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Retained foreign bodies are dreadful events associated with invasive procedures. Their occurrence implicate physical complications as well as serious professional and medico-legal consequences. Cases of retained surgical items, in the pericardial space, following cardiothoracic surgery are rare and their management is delicate as the risks of their removal must be thoroughly weighed against the complications of leaving them inside the chest. We report the case of a retained foreign body, discovered in an asymptomatic patient, on a routine medical check-up, 4 years after cardiac surgery. Clinical and paraclinical manifestations of retained surgical foreign bodies are nonspecific. The progress of cardiac imaging means makes it possible to identify these rare foreign bodies with greater precision, and allows, with extreme caution, to monitor patients who are perfectly asymptomatic and who are reluctant to undergo surgery. [ABSTRACT FROM AUTHOR]

L'anévrisme du sinus de Valsalva est une anomalie cardiaque rare qui peut être congénitale ou acquise dont la complication la plus fréquente est la rupture dans le ventricule droit ou l'oreillette droite et rarement vers les cavités gauches ou le péricarde. La rupture de l'anévrisme du sinus de Valsalva peut être symptomatique et bien tolérée mais parfois peut entraîner une instabilité hémodynamique grave, telle qu'une insuffisance cardiaque aiguë voire une mort subite. Nous rapportons le cas d'une patiente de 24 ans sans antécédents présentant un anévrisme du sinus postérieur et droit, rompu partiellement dans le péricarde et fort heureusement colmaté par un hématome de la racine aortique et diagnostiqué initialement à tort comme « épanchement péricardique idiopathique. Nous décrivons les modalités diagnostiques et la prise en charge. Aneurysm of the sinus of Valsalva is a rare cardiac condition, which could be either acquired or congenital. The most frequent complication is a rupture into right cavities or more rarely into left cavities or pericardium. Rupture could be either asymptomatic or poorly tolerated with hemodynamic instability, acute heart failure or sudden death. We report the case of a 24-year-old patient with no past medical history presenting with a partially ruptured sinus of Valsalva into the pericardium and in whom the initial diagnosis was idiopathic pericardial effusion; we describe diagnostic modalities and management [ABSTRACT FROM AUTHOR]

Background: As a new surgical method for older adults with cardiac insufficiency, transapical mitral valve clamp surgery requires the cooperation of practitioners across multiple disciplines to ensure appropriate treatment and nursing care. This study aimed to explore the utility of a multidisciplinary team nursing model in the clinical treatment and nursing care of patients undergoing transapical mitral valve clamping.Methods: Our sample of ten patients included four men (40%) and six women (60%), with a mean age of 71.4 ± 5.2 years. The multidisciplinary team comprised nurses that specialized in severe illness, cardiac health, rehabilitation, psychology, nutrition, and pain. The team engaged in comprehensive discussions regarding problems specific to the patients undergoing transapical mitral valve surgery, allowing them to formulate individualized nursing measures and implement precise policies.Results: No serious postoperative complications occurred in any of the ten patients included in this study, and a significant improvement was noted in the cardiac status of all the patients. Color ultrasound findings at discharge indicated that the degree of reflux of all the patients was ≤2+. Among the ten patients, the Activity of Daily Living Scale scores at discharge were significantly higher than before the operation (69.0 ± 4.6 vs. 55.0 ± 5.8). In addition, the 6-min walking test results at discharge were significantly better than those observed before the operation (318.0 ± 21.7 m vs. 295.2 ± 18.4 m).Conclusions: Utilization of a multidisciplinary team allows nurses across various specialties to provide more comprehensive and systematic care for patients undergoing a mitral valve clamping operation, thus promoting patient recovery. [ABSTRACT FROM AUTHOR]

L'objectif de notre étude est de détailler notre expérience relative aux implantations d'ECMO pour choc réfractaire post-cardiotomie, en analysant les facteurs pré-ECMO (antécédents, type de chirurgie, FEVG), les facteurs relatifs à l'ECMO (délai implantation, durée) et les facteurs post-ECMO (sevrage, complications) afin de mettre en évidence ceux éventuellement associés à une mortalité élevée. Il s'agit d'une étude rétrospective uni- et multivariée des données des ECMO mises en place entre 2011 et 2019 au Centre Hospitalier Universitaire Grenoble Alpes au décours d'une chirurgie cardiaque. Le délai d'implantation de l'ECMO a été de moins de 3 heures (peropératoire) entre 3 et 24 heures (post-opératoire précoce) et entre 24 et 48 heures après le déclampage aortique (post-opératoire tardive). Une contre-pulsion par ballon intra-aortique (CPBIA) préopératoire ou post-opératoire pouvait être associée. 114 ECMO veino-artérielles ont été implantées pour choc cardiogénique réfractaire au décours de 5702 chirurgies cardiaques (1,9 %) avec un taux de survie de 30,7 %. L'âge moyen des patients était de 68,6 + -10,5 ans. L'implantation de l'ECMO a été réalisée en peropératoire chez 71 patients (62,2 %), en post-opératoire précoce chez 22 patients (19,2 %) et en post-opératoire tardif chez 21 patients (18,4 %). La durée d'assistance a été de moins de 48 h chez 27 patients (23,6 %), entre 48 h et une semaine chez 58 patients (50,9 %) et de plus d'une semaine chez 29 patients (25,5 %). L'analyse univariée a mis en évidence une association statistiquement significative entre taux de mortalité et le sexe masculin (p = 0,002), les pneumopathies nosocomiales (p = 0,021), association absente avec les autres caractéristiques préopératoires, délai d'implantation d'ECMO, la pose de CPBIA, caractéristiques post-opératoires et suites en réanimations. L'analyse multivariée sur l'ensemble de la population étudiée, a démontré que la pose d'ECMO pour arrêt cardio-respiratoire (ACR) était le seul facteur de risque indépendant de mortalité (OR =7,57 [1,41–40,62]). Après nouvelle analyse multivariée en excluant les patients ayant eu une pose d'ECMO pour ACR, l'âge, l'insuffisance rénale pré-opératoire, le type d'intervention et l'EuroSCORE II étaient des facteurs de risque de mortalité. Dans cette étude, le sexe masculin, le type d'intervention, la survenue d'arrêt cardiaque et de pneumopathie nosocomiale étaient associés au taux de mortalité de manière significative. Une étude de plus grande puissance, multicentrique, et avec un échantillon plus important, devra être réalisée pour atteindre la significativité. The objective of our study is to detail our experience relating to ECMO implantations for post-cardiotomy refractory shock, by analyzing the pre-ECMO factors (history, type of surgery, LVEF), factors relating to ECMO (implantation time, duration) and post-ECMO factors (weaning, complications) in order to highlight those possibly associated with high mortality. This is a univariate and multivariate retrospective study of ECMO data implemented between 2011 and 2019 at the Grenoble Alpes University Hospital Center following cardiac surgery. The time to implantation of ECMO was less than 3 hours (intraoperative) between 3 and 24 hours (early postoperative) and between 24 and 48 hours after aortic unclamping (late postoperative). Preoperative or postoperative intra-aortic balloon counterpulsation (CPBIA) could be associated. 114 veino-arterial ECMOs were implanted for refractory cardiogenic shock after 5702 cardiac surgeries (1.9%) with a survival rate of 30.7%. The mean age of the patients was 68.6 + - 10.5 years. The implantation of ECMO was performed intraoperatively in 71 patients (62.2%), early postoperatively in 22 patients (19.2%) and late postoperatively in 21 patients (18.4%). The duration of assistance was less than 48 hours in 27 patients (23.6%), between 48 hours and one week in 58 patients (50.9%) and more than one week in 29 patients (25.5%). Univariate analysis revealed a statistically significant association between mortality rate and male sex (P = 0.002), association absent with other preoperative characteristics, delay in implantation of ECMO, installation of CPBIA, post-operative characteristics and resuscitation suites. Multivariate analysis of the entire study population demonstrated that the use of ECMO for cardio-respiratory arrest was the only independent risk factor for mortality (OR = 7.57 [1.41-40, 62]). After multivariate reanalysis excluding patients with ECMO placement for cardio respiratory arrest, age, preoperative renal failure, type of procedure and EuroSCORE II were risk factors for mortality. In this study, male gender, type of intervention, occurrence of cardiac arrest were significantly associated with the death rate. A study of greater power, multicentric, and with a larger sample, will have to be carried out to reach significance. [ABSTRACT FROM AUTHOR]

Les patients opérés cardiaques sont plus âgés; ils présentent parfois des pathologies complexes et sont porteurs de plus de comorbidités, mais ils doivent sortir plus vite de l'hôpital ! Ceci a considérablement modifié les missions des centres de réadaptation cardiaque. En effet, si 15 à 25 % des patients opérés vont présenter une complication postopératoire nécessitant une prise en charge hospitalière (infectieuse, péricardique, rythmique, neurologique, pulmonaire, digestive, etc.), plus des 2/3 de ces événements aigus peuvent être gérés par les centres de réadaptation cardiaque pour un moindre coût. Ainsi, plus le malade est transféré rapidement en réadaptation cardiaque, plus le service de chirurgie cardiaque peut « rentabiliser » ses lits. Les complications infectieuses sont les plus redoutables et en particulier la médiastinite. Patients undergoing cardiac surgery are older, have complex pathologies and several comorbidities, but need to leave the hospital quickly! Therefore, the mission of cardiac rehabilitation centres has substantially changed. Indeed, if 15 to 25% of patients undergoing cardiac surgery will have a postoperative complication requiring a hospital management (infectious, pericardial, rhythmic, neurologic, pulmonary, digestive, etc.), more than 2/3 of these acute events could be managed by cardiac rehabilitation centres for a lower cost. Therefore, the quickest the patient is transferred to a cardiac rehabilitation centre, the easier the cardiac surgery centre could manage his beds. Infectious complications are the most dreadful, particularly mediastinitis. [ABSTRACT FROM AUTHOR]

Pituitary apoplexy is a >rare entity that presents with a sudden onset of headache associated with visual and endocrinological disturbances due to pituitary hemorrhage or infarction. It usually occurs in patients with an unknown pituitary adenoma. Cardiac surgery, and especially coronary artery bypass grafting, can be a precipitating factor in these patients. We report an 82-year-old male patient who presented with sudden headache and delirium, a right sixth cranial nerve palsy, a right temporal hemianopsia, and a severe loss of left eye visual acuity in the immediate post-operative course of a coronary artery bypass surgery. Pituitary apoplexy was demonstrated on both MRI and CT-scan. Trans-sphenoidal surgical decompression was performed 13 days after coronary artery bypass grafting, with immediate beneficial effect on the delirium and a partial recovery of visual disturbances. Pituitary apoplexy is a rare and life-threatening complication that may occur after cardiac surgery (coronary artery bypass, cardiac valve surgery), often precipitated by the use of cardiopulmonary bypass. It can occur after other surgical procedures (orthopedic, digestive, thoracic). The diagnosis must be considered during the early postoperative period in the presence of unusual and severe headache associated with visual disturbances. [ABSTRACT FROM AUTHOR]

Évaluer le délai diagnostique (du premier contact médical hospitalier au diagnostic) et le délai chirurgical (du diagnostic à incision) des syndromes aortiques aigus de type A (SAAA) au sein du RENAU (RÉseau Nord Alpin des Urgences) qui structure l'organisation des soins de médecine d'urgence dans l'arc nord-alpin français. Étude observationnelle rétrospective multicentrique entre 2012 et 2016 sur les SAAA opérés dans les centres de chirurgie cardiaque du RENAU (Annecy, Grenoble). Nous avons exclu les lésions post-traumatiques ou iatrogènes, les lésions chroniques, les découvertes fortuites et les décès avant chirurgie. Cent quatre-vingt-dix-sept patients ont été inclus d'un âge médian [IQR] de 65 ans [58 ;73], 67 % étaient des hommes. Le délai diagnostique médian était de 88 min [46 ;241] et le délai chirurgical de 193 min [146 ;249]. La prise en charge initiale était réalisée par le SMUR pour 102 patients (52 %), 7 % ont bénéficié d'une échographie transthoracique pré-hospitalière. Au total, 52 patients (26 %) se sont présentés spontanément aux urgences. Les patients étaient admis initialement dans un centre non chirurgical dans 65 % des cas. Le scanner était l'examen diagnostique dans 81 % des cas. La mortalité hospitalière postopératoire était de 16 %. En se référant aux données de l'International Registry of Acute Aortic Dissection (IRAD) qui rapporte un délai diagnostique et chirurgical médian de 258 min, notre étude suggère que l'organisation du RENAU pourrait être associée à une réduction des délais diagnostiques et chirurgicaux des patients présentant un SAAA. To assess the diagnostic delay (between first hospital medical contact and diagnosis) and the surgical delay (between diagnosis and incision) of type A acute aortic syndromes (AAAS) within the RENAU (REseau Nord Alpin des Urgences), organizing the management of emergency medicine care in the French North Alpine Arc. Multicenter retrospective study between 2012 and 2016 on the AAAS operated in the RENAU heart surgical centers (Annecy, Grenoble). Post-traumatic, iatrogenic or chronic lesions, incidental discoveries and deaths before surgery were excluded. One hundred and ninety-seven patients were included with a median age [IQR] of 65 years [58; 73] of which 67% were men. The median diagnosis delay was 88 min [46;241] and the median surgical delay was 193 min [146;249]. Initial management was performed by the SMUR for 102 patients (52%), 7% of whom received a pre-hospital transthoracic ultrasound. 52 patients (26%) presented themselves spontaneously to the emergency department. Patients were initially admitted in a center without cardiac surgery in 65% of cases. The CT scan was the diagnostic test in 81% of cases. The postoperative hospital mortality was 16%. Referring to IRAD data reporting a median diagnostic and surgical delay of 258 min each, our study suggests that the RENAU organization may be associated with reduced diagnostic and surgical delays for patients with SAAA. [ABSTRACT FROM AUTHOR]

The goal of this retrospective study was to evaluate results of pediatric cardiac surgery related to mortality and morbidity. Patients and methods: It's a retrospective and analytic study based on cases of pediatric cardiac interventions in thoracic and cardiovascular center in Fann hospital from October 2015 to august 2016. Data was analyzed using SPSS, Epi Info7, Sata and Excel software. Forty three patients was enrolled, 56% was female. Mean age was 9 years (range: 3-15 years). Stage 2 dyspnea related to the New York Heart association functional classification was the main symptom. Rheumatic heart disease was predominant. Mitral regurgitation and tetralogy of Fallot represented respectively 28% and 26%. Mean pump duration time was 89 min. Mean cross clamp time was 61 min. Was done ; mitral valve replacement (16,3%), aortic valve replacement (2,3%); tricuspid valve repair (9,3%), foramen ovale closure (2,3%), ventricular septal defect closure (4,7%), atrial septal defect closure (21%), tetralogy of Fallot repair (26%), infra aortic valve membrane resection (9,3%). The overall mortality was zero at 6 months follow up; Anemia (30%) was the main complication. Open Heart surgery is evolving in our country because cardiac surgeons and nurse acquired a good training. It's why the overall mortality and complications related to open cardiac surgery is low. [ABSTRACT FROM AUTHOR]

Cardiac surgery with extracorporeal circulation (ECC) is usually associated with the loss of a significant amount of blood. Adequate prophylaxis against blood loss and good perioperative hemostasis are known as processes limiting postoperative bleeding. Until now, the need for platelets in patients operated with extracorporeal circulation in our Department has been compensated for by total blood transfusion or platelet concentrates collected from several donors. We here report our first experience with platelet concentrate collection by apheresis at the General Hospital in Douala. [ABSTRACT FROM AUTHOR]

Introduction: This prospective study was conducted at the Laboratoy of Biochemistry of the HMIMV, Rabat, over a period of 1 year. It aimed to analyse the kinetics of troponin lc (cTnl) after on-pump cardiac surgery in order to establish threshold values for the diagnosis of perioperative myocardial infarction. Methods: The study included 58 patients who had undergone on-pump valvular surgery or on-pump coronary artery bypass surgery. These patients were separated into 3 groups according to their clinical and electrical evolution as well as their laboratory tests (cTnI) during the immediate post-operative period. We batched and followed the kinetics of cTnl using immuno-enzymatic technique, CTNI Flex® reagent, before and after on-pump cardiac surgery, at H0, H3, H6, H12, H21, H24 and H72 using automatic SIEMENS Dimension Xpand Plus. Results: The results were higher than in cardiology, even among the group of patients without postoperative cardiac complications, with an average cTnl rate of approximately 2.5 times higher than the threshold value in cardiology. The kinetics of release differed significantly among the 3 groups (p‹ 0.05). Conclusion: The threshold value that we propose to confirm the diagnosis of perioperative myocardial infarction is 13ng/ml obtained between H12 and H24. We recommend to collect 1-2 samples at H12 and then between H20 and H24. [ABSTRACT FROM AUTHOR]

Introduction: Postoperative rehabilitation after cardiac surgery is based on medical-surgical management in order to reduce the lenght of stay in hospital and the costs of this high risk surgery. Early tracheal extubation (within the first 6 hours) is the cornerstone of fast-track surgery. Our study aimed to evaluate fast-track practice and early tracheal extubation in scheduled cardiac surgery for adult patients in our Institution. Methods: We conducted a descriptive study including all patients aged over 18 years who consecutively had undergone scheduled cardiac surgery and postoperative treatment in the post-operative intensive care unit in the Department of Thoracic and Cardiovascular Surgery at the Habib Bourguiba University Hospital, Sfax. Inclusion criteria were: patients aged 18 years and older who had undergone scheduled cardiac surgery and postoperative treatment in the post-operative intensive care unit in the Department of Thoracic and Cardiovascular Surgery. Standardized anaesthetic protocol was used in all cases: propofol, remifentanil, cisatracrium. We recorded the mean postoperative extubation time and the factors affecting extubation time. Results: We collected data from 200 patients who consecutively had undergone scheduled cardiac surgery. Among these patients, 115 underwent coronary artery bypass surgery, 79 valvular surgery and 6 combined surgery or another surgical procedure. Patients' demographic characteristics were comparable. 152 patients (76%) underwent postoperative extubation within the first 6 hours. 48 patients couldn't be extubated within the FIrst 6 hours. The main causes of early extubation failure were: catecholamines in high doses, bleeding, arrhythmia and neurological disorders. Conclusion: Our study demonstrates that postoperative rehabilitation can be performed in our Institution and that all patients undergoing scheduled cardiac surgery should be candidates for early extubation. [ABSTRACT FROM AUTHOR]

Résumé Introduction Grâce aux progrès réalisés au cours des dernières décennies dans le domaine des cardiopathies congénitales tant en imagerie qu’en thérapeutique, un grand nombre de cardiopathie est diagnostiqué bien avant la naissance. Beaucoup d’entre eux bénéficient de la chirurgie et atteignent l’âge adulte ne nécessitant pas de geste ultérieur. Certains d’entre eux développent plus tard au cours de leur vie d’autres problèmes nécessitant une réintervention à l’âge adulte. Ceci a suscité la naissance d’une sous-spécialité au sein du département des cardiopathies congénitales : unité GUCH « grown up congenital heart disease ». Dans les pays en voie de développement, peu de cardiopathies sont dépistées durant l’enfance, une minorité d’entre elles sont opérées et très peu atteignent l’âge adulte soit avec des cardiopathies mineures, soit assez évoluées devenues alors inopérable. Seule une partie peut tirer encore profit de la chirurgie à cet âge. L’objectif de notre étude est de décrire le spectre et les caractéristiques des cardiopathies congénitales à l’âge adulte dans un centre algérois de chirurgie cardiovasculaire. Population et méthode Étude descriptive rétrospective des patients âgés de 15 ans et plus, opérés de cardiopathies congénitales entre 1995 et 2011. Résultats Cinq cent quarante patients âgés de 15 à 76 ans (29 ± 10 ans) dont 314 femmes et 226 hommes sont opérés de cardiopathies congénitales entre 1995 et 2011. Les shunts gauche droite représentent deux tiers des cardiopathies, représentées majoritairement (50 %) par des communications interauriculaire. Les obstacles à l’éjection du cœur gauche représentent un quart des cas avec une prédominance du rétrécissement aortique sous-valvulaire. Nous retrouvons des cardiopathies natives dont la survie est jugée exceptionnelle à l’âge adulte en l’absence de chirurgie, telles que la tétralogie de Fallot, large fenêtre aortopulmonaire, ventricule droit à double issue et Canal atrioventriculaire qui tirent toujours profit de la chirurgie. Les résultats sont encourageants avec une mortalité périopératoire faible (2 %). Conclusion L’approche des cardiopathies congénitales dans les pays en voie de développement est différente de celle des pays développés. Des efforts méritent d’être déployés dans le dépistage précoce et le suivi des cardiopathies congénitales et facilitent l’accès aux centres de chirurgie avec l’étroite collaboration de pédiatres, cardiologues et obstétriciens. Introduction With advances in recent decades in the field of congenital heart disease both for imaging in medical therapy, a large number of heart disease is diagnosed before birth. Many of them benefit from surgery and reach adulthood, they do not require further action. Some of them develop later in their lives other problems requiring reoperation in adulthood. This sparked the birth of a subspecialty within the department of congenital heart disease: GUCH Unit “grown up congenital heart disease”. In developing countries, little heart are detected in childhood, a minority of them are operated and very few reach adulthood or with minor heart disease or become advanced enough then inoperable. Only part may still take advantage of surgery at this age. The aim of our study is to describe the spectrum and characteristics of congenital heart disease in adulthood in Algiers a center of cardiovascular surgery. Population and methods A retrospective descriptive study of patients aged 15 and above operated for congenital heart defects between 1995 and 2011. Results Five hundred and forty patients aged 15 to 76 years (29 ± 10 years), including 314 women and 226 men are operated congenital heart defects between 1995 and 2011. The left-right shunts represent two thirds of heart disease, represented mainly (50%) by the atrial septal defect. Barriers to the ejection of the left heart represent one forth of cases with a predominance of subvalvular aortic stenosis. We find the native heart whose survival is considered exceptional in adulthood in the absence of surgery, such as tetralogy of Fallot, aortopulmonary windows wide, double outlet right ventricle and atrioventricular canal that take advantage of always surgery. The results are encouraging with low perioperative mortality (2%). Conclusion The approach of congenital heart disease in developing countries is different from that of developed countries. Efforts need to be made in early detection and monitoring of congenital heart disease and improve access to surgery centers in close collaboration with pediatricians, cardiologists and obstetricians. [ABSTRACT FROM AUTHOR]

Le ballon de contre pulsion intra-aortique (BCPIA) est fréquemment utilisé en chirurgie cardiaque, comme moyen d'assistance circulatoire en cas de bas débit cardiaque. Il est d'intérêt clinique de déterminer les facteurs pronostiques chez les patients porteurs d'un BCPIA en chirurgie cardiaque, et qui restent un sujet rarement élucidé dans la littérature. L'objectif de notre travail est de déterminer les facteurs prédictifs de morbimortalité chez les patients sous ballon de contre pulsion intraortique en périopératoire d'une chirurgie cardiaque. Il s'agit d'une étude rétrospective portant sur l'ensemble des patients opérés en chirurgie cardiaque sous circulation extracorporelle, et ayant bénéficiés de la mise en place d'un ballon de contre pulsion intra-aortique en périopératoire, au service de chirurgie cardiovasculaire de l'Hôpital Militaire Mohamed V de Rabat, entre le mois de janvier 2005 et le mois d'aout 20014. Soixante dix patients ont été inclus dans notre étude. En analyse univariée l'âge, la dyspnée de stade III et IV, l'insuffisance cardiaque, la présence d'un infarctus du myocarde, d'une coronaropathie mono et bitronculaire, les anomalies du doppler de trons supra-aortique et du membre inférieur, le caractère urgent de la chirurgie, la durée de la circulation extracorporelle, l'instabilité hémodynamique postopératoire, le saignement et l'insuffisance rénale postopératoire étaient statistiquement associés à une mortalité postopératoire élevée. La dyskinésie préopératoire et la sortie de circulation extracorporelle sous drogues étaient associées à une morbidité globale élevée. En analyse multi variée, seule l'âge, constituait un facteur de risque indépendant de mortalité dans notre série avec un Odds Ratio (OR): 1,89 ; un Intervalle de Confiance (IC) 95% de (1,52-4,97) et un p =0,045. Au terme de notre étude, le taux de mortalité était de 48,57% et de morbidité globale était de 87,1%. Il nous parait donc nécessaire pour diminuer l'incidence de cette morbimortalité dans notre population, d'agir sur les facteurs que nous jugeons modifiables tels l'amélioration de la fonction cardiaque préopératoire, l'optimisation de la fonction rénale, la réduction de la durée de CEC et le contrôle du saignement. [ABSTRACT FROM AUTHOR]

Les fistules coronaires sont des anomalies congénitales ou acquises relativement rares, au travers desquelles le flux sanguin coronaire est drainé vers une chambre cardiaque, un gros vaisseau ou une autre structure. Une cavité réceptrice à basse pression est souvent le site de drainage de ces fistules. Nous rapportons le cas d'un homme âgé de 30ans présentant des précordialgies atypique. L'épreuve d'effort est positive. L'évaluation par coronarographie met en évidence un réseau coronaire sain et un aspect de fistule coronarocamérale. L'objectif de cet article est d'aborder Les aspects cliniques, diagnostiques et thérapeutiques des fistules coronaires. [ABSTRACT FROM AUTHOR]

Résumé Objectifs L’accident vasculaire cérébral ischémique (AVCI) est une complication postopératoire connue après chirurgie cardiaque et carotidienne. En revanche, peu d’études sont disponibles concernant les AVCI après chirurgie générale. Son importante morbi-mortalité justifie une analyse des données épidémiologiques récentes. Type d’étude Revue générale systématique. Sources de données Banques de données Medline et Ovid avec les mots cléfs : AVCI, chirurgies cardiaque, carotidienne, générale non cardiaque et non carotidienne ; données épidémiologiques nationales et européennes ; recommandations d’experts et de la Haute Autorité de santé ; chapitres d’ouvrage de référence. Synthèse des données En chirurgie cardiaque, avec une incidence de 1,2 à 10 % suivant les procédures, les AVCI surviennent en période périopératoire dans environ 50 % des cas et la majorité des autres dans les 48 premières heures postopératoires. Pour la chirurgie carotidienne, l’incidence varie de 1 à 20 % suivant la technique et l’expérience des opérateurs. Rare en chirurgie générale (en moyenne 0,15 % avec des extrêmes de 0,02 à 1 %), il survient exceptionnellement en période peropératoire, mais à partir des 24–48 heures postopératoires et pour 40 % d’entre eux dans la première semaine postopératoire, plus souvent chez des sujets âgés à risque (prothèse de hanche, chirurgie vasculaire). L’AVCI postopératoire est responsable de surmortalité par rapport à une population témoin d’opérés, quelle que soit la chirurgie. Conclusion Avec une incidence différente selon la chirurgie, l’AVCI périopératoire se distingue par son horaire de survenue et la surmortalité qu’il engendre pour chaque type de chirurgie. Objectives Stroke is a well-described postoperative complication, after carotid and cardiac surgery. On the contrary, few studies are available concerning postoperative stroke in general non-cardiac non-carotid surgery. The high morbid-mortality of stroke justifies an extended analysis of recent literature. Article type Systematic review. Data sources Firstly, Medline and Ovid databases using combination of stroke, cardiac surgery, carotid surgery, general non-cardiac non-carotid surgery as keywords; secondly, national and European epidemiologic databases; thirdly, expert and French health agency recommendations; lastly, reference book chapters. Results In cardiac surgery, with an incidence varying from 1.2 to 10% according to procedure complexity, stroke occurs peroperatively in 50% of cases and during the first 48 postoperative hours for the others. The incidence of stroke after carotid surgery is 1 to 20% according to the technique used as well as operator skills. Postoperative stroke is a rare (0.15% as mean, extremes around 0.02 to 1%) complication in general surgery, it occurs generally after the 24–48th postoperative hours, exceptional peroperatively, and 40% of them occurring in the first postoperative week. It concerned mainly aged patient in high-risk surgeries (hip fracture, vascular surgery). Postoperative stroke was associated to an increase in perioperative mortality in comparison to non-postoperative stroke operated patients. Conclusion Postoperative stroke is a quality marker of the surgical teams’ skill and has specific onset time and induces an increase of postoperative mortality. [ABSTRACT FROM AUTHOR]

Résumé L’anévrysme du sinus de Valsalva constitue une entité très rare et souvent asymptomatique. Les manifestations cliniques dépendent surtout des complications induites notamment la rupture ou la dissection. Nous rapportons le cas d’un homme de 54 ans se présentant avec une dyspnée liée à l’effort d’apparition récente et chez lequel on a découvert un important anévrysme du sinus gauche de Valsalva. L’angiographie a objectivé également la présence de sténoses serrées de la coronaire gauche. Il a bénéficié avec succès d’une réparation chirurgicale par patch péricardique avec pontage aortocoronaire. Sinus of Valsalva aneurysms are very rare and are often asymptomatic. Clinical manifestations depend on associated complications, most commonly rupture or dissection. We describe the case of a 54-year-old male presenting with exercise-related angina and dyspnea and in whom we found a large unruptured aneurysm of the left sinus of Valsalva. On angiography, he also had a severe stenosis of the left artery descending and the diagonal. He underwent a successful surgical intervention with bypass and closure of the aneurysm. [ABSTRACT FROM AUTHOR]

Résumé Objectifs La thrombopénie induite par l’héparine (TIH), bien que rare, se caractérise par des manifestations thromboemboliques associées à une morbimortalité élevée. Moins fréquente avec les héparines de bas poids moléculaire (HBPM) qu’avec l’héparine non fractionnée (HNF), cette pathologie est observée plus fréquemment dans les circonstances où l’HNF reste indiquée, comme en chirurgie cardiaque. L’argatroban, inhibiteur sélectif de la thrombine récemment disponible, a été proposé comme traitement de la TIH. Cette mise au point présente les principales caractéristiques de ce produit, ses indications et ses modalités d’utilisation en chirurgie cardiaque de l’adulte et en réanimation. Méthodologie Recherche bibliographique des 15 dernières années sur base de données Medline, avec les mots clés suivants : argatroban, chirurgie cardiaque, assistance circulatoire, circulation extracorporelle. Résultats Malgré une cinétique d’action rapide, l’argatroban est inadapté à la prise en charge de la circulation extracorporelle (CEC) peropératoire. En revanche, il est utilisable pour la période postopératoire des différents types de chirurgie cardiaque (standard, cœur battant, assistance circulatoire). Néanmoins, une surveillance biologique étroite (tests spécifiques) est recommandée en raison de l’existence fréquente chez ces opérés de défaillances viscérales (rénale, cardiaque ou hépatique). Les principaux freins à l’utilisation de ce médicament novateur sont l’absence d’antidote, sa contre-indication chez l’insuffisant hépatique sévère, et son utilisation exclusive par voie intraveineuse. Conclusion L’argatroban est un nouvel inhibiteur direct de la thrombine bien évaluée en chirurgie cardiaque comme anticoagulant en cas de TIH. Son intérêt est encore renforcé avec la disparition de la lépirudine et les difficultés d’approvisionnement du danaparoïde. Objectives Although heparin-induced thrombocytopemia (HIT) is uncommon, its thromboembolic complications are potentially life-threatening. The low-molecular weight heparins are less responsible of HIT than unfractionated heparin (UFH) but this latter is still indicated in some circumstances such as cardiac surgery. Argatroban, a selective thrombin inhibitor, recently available, has been indicated in HIT treatment. This review presents the main pharmacological characteristics, its indications and uses in the context of cardiac surgery and in intensive care medicine. Methods Review of the literature in Medline database over the past 15 years using the following keywords: argatroban, cardiac surgery, circulatory assistance, cardiopulmonary bypass. Results Despite its short-acting pharmacokinetic, argatroban cannot be recommended during cardiopulmonary bypass. On the contrary, argatroban is indicated in many circumstances in postoperative period of various cardiac surgeries (on-pump, off-pump, circulatory assistance). Nevertheless, after cardiac surgery, doses have to be adapted according to coagulation laboratory testing (ACT), particularly in patients presenting acute organ failure (kidney injury, heart failure, liver failure). This compound has no antagonist and is excluded during severe hepatic failure. The continuous intravenous administration is a drawback. Conclusion Argatroban is a new direct competitive thrombin inhibitor well evaluated as treatment of HIT after cardiac surgery. In HIT management, argatroban is an interesting alternative to lepirudin that is not anymore available and danaparoid because of supply disturbances. [ABSTRACT FROM AUTHOR]

Abstract: Deep sternal wound infection is the major infectious complication in patients undergoing cardiac surgery, associated with a high morbidity and mortality rate, and a longer hospital stay. The most common causative pathogen involved is Staphylococcus spp. The management of post sternotomy mediastinitis associates surgical revision and antimicrobial therapy with bactericidal activity in blood, soft tissues, and the sternum. The pre-, per-, and postoperative prevention strategies associate controlling the patient's risk factors (diabetes, obesity, respiratory insufficiency), preparing the patient's skin (body hair, preoperative showering, operating site antiseptic treatment), antimicrobial prophylaxis, environmental control of the operating room and medical devices, indications and adequacy of surgical techniques. Recently published scientific data prove the significant impact of decolonization in patients carrying nasal Staphylococcus aureus, on surgical site infection rate, after cardiac surgery. [Copyright &y& Elsevier]

Résumé: Introduction: L’hémorragie massive reste une cause importante de mortalité dans les pays développés, particulièrement en obstétrique, chez le polytraumatisé et dans les chirurgies majeures. Le facteur VII activé recombinant (rFVIIa) (Novoseven®) a été développé pour le traitement substitutif des hémophiles, mais était actuellement utilisé dans d’autres indications de saignement aigu. L’objectif de cette étude était d’évaluer le respect des critères d’utilisation hors AMM du rFVIIa selon les groupes définis par l’Afssaps, dans les hôpitaux de l’assistance publique à Paris (AP–HP) en 2010. Patients et méthodes: Nous avons rétrospectivement contacté les services d’anesthésie-réanimation des centres ayant une activité en obstétrique, d’accueil de polytraumatisés, de chirurgie cardiaque, hépatique et pédiatrique pour récupérer tous les dossiers d’utilisation hors AMM du rFVIIa en 2010. La qualité de l’indication et de son utilisation a été analysée sur la base des recommandations françaises ou européennes ou selon la littérature existante dans les domaines considérés. Trois catégories de prescriptions ont été établies : conforme, acceptable et non conforme. Résultats: Sur les 59 patients ayant reçu du rFVIIa hors AMM en 2010, 49 prescriptions ont pu être analysées. L’indication et le moment d’administration étaient conformes dans 100 % des prescriptions pour le polytraumatisme et 83 % des prescriptions pour les hémorragies du postpartum. Les critères biologiques étaient remplis dans deux tiers des prescriptions. La prescription a été jugée conforme ou acceptable dans 82 % des cas, toutes indications confondues. Conclusion: Dans la grande majorité des cas, les prescriptions de rFVIIa, utilisé hors AMM à l’AP–HP en 2010, respectaient les recommandations en vigueur. [ABSTRACT FROM AUTHOR]

Résumé: Objectifs: Décrire les aspects pratiques de l’entraînement électrosystolique (EES) post-chirurgie cardiaque via les électrodes épicardiques temporaires. Méthodologie: Synthèse des données publiées durant les cinq dernières années sur l’EES épicardique temporaire (indications, modes de stimulation, électrodes et stimulateurs utilisés). Les bases de données ScienceDirect et Pubmed ont été utilisées et les publications en langue française ou anglaise ont été analysées. Synthèse des données: L’EES épicardique temporaire permet le traitement des troubles conductifs et/ou du rythme graves post-chirurgie cardiaque, mais aussi l’optimisation hémodynamique par la modification de certains paramètres de stimulation. En pratique, l’EES épicardique temporaire consiste à choisir le meilleur mode de stimulation compte tenu du contexte (patient, intervention, troubles de la conduction) et à régler les paramètres de l’EES pour assurer : i) un fonctionnement optimal du dispositif ; ii) la préservation de la durée de vie des électrodes ; iii) un bénéfice hémodynamique maximal. La connaissance des réglages de l’EES, ainsi que la vérification régulière, au moins quotidienne, de ces paramètres et leur ajustement en fonction de l’évolution des seuils des électrodes s’inscrivent dans les bonnes pratiques. La littérature française manque toutefois de recommandations officielles pour l’EES épicardique temporaire. Conclusion: L’EES épicardique temporaire post-chirurgie cardiaque est une technique simple, plus efficace que la stimulation transcutanée et plus rapidement disponible que la stimulation interne. Les modalités de bonnes pratiques de l’EES doivent être connues de tous les opérateurs amenés à l’initier (anesthésistes-réanimateurs, chirurgiens cardiaques), ainsi que du personnel paramédical, pour éviter les risques liés à un fonctionnement suboptimal. Un protocole de bonne utilisation est proposé. [ABSTRACT FROM AUTHOR]

Résumé: Objectif: La variation respiratoire de la pression pulsée (ΔPP) est un indice dynamique d’évaluation de la précharge dépendance. L’influence du mode de ventilation sur sa valeur, et notamment d’une ventilation en pression contrôlée, n’est pas connue. Notre objectif était de comparer les valeurs du ΔPP mesurées alternativement lors de ventilation en modes volume-contrôlé (VVC) et pression contrôlée (VPC). Type d’étude: Étude randomisée, double insu, cross-over. Patients: Patients hospitalisés en réanimation, inclus dans les deux heures suivant une chirurgie cardiaque. Méthode: Les patients étaient ventilés successivement selon deux modes de ventilation : VVC et VPC (ordre attribué par la randomisation). Les autres paramètres de ventilation étaient identiques. Le ΔPP était calculé dans les deux modes de ventilation pour un même patient. Résultats: Sur les 26 patients analysés, la valeur de ΔPP était de 14,0±7,3 % en VVC et de 11,8±6,2 % en VPC (p <0,0001). Le biais moyen était de +2,2±2,3 % et les limites de concordance inférieures et supérieures respectivement de −2,3 et 6,7 % (représentation de Bland-Altman). Les pressions artérielles et veineuses centrales, et la fréquence cardiaque n’étaient pas modifiées. Conclusion: Les conditions de VVC et en VPC n’étaient pas interchangeables pour le calcul du ΔPP en postopératoire de chirurgie cardiaque. En moyenne, le ΔPP diminue de plus de deux points lors du passage de VVC à VPC, pour un patient donné, toutes choses égales par ailleurs. Cette modification semble avoir un impact clinique modéré. [ABSTRACT FROM AUTHOR]

Abstract: The occurrence of abnormal bleeding in postoperative cardiac surgery performed under cardiopulmonary bypass is relatively common. If the option of reoperation is not retained, the initiation of medical treatment is inevitable. Next to the transfusion of blood products, other therapies were often used empirically and as “off-label”. The place of each in a future regimen should be based on well-conducted clinical studies to determine the optimal risk/benefit ratio. [Copyright &y& Elsevier]

Introduction L'objectif de ce travail était d'étudier la cinétique de la Troponine Ic (TnIc) après chirurgie cardiaque sous circulation extracorporelle (CEC) et établir des valeurs seuils de TnIc pour le diagnostic d'infarctus du myocarde (IDM) post opératoire. Il s'agissait d'une étude prospective type cohorte observationnelle. Méthodes Nous avons inclus 37 patients âgés de plus de 18 ans proposés pour chirurgie valvulaire ou pontage aorto coronarien sous CEC. Nous avons suivi la cinétique de TnIc par des dosages immunoenzymatique sur mini-vidas® avant et après la CEC, à H4 et H12 postopératoire puis tous les jours les 4 premiers jours. Le cutoff pour le diagnostic d'IDM post opératoire a été défini comme la valeur moyenne de troponine + deux déviations standards des patients indemnes de complications cardiaques. Résultats Les valeurs de TnIc en préopératoire étaient toutes inférieures au seuil de détection de la méthode de dosage (<0,01µg/l). Les valeurs de TnIc augmentent en postopératoire immédiat pour atteindre un maximum à H4 puis diminuent progressivement pour se normaliser après 4 à 5 jours. Les valeurs seuils ont été déterminées pour H0, H4,H12, H24, H48, H72, H96 et ont été respectivement 1.36, 2.58, 3.1, 3.23, 2.13, 1.53, 1.17 pour la chirurgie coronaire et 3.75, 5.39, 4.22, 3.41, 1.65, 1.3 1.19 pour la chirurgie valvulaire. Conclusion La connaissance de la cinétique de TnIc lors de chirurgie cardiaque non compliquée et la fixation de valeur seuil ou Cutoff permet aux cliniciens de distinguer entre dommage myocardique secondaire à la chirurgie et IDM. [ABSTRACT FROM AUTHOR]

L'agitation post-opératoire constitue une pathologie extrêmement fréquente. Les étiologies à évoquer en réanimation sont nombreuses. Le syndrome de sevrage à la nicotine est une cause possible mais rarement évoquée. Nous rapportons le cas d'un patient tabagique qui a été admis en unité de soins intensifs pour un triple pontage aorto-coronaire sous circulation extracorporelle. Les suites opératoires ont été marquées par des difficultés de sédation du patient et puis la survenue d'une agitation au réveil et d'un échec du sevrage de la ventilation mécanique. Après avoir éliminer toutes les causes organiques d'agitation, le syndrome de sevrage à la nicotine a été évoqué et la mise en place d'un timbre de nicotine a permis une amélioration rapide de l'agitation et le sevrage de la ventilation mécanique. Cette observation suggère que le syndrome de sevrage nicotinique peut être responsable d'un véritable delirium et la mise en place d'un timbre transdermique à la nicotine pourrait constituer un moyen diagnostique et thérapeutique simple. [ABSTRACT FROM AUTHOR]

Abstract: Near infrared spectroscopy (NIRS) seems to be an interesting technology to study microcirculatory dysfunction. These alterations have been described after cardiac surgery under cardiopulmonary bypass. We report two case study reports with monitoring of StO2 and reperfusion slope after an ischemic challenge. These two parameters are early altered notably in case of cardiac dysfunction (decrease of StO2 and reperfusion slope). We discuss the interest of microcirculatory measurement in this context. [Copyright &y& Elsevier]

Abstract: Objectives: High-flow nasal oxygen (Optiflow™) is validated in paediatric intensive care but not in adults’ patients for severe hypoxemia. The aim of this study was to evaluate this oxygen system delivery in adults’ patients for postoperative hypoxemia after cardiac surgery. Study design: Prospective, open study for evaluation of medical practice. Patients and methods: Patients operated upon for cardiac surgery with immediate postoperative hypoxemia characterized by SpO2 <0.96 with 50% oxygen with a Venturi mask were treated with the high-flow nasal oxygen system (O group) when it was available or with the classical high-flow oxygen face mask (M group). Gas exchanges were measured at the end of the surgery, at the beginning of the treatment and 1 hour, 6 hours after the inclusion and at day 1 and 2 post-treatment. Parameters studied were: duration of hypoxemia, duration of ICU stay, postoperative pneumonia occurrence, requirement of re-intubation, non invasive ventilation and catecholamine. Tolerance was evaluated with measurement of pain (visual scale), satisfaction (visual scale), and dryness of mouth. Results: Forty patients were included, 19 in group O, 21 in group M. Patient''s characteristics did not differ between the two groups before treatment. There were no significant differences between groups for duration of hypoxemia (3.8±2.2 days in O group versus 4.3±2.3 days in M group), duration of hypoxemia, duration of ICU stay, postoperative pneumonia occurrence, requirement of re-intubation, non invasive ventilation and catecholamine. Pain was not significantly different between groups, satisfaction was better (P <0.001) and mouth drier (P <0.001) in group O than in group M. Conclusion: These results give good arguments for an improvement in gas exchange and better tolerance of high-flow nasal oxygen (Optiflow™) versus classical high-flow oxygen face mask in postoperative cardiac patients. These results must be confirmed by a randomised study with a larger population. [Copyright &y& Elsevier]

Abstract: Objective: To compare the PaCO2 with the ETCO2 obtained with the Smart Capnoline™ in the postoperative setting of cardiac surgery during ventilation and after extubation Type of study: Prospective, observational. Patients: Twenty patients after cardiac surgery. Methods: In the intensive care unit, arterial blood gases were measured concomitantly with ETCO2, and difference between PaCO2 and ETCO2 were calculated. Three CO2 sensors were utilized: Filterline H set for intubated patients, Smart Capnoline HO2 (nasal version) and Smart Capnoline O2 (bucconasal version) after extubation. Data were compared with Wilconson test and the intraclass correlation coefficient was calculated. Results: The difference PaCO2 – ETCO2 was significantly larger in extubated patients compared to intubated patients, which is also confirmed for the bucconasal sensor (intubated patients: 6.6±4.3mmHg, nasal sensor: 9.3±3.5mmHg, bucconasal sensor: 15,4±12.9mmHg). Conclusion: In the postoperative setting of cardiac surgery, ETCO2 measurements allow a reliable estimation of PaCO2 in intubated patients in contrast to measurements in extubated patients. The bucconasal CO2 sensor does not show more reliable measurements compared to nasal sensors in the postoperative setting of cardiac surgery. [Copyright &y& Elsevier]

Abstract: Introduction: Cardiopulmonary bypass (CPB) is a medical act that can be performed by nurses as long as they are constantly supervised by a physician. No initial formalized training course is required. The personal responsibilities of nurses and physicians about CPB have not been defined. Objectives: The purpose of this study was: to list perfusionists; to evaluate the training of perfusionists; to determine which physicians are considered as in charge during actions performed by paramedics, as well as their qualification; to point out the changes since 1997. Type of study: Professional practice assessment. Methods: A questionnaire was sent to all perfusionists in activity in France. Results: There were 71% of replies. We found an aging of perfusionists (median 49 years vs. 40 years in 1997), a fall in the proportion of trained physicians (13% of perfusionists had a training course in adequacy with professional guidelines, 25% of perfusionists said they worked with a physician who could intervene at all time, and 61% declared only one physician was in charge). There is no CPB referent in 26% of perfusion units. Conclusion: An urgent need appears to define the respective responsibilities of medical and paramedical perfusion staff, especially as this technique spreads out of the conventional cardiac surgery operating theatres. [Copyright &y& Elsevier]

Abstract: Type II heparin-induced thrombocytopenia (HIT) has a low incidence in cardiac surgery, but its mortality once declared is high. Its clinical recognition can be difficult with these patients who usually have thrombocytopenia in postoperative period and who are predisposed to develop HIT prematurely. Thromboses in this context must be specific, and treatment, which is nowadays well codified, must be begun without waiting for biologic results. Besides, specificity of Elisa''s test is weakened in this population since there is a high rate of serum conversion; yet, its preoperative realization associated with pre-test probability scoring for HIT, can turn out useful. [Copyright &y& Elsevier]

Abstract: Objective: Compare three ventilatory strategies during the immediate postoperative transfer of cardiac surgical patient. Study design: Prospective, comparative and observational study. Patients and methods: After approval by our local ethical committee, 330 patients undergoing on-pump cardiac surgery were consecutively included. Patients suffering from chronic obstructive pulmonary disease, exhibiting intraoperative hypoxemia or requiring nitric oxide were excluded. The ventilatory mode was left at the discretion of the anesthesiologist and included: controlled mechanical ventilation (FiO2 =1, N =124) or (FiO2 =0.6, N =106), and manual ventilation using rebreathing bag (N =100). A blood gas analysis was performed immediately prior to connecting patient at ventilator at the arrival in ICU. Results: The mean duration of transfer was 3.9±1.4min. Invasive pressure monitoring was used in all patients. The pulse oxymetry and electrocardiogram were respectively used in 78% and 24% of patients. PaO2 values less than 100mmHg and those more than 300mmHg were more frequently found in patients ventilated by rebreathing bag (42%) and mechanical ventilation FiO2 1 (52%), respectively. No significant difference was found between groups regarding PaCO2 values. Conclusion: When rebreathing bag is used for transfer in ICU, severe decrease in PaO2 may be observed. In absence of intraoperative hypoxemia, a mechanical ventilation with FiO2 0.6 seems to be the most suitable ventilatory strategy for such short immediate postoperative transfer. [Copyright &y& Elsevier]

Abstract: Objective: A single bolus dose of etomidate decreases cortisol synthesis by inhibiting the 11-β hydroxylase, a mitochondrial enzyme in the final step of cortisol synthesis. In our institution, all the patients undergoing cardiac surgery receive etomidate at anesthesia induction. The purpose of this study was to assess the incidence of adrenocortical dysfunction after a single dose of etomidate in selected patients undergoing major cardiac surgery and requiring high-dose norepinephrine postoperatively. Study design: Retrospective descriptive study in the surgical ICU of a university hospital. Patients and methods: Sixty-three patients presented acute circulatory failure requiring norepinephrine (>0,2μg/kg/min) during the 48 hours following cardiac surgery. Absolute adrenal insufficiency was defined as a basal cortisol below 414nmo/l (15μg/dl) and relative adrenal insufficiency as a basal plasma cortisol between 414nmo/l (15μg/dl) and 938nmo/l (34μg/dl) with an incremental response after 250μg of synthetic corticotropin (measured at 60 minutes) below 250nmol/l (9μg/dl). Results: Fourteen patients (22%) had normal corticotropin test results, 10 (16%) had absolute and 39 (62%) relative adrenal insufficiency. All patients received a low-dose steroid substitution after the corticotropin test. Substituted patients had similar clinical outcomes compared to patients with normal adrenal function. Conclusion: A high incidence of relative adrenal failure was observed in selected cardiac surgery patients with acute postoperative circulatory failure. [Copyright &y& Elsevier]

Abstract: The coronary fistula is a rare abnormality making communicate a coronary artery with a cardiac cavity or a great vessel, so bypassing the myocardial capillary network. The majority of these fistulas are congenital but can nevertheless arise after a cardiac surgery. The right coronary artery and the left anterior descending coronary artery are mostly concerned. The circumflex coronary artery is rarely involved. The most frequent site of drainage is the right ventricle. We report the case of a 2-year-old child, brought by his parents for dyspnoea of effort. The diagnosis of coronary fistula was confirmed by the coronary angiography which showed an aneurysmal circumflex artery, draining into the right ventricle. The intervention was led under cardiopulmonary bypass. We proceeded to the longitudinal opening of the aneurysm then to the blindness of the fistula. The postoperative course was simple. [Copyright &y& Elsevier]

Summary: Endocarditis is uncommon in infants and is exceptionally related to Candida albicans on pulmonary banding. We report on a case in a 7-month-old infant who had pulmonary artery banding for a ventricular septal defect and who presented with candidal endocarditis. Banding was chosen because of the patient''s poor trophic and unstable status, which could be risky for surgery involving extracorporeal circulation. A few weeks after the banding, the patient developed systemic Candida infection, which was treated successfully. At 7 months, cardiac failure appeared without fever or inflammatory signs. Cardiac echography showed that the banding was not protective as well as a hyperechogenic image on the pulmonary bifurcation. The angioscan showed a hypodense thrombus. Emergency surgery was performed consisting of pulmonary artery exploration, thrombectomy, and ventricular septal defect closure. The exploration showed a pulmonary artery perforation caused by the infected pseudoaneurysm and the migration of the banding into the pulmonary artery. The anatomopathologic analysis of the vegetation identified multisensitive Candida albicans. After surgery and prolonged antifungal treatment, progression was satisfactory. [Copyright &y& Elsevier]

Abstract: Objective: Thoracic bioimpedance has been proposed for cardiac output (CO) determination and monitoring without calibration or thermodilution (ICG Monitor 862146, Philips Medical System, Philips, Suresnes, France). The accuracy and clinical applicability of this technology has not been fully evaluated in the cardiac surgery setting. We designed this prospective study to compare the accuracy of the ICG Monitor (COICG) versus pulmonary artery catheter standard bolus thermodilution (COPAC) in patients after cardiac surgery or having benefited from cardiac surgery. Study design: Prospective, monocentric. Material and methods: We studied 13 patients in the postoperative period. COICG and COPAC were determined at the arrival in the intensive care unit and every four hours. Bland-Altman and Critchley and Critchley''s analysis were used to assess the agreement between COICG and COPAC. Results: COPAC ranged from 2.6 to 11.0l/min and COICG ranged from 1.8 to 11.7l/min. There was a significant relationship between COPAC and COICG (r =0.61 ; p <0.001). Agreement between COPAC and COICG was −0.5±1.3l/min (Bland-Altman analysis). Percentage error between the two methods was 49% (Critchley and Critchley''s analysis). Conclusion: We found clinically unacceptable agreement between COICG and COPAC in this setting. Despite its non invasiveness, this device cannot be recommended for CO monitoring in the postoperative period following cardiac surgery. [Copyright &y& Elsevier]

Abstract: Objectives: Insertion of Swan-Ganz catheter for a few days may be necessary in cardiac surgery. This study was aimed at determining the incidence and the evolution of thrombotic images within the internal jugular vein as well as assessing their association with the presence of a prolonged fever at postoperative day 7 in the lack of any documented infection. Material and methods: All the patients undergoing cardiac surgery had a two-dimensional ultrasonography of internal jugular veins preoperatively, at discharge (day 7) and at postoperative day 90 if thrombotic images were seen at day 7. Results: Sleeve-like and compact thrombotic images have been observed in site of venipuncture in 52 patients (70.3%). None had any residual thrombotic image 90 days after the operation. No clinical thromboembolic migration has been observed. There was no statistical association between the presence of a thrombotic image at the ultrasonography and the duration of catheterization. Moreover, there was no association between the anticoagulation before, during and after the surgery and the presence of a thrombotic image. We found a non-significant association between fever at day 7 and the presence of a thrombotic image within the internal jugular vein. Conclusion: Thrombotic images in the internal jugular vein after catheterization are frequent and disappear at day 90. The limited sample size of this study does not provide strong evidence of the role of jugular thrombi in the prolongation of fever after cardiac surgery. [Copyright &y& Elsevier]

Abstract: Objective: To study the concordance of cardiac index (CI), mixed venous oxygen saturation (SvO2) and the arterial-mixed venous O2 content difference, i.e.: C(a–v)O2, postoperatively to cardiac surgery. We hypothesized that significant discrepancies would be measurable between C(a–v)O2 and SvO2, and CI, because the latter two indices encompass less metabolic components than the former. Design: Analysis of variables collected as part of routine care. Patients: Eighty anesthetized patients receiving mechanical ventilation after heart surgery. Measurements and results: Using linear regression of SvO2 versus C(a–v)O2 (Reg 1) and CI versus C(a–v)O2 (Reg 2), respectively we found that CI=2.2Lmin−1 m−2 and SvO2 =70% were equivalent to C(a–v)O2 =5ml/100ml. The error reflected by the vertical scatter of points around the regression line, once normalized was 3.24 times greater in Reg 2 than in Reg 1. Conclusions: The correspondence of CI, SvO2 and C(a–v)O2 values observed in a population of patients studied immediately after scheduled heart surgery match those reported in critically ill patients. SvO2 and furthermore CI induced a sizeable scatter of points around regression line. Accordingly, they appear as a lesser estimate of the flow/metabolism balance that may at best be inferred from C(a–v)O2. [Copyright &y& Elsevier]

Abstract: This paper reviews current knowledge on the indications for and timing of cardiac surgery in patients with infective endocarditis. The main indications for surgery are haemodynamic compromise, persisting infection, peripheral embolisation, large size of vegetations, large valvular and paravalvular damage and infections caused by certain microorganisms. [Copyright &y& Elsevier]

Abstract: The cardiac location of the echinococcosis is rare. It is associated with complications potentially severe. Indeed, the break inside the cardiac chambers with pulmonary embolism is the inevitable complication of the echinococcosis of the right heart. Between January 1992 and January 2006, five patients were operated in the department of cardiac surgery of Sousse (Tunisia) for an emboligenous hydatid cyst of the right heart. The average age is of 30 years with extremes from 18 to 65 years. The cardio-pulmonary bypass is the technique of choice. We regretted a single death in immediate postoperative period. All the patients were controlled with an average recession of 36 months. A single late death was noticed. No recurrence was observed. [Copyright &y& Elsevier]

Abstract: Introduction: Several surveys demonstrated that cardiopulmonary bypass (CPB) is associated with incidents that negatively affect the outcome of cardiac surgery. Objectives: In 2004, the French “Haute Autorité de santé” (an independent public scientific authority) and the French “College of Perfusion” issued recommendations concerning safety and monitoring devices for CPB. The aims of the present study were to: 1) investigate the difference between the recommendations and the clinical practice of CPB shortly after publication of the recommendations; 1) investigate the type and rate of perfusion incidents and their outcome. Study design: Retrospective survey. Methods: A 62 items questionnaire was sent to all 66 centres performing cardiac surgery in France. Results: Fifty-seven centres totalling 34,496 CPB procedures (response rate 86%) returned the questionnaire. There was a wide difference between the recommendations and the reported use of safety and monitoring devices. An incident was reported for every 198 CPB procedures with death occurring 1:4,864 and permanent sequelae 1:11,349 procedures respectively (permanent injury or death 1:3,220 procedures). The most frequent perfusion incidents were adverse effects to protamine (1:1,702), dissection at the arterial canulation site (1:1,792) and coagulation of the circuit (1: 4,864). Conclusion: This survey demonstrates that an important effort must be made in order to fill the gap between the recommendations and clinical use of monitoring and safety devices. The analysis of CPB-related incidents suggests that, with the exception of protamine adverse effects, the majority of deaths and severe permanent injuries could probably be avoided by improved use of the monitoring and safety devices. [Copyright &y& Elsevier]

Abstract: Introduction: Upper gastrointestinal haemorrhage (UGH) following cardiac surgery is infrequent with high mortality. The aim of this study is to compare the frequency and outcome of UGH in patients who had undergone open heart surgery at our institution. Patients and methods: From January 1994 to December 2005, 1278 cardiac operations were performed. A systematic prophylaxis antiacid was used by antagonists of histaminic receptor (anti-H2, ranitidine 150 mg/12 h) in all patients. The diagnosis was based on clinical symptoms (haematemesis and/or melaena) in the postoperative period and confirmed by fibroscopy. We conducted a retrospective study of these patients. Results: Only 8 of the 1278 (0,6%) cardiac operations were complicated by UGH. Demographic data were reported in Table 1. The mean interval between surgery and UGH was 10±3,7 days (range 5,15 days). Gastro-duodenal ulcer was the most common cause of UGH in 5 patients (62%), ulcero-hemorrhagic eosophagitis was developed in one patient (12,5%), candidosic eosophagitis in one and multiple gastric ulcer in one patient (12,5%). Medical treatment was applied in 6 patients (72%) with successful result. Surgical intervention was necessary in 2 patients (25%). 2 patients had repeat gastrointestinal bleeding. One patient was died; he was recorded as having severe sepsis and multiple organ failure in addition to UGH. Conclusion: UGH in patients undergoing heart operation is rare but associated with poor prognosis despite antiacid prophylaxis. These complications occurred in patients who had in postoperative bad hemodynamic conditions. [Copyright &y& Elsevier]

Abstract: Steroids are indicated in paediatric intensive care as anti-inflammatory drugs or for substitutive treatment. During septic shock, the incidence of adrenal insufficiency (AI) varies between 18 à 52%, depending on the relative or absolute nature of the AI. Contrary to adults, for whom long courses of low doses of corticosteroids were shown to reduce mortality and increased shock reversibility, particularly in those with a negative synacthene test, no study provided sufficient evidence to show a benefit of steroids in terms of outcome in children with septic shock. In neonates, AI occurs frequently after cardiac surgery and the administration of steroids can improve haemodynamic condition. The recommended dose of hydrocortisone during septic shock or after cardiac surgery is 30 to 100 mg/m2/d. Dexamethasone is efficient to reduce postextubation stridor in children and neonate and the rate of reintubations in neonate. During croup, oral or parenteral steroids reduce clinical symptoms. Dexamethasone also reduces the incidence of severe chronic lung disease and the duration of tracheal intubation in premature infants. However the high incidence of side effects, particularly on the central nervous system, makes steroids currently not recommended for bronchopulmonary dysplasia. At last, steroids are indicated for severe asthma and for bacterial meningitis. In this latter indication, dexamethasone was shown to improve neurological outcome, indeed mortality in Haemophilus influenzae and Streptococcus pneumoniae meningitis. [Copyright &y& Elsevier]

Abstract: Objectives: The evaluation of the renal function in cardiac surgery is difficult. The gold standard remains the creatinine clearance in clinical practice. Cystatin C was recently proposed in order to evaluate the renal function. The aim of our study was to evaluate the cystatin C in cardiac surgery with CPB. Patients and methods: After informed consent and ethical committee agreement, 60 patients operated in cardiac surgery with CPB were prospectively included. Cystatin C,measured and calculated (Cockcroft and MDRD methods) creatinine were compared with the Student t-test and with the Bland and Altman method. p <0,05 was considered as a significant threshold. Results: The reproducibility of the calculated creatinine clearance was better when the urinary collecting time was below 400 minutes. The estimation of the creatinine clearance by the Cockcroft and MDRD methods is better when the clearance is low. A significant correlation between the creatinine clearance and the cystatin C does exist, but the correlation coefficient was low. In case of acute renal dysfunction, the increase of the creatinine occurred earlier than the increase of the cystatin C. Conclusion: In cardiac surgery with CPB, the evaluation of the renal function was not improved by the cystatin C. [Copyright &y& Elsevier]

Abstract: Introduction: According to the Stewart approach of acid-base regulation, chloride from either volume replacement or cardiopulmonary bypass (CPB) priming solution may induce metabolic acidosis. The alternative hypothesis stands in volume dilution with solutions free of bicarbonate. Objectives: Evaluate the acid-base status of patients undergoing cardiac surgery with CPB priming containing chloride and bicarbonate. Material and methods: Prospective study. Methods: Twenty-eight patients were prospectively included. Priming of CPB contained 47.4 mmol/l of bicarbonate and 97.7 mmol/l of chloride. Arterial blood samples were taken at 3 timings: prior (T1) and after (T2) CPB, and on arrival in the ICU (T3). Following measurements were performed: Na+, K+, Cl-, Mg++, Ca++, phosphates, albumin, lactate and arterial blood gases. Results: After CPB respiratory acidosis was observed. There was a significant increase of chloride with a decrease in apparent strong ion difference (SIDa). At the same time bicarbonate and base excess (BE) remained constant. A significant but weak correlation between BE and SIDa existed (r2 = 0.06, p =0.024). On the contrary, no correlation was found between variations of BE and SIDa. However, the correlation was stronger between values and variations of bicarbonate and BE (respectively r2 =0.605, p <0.0001 and r2=0.495, p <0.0001). Conclusion: No metabolic acidosis occurred after cardiac surgery when CPB was primed with bicarbonate. Therefore, it appears that chloride administration is not the main mechanism being involved in the acid-base regulation. This reinforces the hypothesis that metabolic acidosis during CPB may mainly be due to dilution of bicarbonate. [Copyright &y& Elsevier]

Abstract: In a patient with heparin-induced thrombocytopenia few antithrombotic alternate treatments are proposed for cardiac surgery with or without cardiopulmonary bypass: danaparoid, lepirudine or powerful antiplatelet agent. Recently, the platelet GPIIbIIIa antagonist tirofiban (Aggrastat®) was tested in humans. We reported two cases of patients operated upon for cardiac surgery with unfractionnated heparin (UFH) and tirofiban. The first patient underwent an off-pump coronary artery bypass graft and the second one a mitral valvular replacement under cardiopulmonary bypass. Tirofiban was associated with UFH and aprotinine. Postoperative bleeding was in the normal range for the two types of surgeries and haemodynamic tolerance was good. These two case reports support the possibility of secure cardiac surgery under efficient platelet inhibition with tirofiban. The management of cardiac surgery with tirofiban without monitoring of platelet aggregation appeared to be more simple than with the other alternate antithrombotic agents. [Copyright &y& Elsevier]

Abstract: Thrombocytopenia is frequently reported in the presence of intra-aortic balloon pumping (IABP) after cardiac surgery and in cardiology, but heparin-induced thrombocytopenia (HIT) is rarely responsible of it in this circumstance. A case-report if HIT in a patient with IABP is presented. This case emphasised the difficulty in diagnosis of HIT in this situation. An acute decrease in platelet count lasting after removal of IABP could suggest the diagnosis of HIT when other origins for thrombocytopenia are excluded. [Copyright &y& Elsevier]

Abstract: Pulmonary artery catheterization is almost uniformly used nowadays in cardiac surgery. Although rare, rupture of the pulmonary artery following catheterization is highly lethal. This review examines ways of avoiding its occurrence and means of improving outcomes in case of rupture. [Copyright &y& Elsevier]

Abstract: Aims. – Conductive disorders following open-heart valvular surgery represent serious complications that may require definitive pacemaker implantation. The natural history of these troubles is not well established thus, controversy persist concerning the timing of pacemaker implantation. In this study we identify the predictive factors of permanent conductive disorders in order to assess the optimal time of pacing. Methods and results. – Two hundred thirty valvular replacements were done between 1993 and 2003. The mean age of our patients was 42±13.4 years. Rheumatic valvulopathies accounted for 76% of cases, with 54% of multiple valvulopathies. Twenty-two patients (9,5%) had an early postoperative conductive disorder, 9 of them (4%) were definitively implanted after a mean delay of 31.8 days. Preoperative bifascicular bloc and early installation of postoperative high-grade conduction disturbances and its persistence for more than 48 hours are significantly associated with permanent postoperative conductive disorders (respectively P =0.04 and=0.03). Aortic valve surgery and infective endocarditis were more frequent in the implanted group but the difference was not significant. Conclusion. – After open-heart valvular surgery; predictive factors of definitive conductive troubles justify an earlier pacemaker implantation. This attitude may accelerate the hospital discharge and decrease the disease cost effectiveness. [Copyright &y& Elsevier]

Abstract: The systemic inflammatory response in cardiac surgery is closely related to the haemostasis disturbances. It is responsible of a significant morbidity and mortality that was previously suspected to be caused by cardiopulmonary bypass alone. However, it is time now to clearly identify the factors that are material-dependent from that material-independent. From this point of view, off-pump surgery allowed for better comprehension of the multiple sources of the inflammatory response. Numerous pathways are activated, involving complement, platelets, neutrophiles and monocytes. The tissue pathway of the coagulation system, through tissue factor, is of major importance and has to be surgically considered in order to reduce the whole body inflammatory response postoperatively. The quality of the extracorporeal perfusion through its consequences on organ perfusion, particularly in the splanchnic area, also participates to this pathophysiological process. Beyond the progress of technology provided by the industry, particularly the minimally extracorporeal circulation derived from off-pump surgery evolution, the surgical approach is of major importance in the control of the systemic inflammatory response and must not be ignored yet. [Copyright &y& Elsevier]

Abstract: Introduction. – Cognitive defects are frequently described after cardiac surgery. They occur in 30 to 79% cases. They might be related to the use of a cardiopulmonary bypass (CPB). They are poorly evaluated in clinical practice. Objectives. – To evaluate the usefulness of the Mini Mental State Examination (MMSE) to screen patients scheduled for cardiac surgery. Study design. – Prospective, open study. Patients and methods. – 100 consecutive patients undergoing coronary artery bypass or valvular replacement under CPB were enrolled in the study. The MMSE was performed the day before surgery and five days later. Patients exhiting a postoperative defect≥4 points were compared to those without changes or with improved results. Results. – 73 patients completed both tests. The mean score decreased postoperatively in 12 patients (15%). They were older (70±8 years), had longer CBP durations (128±50 min) and the lowest temperatures (30 °C±3) compared to the other patients. At the opposite, five patients (9%) improved their scores. Conclusion. – These results entourage to carry out a more strict follow-up for the oldest patients in cardiac surgery. The MMSE could be systematically integrated to the pre and postoperative screening. The detection of cognitive dysfunction should lead to address the patient to a geriatrician for a prolonged follow-up. [Copyright &y& Elsevier]