Starting and finishing a cardiac case: Sternotomy, hemostasis, and closure.

The cardiac multimedia literature is abundant, but a significant gap exists in educational videos demonstrating routine essential steps such as the sternotomy or the closure. These components are common and carry significant mortality and morbidity should a sternal complication occur, highlighting the importance for the cardiothoracic surgeon to master these steps.

The radial artery: Open harvesting technique.

The radial artery is an important conduit in coronary artery surgical revascularization due to its robust long-term clinical outcomes. The use of the radial artery has become popularized in recent times. Therefore it is essential for junior surgeons to master harvest techniques that are safe, reliable, and easy to replicate.

Video-assisted thoracoscopy in the management of intrapleural extravasation of cytotoxic chemotherapy.

The extravasation of cytotoxic agents into subcutaneous tissue is a serious complication of chemotherapy. Unfortunately, if such extravasation occurs into the pleural space, limited data is available to guide appropriate management. We present the first report in the literature of video-assisted thoracoscopy combined with a topoisomerase II inhibitor and iron chelator, dexrazoxane, in the successful management of this complication.

Bacteraemia in ventricular assist devices: a common complication that need not affect clinical outcomes.

BACKGROUND: Ventricular assist device (VAD) implantation has become an effective option for patients with severe heart failure. However, device-related infections remain a significant problem. The aim of this study was to describe the incidence and microbiological aetiology of bacteraemia in patients with VADs, and to assess the impact of bacteraemia on clinical outcomes. METHODS: A retrospective study was conducted of patients having VAD implantation at the Alfred Hospital (Melbourne, Australia) from October 1990 to July 2009. Medical records and microbiology databases were reviewed. Patients who were supported with a VAD for 72h or more were evaluated for demographic data, VAD type, the occurrence of bacteraemia and clinical outcomes. RESULTS: During the 19-year period, 135 VAD patients (89 Thoratec PVAD, 10 Novacor, and 36 Ventrassist) supported for a total duration of 17,304 (median 74) support days were included. Sixty-one patients (45%) developed VAD-associated bacteraemia, an incidence of 5.6 episodes per 1000 support days. The incidence of bacteraemia per 1000 days of support was similar for the three devices used: Thoratec PVAD, Novacor and Ventrassist VADs (7.8±0.8, 5.2±1.5 and 3.4±0.5, respectively, p=0.74). Staphylococcus aureus was the most common pathogen (25%). The rates of death on device, survival to transplant, recovery with explant and outcomes after transplantation, including 30-day mortality, median survival time and incidence of cerebrovascular accidents were not significantly impacted upon by bacteraemia. CONCLUSIONS: Bacteraemia is common in VAD patients. However, the incidence of VAD-associated bacteraemia is independent of device type and with aggressive antimicrobial therapy; clinical outcomes need not be affected by the bacteraemia.

Phrenic nerve injury during cardiac surgery: mechanisms, management and prevention.

Phrenic nerve injury is a well-recognised complication of cardiac surgery that can lead to disabling effects from diaphragmatic dysfunction, especially in children and patients with a history of chronic obstructive airway disease. Various mechanisms of injury have been recognised including hypothermia, mechanical trauma and possibly ischaemia. A clear understanding of these mechanisms is important in order to modify surgical techniques to prevent this serious complication of cardiac surgery.