Fibrin Sealant Patch for the Management of Intractable Bleeding From an LVAD Apex Cannula.

BACKGROUND: Intractable bleeding from the apical cannulation site of a left ventricular assist device (LVAD) is a dreaded complication. CASE REPORT: A 52-year-old male suffering from dilative cardiomyopathy (DCM) with fixed pulmonary hypertension underwent reoperative LVAD implantation after previous mitral valve surgery. The patient underwent three rethoracotomies for bleeding from the apex cannulation site without achieving hemostasis. Conventional techniques and application of fibrin sealants and polymeric sealing devices did not fix the problem. The bleeding stopped after application of the EVARREST® Fibrin Sealant Patch (FSP), and he needed no further transfusions. CONCLUSION: This patch might become a useful tool for intractable bleeding problems in LVAD surgery.

Localizations of Na(+)-D-glucose cotransporters SGLT1 and SGLT2 in human kidney and of SGLT1 in human small intestine, liver, lung, and heart.

Novel affinity-purified antibodies against human SGLT1 (hSGLT1) and SGLT2 (hSGLT2) were used to localize hSGLT2 in human kidney and hSGLT1 in human kidney, small intestine, liver, lung, and heart. The renal locations of both transporters largely resembled those in rats and mice; hSGLT2 and SGLT1 were localized to the brush border membrane (BBM) of proximal tubule S1/S2 and S3 segments, respectively. Different to rodents, the renal expression of hSGLT1 was absent in thick ascending limb of Henle (TALH) and macula densa, and the expression of both hSGLTs was sex-independent. In small intestinal enterocytes, hSGLT1 was localized to the BBM and subapical vesicles. Performing double labeling with glucagon-like peptide 1 (GLP-1) or glucose-dependent insulinotropic peptide (GIP), hSGLT1 was localized to GLP-1-secreting L cells and GIP-secreting K cells as has been shown in mice. In liver, hSGLT1 was localized to biliary duct cells as has been shown in rats. In lung, hSGLT1 was localized to alveolar epithelial type 2 cells and to bronchiolar Clara cells. Expression of hSGLT1 in Clara cells was verified by double labeling with the Clara cell secretory protein CC10. Double labeling of human heart with aquaporin 1 immunolocalized the hSGLT1 protein in heart capillaries rather than in previously assumed myocyte sarcolemma. The newly identified locations of hSGLT1 implicate several extra renal functions of this transporter, such as fluid absorption in the lung, energy supply to Clara cells, regulation of enteroendocrine cells secretion, and release of glucose from heart capillaries. These functions may be blocked by reversible SGLT1 inhibitors which are under development.

[Indications, risk factors, specialities and after-care of surgical treatment for cardiac and thoracic vascular diseases]. / Herz- und thorakale Gefäßchirurgie - OP-Indikationen, Risiken und Besonderheiten sowie OP-Nachsorge.

Despite a known high risk and complexity in the operative therapy of cardio-thoracic patients, cardiac surgery is medical routine activity today. The German Society of Cardiothoracic Surgery regularly analyses the more than 100.000 cases a year in Germany. Fixing procedural statics, it gives us the knowledge of individual risk factors and success rates for surgical therapy of our patients.Following we want to shortly summarize indications, risk factors, specialities and after-care of surgical treatment for cardiac and thoracic vascular diseases in adults.

Clinical outcomes after inferior vena cava resection for malignant disease. A single center experience of 51 vena cava resections.

BACKGROUND AND OBJECTIVE: For tumors involving inferior vena cava (IVC), surgery with complete resection remains the first line treatment. Management of IVC after resection, either ligation without reconstruction or primary reconstruction, is debated. Our study aimed to evaluate type of venous reconstruction, anticoagulation management and morbidity. METHODS: A French single center database of patients who underwent partial or total circumferencial resection of the IVC for malignant disease was analyzed. Inclusion criteria were any oncologic procedure for a retroperitoneal neoplasm requiring concomitant resection of the IVC with or without venous reconstruction with prosthesis. Exclusion criteria were surgery before year 2000. Data were descriptive and reverse Kaplan Meier was used for follow-up calculation. The endpoints were the rate of prosthetic reconstruction, the use of anticoagulation and the post-operative outcomes. RESULTS: Fifty - one patients were included with a median duration of follow-up of 54.8 months. The majority of patients were men (56.9%). Median age of the population was 44.1 years. Most of the patients underwent surgery for primary testicular cancer and for sarcoma. Complete IVC resections were performed in 46 (90,2%) patients, 32 having a concomitant prosthetic replacement. Eight patients underwent aortic resection in the same operative time. Postoperative morbidity was 33.3%. Post-operative anticoagulation was done in 24 patients. At 1 month, four patients developed thrombosis in the prosthesis. CONCLUSIONS: IVC resections are feasible and safe. Venous reconstruction and postoperative management were planned according to the preoperative imaging and intraoperative findings. We propose a decision-tree for peri-operative management and anticoagulation.

C-type natriuretic peptide/cGMP/FoxO3 signaling attenuates hyperproliferation of pericytes from patients with pulmonary arterial hypertension.

Pericyte dysfunction, with excessive migration, hyperproliferation, and differentiation into smooth muscle-like cells contributes to vascular remodeling in Pulmonary Arterial Hypertension (PAH). Augmented expression and action of growth factors trigger these pathological changes. Endogenous factors opposing such alterations are barely known. Here, we examine whether and how the endothelial hormone C-type natriuretic peptide (CNP), signaling through the cyclic guanosine monophosphate (cGMP) -producing guanylyl cyclase B (GC-B) receptor, attenuates the pericyte dysfunction observed in PAH. The results demonstrate that CNP/GC-B/cGMP signaling is preserved in lung pericytes from patients with PAH and prevents their growth factor-induced proliferation, migration, and transdifferentiation. The anti-proliferative effect of CNP is mediated by cGMP-dependent protein kinase I and inhibition of the Phosphoinositide 3-kinase (PI3K)/AKT pathway, ultimately leading to the nuclear stabilization and activation of the Forkhead Box O 3 (FoxO3) transcription factor. Augmentation of the CNP/GC-B/cGMP/FoxO3 signaling pathway might be a target for novel therapeutics in the field of PAH.

Evaluation of Tick Abundance and Pyrethroid Resistance Via Determination of Glutathione-S-Transferases Activity.

Controlling the number of ticks as carriers of infectious diseases is very important. The process is sometimes compromised by activating the protective mechanisms of the tick itself. Glutathione-S-transferases activity (GSTs) was the subject of our investigation of tick abundance after pyrethroid treatment. We determined GSTs activity in ticks collected from six locations in Belgrade before and after pyrethroid treatment and correlated it with the number of ticks in the locations. The results showed that tick abundance correlated with GSTs activity. On the other hand, treatment efficiency was location-dependent, being similar in each particular location in both April (spring) and October (autumn). Our results suggest that GSTs activity reflects the influence of both present local allelochemicals from different environmental seasonal vegetation and applied pyrethroid. We can conclude that by evaluating GSTs activity in ticks from particular locations as well as during the treatment with acaricides tick removal practice could be improved.

Multiorgan recovery in a cadaver body using mild hypothermic ECMO treatment in a murine model.

BACKGROUND: Transplant candidates on the waiting list are increasingly challenged by the lack of organs. Most of the organs can only be kept viable within very limited timeframes (e.g., mere 4-6 h for heart and lungs exposed to refrigeration temperatures ex vivo). Donation after circulatory death (DCD) using extracorporeal membrane oxygenation (ECMO) can significantly enlarge the donor pool, organ yield per donor, and shelf life. Nevertheless, clinical attempts to recover organs for transplantation after uncontrolled DCD are extremely complex and hardly reproducible. Therefore, as a preliminary strategy to fulfill this task, experimental protocols using feasible animal models are highly warranted. The primary aim of the study was to develop a model of ECMO-based cadaver organ recovery in mice. Our model mimics uncontrolled organ donation after an "out-of-hospital" sudden unexpected death with subsequent "in-hospital" cadaver management post-mortem. The secondary aim was to assess blood gas parameters, cardiac activity as well as overall organ state. The study protocol included post-mortem heparin-streptokinase administration 10 min after confirmed death induced by cervical dislocation under full anesthesia. After cannulation, veno-arterial ECMO (V-A ECMO) was started 1 h after death and continued for 2 h under mild hypothermic conditions followed by organ harvest. Pressure- and flow-controlled oxygenated blood-based reperfusion of a cadaver body was accompanied by blood gas analysis (BGA), electrocardiography, and histological evaluation of ischemia-reperfusion injury. For the first time, we designed and implemented, a not yet reported, miniaturized murine hemodialysis circuit for the treatment of severe hyperkalemia and metabolic acidosis post-mortem. RESULTS: BGA parameters confirmed profound ischemia typical for cadavers and incompatible with normal physiology, including extremely low blood pH, profound negative base excess, and enormously high levels of lactate. Two hours after ECMO implantation, blood pH values of a cadaver body restored from < 6.5 to 7.3 ± 0.05, pCO2 was lowered from > 130 to 41.7 ± 10.5 mmHg, sO2, base excess, and HCO3 were all elevated from below detection thresholds to 99.5 ± 0.6%, - 4 ± 6.2 and 22.0 ± 6.0 mmol/L, respectively (Student T test, p < 0.05). A substantial decrease in hyperlactatemia (from > 20 to 10.5 ± 1.7 mmol/L) and hyperkalemia (from > 9 to 6.9 ± 1.0 mmol/L) was observed when hemodialysis was implemented. On balance, the first signs of regained heart activity appeared on average 10 min after ECMO initiation without cardioplegia or any inotropic and vasopressor support. This was followed by restoration of myocardial contractility with a heart rate of up to 200 beats per minute (bpm) as detected by an electrocardiogram (ECG). Histological examinations revealed no evidence of heart injury 3 h post-mortem, whereas shock-specific morphological changes relevant to acute death and consequent cardiac/circulatory arrest were observed in the lungs, liver, and kidney of both control and ECMO-treated cadaver mice. CONCLUSIONS: Thus, our model represents a promising approach to facilitate studying perspectives of cadaveric multiorgan recovery for transplantation. Moreover, it opens new possibilities for cadaver organ treatment to extend and potentiate donation and, hence, contribute to solving the organ shortage dilemma.

The effect of different lung-protective strategies in patients during cardiopulmonary bypass: a meta-analysis and semiquantitative review of randomized trials.

OBJECTIVES: A variety of lung-protective techniques, including continuous positive airway pressure and vital capacity maneuvers, have been suggested as beneficial when applied during cardiopulmonary bypass (CPB). To better define the efficacy of these techniques, a systematic review of different ventilation strategies during and after CPB was performed. DESIGN: A systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. SETTING: Hospitals. PARTICIPANTS: Eight hundred fourteen participants of 16 randomized controlled trials. INTERVENTIONS: Continuous positive airway pressure (CPAP), low-volume ventilation, or vital capacity maneuvers (VCMs) during CPB. MEASUREMENTS AND MAIN RESULTS: The methodologic validity of the included trials was scored according to the Oxford scale. Included trials had to report on at least 1 of the following parameters: oxygenation, oxygenation index, alveolar-arterial oxygen difference, or shunt fraction. The average quality of the included trials was as low as 2 on a scale from 1 to 5. The use of CPAP or VCM during CPB led to a significant increase in oxygenation parameters immediately after weaning from CPB, but this effect was not sustainable and did not improve patient outcome. CONCLUSIONS: This meta-analysis showed that the positive effects of the designated techniques are probably short-lived with a questionable impact on the long-term clinical outcome of the treated patients. Based on the available data, it might be impossible to advise an optimal or best-evidence strategy of lung preservation during CPB.

Left Ventricular Assist Device Implantation in a Patient with Ventricular Pseudoaneurysm.

Background Left ventricular assist device (LVAD) implantation after contained LV rupture (pseudoaneurysm) represents a difficult surgical problem. Case Description We describe the surgical approach for such a patient. The sewing ring was implanted utilizing a Dacron patch for reconstruction of the free wall, fibrotic LV wall remnants, and a Teflon strip giving additional support for cannula position and hemostasis. The patient had an uneventful recovery and is well 19 months after the procedure. Conclusion LV pseudoaneurysm is not a contraindication for permanent LVAD implantation.

Subacute Aortic Rupture Due to Mechanical Chest Compression with Indwelling Impella.

Mechanical cardiopulmonary resuscitation (CPR) devices like Lund University Cardiopulmonary Assist System (LUCAS) cause more skeletal and visceral injuries than standard CPR. A 62-year-old woman with ST-elevation myocardial infarction was resuscitated with LUCAS and Impella CP for refractory cardiogenic shock during percutaneous coronary intervention. She suffered delayed ascending aortic rupture necessitating supracommissural ascending aortic replacement plus triple bypass grafting. Prolonged mechanical CPR with concomitant Impella may lead to aortic rupture. The combined use of LUCAS and Impella may have disastrous consequences.

Bioactive glass grants equivalent fusion compared to autologous iliac crest bone for ALIF: a within-patient comparative study.

PURPOSE: To determine within-patient fusion rates of chambers filled with bioactive glass versus autologous iliac crest bone on computed tomography (CT) following anterior lumbar interbody fusion (ALIF). METHODS: A consecutive series of 40 patients (58 levels) that underwent single-level (L5-S1 only) or two-level (L5-S1 and L4-L5) ALIF were assessed. Indications for fusion were one or more of the following: degenerative disc disease with or without Modic changes, spondylolisthesis, and stenosis. Each intervertebral cage had a middle beam delimiting two chambers, one of which was filled with bioactive glass and the other with autologous iliac crest bone. CT scans were graded using the Bridwell classification (grade I, best; grade IV, worst). Patients were evaluated using the Oswestry Disability Index (ODI), and by rating pain in the lower back and legs on a Visual Analog Scale (pVAS); complications and reoperations were noted. RESULTS: At 15 ± 5 months follow-up, there were no significant differences in fusion across chambers filled with bioactive glass versus chambers filled with autologous bone (p = 0.416). Two patients with Bridwell grade III at both chambers of the L4-L5 cages required reoperation using posterior instrumentation. Clinical assessment of the 38 remaining patients (54 levels) at 25 ± 2 months, revealed ODI of 15 ± 12, lower back pVAS of 1.4 ± 1.5 and legs pVAS of 1.9 ± 1.6. CONCLUSIONS: For ALIF at L5-S1 or L4-L5, within-patient fusion rates were equivalent for bioactive glass compared to autologous iliac crest bone; thus, bioactive glass can substitute autologous bone, avoiding increased operative time and blood loss, as well as donor site morbidity.

Benefits of Intra-Aortic Balloon Pump Support in Patients with Postcardiotomy Shock Requiring Venoarterial Extracorporeal Membrane Oxygenation.

BACKGROUND: The benefit of the combined use of an intra-aortic balloon pump (IABP) and venoarterial extracorporeal membrane oxygenation (VA-ECMO) for postcardiotomy shock remains unclear. We aimed to analyse the potential benefits and safety of combining these two devices. METHODS: We enrolled 200 patients treated with either VA-ECMO only or in combination with IABP (ECMO-I group) between January 2012 and January 2021. To adjust the patients' backgrounds, we used propensity score matching for additional analyses, resulting in 57 pairs. The primary endpoint was 30-day survival. Secondary endpoints included successful weaning and complication rates. We also analysed hemodynamic parameters in both groups. RESULTS: After propensity score matching, 30-day survival was better in the ECMO-I group (log-rank p = 0.004). The ECMO-I and ECMO-only groups differed regarding the secondary endpoints, including successful weaning (50.9% and 26.3%, respectively; p = 0.012) and the need for continuous renal replacement therapy (28.1% and 50.9%, p = 0.021). Complication rates were not statistically different between the two groups. CONCLUSION: Compared to VA-ECMO alone, the combined use of VA-ECMO and IABP is beneficial regarding 30-day survival in selected patients with postcardiotomy shock; successful ECMO weaning and freedom from renal replacement therapy is more common in patients supported with VA-ECMO plus IABP.

Central Versus Peripheral Arterial Cannulation for Veno-Arterial Extracorporeal Membrane Oxygenation in Post-Cardiotomy Patients.

Different arterial cannulation strategies are feasible for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in postcardiotomy shock. We aimed to analyze potential benefits and safety of different arterial cannulation strategies. We identified 158 patients with postcardiotomy cardiogenic shock requiring VA-ECMO between 01/10 and 01/19. Eighty-eight patients were cannulated via axillary or femoral artery (group P), and 70 centrally via the ascending aorta directly or through an 8 mm vascular graft anastomosed to the ascending aorta (group C). Demographics and operative parameters were similar. Change of cannulation site for Harlequin's syndrome or hyperperfusion of an extremity occurred in 13 patients in group P but never in group C (p = 0.001). Surgical revision of cannulation site was also encountered more often in group P than C. The need for left ventricular (LV) unloading was similar between groups, whereas surgical venting was more often implemented in group C (11.4% vs. 2.3, p = 0.023). Stroke rates, renal failure, and peripheral ischemia were similar. Weaning rate from ECMO (52.9% vs. 52.3%, p = NS) was similar. The 30 day mortality was higher in group P (60% vs. 76.1%, p = 0.029). Central cannulation for VA-ECMO provides antegrade flow without Harlequin's syndrome, changes of arterial cannula site, and better 30 day survival. Complication rates regarding need for reexploration and transfusion requirements were similar.

Heartmate II implantation with right coronary bypass grafting in ischemic cardiomyopathy with "fixed" pulmonary hypertension: treatment strategy to protect right ventricular function.

A 49-year-old male patient suffering from end-stage ischemic cardiomyopathy with a left ventricular ejection fraction below 15% was presented to redo coronary artery bypass grafting (CABG). Coronary angiogram demonstrated an occluded left anterior descending artery and occluded right coronary artery, perfused retrogradely from the circumflex artery. Since positron emission tomography did not demonstrate viable left ventricular myocardium except for the basis of the left ventricle, CABG was considered futile. Cardiac transplantation was contra-indicated due to pharmacologically unresponsive pulmonary artery hypertension. The patient successfully underwent left ventricular assist device implantation in combination with right coronary artery revascularization. The article reflects the regimen of right ventricular preservation in this patient.

Outcomes of stand-alone anterior lumbar interbody fusion of L5-S1 using a novel implant with anterior plate fixation.

BACKGROUND CONTEXT: Compared with other approaches, anterior lumbar interbody fusion (ALIF) is believed to be more effective at restoring segmental lordosis and reducing risks of adjacent-segment disease. It remains controversial, however, whether ALIF improves global lumbar lordosis or influences pelvic parameters, possibly because of the heterogeneity of implants and levels studied. PURPOSE: To report clinical outcomes of stand-alone ALIF with anterior plate fixation for L5-S1 and to determine the effect on global lumbar lordosis and pelvic parameters. STUDY DESIGN: This is a retrospective case series. PATIENT SAMPLE: Patients that underwent isolated mini-ALIF with anterior plate fixation for L5-S1. OUTCOME MEASURES: Oswestry Disability Index (ODI), Short Form 12, lower back and legs pain on Visual Analog Scale, as well as spino-pelvic parameters. METHODS: The authors reviewed the records of all patients that underwent retroperitoneal mini-ALIF for single-level L5-S1 fusion between August 2012 and December 2016. A total of 129 patients were included, but 9 patients had incomplete preoperative radiographic data, and one patient had schizophrenia and was unable to respond to outcome questionnaires, leaving 119 patients eligible for outcome assessment. At a minimum follow-up of 1 year, seven patients refused to participate in the study or could not be reached, which left a final cohort of 112 patients. RESULTS: Nine patients were reoperated without implant removal (four pseudarthrosis, two hematomas, one sepsis, one L4-L5 disc hernia, and one L4-L5 disc degeneration). At a mean of 20±9 months, all scores improved significantly from baseline values, with net improvement in ODI of 23.3±19.9. Multivariable analyses confirmed better postoperative ODI in patients that received 18° cages (ß=-9.0, p=.017), but revealed no significant trends for net improvement in ODI. Comparison of preoperative and last follow-up radiographs revealed that global lumbar lordosis increased by 4.2±7.1° (p<.001), L5-S1 segmental lordosis increased by 11.8±6.7° (p<.001), and L4-L5 segmental lordosis decreased by 1.9±3.3° (p<.001). All pelvic parameters changed: pelvic incidence increased by 0.6±2.7° (p=.003), pelvic tilt decreased by 2.5±4.1° (p<.001) and sacral slope increased by 3.3±4.7° (p<.001). CONCLUSIONS: Stand-alone mini-ALIF with anterior plate fixation for L5-S1 can change pelvic parameters while improving global and segmental lumbar lordosis. The procedure resulted in a fusion rate of 96% and comparable improvements in ODI to other studies.

First clinical experience with the novel cold storage SherpaPak™ system for donor heart transportation.

BACKGROUND: The current gold standard for donor heart preservation is a three-bag-technique and storage in a cooler filled with slush ice. This technique can cause freezing injury with protein denaturation. We report our early experience with a single-use disposable device (SherpaPak™, Paragonix Technologies, MA, USA) specifically designed for sterile permanent temperature-controlled transportation of donor hearts. METHODS: In this case control study with 2:1 matching we identified 21 patients after heart transplantation depending on type of organ transport (standard three-bag-technique vs. SherpaPak™). The outcome after donor heart storage in the SherpaPak™ was compared with donor heart transportation with the standard technique. RESULTS: Since July 2018 seven patients (5 males; mean age 50.3±13.2years) underwent heart transplantation with the SherpaPak™ system. Cold ischemic time was longer in the SherpaPak™ group (207.7±23.3 vs. 181.6±21.9, P=0.027). SherpaPak™ kept the organ temperature at 5.1±0.8 °C, with an average outside temperature of 21.4±3.6 °C. Among all 21 transplanted patients four developed fatal early graft failure (28.6% vs. 21.4%, P=0.432). Over the first hours we noticed no difference in hemodynamic parameters, CK-MB levels or vasoactive-inotropic score. During first follow-up we noticed slightly better right heart function in the SherpaPak™ group (TAPSE 17.83±2.71 vs. 14.52±2.61 mm, P=0.020). We identified no positive blood cultures in the SherpaPak™ group within the first 30 days after heart transplantation. CONCLUSIONS: The SherpaPak™ provides a constant temperature during transportation with permanent monitoring, never dropping below 4 °C. Organs transported with this novel device showed a normal perioperative function.

Critical closing pressure as the arterial downstream pressure with the heart beating and during circulatory arrest.

BACKGROUND: Calculation of systemic vascular resistance, used for hemodynamic decision-making, is based on central venous pressure taken as the downstream pressure. However, during circulatory arrest, arterial pressure decreases to a plateau higher than central venous pressure, the critical closing pressure (Pcrit). The authors assessed in humans undergoing arrest whether two-compartment and pressure-dependent conductivity models better estimate arterial pressure decay and Pcrit than a single-compartment model, and whether Pcrit corresponds to Pcrit calculated with the heart beating. METHODS: Aortic pressure decay was fitted to single-compartment, two-compartment, and pressure-dependent conductivity models using specified time intervals during arrest and natural diastole in 10 patients during defibrillator implantation. RESULTS: Although all models closely predicted Pcrit with an arrest of > or = 7s, both two-compartment and pressure-dependent conductivity models better estimated pressure decay than a single-compartment model. However, Pcrit calculated from natural diastolic pressure decay was greater (53 mmHg +/- 15.6) than Pcrit 15 s (26.6 mmHg +/- 7.8, P = 0.001) and 30 s (23.9 mmHg +/- 7.1, P = 0.001) during arrest, and also greater than Pcrit calculated for the same time interval during initial arrest. CONCLUSIONS: Thus, during arrest, Pcrit can be closely predicted after > or = 7 s, regardless of the model; two-compartment and pressure-dependent conductivity models provide a better fit than a single-compartment model, and actual Pcrit is much less than Pcrit calculated with the heart beating. Irrespective of uncertainties in whether Pcrit calculated with the heart beating or during arrest is the "true" Pcrit prevailing physiologically, linear vascular resistance is markedly less when substituting Pcrit for central venous pressure as the downstream pressure.

Sternal closure techniques and postoperative sternal wound complications in elderly patients.

OBJECTIVE: Postoperative sternal wound complications (PSWC) including deep sternal wound infection (DSWI) and sternal dehiscence (SD) cause significant morbidity and mortality. Elderly patients with several risk factors are particularly prone to suffer PSWC. METHODS: We present (I) a subset of 86 patients, all aged > or =75 years out of 339 cardiac surgery patients prospectively randomised to receive either conventional sternal closure or a Robicsek type closure. Primary end-points were SD and DSWI; secondary end-points included a composite of clinical parameters; (II) we retrospectively assessed data of 54/5273 patients with mediastinitis regarding the influence of advanced age. In addition, we report an epidemiological overview of different sternal closure techniques. RESULTS: (I) The Robicsek technique showed an impact on SD and DSWI, and several secondary end-points: ventilator support (p=0.03), postoperative blood loss (p=0.04), and chest pain >3 days (p=0.04). (II) A total of 54/5273 (1.02%) patients developed postoperative mediastinitis. Twelve out of 54 (22%) patients died within 6 months of the initial operation. Predictors of mortality were insulin-dependent diabetes mellitus (p=0.05), renal insufficiency (p=0.01), delayed sternal closure (p=0.05), ICU-stay >10 days (p=0.01), and methicillin-resistant Staphylococcus aureus (p=0.03) or fungal infection (p=0.02). CONCLUSIONS: No statistical difference in sternal dehiscence or mediastinitis was found irrespective of whether the bilateral and longitudinal parasternal closure or the conventional peri/trans-sternal wiring technique was used, but there was an obvious, positive influence on sternal dehiscence, deep sternal wound infection, and clinical parameters. However, the study population is relatively small.

Venovenous extracorporeal membrane oxygenation for the management of contralateral iatrogenic bronchus perforation during lower bilobectomy.

Tracheobronchial rupture by a double-lumen endobronchial tube is a rare but life-threatening complication. We report a case of bronchial rupture during contralateral bilobectomy. Venovenous extracorporeal membrane oxygenation support was instituted via the right femoral vein and the internal jugular vein with the patient in the left lateral decubitus position. Sleeve resection of the ruptured bronchus was performed. The patient was successfully discharged home. Rapid institution of venovenous extracorporeal membrane oxygenation is helpful to manage this intraoperative complication.

Donor heart selection and outcomes: An analysis of over 2,000 cases.

BACKGROUND: Decision-making when offered a donor heart for transplantation is complex, and supportive data describing outcomes according to acceptance or non-acceptance choices are sparse. Our aim was to analyze donor heart acceptance decisions and associated outcomes at a single center, and after subsequent acceptance elsewhere. METHODS: This investigation was a retrospective analysis of data obtained from the University of Vienna Medical Center and Eurotransplant centers for the period 2001 to 2015. RESULTS: Our center accepted 31.8% (699 of 2,199) of donor hearts offered. Unlike other centers, the acceptance rate, with or without transplantation, did not increase over time. Of the donor hearts rejected by our center, 38.1% (572 of 1,500) were later accepted elsewhere. Acceptance rates were twice as high for donor hearts initially rejected for non-quality reasons (339 of 601, 56.4%) compared with initial rejection for quality reasons (233 of 899, 25.9%). Three-year patient survival rate was 79% at Vienna; for donor hearts initially rejected by Vienna for non-quality reasons or quality reasons, it was 73% and 63%, respectively (p < 0.001). Outcomes at other centers after transplantation of grafts rejected by Vienna varied according to the reason for rejection, with good 3-year survival rates for rejection due to positive virology (77%), high catecholamines (68%), long ischemic time (71%), or low ejection fraction (68%), but poor survival was observed for hearts rejected for hypernatremia (46%), cardiac arrest (21%), or valve pathology (50%). CONCLUSIONS: A less restrictive policy for accepting donor hearts at our center, particularly regarding rejection for non-quality reasons or for positive virology, high catecholamine levels, longer ischemic time, or low ejection fraction, could expand our donor pool while maintaining good outcomes.