Is intra-aortic balloon pump absolutely contraindicated in type A aortic dissection?

AIM: Circulatory failure following surgery for type A aortic dissection is frequent and associated with a high mortality rate. The intra-aortic balloon pump (IABP) is used to treat postcardiotomy cardiogenic shock but aortic dissection is traditionally a contraindication. In 10 patients we used IABP for severe cardiogenic shock following aortic dissection surgery, here we report on the short and midterm results. METHODS: From January 2000 to April 2008, among 151 patients with type A aortic dissection 10 received a postoperative IABP. False lumen extension was limited to the ascending aorta for 3 patients, reached the arch for 1 and the descending aorta for 6. RESULTS: The device was placed in the operative room (7 patients), intensive care unit (2) and preoperatively (1). IABP was introduced percutaneously except for one who required surgical placement. The mean duration of IABP therapy was 3.8 days. Four patients died, but no death was directly related to IABP. Improvement in hemodynamics allowed 8 patients to be weaned off IABP. None suffered extension of the dissection. Two patients developed IABP-related complications. Six required extrarenal purification. Among the survivors, one died of a stroke at 38 months, 2 recovered the same quality of life and 3 had neurological sequelae without loss of autonomy. CONCLUSION: IABP should only be used as a salvage option in cases of severe cardiogenic shock following type A aortic dissection. No patient suffered device-related aortic rupture or extension of the dissection. High mortality and morbidity underline the gravity of cardiogenic shock in this setting.

[Hip and pelvic injuries in the elderly]. / Traumatismes de l'extrémité supérieure du fémur et du bassin chez le sujet âgé.

Fractures of the hip and pelvis are frequent and serious injuries in elderly patients. Due to the aging population, their incidence should double by 2050. Therefore, the social and economical implications of these fractures are significant. Delay in diagnosis increases the associated morbidity and mortality. The purpose is to review the imaging features of these fractures, the imaging techniques (projections, CT) to depict them and their classification based on severity.

[The association of VAC® therapy, titanium plates osteosynthesis and bilateral pectoral muscle flaps in the management of postoperative mediastinitis in an obese and diabetic patient]. / Intérêt de l'association VAC®-thérapie, ostéosynthèse sternale et lambeaux pectoraux d'avancement dans la prise en charge d'une médiastinite postopératoire après chirurgie cardiaque chez une obèse diabétique.

Postoperative mediastinitis is one of the most worrisome complications after heart surgery. Until now there is no universally accepted strategy in the management of this infectious complication. Recently, various novel techniques like negative pressure therapy and titanium plates sternal reconstruction have allowed a dramatic decrease of mortality and morbidity after mediastinitis. We report the case of a diabetic patient suffering from morbid obesity who developed a severe postoperative mediastinitis after a coronary artery bypass; she was successfully treated by combining negative pressure therapy, titanium plates osteosynthesis and bilateral pectoral muscle flaps.

Dramatic improvement in survival after lung transplantation over time: a single center experience.

Lung transplantation (LT) is a recognized procedure for selected patients with end-stage respiratory failure. We performed 123 LT, including 32 single lung, 84 double lung, and 7 heart-lung transplantations in 48 patients with chronic obstructive pulmonary disease (COPD), 13 patients with pulmonary hypertension (PH), 33 with cystic fibrosis (CF), and 29 with interstitial lung disease (ILD) between July 1990 and January 2008. Survival was compared for periods before and after December 2001. The mean age of patients was 44.4 years (range 16-66.5 years); 84 (69%) were men. Before LT, 1 second forced expiratory volume was 28.7% +/- 18.1% and PaCO(2) = 6.3 kPa. Fifty-five patients were on noninvasive ventilation. Cold ischemia time was 320 +/- 91 minutes. Cardiopulmonary bypass (CPB) was used in 77 patients (64%). There were 18 early surgical reinterventions, 8 extracorporeal membrane oxygenations, and 38 bronchial stent insertions among 206 at-risk bronchial sutures. Crude survivals were 69%, 58%, 41%, and 18% at 1, 2, 5, and 10 years, respectively. Comparing before (n = 70 with 15 CF) vs after December 2001 (n = 53 with 17 CF), survivals were 63% vs 78%, 51% vs 71%, and 33% vs 60% at 1, 2, and 5 years, respectively (P = .01) and for CF patients, 52% vs 100%, 52% vs 94%, and 25% vs 94% at 1, 2, and 5 years, respectively (P = .005). There was significant improvement in survival before and after 2001 in 123 LT and particularly among CF patients. Improvement in survival after LT may be related to the sum of numerous changes in our practice since December 2001, including the use of pulmonary rehabilitation pre-LT, extracellular pneumoplegia, statins, macrolides for chronic rejection, monitoring of Epstein-Barr blood load, changes in maintenance immunosuppressants, as well as position movement up the coordinator nurse and learning curve.

[Prospective evaluation of fracture risk in osteoporotic patients after low cement volume vertebroplasty]. / Suivi prospectif du risque fracturaire après vertébroplastie utilisant un faible volume de ciment chez des patients ostéoporotiques.

PURPOSE: To prospectively compare the incidence of new fractures (as demonstrated on MR) within the first 3 months after an initial fracture in a population treated with low cement volume vertebroplasty and a population treated conservatively. MATERIALS AND METHODS: From 49 patients admitted for osteoporotic vertebral compression fracture, 22 underwent CT guided vertebroplasty with injection of 1-3 ml of PMMA, and 27 were treated conservatively. All patients underwent MR at presentation and at 3 months to detect new compression fractures. RESULTS: Twelve patients (54%) treated with vertebroplasty showed new fractures at 3 months compared to 10 (37%) in the control group. This was not statistically different (p=0.049). In the vertebroplasty group, the new fractures involved vertebrae adjacent to the treated vertebra in 77% of cases (p=0.009) compared to only 15% in the control group. During the 3-month period, 3 patients, including 2 treated with vertebroplasty, required hospital admission due to fracture related acute lumbar back pain. CONCLUSION: The small amount of injected cement does not prevent fractures of adjacent vertebrae but does reduce the extravasation of PMMA in adjacent tissues.

[Imaging of traumatic injuries of the knee]. / Imagerie des traumatismes du genou.

Traumatic injuries to the knee are frequent (road or sports related accidents, falls in elderly people). The Ottawa knee rules are applied and dictate the need for additional evaluation. Some fractures are adequately assessed on plain radiographs alone whereas other fractures (tibial plateau fracture) require additional evaluation with CT. Some fractures may be occult: the significance of lipohemarthrosis (indirect sign of intra-articular fracture on the lateral radiograph with horizontal beam) must be known. Benign appearing avulsion fractures suggest the presence of underlying capsuloligamentous injuries requiring further evaluation with MRI. The imaging work-up of sprains is usually negative. MRI may show areas of bone contusion that further the understanding of the mechanism of injury, predict and confirm the presence of capsuloligamentous injuries. Angiography is performed to detect popliteal artery injuries after knee dislocation which is associated with a risk of ischemia.

[Imaging of traumatic injuries of the foot and ankle]. / Imagerie des traumatismes de la cheville et du pied.

Traumatic injuries of the foot and ankle are frequent and constitute a true public health problem with over 6000 daily cases in France. The complex anatomy of this area and its association to other injuries in polytraumatized patients can lead to delayed diagnosis with worsened functional prognosis. Accurate diagnosis relies on good knowledge of osseous and ligamentous lesions and their associations and sometimes requires the use of additional imaging techniques including US and CT.

[Treatment of hydroxychloroquine poisoning with extracorporeal circulation]. / Traitement d'une intoxication à l'hydroxychloroquine par circulation extracorporelle.

We report a case of massive overdose of hydroxychloroquine treated with circulatory assistance by peripheral extracorporeal circulation (ECC). We expose the case of a 39-year-old woman who ingested 12 g of hydroxychloroquine with bromazepam, paroxetine, and zolpidem, in a suicide attempt. Patient has developed central nervous system depression, hemodynamic failure, life-threatening ventricular arrhythmias, and serious hypokalemia. Initially the patient has received conventional treatment with gastric lavage and activated charcoal for gastrointestinal decontamination, blood volume expansion and vasopressive drugs, intubation and mechanical ventilation, high dose of diazepam, and potassium replacement. A ventricular fibrillation was treated with external cardiac massage. In spite of this treatment, cardiogenic shock was uncontrolled, and imposed circulatory assistance. After extracorporeal circulation, we observed a spectacular improvement of hemodynamic parameters and electrocardiographic normalization at day one. Extracorporeal circulation could be used as a rescue treatment of cardiotrope and hydroxychloroquine overdoses.

[Imaging of the diabetic foot]. / Imagerie ostéo-articulaire du pied diabétique.

Destruction in diabetic feet is secondary to neuropathy (peripheral and autonomic nervous system) in association with microangiopathy. The loss of sensation to pain and the static trouble lead to increase the pressure in some areas and predispose to pedal skin ulceration, the precursor of osteomyelitis. Plain radiography should be the first step in the evaluation for diagnosis and follow-up. The initial patterns are nonspecific but very rapid evolution associating osteolysis, osteosclerosis and fragmentation lead to the Charcot foot. When osteomyelitis is suspected, scintigraphy with labelled white blood cells and MRI are necessary to differentiate infection from neuropathy.

Atypical primary epithelioid hemangioendothelioma of the heart.

We report an unusual case of primary cardiac epithelioid hemangioendothelioma (EHE) with atypical features, which was treated by orthoptic transplantation with a good outcome for 10 years despite recurrent pulmonary and nodal metastases. EHE is a rare vascular tumor that belongs to the group of malignant proliferations from the new World Health Organization classification of soft tissue tumors. EHE may harbor atypical features that confer a more aggressive course, albeit better than that of conventional angiosarcomas. Histological examination of the primary cardiac tumor revealed a proliferation of large epithelioid tumor cells presenting atypical features and a mitotic index of 3 mitoses per 10 high power fields. In contrast, pulmonary metastases exhibited typical features of EHE, and CD 34 and CD 31 immunostainings strongly stained cytoplasmic vascular lumen. In this report, we illustrate the potential aggressiveness of the atypical variant of EHE and suggest that transplantation might be considered as an alternative therapy in the treatment of EHE of the heart.

[Continuous infusion of remifentanil and target-controlled infusion of propofol for coronary surgery in elderly patients: comparison with continuous infusion of remifentanil and propofol]. / Perfusion continue de rémifentanil et propofol en anesthésie intraveineuse à objectif de concentration au cours de la chirurgie coronaire du sujet âgé: comparaison avec l'alfentanil et le propofol en perfusion continue.

OBJECTIVES: Comparison of the length of mechanical ventilation and postoperative complications after coronary surgery in elderly patients anaesthetised with propofol associated with either alfentanil or remifentanil. STUDY DESIGN: Retrospective study with an historic control group. PATIENTS: Three hundred thirty-eight consecutive patients (75-year-old or more) undergoing isolated coronary surgery. One hundred and fifty seven patients operated between January 1998 and June 2000 received alfentanil (1 microg/kg/minute) with a manually control infusion of propofol, 181 operated between July 2000 and 2002, remifentanil 0.25 microg/kg/minute with target controlled infusion of propofol (target blood concentration: 1.5 to 2 microg/ml). METHODS: The two groups were compared for preoperative and surgical data. The length of mechanical ventilation, stay in ICU and the main postoperative complications were compared between the two groups. RESULTS: Length of mechanical ventilation was significantly reduced in the remifentanil group (6 +/- 9 h vs. 13 +/- 63 h ; p <0.0001), 70% of the patients were extubated before the 6th postoperative hours against 53% in the alfentanil group (p =0.0023). This was not associated with a reduction of stay in ICU or postoperative complications. During surgery, an increased used of vasopressor was observed in the remifentanil group (40.2% vs 2.4% ; p <0.0001) with a postoperative elevation of blood concentration of CKMb (35.7 +/- 38.2 microg/l, vs. 27.7 +/- 31.9 microg/l, p =0.02). CONCLUSION: Elderly patients undergoing coronary surgery were extubated earlier with remifentanil. However, this had no effect on duration of ICU stay but was associated with an increased used of vasopressor.

[Does the time between preoperative interruption of aspirin intake and operation influence postoperative blood loss and transfusion requirement in coronary artery bypass graft?]. / L'intervalle entre l'arrêt préopératoire de l'aspirine et l'intervention chirurgicale a-t-il une influence sur le saignement et la transfusion en chirurgie coronaire?

OBJECTIVE: Impact of the interval between interruption of aspirin intake and surgery on postoperative bleeding and transfusion in coronary artery bypass graft (CABG), with extracorporeal circulation (ECC). STUDY DESIGN: Retrospective study. PATIENTS AND METHODS: Four hundred and twelve patients having undergone CABG were retrospectively reviewed. Three groups were evaluated according to the length of the interval defined above: Group I (< 3 days), Group II (3-7 days), Group III (> 7 days or without aspirin intake). Postoperative blood loss at 3rd, 6th, 12th, and 24th hour and transfusion requirements were assessed for the 3 groups. Aprotinin (low dose, 2 M KIU) was systematically included in the priming of the ECC circuit. RESULTS: There were no significant differences among groups for weight, size, duration of ECC, and number of bypasses. No significant correlation was noted among the 3 groups for postoperative blood loss and transfusion. Multivariate analysis showed that factors associated to a higher risk of excessive bleeding were ECC duration and number of arterial grafts. Factors associated with a higher risk of transfusion were: emergency, minimum patient temperature during ECC, weight and preoperative haemoglobin level. Aspirine intake was not associated with an increase of bleeding or transfusion. CONCLUSION: Our study showed that in our practice using systematic low dose of aprotinin when priming the ECC circuit, aspirin did not significantly increase bleeding or transfusion requirements in CABG with ECC, whatever the interval between interruption of aspirin intake and surgery. Consequently, in our practice, aspirin intake is interrupted on hospitalisation, one day before surgery.

Blunt traumatic rupture of the pericardium with cardiac herniation: two cases diagnosed using computed tomography.

Traumatic ruptures of the pericardium with cardiac herniation are infrequent, and their radiological pattern little familiar, so that they are often missed preoperatively. Few reports have emphasised the use of a CT scan as a tool for diagnosis and CT scan signs have not been well documented. We report on two cases of traumatic herniation of the heart for which a CT scan brought a major contribution for diagnosis. We describe the presence of an empty pericardial sac on CT slices which allowed us to diagnose the cardiac herniation. These observations demonstrate that CT scans can contribute to the diagnosis of pericardial rupture with cardiac herniation.

Thromboxane A(2) modulates cyclic AMP relaxation and production in human internal mammary artery.

Two forms of thromboxane A(2) (TP) receptors, TPalpha and TPbeta receptors, have recently been cloned. These receptors regulate adenylate cyclase activity in two opposite ways: TPalpha receptors activate, whereas TPbeta receptors inhibit adenylate cyclase and cAMP generation. The aim of this study was to examine the effects of the thromboxane A(2) analogue, U46619 (9,11-dideoxy-9alpha,11 alpha-methanoepoxy-prostaglandin F(2alpha)), on forskolin-induced relaxation and cAMP accumulation in human internal mammary artery (IMA) and saphenous vein (SV). In organ baths, IMA rings precontracted with U46619 (3.10(-9) and 3.10(-8) M) were less sensitive to forskolin than rings precontracted with methoxamine (3. 10(-6) M). In contrast, the sensitivity to forskolin was similar in SV rings contracted with the same concentrations of these agonists. U46619 reduced significantly the ten-fold increase in cAMP induced by forskolin in IMA but not in SV rings. Sensitivity and maximal relaxation in response to sodium nitroprusside were not altered in either IMA or SV. In summary, stimulation of TP receptors with the thromboxane A(2) analogue, U46619, inhibited the cAMP pathway of relaxation through the inhibition of cAMP synthesis in human IMA but not in SV. It is suggested that thromboxane A(2) may play a role in the control of muscle tone in IMA both by its potent contractile effect and by its inhibitory effect on the cAMP pathway of relaxation.

Prevalence and consequences of nutritional depletion in lung transplant candidates.

Nutritional status was studied in lung transplant (LT) candidates. The hypotheses were that nutritional depletion was highly prevalent and lean body mass depletion was a risk factor for a higher mortality both before and after LT. Of 78 consecutive patients listed for LT, 16 (21%) died while on the waiting list, eight (10%) were alive awaiting LT, and 54 (69%) received a graft. Mean age was 42.3+/-4.4 (mean+/-SD). Thirty-eight per cent had a diagnosis of bronchiectasis or cystic fibrosis (BRO/CF), 33% of emphysema, 20% of idiopathic pulmonary fibrosis (IPF) and 8% of primary pulmonary hypertension. Body mass index (BMI) was 20.4+/-4.3 kg.m2, weight was 87.9+/-16.6% of ideal body weight (IBW). Patients were classed into four nutritional groups according to IBW and creatinine height index (CHI): 1: weight <90% IBW and CHI <60% of predicted (28% of cases); II: weight <90% IBW and CHI > or =60% (27%); III: weight > or =90% IBW and CHI <60% (17%); IV: weight > or =90% IBW and CHI > or =60% (28%). Overall, 72% were depleted corresponding to groups 1, II and III. Lean body mass depletion occurred despite normal weight in 17% of the cases (group III). Subjects with BRO/CF were mostly in groups 1, II, III whereas IPF were concentrated in group II. Lean body mass depletion was associated with more severe hypoxaemia, reduced 6-minute walking distance and a higher mortality while awaiting. After LT, duration of mechanical ventilation, time spent in intensive care unit (ICU) was related to initial body composition. Survival after LT was lowest in group III. To conclude, nutritional depletion in lung transplant candidates is highly prevalent and should be more precisely assessed with a special reference to lean body mass since it has specific consequences both while awaiting and after lung transplant. Attempts should be made to increase lean body mass before lung transplant.

Computer-guided pericardiocentesis: experimental results and clinical perspectives.

Percutaneous pericardial puncture is a relatively safe and effective technique in case of large pericardial effusions when practiced under echographic or radiological control. The goal of our project is to improve the performance of this technique, mainly in case of smaller and loculated effusions using an accurate guidance towards a preplanned target, based on a model of the pericardial effusion. This paper presents preclinical results of this new computer-assisted technique used to reach the pericardial cavity. The procedure is divided into 3 steps: 1. acquisition of ultrasound data, using an echocardiographic device connected to a 3-D localizer and to a computer, 2. modeling procedure to define the optimal strategy taking into account the mobility of organs on a digital model, 3. guided puncture with a localized needle to reach the predefined target using a passive guidance system. After validation on a dynamic phantom and a feasibility study on dogs, an accuracy and reliability analysis protocol was realized on pigs with experimental pericardial effusion. Feasibility of the technique is demonstrated on animal study with an accuracy of at least 2.5 mm. Further clinical investigation is in progress using a more ergonomic and less cumbersome system. This study demonstrates the feasibility of computer-assisted pericardiocentesis. Beyond the simple improvement of the current technique, this could be a new way to reach the heart or a new tool for percutaneous access and image-guided puncture of soft tissues.

Reactivity of the Human Internal Mammary Artery and the Gastroepiploic Artery to Constrictor Substances.

The internal mammary artery (IMA) and the gastroepiploic artery (GEA) are frequently used to construct coronary artery bypass grafts. In order to determine and to compare their contractile properties, we studied the effects of constricting agents which are liberated or infused during coronary bypass surgery. IMA and GEA were arranged as ring segments and suspended in organ baths at optimal stretch using a normalization procedure. Concentration-contraction curves to angiotensin II, norepinephrine, U-46619, endothelin-1, leukotriene C(4) and KCl were performed. The sensitivity (pD(2)) of GEA and IMA to all the agents did not differ. However, GEA developed stronger maximal contraction force than IMA to angiotensin II (P < 0.001), norepinephrine (P < 0.05), U-46619 (P = 0.06), endothelin-1 (P < 0.01), and KCl (P < 0.01), whereas leukotriene C(4) did not induce a significant contraction on GEA and IMA. The higher contractility of GEA may explain that it is more prone to spasm than IMA in the clinical setting. This study reinforces IMA as a first-choice conduit for coronary artery bypass and emphasizes the need for antispastic drugs particularly when GEA is used as bypass vessel.http://link.springer-ny.com/link/service/journals/00547/bibs/8n4p187.html

Vasorelaxant actions of enoximone, dobutamine, and the combination on human arterial coronary bypass grafts.

Enoximone (a type III-selective phosphodiesterase inhibitor) and dobutamine (a beta-receptor agonist) are positive inotropic drugs frequently used in the postoperative management of coronary bypass surgery. The purpose of this study was to characterize their relaxant effects on the human internal mammary artery (IMA) and the gastroepiploic artery (GEA) and to test the hypothesis that their combination may have greater than additive relaxant effects. In organ baths, the relaxant effects of enoximone and dobutamine were tested on rings of IMA (n = 86) precontracted with U46619 (a thromboxane A2 mimetic), norepinephrine (NE), or KCl. The relaxant effects of dobutamine and enoximone also were tested on rings of GEA (n = 42) precontracted with U46619 and NE. The effect of the combination of enoximone and dobutamine were tested on rings of IMA (n = 24) precontracted with U46619 or NE. With respect to maximal relaxations induced by papaverine (10(-4) M), enoximone (< or =10(-3) M) caused full relaxations of IMA precontracted with NE, U46619, or KCI. Dobutamine (< or =10(-3) M) caused full relaxations of IMA precontracted with NE or KCI but only 46% (95% CI, 27-65) relaxation in the rings precontracted with U46619. Similar patterns of relaxation were observed in GEA rings, with dobutamine inducing partial relaxation in GEA precontracted with U46619. The pD2 values of enoximone and dobutamine were both significantly lower in segments precontracted with U46619. The in vitro threshold relaxant concentrations were in the upper limits or over the range of therapeutic plasma concentrations. The relaxant effect of the combination was significantly more important than the theoretic additive effect in IMA contracted with U46619 or NE. Enoximone and dobutamine are potent in vitro vasodilators but exert weak relaxant effects in IMA and GEA at concentrations in the therapeutic range. There is, however, a greater than additive vasorelaxant effect of the combination, suggesting that the vasorelaxant effect of the combination, in addition to the additive inotropic effect, may be beneficial to patients undergoing coronary bypass grafting.