Impact of antimicrobial therapy on prognosis of patients requiring valve surgery during active infective endocarditis.

OBJECTIVES: We examined the characteristics and outcomes of patients requiring valve surgery during active infective endocarditis (IE), focusing on the impact of antimicrobial therapy. METHODS: In this retrospective study, medical charts of all consecutive patients admitted to our cardiovascular surgery department from January 1998 to December 2010, with a diagnosis of IE requiring surgical management, were reviewed. Adult patients were enrolled in the study if they had definite or possible active IE and if the antimicrobial treatment was evaluable. RESULTS: After initial screening of medical records, we selected 173 surgically treated patients (135 men; mean age, 55.8 years). Native valves were involved in 150 (87%) patients. IE mainly involved the aortic valve (n = 113) and then mitral (n = 83), tricuspid (n = 13), and pulmonary (n = 3) valves. The most common causative pathogens were streptococci (n = 70), staphylococci (n = 60), and enterococci (n = 29). Operative mortality was 15%. Multivariate logistic regression analysis demonstrated that adequacy of the overall antimicrobial treatment (adjusted odds ratio, 0.292; 95% confidence interval, 0.117-0.726; P = .008) and temperature greater than 38°C at the time of diagnosis (adjusted odds ratio, 0.288; 95% confidence interval, 0.115-0.724; P = .008) were independently associated with a lower risk of mortality. Conversely, age greater than 60 years (adjusted odds ratio, 4.42; 95% confidence interval, 1.57-12.4; P = .005) was associated with a greater risk of operative mortality. CONCLUSIONS: Surgery for active IE is still associated with a high mortality rate, but its prognosis is significantly improved by adequate antimicrobial therapy.

Endovascular fenestration in aortic dissection with acute malperfusion syndrome: immediate and late follow-up.

OBJECTIVE: To evaluate the immediate and long-term results of fenestration in aortic dissection with acute malperfusion syndrome. METHODS: Between 1999 and 2007, 35 patients (31 men; age, 57 ± 11 years) with aortic dissection (19 with type A and 16 with type B) were treated by fenestration for malperfusion syndrome (27 renal, 27 bowel, and 14 lower limb) due to dynamic compression. Fenestration was performed with 2 rigid guidewires inserted in one 8F sheath (45 cm long). The mean interval between aortic dissection and fenestration was 5 days (28 patients within 3 days and 7 patients between 9 and 41 days). RESULTS: Fenestration (100% technical success rate) with an additional endovascular procedure (29 peripheral stents and 1 thoracic stent graft) resulted in angiographic success in 97% of the patients. Bowel surgery was performed in 7 patients. Mortality within the first month (12/35) was related to bowel ischemia (n = 5), neurologic complications (n = 3), type A surgery (n = 2), and late treatment (n = 2). At a mean follow-up of 48 ± 30 months, 4 of the remaining 23 patients had died and 2 had withdrawn from the study. The diameter of the aorta, as measured using computed tomography/magnetic resonance imaging, remained stable in 12 of the remaining 17 patients and had increased in 5 (1 with Marfan syndrome and 4 with multiple arterial ectasia). CONCLUSIONS: In emergencies, fenestration saved 69% of the patients with acute malperfusion syndrome in complicated aortic dissection. During the follow-up period, the aortic diameter remained stable in most of the surviving patients.

[Chronic aortic syndrome: how to follow patients, which complications and when to treat?]. / Syndromes aortiques: à distance de la phase aiguë, comment surveiller l'aorte et quel traitement spécifique proposer?

After the acute phase, if patient survives, the disease is still present. Chronic stage is defined as the period after the first month following the acute phase. Follow-up of the thoracic aorta is mandatory and even at the abdominal level to check the risk of rupture. In case of aortic dissection, late complications such as chronic malperfusion syndrome, but also secondary localisation of the disease, the risk factor indicate a role for the global management of the patient. The main objective of this article is to insist on the necessity to a close follow-up.

Profile of macrophages in human abdominal aortic aneurysms: a transcriptomic, proteomic, and antibody protein array study.

Abdominal aortic aneurysms (AAA) are defined by an increased aortic diameter and characterized by impairment of the extracellular matrix, macrophages infiltration and decreased density of smooth muscle cells. Our aim is to identify the key molecules involved in the pathogenesis of AAAs. This study investigated transcriptomic and proteomic profiles of macrophages from AAA patients (>50 mm aortic diameter) (n = 24) and peripheral arterial occlusion (PAO) patients without AAA detected (n = 18), who both needed a surgery. An antibody protein microarray, generated by printing antibodies onto membranes against proteins selected from the transcriptomic and proteomic analysis, was performed to validate the proteins differentially expressed specifically in macrophages and plasma from the same patients. We found a restricted number of proteins differentially expressed between AAA and PAO patients: TIMP-3, ADAMTS5, and ADAMTS8 that differ significantly in plasma of AAA patients compared to PAO patients, as found in the macrophages. In contrast to plasma MMP-9, soluble glycoprotein V (sGPV) and plasmin-antiplasmin complex levels, plasma TIMP-3 levels were not correlated to AAA size but interestingly correlated to sGPV, a platelet activation marker. Combining transcriptomic and proteomic is a valid approach to identify diseases causing proteins and potential biomarkers.

A new form of coronary subclavian steal syndrome: 'the spinning wheels' syndrome.

Coronary subclavian steal syndrome refers to decreased or reversed internal mammary artery flow, which causes angina related to severe subclavian steno-occlusive disease in patients with in situ internal mammary-to-coronary artery graft. We report a case, the first in the literature, of a right internal mammary artery-coronary-subclavian unidirectional steal syndrome. Clinical features, pathophysiology, and diagnostic and therapeutic strategies of this unusual adverse event are discussed.

Extracorporeal membrane oxygenation in severe acute respiratory failure in postpartum woman with rheumatic mitral valve disease: benefit, factors furthering the success of this procedure, and review of the literature.

Pregnancy is a common decompensation factor for women with post-rheumatic mitral disease. However, valvular heart diseases causing severe acute respiratory distress are rare. Use of extracorporeal membrane oxygenation (ECMO) early in the event of cardiorespiratory failure after cardiac surgery may be of benefit. Indeed, ECMO cardiopulmonary bypass (CPB) support could help pulmonary recovery if the mitral pathology is involved. A 31-year-old female patient at 30 weeks of amenorrhea was admitted to the obstetrics department with 40 degrees C hyperthermia and New York Heart Association (NYHA) class 4 dyspnea. The patient's medical history included a post-rheumatic mitral stenosis. Blood gases showed severe hypoxemia associated with hypocapnia. The patient needed to be rapidly intubated and was placed on ventilatory support because of acute respiratory failure. Transesophageal echocardiography showed a severe mitral stenosis, mild mitral insufficiency, and diminished left ventricular function, hypokinetic, dilated right ventricle, and a severe tricuspid regurgitation. An urgent cesarean section was performed. Because of the persistent hemodynamic instability, a mitral valvular replacement and tricuspid valve annuloplasty were performed. In view of the preoperative acute respiratory distress, we decided, at the beginning of the operation, to carry on circulatory support with oxygenation through an ECMO-type CPB at the end of the operation. This decision was totally justified by the unfeasible CPB weaning off. ECMO use led to an efficient hemodynamic state without inotropic drug support. The surgical post-operative course was uneventful. Early use of cardiorespiratory support with veno-arterial ECMO allows pulmonary and right heart recovery after cardiac surgery, thus avoiding the use of inotropic drugs and complex ventilatory support.