Aspects post-opératoires de l'aorte ascendante.

Messages à retenir: Connaître le principe des principales chirurgies du segment I de l'aorte (Tirone David, Ross, Bentall..). Le scanner MD est l'imagerie clé pour visualiser la réimplantation des coronaires natives ou un pontage associé. Le protocole scanographique le plus courant est une acquisition synchronisée en mode prospectif. Le mode rétrospectif peut être utilisé en cas de suspicion de dysfonction d'une valve mécanique. Après une TAVI, le scanner est un examen clé pour juger de la hauteur, de la circularité, de l'adossement de la prothèse et de son rapport avec les coronaires. Résumé: Les aspects post opératoires de l'aorte ascendante sont au mieux étudiés par un scanner multidétecteur injecté avec synchronisation ECG. Le mode prospectif avec bas kilovoltage est privilégié pour réduire la dose dans cette population majoritairement jeune. La communication avec l'équipe chirurgicale est importante pour l'analyse des images (le radiologue doit connaître le type de montage effectué). Parmi les gestes de cardiologie interventionnelle, la TAVI est devenue courante et les éléments de contrôle de la procédure par le scanner doivent être connus.

EACTS Day in the new EACTS House.

There is no doubt that the European Association for Cardio-Thoracic Surgery is a success story. In 2011, we celebrated the 25th anniversary of this professional organization. In 2012, we will celebrate the 25th anniversary of the European Journal of Cardio-Thoracic Surgery. In addition, two other journals have been initiated, Interactive CardioVascular and Thoracic Surgery and the Multimedia Manual of Cardio-Thoracic Surgery, and all of them can be accessed through CTSnet (www.ctsnet.org). The most recent development was the birth of EACTS House, and it was to celebrate the official opening of EACTS House on 10 February 2011, that we held the second Strategic meeting, 'EACTS in the Future'. On this occasion, the EACTS council and delegates of the EACTS Domains (Domain of Thoracic Disease, Domain of Vascular Disease, Domain of Congenital Cardiac Disease and Domain of Adult Cardiac Disease) came together with representative thoracic and cardio-vascular surgeons from North America, Asia and BRICS countries as well as senior managers from industry in order to decide where to go from there. As a basis for starting the discussions, a sector analysis of the activities of the Department of Cardio-Vascular Surgery at CHUV in Lausanne, Switzerland was performed in order to identify the trends in the activities of our group of surgeons by pulling the consolidated data for the period running from 1 January 1995 to 31 December 2010. Interestingly enough, the most frequent procedures like coronary artery bypass graft and valve repair/replacement did not increase despite a growing programme. In our setting, the compensation came mainly from vascular surgery and mechanical circulatory support. These data have to be put in perspective by the reports provided by the EACTS domain chairs in order to identify the challenges and opportunities for the future development of our specialties.

ESCMID* guideline for the diagnosis and management of Candida diseases 2012: non-neutropenic adult patients.

This part of the EFISG guidelines focuses on non-neutropenic adult patients. Only a few of the numerous recommendations can be summarized in the abstract. Prophylactic usage of fluconazole is supported in patients with recent abdominal surgery and recurrent gastrointestinal perforations or anastomotic leakages. Candida isolation from respiratory secretions alone should never prompt treatment. For the targeted initial treatment of candidaemia, echinocandins are strongly recommended while liposomal amphotericin B and voriconazole are supported with moderate, and fluconazole with marginal strength. Treatment duration for candidaemia should be a minimum of 14 days after the end of candidaemia, which can be determined by one blood culture per day until negativity. Switching to oral treatment after 10 days of intravenous therapy has been safe in stable patients with susceptible Candida species. In candidaemia, removal of indwelling catheters is strongly recommended. If catheters cannot be removed, lipid-based amphotericin B or echinocandins should be preferred over azoles. Transoesophageal echocardiography and fundoscopy should be performed to detect organ involvement. Native valve endocarditis requires surgery within a week, while in prosthetic valve endocarditis, earlier surgery may be beneficial. The antifungal regimen of choice is liposomal amphotericin B +/- flucytosine. In ocular candidiasis, liposomal amphotericin B +/- flucytosine is recommended when the susceptibility of the isolate is unknown, and in susceptible isolates, fluconazole and voriconazole are alternatives. Amphotericin B deoxycholate is not recommended for any indication due to severe side effects.

The fibrinogen- and fibronectin-binding domains of Staphylococcus aureus fibronectin-binding protein A synergistically promote endothelial invasion and experimental endocarditis.

Staphylococcus aureus experimental endocarditis relies on sequential fibrinogen binding (for valve colonization) and fibronectin binding (for endothelial invasion) conferred by peptidoglycan-attached adhesins. Fibronectin-binding protein A (FnBPA) reconciles these two properties--as well as elastin binding--and promotes experimental endocarditis by itself. Here we attempted to delineate the minimal subdomain of FnBPA responsible for fibrinogen and fibronectin binding, cell invasion, and in vivo endocarditis. A large library of truncated constructs of FnBPA was expressed in Lactococcus lactis and tested in vitro and in animals. A 127-amino-acid subdomain spanning the hinge of the FnBPA fibrinogen-binding and fibronectin-binding regions appeared necessary and sufficient to confer the sum of these properties. Competition with synthetic peptides could not delineate specific fibrinogen- and fibronectin-binding sites, suggesting that dual binding arose from protein folding, irrespective of clearly defined binding domains. Moreover, coexpressing the 127-amino-acid subdomain with remote domains of FnBPA further increased fibrinogen binding by > or =10 times, confirming the importance of domain interactions for binding efficacy. In animals, fibrinogen binding (but not fibronectin binding) was significantly associated with endocarditis induction, whereas both fibrinogen binding and fibronectin binding were associated with disease severity. Moreover, fibrinogen binding also combined with fibronectin binding to synergize the invasion of cultured cell lines significantly, a feature correlating with endocarditis severity. Thus, while fibrinogen binding and fibronectin binding were believed to act sequentially in colonization and invasion, they appeared unexpectedly intertwined in terms of both functional anatomy and pathogenicity (in endocarditis). This unforeseen FnBPA subtlety might bear importance for the development of antiadhesin strategies.

Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence.

BACKGROUND: We reviewed the current evidence on the benefit and harm of pre-hospital tracheal intubation and mechanical ventilation after traumatic brain injury (TBI). METHODS: We conducted a systematic literature search up to December 2007 without language restriction to identify interventional and observational studies comparing pre-hospital intubation with other airway management (e.g. bag-valve-mask or oxygen administration) in patients with TBI. Information on study design, population, interventions, and outcomes was abstracted by two investigators and cross-checked by two others. Seventeen studies were included with data for 15,335 patients collected from 1985 to 2004. There were 12 retrospective analyses of trauma registries or hospital databases, three cohort studies, one case-control study, and one controlled trial. Using Brain Trauma Foundation classification of evidence, there were 14 class 3 studies, three class 2 studies, and no class 1 study. Six studies were of adults, five of children, and three of both; age groups were unclear in three studies. Maximum follow-up was up to 6 months or hospital discharge. RESULTS: In 13 studies, the unadjusted odds ratios (ORs) for an effect of pre-hospital intubation on in-hospital mortality ranged from 0.17 (favouring control interventions) to 2.43 (favouring pre-hospital intubation); adjusted ORs ranged from 0.24 to 1.42. Estimates for functional outcomes after TBI were equivocal. Three studies indicated higher risk of pneumonia associated with pre-hospital (when compared with in-hospital) intubation. CONCLUSIONS: Overall, the available evidence did not support any benefit from pre-hospital intubation and mechanical ventilation after TBI. Additional arguments need to be taken into account, including medical and procedural aspects.