SEPSISPAM : évaluation de l’effet de deux niveaux de pression artérielle sur la survie des patients en choc septique

The treatment of hemodynamic failure in patients with septic shock is based on fluid resuscitation and vasoconstrictors like norepinephrine. Its objective is to achieve a sufficient mean arterial pressure (MAP) to maintain adequate tissue perfusion pressure and thus ensure tissue oxygenation. Current recommendations suggest maintaining MAP ≥ 65 mmHg, but as available data are sparse, the optimal MAP level to achieve is not defined in these recommendations, particularly in relation to patient characteristics (i.e. age, cardiovascular diseases). Only five prospective studies have compared the effect of increasing MAP using norepinephrine titration. The benefit of this strategy was not demonstrated, probably because these studies have included a small number of patients. However, in retrospective studies, mortality does not seem to be correlated with the level of MAP, except for the lowest values. Moreover, in large clinical trials assessing different vasopressor treatments, MAP levels of 75 to 90 mmHg are often achieved, without significant adverse effects. Finally, the effect of incremental infusion of norepinephrine has never been evaluated during the early phase of septic shock. Altogether, these data suggest that early administration of norepinephrine to achieve a MAP level between 80 and 85 mmHg may reduce mortality. This hypothesis has never been evaluated to date, and this is the objective of the SEPSIS-PAM multicenter and randomized French study. The primary endpoint will be the mortality rate at day 28. Two early resuscitation strategies based on two different MAP levels will be compared: a control group with a MAP level objective of 65 to 70 mmHg, in accordance with current recommendations, and an interventional group with a MAP target of 80 to 85 mmHg achieved with the optimization of vascular challenge and norepinephrine titration before the first six hours following the diagnosis of septic shock. This trial began in March 2010 in 29 French ICU centers and will include 800 patients.     

Paravalvular leak and other events in silzone-coated mechanical heart valves: a report from AVERT

BACKGROUND: The Artificial Valve Endocarditis Reduction Trial (AVERT) was designed to compare endocarditis rates in Silzone versus conventional valves. Recruitment ended January 21, 2000, because of higher rates of paravalvular leakage in patients receiving the Silzone prosthesis. The present analysis determined late event rates that might be used in the management of approximately 36,000 patients who have received the Silzone prosthesis. METHODS: A total of 807 patients in 19 centers in North America and Europe were randomized. Mean age was 61+/-11 years; 41% were women. Operations included aortic valve replacement in 59%, mitral valve replacement in 32%, and aortic and mitral valve replacements in 9%; 41% had concomitant operations (26% coronary artery bypass grafting). RESULTS: Major paravalvular leakage (followed by repair, explant, or mortality) occurred in 18 of 403 patients receiving Silzone valves and 4 of 404 patients without Silzone valves (2-year event-free rates: 91.1% versus 98.9% conventional, p < 0.003). Similarly, 2-year freedom from any explant was lower in the Silzone arm (19 versus 2 events; 90.1% versus 99.4%, p = 0.0002). Rates of mortality and stroke were similar during follow-up. CONCLUSIONS: Continued follow-up of AVERT supports the conclusion that the Silzone prosthesis has increased risk of paravalvular leakage requiring reoperation. Overall survival is similar in the two groups.     

Pneumothorax after left pneumonectomy: implantation of an intrapleural prosthesis

Postpneumonectomy syndrome is defined as an airway obstruction due to mediastinal shift and rotation after pneumonectomy. A patient who had undergone a left pneumonectomy for bronchial carcinoma 13 years before presented with tension pneumothorax of her remaining lung. Although all factors relevant to the development of postpneumonectomy syndrome were ascertained, the patient had a pneumothorax rather than an airway obstruction. This pneumothorax was treated surgically. The goal of this operation was to reduce the right pleural cavity volume by implanting an intrapleural prosthesis in the pneumonectomy cavity. This treatment is identical to that used for postpneumonectomy syndrome, which allows the right lung to be rejoined with the thoracic wall.     

One-stage repair of aortic isthmus atresia, aortic arch hypoplasia and ascending aorta aneurysm via midline sternotomy and normothermic perfusion.

One-stage repair of aortic isthmus atresia, aortic arch hypoplasia and ascending aorta aneurysm was performed via a standard midline sternotomy. Ascending aortoplasty was performed during a 19-min cardiac arrest. With the heart beating and continuous normothermic perfusion of the upper and lower part of the body, the aortic arch was then enlarged using the Amato technique and the harvested ascending aorta wall as autologous patch. A classical Crafoord procedure then restored continuity between the aortic arch and the descending thoracic aorta.     

Fibromuscular dysplasia of the arteries of the leg. Apropos of 1 case

A 40 year old man presented fibromuscular hyperplasia of posterior tibial artery media, a rare lesion, and only exceptionally reported in the calves since a total of 3 cases were found in the literature.