Catégorie : Vol. 20 JA2016 – cardiac

Vol. 20 JA2016 - cardiac

C-01 – Von Willebrand factor multimers during TAVI
Francis Juthier, Natacha Rousse, Agnès Mugnier, Valentin Loobuyck, André Vincentelli, Alain Prat, Emmanuel Robin, Sophie Susen, Eric van Belle Institution : Service de chirurgie cardiaque, CHRU de Lille Objectives : Postprocedural aortic regurgitation occurs in 10 to 20% of patients undergoing transcatheter aortic-valve replacement (TAVR) for aortic stenosis. We hypothesized that assessment of defects in high-molecular-weight (HMW) multimers of von Willebrand factor or point-of-care assessment of hemostasis could be used to monitor aortic regurgitation during TAVR. Methods : We enrolled 183 patients undergoing TAVR. Patients with aortic regurgitation after the initial implantation, as identified by means of transesophageal echocardiography, underwent additional balloon dilation to correct aortic regurgitation. HMW multimers and the closure time with adenosine diphosphate (CT-ADP), a point-of-care measure of hemostasis, were assessed at baseline and 5 minutes after each step of the procedure. Mortality was evaluated at 1 year. A second cohort (201 patients) was studied to validate the use of CT-ADP in order to identify patients with aortic regurgitation. Results : After the initial implantation, HMW multimers normalized in patients without aortic regurgitation (137 patients). Among the 46 patients with aortic regurgitation, normalization occurred in 20 patients in whom additional balloon dilation was successful but did not occur in the 26 patients with persistent aortic regurgitation. A similar sequence of changes was observed with CT-ADP. A CT-ADP value of more than 180 seconds had sensitivity, specificity, and negative predictive value of 92.3%, 92.4%, and 98.6%, respectively, for aortic regurgitation, with similar results in the validation cohort. Multivariable analyses showed that the values for HMW multimers and CT-ADP at the end of TAVR were each associated with mortality at 1 year. Conclusion : The presence of HMW-multimer defects and a high value for a point-of-care hemostatic test, the CT-ADP, were each predictive of the presence of aortic regurgitation after TAVR and were associated with higher mortality 1 year after the procedure.
novembre 29, 2016
Vol. 20 JA2016 - cardiac

C-02 – Is TAVI becoming the treatment of choice in patients undergoing aortic valve replacement with previous patent IMA?
Georges Tedy, Paul Karam, Violette Karam, Patricia Nehme, Paul Naser Institution : hôpital Mont Liban, Beyrouth, Liban Objectives : Transcatheter aortic valve replacement (TAVR) has been shown to be successful in high risk patients . redo-aortic valve surgery (redo-AVR) in patients with previous coronary artery bypass grafting (CABG) and patent grafts carries a high mortality. To define the best treatment strategy for this cohort of patients, we reviewed our experience with redo-AVR. Methods : From January 2010 to December 2015, 35 consecutive patients underwent  redo-AVR at our Insitution. A peripheral femoro-femoral bypass had been installed to all patients prior to the sternotomy. 3 injuries of the IMA grafts had been noted and provoqued a recuperable Ventricular fibrillation, 2 injuries of the right ventricule and 2 of the inominate vein which precipitate a partial departure of bypass to allowed a correct surgical repair. Results : The 30-day mortality was 8.5%, and the incidence of debilitating strokes (3%), sepsis (6%). Following the procedure, the mean CSU stay was 3 days and the total in hospital stay of 7 days. The range of mortality in the literature is between 7% and 20%. Conclusion : Our results show that conventional AVR as a redo procedure after CABG even in case of both patent IMA grafts can be performed with excellent results and a lower mortality than estimated, thanks to the use of an adapted surgical strategy.
novembre 29, 2016
Vol. 20 JA2016 - cardiac

C-03 – Early systemic inflammatory response syndrome after elective cardiac surgery with cardiopulmonary bypass
Michel Kindo, Tam Hoang Minh, Stéphanie Perrier, Jonathan Bentz, Clément Schneider, Dharmesh Ramlugun, Gharib Ajob, Mircea Cristinar, Ollivier Collange, Sandrine Marguerite, Anne-Lorraine Bourquiaux, Arnaud Mommerot, Philippe Billaud, Jean-Philippe Mazzucotelli Institution : Service de chirurgie cardiaque, hôpitaux universitaires de Strasbourg Objectives : The systemic inflammatory response syndrome (SIRS) is associated with significant mortality and morbidity. The aim of this study was to evaluate the incidence, the risk factors, the hemodynamic impact and the morbi-mortality of the early SIRS (<24 hours) after elective cardiac surgery with cardiopulmonary bypass (CPB) in adults. Methods : This prospective observational study included 500 patients who underwent elective cardiac surgery with CPB (ClinicalTrials.gov Identifier: NCT00699673). The mean age was 68.1±11.5 years. The predicted mortality by the EuroSCORE II was 2.5±3.2%. The SIRS was defined as a body temperature >38°C and leucocyte count > 12000 109/l during the first 24 hours. Two groups were defined (control group and SIRS group). Using a multivariate logistical analysis, SIRS risk factors were identified. Results : An early SIRS was observed in 85 patients (17.2%). The postoperative temperature peak occurred at 7.9±5.1 hours. The pre- and peroperative risk factors of SIRS in the multivariate analysis were age (OR=0.964; 95%CI=0.943-0.986; P=0.001) and preoperative leucocyte count (OR=1.260; 95%CI=1.095-1.449; P=0.001). The mean arterial pressure at the temperature peak was significantly lower in the SIRS group than in the control group (77.9±12.7 mmHg vs. 72.9±11.3 mmHg respectively; P=0.001). No significant differences were observed regarding the inotropic or vasopressor supports. The hospital mortality was 1.2% and 3.5% in the control and SIRS groups respectively (P=0.144). The lengths of mechanical ventilation and intensive care unit stay did not significantly differ between the two groups as well as for the postoperative glomerular filtration rate peak. Furthermore, no significant differences were observed between the 2 groups regarding the cardiac, pulmonary, neurological and infectious morbidities. Conclusion : The early SIRS after elective cardiac surgery under CPB is a frequent complication without significant impact on hospital morbidity and mortality.
novembre 29, 2016
Vol. 20 JA2016 - cardiac

C-04 – Pronostic of moderate and severe pulmonary arterial hypertension after mitral valve surgery
Soumaia Bendjaballah, Farid Aimar, Rabeh Bouharraga, Redha Lakehal, Redhouane Boukerroucha, Rafik Nezzal, Redouane Bellara, Abdelmalek Brahami Institution : Service de chirurgie cardio-vasculaire, EHS Djeghri-Mokhtar (ex Erriadh), Constantine, Algérie Objectives : Rheumatic heart diseases (mitral stenosis +++) are redoubtable complication of acute articular rheumatic. Without treatment, pulmonary hypertension and right heart failure may occur. This pulmonary hypertension was admitted as predictor of worse outcome after surgery. The aim of our study is to value the results after mitral surgery in patients with moderate and severe pulmonary hypertension. Methods : This is an observational descriptive retrospective study between January 2006 and December 2012; a total of 201 patients were operated for mitral or mitro-tricuspid disease with pulmonary arterial hypertension in Djeghri Mokhtar hospital.These patients are divided into two groups according to preoperative pulmonary hypertension (PAH)degree: GroupA: 102 patients in moderate PAH, 40≤ sPAP <60 mmHg; Group B: 99 patients in severe PAH, sPAP ≥60 mmHg. In our study, sPAP was measured with Doppler echocardiography. Preoperative, operative and postoperative data collection included age, sex, functional class, type of surgery and cardiopulmonary bypass. Pulmonary arterial systolic pressure, left atrial diameter, left ventricular end-diastolic diameter, and left ventricular ejection fraction were recorded and compared. Results : The follow up is in mean of 61.73 months (from 30 to 108 months). The functional class was improved in majority of patients. There is a significant decrease in mean sPAP during follow up (48.72 ± 5.85 versus 29.12 ± 8.29 mmHg in group A; 77.90±15.62 versus 28.87±10.61 mmHg in group B). Global hospital mortality is 0.49% (0% in group A, 0.98% in group B). Late mortality is 2.48% (3.92% in group A; 1.01% in group B). Survival at 5 years is 96.5%. Conclusion : Pulmonary arterial systolic pressure decreased near normal value in most patients after surgery. Severe pulmonary hypertension must not be an absolute contraindication for mitral surgery, the outcome has been improved by developing cardiopulmonary bypass, myocardial protection and anesthetic technique.
novembre 29, 2016
Vol. 20 JA2016 - cardiac

C-05 – Early results: two years of CardioCel® patch implantation in children
Carine Pavy, Guido Michielon, Jan Lukas Robertus, Francois Lacour-Gayet, Olivier Ghez Institution : Service de chirurgie cardiaque congénital, Royal Brompton, Londres, Royaume-Uni Objectives : To present the early results of 2 years of CardioCel® patch (Admedus Regen Pty Ltd, Perth, WA, Australia) implantation in pediatric patients for congenital heart disease. Methods : Single center retrospective study of all patients aged 18 years and under operated for congenital heart diseases. Standard follow-up was performed clinical exams and echocardiograms. In case of re-operation for graft failure, the patch was removed and sent to pathology Results : Between March 2014 and April 2016, 101 patients with a congenital heart disease had a surgical repair using the CardioCel® patch. The mean age was 7 months old (range: 3 days - 18 years) and the mean weight was 6.7kg (range: 1.83-96 kg). The mean bypass time was 156 min (±74 min) and the mean aortic cross clamp time was 103 min (±49 min). No infections and no intraoperative implantation difficulties were related to the patch. The mean follow up was 175 days (range: 4-726 days). The 30-day overall post-operative mortality was n=4 (3.8%), none were related to graft failure. 4 infants were re-operated because of graft failure, all in aortic position. The indication for the patch in aortic position was truncus arteriosus, coarctation and aortic arch hypoplasia repair. The mean time between the first and the second operation for graft failure was 189 days (range: 16-480 days). Conclusion : Our experience shows a good tolerance of the patch in septal, valvar and pulmonary artery position. However, we experienced graft failures in infants in aortic position.
novembre 29, 2016
Vol. 20 JA2016 - cardiac

C-06 – Surgery of cardiac tumors: about 100 patients
Redha Lakehal, Radouane Boukaroucha, Farid Aimar, Rabeh Bouharraga, Radouane Bellara, Rafik Nazzel, Fateh Guériti, Amine Amros, Rabeh Daoud, Samiha Chérif, Nadjet Massikh, Baya Aziza, Soumaia Bendjaballah, Abdelmalek Brahami Institution : Service de chirurgie cardiaque, EHS Djeghri-Mokhtar (ex Erriadh), Constantine, Algérie Objectives : Cases of cardiac tumors including primitives described in the literature remains infrequent compared to metastatic one (secondary tumors). Frequency: 0.001% and 0.28%. The diagnosis become increasingly early by dint of modern imaging advent, which facilitated curative surgery and a better prognosis particularly for benign tumors. The Aim of the study: Bring the experience of our service center in the management of cardiac tumors, their clinical presentation, treatment modalities, morbidity and mortality and recurrences frequency. Methods : During the period between January 2000 to December 2015: 100 patients underwent open heart surgery for cardiac tumor (35 men and 65 women). The average age: 48.79 years with extremes (5-77 years). The symptomatologyis dominated by dyspnea (71% are patients with stage II-III NYHA), palpitations, fainting/syncope, or embolic complications. The transthoracic echocardiographic confirms the diagnosis in all cases. In some cases: a chestCT. Results : Surgical excision with cardiopulmonary bypass (CPB) in 12 patients (without clamping). Surgical expertise specified the type-nature of the tumor: 92% of benign tumors (70% are myxomas). The preferred seat is the left atrium (67 patients). The pathological forms are 1 polymorphic poorly differentiated sarcoma; 2 fibrosarcoma; 1 embryonal rhabdomyosarcoma (girl of 5 years); 1 Kaposi; 1 angiosarcoma, 2 non Hodgkin’s lymphoma. Total operative mortality: 6% (6 patients). Immediate complications: conduction disorder in 2 patients. The average follow up is between 1 month to 7 years. Late deaths (3%) due to extra cardiac causes. 3 recurrences: 2 for myxoma, 1 for fibrosarcoma. By cons there was a very good evolution in the patient with non Hodgkin’s lymphoma. Conclusion : Thanks to modern imaging advent, diagnosis can be early before the onset of serious complications; if only one clinically suspicious. The prognosis of benign cardiac tumors depends on the quality of surgical treatment. Surgery gives very good immediate and remote insisting on a periodic and regular monitoring; by cons for malignant tumors, it remains worse and depends on early in the surgical management, which is not hollowing since become symptomatic tumors are not at an advanced stage, in addition requires good protocols codified for these very rare and also very serious tumors.
novembre 29, 2016
Vol. 20 JA2016 - cardiac

C-07 – Preventive strategy of right heart failure after LVAD implantation: a single-centre, prospective analysis
Matteo Pozzi, Jacques Robin, Daniel Grinberg, Laurent Sebbag, Pascale Boissonnat, Élisabeth Hugon-Vallet, Claire Flamens, Sylvie Paulus, Laure Olivier-Soubirou, Jean-François Obadia Institution : Service de chirurgie cardiaque, hôpital cardiologique Louis-Pradel, hospices civils de Lyon, université Claude-Bernard, Lyon Objectives : Left ventricular assist devices (LVADs) display better outcome than biventricular assist devices. However right heart failure (RHF) is a common finding in end-stage heart failure as well as a life-threatening complication after LVAD implantation. The aim of this report is to describe the results of our preventive strategy of very-low threshold for indication of temporary right ventricular assist device (t-RVAD) support in LVAD recipients. Methods : We performed a prospective observational analysis of our single-centre experience. The t-RVAD was represented by an extracorporeal membrane oxygenation (ECMO) established between the femoral vein and the pulmonary artery via a Dacron prosthesis according to an original technique. Results : Between December 2014 and August 2016, we implanted 16 LVAD. A t-RVAD was used in 12 (75%) of them and they represented our study population (mean age 53.6 years, males 83.3%). The indication for LVAD implantation was ischemic (n=5, 41.7%) or idiopathic (n=4, 33.3%) cardiomyopathy and other (n=3, 25%). INTERMACS profile was 2 (n=2, 16.7%), 3 (n=7, 58.3%) and 4 (n=3, 25%). Device strategy was bridge-to-transplantation (n=6, 50%), bridge-to-candidacy (n=3, 25%) and destination therapy (n=3, 25%). Mean RHF risk score was 3.0 ± 1.8. Four (33.3%) patients underwent surgical re-exploration for bleeding. One (8.3%) patient experienced deep sternal wound infection requiring surgical debridement while we encountered no infections at the Dacron graft’s percutaneous exit site in the remaining 11 patients. Two (16.7%) patients died while on t-RVAD support (multiple organ failure n=1, intestinal ischemia n=1). Ten (83.3%) patients were successfully weaned off after a mean t-RVAD support of 7.0 ± 3.8 days. Weaning procedures were uneventful in awake patients on local anesthesia directly at bedside. No patient required a further mechanical circulatory support implantation for recurrent RHF. After a mean follow-up time of 6.5 ± 5.6 months, 4 (33.3%) patients died on LVAD (septic shock n=2, hemorrhagic stroke n=1, suicide n=1), 3 (25%) were alive on LVAD support and 3 (25%) were successfully bridged to heart transplantation. Conclusion : A very-low threshold implantation of t-RVAD is a valuable strategy in LVAD recipients with a satisfactory short-term outcome in such a critically ill population.
novembre 29, 2016
Vol. 20 JA2016 - cardiac

C-08 – Predicting right ventricular failure in the era of continuous flow assist devices: why we are always wrong
Piergiorgio Tozzi, Roger Hullin, Fabrizio Gronchi, Matthias Kirsch Institution : Service de chirurgie cardiaque, service de cardiologie, service d’anesthésie, CHUV, Lausanne, Suisse Objectives : In the era of continuous flow left ventricular assist devices (LVAD), the decision of whether a patient will tolerate isolated LVAD support or will need biventricular support (BIVAD) can be challenging. Incorrect decision making with delayed right ventricular (RV) assist device implantation results in increased morbidity and mortality. Several risk stratification tools have been developed to predict the need of right assist device (RVAD), but none seems to outperform the others. We reviewed our experience to validate the most recent strategies to identify patients who are at risk of post LVAD right ventricular failure (RVF). Methods : We collected variables for 34 consecutive patients who underwent VAD implant from 2010 through June 2015 (LVAD=32, BIVAD=2). We defined pre-operative RVF based upon echocardiographic parameters. Post-operative RV failure was defined according to INTERMACS Protocol 3 definition (CVP >18mmHg, CI <2l/min/m2, need for nitric oxide or inotrope therapy >7 days after LVAD implant). For each patient, we calculated the CRITT score and applied the Pittsburgh Decision Tree (PDT). We assessed the performance of the score by entering it in a logistic regression model. Results : The mean age was 52±12; 70.5% were men. The indication was bridge to transplant in 100%. Etiology was ischemic in 42%; 14.7% required additional mechanical circulatory support after LVAD implant (BVAD=2, ECMO=3). All patients received continuous flow LVADs (Heartmate II=13, HeartWare=21). By 30 days, 22 patients (64.7%) developed RVF defined as the need for RVAD (n=2); pulmonary vasodilator use >48h (n=18); inotropes for > 14 days post LVAD (n=22). According to CRITT score the RVF expected rate was 29% (10 patients had 4 or 5 corresponding to 80% risk of RVF). According to PDT, 8 patients needed BVAD. CRITT score achieved best performances (CI 95%; sensitivity = 90%; specificity 8.3%; accuracy 61.8%). Conclusion : These data indicate that even clinical RVF risk prediction models developed in the era of continuous flow pumps have rather limited clinical applicability. We definitely need new clinical test based on quantitative pre-operative imaging data, able to quantify the functional reserve of RV to drive our clinical decision about using an isolated LVAD versus BiVAD, especially in the destination therapy perspective.
novembre 29, 2016
Vol. 20 JA2016 - cardiac

C-09 – Prognostic impact and economic burden of blood products transfusion in ECLS/ECMO single-centre program
Guillaume Guimbretière, Erwan Flecher, Pierre-Emmanuel Noly, Antoine Roisne, Bernard Lelong, Jean-Philippe Verhoye, Amedeo Anselmi Institution : Service de chirurgie thoracique, cardiaque et vasculaire, CHU de Rennes Objectives : To describe the transfusion requirements, prognostic and economic impact of blood transfusions in ECMO/ECLS recipients in a single-center practice. Methods : We reviewed the prospectively collected data of 509 patients receiving ECMO/ECLS therapy at a tertiary referral center during the 2005-2016 period. Follow-up was prospectively conducted by dedicated personnel (average: 80.25 months ±85.13, 100 % complete). Results : ECLS was employed in 80.1 % of cases; indications were after heart transplant in 10.6%, post-cardiotomy myocardial failure, 23.1% other indications in 65.6 %. ECMO was employed in the remainders (adult respiratory distress syndrome). Mean age was 53.3 years ±14.9; ECLS patients were significantly older (54.6 years±14.1 vs. 48.2 years±16.9 p<0.001). Platelets and TP levels were significantly lower in the ECLS group at implantation (150.9±83.5 vs. 200.9±123.5 G/mm3 for platelets p<0.001) and (46.2±17 vs. 59.6±18.3 G/mm3 for TP p<0.001). ECLS patients had a higher rate of thrombotic/hemorrhagic complications (60.3% vs. 35.4% p<0.001), and received more frequently both fresh frozen plasma (FFP) (60.5% vs. 31.8% p<0.001) and platelet units (PU) (61.7% vs. 34.1% p<0.001) than ECMO patients. There was no difference in the rate of transfusion of packed red blood cell (pRBC) (83.2 % vs. 80.9%, p=0.6). Post-cardiotomy and post-transplantation patients had significantly higher rate of pRBC, FFP and PU transfusions than other ECLS cases (p<0.001 all). Mortality exceeded 80% among patients who received more than 19 pRBC, 5 PA and/or 12 FFP. The total cost of blood products transfusions was 2,428.8±2,314.4 euros and 2,877.5±2,852.1 euros in survivors vs. non-survivors, respectively (p=0.08); cost was higher in ECLS patients than in ECMO patients (2,850.8±2,622.3 euros vs. 1,885.8±2,583.0 euros respectively; p=0.004). Conclusion : ECLS/ECMO programs are associated with important consumption of blood products. ECLS patients are likely to have a greater transfusion burden than ECMO patients, particularly in post-cardiotomy and post-transplantation instances. Nonetheless, mortality is greater in cases associated with extreme transfusion requirements. Individualized case discussion is required to avoid futile consumption of blood bank resources.
novembre 29, 2016
Vol. 20 JA2016 - cardiac

C-10 – First series of circulatory support with HeartMate 3®: report of referral institutions experience
Matthias Kirsch1, Piergiorgio Tozzi1, Carlo Banfi2, Kamran Ahmadov1, Roger Hullin3, Philippe Meyer4, Raphaël Giraud5, Lucas Liaudet6, Fabrizio Gronchi7, Christophe Ellenberger8, Christophe Huber2 Institutions : 1. Service de chirurgie cardiaque, CHUV, Lausanne, Suisse 2. Service de chirurgie cardiovasculaire, HUG, Genève, Suisse 3. Service de cardiologie, CHUV, Lausanne, Suisse 4. Service de cardiologie, HUG, Genève, Suisse 5. Service de soins intensifs, HUG, Genève, Suisse 6. Service de soins intensifs, CHUV, Lausanne, Suisse 7. Service d’anesthésie, CHUV, Lausanne, Suisse 8. Service d’anesthésiologie, HUG, Genève, Suisse Objectives : New generation devices for long term mechanical circulatory support are centrifugal pumps having fully magnetically levitated rotors to reduce blood trauma. Recently, the novel HeartMate 3® was cleared for clinical application in Switzerland. Methods : In 2 Swiss University Hospitals, 10 patients in end-stage heart failure received the HeartMate 3®. Device implantation criteria were persistent low output syndrome despite optimal medical treatment. The primary endpoint of the study was survival to 90 days on the device. Results : Five patients (50%) were in INTERMACS class 1 and 2 (2 were under V-A ECMO), and five were in class 3 and 4. The indication was bridge-to-transplant in 7 patients, and destination therapy in 3. Two patients (20%) received concomitant aortic valve surgery. Four patients (40%) required temporary right ventricle support (tRVAD) for a mean of 8±1.5 days. Bleeding requiring surgical revision occurred in 5 (50%) patients, 2 during the tRVAD support. At the 90-day endpoint survival was 90%, one (10%) died due to respiratory failure. Three (30%) experienced critical illness polyneuropathy. Two had body temperature over 38.5°C for more than 7 days after implant, without infections. Two (20%) had late driveline infection. Conclusion : The pump allowed rapid improvement of patients’ clinical conditions even in severely compromised patients. Post-operative bleeding was mainly due to over-anticoagulation. No haemolysis or pump thrombosis occurred. Fever occurred frequently but was harmless. The 90% survival rate at 90 days proves that hemodynamic support was consistent over time without significant adverse events.
novembre 29, 2016