantified by multidetector computed tomography (MDCT) between the ascending aorta's long axis and, the left ventricular inflow long axis (LVLA), or the left ventricule outflow tract long axis, and the occurrence of post-transcatheter aortic valve replacement (TAVR) aortic regurgitation (AR). METHODS: We prospectively included 136 consecutive patients who underwent a transfemoral TAVR with a preoperative MDCT. The groups were defined according to AR <2 or ≥2 assessed by echocardiography at 1 month. RESULTS: AR ≥2 identified in 21 patients (15.4%), was associated with increased rates of mortality (p value 0.02) and heart failure (p value 0.001) at 1-year follow-up. The aorta-LVLA angle was significantly higher in patients with AR ≥2 (130.5° ± 8.8° vs. 124.6° ± 9.5°; p = 0.009). On univariate analysis, aorta-LVLA angle was predictive of AR ≥2 [OR 1.07 per degree (1.02-1.13); p = 0.011]. After adjustment on annular calcification extent, the percentage of prosthesis-annular mismatch and the type of prosthesis, the relationship between aorta-LVLA angle and the risk of AR ≥2 remained unchanged. CONCLUSIONS: We showed that increased angulation between the ascending aorta and the LVLA is associated with higher rates of AR post-TAVR independent of other potential correlates.

Predicting Survival After Extracorporeal Membrane Oxygenation for ARDS: An External Validation of RESP and PRESERVE Scores.

BACKGROUND: We aimed to test the performance of PRESERVE and RESP scores to predict death in patients with severe ARDS receiving extracorporeal membrane oxygenation (ECMO) with different case mixes. METHODS: All consecutive patients treated with ECMO for refractory ARDS, regardless of cause, in the Caen University Hospital in northwestern France over the last decade were included in a retrospective cohort study. The receiver operating characteristic curves of each score were plotted, and the area under the curve was computed to assess their performance in predicting mortality (c-index). RESULTS: Forty-one subjects were included. Pre-ECMO ventilator settings were: mean VT, 6.1 ± 0.9 mL/kg; breathing frequency, 32 ± 4 breaths/min; PEEP, 11 ± 4 cm H2O; peak inspiratory pressure, 48 ± 9 cm H2O; plateau pressure, 30.4 ± 4.4 cm H2O. At ECMO initiation, blood gas results were: pH 7.22 ± 0.17, PaO2 /FIO2 = 63 ± 22 mm Hg; PaCO2 = 56 ± 18 mm Hg; FIO2 = 99 ± 2%. Pre-ECMO data were available in 35 and 27 subjects for calculation of the PRESERVE score and RESP score, respectively. Pre-ECMO scoring system results were: median PRESERVE score, 4 (interquartile range 2-5), and median RESP score, 0 (interquartile range -2 to 2). Twenty-three subjects (56%) died, including 19 receiving ECMO. In univariate analysis, plateau pressure (P = .031), driving pressure (P = <.001), and compliance (P = .02) recorded at the time of ECMO initiation as well as the PRESERVE score (P = .032) were significantly associated with mortality. With a c-index of 0.69 (95% CI 0.53-0.87), the PRESERVE score had better discrimination than the RESP score (c-index of 0.60 [95% CI 0.41-0.78]) for predicting mortality. CONCLUSIONS: The use of these scores in helping physicians to determine the patients with ARDS most likely to benefit from ECMO should be limited in clinical practice because of their relatively poor performance in predicting death in subjects with severe ARDS receiving ECMO support. Before widespread use is initiated, these scoring systems should be tested in large prospective studies of subjects with severe ARDS undergoing ECMO treatment.

Extracorporeal Life Support for Refractory Cardiac Arrest or Shock: A 10-Year Study.

We aimed to identify factors associated with hospital mortality among patients receiving extracorporeal life support (ECLS). All consecutive patients treated with ECLS for refractory cardiac arrest or shock in the Caen University Hospital in northwestern France during the last decade were included in a retrospective cohort study. Sixty-four patients were included: 29 with refractory cardiac arrest and 35 with refractory shock. The main reasons for ECLS were acute coronary syndrome (n = 23) and severe poisoning caused by drug intoxication (n = 19). At ECLS initiation, the left ventricular ejection fraction was 16% (±11). Initial blood test results were arterial pH = 7.19 (±0.20) and plasma lactate = 8.02 (±5.88) mmol/L. Forty (63%) patients died including 33 under ECLS. In a multivariate analysis, two factors were independently associated with survival: drug intoxication as the reason for ECLS (adjusted odds ratio [AOR], 0.07; 95% confidence intervals [CI], 0.01-0.28; p < 0.001) and arterial pH (an increase of 0.1 point [AOR, 0.013; 95% CI, <0.001-0.27; p < 0.01]). This study supports early ECLS as a last resort therapeutic option in a highly selected group of patients with refractory cardiac arrest or shock, in particular before profound acidosis occurs and when the cause is reversible.

Late complication after repair of aortic coarctation.

BACKGROUND: Coarctation of the aorta is a congenital malformation that has long been considered completely correctable with appropriate surgery in childhood. However, with the aging of these patients, many late complications have been reported, and this notion must be reevaluated. METHODS: We retrospectively reviewed all patients who underwent reoperation between 1992 and 2012 in our adult cardiac surgery department following surgical correction of coarctation in childhood; 18 patients over 15-years old were included in the study. RESULTS: The median time from coarctation repair to reoperation was 25 years. Patients were reoperated on for several late complications: aortic valve disease secondary to bicuspid aortic valve, ascending aortic aneurysm, recoarctation, aortic arch hypoplasia, pseudoaneurysm, associated recoarctation and pseudoaneurysm, subvalvular aortic obstruction, and descending thoracic aortic aneurysm. One patient died due to an intraoperative complication. In the other cases, the surgical results were satisfactory at the 6-month follow-up. According to literature data, age at coarctation repair and surgical technique appear to be essential factors in late complications: older age and surgical repair with prosthesis interposition are associated with a higher rate of reintervention. CONCLUSION: Patients who have undergone repair of aortic coarctation frequently remain asymptomatic for a long time. Late complications can be appropriately treated when diagnosed early. Consequently, all coarctation patients need careful lifelong follow-up, especially those with congenital aortic valve disease or surgery in childhood with interposition of prosthetic material.

Right origin of the circumflex artery and posterior aortic annulus enlargement.

We present the case of a patient who required posterior enlargement of the aortic annulus during aortic valve replacement in the presence of abnormal origin of the circumflex artery from the right coronary artery, with a retroaortic course.

Enterobacteriaceae surgical site infection after cardiac surgery: the hypothetical role of vancomycin.

BACKGROUND: In the middle of October 2011, the Hygiene Department of Caen University Hospital suspected an outbreak of surgical site infections (SSI) after open-heart operations with an unusually high proportion of microorganisms belonging to the Enterobacteriaceae family. The attack rate was 3.8%, significantly different (p = 0.035) from the attack rate of 1.2% in 2010 over the equivalent period. A case-control study was conducted to search specifically for risk factors for Enterobacteriaceae infections after median sternotomy in cardiac patients. METHODS: Case patients were defined retrospectively as patients with superficial or deep surgical site infection with Enterobacteriaceae within 30 days of median sternotomy. Four control patients were selected per case patient from patients matched for date of operation (± 15 days) and European System for Cardiac Operative Risk Evaluation (<5, [5-10], >10). RESULTS: Univariate analysis identified the following risk factors: inappropriate skin preparation on the morning of the intervention (p = 0.046), use of vancomycin (p = 0.030), and number of sternotomy dressings (p = 0.033). A multivariate logistic regression analysis found that vancomycin use was independently associated with an increased risk of postoperative SSI with Enterobacteriaceae (p = 0.019; odds ratio = 7.4). CONCLUSIONS: Although vancomycin is known to be effective for preventing infection with methicillin-sensitive organisms, our results suggest that it was associated with a risk for the development of SSI with gram-negative organisms after median sternotomy. This study led to a multidisciplinary meeting that defined new guidelines for prophylactic antibiotic therapy before open-heart operations.

Corpus callosum hemorrhage during left ventricular-assist device support.

Patients supported by left ventricular-assist devices are at high risk of bleeding, but among the numerous hemorrhagic complications, those involving the corpus callosum are very uncommon. We report the case of a 35-year-old woman who suddenly experienced neurological symptoms 4 months after HeartMate II implantation. Cranial computed tomography showed a voluminous hematoma involving the corpus callosum.

Iatrogenic bidirectional dissection of the right coronary artery and the ascending aorta: the worst nightmare for an interventional cardiologist.

Although rare, iatrogenic aortocoronary dissection is one of the complications most dreaded by the interventional cardiologist. If not managed promptly, it can have redoubted and serious consequences. Herein, we present the case of a 70 year-old woman who was treated by stenting of the second segment of the right coronary artery (RCA) for recurrent angina but, unfortunately, the procedure was complicated by anterograde dissection of the RCA with a simultaneous retrograde propagation to the proximal part of the ascending aorta. Successful stenting of the entry point was able to recuperate the RCA and to limit the retrograde propagation to the ascending aorta, but there was an extension of the dissection to the aortic valve leaflets resulting in a massive aortic insufficiency. Therefore, surgical aortic valve replacement with prosthetic tube graft was performed [corrected].