Sudden Tamponade From Vein Graft Side Branch Avulsion on Removal of Temporary Pacemaker Wires.

Temporary epicardial pacing wires are universally used in cardiac surgery and are associated with very low morbidity and mortality. Although rare, serious complications can occur with pacing wires. We present a case of avulsion of a saphenous vein graft side branch caused by removal of pacing wires and leading to pericardial tamponade. Our case favors the use of silk ties rather than hemoclips for occlusion of saphenous vein side branches and illustrates the importance of the location of pacing wires relative to the grafts at the time of coronary artery bypass surgery.

Pericardiectomy for Constrictive Pericarditis: 20 Years of Experience at the Montreal Heart Institute.

BACKGROUND: The aim of this study was to evaluate our single-center experience with pericardiectomy for constrictive pericarditis. The main objectives of our analysis were long-term survival, clinical outcome, and identification of risk factors. METHODS: Over a 20-year period, 99 consecutive patients underwent pericardiectomy at the Montreal Heart Institute. The indications for operation were idiopathic pericarditis (61%), postsurgical (13%), infectious (15%), postirradiation (2%), and miscellaneous (9%). Associated procedures were performed in 36% of cases. The duration of symptoms was longer than 6 months in 53% of cases, and two thirds of patients were in New York Heart Association class III or IV. RESULTS: Hospital mortality was 9% in the whole series and 7.9% in case of isolated pericardiectomy. The patients operated on within 6 months after the onset of symptoms showed a lower risk of mortality. Conversely, preoperative hepatomegaly and concomitant valvular operation were associated with significantly higher mortality on both univariate and multivariate analysis. In cases of isolated pericardiectomy, the outcome was mainly conditioned by associated comorbidities. The long-term survival was satisfactory, and the functional status at follow-up was improved in most cases. CONCLUSIONS: The clinical outcome of pericardiectomy for constrictive pericarditis is still marked by high operative mortality. Nevertheless, surgical treatment is able to improve the functional class in the majority of late survivors. Preoperative clinical conditions and associated comorbidities are crucial in predicting the risk of mortality, and early operation seems to be the most appropriate choice. The most suitable surgical strategy in cases of associated valvular operation remains to be determined.

Twenty-year experience with the CarboMedics mechanical valve prosthesis.

BACKGROUND: The CarboMedics mechanical prosthesis (CarboMedics Inc, Austin, TX) has been used for mitral and aortic valve replacement for more than 20 years in our institution. This study describes the long-term survival of patients with this prosthesis as well as the valve-related events. METHODS: Between June 1988 and May 2010, 3,297 patients underwent either single aortic valve replacement (AVR) (2,242 patients) or mitral valve replacement (MVR) (1,055 patients) with the CarboMedics mechanical valve prosthesis. They were followed annually for valve-related complications at the Montreal Heart Institute valve clinic. RESULTS: Operative mortality was 4% with AVR and 7% with MVR. Total follow-up was 23,671 patient-years (range, 1 month to 21 years; average, 7.5 ± 5.3 years). At 20 years, patient freedom from late mortality was 43.2% in the AVR group and 40.9% in the MVR group. Freedom from valve-related mortality was 78.3% for AVR and 74.6% for MVR. Freedom from thromboembolic event was 91.6% for AVR and 88.5% for MVR. Freedom from reoperation was 89.2% for AVR and 80.3% for MVR. Freedom from bleeding event was 89.5% for AVR and 88% for MVR. Freedom from endocarditis was 97.3% for both AVR and MVR. Freedom from valve thrombosis was 98.9% for AVR and 91.4% for MVR. There was no structural valve failure in our cohort. CONCLUSIONS: The CarboMedics valve is an effective and durable mechanical valve prosthesis with a low event rate and no structural failure at 20 years.

Retrospective cohort analysis of 926 tricuspid valve surgeries: clinical and hemodynamic outcomes with propensity score analysis.

BACKGROUND: The objectives were to describe morbidity and mortality after tricuspid valve (TV) surgery, to compare outcomes after repair versus replacement, and to assess risk factors for mortality and tricuspid regurgitation (TR) recurrence. METHODS: A retrospective cohort study including 926 consecutive cases of TV surgery (792 repairs and 134 replacements) performed at the Montreal Heart Institute was conducted. Median follow-up was 4.3 years (4,657 patient-years). Median age was 62 years (interquartile range 53-69 years), and 72% of patients were women. RESULTS: Operative mortality was 14% (128 patients: 1977-1998 20%, 1999-2008 7%, P < .001). Independent risk factors for operative mortality in the 1999 to 2008 period were hypertension (odds ratio [OR] 6.03, P = .02), daily furosemide dose (by 10 mg) (OR 1.06, P = .05), weight (by 10 kg) (OR 0.36, P < .01), and cardiopulmonary bypass time (by 10 minutes) (OR 1.29, P < .001). Ten-year survival was 49% ± 2% and 38 ± 5% in the repair and replacement groups, respectively (P = .012). At discharge, severity of TR was ≥3/4 in 13% and 2% of patients in the repair and replacement groups, respectively (P = .01). Propensity score analysis showed that tricuspid repair was associated with higher rates of TR ≥3/4 at follow-up compared with replacement (hazard ratio 2.15, P = .02). Forty-eight reoperations (7% of patients at risk) were performed during follow-up (repair group, 6%; replacement group, 15%; P = .01). At last follow-up, New York Heart Association functional class was improved compared with baseline in both groups (P < .001). CONCLUSION: Tricuspid valve surgery is associated with substantial early and late mortalities but with significant functional improvement. Replacement is more effective in early and late corrections of regurgitation, but it does not translate into better survival outcomes.

Statin treatment equalizes long-term survival between patients with single and bilateral internal thoracic artery grafts.

BACKGROUND: The use of 2 internal thoracic artery (ITA) grafts increases survival 10 years after coronary artery bypass grafting (CABG) compared with single ITA grafting. Statin treatment was also shown to decrease development and progression of saphenous vein graft atherosclerosis. This study examined the effect of statin treatment on long-term survival after CABG. METHODS: Operative, survival, and pharmacologic data of 6655 patients who underwent CABG with ITAs between 1995 and 2007 in our institution were obtained. RESULTS: Patients with bilateral ITA grafts had an average 10-year-survival rate of 83% +/- 2% compared with 67% +/-1% in patients with single ITA grafts (p = 0.0001). Statin treatment caused a significant decrease in the long-term risk of death among patients who underwent single ITA grafting (hazard ratio [HR], 0.735, p = 0.0001). However, statin treatment had no effect on the risk of long-term death among patients who underwent bilateral ITA grafting (HR, 1.053; p = 0.7806). CONCLUSIONS: Statin treatment initiated early after grafting improved long-term survival in patients with a single ITA graft but not in those with bilateral ITA grafts. Survival of statin-treated patients with single ITA grafts was similar to bilateral ITA patients.

Contained rupture of left ventricular false aneurysm after acute myocardial infarction secondary to left anterior descending artery embolism.

Left ventricular free wall rupture is a rare complication of acute myocardial infarction and accounts for a significant number of fatalities. Pseudoaneurysm is a variety of left ventricular rupture whereby the pericardium seals the defect, forming the wall of the pseudoaneurysm. The diagnosis is usually confirmed with echocardiography, and emergent surgical repair is required in suspected impending rupture. The present report describes the case of a 58-year-old woman who presented with a myocardial infarction due to distal left anterior descending artery occlusion, complicated by ventricular pseudoaneurysm with impending rupture. The patient had an otherwise normal coronary tree.

Dynamic right ventricular outflow tract obstruction in cardiac surgery.

BACKGROUND: Right ventricular outflow tract obstruction can be a cause of hemodynamic instability but it has not been described in non-congenital cardiac surgery. METHODS: The prevalence of right ventricular outflow tract obstruction was retrospectively studied in 670 consecutive patients undergoing cardiac surgery. Significant right ventricular outflow tract obstruction was diagnosed if the right ventricular systolic to pulmonary artery peak gradient was more than 25 mm Hg. The diagnosis was based on measurement of the right ventricular and pulmonary artery systolic pressure through the paceport and distal opening of the pulmonary artery catheter. To further validate the prevalence and the importance of right ventricular outflow tract obstruction, 130 patients were prospectively studied over a 12-month period. RESULTS: In the retrospective cohort, 6 patients (1%) undergoing various types of cardiac surgical procedures were found to have significant dynamic right ventricular outflow tract obstruction with a mean gradient of 31 +/- 4 mm Hg (26 to 35 mm Hg). In the prospective study significant dynamic right ventricular outflow tract obstruction was identified in 5 patients (4%) (average peak: 37 +/- 15 mm Hg; range: 27 to 60 mm Hg). The typical transesophageal echocardiography finding was end-systolic obliteration of the right ventricular outflow tract. In patients with significant dynamic right ventricular outflow tract obstruction, hemodynamic instability was present in 10/11 patients (91%). CONCLUSIONS: Right ventricular outflow tract obstruction is easily diagnosed using the paceport of the pulmonary artery catheter and should be considered as a potential cause of hemodynamic instability especially when transesophageal echocardiography reveals systolic right ventricular cavity obliteration.

Fifteen years of clinical and echocardiographic follow up with the carbomedics heart valve.

BACKGROUND AND AIM OF THE STUDY: Mechanical prostheses are used in young patients, the CarboMedics valve having been the mechanical valve of choice of the present authors during the past 15 years. The study aim was to analyze long-term clinical and echocardiographic results obtained with CarboMedics mechanical valves. METHODS: A total of 2,953 patients underwent valve replacement with the CarboMedics valve between 1988 and 2004 at the Montreal Heart Institute. Patients were prospectively followed at the outpatient valve clinic. Subsequently, 1,004 patients underwent echocardiographic examinations during follow up. RESULTS: In total, 1,597 patients (mean age 57 +/- 12 years) underwent isolated aortic valve replacement (AVR), 1,043 patients (mean age 59 +/- 10 years) underwent isolated mitral valve replacement (MVR), and 313 patients (mean age 58 +/- 11 years) underwent AVR+MVR. The mean five-, 10- and 15-year actuarial survival rates were 83 +/- 1%, 70 +/- 2% and 62 +/- 3% in AVR patients, 76 +/- 1%, 59 +/- 2% and 40 +/- 14% in MVR patients, and 68 +/- 3%, 51 +/- 4% and 33 +/- 9% in AVR+MVR patients. The mean 15-year freedom from cerebral embolism, hemorrhage and reoperation was 95 +/- 1%, 97 +/- 1% and 95 +/- 1% in AVR patients, 92 +/- 1%, 97 +/- 1% and 93 +/- 1% in MVR patients, and 94 +/- 2%, 93 +/- 2% and 91 +/- 4% in AVR+MVR patients. AVR patients had a mean aortic gradient of 29 +/- 14, 20 +/- 8, 18 +/- 7, 16 +/- 7, 12 +/- 5 and 11 +/- 5 mmHg with 19, 21, 23, 25, 27 and 29 mm prostheses, respectively (p = 0.001). MVR patients had a mean mitral gradient of 5.3 +/- 3, 4.9 +/- 2.2, 4.6 +/- 2, 4.4 +/- 2.9 and 4.9 +/- 1.8 mmHg with 25, 27, 29, 31 and 33 mm prostheses, respectively (p = 0.63). CONCLUSION: Patient survival and valve-related complications were satisfactory at 15 years after valve replacement with the CarboMedics valve. Mean aortic gradients were high with the 19-mm aortic prostheses, but all other valve sizes showed good hemodynamic performance, as measured using transthoracic echocardiography.

Increased early postoperative morbidity with off-pump coronary artery bypass grafting surgery in patients with diabetes.

BACKGROUND: Patients with diabetes constitute a high-risk population for myocardial revascularization due to extensive coronary disease. OBJECTIVE: To compare the early postoperative outcomes of patients with diabetes undergoing off-pump or on-pump coronary artery bypass surgery. METHODS AND RESULTS: Over a four-year period (1995 to 1998), 885 diabetics were operated for primary isolated coronary bypass; 156 patients had off-pump and 729 had on-pump coronary artery bypass surgery. Patients in the off-pump group were significantly older, had a higher incidence of hypertension and renal failure, and received fewer distal anastomoses (2.7 versus 2.9, P=0.004). Postoperative myocardial infarction, reintubation and postoperative use of intra-aortic balloon pump occurred significantly more frequently in the off-pump group (10.3% versus 5.5%, P=0.04; 8.3% versus 3.6%, P=0.03; 7.7% versus 1.5%, P=0.0001, respectively). Multivariate analysis revealed that type of surgery was an independent predictor of these complications, which occurred 1.9, 2.7 and 7.9 times more often, respectively, in the off-pump group. The 30-day mortality rate was not significantly different between the groups. CONCLUSIONS: Off-pump coronary artery bypass surgery is associated with an increased early postoperative morbidity in patients with diabetes and, thus, should be used with caution.

Twenty-five years' clinical experience with repair of tricuspid insufficiency.

BACKGROUND AND AIM OF THE STUDY: Tricuspid regurgitation secondary to pulmonary hypertension due to left-sided heart valve lesions is common. Here, the results are reported of 25 years' experience with three surgical techniques; the De Vega semicircular annuloplasty, the Bex flexible linear reducer, and the Carpentier-Edwards prosthetic ring annuloplasty. METHODS: Between 1976 and 2002, 463 patients underwent 478 tricuspid annuloplasty procedures to correct valve regurgitation during associated left-sided valve surgery. Patients were followed prospectively at the Montreal Heart Institute Valve Clinic. RESULTS: A total of 107 patients (23%) underwent the De Vega semicircular annuloplasty, 267 (58%) the Bex flexible linear reducer, and 89 (19%) the Carpentier-Edwards prosthetic ring annuloplasty. Excluding 30-day mortality, the mean 5-, 10- and 15-year patient survival was 82+/-4%, 58+/-6% and 30+/-6% respectively after the De Vega semicircular annuloplasty, 76+/-3%, 54+/-4% and 36+/-6% respectively after the Bex flexible linear reducer, and the mean five-year patient survival was 88+/-4% after the Carpentier-Edwards prosthetic ring annuloplasty (p = 0.65, for comparison of the three survival curves). The mean freedom rate from tricuspid repair failure (clinical right heart failure, redo annuloplasty, tricuspid valve replacement at follow up) was 95+/-3%, 93+/-3% and 72+/-8% at 5, 10 and 15 years respectively after the De Vega semicircular annuloplasty, and 97+/-1%, 87+/-4% and 66+/-9% after the Bex flexible linear reducer. The mean freedom rate from repair failure was 94+/-3% at five years after the Carpentier-Edwards prosthetic ring annuloplasty (p = 0.18 for comparison of the three freedom from failure curves). CONCLUSION: All three techniques of tricuspid valve repair resulted in a low rate of failure, and in good patient survival at long-term follow up.

Prosthetic valve thrombosis: twenty-year experience at the Montreal Heart Institute.

BACKGROUND: Prosthetic valve thrombosis is a life-threatening complication. We reviewed the incidence, risk factors, and treatment strategies of this rare complication. METHODS: From February 1981 through January 2001, 5430 valve operations were performed in 4924 patients at the Montreal Heart Institute. Of this cohort, 39 patients presented with prosthetic valve thrombosis and had complete follow-up data obtained from our prospective valve clinic database. RESULTS: In this series 82% of patients were women, and the mean age was 58 +/- 11 years. The underlying pathology involved the mitral valve in 75% of cases. Most prosthetic valve thromboses occurred with mechanical prostheses (95%). The time interval from first valve replacement to prosthetic valve thrombosis was 39 +/- 42 months. The most frequent clinical presentation was severe congestive heart failure (44%). On prosthetic valve thrombosis presentation, the international normalized ratio was less than 2.5 in 54%, with inadequate anticoagulation management in 26% and poor compliance in 26%. Eighty-two percent of patients underwent a surgical procedure, consisting of thrombectomy in 47%, mitral valve replacement in 47%, and aortic valve replacement in 6% of patients. The 30-day operative mortality and total in-hospital mortality after prosthetic valve thrombosis were 25% and 41%, respectively. The 10-year actuarial survival after prosthetic valve thrombosis was 46% +/- 10%. CONCLUSION: Inadequate level of anticoagulation is the most important factor involved in the pathogenesis of prosthetic valve thrombosis. The overall mortality rate despite surgical treatment remains high. This study underscores the importance of meticulous surveillance of anticoagulation therapy in patients with prosthetic valves.

Improving neurologic outcome in off-pump surgery: the "no touch" technique.

BACKGROUND: As patients referred for cardiac surgery include increasingly older individuals, the prevalence of comorbid factors, such as previous cerebrovascular disease, carotid disease, aortic atherosclerosis, and reoperations, is on the rise. Avoiding manipulation of the ascending aorta in this high-risk subgroup may become a necessity to perform safe coronary artery bypass grafting (CABG) surgery. METHODS: We retrospectively reviewed our database of 640 off-pump CABG patients and identified 84 patients in whom we adopted the "no touch" technique (NTT). Revascularization was carried out with single or bilateral internal thoracic arteries (ITA) and by connecting additional coronary grafts (saphenous vein, radial artery) in a T or Y configuration. The right gastroepiploic artery was used as a conduit in 2 patients. The brachiocephalic artery was used as an alternative inflow site in 3 patients (reoperation). RESULTS: Age, sex, risk factors, functional class, and history of congestive heart failure were comparable in the two groups. In the NTT group, the frequencies were higher for severe atherosclerosis of the aorta (13% versus 0%; P =.00), carotid disease (25% versus 16%; P =.02), and history of previous cerebrovascular accidents (17% versus 8%; P =.04). Complete revascularization was achieved in 96% of the patients in the off-pump CABG group, compared with 90% in the NTT group (P =.17). No differences in the prevalence of postoperative low cardiac output syndrome, intra-aortic balloon pump use, perioperative myocardial infarction, or operative mortality at 30 days were observed between the two groups. In the NTT group, weak trends toward a lower incidence of postoperative delirium (8% versus 15%; P =.12), a lower incidence of stroke (0% versus 1%; P =.85), and a shorter intensive care unit stay (P =.07) were observed. Hospital stay was also shorter in the NTT group (P =.04). CONCLUSION: Avoiding aortic manipulations in patients with severe atherosclerosis of the aorta, carotid disease, and a previous history of cerebrovascular accidents is technically feasible and is associated with a low risk of mortality and good shortterm results. Adopting this practice may reduce the incidence of stroke and improve early outcome in this subset of patients.

Tricuspid valve replacement: an analysis of 25 years of experience at a single center.

BACKGROUND: Tricuspid valve replacement is seldom used in clinical practice, but the choice between mechanical and biologic prostheses remains controversial. METHODS: Between 1977 and 2002, 97 patients underwent tricuspid valve replacement and were followed at the Montreal Heart Institute Valve Clinic. Patients underwent replacement with bioprostheses (n = 82) and mechanical valves (n = 15). RESULTS: Patients with bioprosthetic tricuspid replacements averaged 53 +/- 13 years of age compared with 48 +/- 11 years in those with tricuspid mechanical valve replacements (p = 0.2). Isolated tricuspid valve replacement was performed in 11 patients (73%) in the mechanical valve group compared with 31 patients (38%. p = 0.01) in the bioprosthetic replacement group. In patients undergoing bioprosthetic tricuspid replacement, 51 (62%) underwent multiple associated valve replacements. The 5-year survival after tricuspid replacement averaged 60% +/- 13% in the mechanical valve group and 56% +/- 6% in the biologic replacement group (p = 0.8). The 5-year freedom rate from tricuspid valve reoperation averaged 91% +/- 9% in patients with mechanical valves and 97% +/- 3% in those with biologic valves (p = 0.2). CONCLUSIONS; Patient survival after tricuspid valve replacement is suboptimal but related to the clinical condition at operation. The use of biologic prostheses for tricuspid valve replacement remains a good option in young patients because of limited life expectancy unrelated to the type of tricuspid prostheses at long-term follow-up.

Reduced mortality and strokes with off-pump coronary artery bypass grafting surgery in octogenarians.

BACKGROUND: Off-pump coronary artery bypass surgery (OPCAB) has been revived and has gained popularity, although the exact subsets of patients who might benefit most from this technique are unknown. The aim of this retrospective study was to compare the results of coronary artery bypass grafting surgery (CABG) in octogenarians using cardiopulmonary bypass (CPB) or OPCAB techniques. METHODS AND RESULTS: Over a 5-year period (1995-1999), 125 patients older than 80 years of age were operated for isolated myocardial revascularization (63 using CPB and 62 with OPCAB). There was no statistically significant difference in preoperative comorbidities between groups or in mean left ventricular ejection fraction (54.5+/-15.3% in the CPB group and 50.9+/-13.5% in the OPCAB group, respectively). The mean number of distal anastomosis per patient was 2.9 in CPB group and 2.6 in OPCAB group (P=ns). The majority of patients in both groups had unstable angina and were operated on an urgent basis. The operative mortality was 15.9% in the CPB group and 4.8% in the OPCAB group (P=0.04). There were 4 postoperative strokes (6.3%) in the CPB group and none (0%) in the OPCAB group (P=0.04). The percentage of patients transfused was 92.1% in the CPB group and 72.6% in the OPCAB group (P<0.01). Postoperative myocardial infarction occurred in 11.3% in the CPB group and 14.5% in the OPCAB group (P=NS). For all the parameters entered in the multivariate analysis with logistic regression model, the type of surgery (CPB or OPCAB) was an independent predictor of operative mortality and stroke (P=0.0375). The odds ratio (OR) indicates that operative mortality and stroke occur 4 times (OR=4.171) more often in CPB patients than in OPCAB patients. Follow-up showed no significant difference between the 2 groups in terms of cardiac events and mortality. CONCLUSIONS: This retrospective study suggests a benefit of OPCAB in terms of operative mortality and stroke for octogenarian patients when compared with CPB in our institution.

Long-term results with triple valve surgery.

BACKGROUND: Whether to use biological or mechanical prostheses and whether to repair or replace the tricuspid valve during primary and reoperative triple valve surgery remains controversial. The objective of the present study was to review our experience with primary and reoperative triple valve surgery using CarboMedics (CM) and Carpentier-Edwards (C-E) heart valves. METHODS: All 73 patients undergoing triple valve surgery since 1982 were prospectively followed at the Montreal Heart Institute valve clinic. Aortic valve replacement was performed with CM prostheses (57 patients) and with C-E prostheses (16 patients). Mitral valve replacement was performed with mechanical prostheses (56 patients) and with biological valves (14 patients). Mitral valve repair was done in 3 patients. Tricuspid valve annuloplasty or commissurotomy or both were performed in 66 patients and the tricuspid valve was replaced in 7 patients. Patient survival, complications, and the type of valve procedures were analyzed. RESULTS: Thirty patients averaging 62+/-10 years of age underwent primary triple valve surgery and 43 patients averaging 60+/-10 years of age underwent reoperative triple valve surgery (p = 0.5). Tricuspid repair consisted of annuloplasty with the Bex linear reducer (n = 47), the C-E ring (n = 13), or the De Vega technique (n = 5). Tricuspid valve replacement was done using the C-E pericardial prostheses. The 30-day mortality was 17% and 12% in patients with primary and reoperative surgery, respectively (p = 0.5) and patient survival averaged 80%+/-7%, 75%+/-8%, and 41%+/-15%, and 70%+/-7%, 57%+/-9%, and 50%+/-10%, respectively 1, 5, and 10 years following surgery (p = 0.5). The freedom rate from thromboembolism and from bleeding complications were 87%+/-6% and 95%+/-3% in primary and reoperative patients, respectively, 5 years following surgery. CONCLUSIONS: Triple valve surgery, either as a primary or a reoperative procedure, results in acceptable long-term survival with both mechanical and biological prostheses.

Methicillin-resistant Staphylococcus aureus infection in a cardiac surgical unit.

BACKGROUND: Increased antibiotic resistance of common bacteria is attributed in part to the widespread use of various antibiotic agents. Prophylactic and therapeutic antibiotic treatments are routinely used in cardiac surgical units, and it is no surprise that methicillin-resistant Staphylococcus aureus infection is becoming a major cause of surgical infections in cardiac patients. METHODS: We reviewed our experience with patients who underwent cardiac surgery and experienced infection caused by methicillin-resistant Staphylococcus aureus. Between 1992 and 2000 at the Montreal Heart Institute, 39 patients had methicillin-resistant Staphylococcus aureus surgical infections, and 13,199 patients underwent cardiac surgery. The yearly incidence of methicillin-resistant Staphylococcus aureus infection, the relative risk of acute mediastinitis and of superficial wound infections or other types of methicillin-resistant Staphylococcus aureus infection episodes, and the effect of preventive measures were analyzed. RESULTS: The annual incidence of methicillin-resistant Staphylococcus aureus acute mediastinitis decreased from 0.37% (5/1321) of cardiac patients in 1992 and 0.44% (6/1355) in 1993 to 0% between 1994 and 1997, 0.13% (2/1528) in 1999, and 0% (0/1700) in 2000. The total incidence of methicillin-resistant Staphylococcus aureus infection, including mediastinitis, superficial and deep sternal and leg wound infection, and all systemic infection episodes ranged from 0.68% of patients in 1992 and 0.96% of patients in 1993 to 0.46% of patients in 1999 and 0.53% of patients in 2000. The relative risk of severe mediastinal methicillin-resistant Staphylococcus aureus infection to all other methicillin-resistant Staphylococcus aureus infection episodes decreased from 1.65 in 1992 to 0.41 in 1999 and 0 in 2000. Beginning in 1993, all patients given a diagnosis methicillin-resistant Staphylococcus aureus infection and all nasal carriers of methicillin-resistant Staphylococcus aureus were strictly isolated on the surgical unit, and vancomycin was used as the prophylactic antibiotic agent for cardiac surgery in these patients. Moreover, since 1998, all patients admitted in the hospital were screened, and nasal carriers were isolated and treated with topical antibiotic ointment. CONCLUSION: Mediastinal and other infections caused by methicillin-resistant Staphylococcus aureus have a significant morbidity in cardiac surgical patients. After an outbreak of methicillin-resistant Staphylococcus aureus mediastinal infections, several preventive measures to control methicillin-resistant Staphylococcus aureus contamination of surgical patients were implemented (nasal screening, preventive isolation, application of mupirocin, prophylaxis with vancomycin and alcohol gels) and were effective in decreasing the incidence of methicillin-resistant Staphylococcus aureus infection and mediastinitis after cardiac surgery.

Vacuum-assisted venous drainage does not increase the neurological risk.

BACKGROUND: Vacuum-assisted venous drainage (VAVD) with negative pressure applied to integral sealed-hardshell venous reservoir facilitates valvular surgery through minimally invasive approaches. Despite concerns regarding air entrainment from the right atrium, cerebral microemboli of air and neurological complications, VAVD was used in patients who underwent valvular surgery throughout the last two years in our institution. METHODS: We compared the rate of neurological complications in patients who underwent surgery with and without VAVD from June 1997 to July 2001. VAVD was added to solid venous reservoirs with membrane oxygenators and arterial filters. Clinical results were prospectively entered in our valve database and were used for the analysis. RESULTS: Eight hundred twenty-two consecutive patients averaging 65 +/- 11 years of age underwent aortic, mitral and tricuspid valve replacements including 40 redos (40/822, 5%) and 265 associated CABG (265/822, 32%) with VAVD in 1999 to 2001 compared to 723 patients averaging 63 +/- 11 years of age (p = 0.01) who underwent the same procedures with 79 redos (79/723, 11%) and 177 CABG (177/723, 24%) without VAVD in 1997 to 1999. CPB time averaged 117 +/- 50 minutes in VAVD patients compared to 108 +/- 43 minutes in those without VAVD (p = 0.001). Thirty-day mortality averaged 5% (39/822) in patients with VAVD and 4% (30/723) in those without VAVD (p = 0.6). Seven patients of the VAVD group (7/822, 1%) and 11 patients without VAVD (11/723, 1.5%, p = 0.2) suffered from temporary or permanent neurological deficit. CONCLUSION: VAVD is a useful adjunct to modern cardiopulmonary bypass systems. When used with appropriate care, VAVD does not appear to significantly increase air microemboli and is not associated with an increased neurological risk following valvular surgery.