Extracorporeal Cardiopulmonary Resuscitation and Survival After Refractory Cardiac Arrest: Is ECPR Beneficial?

The level of evidence of expert recommendations for starting extracorporeal cardiopulmonary resuscitation (ECPR) in refractory out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) is low. Therefore, we reported our experience in the field to identify factors associated with hospital mortality. We conducted a retrospective cohort study of all consecutive patients treated with ECPR for refractory cardiac arrest without return to spontaneous circulation, regardless of cause, at the Caen University Hospital. Factors associated with hospital mortality were analyzed. Eighty-six patients (i.e., 35 OHCA and 51 IHCA) were included. The overall hospital mortality rate was 81% (i.e., 91% and 75% in the OHCA and IHCA groups, respectively). Factors independently associated with mortality were: sex, age > 44 years, and time from collapse until extracorporeal life support (ECLS) initiation. Interestingly, no-shockable rhythm was not associated with mortality. The receiver operating characteristic-area under the curve values of pH value (0.75 [0.60-0.90]) and time from collapse until ECLS initiation over 61 minutes (0.87 [0.76-0.98]) or 74 minutes (0.90 [0.80-1.00]) for predicting hospital mortality showed good discrimination performance. No-shockable rhythm should not be considered a formal exclusion criterion for ECPR. Time from collapse until ECPR initiation is the cornerstone of success of an ECPR strategy in refractory cardiac arrest.

Direct measurement of cardiac stiffness using echocardiographic shearwave imaging during open-chest surgery: A pilot study in human.

PURPOSE: Cardiac stiffness is a marker of diastolic function with a strong prognostic significance in many heart diseases that is not measurable in clinical practice. This study investigates whether elastometry, a surrogate for organ stiffness, is measurable in the heart using ShearWave Imaging. METHODS: In 33 anesthetized patients scheduled for cardiac surgery, ShearWave imaging was acquired epicardially using a dedicated ultrasound machine on the left ventricle parallel to the left anterior descending coronary artery in a loaded heart following the last cardiac beat. Cardiac elastometry was measured offline using the Young modulus with customized software. RESULTS: Overall, the ejection fraction was 61 ± 10%. E/A and E/e' ratios were 1.0 ± 0.5 and 10.5 ± 4.1, respectively. Cardiac elastometry averaged 15.3 ± 5.3 kPa with a median of 18 kPa. Patients with high elastometry >18 kPa were older (P = .04), had thicker (P = .02) but smaller LV (P = .004), had larger left atria (P = .05) and a higher BNP level (P = .04). We distinguished three different transmural elastometry patterns: higher epicardial, higher endocardial, or uniformly distributed elastometry. CONCLUSION: Elastometry measurement was feasible for the human heart. This surrogate for cardiac stiffness dichotomized patients with low and high elastometry, and provided three different phenotypes of transmural elastometry with link to diastolic function.

Spironolactone and perioperative atrial fibrillation occurrence in cardiac surgery patients: Rationale and design of the ALDOCURE trial.

BACKGROUND: After artery bypass grafting (CABG), the presence of perioperative AF (POAF) is associated with greater short- and long-term cardiovascular morbidity. Underlying POAF mechanisms are complex and include the presence of an arrhythmogenic substrate, cardiac fibrosis and electrical remodeling. Aldosterone is a key component in this process. We hypothesize that perioperative mineralocorticoid receptor (MR) blockade may decrease the POAF incidence in patients with a left ventricular ejection fraction (LVEF) ≥50% who are referred for CABG with or without aortic valve replacement (AVR). STUDY DESIGN: The ALDOCURE trial (NCT03551548) will be a multicenter, randomized, double-blind, placebo-controlled trial testing the superiority of a low-cost MR antagonist (MRA, spironolactone) on POAF in 1500 adults referred for on-pump elective CABG surgery with or without AVR, without any history of heart failure or atrial arrhythmia. The primary efficacy end point is the occurrence of POAF from randomization to within 5 days after surgery, assessed in a standardized manner. The main secondary efficacy end points include the following: postoperative AF occurring within 5 days after cardiac surgery, perioperative myocardial injury, major cardiovascular events and death occurring within 30 days of surgery, hospital and intensive care unit length of stay, need for readmission, LVEF at discharge and significant ventricular arrhythmias within 5 days after surgery. Safety end points, including blood pressure, serum potassium levels and renal function, will be monitored regularly throughout the trial duration. CONCLUSION: The ALDOCURE trial will assess the effectiveness of spironolactone in addition to standard therapy for reducing POAF in patients undergoing CABG. CLINICAL TRIAL REGISTRATION: NCT03551548.

Assessment of changes in blood glucose concentration with intravascular microdialysis.

Blood glucose and its variability of is a major prognostic factor associated with morbidity. We hypothesized that intravenous microdialysis incorporated in a central venous catheter (CVC) would be interchangeable with changes in blood glucose measured by the reference method using a blood gas analyzer. Microdialysis and central venous blood glucose measurements were simultaneously recorded in high-risk cardiac surgical patients. The correlation between absolute values was determined by linear regression and the Bland-Altman test for repeated measurements was used to compare bias, precision, and limits of agreement. Changes in blood glucose measurement were evaluated by four-quadrant plot and trend interchangeability methods (TIM). In the 23 patients analyzed, the CVC was used as part of standard care with no complications. The correlation coefficient for absolute values (N = 99) was R = 0.91 (P < 0.001). The bias, precision and limits of agreement were - 9.1, 17.4 and - 43.2 to 24.9 mg/dL, respectively. The concordance rate for changes in blood glucose measurements (N = 77) was 85% with the four-quadrant plot. The TIM showed that 14 (18%) changes of blood glucose measurements were uninterpretable. Among the remaining 63 (82%) interpretable changes, 23 (37%) were interchangeable, 13 (20%) were in the gray zone, and 27 (43%) were not interchangeable. Microdialysis using a CVC appears to provide imprecise absolute blood glucose values with risk of insulin misuse. Moreover, only one third of changes in blood glucose measurements were interchangeable with the reference method using the TIM.

Angles between the aortic root and the left ventricle assessed by MDCT are associated with the risk of aortic regurgitation after transcatheter aortic valve replacement.

OBJECTIVES: To evaluate the impact of the angles quantified by multidetector computed tomography (MDCT) between the ascending aorta's long axis and, the left ventricular inflow long axis (LVLA), or the left ventricule outflow tract long axis, and the occurrence of post-transcatheter aortic valve replacement (TAVR) aortic regurgitation (AR). METHODS: We prospectively included 136 consecutive patients who underwent a transfemoral TAVR with a preoperative MDCT. The groups were defined according to AR <2 or ≥2 assessed by echocardiography at 1 month. RESULTS: AR ≥2 identified in 21 patients (15.4%), was associated with increased rates of mortality (p value 0.02) and heart failure (p value 0.001) at 1-year follow-up. The aorta-LVLA angle was significantly higher in patients with AR ≥2 (130.5° ± 8.8° vs. 124.6° ± 9.5°; p = 0.009). On univariate analysis, aorta-LVLA angle was predictive of AR ≥2 [OR 1.07 per degree (1.02-1.13); p = 0.011]. After adjustment on annular calcification extent, the percentage of prosthesis-annular mismatch and the type of prosthesis, the relationship between aorta-LVLA angle and the risk of AR ≥2 remained unchanged. CONCLUSIONS: We showed that increased angulation between the ascending aorta and the LVLA is associated with higher rates of AR post-TAVR independent of other potential correlates.

Preoperative plasma aldosterone and the risk of atrial fibrillation after coronary artery bypass surgery: a prospective cohort study.

OBJECTIVE: Postoperative atrial fibrillation (POAF) is associated with poor outcomes after coronary artery bypass graft (CABG) surgery. We aimed to assess the additional value of preoperative plasma aldosterone levels, a biomarker promoting proarrhythmic and profibrotic pathways, for predicting POAF after CABG. METHODS: We conducted a prospective cohort study involving consecutive patients with left ventricular ejection fraction (LVEF) more than 50% requiring elective CABG in our university hospital. Plasma aldosterone levels, two-dimensional echocardiography including left atrial strain analysis and galectin-3 (Gal-3) examination were assessed before cardiac surgery. The primary endpoint was the occurrence of POAF within 30 days after surgery. RESULTS: POAF occurred in 34 (24.8%) out of the 137 included patients. Compared with controls, patients experiencing POAF were significantly older (73 years old ±â€Š8 vs 65 ±â€Š11, P < 0.001) and had higher preoperative plasma aldosterone levels [183 pmol/l (interquartile range 138-300) vs 143 pmol/l (interquartile range 96.5-216.5), P < 0.01]. Age [odds ratio (OR), 1.088; 95% confidence interval (CI) (1.038-1.140); P = 0.0004] and plasma aldosterone levels [OR, 1.007; 95% CI (1.003-1.012); P = 0.0013] were independently associated with POAF in multivariate analysis and could therefore be combined to predict the occurrence of POAF ['Aldoscore', OR, 2.7; 95% CI (1.7-4.3); P < 0.0001]. Reverse transcriptase PCR analysis performed on right atrial appendage and plasma examination revealed that Gal-3 was activated in POAF patients. CONCLUSION: We developed the preoperative 'Aldoscore' for POAF risk stratification among patients with preserved LVEF requiring elective CABG. This new tool may be helpful to identify good responders to interventions targeting the proarrhythmic and profibrotic pathways of aldosterone.

The role of age and comorbidities in postoperative outcome of mitral valve repair: A propensity-matched study.

The average age of patients undergoing mitral valve repair is increasing each year. This retrospective study aimed to compare postoperative complications of mitral valve repair (known to be especially high-risk) between 2 age groups: under and over the age of 80.Patients who underwent mitral valve repair were divided into 2 groups: group 1 (<80 years old) and group 2 (≥80 years old). Baseline characteristics, pre- and postoperative hemodynamic data, surgical characteristics, and postoperative follow-up data until hospital discharge were collected.A total of 308 patients were included: 264 in group 1 (age 63 ±â€Š13 years) and 44 in group 2 (age 83 ±â€Š2 years). Older patients had more comorbidities (atrial fibrillation, history of cardiac decompensation, systemic hypertension, pulmonary hypertension, and chronic kidney disease) and they presented more postoperative complications (50.0% vs 33.7%; P = 0.043), with a longer hospital stay (8.9 ±â€Š6.9 vs 6.6 ±â€Š4.6 days; P = 0.005). To assess the burden of age, a propensity score was awarded to postoperative complications. Active smoking, chronic pulmonary disease, chronic kidney disease, associated ischemic heart disease, obesity, and cardio pulmonary by-pass duration were described as independent risk factors. When matched on this propensity score, there was no difference in morbidity or mortality between group 1 and group 2.Older patients suffered more postoperative complications, which were related to their comorbidities and not only to their age.

Assessment of changes in cardiac index with calibrated pulse contour analysis in cardiac surgery: A prospective observational study.

OBJECTIVES: To assess the trending ability of calibrated pulse contour cardiac index (CIPC) monitoring during haemodynamic changes (passive leg raising [PLR] and fluid loading) compared with transpulmonary thermodilution CI (CITD). METHOD: Seventy-eight mechanically-ventilated patients admitted to intensive care with calibrated pulse contour following cardiac surgery were prospectively included and investigated during PLR, and after fluid loading. Fluid responsiveness was defined as a≥15% CITD increase after a 500ml bolus. Areas under the empiric receiver operating characteristic curves (ROCAUC) for changes in CIPC (ΔCIPC) during PLR to predict fluid responsiveness and after fluid challenge to predict an increase at least 15% in CITD after fluid loading were calculated. RESULTS: Fifty-five patients (71%) were classified as responders, 23 (29%) as non-responders. ROCAUC for ΔCIPC during PLR in predicting fluid responsiveness, its sensitivity, specificity, and percentage of patients within the inconclusive class of response were 0.67 (95% CI=0.55-0.77), 0.76 (95% CI=0.63-0.87), 0.57 (95% CI=0.34-0.77) and 68%, respectively. Bias, precision and limits of agreements and percentage error between CIPC and CITD after fluid challenge were 0.14 (95% CI: 0.08-0.20), 0.26, -0.37 to 0.64 l min(-1)m(-2), and 20%, respectively. The concordance rate was 97% and the polar concordance at 30° was 91%. ROCAUC for ΔCIPC in predicting an increase of at least 15% in CITD after fluid loading was 0.85 (95% CI: 0.76-0.92). CONCLUSION: Although ΔCIPC after fluid loading could track the direction of changes of CITD and was interchangeable with bolus transpulmonary thermodilution, PLR could not predict fluid responsiveness in cardiac surgery patients.

Near-infrared spectroscopy to assess microvascular dysfunction: A prospective pilot study in cardiac surgery patients.

PURPOSE: The diagnosis of microvascular dysfunction remains challenging after cardiac surgery. We hypothesized that peripheral near-infrared spectroscopy (NIRS) monitoring in combination with a vascular occlusion test could reliably assess postoperative microvascular dysfunction in that setting. MATERIALS AND METHODS: Twenty-two patients undergoing cardiac surgery with cardiopulmonary bypass and 10 healthy volunteers were prospectively investigated. Relevant NIRS parameters (regional tissue oxygen saturation, desaturation, and resaturation rates) were recorded the day before surgery (D-1), at the arrival in the intensive care unit (postoperative day [POD] 0) and on POD 1 and POD 2. RESULTS: No difference in NIRS parameters was found at baseline between healthy volunteers and cardiac surgical patients. Absolute values of regional tissue oxygen saturation significantly increased at POD 0 and POD 1 when compared with D-1: 78% (75%-81%) and 75% (73%-78%) vs 68% (64%-72%), P < .001. No statistical difference was evidenced within the postoperative period in desaturation and resaturation rates compared with D-1: desaturation rate, 0.11% · s(-1) (0.08-0.14) and 0.15% · s(-1) (0.08-0.22) vs 0.14% · s(-1) (0.10-0.17), P = .233, and resaturation rate, 0.76% · s(-1) (0.41-1.11) and 0.77% · s(-1) (0.53-1.02) vs 0.79% · s(-1) (0.61-0.97), P = .453. The use of postoperative norepinephrine infusion did not change the results. CONCLUSIONS: Peripheral NIRS monitoring in combination with a vascular occlusion test failed to assess cardiopulmonary bypass-induced microvascular dysfunction.

Late complication after repair of aortic coarctation.

BACKGROUND: Coarctation of the aorta is a congenital malformation that has long been considered completely correctable with appropriate surgery in childhood. However, with the aging of these patients, many late complications have been reported, and this notion must be reevaluated. METHODS: We retrospectively reviewed all patients who underwent reoperation between 1992 and 2012 in our adult cardiac surgery department following surgical correction of coarctation in childhood; 18 patients over 15-years old were included in the study. RESULTS: The median time from coarctation repair to reoperation was 25 years. Patients were reoperated on for several late complications: aortic valve disease secondary to bicuspid aortic valve, ascending aortic aneurysm, recoarctation, aortic arch hypoplasia, pseudoaneurysm, associated recoarctation and pseudoaneurysm, subvalvular aortic obstruction, and descending thoracic aortic aneurysm. One patient died due to an intraoperative complication. In the other cases, the surgical results were satisfactory at the 6-month follow-up. According to literature data, age at coarctation repair and surgical technique appear to be essential factors in late complications: older age and surgical repair with prosthesis interposition are associated with a higher rate of reintervention. CONCLUSION: Patients who have undergone repair of aortic coarctation frequently remain asymptomatic for a long time. Late complications can be appropriately treated when diagnosed early. Consequently, all coarctation patients need careful lifelong follow-up, especially those with congenital aortic valve disease or surgery in childhood with interposition of prosthetic material.

Early goal-directed therapy based on endotracheal bioimpedance cardiography: a prospective, randomized controlled study in coronary surgery.

The objective was to compare the impact of an early goal-directed hemodynamic therapy based on cardiac output monitoring (Endotracheal Cardiac Output Monitor, ECOM) with a standard of care on postoperative outcome following coronary surgery. This prospective, controlled, parallel-arm trial randomized 100 elective primary coronary artery bypass grafting patients to a study group (ECOM; n = 50) or a control group (control; n = 50). In the ECOM group, hemodynamic therapy was guided by respiratory stroke volume variation and cardiac index given by the ECOM system. A standard of care was used in the control. Goal-directed therapy was started immediately after induction of anesthesia and continued until arrival in the intensive care unit (ICU). The primary endpoint was the time when patients fulfilled discharge criteria from hospital (possible hospital discharge). Secondary endpoints were the hospital discharge, the time to reach extubation, the length of stay in ICU, the number of major adverse cardiac events, and in-hospital mortality. Patients in the ECOM group received more often fluid loading and dobutamine. The time to reach extubation was reduced in the ECOM group: 510 min [360-1,110] versus 570 min [320-1,520], P = 0.005. No significant differences were found between both groups for possible hospital discharge [Hazard Ratio = 0.96 (95 % CI 0.64-1.45)] and hospital discharge [Hazard Ratio = 1.20 (95 % CI 0.79-1.81)]. A mini-invasive early goal-directed hemodynamic therapy based on ECOM can reduce the time to reach extubation but fails to significantly reduce the length of stay in hospital and the rate of major cardiac morbidity.

Cephalic versus digital plethysmographic variability index measurement: a comparative pilot study in cardiac surgery patients.

OBJECTIVES: Noninvasive measurement of digital plethysmographic variability index (PVI(digital)) has been proposed to predict fluid responsiveness, with conflicting results. The authors tested the hypothesis that cephalic sites of PVI measurement (namely PVI(ear) and PVI(forehead)) could be more discriminant than PVI(digital) to predict fluid responsiveness after cardiac surgery. DESIGN: A prospective observational study. SETTING: A cardiac surgical intensive care unit of a university hospital. PARTICIPANTS: Fifty adult patients. INTERVENTIONS: Investigation before and after fluid challenge. MEASUREMENT AND MAIN RESULTS: Patients were prospectively included within the first 6-hour postoperative period and investigated before and after fluid challenge. A positive response to fluid challenge was defined as a 15% increase in cardiac index. PVI(digital), PVI(ear), PVI(forehead), and invasive arterial pulse-pressure variation (PPV) measurements were recorded simultaneously, and receiver operating characteristic (ROC) curves were built. Forty-one (82%) patients were responders and 9 (18%) patients were nonresponders to fluid challenge. ROCAUC were 0.74 (95% confidence interval [95% CI]: 0.60-0.86), 0.81 (95% CI: 0.68-0.91), 0.88 (95% CI: 0.75-0.95) and 0.87 (95% CI: 0.75-0.95) for PVI(digital), PVI(ear), PVI(forehead), and PPV, respectively. Significant differences were observed between PVI(forehead) and PVI(digital) (absolute difference in ROCAUC = 0.134 [95% CI: 0.003-0.265], p = 0.045) and between PPV and PVI(digital) (absolute difference in ROCAUC = 0.129 [95% CI: 0.011-0.247], p = 0.033). The percentage of patients within the inconclusive class of response was 46%, 70%, 44%, and 26% for PVI(digital), PVI(ear), PVI(forehead), and PPV, respectively. CONCLUSIONS: PVI(forehead) was more discriminant than PVI(digital) and could be a valuable alternative to arterial PPV in predicting fluid responsiveness.

Right origin of the circumflex artery and posterior aortic annulus enlargement.

We present the case of a patient who required posterior enlargement of the aortic annulus during aortic valve replacement in the presence of abnormal origin of the circumflex artery from the right coronary artery, with a retroaortic course.

Octreotide for recurrent intestinal bleeding due to ventricular assist device.

We report the case of a 64-year-old Jarvik 2000 recipient with a high risk of bleeding (anticoagulation treatment and acquired von Willebrand disease), who presented with intractable gastrointestinal hemorrhage due to severe gastric angiodysplasia. He was successfully treated with long-acting octreotide.

Iatrogenic bidirectional dissection of the right coronary artery and the ascending aorta: the worst nightmare for an interventional cardiologist.

Although rare, iatrogenic aortocoronary dissection is one of the complications most dreaded by the interventional cardiologist. If not managed promptly, it can have redoubted and serious consequences. Herein, we present the case of a 70 year-old woman who was treated by stenting of the second segment of the right coronary artery (RCA) for recurrent angina but, unfortunately, the procedure was complicated by anterograde dissection of the RCA with a simultaneous retrograde propagation to the proximal part of the ascending aorta. Successful stenting of the entry point was able to recuperate the RCA and to limit the retrograde propagation to the ascending aorta, but there was an extension of the dissection to the aortic valve leaflets resulting in a massive aortic insufficiency. Therefore, surgical aortic valve replacement with prosthetic tube graft was performed [corrected].

Stentless bioprosthesis for treatment of traumatic aortic valve rupture.

Aortic valve rupture after blunt trauma to the chest is an infrequent complication that should be considered at the outset in examination of an accident victim. The presence of aortic regurgitation with hemodynamic instability is an indication for surgery. We implanted a stentless bioprosthesis after aortic valve rupture due to chest trauma in a 31-year-old man with schizophrenia.