Extracorporeal Life Support in Out‐of‐Hospital Refractory Cardiac Arrest

Out‐of‐Hospital refractory Cardiac Arrest (OHrCA) has a mortality rate between 90 and 95%. Since 2009, French medical academic societies have recommended the use of extracorporeal life support (ECLS) for OHrCA. According to these guidelines, patients were eligible for ECLS support if vital signs were still present during cardiopulmonary resuscitation (CPR), or if cardiac arrest was secondary to intoxication or hypothermia (≤32°C). Otherwise, patients would receive ECLS if (i) no‐flow duration was less than 5 min; (ii) time delays from CPR to ECLS start (low flow) were less than 100 min; and (iii) expiratory end tidal CO₂ (ETCO₂) was more than 10 mm Hg 20 min after initiating CPR. We have reported here our experience with ECLS in OHrCA according to the previous guidelines. We retrospectively analyzed mortality rates of patients supported with ECLS in case of OHrCA. From December 2009 to December 2013, 183 patients were assisted with ECLS, among which 32 cases were of OHrCA. Mean age for the OHrCA patients was 43.6 years. Over two‐thirds were male (71.9%). Causes of OHrCA included intoxication, isolated hypothermia <32°C, acute coronary syndrome, pulmonary edema, and other cardiac pathology. Despite adherence to protocols, only two patients (6.2%) with hypothermia and acute myocardium ischemia, respectively, could be discharged from hospital after cardiac recovery. Causes of death were brain death and multiple organ failure. Despite ECLS support setting in accordance with French guidelines in case of refractory OHrCA, mortality rates remained high. French ECLS support recommendations for OHrCA due to presumed cardiac cause should be re‐examined through new studies. Low flow duration should be improved by a shorter time of CPR before hospital transfer.     

Vacuum‐Assisted Closure for Mediastinitis in Pediatric Cardiac Surgery: A Single‐Center Experience

Vacuum‐assisted closure (VAC) has been widely used to treat mediastinitis after congenital cardiac surgery, which is associated with a high risk of morbidity and mortality. The aim in this study is to review our 14 cases of mediastinitis treated with VAC therapy after congenital cardiac surgery. We retrospectively reviewed the medical records of 14 congenital heart patients with mediastinitis from January 2012 to March 2017. Patients with fever, wound discharge, sternal dehiscence, a positive wound culture or abscess diagnosed with computed tomography are accepted as mediastinitis. A VAC was applied to all our patients without irrigation or dressing the wound because of sterility concerns. The vacuuming of the wound was either 50 mm Hg or 75 mm Hg according to the sternal intactness. We gradually decreased the pressures and changed the VAC systems once every three days, after wound healing was seen and a negative culture was obtained and VAC was terminated. There were 14 patients (8 male and 6 female) with mediastinitis and all of them were treated using VAC. The mean age of the patients was 6.96 months (ranging from 0.5‐26 months). The mean weight was 5.16 kg (2.8‐12 kg). Three patients needed extracorporeal membrane oxygenation after the surgery. Mean onset of mediastinitis was 25.3 days. The wound cultures showed methicillin resistant coagulase negative streptococcus and methicillin‐sensitive staphylococcus aureus in most cases. Acinetobacter, serratia, pseudomonas, and klebsiella were the other bacterial species seen in cultures. Two patients had mediastinitis symptoms, but their cultures were negative. VAC systems were changed 3.85 times on average. Mean duration of hospital stay was 49.9 days (21‐104 days). One patient needed a muscle flap to close the thoracic cavity after mediastinitis. Two patients did not survive. Mediastinitis is a serious postoperative condition in pediatric cardiac surgery patients. Classical wound dressing and irrigation methods are not suitable in mediastinitis for the pediatric age group. Therefore, VAC therapy can be an effective way to successfully treat the situation.     

Donor hypo‐ and hypernatremia are predictors for increased 1‐year mortality after cardiac transplantation

Donor hypernatremia is known to be associated with initial graft dysfunction in liver transplantation. Controversial data exist regarding the impact of sodium dysregulation on patient survival after heart transplantation (HTX). The aim of this study was to investigate the influence of donor sodium levels on survival in a large cohort of heart transplant recipients from the Eurotransplant registry. From 1997 to 2005, all consecutive adult HTX performed in the Eurotransplant region were included into this study (n = 4641 patients). Multivariate analysis was applied to investigate possible clinical predictors for 1‐year post‐transplant survival after cardiac transplantation (donor sodium levels, donor age, donor cause of death, recipient age, primary disease, urgency status, cold ischemia time). In multivariate analysis, recipients receiving a donor heart with serum sodium level lower than 130 mmol/l or higher than 170 mmol/l had a 1.25‐fold higher risk for 1‐year post‐transplant mortality than patients with normal donor sodium ranges (P = 0.007). Other independent risk factors for impaired 1‐year survival were recipient age, the indication for transplantation and the urgency status of the recipient. Our study demonstrates that hyponatremia as well as hypernatremia show a strong U‐shaped correlation with poor survival after cardiac transplantation. Accurate donor management to avoid electrolyte disorder seems to be crucial for ensuring good quality of donor hearts.     

Transplant tourism complicated by life‐threatening New Delhi metallo‐β‐lactamase‐1 infection

Transplant tourism, which is the practice of traveling to other countries for transplant, continues to be a major problem worldwide. We describe a patient who traveled to Pakistan and underwent commercial kidney transplant. He developed life‐threatening infections from New Delhi metallo‐β‐lactamase‐1–producing Enterobacter cloacae and Rhizopus oryzae, resulting in a necrotizing kidney allograft infection and subsequent external iliac artery rupture. He survived after a prolonged course of nonstandardized antimicrobial therapy, including a combination of aztreonam and ceftazidime‐avibactam, and aggressive surgical debridement with allograft nephrectomy. The early timing of infection with these unusual organisms localized to the allograft suggests contamination and substandard care at the time of transplant. This case highlights the challenges of caring for these infections and serves as a cautionary tale for the potential complications of commercial transplant tourism.     

Eculizumab Salvage Therapy for Antibody‐Mediated Rejection in a Desensitization‐Resistant Intestinal Re‐Transplant Patient

The presence of elevated calculated panel reactive antibody (cPRA) and anti‐HLA donor specific antibodies (DSA) are high risk factors for acute antibody‐mediated rejection (AAMR) in intestinal transplantation that may lead to graft loss. Eculizumab has been used for the treatment of AAMR in kidney transplantation of sensitized patients that do not respond to other treatment. Here, we report a case where eculizumab was used to treat AAMR in a desensitization‐resistant intestinal re‐transplant patient. A male patient lost his intestinal graft to AAMR 8.14 years after his primary transplant. He received a second intestinal graft that had to be explanted a month later due to refractory AAMR. The patient remained highly sensitized despite multiple treatments. He received a multivisceral graft and presented with severe AAMR on day 3 posttransplantation. The AAMR was successfully treated with eculizumab. The patient presently maintains an elevated cPRA level above 90% but his DSAs have decreased from 18 000 MFI (mean fluorescent intensity) to below the positive cut‐off value of 3000 MFI and remains rejection free with a 2‐year follow‐up since his multivisceral transplant. Eculizumab offers an alternative to treat AAMR in intestinal transplantation in desensitization‐resistant patients.     

Exosomes expressing the self‐antigens myosin and vimentin play an important role in syngeneic cardiac transplant rejection induced by antibodies to cardiac myosin

Long‐term success of heart transplantation is hindered by humoral and cell‐mediated immune responses. We studied preexisting antibodies to cardiac self‐antigens, myosin and vimentin, and exosomes induced by antibodies to self‐antigens in eliciting immune responses to cardiac grafts. After syngeneic heterotopic murine heart transplantation, rabbit anti‐myosin or normal rabbit immunoglobulin was administered at day 0 or 7. Sera were collected after heartbeat cessation, cellular infiltration was analyzed, and exosomes were isolated from sera. Histopathologic examination of the controls' transplanted hearts demonstrated normal architecture, and their sera demonstrated neither antibodies to self‐antigens nor exosomes expressing self‐antigens. Administration of antibodies to cardiac myosin immediately posttransplantation (day 0) but not on day 7 triggered graft failure on day 7, and histopathologic examination revealed marked cellular infiltration with neutrophils and lymphocytes. Histopathologic examination of rejected hearts also demonstrated myocyte damage as sera had increased antibodies to myosin and vimentin and development of exosomes expressing self‐antigens. Administration of exosomes isolated from failed grafts containing self‐antigens induced graft dysfunction; exosomes isolated from stable mice did not induce graft failure. Antibodies to self‐antigens can induce exosomes containing self‐antigens, initiating an immune response and causing graft failure after cardiac transplantation.     

Postoperative outcomes following cardiac surgery in non‐anaemic iron‐replete and iron‐deficient patients – an exploratory study

Iron deficiency anaemia is strongly associated with poor outcomes after cardiac surgery. However, pre‐operative non‐anaemic iron deficiency (a probable anaemia precursor) has not been comprehensively examined in patients undergoing cardiac surgery, despite biological plausibility and evidence from other patient populations of negative effect on outcome. This exploratory retrospective cohort study aimed to compare an iron‐deficient group of patients undergoing cardiac surgery with an iron‐replete group. Consecutive non‐anaemic patients undergoing elective coronary artery bypass grafting or single valve replacement in our institution between January 2013 and December 2015 were considered for inclusion. Data from a total of 277 patients were analysed, and were categorised by iron status and blood haemoglobin concentration into iron‐deficient (n = 109) and iron‐replete (n = 168) groups. Compared with the iron‐replete group, patients in the iron‐deficient group were more likely to be female (43% vs. 12%, iron‐replete, respectively); older, mean (SD) age 64.4 (9.7) vs. 63.2 (10.3) years; and to have a higher pre‐operative EuroSCORE (median IQR [range]) 3 (2–5 [0–10]) vs. 3 (2–4 [0–9]), with a lower preoperative haemoglobin of 141.6 (11.6) vs. 148.3 (11.7) g.l^?1. Univariate analysis suggested that iron‐deficient patients had a longer hospital length of stay (7 (6–9 [2–40]) vs. 7 (5–8 [4–23]) days; p = 0.013) and fewer days alive and out of hospital at postoperative day 90 (83 (80–84 [0–87]) vs. 83 (81–85 [34–86]), p = 0.009). There was no evidence of an association between iron deficiency and either lower nadir haemoglobin or higher requirement for blood products during inpatient stay. After adjusting the model for pre‐operative age, sex, renal function, EuroSCORE and haemoglobin, the mean increase in hospital length of stay in the iron‐deficient group relative to the iron‐replete group was 0.86 days (bootstrapped 95%CI ?0.37 to 2.22, p = 0.098). This exploratory study suggests there is weak evidence of an association between non‐anaemic iron deficiency and outcome after cardiac surgery after controlling for potentially confounding variables.     

Cardiac Disease‐Induced Post‐traumatic Stress Symptoms (CDI‐PTSS) Among Patients' Partners

It is well established that a patient's partner can be deeply affected by the traumatizing nature of the patient's illness. Yet, no study to date has focused on post‐traumatic stress symptoms (PTSS) among partners of patients coping with an acute coronary syndrome (ACS). The current study's main aims were to address this gap and to evaluate cardiac disease‐induced (CDI) PTSS prevalence in partners of patients who experienced ACS. Patients who experienced ACS and their partners were interviewed by telephone 2 to 6 months after patients' hospitalization. All patients and partners were screened for CDI‐PTSS. Demographic and medical variables as well as partners' level of exposure to the cardiac event were assessed. Prevalence of CDI‐PTSS was higher among partners than among patients. Partners' number of CDI‐PTSS was not significantly associated with patients' number of CDI‐PTSS or with any of the other explanatory factors measured, except for education level. The preliminary results that arose from the current study point to the vast number of individuals who must act as caregivers for their ill partners while having to cope with their own PTSS. Much effort should be channelled into integrating partners into cardiac recovery programmes. Copyright © 2016 John Wiley & Sons, Ltd.     

Parathyroid hormone‐related peptide‐producing non‐familial pheochromocytoma in a child

We experienced a case of parathyroid hormone‐related peptide (PTHrP)‐producing pheochromocytoma, which was found in a 12‐year‐old boy with hypercalcemia. The leading symptom was abdominal pain, and severe hypertension and tachycardia were noticed at the initial visit. His medical and familial histories were unremarkable. Laboratory examinations showed hypercalcemia (3.3 mmol/L of serum‐calcium). Computed tomography showed a heterogeneous mass measuring 5.0 cm in the right adrenal gland, which had abnormal uptake with 123‐I metaiodobenzylguanidine scintigraphy. Serum/urine catecholamines were highly elevated, and serum PTHrP also increased (1.4 pmol/L). The patient underwent laparoscopic right adrenalectomy. The tumor was histologically diagnosed as typical pheochromocytoma and the expression of PTHrP was confirmed with immunohistochemistry. The serum PTHrP level was normalized after surgery. He was free of disease postoperatively for 12 months. There has been no described pediatric patient with PTHrP‐producing pheochromocytoma. We showed evidence that the present tumor is a complex neoplasm involving various neuroendocrine activities with the dual‐lineage differentiation.     

Grade III bleeding haemorrhoids in a 6‐year‐old boy

We report a case of grade 3 bleeding haemorrhoids in a 6‐year‐old boy, who had a history of bleeding per rectum since he was 1‐year‐old. The diagnosis was made on anoscopic examination after ruling out other colorectal pathologies by a full‐length colonoscopy. There was no evidence of portal hypertension. He was successfully treated with haemorrhoidectomy. A congenital weakness of the haemorrhoid vein wall was thought to be the probable cause of disease for want of any other causative factor. Though rare to be found at the age of 6 years without any obvious aetiology, haemorrhoids should be considered as one of the causes of bleeding per rectum in children.     

An observational study of the macro‐ and micro‐haemodynamic implications of epidural anaesthesia in children

The haemodynamic implications of epidural anaesthesia in children are poorly documented. We report macro‐ and micro‐haemodynamic data from an observational study of 25 children ranging from neonates to six‐years old, who underwent surgery conducted with a specific combination of monitoring systems. We analysed 90 min of study‐related monitoring after epidural catheterisation, with skin incision taking place after around 30 min. We recorded macrohaemodynamic parameters (monitored using LiDCO rapid ) including heart rate, mean arterial pressure, cardiac output, stroke volume, systemic vascular resistance and stroke volume variation. Microhaemodynamic parameters (monitored using Invos?) included cerebral and peri‐renal oxygenation. Based on the entire 90 min of study‐related monitoring, we found significant increases in cardiac output (p = 0.009), stroke volume (p = 0.006) and stroke volume variation (p = 0.008), as well as decreases in systemic vascular resistance (p = 0.007) around 30 min after epidural blockade. There were no significant changes in heart rate, arterial pressure and cerebral or peri‐renal oxygenation during these 90 min. Considering that the microhaemodynamic parameters were not affected by the macrohaemodynamic changes, we conclude that autoregulation of the brain and the kidneys was maintained in children under epidural anaesthesia.     

Preoperative pulseless electrical activity of acute type A aortic dissection; report of a case

An 80-year-old man with acute type A aortic dissection, who was preoperatively observed in the intensive care unit, suddenly became unresponsive. The patient was immediately intubated, but a pulse check was delayed because the cardiac monitor seemingly showed a normal sinus rhythm. Bedside echocardiography, while continuing cardiopulmonary resuscitation, revealed massive pericardial effusion. It indicated the patient's cardiac arrest was pulseless electrical activity (PEA) due to cardiac tamponade. After pericardiocentesis, a perfusion rhythm was restored with palpable distal pulse. He successfully underwent a prosthetic graft replacement of the ascending aorta and was discharged after physical rehabilitation.     

Multiple anal fistulae in a 5‐year‐old boy

We report a case of multiple fistulae in a 5‐year‐old boy, who had a history of episodes of pain and pus discharge from openings around the anus since he was 4 years of age. He underwent simultaneous fistulotomy at three different sites under anaesthesia with complete healing.     

Long‐term outcomes and cost effectiveness of high‐dose dexamethasone for cardiac surgery: a randomised trial

Prophylactic intra‐operative administration of dexamethasone may improve short‐term clinical outcomes in cardiac surgical patients. The purpose of this study was to evaluate long‐term clinical outcomes and cost effectiveness of dexamethasone versus placebo. Patients included in the multicentre, randomised, double‐blind, placebo‐controlled DExamethasone for Cardiac Surgery (DECS) trial were followed up for 12 months after their cardiac surgical procedure. In the DECS trial, patients received a single intra‐operative dose of dexamethasone 1 mg.kg^?1 (n = 2239) or placebo (n = 2255). The effects on the incidence of major postoperative events were evaluated. Also, overall costs for the 12‐month postoperative period, and cost effectiveness, were compared between groups. Of 4494 randomised patients, 4457 patients (99%) were followed up until 12 months after surgery. There was no difference in the incidence of major postoperative events, the relative risk (95%CI) being 0.86 (0.72‐1.03); p = 0.1. Treatment with dexamethasone reduced costs per patient by £921 [€1084] (95%CI £?1672 to ?137; p = 0.02), mainly through reduction of postoperative respiratory failure and duration of postoperative hospital stay. The probability of dexamethasone being cost effective compared with placebo was 97% at a threshold value of £17,000 [€20,000] per quality‐adjusted life year. We conclude that intra‐operative high‐dose dexamethasone did not have an effect on major adverse events at 12 months after cardiac surgery, but was associated with a reduction in costs. Routine dexamethasone administration is expected to be cost effective at commonly accepted threshold levels for cost effectiveness.     

Peri‐operative management of anti‐platelet agents

Background: Increasing numbers of patients treated with anti‐platelet agents are presenting for non‐cardiac surgery. We examined the peri‐operative management of anti‐platelet therapy in patients undergoing elective non‐cardiac surgery and the process by which patients received instructions. Methods: We interviewed and collected outcome data on 213 consecutive patients aged ≥45 years presenting for elective non‐cardiac surgery at our institution over a 6‐week period regarding the peri‐operative management of anti‐platelet and warfarin therapy. Results: Anti‐platelet therapy was prescribed in 22.5% and warfarin in 5.2% of the study subjects. Aspirin was stopped peri‐operatively in 55.3%, while clopidogrel was stopped in the sole patient treated with this. The frequency of anti‐platelet agent discontinuation was similar for major and minor surgery. Warfarin was discontinued prior to surgery in all cases. Only 54.2% of those treated with anti‐platelet therapy recalled being given instruction regarding pre‐operative management of their anti‐platelet therapy compared with 90.9% of patients treated with warfarin (P= 0.04). In the absence of instructions, a number of patients made their own decision to stop their aspirin pre‐operatively. Post‐operatively, only 37% recalled receiving instructions regarding restarting anti‐platelet therapy. As a result, three patients failed to do so. In contrast, all those treated with warfarin received clear post‐operative instructions. Conclusion: Peri‐operative anti‐platelet management and communication with patients appears to be sub‐optimal. There is a need for standardized processes whereby informed decisions regarding peri‐operative anti‐platelet therapy are made and communicated clearly to the patients.     

The utility of intra‐operative three‐dimensional transoesophageal echocardiography for dynamic measurement of stroke volume

Measurement of left ventricular stroke volume and cardiac output is very important for managing haemodynamically unstable or critically ill patients. The aims of this study were to compare stroke volume measured by three‐dimensional transoesophageal echocardiography with stroke volume measured using a pulmonary artery catheter, and to examine the ability of three‐dimensional transoesophageal echocardiography to track stroke volume changes induced by haemodynamic interventions. This study included 40 cardiac surgery patients. Haemodynamic variables were measured before and 2 min after haemodynamic interventions, which consisted of phenylephrine 100 μg or ephedrine 5 mg. We used Bland–Altman analysis to assess the agreement between the stroke volume measured by three‐dimensional transoesophageal echocardiography and by the pulmonary artery catheter. Polar‐plot and 4‐quadrant plot analyses were used to assess the trending ability of three‐dimensional transoesophageal echocardiography compared with the pulmonary artery catheter. Bias and percentage error were ?1.2 ml and 20%, respectively. The concordance rate in the 4‐quadrant analysis after phenylephrine and ephedrine administration was 75% and 84%, respectively. In the polar‐plot analysis, the angular concordance rate was 66% and 73% after phenylephrine and ephedrine administration, respectively. Three‐dimensional transoesophageal echocardiography was clinically acceptable for measuring stroke volume; however, it was not sufficiently reliable for tracking stroke volume changes after haemodynamic interventions.