A randomized prospective multicenter trial for stroke prevention by prophylactic surgical closure of the left atrial appendage in patients undergoing bioprosthetic aortic valve surgery--LAA-CLOSURE trial protocol.

Patients undergoing surgical aortic valve replacement (SAVR) are at high risk for atrial fibrillation (AF) and stroke after surgery. There is an unmet clinical need to improve stroke prevention in this patient population. The LAA-CLOSURE trial aims to assess the efficacy and safety of prophylactic surgical closure of the left atrial appendage for stroke and cardiovascular death prevention in patients undergoing bioprosthetic SAVR. This randomized, open-label, prospective multicenter trial will enroll 1,040 patients at 13 European sites. The primary endpoint is a composite of cardiovascular mortality, stroke and systemic embolism at 5 years. Secondary endpoints include cardiovascular mortality, stroke, systemic embolism, bleed fulfilling academic research consortium (BARC) criteria, hospitalization for decompensated heart failure and health economic evaluation. Sample size is based on 30% risk reduction in time to event analysis of primary endpoint. Prespecified reports include 30-day safety analysis focusing on AF occurrence and short-term outcomes and interim analyses at 1 and 3 years for primary and secondary outcomes. Additionally, substudies will be performed on the completeness of the closure using transesophageal echocardiography/cardiac computed tomography and long-term ECG recording at one year after the operation.

Low mortality and low rate of perceived and documented arrhythmias after Cox maze III surgery for atrial fibrillation.

BACKGROUND: To report a long-term single-site experience of the cut-and-sew Cox maze III procedure for atrial fibrillation (AF). METHODS: A total of 232 consecutive patients underwent the Cox maze III procedure for symptomatic therapy-refractory AF, with concomitant surgery in 34 patients. Follow-up data were obtained from electrocardiograms, patient visits, questionnaires, and medical files. RESULTS: There were 103 patients (44%) with paroxysmal AF during 8.8 ± 6.5 years and 129 patients (56%) with nonparoxysmal AF for 7.3 ± 6.7 years. The preoperative New York Heart Association class was better in patients with paroxysmal AF (P < 0.0001); the left ventricular ejection fraction was 59 ± 7% versus 56 ± 8%, P = 0.003, and the left atrial area 24 ± 6 versus 27 ± 6 cm(2) , P = 0.01. Early and late postoperative adverse events occurred at similar rates. Four patients from each group died of reasons unrelated to surgery. The mean follow-up was 66 ± 42 (5-155) months. In total, 184/229 (80%) patients were free of documented AF/atrial flutter/atrial tachycardia (AF/AFl/AT) off antiarrhythmic drugs (AA) and 189/229 (83%) on or off AA. The hazard ratio (HR) for paroxysmal versus nonparoxysmal AF patients regarding documented AF/AFl/AT was 0.8 (95% confidence interval [CI] 0.4-1.4; P = 0.40). For patients without versus with concomitant surgery, the corresponding HR was 0.4 (95% CI 0.2-0.8; P = 0.008). Of 197 patients (89%) responding to the questionnaire, 41 had sought care for symptoms of arrhythmia, 29 of whom had documented AF/AFl/AT, whereas another six had other arrhythmias. CONCLUSION: Cut-and-sew Cox maze III surgery provided long-lasting high efficacy, also in patients with nonparoxysmal AF of long duration and/or concomitant surgery, and was associated with low rates of subsequent adverse events.

A Swedish consensus on the surgical treatment of concomitant atrial fibrillation.

Atrial fibrillation (AF) is a common arrhythmia among patients scheduled for open heart surgery and is associated with increased morbidity and mortality. According to international guidelines, symptomatic and selected asymptomatic patients should be offered concomitant surgical AF ablation in conjunction with valvular or coronary surgery. The gold standard in AF surgery is the Cox Maze III ("cut-and-sew") procedure, with surgical incisions in both atria according to a specified pattern, in order to prevent AF reentry circuits from developing. Over 90% of patients treated with the Cox Maze III procedure are free of AF after 1 year. Recent developments in ablation technology have introduced several energy sources capable of creating nonconducting atrial wall lesions. In addition, simplified lesion patterns have been suggested, but results with these techniques have been unsatisfactory. There is a clear need for standardization in AF surgery. The Swedish Arrhythmia Surgery Group, represented by surgeons from all Swedish units for cardiothoracic surgery, has therefore reached a consensus on surgical treatment of concomitant AF. This consensus emphasizes adherence to the lesion pattern in the Cox Maze III procedure and the use of biatrial lesions in nonparoxysmal AF.

Cardiac function in relation to rhythm outcome after intraoperative epicardial left atrial cryoablation.

OBJECTIVES: To assess the effects of intraoperative left atrial epicardial cryoablation on rhythm and atrial and ventricular function. DESIGN: Thirty five patients with coronary artery disease and documented atrial fibrillation underwent coronary artery bypass surgery and concomitant cryoablation. An age and gender matched control group of 35 patients with atrial fibrillation underwent bypass surgery alone. Echocardiography was performed 9 ? 32 days before and 22 ? 6 months after surgery. RESULTS: The proportion of patients in sinus rhythm at follow-up was 63% and 34% (p = 0.04) in the cryoablation and control groups, respectively. In patients with sinus rhythm both before surgery and at follow-up, the left atrial area increased (p = 0.002) and the mitral annular excursion during atrial contraction decreased (p = 0.01) after cryoablation. The mitral flow velocity during atrial systole decreased after cryoablation (p = 0.002). The LV diameter increased (p = 0.03) and the left ventricular ejection fraction (LVEF) decreased (p = 0.03) in cryoablated but not in control patients. Continued deterioration was seen in patients with atrial fibrillation both pre- and postoperatively. CONCLUSIONS: At long-term follow-up, a significantly higher proportion of patients was in sinus rhythm in the cryoablation than in the control group. The atrial and ventricular function had decreased at follow-up two years after surgery. This decrease was small and occurred within or close to the reference values in patients with sinus rhythm at follow-up, while patients remaining in atrial fibrillation showed a significant continued deterioration. Some subgroups were small, and the findings, although statistically significant, should be interpreted with caution.

The prevalence of moderate mitral regurgitation in patients undergoing CABG.

OBJECTIVE: The aim of this study was to determine the prevalence of moderate ischemic mitral regurgitation (IMR) in the contemporary CABG population. We also aimed to correlate the effective regurgitant orifice area (ERO) of any regurgitant mitral valve in patients with coronary artery disease with the semiquantitative integrated scale of IMR. DESIGN: From March 15 through June 15, 2006, 510 consecutive CABG patients in three tertiary centres were included in the study. All patients showing any sign of mitral regurgitation (MR) at the referring hospital underwent a preoperative transthoracic echocardiographic estimation of the degree of MR using the integrated scale (1-4) and ERO. RESULTS: IMR was found in 141 patients (28%). The prevalence of moderate 2+ or worse IMR was 4% (95% CI; 2.5-6.1%) and the ERO corresponding to 2+ IMR or more ranged from 5 to 30 mm(2). Fourteen patients had an ERO between 15-30 mm(2). CONCLUSIONS: According to our study, patients with moderate IMR, defined as an ERO between 15-30 mm(2), account for only 2.7% (95% CI; 1.5-4.7%) of a non-emergency CABG population.

Moderate mitral regurgitation in patients undergoing CABG--the MoMIC trial.

BACKGROUND: The presence of mild to moderate ischemic mitral regurgitation (IMR) marks a significantly reduced long-term survival and increased hospitalizations due to heart-failure. However, it is common practice in many institutions to refrain from repairing the mitral valve in these patients. There are no available conclusive data to support this practice, and thus there is a need for an adequately powered randomized trial. STUDY DESIGN: The Moderate Mitral Regurgitation In Patients Undergoing CABG (MoMIC) trial is the first international multi-center, large-scale study to clarify whether moderate IMR in CABG patients should be corrected. A total of 550 CABG patients with moderate IMR are to be randomized to treatment of either CABG alone or CABG plus mitral valve correction. The primary end point is a composite end point of mortality and rehospitalization for heart failure at five years. The inclusion and randomization of patients started in February 2008. IMPLICATION: If correction of moderate IMR in CABG patients proves to be the superior strategy, most patients should be treated accordingly.

Surgical treatment for isolated mitral valve endocarditis: a 16-year single-centre experience.

OBJECTIVES: Despite progress in management, mitral valve endocarditis (MVE) is still a life-threatening disease. We report our experience in surgical treatment of infective isolated MVE. METHODS: A total of 140 operations in 128 patients for MVE performed between January 2000 and December 2015 were included in a retrospective study. There were 109 (78%) operations for native and 31 (22%) operations for prosthetic valve endocarditis. Preoperative and postoperative characteristics and mortality of patients were registered. Cox regression identified factors associated with mortality. Mean follow-up period was 68 months (range 1-168 months) and 100% complete. RESULTS: There were 13 deaths within 30 days after the 140 operations (9%). Severe perioperative complications occurred in 59 (42%) operations. Overall cumulative survival was 73% ± 4 at 5 years and 62 ± 5% at 10 years after the first operation. Age, diabetes, EuroSCORE II and perivalvular abscess were independent predictors for long-term mortality. Valve repair was performed in 76 (54%) operations and replacement in 64 (46%) operations. Thirty-day mortality for repair was 1%, and 5-year and 10-year cumulative survival was 86 ± 4% and 77 ± 6%, respectively. In the replacement group the 30-day mortality was 19% and cumulative survival at 5 years and 10 years was 55 ± 7% and 41 ± 8%, respectively. Postoperative complications occurred in 21% and 67%, respectively, after operations for repair and replacement. Ten (8%) patients had 12 reoperations for recurrent endocarditis. CONCLUSIONS: MVE requiring surgical treatment is a challenging disease with high hospital mortality after valve replacement. Mitral valve repair can be performed in suitable endocarditis patients with excellent results. Age, diabetes and EuroSCORE were independently associated with mortality in a multivariable model.

Modified prophylaxis for preventing deep sternal wound infection after cardiac surgery.

In order to prevent deep sternal wound infection after cardiac surgery we decided at the Sahlgrenska University Hospital to revise our protocol for antibiotic prophylaxis by adding an application of local collagen-gentamicin between the sternum halves to our standard prophylaxis. In addition, we focused specifically on the wiring technique. This quite simple modification of the prophylaxis program has been successful. The infection rate during 2006 is the lowest rate we have recorded since we started measuring it in 1995. We conclude that with application of local collagen-gentamicin and modification of the sternal closure method we have been able to significantly decrease the incidence of wound infections after cardiac surgery.

Long-Term Risk of Ischemic Stroke After the Cox-Maze III Procedure for Atrial Fibrillation.

BACKGROUND: The long-term risk of stroke after surgical treatment of atrial fibrillation is not well known. We performed an observational cohort study with long follow-up after the "cut-and-sew" Cox-maze III procedure (CM-III), including left atrial appendage excision. The aim was to analyze the incidence of stroke/transient ischemic attack (TIA) and the association to preoperative CHA2DS2-VASc (age in years, sex, congestive heart failure history, hypertension history, stroke/TIA, thromboembolism history, vascular disease history, diabetes mellitus) score. METHODS: Preoperative and perioperative data were collected in 526 CM-III patients operated in four centers 1994 to 2009, 412 men, mean age of 57.1 ± 8.3 years. The incidence of any stroke/TIA was identified through analyses of the Swedish National Patient and Cause-of-Death Registers and from review of individual patient records. The cumulative incidence of stroke/TIA and association with CHA2DS2-VASc score was estimated using methods accounting for the competing risk of death. RESULTS: Mean follow-up was 10.1 years. There were 29 patients with any stroke/TIA, including 6 with intracerebral bleedings (2 fatal) and 4 with perioperative strokes (0.76%). The remaining 13 ischemic strokes and six TIAs occurred at a mean of 7.1 ± 4.0 years postoperatively, with an incidence of 0.36% per year (19 events per 5,231 patient-years). In all CHA2DS2-VASc groups, observed ischemic stroke/TIA rate was lower than predicted. A higher risk of ischemic stroke/TIA was seen in patients with CHA2DS2-VASc score 2 or greater compared with score 0 or 1 (hazards ratio 2.15, 95% confidence interval: 0.87 to 5.32) but no difference by sex or stand-alone versus concomitant operation. No patient had ischemic stroke as cause of death. CONCLUSIONS: This multicenter study showed a low incidence of perioperative and long-term postoperative ischemic stroke/TIA after CM-III. Although general risk of ischemic stroke/TIA was reduced, patients with CHA2DS2-VASc score 2 or greater had a higher risk compared with score 0 or 1. Complete left atrial appendage excision may be an important reason for the low ischemic stroke rate.

Continuous improvement in outcome after heart transplantation - Long-term follow-up after three decades of experience.

AIMS: Heart transplantation (HTx) has become the standard treatment for patients with end-stage heart disease. We report on the long-term outcome after HTx at our centre and investigate trends in outcome over time. METHODS: During the period, between 1984 and 2014, a total of 610 HTx procedures were performed in 595 patients (median 48years; IQR 31-57years; range 24days-71years; mean 43years; 75% male) in our institution. Long-term outcome was investigated in the whole cohort, among children (n=76), bridged with mechanical circulatory support (MCS, n=131), re-transplanted (n=17), and concomitant kidney transplantation (n=12). RESULTS: Long-term survival was at 1, 5, 10, 15 and 20years: 86% (95CI 0.83-0.89); 77% (95CI 0.73-0.80); 63% (95CI 0.59-0.68); 48% (95CI 0.43-0.54) and 30% (95CI 0.25-0.36), respectively. The median survival for the whole cohort was 14.1years. Patients transplanted during the most recent time period (2010-2014) had a better survival compared to previous eras, with a 1- and 3-year survival of 94% (95CI 0.89-0.97) and 93% (95CI 0.88-0.96), respectively (p<0.001). However, when survival was analysed for long-term MCS (n=80) versus short term MCS (n=35), there was a significantly poorer survival for the short-term MCS group (p=0.001). Independent predictors of long-term mortality included recipient age (p=0.041); previous smoking (p=0.034); ischemic heart disease (p=0.002); and preoperative ventilator therapy (p=0.004). CONCLUSIONS: We have shown that continuous improvement in outcome after HTx still occurs. In the last time era, direct transplantation from short-term MCS was abandoned, which may have inflicted outcome during the last time era.

Effect of lung volume reduction surgery for emphysema on diaphragm function.

Preoperative prediction of a successful outcome following lung volume reduction surgery (LVRS) for emphysema is imperfect. One mechanism could be improvement in respiratory muscle function yet controversy exists regarding the magnitude and mechanism of such an improvement. Therefore, we measured diaphragm strength in 18 patients before and after LVRS. Mean (S.D.) FRC fell from 6.53 to 5.40 l (p = 0.0001). Mean sniff transdiaphragmatic pressure increased from 76 to 87 cm H2O (14%, p < 0.03) and mean twitch transdiaphragmatic pressure (Tw Pdi) increased by 2.5 cm H2O at 3 months (12%, p = 0.03). There was a highly significant increase in twitch esophageal pressure (Tw Pes) (60%, p < 0.0001), which was maintained at 12 months (46% increase, p = 0.0004). No change was observed in quadriceps twitch tension in nine subjects in whom it was measured. After LVRS the ratio Tw Pes:Tw Pdi increased from 0.24 to 0.37 at 3 months (p = 0.0003) and 0.36 at 12 months (p = 008). Low values of Sn Pdi, Sn Pes, Tw Pes and a high RV/TLC ratio were the preoperative variables most predictive of improvement in shuttle walking distance. We conclude that LVRS improves diaphragm function primarily by alteration of lung volume. Patients with poor diaphragm function and high RV/TLC ratio preoperatively are most likely to benefit from the procedure.

Long-Term Follow-Up of Cardiac Rhythm in 320 Patients After the Cox-Maze III Procedure for Atrial Fibrillation.

BACKGROUND: The Cox-maze III (CM-III) procedure is the gold standard for surgical treatment of atrial fibrillation (AF). Excellent short-term results have been reported, but long-term outcomes are lesser known. The aim was to evaluate current cardiac rhythm in a nationwide cohort of CM-III patients with very long follow-up. METHODS: Perioperative characteristics were retrospectively analyzed in 536 "cut-and-sew" CM-III patients operated on from 1994 to 2009 in 4 centers. Of these, 54 patients had died and 20 were unavailable at follow-up. The remaining 462 patients received a survey concerning arrhythmia symptoms, rhythm, and medication; of these, 320 patients (69%), comprising 252 men, with a mean age of 67 years (range, 47 to 87 years), and 83% with stand-alone CM-III, returned a current 12-lead electrocardiogram. Long-term monitoring was evaluated in 40 sinus rhythm patients. Postoperative stroke/transient ischemic attack was evaluated by register analysis. RESULTS: Mean follow-up was 111 ± 44 months (range, 36-223 months). Electrocardiogram analysis showed sinus rhythm in 219 of 320 patients (68%), and regular supraventricular rhythm (sinus, nodal, or atrial pacing) in 262 (82%), with 75% off class I/III antiarrhythmic medication. This group had lower arrhythmia symptom scores and medication use. Rhythm outcome did not differ by gender, age, type of AF, or stand-alone vs concomitant operation. Patients with more than 10 years of follow-up had a lower rate of regular supraventricular rhythm (69% vs 91%, p = 0.02). Long-term monitoring showed freedom from AF/atrial flutter in 38 of 40 patients (95%). The incidence of stroke/transient ischemic attack was 0.37% per year (11 patients). CONCLUSIONS: In a single-moment electrocardiogram evaluation 9 years after the cut-and-sew CM-III, 82% of patients were in sinus rhythm or other regular supraventricular rhythm. These findings support a long-lasting positive effect of the CM-III procedure, which is relevant when evaluating current nonpharmacologic therapies for AF.

Effects of lung volume reduction surgery on left ventricular diastolic filling and dimensions in patients with severe emphysema.

STUDY OBJECTIVES: Data on the influence of lung volume reduction surgery (LVRS) on cardiac function and hemodynamics are scarce and controversial. Previous studies have focused mainly on right ventricular function and pulmonary hemodynamics. Here, we evaluated the effects of LVRS on left ventricular (LV) end-diastolic filling pattern, dimensions, stiffness, and performance, as well as pulmonary and systemic hemodynamics. DESIGN: A prospective, open, controlled study. PATIENTS: Patients with severe emphysema undergoing LVRS (10 patients). Patients scheduled for pulmonary lobectomy due to carcinoma (ie, the lobectomy group) served as control subjects (10 patients). MEASUREMENTS: LV dimensions and mitral flow velocities were measured by transesophageal, two-dimensional, Doppler echocardiography, and central hemodynamics were measured by a pulmonary artery thermodilution catheter. Measurements were performed during anesthesia in the supine position, before and after surgery, without and with passive leg elevation. RESULTS: Baseline cardiac index (CI) [- 21%], stroke volume index (SVI) [- 31%], stroke work index (SWI) [- 26%], and LV end-diastolic area index (EDAI) [- 15%] were significantly (p < 0.001) lower, whereas LV end-diastolic stiffness (LVEDS) did not differ in the LVRS group compared to the lobectomy group. The time from peak early diastolic filling to zero flow (E-dec time) [58%] and the deceleration slope of early diastolic filling (E-dec slope) [45%] were significantly higher (p < 0.01), whereas peak early diastolic filling velocity (E-max) [- 31%; p < 0.01] and the proportion of E-max vs peak late diastolic filling velocity (A-max) [ie, the E/A ratio] (- 27%; p < 0.001) were significantly lower compared to the lobectomy group. LVRS significantly increased CI (40%; p < 0.001), SVI (34%; p < 0.001), SWI (58%; p < 0.001), LV EDAI (18%; p < 0.001), E-max (44%; p < 0.01), A-max (15%; p < 0.05) and E/A ratio (28%; p < 0.01), decreased E-dec time (- 31%; p < 0.05) and E-dec slope (- 98%; p < 0.01), and had no effect on LVEDS. In the lobectomy group, surgery affected none of these variables. CONCLUSIONS: LV function is impaired in patients with severe emphysema due to small end-diastolic dimensions. LVRS increases LV end-diastolic dimensions and filling, and improves LV function.

Mortality after mitral regurgitation surgery: importance of clinical and echocardiographic variables.

OBJECTIVES: The management of patients with mitral regurgitation (MR) constitutes a challenge due to its heterogeneity in terms of etiology and possible treatment strategies. In the present study, we sought to describe the importance of preoperative echocardiographic and clinical variables in relation to outcome 5 years after surgical treatment of MR. METHODS: The echocardiographic reports (transthoracic) from 298 patients were analyzed and the anatomic lesions were classified into one of three main groups (functional, organic degenerated with hypermobile valve or organic degenerated without hypermobility). 5-year cumulative survival was compared with the expected survival in an age- and gender-matched normal population. Risk functions were determined with a Poisson regression model. RESULTS: Operative mortality was 4.4%, with higher mortality in patients with concomitant coronary artery bypass grafting (CABG) (7.6 vs. 2.2%, P=0.03). Survival after 5 years was 65% in patients with concomitant CABG, compared with the expected 86% (P<0.001), 70 vs. 88% (P<0.001) in patients with preoperative NYHA class III/IV, while survival in patients with NYHA class I/II did not differ from the expected (90 vs. 90%, P=0.56). In patients with a hypermobile valve without CABG, postoperative survival did not differ from the expected (91 vs. 89%, P=0.92). The estimated risk ratio for death, repair versus prosthesis, was 0.57 (95% confidence interval 0.32-1.00, P=0.05). CONCLUSIONS: The present study shows that it is possible, using transthoracic echocardiography and clinical data, to identify patients with an excellent outcome. The adverse effects of severe symptomatology and replacement compared with repair are demonstrated. The findings encourage early intervention before severe symptoms occur, especially if repair is possible.

The Berglin apical stitch: a simple technique to straighten things out in atrial fibrillation surgery.

In the Cox-Maze IV procedure, or in endocardial left atrial ablation, correct positioning of the surgical ablation probe within the left atrium might be difficult due to bulging or folds in the posterior left atrial wall. The Berglin apical stitch is a simple trick of the trade to create a smooth surface in the posterior left atrium that facilitates performing a safe transmural lesion and, consequently, may increase antiarrhythmic efficiency.

A structured blood conservation programme reduces transfusions and costs in cardiac surgery.

OBJECTIVES: Transfusions of blood products can be lifesaving, but they are also associated with considerable risks and adverse effects, including immune response and infections. In cardiac surgery, transfusions have also been associated with increased mortality. We prospectively studied the effects of a structured programme to reduce transfusions and transfusion-associated costs in cardiac surgery. METHODS: The programme included: (i) education of all staff about the risks and benefits of blood transfusions; (ii) revised guidelines for transfusions; and (iii) a transfusion log where indication for transfusion, status of the patient and prescribing physician were registered. Transfusion prevalence, complications and costs for blood products were registered for all acute and elective cardiac operations during a 12-month period before (n = 1128) and after (n = 1034) the programme was started. The two time periods were compared. In addition, the prevalence of transfusions was registered for 2 more years after the programme was initiated. RESULTS: The first year after the programme was initiated the proportion of patients transfused with red blood cell concentrate decreased by 21.8% (from 58.2 to 45.5%, P <0.001), plasma by 37.4% (from 30.8 to 19.3%, P <0.001) and platelets by 21.0% (from 20.5 to 16.2%, P = 0.010). Reoperations for bleeding (5.8 vs 5.0%), early complication rate and 30-day mortality (2.5 vs 2.6%) were not significantly different before and after the start date. Based on the 2009 institutional prices for red blood cell concentrate (102 €/unit), plasma (35 €/unit) and platelets (290 €/unit), the savings on blood products were €161,623 during the first 12 months after the programme was launched. The proportion of patients transfused with any blood product was 60.9% before the programme was started and 48.3, 54.0 and 50.7% 1-3 years after its start (all P <0.001), respectively. CONCLUSIONS: A structured blood conservation programme reduces transfusions and costs for blood products in cardiac surgery, without any signs of compromised medical safety. The effects of introducing such a programme are maintained over at least 3 years.

Triclosan-coated sutures reduce surgical site infection after open vein harvesting in coronary artery bypass grafting patients: a randomized controlled trial.

OBJECTIVES: The incidence of surgical site infection (SSI) after open vein harvesting in coronary artery bypass grafting (CABG) patients ranges in different studies between 2 and 20%. Triclosan is an antibacterial substance that reduces the growth of bacteria by inhibiting fatty acid synthesis. We hypothesized that wound closure with triclosan-coated sutures would reduce SSI after open vein harvesting. METHODS: An investigator-initiated prospective randomized double-blind single-centre study was performed with 374 patients, randomized to subcutaneous and intracutaneous leg-wound closure with either triclosan-coated sutures (Vicryl Plus and Monocryl Plus, Ethicon, Somerville, NJ, USA) (n = 184) or identical sutures without triclosan (n = 190) from the same manufacturer. All patients were followed up after 30 days (clinical visit) and 60 days (telephone interview). Primary endpoint was SSI within 60 days after surgery according to the definition of Center for Disease Control. Predefined secondary endpoints included culture-proven and antibiotic-treated SSI. RESULTS: The primary endpoint occurred in 23 patients (12.5%) with triclosan-coated sutures and in 38 patients (20.0%) in the group without triclosan (P = 0.0497, risk ratio 0.63, (95% confidence interval 0.39-1.00). Corresponding figures for culture-proven infections were 7.6 vs 12.1%, (P = 0.15), and for antibiotic-treated infections, 10.9 vs 18.4%, (P = 0.039). Staphylococcus aureus and coagulase-negative staphylococci were the most common pathogens in both groups. Insulin-treated diabetes and vein-harvesting time were associated with SSI after vein harvesting. CONCLUSIONS: Leg-wound closure with triclosan-coated sutures in CABG patients reduces SSIs after open vein harvesting. (ClinicalTrials.gov number NCT01212315).

Pressure reflection in the pulmonary circulation in patients with severe mitral regurgitation indicates adverse postoperative outcome.

OBJECTIVES: Severe pulmonary hypertension (PH) is a known risk factor in valvular surgery. In the present study, we hypothesized that the assessment of pressure reflection (PR) in the pulmonary circulation, indicating increased pulmonary vascular resistance, might improve the identification of patients with increased morbidity and mortality following surgery for severe mitral regurgitation. METHODS: A total of 103 patients without atrial fibrillation were divided into three groups: Group 1 (n = 48), patients without PR; Group 2 (n = 36), patients with PR and pulmonary artery systolic pressure (PASP) ≤ 60 mmHg and Group 3 (n = 19), patients with PR and PASP >60 mmHg. Three variables related to PR were selected: the acceleration time in the right ventricular outflow tract (RVOT), the interval between peak velocity in the RVOT and peak tricuspid regurgitant jet velocity and the right ventricular pressure increase after peak RVOT velocity. RESULTS: There were no differences between groups in age, ejection fraction, need for coronary bypass grafting or creatinine. Patients with PR (Groups 2 and 3) had more use of vasoactive drugs (overall P < 0.0001, Group 1 vs Group 2 P = 0.018). The proportion of patients with >24 h in the intensive care unit was 27% in Group 1, 54% in Group 2 and 84% in Group 3 (overall P < 0.0001, Group 1 vs Group 2 P = 0.006). The in-hospital mortality in patients without PR (n = 49) was 0% compared with 10.9% in patients with PR (P = 0.029). CONCLUSIONS: Echocardiography assessment of PR in the pulmonary circulation and severe PH may identify patients with adverse outcome following mitral surgery.

Usefulness of extracorporeal membrane oxygenation as a bridge to lung transplantation: a descriptive study.

BACKGROUND: This retrospective study investigated early outcome in patients with end-stage pulmonary disease bridged with extracorporeal membrane oxygenation (ECMO) with the intention of lung transplantation (LTx) in 2 Scandinavian transplant centers. METHODS: ECMO was used as a bridge to LTx in 16 patients between 2005 and 2009 at Sahlgrenska and Helsinki University Hospitals. Most patients were late referrals for LTx, and all failed to stabilize on mechanical ventilation. Thirteen patients (7 men) who were a mean age of 41 ± 8 years (range, 25-51 years) underwent LTx after a mean ECMO support of 17 days (range, 1-59 days). Mean follow-up at 25 ± 19 months was 100% complete. RESULTS: Three patients died on ECMO while waiting for a donor, and 1 patient died 82 days after LTx; thus, by intention-to-treat, the success for bridging is 81% and 1-year survival is 75%. All other patients survived, and 1-year survival for transplant recipients was 92% ± 7%. Mean intensive care unit stay after LTx was 28 ± 18 days (range, 3-53 days). All patients were doing well at follow-up; however, 2 patients underwent retransplantation due to bronchiolitis obliterans syndrome at 13 and 21 months after the initial ECMO bridge to LTx procedure. Lung function was evaluated at follow-up, and mean forced expiratory volume in 1 second was 2.0 ± 0.7 l (62% ± 23% of predicted) and forced vital capacity was 3.1 ± 0.6 l (74% ± 21% of predicted). CONCLUSION: ECMO used as a bridge to LTx results in excellent short-term survival in selected patients with end-stage pulmonary disease.