Antiphospholipid antibodies proposed in the diagnosis of infective endocarditis.

Antiphospholipid antibodies (aPL) may occur alone or associated with other diseases. To evaluate aPL, tested as anticardiolipin antibodies (IgG aCL) in infective endocarditis (IE) diagnosis, we investigated their prevalence in a cohort of 651 patients with IE suspicion. aPL was significantly associated with definite IE versus IE-rejected patients. Their mean levels were significantly higher in patients with definite IE versus possible IE. When applied as Duke minor criterion, they were significantly more often positive, and at higher levels, in patients with definite IE than in patients with possible or rejected IE. aPL could be helpful in difficult cases of IE diagnosis.

Incidence and determinants of spinal cord ischaemia in stent-graft repair of the thoracic aorta.

OBJECTIVES: Endovascular repair of descending thoracic aortic lesions is associated with a substantial risk of perioperative spinal cord ischaemia (SCI) which may lead to permanent paraplegia. We performed a retrospective analysis of our experience in the endovascular treatment of descending thoracic aortic lesions to define the incidence of SCI and to identify factors that contributed to its development. METHODS: 67 consecutive patients underwent stent graft repair for descending thoracic aortic lesions including degenerative aneurysm (n=19), type B dissection (acute n=2, chronic n=15), traumatic rupture (acute n=14, chronic n=4), penetrating aortic ulcer (n=5), anastomotic false aneurysm (n=4), mycotic aneurysm (n=3) and embolic aortic lesion (n=1) between June 2000 and June 2005. All procedures were performed with the patient under general anaesthesia and strict blood pressure monitoring. No patient had intra-operative monitoring of spinal evoked potential or cerebrospinal fluid (CSF) drainage to prevent SCI. Neurological evaluation was realized after recovery from general anaesthesia. Fifteen factors, including nature of aortic disease, length of aortic coverage, number of stent-grafts, coverage of the distal third of the thoracic aorta and subclavian artery coverage, were investigated as possible predictors of postoperative SCI. RESULTS: Five patients (7.5%) had postoperative neurological deficits (immediate n=2, delayed n=3) referable to SCI. Univariate analysis showed that length of aortic coverage (p<0.001) and number of stent-grafts deployed (p=0.02) were significant predictors of SCI. Multivariate logistic regression analysis showed that length of aortic coverage was the only independent significant predictor of SCI. ROC curve analysis revealed 205mm of aortic length coverage as the threshold for increased risk of postoperative SCI (p=0.001), with specificity and sensitivity of 95.2 and 80% respectively. CONCLUSION: In our study, length of aortic coverage is the only independent predictive factor of SCI after endovascular treatment with 205mm as a threshold for increased risk. Hence, methods to prevent SCI, especially those aimed at restoration of an adequate spinal cord perfusion pressure, should be offered to patients requiring extensive coverage of the descending thoracic aorta.

[Surgical management of cardiac wounds: cardiac or general surgical service?]. / Plaies du coeur, prise en charge de chirurgie cardiaque ou générale?

OBJECTIVE: To define modalities of cardiac wound management with a special emphasis on the initial direction of the patient toward a surgical service, rapid diagnosis, and surgical treatment. METHOD: Sixteen patients with thoracic injury to the region of the heart treated between 1996 and 2006 were evaluated retrospectively. Pre-operative clinical data, echography, and CT results were collected; time elapsed between injury and treatment, type of surgical treatment, use of cardio-pulmonary bypass, morbidity and mortality were evaluated. RESULTS: There were 16 patients (12 men); age ranged from 18 to 80 with an average of 45.7 years. Nine patients had penetrating cardiac wounds, two had blunt trauma, and five suffered iatrogenic trauma. Cardio-pulmonary bypass was used in two cases. The mean time elapsed between trauma and surgical evaluation was 63 minutes (p=0.18). In all cases, surgery consisted of a myorraphy without coronary or valvular repair. Post-operative complications occurred in 4 patients (25%) and resulted in 2 deaths (12.5%). Complication and death were associated with a prolonged interval between injury and surgical management. CONCLUSION: Patients with cardiac wounds should be transported to the nearest surgical hospital. There are no benefits to cardio-pulmonary bypass in cardiac trauma.

Value of CMR in quantification of paravalvular aortic regurgitation after TAVI.

AIMS: To assess the value of cardiac magnetic resonance (CMR) using phase-contrast velocity mapping for paravalvular aortic regurgitation (PAR) quantification. METHODS AND RESULTS: All patients undergoing transcatheter aortic valve implantation (TAVI) in our centre between November 2012 and August 2013, without CMR-contraindication were included. PAR severity was assessed 5 days after TAVI using: transthoracic echocardiography (TTE) and CMR [regurgitant volume (RV), regurgitant fraction (RF)]. Aortic regurgitation (AR) index was obtained during TAVI. Thirty of 51 patients who underwent TAVI were included (COREVALVE, n = 10; or EDWARDS SAPIEN XT, n = 20). At TTE, PAR was mild in 22, moderate in 3, and severe in 5 patients. Reliable phase-contrast images were acquired at the sino-tubular junction for SAPIEN and at the tubular portion of the ascending aorta for COREVALVE. The reproducibility of CMR was high (coefficient of correlation = 0.99 for intra- and inter-operator variability). At CMR, RV, and RF were significantly (P < 0.0005) correlated with AR severity at TTE, with mean RF values at 9.2 ± 7.6% in mild, 20.3 ± 4.2% in moderate, and 46.8 ± 10.8% in severe PAR. A cut-off value of RF < 14% at CMR accurately discriminated mild from moderate/severe (sensitivity: 100%, specificity: 82%). The mean AR index was 29.4 ± 6 for mild and 13.8 ± 5 for moderate/severe PAR. Three patients had a RF > 14% and a low AR index <25 despite a mild PAR at TTE, suggesting an underestimation at TTE. CONCLUSION: CMR is a reproducible, accurate, and reliable method to assess PAR severity. CMR may allow correcting an underestimation at TTE when AR index is doubtful.

Prone positioning during veno-venous extracorporeal membrane oxygenation for severe acute respiratory distress syndrome in adults.

BACKGROUND: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is an effective rescue therapy for improving oxygenation in selected severe acute respiratory distress syndrome (ARDS). Prone position (PP) is usually considered before vvECMO and few data are available on the association of PP during VV-ECMO. Thus, we investigated the effect on oxygenation and the safety of PP during vvECMO. METHODS: During a two-year period, 15 patients with severe ARDS were turned into PP during VV-ECMO therapy for at least one of the three following conditions: severe hypoxemia (PaO2/FiO2 ratio below 70) despite maximal oxygenation, injurious ventilation parameters with plateau pressure exceeding 32 cmH2O or failure of attempt to wean ECMO after at least 10 days on ECMO support. RESULTS: PP was considered after a median of 9 days of ECMO and applied for a median of 12 hours and an average of 1.4 sessions per patient resulting in a total of 21 procedures. We found significant improvement in PaO2/FiO2 ratio at 6 hours (P=0.03) and 12 hours (P=0.007) after reversal. The improvement in oxygenation has still persisted 1hour (P=0.017) and 6 hours (P=0.013) after back to the supine position. No change in PaCO2, respiratory system (RS) compliance was observed. ECMO flow was maintained constant during the procedure. No complication related to PP was detected. CONCLUSION: PP may be considered in selected patients difficult to wean or remaining very hypoxemic despite VV-ECMO support.

[MESRCA/MESRRA: material aspects]. / UMAC / UMAR: aspects matériels.

Mobile ECMO support for remote cardiac or respiratory assistance (MESRCA and MESRRA) allows mobilization of the medical and paramedical team 24/7 in a very large geographical area. Mobility and autonomy require adapted devices. During many years, teams had to deal with non useful equipment. Recently, thanks to interest of medical world and laboratories, many materials especially suitable for this activity are developed. We describe our local experience and solutions we tented to fi nd to deal with material difficulties.

[Cardiac tumors]. / Les tumeurs cardiaques.

Primary cardiac tumor is a rare disease, with an incidence ranging from 0.001 to 0.03%. Eighty percent of them are benign tumors, and among them 70% are myxomas, the others are: fibroelastoma, rhabdomyoma, fibroma, angioma and lipoma. Primary malignant tumors of heart are in 95% of cases sarcomas, the remaining 5% are lymphomas. Cardiac's metastases are more frequent than primary tumors. Diagnosis is made by echocardiography TAC and MRI. Whereas surgery is indicated in patients with benign tumors, or localised sarcomas, chemotherapy in those with widespread disease and radiotherapy and chemotherapy in lymphoma. Prognosis is excellent in benign cardiac tumor. Mean survival for sarcomas is 11 months, and lymphoma 5 years.