Obesity and Preoperative Anaemia as Independent Risk Factors for Sternal Wound Infection After Coronary Artery Bypass Graft Surgery with Pedicled (Non-Skeletonized) Internal Mammary Arteries: The Role of Thoracic Wall Ischemia?

PURPOSE: Obesity remains statistically associated with coronary artery disease, for which coronary artery bypass graft surgery (CABG) remains the standard of care. However, obesity is also associated with sternal wound infection (SWI) which is a severe complication of CABG despite advances in surgery and in infection prevention and control. Strategies to reduce the incidence of SWI are still being investigated, and we therefore conducted a retrospective study to revisit factors other than obesity associated with SWI after CABG. PATIENTS AND METHODS: Data were extracted from the medical records of 182 patients who underwent elective on-pump CABG using one or both pedicled internal mammary artery grafts in Reims University Hospital between May 2015 and May 2016. All preoperative or perioperative variables with a p value<0.10 in univariate analysis were entered into a stepwise logistic regression model. RESULTS: Among the 182 patients (145 male (79.6%), median age 68.0 [45.0-87.0] years), 138 (75.8%) underwent CABG using bilateral internal mammary artery grafts. Median BMI was 27.7 [18.7-50.5] kg/m2, and there were 51 (28.0%) and 79 (43.4%) patients with obesity and overweight, respectively. Twenty-three out of the 182 patients (12.6%) developed SWI. In-hospital mortality was not statistically different between patients with and without SWI but the median length of stay was (6.0 [2.0-38.0] versus 5.0[3.0-21.0] days in the intensive care unit, p=0.03, and 26.0 [9.0-134.0] versus 9.0 [7.0-51.0] days in hospital, p<0.0001). Obesity and preoperative anaemia were independently associated with SWI, as was the number of red blood cell (RBC) units transfused (OR 14.61 [2.64-80.75], OR 4.64 [1.61-13.34] and OR 1.27 [1.02-1.58], respectively). CONCLUSION: The independent association of SWI with the number of RBC units transfused and the existence of preoperative anaemia and obesity suggests a mechanism of thoracic wall ischemia in SWI after CABG, thus leaving insufficient perfusion of the thoracic wall in patients with obesity. Medical strategies are warranted to try to prevent this costly complication.

Negative Pressure versus Conventional Sternal Wound Dressing in Coronary Surgery Using Bilateral Internal Mammary Artery Grafts.

BACKGROUND: Sternal wound infection (SWI) is a major complication occurring often after coronary artery bypass grafting (CABG) using bilateral internal mammary artery (BIMA) grafts. The aim of this study is to assess whether such a risk may be reduced by using incision negative pressure wound therapy (INPWT). METHODS: Data on patients undergoing isolated CABG using BIMA grafts at the Reims University Hospital, France, from 2013 to 2016 without or with INPWT was prospectively collected.  Results: INPWT was used in 161 patients and conventional sterile wound dressing was used in 266 patients. Propensity score matching resulted in 128 pairs with similar characteristics. SWIs were similarly distributed between the conventional sterile wound dressing (10.9%) and the INPWT cohorts (10.2%) (P = 1.00). Patients treated with INPWT had a lower rate of deep SWI/mediastinitis than patients who had conventional sterile dressing (5.5% versus 10.2%, P = .210), but the difference did not reach statistical significance. Tests for interaction confirmed these findings in different patient subgroups. CONCLUSION: The routine use of INPWT may not significantly reduce the risk of SWI in patients undergoing BIMA grafting. In view of previous reports showing a benefit with the use of this method, a large randomized study is justified to assess the efficacy of INPWT in patients undergoing cardiac surgery.

Enterovirus but not Parvovirus B19 is associated with idiopathic dilated cardiomyopathy and endomyocardial CD3, CD68, or HLA-DR expression.

We assessed Enterovirus (EV) &Parvovirus B19 (PVB19) genomes and CD3, CD68&HLA-DR detection in dilated cardiomyopathies (DCM). EV&PVB19 genomes and CD3, CD68&HLA-DR were detected by PCR and immunohistochemistry assays in 115 endomyocardial biopsies obtained in 13 idiopathic DCM (iDCM) and 10 explained DCM (eDCM) patients. Results were compared with those of 47 atrial surgical samples (47 surgery controls) and 22 autoptic cardiac samples (11 healthy heart controls) (2008-2014, Reims, France). EV was detected in 23.1% of iDCM patients but not in eDCM and controls (P = 0.003) (viral load 803 copies/µg). PVB19 was detected in 76.9%, 80.0%, 63.6% and 78.2% of iDCM, eDCM, healthy heart and surgery controls (P = 0.99) with a mean viral load of 413, 346, 1,428, and 71 copies/µg. CD3, CD68 or HLA-DR were detected in 100 and 50% of EV and PVB19 "mono-infected" iDCM patients. EV was exclusively detected in iDCM cases in association with CD3, CD68, or HLA-DR indicating that EV could be an etiological cause in a subset of iDCM cases. By contrast the equal frequent detection of PVB19 in iDCM cases and controls without association with CD3, CD68, or HLA-DR suggested that PVB19 could be a bystander in many DCM cases. J. Med. Virol. 89:55-63, 2017. © 2016 Wiley Periodicals, Inc.

Redo aortic valve surgery with endovascular control of the internal thoracic artery graft.

BACKGROUND AND AIM OF THE STUDY: Redo aortic valve surgery (AVS) in patients with patent pedicled internal thoracic artery (ITA) grafts remains a challenging procedure because of the possibility of injury to the grafts and difficulties in optimal myocardial protection. This procedure is associated with a significant mortality and morbidity. Different approaches to myocardial protection and ITA graft dissection and control have been described. An intraoperative technique is proposed that provides endovascular control of the ITA graft, using an angioplasty balloon positioned during cross-clamping. METHODS: Ten consecutive patients with previous coronary artery bypass grafting (CABG) and a patent pedicled ITA who underwent AVS were studied. The ITA grafts were occluded by using an angioplasty balloon during cross-clamping, but were not dissected and controlled. RESULTS: Endovascular control of the ITA graft was feasible in all cases, without complication. Two intraoperative complications (both graft injuries) were observed; one injury of an ITA graft, and one injury of a radial artery graft. There was no postoperative mortality. One myocardial infarct was related to the injury of a radial graft. The clamped ITA grafts were studied at two months after the procedure in five patients, and showed all grafts to be patent. At a mean follow up of 13 months, all patients were alive without any coronary events. CONCLUSION: The endovascular control of a patent ITA graft during redo AVS is a safe and simple technique that reduces the risk of ITA graft injury and also improves myocardial protection.

[Edema and protein-losing enteropathy complicating chronic constrictive pericarditis associated with an ascending aortic aneurysm]. / Oedèmes et entéropathie exsudative compliquant une péricardite chronique constrictive associée à un anévrisme de l'aorte ascendante.

INTRODUCTION: Chronic constrictive pericarditis is suspected on clinical and echocardiographic grounds. Its treatment is surgical. CASE: We report here the case of a 45-year-old man, admitted for edema characteristic of lymphatic obstruction. Examination revealed ascending aorta ectasia, associated with chronic constrictive pericarditis. Measurement of alpha-1 antitrypsin clearance confirmed protein-losing enteropathy. Total recovery followed pericardectomy and aneurysm resection. DISCUSSION: The clinical edema in this case was due to several phenomena: protein-losing enteropathy from a functional lymphatic overload, induced by chronic constrictive pericarditis and by compression of the right atrium and vena cava by an aortic aneurysm. The hypoalbuminemia induced by protein loss may also magnify edema. An association between chronic constrictive pericarditis and ascending aortic aneurysm is uncommon. No cause for this association was found.

Endovascular control of patent internal thoracic artery graft in aortic valve surgery.

Aortic valve replacement in patients who underwent previous coronary artery bypass with a patent internal thoracic artery is often a challenge because of the risk of graft injury during dissection or difficulties to obtain optimum myocardial protection. Different approaches to myocardial protection or internal thoracic graft dissection and control have been described. Endovascular control of the internal thoracic graft by an angioplasty balloon catheter positioned in the operating room before the operation can be a safe and simple alternative. We report the case of a patient who underwent this technique for aortic valve replacement.

Transection of left common carotid artery with arch extension after blunt chest trauma.

We report the case of a 63-year-old man, admitted after a traffic accident. Clinical examination found chest trauma, mandibular and long bone fractures but there was no cerebral ischemic signs. The chest X-ray showed a widening of the mediastinum; therefore an aortography demonstrated a false aneurysm, an intimal flap of the left common carotid artery (LCCA) and a middle aortic arch disruption. Surgical reconstruction was accomplished by inserting Dacron prosthesis from the ascending aorta to the LCCA. The aortic arch wound was reconstructed by an autologous pericardial patch. In light of this surgical case, we discuss early methods of diagnosis and details of medical, surgical or endovascular treatments.