Mediastinitis superinfected by Achromobacter xylosoxidans. A case report.

We describe an extremely rare case of mediastinitis superinfected by emerging Achromobacter xylosoxidans. After mitral and aortic valves replacement, the patient first developed a Staphylococcus aureus mediastinitis, and five days after starting adapted antibiotic therapy, superficial pus analysis revealed the presence of Achromobacter xylosoxidans. This superinfection was considered superficial and focus was made on Staphylococcus aureus mediastinitis. Three weeks later, no more Staphylococcus aureus was found in pus samples and the sepsis seemed under control. Unfortunately, blood cultures were again positive for Achromobacter xylosoxidans three weeks later and the patient died from septic shock.

Transportation of patients under extracorporeal membrane oxygenation support on an airliner: Flying bridge to transplantation.

BACKGROUND: A retrieval programme was developed in Martinique (French West Indies) to provide extracorporeal membrane oxygenation for patients in the Caribbean, where heart transplantation and ventricular assist devices are not available. In 2011, the Department of Cardiac Surgery at the University Hospital of Fort-de-France (Martinique) developed a transfer programme to Paris (France) on an airliner, to refer patients for whom extracorporeal membrane oxygenation was not weanable to heart transplantation or a ventricular assist device. AIM: To report this unique experience of transportation of patients under extracorporeal membrane oxygenation support on an airliner from the French West Indies to Paris. METHODS: This was an observational and retrospective study of all patients under extracorporeal membrane oxygenation support who were transferred from Martinique to the Pitié-Salpêtrière Hospital/Sorbonne University in Paris between September 2011 and September 2019. Transport characteristics, complications during repatriation, cost and clinical outcomes at 30days and 1year were reported. RESULTS: Twenty-six patients were transferred on an airliner; the retrieval distance was 7260km, and the mean duration was 14hours. Only two patients developed complications (pulmonary oedema and leg ischaemia), and no patient died during the flight. Nine patients had a ventricular assist device implanted, and six patients were transplanted. Thirty-day survival was 65.4%, and 1-year survival was 38.5%. CONCLUSIONS: Transport under extracorporeal membrane oxygenation support on an airliner is safe and efficient, with an acceptable cost. This programme allowed patients under extracorporeal membrane oxygenation support in a remote centre, without access to transplantation or a ventricular assist device, to be referred for these techniques in specialized centres. This experience strengthens the strategy of developing regional networks around specialized extracorporeal membrane oxygenation centres.

Bothrops lanceolatus snake venom impairs mitochondrial respiration and induces DNA release in human heart preparation.

INTRODUCTION: Envenomations by Bothrops snakebites can induce overwhelming systemic inflammation ultimately leading to multiple organ system failure and death. Release of damage-associated molecular pattern molecules (DAMPs), in particular of mitochondrial origin, has been implicated in the pathophysiology of the deregulated innate immune response. OBJECTIVE: To test whether whole Bothrops lanceolatus venom would induce mitochondrial dysfunction and DAMPs release in human heart preparations. METHODS: Human atrial trabeculae were obtained during cannulation for cardiopulmonary bypass from patients who were undergoing routine coronary artery bypass surgery. Cardiac fibers were incubated with vehicle and whole Bothrops lanceolatus venom for 24hr before high-resolution respirometry, mitochondrial membrane permeability evaluation and quantification of mitochondrial DNA. RESULTS: Compared with vehicle, incubation of human cardiac muscle with whole Bothrops lanceolatus venom for 24hr impaired respiratory control ratio and mitochondrial membrane permeability. Levels of mitochondrial DNA increased in the medium of cardiac cell preparation incubated with venom of Bothrops lanceolatus. CONCLUSION: Our study suggests that whole venom of Bothrops lanceolatus impairs mitochondrial oxidative phosphorylation capacity and increases mitochondrial membrane permeability. Cardiac mitochondrial dysfunction associated with mitochondrial DAMPs release may alter myocardium function and engage the innate immune response, which may both participate to the cardiotoxicity occurring in patients with severe envenomation.

Giant Localized Atheroma Mimicking a Coarctation of the Aorta: A Rare Entity to Consider.

We describe the case of a patient who developed resistant hypertension due to a giant atheroma with acquired physiologic mimic of coarctation of the aorta. This presentation illustrates an extremely rare etiology to consider in adults in whom aortic isthmus stenosis remains often of congenital origin. (Level of Difficulty: Intermediate.).

[Sacroiliitis with Erysipelothrix Rhusiopathiae revealing tricuspid endocarditis, the first case reported on the Guiana Shield: clinical case and review of the literature]. / Sacro-Iliite à Erysipelothrix Rhusiopathiae révélant une endocardite tricuspide, premier cas rapporté sur le bouclier des Guyanes : cas clinique et revue de la littérature.

We report here an atypical case of acute sacroiliitis caused by Erysipelothrix rhusiopathiae revealing tricuspid endocarditis in a 53-year-old woman without medical history. She was admitted to Cayenne hospital because of intense right hip and thigh pain, associated with fever. A right sacroiliitis was visible on the computed tomography (CT) scan, confirmed on MRI. Transesophageal echocardiography revealed a large mobile tricuspid vegetation. Blood cultures were positive for E. rhusiopathiae. CT scan showed pulmonary alveolar opacities, consistent with septic emboli. Clinical improvement was obtained under ceftriaxone followed by ciprofloxacin for 6 weeks of treatment. We present a review of bone and joint infections caused by E. rhusiopathiae. So far, not a single case has been reported in Latin America.

Popliteal arteriovenous fistula due to a gunshot injury.

We report the case of a 22-year-old man who presented with a popliteal arteriovenous fistula after a gunshot injury to his right knee. The diagnosis, made in the Emergency Department, was confirmed by arteriography, allowing quick therapeutic intervention. The lesions to the popliteal artery and vein were repaired with a double venous bypass, followed by relieving fasciotomy. Satisfactory clinical results were achieved after 2 months and magnetic resonance imaging revealed normal permeability of the vascular axes. Three years after his operation, our patient has normal function of his knee. The physiopathology, diagnostic difficulties, and management of this type of lesion are discussed with a review of the literature.

Infective Endocarditis in French West Indies: A 13-Year Observational Study.

We conducted an observational study to describe the characteristics of infective endocarditis (IE) in French West Indies (FWI) and to identify variables associated with in-hospital case fatality. The records of the patients admitted for IE to the University Hospital of Martinique between 2000 and 2012 were collected using an electronic case report form. Only Duke-Li definite cases were considered for this analysis. Variables associated with in-hospital mortality were tested using univariate logistic regression analysis. The analysis included 201 patients (median age 58 years, sex ratio: two males to one female). There was no previously known heart disease in 45.8%, a prosthetic valve in 21.4%, and previously known native valve disease in 32.8% of the cases. Community-acquired IE represented 59.7% of all cases, health-care-associated IE represented 38.3% and injection-drug-use-acquired IE represented 1.5%. Locations of IE were distributed as follows: 42.3% were mitral valve IE, 34.8% were aortic valve IE, and 7% were right-sided IE. Microorganisms recovered from blood cultures included 30.4% streptococci, 28.9% staphylococci, and 5% enterococci. Blood cultures were negative in 20.9% of the cases. Surgical treatment was performed in 53% of the patients. In-hospital case fatality rate was 19%. Advanced age, Staphylococcus aureus IE, and health-care-associated IE were associated with in-hospital case fatality. The epidemiological and microbiological profile of IE in FWI is in between those observed in developed countries and developing countries: patients were younger, blood cultures were more frequently negative, and IE due to group D streptococci and enterococci were less common than in industrialized countries.

Regional differences in surgical heart valve disease in Europe: comparison between northern and southern subsets of the EuroSCORE database.

BACKGROUND AND AIMS OF THE STUDY: Although rates for coronary and valve surgery vary between northern and southern Europe, differences in the features of valve disease leading to surgery in Europe are poorly documented. The study aim was to compare demographics, risk factors, procedures and outcome in valve surgery between European regions, using the EuroSCORE database. METHODS: Between September and December 1995, information on 98 variables (risk factors, procedures and outcome) were collected on valve surgery patients in 128 European centers. Patients were allocated to two geographic subgroups (north, n = 1,990; south, n = 3,682). The distribution of variables was assessed. Subsequently, the impact of preoperative and operative risk factors on mortality was analyzed in both groups using a bivariate analysis. Risk-adjusted outcomes were then compared according to the EuroSCORE. RESULTS: Significant differences were identified for clinical features, risk factors and procedures. In northern Europe, surgery was performed on older patients with more severe coronary or associated disease, whilst in the south the cardiac status seemed more severely compromised. Degenerative aortic disease prevailed in the north (aortic valve replacement in 72.7% of cases), whilst in the south mitral surgery accounted for 46.1% of procedures. Despite differences in crude mortality (6.9% north versus 5.7% south), outcomes (when adjusted to risks) seemed comparable (observed-to-expected mortality ratio 0.90 for north versus 0.84 for south). The impact of individual risk factors on mortality was similar, except for atrial fibrillation. CONCLUSION: Despite large epidemiological differences between northern and southern Europe in terms of valve surgery, performances and outcomes were similar when individual risk factors and overall risk profiles were taken into account.

Logistic or additive EuroSCORE for high-risk patients?

OBJECTIVES: To assess whether the use of the full logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) is superior to the standard additive EuroSCORE in predicting mortality in high-risk cardiac surgical patients. METHODS: Both the simple additive EuroSCORE and the full logistic EuroSCORE were applied to 14,799 cardiac surgical patients from across Europe, of whom there were 4293 high-risk patients (additive EuroSCORE of 6 or more). The systems were compared for absolute prediction and discrimination (area under the receiver operating characteristic (ROC) curve). RESULTS: Actual mortality was 4.72%. The logistic model was closer to this than the additive model (4.84% (4.72-4.94) versus 4.21 (4.21-4.26)). Most of this difference was due to high-risk patients where actual mortality was 11.18% and predicted was 7.83% (additive) and 11.23% (logistic). Discrimination was similar in both systems as measured by the area under the ROC curve (additive 0.783, logistic 0.785). CONCLUSIONS: The additive EuroSCORE model remains a simple "gold standard" for risk assessment in European cardiac surgery, usable at the bedside without complex calculations or information technology. The logistic model is a better risk predictor especially in high-risk patients and may be of interest to institutions engaged in the study and development of risk stratification.

Validation of European System for Cardiac Operative Risk Evaluation (EuroSCORE) in North American cardiac surgery.

OBJECTIVE: To assess the performance of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) when applied in a North American cardiac surgical population. METHODS: The simple additive EuroSCORE model was applied to predict operative mortality (in-hospital or 30-day) in 401684 patients undergoing coronary or valve surgery in 1998 and 1999 as well as in 188913 patients undergoing surgery in 1995 in the Society of Thoracic Surgeons (STS) database. RESULTS: The proportion of isolated coronary artery bypass grafting (CABG) was greater in STS patients (84%) than in Europe (65%). STS patients were also older (mean age 65.3 versus 62.5), and had more diabetes (30 versus 17%) and prior cardiac surgery (11 versus 7%). Other comorbidity was also significantly more prevalent in STS patients. EuroSCORE predicted overall mortality was virtually identical to the observed mortality (1998/1999: predicted 3.994%, observed 3.992%; 1995: observed and predicted 4.156%). Predicted mortality also closely matched observed mortality across the risk groups. Discrimination was good to very good for the population overall and for isolated CABG in both time periods, with the area under the receiver operating characteristic curve between 0.75 and 0.78. CONCLUSION: Despite substantial demographic differences between Europe and North America, EuroSCORE performs very well in the STS database, and can be recommended as a simple, additive risk stratification system on both sides of the Atlantic.

Preoperative risk prediction and intraoperative events in cardiac surgery.

OBJECTIVE: To examine the relationship between preoperative risk prediction and intraoperative events. METHODS: A total of 3118 patients operated in 1999 and 2000 at our institution were analysed, all of whom had their EuroSCORE collected prospectively. The intraoperative variables studied were consultant or trainee operating, long bypass time, long ischaemic time, return on bypass in theatre and use of intra-aortic balloon pump at the end of the procedure. The outcomes are reported as hospital mortality, prolonged length of stay in the intensive therapy unit (pLOS-ITU, >48 h) and death or pLOS-ITU. Risk models were constructed by logistic regression for predicting these three outcomes. RESULTS: With the exception of prolonged cross-clamp time, all variables analysed were independently predictive of a negative outcome. Trainee operating had an apparent protective effect. All risk models performed well. The area under the receiver operating characteristic (ROC) curve (95% CI) increased from 0.857 (0.81, 0.90) for EuroSCORE to 0.874 (0.83, 0.92) for the risk of death model. Similarly, the area under the ROC curve for the pLOS-ITU model increased from 0.687 (0.642, 0.732) to 0.734 (0.691, 0.777) and for the death or pLOS-ITU model from 0.717 (0.677, 0.756) to 0.757 (0.719, 0.795). CONCLUSIONS: Knowledge of adverse intraoperative events enhances preoperative risk prediction. This type of analysis could be used for identifying "near miss" outcomes in adult cardiac surgery.

EuroSCORE II.

OBJECTIVES: To update the European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk model. METHODS: A dedicated website collected prospective risk and outcome data on 22,381 consecutive patients undergoing major cardiac surgery in 154 hospitals in 43 countries over a 12-week period (May-July 2010). Completeness and accuracy were validated during data collection using mandatory field entry, error and range checks and after data collection using summary feedback confirmation by responsible officers and multiple logic checks. Information was obtained on existing EuroSCORE risk factors and additional factors proven to influence risk from research conducted since the original model. The primary outcome was mortality at the base hospital. Secondary outcomes were mortality at 30 and 90 days. The data set was divided into a developmental subset for logistic regression modelling and a validation subset for model testing. A logistic risk model (EuroSCORE II) was then constructed and tested. RESULTS: Compared with the original 1995 EuroSCORE database (in brackets), the mean age was up at 64.7 (62.5) with 31% females (28%). More patients had New York Heart Association class IV, extracardiac arteriopathy, renal and pulmonary dysfunction. Overall mortality was 3.9% (4.6%). When applied to the current data, the old risk models overpredicted mortality (actual: 3.9%; additive predicted: 5.8%; logistic predicted: 7.57%). EuroSCORE II was well calibrated on testing in the validation data subset of 5553 patients (actual mortality: 4.18%; predicted: 3.95%). Very good discrimination was maintained with an area under the receiver operating characteristic curve of 0.8095. CONCLUSIONS: Cardiac surgical mortality has significantly reduced in the last 15 years despite older and sicker patients. EuroSCORE II is better calibrated than the original model yet preserves powerful discrimination. It is proposed for the future assessment of cardiac surgical risk.

The French airbridge for circulatory support in the Carribean.

OBJECTIVES: We report the assessment and the activities for the first year of our airborne circulatory support mobile unit (CSMU) in the French Caribbean. METHODS: From January 2010 to June 2011, 12 patients (mean age = 35.7 years; range: 15-62 years; sex ratio = 1:1) were attended outside Martinique by our CSMU and transferred to our unit by air. RESULTS: Eight patients had acute respiratory distress syndrome and were assisted by veno-venous extra corporeal membrane oxygenation (ECMO) four had refractory cardiogenic shock, assisted by extra corporeal life support (ECLS). The average air transfer distance for patients was 912 km (range: 198-1585 km). The average flying time was 124 min (range: 45-255 min). The aircraft used were helicopter, military transport or private jet. The setting-up of assistance devices and transfer of patients was uneventful. One patient subsequently benefited from heart transplantation after long-term circulatory support. One patient died under ECMO support after 51 days of assistance and another died on the 60th day after withdrawal of ECLS. CONCLUSIONS: CSMUs can be very efficient in providing support to patients in refractory shock, when remote from a cardiac surgery centre. The airborne transfer of patients on ECMO/ECLS can be achieved safely, even over long distances.

Aortic bullet embolization revealed by peripheral ischemia after a thoracic gunshot wound.

We present the case of a 21-year-old male who came to the emergency ward for a thorax bullet wound. At our first check-up, the computed tomography (CT)-scan showed a pulmonary contusion, a hemothorax and a suspicious image of a thoracic aortic wound. The patient was stable, but soon after admission a distal ischemic syndrome appeared which revealed the emboli of the projectile. We removed it and a stent graft was implanted into the thoracic aorta. We report our experience of the treatment and the mechanisms that explain how such a wound did not kill the patient.

Limitations in the inter-observer reliability of EuroSCORE: what should change in EuroSCORE II?

OBJECTIVES: To carry out an in-depth single-centre analysis of the inter-observer reliability of the EuroSCORE (European System for Cardiac Operative Risk Evaluation) to propose changes for the EuroSCORE II. METHODS: Data for the EuroSCORE additive and logistic models were prospectively collected by surgeons (computer-assisted calculation) (SurgAE and SurgLE) and perfusionists (on A4 data collection forms; PerfAE) for 1719 consecutive adult heart operations. The performance of the EuroSCORE was first analysed, then inter-observer discrepancies in the score were assessed globally and for any of its 17 risk factors. RESULTS: Hospital mortality was 4.3% (SurgAE and SurgLE: 5.3 and 7.3, respectively). The predictive ability and the calibration of the score were acceptable (area under the receiver operating characteristics curve: 0.75 for SurgAE and 0.753 for SurgLE, p = 0.98, Hosmer and Lemeshow goodness-of-fit test). Overall inter-observer concordance was satisfactory (Kappa coefficient: 0.71) but SurgAE and PerfAE were different in 26.3% of cases (SurgAE>PerfAE in 18.6%, and PerfAE>SurgAE in 7.7%). Five of the 17 risk factors accounted for most of the variability: left-ventricular ejection fraction, extracardiac arteriopathy, surgery other than isolated coronary artery bypass graft, recent myocardial infarction and pulmonary hypertension (with discrepancies respectively noticed in 7.6%, 5.3%, 5%, 3.9% and 3% of cases). Encoding mismatches for EuroSCORE items have been either assigned to human errors related to interpretation or conflicting information in the charts. Both situations may reflect structural weaknesses of the EuroSCORE. CONCLUSIONS: The EuroSCORE is a widely used score, but its predictive power and reliability are declining due to changes in cardiac surgery case mix and outcomes in recent years. The present work highlights the fact that the encoding system in the EuroSCORE still gives room for interpretation. Along with other possible modifications described elsewhere, it is suggested that reliability and predicting ability of the score might be increased by changes in some definitions of risk factors and by the use of numeric values instead of intervals of values.