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International audience; Spinal cord complications including paraplegia and partial neurologic deficits remain a frequent problem during repair of descending thoracic or thoracoabdominal aortic aneurysms. Effective prevention of this dreaded complication is of paramount importance. Among the many adjuncts that have been proposed to prevent spinal cord complications, spinal fluid drainage is one that has been used by numerous teams. The aim of this review is to answer the following question: does spinal fluid drainage afford spinal cord protection during both open and endovascular repair of thoracic or thoracoabdominal aortic aneurysms?

Acute cardiac events are a frequent cause of morbidity after vascular surgery. The impact of early evidence-based treatment for patients with an acute cardiac event after vascular surgery on long-term postoperative outcomes has not been extensively studied. We hypothesized that providing appropriate evidence-based treatment to patients with elevated postoperative cardiac troponin levels may limit long-term mortality.We conducted a study of 667 consecutive major vascular surgery patients with an elevated postoperative troponin I level. We then determined which of these patients received medical therapy as per the 2007 American College of Cardiology/American Heart Association recommendations for the medical management of patients with chronic stable angina. All patients with troponin elevation were then matched with 2 control patients without postoperative troponin elevation. Matching was done using logistic regression and nearest-neighbor matching methods. The primary study end point was 12 months survival without a major cardiac event (i.e., death, myocardial infarction, coronary revascularization, or pulmonary edema requiring hospitalization).Therapy was intensified in 43 of 66 patients (65%) who suffered a troponin I elevation after surgery. Patients with a troponin I elevation not receiving intensified cardiovascular treatment had a hazard ratio (HR) of 1.77 (95% confidence interval (CI), 1.13-2.42; P = 0.004) for the primary study outcome as compared with the control group. In contrast, patients with a troponin I elevation who received intensified cardiovascular treatment had an HR of 0.63 (95% CI, 0.10-1.19; P = 0.45) for the primary outcome as compared with the control group. Patients with a troponin I elevation not receiving treatment intensification likely were at higher risk for a major cardiac event (HR, 2.80; 95% CI, 1.05-24.2; P = 0.04) compared with patients who did receive treatment intensification.The main finding of this study was that in patients with elevated troponin I levels after noncardiac surgery, long-term adverse cardiac outcomes may likely be improved by following evidence-based recommendations for the medical management of acute coronary syndromes.

Background: Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study’s four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. Methods: In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated “abnormal” laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. Results: An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors’ diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96–5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6–41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Conclusion: Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

Background The use of β-blockers during the perioperative period remains controversial. Although some studies have demonstrated their protective effects regarding postoperative cardiac complications, others have demonstrated increased mortality when β-blockers were introduced before surgery. Methods In this observational study involving 1,801 patients undergoing aortic reconstruction, we prospectively assessed β-blocker therapy compared with no β-blocker therapy, with regard to cardiac and noncardiac postoperative outcomes using a propensity score approach. The impact of β-blockers was analyzed according to the intraoperative bleeding estimated by transfusion requirements. Results In-hospital mortality was 2.5% (n=45), β-blocker use was associated with a reduced frequency of postoperative myocardial infarction (OR=0.46, 95% CI [0.26; 0.80]) and myocardial necrosis (OR=0.62, 95% CI [0.43; 0.88]) in all patients, but also with an increased frequency of multiple organ dysfunction syndromes (OR=2.78, 95% CI [1.71; 4.61]). In patients with severe bleeding (n=163; 9.1%), the frequency of in-hospital death (OR=6.65, 95% CI [1.09; 129]) and/or multiple organ dysfunction syndromes (OR=4.18, 95% CI [1.81; 10.38]) were markedly increased. Furthermore, no more than 28% of the patients who died presented with postoperative myocardial infarction, whereas 69% of the patient with a postoperative myocardial infarction also presented an excessive bleeding. Conclusions Perioperative β-blocker therapy was associated with an overall reduction in postoperative cardiac events. In the vast majority of patients with low perioperative bleeding, the global effect of β-blockers was protective; in contrast, patients given β-blockers who experienced severe bleeding had higher mortality and an increased frequency of multiorgan dysfunction syndrome.

Background Respiratory arterial pulse pressure variations (PPV) are the best predictors of fluid responsiveness in mechanically ventilated patients during general anesthesia. However, previous studies were performed in a small number of patients and determined a single cutoff point to make clinical discrimination. The authors sought to test the predictive value of PPV in a large, multicenter study and to express it using a gray zone approach. Methods The authors studied 413 patients during general anesthesia and mechanical ventilation in four centers. PPV, central venous pressure, and cardiac output were recorded before and after volume expansion (VE). Response to VE was defined as more than 15% increase in cardiac output after VE. The following approaches were used to determine the gray zones: resampled and two-graph receiver operator characteristic curves. The impact of changes in the benefit-risk balance of VE on the gray zone was also evaluated. Results The authors observed 209 responders (51%) and 204 nonresponders (49%) to VE. The area under receiver operating characteristic curve was 0.89 (95% CI: 0.86-0.92) for PPV, compared with 0.57 (95% CI: 0.54-0.59) for central venous pressure (P < 10). The gray zone approach identified a range of PPV values (between 9% and 13%) for which fluid responsiveness could not be predicted reliably. These PPV values were seen in 98 (24%) patients. Changes in the cost ratio of VE moderately affected the gray zone limits. Conclusion Despite a strong predictive value, PPV may be inconclusive (between 9% and 13%) in approximately 25% of patients during general anesthesia.

Objectif Preciser les facteurs pre- et per-operatoires predictifs de mortalite precoce, de complications medullaires et d'ischemie intestinale aigue apres chirurgie des anevrysmes thoraco-abdominaux de type IV (ATA IV) de facon a optimiser les indications et les techniques chirurgicales. Malades et methodes De Janvier 1991 a Juin 2006 nous avons opere 171 malades d'ATA IV. Il s'agissait de 149 hommes (87,1 %), d'un âge moyen de 65,0 ± 10,9 ans (extremes 23 et 82 ans). L'anevrysme etait d'origine degenerative chez 143 malades (83,6 %). Vingt deux malades (12,8 %) ont ete operes en urgence. Soixante dix huit malades (45,6 %) etaient coronariens (dont 39 avaient eu une revascularisation myocardique premiere), 121 (70,1 %) etaient hypertendus, 81 (47,4 %) avaient une bronchopneumopathie chronique obstructive et 58 (33,9 %) une insuffisance renale chronique. Des lesions associees d'au moins une des arteres viscerales etaient presentes chez 76 malades (44,4 %). Une arteriographie medullaire pre-operatoire a ete faite chez 91 malades (53,2 %). Chez 25 (27,5 %) d'entre eux elle a montre que l'artere d'Adamkiewicz naissait au niveau ou au-dessous de D12, imposant un geste de revascularisation. L'intervention a ete faite par clampage simple chez 160 malades (93,6 %). Une CEC partielle a ete utilisee chez 11 malades (6,4 %). Resultats Il y a eu 23 deces post-operatoires (13,4 %) (9 ischemies intestinales aigues, 7 defaillances polyviscerales, trois coagulopathies, deux complications cardiaques et deux accidents vasculaires cerebraux). Il y a eu 8 complications medullaires (4,7 %), dont deux chez des malades decedes. En analyse univariee, les facteurs predictifs significatifs (p Conclusions Les malades porteurs d'ATA IV sont volontiers des malades atherosclereux, chez lesquels l'âge, l'insuffisance coronaire et l'insuffisance renale chronique expliquent une partie de la mortalite precoce, qui reste importante. La frequence des complications medullaires passe sans doute par la realisation systematique d'une arteriographie medullaire, en l'absence de complication. La frequence de l'ischemie intestinale aigue pose probleme. Une meilleure comprehension de sa physiopathologie devrait en permettre la prevention.

El objetivo del presente estudio fue identificar las variables pronosticas preoperatorias e intraoperatorias de mortalidad inmediata, lesion de la medula espinal o isquemia intestinal aguda despues de la correccion de aneurismas toracoabdominales tipo IV (ATA IV) como base para optimizar las indicaciones y tecnicas quirurgicas. Desde enero de 1991 hasta junio de 2006, operamos a 171 pacientes portadores de ATA IV. Esta serie incluyo a 149 hombres (87,1%) y 22 mujeres (12,9%), con una edad media de 65,0 ± 10,9 anos (limites 23-82). La etiologia subyacente fue enfermedad aneurismatica degenerativa en 143 pacientes (83,6%). Se sometieron a una intervencion quirurgica con caracter urgente 22 (12,8%) pacientes. Las comorbilidades incluyeron coronariopatia en 72 casos (45,6%), incluidos 39 que se sometieron a un procedimiento de revascularizacion coronaria, hipertension arterial en 121 (70,1%), enfermedad pulmonar obstructiva cronica en 81 (47,4%) e insuficiencia renal cronica en 58 (33,9%). Presentaban lesiones concurrentes que afectaban, como minimo, a una arteria visceral 76 (44,4%) pacientes. Se efectuo arteriografia de medula espinal en 91 pacientes (53,2%). En 25 casos (27,5%) los hallazgos arteriograficos demostraron la necesidad de revascularizacion de la arteria de Adamkiewicz debido a la localizacion del ostium a nivel de T12 o por debajo de esta. La correccion se llevo a cabo con clampaje directo en 160 casos (93,6%). En 11 pacientes (6,4%) se utilizo bypass cardiopulmonar parcial. En el postoperatorio fallecio un total de 23 pacientes (13,4%). La causa de la muerte fue una isquemia intestinal aguda en nueve casos, insuficiencia multiorganica en siete, trastorno de la coagulacion en tres, complicaciones cardiacas en dos e ictus en dos. La lesion de la medula espinal afecto a ocho pacientes (4,7%) incluidos dos que fallecieron. De acuerdo con el analisis univariado, las variables pronosticas de muerte inmediata fueron una edad mayor de 70 anos, enfermedad aneurismatica degenerativa, coronariopatia, insuficiencia renal cronica o lesiones de arterias viscerales, cirujano, duracion de la isquemia intestinal, y uso de una tecnica quirurgica “compleja”. A pesar de que la unica variable pronostica significativa de lesion de medula espinal fue la isquemia digestiva, se observo una tendencia casi significativa (p

Background The goal of the study was to compare stroke volume (SV) and respiratory stroke volume variation (SVV) measured by pulse-contour analysis and aortic Doppler. Methods These were measured by pulse-contour analysis and thermodilution (PiCCO) and by aortic pulsed wave Doppler with transoesophageal echocardiography in patients undergoing abdominal aortic surgery. Simultaneous measurements were done at different times of surgery. All data were recorded on PiCCOwin software and videotape and analysed off-line by a blinded investigator. Results A total of 114 measurements were achieved in 20 patients. There was a good correlation and small bias between the PiCCO and the echo-Doppler values of the mean SV [r=0.885; bias=0.2 (8) ml], and between the minimum [r=0.842; bias=1 (9) ml] and maximum SV [r=0.840; bias=2 (10) ml] values. Conclusions There is a fair correlation between pulse-contour analysis and aortic Doppler for beat-by-beat measurement of SV but not for calculation of SV respiratory ventilation.

Background In cardiac patients, pulmonary capillary wedge pressure (PCWP) is estimated using color M-mode Doppler study of left ventricular filling and Doppler tissue imaging. The goal of this study was to assess whether echocardiography accurately estimates PCWP in critically ill patients. Methods Sixty ventilated patients admitted for septic shock and acute lung injury were prospectively studied using simultaneously transesophageal echocardiography and pulmonary artery catheterization. Initial PCWP values and their changes measured invasively were compared to initial values and corresponding changes of early diastolic velocity of mitral annulus displacement measured by Doppler tissue imaging (Ea), flow propagation velocity of early diastolic mitral inflow measured by color M-mode Doppler (Vp), and their respective ratio to early mitral inflow velocity (E) measured by conventional Doppler: E/Ea and E/Vp. Relations between E/Ea, E/Vp, and PCWP were prospectively tested in 20 additional patients. Results E/Ea and E/Vp gave a rough estimate of initial PCWP values with mean biases of 0.4 +/- 2.2 and 0.1 +/- 2.9 mmHg, respectively. Receiving operating characteristic curves demonstrated that an E/Ea of 6 or greater is an accurate predictor of a PCWP of 13 mmHg or greater and that an E/Ea of 5.4 is a good predictor of a PCWP of 8 mmHg or less. Changes in PCWP were significantly correlated to changes in E/Ea (Rho = 0.84, P < 0.0001). Conclusions In patients with postoperative circulatory shock and acute lung injury, transesophageal echocardiography estimates noninvasively PCWP. However, echocardiographic estimation of PCWP may not be accurate enough for adjusting therapy.

Physicians in charge of patients undergoing thoracic or thoraco-abdominal aneurysmectomy, frequently use lumbar spinal drainage of the cerebrospinal fluid (CSF) to prevent paraplegia. Whereas the profit of this technique is a much debated question, we report 2 case reports of delayed sub-dural hemorrhage, after lumbar spinal drainage of CSF. Cross clamping of the aorta decreases the spinal cord artery pressure, increases the cerebral pressure and by alterations of distribution of the venous return, is responsible for an increase of the CSF pressure. This increase of the CSF pressure decreases the spinal cord driving pressure. Lumbar spinal drainage of CSF aims to improve the spinal cord driving pressure close to the normal (where driving pressure = aortic pressure - CSF pressure). The two case reports have to be added to the liability of a method of prevention that, as attractive that it is, did not give the proof of its efficiency to decrease the frequency and/or the severity of paraplegia after thoracic or thoraco-abdominal aneurysmectomy. At this time, this technique should be reserved to the patients with documented risk, as it is possible using preoperative spinal cord arteriography. The insertion and the withdrawal of the catheter must be done in the usual conditions of medullar puncture with regard to anticoagulant and antiplatelet agents

Background: Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study's four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. Methods: In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated abnormal laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. Results: An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors' diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96-5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6-41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Conclusion: Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

CASE REPORT A 20-year-old man was admitted in our trauma center after being stabbed with a small-bladed stiletto knife in the left hemithorax. The patient had no medical history. At the scene, the patient presented no hemodynamic or respiratory distress. Bleeding from the thoracic wound was moderate and no hemoptysis was found. During transportation to the hospital, the patient rapidly developed hemodynamic instability and received a continuous infusion of norepinephrine from the mobile medical team. At the admission to the hospital, the patient was alert and responsive, despite a very low-blood pressure (60/40 mm Hg). No other sign suggesting cardiac tamponade as distension of jugular vein or paradoxical pulse were present. The patient showed a 1.5-cm horizontal stab wound in the left parasternal region at 5 cm of sternum in the left-fourth intercostal space. A transthoracic echocardiography was immediately performed at the bedside showing circumferential pericardial effusion with diastolic right ventricular (RV) collapse indicating a cardiac tamponade. A median thoracotomy was performed, the pericardium was opened, and an important pericardial effusion was evacuated followed by a dramatic increase of blood pressure. A transmural injury of RV anterior free wall was closed. At the end of surgery the patient was stable, with no active bleeding. No thrill at palpation of the right ventricle could be detected. A transesophageal echocardiography (TEE) was performed showing a false signal jet (spectral folding in color Doppler with lowering of pulse repetition frequency for high frequencies caused by an acceleration of flow at the exit of the stenosis on the level of the fistula) in the RV outflow tract (Fig. 1). A mid esophageal atrioventicular long axis 130° view revealed a high-velocity jet between the aorta and the RV during the whole cardiac cycle. No aortic or tricuspid injury was observed (Fig. 2). The fistula was significant enough to require another immediate repair with cardiopulmonary bypass. Electromechanical arrest was achieved with antegrade cardioplegia. Two different lesions could be found and repaired: one was located at the right coronary sinus and the second one at posterior part of the right ventricle free wall. The initial follow-up was eventless. At day 13, physical examination revealed a new heart murmur leading to a new transthoracic echocardiography and a diagnosis of recurring aortoventricular fistula at the same location, probably due to inefficacy of the first sutures. A new intervention was equally performed by cardiopulmonary bypass and satisfactory result was checked by TEE examination. Hospital discharge was obtained at day 25 with good cardiac function recovery.

Transoesophageal echocardiography (TOE) is an outstanding tool for the clinical management of trauma patients. It provides valuable information on haemodynamic instability, diagnosis of myocardial contusion, traumatic valve dysfunction, traumatic aortic injuries, intrathoracic bleeding and systemic gas embolism related to pulmonary contusion. The accuracy of TOE in the diagnosis of traumatic aortic injuries is not perfectly determined: the main limitation is the operator dependency. Experience of trauma patients and specific signs of cardiovascular injuries are the keys to the extensive use of TOE in trauma centres. The main interest in TOE is the capability to perform TOE promptly upon admission, in the intensive care unit and in the operative room. In the case of delayed surgery of aortic injuries, TOE examination can participate in the decision-making process.

Summary Background Diabetes insipidus is common among brain-dead donors and may lead to decreased graft function. The use of desmopressin to limit the consequences of diabetes insipidus is controversial. We assessed the effects of desmopressin administered to brain-dead donors on early and long-term graft function in kidney recipients. Methods In a randomised controlled study, 97 brain-dead donors received desmopressin as 1 μg bolus every 2 h when diuresis was more than 300 mL/h (desmopressin group n=49) or no desmopressin (control group n=48). In 175 kidney recipients (controls n=89, desmopressin group n=86) we measured serum concentrations of creatinine and haemodialysis requirements to assess early renal function in the first 15 days after transplantation. We assessed longterm results of transplantation (median time 45 months) for a homogeneous subgroup of 95 recipients (48 in the desmopressin group). Findings We found no significant differences between the two groups of brain-dead donors, except for final diuresis, which was lower in the desmopressin group than among controls. Haemodialysis requirement in controls and the desmopressin group (20 vs 23%, p=0·63) and serum creatinine concentrations (decrease from 903 μmol/L to 206 μmol/L vs814 μmol/L to 193 μmol/L, p=0·14) did not differ significantly in the first 15 days after transplantation. Long-term graft survival was similar in the two groups (88 vs 87%). Interpretation Desmopressin can be given to brain-dead donors to limit the harmful effects of diabetes insipidus without any substantial effects to graft function in recipients.

This prospective study was conducted to describe the signs on transesophageal echocardiography (TEE) associated with traumatic aortic injury (TAI). Twenty-eight patients with TAI underwent TEE, and they were compared with a control group of 30 thoracic trauma patients without aortic injury. The TEE signs were classified as direct or indirect signs, and the quality of imaging was assessed. Patients' TEE images were compared with their anatomic lesions. The direct signs were thick stripes (n= 19), false aneurysm (n= 7), aortic dissection (n= 6), free-edge intimal flap (n= 15), aortic wall hematoma (n= 2), fusiform aneurysm (n= 13), and complete aortic obstruction (n= 2). The indirect signs included minor increases in aortic diameter (n= 7), impairment of the aortic Doppler color flow (n= 18), and an increase of aorta-probe distance, indicating hemomediastinum (n= 23). TEE allowed diagnosis of recently described limited intimal lesions frequently missed by other conventional methods, and permitted rapid diagnosis of complete rupture in which fast degeneration means that more time-consuming methods are not practicable. Significant blurring of the aortic outline was noted in 20% of cases and intraluminal artifacts were observed in 36% of cases, but neither sign impaired accurate diagnosis of TAI. The echocardiographic signs of aortic injury are complex and may be confined to a short section of the aorta. Therefore, examination by a physician highly trained in echocardiography is necessary in such cases.

Myocardial contusion may induce life-threatening complications, but its diagnosis is difficult. Circulating cardiac troponin T is considered a highly sensitive and specific marker of myocardial cell injury. We investigate the value of cardiac troponin T measurement in the diagnosis of myocardial contusion.Prospective study.Level 1 trauma center.We prospectively measured circulating cardiac troponin T and performed echocardiography and continuous Holter monitoring in patients who had suffered blunt trauma. Myocardial contusion was diagnosed in patients who fulfilled one of the following criteria: (1) an abnormal echocardiography compatible with myocardial contusion; (2) severe cardiac rhythm abnormalities; (3) severe cardiac conduction abnormalities; and (4) hemopericardium.One hundred twenty-eight patients were included and myocardial contusion was diagnosed in 29 patients. Patients with myocardial contusion had more severe trauma, experienced more frequently associated thoracic lesions, and had a lower left ventricular ejection fraction area (48 +/- 15 vs 61 +/- 10%; p0.001). Elevated circulating cardiac troponin T concentrations were significantly more frequent in patients with a myocardial contusion (31 vs 9%; p0.007). An elevated circulating cardiac troponin T concentration (or = 0.5 microgram/L) was more accurate than MB fraction of creatine kinase (CK) (CK-MB) and CK-MB/CK ratio in the diagnosis of myocardial contusion, as shown by an area under the receiver operating characteristic (ROC) curve (AROC), which was significantly different from 0.50 (AROC = 0.69; 95% confidence interval, 0.56 to 0.80). However, this improvement was not clinically acceptable (sensitivity, 0.31; specificity, 0.91).Circulating cardiac troponin T measurement had a slightly greater diagnostic value than usual biological parameters (CK-MB, CK-MB/CK) in myocardial contusion. Nevertheless, it was concluded that an elevated circulating cardiac troponin T concentration has no important clinical value in the diagnosis of myocardial contusion.

Background Cardiac output (CO) is rarely monitored during surgery, and arterial pressure remains the only hemodynamic parameter for assessing the effects of volume expansion (VE). However, whether VE-induced changes in arterial pressure accurately reflect changes in CO has not been demonstrated. The authors studied the ability of VE-induced changes in arterial pressure and in pulse pressure variation to detect changes in CO induced by VE in the perioperative period. Methods The authors studied 402 patients in four centers. Hemodynamic variables were recorded before and after VE. Response to VE was defined as more than 15% increase in CO. The ability of VE-induced changes in arterial pressure to detect changes in CO was assessed using a gray zone approach. Results VE increased CO of more than 15% in 205 patients (51%). Areas under the receiver operating characteristic curves for VE-induced changes in systolic, diastolic, means, and pulse pressure ranged between 0.64 and 0.70, and sensitivity and specificity ranged between 52 and 79%. For these four arterial pressure-derived parameters, large gray zones were found, and more than 60% of the patients lay within this inconclusive zone. A VE-induced decrease in pulse pressure variation of 3% or more allowed detecting a fluid-induced increase in CO of more than 15% with a sensitivity of 90% and a specificity of 77% and a gray zone between 2.2 and 4.7% decrease in pulse pressure variation including 14% of the patients. Conclusion Only changes in pulse pressure variation accurately detect VE-induced changes in CO and have a potential clinical applicability.

Introduction La troponine est un marqueur biologique dont l’elevation permet de porter le diagnostic de necrose myocardique aigue postoperatoire [1] . Alors que les valeurs seuils de troponine standard permettant de porter le diagnostic d’infarctus du myocarde postoperatoire (IDM) ont ete parfaitement etablies, la cinetique de la troponine de cinquieme generation UltraSensible (US) chez des operes a risque coronaire n’a pas ete evaluee. Cette etude a pour but de determiner la cinetique de la troponine US chez des operes de chirurgie vasculaire. Materiel et methodes De septembre 2013 a mars 2014, tous les operes de chirurgie vasculaire ont beneficie d’une mesure de la troponine US preoperatoire, et repetee le jour de l’intervention (j0) puis a j1, j2 et j3 postoperatoire. Alors que la valeur du 99 eme percentile du dosage de troponine US est de 14 ng/L, le diagnostic biologique de la necrose myocardique aigue postoperatoire a ete porte par un taux de troponine US > 50 ng/L, associe a une elevation de plus de 50 % du taux de troponine US compare a la valeur preoperatoire [2] . Un comite d’experts a confirme ou infirme le diagnostic de necrose myocardique postoperatoire porte sur la cinetique de la troponine US, notamment en excluant les cas ou l’elevation de troponine pouvait etre rattachee a une autre cause (sepsis ou insuffisance renale aigue definie par le doublement de la creatininemie par rapport a la valeur preoperatoire). Resultats Les pathologies presentees par les 354 operes de l’etude etaient : HTA (49 %), cardiopathie ischemique (33 %), tabagisme actif (52 %), AIT ou AVC (15 %), diabete (27 %), hypercholesterolemie (71 %), obesite (16 %), insuffisance renale chronique (debit de filtration glomerulaire 50 ng/L est retrouvee chez 36 operes (10,1 %). Chez 15 de ces patients (41,6 %), la troponine US postoperatoire > 50 ng/L n’etait pas augmentee de plus de 50 % de la valeur preoperatoire, ils souffraient tous d’une insuffisance renale chronique. Le diagnostic d’IDM n’a pas ete retenu chez 9 patients ayant presente une autre cause pouvant expliquer l’augmentation de troponine (6 cas de sepsis evolutif et 3 d’insuffisance renale aigue). Le diagnostic d’IDM postoperatoire a ete porte sur les criteres biologiques et confirme par le comite d’expert chez 12 operes (3,4 % des patients), soit 33 % des patients ayant une troponine US postoperatoire superieure a 50 ng/L. L’incidence de l’IDM postoperatoire et les valeurs de troponine US moyennes (± deviation standard) si IDM (IDM+) et en absence d’IDM postoperatoire (IDM−) sont donnees dans le Tableau 1 . Discussion L’etude montre l’interet de la troponine US pour porter precocement le diagnostic d’infarctus du myocarde postoperatoire sous reserve que soit prise en compte la valeur de troponine preoperatoire, d’autant plus que les operes ont une insuffisance renale chronique preoperatoire.

Introduction L’insuffisance coronaire aigue postoperatoire se caracterise par une elevation du taux de troponine plasmatique postoperatoire (autre cause d’elevation eliminee). Son traitement comporte notamment l’association de deux antiagregants plaquettaires des que le risque hemorragique chirurgical le permet. A la difference du clopidogrel, dont l’effet n’apparait en quelques heures que s’il est administre a la dose de charge de 300 mg, posologie contre indiquee en postoperatoire, le ticagrelor est un nouvel antiplaquettaire constant dans son action, rapidement efficace sans dose de charge [1] . Le but de l’etude est de determiner l’intensite et la rapidite d’instauration de l’effet antiplaquettaire du ticagrelor administre dans la prise en charge de l’insuffisance coronaire aigue postoperatoire. Materiel et methodes Cette etude prospective est realisee chez des operes consecutifs de chirurgie vasculaire presentant une insuffisance coronaire aigue postoperatoire definie par une elevation de la troponine standard I superieure a 0,15 ng/mL dans les trois premiers jours postoperatoires et dont l’intervention chirurgicale et l’absence de saignement ne contre indiquent pas l’administration d’antiplaquettaires. Le traitement medical comporte 90 mg toutes les douze heures de ticagrelor, 100 mg par jour d’aspirine et 40 mg d’atorvastatine. La troponine et l’effet antiplaquettaire du ticagrelor (Verify Now ® et index VASP ® ) sont mesures au debut du traitement medical de l’insuffisance coronaire aigue, puis 4 et 12 heures apres et enfin toutes les 24 heures pendant 4 jours. Resultats Dix operes (âge moyen 68 ans) ont ete inclus dans l’etude. Six etaient traites au long cours par de l’aspirine, interrompue trois jours avant le debut de l’intervention chirurgicale. L’index VASP ® qui mesure l’inhibition de la voie (P2Y12) d’activation des plaquettes et le Verify Now ® qui apprecie l’inhibition de l’agregation plaquettaire simulee par l’ADP montrent que le ticagrelor est rapidement efficace. Des la 4 e heure, 8 des 10 operes, ont un effet antiplaquettaire patent (diminution de l’index VASP de plus de 30 % et inhibition plaquettaire mesurees au Verify Now ® de plus de 50 %). Au deuxieme jour de traitement, l’inhibition plaquettaire est stabilisee chez tous les operes. Un opere a presente a j2 d’un pontage femoro-poplite un saignement du site operatoire necessitant une transfusion de 2CGR dans un contexte associe de surdosage en heparine et un patient a presente a j2 d’une endarteriectomie carotidienne une transformation hemorragique d’un AVC ischemique sans repercussion clinique ( Tableau 1 ). Discussion L’administration du ticagrelor a la posologie de 90 mg toutes les 12 heures, permet d’obtenir un effet antiplaquettaire rapide et stable chez les operes ayant souffert d’un syndrome coronaire aigu en postoperatoire d’une intervention de chirurgie vasculaire.

Background Chronic statin therapy is associated with reduced postoperative mortality. Renal and cardiovascular benefits have been described, but the effect of chronic statin therapy on postoperative adverse events has not yet been explored. Methods In this observational study involving 1,674 patients undergoing aortic reconstruction, we prospectively assessed chronic statin therapy compared with no statin therapy, with regard to serious outcomes, by propensity score and multivariable methods. Results In propensity-adjusted multivariable logistic regression (c-index: 0.83), statins were associated with an almost threefold reduction in the risk of death in patients undergoing major vascular surgery (odds ratio: 0.40; 95% CI: 0.28-0.59) and an almost twofold reduction in the risk of postoperative myocardial infarction (odds ratio: 0.52; 95% CI: 0.38-0.71). Likewise, the use of chronic statin therapy was associated with a reduced risk of postoperative stroke and renal failure. Statins did not significantly reduce the risk of pneumonia, multiple organ dysfunction syndrome, and surgical complications; however, in the case of postoperative multiple organ dysfunction syndrome (odds ratio: 0.34; 95% CI: 0.12-0.94) and surgical complications (odds ratio: 0.39; 95% CI: 0.17-0.86), reduced mortality was observed. Conclusions Chronic statin therapy was associated with a reduction in all cardiac and vascular outcomes after major vascular surgery. Furthermore, in major adverse events, such as multiple organ dysfunction syndrome and surgical complications, statins were also associated with decreased mortality.

Our purpose was to identify preoperative and intraoperative predictors of early mortality, spinal cord injury, or acute intestinal ischemia after repair of type IV thoracoabdominal aneurysm (TAA IV) as a basis for optimizing surgical indications and techniques. From January 1991 to June 2006 we operated on 171 patients for TAA IV. There were 149 men (87.1%) and 22 women (12.9%), with a mean age of 65.0 +/- 10.9 years (range 23-82). The underlying etiology was degenerative aneurysmal disease in 143 patients (83.6%). Twenty-two patients (12.8%) underwent emergent operation. Comorbidity included coronary disease in 72 patients (45.6%) including 39 who had undergone a revascularization procedure, arterial hypertension in 121 (70.1%), chronic obstructive pulmonary disease in 81 (47.4%), and chronic kidney insufficiency in 58 (33.9%). Seventy-six patients (44.4%) presented concurrent lesions involving at least one visceral artery. Spinal cord arteriography was performed in 91 patients (53.2%). In 25 cases (27.5%) arteriographic findings demonstrated the need for revascularization of the Adamkiewicz artery due to location of the ostium at or below the T12 level. Repair was carried out with cross-clamping only in 160 cases (93.6%). Partial cardiopulmonary bypass was used in 11 patients (6.4%). A total of 23 patients (13.4%) died postoperatively. The cause of death was acute intestinal ischemia in nine cases, multiple organ failure in seven, coagulation disorder in three, cardiac complications in two, and stroke in two. Spinal cord injury occurred in eight patients (4.7%) including two who died. According to univariate analysis, the significant predictors of early death were age over 70 years, degenerative aneurysmal disease, coronary artery disease, chronic renal insufficiency or visceral artery lesions, operator, duration of intestinal ischemia and use of a "complex" surgical technique. Although the only significant predictor of spinal cord injury was duration of digestive ischemia, an almost significant trend (p < 0.1) was observed for coronary artery disease, coronary bypass, and renal insufficiency. The significant predictors of acute intestinal ischemia were kidney insufficiency and visceral artery lesions, but coronary artery disease and previous coronary bypass were almost significant (p = 0.06). Frequent association of TAA IV with arteriosclerotic disease in elderly patients presenting coronary artery disease and chronic kidney insufficiency partly explains why early postoperative mortality remains high. The incidence of spinal cord injury suggests that preoperative spinal cord arteriography is mandatory for prevention. The frequency of intestinal ischemia is more problematic, but a better understanding of the underlying mechanism should enable development of preventive strategies.

A patient underwent aortic arch replacement by the elephant trunk technique as the first part of treatment of a Stanford type A aortic dissection with retrograde extension into the aortic arch. The aortic arch was approached through a median sternotomy and was replaced because of extended dissection to left subclavian artery. Cardiopulmonary bypass (123 min) and deep hypothermic circulatory arrest at 18°C (34 min) allowed both anastomosis of the elephant trunk and cerebral protection. An intimal tear was clearly identified 50 mm after the origin of left subclavian artery. The proximal end of a 22-mm aortic prosthesis (Polythese, LPI France) was sutured to the ascending aorta 10 mm distal to the sinotubular junction. Then, the innominate and left common carotid arteries were implanted directly onto the graft. The left subclavian artery was transposed onto the left common carotid artery. The length of the inserted prosthesis was 150 mm. A large portion of intimal flap was resected as far as possible into the aorta (leaving at least 1 cm on both sides of the membrane to avoid injury to the aorta) to allow insertion of the distal part of the prosthesis. The final result of the procedure is described on Figure 1. After placement of several clips to facilitate radiologic visualization, the distal end of the prosthesis was introduced and left free in the descending thoracic aorta. A major enlargement of the mediastinum appeared 28 days after surgery on chest radiograph with the upside-down position of metallic clips marking the distal part of the aortic prosthesis. A pressure gradient between the arm and leg was then noted (125/65 and 85/45, respectively) 28 days after surgery. Our patient’s clinical examination was normal and there was no sign of organ failure. A transesophageal echocardiography (TEE) examination was then performed showing on a descending aorta short-axis view (desc aorta SAX) a double-lumen aspect of the distal part of the prosthesis. A descending aorta long-axis view revealed a complete kinking of the prosthesis with the distal end in cephalad direction (Fig. 2). A high velocity (yellow) and turbulent color Doppler flow pattern (mosaic) was noted at the kinking level and at the distal end of the prosthesis (please see video loop at www.anesthesia-analgesia.org). Further TEE examination showed that the prosthesis was positioned inside the false lumen without intimal membrane in the initial part of descending aorta. Swirling echo reflections indicative of low flow were noted in the false lumen. Complete examination of the descending aorta revealed that the intimal membrane was preserved in the distal part of the aneurysm with false This article has supplementary material on the Web site: www.anesthesia-analgesia.org.

Introduction Le dommage myocardique ischemique (MINS) est la premiere cause de morbi-mortalite en chirurgie vasculaire. L’utilisation actuelle de la troponine ultrasensible (TUS), impose de redefinir les criteres diagnostiques du MINS. En effet, le 99 e percentile de la mesure de TUS determine dans une population standard (fixe a 14 ng/L) ne semble pas adapte aux operes de chirurgie vasculaire. L’objectif de cette etude est double : determiner les facteurs associes a une TUS preoperatoire (TUS preop) superieure a 14 ng/L et etudier la relation entre TUS preop et score de LEE. Patients et methodes De septembre 2013 a septembre 2014, tous les operes de chirurgie vasculaire de notre institution ont beneficie d’une mesure de TUS preop. Les patients operes d’anevrysme de l’aorte thoracique ou d’une intervention sous circulation extracorporelle ont ete exclus. Une clairance renale estimee par le modification of the diet in renal disease (MDRD) inferieure a 60 mL/min/1,73 m 2 a defini les patients insuffisants renaux chroniques (IRC). Les facteurs associes a une TUS preop superieure a 14 ng/L ont ete determines par analyse multivariee. Une analyse de variance (Anova) a compare les valeurs medianes de TUS preop selon le score de LEE. Resultats La TUS preop mediane des 690 patients inclus etait de 9,3 ng/L [5,7 ; 16,8] et le 99 e percentile de 115,6 ng/L. Tous les facteurs cliniques associes a une TUS preop superieure a 14 ng/L sont donnes dans le Tableau 1 . Pour tous ces facteurs cliniques, le 99 e percentile de TUS preop etait superieur a 99 ng/L ( Tableau 1 ). La TUS preop etait significativement differente selon le score de LEE ( p Fig. 1 ). Discussion De nombreux facteurs cliniques sont associes a une augmentation de la TUS preop. Ils doivent etre pris en compte pour doser la TUS preoperatoire afin de faciliter l’interpretation d’une elevation de TUS postoperatoire. Plus le score de LEE est eleve et plus la TUS preop est elevee. La stratification du risque cardiovasculaire postoperatoire a l’aide de la TUS preop merite de nouvelles explorations.

Traumatic aorta rupture survival depends on early diagnosis requiring aortography. Aortography is the "gold standard" method, but it is time-consuming and may be dangerous in trauma patients with multiple organ injuries. Transesophageal echocardiography is a noninvasive technology that can be performed at the bedside. We report two cases in which transesophageal echocardiography enabled us to make the early diagnosis of thoracic descending aorta rupture.

Introduction La lesion myocardique aigue postoperatoire ou Myocardial Injury after Noncardiac Surgery (MINS) [1] est definie par une elevation isolee de troponine en postoperatoire de chirurgie non cardiaque. Les dosages de troponine T UltraSensible de 5eme generation (TNTus), permettent une mesure plus precise de la troponine, tout en maintenant une excellente specificite pour l’origine cardiaque de la lesion (sans prejuger du mecanisme). L’objectif de cette etude est de determiner si un dosage de troponine TNTus preoperatoire (preTNTus) ameliore la stratification du risque de MINS, et, le cas echeant, de definir des valeurs seuils conditionnant le risque postoperatoire. Materiel et methodes Tous les patients operes en chirurgie vasculaire de septembre 2013 a mars 2014 ont ete inclus. Les caracteristiques cliniques et les dosages biologiques etaient colliges. Le critere de jugement principal etait le MINS selon la definition internationale. Les performances des preTNTus pour stratifier le risque de MINS etaient d’abord analysees avec des courbes ROC reechantillonnees sans prendre en compte les covariables. La zone d’incertitude decisionnelle etait determinee. L’apport de la preTNTus etait ensuite determine en prenant en compte les facteurs predictifs de MINS. L’apport predictif de la preTNTus etait alors estime a l’aide de la difference d’aire sous la courbe et du net reclassification index (NRI). Resultats Trois cent cinquante-six operes consecutifs ont etes etudies (96 chirurgies aortiques abdominales, 99 pontages distaux, 113 endarteriectomies carotidiennes, 21 anevrysmes femoro-poplites, 14 procedures endovasculaires, 8 amputations et 5 fistules arterio-veineuses). L’incidence des comorbidites etaient : HTA (49 %), cardiopathie ischemique (33 %), tabagisme actif (52 %), antecedent de pathologie cerebro-vasculaire (15 %), diabete (27 %), hypercholesterolemie (71 %), obesite (16 %), insuffisance renale chronique moderee (32 %) ; 76 % des operes etaient traites par antiagregants plaquettaires et 63 % par statine. L’incidence des MINS etait de 18,6 % [IC95 % : 14,9 %–23,0 %]. L’aire sous la courbe ROC etait de 0,84. La distribution des seuils optimaux est presentee sur la Figure 1 . Toute valeur superieure a 14 ng/L (borne inferieure de la zone d’incertitude decisionnelle) etait ensuite consideree comme anormale. Cent dix-sept (33 %) patients presentaient une preTNTus superieure a 14 ng/L. Parmi eux, 48 % presentaient un MINS, lorsque seulement 4,2 % des patients avec une preTNTus inferieure a 14 ng/L presentaient un MINS (p Discussion Cette etude demontre de l’interet de la preTNTus pour stratifier les operes avant une chirurgie vasculaire. Ainsi, une preTNTus permet d’identifier parmi des patients asymptomatiques programmes pour une chirurgie, des sujets ayant pres d’une chance sur deux de presenter un MINS.

Background Traumatic aortic injury is a frequent cause of death after blunt trauma, but few patients survive to reach a trauma center. The role of transesophageal echocardiography (TEE) in the diagnosis of traumatic aortic injury remains debated. Methods Over a 9-yr period, 209 blunt trauma patients (mean age, 34 +/- 13 yr) were suspected of having traumatic aortic injury because of enlarged mediastinum and/or sudden deceleration, and underwent TEE and angiography (aortography and/or contrast-enhanced computed tomography. Results Traumatic aortic injury was diagnosed in 42 patients (20%). Angiography (aortography and/or contrast-enhanced computed tomography) was less accurate (sensitivity, 83%; specificity, 100%) than TEE (sensitivity, 98%; specificity, 100%) for the diagnosis of aortic injury because it failed to diagnose most minor injuries (intramural hematoma or limited intimal flap, n = 7). However, when considering only patients with major aortic injury (n = 33; i.e., those who might need surgery), angiography (sensitivity, 97%; specificity, 100%) and TEE (sensitivity, 97%; specificity, 100%) were equivalent. Conclusion Transesophageal echocardiography is an accurate method for diagnosis of traumatic aortic injury. Nevertheless, the clinical implications of limited aortic injuries diagnosed by the technique have yet to be determined.

Brain death is associated with altered cardiac function and low concentrations of circulating triiodothryronine (T3). However, the effects of T3 administration on hemodynamic status and cardiac function in potential heart donors remain controversial. Thirty-seven brain-dead patients were randomly and blindly allocated to receive an intravenous bolus of either 0.2 microgram/kg T3 (n = 19) or saline placebo (n = 18). Measurements included conventional hemodynamic and echocardiographic variables of cardiac volume conditions and systolic function of the left ventricle (fractional area change [FAC], velocity of myocardial fiber shortening) using a transesophageal probe, arterial and mixed venous blood gas parameters, and serum thyroid hormone concentrations. The mean concentration of T3 was 1.86 +/- 1.55 pmol/L, and only six patients (16%) had normal values of T3 in control conditions. There was no significant correlation between T3 concentration and FAC (R = 0.17, not significant). All patients receiving T3 had normalized serum T3 concentration (7.55 +/- 2.56 pmol/L) in contrast to patients receiving saline (1.48 +/- 1.26 pmol/L). No significant differences in hemodynamic and echocardiographic parameters were observed between the placebo and T3 groups. Indeed, FAC remained unchanged after T3 (44% +/- 17% vs 46% +/- 22%) or placebo (47% +/- 18% vs 50% +/- 14%) administration. In 20 patients with impaired left ventricular function (FAC50%), FAC remained unchanged after T3 (n = 10; 34% +/- 12% vs 30% +/- 10%) or placebo (n = 10; 38% +/- 12% vs 35% +/- 13%) administration. In 17 patients in whom organ harvesting was delayed, transesophageal echocardiography was performed 6 h later and no significant changes in FAC were noted in the T3 group (n = 8; 49% +/- 17% vs 44% +/- 17%) and the placebo group (n = 9; 51% +/- 18% vs 47% +/- 18%). In conclusion, T3 administration did not improve hemodynamic status and myocardial function in brain-dead patients, suggesting that the euthyroid sick syndrome is not the main determinant of myocardial dysfunction in these patients.

Systemic air embolism has been frequently reported after penetrating thoracic trauma. In blunt thoracic trauma, systemic air embolism has been rarely diagnosed, and then only after an invasive procedure such as thoracotomy. Transesophageal echocardiography has been recently introduced for the early assessment of trauma patients and is considered a sensitive noninvasive procedure to diagnose air embolism. We report three cases of systemic air embolism in patients with pulmonary contusion secondary to a blunt thoracic trauma requiring controlled ventilation. Transesophageal echocardiography was performed for evaluation of hemodynamic instability, and it showed air bubbles in the left atrium and left ventricle during the insufflation phase, which disappeared during apnea. A decrease in airway pressure (release of PEEP, low tidal volume, high frequency jet ventilation) significantly reduced the systemic air embolism. We concluded that systemic air embolism can occur after blunt thoracic trauma, and transesophageal echocardiography enables a rapid and accurate diagnosis that may be useful for therapeutic management.

In patients with blunt chest trauma, early diagnosis of mediastinal hematoma is important, because it could be associated with thoracic vessel injury. Mediastinal hematoma is generally evoked because of a widened mediastinum on chest radiograph, but radiologic diagnosis may lead to excessive angiography being performed. Transesophageal echocardiography (TEE) provides accurate views of the mediastinum and can be rapidly performed at the bedside. Thus, we conducted a prospective study to define TEE signs of mediastinal hematoma. TEE was performed in 22 thoracic trauma patients (trauma group) and in 20 brain-dead patients without thoracic trauma (control group). The positive diagnosis of mediastinal hematoma was made using thoracic surgery or computed tomographic scan. The specificity of TEE was 75 percent and sensitivity was 100 percent. In the trauma group, there was only one false positive but angiography discovered a traumatic aneurysm of the proximal right subclavian artery. No false negative was noted. We described three different TEE signs of mediastinal hematoma: (1) an increased distance between the probe and the aortic wall; (2) a double contour of the aortic wall; and (3) visualization of the ultrasound signal between the aortic wall and the visceral pleura. The distance between the esophageal probe and the aortic wall was the most accurate sign because it could be easily obtained; the threshold value for this distance was 3 mm. TEE appears to be an accurate method to diagnose traumatic mediastinal hematoma.

Background and Goal of Study: General anesthesia (GA) during carotid endarterectomy (CEA) requires a tight hemodynamic control in order to limit neurological and cardiovascular complications. This study aimed to demonstrate that the hemodynamic stability is bet ter respected with Xenon than with sevoflurane during CEA under GA in old patients. Materials and Methods: This randomized controlled trial was approved by our local ethic commit tee (CPP ParisVI). Patients older than 65 years scheduled for CEA were included. Anesthesia was induced in both groups with propofol and remifentanil and a non-depolarizing neuromuscular blocking agents (atracurium) was used for tracheal intubation. For the maintenance phase, patients were randomly allocated to either Xenon (60%) or Sevoflurane (1.7%). 30% of oxygen was used for all patients. Both groups received remifentanil targeted concentration of 2 ng/ml and adapted according to clinical needs and spontaneous EEG (BIS) monitoring. Continuous recording of arterial blood pressure (ABP), airway pressure and electrocardiogram was done (Biopac(tm)). Tachycardia, bradycardia, hyper and hypotension were defined as a change of more than 40% compared to the basal state recorded at rest before induction. Intraoperative hemodynamic variability was calculated using sequential analysis of one minute provided by the continuous recordings of ABP. Af ter integration over the time, hemodynamic variability was expressed as a continuous variable in %.min. Fisher exact test and non parametric Wilcoxon test were used to compare these endpoints. Results and Discussion: 46 old patients (mean age was 75 +/7) were included in the two groups.

Background and Objectives Postoperative acute cardiac events are one of the most common causes of mortality following vascular surgery. The repercussions of myocardial infarction (MI) exacerbate immediate postoperative mortality and seriously impact on life expectancy. Postoperative surveillance to detect elevated troponin I (cTnI) levels (the most accurate cardiac biomarker for postoperative MI) is not only crucial to early diagnosis of postoperative MI but can also help limit long-term mortality by prompting appropriate treatment. However, the impact of such treatment on short- and long-term postoperative morbidity and mortality has not been studied. Management might be suboptimal. Our objective was to analyse the immediate and longer term (1 year) impact of following recommendations based on evidence-based data by intensifying treatment of coronary artery disease in patients presenting elevated postoperative cardiac cTnI levels following major vascular surgery. Programme We undertook a retrospective case-controlled study on a population of 665 consecutive patients who had undergone vascular surgery. The case subjects were the 66 patients (9.9%) with elevated postoperative cTnI. For each case, we selected 2 controls from the remaining patients using logistic regression and nearest neighbour matching methods applied to preoperative and intra-operative sets of variables Results According to an independent expert committee, 44 (67%) of the 66 patients had received treatment intensification. Mean follow-up was 14 months (range, 6–31). Intensified postoperative cardiovascular treatment was associated with significant benefit in terms of 1-year mortality (p=0.027) on comparing patients who had or had not received intensified treatment. There was no difference in mortality between patients receiving intensified postoperative therapy and those who did not experience a postoperative elevation in cTn1, suggesting that treatment might normalise life expectancy in patients with elevated cTnI. In over 70% of patients, the treatment taken at 1 year on a regular basis was no different from the treatment they had been given on discharge from hospital. Discussion and Conclusion In patients with elevated postoperative cTnI, short- and long-term outcomes can be improved by following evidence-based recommendations for the management of acute coronary syndromes. In addition, appropriate secondary prevention of coronary artery disease following hospital discharge contributes towards a positive impact on life expectancy in these patients. Contexte et objectifs L9insuffisance coronaire aigue reste l9une des principales causes de morbidite et de mortalite chez les operes de chirurgie vasculaire. Cette complication aggrave le risque postoperatoire immediat et altere de facon importante l9esperance de vie a moyen terme des operes. La mise en evidence d9une elevation de troponine (TnI) post operatoire qui detecte avec fiabilite une insuffisance coronaire aigue post operatoire, permet d9instaure un traitement adapte qui permettra une reduction de la mortalite a long terme. Cette hypothese est etayee par le fait que la prise en charge de l9insuffisance coronaire aigue postoperatoire parait souvent inadaptee, car l9impact de la prise en charge moderne de l9insuffisance coronaire aigue sur la mortalite a court terme et l9esperance de vie des operes n9a jamais ete etudie. Dans cette etude nous evaluons l9impact a long terme de l9intensification d9un traitement anti-ischemique coronaire chez des patients ayant presente une elevation post-operatoire de TnI (le bio-marqueur cardiaque le plus fiable pour le diagnostic d9insuffisance coronaire aigue post-operatoire). Programme Une etude cas temoins a donc ete realisee chez 665 operes consecutifs de chirurgie aortique. Les 66 cas (10 %) identifies correspondaient aux patients ayant presentes une elevation postoperatoire de TnI durant la periode d9etude. Pour chaque cas 2 temoins etaient apparies sur un groupe de variables preoperatoire (age, sexe, antecedent d9IDM, diabete…) et sur un groupe de variable per-operatoire (Volume de saignement, duree de chirurgie…). L9analyse statistique reposee sur des regressions logistiques et sur un appariement au plus proche. Resultats Une difference significative etait observee sur la mortalite a 1 an des patients ayant beneficie d9une intensification du traitement a visee coronaire (p=0.027). De plus, on n9observait pas de difference entre les courbes de survie des patients ayant beneficier d9une intensification de leur traitement et ceux n9ayant pas presentes d9elevation postoperatoire de TnI, ceci suggerant que cette strategie therapeutique a permis de normaliser l9esperance de vie des patients ayant presentes une elevation de TnI postoperatoire. Finalement, le traitement retrouve a un an n9etait pas different du traitement de sortie d9hospitalisation dans plus de 70% des cas. Conclusion Chez les operes souffrant d9une insuffisance coronaire aigue postoperatoire mise en evidence par une elevation du taux de troponine, la mortalite postoperatoire et l9esperance de vie a un an sont ameliores de facon significative par une prise en charge medicale de l9insuffisance coronaire aigue conforme aux recommandations de la litterature. Une prevention secondaire adaptee de l9insuffisance coronaire apres la sortie du malade de l9hopital participe a l9amelioration de l9esperance de vie notee a un an chez ces operes.