Fractured sternal wire causing a cardiac laceration.

BACKGROUND: Hemopericardium is a serious complication that can occur after cardiac surgery. While most post-operative causes are due to inflammation and bleeding, patients with broken sternal wires and an unstable sternum may develop hemopericardium from penetrating trauma. CASE PRESENTATION: We present the case of a 62-year-old male who underwent triple coronary bypass surgery and presented five months later with sudden anterior chest wall pain. Chest computed tomography revealed hemopericardium with an associated broken sternal wire that had penetrated into the pericardial space. The patient underwent a redo-sternotomy which revealed a 3.5 cm bleeding, jagged right ventricular laceration that correlated to the imaging findings of a fractured sternal wire projecting in the pericardial space. The laceration was repaired using interrupted 4 - 0 polypropylene sutures in horizontal mattress fashion between strips of bovine pericardium. The patient's recovery was uneventful and he was discharged on post-operative day four without complications. CONCLUSION: Patients with broken sternal wires and an unstable sternum require careful evaluation and management as these may have potentially life-threatening complications if left untreated.

Surgical management of aortic valve disease in the elderly: A retrospective comparative study of valve choice using propensity score analysis.

BACKGROUND AND AIM OF THE STUDY: Aortic valve dysfunction is the most common form of valvular heart disease. As the population continues to age, a greater number of patients will become candidates for aortic valve replacement (AVR); hence, prosthetic valve choice becomes of paramount importance. METHODS: A retrospective analysis was conducted on 801 patients aged > or =65 years who underwent isolated AVR or AVR + coronary artery bypass grafting (CABG) between January 1989 and June 2003 with a Carpentier Edwards Perimount (CEP) pericardial bioprosthesis (n = 398) or a St. Jude Medical (SJM) mechanical valve (n = 403). The mean age of CEP patients was 74.5 years (range: 65-89 years), and of SJM patients 73.9 years (range: 65-90 years). The follow up was 96.2% and 96.5% complete for CEP and SJM patients, respectively. Propensity scoring was used to establish homogeneity of the groups and reduce bias. RESULTS: The operative mortality was 4.0% (n = 16) among CEP patients and 6.5% (n = 26) among SJM patients. Predictors of hospital mortality included: peripheral vascular disease (p = 0.018), surgical urgency (p = 0.010), preoperative intra-aortic balloon pump (IABP) (p = 0.010), intraoperative perfusion time (p = 0.046) and intraoperative IABP (p = 0.001). Postoperative morbidities were similar for the two groups. The mean follow up was 72.4 and 59.2 months for CEP and SJM patients, respectively. The five-year actuarial survival was 70.9 +/- 2.3% for CEP and 71.8 +/- 2.4% for SJM patients; at 10 years the actuarial survival was 32.6 +/- 3.3% and 38.2 +/- 3.8%, respectively. Freedom from reoperation for AVR, stroke and non-fatal myocardial infarction was 98.8% (159/161), 99.4% (160/161) and 99.4% (160/161), respectively, in CEP patients, and 100.0% (220/220), 97.7% (215/220) and 97.7% (215/220), respectively, in SJM patients (p = NS). Predictors of late death (>30 days) included chronic obstructive pulmonary disease (p = 0.001) and mechanical valve replacement (p = 0.001). CONCLUSION: In comparable elderly patients, the outcomes of CEP and SJM valves after AVR showed no significant differences in hospital morbidity, mortality, mid-term survival or late cardiac events. However, the cumulative risk of lifelong anticoagulation with a mechanical valve is a serious consideration that must be factored into the selection algorithm.

Routine use of the direct thrombin inhibitor bivalirudin for off-pump coronary artery bypass grafting is safe and effective.

Anticoagulation with unfractionated heparin has been the standard of care for more than a half-century for patients undergoing cardiac surgery. The risk of heparin-induced adverse reactions dictates the need for a safe and effective alternative, particularly in off-pump coronary artery bypass (OPCAB) surgery, an approach associated with a perioperative prothrombotic condition that may negatively influence graft patency. Between March 2003 and January 2005, 243 consecutive patients underwent OPCAB with bivalirudin (0.75 mg/kg bolus with 1.75 mg/kg per hour infusion). There were 171 men (70.4%) and 72 women (29.6%). The mean age was 64.9 +/- 10.9 years (age range 32-88 years). There were 147 patients (60.5%) with 3-vessel disease; 46 (18.9%) had substantial (>50%) stenosis of the left main coronary artery; 104 (42.8%) had a moderately reduced (0.30 to 0.50) ejection fraction; and 9 (3.7%) had a severely reduced (<0.30%) ejection fraction. Five patients (2.1%) required conversion to cardiopulmonary bypass and subsequently received heparin. Postoperative complications included perioperative myocardial infarction in 6 patients (2.5%), stroke in 3 (1.2%), prolonged ventilation in 4 (1.6%), reoperation for bleeding in 3 (1.2%), renal insufficiency in 14 (5.8%), atrial fibrillation in 26 (10.7%), low cardiac output in 3 (1.2%), and deep sternal infection in 1 (0.4%). Blood products were used in 117 patients (48.1%). The overall hospital mortality rate was 0.4% (1 of 243). Bivalirudin is a safe and effective anticoagulant that may be routinely used as an alternative to heparin and protamine in patients undergoing OPCAB. This is evidenced by low hospital mortality and morbidity rates. Further follow-up is warranted to discern the influence of bivalirudin on long-term clinical outcomes.

Is the St. Jude Medical mechanical valve an appropriate choice for elderly patients?: A long-term retrospective study measuring quality of life.

BACKGROUND AND AIM OF THE STUDY: The selection of a suitable valve substitute in patients requiring valvular heart surgery is an important element in the preoperative decision-making process between cardiologist, surgeon, and patient. Controversy persists regarding the use of mechanical valves in the elderly. With the population living longer, reoperative risk becomes of paramount importance. Quality of life (QOL) considerations are often as important to the patient as longevity. The influence of mechanical valve replacement on QOL in elderly patients has not been well documented. METHODS: Between June 1981 and December 1999, a total of 1,125 consecutive patients aged > or = 65 years (582 men, 543 women; mean age 71.4 +/- 4.9 years) underwent valve replacement with at least one St. Jude Medical (SJM) mechanical valve. Preoperatively, 138 patients (12.3%) were in NYHA class II, 775 (68.9%) in class III, and 212 (18.8%) in class IV. In 535 patients (47.6%), coronary artery disease required surgical intervention. Survivors were administered the Short Form (SF)-36 QOL Survey at follow up, which was 96.1% complete. RESULTS: Hospital mortality was 7.6% (85/1,125). Mean follow up was 5.9 years (range: 9 months to 18.4 years). Mean (+/- SEM) actuarial survival was 70.6 +/- 1.4% at five years, and 40.6 +/- 2.0% at 10 years. Male patients scored significantly higher on the SF-36 than controls in physical (p = 0.012) and mental health (p = 0.004). Comparing female patients with controls revealed no significant difference in physical health; however, they scored higher in mental health than controls (p = 0.001). CONCLUSION: The study results clearly demonstrate that heart surgery in the elderly with the SJM mechanical valve can be accomplished with acceptable hospital mortality, morbidity, and excellent long-term results. Moreover, long-term QOL in elderly patients with a SJM valve can be expected to meet or exceed that of age- and gender-matched controls.

Comparison of bovine and porcine heparin in heparin antibody formation after cardiac surgery.

BACKGROUND: Heparin-induced thrombocytopenia (HIT) is a potentially devastating complication of heparin therapy. The incidence of clinical HIT after cardiovascular surgery is less than 2%, although asymptomatic antibodies to heparin-platelet factor 4 (PF4) occur more frequently. Bovine heparin is thought to cause more HIT than porcine heparin, although this has never been established for heparin use during coronary artery bypass grafting. We therefore undertook a randomized, prospective study of heparin-PF4 antibody formation in patients undergoing first-time CABG given intraoperative bovine or porcine heparin. METHODS: Two hundred seven patients (108 porcine, 99 bovine) completed the study. Heparin given pre- or postoperatively was always porcine. Platelet counts and heparin-PF4 antibody tests (enzyme-linked immunosorbent assays) were performed preoperatively and daily until postoperative day 7 or discharge if earlier. RESULTS: The overall incidence of heparin-PF4 antibody formation was 42%. Six patients (2.9%) were positive preoperatively, of which, 1 developed clinical HIT. When these were excluded, seroconversion rates were 44 of 99 (44.4%) and 33 of 108 (30.6%) for bovine and porcine heparin, respectively (p = 0.041). Among patients who produced antibodies, most (90% bovine, 85% porcine) seroconverted after postoperative day 2. There were no differences in postoperative platelet counts; only 1 patient developed thrombosis associated with seroconversion, but without developing thrombocytopenia. The seroconversion rates for patients having cardiopulmonary bypass or off-pump surgery were not significantly different. CONCLUSIONS: This study confirms the high frequency of heparin-PF4 antibodies after coronary artery bypass grafting and demonstrates a significantly higher incidence after bovine heparin. However, because some patients may seroconvert after discharge, our study may underestimate the true incidence.

Midterm outcomes using the physio ring in mitral valve reconstruction: experience in 492 patients.

BACKGROUND: Mitral valve reconstruction using standardized Carpentier techniques is the treatment of choice for most patients with regurgitant lesions. Demonstrated predictability and stability make it an attractive alternative to valve replacement. The Physio Ring's inherent flexibility provides a viable alternative in the application of remodeling techniques and appears to be physiologically superior to traditional approaches. METHODS: Between April 1994 and October 2000, 492 consecutive patients underwent mitral valve reconstruction using standardized Carpentier techniques with the Carpentier-Edwards Physio Ring (Edwards Lifesciences LLC, Irvine, CA). There were 267 men (54.3%) and 225 women (45.7%). Mean age was 64.2 years (range, 18 to 86). Almost one-half (44.3%) were 70 years of age or over. The mitral valve etiology was congenital in 7 patients (1.4%), myxomatous in 351 patients (71.3%), ischemic in 88 (17.9%), rheumatic in 26 (5.3%), endocarditis in 9 (1.8%), calcific in 8 (1.6%), and other abnormalities in 3 (0.6%). RESULTS: Isolated mitral valve reconstruction was performed in 282 patients (57.3%), with coronary artery bypass grafting (CABG) in 182 (37.0%), with valve replacement in 11 (2.2%), and with CABG and valve replacement in 17 (3.5%). All patients (100.0%) had ring annuloplasty, 263 (53.5%) leaflet resection, 140 (28.5%) chordal resection, 55 (11.2%) chordal transposition, 48 (9.8%) chordal shortening, and 15 (3.0%) commissurotomy. Overall hospital mortality was 3.5% (17 of 492). Postoperative complications included respiratory insufficiency in 55 patients (11.2%), low cardiac output in 13 (2.6%), stroke in 14 (2.8%), reoperation for bleeding in 13 (2.6%), renal insufficiency in 21 (4.3%), and myocardial infarction in 5 (1.0%), and new onset of atrial fibrillation in 74 patients (15.0%). The cumulative follow-up for the series was 1,522.9 patient years and ranged from 1 to 101.0 months (mean, 38.5 months). There were 11 reconstruction failures (2.3%) requiring ring explant. Actuarial survival was 81.5% +/- 2.1% at 4 years and 67.9% +/- 4.6% at 7 years. Freedom from reoperation at 4 years was 81.5% +/- 2.1% and 67.9% +/- 4.6% at 7 years. CONCLUSIONS: Mitral valve reconstruction with the Physio Ring can be accomplished with low hospital mortality and morbidity even in combined procedures. Moreover, the low incidence of reoperation and late cardiac events suggests that the Physio Ring, with its inherent flexibility, offers a definite advantage in the application of remodeling techniques in mitral valve reconstruction.