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Purpose Pre-formed donor-specific antibodies (pf-DSA) are associated with worse outcome after lung transplantation (LTx) and might limit access to LTx. A virtual crossmatch (CXM)-based strategy for perioperative desensitization protocol has been used for immunized LTx candidates since 2012 at Foch hospital. We compared the outcome of desensitized LTx candidates with high pf-DSA mean fluorescence intensity (MFI) and those with low or no pf-DSA, not desensitized. Methods For all consecutive LTx recipients (January 2012-March 2018), freedom from CLAD and graft survival were assessed by Kaplan-Meier analysis and Cox proportional-hazards multivariate analysis. Results We compared outcomes for desensitized patients with high pf-DSA (n=39) and those with no (n=216) or low pf-DSAs (n=66). The desensitization protocol decreased the level of immunodominant pf-DSA (class I/II) at 1, 3, and 6 month post-LTx (p Conclusion The desensitization protocol in LTx recipients with high pf-DSAs was associated with satisfactory outcome, with cleared high pf-DSAs after desensitization identified as an independent predictor of graft survival.

Purpose Fast-tracking in cardiothoracic surgery is highly challenging. Early postoperative extubation an aspect of this strategy. The objective of the present study was to report our whole experience of immediate end-surgery extubation (OR extubation) after lung transplantation. Methods This retrospective study was apporved by the Ethical Board of the French Society for Anesthesia and Intensive Care. All consecutive patients undergoing double-lung transplantation from 2012 to 2018 were analyzed, except repeated transplantation during the study period, and transplantation under cardiopulmonary bypass. The strategy is possible due to short acting drugs and a strict cardio-respiratory weaning protocol based on inhaled nitric oxyde and ECMO removale at end-surgery when is possible (see Figure). The aims of the study were: to identify predictive factors of immediate extubation, and to compare outcome among patients. Results Among the 410 patients included, 142 (34.6%) were extubated in the OR. Predictive factors for OR extubation are reported in Table 1. Postoperative outcomes are summarized in Table 2. Conclusion Immediate extubation via a fast-tracking protocol is feasible in one third of patients after lung transplantation. It requires transdisciplinary collaboration. It forecasts a positive outcome.

Purpose Fast-tracking in cardiac-thoracic surgery is highly challenging. It requires multimodal and transdisciplinary collaboration. Early postoperative extubation in the operating room (OR) is an aspect of this strategy1. The objective of the present study was to report our whole experience of immediate end-surgery extubation after lung transplantation. Methods The Ethical Board of the French Society for Anesthesia and Intensive Care approved this analysis of the prospectively Lung Transplant database. All consecutive patients undergoing double-lung transplantation from January 2012 to December 2018 were analyzed, except repeated transplantation during the study period, and transplantation under cardiopulmonary bypass. The cardio-respiratory weaning protocol has been previously published2 (Figure). The aims of the study were: to identify factors predicting immediate extubation, and to compare outcome among patients. Results Among the 410 patients included, 142 (34.6%) were extubated in the OR. Predictive factors for OR extubation are reported in Table 1. Postoperative outcomes are summarized in Table 2. Conclusion Immediate extubation via a fast-tracking protocol is feasible after lung transplantation. It forecasts a positive outcome. It requires transdisciplinary collaboration.

Purpose The thundering evolution of lung transplantation management during the past ten years and primary graft dysfunction (PGD) new definition have led to new predictive factors of PGD. Therefore, we retrospectively analyzed a monocenter database using a machine-learning method, to determine the predictive factors of grade 3 PGD (PGD3), defined as a PaO2/FiO2 ratio Methods We included all double lung transplantation from 2012 to 2019 and excluded multi-organ transplant, cardiopulmonary bypass, or repeated transplantation during the study period for the same patient. Recipient, donor and intraoperative data were added in a gradient boosting algorithm step-by-step according to standard transplantation stages. Dataset was split randomly as 80% training set and 20% testing set. Relationship between predictive factors and PGD3 was represented as ShHapley Additive exPlanation (SHAP) values. Results A total 478 patients were included in the analysis, 83 (17.3%) had PGD3. Highest performance analysis was achieved at the end-surgery stage (0.87, IC95 [0.867-0.873]) with 6 predictive factors: being under ECMO at some point in the intervention and whatever the reason for its implementation is a predictor; a recipient low total lung capacity is a predictor; ECMO is a predictor whatever the time of implantation; having a cystic fibrosis or a COPD/emphysema is protective while having a lung pulmonary fibrosis or another pathology is predictive. Conclusion Gradient boosting predicted PGD3 with high performance using variables available at the end of double lung transplantation. The implementation of strategies adapted to modifiable variables could make it possible to limit the occurrence of a PGD or its severity.

Purpose Lactic acidosis has been recently propose as independently associated with longer intubation times and length of stay in lung transplantation(1). However, there is no data on the association between elevated blood lactate concentration (BLC) and grade 3 primary graft dysfunction at day 3 after lung transplantation (PGD3). The purpose of the study was to investigate the profile of BLC during double-lung transplantation and it association with PGD3. Methods We performed a retrospective observational study of all bilateral lung transplantations at the Foch Hospital from January 2012 to December 2019, excluding those on bridge-to-transplantation, under cardiopulmonary bypass, and multiple-organ transplantation. BLC was measured at every key time of the invention: initially, at every pulmonary artery clamping or declamping, and at end-surgery stage. The ethical committee of the French Society of Anesthesia and Critical Care (SFAR) approved the study. The evolution of intraoperative BLC was evaluated with a paired T-test with Holm correction to compare lactate. AUC was constructed to determine Sp and Se. The optimal threshold of lactates variable used for separation of PGD3 was calculated using the Youden-index. Results Over 478 patients were included, 83 (17.3%) had a PGD3. BLC evolution during surgery is illustrated in figure 1. The median of BLC at end-surgery was 2 [1.5 - 3.1] and 3.3 [2.4 - 4.9] mmol/L in no PGD3 and PGD3 groups respectively, p = 0.02. BLC kinetic illustrated by its variability was the best predictive factor of PGD3 (AUC=0.84, Se= 77.03, Sp=79.82%). Conclusion Hyperlactatemia reflects anaerobic metabolism during peroperative hemodynamic unstable conditions and poor oxygen exchange after implantation of the grafts. Blood lactate variability during surgery is associated with PGD3.1. Worrell SG, et al. Is Lactic Acidosis After Lung Transplantation Associated With Worse Outcomes The Annals of Thoracic Surgery. 2020 Aug;110(2):434-40.

Purpose Lung transplantation (LT) is limited by the shortage of suitable donors. To overcome this problem, many programs have begun to use extended criteria donors. However, the use lung donors over 65 years old is rarely reported especially among a population of young cystic fibrosis (CF) recipient. Methods We report a single center experience of lung transplantations for CF recipients between January 2005 and september 2019. Two cohorts were built and compared according to lung donor age Results Among this period, 378 bilateral lung transplantations (BLT) for CF were performed. 344 BLT were done with donors aged Conclusion Use of donor lungs over 65 years for CF recipients allows donor pool extension without compromising early and midterm results. However, longer follow up is needed to appreciate long term results.

Purpose The extreme difficulty of carrying out randomized studies in lung transplantation leads us to consider statistical methods derived from artificial intelligence. Previous studies in kidney and liver transplantations, as well as in heart surgery, showed better predictive ability than traditional statistical analysis to predict postoperative outcomes. Methods We analyzed a prospective database of all 410 double lung transplantations performed in our center, from January 2012 to June 2018. We used a Random Forest approach over 284 variables, in order to predict one-year mortality. Performance of the predictive model is evaluated at successive temporal stages of the transplantation process. Variables are incrementally acquired during the process, starting with patient-only variables at stage 1, ending with patient, donor and surgery-related measurements at stage 12. At each stage of the process, a machine-learning model has been trained based on available variables. A 80-20-cross-validation procedure has been performed at each stage, and repeated 40 times, resulting in a set of 40 area under ROC curve scores, whose distribution has been summarized using boxplots (median, 25 and 75 percentiles). Gini score allowed to each variable its weight in the model. Results The AUROC performance starts at 0.65 for step 1 and reaches 0.75 (figure) at the final step. Gini score found Lung Allocation Score as the best predictor of one-year mortality (3.17), followed by hyperlactatemia at second lung implantation (2.62), PaO2/FiO2 ratio at end-surgery (2.46) and age (2.35). Second lung ischemic time was a the 20th position in Gini Score (1.6). Conclusion Conclusion: Machine-learning approach is feasible to predict one-year mortality after lung transplantation. This study is encouraging to go further in the analysis of our database.

We used an automated bispectral index (BIS)-guided dual-loop controller to determine propofol and remifentanil requirements during general anaesthesia in obese and lean surgical patients.Obese patients, BMI35 kg m(-2), and lean patients (25 kg m(-2)) having laparoscopic procedures were prospectively evaluated in this multicentre single-blind study. The automated controller targeted BIS between 40 and 60 by adjusting propofol and remifentanil administration. Propofol and remifentanil consumptions were calculated using both total body weight (TBW) and ideal body weight (IBW). Results are expressed as medians (inter-quartile range).Thirty obese [BMI=43 (40-49) kg m(-2)] and 29 lean [BMI=23 (21-25) kg m(-2)] patients completed the study. BIS was between 40 and 60 during 84 (69-91)% vs 85 (78-92)% of the anaesthetic time, P=0.46. The amount of propofol given during induction [1.2 (1.1-1.6) vs 1.3 (1.0-1.7) mg kg(-1), P=0.47] and maintenance [5.2 (4.1-6) vs 5.3 (4.7-6.4) mg kg(-1) h(-1), P=0.39] calculated using TBW was similar between the two groups. The dual-loop controller delivered half as much remifentanil to the obese patients during induction [1.0 (0.8-1.6) vs 2.2 (1.5-2.7) µg kg(-1), P0.001] and maintenance [0.12 (0.07-0.16) vs 0.25 (0.17-0.29) µg kg(-1) min(-1), P0.001] calculated using TBW. But when remifentanil consumption was calculated using IBW, the amounts were similar during induction at 2.2 (1.6-3.5) vs 2.0 (1.6-3.0) µg kg(-1) IBW, P=0.48, and during maintenance at 0.26 (0.16-0.34) vs 0.27 (0.18-0.33 ) µg kg(-1) min(-1), P=0.50.The amount of propofol-remifentanil administered by the controller is consistent with current knowledge, propofol is best dosed using TBW whereas remifentanil is best dosed using IBW.NCT00779844.

OBJECTIVES Only 15% of brain death donors are considered suitable for lung transplantation (LTx). The normothermic ex vivo lung perfusion technique is used to potentially increase the availability of high-risk lung donors. We report our experience of LTx with initially rejected donors after ex vivo lung reconditioning (EVLR). METHODS From April 2011 to May 2013, we performed EVLR for 32 pairs of donor lungs deemed unsuitable for transplantation and rejected by the 11 French lung transplant teams. After EVLR, lungs with acceptable function were transplanted. During the same period, 81 double-lung transplantations (DLTx) were used as controls. RESULTS During EVLR, 31 of 32 donor lungs recovered physiological function with a median PO2/FiO2 ratio increasing from 274 (range 162-404) mmHg to 511 (378-668) mmHg at the end of EVLR (P < 0.0001). Thirty-one DLTx were performed. The incidence of primary graft dysfunction 72 h after LTx was 9.5% in the EVLR group and 8.5% in the control group (P = 1). The median time of extubation, intensive care unit and hospital lengths of stay were 1, 9 and 37 days in the EVLR group and 1 (P = 0.17), 6 (P = 0.06) and 28 days (P = 0.09) in the control group, respectively. Thirty-day mortality rates were 3.3% (n = 1) in the EVLR group and 3.7% (n = 3) in the control group (P = 0.69). One-year survival rates were 93% in the EVLR group and 91% in the control group. CONCLUSIONS EVLR is a reliable and repeatable technique that offers a significant increase of available donors. The results of LTx with EVLR lungs are similar to those obtained with conventional donors.

Introduction De multiples causes de dysphagie peuvent etre retrouvees. Parmi celles-ci, un obstacle extrinseque, comme les osteophytes de vertebres cervicales arthrosiques, peut etre responsable d’une obstruction pharyngo-œsophagienne haute. Bien que frequemment retrouves chez les sujets âges dysphagiques, les osteophytes cervicaux ne sont que rarement responsables de dysphagie severe. Nous rapportons le cas d’une jeune patiente. Observation Une femme de 43 ans est adressee en medecine interne pour l’exploration d’une dysphagie severe aux solides et aux liquides avec fibroscopie œso-gastroduodenale normale (y compris les biopsies systematiques). Elle a pour antecedent un ulcere gastrique, des douleurs articulaires chroniques, une rosacee et une agression a l’arme blanche ancienne avec des lesions au niveau du bras droit, du diaphragme et un pneumothorax. Cliniquement, il existe une stase salivaire, des troubles de la deglutition avec douleurs et fausses routes, pas de perte d’appetit. Malgre une alimentation lente (> 1 h par repas), precautionneuse et hypercalorique, ces troubles sont responsables d’une perte de poids de plus de 10 kg en 6 mois. Le reste de l’examen est sans particularite, il n’y pas de fievre, de signe infectieux, de deficit neurologique, de trouble respiratoire. Pas de troubles du transit, ni reflux gastro-œsophagien. Le bilan biologique standard est sans particularite, il n’y a pas de syndrome inflammatoire, pas de carence nutritionnelle, le bilan thyroidien et martial sont normaux. Le bilan auto-immun est negatif (Ac anti-recepteur de l’acetylcholine, anti-MUSK, anti-ADN natif, antinucleaire a 1/80) hormis les anticorps anti-Mi2b au DOT myosite mais a titre faible. Les CPK sont normales, un electromyogramme des 4 membres et des muscles cervicaux ne montre pas d’anomalie, permettant d’exclure une pathologie neuromusculaire systemique. Une manometrie œsophagienne ne retrouve pas d’anomalie de la motricite œsophagienne ou de pathologie des sphincters superieur et inferieur de l’œsophage. Un scanner cervico-thoraco-abdomino-pelvien retrouve en premiere lecture de l’arthrose moderee entre C4 et C7. L’examen fibroscopique ORL ne visualise pas d’obstacle, ni paralysie des cordes vocales. Finalement, la realisation d’un transit œso-gastroduodenal met en evidence des becs osseux osteophytiques marginaux anterieurs en C4–C5 et C5–C6 entrainant une empreinte sur la face posterieure de l’œsophage pouvant expliquer la dysphagie. Il n’est visualise de diverticule de Zenker. En reprenant l’interrogatoire, la patiente revele avoir ete victime de multiples traumatismes dans l’enfance et l’adolescence (maltraitance) pouvant etre responsables d’arthrose precoce. Devant la severite des symptomes avec echec des mesures d’adaptation dietetiques, une solution chirurgicale est envisagee. Les reconstructions 3D au scanner precisent la compression de l’œsophage par de volumineux osteophytes anterieurs. Discussion La dysphagie liee a une osteophytose cervicale anterieure resulte d’une compression mecanique extrinseque par un ou plusieurs osteophytes volumineux (> 10 mm), principalement au niveau C3–C5 [1] mais aussi de phenomenes inflammatoires locaux lies a l’irritation des tissus. Bien que connu depuis longtemps, peu de cas ont ete rapportes dans la litterature, principalement chez les sujets âges. Chez le sujet âge, une dysphagie peut aussi etre associee a une maladie de Forestier (ou hyperostose vertebrale engainante) mais la presence d’anomalies osseuses n’est pas suffisante pour retenir leur responsabilite et un bilan etiologique exhaustif doit etre entrepris, comprenant une etude videoradiographique de la deglutition (TOGD). Un traitement conservateur (mesures dietetiques, AINS, reeducation a la deglutition) doit etre entrepris le plus tot possible. Une intervention chirurgicale, risquee, (resection des osteophytes) doit etre envisagee pour les cas refractaires ou severes, avant que les compressions n’entrainent des degâts irreversibles sur la motricite de l’œsophage. L’experience dans la litterature montre qu’elle ameliore les symptomes dans la majorite des cas [1] . Conclusion Parmi les causes de dysphagie, l’existence d’osteophyte vertebraux cervicaux est a rechercher, y compris chez le sujet jeune, par la realisation d’un transit œso-gastroduodenal. Sa presentation atypique peut parfois etre severe et necessiter un traitement chirurgical.

Resume Nous rapportons la survenue d’une hyperthermie maligne chez un jeune patient de 21 ans polytraumatise. Ce cas presente pour particularites : une survenue brutale apres 4 heures de chirurgie ; une association de multiples facteurs declenchants et un diagnostic genetique prefere aux tests habituels de declenchement sur biopsie musculaire compte tenu d’anesthesies generales iteratives programmees. Les differents points sont discutes avec proposition d’un arbre diagnostique adapte au contexte.

Background Although many physiological and pathological conditions affect minimal alveolar concentration (MAC), there are no reliable data on the MAC for halogenated anaesthetics during left ventricular hypertrophy (LVH) and congestive heart failure (CHF). The aim of this experimental study was to determine the MAC values of halothane, isoflurane, and sevoflurane in rats, at early and later stages of cardiomyopathic hypertrophy. Methods LVH was induced by ascending aortic stenosis in 3–4-week-old rats. LVH and CHF in each animal were assessed weekly by echocardiography. MAC of halothane, isoflurane, and sevoflurane was determined using the tail-clamp technique in spontaneously breathing rats from each group. Response vs no-response data were analysed using logistic regression analysis. Data are medians (95% confidence interval). Results The MAC of halothane [1.30% (1.26–1.34)], isoflurane [1.52% (1.48–1.57)], and sevoflurane [2.93% (2.78–3.07)] in rats with LVH was not different from sham-operated rats [respectively, 1.23% (1.20–1.26), 1.52% (1.47–1.56), and 2.90% (2.79–3.00)]. Conversely, the MAC of halothane [1.44 (1.39–1.50)] and isoflurane [1.74 (1.69–1.78)], but not sevoflurane [2.99 (2.93–3.06)], was significantly increased in rats with CHF. Conclusions MAC values for halothane, isoflurane, and sevoflurane were unchanged in rats with pressure-induced overload LVH. Conversely, the MAC for halothane and isoflurane, but not sevoflurane, was significantly increased in rats with CHF.

Resume Malgre des resultats cliniques controverses en traumatologie crânienne, l'hypothermie reste une therapeutique encore preconisee et largement etudiee pour de multiples raisons. Des effets protecteurs sont demontres apres ischemie cerebrale dans les etudes animales et apres arret cardiaque chez l'homme. Par ailleurs, l'importance et la duree d'un episode d'hyperthermie sont des facteurs independants d'aggravation du pronostic apres une agression cerebrale ischemique ou traumatique. De plus, il existe une etroite correlation entre niveau de PIC et niveau de temperature, et l'hypothermie permet une diminution de l'hypertension intracrânienne. Cependant, de nombreux problemes restent a resoudre et expliquent probablement les discordances entre les etudes cliniques : la mesure directe de la temperature cerebrale, les liens entre PIC, temperature et PaCO2, les modalites (duree et profondeur) de l'hypothermie therapeutique, et enfin, les conditions precises de refroidissement et surtout de rechauffement. Ces problematiques sont importantes a maitriser meme s'il s'agit seulement de lutter contre l'hyperthermie.

Anterior Cruciate Ligament (ACL) injury is one of the most frequent injury type in individuals who participate in pivoting sports, with an annual incidence of more than 200,000 cases according to the American Academy of Orthopaedic Surgeons (2007).This has motivated numerous studies on risk factors and prevention strategies (see Griffin et al., 2000 for review), as well as on ACL reconstructiontechnics (see Spindler et al., 2004 as an example). The most prevalent complications after ACL reconstruction are quadriceps weakness, flexion contracture, and patellofemoral pain (Sachs et al., 1989).Patellofemoral Pain Syndrome (PFPS) is characterised by pain around the patella mainly at activities that load the patellofemoral joint like bending knees, walking stairs or kneeling. The origin of the complaints is not fully understood although weakness and/or tightness of the extensor muscles, changes in medial and lateral quadriceps muscle reflex time, patellar laxity and increased navicular drop are suggested to be associated with PFPS (Boling et al., 2009; Witvrouw et al., 2000). This study therefore aimed at comparing the isokinetic profile in female athletes with and without PFPSto gain further understanding in characteristics and prognosis of PFPS after ACL reconstruction.

The Salsigne gold deposit contains a complex association of sulphide layers, gold-rich disseminations, quartz-bearing veins and flat reefs, which are hosted by folded and slightly metamorphosed Paleozoic sediments on both sides of a major thrust zone. It is demonstrated that these various Au-As ore types have similar lead-isotope compositions (206Pb/204Pb = 18.22–18.56), which are characteristic of Hercynian ore deposits in the southern Massif Central. The Lower Cambrian to Devonian host rocks and associated Pb-Zn-Ba occurrences display distinctly less radiogenic corrected isotopic signatures (206Pb/204Pb = 17.83–17.98), which are characteristic of Cambrian lead in the Montagne-Noire. Concerning the controversial origin of the Salsigne gold mineralization, these results disagree with the former syngenetic hypothesis and support a new model of Hercynian syntectonic gold concentration.

Les Malines Mine (Cevennes, France) provides an example of Pb-Zn ore bodies that underwent a polyphased evolution. On the Pb-Pb diagram, experimental points of the Les Malines ore types always plot in the central part of the field defined for the Cevennes metallogenic province. This homogeneity, the similarities with the Pb isotopic compositions of the surrounding rocks and the comparison with Pb isotopes evolution of whole rocks and minerals of the neighbouring continental lands, which emerged during Triassic and Liassic times, rule out the participation of extraneous Pb during the successive concentration stages and agree with an initial metal stock transformed and mobilized in a Pb closed system. Hercynian K-feldspars are the main source of the Pb preconcentrated during Triassic times. Most of the Cevennes Pb-Zn ore bodies could derive from this Triassic metal stock; nevertheless, local Pb isotopic anomalies suggest hydrothermal sources for some Pb-Zn ore bodies located along the Cevennes fault.

Introduction L’evaluation objective de therapeutiques antalgiques en cas de douleurs chroniques de type algoneurodystrophie ou CPRS (Complex Regional Pain Syndrome) constitue un veritable challenge [1] . L’Analgesia Nociception Index (ANI) est un outil d’hetero-evaluation de la douleur basee sur ses effets sur le systeme nerveux autonome. L’objectif de cette etude est d’evaluer l’interet de ANI comparativement a l’Echelle Visuelle Analogique (EVA) chez des patients traites par blocs peri-nerveux en ambulatoire [2] . Materiel et methodes Apres accord du CCP (ID RCB : 2011-A01676-35) et recueil du consentement, les patient(e)s adultes souffrant de CPRS aux membres inferieurs ou superieurs avec confirmation a la scintigraphie osseuse etaient eligibles. Les criteres d’exclusion etaient le refus, l’infection locale ou generale, l’arythmie cardiaque et la prise de betabloquants. Avant la realisation d’un bloc peri-nerveux, chaque patient remplissait un questionnaire d’anxiete et de gene fonctionnelle articulaire. Apres 5 minutes d’enregistrement au repos, l’EVA et l’ANI etaient collectes avant et apres stimulation algogene standardisee. Cette mesure etait repetee apres la pratique du bloc sous echographie realise en condition aseptique avec mise en place d’un catheter peri-nerveux (Contiplex BBRAUN) avec administration de 10 mL de Naropeine 0,2 %. La comparaison a porte sur les periodes avant-apres bloc regional (test t de Student apparie) et sur le calcul du coefficient kappa de concordance. Une valeur de p Resultats Parmi les 30 patients, 8 hommes ont ete inclus dans cette etude monocentrique prospective. L’EVA au repos et a la stimulation diminuait significativement apres le bloc tandis que l’ANI s’elevait significativement. L’amplitude de la reponse de l’ANI etait faiblement correlee a l’amplitude de baisse de l’EVA (r = 0,05) si la concordance dans la reponse est bonne : K = 0,88. La courbe ROC determinant la capacite de l’ANI de detecter une douleur moderee a severe presentait une aire sous la courbe de 0,65 avec un point d’inflexion pour une valeur de 69 avec une sensibilite et une specificite de 0,77 et 0,70 respectivement. L’anxiete ne ressort pas comme correlee aux mesures de l’EVA ( Tableau 1 ). Discussion Une valeur d’ANI ne permet pas de discriminer de facon satisfaisante les patients en fonction de l’intensite de leur douleur avant un bloc en cas de CPRS. Toutefois, la variation de la valeur renseigne correctement du succes de la technique.