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Rationale: For veno-arterial extracorporeal membrane oxygenation (ECMO), the femoral artery is the preferred cannulation site (femoro-femoral: Vf-Af). This results in retrograde aortic flow, which increases the left ventricular afterload and can lead to severe pulmonary edema and thrombosis of the cardiac chambers. Right axillary artery cannulation (femoral-axillary: Vf-Aa) provides partial anterograde aortic flow, which may prevent some complications. This study aimed to compare the 90-day mortality and complication rates between VF-AA and VF-AF., Methods: Consecutive adult patients with cardiogenic shock who received peripheral VA-ECMO between 2013 and 2019 at our institution were retrospectively included. The exclusion criteria were refractory cardiac arrest, multiple VA-ECMO implantations due to vascular access changes, weaning failure, or ICU readmission. A statistical approach using inverse probability of treatment weighting was used to estimate the effect of the cannulation site on the outcomes. The primary endpoint was the 90-day mortality. The secondary endpoints were vascular access complications, stroke, and other complications related to retrograde blood flow. Outcomes were estimated using logistic regression analysis., Results: VA-ECMO was performed on 534 patients. Patients with refractory cardiac arrest ( n = 77 (14%)) and those supported by multiple VA-ECMO ( n = 92, (17%)) were excluded. Out of the 333 patients studied ( n = 209 Vf-Aa; n = 124 VF-AF), the main indications for VA-ECMO implantation were post-cardiotomy (33%, n = 109), dilated cardiomyopathy (20%, n = 66), post-cardiac transplantation (15%, n = 50), acute myocardial infarction (14%, n = 46) and other etiologies (18%, n = 62). The median SOFA score was 9 [7-11], and the crude 90-day mortality rate was 53% ( n = 175). After IPTW, the 90-day mortality was similar in the Vf-Aa and VF-AF groups (54% vs 58%, IPTW-OR = 0.84 [0.54-1.29]). Axillary artery cannulation was associated with significantly fewer local infections (OR = 0.21, 95% CI:0.09-0.51), limb ischemia (OR = 0.37, 95% CI:0.17-0.84), bowel ischemia (OR = 0.16, 95% CI:0.05-0.51) and pulmonary edema (OR = 0.52, 95% CI:0.29-0.92) episodes, but with a higher rate of stroke (OR = 2.87, 95% CI:1.08-7.62) than femoral artery cannulation., Conclusion: Compared to VF-AF, axillary cannulation was associated with similar 90-day mortality rates. The high rate of stroke associated with axillary artery cannulation requires further investigation., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Aim: The objective of this study was to evaluate the diagnostic performance of white blood cells (WBC)-SPECT imaging in patients with suspicion of prosthetic valve endocarditis (PVE) against intra-operative findings., Methods: 36 consecutive patients who underwent cardiac surgery 30 days after WBC-SPECT imaging were identified retrospectively. Clinical, imaging, and biological results were collected from reports. WBC-SPECT results were classified as positive or negative and, if positive, the intensity of signal graded as intense or mild. Lesions observed during cardiac surgery were collected from surgeons' reports., Results: The 20 patients with positive WBC-SPECT study had confirmed PVE intra-operatively. Patients with intense signal on WBC-SPECT had high prevalence of abscesses (83%) compared to patients with only mild signal (12%). The three patients with negative WBC-SPECT but confirmed PVE had longer duration of antibiotic treatment before imaging and had no perivalvular abscess. Sensitivity, specificity, positive predictive and negative values, and accuracy of WBC-SPECT were measured at 87%, 100%, 100%, 81%, and 92%, respectively. Addition of WBC-SPECT results to the modified Duke score helped re-classify correctly 25% of patients from possible to definite PVE., Conclusion: In patients with suspicion of PVE, WBC-SPECT imaging provides excellent diagnostic performance against intra-operative findings., (© 2021. American Society of Nuclear Cardiology.)

Objective: Coronary stent infection is a fearsome complication with high mortality rate. Since antibiotics may have only partial efficacy, invasive surgery may be needed. We present a systematic review about outcomes achieved by surgical versus medical treatment in this scenario., Methods: A literature search through Medline and Google Scholar was performed over a 30-years period according to PRISMA guidelines. Demographics, clinical data, imaging findings and treatment modalities were collected. Outcomes were analysed according to treatment., Results: Among 1727 articles identified, after duplicate removal the title/abstract screening excluded 821 articles. After full-text screening, 31 studies were included totalling 34 patients (n 28, 82.4% male, mean age 61.7 SD +/- 10 years old). The majority of infection were sustained by S. Aureus (n 28, 82.4%), occurred within one month (median 7 days, range 1-1440) from stenting and mostly over drug-eluting stents (n21, 61.8%). The majority of patients (n30, 88.2%) underwent antibiotics at first: 12 patients (35.3%) didn't undergo additional treatment because they died, were unfit or refused major surgery or responded favorably to medical treatment; surgery was scheduled in a total of 20 patients (58.8%), as an emergent approach (n2) or after failure of antibiotics (n18). More than half of patients medically treated died (n6/11, 54.5%) versus 35% (n7/20) in surgery group., Conclusions: Coronary stent infections are associated with high morbi-mortality rate. Medical treatment may be the only possible approach in extremely fragile patients, however timely surgical referral is the only definitive treatment, and it is recommended whenever possible., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objectives: Our goal was to assess the safety, outcomes and complication rate of axillary artery cannulation for venoarterial extracorporeal membrane oxygenation (VA-ECMO)., Methods: A retrospective analysis was conducted on data obtained from the review of medical charts of all consecutive patients undergoing VA-ECMO implantation between January 2013 and December 2017 at a teaching hospital. Only patients with right axillary VA-ECMO implantation in a non-emergency setting were included. Post-procedural outcomes and local and systemic complications were analysed., Results: One hundred and seventy-four [131 male (75.3%), 43 female (24.7%); mean age 56.8 ± 15.1 years] patients underwent femoral-axillary VA-ECMO. Indications were cardiogenic shock from any cause (n = 78, 44.8%) or post-cardiotomy syndrome (n = 96, 55.2%). Fifty-three (30.5%) patients died while on VA-ECMO support. At the time of VA-ECMO ablation, 89 (51.1%) patients had recovered; 13 (7.5%) patients were bridged to a long-term mechanical support device and 19 (10.9%) patients underwent heart transplants. Thirty-day and 1-year mortality was 36.2% (n = 63) and 49.4% (n = 86), respectively. The 1-year survival rate of patients who were weaned from VA-ECMO support was 72.7% (n = 88). The complications of axillary cannulation were bleeding (n = 7, 4%), local infection (n = 3, 1.7%), upper limb ischaemia (n = 2, 1.1%) and brachial plexus injury (n = 1, 0.6%). Left ventricle unloading was required for 9 (5.2%) patients. The median duration of VA-ECMO support was 7 (range 1-26) days., Conclusions: Right axillary artery cannulation is a safe and reliable method for VA-ECMO support with a low rate of local complications. In the absence of a control group with femoro-femoral cannulation, no definitive conclusion about the superiority of axillary over femoral cannulation can be drawn., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background/objectives: Tools for prognostication of neurologic outcome of adult patients under venoarterial ECMO (VA-ECMO) have not been thoroughly investigated. We aimed to determine whether early standard electroencephalography ( std EEG) can be used for prognostication in adults under VA-ECMO., Methods: Prospective single-center observational study conducted in two intensive care units of a university hospital, Paris, France. Early std EEG was performed on consecutive adult patients treated with VA-ECMO for refractory cardiogenic shock or refractory cardiac arrest. The association between std EEG findings and unfavorable outcome was investigated. The primary endpoint was 28-day mortality. The secondary endpoint was severe disability or death at 90 days, defined by a score of 4-6 on the modified Rankin scale., Results: A total of 122 patients were included, of whom 35 (29%) received cardiopulmonary resuscitation before VA-ECMO cannulation. Main std EEG findings included low background frequency ≤ 4 Hz (n = 27, 22%) and background abnormalities, i.e., a discontinuous (n = 20, 17%) and/or an unreactive background (n = 12, 10%). Background abnormalities displayed better performances for prediction of unfavorable outcomes, as compared to clinical parameters at time of recording. An unreactive std EEG background in combination with a background frequency ≤ 4 Hz had a false positive rate of 0% for prediction of unfavorable outcome at 28 days and 90 days, with sensitivities of 8% and 6%, respectively. After adjustment for confounders, a lower background frequency was independently associated with unfavorable outcome at 28 days (adjusted odds ratio per 1-Hz increment, 95% CI 0.71, 0.52-0.97), whereas no such independent association was observed at 90 days., Conclusion: Standard EEG abnormalities recorded at time of VA-ECMO initiation are predictive of unfavorable outcomes. However, the low sensitivity of these parameters highlights the need for a multimodal evaluation for improving management of care and prognostication.

Objectives: We aimed to determine if elevations in serum neuron-specific enolase are associated with brain injury and outcomes in adults who require venoarterial extracorporeal membrane oxygenation., Design: Prospective observational study., Setting: Two ICUs of a university hospital, Paris, France., Patients: Consecutive adult patients treated with venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock or in-hospital refractory cardiac arrest., Interventions: None., Measurements and Main Results: Serum sampled 1, 3, and 7 days after venoarterial extracorporeal membrane oxygenation cannulation was stored at -80°C and neuron-specific enolase concentrations were measured in batches at the end of the study. The association between neuron-specific enolase concentrations and outcomes (28-d mortality and poor outcome, defined by a score of 4-6 on the modified Rankin scale at 90 d) were explored by multivariable logistic regression, with neuron-specific enolase concentrations dichotomized according to median values. One-hundred three patients were included, of whom 26 (25%) received preextracorporeal membrane oxygenation cardiopulmonary resuscitation. Median (interquartile range) day-1, day-3, and day-7 neuron-specific enolase serum concentrations were 37 μg/L (26-51 μg/L), 25 μg/L (19-37) μg/L, and 22 μg/L (17-31 μg/L). After adjustment for Simplified Acute Physiology Score II, preextracorporeal membrane oxygenation cardiopulmonary resuscitation, and Sepsis Organ Failure Assessment score at time of cannulation, a day-3 neuron-specific enolase greater than 25 μg/L remained independently associated with 28-day mortality (adjusted odds ratio, 4.98; 95% CI, 1.86-13.32) and poor outcome at 90 days (adjusted odds ratio, 4.63; 95% CI, 1.81-11.84). A day-3 neuron-specific enolase threshold greater than 80 μg/L had a 100% specificity for prediction of both mortality (95% CI, 92-100%) and poor functional outcome (95% CI, 89-100%). In a subset of patients who underwent brain CT, neuron-specific enolase concentrations were significantly higher in patients diagnosed with stroke, as compared with those without stroke., Conclusions: In adult patients under venoarterial extracorporeal membrane oxygenation, day-3 serum neuron-specific enolase concentrations are independently associated with short-term mortality and poor functional outcomes. These findings deserve validation in a multicenter setting., Competing Interests: Dr. Sonneville received grants from the French Ministry of Health, the French Society of Intensive Care Medicine (Société de Réanimation de Langue Française) and the European Society of Intensive Care Medicine, and lecture fees from Baxter. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Objectives: Despite rapid implementation of anti-arrhythmic treatment and sedation and controlling the triggering event, rare patients develop treatment-refractory electrical storm and their hemodynamic instability prevents emergency catheter ablation. In that context, venoarterial extracorporeal membrane oxygenation could rapidly restore hemodynamics and tissue perfusion and reduce myocardial oxygen consumption, until adequate anti-arrhythmic drug levels are reached to safely perform catheter ablation., Design: Retrospective, multicenter study over an 8-year period., Setting: Two French tertiary care centers., Patients: Eighty-three consecutive adults with venoarterial extracorporeal membrane oxygenation-supported treatment-refractory electrical storm (median [interquartile range] age, 55 yr [48-63 yr])., Measurements and Main Results: Fifty-nine percent of these patients had acute ischemic cardiomyopathy and 66% underwent cardiopulmonary resuscitation prior to venoarterial extracorporeal membrane oxygenation initiation, with 18% cannulated during it. Fifty patients (60%) had ventricular tachycardia and/or ventricular fibrillation alternating with short periods of sinus rhythm and 33 (40%) had refractory ventricular tachycardia and/or ventricular fibrillation. Twelve patients (15%) underwent safe catheter ablation under venoarterial extracorporeal membrane oxygenation. After a median of 3 days (1-13 d) on extracorporeal membrane oxygenation support, 37 patients (45%) were successfully weaned off and 42% were alive 6 months post-ICU admission. Multivariable analysis retained ventricular tachycardia and/or ventricular fibrillation episodes alternating with short periods of sinus rhythm (odds ratio, 0.18; 95% CI, 0.06-0.52; p = 0.002) and age less than 50 years (odds ratio, 0.32; 95% CI, 0.18-0.89; p = 0.002) as being independent protective factors with 6-month survival, regardless of the underlying electrical storm cause., Conclusions: Among venoarterial extracorporeal membrane oxygenation-supported drug-refractory electrical storm patients, 42% survived 6 months post-ICU admission. Ventricular tachycardia and/or ventricular fibrillation episodes alternating with short periods of sinus rhythm and age less than 50 years were independently associated with better survival.

Primary cardiac synovial sarcoma is an extremely rare disease. Its prognosis is poor with a median survival time of 24 months, even when adequate and timely treatment is given. This case reports a 61-year-old woman presenting with primary cardiac synovial sarcoma with an 8-year survival time following surgical and adjuvant chemotherapy.

Tracheobronchomegaly is a rare condition characterised by marked dilation of the trachea and the main bronchi. The clinical presentation of this disease is nonspecific and the diagnosis is based on the radiological features, especially computed tomography of chest. Pulmonary function tests are often abnormal showing airflow limitation with increased residual volume. The authors report a rare case of a 31-year-old man presenting tracheobronchomegaly is normal pulmonary function test., (Copyright © 2009 Elsevier Masson SAS. All rights reserved.)

Our study investigated alpha 1 antitrypsin deficiency (AATD) diagnosis in a family originated from central Tunisia and showing a familial history of asthma. Biochemical and genetic diagnosis for AATD was performed according to current diagnostic standards. AAT level quantification in affected individuals showed plasma AAT levels consistent with intermediate AATD (ranged from 0.91 to 1.04 g/L). The molecular analysis was assessed using the genotyping of the most prevalent PI*S and PI*Z SERPINA1 mutations and the sequencing of AAT coding exons for rare AATD variants detection. No PI*S or PI*Z deficient variants were seen in this family. Sequencing results showed the inheritance of the deficient rare variant PI*M(wurzburg) (P369S) at the heterozygous state in the mother and two affected siblings. However, AATD status remains unexplained in the third affected case, with no mutations detected in the AAT coding exons.

Lung cancer is the world's first cause of death by cancer. Locally advanced and metastatic non small cell cancers represent 2/3rd of cases at diagnosis and are of worst prognosis. We conducted a retrospective study of 202 patients to investigate the effect of chemotherapy on survival and quality of life. 95 patients received chemotherapy with VP16-CDDP (88%) or Gemcitabin-CDDP. Improvement survival was observed in the chemotherapy group: 8 month IC 95% [6.6-9.3] 4 month IC 95% [3.1-4.9] in the control group. Chemotherapy also had a good perfect on the quality of life with improvement of performance status, symptoms and need of analgesic. However although significant, the role of chemotherapy in NSCLC remains modest and new therapeutic approaches are needed including prevention and early detection which are probably more effective and cheaper.