Regional anaesthesia via parasternal catheters inserted preoperatively and postoperative delirium after cardiac surgery: A prospective unrandomised clinical trial.

VISUAL ABSTRACT: http://links.lww.com/EJA/A927.

Bilateral sternal infusion of ropivacaine and length of stay in ICU after cardiac surgery with increased respiratory risk: A randomised controlled trial.

BACKGROUND: The continuous bilateral infusion of a local anaesthetic solution around the sternotomy wound (bilateral sternal) is an innovative technique for reducing pain after sternotomy. OBJECTIVE: To assess the effects of the technique on the need for intensive care in cardiac patients at increased risk of respiratory complications. DESIGN: Randomised, observer-blind controlled trial. SETTING: Single centre, French University Hospital. PATIENTS: In total, 120 adults scheduled for open-heart surgery, with one of the following conditions: age more than 75 years, BMI >30 kg m, chronic obstructive pulmonary disease, active smoking habit. INTERVENTION: Either a bilateral sternal infusion of 0.2% ropivacaine (3 ml h through each catheter; 'intervention' group), or standardised care only ('control' group). Analgesia was provided with paracetamol and self-administered intravenous morphine. MAIN OUTCOME MEASURES: The length of time to readiness for discharge from ICU, blindly assessed by a committee of experts. RESULTS: No effect was found between groups for the primary outcome (P = 0.680, intention to treat); the median values were 42.4 and 37.7 h, respectively for the control and intervention groups (P = 0.873). Similar nonsignificant trends were noted for other postoperative delays. Significant effects favouring the intervention were noted for dynamic pain, patient satisfaction, occurrence of nausea and vomiting, occurrence of delirium or mental confusion and occurrence of pulmonary complications. In 12 patients, although no symptoms actually occurred, the total ropivacaine plasma level exceeded the lowest value for which neurological symptoms have been observed in healthy volunteers. CONCLUSION: Because of a small size effect, and despite significant analgesic effects, this strategy failed to reduce the time spent in ICU. TRIAL REGISTRATION: EudraCT (N°: 2012-005225-69); ClinicalTrials.gov (NCT01828788).

Sutureless aortic bioprosthesis valve implantation and bicuspid valve anatomy: an unsolved dilemma?

Interest is growing in the clinical use of sutureless (SU) valves. However, indications in some anatomical sub-settings, like bicuspid aortic valves (BAV), have been so far limited. We discuss herein our initial experience with the implantation of the 3f Enable SU bioprosthesis in patients with a BAV. Patients with a BAV were selected in our unit between March 2011 and September 2014 for a SU 3f Enable valve implantation. Twenty of the 198 patients who underwent a 3f Enable valve implantation in our unit had a BAV. Procedural success was 100 %, but reclamping was necessary in one (5 %) case. Median size of implanted bioprosthesis was 23 mm. After a mean follow-up of 13.8 ± 10.7 months, survival was 100 %. Two patients (10 %) showed an immediate grade 1 paravalvular leak (PVL) that progressed to grade 2 and 3+ (moderate/severe), respectively, during follow-up. Type of bicuspidy (Sievers classification) in these two patients was 0 and intraoperatively aortic annuli admitted the 25 mm calibrator. Among the 18 patients without PVL, no one had a type 0 large BAV. At 1 year, implantation of the 3f Enable SU bioprosthesis appears to be safe in patients with BAV type I and II, while in type 0 use of the SU valve seems to be safe only if the annular diameter is <25 mm. Larger studies are necessary to confirm our findings in order to clarify the indications for SU technology in the subset of bicuspid patients.

Combined Minimally Invasive Redo Mitral Surgery and Pectus Excavatum Correction.

We present a technique of mitral valve surgery performed in a patient with severe pectus excavatum and previous Bentall surgery. Neither redo sternotomy nor conventional right minithoracotomy were thought to provide adequate surgical access to the mitral valve. We therefore opted for a combined procedure comprising sternal reconstruction and right minithoracotomy mitral valve replacement. The mitral valve was replaced and the sternum reconstructed according to the Ravitch technique.

Body adiposity dictates different mechanisms of increased coronary reactivity related to improved in vivo cardiac function.

BACKGROUND: Saturated fatty acid-rich high fat (HF) diets trigger abdominal adiposity, insulin resistance, type 2 diabetes and cardiac dysfunction. This study was aimed at evaluating the effects of nascent obesity on the cardiac function of animals fed a high-fat diet and at analyzing the mechanisms by which these alterations occurred at the level of coronary reserve. MATERIALS AND METHODS: Rats were fed a control (C) or a HF diet containing high proportions of saturated fatty acids for 3 months. Thereafter, their cardiac function was evaluated in vivo using a pressure probe inserted into the cavity of the left ventricle. Their heart was isolated, perfused iso-volumetrically according to the Langendorff mode and the coronary reserve was evaluated by determining the endothelial-dependent (EDV) and endothelial-independent (EIV) vasodilatations in the absence and presence of endothelial nitric oxide synthase and cyclooxygenase inhibitors (L-NAME and indomethacin). The fatty acid composition of cardiac phospholipids was then evaluated. RESULTS: Although all the HF-fed rats increased their abdominal adiposity, some of them did not gain body weight (HF- group) compared to the C group whereas other ones had a higher body weight (HF+). All HF rats displayed a higher in vivo cardiac activity associated with an increased EDV. In the HF- group, the improved EDV was due to an increase in the endothelial cell vasodilatation activity whereas in the HF+ group, the enhanced EDV resulted from an improved sensitivity of coronary smooth muscle cells to nitric oxide. Furthermore, in the HF- group the main pathway implicated in the EDV was the NOS pathway while in the HF+ group the COX pathway. CONCLUSIONS: Nascent obesity-induced improvement of cardiac function may be supported by an enhanced coronary reserve occurring via different mechanisms. These mechanisms implicate either the endothelial cells activity or the smooth muscle cells sensitivity depending on the body adiposity of the animals.

Endovascular retrieval of a migrated contraceptive implant into the pulmonary artery : case report and review of literature.

BACKGROUND: The migration of contraceptive devices into pulmonary arteries is extremely rare, reported to be 1 in 100,000. CASE PRESENTATION: A 19-year-old female presented no sensation of a contraceptive implant in her arm which had been placed one year prior. A CT scan confirmed that the implant had migrated into the left lower segmentary pulmonary artery. After a multidisciplinary meeting, an endovascular approach was attempted. Following right femoral venous access, a 8F NeuronMax® introducer was placed into the left pulmonary artery under fluoroscopic guidance. The contraceptive device was removed using a 25-mm loop snare, with a proximal capture technique. The patient was discharged the following day, with no reported complications. CONCLUSION: In cases of contraceptive device migration, the first medical decision involves deciding between removal or 'watching and waiting'. Previous reports describe two removal options: endovascular or surgical approaches. Fourteen reports have been published, with high technical success and low rates of complications. The loop snare technique is described as the optimal technique for an endovascular approach. Due to their invasive nature, surgical approaches should be reserved for cases of endovascular removal failure, after evaluating risks and benefits.

Factors Influencing Unfractionated Heparin Pharmacokinetics and Pharmacodynamics During a Cardiopulmonary Bypass.

BACKGROUND: Unfractionated heparin (UFH) is commonly used during cardiac surgery with a cardiopulmonary bypass to prevent blood clotting. However, empirical administration of UFH leads to variable responses. Pharmacokinetic and pharmacodynamic modeling can be used to optimize UFH dosing and perform real-time individualization. In previous studies, many factors that could influence UFH pharmacokinetics/pharmacodynamics had not been taken into account such as hemodilution or the type of UFH. Few covariates were identified probably owing to a lack of statistical power. This study aims to address these limitations through a meta-analysis of individual data from two studies. METHODS: An individual patient data meta-analysis was conducted using data from two single-center prospective observational studies, where different UFH types were used for anticoagulation. A pharmacodynamic/pharmacodynamic model of UFH was developed using a non-linear mixed-effects approach. Time-varying covariates such as hemodilution and fluid infusions during a cardiopulmonary bypass were considered. RESULTS: Activities of UFH's anti-activated factor/anti-thrombin were best described by a two-compartment model. Unfractionated heparin clearance was influenced by body weight and the specific UFH type. Volume of distribution was influenced by body weight and pre-operative fibrinogen levels. Pharmacodynamic data followed a log-linear model, accounting for the effect of hemodilution and the pre-operative fibrinogen level. Equations were derived from the model to personalize UFH dosing based on the targeted activated clotting time level and patient covariates. CONCLUSIONS: The population model effectively characterized UFH's pharmacokinetics/pharmacodynamics in cardiopulmonary bypass patients. This meta-analysis incorporated new covariates related to UFH's pharmacokinetics/pharmacodynamics, enabling personalized dosing regimens. The proposed model holds potential for individualization using a Bayesian estimation.

Results of the first randomized French study evaluating self-testing of the International Normalized Ratio.

BACKGROUND AND AIM OF THE STUDY: In this single-center French study, the conventional management of patients receiving vitamin K antagonists (VKAs) was compared with an International Normalized Ratio (INR) self-testing program. The aim was to determine the reliability of self-testing devices, and to estimate the variability of the self-measured INR within the therapeutic and target range. METHODS: A total of 206 patients who had undergone valve replacement with a mechanical prosthesis, with or without myocardial revascularization, between May 2004 and September 2007 was randomized into two groups. Group 1 patients (n = 103) underwent INR monitoring at a laboratory, while Group 2 patients (n = 103) underwent self-testing INR using either the CoaguChek (Roche) (Group 2A; n = 55) or INRatio (Hemosense) (Group 2B; n = 48) system. Patients in Group 1 underwent at least once-monthly INR measurement, while those in Group 2 carried out once-weekly self-testing, and also underwent once-monthly INR measurement at the laboratory. The large majority of patients (97.9%) were treated with fluindione. RESULTS: The mean follow up period was 49.0 +/- 10.3 weeks. Self-testing was reliable, with a correlation coefficient between device- and laboratory-measured INRs of 0.80 [CI: 0.78, 0.82] (p < 0.0001). The proportion of time spent within the INR target range was significantly higher for Group 2 (61.5 +/- 19.3% versus 55.5 +/- 19.9%; p < 0.05), while the absolute mean deviation of INR from the target range was higher in Group 1 (60.1 +/- 70.2% versus 47.4 +/- 51.5%). Adverse events were reported by seven patients in Group 1, but by no patients in Group 2 (p < 0.01). CONCLUSION: INR self-testing devices are reliable and beneficial. Moreover, INR self-monitoring allows an enhanced stability within a target range, and also helps to prevent serious postoperative complications.

Rapid-deployment aortic valve replacement in high-risk patients: A case-control study.

Introduction: Aortic valve stenosis is the most frequent cardiac valve pathology in the western world. In high-risk patients, conventional aortic valve replacement (C-AVR) carries high rates of morbidity and mortality. In the last few years, rapid-deployment valves (RDV) have been developed to reduce the surgical risks. In this work, we aimed to compare the mid-term outcomes of rapid-deployment AVR (RD-AVR) with those of the C-AVR in high-risk patients. Methods: This retrospective case-control study identified 23 high-risk patients who underwent RD-AVR between 12/2015 to 01/2018. The study group was compared with a control group of 46 patients who were retrospectively selected from a database of 687 C-AVR patients from 2016 to 2017 which matched with the study group for age and Euro SCORE II. Results: RD-AVR group presented more cardiovascular risk factors. Euro SCORE II was higher in the RD-AVR group (P =0.06). In the RD-AVR group, we observed significantly higher mean prosthetic size (P <0.001). In-hospital mortality was zero in RD-AVR group versus 2 deaths in C-AVR group. Hospital stay was longer in the RD-AVR group with statistical significance (P =0.03). In the group AVR with associated cardiac procedures, while comparing subgroups RD-AVR versus C-AVR, early mean gradient was lower in the first cited (P =0.02). The overall mean follow-up was 10.9 ± 4.3 months. Conclusion: The RD-AVR technique is reliable and lead to positive outcomes. This procedure provides a much larger size with certainly better flow through the aortic root. It is an alternative to C-AVR in patients recognized to be surgically fragile.

Inaugural experience and early results of minimally invasive approach in cardiac surgery in Auvergne region, France.

Introduction: Minimally invasive approach in cardiac surgery has become an established and common technique in many cardiac surgery centres throughout the world. We report how we safely introduced minimally invasive approach in cardiac surgery in our department and we aim to demonstrate that this approach is feasible in any medium-size cardiac surgical centre. Methods: it consisted of retrospective and descriptive study on 60 patients who underwent minimally invasive mitral valve (45) or aortic valve surgery (15) from January 2017 to Februry 2018. The approach was 3 to 6-cm right thoracotomy through the 4th and 5th intercostal space. The Cor-KnotTM system was used to tie the knots of the prosthesis in case of mitral valve replacement and aortic valve replacement and the ring if mitral valve repair. Results: There was no conversion of thoracotomy to sternotomy. The average duration in ICU was 4.3± 2.3 days and 3.3 ± 1.5 respectively for mitral and aortic valve surgery. Four mitral patients and 1 aortic patient were reoperated for bleeding. No in-hospital death was observed. The postoperative discharge echocardiogram was normal in 95.6% of the mitral valve patients the trans-aortic mean gradient for the aortic valve patients was 16.3 ± 6 mm Hg. The thirty-day mortality was zero. In the majority of the patients, the scar of the thoracotomy were almost unseen. Conclusion: It is possible to safely implement this new approach in any mid-size cardiac centers. The use of modern technology such as 3D video and Cor Knot allows achievement of excellent short term outcomes.

A procedure to extract functional isolated mitochondria from small-sized human atrial samples. Application to obesity with a partial characterisation of the organelles.

Evaluating the activity of cardiac mitochondria is probably the best way to estimate early cellular damage in chronic pathology. Early diagnosis allows rapid therapeutic intervention thus increasing patient survival rate in a number of diseases. However, data on human cardiac mitochondria are scarce in the international literature. Here, we describe a method to extract and study functional mitochondria from the small-sized right atrial aliquots (minimum of 400 mg) obtained during extracorporeal circulation and usually considered as surgical waste products. The mitochondria were purified through several mechanical processes (fine myocardial cutting, tissue grinding and potter Elvehjem homogenising), an enzymatic proteolytic action (subtilisin) and differential centrifugations. In chronic pathologies, including obesity, early disturbances of mitochondrial function can occur. The effects of obesity on the rate of mitochondrial oxygen consumption and H2O2 release were thus determined with three different substrates (glutamate/malate, succinate/rotenone and palmitoylcarnitine/malate). The human atrial mitochondria were of high quality from a functional viewpoint, compared to rat ventricle organelles, but the extraction yield of the human mitochondria was twice lower than that of rat mitochondria. Tests showed that glutamate/malate-related ADP-stimulated respiration was strongly increased in obese subjects, although the oxidation of the other two substrates was unaffected. Reactive oxygen species (ROS) production by the isolated mitochondria was low in comparison with that of the lean subjects. These results confirm those found in one of our previous studies in the ventricles of rats fed a high-fat diet. In conclusion, the described method is simple, reliable and sensitive. It allows for the description of the impact of obesity on the function of atrial mitochondria while using only a small patient sampling (n = 5 in both the lean and the obese groups).

Improving cardiac function after cardiac surgery by biventricular pacing in patient selected by three-dimensional echocardiography.

We present the case of a 57-year-old woman with severe aortic regurgitation and ventricular dysfunction (ejection fraction 34%) requiring surgical intervention. In pre-operative period, no left ventricular (LV) asynchrony was detected by QRS duration and current echocardiographic techniques, including tissue Doppler imaging. A new echocardiographic technology, the timing of regional volumetric changes by three-dimensional echocardiography (3DEcho), demonstrated an intraventricular mechanical asynchrony. Indeed, during surgery, epicardial leads were attached to the right atrium and the right ventricle as part of the standard management. Two additional epicardial leads were attached to the left ventricle on the most delayed wall localized precisely by 3DEcho on the inferolateral wall. In post-operative period, biventricular (BiV) pacing showed improvement in the LV mechanical synchronization, resulting in improvement in the LV systolic function compared with right ventricular pacing or no pacing. This case shows the potential utility of 3DEcho in prediction of favourable response of the BiV pacing in patients with depressed LV systolic function ongoing cardiac surgery.

About the controversies of the cardioprotective effect of n-3 polyunsaturated fatty acids (PUFAs) between animal studies and clinical meta-analyses: a review with several strategies to enhance the beneficial effects of n-3 PUFAs.

Several meta-analyses describing the effect of n-3 polyunsaturated fatty acids on the survival rate of the victims of an acute coronary event do not clearly support a beneficial impact of these fatty acids. Yet, animal studies consistently show n-3 PUFA-induced protection against ischemia-reperfusion-induced myocardial injuries. The impact on reperfusion arrhythmias of these PUFAs is more controversial. The literature shows the anti-arrhythmic properties of circulating n-3 PUFAs. However, when these fatty acids are incorporated in the cardiac membrane, they protect the myocardial tissue vis a vis cellular damage but they can be either pro- or anti-arrhythmic during reperfusion, depending on the severity of tissue injuries. The latter elements can explain the lack of beneficial effect observed in the meta-analyses, but a proper use of n-3 PUFAs may provide advantages in terms of survival rate. This review discusses the different results obtained in humans and animals and presents several strategies to enhance the beneficial effects of n-3 PUFAs.

Dietary EPA Increases Rat Mortality in Diabetes Mellitus, A Phenomenon Which Is Compensated by Green Tea Extract.

: Diabetes is characterized by a high mortality rate which is often associated with heart failure. Green tea and eicosapentaenoic acid (EPA) are known to lessen some of the harmful impacts of diabetes and to exert cardio-protection. The aim of the study was to determine the effects of EPA, green tea extract (GTE), and a combination of both on the cardiac consequences of diabetes mellitus, induced in Wistar rats by injection of a low dose of streptozotocin (33 mg/kg) combined with a high fat diet. Cardiac mechanical function, coronary reactivity, and parameters of oxidative stress, inflammation, and energy metabolism were evaluated. In the context of diabetes, GTE alone limited several diabetes-related symptoms such as inflammation. It also slightly improved coronary reactivity and considerably enhanced lipid metabolism. EPA alone caused the rapid death of the animals, but this effect was negated by the addition of GTE in the diet. EPA and GTE combined enhanced coronary reactivity considerably more than GTE alone. In a context of significant oxidative stress such as during diabetes mellitus, EPA enrichment constitutes a risk factor for animal survival. It is essential to associate it with the antioxidants contained in GTE in order to decrease mortality rate and preserve cardiac function.

Antioxidant and Cardioprotective Effects of EPA on Early Low-Severity Sepsis through UCP3 and SIRT3 Upholding of the Mitochondrial Redox Potential.

Sepsis still causes death, often through cardiac failure and mitochondrial dysfunction. Dietary ω3 polyunsaturated fatty acids are known to protect against cardiac dysfunction and sepsis lethality. This study set out to determine whether early low-severity sepsis alters the cardiac mitochondrial function in animals fed a Western-type diet and whether dietary eicosapentaenoic acid (EPA) administration protects the myocardium against the deleterious effects of sepsis and if so to seek possible mechanisms for its effects. Rats were divided into two groups fed either an ω3 PUFA-deficient diet ("Western diet," DEF group) or an EPA-enriched diet (EPA group) for 5 weeks. Each group was subdivided into two subgroups: sham-operated rats and rats subjected to cecal ligation and puncture (CLP). In vivo cardiac mechanical function was examined, and mitochondria were harvested to determine their functional activity. Oxidative stress was evaluated together with several factors involved in the regulation of reactive oxygen species metabolism. Sepsis had little effect on cardiac mechanical function but strongly depressed mitochondrial function in the DEF group. Conversely, dietary EPA greatly protected the mitochondria through a decreased oxidative stress of the mitochondrial matrix. The latter was probably due to an increased uncoupling protein-3 expression, already seen in the sham-operated animals. CLP rats in the EPA group also displayed increased mitochondrial sirtuin-3 protein expression that could reinforce the upholding of oxidative phosphorylation. Dietary EPA preconditioned the heart against septic damage through several modifications that protect mitochondrial integrity. This preconditioning can explain the cardioprotective effect of dietary EPA during sepsis.

Evolution of chronic kidney disease after surgical aortic valve replacement or transcatheter aortic valve implantation.

BACKGROUND: Immediate improvement in kidney function has been reported after surgical aortic valve replacement or transcatheter aortic valve implantation. Long-term data, however, are not available. AIM: To assess the evolution of kidney function in chronic kidney disease stage 3b-5, 1 year after surgical aortic valve replacement or transcatheter aortic valve implantation. METHODS: All patients with chronic kidney disease stage 3b-5 undergoing surgical aortic valve replacement or transcatheter aortic valve implantation for aortic stenosis in a single centre were included. Kidney function was assessed 1 year postprocedure. Improvement or deterioration in estimated glomerular filtration rate was defined by an increase or decrease of 5mL/min/1.73 m2, respectively. RESULTS: Overall, 127 procedures were analysed (54 surgical aortic valve replacements and 73 transcatheter aortic valve implantations). Kidney function improved in 51% of patients at 1 year (45% of the surgical aortic valve replacement group versus 57% of the transcatheter aortic valve implantation group; P=0.21), and deteriorated in only 14% of patients at 1 year (18% of the surgical aortic valve replacement group versus 10% of the transcatheter aortic valve implantation group; P=0.22). Almost a quarter of patients (23%) had an improvement in estimated glomerular filtration rate of>15mL/min/1.73 m2, and this was consistent at later follow-up. Few patients went onto chronic dialysis at 1 year (three after surgical aortic valve replacement and one after transcatheter aortic valve implantation). Acute kidney injury was an independent prognostic factor for long-term deterioration in kidney function (odds ratio 2.1, 95% confidence interval 1.4-3.6; P=0.006). CONCLUSION: Aortic valve replacement, whether by surgical aortic valve replacement or transcatheter aortic valve implantation, improved estimated glomerular filtration rate at 1 year in more than half of patients with chronic kidney disease stage 3b-5.

Indications and perioperative outcomes of extracorporeal life support in clermont-ferrand.

OBJECTIVES: To report the epidemiological profile of the patients who underwent extracorporeal life support (ECLS) and then analyze the indications and outcomes of this procedure. METHODS: It consisted of a retrospective and descriptive study based on the database from the department of cardiovascular surgery. SETTING: University hospital clinic. PATIENTS: One hundred and sixty-one patients have participated in the study. Included were all patients who presented with left-sided heart or biventricular failure. Those who were suffering from either isolate respiratory failure or isolate right ventricle failure were excluded. INTERVENTIONS: Participants underwent ECLS: central ECLS or peripheral ECLS. RESULTS: : The mean age of the patients was 54 years; there were 73% of male patients and the mean duration of ECLS was 5.3 days. There were two types of ECLS: central (71%) and peripheral (29%). Indications for support were dominated by cardiogenic shock in 69%. Bleeding was the most frequent complication (23.5%). The overall in-hospital mortality of patients who underwent ECLS was 60%. CONCLUSION: The number of ECLS performed increases in proportion to mastery of surgical technique. There is a high rate of mortality and morbidity with ECLS. However, it remains a lifesaving therapy for many clinically urgent situations.