Osama Abou-Arab

Aims: Cardiogenic shock (CS) remains associated with high mortality. Severity is traditionally stratified by the Society for Cardiovascular Angiography and Interventions (SCAI) staging system despite substantial heterogeneity within stages. Whether vasoactive therapy intensity or combination provides additional prognostic information beyond SCAI staging remains unknown. This study assessed whether vasoactive support intensity, quantified by the vasoactive–inotropic score (VIS), improves mortality prediction beyond SCAI staging. Methods and results: In this retrospective bicentric cohort, consecutive adults admitted for CS between 2018 and 2023 were included. The VIS was calculated. The primary outcome was 90-day mortality. Multivariable logistic regression models adjusted for baseline severity assessed interactions with SCAI stage and the incremental prognostic value of VIS using nested models. Among 1167 patients, 90-day mortality increased across SCAI stages C, D, and E (20.1%, 27.4%, and 45.6%; P < 0.001, respectively), with substantial heterogeneity within stages. In stage C, dobutamine alone was associated with lower mortality than norepinephrine alone [OR = 0.25 (0.09–0.74); P = 0.009]; in stage E, dobutamine plus norepinephrine was associated with higher mortality [OR = 2.39 (1.07–5.36); P = 0.028]. The number of vasoactive agents was associated with mortality (OR = 1.27 per additional agent; P = 0.041) but proved a crude marker, providing only marginal incremental discrimination (R2 = 0.233; Δ = +0.011), with its prognostic information fully captured by VIS (R2 = 0.286 vs. 0.287 with and without number of agents). Adding SCAI stage minimally improved discrimination (R2 = 0.222–0.226; Δ = +0.004), whereas VIS substantially improved model performance (R2 = 0.286; Δ = +0.060; P < 0.001). Conclusion: Vasoactive intensity quantified by the VIS improved 90-day mortality prediction beyond SCAI staging and the simple count of vasoactive drugs, providing incremental prognostic information beyond SCAI staging.

La dysfonction vasculaire est fréquente en postopératoire de chirurgie cardiaque. Les lésions d'ischémie reperfusion et l'inflammation induite sont à l'origine de cette dysfonction bien que des progrès en chirurgie aient été faites pour diminuer l'inflammation. Les soins courants amènent à constater que malgré une optimisation du débit cardiaque et de la pression artérielle moyenne, une production de lactate peut persister témoin d'un métabolisme anaérobie des cellules et facteur de morbi mortalité. Ainsi malgré un contrôle des paramètres macro hémodynamiques, la délivrance en oxygène cellulaire est insuffisante supposant une atteinte micro circulatoire. Le maintien de l'homéostasie des artérioles et des capillaires est nécessaire pour assurer l'oxygénation cellulaire. L'analyse des biomarqueurs endothéliaux en chirurgie cardiaque pourraient aider à diagnostiquer et monitorer la fonction vasculaire. Le syndrome vasoplégique, entité de dysfonction vasculaire, a fait l'objet d'un chapitre de livre pour synthétiser la physiopathologie et la prise en charge thérapeutique. Dans une première étude, nous avons confirmé que la production de monoxyde d'azote (NO) est majorée chez les patients ayant un syndrome vasoplégique après une chirurgie cardiaque. Dans une 2ème étude, nous avons étudié le glycocalyx. Le glycocalyx pourrait avoir un rôle de régulation de la production de NO. Chez les patients avec un syndrome vasoplégique, les produits de dégradation du glycocalyx étaient plus bas suggérant une meilleure préservation. Les angiopoiétines sont impliquées dans la perméabilité capillaire en chirurgie cardiaque avec une fuite lorsque l'angiopoiétine 2 augmente. Dans une 3ème étude, nous avons comparé les angiopoiétines en chirurgie cardiaque et cardiologie interventionnelle après un remplacement de valve. La production de l'angiopoiétine 2 est moindre en cardiologie interventionnelle. La dysfonction vasculaire est de présentation variée mais l'analyse des biomarqueurs peut aider à déceler des mécanismes précis. Les perspectives à venir sont de moduler la réponse inflammatoire pendant une chirurgie cardiaque afin de préserver la fonction vasculaire

Objectives: Prolonged air leaks are common after thoracic surgery and may be managed with synthetic aerostatic devices. This study assessed the impact of the Neoveil patch on air leak duration, hospital stay, and postoperative pneumonia. Methods: We conducted a retrospective monocentric study at Amiens University Hospital including adults undergoing lung resection between 2014 and 2024. Patients were divided into three groups: those receiving Neoveil, those not receiving it because of absence of indication, and those operated before its introduction in 2017. For analysis, the two latter groups were pooled as the Non-Neoveil arm. To address confounding, a propensity score was built from baseline covariates with standardized mean difference >5%, and inverse probability weighting was applied. The primary end-point was air leak duration, assessed with weighted linear regression. Secondary outcomes were hospital stay and postoperative pneumonia, analyzed with weighted linear and logistic regression. Results: Among 1216 patients, 313 (26%) received Neoveil. Compared with the control group, Neoveil use was associated with shorter air leak duration both before adjustment (−1.01 days; P = .0004) and after adjustment (−0.67 days; P = .0042). Hospital stay was also reduced (−1.88 days before adjustment; −1.09 days after adjustment; P = .0022). No significant difference was observed for postoperative pneumonia after adjustment (adjusted Odds Ratio 0.73, 95% Confidence Interval 0.48-1.11; P = .14). Conclusions: Neoveil use was associated with reduced air leak duration and shorter hospital stay following lung resection, without significant impact on pneumonia. These findings support its potential role in enhancing postoperative recovery and highlight the need for confirmation in prospective multicentre studies.

Background: Coronary artery bypass grafting (CABG) is a widely used procedure to treat coronary artery disease, performed either alone or in conjunction with other cardiac procedures. Perioperative myocardial infarction (pMI) remains a major complication after on-pump CABG and negatively influences survival. Its reported incidence varies with the applied definition, and little is known about its prognostic effect in combined surgeries. Objective: The aim of this study was to investigate the impact of pMI on 5-year survival after isolated or combined on-pump CABG. Methods: We retrospectively reviewed adult patients undergoing urgent or elective CABG with cardiopulmonary bypass at Amiens University Hospital between 2013 and 2017. Diagnosis of pMI followed the Fourth Universal Definition of myocardial infarction. The primary outcome was all-cause death within 5 years. Logistic regression and Cox proportional hazards analyses were performed, and inverse probability weighting based on propensity scores was used to minimize confounding. Results: Out of 712 patients, 112 (16%) experienced pMI. Five-year mortality was 32% in the pMI subgroup compared with 11% in those without pMI (p < 0.001). Before adjustment, pMI was associated with higher long-term mortality (HR = 2.62, 95%CI [1.73–4.00], p < 0.001). This effect persisted after weighting (HR = 2.43, 95% CI [1.56–3.78], p = 0.041). A landmark analysis excluding the first 30 postoperative days showed no significant link with later mortality (HR = 1.13, 95%CI [0.54–2.34], p = 0.74). Independent predictors of pMI included active smoking (OR = 2.24, 95% CI [1.36–3.69], p = 0.001) and prolonged bypass duration (>180 min) (OR = 2.57, 95% CI [1.19–5.34], p = 0.015). Conclusions: When defined by the Fourth Universal Definition, pMI was independently related to increased 5-year mortality following CABG, explained mainly by deaths occurring early after surgery.

Background: Intraoperative hypotension is a strong predictor of adverse outcomes in major abdominal surgery. However, data on the occurrence of intraoperative hypotension during the induction of general anesthesia are scarce. We hypothesized that early prevention of postinduction hypotension using a vasopressor could reduce postoperative adverse outcomes. Methods: In this single-center randomized trial at Amiens Hospital University (Amiens, France), adults older than 50 yr with American Society of Anesthesiologists (Schaumburg, Illinois) Physical Status II or greater undergoing major abdominal surgery were assigned to ephedrine or norepinephrine groups. In the ephedrine group, titration with iterative boluses of ephedrine (3 mg · ml ^-1 ) was performed at the induction if intraoperative hypotension occurred. In the norepinephrine group, continuous intravenous injection of norepinephrine (0.016 mg · ml ^-1 ) was started at a rate of 0.48 mg · h ^-1 from the induction of anesthesia and was titrated if intraoperative hypotension occurred. The primary endpoint was any medico-surgical complication within 30 days (Clavien–Dindo score of 1 or greater). Secondary endpoints included hospital stay length, acute kidney injury, 1-month mortality, and cardiovascular, respiratory, neurologic, and infectious complications. Results were assessed by blinded evaluators. Results: A total of 500 patients were randomized, and 473 were included in the intention-to-treat analysis. The cumulative episodes of intraoperative hypotension were significantly lower in the norephedrine group in comparison to the ephedrine group (respectively, 35 [15%] vs. 176 [74%]; P < 0.001). The primary endpoint occurred in 137 patients (58%) in the ephedrine group and 103 patients (44%) in the norepinephrine group (relative risk, 0.58 [0.40 to 0.83]; P = 0.004). No significant differences were observed in secondary endpoints, except for pulmonary complications, which were lower in the norepinephrine group than in the ephedrine group (respectively; 40 [17%] vs. 74 [31%]; relative risk, 0.46 [0.29; 0.70]; P < 0.001). Conclusions: Prophylactic titrated norepinephrine infusion to prevent postinduction hypotension was more effective than repeated ephedrine boluses and may reduce postoperative complications in major abdominal surgery.