Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump.

OBJECTIVE: To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay. DESIGN: A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence. METHODS: Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method. RESULTS: The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions. CONCLUSIONS: Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.

Femoral Versus Nonfemoral Peripheral Access for Transcatheter Aortic Valve Replacement.

BACKGROUND: Femoral access is the gold standard for transcatheter aortic valve replacement (TAVR). Guidelines recommend reconsidering surgery when this access is not feasible. However, alternative peripheral accesses exist, although they have not been accurately compared with femoral access. OBJECTIVES: This study compared nonfemoral peripheral (n-FP) TAVR with femoral TAVR. METHODS: Using the data from the national prospective French registry (FRANCE TAVI [French Transcatheter Aortic Valve Implantation]), this study compared the characteristics and outcomes of TAVR procedures according to whether they were performed through a femoral or a n-FP access, using a pre-specified propensity score-based matching between groups. Subanalysis during 2 study periods (2013 to 2015 and 2016 to 2017) and among low/intermediate-low and intermediate-high/high volume centers were performed. RESULTS: Among 21,611 patients, 19,995 (92.5%) underwent femoral TAVR and 1,616 (7.5%) underwent n-FP TAVR (transcarotid, n = 914 or trans-subclavian, n = 702). Patients in the n-FP access group had more severe disease (mean logistic EuroSCORE 19.95 vs. 16.95; p < 0.001), with a higher rate of peripheral vascular disease, known coronary artery disease, chronic pulmonary disease, and renal failure. After matching, there was no difference in the rate of post-procedural death and complications according to access site, except for a 2-fold lower rate of major vascular complications (odds ratio: 0.45; 95% confidence interval: 0.21 to 0.93; p = 0.032) and unplanned vascular repairs (odds ratio: 0.41; 95% confidence interval: 0.29 to 0.59; p < 0.001) in those who underwent n-FP access. The comparison of outcomes provided similar results during the second study period and in intermediate-high/high volume centers. CONCLUSIONS: n-FP TAVR is associated with similar outcomes compared with femoral peripheral TAVR, except for a 2-fold lower rate of major vascular complications and unplanned vascular repairs. n-FP TAVR may be favored over surgery in patients who are deemed ineligible for femoral TAVR and may be a safe alternative when femoral access risk is considered too high.

Functional assessment of mitral regurgitation by transthoracic echocardiography using standardized imaging planes diagnostic accuracy and outcome implications.

OBJECTIVES: We sought to assess the value of transthoracic echocardiography (TTE) using standardized imaging planes for the functional analysis of mitral regurgitation (MR) as well as for postoperative outcome implications. BACKGROUND: The feasibility of mitral valve repair is based on functional assessment of MR, mainly by transesophageal echocardiography (TEE). Considering the recent advances in TTE imaging, the incremental value of TEE in this setting needs to be re-examined. METHODS: Consecutive patients (n = 279; 181 men; median age 68 years [quartiles, 61 to 74]) who underwent surgery for MR were enrolled prospectively in two tertiary care centers. The accuracy of TTE (harmonic imaging) versus TEE for functional assessment of MR was evaluated against surgical findings. RESULTS: Valve repair (n = 237 patients, 85%) or replacement (n = 42) was predicted accurately by TTE in 97% of cases; TEE added significant information for only two patients. In the subgroup of degenerative MR (n = 190), agreement with surgical findings for the localization of prolapsed segments was 91% for TTE (kappa, 0.81) and 93% for TEE (kappa, 0.85) without incremental value of TEE (p = 0.40). Patients with single prolapse of the middle posterior scallop (P2) had a better postoperative outcome as compared with patients who had non-P2 lesions (p = 0.008). Furthermore, mitral replacement predicted by TTE was an independent predictor for postoperative long-term mortality (odds ratio 5.7, 95% confidence interval 1.97 to 16.4, p = 0.001). CONCLUSIONS: In experienced hands, functional assessment of MR by TTE can predict accurately valve repairability and has a strong influence on postoperative outcome. Thus, in most cases preoperative TEE is not mandatory, provided intraoperative TEE is performed.

The risk of reoperative heart valve procedures in Octogenarian patients.

BACKGROUND AND AIM OF THE STUDY: The authors' experience is reported of cardiac reoperations for valvular heart disease in octogenarian patients. METHODS: The records of 22 consecutive patients (10 men, 12 women) aged > or =80 years (mean age 82.4+/-2.3 years) who underwent cardiac reoperation for aortic and/or mitral valvular heart disease at the authors' institution between 1991 and 2001 were retrospectively reviewed. RESULTS: Indications for reoperation were structural dysfunction of a previously implanted bioprosthetic valve in 11 patients (50%), new valvular heart disease in six (27%), progression of rheumatic valvular heart disease in four (18%), and prosthetic valve infective endocarditis in one patient (5%). Fourteen patients (64%) underwent isolated aortic valve replacement (AVR), two (9%) had AVR plus coronary artery bypass grafting (CABG), one patient (5%) had aortic root replacement plus CABG, three patients (14%) had isolated mitral valve replacement (MVR), one patient (5%) had MVR plus ascending aorta replacement, and one (5%) had AVR plus MVR. Postoperative complications occurred in 18 patients (82%). The hospital mortality rate was 32%. Actuarial survival estimates at one year, and at three and five years were 62.6%, 56.3% and 40.2%, respectively. CONCLUSION: Cardiac reoperations for valvular heart disease in octogenarians carry a high postoperative morbidity and mortality. These findings must be taken into account in the management of associated mild or moderate valvular heart disease, and in the choice of heart valve prosthesis at the initial operation in younger patients.

Usefulness of routine epicardial pacing wire culture for early prediction of poststernotomy mediastinitis.

Poststernotomy mediastinitis (PSM) is one of the most serious complications of cardiac surgery, and its associated morbidity and mortality demand early recognition for emergency therapy. In this study, we investigated the usefulness of epicardial pacing wire (EPW) cultures for the prediction of PSM. Among 2,200 patients who underwent a cardiac surgical procedure at our hospital between 1 January 1999 and 31 December 2001, 82 (3.7%) had PSM; Staphylococcus aureus was the organism (45.1%) most frequently isolated at the time of surgical debridement. EPWs from 1,607 (73.0%) patients, 73 (4.5%) of whom developed PSM, were cultured. EPW cultures from 466 (29.0%) were positive, most often (74.9%) for coagulase-negative Staphylococci. EPW cultures were truly positive in 26 cases, truly negative in 1,106 cases, falsely positive in 428 cases, and falsely negative in 47 cases (with sterile cultures in 35 cases and a culture positive for an organism different from that isolated at the time of debridement in 12 cases). EPW culture had a positive predictive value of only 5.7% and a high negative predictive value (95.9%) for the diagnosis of PSM, with an accuracy of 70.4%. However, the likelihood ratio of positive (1.27) and negative (0.89) tests indicated only small changes in pretest-to-posttest probability. Therefore, a strategy of routine culture of EPWs to predict PSM seems questionable.

Platelet activation and aggregation profile in prolonged external ventricular support.

BACKGROUND: Platelet function plays a major role in the understanding of thromboembolic events in prolonged mechanical support. We studied the platelet activation, platelet aggregation profile, and efficacy of aspirin in patients in whom an external ventricular assist device had been implanted. PATIENTS AND METHODS: Fifteen patients were studied prospectively up to 6 weeks after implantation of the same type of ventricular assist device. Platelet function was studied weekly before daily aspirin administration. Aspirin efficacy was tested ex vivo by measuring platelet aggregation triggered by arachidonic acid. Flow cytometry was used to quantify the spontaneous and induced (adenosine diphosphate stimulation) expression of glycoproteins alphaIIbbeta3, Ibalpha, and CD62P on platelet membranes. The plasma levels of von Willebrand factor (von Willebrand factor activity and von Willebrand factor antigen) and fibrinogen were also determined. RESULTS: Six of the 15 patients (26%) maintained an arachidonic acid-induced platelet aggregation despite daily aspirin treatment (250 mg). CD62P values remained increased during a 5-week postoperative period. Spontaneous levels of glycoproteins alphaIIbbeta3 and Ibalpha on platelet membranes remained within a normal range with a preserved reactivity. The plasma levels of fibrinogen and von Willebrand factor remained increased during the entire study period. CONCLUSION: In patients with an implanted external ventricular assist device, the platelet activation profile displays a persistent activation with a preserved reactivity associated with a persistent high inflammatory state and endothelial activation.

beta2-Adrenergic signaling in human heart: shift from the cyclic AMP to the arachidonic acid pathway.

We have recently established that enhancement of intracellular calcium cycling and contraction in response to beta2-adrenergic receptor (beta2-AR) stimulation exclusively relies on the activation of the cytosolic phospholipase A2 (cPLA2) and arachidonic acid production, via a pertussis toxin-sensitive G protein (possibly Gi), in embryonic chick cardiomyocytes. We aimed to investigate the relevance of the beta2-AR/Gi/cPLA2 pathway in the human myocardium. In left ventricular biopsies obtained from explanted hearts, beta2-AR stimulation exerted either an inhibition of cPLA2 that was insensitive to pertussis toxin (PTX) treatment, or an activation of cPLA2, sensitive to PTX treatment. In right atrial appendages from patients who were undergoing open heart surgery, we demonstrated that beta2-AR-induced activation of cPLA2 was favored in situations of altered beta1-AR and/or beta2-AR/adenylyl cyclase (AC) stimulations. Alterations were characterized by an increase in EC50value of norepinephrine and a decrease in the maximal AC activation in response to zinterol, respectively. Quantitative reverse transcription-polymerase chain reaction analyses highlighted a positive correlation between the expression of AC5 and AC6 mRNAs in human cardiac atria, which suggested that functional alterations in AC responses were unlikely to be related to changes in the AC5/AC6 mRNA ratio. In addition, the shift from the cyclic AMP to the arachidonic acid pathway was not supported at the transcriptional level by opposite regulation of AC and cPLA2mRNAs expression. This study gives the first evidence of the recruitment of cPLA2by beta2-ARs in the human heart and suggests that the Gi/cPLA2pathway could substitute for a deficient Gs/AC pathway in mediating beta2-AR responses.

Risk factor analysis for proximal and distal reoperations after surgery for acute type A aortic dissection.

OBJECTIVE: This study was undertaken to determine significant risk factors for proximal or distal reoperations after surgical correction of acute type A aortic dissection. METHODS: Between 1980 and 2000, a total of 160 consecutive patients (mean age 57.5 +/- 13.3 years, 126 men) underwent surgery for acute type A aortic dissection. Proximal repair was performed by means of ascending aorta replacement with valve resuspension in 130 cases (81.3%), composite graft replacement in 19 cases (11.9%), separate aortic valve and ascending aorta replacement in 7 cases (4.4%), and aortic repair in 1 case (0.6%). Distal repair required arch replacement in 23 cases. Follow-up time averaged 4.51 +/- 5.6 years per patient. RESULTS: Survival estimates after initial operation were 66.1% +/- 3.8%, 57.7% +/- 4.2%, 52.2% +/- 4.6%, and 42.5% +/- 5.8% at 1, 5, 10, and 15 years, respectively. Thirty patients required 37 reoperations at a mean interval of 5.7 +/- 4.5 years after the initial operation. Freedoms from reoperation were 96.9% +/- 1.8%, 74.7% +/- 5.3%, 60.8% +/- 6.8%, and 39.3% +/- 9.1% at 1, 5, 10, and 15 years, respectively. Reoperations included procedures on the proximal aorta (aortic root or valve) in 21 cases and on the distal aorta or its side branches in 19 cases. Cox regression analysis distinguished severe preoperative aortic valve insufficiency as the only significant risk factors for proximal reoperation; younger patient age, more distal extent of dissection, and more recent operative date were found to be significant risk factors for distal reoperation. CONCLUSION: Patients with acute type A aortic dissection who have severe aortic valve insufficiency are at increased risk for proximal reoperation. These patients should benefit from a more aggressive proximal repair at initial operation. Distal extent of aortic resection at initial operation did not significantly influence the risk of distal reoperation.

Aortic wall alterations after use of gelatin-resorcinol-formalin glue.

We report the case of a patient who underwent reoperation 8 years after aortic valve replacement because of aneurysmal dilatation of the aortic root. During the initial intervention, gelatin-resorcinol-formalin glue had been applied on the outside of the aortic root. Perioperative examination revealed a necrotic appearance of the right coronary sinus, with contained ruptures at two different sites. Histologic analysis showed major destruction of the aortic root media, leading to vascular wall thinning and rupture. The use of gelatin-resorcinolformalin glue may expose patients to major alterations of the aortic wall.