Giant-cell myocarditis (GCM) is a rare and often fatal form of myocarditis. Only a few reports have focused on fulminant forms. We describe the clinical characteristics, management and outcomes of ...GCM patients rescued by mechanical circulatory support (MCS).
The clinical features, diagnoses, treatments and outcomes of MCS-treated patients in refractory cardiogenic shock secondary to fulminant GCM admitted to eight French intensive care units (2002–2016) were analysed. We also conducted a systematic review of this topic. Thirteen patients (median age 44 range 21–76years, Simplified Acute Physiology Score II 55 40–79) in severe cardiogenic shock (median range left ventricular ejection fraction 15% 15–35% and blood lactate 4 mmol/L) were placed on MCS 4 0–28days after hospital admission. Severe arrhythmic disturbances were frequent (77%), with six (46%) patients experiencing an electrical storm prior to MCS. Venoarterial extracorporeal membrane oxygenation was the first MCS option for 11 (85%) patients. GCM was diagnosed in five (38%) patients before transplant or death and treated with immunosuppressants; infections were the main complication (80%). Four patients died on MCS and no patient presented long-term survival free from heart transplant (nine patients, 69%). All transplanted patients were alive 1year later and no GCM recurrence was reported after median follow-up of 42 12–145months.
Outcomes of fulminant GCMs may differ from those of milder forms. In this context, heart transplant might likely be the only long-term survival option.
Summary Background The development of artificial hearts in patients with end-stage heart disease have been confronted with the major issues of thromboembolism or haemorrhage. Since valvular ...bioprostheses are associated with a low incidence of these complications, we decided to use bioprosthetic materials in the construction of a novel artificial heart (C-TAH). We report here the device characteristics and its first clinical applications in two patients with end-stage dilated cardiomyopathy. The aim of the study was to evaluate safety and feasibility of the CARMAT TAH for patients at imminent risk of death from biventricular heart failure and not eligible for transplant. Methods The C-TAH is an implantable electro-hydraulically actuated pulsatile biventricular pump. All components, batteries excepted, are embodied in a single device positioned in the pericardial sac after excision of the native ventricles. We selected patients admitted to hospital who were at imminent risk of death, having irreversible biventricular failure, and not eligible for heart transplantation, from three cardiac surgery centres in France. Findings The C-TAH was implanted in two male patients. Patient 1, aged 76 years, had the C-TAH implantation on Dec 18, 2013; patient 2, aged 68 years, had the implantation on Aug 5, 2014. The cardiopulmonary bypass times for C-TAH implantation were 170 min for patient 1 and 157 min for patient 2. Both patients were extubated within the first 12 postoperative hours and had a rapid recovery of their respiratory and circulatory functions as well as a normal mental status. Patient 1 presented with a tamponade on day 23 requiring re-intervention. Postoperative bleeding disorders prompted anticoagulant discontinuation. The C-TAH functioned well with a cardiac output of 4·8–5·8 L/min. On day 74, the patient died due to a device failure. Autopsy did not detect any relevant thrombus formation within the bioprosthesis nor the different organs, despite a 50-day anticoagulant-free period. Patient 2 experienced a transient period of renal failure and a pericardial effusion requiring drainage, but otherwise uneventful postoperative course. He was discharged from the hospital on day 150 after surgery with a wearable system without technical assistance. After 4 months at home, the patient suffered low cardiac output. A change of C-TAH was attempted but the patient died of multiorgan failure. Interpretation This preliminary experience could represent an important contribution to the development of total artificial hearts using bioprosthetic materials. Funding CARMAT SA.
We evaluated the influence of the proximal fixation systems of stentgrafts on proximal inter-renal or infrarenal aneurysm neck dilatation after endovascular repair of abdominal aortic aneurysms. ...Anatomic and clinical predictive factors of neck dilatation and stentgraft proximal migration were searched for.
Taking account of a prospective and monocenter register, 58 patients' files, with a complete minimum 3-year follow-up, were analyzed after treatment with stentgrafts with a suprarenal fixation (SRF: 33 Talent) or an infrarenal fixation (IRF: 25 AneuRx). Both groups were compared in terms of inter-renal neck dilatation (D1: diameter between the two renal arteries), infrarenal neck dilatation (D2: 7-mm diameter under the lowest renal artery), and specific complication (proximal migration, endoleak). The diameter measured on the last control computed tomography scan was compared with the postoperative diameter. Neck dilatation was defined by a diameter increase exceeding 3 mm and by the proximal migration due to a caudal displacement of the stentgraft ≥10 mm. Predictive factors of proximal migration or neck dilatation were searched for (anatomy of the neck, aneurysm anatomy, stent graft oversize percentage, demographic factors).
Preoperatively, both groups were comparable in terms of anatomic and demographic characteristics of the aneurysm. Mean follow-up was longer in the AneuRx group (62 ± 17 months vs. 53 ± 13 months, p = 0.045) and the percentage of stent graft oversize was greater in the Talent group (18 ± 6% vs. 13 ± 5%, p < 10(-4)). Freedom from a dilatation exceeding 3 mm in D1 and D2 did not bring any significant difference between the two groups. In each group, the remodeling of the aneurysmal sac (AneuRx median = -4 mm, Talent median = -5 mm, p > 0.05) was only moderately related to proximal neck remodeling. A small angulation of the neck and a smaller neck were the only predictive factors of neck dilatation found respectively in D1 (p = 0.007) and in D2 (p = 0.022). Stent graft proximal migration was more frequent in the AneuRx group (p = 0.031) and was more frequent with large aneurysms (p = 0.029).
In the long term, the absence of proximal stent graft fixation system on the dilatation of the aneurysm proximal neck enhances proximal migration. Conversely, the inter-renal or infrarenal proximal neck dilatation does not depend on the type of proximal fixation but on anatomic factors and on the natural evolution of the aneurysmal disease.
L’ Evidence-Based Medicine (EBM) est définie comme « l’utilisation consciencieuse et judicieuse des meilleures données actuelles de la recherche clinique dans la prise en charge personnalisée de ...chaque patient ». L’EBM met en œuvre des standards de qualité du plus haut niveau par le tri actif de toutes les études cliniques disponibles. D’un côté, elle remet en question le fondement des savoirs pratiques basé sur l’intuition, l’expérience clinique et le mécanisme des maladies. D’un autre, elle refuse l’autorité des experts et leurs recommandations. Si l’intention de l’EBM d’améliorer la pratique clinique est louable, elle ne peut résoudre la question cruciale de l’expertise clinique. En se concentrant sur les études cliniques, l’EBM oublie que le savoir clinique nécessite de rassembler plusieurs formes de savoirs. Dès lors, il manque à l’EBM une connaissance tacite, non formalisable, qu’elle rejette pour son absence supposée d’objectivité. L’expertise clinique comme incorporation de gestes à la fois intellectuels et techniques nécessite un travail de synthèse entre les connaissances implicites et explicites afin de revenir à son but : le soin au patient dans sa particularité.
Introduction: Circulatory assistance from a SynCardia Total Artificial Heart (SynCardia-TAH) is a reliable bridge-to-transplant solution for patients with end-stage biventricular heart failure. ...Ischemic strokes affect about 10% of patients with a SynCardia-TAH. We report for the first time in the literature two successful thrombectomies to treat the acute phase of ischemic stroke in two patients treated with a SynCardia-TAH in the bridge-to-transplant (BTT). Case report: We follow two patients with circulatory support from a SynCardia-TAH in the bridge-to-transplant for terminal biventricular cardiac failure with ischemic stroke during the support period. An early in-hospital diagnosis enables the completion of a mechanical thrombectomy within the first 6 h of the onset of symptoms. There was no intracranial hemorrhagic complication during or after the procedure and the patients fully recovered from neurological deficits, allowing a successful heart transplant. Conclusion: This case report describes the possibility of treating ischemic strokes under a SynCardia-TAH by mechanical thrombectomy following the same recommendations as for the general population with excellent results and without any hemorrhagic complication during or after the procedure.
In order to solve public health problems posed by the epidemiology of risk factors centered on the individual and neglecting the causal processes linking the risk factors with the health outcomes, ...Mervyn Susser proposed a multilevel epidemiology called eco-epidemiology, addressing the interdependence of individuals and their connection with molecular, individual, societal, environmental levels of organization participating in the causal disease processes. The aim of this epidemiology is to integrate more than a level of organization in design, analysis and interpretation of health problems. After presenting the main criticisms of risk-factor epidemiology focused on the individual, we will try to show how eco-epidemiology and its development could help to understand the need for a broader and integrative epidemiology, in which studies designed to identify risk factors would be balanced by studies designed to answer other questions equally vital to public health.
The study was conducted to determine the long-term outcome of patients who underwent heart transplantation 15 to 20 years ago, in the cyclosporine era, and identify risk factors for death.
A ...retrospective analysis was done of 148 patients who had undergone heart transplantation between 1985 and 1991 at a single center. Operative technique and immunosuppressive treatment were comparable in all patients.
Actuarial survival rates were 75% (n = 111), 58% (n = 86), and 42% (n = 62) at 5, 10, and 15 years, respectively. The mean follow-up period was 12.1 +/- 5.6 years for patients who survived more than 3 months after transplantation (n = 131). The major causes of death were malignancy (35.8%) and cardiac allograft vasculopathy (24.7%). No death related to acute rejection was reported after the first month of transplantation. Graft coronary artery disease was detected on angiography in 66 (50.3%), and 7 (5.3%) had retransplantation. Malignancies developed in 131 patients (48.1%), including skin cancers in 31 (23.6%), solid tumors in 26 (19.8%), and hematologic malignancies in 14 (10.6%). Severe renal function requiring dialysis or renal transplantation developed in 27 patients (20.6%). By multivariable analysis, the only pre-transplant risk factor found to affect long-term survival was a history of cigarette use (p < 0.0004).
Long-term survival at 15 years after cardiac transplantation remains excellent in the cyclosporine era. Controlling acute allograft rejection can be achieved but seems to carry a high rate of cancers and renal dysfunction. History of cigarette use affects significantly long-term survival in our study.
L’éco-épidémiologie Bizouarn, Philippe
M.S. Médecine sciences,
2016, Letnik:
32, Številka:
5
Journal Article
Recenzirano
Afin de résoudre les problèmes de santé publique posés par l’épidémiologie des facteurs de risque centrée sur l’individu, et négligeant les processus causals en œuvre reliant les facteurs ...d’exposition aux maladies, Mervyn Susser a proposé une épidémiologie multiniveau appelée éco-épidémiologie. Celle-ci rend compte de l’interdépendance des individus et de la connexion entre différents niveaux d’organisation (moléculaires, individuels, socio-environnementaux) participant au processus causal des maladies. Le but de cette épidémiologie est d’intégrer plus d’un niveau d’organisation dans la conception, l’analyse et l’interprétation des problèmes de santé. Après avoir formulé les principales critiques de l’épidémiologie des facteurs de risque centrée sur le seul niveau individuel, nous nous attacherons à montrer comment l’éco-épidémiologie et ses développements pourraient permettre de comprendre la nécessité d’une conception plus large de l’épidémiologie, associant les études qui visent à identifier les facteurs de risque et celles qui cherchent à répondre à d’autres questions tout aussi importantes pour la santé publique.
In order to solve public health problems posed by the epidemiology of risk factors centered on the individual and neglecting the causal processes linking the risk factors with the health outcomes, Mervyn Susser proposed a multilevel epidemiology called eco-epidemiology, addressing the interdependence of individuals and their connection with molecular, individual, societal, environmental levels of organization participating in the causal disease processes. The aim of this epidemiology is to integrate more than a level of organization in design, analysis and interpretation of health problems. After presenting the main criticisms of risk-factor epidemiology focused on the individual, we will try to show how eco-epidemiology and its development could help to understand the need for a broader and integrative epidemiology, in which studies designed to identify risk factors would be balanced by studies designed to answer other questions equally vital to public health.
•Amphetamine exposure can induce reverse Tako-Tsubo.•ECMO may be considered for the management of these transient cardiogenic shocks.•Levosimendan may be an alternative to catecholamines in this ...context.
Stress-induced cardiomyopathy, also known by various names such as Tako-Tsubo cardiomyopathy (TTC), is a cardiomyopathy that presents different types of transient left ventricular dysfunction. We present two cases of reverse TTC occurring in two young men after amphetamine use and complicated by cardiogenic shock necessitating venoarterial extra-corporeal membrane oxygenation (VA-ECMO). Levosimendan was used in one case to prevent subsequent aggravation of left ventricular function provoked by the use of catecholamine in this context. In both cases, myocardial function recovered rapidly. Amphetamine use can lead to reverse TTC requiring transient mechanical assistance and inotropic support.
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