Veno-arterial extracorporeal membrane oxygenation for circulatory failure in COVID-19 patients: insights from the ECMOSARS registryAnselmi, Amedeo; Mansour, Alexandre; Para, Marylou; Mongardon, Nicolas; Porto, Alizée; Guihaire, Julien; Morgant, Marie-Catherine; Pozzi, Matteo; Cholley, Bernard; Falcoz, Pierre-Emmanuel; Gaudard, Philippe; Lebreton, Guillaume; Labaste, François; Barbanti, Claudio; Fouquet, Olivier; Chocron, Sidney; Mottard, Nicolas; Esvan, Maxime; Fougerou-Leurent, Claire; Flecher, Erwan; Vincentelli, André; Nesseler, Nicolas; ,
2023 European Journal of Cardio-Thoracic Surgery
doi: 10.1093/ejcts/ezad229pmid: 37280062
OBJECTIVESThe clinical profile and outcomes of patients with Coronavirus Disease 2019 (COVID-19) who require veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or veno-arterial-venous extracorporeal membrane oxygenation (VAV-ECMO) are poorly understood. We aimed to describe the characteristics and outcomes of these patients and to identify predictors of both favourable and unfavourable outcomes.METHODSECMOSARS is a multicentre, prospective, nationwide French registry enrolling patients who require veno-venous extracorporeal membrane oxygenation (ECMO)/VA-ECMO in the context of COVID-19 infection (652 patients at 41 centres). We focused on 47 patients supported with VA- or VAV-ECMO for refractory cardiogenic shock.RESULTSThe median age was 49. Fourteen percent of patients had a prior diagnosis of heart failure. The most common aetiologies of cardiogenic shock were acute pulmonary embolism (30%), myocarditis (28%) and acute coronary syndrome (4%). Extracorporeal cardiopulmonary resuscitation (E-CPR) occurred in 38%. In-hospital survival was 28% in the whole cohort, and 43% when E-CPR patients were excluded. ECMO cannulation was associated with significant improvements in pH and FiO2 on day 1, but non-survivors showed significantly more severe acidosis and higher FiO2 than survivors at this point (P = 0.030 and P = 0.006). Other factors associated with death were greater age (P = 0.02), higher body mass index (P = 0.03), E-CPR (P = 0.001), non-myocarditis aetiology (P = 0.02), higher serum lactates (P = 0.004), epinephrine (but not noradrenaline) use before initiation of ECMO (P = 0.003), haemorrhagic complications (P = 0.001), greater transfusion requirements (P = 0.001) and more severe Survival after Veno-Arterial ECMO (SAVE) and Sonographic Assessment of Intravascular Fluid Estimate (SAFE) scores (P = 0.01 and P = 0.03).CONCLUSIONSWe report the largest focused analysis of VA- and VAV-ECMO recipients in COVID-19. Although relatively rare, the need for temporary mechanical circulatory support in these patients is associated with poor prognosis. However, VA-ECMO remains a viable solution to rescue carefully selected patients. We identified factors associated with poor prognosis and suggest that E-CPR is not a reasonable indication for VA-ECMO in this population.
Evaluation of the therapeutic effects of oestradiol on the systemic inflammatory response and on lung injury caused by the occlusion of the proximal descending aorta in male ratsde Sousa, Marcelo Nunes; da Anunciação, Lucas Ferreira; de Freitas, Pedro Luiz Zonta; Ricardo-da-Silva, Fernanda Yamamoto; Moreira, Luiz Felipe Pinho; Correia, Cristiano Jesus; Breithaupt-Faloppa, Ana Cristina
2023 European Journal of Cardio-Thoracic Surgery
doi: 10.1093/ejcts/ezad253pmid: 37410160
OBJECTIVESIschaemia and reperfusion-induced microvascular dysfunction is a serious problem encountered during a variety surgical procedures, leading to systemic inflammation and affecting remote organs, specially the lungs. 17β-Oestradiol reduces pulmonary repercussions from various acute lung injury forms. Here, we focused on the 17β-oestradiol therapeutic effects after aortic ischaemia and reperfusion (I/R) by evaluating lung inflammation.METHODSTwenty-four Wistar rats were submitted to I/R by insufflation of a 2-F catheter in thoracic aorta for 20 min. Reperfusion took 4 h and 17β-oestradiol (280 µg/kg, i.v.) was administered after 1 h of reperfusion. Sham-operated rats were controls. Bronchoalveolar lavage was performed and lung samples were prepared for histopathological analysis and tissue culture (explant). Interleukin (IL)-1β, IL-10 and tumour necrosis factor-α were quantified.RESULTSAfter I/R, higher number of leukocytes in bronchoalveolar lavage were reduced by 17β-oestradiol. The treatment also decreased leukocytes in lung tissue. I/R increased lung myeloperoxidase expression, with reduction by 17β-oestradiol. Serum cytokine-induced neutrophil chemoattractant 1 and IL-1β increased after I/R and 17β-oestradiol decreased cytokine-induced neutrophil chemoattractant 1. I/R increased IL-1β and IL-10 in lung explants, reduced by 17β-oestradiol.CONCLUSIONSOur results showed that 17β-oestradiol treatment performed in the period of reperfusion, modulated the systemic response and the lung repercussions of I/R by thoracic aortic occlusion. Thus, we can suggest that 17β-oestradiol might be a supplementary approach leading the lung deterioration after aortic clamping in surgical procedures.
Is EuroSCORE II still a reliable predictor for cardiac surgery mortality in 2022? A retrospective study studyMastroiacovo, Giorgio; Bonomi, Alice; Ludergnani, Monica; Franchi, Matteo; Maragna, Riccardo; Pirola, Sergio; Baggiano, Andrea; Caglio, Alice; Pontone, Gianluca; Polvani, Gianluca; Merlino, Luca
2023 European Journal of Cardio-Thoracic Surgery
doi: 10.1093/ejcts/ezad294pmid: 37669150
OBJECTIVESThe European System for Cardiac Operation Risk Evaluation II (EuroSCORE II) is the most common tool used to evaluate the perioperative risk of mortality after cardiac surgery in Europe, and its use is currently recommended by the relevant guidelines. However, recently, its role has been questioned: Several papers have suggested that these algorithms may no longer be adequate for risk prediction due to an overestimation of adult cardiac surgical risk. Our goal was to validate the EuroSCORE II in the prediction of 30-day in-hospital mortality in patients undergoing open cardiac surgery in a high-volume hospital.METHODSIn this retrospective cohort study, we included all patients who underwent cardiac surgery from January 2016 to May 2022 within the departments of cardiac surgery of the Monzino Cardiology Centre in Milan, Italy. We evaluated the discrimination power of the EuroSCORE II by using the receiver operating characteristic curve and the corresponding area under the curve. We performed calibration plots to assess the concordance between the model’s prediction and the observed outcomes.RESULTSA total of 4,034 patients were included (mean age = 65.1 years; 68% males), of which 674 (16.7%) underwent isolated coronary artery bypass grafting. The EuroSCORE II showed a good discrimination power in predicting 30-day in-hospital mortality (area under the curve = 0.834). However, for interventions performed in an elective setting, very low values of the EuroSCORE II overestimated the observed mortality, whereas for interventions performed in an emergency setting, EuroSCORE II values above 10 extensively underestimated the observed mortality.CONCLUSIONSOur study suggests that the EuroSCORE II seems not to be a reliable score in estimating the true risk of death, especially in high-risk patients.
The significance of general data protection regulation in the compliant data contribution to the European Society of Thoracic Surgeons databaseBertolaccini, Luca; Falcoz, Pierre-Emmanuel; Brunelli, Alessandro; Batirel, Hasan; Furak, Jozsef; Passani, Stefano; Szanto, Zalan
2023 European Journal of Cardio-Thoracic Surgery
doi: 10.1093/ejcts/ezad289pmid: 37589648
The General Data Protection Regulation (GDPR), enacted in the European Union in 2018, has significantly transformed the landscape of personal data management and protection. This article provides an overview of GDPR's impact, focusing on its applicability, fundamental principles and influence on data management practices, particularly within the European Society of Thoracic Surgeons (ESTS) database.GDPR's reach extends to all entities collecting and processing personal data of European Union residents, regardless of their location. It encompasses various data types, emphasizing meticulous handling and protection of identifiable information. Special categories of data, such as health and sensitive attributes, require even more stringent protection. The regulation sets legal, fair and transparent data processing principles, emphasizing accuracy, purpose limitation and data minimization. It also stresses accountability, leading to the appointment of Data Protection Officers and significant penalties for non-compliance.The ESTS database, designed to enhance thoracic surgical research and care, collects data on European procedures. It follows GDPR principles by pseudonymizing data, ensuring secure data transmission and providing clear instructions for data submission. The database contributes to research, policymaking and practice improvement in thoracic surgery by offering a comprehensive dataset for analysis. Here, we aim to shed light on the complexities of GDPR implementation and emphasize the need for comprehensive data management strategies to ensure compliance and enhance privacy protection with the contribution to the ESTS database.GDPR compliance comes with challenges, including potential human dignity and privacy rights violations. Data breaches can result in unauthorized disclosures, and non-compliance can lead to substantial fines and reputational damage. The implementation of GDPR encourages organizations to prioritize ethical data practices, security measures and transparent data handling.In conclusion, GDPR has revolutionized personal data protection by emphasizing accountability, transparency and individual rights. It has impacted organizations globally, promoting responsible data management practices. Adhering to GDPR ensures privacy protection, trust-building and overall enhancement of data management in today's data-driven environment.
Is the Epithor conversion score reliable in robotic-assisted surgery anatomical lung resection?Armand, Elsa; Fourdrain, Alex; Lafouasse, Chloé; Resseguier, Noémie; Trousse, Delphine; D’Journo, Xavier-Benoît; Thomas, Pascal-Alexandre
2023 European Journal of Cardio-Thoracic Surgery
doi: 10.1093/ejcts/ezad283pmid: 37584685
OBJECTIVESDespite an improvement in surgical abilities, the need for an intraoperative switch from a minimally invasive procedure towards an open surgery (conversion) still remains. To anticipate this risk, the Epithor conversion score (ECS) has been described for video-assisted thoracoscopic surgery (VATS). Our objective was to determine if this score, developed for VATS, is applicable in robotic-assisted thoracoscopic surgery (RATS).METHODSThis was a retrospective monocentric study from January 2006 to June 2022, and data were obtained from the EPITHOR database. Patients included were those who underwent anatomic lung resection either by VATS or RATS. The ECS was calculated for all patients studied. Discrimination and calibration of the test were measured by the area under the curve and Hosmer–Lemeshow test.RESULTSA total of 1685 were included. There were 183/1299 conversions in the VATS group (14.1%) and 27/386 conversions in the RATS group (6.9%). Patients in the RATS group had fewer antiplatelet therapy and peripheral arterial disease. There were more segmentectomies in the VATS group. As for test discrimination, the area under the curve was 0.66 [0.56–0.78] in the RATS group and 0.64 [0.60–0.69] in the VATS group. Regarding the calibration, the Hosmer–Lemeshow test was not significant for both groups but more positive (better calibrated) for the VATS group (P = 0.12) compared to the RATS group (P = 0.08).CONCLUSIONSThe ECS seems applicable for patients operated with RATS, with a correct discrimination but a lower calibration performance for patients operated with VATS. A new score could be developed to specifically anticipate conversion in patients operated on by RATS.
Aortic valve repair in neonates, infants and children: a systematic review, meta-analysis and microsimulation studyNotenboom, Maximiliaan L; Rhellab, Reda; Etnel, Jonathan R G; van den Bogerd, Nova; Veen, Kevin M; Taverne, Yannick J H J; Helbing, Willem A; van de Woestijne, Pieter C; Bogers, Ad J J C; Takkenberg, Johanna J M
2023 European Journal of Cardio-Thoracic Surgery
doi: 10.1093/ejcts/ezad284pmid: 37584683
OBJECTIVESTo support clinical decision-making in children with aortic valve disease, by compiling the available evidence on outcome after paediatric aortic valve repair (AVr).METHODSA systematic review of literature reporting clinical outcome after paediatric AVr (mean age at surgery <18 years) published between 1 January 1990 and 23 December 2021 was conducted. Early event risks, late event rates and time-to-event data were pooled. A microsimulation model was employed to simulate the lives of individual children, infants and neonates following AVr.RESULTSForty-one publications were included, encompassing 2 623 patients with 17 217 patient-years of follow-up (median follow-up: 7.3 years; range: 1.0–14.4 years). Pooled mean age during repair for aortic stenosis in children (<18 years), infants (<1 year) or neonates (<30 days) was 5.2 ± 3.9 years, 35 ± 137 days and 11 ± 6 days, respectively. Pooled early mortality after stenosis repair in children, infants and neonates, respectively, was 3.5% (95% confidence interval: 1.9–6.5%), 7.4% (4.2–13.0%) and 10.7% (6.8–16.9%). Pooled late reintervention rate after stenosis repair in children, infants and neonates, respectively, was 3.31%/year (1.66–6.63%/year), 6.84%/year (3.95–11.83%/year) and 6.32%/year (3.04–13.15%/year); endocarditis 0.07%/year (0.03–0.21%/year), 0.23%/year (0.07–0.71%/year) and 0.49%/year (0.18–1.29%/year); and valve thrombosis 0.05%/year (0.01–0.26%/year), 0.15%/year (0.04–0.53%/year) and 0.19%/year (0.05–0.77%/year). Microsimulation-based mean life expectancy in the first 20 years for children, infants and neonates with aortic stenosis, respectively, was 18.4 years (95% credible interval: 18.1–18.7 years; relative survival compared to the matched general population: 92.2%), 16.8 years (16.5–17.0 years; relative survival: 84.2%) and 15.9 years (14.8–17.0 years; relative survival: 80.1%). Microsimulation-based 20-year risk of reintervention in children, infants and neonates, respectively, was 75.2% (72.9–77.2%), 53.8% (51.9–55.7%) and 50.8% (47.0–57.6%).CONCLUSIONSLong-term outcomes after paediatric AVr for stenosis are satisfactory and dependent on age at surgery. Despite a high hazard of reintervention for valve dysfunction and slightly impaired survival relative to the general population, AVr is associated with low valve-related event occurrences and should be considered in children with aortic valve disease.
The impact of annuloplasty ring or band implantation on post-repair mitral valve haemodynamic performanceTomšič, Anton; Sandoval, Elena; Meucci, Maria C; Nabeta, Takeru; Castella, Manuel; Muro, Anna; Klautz, Robert J M; Ajmone Marsan, Nina; Pereda, Daniel; Palmen, Meindert
2023 European Journal of Cardio-Thoracic Surgery
doi: 10.1093/ejcts/ezad307pmid: 37688566
OBJECTIVESThe clinical importance of optimal post-repair mitral valve diastolic performance is increasingly being recognized. The haemodynamic effect of a partial annuloplasty band implantation, in comparison to a full ring, remains insufficiently explored.METHODSPatients undergoing mitral valve repair for pure degenerative disease between 2011 and 2019 at 2 experienced heart valve centres were eligible for inclusion. Exclusion criteria were concomitant procedures other than tricuspid valve repair and ablation procedures for atrial fibrillation. Pre-discharge and follow-up echocardiograms (1–4 years after surgery) were analysed to assess haemodynamic mitral valve performance.RESULTSOf 535 patients meeting the inclusion criteria, 364 (68.0%) patients underwent full annuloplasty ring and 171 (31.0%) partial band implantation. On predischarge echocardiogram, post-repair mitral valve gradient and area did not differ between groups [2.89 mmHg (IQR 2.26–3.72) vs 2.60 mmHg (IQR 1.91–3.55), P = 0.19 and 1.98 cm2 (IQR 1.66–2.46) vs 2.03 cm2 (IQR 1.55–3.06), P = 0.15]. However, multivariable linear regression analysis demonstrated band annuloplasty as a determinant of larger valve area (coefficient 0.467 cm2, standard error 0.105, P < 0.001). On multivariable analysis, no significant impact on post-repair gradient was observed (–0.370 mmHg, standard error 0.167, P = 0.36). At follow-up, the differences between groups disappeared and multivariable regression analysis failed to demonstrate a significant impact of annuloplasty device type on mitral valve gradient (coefficient –0.095 mmHg, standard error 0.171, P = 1.00) or area (coefficient –0.085 cm2, standard error 0.120, P = 1.00). These results were confirmed with a linear mixed model analysis.CONCLUSIONSPartial band annuloplasty was related to an improved haemodynamic profile directly after valve repair for degenerative disease but the effect was short-lived. Our results suggest that the type of annuloplasty device has no durable impact on diastolic valve performance.
Dynamics in cardiac surgery: trends in population characteristics and the performance of the EuroSCORE II over timevan Dijk, Wouter B; Leeuwenberg, Artuur M; Grobbee, Diederick E; Siregar, Sabrina; Houterman, Saskia; Daeter, Edgar J; de Vries, Martine C; Groenwold, Rolf H H; Schuit, Ewoud; ,
2023 European Journal of Cardio-Thoracic Surgery
doi: 10.1093/ejcts/ezad301pmid: 37672025
OBJECTIVESThe aim of this study was to investigate the performance of the EuroSCORE II over time and dynamics in values of predictors included in the model.METHODSA cohort study was performed using data from the Netherlands Heart Registration. All cardiothoracic surgical procedures performed between 1 January 2013 and 31 December 2019 were included for analysis. Performance of the EuroSCORE II was assessed across 3-month intervals in terms of calibration and discrimination. For subgroups of major surgical procedures, performance of the EuroSCORE II was assessed across 12-month time intervals. Changes in values of individual EuroSCORE II predictors over time were assessed graphically.RESULTSA total of 103 404 cardiothoracic surgical procedures were included. Observed mortality risk ranged between 1.9% [95% confidence interval (CI) 1.6–2.4] and 3.6% (95% CI 2.6–4.4) across 3-month intervals, while the mean predicted mortality risk ranged between 3.4% (95% CI 3.3–3.6) and 4.2% (95% CI 3.9–4.6). The corresponding observed:expected ratios ranged from 0.50 (95% CI 0.46–0.61) to 0.95 (95% CI 0.74–1.16). Discriminative performance in terms of the c-statistic ranged between 0.82 (95% CI 0.78–0.89) and 0.89 (95% CI 0.87–0.93). The EuroSCORE II consistently overestimated mortality compared to observed mortality. This finding was consistent across all major cardiothoracic surgical procedures. Distributions of values of individual predictors varied broadly across predictors over time. Most notable trends were a decrease in elective surgery from 75% to 54% and a rise in patients with no or New York Heart Association I class heart failure from 27% to 33%.CONCLUSIONSThe EuroSCORE II shows good discriminative performance, but consistently overestimates mortality risks of all types of major cardiothoracic surgical procedures in the Netherlands.