Improved results of the vacuum assisted closure and Nitinol clips sternal closure after postoperative deep sternal wound infection.

OBJECTIVE: Postoperative deep sternal wound infection is a severe complication of cardiac surgery, with a high mortality rate and a high morbidity rate. The objective of this prospective study is to report our experience with the vacuum assisted closure (VAC) system for the management of deep wound infection. We also devised an innovative closure technique post VAC therapy using thermo reactive clips. The advantage of this technique is that the posterior face of the sternum does not have to be separated from the mediastinal structures thus minimising the risk of damage. METHODS: From October 2006 to October 2008, we prospectively evaluated 21 patients affected by mediastinitis after sternotomy. Nineteen patients had sternotomy for coronary artery bypass grafting (CABG), one patient for aortic valve replacement (AVR) and another one for ascending aortic replacement (AAR). All patients were treated with the VAC system at the time of infection diagnosis. When the wound tissue appeared viable and the microbiological cultures were negative, the chest was closed using the most suitable procedure for the patient in question; nine patients were closed using pectoralis flaps, nine patients using Nitinol clips, one patient with a combined technique (use of Nitinol clips and muscle flap), one patient with a direct wound closure and another patient, who needed AAR with a homograft performed in another institution, was closed using sternal wires. RESULTS: We had no mortality; wound healing was successfully achieved in all patients. In more than 50% of the patients, the VAC therapy allowed direct sternal resynthesis. The average duration of the vacuum therapy was 26 days (range 14-37 days). CONCLUSIONS: VAC is a safe and effective option in the treatment of post-sternotomy mediastinitis, with excellent survival and immediate improvement of local wound conditions; furthermore, the use of Nitinol clips after VAC therapy demonstrated to be a safe and non-invasive option for sternal resynthesis. After VAC therapy, a reduction in number of muscular flaps used and an increase of direct sternal resynthesis were observed.

[Two cardiac tumors with left ventricular location: myxoma and papillary fibroelastoma]. / Due rari casi di tumori cardiaci in sede ventricolare sinistra: mixoma ventricolare e fibroelastoma papillare.

We report 2 clinical cases of cardiac tumors, myxoma and papillary fibroelastoma, with unusual ventricular location. The clinical manifestations of these entities are not well described. Usually the patients are asymptomatic even if they have a high risk for cardiac and systemic embolic events so that these neoplasms are recognized during life more often in patients evaluated for embolic events of unclear pathology. The routine use of echocardiography has increased the detection of these tumors in living patients. In the surgical treatment, the approach should allow minimal manipulation of the tumors, inspection of all four cardiac chambers to overlook if tumors are multifocal and provide adequate exposure for complete resection. In our experience, we used two surgical approaches, via the left ventricle and via the aortic valve.

[Repair of post-infarct left ventricular rupture with pericardial patch]. / Tecnica di riparazione della rottura della parete libera del ventricolo postinfartuale con "patch" di pericardio.

The devolpment of a left ventricular rupture after myocardial infarction is not a rare complication. We report a case of 70-year-old male patient with clinical and instrumental signs of cardiac tamponade after left ventricular rupture. We repaired this lesion with pericardial patch and biological Glue without extracorporeal circulation and sutureless.

[Repair technique of post-infarction ventricular free wall rupture with pericardial patch]. / Tecnica di riparazione della rottura della parete libera del ventricolo postinfartuale con "patch" di pericardio.

The development of a left ventricular rupture after myocardial infarction is not a rare complication. We report a case of 70-year-old male patient with clinical and instrumental signs of cardiac tamponade after left ventricular rupture. We repaired this lesion with pericardial patch and biological Glue without extracorporeal circulation and sutureless.