Extracorporeal Membrane Oxygenation for Respiratory Failure Related to COVID-19: A Nationwide Cohort Study.

BACKGROUND: Despite expanding use, knowledge on extracorporeal membrane oxygenation support during the COVID-19 pandemic remains limited. The objective was to report characteristics, management, and outcomes of patients receiving extracorporeal membrane oxygenation with a diagnosis of COVID-19 in France and to identify pre-extracorporeal membrane oxygenation factors associated with in-hospital mortality. A hypothesis of similar mortality rates and risk factors for COVID-19 and non-COVID-19 patients on venovenous extracorporeal membrane oxygenation was made. METHODS: The Extracorporeal Membrane Oxygenation for Respiratory Failure and/or Heart failure related to Severe Acute Respiratory Syndrome-Coronavirus 2 (ECMOSARS) registry included COVID-19 patients supported by extracorporeal membrane oxygenation in France. This study analyzed patients included in this registry up to October 25, 2020, and supported by venovenous extracorporeal membrane oxygenation for respiratory failure with a minimum follow-up of 28 days after cannulation. The primary outcome was in-hospital mortality. Risk factors for in-hospital mortality were analyzed. RESULTS: Among 494 extracorporeal membrane oxygenation patients included in the registry, 429 were initially supported by venovenous extracorporeal membrane oxygenation and followed for at least 28 days. The median (interquartile range) age was 54 yr (46 to 60 yr), and 338 of 429 (79%) were men. Management before extracorporeal membrane oxygenation cannulation included prone positioning for 411 of 429 (96%), neuromuscular blockage for 419 of 427 (98%), and NO for 161 of 401 (40%). A total of 192 of 429 (45%) patients were cannulated by a mobile extracorporeal membrane oxygenation unit. In-hospital mortality was 219 of 429 (51%), with a median follow-up of 49 days (33 to 70 days). Among pre-extracorporeal membrane oxygenation modifiable exposure variables, neuromuscular blockage use (hazard ratio, 0.286; 95% CI, 0.101 to 0.81) and duration of ventilation (more than 7 days compared to less than 2 days; hazard ratio, 1.74; 95% CI, 1.07 to 2.83) were independently associated with in-hospital mortality. Both age (per 10-yr increase; hazard ratio, 1.27; 95% CI, 1.07 to 1.50) and total bilirubin at cannulation (6.0 mg/dl or more compared to less than 1.2 mg/dl; hazard ratio, 2.65; 95% CI, 1.09 to 6.5) were confounders significantly associated with in-hospital mortality. CONCLUSIONS: In-hospital mortality was higher than recently reported, but nearly half of the patients survived. A high proportion of patients were cannulated by a mobile extracorporeal membrane oxygenation unit. Several factors associated with mortality were identified. Venovenous extracorporeal membrane oxygenation support should be considered early within the first week of mechanical ventilation initiation.

Risk Factors and Consequences of Late-Onset Hyperlactatemia After Cardiac Surgery With Cardiopulmonary Bypass: A Single-Center Retrospective Study.

OBJECTIVE: Mechanisms and consequences of late-onset hyperlactatemia after cardiac surgery remain unclear. The aim of this study was to identify risk factors and outcomes of late hyperlactatemia, defined as a lactate value ≥3 mmol/L developing in the intensive care unit (ICU) after not being elevated on admission after cardiac surgery with cardiopulmonary bypass. DESIGN: A retrospective analysis of prospectively collected data. SETTING: A single-center University Hospital. PARTICIPANTS: Patients who underwent elective cardiac surgery with cardiopulmonary bypass in 2019 and who had normal lactatemia at ICU admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were divided in 2 groups according to their lactatemia on postoperative day 1 (14.0 ± 3.0 hours after ICU admission): normal lactatemia (control group) and late hyperlactatemia (HL group). Risk factors for late hyperlactatemia were identified using a multivariate analysis, and postoperative outcomes were compared using a composite criterion of severe outcomes. Of the 432 included patients, 37 (8.5%) presented with late hyperlactatemia. Risk factors independently associated with hyperlactatemia were afternoon surgery (odds ratio [OR] 4.24, 95% CI 2.00-9.35), a bleeding >300 mL within the 6 hours after surgery (H6) (OR 3.77, 95% CI 1.71-8.30), and H6 fluid loading >250 mL (OR 2.64, 95% CI 1.22-5.55). Patients with hyperlactatemia presented more frequently with major postoperative complications, including acute kidney injury, and received more frequent red-cell transfusion. CONCLUSION: The strongest risk factors associated with late-onset hyperlactatemia in the authors' population were afternoon surgery and H6 bleeding >300 mL. Poor postoperative outcomes were more frequent in patients with late hyperlactatemia, even in the absence of early hyperlactatemia or severe obvious condition.

Metabolomic Profiling of Angiotensin-II-Induced Abdominal Aortic Aneurysm in Ldlr-/- Mice Points to Alteration of Nitric Oxide, Lipid, and Energy Metabolisms.

Aneurysm is the second-most common disease affecting the aorta worldwide after atherosclerosis. While several clinical metabolomic studies have been reported, no study has reported deep metabolomic phenotyping in experimental animal models of aortic aneurysm. We performed a targeted metabolomics study on the blood and aortas of an experimental mice model of aortic aneurysm generated by high-cholesterol diet and angiotensin II in Ldlr-/- mice. The mice model showed a significant increase in media/lumen ratio and wall area, which is associated with lipid deposition within the adventitia, describing a hypertrophic remodeling with an aneurysm profile of the abdominal aorta. Altered aortas showed increased collagen remodeling, disruption of lipid metabolism, decreased glucose, nitric oxide and lysine metabolisms, and increased polyamines and asymmetric dimethylarginine (ADMA) production. In blood, a major hyperlipidemia was observed with decreased concentrations of glutamine, glycine, taurine, and carnitine, and increased concentrations of the branched amino acids (BCAA). The BCAA/glycine and BCAA/glutamine ratios discriminated with very good sensitivity and specificity between aneurysmatic and non-aneurysmatic mice. To conclude, our results reveal that experimental induction of aortic aneurysms causes a profound alteration in the metabolic profile in aortas and blood, mainly centered on an alteration of NO, lipid, and energetic metabolisms.

Extracorporeal circulation during on-pump cardiac surgery: An evaluation of the energy equivalent pressure index based on waveforms decomposition in harmonics.

The use of pulsatile perfusion instead of nonpulsatile perfusion during cardiopulmonary bypass continues to be a source of debate. The disagreements among the conclusions of the published studies may be due to different factors: differences in the type of patients included in the studies, differences in the protocol of the studies, and difficulty to quantify the pulsatility of the flow. In the present paper, we propose a quantitative evaluation of Shepard's energy equivalent pressure index, based on the harmonic decomposition of the physiological aortic pressure and flow rate signal. It is thus demonstrated that the surplus energy provided by pulsatile flow remains moderate (of order 10 mm Hg), but that it can be improved by changing the relative shapes of the pressure and flow waves.

Combined frozen elephant trunk and endovascular repair for extensive thoracic aortic aneurysms.

BACKGROUND: We describe a 1-step treatment of extensive arch and descending aortic aneurysm by combination of frozen elephant trunk (FET) (hybrid endoprosthesis) and of conventional endoprosthesis deployment. METHODS: In a single-center, prospective, treatment-only study, the clinical data of 4 patients receiving combined FET and distal endoprosthesis deployment in the descending aorta were prospectively collected. Thoracic endoprostheses were deployed either retrogradely (off-pump from the femoral arterial access) or antegradely (from the aortic arch during hypothermic arrest). A distal-first approach was used ("trombone" mechanism). Spinal cord protection was achieved by transposition of the left subclavian artery to the left common carotid artery and selective antegrade cerebral perfusion. Preoperative computed tomography scan was performed to identify the collateral circulation. Preoperative planning was assisted by a sizing software (Endosize, Therenva Inc.). RESULTS: The aortic coverage was extended down to the orifice of the celiac trunk in one case and to the T8 level in the remainders. There was no operative mortality, 1 transient paraparesis, and 1 case of renal insufficiency. Follow-up results were satisfying (no device migration, no endoleak, no endotension, and no late neurologic complications). CONCLUSIONS: The present strategy may abolish the risks connected with the waiting time between the surgical first step and the later completion (aortic-related adverse events and drop-out) and deserves further investigations to determine its safety and feasibility profile.

Mesenchymal stromal cells orchestrate follicular lymphoma cell niche through the CCL2-dependent recruitment and polarization of monocytes.

Accumulating evidence indicates that infiltrating stromal cells contribute directly and indirectly to tumor growth in a wide range of cancers. In follicular lymphoma (FL), malignant B cells are found admixed with heterogeneous lymphoid-like stromal cells within invaded lymph nodes and BM. In addition, mesenchymal stromal cells (MSCs) support in vitro FL B-cell survival, in particular after their engagement toward lymphoid differentiation. We show here that BM-MSCs obtained from patients with FL (FL-MSCs) display a specific gene expression profile compared with MSCs obtained from healthy age-matched donors (HD-MSCs). This FL-MSC signature is significantly enriched for genes associated with a lymphoid-like commitment. Interestingly, CCL2 could be detected at a high level within the FL-cell niche, is up-regulated in HD-MSCs by coculture with malignant B cells, and is overexpressed by FL-MSCs, in agreement with their capacity to recruit monocytes more efficiently than HD-MSCs. Moreover, FL-MSCs and macrophages cooperate to sustain malignant B-cell growth, whereas FL-MSCs drive monocyte differentiation toward a proangiogenic and lipopolysaccharide-unresponsive phenotype close to that of tumor-associated macrophages. Altogether, these results highlight the complex role of FL stromal cells that promote direct tumor B-cell growth and orchestrate FL-cell niche, thus emerging as a potential therapeutic target in this disease.

Preoperative endothelial dysfunction for the prediction of acute kidney injury after cardiac surgery using cardiopulmonary bypass: a pilot study based on a second analysis of the MONS study.

BACKGROUND: Up to 42% of patients develop acute kidney injury (AKI) after cardiac surgery. The aim of this study was to describe the relationship between preoperative microcirculatory function and postoperative AKI after cardiac surgery using cardiopulmonary bypass (CPB). METHODS: The prospective observational cohort MONS enrolled 60 patients scheduled for valvular (n = 30, 50%) or coronary (n = 30, 50%) surgery using CPB. Preoperative microcirculation was assessed during preoperative consultation from January 2019 to April 2019 at the University Hospital of Angers, France, using endothelium-dependent and endothelium-independent reactivity tests on the forearm (iontophoresis of acetylcholine (ACh) and sodium nitroprusside (SNP), respectively). Skin blood flow was measured by laser speckle contrast imaging. The primary endpoint was the occurrence of AKI according to the KDIGO classification during the hospital stay. RESULTS: Forty-three (71.7%) patients developed AKI during the in-hospital follow-up, and 15 (25%) were classified as KDIGO stage 1, 20 (33%) KDIGO stage 2, and 8 (13%) KDIGO stage 3. Regarding preoperative microcirculation, a higher peak amplitude of vasodilation in response to iontophoresis of ACh was found in patients with postoperative occurrence of AKI (35 [20-49] vs 23 [9-44] LSPU, p = 0.04). Iontophoresis of SNP was not significantly different according to AKI occurrence (34 [22-49] vs 36 [20-50] LSPU, p = 0.95). In a multivariable model, the preoperative peak amplitude at iontophoresis of ACh was independently associated with postoperative AKI (OR 1.045 [1.001-1.092], p = 0.045). CONCLUSIONS: The preoperative peak amplitude of endothelium-dependent vasodilation is independently associated with the postoperative occurrence of AKI. TRIAL REGISTRATION: Clinical-Trials.gov, NCT03631797. Registered 15 August 2018, https://clinicaltrials.gov/ct2/show/NCT03631797.

Effect of superficial and deep parasternal blocks on recovery after cardiac surgery: study protocol for a randomized controlled trial.

BACKGROUND: Pain is frequent after cardiac surgery and source of multiple complications that can impair postoperative recovery. Regional anesthesia seems to be an interesting technique to reduce the pain in this context, but its effectiveness in improving recovery has been poorly studied so far. The objective of this study is to compare the effectiveness of two of the most studied chest wall blocks in cardiac surgery, i.e., the superficial and the deep parasternal intercostal plane blocks (SPIP and DPIP respectively), in addition to standard care, versus the standard care without regional anesthesia, on the quality of postoperative recovery (QoR) after cardiac surgery with sternotomy. METHODS: This is a single-center, single-blind, controlled, randomized trial with a 1:1:1 ratio. Patients (n = 254) undergoing cardiac surgery with sternotomy will be randomized into three groups: a control group with standard care and no regional anesthesia, a SPIP group with standard care and a SPIP, and a DPIP with standard care and a DPIP. All groups will receive the usual analgesic protocol. The primary endpoint is the value of the QoR evaluated by the QoR-15 at 24 h after the surgery. DISCUSSION: This study will be the first powered trial to compare the SPIP and the DPIP on global postoperative recovery after cardiac surgery with sternotomy. TRIAL REGISTRATION: ClinicalTrials.gov NCT05345639. Registered on April 26, 2022.

Analysis of a multicenter registry on evaluation of transit-time flow in coronary artery disease surgery.

Objective: The Evaluation of Transit-Time Flow in Coronary Artery Disease Surgery (EFCAD) registry aims to assess the influence of transit-time flow measurement (TTFM) in daily practice. Methods: EFCAD is a prospective, multicenter study involving 9 centers performing TTFM during isolated coronary artery bypass grafting. Primary end point was occurrence and risk factors of major adverse cardiac events, including perioperative myocardial infarction, urgent postoperative coronary angiogram and/or revascularization, and hospital mortality. Secondary end points were rate of graft revision during surgery and factors affecting graft flow. We respected the limit values set by the experts: mean graft flow >15 mL/minute and pulsatility index ≤5. Results: Between May 2017 and March 2021, 1616 patients were registered in the EFCAD database. After review, 1414 were included for analyses. Of those, 1176 were eligible for primary end point analysis. Graft revision, mainly due to inadequate TTFM values, occurred in 2% (29 patients). The primary end point occurred in 46 (3.9%) patients, and it was related with left anterior descending artery graft flow ≤15 mL/minute (odds ratio, 3.64; P < .001). Graft flow was related with number of grafts (3 vs 1-2, ß = -1.6; 4-6 vs 1-2, ß = -4.1; P < .001; ß > 0 indicates higher flow), and graft origin (aorta vs Y, ß = 9.2; in situ left internal thoracic artery vs Y, ß = 3.2; in situ right internal thoracic artery vs Y, ß = 2.3; P < .001). Conclusions: Data from EFCAD study suggest that TTFM is reliable to evaluate graft flow, and acceptance of inadequate flow on left anterior descending artery anastomosis influence postoperative outcomes. In our opinion, TTFM assessment should be routinely used in coronary artery bypass procedures, even if interpretation depends on learning curves.

Veno-arterial extracorporeal membrane oxygenation for circulatory failure in COVID-19 patients: insights from the ECMOSARS registry.

OBJECTIVES: The clinical profile and outcomes of patients with Coronavirus Disease 2019 (COVID-19) who require veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or veno-arterial-venous extracorporeal membrane oxygenation (VAV-ECMO) are poorly understood. We aimed to describe the characteristics and outcomes of these patients and to identify predictors of both favourable and unfavourable outcomes. METHODS: ECMOSARS is a multicentre, prospective, nationwide French registry enrolling patients who require veno-venous extracorporeal membrane oxygenation (ECMO)/VA-ECMO in the context of COVID-19 infection (652 patients at 41 centres). We focused on 47 patients supported with VA- or VAV-ECMO for refractory cardiogenic shock. RESULTS: The median age was 49. Fourteen percent of patients had a prior diagnosis of heart failure. The most common aetiologies of cardiogenic shock were acute pulmonary embolism (30%), myocarditis (28%) and acute coronary syndrome (4%). Extracorporeal cardiopulmonary resuscitation (E-CPR) occurred in 38%. In-hospital survival was 28% in the whole cohort, and 43% when E-CPR patients were excluded. ECMO cannulation was associated with significant improvements in pH and FiO2 on day 1, but non-survivors showed significantly more severe acidosis and higher FiO2 than survivors at this point (P = 0.030 and P = 0.006). Other factors associated with death were greater age (P = 0.02), higher body mass index (P = 0.03), E-CPR (P = 0.001), non-myocarditis aetiology (P = 0.02), higher serum lactates (P = 0.004), epinephrine (but not noradrenaline) use before initiation of ECMO (P = 0.003), haemorrhagic complications (P = 0.001), greater transfusion requirements (P = 0.001) and more severe Survival after Veno-Arterial ECMO (SAVE) and Sonographic Assessment of Intravascular Fluid Estimate (SAFE) scores (P = 0.01 and P = 0.03). CONCLUSIONS: We report the largest focused analysis of VA- and VAV-ECMO recipients in COVID-19. Although relatively rare, the need for temporary mechanical circulatory support in these patients is associated with poor prognosis. However, VA-ECMO remains a viable solution to rescue carefully selected patients. We identified factors associated with poor prognosis and suggest that E-CPR is not a reasonable indication for VA-ECMO in this population.

AORTLANTIC: French registry of aortic valve-sparing root replacement, preliminary multicentre results from western France.

OBJECTIVES: Aortic root aneurysms often affect younger patients in whom valve-sparing surgery is challenging. Among current techniques, aortic valve-sparing root replacement described by Tirone David has shown encouraging results. The AORTLANTIC registry was instituted for a multicentre long-term evaluation of this procedure. The current initial study evaluates the hospital outcomes of the procedure. METHODS: This is a retrospective study of patients operated between 1 January 2004 and 31 December 2020 in 6 hospitals in western France. All study data were recorded in the national digital database of the French Society of Cardiac Surgery: EPICARD. RESULTS: A total of 524 consecutive patients with a mean age of 53 (15.1) years underwent surgery. 13% (n = 68) of patients presented with acute aortic dissection, 16.5% (n = 86) had associated connective tissue pathology and 7.3% (n = 37) had bicuspid aortic valves. Preoperative aortic regurgitation (AR) ≥2/4 was present in 65.3% (n = 341) of patients. Aortic valvuloplasty was required in 18.6% (n = 95) of patients. At discharge, 92.8% (n = 461) of patients had no or 1/4 AR. The stroke rate was 1.9% (n = 10). Intra-hospital mortality was 1.9% (n = 10). CONCLUSIONS: The AORTLANTIC registry includes 6 centres in western France with >500 patients. Despite numerous complex cases (acute aortic dissections, bicuspid aortic valves, preoperative AR), aortic valve-sparing root replacement has a low intra-hospital mortality. The initial encouraging results of this multicentre study warrant further long-term evaluation by future studies.

Current-Induced Vasodilation Specifically Detects, and Correlates With the Time Since, Last Aspirin Intake: An Interventional Study of 830 Patients.

BACKGROUND: Galvanic current-induced vasodilation (CIV) is impaired in patients under low-dose aspirin (ASA; ≤ 500 mg/day), but potential covariates and the impact of the time since the last ASA intake are unknown. OBJECTIVES: We used tissue viability imaging (TiVi) in patients at risk of cardiovascular disease and examined its association with self-reported treatments. PATIENTS/METHODS: We recorded the age, gender, height, weight, smoking status, and use of 14 different drug categories in 822 patients either with known peripheral artery disease or at risk thereof. The difference between TiVi arbitrary units (TAUs) where stimulation was applied and an adjacent skin area was recorded, as well as the time since the last ASA intake. Step-by-step regression analysis was used to determine the factors that affect CIV amplitude. RESULTS AND CONCLUSIONS: CIV was 28.2 ± 22.9 vs. 14.6 ± 18.0 TAUs (P < 0.001) in patients treated with ASA (n = 287) and not treated with ASA (n = 535), respectively. The main determinants of CIV amplitude, by order of importance, were: aspirin intake, diabetes mellitus, age, and male sex. In ASA-treated patients, the main determinants were diabetes mellitus, time since the last ASA intake, male gender, and age. Non-invasive determination of the physiological effects of low-dose ASA is feasible in routine clinical practice. It could be a clinical approach to provide objective evidence of ASA intake, and potentially could be used to test adherence to treatment in ASA-treated patients.

Aortic homograft for aortic valve replacement in patient with Alpha-Gal allergy.

Allergy to Galactose-Alpha-1,3-Galactose is an allergy to mammalian proteins, that are present on the surface of standard bioprosthestic valves, and could result in a catastrophic allergic reaction or may cause early deterioration of the bioprostheses. Aortic homograft is an acceptable alternative to standard prosthetic valves (biological and mechanical) to avoid a potential allergic manifestation and the need for definitive oral anticoagulation. We report the implantation of an aortic homograft in a patient with an aortic stenosis who presents a documented AlphaGal allergy.

Preservation of the Aortic Root During Type A Aortic Dissection Surgery: An Effective Strategy?

BACKGROUND: Management of the aortic root during acute Type A aortic dissection (TAAD) repair remains controversial in term of long-term evolution and reoperation. The aim of this study was to assess the long-term outcomes of the aortic root after conservative management during primary surgery. METHODS: One hundred sixty-four consecutive patients were included in this monocentric retrospective study. The primary endpoint was reoperation on the aortic root during long-term follow-up. Forty-six patients had aortic root replacement (ARR) and 118 had supracoronary aortic replacement (SCR). The 10-year survival, occurrence of significant aortic regurgitation, and radiologic aortic root dilatation in each group were assessed during follow-up. RESULTS: Patients from ARR group were younger than those from SCR group (p < 0.0001). Median follow-ups of ARR group and SCR group are 4.4 (interquartile range [IR]: 2.6-8.3) and 6.15 (IR: 2.8-10.53) years, respectively. Reoperation of the aortic root during long-term follow-up was similar in both groups (ARR group: 5.1%, SCR group: 3.3%, p = 0.636). The 10-year survivals of ARR and SCR groups were 64.8 ± 12.3% and 46.3 ± 5.8% (p = 0.012), respectively. Long-term significant aortic regurgitation occurred in one patient (1.7%) and seven patients (7.6%) of the ARR and SCR groups (p = 0.176), respectively. Radiologic aortic root diameters in the SCR group were similar between postoperative period and follow-up studies (p = 0.58). Reoperation on the distal aorta (p = 0.012) and patent radiologic false lumen of the descending aorta (p = 0.043) were independent risk factors of late death. CONCLUSION: SCR is an effective technique for primary TAAD surgery and does not increase the rate of late reoperation on the aortic root.

STABILISE Technique via a Transapical Approach to Repair Residual Type A Aortic Dissection.

The stent-assisted balloon-induced intimal disruption and relamination in aortic dissection or STABILISE concept is a novel endovascular strategy in Type A and Type B dissections. We report a case of Type A aortic dissection repair combining, first, an open thoracic aortic surgery with an elephant trunk procedure and, second, an endovascular treatment using the STABILISE technique via a combined transapical approach commonly used for transcatheter aortic valve implantation and a femoral pathway.

Preoperative endothelial dysfunction in cutaneous microcirculation is associated with postoperative organ injury after cardiac surgery using extracorporeal circulation: a prospective cohort study.

BACKGROUND: Cardiac surgery is known to induce acute endothelial dysfunction, which may be central to the pathophysiology of postoperative complications. Preoperative endothelial dysfunction could also be implicated in the pathophysiology of postoperative complications after cardiac surgery. However, the relationship between preoperative endothelial function and postoperative outcomes remains unknown. The primary objective was to describe the relationship between a preoperative microcirculatory dysfunction identified by iontophoresis of acetylcholine (ACh), and postoperative organ injury in patients scheduled for cardiac surgery using cardiopulmonary bypass (CPB). METHODS: Sixty patients undergoing elective cardiac surgery using CPB were included in the analysis of a prospective, observational, single-center cohort study conducted from January to April 2019. Preoperative microcirculation was assessed with reactivity tests on the forearm (iontophoresis of ACh and nitroprusside). Skin blood flow was measured by laser speckle contrast imaging. Postoperative organ injury, the primary outcome, was defined as a Sequential Organ Failure Assessment score (SOFA) 48 h after surgery greater than 3. RESULTS: Organ injury at 48 h occurred in 29 cases (48.3%). Patients with postoperative organ injury (SOFA score > 3 at 48 h) had a longer time to reach the peak of preoperative iontophoresis of acetylcholine (133 s [104-156] vs 98 s [76-139] than patients without, P = 0.016), whereas endothelium-independent vasodilation to nitroprusside was similar in both groups. Beyond the proposed threshold of 105 s for time to reach the peak of preoperative endothelium-dependent vasodilation, three times more patients presented organ dysfunction at 48 h (76% vs 24% below or equal 105 s). In multivariable model, the time to reach the peak during iontophoresis of acetylcholine was an independent predictor of postoperative organ injury (odds ratio = 4.81, 95% confidence interval [1.16-19.94]; P = 0.030). CONCLUSIONS: Patients who postoperatively developed organ injury (SOFA score > 3 at 48 h) had preoperatively a longer time to reach the peak of endothelium-dependent vasodilation. Trial registration Clinical-Trials.gov, NCT03631797. Registered 15 August 2018, https://clinicaltrials.gov/ct2/show/NCT03631797.

Author's reply (in reference to letter to editor proposed by Etem Caliskan, Catherine J. Pachuk, Louis P. Perrault, Maximilian Y Emmert and entitled: preservation solutions to improve graft patency: The devil is in the detail).

Not applicable.

Cardiopulmonary bypass and internal thoracic artery: Can roller or centrifugal pumps change vascular reactivity of the graft? The IPITA study: A randomized controlled clinical trial.

BACKGROUND: Cardiopulmonary bypass (CPB) induces a systemic inflammatory response (SIRS) and affects the organ vascular bed. Experimentally, the lack of pulsatility alters myogenic tone of resistance arteries and increases the parietal inflammatory response. The purpose of this study was to compare the vascular reactivity of the internal thoracic arteries (ITAs) due to the inflammatory response between patients undergoing coronary artery bypass grafting (CABG) under CPB with a roller pump or with a centrifugal pump. METHODS: Eighty elective male patients undergoing CABG were selected using one or two internal thoracic arteries under CPB with a roller pump (RP group) or centrifugal pump (CFP group). ITA samples were collected before starting CPB (Time 1) and before the last coronary anastomosis during aortic cross clamping (Time 2). The primary endpoint was the endothelium-dependent relaxation of ITAs investigated using wire-myography. The secondary endpoint was the parietal inflammatory response of arteries defined by the measurements of superoxide levels, leukocytes and lymphocytes rate and gene expression of inflammatory proteins using. Terminal complement complex activation (SC5b-9) and neutrophil activation (elastase) analysis were performed on arterial blood at the same times. RESULTS: Exposure time of ITAs to the pump flow was respectively 43.3 minutes in the RP group and 45.7 minutes in the CFP group. Acetylcholine-dependent relaxation was conserved in the two groups whatever the time. Gene expression of C3 and C4a in the artery wall decreased from Time 1 to Time 2. No oxidative stress was observed in the graft. There was no difference between the groups concerning the leukocytes and lymphocytes rate. SC5b-9 and elastase increased between Time 1 and Time 2. CONCLUSION: Endothelium-dependent relaxation of the internal thoracic arteries was preserved during CPB whatever the type of pump used. The inflammatory response observed in the blood was not found in the graft wall within this time frame. TRIAL REGISTRATION: Name of trial study protocol: IPITA Registration number (ClinicalTrials.gov): NCT04168853.