Publications by authors named "Éric Charbonneau"

39 Publications

Effect of Acute Immunosuppression on Left Ventricular Recovery and Mortality in Fulminant Viral Myocarditis: A Case Series and Review of Literature.

CJC Open 2021 Mar 11;3(3):292-302. Epub 2020 Nov 11.

Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada.

Background: Fulminant viral myocarditis (FVM) is a rare cause of cardiogenic shock associated with high morbidity and mortality rates. An inappropriately activated immune system results in severe myocardial inflammation. Acute immunosuppressive therapy for FVM therefore gained in popularity and was described in numerous retrospective studies.

Methods: We conducted an extensive review of the literature and compared it with our single-centre retrospective review of all cases of FVM from 2009-2019 to evaluate the possible effect of acute immunosuppression with intravenous immunoglobulins and/or high dose corticosteroids in patients with FVM.

Results: We report on 17 patients with a mean age of 46 ± 15 years with a mean left ventricular ejection fraction (LVEF) of 15 ± 9% at admission. Fourteen (82%) of our patients had acute LVEF recovery to ≥ 45% after a mean time from immunosuppression of 74 ± 49 hours (3.1 days). Extracorporeal membrane oxygenation (ECMO) was required in 35% (6/17) of our patients for an average support of 126 ± 37 hours. Overall mortality was 12% (2/17). No patient needed a long-term left ventricular assist device or heart transplant. All surviving patients achieved complete long-term LVEF recovery.

Conclusions: Our cohort of 17 severely ill patients received acute immunosuppressive therapy and showed a rapid LVEF recovery, short duration of ECMO support, and low mortality rate. Our suggested scheme of investigation and treatment is presented. These results bring more cases of successfully treated FVM with immunosuppression and ECMO to the literature, which might stimulate further prospective trials or a registry.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cjco.2020.10.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985012PMC
March 2021

Non-invasive diagnostic imaging tests largely underdiagnose cardiac cirrhosis in patients undergoing advanced therapy evaluation: How can we identify the high-risk patient?

Clin Transplant 2021 Mar 7:e14277. Epub 2021 Mar 7.

Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Canada.

Background: Patients with liver cirrhosis are generally considered ineligible for isolated cardiac transplantation or left ventricular assist device (LVAD) implantation. The aim of this retrospective study is to explore the diagnostic value of abdominal ultrasound, computed tomography scan (CT scan) and liver-spleen scintigraphy to detect the presence of cirrhosis in patients with advanced heart failure.

Methods: Among 567 consecutive patients who underwent pre-transplantation or LVAD evaluation, 54 had a liver biopsy to rule out cardiac cirrhosis; we compared the biopsy results with the imaging investigations.

Results: In about 26% (n = 14) of patients undergoing liver biopsy, histopathological evaluation identified cirrhosis. The respective sensitivity of abdominal ultrasound, CT scan and liver-spleen scintigraphy to detect cirrhosis was 57% [29-82], 50% [16-84], and 25% [3-65]. The specificity was 80% [64-91], 89% [72-98], and 44% [20-70], respectively.

Conclusion: Ultrasonography has the best-combined sensitivity and specificity for the diagnosis of cirrhosis. However, more than a third of patients with cirrhosis will go undiagnosed by conventional imaging. As liver biopsy is associated with a low rate of complication, it should be considered in patients with a high-risk of cirrhosis or with evidence of portal hypertension to assess their eligibility for heart transplantation or LVAD implantation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ctr.14277DOI Listing
March 2021

Usefulness of Left Ventricular Assist Device in the Recovery of Severe Amphetamine-Associated Dilated Cardiomyopathy.

Can J Cardiol 2020 02 12;36(2):317.e5-317.e7. Epub 2019 Oct 12.

Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Quebec, Canada. Electronic address:

Exposure to synthetic drugs such as amphetamines may lead to significant consequences on the cardiovascular system. The prognosis of young adults with amphetamine-induced cardiomyopathy remains poor. We present 2 young patients (aged <40 years) who developed severe dilated cardiomyopathy after chronic amphetamine use. Thorough psychological evaluations demonstrated favorable features with patients being reliable and committed to their health problems. A left ventricular assist device (HeartMate II; Abbott, Chicago, IL) was implanted in the patients shortly after admission to optimize hemodynamic support and evaluate the potential for recovery. Within less than 1 year, significant improvement was achieved and successful explantation of left ventricular assist device was performed in both patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cjca.2019.09.024DOI Listing
February 2020

Do Energy Drinks Really Give You Wings? Left Ventricular Assist Device Therapy as a Bridge to Recovery for an Energy Drink-Induced Cardiomyopathy.

Can J Cardiol 2020 02 27;36(2):317.e1-317.e3. Epub 2019 Sep 27.

Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada. Electronic address:

The deleterious effect of energy drinks is increasingly recognized. We present a 26-year-old woman with inotrope-dependent severe dilated cardiomyopathy, potentially caused by chronic ingestion of energy drinks. The results of extensive investigation-consisting of cardiac magnetic resonance, F-18-fluorodesoxyglucose-positron emission tomography, coronary angiography, and endomyocardial biopsy-were normal. A left ventricular assist device (LVAD) was implanted as a potential bridge to recovery. After 10 months of mechanical support and pharmacological treatment, cardiac function was recovered, and the LVAD was successfully explanted. This is the first case report of energy drink abuse leading to severe heart failure requiring mechanical support for recovery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cjca.2019.09.011DOI Listing
February 2020

Clinical and echocardiographic presentation of postmyocardial infarction papillary muscle rupture.

Echocardiography 2019 07 17;36(7):1322-1329. Epub 2019 Jun 17.

Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Quebec, Canada.

Background: Severe mitral regurgitation (MR) can occur following myocardial infarction (MI) with either partial or complete papillary muscle rupture (pPMR or cPMR). Although the incidence of this complication has significantly decreased, it is still associated with significant mortality. We sought to evaluate the different echocardiographic and clinical presentations of pPMR and cPMR.

Methods And Results: A review of all the urgent procedures for ischemic MR between January 2000 and June 2016 was performed to identify patients who underwent surgery for PMR. Surgical protocols and echocardiographic studies were used to identify patients with cPMR and pPMR. A total of 37 patients had cardiac surgery for PMR (18 cPMR, 19 pPMR). All patients with cPMR were in cardiogenic shock at the time of diagnosis, as opposed to only 53% of patients with pPMR (P = 0.0008). Between the time of diagnosis and surgery, 7 patients with pPMR developed cardiogenic shock. Transthoracic echocardiography (TTE) led to the diagnosis in 72% of cPMR and 32% of pPMR (P = 0.02). TEE had a yield of 100% for both cPMR and pPMR. Six pathologic varieties of post-MI PMR were recognized on echocardiography and during surgery. Early postoperative, 1 (72% vs 84%), 3 (67% vs 84%), and 5 years (67% vs 74%) survival rates were similar for cPMR and pPMR (P = 0.26).

Conclusions: Partial PMR is associated with a different clinical and echocardiographic presentation than cPMR. Still, most pPMR patients progress toward cardiogenic shock. Prompt diagnosis and referral for surgery are critical and could potentially decrease mortality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/echo.14402DOI Listing
July 2019

Intramyocardial Injection of Mesenchymal Precursor Cells and Successful Temporary Weaning From Left Ventricular Assist Device Support in Patients With Advanced Heart Failure: A Randomized Clinical Trial.

JAMA 2019 03;321(12):1176-1186

Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina.

Importance: Left ventricular assist device (LVAD) therapy improves myocardial function, but few patients recover sufficiently for explant, which has focused attention on stem cells to augment cardiac recovery.

Objective: To assess efficacy and adverse effects of intramyocardial injections of mesenchymal precursor cells (MPCs) during LVAD implant.

Design, Setting, And Participants: A randomized phase 2 clinical trial involving patients with advanced heart failure, undergoing LVAD implant, at 19 North American centers (July 2015-August 2017). The 1-year follow-up ended August 2018.

Interventions: Intramyocardial injections of 150 million allogeneic MPCs or cryoprotective medium as a sham treatment in a 2:1 ratio (n = 106 vs n = 53).

Main Outcomes And Measures: The primary efficacy end point was the proportion of successful temporary weans (of 3 planned assessments) from LVAD support within 6 months of randomization. This end point was assessed using a Bayesian analysis with a predefined threshold of a posterior probability of 80% to indicate success. The 1-year primary safety end point was the incidence of intervention-related adverse events (myocarditis, myocardial rupture, neoplasm, hypersensitivity reactions, and immune sensitization). Secondary end points included readmissions and adverse events at 6 months and 1-year survival.

Results: Of 159 patients (mean age, 56 years; 11.3% women), 155 (97.5%) completed 1-year of follow-up. The posterior probability that MPCs increased the likelihood of successful weaning was 69%; below the predefined threshold for success. The mean proportion of successful temporary weaning from LVAD support over 6 months was 61% in the MPC group and 58% in the control group (rate ratio [RR], 1.08; 95% CI, 0.83-1.41; P = .55). No patient experienced a primary safety end point. Of 10 prespecified secondary end points reported, 9 did not reach statistical significance. One-year mortality was not significantly different between the MPC group and the control group (14.2% vs 15.1%; hazard ratio [HR], 0.89; 95%, CI, 0.38-2.11; P = .80). The rate of serious adverse events was not significantly different between groups (70.9 vs 78.7 per 100 patient-months; difference, -7.89; 95% CI, -39.95 to 24.17; P = .63) nor was the rate of readmissions (0.68 vs 0.75 per 100 patient-months; difference, -0.07; 95% CI, -0.41 to 0.27; P = .68).

Conclusions And Relevance: Among patients with advanced heart failure, intramyocardial injections of mesenchymal precursor cells, compared with injections of a cryoprotective medium as sham treatment, did not improve successful temporary weaning from left ventricular assist device support at 6 months. The findings do not support the use of intramyocardial mesenchymal stem cells to promote cardiac recovery as measured by temporary weaning from device support.

Trial Registration: clinicaltrials.gov Identifier: NCT02362646.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jama.2019.2341DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439694PMC
March 2019

Post esophagectomy diaphragmatic hernia: a case report of a rare cause of acute respiratory distress.

J Cardiothorac Surg 2018 Nov 15;13(1):114. Epub 2018 Nov 15.

Service of Cardiac Surgery, Multidisciplinary Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, QC, Canada.

Background: Diaphragmatic hernia is frequent among the elderly and is usually associated with mild chronic digestive and respiratory symptoms.

Case Presentation: An elderly post-esophagectomy male patient, in the early postoperative period of cardiac surgery, presented with acute respiratory distress. An emergent surgery was performed to reduce a giant diaphragmatic herniation.

Conclusions: An acute transhiatal herniation can cause serious respiratory impairment; surgical repair should be considered in select patients of cardiac surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13019-018-0802-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6238405PMC
November 2018

Cardiac Implantable Electronic Device Infection: Detailed Analysis of Cost Implications.

Can J Cardiol 2018 08 7;34(8):1026-1032. Epub 2018 May 7.

Electrophysiology Division, Institut Universitaire de cardiologie et de pneumologie de Québec, Québec, Canada. Electronic address:

Background: Infections of cardiac implantable electronic devices (CIED) are associated with significant morbidity and mortality. Despite many preventive measures, this condition is associated with significant costs for the health care system.

Methods: We retrospectively analyzed all infection cases referred for lead extraction at a single university hospital over 1 year (2015-2016). We then calculated all costs related to the infection episode per patient using hospital databases and charts review.

Results: Thirty-eight patients with CIED infections (29% women-mean age 71 ± 14 years) were referred for lead extraction (27 pocket infections, 11 endocarditis). Devices were mainly pacemakers (60%). When the pathogen was identified, Staphylococcus aureus methicillin sensitive was the main cause. Extraction was performed in all but 3 cases (92%). One death occurred in the nonextracted group. Respective durations of hospitalization and intravenous and antibiotic administration for patients undergoing extraction were 21 and 36 days. The calculated mean total cost for CIED infection management was CAD$29,907 (median: 26,879; range: CAD$4,827-$62,585). Mean hospital charges were CAD$12,291, accounting for 41% of the total costs.

Conclusions: This study represents the first analysis of the direct costs associated with lead extraction in Canada. Device infections are associated with significant costs and increased morbidity. Any preventive measure will have a significant impact on the economic burden of the health care system and patient outcome after lead extraction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cjca.2018.05.001DOI Listing
August 2018

Pregnancy after heart transplantation: a well-thought-out decision? The Quebec provincial experience - a multi-centre cohort study.

Transpl Int 2018 Feb 26. Epub 2018 Feb 26.

Research Center, Montreal Heart Institute, University of Montreal, Montreal, QC, Canada.

Despite reports of successful pregnancies in heart transplant (HTx) recipients, many centers recommend their patients against maternity. We reviewed our provincial experience of pregnancy in HTx recipients by performing charts review of all known gestations following HTx in the province of Quebec (Canada), stratified between planned and unplanned pregnancies. Long-term survival was compared to HTx recipient women of childbearing age who did not become pregnant. Eighteen pregnancies, 56% unplanned, occurred in eight patients, 10.1 (2.6-27.0) years after HTx. Immunosuppression was CNI-based, with a mean dose increase of 48.3% (tacrolimus) and 26.5% (cyclosporine), without rejection. Cardiometabolic complications were high compared to the general Canadian population, including preeclampsia (15.4% vs. 5.5%), hypertension (38.5% vs. 4.6%), and diabetes (15.4% vs. 5.6%). Mean gestational age was 35.1 (23.4-39.6) weeks (72.2% live births; 53.8% prematurity). Mean birthweight was 2418 (660-3612) g. Serum creatinine increased during pregnancy, becoming significant after delivery (P = 0.0239), and returning to preconception level in all but three patients within a year. After 4.6 (1.2-17.2) years of follow-up, two rejection episodes occurred in one patient. Long-term mortality was similar to overall HTx women (Kaplan-Meier; P = 0.8071). Pregnancy in HTx carries high cardiometabolic complications and decreased kidney function, but is feasible with acceptable outcomes and no impact on mother's survival.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/tri.13144DOI Listing
February 2018

Mitral Annular Calcification and Mitral Valve Replacement: A New Approach.

Ann Thorac Surg 2018 Feb;105(2):e55-e57

Service of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada. Electronic address:

Mitral valve replacement is technically challenging in the context of mitral annular calcification. A new surgical strategy is described that was used in a 71-year-old obese patient, where intraatrial prosthesis insertion and valve fixation into native uncalcified structures were performed without calcium debridement.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2017.09.028DOI Listing
February 2018

Implication of Inflammation and Epigenetic Readers in Coronary Artery Remodeling in Patients With Pulmonary Arterial Hypertension.

Arterioscler Thromb Vasc Biol 2017 08 4;37(8):1513-1523. Epub 2017 May 4.

From the Pulmonary Hypertension and Vascular Biology Research Group of the Quebec Heart and Lung Institute (J.M., M.-C.L., V.N., M.M., F.P., C.L., E.T., G.V., S.B.-B., O.B., S.P., R.P., S.B.) and the Division of Cardiac Surgery of the Quebec Heart and Lung Institute (E.C.), Laval University, Department of Medicine, Quebec, Canada.

Objective: Pulmonary arterial hypertension (PAH) is a vascular disease not restricted to the lungs. Many signaling pathways described in PAH are also of importance in other vascular remodeling diseases, such as coronary artery disease (CAD). Intriguingly, CAD is 4× more prevalent in PAH compared with the global population, suggesting a link between these 2 diseases. Both PAH and CAD are associated with sustained inflammation and smooth muscle cell proliferation/apoptosis imbalance and we demonstrated in PAH that this phenotype is, in part, because of the miR-223/DNA damage/Poly[ADP-ribose] polymerase 1/miR-204 axis activation and subsequent bromodomain protein 4 (BRD4) overexpression. Interestingly, BRD4 is also a trigger for calcification and remodeling processes, both of which are important in CAD. Thus, we hypothesize that BRD4 activation in PAH influences the development of CAD.

Approach And Results: PAH was associated with significant remodeling of the coronary arteries in both human and experimental models of the disease. As observed in PAH distal pulmonary arteries, coronary arteries of patients with PAH also exhibited increased DNA damage, inflammation, and BRD4 overexpression. In vitro, using human coronary artery smooth muscle cells from PAH, CAD and non-PAH-non-CAD patients, we showed that both PAH and CAD smooth muscle cells exhibited increased proliferation and suppressed apoptosis in a BRD4-dependent manner. In vivo, improvement of PAH by BRD4 inhibitor was associated with a reduction in coronary remodeling and interleukin-6 expression.

Conclusions: Overall, this study demonstrates that increased BRD4 expression in coronary arteries of patient with PAH contributes to vascular remodeling and comorbidity development.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/ATVBAHA.117.309156DOI Listing
August 2017

Prevalence and Impact of Prosthesis-Patient Mismatch Following Surgical Aortic Valve Replacement for Pure Aortic Regurgitation.

J Heart Valve Dis 2016 09;25(5):543-551

Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Quebec, Canada. Electronic correspondence:

Background: Prosthesis-patient mismatch (PPM) is highly prevalent among patients undergoing aortic valve replacement (AVR) to treat aortic stenosis. Data regarding the prevalence and impact of PPM on left ventricular remodeling and outcomes in patients who have undergone surgical AVR to treat pure severe aortic regurgitation (AR) are, however, scarce.

Methods: A retrospective analysis was conducted of clinical and echocardiographic data acquired from 50 consecutive patients with pure severe AR, without evidence of significant coronary artery disease, who underwent AVR between 2004 and 2010 at the authors' institution. PPM was defined as a projected in vivo effective orifice area (EOA) 0.85 cm2/m2.

Results: The incidence of PPM was 16%, but no severe mismatch occurred. At a mean follow up of 52 ± 39 months, event-free survival (a composite of all-cause mortality and hospitalization for cardiovascular causes) was similar between patients with and without PPM (p = 0.73). Within seven days after surgery, mean reductions in indexed left ventricular end-diastolic diameter (LVEDD) and indexed left ventricular end-systolic diameter (LVESD) were similar between patients with and without PPM [4.4 mm/m2 versus 5.0 mm/m2; p = 0.67 and 1.6 mm/m2 versus 2.2 mm/m2; p = 0.35, respectively]. At follow up, no difference was observed for mean reductions in indexed LVEDD and indexed LVESD [6.9 mm/m2 versus 7.1 mm/m2; p = 0.91 and 4.1 mm/m2 versus 5.1 mm/m2; p = 0.57, respectively], and mean improvement in left ventricular ejection fraction (4.4% versus 5.1%; p = 0.87).

Conclusions: PPM occurs less frequently in patients undergoing AVR for pure severe AR than for aortic stenosis, and seems to have a less significant impact on ventricular remodeling and outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
September 2016

Usefulness of cardiac resynchronization therapy in the recovery of patients with left ventricular assist devices.

Int J Cardiol 2016 Nov 12;223:297-298. Epub 2016 Aug 12.

Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec City, Quebec, Canada. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijcard.2016.08.197DOI Listing
November 2016

Risk factors of mortality after surgical correction of ventricular septal defect following myocardial infarction: Retrospective analysis and review of the literature.

Int J Cardiol 2016 Mar 14;206:27-36. Epub 2015 Dec 14.

Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Canada. Electronic address:

Background: Rupture of the ventricular septum following acute myocardial infarction (AMI) is an uncommon but serious complication, usually leading to congestive heart failure and cardiogenic shock. Surgical repair is the only definitive treatment for this condition.

Methods: We review our experience of surgical repair of post-infarction ventricular septal defects (VSDs), analyze the associated risk factors and outcomes, and do a complete review of the literature. A retrospective study was performed on 34 consecutive patients who had undergone surgical repair for VSDs following AMI from December 1991 to July 2014. Preoperative, clinical and echocardiographic variables were studied by uni-and multivariate analyses.

Results: Mortality was analyzed for the entire group of patients. Mean age was 69 ± 7 years with 44% women. VSDs were anterior in 11 (32%) and posterior in 23 (68%) patients. A majority, 24 (71%) patients were in cardiogenic shock. Median interval from myocardial infarction to VSDs repair was 7 days. The 30 days operative mortality was 65%. Mortality within the posterior VSDs group was 74% and the anterior VSDs group was 46% (P=0.14). Concomitant coronary artery bypass graft (CABG) did not influence early or late survival. Multivariate analysis identified older age (HR=1.11, P=0.0001) and shorter time between AMI and surgery (HR=0.90, P=0.015) as independent predictors of 30-day and long-term mortality.

Conclusion: In conclusion, surgical repair of post-AMI VSDs carries a high operative mortality. An algorithm of treatment for the management of these patients is suggested.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijcard.2015.12.011DOI Listing
March 2016

Extra-anatomic Course of a Right Ventricular Pacing Lead: Clinical Implications.

Can J Cardiol 2016 06 17;32(6):830.e5-6. Epub 2015 Jul 17.

Electrophysiology Division, Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Québec City, Québec, Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cjca.2015.06.036DOI Listing
June 2016

Impact of the Radial Artery as an Additional Arterial Conduit During In-Situ Bilateral Internal Mammary Artery Grafting: A Propensity Score-Matched Study.

Ann Thorac Surg 2016 Mar 11;101(3):913-8. Epub 2015 Nov 11.

Division of Cardiac Surgery, Quebec Heart and Lung University Institute, Quebec City, Quebec, Canada.

Background: Bilateral internal mammary artery (BIMA) grafting has been associated with improved long-term outcomes after CABG. We sought to evaluate the early results and long-term survival among coronary artery bypass graft patients who underwent in-situ BIMA grafting with the radial artery (RA) as an additional arterial conduit compared with those who underwent BIMA with additional saphenous vein graft (SVG).

Methods: Between 1991 and 2013, 1,750 consecutive patients with triple-vessel disease or left main plus right coronary system disease underwent primary isolated in-situ BIMA grafting with at least one internal mammary artery to the left anterior descending artery. Patients were divided into a BIMA-RA group (n = 255) and BIMA-SVG group (n = 1,495). Propensity score matching was used to create two comparable cohorts: 249 BIMA-RA patients were one-to-one-matched to 249 BIMA-SVG patients. The date of death was obtained from provincial vital statistics. The median follow-up was 8 years.

Results: There was no difference in operative mortality between matched BIMA-RA and BIMA-SVG (0.8% versus 0.4%, respectively; p = 0.6). Five-year, 10-year, and 15-year survival rates were 98.3%, 92.0%, and 92.0%, respectively, among BIMA-RA patients, versus 96.5%, 93.0%, and 87.0% in the matched BIMA-SVG group (log rank p = 0.44). When we stratified the BIMA-RA patients into subgroups according to the severity of target artery stenosis, late survival was also similar among the BIMA-RA subgroups matched to BIMA-SVG patients (log rank p = 0.12).

Conclusions: The use of the RA as an additional arterial graft in patients undergoing coronary artery bypass graft surgery with in-situ BIMA does not prolong late survival when compared with BIMA patients who received additional SVG.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2015.08.054DOI Listing
March 2016

Surgical aortic valve replacement outcomes in the transcatheter era.

J Thorac Cardiovasc Surg 2015 Dec 26;150(6):1582-8. Epub 2015 Sep 26.

Division of Cardiac Surgery, Quebec Heart and Lung University Institute, Laval University, Quebec City, Quebec, Canada. Electronic address:

Background: The primary objective of this study was to evaluate the influence of transcatheter aortic valve implantation (TAVI) on the characteristics and outcomes of patients undergoing surgical aortic valve replacement (SAVR) in a single high-volume Canadian center.

Methods: Between January 2003 and December 2013, 1593 patients underwent isolated SAVR at our institution. The study period was divided into 2 distinct cohorts of patients undergoing SAVR: before (n = 529) and after (n = 1064) the first TAVI procedure in May 2007. We compared the risk profiles and clinical outcomes of the 2 cohorts and assessed the multivariate predictors of in-hospital mortality.

Results: The ratio of isolated SAVR to the total number of cardiac surgery cases per year rose significantly after the introduction of TAVI (7.2% vs 9.1%; P < .0001). There was significantly more diabetes, obesity, recent myocardial infarction, and use of a bioprosthesis among SAVR patients in the post-TAVI era (all P values < .05). In-hospital mortality decreased significantly among SAVR patients following the introduction of TAVI (3.6% vs 1.8%; P = .03). Independent risk factors for in-hospital mortality among the entire study population were SAVR in the pre-TAVI era, baseline creatinine, age, and prosthesis size ≤ 21 mm for the pre-TAVI group only.

Conclusions: The number of isolated SAVR cases increased following the introduction of TAVI. There was a significant reduction in operative mortality of SAVR in the post-TAVI era despite greater severity of several markers of risk. Patient referrals for TAVI should take into consideration the changing risk profiles and improved results of conventional surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jtcvs.2015.08.077DOI Listing
December 2015

Downregulation of MicroRNA-126 Contributes to the Failing Right Ventricle in Pulmonary Arterial Hypertension.

Circulation 2015 Sep 10;132(10):932-43. Epub 2015 Jul 10.

From Pulmonary Hypertension Research Group of the Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Quebec City, QC, Canada (F.P., G.R., A.D., C.T., S.B.-B., E.T., V.N., R. Paradis, C.G., R.W., I.J., A.C.L., J.P., E.C., P.J., P.P., S.P., S.B.); and Vascular Biology Research Group, Department of Medicine, University of Alberta, Edmonton, AB, Canada (R. Paulin, E.D.M.).

Background: Right ventricular (RV) failure is the most important factor of both morbidity and mortality in pulmonary arterial hypertension (PAH). However, the underlying mechanisms resulting in the failed RV in PAH remain unknown. There is growing evidence that angiogenesis and microRNAs are involved in PAH-associated RV failure. We hypothesized that microRNA-126 (miR-126) downregulation decreases microvessel density and promotes the transition from a compensated to a decompensated RV in PAH.

Methods And Results: We studied RV free wall tissues from humans with normal RV (n=17), those with compensated RV hypertrophy (n=8), and patients with PAH with decompensated RV failure (n=14). Compared with RV tissues from patients with compensated RV hypertrophy, patients with decompensated RV failure had decreased miR-126 expression (quantitative reverse transcription-polymerase chain reaction; P<0.01) and capillary density (CD31(+) immunofluorescence; P<0.001), whereas left ventricular tissues were not affected. miR-126 downregulation was associated with increased Sprouty-related EVH1 domain-containing protein 1 (SPRED-1), leading to decreased activation of RAF (phosphorylated RAF/RAF) and mitogen-activated protein kinase (MAPK); (phosphorylated MAPK/MAPK), thus inhibiting the vascular endothelial growth factor pathway. In vitro, Matrigel assay showed that miR-126 upregulation increased angiogenesis of primary cultured endothelial cells from patients with decompensated RV failure. Furthermore, in vivo miR-126 upregulation (mimic intravenous injection) improved cardiac vascular density and function of monocrotaline-induced PAH animals.

Conclusions: RV failure in PAH is associated with a specific molecular signature within the RV, contributing to a decrease in RV vascular density and promoting the progression to RV failure. More importantly, miR-126 upregulation in the RV improves microvessel density and RV function in experimental PAH.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCULATIONAHA.115.016382DOI Listing
September 2015

Lessons learned from the use of 1,977 in-situ bilateral internal mammary arteries: a retrospective study.

J Cardiothorac Surg 2014 Sep 20;9:158. Epub 2014 Sep 20.

Division of Cardiac Surgery, Quebec Heart and Lung Institute, Quebec City, QC, Canada.

Background: We sought to determine the early and long-term results of in-situ bilateral internal mammary artery (BIMA) grafting in patients undergoing coronary artery bypass graft surgery (CABG).

Methods: Between 1992 and 2011, 16,364 patients underwent primary isolated CABG involving at least one in-situ IMA at our institution. Among these, 1,977 patients underwent in-situ BIMA grafting: the right IMA was used to revascularize the right coronary artery system in 1,279, the circumflex system in 454 patients, and the left anterior descending (LAD) in 244. Logistic and Cox regression analyses were used to predict in-hospital mortality and cumulative late death.

Results: Late survival among BIMA patients was negatively and independently influenced by chronic obstructive pulmonary disease (hazard ratio (HR) 2.4, 95% confidence interval (CI) 1.6-3.4, p = 0.0005), age (HR 1.2, 95% CI 1.1-1.3, p < 0.001), and mediastinitis (HR 2.1, 95% CI 1.1-4.2, p < 0.03). Gender, body mass index, diabetes, choice of target for the second (non-LAD) IMA, and conduit grafted to the LAD (RIMA vs. LIMA) did not influence late survival among BIMA patients. A BIMA grafting strategy was significantly beneficial for younger patients. However, it was not associated with superior late survival for patients aged 66 years and above at the time of CABG, and showed a trend to harm among octogenarians (HR 1.05, 95% CI 0.70-1.56, p = 0.80).

Conclusions: Female gender, non-insulin dependent diabetes, and the site of second IMA anastomosis did not influence early and long-term outcomes in patients undergoing CABG with in-situ BIMA grafting. The right and left IMAs are equally effective conduits for the LAD. However, advanced age, chronic obstructive pulmonary disease, and insulin-treated diabetes mellitus have a negative impact on late survival among patients with BIMA grafts.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13019-014-0158-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4177259PMC
September 2014

Predictors and prognosis of early ischemic mitral regurgitation in the era of primary percutaneous coronary revascularisation.

Cardiovasc Ultrasound 2014 Apr 3;12:14. Epub 2014 Apr 3.

Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 chemin Sainte-Foy, G1V 4G5 Quebec City, Quebec, Canada.

Background: Studies assessing ischemic mitral regurgitation (IMR) comprised of heterogeneous population and evaluated IMR in the subacute setting. The incidence of early IMR in the setting of primary PCI, its progression and clinical impact over time is still undetermined. We sought to determine the predictors and prognosis of early IMR after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI).

Methods: Using our primary PCI database, we screened for patients who underwent ≥2 transthoracic echocardiograms early (1-3 days) and late (1 year) following primary PCI. The primary outcomes were: (1) major adverse events (MACE) including death, ischemic events, repeat hospitalization, re-vascularization and mitral repair or replacement (2) changes in quantitative echocardiographic assessments.

Results: From January 2006 to July 2012, we included 174 patients. Post-primary PCI IMR was absent in 95 patients (55%), mild in 60 (34%), and moderate to severe in 19 (11%). Early after primary PCI, IMR was independently predicted by an ischemic time > 540 min (OR: 2.92 [95% CI, 1.28 - 7.05]; p = 0.01), and female gender (OR: 3.06 [95% CI, 1.42 - 6.89]; p = 0.004). At a median follow-up of 366 days [34-582 days], IMR was documented in 44% of the entire cohort, with moderate to severe IMR accounting for 15%. During follow-up, MR regression (change ≥ 1 grade) was seen in 18% of patients. Moderate to severe IMR remained an independent predictor of MACE (HR: 2.58 [95% CI, 1.08 - 5.53]; p = 0.04).

Conclusions: After primary PCI, IMR is a frequent finding. Regression of early IMR during long-term follow-up is uncommon. Since moderate to severe IMR post-primary PCI appears to be correlated with worse outcomes, close follow-up is required.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/1476-7120-12-14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3977603PMC
April 2014

Bilateral internal thoracic artery use in patients with low ejection fraction: is there any additional long-term benefit?

Eur J Cardiothorac Surg 2014 Sep 19;46(3):425-31; discussion 431. Epub 2014 Feb 19.

Division of Cardiac Surgery, Quebec Heart and Lung University Hospital, Quebec City, Quebec, Canada.

Objectives: The use of bilateral internal thoracic arteries (BITA) has been associated with improved long-term outcomes following coronary artery bypass graft (CABG) surgery. The objective of this study was to evaluate the impact of BITA use on long-term survival among patients with low ejection fraction (EF) undergoing CABG.

Methods: Between April 1991 and October 2011, 2035 consecutive patients underwent primary BITA grafting. Among them, there were 129 patients with left ventricular EF ≤40%. During the same time period, 1666 primary CABGs were performed using a single internal thoracic artery (SITA) in patients with EF ≤40%. A propensity score optimal matching algorithm was used to create the matched SITA and BITA groups (n = 111 in each group). Also, Cox regression multivariable analyses were performed to determine the independent risk factors for long-term mortality. The date of death was obtained from provincial vital statistics.

Results: There was no difference in operative mortality between matched BITA and SITA (n = 2, 1.8% vs n = 1, 0.9%, respectively, P = 0.6) groups. The mean follow-up was 8.6 ± 5.1 and 7.7 ± 5.5 years for BITA and SITA groups, respectively (P = 0.2). Five-, 10- and 15-year survival rates were 93.7, 77.5 and 59.0% in the matched BITA patients vs 82.8, 68.1 and 65.2% in the matched SITA patients (P = 0.3). In multivariate analysis, the independent risk factors for late mortality among hospital survivors were: insulin-dependent diabetes [adjusted hazard ratio (HR): 3.4, 95% confidence interval (CI): 1.4-8.4, P = 0.008], perioperative intra-aortic balloon pump insertion (HR: 3.2, 95% CI: 1.5-6.9, P = 0.004), postoperative deep sternal wound infection (HR: 7.4, 95% CI: 2.2-24.1, P = 0.001) and neurological complications (HR: 3.5, 95% CI: 1.4-8.4, P = 0.006). Choice of BITA versus SITA was not an independent predictor of long-term mortality (P = 0.3).

Conclusions: The use of a second internal thoracic artery (ITA) does not prolong late survival in patients with low EF undergoing CABG compared with a propensity-matched group of SITA graft patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ejcts/ezu023DOI Listing
September 2014

Should eligibility for heart transplantation be a requirement for left ventricular assist device use? Recommendations based on a systematic review.

Can J Cardiol 2013 Dec 23;29(12):1712-20. Epub 2013 Aug 23.

Institut national d'excellence en santé et en services sociaux (INESSS), Montreal, Québec, Canada. Electronic address:

Left ventricular assist devices (LVADs) are used in chronic end-stage heart failure as "bridge to transplantation" (BTT) and, more recently, for transplant-ineligible patients as "destination therapy" (DT). We reviewed the evidence on clinical effects and cost-effectiveness of 2 types of continuous-flow LVADs (HeartMate II [HM II] and HeartWare), for BTT and DT patients. We systematically searched the scientific literature (January 2008-June 2012) and identified 14 clinical studies (approximately 2900 HM II and approximately 200 HeartWare patients), and 3 economic evaluations (HM II) using simulation models. Data were, however, limited to 2-3 studies per outcome. We made policy recommendations on the basis of our systematic review. Although complications after implantation are frequent, LVAD therapy is often highly effective across transplantation eligibility status and device, with 1-year survival reaching 86% for BTT and 78% for DT (compared with 25% for medical therapy). Neither BTT nor DT currently meet traditional cost-effectiveness limits in models using historical data, although BTT is standard practice for a limited number of patients in many regions. We found that BTT and DT as implantation strategies tend to be no longer mutually exclusive. We conclude that evidence is sufficient to support LVAD use, regardless of transplantation eligibility status, as long as patients are carefully selected and program infrastructure and budget are adequate. However, evidence gaps, limitations in economic models, and the lack of Canadian data point to the importance of mandatory, systematic monitoring of LVAD use and outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cjca.2013.05.014DOI Listing
December 2013

Surgical site infections following transcatheter apical aortic valve implantation: incidence and management.

J Cardiothorac Surg 2012 Nov 13;7:122. Epub 2012 Nov 13.

Department of Cardiac Surgery, Université Laval, Québec City, Qc, Canada.

Objective: The present study was undertaken to examine the incidence and management of surgical site infection (SSI) in patients submitted to transapical transcatheter aortic valve implantation (TA-TAVI).

Methods: From April 2007 to December 2011, 154 patients underwent TA-TAVI with an Edwards Sapien bioprosthesis (ES) at the Institut Universitaire de Cardiologie et Pneumologie de Québec (IUCPQ) as part of a multidisciplinary program to prospectively evaluate percutaneous aortic valve implantation. Patient demographics, perioperative variables, and postoperative complications were recorded in a prospective registry.

Results: Five (3.2%) patients in the cohort presented with an SSI during the study period. The infections were all hospital-acquired (HAI) and were considered as organ/space SSI's based on Center for Disease Control criteria (CDC). Within the first few weeks of the initial procedure, these patients presented with an abscess or chronic draining sinus in the left thoracotomy incision and were re-operated. The infection spread to the apex of the left ventricle in all cases where pledgeted mattress sutures could be seen during debridement. Patients received multiple antibiotic regimens without success until the wound was surgically debrided and covered with viable tissue. The greater omentum was used in three patients and the pectoralis major muscle in the other two. None of the patients died or had a recurrent infection. Three of the patients were infected with Staphylococcus epidermidis, one with Staphylococcus aureus, and one with Enterobacter cloacae. Patients with surgical site infections were significantly more obese with higher BMI (31.4±3.1 vs 26.2±4.4 p=0.0099) than the other patients in the cohort.

Conclusions: While TA-TAVI is a minimally invasive technique, SSIs, which are associated with obesity, remain a concern. Debridement and rib resection followed by wound coverage with the greater omentum and/or the pectoralis major muscle were used successfully in these patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/1749-8090-7-122DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3541989PMC
November 2012

The impact of complete revascularization on long-term survival is strongly dependent on age.

Ann Thorac Surg 2012 Oct 28;94(4):1166-72. Epub 2012 Jun 28.

Hospices Civils de Lyon, Service de Biostatistique, Lyon, France.

Background: Complete revascularization during coronary artery bypass grafting (CABG) has been reported to be associated with better short-term and long-term outcomes. We hypothesized that the survival benefit of complete revascularization would be less in old patients than in young patients.

Methods: We analyzed data from 6,539 consecutive patients who had undergone a first isolated on-pump CABG procedure between 2000 and 2008. We investigated the impact of complete revascularization and its interaction with age on operative and long-term survival using propensity-score-based analyses.

Results: Patients with incomplete (versus complete) revascularization (n=318 [4.9%]) were sicker overall. During a mean follow-up of 5.8±2.2 years, 909 patients died. In the propensity-score-matched analysis, operative mortality was not significantly different between patients with complete revascularization and those with incomplete revascularization (1.9% versus 2.8%; odds ratio [OR], 1.46; 95% confidence interval [CI], 0.56-3.46; p=0.48). In contrast, incomplete revascularization had an independent negative impact on long-term survival, which was strongly age dependent (hazard ratio [HR] for interaction, 0.96 per year increment; p=0.02). In a propensity-score-matched analysis, incomplete revascularization was independently associated with higher long-term mortality in patients younger than 60 years (HR, 3.27; 95% CI, 1.21-8.86; p=0.02), whereas it was not in patients 60 to 70 years and 70 years of age and older (p=0.87 and p=0.24, respectively).

Conclusions: Contrary to what is observed in patients younger than 60 years, complete revascularization does not seem to improve long-term survival in older patients. This suggests that elderly patients at high operative risk may be considered, when deemed clinically appropriate, for limited coronary revascularization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2012.05.023DOI Listing
October 2012

Impact of aortic stenosis severity and its interaction with prosthesis-patient mismatch on operative mortality following aortic valve replacement.

J Heart Valve Dis 2012 Mar;21(2):158-67

Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Department of Cardiology, Laval University, Québec, Canada.

Background And Aim Of The Study: The optimal timing of aortic valve replacement (AVR) in patients with severe aortic stenosis (AS) is a source of debate. Moreover, it has been shown previously that prosthesis-patient mismatch (PPM) is an independent predictor of operative mortality after AVR. The study aim was to assess the effect of the preoperative severity of AS and its interaction with PPM with respect to operative mortality after AVR.

Methods: The data were analyzed from 2,104 consecutive patients who had undergone AVR for severe AS. The patients were allocated to tertiles according to their preoperative indexed aortic valve area (AVAi) as: < 0.35 cm2/m2, 0.35 to 0.43 cm2/m2, and > 0.43 cm2/m2. PPM was defined as a projected postoperative indexed effective orifice area (EOAi) of the implanted prosthesis < 0.85 cm2/m2.

Results: The operative mortality was 5.7% (n = 120). On multivariate analysis, an independent association was identified between the preoperative severity of AS and operative mortality (odds ratio [OR] = 2.00, p = 0.03 for AVAi < 0.35 cm2/m2; OR = 1.39, p = 0.32 for AVAi 0.35-0.43 cm2/m2). Notably, the impact of PPM was more important in patients with more severe AS (p = 0.046 for AVAi x EOAi interaction).

Conclusion: The study results confirmed that very severe AS (AVAi < 0.35 cm2/m2) is independently associated with operative mortality after AVR. The results also emphasized the importance of avoiding PPM in these patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
March 2012

Fatal late migration of viacor percutaneous transvenous mitral annuloplasty device resulting in distal coronary venous perforation.

Can J Cardiol 2013 Jan 22;29(1):130.e1-4. Epub 2012 May 22.

Québec Heart and Lung Institute, Québec City, Québec, Canada.

We present the case of a patient with dilated ischemic cardiomyopathy and severe mitral regurgitation. Due to several comorbidities, he underwent percutaneous transvenous mitral annuloplasty. Postoperatively, he complained of atypical chest pain. He was treated for pericarditis and died suddenly 10 days after the procedure. Autopsy showed distal perforation of the anterior interventricular vein with migration of the device on the diaphragm.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cjca.2012.03.014DOI Listing
January 2013

Severe upper gastrointestinal bleeding in Heartmate II induced by acquired von Willebrand deficiency: anticoagulation management.

Ann Thorac Surg 2012 Aug 11;94(2):e41-3. Epub 2012 May 11.

Québec Heart and Lung Institute, Québec City, Québec, Canada.

Patients treated with continuous flow assist devices may have increased bleeding tendencies due to an induced high molecular weight von Willebrand factor (VWF) multimer deficiency. We report a patient supported with a HeartMate II (Thoratec, Pleasanton, CA) who developed severe gastrointestinal bleeding refractory to conventional therapy and needing a total of 60 transfusions. After documenting the lack of large VWF multimers, suggestive of a defective platelet function, the patient was switched from aspirin to warfarin therapy (target international normalized ratio between 1.5 and 2.0). Three days after changing the anticoagulant regimen, the patient stopped bleeding and required no further transfusion.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2012.01.087DOI Listing
August 2012

Completeness of revascularization and survival among octogenarians with triple-vessel disease.

Ann Thorac Surg 2012 May 4;93(5):1432-7. Epub 2012 Apr 4.

Department of Cardiac Surgery, Quebec Heart and Lung University Institute, Quebec City, Quebec, Canada.

Background: We sought to determine the impact of the completeness of surgical revascularization among octogenarians with triple-vessel disease.

Methods: Between 1992 and 2008, 476 consecutive patients aged 80 years or more who underwent primary isolated coronary artery bypass grafting (CABG) procedures were identified. Early and late survival were compared among patients who underwent complete revascularization (CR, n=391) and incomplete revascularization (IR, n=85). IR was present when 1 or more of the 3 main coronary arteries with 50% or greater stenosis that were identified preoperatively as a surgical target by the operating surgeon were not grafted. The mean follow-up was 5.4±3.0 years (maximum 15.3 years).

Results: Baseline risk was similar between the 2 groups of patients. IR was more frequent in off-pump compared with on-pump CABG (34.9% versus 16.2%, respectively; p=0.002). The most common reason for IR was small or severely diseased arteries (87%). The incidence of postoperative myocardial infarction (MI) was similar in both groups (CR, 18.4% versus IR, 17.3%; p=0.81). In-hospital mortality was 7.2% among patients with CR and 4.7% among patients with IR (p=0.60). Three, 5-, and 8-year freedom from all-cause mortality among patients who underwent CR were 89.2%, 74.1%, and 54.3%, respectively, and were not significantly different from those patients who underwent IR (86.6%, 74.5%, and 49.4%, respectively) (p=0.40).

Conclusions: In octogenarians with triple-vessel disease, a strategy of incomplete revascularization during CABG does not negatively impact early or long-term survival.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2012.02.033DOI Listing
May 2012