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BACKGROUND: Since publication of Duke criteria for infective endocarditis (IE) diagnosis, several modifications have been proposed. We aimed to evaluate the diagnostic performance of the Duke-ISCVID (International Society of Cardiovascular Infectious Diseases) 2023 criteria compared to prior versions from 2000 (Duke-Li 2000) and 2015 (Duke-ESC [European Society for Cardiology] 2015). METHODS: This study was conducted at 2 university hospitals between 2014 and 2022 among patients with suspected IE. A case was classified as IE (final IE diagnosis) by the Endocarditis Team. Sensitivity for each version of the Duke criteria was calculated among patients with confirmed IE based on pathological, surgical, and microbiological data. Specificity for each version of the Duke criteria was calculated among patients with suspected IE for whom IE diagnosis was ruled out. RESULTS: In total, 2132 episodes with suspected IE were included, of which 1101 (52%) had final IE diagnosis. Definite IE by pathologic criteria was found in 285 (13%), 285 (13%), and 345 (16%) patients using the Duke-Li 2000, Duke-ESC 2015, or the Duke-ISCVID 2023 criteria, respectively. IE was excluded by histopathology in 25 (1%) patients. The Duke-ISCVID 2023 clinical criteria showed a higher sensitivity (84%) compared to previous versions (70%). However, specificity of the new clinical criteria was lower (60%) compared to previous versions (74%). CONCLUSIONS: The Duke-ISCVID 2023 criteria led to an increase in sensitivity compared to previous versions. Further studies are needed to evaluate items that could increase sensitivity by reducing the number of IE patients misclassified as possible, but without having detrimental effect on specificity of Duke criteria.
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Enfermedades Transmisibles , Endocarditis Bacteriana , Endocarditis , Prótesis Valvulares Cardíacas , Humanos , Endocarditis Bacteriana/diagnóstico , Endocarditis/diagnóstico , Prótesis Valvulares Cardíacas/microbiología , Fluorodesoxiglucosa F18RESUMEN
BACKGROUND: Streptococci are a common cause of infective endocarditis (IE). We aimed to evaluate the performance of the HANDOC score to identify patients at high risk for IE and the Duke clinical criteria of the European Society of Cardiology (ESC; 2015 and 2023 versions) and the 2023 version from the International Society of Cardiovascular Infectious Diseases (ISCVID) in diagnosing IE among patients with streptococcal bacteremia. METHODS: This retrospective study included adult patients with streptococcal bacteremia hospitalized at Lausanne University Hospital. Episodes were classified as IE by the Endocarditis Team. A HANDOC score >2 classified patients as high risk for IE. RESULTS: Among 851 episodes with streptococcal bacteremia, IE was diagnosed in 171 episodes (20%). Among 607 episodes with non-ß-hemolytic streptococci, 213 (35%) had HANDOC scores >2 points; 132 (22%) had IE. The sensitivity of the HANDOC score to identify episodes at high risk for IE was 95% (95% confidence interval [CI], 90%-98%), the specificity 82% (95% CI, 78%-85%), and the negative predictive value (NPV) 98% (95% CI, 96%-99%). 2015 Duke-ESC, 2023 Duke-ISCVID, and 2023 Duke-ESC clinical criteria classified 114 (13%), 145 (17%), and 126 (15%) episodes as definite IE, respectively. Sensitivity (95% CI) for the 2015 Duke-ESC, 2023 Duke-ISCVID, and 2023 Duke-ESC clinical criteria was calculated at 65% (57%-72%), 81% (74%-86%), and 73% (65%-79%), respectively, with specificity (95% CI) at 100% (98%-100%), 99% (98%-100%), and 99% (98%-100%), respectively. CONCLUSIONS: The HANDOC score showed an excellent NPV to identify episodes at high risk for IE. Among the different versions of the Duke criteria, the 2023 Duke-ISCVID version fared better for the diagnosis of IE among streptococcal bacteremia.
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Bacteriemia , Infecciones Estreptocócicas , Humanos , Infecciones Estreptocócicas/diagnóstico , Infecciones Estreptocócicas/microbiología , Infecciones Estreptocócicas/complicaciones , Estudios Retrospectivos , Masculino , Femenino , Bacteriemia/diagnóstico , Bacteriemia/microbiología , Persona de Mediana Edad , Anciano , Sensibilidad y Especificidad , Endocarditis Bacteriana/diagnóstico , Endocarditis Bacteriana/microbiología , Endocarditis/diagnóstico , Endocarditis/microbiología , Endocarditis/complicaciones , AdultoRESUMEN
BACKGROUND: The Duke criteria for infective endocarditis (IE) diagnosis underwent revisions in 2023 by the European Society of Cardiology (ESC) and the International Society for Cardiovascular Infectious Diseases (ISCVID). This study aims to assess the diagnostic accuracy of these criteria, focusing on patients with Staphylococcus aureus bacteremia (SAB). METHODS: This Swiss multicenter study conducted between 2014 and 2023 pooled data from three cohorts. It evaluated the performance of each iteration of the Duke criteria by assessing the degree of concordance between definite S. aureus IE (SAIE) and the diagnoses made by the Endocarditis Team (2018-23) or IE expert clinicians (2014-17). RESULTS: Among 1344 SAB episodes analyzed, 486 (36%) were identified as cases of SAIE. The 2023 Duke-ISCVID and 2023 Duke-ESC criteria demonstrated improved sensitivity for SAIE diagnosis (81% and 82%, respectively) compared to the 2015 Duke-ESC criteria (75%). However, the new criteria exhibited reduced specificity for SAIE (96% for both) compared to the 2015 criteria (99%). Spondylodiscitis was more prevalent among patients with SAIE compared to those with SAB alone (10% vs 7%, P = .026). However, when patients meeting the minor 2015 Duke-ESC vascular criterion were excluded, the incidence of spondylodiscitis was similar between SAIE and SAB patients (6% vs 5%, P = .461). CONCLUSIONS: The 2023 Duke-ISCVID and 2023 Duke-ESC clinical criteria show improved sensitivity for SAIE diagnosis compared to 2015 Duke-ESC criteria. However, this increase in sensitivity comes at the expense of reduced specificity. Future research should aim at evaluating the impact of each component introduced within these criteria.
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Bacteriemia , Cardiología , Discitis , Endocarditis Bacteriana , Endocarditis , Infecciones Estafilocócicas , Humanos , Staphylococcus aureus , Endocarditis Bacteriana/diagnóstico , Endocarditis Bacteriana/epidemiología , Endocarditis/diagnóstico , Infecciones Estafilocócicas/diagnóstico , Infecciones Estafilocócicas/epidemiología , Bacteriemia/diagnóstico , Bacteriemia/epidemiologíaRESUMEN
In this retrospective/prospective study, we assessed the role of fundoscopy in 711 episodes with suspected infective endocarditis (IE); 238 (33%) had IE. Ocular embolic events (retinal emboli or chorioretinitis/endophthalmitis) and Roth spots were found in 37 (5%) and 34 (5%) episodes, respectively, but had no impact on IE diagnosis.
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Embolia , Endocarditis Bacteriana , Endocarditis , Humanos , Estudios de Cohortes , Estudios Retrospectivos , Estudios Prospectivos , Endocarditis/diagnóstico , Endocarditis Bacteriana/diagnóstico por imagenRESUMEN
Among 302 episodes with prosthetic valve endocarditis (PVE), one-year mortality was 31%. There was no evidence indicating that early-onset PVE within 6 months from valve surgery led to a worse outcome compared to late-onset PVE (21% versus 32%; p=0.126), despite similar redo valve surgeries across both categories.
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BACKGROUND: Diagnosing infective endocarditis (IE) poses a significant challenge. This study aimed to compare the diagnostic accuracy of the 2015 and 2023 Duke clinical criteria introduced by the European Society of Cardiology (ESC) in a cohort of patients suspected of having IE. METHODS: Conducted retrospectively at two Swiss University Hospitals between 2014-2023, the study involved patients with suspected IE. Each hospitals' Endocarditis Team categorized case as either IE or not IE. The performance of each iteration of the Duke-ESC clinical criteria was assessed based on the agreement between definite IE and the diagnoses made by the Endocarditis Team. RESULTS: Among the 3127 episodes with suspected IE, 1177 (38%) were confirmed to have IE. Using the 2015 Duke-ESC clinical criteria, 707 (23%) episodes were deemed definite IE, with 696 (98%) receiving a final IE diagnosis. With the 2023 Duke-ESC clinical criteria, 855 (27%) episodes were classified as definite IE, of which 813 (95%) were confirmed as IE. The 2015 and 2023 Duke-ESC clinical criteria categorized 1039 (33%) and 1034 (33%) episodes, respectively, as possible IE. Sensitivity for the 2015 Duke-ESC and the 2023 Duke-ESC clinical criteria was calculated at 59% (95% CI: 56-62%), and 69% (66-72%), respectively, with specificity at 99% (99-100%), and 98% (97-98%), respectively. CONCLUSIONS: The 2023 ESC criteria demonstrated significant improvements in sensitivity compared to the 2015 version, although one-third of episodes were classified as possible IE by both versions.
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PURPOSE: Embolic events (EEs) are a common complication of left-side infective endocarditis (IE). The aim of the present study was to identify risk factors for the occurrence of EEs before or after antibiotic treatment instauration among patients with definite or possible IE. METHODS: This retro-prospective study was conducted at the Lausanne University Hospital, Lausanne, Switzerland, from January 2014 to June 2022. EEs and IE were defined according to modified Duke criteria. RESULTS: A total of 441 left-side IE episodes were included (334: 76% were definite and 107; 24% possible IE). EE were diagnosed in 260 (59%) episodes; in 190 (43%) before antibiotic treatment initiation and 148 (34%) after. Central nervous system (184; 42%) was the most common site of EE. Multivariable analysis identified S. aureus (P 0.022), immunological phenomena (P < 0.001), sepsis (P 0.027), vegetation size ≥ 10 mm (P 0.003) and intracardiac abscess (P 0.022) as predictors of EEs before antibiotic treatment initiation. For EEs after antibiotic treatment initiation, multivariable analysis revealed vegetation size ≥ 10 mm (P < 0.001), intracardiac abscess (P 0.035) and prior EE (P 0.042), as independent predictors of EEs, while valve surgery (P < 0.001) was associated with lower risk for EEs. CONCLUSIONS: We reported a high percentage of EEs among patients with left-side IE; vegetation size, intracardiac abscess, S. aureus and sepsis were independently associated with the occurrence of EEs. In addition to antibiotic treatment, early surgery led to further decrease in EEs incidence.
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Embolia , Endocarditis Bacteriana , Endocarditis , Sepsis , Humanos , Staphylococcus aureus , Estudios Prospectivos , Absceso/complicaciones , Endocarditis Bacteriana/diagnóstico , Endocarditis/tratamiento farmacológico , Endocarditis/complicaciones , Factores de Riesgo , Embolia/etiología , Embolia/complicaciones , Sepsis/tratamiento farmacológico , Antibacterianos/uso terapéuticoRESUMEN
Background and Objectives: Dexmedetomidine, an alpha-2 agonist, is used as an adjunct to anesthesia in enhanced recovery after surgery (ERAS) programs. One of its advantages is the opioid-sparing effect which can facilitate early extubation and recovery. When the ERAS cardiac society was set in 2017, our facility was already using the ERAS program, in which the "fast-track Anesthesia" was facilitated by the intraoperative infusion of dexmedetomidine. Our objective is to share our experience and investigate the potential impact of intraoperative dexmedetomidine use as a part of the ERAS program on patient outcomes in elective cardiac surgery. Materials and Methods: An observational retrospective cohort study was conducted at a university hospital in Switzerland. The patients who underwent elective cardiac surgery with cardiopulmonary bypass between 1 June 2017 and 31 August 2018 were included in this analysis (n = 327). Regardless of the surgery type, all the patients received a standardized fast-track anesthesia protocol inclusive of dexmedetomidine infusion, reduced opioid dose, and parasternal nerve block. The primary outcome was the postoperative time when the criteria for extubation were met. Three groups were identified: group 0-(extubated in the operating room), group < 6 (extubated in less than 6 h), and group > 6 (extubated in >6 h). The secondary outcomes were adverse events, length of stay in ICU and in hospital, and total hospitalization costs. Results: Dexmedetomidine was well-tolerated, with no significant adverse events reported. Early extubation was performed in 187 patients (57%). Group 3 had a significantly longer length of stay in the ICU (median: 70 h vs. 25 h) and in hospital (17 vs. 12 days), and consequently higher total hospitalization costs (CHF 62,551 vs. 38,433) compared to the net data from the other two groups (p < 0.0001). Conclusions: Our findings suggest that dexmedetomidine can be safely used as part of the opioid-sparing anesthesia protocol in patients undergoing elective cardiac surgery with cardiopulmonary bypass with the potential to facilitate early extubation, shorter ICU and hospital stays, and reduced hospitalization costs.
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Procedimientos Quirúrgicos Cardíacos , Dexmedetomidina , Recuperación Mejorada Después de la Cirugía , Humanos , Dexmedetomidina/administración & dosificación , Dexmedetomidina/uso terapéutico , Estudios Retrospectivos , Masculino , Femenino , Procedimientos Quirúrgicos Cardíacos/métodos , Persona de Mediana Edad , Anciano , Recuperación Mejorada Después de la Cirugía/normas , Estudios de Cohortes , Suiza , Tiempo de Internación/estadística & datos numéricos , Cuidados Intraoperatorios/métodosRESUMEN
BACKGROUND: Cerebral embolic events (CEEs) are common complications of infective endocarditis (IE), and their presence can modify diagnosis and therapeutic plans. The aim of the present study was to assess the role of cerebral imaging (Cer-Im) on diagnosis and management of patients with suspected IE. METHODS: This study was conducted at the Lausanne University Hospital, Lausanne, Switzerland, from January 2014 to June 2022. CEEs and IE were defined according to modified Duke criteria of the European Society of Cardiology (ESC) guidelines. RESULTS: Among 573 patients with IE suspicion and Cer-Im, 239 (42%) patients had neurological symptoms. At least 1 CEE was found in 254 (44%) episodes. Based on Cer-Im findings, episodes were reclassified from rejected to possible or from possible to definite IE in 3 (1%) and 25 (4%) patients, respectively (0% and 2% in asymptomatic patients, respectively). Among the 330 patients with possible or definite IE, at least 1 CEE was found in 187 (57%) episodes. A new surgical indication (in association with left-side vegetation >10 mm) was established in 74/330 (22%) IE patients and 30/155 (19%) asymptomatic IE patients, respectively. CONCLUSIONS: Cer-Im in asymptomatic patients with IE suspicion showed limited potential for improving the diagnosis of IE. In contrast, performing Cer-Im in asymptomatic patients with IE may be useful for decision making, because Cer-Im findings led to the establishment of new operative indication for valvular surgery in one fifth of patients according to ESC guidelines.
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Endocarditis Bacteriana , Endocarditis , Humanos , Endocarditis/diagnóstico por imagen , Endocarditis Bacteriana/diagnóstico por imagen , Endocarditis Bacteriana/terapia , SuizaRESUMEN
OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) has been the favored approach for the treatment of type B aortic dissection (TBAD). To obtain an adequate proximal landing zone, coverage of the left subclavian artery (LSA) will often be necessary. The occurrence of possible neurologic complications has continued to be debated. We investigated the management of the LSA in patients with TBAD undergoing endovascular repair. METHODS: We searched the PubMed and MEDLINE databases to October 2020 for studies of TEVAR for TBAD. Data on the study design, demographics, endograft details, LSA coverage and revascularization, mortality, complications, and follow-up were extracted and analyzed. The effects of LSA coverage and revascularization on neurologic complications and outcomes were investigated. RESULTS: A total of 26 reports (24 retrospective and 2 prospective) were deemed eligible for our study. A total of 1483 patients (mean age, 56.9 ± 6.2 years) had undergone TEVAR for acute (n = 932; 62.9%), subacute (n = 36; 2.4%), or chronic (n = 515; 34.7%) TBAD, with a success rate of 97.8% and hospital mortality of 4.9%. The LSA origin had been covered for 707 patients (47.7%), and 326 had undergone LSA revascularization (surgical, n = 96; endovascular, n = 170; unspecified or not reported, n = 60). LSA revascularization was concomitant for 68.1% of cases, after TEVAR for 1.8%, and not reported for 30.1%. Of 1146 patients, 10 (0.9%) had experienced left arm claudication, and the overall stroke rate was 3.3% (2.7% for the LSA group and 1% for the uncovered LSA group; P = .0815). Of the patients with stroke and a covered LSA, 1% (2 of 203) had undergone LSA revascularization and 4.8% (5 of 105) had not (P = .0478). Twenty-six patients (1.9%) had developed paraplegia: 0.7% (3 of 433) with a covered LSA, 1.4% (7 of 491) with an uncovered LSA (P = .3508), and not reported for 16 patients. Endoleak was present in 138 patients (13.4%) at a mean follow-up of 32.1 ± 25.6 months. CONCLUSIONS: Our review has shown that LSA coverage during endovascular repair for complicated TBAD will does not significantly increase the risk of neurologic complications; however, revascularization of the LSA should be always recommended.
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Aneurisma de la Aorta Torácica , Disección Aórtica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Humanos , Persona de Mediana Edad , Prótesis Vascular , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/cirugía , Implantación de Prótesis Vascular/efectos adversos , Estudios Retrospectivos , Estudios Prospectivos , Resultado del Tratamiento , Procedimientos Endovasculares/efectos adversos , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/cirugía , Stents , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugíaRESUMEN
OBJECTIVE: Small-diameter endografts can be used for the treatment of the peripheral vascular disease, but the patency rate during the follow-up is still under debate. With this review, we aimed at analyzing the mid-term patency of small-diameter Viabahn stent-grafts and investigating the relationship between patency and the length of the graft. METHODS: We performed a review of articles published until September 2020 and reporting use of ≤7-mm-diameter Viabahn stent-grafts in diseased peripheral arteries. Data on study type, demographic, lesion length, stent-graft diameter, length, and patency (1-year, 3-year, 5-year primary patency, primary-assisted patency, and secondary patency), follow-up, endoleak, and re-intervention rates were extracted and analyzed. A statistical test was applied to identify a correlation between stent-graft length and patency. RESULTS: 16 retrospective and 7 prospective studies reported the outcome of 1613 patients (mean age: 69.6±33.7 years). There was considerable heterogeneity in reporting standards among studies. The diameter of Viabahn stent-grafts ranged 5 to 7mm and the average length was 23.6±12.4cm. Heparin-bonded grafts were used in 46.4% of cases. Mean follow-up time was 26.4±17.6 months. The 1- and 5-year primary patency rate was 75.7% (95% CI, 73.6%-77.8%) and 46.8% (95% CI, 41.0%-52.6%), respectively. The 1- and 5-year primary-assisted patency rate was 80.9% (95% CI, 73.9%-87.8%) and 60.9% (95% CI, 46.4-75.5%), respectively. The 1- and 5-year second-assisted patency was 90.4% (95% CI, 87.4%-93.3%) and 73.7% (95% CI, 64.7%-82.8%), respectively. No correlation between the stent-graft length and patency was found. CONCLUSIONS: Small-diameter Viabahn stent-graft implantation represents a safe treatment for patients with peripheral artery disease, and the mid-term patency rate seems not be affected by the length of the graft. CLINICAL IMPACT: The use of small diameter stent-grafts for peripheral vascular disease is an established technique but the patency rate is still under debate. With this review we have investigated the relationship between the mid-term patency and the diameter of the stent-grafts. Afterv having analysed data from 23 published studies including 1613 patients we can conclude that the treatment of the peripheral artery disease with small diameter stent-grafts is safe and the mid-term patency rate seems not be affected by the lenght of the grafts.
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Few patients with coronavirus disease 2019-associated severe acute respiratory distress syndrome (ARDS) require veno-venous extracorporeal membrane oxygenation (VV-ECMO). Prolonged VV-ECMO support necessitates repeated oxygenator replacement, increasing the risk for complications. Transient hypoxemia, induced by VV-ECMO stop needed for this procedure, may induce transient myocardial ischemia and acutely declining cardiac output in critically ill patients without residual pulmonary function. This is amplified by additional activation of the sympathetic nervous system (tachycardia, pulmonary vasoconstriction, and increased systemic vascular resistance). Immediate reinjection of the priming solution of the new circuit and induced acute iatrogenic anemia are other potentially reinforcing factors. The case of a critically ill patient presented here provides an instructive illustration of the hemodynamic relationships occurring during VV-ECMO support membrane oxygenator exchange.
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COVID-19 , Oxigenación por Membrana Extracorpórea , Síndrome de Dificultad Respiratoria , Humanos , COVID-19/terapia , Enfermedad Crítica , Oxigenación por Membrana Extracorpórea/efectos adversos , Oxigenación por Membrana Extracorpórea/métodos , Hemodinámica , Oxigenadores , Síndrome de Dificultad Respiratoria/etiología , Síndrome de Dificultad Respiratoria/terapia , SARS-CoV-2RESUMEN
BACKGROUND AND AIM OF THE STUDY: Guidelines indicate for type 5 myocardial infarction (MI) that postoperative troponin need not be exclusively ischemic but may also be caused by epicardial injury. Complexity arises from the introduction of high-sensitive troponin. This study attempts to contribute to the understanding of postoperative high-sensitive cardiac troponin T (hs-cTnT) increase. METHODS: The median enzyme increase of different cardiac operations was compared. Linear regression analyses were used to determine correlations between enzyme rise and independent parameters. Receiver-operating characteristics (ROC) served to evaluate the discriminatory power of enzyme rise in detecting ischemia and to determine possible thresholds. RESULTS: Among 400 patients, 2.8% had intervention-related ischemia analogous to type 5 MI definition. The median postoperative hs-cTnT/creatine kinase myocardial band (CK-MB) increase varied according to types of surgery, with highest increase after mitral valve and lowest after off-pump coronary surgery. After ruling out patients with preoperatively elevated hs-cTnT, regression analysis confirmed Maze procedure (p < .001), intra-pericardial defibrillation (p = .002), emergency intervention (p = .01), blood transfusions (p = .02), and cardiopulmonary bypass time (p = .03) as significant factors associated with hs-cTnT increase. In addition, CK-MB increase was associated with mortality (p = .002). ROC confirmed good discriminatory power for hs-cTnT and CK-MB with ischemia-indicating thresholds of 1705.5 ng/L (hs-cTnT) and 113 U/L (CK-MB) considering different types of operations. CONCLUSIONS: The Influence of the type of surgery and intervention-related parameters on hs-cTnT increase was confirmed. Potential thresholds indicating perioperative ischemia appear to be significantly elevated for high sensitive markers.
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Infarto del Miocardio/diagnóstico , Troponina T , Biomarcadores , Creatina Quinasa , Humanos , Periodo Posoperatorio , Troponina T/sangreRESUMEN
Aspergillus endocarditis is a rare infection that may affect immunocompetent patients following heart valve replacement or heart surgery. We report the case of a 39 year old woman with a history of intravenous drug use who developed endocarditis with direct examination of the resected valve and vegetation showing the presence of mycelia. Cultures were positive for an Aspergillus of section Nigri, which was subsequently identified as Aspergillus tubingensis by sequencing. The clinical course was favorable following surgery and prolonged antifungal therapy (8 months in total). Antifungal susceptibility testing showed good in vitro activity of amphotericin B, voriconazole and echinocandins against planktonic cells of this A. tubingensis isolate. However, only amphotericin B displayed significant activity against biofilms. In vitro combinations of voriconazole or amphotericin B with echinocandins did not meet the criteria of synergism. Our review of the literature identified 17 other cases of endocarditis attributed to Aspergillus of section Nigri with an overall mortality rate of 57% (100% in the absence of surgery). Endocarditis caused by Aspergillus niger and related cryptic species are rare events, for which surgical management appears to be crucial for outcome. While amphotericin B was the only antifungal drug displaying significant anti-biofilm activity, the type and duration of antifungal therapy remain to be determined.
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Aspergilosis , Endocarditis , Adulto , Anfotericina B/farmacología , Anfotericina B/uso terapéutico , Antifúngicos/farmacología , Antifúngicos/uso terapéutico , Aspergilosis/diagnóstico , Aspergilosis/tratamiento farmacológico , Aspergilosis/microbiología , Aspergillus , Equinocandinas/farmacología , Equinocandinas/uso terapéutico , Endocarditis/diagnóstico , Endocarditis/tratamiento farmacológico , Femenino , Humanos , Pruebas de Sensibilidad Microbiana , Voriconazol/farmacología , Voriconazol/uso terapéuticoRESUMEN
BACKGROUND: Postoperative atrial fibrillation (POAF) is the most common complication occurring after cardiac surgery. Guidelines for the management of this complication are scarce, often resulting in differences in treatment strategy use among patients. OBJECTIVE: To evaluate the management of POAF in a cardiac surgery department, characterize the extent of its variability, and develop a standardized protocol. METHODS: This was an observational retrospective study with data from patients who underwent cardiac surgeries with subsequent POAF between January 1, 2017, and June 1, 2018. We assessed the difference in the proportions of patients whose first POAF episodes were treated with a rate control (RaC) strategy, a rhythm control (RhC) strategy, and both among different hospital units. We also assessed the mean duration of POAF episodes, POAF recurrences, and the management of anticoagulation. RESULTS: Data from 97 patients were included in this study. The POAF management strategy differed significantly among the 3 types of hospital units (P = 0.001). Considering all POAF episodes (including all recurrences), 83 of the 97 patients (85.6%) received amiodarone as part of the RhC strategy. Anticoagulation was used in 58 (59.8%) patients and was suboptimal according to the study criteria in 29.5% of the patients included. Based on these results, a hospital working group developed a standardized protocol for POAF management. CONCLUSIONS AND RELEVANCE: POAF management was heterogeneous at our institution. This article highlights the need for clear practice guidelines based on large prospective studies to provide care according to best practices.
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Fibrilación Atrial , Procedimientos Quirúrgicos Cardíacos , Fibrilación Atrial/epidemiología , Fibrilación Atrial/etiología , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Humanos , Estudios Observacionales como Asunto , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: High levels of arterial oxygen pressures (PaO2) have been associated with increased mortality in extracorporeal cardiopulmonary resuscitation (ECPR), but there is limited information regarding possible mechanisms linking hyperoxia and death in this setting, notably with respect to its hemodynamic consequences. We aimed therefore at evaluating a possible association between PaO2, circulatory failure and death during ECPR. METHODS: We retrospectively analyzed 44 consecutive cardiac arrest (CA) patients treated with ECPR to determine the association between the mean PaO2 over the first 24 h, arterial blood pressure, vasopressor and intravenous fluid therapies, mortality, and cause of deaths. RESULTS: Eleven patients (25%) survived to hospital discharge. The main causes of death were refractory circulatory shock (46%) and neurological damage (24%). Compared to survivors, non survivors had significantly higher mean 24 h PaO2 (306 ± 121 mmHg vs 164 ± 53 mmHg, p < 0.001), lower mean blood pressure and higher requirements in vasopressors and fluids, but displayed similar pulse pressure during the first 24 h (an index of native cardiac recovery). The mean 24 h PaO2 was significantly and positively correlated with the severity of hypotension and the intensity of vasoactive therapies. Patients dying from circulatory failure died after a median of 17 h, compared to a median of 58 h for patients dying from a neurological cause. Patients dying from neurological cause had better preserved blood pressure and lower vasopressor requirements. CONCLUSION: In conclusion, hyperoxia is associated with increased mortality during ECPR, possibly by promoting circulatory collapse or delayed neurological damage.
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Reanimación Cardiopulmonar/efectos adversos , Oxigenación por Membrana Extracorpórea/efectos adversos , Paro Cardíaco/complicaciones , Hiperoxia/etiología , Choque/etiología , Femenino , Paro Cardíaco/mortalidad , Paro Cardíaco/terapia , Mortalidad Hospitalaria , Humanos , Hiperoxia/mortalidad , Masculino , Persona de Mediana Edad , Oxígeno/sangre , Estudios RetrospectivosRESUMEN
For a decade, aortic valve replacement (AVR) surgery has been simplified thanks to the development of sutureless or rapid deployment valves (SU-RD valves), which offer an alternative to sutured valves. These SU-RD valves, inspired by the TAVI (Transcatheter Aortic Valve Implantation), allow significant operating time reduction and facilitate minimally invasive surgery. They are particularly indicated for patients that are more fragile and in combined procedures (for example AVR associated with coronary bypass surgery). Recent studies report high reliability and excellent outcomes with lower morbidity and mortality compared to other AVR modalities, including TAVI. Considering the constant technical improvement, SU-DR valves may become the new standard in AVR.
Depuis une décennie, la chirurgie du remplacement valvulaire aortique (RVA) s'est simplifiée grâce à l'apparition de valves dites « sutureless ¼ ou à « déploiement rapide ¼ (valves SU-DR) qui offrent une alternative aux valves suturées. Ces valves SU-DR, inspirées du Transcatheter Aortic Valve Implantation (TAVI), permettent un gain de temps opératoire important et facilitent la chirurgie mini-invasive. Elles sont notamment indiquées chez les patients plus fragiles et lors de procédures combinées (par exemple, RVA et pontages coronariens associés). Des études récentes rapportent une grande fiabilité et d'excellents résultats avec une moindre morbi-mortalité par rapport aux autres modalités de RVA, y compris le TAVI. Considérant l'amélioration technique constante, les valves SU-RD pourraient bien devenir le nouveau standard dans le RVA.
Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Reemplazo de la Válvula Aórtica Transcatéter , Válvula Aórtica/cirugía , Humanos , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: Outcomes after VAD implantation may be dependent on institutional procedural volume. Specifically, it is claimed that high volumes are associated to better clinical results. This study aims to determine if this procedure is safe even in low-volume center. METHODS: Single center, retrospective cohort study, including Heart Failure consecutive patients who received long-term VAD from 2007 to 2017. Primary outcome was survival to transplant or ongoing MCS at 1-year. Survival analysis was performed using Kaplan-Meier method. RESULTS: Data concerning 50 adult patients were examined; 35 male (70%), mean age 49+/- 8 years. VAD was implanted as BTT in 48 and DT in 2. Devices implanted were: HeartMate II in 18 (36%), HeartWare in 20 (40%), HeartMate III in 12 (24%). Outcomes were: Death in 16 (32%), heart transplant in 24 (48%), uneventful ongoing support 10 (20%). Data were analysed according to pre and post-heart team creation and 2 groups of 25 patients were identified: 2007-2013 (mean INTERMACS level 3.1) and 2014-2017 (mean INTERMACS level 3.9) showing 1-year survival of 56% and 80% respectively. According to the type of device implanted, 3 groups were identified: HMII = 18 (mean INT. level 2.7), HW=20 (mean INT. level 3.3) and HMIII=12 (mean INT. level 3.7), showing survival of 52%, 78% and 91% respectively. CONCLUSIONS: Long term MCS can be implanted at low-volume centers with survival rate not inferior to high volume centers. A Heart team specifically trained in heart failure is probably more important than institutional volume in determining outcomes after VAD implantation.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Insuficiencia Cardíaca/cirugía , Corazón Auxiliar , Hospitales de Bajo Volumen/estadística & datos numéricos , Grupo de Atención al Paciente , Rol del Médico , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Suiza/epidemiología , Resultado del TratamientoRESUMEN
Despite the benefit of the drugs acting on neuro-humoral activation and cardiac resynchronization therapy, some patients will end in a severe refractory form of heart failure: advanced heart failure. The only therapeutic options with a positive impact on mortality and quality of life are heart transplantation and permanent left ventricular assist device (LVAD). The significant technological improvements of the past 20 years lead to a reduction of the complications associated with these devices, which now allow their use not only during the waiting period preceding heart transplantation (bridge to transplant), but also as a durable therapeutic option (destination therapy).
Malgré le bénéfice des médicaments agissant sur l'activation neuro-humorale et de la thérapie de resynchronisation, certains patients vont évoluer vers une forme sévère et réfractaire d'insuffisance cardiaque : l'insuffisance cardiaque avancée (ICA). Les seules options thérapeutiques de l'ICA ayant démontré un impact favorable sur la survie et la qualité de vie sont la transplantation cardiaque et l'implantation d'un dispositif d'assistance ventriculaire gauche permanent (LVAD, Left Ventricular Assist Device). Les importantes améliorations technologiques des vingt dernières années ont permis de réduire significativement les complications associées à ces dispositifs, permettant non seulement leur utilisation dans l'attente du greffe cardiaque (bridge to transplant), mais aussi comme option thérapeutique définitive (destination therapy).
RESUMEN
Acute spinal cord ischemia during thoracoabdominal aorta replacement is a dreadful complication. Existing tools (motor evoked potential [MEP] and somatosensory evoked potential [SSEP]) do not allow differentiating between central and peripheral paraplegia. Therefore, the surgeon often performs unnecessary reimplantation of intercostal arteries: this is time consuming, and significantly increases bleeding complications. We present a simple technique combining MEP and peripheral compound muscle action potential induced by posterior tibialis nerve stimulation, enabling the surgeon to quickly discriminate between central and peripheral neurologic injury. The surgeon has one more tool to drive in real time the optimal surgical strategy. This strategy guides the decision as to which side branches ought to be reimplanted, thus minimizing the risk of paraplegia.