Technological incremental developments have led to a panel of mechanical devices making possible circulatory support and cardiac replacement in patients with advanced cardiac failure. These devices allow the management of both the acute events and the chronic evolu-tion. Cardiac transplantation remains the gold standard for the treatment of these patients. The mechanical devices are quite complementary, making possible which a safe survival until a cardiac graft becomes available or in case of contraindication for transplantation a perma-nent implantation. Critical analysis of the French experience points out the underuse of these therapeutic modalities, the late referral of the patients, the sub-optimal outcomes, the active technological research. Health care delivery, presently sub-optimal, should take advantage of the recommendations of the scientific societies: concentration of resources in few expert cen-ters, with adequate medical and nursing staff. Improvement of the information of the patients and the cardiologists is mandatory for a more adequate use of these new techniques.& COPY; 2023 l'Academie nationale de medecine. Published by Elsevier Masson SAS. All rights reserved.

Veno-arterial extra corporeal membrane oxygenation(VA ECMO) is clinically instituted peripherally or centrally. In this study, a computational fluid dynamic method was used to compare the hemodynamic performance of peripheral ECMO and central ECMO. And the geometry of cannulation and blood vessels was built based on the clinical advice. Numerical simulation was used to investigate the flow pattern in the aorta to femoral artery and their branches such as blood flow distribution, flow interface. Same total blood supply was set as boundary conditions. The results demonstrated that peripheral ECMO has a better perfusion to the upper limb and brain than central ECMO(0.068kg/s>0.061kg/s) while for the downstream perfusion central ECMO has advantage over peripheral ECMO(0.061kg/s>0.055kg/s). It is easy to produce vertex in the cannulation outlet region for speed difference and blood interface region for different flow direction and the vertex and interface is related with blood bifurcation.

The growing number of heart failure patients and the scarcity of organ donors account for the huge need for the development of mechanical circulatory systems, including ventricular assist devices (VADs) and artificial hearts, in China. Several research programmes on blood pumps have been under way for the last three decades. However, unlike in other countries, the development of VADs has been extremely slow, and no system is currently approved and available for clinical application. There are many reasons for this situation. This article provides an overview of the present development of experimental and clinical research on VADs in China. In addition, the challenges for the clinical development of mechanical circulatory support in China are discussed.

ipe.2012.0948 Auteur(s) : Daniel Loisance au nom de la Commission XV, 5 juin 2012 L’Academie nationale de medecine suit avec attention l’evolution du fonctionnement des hopitaux publics et a deja ete amenee a s’exprimer, a plusieurs reprises, a ce sujet [1-4]. Les Ordonnances de mai 2005 et la loi Hopital Patients Sante Territoires ont profondement modifie l’organisation hospitaliere. Aujourd’hui, elle souhaite faire connaitre son inquietude devant la tentative d’effacement [...]

Complex administrative procedures have gradually been established for the evaluation of implantable medical devices, resulting in improved patient safety. These procedures include in vitro testing, animal experimentation, clinical premarketing studies, and post-market surveillance. Further improvements are needed, however, including more independent experts and clinical studies, while ensuring that the approval process is neither to slow nor too hasty.

Background Patients undergoing mechanical circulatory support using ventricular assist devices (VADs) experience a postoperative mixed antagonistic (proinflammatory and antiinflammatory) response syndrome. This response can result in immunoparalysis, exposing VAD recipients to infection and interfering with patient recovery despite adequate hemodynamic support. We undertook the present study to evaluate whether postoperative monocytic human leukocyte antigen-DR (mHLA-DR) expression is of prognostic value for mortality or infection of VAD recipients during their initial intensive care unit (ICU) stay after implantation. Methods Since 2004, we have monitored postoperative mHLA-DR expression in 50 VAD recipients using flow cytometry. Results Thirty-seven patients (74%) developed infection, and 22 patients (44%) died during their initial ICU stay. mHLA-DR expression was lowest in the immediate postoperative period (postoperative days [PODs] 1–3) but increased progressively thereafter. Multiple regression analysis showed that preoperative aspartate aminotransferase level was the only significant and independent predictor of the percentage of HLA-DR-positive monocytes on PODs 1–3 (β=-0.726, p=0.0001). ICU death and infection were associated with significantly lower percentages of HLA-DR-positive monocytes on PODs 1–3. ROC curve analysis revealed that the percentage of HLA-DR-positive monocytes on PODs 1–3 had significant discriminative power for ICU death (area under the curve = 0.73, 95% confidence interval, 0.545–0.912, p=0.037), but not for infection. Conclusions Postoperative mHLA-DR expression was closely related to preoperative hepatic cytolysis. It appeared to be the only early postoperative biological parameter that had some predictive power for death of VAD recipients in the ICU.

This study was undertaken to identify perioperative risk factors for hospital death in patients undergoing surgery for acute type A aortic dissection. Between 2000 and 2009, 101 consecutive patients underwent emergency surgery for acute type A aortic dissection. Four patients died before institution of cardiopulmonary bypass or completion of the procedure. In the remaining 97 (68 men; mean age, 63.4±16.7 years), proximal repair was performed using ascending aortic replacement with valve re-suspension in 52 (53.6%) and composite valve graft replacement in 44 (45.4%). Distal repair required hemi- or total arch replacement in 42 (43.3%) patients. Overall hospital mortality reached 25.8% (25/97 patients). Logistic regression analysis revealed that advanced age, location of an intimal tear in the arch or more distally, and preoperative coronary malperfusion were significant independent risk factors for hospital death. No procedure-related variables were significant risk factors. Current hospital mortality in patients undergoing emergency surgery for acute type A aortic dissection remains high, but seems to be mainly determined by preoperative variables. More aggressive proximal or distal repairs were not associated with increased mortality.

OBJECTIVES:To evaluate the influence, on early postoperative outcomes, of temperature during hypothermic circulatory arrest in emergent surgery for acute type A aortic dissection.DESIGN:Hypothermic circulatory arrest (HCA) with antegrade cerebral perfusion was performed in 63 patients who underwent emergent surgery for acute type A aortic dissection between 2000 and 2009. Patients were retrospectively separated in two groups: ( 1 ) deep HCA, lowest nasopharyngeal temperature < 17 °C (n = 29; 46%) and ( 2 ) moderate HCA, lowest nasopharyngeal temperature ≥ 17 °C (n = 34; 54%).RESULTS:Hospital mortality reached 27%. The nasopharyngeal temperature did not influence postoperative mortality or neurological outcome. Patients with deep HCA had significantly lower rate of infection (33% vs. 69%; p = 0.009) and shorter median intensive care unit length of stay (4 days ( 17 ) vs. 15.5 days ( 26 ) p = 0.017). Multiple regression analysis revealed that the lowest nasopharyngeal temperature was the only significant variable associated with intensive care unit length of stay (p = 0.005).CONCLUSIONS:Patients suffering from acute type A aortic dissection might benefit from colder hypothermia during circulatory arrest.

Complex administrative procedures have gradually been established for the evaluation of implantable medical devices, resulting in improved patient safety These procedures include in vitro testing, animal experimentation, clinical premarketing studies, and post-market surveillance. Further improvements are needed, however; including more independent experts and clinical studies, while ensuring that the approval process is neither to slow nor too hasty.

The prevalence of the risk factors and the risk of cardiac failure are both increasing in China. This might be the consequence of the changes of the life conditions (emigration to the urban areas, changes in the diet and life style, lack of physical exercise, etc.). The wide range of clinical presentations of cardiac failure (acute or chronic) and of therapeutic approaches (medical or surgical) makes necessary the integration within the same structure of the various experts involved in the diagnosis and the treatment of cardiac diseases. Technologic and human resources required to offer all the options represent a multifaceted commitment which should be focused optimally in dedicated centers. In these centers, collaboration should replace competition between the medical and the surgical cardiac specialists. Development of team work should permit to optimize the cost efficacy of the treatments. Most of all, such a structure will facilitate the translation of innovative therapies between the research centers and clinical facilities.

La formation initiale du chirurgien qui a longtemps reposé sur le compagnonnage, doit intégrer les grands changements que connaît la spécialité. La formation à la gestuelle et aux techniques chirurgicales, la formation clinique et l’apport constitué par la recherche clinique et expérimentale, la formation au travail en équipe et à la gestion du risque doivent être menées de front et sont indispensables pour que perdure dans l’avenir la position de leader du chirurgien.