A study of ChatGPT in facilitating Heart Team decisions on severe aortic stenosis.

BACKGROUND: Multidisciplinary Heart Teams (HTs) play a central role in the management of valvular heart diseases. However, the comprehensive evaluation of patients' data can be hindered by logistical challenges, which in turn may affect the care they receive. AIMS: This study aimed to explore the ability of artificial intelligence (AI), particularly large language models (LLMs), to improve clinical decision-making and enhance the efficiency of HTs. METHODS: Data from patients with severe aortic stenosis presented at HT meetings were retrospectively analysed. A standardised multiple-choice questionnaire, with 14 key variables, was processed by the OpenAI Chat Generative Pre-trained Transformer (GPT)-4. AI-generated decisions were then compared to those made by the HT. RESULTS: This study included 150 patients, with ChatGPT agreeing with the HT's decisions 77% of the time. The agreement rate varied depending on treatment modality: 90% for transcatheter valve implantation, 65% for surgical valve replacement, and 65% for medical treatment. CONCLUSIONS: The use of LLMs offers promising opportunities to improve the HT decision-making process. This study showed that ChatGPT's decisions were consistent with those of the HT in a large proportion of cases. This technology could serve as a failsafe, highlighting potential areas of discrepancy when its decisions diverge from those of the HT. Further research is necessary to solidify our understanding of how AI can be integrated to enhance the decision-making processes of HTs.

Identification of High Platelet Reactivity Despite ADP P2Y 12 Inhibitor Treatment: Two Populations in the Vasodilator-Stimulated Phosphoprotein Assay and Variable PFA-P2Y Shapes of Curve.

Introduction Response to ADP P2Y 12 receptor inhibition by clopidogrel can be evaluated by various techniques. Here, we compared a functional rapid point-of-care technique (PFA-P2Y) with the degree of biochemical inhibition assessed by the VASP/P2Y 12 assay. Methods Platelet response to clopidogrel was investigated in 173 patients undergoing elective intracerebral stenting (derivation cohort n = 117; validation cohort n = 56). High platelet reactivity (HPR) was defined as PFA-P2Y occlusion time <106 seconds or VASP/P2Y 12 platelet reactivity index (PRI) >50%. Results In the derivation cohort, receiver operator characteristics analysis for the ability of PFA-P2Y to detect biochemical HPR showed high specificity (98.4%) but poor sensitivity (20.0%) and a very low area under the curve (0.59). The VASP/P2Y 12 assay revealed two coexisting platelet populations with different levels of vasodilator-stimulated phosphoprotein (VASP) phosphorylation: a fraction of highly phosphorylated, inhibited platelets and another of poorly phosphorylated, reactive platelets. Analysis of the PFA-P2Y curve shape revealed different types, categorized by time of occlusion (<106 seconds, 106 to 300 seconds, >300 seconds), and pattern (regular, irregular, and atypical). Noteworthy, curves with late occlusion and permeable curves with an irregular or atypical pattern correlated with VASP-PRI >50% and smaller sizes of the inhibited platelet subpopulation. Considering the PFA-P2Y shape of the curve for the detection of HPR improved sensitivity (72.7%) and preserved specificity (91.9%), with a rather high AUC (0.823). The validation cohort confirmed the VASP/P2Y 12 assay data and the usefulness of considering the PFA-P2Y curve shape. Conclusion In patients treated with acetylsalicylic acid and clopidogrel for 7-10 days, the VASP/P2Y 12 assay reveals two coexisting subpopulations of differentially inhibited platelets, whose relative sizes predict global PRI and distinct PFA-P2Y curve patterns, indicating incomplete clopidogrel efficacy. The detailed analysis of both VASP/P2Y 12 and PFA-P2Y is necessary for optimal detection of HPR.

How to Solve the Conundrum of Heparin-Induced Thrombocytopenia during Cardiopulmonary Bypass.

Heparin-induced thrombocytopenia (HIT) is a major issue in cardiac surgery requiring cardiopulmonary bypass (CPB). HIT represents a severe adverse drug reaction after heparin administration. It consists of immune-mediated thrombocytopenia paradoxically leading to thrombotic events. Detection of antibodies against platelets factor 4/heparin (anti-PF4/H) and aggregation of platelets in the presence of heparin in functional in vitro tests confirm the diagnosis. Patients suffering from HIT and requiring cardiac surgery are at high risk of lethal complications and present specific challenges. Four distinct phases are described in the usual HIT timeline, and the anticoagulation strategy chosen for CPB depends on the phase in which the patient is categorized. In this sense, we developed an institutional protocol covering each phase. It consisted of the use of a non-heparin anticoagulant such as bivalirudin, or the association of unfractionated heparin (UFH) with a potent antiplatelet drug such as tirofiban or cangrelor. Temporary reduction of anti-PF4 with intravenous immunoglobulins (IvIg) has recently been described as a complementary strategy. In this article, we briefly described the pathophysiology of HIT and focused on the various strategies that can be applied to safely manage CPB in these patients.

Post-transplant survival with pre-transplant durable continuous-flow mechanical circulatory support in a Swiss cohort of heart transplant recipients.

BACKGROUND: Worldwide, almost half of all heart transplantation candidates arrive today at their transplant operation with durable continuous-flow mechanical circulatory support (CF-MCS). This evolution is due to a progressive increase of waiting list time and hence an increased risk of haemodynamic worsening. Longer duration of CF-MCS is associated with a higher risk of device-related complications with potential adverse impact on post-transplant outcome as suggested by recent results from the United Network of Organ Sharing of the United States. METHODS: A 2-centre Swiss heart transplantation programme conducted a retrospective observational study of consecutive patients of theirs who underwent a transplant in the period 2008-2020. The primary aim was to determine whether post-transplant all-cause mortality is different between heart transplant recipients without or with pre-transplant CF-MCS. The secondary outcome was the acute cellular rejection score within the first year post-transplant. RESULTS: The study participants had a median age of 54 years; 38/158 (24%) were females. 53/158 study participants (34%) had pre-transplant CF-MCS with a median treatment duration of 280 days. In heart transplant recipients with pre-transplant CF-MCS, the prevalence of ischaemic cardiomyopathy was higher (51 vs 32%; p = 0.013), the left ventricular ejection fraction was lower (20 vs 25; p = 0.047) and pulmonary vascular resistance was higher (2.3 vs 2.1 Wood Units; p = 0.047). Over the study period, the proportion of heart transplant recipients with pre-transplant CF-MCS and the duration of pre-transplant CF-MCS treatment increased (2008-2014 vs 2015-2020: 22% vs 45%, p = 0.009; increase of treatment days per year: 34.4 ± 11.2 days, p = 0.003; respectively). The primary and secondary outcomes were not different between heart transplant recipients with pre-transplant CF-MCS or direct heart transplantation (log-rank p = 0.515; 0.16 vs 0.14, respectively; p = 0.81). CONCLUSION: This data indicates that the strategy of pre-transplant CF-MCS with subsequent orthotopic heart transplantation provides post-transplant outcomes not different to direct heart transplantation despite the fact that the duration of pre-transplant assist device treatment has progressively increased.

Vasoplegic Syndrome after Cardiopulmonary Bypass in Cardiovascular Surgery: Pathophysiology and Management in Critical Care.

Vasoplegic syndrome (VS) is a common complication following cardiovascular surgery with cardiopulmonary bypass (CPB), and its incidence varies from 5 to 44%. It is defined as a distributive form of shock due to a significant drop in vascular resistance after CPB. Risk factors of VS include heart failure with low ejection fraction, renal failure, pre-operative use of angiotensin-converting enzyme inhibitors, prolonged aortic cross-clamp and left ventricular assist device surgery. The pathophysiology of VS after CPB is multi-factorial. Surgical trauma, exposure to the elements of the CPB circuit and ischemia-reperfusion promote a systemic inflammatory response with the release of cytokines (IL-1ß, IL-6, IL-8, and TNF-α) with vasodilating properties, both direct and indirect through the expression of inducible nitric oxide (NO) synthase. The resulting increase in NO production fosters a decrease in vascular resistance and a reduced responsiveness to vasopressor agents. Further mechanisms of vasodilation include the lowering of plasma vasopressin, the desensitization of adrenergic receptors, and the activation of ATP-dependent potassium (KATP) channels. Patients developing VS experience more complications and have increased mortality. Management includes primarily fluid resuscitation and conventional vasopressors (catecholamines and vasopressin), while alternative vasopressors (angiotensin 2, methylene blue, hydroxocobalamin) and anti-inflammatory strategies (corticosteroids) may be used as a rescue therapy in deteriorating patients, albeit with insufficient evidence to provide any strong recommendation. In this review, we present an update of the pathophysiological mechanisms of vasoplegic syndrome complicating CPB and discuss available therapeutic options.

Has the profile of heart transplantation recipients changed within the last three decades?

BACKGROUND: Heart transplantation remains the most durable treatment for patients with end-stage heart failure refractory to medical treatment. Central elements of the listing criteria for heart transplantation have remained largely unchanged in the last three decades whereas treatment of heart failure has significantly increased survival and reduced disease-related symptoms. It remains unknown whether the improvement of heart failure therapy changed the profile of heart transplantation candidates or affected post-transplant survival. METHODS: The study investigated a total of 323 heart transplant recipients of the Lausanne University Hospital with 328 transplant operations between 1987 and 2018. Patients were separated into three groups on the basis of availability of heart failure therapy: period 1 (1987-1998; n = 115) when renin-angiotensin system blockade and diuretic treatment were available; period 2 (1999-2010; n = 106) marked by the addition of beta-blocker and mineralocorticoid receptor antagonist treatment in severe heart failure, and the establishment of cardiac defibrillator and resynchronisation therapy; period 3 (2011-2018; n = 107) characterised by the increasing use of ventricular assist devices for bridge to transplantation. RESULTS: The patient characteristics age (all: 53.4 years), male sex (all: 79%) and body mass index (all: 24.5 kg/m2) did not differ between periods. History of arterial hypertension was less prevalent in period 2 (period 1 vs 2 vs 3: 44 vs 28 vs 43%, p = 0.04) whereas other cardiovascular risk factors were equally distributed. Left ventricular ejection fraction, VO2max, and pulmonary vascular resistance were not different between the three periods. The prevalence of ischaemic cardiomyopathy was higher in periods 1 and 3; dilated non-ischaemic cardiomyopathy was more frequent in period 2. Post-transplant 1-year survival was highest in period 3 (1 vs 2 vs 3: 87.2 ± 3.2% vs 70.8 ± 4.4% vs 93.0 ± 2.6%, p always ≤0.02), and the Kaplan-Meier estimates of survivors of the first year post-transplant were not different between the three periods. In descriptive analysis, early mortality was not associated with acknowledged pretransplant predictors of post-transplant mortality. CONCLUSION: Availability of different medical heart failure treatments did not result in greatly different pretransplant characteristics of heart transplantation recipients across the three periods. This suggests that the maintained central criteria of listing for heart transplantation still identify end-stage heart failure patients with a similar profile. This finding can explain the unchanged overall mortality on condition of 1-year survival across the three periods, since pretransplant characteristics are relevant for long-term survival after heart transplantation.

Challenges in Patient Blood Management for Cardiac Surgery: A Narrative Review.

About 15 years ago, Patient Blood Management (PBM) emerged as a new paradigm in perioperative medicine and rapidly found support of all major medical societies and government bodies. Blood products are precious, scarce and expensive and their use is frequently associated with adverse short- and long-term outcomes. Recommendations and guidelines on the topic are published in an increasing rate. The concept aims at using an evidence-based approach to rationalize transfusion practices by optimizing the patient's red blood cell mass in the pre-, intra- and postoperative periods. However, elegant as a concept, the implementation of a PBM program on an institutional level or even in a single surgical discipline like cardiac surgery, can be easier said than done. Many barriers, such as dogmatic ideas, logistics and lack of support from the medical and administrative departments need to be overcome and each center must find solutions to their specific problems. In this paper we present a narrative overview of the challenges and updated recommendations for the implementation of a PBM program in cardiac surgery.

Impact of an enhanced recovery after surgery pathway on thoracoscopic lobectomy outcomes in non-small cell lung cancer patients: a propensity score-matched study.

BACKGROUND: This study evaluates the effect of enhanced recovery after surgery (ERAS) pathways on postoperative outcomes of non-small cell lung cancer (NSCLC) patients undergoing video-assisted thoracic surgery (VATS) lobectomy. METHODS: We retrospectively reviewed all consecutive patients undergoing VATS lobectomy for NSCLC between January 2014 and October 2019 and assigned them to the relevant group ("pre-ERAS" or "ERAS"). Length of stay, readmissions and complications within 30 days were compared between both groups. A propensity score-matched analysis was performed based on sex, age, type of operation, comorbidities, American Society of Anesthesiologists (ASA) score and preoperative pulmonary functions. RESULTS: A total of 307 records (164 male/143 female; 140 ERAS/167 pre-ERAS; median age: 67) were reviewed. There was no statistical difference in patient's characteristics. Overall ERAS compliance was 81%. The ERAS group presented significantly shorter length of stay (median 5 vs. 7 days; P=0.004) without significant difference in cardiopulmonary complication rate (27.1% vs. 35.9%; P=0.1). Readmission (3.6% vs. 5.4%; P=0.75) and duration of drainage (median 2 vs. 3 days; P=0.14) were similar between groups. The propensity score-matched analysis showed that the length of hospital stay was reduced by 1.4 days (P=0.034) and the postoperative cardiopulmonary complication rate by 13% (P=0.044) in the ERAS group. CONCLUSIONS: Adoption of an ERAS pathway for VATS lobectomies in NSCLC patients has decreased the length of hospital stay and the cardiopulmonary complication rate without affecting the readmission rate.

Massive Hemorrhage: The Role of Whole Blood Viscoelastic Assays.

Viscoelastic whole blood tests are increasingly used to guide hemostatic therapy in bleeding patients in the perioperative, trauma, and obstetric settings. Compared with standard laboratory tests of hemostasis, they have a shorter turnaround time and provide simultaneous information on various aspects of clot formation and lysis. The two available brands TEG (thromboelastography) and ROTEM (rotational thromboelastometry) provide devices that are either manually operated or fully automated. The automation allows for the assays to be used as point-of-care tests increasing their usefulness in massively bleeding patients with rapidly changing hemostatic profiles. While the number of research papers on the subject and the number of published treatment algorithms increase rapidly, the influence of the use of these devices on patient outcome needs yet to be established. In this article, we first review the technology of these devices and the parameters provided by the assays. Next, we present the problems encountered when choosing cut-off values that trigger intervention. Furthermore, we discuss the studies examining their influence on clinical outcomes, and finally, we briefly highlight some of the most important limitations and pitfalls inherent to these assays.

Transapical approach versus transcervical approach for transcatheter aortic valve replacement: a retrospective monocentric study.

OBJECTIVES: Transfemoral approach is the standard access-route for transcatheter aortic valve replacement (TAVR). However, alternative approaches are needed in a number of patients and accesses such as transapical (TA) TAVR or transcervical (TC) are used. We aimed to compare clinical and echocardiographic outcomes after TA-TAVR or TC-TAVR. METHODS: All patients who underwent TA- and TC-TAVR for severe aortic stenosis in our institution between 2008 and 2020 were retrospectively included. End points included 30-day all-cause mortality, procedural complications (according to the Valve Academic Research Consortium-2 criteria), procedure duration, intensive care unit (ICU) length of stay (LOS) and overall hospital LOS. For 30-day all-cause mortality, we furthermore used a Cox proportional-hazards model to adjust for significant between-group differences in baseline characteristics as well as difference in year of intervention. RESULTS: TAVR was performed in 176 patients, using a TA approach (n = 127) or a TC approach (n = 49). Baseline clinical and echocardiographic characteristics were comparable between the 2 groups, except age and peripheral artery disease. All-cause 30-day mortality rates were not significantly different (8.5% in the TA group vs 2.3% in the TC group, P = 0.124). TC approach was associated with significantly shorter procedure duration {71.0 [interquartile range (IQR) 52.5-101.0] vs 93 [IQR 80.0-120.0] min, P < 0.001}, shorter ICU LOS [0.0 (IQR 0.0-0.0) vs 1.0 (IQR 1.0-3.0) days, P < 0.001] and shorter hospital LOS [7.0 (IQR 5.0-9.5) vs 14.0 (IQR 10.0-22.0) days, P < 0.001]. CONCLUSIONS: The TC approach may be a good first-choice alternative in case of contraindications to transfemoral-TAVR.

Pulmonary complications associated with veno-arterial extra-corporeal membrane oxygenation: a comprehensive review.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a life-saving technology that provides transient respiratory and circulatory support for patients with profound cardiogenic shock or refractory cardiac arrest. Among its potential complications, VA-ECMO may adversely affect lung function through various pathophysiological mechanisms. The interaction of blood components with the biomaterials of the extracorporeal membrane elicits a systemic inflammatory response which may increase pulmonary vascular permeability and promote the sequestration of polymorphonuclear neutrophils within the lung parenchyma. Also, VA-ECMO increases the afterload of the left ventricle (LV) through reverse flow within the thoracic aorta, resulting in increased LV filling pressure and pulmonary congestion. Furthermore, VA-ECMO may result in long-standing pulmonary hypoxia, due to partial shunting of the pulmonary circulation and to reduced pulsatile blood flow within the bronchial circulation. Ultimately, these different abnormalities may result in a state of persisting lung inflammation and fibrotic changes with concomitant functional impairment, which may compromise weaning from VA-ECMO and could possibly result in long-term lung dysfunction. This review presents the mechanisms of lung damage and dysfunction under VA-ECMO and discusses potential strategies to prevent and treat such alterations.

Impact of Compliance With Components of an ERAS Pathway on the Outcomes of Anatomic VATS Pulmonary Resections.

OBJECTIVES: Implementation of an Enhanced Recovery After Surgery (ERAS) program is associated with better postoperative outcomes. The aim of this study was to evaluate the impact of ERAS compliance (overall and to specific elements of the program) on them. DESIGN: Retrospective analysis of prospectively collected data. SETTING: University hospital, monocentric. PARTICIPANTS: All adult (≥18 years old) patients undergoing video-assisted thoracic surgery (VATS) anatomic pulmonary resection. INTERVENTIONS: ERAS-governed VATS anatomic pulmonary resection. MEASUREMENTS AND MAIN RESULTS: Demographics, surgical characteristics and pre-, peri-, and postoperative compliance with 16 elements of the ERAS program were assessed. Postoperative outcomes and length of stay were compared between low- (<75% of adherence) and high-compliance (≥75%) groups. From April 2017 to November 2018, 192 ERAS patients (female/male: 98/94) of median age of 66 years (interquartile range 58-71) underwent VATS resection (109 lobectomies, 83 segmentectomies). There was no 30-day mortality and resurgery rate was 5.7%. Overall ERAS compliance was 76%. High compliance was associated with fewer complications (18% v 48%, p < 0.0001) and lower rate of delayed discharge (37% v 60%, p = 0.0013). Early removal of chest tubes (odds ratio [OR]: 0.26, p < 0.002), use of electronic drainage (OR: 0.39, p = 0.036), opioid cessation on day 3 (OR: 0.28, p = 0.016), and early feeding (OR: 0.12, p = 0.014) were associated with reduced rates of postoperative complications. Shorter hospital stay was correlated with early removal of chest tubes (OR: 0.12, p < 0.0001) and opioid cessation on day 3 (OR: 0.23, p = 0.001). CONCLUSIONS: High ERAS compliance is associated with better postoperative outcomes in patients undergoing anatomic pulmonary VATS resections.

Potential and Limitations of the New P2Y12 Inhibitor, Cangrelor, in Preventing Heparin-Induced Platelet Aggregation During Cardiac Surgery: An In Vitro Study.

BACKGROUND: Heparin-induced thrombocytopenia (HIT) can put cardiac surgery patients at a high risk of lethal complications. If anti-PF4/heparin antibodies (anti-PF4/Hep Abs) are present, 2 strategies exist to prevent intraoperative aggregation during bypass surgery: first, using an alternative anticoagulant, and second, using heparin combined with an antiaggregant. The new P2Y12 inhibitor, cangrelor, could be an attractive candidate for the latter strategy; several authors have reported its successful use. The present in vitro study evaluated cangrelor's ability to inhibit heparin-induced platelet aggregation in the presence of anti-PF4/Hep Abs. METHODS: Platelet-poor plasma (PPP) from 30 patients with functional anti-PF4/Hep Abs was mixed with platelet-rich plasma (PRP) from 5 healthy donors.Light transmission aggregometry was used to measure platelet aggregation after adding 0.5 IU·mL of heparin (HIT) to the plasma, and this was compared with samples spiked with normal saline (control) and samples spiked with cangrelor 500 ng·mL and heparin 0.5 IU·mL (treatment). Friedman test with post hoc Dunn-Bonferroni test was used for between-group comparisons. RESULTS: Heparin 0.5 IU·mL triggered aggregation in 22 of 44 PPP-PRP mixtures, with a median aggregation of 86% (interquartile range [IQR], 69-91). The median aggregation of these 22 positive samples' respective control tests was 22% (IQR, 16-30) (P < .001). Median aggregation in the cangrelor-treated samples was 29% (IQR, 19-54) and significantly lower than the HIT samples (P < .001). Cangrelor inhibited heparin-induced aggregation by a median of 91% (IQR, 52-100). Cangrelor only reduced heparin-induced aggregation by >95% in 10 of the 22 positive samples (45%). Cangrelor inhibited heparin-induced aggregation by <50% in 5 of the 22 positive samples (22%) and by <10% in 3 samples (14%). CONCLUSIONS: This in vitro study found that cangrelor was an unreliable inhibitor of heparin-induced aggregation in the presence of anti-PF4/Hep Abs. We conclude that cangrelor should not be used as a standard antiaggregant for cardiac patients affected by HIT during surgery. Unless cangrelor's efficacy in a particular patient has been confirmed in a presurgery aggregation test, other strategies should be chosen.

Comparison of ROTEM Sigma to Standard Laboratory Tests and Development of an Algorithm for the Management of Coagulopathic Bleeding in a Tertiary Center.

OBJECTIVE: The ROTEM sigma whole blood viscoelastic test uses different technology than the former delta model. Existing ROTEM based algorithms use cutoff values based on the delta model, and cannot be applied to the sigma model. The authors tested sensitivity and specificity of ROTEM sigma parameters to detect specific hemostatic deficiencies and established cutoff values with the aim of developing a treatment algorithm. DESIGN: Prospective observational evaluation of diagnostic accuracy. SETTING: This study was performed in a tertiary center. PARTICIPANTS: Blood samples for standard laboratory tests (SLTs) and ROTEM sigma analysis were obtained from 14 healthy volunteers and 35 patients showing various hemostatic disorders (isolated factor deficiencies, von Willebrand's disease, thrombocytopenia, hypofibrinogenemia, hyperfibrinogenemia, and patients undergoing cardiac surgery). INTERVENTION: Correlation coefficients were calculated between SLTs and ROTEM parameters in the extrinsic pathway activation, intrinsic pathway activation, and extrinsic pathway activation with platelet inhibition tests. Receiver operator characteristics defined the values of ROTEM parameters, which best predict plasma fibrinogen level measured by Clauss method <1.5 g/L and <2.0 g/L, platelet < 50 × 109/L and < 100 × 109/L, prothrombin time (PT) <80% and activated partial thromboplastin time (aPTT) >37 seconds and 1.5 times the upper normal limit. MEASUREMENT AND MAIN RESULTS: The combination of FIBTEM A5 ≤12 mm and EXTEM A5 ≤44 mm identified a fibrinogen level <1.5 g/L with 100% sensitivity and 77.5% specificity. PLTEM describes the platelet contribution to clot firmness and is calculated as EXTEM - FIBTEM. PLTEM A5 ≤16 mm sensitivity and specificity were 100% and 96.4% for a platelet count < 50 × 109/L. EXTEM coagulation time (CT) >80 seconds had a 25.0% sensitivity and a 100% specificity for a PT <80%. The INTEM CT >204 seconds showed a sensitivity of 75.0% and a specificity of 97.4% for an aPTT >37 and a sensitivity of 100% and a specificity of 80.0% for an aPTT >55 seconds. CONCLUSION: The authors present the first ROTEM sigma-based algorithm for the treatment of coagulopathic bleeding. The algorithm uses parameters with optimal sensitivity and specificity for critical values of SLTs determined from a heterogenous group of donors.

Cardiac Surgery Successfully Managed With Cangrelor in a Patient With Persistent Anti-PF4/Heparin Antibodies 8 Years After Heparin-Induced Thrombocytopenia.

A 66-YEAR-OLD female requiring cardiac surgery had persisting anti-platelet factor 4 (PF4)/heparin antibodies (HIT-abs) 8 years after heparin-induced thrombocytopenia (HIT). In 2010, she developed thrombotic thrombocytopenic purpura (TTP) (ADAMTS-13 <5%, inhibitor at 1.0 BU/mL), which was treated successfully with corticotherapy, plasmapheresis, and intravenous heparin. While taking heparin, she developed HIT, as evidenced by a positive functional test. Her platelet count fully resolved without thrombotic complications with danaparoid treatment. In 2018, the preoperative titer of HIT-abs was still 0.38 U/mL by chemoluminescent immunoassay (CLIA), and positive by particle-gel agglutination immunoassay (PaGIA) with a titer of 2 and was strongly positive on an enzyme-linked immunosorbent assay (ELISA). The authors of the case report chose to use cangrelor combined with heparin during cardiopulmonary bypass (CPB). Cangrelor was used without increased postoperative bleeding or thrombotic complications. Postoperatively she exhibited a huge rise in HIT-abs (14.22 U/mL on postoperative day 11) with a positive functional assay. There was no recurrence of HIT, however. This case illustrates the importance of excluding the presence of persisting HIT-abs before CPB and ensuring close medical follow-up after even a single exposure to heparin.

Cytokine clearance with CytoSorb® during cardiac surgery: a pilot randomized controlled trial.

BACKGROUND: Cardiopulmonary bypass (CPB) is often associated with degrees of complex inflammatory response mediated by various cytokines. This response can, in severe cases, lead to systemic hypotension and organ dysfunction. Cytokine removal might therefore improve outcomes of patients undergoing cardiac surgery. CytoSorb® (Cytosorbents, NJ, USA) is a recent device designed to remove cytokine from the blood using haemoadsorption (HA). This trial aims to evaluate the potential of CytoSorb® to decrease peri-operative cytokine levels in cardiac surgery. METHODS: We have conducted a single-centre pilot randomized controlled trial in 30 patients undergoing elective cardiac surgery and deemed at risk of complications. Patients were randomly allocated to either standard of care (n = 15) or CytoSorb® HA (n = 15) during cardiopulmonary bypass (CPB). Our primary outcome was the difference between the two groups in cytokines levels (IL-1a, IL-1b, IL-2, IL-4, IL-5, IL-6, IL-10, TNF-α, IFN-γ, MCP-1) measured at anaesthesia induction, at the end of CPB, as well as 6 and 24 h post-CPB initiation. In a consecutive subgroup of patients (10 in HA group, 11 in control group), we performed cross-adsorber as well as serial measurements of coagulation factors' activity (antithrombin, von Willebrand factor, factor II, V, VIII, IX, XI, and XII). RESULTS: Both groups were similar in terms of baseline and peri-operative characteristics. CytoSorb® HA during CPB was not associated with an increased incidence of adverse event. The procedure did not result in significant coagulation factors' adsorption but only some signs of coagulation activation. However, the intervention was associated neither with a decrease in pro- or anti-inflammatory cytokine levels nor with any improvement in relevant clinical outcomes. CONCLUSIONS: CytoSorb® HA during CPB was not associated with a decrease in pro- or anti-inflammatory cytokines nor with an improvement in relevant clinical outcomes. The procedure was feasible and safe. Further studies should evaluate the efficacy of CytoSorb® HA in other clinical contexts. TRIAL REGISTRATION: ClinicalTrials.gov NCT02775123 . Registered 17 May 2016.

Outcome after extracorporeal membrane oxygenation-bridged lung retransplants: a single-centre experience.

OBJECTIVES: A lung retransplant has been shown to be a valid option in selected patients with chronic lung allograft dysfunction (CLAD). However, a subgroup of patients may require, in addition to invasive mechanical ventilation, extracorporeal membrane oxygenation (ECMO) as a bridge to a retransplant. Overall and CLAD-free survival after ECMO-bridged retransplants are compared to first transplants with and without bridging ECMO and to retransplants without bridging ECMO. METHODS: We reported a retrospective, single-institution experience based on a prospective data set of all patients undergoing lung transplants between January 2004 and December 2016 with a mean follow-up of 51 ± 41 months. RESULTS: A total of 230 patients (96 men, 134 women, mean age 47.3 years) had lung transplants: 200 had first transplants without bridging ECMO; 13 had first transplants with bridging ECMO; 11 had retransplants without bridging ECMO; and 6 had retransplants with bridging ECMO. The 3- and 5-year survival rates were 81%/76%, 68%/68%, 69%/46% and 50%/25%, respectively. There was no significant difference in overall survival between those who had first transplants with and without bridging ECMO or retransplants without bridging ECMO. In contrast, patients undergoing ECMO-bridged retransplants had a significantly lower overall survival rate than those with a first transplant without bridging ECMO (P = 0.007). In addition, the post-transplant CLAD-free survival curves varied significantly among the 4 treatment groups (P = 0.041), paralleling overall survival. CONCLUSIONS: Patients requiring ECMO as a bridge to a retransplant had lower overall and CLAD-free survival rates compared to those who had a first transplant with and without bridging ECMO and a retransplant without bridging ECMO.

[Therapeutic options in advanced heart failure : place of durable left ventricular assist device (LVAD)]. / Options thérapeutiquesdans l'insuffisance cardiaque avancée : place de l'assistance ventriculaire gauche permanente (LVAD).

Despite the benefit of the drugs acting on neuro-humoral activation and cardiac resynchronization therapy, some patients will end in a severe refractory form of heart failure: advanced heart failure. The only therapeutic options with a positive impact on mortality and quality of life are heart transplantation and permanent left ventricular assist device (LVAD). The significant technological improvements of the past 20 years lead to a reduction of the complications associated with these devices, which now allow their use not only during the waiting period preceding heart transplantation (bridge to transplant), but also as a durable therapeutic option (destination therapy).

Malgré le bénéfice des médicaments agissant sur l'activation neuro-humorale et de la thérapie de resynchronisation, certains patients vont évoluer vers une forme sévère et réfractaire d'insuffisance cardiaque : l'insuffisance cardiaque avancée (ICA). Les seules options thérapeutiques de l'ICA ayant démontré un impact favorable sur la survie et la qualité de vie sont la transplantation cardiaque et l'implantation d'un dispositif d'assistance ventriculaire gauche permanent (LVAD, Left Ventricular Assist Device). Les importantes améliorations technologiques des vingt dernières années ont permis de réduire significativement les complications associées à ces dispositifs, permettant non seulement leur utilisation dans l'attente du greffe cardiaque (bridge to transplant), mais aussi comme option thérapeutique définitive (destination therapy).