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Background: Postoperative bleeding after cardiac surgery is associated with increased morbidity and mortality. We tested the hypothesis that patients with a preoperatively estimated high risk of severe perioperative bleeding may have impaired early outcome after on-pump versus off-pump coronary artery bypass grafting (CABG). Method: Data from 7,352 consecutive patients who underwent isolated CABG from January 2015 to May 2017 were included in the multicentre European Coronary Artery Bypass Grafting registry. The postoperative bleeding risk was estimated using the WILL-BLEED risk score. Of all included patients, 3,548 had an increased risk of severe perioperative bleeding (defined as a WILL-BLEED score ≥4) and were the subjects of this analysis. We compared the early outcomes between patients who underwent on-pump or off-pump CABG using a multivariate mixed model for risk-adjusted analysis. Results: Off-pump surgery was performed in 721 patients (20.3%). On-pump patients received more packed red blood cell units (on-pump: 1.41 [95% confidence interval {CI}, 0.99–1.86]; off-pump: 0.86 [95% CI, 0.64–1.08]; p

Background: Coronary artery bypass grafting (CABG) without cardiopulmonary bypass and minimal or no aortic manipulation may be associated with a lower risk of neurological complications. We investigated this issue in patients with a high risk of perioperative stroke. Methods: Data on 7352 patients who underwent isolated CABG from January 2015 to May 2017 were included in the multicenter study E-CABG (European Coronary Artery Bypass Grafting) registry. Of these, 684 patients had an increased risk of neurological complications, ie, previous stroke or transient ischemic attack, severe carotid artery stenosis or occlusion, or previous carotid artery intervention. In this subgroup, we analyzed the rates of the combined primary endpoint comprising any postoperative stroke or transient ischemic attack. A comparative analysis between CABG with and without aortic cross-clamping was performed. Results: The primary endpoint was more often reached when aortic cross-clamping was used (propensity score matching, without vs with aortic cross-clamp: 0.9% vs 7.2%; P = .016). In comparison with all other revascularization techniques, off-pump CABG with avoidance of aortic manipulation was associated with the lowest rate of neurological complications (0.7%). Conclusions: In patients with increased risk of perioperative stroke, aortic manipulation including the use of cardiopulmonary bypass or partial clamping for central anastomoses is associated with higher rates of postoperative neurological complications. These patients may benefit from off-pump surgery without aortic manipulation if complete revascularization can be ensured.

Aim: The aim of this study was to assess the impact of surgeon experience and centre volume on early operative outcomes in patients undergoing off-pump coronary artery bypass (OPCAB) surgery. Method: Of 7,352 patients in the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) registry, 1,549 underwent OPCAB and were included in the present analysis. Using adjusted regression analysis, we compared major early adverse events after procedures performed by experienced OPCAB surgeons (i.e., ≥20 cases per year; n=1,201) to those performed by non-OPCAB surgeons (n=348). Furthermore, the same end points were compared between procedures performed by OPCAB surgeons in high OPCAB volume centres (off-pump technique used in >50% of cases; n=894) and low OPCAB volume centres (n=307). Results: In the experienced OPCAB surgeon group, we observed shorter procedure times (β -43.858, 95% confidence interval [CI] -53.322 to -34.393; p

Publisher Copyright: © 2022 The Author(s) Objectives: To compare the outcomes of patients with postcardiotomy shock treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) only compared with VA-ECMO and intra-aortic balloon pump (IABP). Design: A retrospective multicenter registry study. Setting: At 19 cardiac surgery units. Participants: A total of 615 adult patients who required VA-ECMO from 2010 to 2018. The patients were divided into 2 groups depending on whether they received VA-ECMO only (ECMO only group) or VA-ECMO plus IABP (ECMO-IABP group). Measurements and Main Results: The overall series mean age was 63 +/- 13 years, and 33% were female. The ECMO-only group included 499 patients, and 116 patients were in the ECMO-IABP group. Urgent and/or emergent procedures were more common in the ECMO-only group. Central cannulation was performed in 47% (n = 54) in the ECMO-IABP group compared to 27% (n = 132) in the ECMO-only group. In the ECMOIABP group, 58% (n = 67) were successfully weaned from ECMO, compared to 46% (n = 231) in the ECMO-only group (p = 0.026). However, inhospital mortality was 63% in the ECMO-IABP group compared to 65% in the ECMO-only group (p = 0.66). Among 114 propensity score-matched pairs, ECMO-IABP group had comparable weaning rates (57% v 53%, p = 0.51) and in-hospital mortality (64% v 58%, p = 0.78). Conclusions: This multicenter study showed that adjunctive IABP did not translate into better outcomes in patients treated with VA-ECMO for postcardiotomy shock. (C) 2022 The Author(s). Published by Elsevier Inc.

Objective There is a paucity of sex-specific data on patients’ postcardiotomy venoarterial extracorporeal membrane oxygenation (VA-ECMO). The present study sought to assess this issue in a multicenter study. Design Retrospective, propensity score–matched analysis of an international registry. Setting Multicenter study, tertiary university hospitals. Participants Data on adult patients undergoing postcardiotomy VA-ECMO. Measurements and Main Results Between January 2010 and March 2018, patients treated with postcardiotomy VA-ECMO at 17 cardiac surgery centers were analyzed. Index procedures considered were coronary artery bypass graft surgery, isolated valve surgery, their combination, and proximal aortic root surgery. Hospital and five-year mortality constituted the endpoints of interest. Propensity score matching was adopted with logistic regression. A total of 358 patients (mean age: 63.3 ± 12.3 years; 29.6% female) were identified. Among 94 propensity score–matched pairs, women had a higher hospital mortality (70.5% v 56.4%, p = 0.049) compared with men. Logistic regression analysis showed that women (odds ratio [OR], 1.87; 95% confidence interval [CI] 1.10-3.16), age (OR, 1.06; 95%CI 1.04-1.08) and pre-ECMO arterial lactate (OR, 1.09; 95%CI 1.04-1.16) were independent predictors of hospital mortality. No differences between female and male patients were observed for other outcomes. Among propensity score–matched pairs, one-, three-, and five-year mortality were 60.6%, 65.0%, and 65.0% among men, and 71.3%, 71.3%, and 74.0% among women, respectively (p = 0.110, adjusted hazard ratio, 1.27; 95%CI 0.96-1.66). Conclusions In postcardiotomy VA-ECMO, female patients demonstrated higher hospital mortality than men. Morbidity and late mortality were similar between the two groups.

Aims Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) support for post-cardiotomy cardiogenic shock (PCS) after adult cardiac surgery is associated with satisfactory hospital survival. However, data on long-term survival of these critically ill patients are scarce. Methods and results Between January 2010 and March 2018, 665 consecutive patients received VA-ECMO for PCS at 17 cardiac surgery centres and herein we evaluated their 5-year survival. The mean follow-up of this cohort was 1.7 ± 2.7 years (for hospital survivors, 4.6 ± 2.5 years). In this cohort, 240 (36.1%) patients survived to hospital discharge. Five-year survival of all patients was 27.7%. The PC-ECMO score was predictive of 5-year survival in these patients (0 point, 50.9%; 1 point, 44.9%; 2 points, 40.0%; 3 points, 34.7%; 4 points, 21.0%; 5 points, 17.6%; ≥6 points, 10.7%; P 70 years old having a remarkably poor 5-year survival ( Conclusion Veno-arterial extracorporeal membrane oxygenation for PCS is associated with satisfactory 5-year survival in young patients without critical pre-ECMO conditions. The use of VA-ECMO for PCS in patients >70 years should be considered only after a judicious scrutiny of patient’s life expectancy. Future studies should evaluate whether satisfactory mid-term survival of these patients translates into a good functional outcome. Trial registration Clinicaltrials.gov—NCT03508505.

Objectives: The aim of this study was to identify the risk factors associated with early mortality after postcardiotomy venoarterial extracorporeal membrane oxygenation. Methods: This is an analysis of the postcardiotomy extracorporeal membrane oxygenation registry, a retrospective multicenter cohort study including 781 patients aged more than 18 years who required venoarterial extracorporeal membrane oxygenation for cardiopulmonary failure after cardiac surgery from 2010 to 2018 at 19 cardiac surgery centers. Results: After a mean venoarterial extracorporeal membrane oxygenation therapy of 6.9 ± 6.2 days, hospital and 1–year mortality were 64.4% and 67.2%, respectively. Hospital mortality after venoarterial extracorporeal membrane oxygenation therapy for more than 7 days was 60.5% (P = 0.105). Centers that had treated more than 50 patients with postcardiotomy venoarterial extracorporeal membrane oxygenation had a significantly lower hospital mortality than lower–volume centers (60.7% vs 70.7%, adjusted odds ratio, 0.58; 95% confidence interval, 0.41–0.82). The postcardiotomy extracorporeal membrane oxygenation score was derived by assigning a weighted integer to each independent pre–venoarterial extracorporeal membrane oxygenation predictors of hospital mortality as follows: female gender (1 point), advanced age (60–69 years, 2 points; ≥70 years, 4 points), prior cardiac surgery (1 point), arterial lactate 6.0 mmol/L or greater before venoarterial extracorporeal membrane oxygenation (2 points), aortic arch surgery (4 points), and preoperative stroke/unconsciousness (5 points). The hospital mortality rates according to the postcardiotomy extracorporeal membrane oxygenation score was 0 point, 45.6%; 1 point, 40.5%; 2 points, 51.1%; 3 points, 57.8%; 4 points, 70.7%; 5 points, 68.3%; 6 points, 77.5%; and 7 points or more, 89.7% (P < 0.0001). Conclusions: Age, female gender, prior cardiac surgery, preoperative acute neurologic events, aortic arch surgery, and increased arterial lactate were associated with increased risk of early mortality after postcardiotomy venoarterial extracorporeal membrane oxygenation. Center experience with postcardiotomy venoarterial extracorporeal membrane oxygenation may contribute to improved results. PC-ECMO Study Group Collaborators of the PC-ECMO Study Group: Kristiina Pälve, MD, PhD, Vesa Anttila, MD, PhD, MD, Thomas Fux, MD, PhD, Gilles Amr, MD, Nikolaos Kalampokas, MD, Artur Lichtenberg, MD, Anders Jeppsson, MD, PhD, Marco Gabrielli, MD, Daniel Reichart, MD, Sidney Chocron, MD, PhD, Mariafrancesca Fiorentino, MD, Ugolino Livi, MD, Ivan Netuka, MD, Dieter De Keyzer, MD, Krister Mogianos, MD, Zein El Dean, MRCS, LLM, Angelo M. Dell’Aquila, MD, Nicla Settembre, MD, PhD, and Stefano Rosato, MSc.

Background We hypothesized that cannulation strategy in venoarterial extracorporeal membrane oxygenation (VA-ECMO) could play a crucial role in the perioperative survival of patients affected by postcardiotomy shock. Methods Between January 2010 and March 2018, 781 adult patients receiving VA-ECMO for postcardiotomy shock at 19 cardiac surgical centers were retrieved from the Postcardiotomy Veno-arterial Extracorporeal Membrane Oxygenation study registry. A parallel systematic review and meta-analysis (PubMed/MEDLINE, Embase, and Cochrane Library) through December 2018 was also accomplished. Results Central and peripheral VA-ECMO cannulation were performed in 245 (31.4%) and 536 (68.6%) patients, respectively. Main indications for the institution VA-ECMO were failure to wean from cardiopulmonary bypass (38%) and heart failure following cardiopulmonary bypass weaning (48%). The doubly robust analysis after inverse probability treatment weighting by propensity score demonstrated that central VA-ECMO was associated with greater hospital mortality (odds ratio 1.54; 95% confidence interval, 1.09-2.18), reoperation for bleeding/tamponade (odds ratio, 1.96; 95% confidence interval, 1.37-2.81), and transfusion of more than 9 RBC units (odds ratio, 2.42; 95% confidence interval, 1.59-3.67). The systematic review provided a total of 2491 individuals with postcardiotomy shock treated with VA-ECMO. Pooled prevalence of in-hospital/30-day mortality in overall patient population was 66.6% (95% confidence interval, 64.7-68.4%), and pooled unadjusted risk ratio analysis confirmed that patients undergoing peripheral VA-ECMO had a lower in-hospital/30-day mortality than patients undergoing central cannulation (risk ratio, 0.92; 95% confidence interval, 0.87-0.98). Adjustments for important confounders did not alter our results. Conclusions In patients with postcardiotomy shock treated with VA-ECMO, central cannulation was associated with greater in-hospital mortality than peripheral cannulation.

Aurélie Brunet,1 Yohan N’Guyen,1,* Annick Lefebvre,2,* Anne Poncet,3 Ailsa Robbins,1 Odile Bajolet,2 Yves Saade,3 Vito Giovanni Ruggieri,3,* Sylvain Rubin3,* 1Internal Medicine, Infectious Diseases and Clinical Immunology, Robert Debré University Hospital, Reims, France; 2Operational Hygiene Team, Robert Debré University Hospital, Reims, France; 3Thoracic and Cardiovascular Surgery, Robert Debré University Hospital, Reims, France*These authors contributed equally to this workCorrespondence: Yohan N’GuyenInternal Medicine, Infectious Diseases and Clinical Immunology, Robert Debré University Hospital, Avenue du général Koenig, Reims 51092, FranceTel (+33) 3 26 78 94 22Fax (+33) 3 26 78 40 90Email yohan.nguyen@wanadoo.frPurpose: Obesity remains statistically associated with coronary artery disease, for which coronary artery bypass graft surgery (CABG) remains the standard of care. However, obesity is also associated with sternal wound infection (SWI) which is a severe complication of CABG despite advances in surgery and in infection prevention and control. Strategies to reduce the incidence of SWI are still being investigated, and we therefore conducted a retrospective study to revisit factors other than obesity associated with SWI after CABG.Patients and Methods: Data were extracted from the medical records of 182 patients who underwent elective on-pump CABG using one or both pedicled internal mammary artery grafts in Reims University Hospital between May 2015 and May 2016. All preoperative or perioperative variables with a p value< 0.10 in univariate analysis were entered into a stepwise logistic regression model.Results: Among the 182 patients (145 male (79.6%), median age 68.0 [45.0– 87.0] years), 138 (75.8%) underwent CABG using bilateral internal mammary artery grafts. Median BMI was 27.7 [18.7– 50.5] kg/m2, and there were 51 (28.0%) and 79 (43.4%) patients with obesity and overweight, respectively. Twenty-three out of the 182 patients (12.6%) developed SWI. In-hospital mortality was not statistically different between patients with and without SWI but the median length of stay was (6.0 [2.0– 38.0] versus 5.0[3.0– 21.0] days in the intensive care unit, p=0.03, and 26.0 [9.0– 134.0] versus 9.0 [7.0– 51.0] days in hospital, p< 0.0001). Obesity and preoperative anaemia were independently associated with SWI, as was the number of red blood cell (RBC) units transfused (OR 14.61 [2.64– 80.75], OR 4.64 [1.61– 13.34] and OR 1.27 [1.02– 1.58], respectively).Conclusion: The independent association of SWI with the number of RBC units transfused and the existence of preoperative anaemia and obesity suggests a mechanism of thoracic wall ischemia in SWI after CABG, thus leaving insufficient perfusion of the thoracic wall in patients with obesity. Medical strategies are warranted to try to prevent this costly complication.Keywords: obesity, preoperative anaemia, coronary artery bypass graft surgery, internal mammary arteries

Background Epiaortic ultrasonography (EAU) is a valid imaging method to detect atherosclerotic changes of the ascending aorta and to guide surgical strategies for the prevention of cerebral embolism in patients undergoing isolated coronary artery bypass grafting (CABG). However, its use is not widespread. Methods The impact of EAU on the outcome after isolated CABG was investigated in patients from the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) registry. A systematic review and meta-analysis of the literature was performed to substantiate the findings of this observational study. Results EAU was performed intraoperatively in 673 of 7241 patients (9.3%) from the E-CABG registry. In the overall series, the rates of stroke without and with aortic manipulation were 0.3% and 1.3%, respectively (P = .003). In 660 propensity score–matched pairs, EAU was associated with significantly lower risk of stroke (0.6% vs 2.6%, P = .007). A literature search yielded 5 studies fulfilling the inclusion criteria. These studies, along with the present one, included 11,496 patients, of whom 3026 (25.7%) underwent intraoperative EAU. Their rate of postoperative stroke was significantly lower than in patients not investigated with EAU (pooled rate, 0.6% vs 1.9%; risk ratio, 0.40; 95% confidence interval, 0.24-0.66; I2 = 0%). On the basis of these pooled rates, the number needed to treat to prevent 1 stroke is 76.9. Conclusions Avoiding aortic manipulation is associated with the lowest risk of stroke in patients undergoing CABG. When manipulation of the ascending aorta is planned, EAU is effective in guiding the surgical strategy to reduce the risk for embolic stroke in these patients.

Objective: To evaluate current results of surgical aortic valve replacement (SAVR) ± coronary artery bypass grafting surgery. Design: Independent, multicenter, prospective registry. Setting: Tertiary university hospitals. Participants: The study comprised 1,192 consecutive patients, stratified as low-, intermediate-, and high-risk according to EuroSCORE II ( 9, respectively). Interventions: SAVR ± coronary artery bypass grafting surgery. Measurements and Main Results: Thirty-day mortality and major morbidity, 2-year actuarial survival and freedom from stroke, and independent predictors of mortality in each risk category were assessed. These data were considered in light of published randomized controlled trials. Thirty-day mortality was 1.0%, 3.0% and 2.1% in the low-, intermediate-, and high-risk patients, with a 2-year actuarial survival of 98.6%, 93.8%, and 94.0%, respectively. Preoperative atrial fibrillation (odds ratio [OR] 8.3), minithoracotomy access (OR 5.8), postoperative dialysis (OR 3.4), type V acute myocardial infarction (OR 20.4), and moderate aortic regurgitation (OR 28.8) predicted 30-day mortality in the low-risk group. Preoperative dialysis (OR 18.3), critical state (OR 36.7), postoperative transfusions of plasma (OR 1.9 per unit transfused), and de-novo dialysis (OR 6.2) predicted 30-day mortality in the intermediate-risk group. Prior cardiac surgery (OR 18.1), postoperative extracorporeal membrane oxygenation (OR 9.8), and gastrointestinal complications (OR 17.2) predicted 30-day mortality in the high-risk group. Although baseline differences existed, low-risk patients demonstrated low 30-day mortality and 30-day to 12-month stroke in light of the PARTNER 3 and EVOLUT Low Risk trial results. Intermediate-risk patients demonstrated low 30-day to 2-year mortality, when the PARTNER 2 trial was considered, and low 30-day to 2-year stroke, when the PARTNER 2 and SURTAVI trials were considered. High-risk patients showed low 30-day to 2-year mortality in light of the results of the PARTNER 1 and CoreValve US trials. Conclusions: SAVR is still a safe and effective surgery for aortic stenosis regardless of risk category.

Bilateral internal mammary artery (BIMA) grafting is increasingly used in the elderly without evidence of its risks or benefits compared to single internal mammary artery (SIMA) grafting. Background. Bilateral internal mammary artery (BIMA) grafting is increasingly used in elderly patients without evidence of its risks or benefits compared with single internal mammary artery (SIMA) grafting.Methods. In all, 2,899 patients aged 70 years or older (855 [29.5%] underwent BIMA grafting) operated on from January 2015 to December 2016 and included in the prospective multicenter Outcome After Coronary Artery Bypass Grafting (E-CABG) study were considered in this analysis.Results. One-to-one propensity matching resulted in 804 pairs with similar preoperative risk profile. Propensity score matched analysis showed that BIMA grafting was associated with a nonstatistically significant increased risk of inhospital death (2.7% versus 1.6%, p = 0.117). The BIMA grafting cohort had a significantly increased risk of any sternal wound infection (7.7% versus 5.1%, p = 0.031) as well as higher risk of deep sternal wound infection/mediastinitis (4.0% versus 2.2%, p = 0.048). The BIMA grafting cohort required more frequently extracorporeal membrane oxygenation (1.0% versus 0.1%, p = 0.02), and the intensive care unit stay (mean 3.6 versus 2.6 days, p < 0.001) and inhospital stay (mean 11.3 versus 10.0 days, p < 0.001) were significantly longer compared with the SIMA grafting cohort. Test for interaction showed that urgent operation in patients undergoing BIMA grafting was associated with higher risk of inhospital death (5.6% versus 1.3%, p = 0.009).Conclusions. Bilateral internal mammary artery grafting in elderly patients seems to be associated with a worse early outcome compared with SIMA grafting, particularly in patients undergoing urgent operation. Until more conclusive results are gathered, BIMA grafting should be reserved only for elderly patients with stable coronary artery disease, without significant baseline comorbidities and with long life expectancy. (C) 2018 by The Society of Thoracic Surgeons

International audience; Objectives: This study sought to describe the procedural and clinical outcomes of patients undergoing transcarotid (TC) transcatheter aortic valve replacement (TAVR) with the Edwards Sapien 3 device.Background: The TC approach for TAVR holds the potential to become the optimal alternative to the transfemoral gold standard. Limited data exist regarding safety and efficacy of TC-TAVR using the Edwards Sapien 3 device.Methods: The French Transcarotid TAVR prospective multicenter registry included patients between 2014 and 2018. Consecutive patients treated in 1 of the 13 participating centers ineligible for transfemoral TAVR were screened for TC-TAVR. Clinical and echocardiographic data were prospectively collected. Perioperative and 30-day outcomes were reported according to the updated Valve Academic Research Consortium (VARC-2).Results: A total of 314 patients were included with a median (interquartile range) age of 83 (78 to 88) years, 63% were males, Society of Thoracic Surgeons mortality risk score 5.8% (4% to 8.3%). Most patients presented with peripheral artery disease (64%). TC-TAVR was performed under general anesthesia in 91% of cases, mostly using the left carotid artery (73.6%) with a procedural success of 97%. Three annulus ruptures were reported, all resulting in patient death. At 30 days, rates of major bleeding, new permanent pacemaker, and stroke or transient ischemic attack were 4.1%, 16%, and 1.6%, respectively. The 30-day mortality was 3.2%.Conclusions: TC-TAVR using the Edwards Sapien 3 device was safe and effective in this prospective multicenter registry. The TC approach might be considered, in selected patients, as the first-line alternative approach for TAVR whenever the transfemoral access is prohibited. Sapien 3 device was safe and effective in our multicenter cohort.

Background: We evaluated perioperative bleeding after coronary artery bypass grafting (CABG) in patients preoperatively treated with ticagrelor or clopidogrel, stratified by discontinuation of these P2Y₁₂ inhibitors. Methods: All patients from the prospective, European Multicenter Registry on Coronary Artery Bypass Grafting (E-CABG) treated with ticagrelor or clopidogrel undergoing isolated primary CABG were eligible. The primary outcome measure was severe or massive bleeding defined according to the Universal Definition of Perioperative Bleeding, stratified by P2Y₁₂ inhibitor discontinuation. Secondary outcome measures included four additional definitions of major bleeding. Propensity score matching was performed to adjust for differences in preoperative and perioperative covariates. Results: Of 2,311 patients who were included, 1,293 (55.9%) received clopidogrel and 1,018 (44.1%) ticagrelor preoperatively. Mean time between discontinuation and the operation was 4.5 ± 3.2 days for clopidogrel and 4.9 ± 3.0 days for ticagrelor. In the propensity score–matched cohort, ticagrelor-treated patients had a higher incidence of major bleeding according to Universal Definition of Perioperative Bleeding when ticagrelor was discontinued 0 to 2 days compared with 3 days before the operation (16.0% vs 2.7%, p = 0.003). Clopidogrel-treated patients had a higher incidence of major bleeding according to the Universal Definition of Perioperative Bleeding when clopidogrel was discontinued 0 to 3 days compared with 4 to 5 days before the operation (15.6% vs 8.3%, p = 0.031). Conclusions: In patients receiving ticagrelor 2 days before CABG and in those receiving clopidogrel 3 days before CABG, there was an increased rate of severe bleeding. Postponing nonemergent CABG for at least 3 days after discontinuation of ticagrelor and 4 days after clopidogrel should be considered.

Background: There is uncertainty whether venoarterial extracorporeal membrane oxygenation (VA-ECMO) should be used in older patients with cardiopulmonary failure after cardiac surgery. Methods: This was a retrospective multicenter study of 781 patients who required postcardiotomy VA-ECMO for cardiopulmonary failure after adult cardiac surgery from 2010 to 2018 at 19 cardiac surgery centers. A parallel systematic review with meta-analysis of the literature was performed. Results: The hospital mortality in the overall Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation (PC-ECMO) series was 64.4%. A total of 255 patients were 70 years old or older (32.7%), and their hospital mortality was significantly higher than in younger patients (76.1% vs 58.7%; adjusted odds ratio, 2.199; 95% confidence interval [CI], 1.536 to 3.149). Arterial lactate level greater than 6 mmol/L before starting VA-ECMO was the only predictor of hospital mortality among patients 70 years old or older in univariate analysis (82.6% vs 70.4%; P = 0.029). Meta-analysis of current and previous studies showed that early mortality after postcardiotomy VA-ECMO was significantly higher in patients aged 70 years or older compared with younger patients (odds ratio, 2.09; 95% CI, 1.59 to 2.75; 5 studies including 1547 patients; I², 5.9%). The pooled early mortality rate among patients aged 70 years or older was 78.8% (95% CI, 74.1 to 83.5; 6 studies including 617 patients; I², 41.8%). Two studies reported 1-year mortality (including hospital mortality) of 79.9% and 75.6%, respectively, in patients 70 years old or older. Conclusions: Advanced age should not be considered a contraindication for postcardiotomy VA-ECMO. However, in view of the high risk of early mortality, meaningful scrutiny is needed before using VA-ECMO after cardiac surgery in older patients.

Background: The outcome after weaning from postcardiotomy venoarterial extracorporeal membrane oxygenation (VA-ECMO) is poor. In this study, we investigated the prognostic impact of arterial lactate levels at the time of weaning from postcardiotomy VA. Methods: This analysis included 338 patients from the multicenter PC-ECMO registry with available data on arterial lactate levels at weaning from VA-ECMO. Results: Arterial lactate levels at weaning from VA-ECMO (adjusted OR 1.426, 95%CI 1.157&ndash, 1.758) was an independent predictor of hospital mortality, and its best cutoff values was 1.6 mmol/L (&lt, 1.6 mmol/L, 26.2% vs. &ge, 1.6 mmol/L, 45.0%, adjusted OR 2.489, 95%CI 1.374&ndash, 4.505). When 261 patients with arterial lactate at VA-ECMO weaning &le, 2.0 mmol/L were analyzed, a cutoff of arterial lactate of 1.4 mmol/L for prediction of hospital mortality was identified (&lt, 1.4 mmol/L, 24.2% vs. &ge, 1.4 mmol/L, 38.5%, p = 0.014). Among 87 propensity score-matched pairs, hospital mortality was significantly higher in patients with arterial lactate &ge, 1.4 mmol/L (39.1% vs. 23.0%, p = 0.029) compared to those with lower arterial lactate. Conclusions: Increased arterial lactate levels at the time of weaning from postcardiotomy VA-ECMO increases significantly the risk of hospital mortality. Arterial lactate may be useful in guiding optimal timing of VA-ECMO weaning.

International audience; Purpose - Minimally invasive aortic valve replacement (MIAVR) procedures remain more complex and technically challenging compared to conventional full sternotomy surgery. This technique involves a restricted surgical field and a limited workspace, which is, at present, strictly reserved for the most experienced surgeons. The MIAVR clinical outcomes are strongly dependent on the appropriate choice of the thoracic incision. This work presents a decision support system to optimize, through an interactive visualization interface, the exposure of the target structure in a limited field of view. Methods - Our approach is based on the computation of relevant anatomical measurements from preoperative CT images, and it takes into account the surgical guidelines in order to propose the surgical access that best fits the patient's morphology. Results - The proposed planning system was applied and tested on 30 datasets from patients affected by severe aortic stenosis for validation purposes. We evaluated the accuracy of the automatic detections and the measurements calculated by the system with those chosen manually by the expert. Conclusions - In 87% of thirty cases, the surgical strategy proposed by the decision support system was correct. For the remaining cases, the graphical user interface (GUI) allowed the user to manually adjust the anatomical features.

Objective This study was planned to pool existing data on outcome and to evaluate the efficacy of postcardiotomy venoarterial extracorporeal membrane oxygenation (VA-ECMO) in adult patients. Design Systematic review of the literature and meta-analysis. Setting Multi-institutional study. Participants Adult patients with acute heart failure immediately after cardiac surgery. Interventions VA-ECMO after cardiac surgery. Studies evaluating only heart transplant patients were excluded from this analysis. Measurements and Main Results A literature search was performed to identify studies published since 2000. Thirty-one studies reported on 2,986 patients (mean age, 58.1 years) who required postcardiotomy VA-ECMO. The weaning rate from VA-ECMO was 59.5% and hospital survival was 36.1% (95% CI 31.5-40.8). The pooled rate of reoperation for bleeding was 42.9%, major neurological event 11.3%, lower limb ischemia 10.8%, deep sternal wound infection/mediastinitis 14.7%, and renal replacement therapy 47.1%. The pooled mean number of transfused red blood cell units was 17.7 (95% CI 13.3-22.1). The mean stay in the intensive care unit was 13.3 days (95% CI 10.2-16.4). Survivors were significantly younger (mean, 55.7 v 63.6 years, p = 0.015) and their blood lactate level before starting VA-ECMO was lower (mean, 7.7 v 10.7 mmol/L, p = 0.028) than patients who died. One-year survival rate was 30.9% (95% CI 24.3-37.5). Conclusions Pooled data showed that VA-ECMO may salvage one-third of patients unresponsive to any other resuscitative treatment after adult cardiac surgery.

Objectives: The aim of this study was to evaluate the prognostic impact of untreated asymptomatic carotid artery stenosis (CS) in patients undergoing isolated coronary artery bypass grafting (CABG). Methods: This was a post hoc analysis of data from a prospective multicentre observational study. Patients without history of stroke or transient ischaemic attack from the multicentre E-CABG registry who were screened for CS before isolated CABG were included. Results: Among 2813 patients screened by duplex ultrasound and who did not undergo carotid intervention for asymptomatic CS, 11.1% had a stenosis of 50–59%, 6.0% of 60–69%, 3.1% of 70–79%, 1.4% of 80–89%, 0.5% of 90–99%, and 1.1% had carotid occlusion. In the screened population post-operative stroke occurred in 25 patients (0.9%), with an incidence of 1.5% among patients with CS ≥ 50% (n = 649). Pre-operative screening had not found a relevant CS in 15 of 25 patients suffering stroke after CABG. Brain imaging identified cerebral ischaemic injury in 20 patients, which was bilateral in five patients (25%), ipsilateral to a CS ≥ 50% in six (30%), and ipsilateral to a CS ≥ 70% in three (15%). In univariable analysis, the severity of CS was associated with a significantly increased risk of stroke (CS < 50%, 0.7%; 50–59%, 1.0%; 60–69%, 0.6%; 70–79%, 1.2%; 80–89%, 5.1%; 90–99%, 7.7%; occluded, 6.7%, p < .001). In multivariable analysis, a CS of 90–99% (OR 12.03, 95% CI 1.34–108.23) and the presence of an occluded internal carotid artery (OR 8.783, 95% CI 1.820–42.40) were independent predictors of stroke along with urgency of the procedure, severe massive bleeding according to the E-CABG classification, and the presence of a porcelain ascending aorta. Conclusions: Among screened patients with untreated asymptomatic patients, CS ≥ 90% was an independent predictor of post-operative stroke. As this condition has a low prevalence and when left untreated is associated with a relatively low rate of stroke, pre-operative screening of asymptomatic CS before CABG may not be justified. Clinical Trial registration: https://clinicaltrials.gov. Unique identifier: NCT02319083.

OBJECTIVES The aim of this study was to assess the impact of frailty on the outcome after coronary artery bypass grafting (CABG) and whether it may improve the predictive ability of European System for Cardiac Operative Risk Evaluation (EuroSCORE II). METHODS The Clinical Frailty Scale (CFS) was assessed preoperatively in patients undergoing isolated CABG from the multicentre E-CABG registry, and patients were stratified into 3 classes: scores 1-2, scores 3-4 and scores 5-7. RESULTS Of the 6156 patients enrolled, 39.2% had CFS scores 1-2, 57.6% scores 3-4, and 3.2% scores 5-7. Logistic regression adjusted for multiple covariates showed that the CFS was an independent predictor of hospital/30-day mortality [CFS scores 3-4, odds ratio (OR) 3.95, 95% confidence interval (CI) 2.19-7.14; CFS scores 5-7, OR 5.90, 95% CI 2.67-13.05] and resulted in an Integrated Improvement Index of 1.3 (P

Background Multiple percutaneous coronary interventions ( PCIs ) are considered determinant of poor outcome in patients undergoing coronary artery bypass grafting ( CABG ), but scarce data exist to substantiate this. Methods and Results Patients who underwent CABG without history of prior PCI or with PCI performed >30 days before surgery were selected for the present analysis from the prospective, multicenter E‐CABG (European Multicenter Study on Coronary Artery Bypass Grafting) registry. Out of 6563 patients with data on preoperative SYNTAX (Synergy between PCI With Taxus and Cardiac Surgery) score, 1181 patients (18.0%) had undergone PCI >30 days before CABG . Of these, 11.6% underwent a single PCI , 4.4% 2 PCI s, and 2.1% ≥3 PCI s. PCI of a single main coronary vessel was performed in 11.3%, of 2 main vessels in 4.9%, and of 3 main vessels in 1.6% of patients. Multivariable analysis showed that differences in early mortality and other outcomes were not significantly different in the study cohorts. The adjusted hospital/30‐day mortality rate was 1.8% in patients without history of prior PCI , 1.9% in those with a history of 1 PCI , 1.4% after 2 PCI s, and 2.5% after ≥3 PCI s (adjusted P =0.8). The adjusted hospital/30‐day mortality rate was 2.0% in those who had undergone PCI of 1 main coronary vessel, 1.3% after PCI of 2 main vessels, and 3.1% after PCI of 3 main coronary vessels (adjusted P =0.6). Conclusions Multiple prior PCI s are not associated with increased risk of early adverse events in patients undergoing isolated CABG . The present results are conditional to survival after PCI and should not be viewed as a support for a policy of multiple PCI as opposed to earlier CABG . Clinical Trial Registration URL : http://www.Clinicaltrials.gov . Unique identifier: NCT 02319083.

Background: The prognostic impact of cross-clamp time (XCT) in patients undergoing isolated coronary artery bypass grafting (CABG) has not been thoroughly investigated. Material and Methods: 2957 patients who underwent on-pump isolated CABG from the prospective multicentre E-CABG study were the subjects of this analysis. Results: The mean XCT in this series was 58 ± 25 minutes Cross-clamp time was >60 minutes in 1134 patients (38.3%), >75 minutes in 619 patients (20.9%) and >90 minutes in 296 patients (10.0%). Multivariate analysis showed that XCT was an independent predictor of 30-day mortality (p < 0.0001, OR 1.027, 95%CI 1.015–1.039) along with age (p < 0.0001), female gender (p = 0.001), pulmonary disease (p = 0.001), poor mobility (p = 0.002), urgency status (p = 0.007), critical preoperative status (p = 0.002) and participating centres (p = 0.015). Adjusted risk of 30-day mortality was highest for XCT >75 minutes (2.9% vs. 1.7%, p = 0.002, OR 3.479, 95%CI 1.609–7.520). Analysis of 428 propensity score matched pairs showed that XCT >75 minutes was associated with significantly increased risk of early mortality, prolonged use of inotropes, postoperative use of intra-aortic balloon pump, use of extracorporeal membrane oxygenation, atrial fibrillation, prolonged stay in the intensive care unit and of composite major adverse events. Conclusions: Isolated CABG is currently performed with prolonged XCT in a significant number of patients and this seems to be a determinant of poor early outcome.

Perioperative bleeding is a determinant of poor outcome in patients undergoing coronary artery bypass grafting (CABG), but there is a lack of adequate stratification of its severity. The ability of the European registry of Coronary Artery Bypass Grafting (E-CABG), Universal Definition of Perioperative Bleeding (UDPB), Study of Platelet Inhibition and Patient Outcomes (PLATO), Clopidogrel and Aspirin Optimal Dose Usage to Reduce Recurrent,Events Seventh Organization to Assess Strategies in Ischemic Syndromes (CURRENT-OASIS 7), Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q Wave Coronary Events (ESSENCE), and SafeTy and Efficacy of Enoxaparin in Percutaneous coronary intervention patients, an internationaL randomized Evaluation (STEEPLE) bleeding classifications to predict early mortality, stroke, acute kidney injury (AKI) stage 3, and deep sternal wound infection/mediastinitis was investigated in 3,730.patients from the prospective, multicentre E-CABG registry. Increasing grades of the E-CABG, UDPB, PLATO, and CURRENT-OASIS 7 classifications were associated with increasing risks of early mortality, had similar receiver-operating characteristic area under the curves (>0.7), and were predictive also when adjusted for EuroSCORE II. The E-CABG and UDPB classifications had satisfactory area under the curves (>0.6) in pre,dicting stroke, AKI stage 3, and deep sternal wound infection/mediastinitis even when adjusted for EuroSCORE II. The PLATO and CURRENT-OASIS 7 classifications had similar predictive ability for stroke and AKI stage 3 as confirmed by multivariate analysis adjusted for EuroSCORE II but showed inferior ability in predicting severe wound infection compared to the E-CABG and UDPB classifications. The STEEPLE and ESSENCE classifications had a poor ability of predicting all these adverse events. Decision curve analysis showed a benefit of the ECABG bleeding classification over the other classifications in predicting all adverse events. In conclusion, the E-CABG, UDPB, PLATO, and CURRENT-OASIS 7 bleeding classifications have a satisfactory ability in predicting adverse events after CABG. Decision curve analysis showed that the E-CABG bleeding classification had the best predictive performance. (C) 2016 Elsevier Inc. All rights reserved.

International audience; Objective To clarify the mid-term durability of the Trifecta bioprosthesis for aortic valve replacement (AVR). Methods We retrospectively analyzed the prospectively collected data of 824 consecutive implants of the Trifecta valve at a single institution. A 100% complete follow-up was available (average duration, 2.2 ± 1.3 years; range, 0.03-6.9 years; 1747.6 patient-years). Echocardiography data at discharge were recorded prospectively. Results Operative mortality was 3.8%; 2.7% in patients receiving isolated AVR. There were 5 valve-related early reoperations, including 1 for infective prosthetic endocarditis and 4 for nonstructural valve dysfunction. The global rate of severe patient–prosthesis mismatch was 1.26%. Overall 5-year survival was 74.9%, and freedom from valve-related death was 97.8%. The majority of deaths attributed to the valve were due to unknown causes. We observed 6 SVD events at 3.4 ± 1.6 years after surgery. At 5 years, the actuarial freedom from SVD was 98% ± 0.9% (n = 6), freedom from reintervention for SVD was 98% ± 0.9% (n = 5, including 2 transcatheter valve-in-valve), and freedom from open reoperation for SVD was 98.9% ± 0.6%. The 5-year freedom from prosthetic endocarditis was 97.7% ± 0.7% (n = 12, 6 requiring reoperation). There was 1 case of late NSVD (5-year freedom, 99.8% ± 0.2%). Freedom from hemorrhagic events was 98.6% ± 0.5% (86% occurring in patients on anticoagulants); there were no thromboembolic events at follow-up. Conclusions The Trifecta bioprosthesis is a reliable device for AVR. We confirm excellent immediate hemodynamic properties and a very low rate of patient–prosthesis mismatch. The absolute number of SVD cases observed remains limited; nevertheless, their timing, pathological characteristics, and clinical presentation mandate continued follow-up.

Background: The evidence of the benefits of using venoarterial extracorporeal membrane oxygenation (VA-ECMO) after coronary artery bypass grafting (CABG) is scarce. Methods: We analyzed the outcomes of patients who received VA-ECMO therapy due to cardiac or respiratory failure after isolated CABG in 12 centers between 2005 and 2016. Patients treated preoperatively with ECMO were excluded from this study. Results: VA-ECMO was employed in 148 patients after CABG for median of 5.0 days (mean, 6.4, SD 5.6 days). Inhospital mortality was 64.2%. Pooled in-hospital mortality was 65.9% without significant heterogeneity between the centers (I-2 8.6%). The proportion of VA-ECMO in each center did not affect in-hospital mortality (p = 0.861). No patients underwent heart transplantation and six patients received a left ventricular assist device. Logistic regression showed that creatinine clearance (p = 0.004, OR 0.98, 95% CI 0.97-0.99), pulmonary disease (p = 0.018, OR 4.42, 95% CI 1.29-15.15) and pre-VA-ECMO blood lactate (p = 0.015, OR 1.10, 95% CI 1.02-1.18) were independent baseline predictors of in-hospital mortality. One-, 2-, and 3-year survival was 31.0%, 27.9%, and 26.1%, respectively. Conclusions: One third of patients with need for VA-ECMO after CABG survive to discharge. In view of the burden of resources associated with VA-ECMO treatment and the limited number of patients surviving to discharge, further studies are needed to identify patients who may benefit the most from this treatment. (C) 2017 Elsevier B.V. All rights reserved.

BACKGROUND Excessive bleeding and blood transfusion are associated with adverse outcome after cardiac surgery, but their mechanistic effects are difficult to disentangle in patients with increased operative risk. This study aimed to evaluate the incidence and prognostic impact of bleeding and transfusion of blood products in low-risk patients undergoing coronary artery bypass grafting (CABG). STUDY DESIGN AND METHODS Sixteen tertiary European centers of cardiac surgery contributed to the prospective European registry of CABG (E-CABG). The severity of bleeding was defined by the E-CABG bleeding severity classification and universal definition of perioperative bleeding (UDPB) classification. RESULTS Of 1213 patients with EuroSCORE II of less than 2% (mean, 1.1 ± 0.4%), 18.5% suffered from mild bleeding (E-CABG bleeding Grade 1) and 3.4% experienced severe bleeding (E-CABG bleeding Grade 2-3). Similarly, 19.7% had UDPB Class 2 and 5.9% had UDPB Classes 3 and 4. Mild and severe bleeding defined by the E-CABG and UDPB classifications were associated with an increased risk of several adverse events as adjusted by multiple covariates. The risk of death, stroke, and acute kidney injury was particularly increased in patients with severe bleeding. CONCLUSION Severe bleeding is rather uncommon in low-risk patients undergoing CABG, but it is associated with an increased risk of major adverse events. Prevention of excessive perioperative bleeding and patient blood management may improve the outcome of cardiac surgery also in low-risk patients.

To investigate the impact of minor perioperative bleeding requiring transfusion of 1-2 red blood cell (RBC) units on the outcome after coronary artery bypass grafting (CABG). Purpose: To investigate the impact of minor perioperative bleeding requiring transfusion of 1-2 red blood cell (RBC) units on the outcome after coronary artery bypass grafting (CABG).Methods: Sixteen cardiac surgical centers contributed to the prospective European CABG registry (E-CABG). 1014 patients receiving 1-2 RBC units during or after isolated CABG were compared to 2264 patients not receiving RBCs.Results: In 827 propensity score matched pairs, transfusion of 1-2 RBC units did not affect the risk of in-hospital/30-day death (p = 0.523) or stroke (p = 0.804). However, RBC transfusion was associated with an increased risk of acute kidney injury (p = 0.008), sternal wound infection (p = 0.001), postoperative use of antibiotics (p = 0.001), prolonged use of inotropes (p < 0.0001), use of intra-aortic balloon pump (p = 0.012), length of intensive care unit stay (p < 0.0001) and length of in-hospital stay (p < 0.0001). Matched paired analysis excluding pre- and postoperative critical hemodynamic conditions showed that RBC transfusion was associated with an increased risk of major complications except in-hospital/30-day death.Conclusion: Minor perioperative bleeding and subsequent transfusion of 1-2 RBC units did not affect the risk of early death, but increased the risk of other major adverse events. Minimizing perioperative bleeding and prevention of even low-volume RBC transfusion may improve the outcome after CABG. (C) 2017 Elsevier Inc. All rights reserved.

Glycated hemoglobin (HbA1c) is a suspected risk factor for sternal wound infection (SWI) after CABG.Methods and Results:Data on preoperative HbA1c and SWI were available in 2,130 patients undergoing isolated CABG from the prospective E-CABG registry. SWI occurred in 114 (5.4%). Baseline HbA1c was significantly higher in patients with SWI (mean, 54±17 vs. 45±13 mmol/mol, P0.0001). This difference was also observed in patients without a diagnosis of diabetes (P=0.027), in insulin-dependent diabetic (P=0.023) and non-insulin-dependent diabetic patients (P=0.034). In the overall series, HbA1c70 mmol/mol (NGSP units, 8.6%) was associated with the highest risk of SWI (20.6% vs. 4.6%; adjusted OR, 5.01; 95% CI: 2.47-10.15). When dichotomized according to the cut-off 53 mmol/mol (NGSP units, 7.0%) as suggested both for diagnosis and optimal glycemic control of diabetes, HbA1c was associated with increased risk of SWI in the overall series (10.6% vs. 3.9%; adjusted OR, 2.09; 95% CI: 1.24-3.52), in diabetic patients (11.7% vs. 5.1%; adjusted OR, 2.69; 95% CI: 1.38-5.25), in patients undergoing elective surgery (9.9% vs. 2.7%; adjusted OR, 2.09; 95% CI: 1.24-3.52) and in patients with bilateral mammary artery grafts (13.7% vs. 4.8%; adjusted OR, 2.35; 95% CI: 1.17-4.69).Screening for HbA1c before CABG may identify untreated diabetic patients, as well as diabetic patients with suboptimal glycemic control, at high risk of SWI.

Objective This study aimed to assess the long-term outcome of combined coronary revascularization. Methods Between January 2000 and September 2010, 106 consecutive patients underwent combined coronary revascularization, either the same day or staged within 90 days. Percutaneous coronary intervention was always performed before coronary artery bypass grafting. We identified three groups as follows: one-stop combined coronary revascularization (n = 20), percutaneous coronary intervention for acute coronary syndrome before subsequent surgery (n = 39), and percutaneous coronary intervention for stable coronary artery disease before subsequent surgery (n = 47). Off-pump technique was used in all cases. Results A total of 107 angioplasties were realized (drug-eluting stents, 21; bare metal stents, 114; balloon angioplasty, 4). Percutaneous coronary intervention was mostly performed in the right coronary artery or branches (85%). The mean (SD) number of grafts was 1.9 (0.6), among them 1.8 (0.7) with arterial grafts. A total of 87.7% of the patients underwent exclusive arterial revascularization. There was one reexploration for bleeding and no in-hospital death. Eleven patients died in the follow-up. Repeat percutaneous coronary intervention was necessary for six patients and repeat surgery for one patient. The mean (SD) follow-up was 6.1 (2.7) years. Complete follow-up was obtained in 96.2% of the patients. Freedom from ischemic events (all-cause deaths, angina, acute coronary syndrome, myocardial infarction) was 86.3% (3.7%) at 5 years and 79.7% (5.2%) at 8 years (no difference between groups). Freedom from major adverse cardiac or cerebrovascular events was 88.8% (3.4%) at 5 years and 75.7% (5.2%) at 8 years (no difference between groups). Conclusions Combined coronary revascularization increases the use of arterial grafts, with good long-term outcome.

International audience; OBJECTIVES: To address the safety (rate of thromboembolic events and circuit complications) and efficacy (rate of bleeding control) of recombinant activated coagulation factor VII (rFVIIa) to treat severe bleeding refractory to all surgical and medical treatments in patients under veno-arterial (VA) or veno-venous (VV) extracorporeal membrane oxygenation (ECMO) support. METHODS: In a tertiary referral University Cardiothoracic Surgery Centre including three intensive care units, 30 patients received the rFVIIa during ongoing VA or VV ECMO support (8.6% of ECMO activity from 2005 to 2014; N = 347). Early and late clinical results were analysed (retrospective analysis of prospectively collected data). In a substudy, a case-matching procedure was performed among ECMO patients who received (Group A) or did not receive (Group B) rFVIIa treatment. RESULTS: The mediastinum was the most common site of refractory bleeding (after heart transplantation or other cardiac surgery; 90%); 90% (n = 27) of patients were on VA ECMO and the remainder on VV ECMO. The survival rate at ECMO explantation and at the 30th post-implantation day was 67 and 50%, respectively. The final efficacy rate of rFVIIa in stopping bleeding was 93.3%. The rate of thromboembolic events was 3.3% (1 case) and the rate of circuit change was 16.7% (without instances of overt circuit clotting). After case-matching, Group A comprised 23 patients and Group B included 43 patients. No statistically significant differences were observed among groups in terms of thromboembolic events (P = 0.99), circuit change, ventilation time (P = 0.71), infectious complications (P = 06) and survival at both ECMO explantation and the 30th post-implantation day. Late survival was comparable (Kaplan-Meier analysis; P = 0.42). CONCLUSIONS: In case of life-threatening bleeding refractory to all conventional therapies, rFVIIa presents an acceptable safety profile in patients under ECMO support. No circuit dysfunctions and limited rates of thromboembolism are observed.

International audience; OBJECTIVES To examine the haemodynamic performance of the St Jude Trifecta valve for aortic valve replacement (AVR) at 3 years after implantation. METHODS In a single-centre, prospective, observational, independent study, we enrolled 122 patients who had AVR using a Trifecta bioprosthesis in the July 2010–June 2011 period. A clinical and echocardiographic in-house follow-up was scheduled. RESULTS In our series, 14.7% of patients received a 19-mm, 28.7% had a 21-mm, 35.2% had a 23-mm and 21.3% had a greater-size prosthesis. There were no cases of operative mortality or of valve-related complications both early and at follow-up (except one sudden unexplained death). Completeness of the 3-year echocardiographic follow-up was 80% among survivors. The average mean transvalvular gradient (mTVG) at 3 years was 14.2, 10.8, 8.6, 7.1 and 6.8 mmHg (sizes 19 to 27/29, respectively). There was no statistically significant difference between average mTVGs measured immediately after implantation versus at the 3-year follow-up in the overall population. The average peak transvalvular gradient (pTVG) at 3 years was 25, 20, 16.8, 13.9 and 14.4 mmHg (sizes 19 to 27/29, respectively). The average indexed effective orifice area (iEOA) at 3 years was 0.8, 0.9, 1, 1.3 and 1.3 cm2/m2 (sizes 19–27, respectively). The rate of moderate patient–prosthesis mismatch (PPM) at 3 years was 15.7%; there were two instances of severe PPM (2.2%). All cases of PPM occurred in the 19, 21 and 23 mm size subgroups. CONCLUSIONS The Trifecta valve retains its excellent haemodynamic properties at the 3-year follow-up. The rate of PPM is considerably low

The optimal timing of discontinuation of ticagrelor before cardiac surgery is controversial. Importance: The optimal timing of discontinuation of ticagrelor before cardiac surgery is controversial.Objective: To evaluate the safety of preoperative use of ticagrelor with or without aspirin in patients with acute coronary syndromes (ACS) undergoing isolated coronary artery bypass grafting (CABG) compared with aspirin alone.Design, Setting, and Participants: This prospective, multicenter clinical trial was performed at 15 European centers of cardiac surgery. Participants were patients with ACS undergoing isolated CABG from the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) registry between January and September 2015.Exposures: Before surgery, patients received ticagrelor with or without aspirin or aspirin alone.Main Outcomes and Measures: Severe bleeding as defined by the Universal Definition of Perioperative Bleeding (UDPB) and E-CABG bleeding classification criteria. A propensity score-matched analysis was performed to adjust for differences in baseline and operative covariates.Results: Of 2482 patients from the E-CABG registry, the study cohort included 786 (31.7%) consecutive patients with ACS (mean [SD] age, 67.1 [9.3] years; range, 32-88 years), and 132 (16.8%) were female. One-to-one propensity score matching provided 215 pairs, whose baseline and operative covariates had a standardized difference of less than 10%. Preoperative use of ticagrelor was associated with a similar risk of bleeding according to the UDPB and E-CABG bleeding classifications, but the incidence of platelet transfusion was higher in the ticagrelor group (13.5% [29 of 215] vs 6.0% [13 of 215]). Compared with those receiving aspirin alone, continuing ticagrelor up to the time of surgery or discontinuing its use less than 2 days before surgery was associated with a higher risk of platelet transfusion (22.7% [5 of 22] vs 6.4% [12 of 187]) and E-CABG bleeding grades 2 and 3 (18.2% [4 of 22] vs 5.9% [11 of 187]) and tended to have an increased risk of UDPB grades 3 and 4 (22.7% [5 of 22] vs 9.6% [18 of 187]). Among patients in whom antiplatelet drug use was discontinued at least 2 days before surgery, the incidence of platelet transfusion was 12.4% (24 of 193) in the ticagrelor group and 3.6% (1 of 28) in the aspirin-alone group.Conclusions and Relevance: In propensity score-matched analyses among patients with ACS undergoing CABG, the use of preoperative ticagrelor with or without aspirin compared with aspirin alone was associated with more platelet transfusion but similar degree of bleeding; in patients receiving ticagrelor 1 day before or up until surgery, there was an increased rate of severe bleeding.

International audience; Background We address the differential long-term results of tricuspid valve replacement and late valve-related events among bioprostheses versus mechanical prostheses. Methods In a single-institution investigation, we reviewed the patients’ prospectively collected data and performed a clinical follow-up. Both the Kaplan-Meier (actuarial) and the competing risks (actual) methodologies were used. Results Overall, 188 tricuspid valve replacements were performed during 1971 to 2012. In this complex population (reoperations, 48.1%; associated procedures in 71.3%), operative mortality was 27.6% (significantly declining in recent years). A bioprosthesis was used in 82.4%. Follow-up was 10.2 ± 9.1 years (as long as 37.3 years, or 1,270 patient-years; 91.2% complete). At 15 years, freedom from structural valve deterioration was 93.3% ± 6.4% (competing risks 94.7 ± 5.1%) in the mechanical group and 85.2% ± 5.4% (competing risks 92% ± 2.9%) in the bioprostheses group (p = 0.19). Freedom from any valve-related adverse events was lower among mechanical valves versus bioprostheses (although not statistically significant). Mechanical valves showed significantly lower freedom from thromboembolic events (actuarial 62.3% ± 14.3% versus 97.7% ± 1.6%; competing risks 74.1% ± 10% versus 98% ± 1.4%; p < 0.001) and earlier adverse events (4.9 ± 4.5 versus 11.1 ± 9.4 years) than bioprostheses. There were 11 reoperations for bioprosthetic structural valve deterioration (89.8% and 94.3% actuarial and actual freedom, respectively). Conclusions Bioprostheses for tricuspid valve replacement have a very good long-term durability. Mechanical valves display earlier and more severe morbidity at follow-up

Referred to by : Joseph M. Bednarczyk, Rohit K. SingalFunctional outcomes after resuscitative extracorporeal membrane oxygenation for cardiac arrest: The patients speak for themselvesThe Journal of Thoracic and Cardiovascular Surgery, Volume 150, Issue 4, October 2015, Pages 955-956; International audience; OBJECTIVES: Extracorporeal life support (ECLS) is an emerging option to treat selected patients with cardiac arrest refractory to cardiopulmonary resuscitation (CPR). Our primary objective was to determine the mortality at 30 days and at hospital discharge among adult patients receiving veno-arterial ECLS for refractory cardiac arrest. Our secondary objectives were to determine the 1-year survival and the health-related quality of life, and to examine factors associated with 30-day mortality. METHODS: In a retrospective, single-center investigation within a tertiary referral center, we analyzed the prospectively collected data of 49 patients rescued from refractory cardiac arrest through emergent implantation of ECLS (E-CPR) (18.1% of our overall ECLS activity, 2005-2013), implanted in-hospital and during ongoing external cardiac massage in all cases. A prospective follow-up with administration of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) questionnaire was performed. RESULTS: The mean age was 47.6 ± 1.6 years; out-of-hospital cardiac arrest occurred in 12% of cases; average low-flow time was 47.2 ± 33 minutes; causes of cardiac arrest were heart disease (61.2%), trauma (14.3%), respiratory disease (4.1%), sepsis (2%), and miscellaneous (18.4%). PRIMARY OBJECTIVE: Rates of survival at E-CPR explantation and at 30 days were 42.9% and 36.7%, respectively; brain death occurred in 24.5% of cases. SECONDARY OBJECTIVES: Increased simplified acute physiology score; higher serum lactate levels and lower body temperature at the time of implantation were associated with 30-day mortality. Bridge to heart transplantation or implantation of a long-term ventricular assist device was performed in 8.2%. No deaths occurred during the follow-up after discharge (36.7% survival; average follow-up was 15.6 ± 19.2 months). The average Physical Component Summary and Mental Component Summary scores (SF-36 questionnaire) were, respectively, 45.2 ± 6.8 and 48.3 ± 7.7 among survivors. CONCLUSIONS: Extracorporeal cardiopulmonary resuscitation is a viable treatment for selected patients with cardiac arrest refractory to CPR. In our series, approximately one third of rescued patients were alive at 6 months and presented quality-of-life scores comparable to those previously observed in patients treated with ECLS

Background We describe a 1-step treatment of extensive arch and descending aortic aneurysm by combination of frozen elephant trunk (FET) (hybrid endoprosthesis) and of conventional endoprosthesis deployment. Methods In a single-center, prospective, treatment-only study, the clinical data of 4 patients receiving combined FET and distal endoprosthesis deployment in the descending aorta were prospectively collected. Thoracic endoprostheses were deployed either retrogradely (off-pump from the femoral arterial access) or antegradely (from the aortic arch during hypothermic arrest). A distal-first approach was used (“trombone” mechanism). Spinal cord protection was achieved by transposition of the left subclavian artery to the left common carotid artery and selective antegrade cerebral perfusion. Preoperative computed tomography scan was performed to identify the collateral circulation. Preoperative planning was assisted by a sizing software (Endosize, Therenva Inc.). Results The aortic coverage was extended down to the orifice of the celiac trunk in one case and to the T8 level in the remainders. There was no operative mortality, 1 transient paraparesis, and 1 case of renal insufficiency. Follow-up results were satisfying (no device migration, no endoleak, no endotension, and no late neurologic complications). Conclusions The present strategy may abolish the risks connected with the waiting time between the surgical first step and the later completion (aortic-related adverse events and drop-out) and deserves further investigations to determine its safety and feasibility profile.

International audience; Background - Operative risk prediction systems (logistic EuroSCORE I, EuroSCORE II and STS Score) are employed together with multidisciplinary discussion to contraindicate conventional surgery in patients with valvular heart disease and propose the employment of alternative transcatheter procedures. The EuroSCORE I has been reported to underperform in these circumstances; we hypothesize that the EuroSCORE II is best suited for the stratification of risk in patients with structural deterioration (SVD) of valvular bioprostheses and potential candidates to the Valve-in-Valve procedure (deployment of a transcatheter valve within a failing valvular bioprosthesis). Methods and evaluation of the hypothesis - A multi-institutional collaboration is required to fully address such hypothesis. Therefore, we performed a preliminary validation study by retrieval of the complete records of 81 patients undergoing reoperative aortic valve replacement for preoperative diagnosis of bioprosthetic SVD at our Institution. Logistic EuroSCORE I, EuroSCORE II and STS Score were calculated by preoperatively available data. Faced to an observed reoperative mortality of 4.9%, average EuroSCORE I was 15.8%±13.4, EuroSCORE II was 7.3%±7.4 and the STS Score was 15%±9.8. The three systems provided sufficient adequacy (Hosmer-Lemeshow p=0.847, p=0.999 and p=0.9948, respectively). Yet, the area under the ROC curve was significantly higher for the EuroSCORE II (0.9903) vs. the EuroSCORE I (0.8994) (p=0.044). The STS Score yielded an intermediate figure (0.9643). The odds ratios (logistic regression) were 1.079 for EuroSCORE I, 1.223 for the STS Score and 1.474 for EuroSCORE II. Conclusions - The three investigated algorithms showed reasonable calibration in the prediction of mortality for reoperative aortic valve replacement, but they evenly overestimated the observed mortality. The hypothesis that the EuroSCORE II is better suited for the selection of candidates to Valve-in-Valve implantation is worth of further multi-institutional investigations on the basis of our preliminary findings and due to the expanding role of transcatheter techniques.

Objective: The authors aimed to validate the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) classification of postoperative Complications in patients undergoing coronary artery bypass grafting (CABG).Design: Retrospective, observational study.Setting: University hospital.Participants: A total of 2,764 patients with severe coronary artery disease. Complete baseline, operative, and postoperative data were available for patients who underwent isolated CABG.Interventions: Isolated CABG.Measurements and Main Results: The E-CABG complication classification was used to stratify the severity and prognostic impact of adverse postoperative events. Primary outcome endpoints were 30-day, 90-day, and long-term all cause mortality. The secondary outcome endpoints was the length of intensive care unit stay. Both the E-CABG complication grades and additive score were predictive of 30-day (area under the receiver operating characteristics curve 0.866, 95% confidence interval [CI] 0.829-0.903; and 0.876; 95% CI 0.844-0.908, respectively) and 90-day (area under the receiver operating characteristics curve 0.850, 95% CI 0.812-0.887; and 0.863, 95% CI 0.829-0.897, respectively) all-cause mortality. The complication grades were independent predictors of increased mortality at actuarial (log-rank: p < 0.0001) and adjusted analysis (p < 0.0001; grade 1: hazard ratio [HR] 1.757, 95% CI 1.111-2.778; grade 2: HR 2.704, 95% CI 1.664-4.394; grade 3: HR 5.081, 95% CI 3.148-8.201). When patients who died within 30 days were excluded from the analysis, this grading method still was associated with late mortality (p < 0.0001). The grading method (p < 0.0001) and the additive score (rho, 0.514; p < 0.0001) were predictive of the length of intensive care unit stay.Conclusions: The E-CABG postoperative complication classification seems to be a promising tool for stratifying the severity and prognostic impact of postoperative complications in patients undergoing cardiac surgery. (C) 2016 Elsevier Inc. All rights reserved.

International audience; BACKGROUND: Clinical evidence in coronary surgery is usually derived from retrospective, single institutional series. This may introduce significant biases in the analysis of critical issues in the treatment of these patients. In order to avoid such methodological limitations, we planned a European multicenter, prospective study on coronary artery bypass grafting, the E-CABG registry. DESIGN: The E-CABG registry is a multicenter study and its data are prospectively collected from 13 centers of cardiac surgery in university and community hospitals located in six European countries (England, Italy, Finland, France, Germany, Sweden). Data on major and minor immediate postoperative adverse events will be collected. Data on late all-cause mortality, stroke, myocardial infarction and repeat revascularization will be collected during a 10-year follow-up period. These investigators provided a score from 0 to 10 for any major postoperative adverse events and their rounded medians were used to stratify the severity of these complications in four grades. The sum of these scores for each complication/intervention occurring after coronary artery bypass grafting will be used as an additive score for further stratification of the prognostic importance of these events. DISCUSSION: The E-CABG registry is expected to provide valuable data for identification of risk factors and treatment strategies associated with suboptimal outcome. These information may improve the safety and durability of coronary artery bypass grafting. The proposed classification of postoperative complications may become a valuable research tool to stratify the impact of such complications on the outcome of these patients and evaluate the burden of resources needed for their treatment. CLINICAL TRIALS NUMBER: NCT02319083

International audience; The visualization of bioprosthesis leaflet morphology might help to better understand the underlying mechanism of dysfunction in degenerated aortic bioprosthesis. Because today such visualization of bioprosthesis leaflet morphology is intricate to impossible with other imaging techniques, we hypothesized that the processing of multi-detector CT images would allow better visualization of the prosthetic valve leaflets after biological aortic valve replacement. The purpose of our study was to prospectively evaluate patients with a degenerated aortic bioprosthesis, waiting for reoperation, by using 64-slice CT to evaluate prosthetic leaflets morphology. A semi-automatic segmentation of pre-operative tomodensitometric images was conducted, using 2 different implementations of the region growing algorithm. Here we report all segmentation steps (selection of the region of interest, filtering, segmentation). Studied degenerated aortic bioprostheses were represented by two Carpentier-Edwards Supra Annular Valve (porcine leaflets), one Edwards Perimount (pericardial leaflets) and one Medtronic Mosaic (porcine leaflets). Both segmentation methods (Isotropic Region Growing and Stick Region Growing) allowed a semi-automatic segmentation with 3D reconstruction of all bioprosthetic components (stent, leaflets, degeneration/calcifications). Explanted bioprosthesis CT images were also processed and used as reference. Segmentation results were compared by means of quantitative criteria. Semi-automatic segmentation using region growing algorithm seems to provide an interesting approach for the morphological characterization of degenerated aortic bioprostheses. We believe that in the next future CT scan images segmentation may play an important role to better understand the mechanism of dysfunction in failing aortic bioprostheses. Moreover, bioprostheses 3D reconstructions could be integrated into preoperative planning tools to optimize valve-in-valve procedure.

ObjectiveWe addressed the long-term results of the Medtronic Mosaic porcine prosthesis in the aortic position.MethodsFrom 1994 to 2004, 1007 Mosaic valves were used for aortic valve replacement. The data were prospectively collected, retrospectively analyzed, and stratified according to patient age at surgery (group 1, 80 years), using both actual (cumulative risks) and actuarial methods.ResultsOperative mortality was 5% (valve related in 14%). Globally, 8122.17 patient-years were available (average follow-up, 8.5 ± 3.9 years; 99.8% complete). Overall, survival at 15 years was lower among the elderly strata (P

BackgroundFew data are currently available about patients characteristics and procedural features associated with AKI after TAVI using the new recommended VARC definition.Methods99 patients underwent TAVI (1 procedural death, 78.8% transfemoral, 12.1% trans-apical/aortic and 9.1% subclavian access) between February 2009 and September 2011 at Rennes university hospital. Creatinine level was assessed daily at least up to 72 hours after TAVI. Patients’ characteristics, procedural features and outcomes according to VARC definitions were studied to evaluate determinants and prognostic impact of AKI.ResultsAKI occurred in 22 patients (22.2%). Among them, 5 were AKI 2 (5.1%), 8 were AKI 3 (9.1%) including 4 who needed dialysis (4%). At baseline, compared to no AKI or AKI 1, AKI 2 or 3 patients had a higher prevalence of moderate or severe chronic kidney disease (p=0.046) and ≥ grade 2 mitral regurgitation (p=0.03). During the post TAVI hospitalization, AKI 2 or 3 was associated to a higher rate of death from any cause (p=0.0009), major bleeding, acute heart failure (both p=0.002), infectious complications (p=0.0008) and longer total and ICU hospitalization duration (p=0.0004 and