Risk Factors for Sternal Wound Infection After Open Heart Operations Vary According to Type of Operation.

BACKGROUND: This study evaluated whether risk factors for sternal wound infections vary with the type of surgical procedure in cardiac operations. METHODS: This was a university hospital surveillance study of 3,249 consecutive patients (28% women) from 2006 to 2010 (median age, 69 years [interquartile range, 60 to 76]; median additive European System for Cardiac Operative Risk Evaluation score, 5 [interquartile range, 3 to 8]) after (1) isolated coronary artery bypass grafting (CABG), (2) isolated valve repair or replacement, or (3) combined valve procedures and CABG. All other operations were excluded. Univariate and multivariate binary logistic regression were conducted to identify independent predictors for development of sternal wound infections. RESULTS: We detected 122 sternal wound infections (3.8%) in 3,249 patients: 74 of 1,857 patients (4.0%) after CABG, 19 of 799 (2.4%) after valve operations, and 29 of 593 (4.9%) after combined procedures. In CABG patients, bilateral internal thoracic artery harvest, procedural duration exceeding 300 minutes, diabetes, obesity, chronic obstructive pulmonary disease, and female sex (model 1) were independent predictors for sternal wound infection. A second model (model 2), using the European System for Cardiac Operative Risk Evaluation, revealed bilateral internal thoracic artery harvest, diabetes, obesity, and the second and third quartiles of the European System for Cardiac Operative Risk Evaluation were independent predictors. In valve patients, model 1 showed only revision for bleeding as an independent predictor for sternal infection, and model 2 yielded both revision for bleeding and diabetes. For combined valve and CABG operations, both regression models demonstrated revision for bleeding and duration of operation exceeding 300 minutes were independent predictors for sternal infection. CONCLUSIONS: Risk factors for sternal wound infections after cardiac operations vary with the type of surgical procedure. In patients undergoing valve operations or combined operations, procedure-related risk factors (revision for bleeding, duration of operation) independently predict infection. In patients undergoing CABG, not only procedure-related risk factors but also bilateral internal thoracic artery harvest and patient characteristics (diabetes, chronic obstructive pulmonary disease, obesity, female sex) are predictive of sternal wound infection. Preventive interventions may be justified according to the type of operation.

Minimized extracorporeal circulation does not impair cognitive brain function after coronary artery bypass grafting.

OBJECTIVES: Objective evaluation of the impact of minimized extracorporeal circulation (MECC) on perioperative cognitive brain function in coronary artery bypass grafting (CABG) by electroencephalogram P300 wave event-related potentials and number connection test (NCT) as metrics of cognitive function. METHODS: Cognitive brain function was assessed in 31 patients in 2013 with a mean age of 65 years [standard deviation (SD) 10] undergoing CABG by the use of MECC with P300 auditory evoked potentials (peak latencies in milliseconds) directly prior to intervention, 7 days after and 3 months later. Number connection test, serving as method of control, was performed simultaneously in all patients. RESULTS: Seven days following CABG, cognitive P300 evoked potentials were comparable with preoperative baseline values [vertex (Cz) 376 (SD 11) ms vs 378 (18) ms, P = 0.39; frontal (Fz) 377 (11) vs 379 (21) ms, P = 0.53]. Cognitive brain function at 3 months was compared with baseline values [(Cz) 376 (11) ms vs 371 (14 ms) P = 0.09; (Fz) 377 (11) ms vs 371 (15) ms, P = 0.04]. Between the first postoperative measurement and 3 months later, significant improvement was observed [(Cz) 378 (18) ms vs 371 (14) ms, P = 0.03; (Fz) 379 (21) vs 371 (15) ms, P = 0.02]. Similar clearly corresponding patterns could be obtained via the number connection test. Results could be confirmed in repeated measures analysis of variance for Cz (P = 0.05) and (Fz) results (P = 0.04). CONCLUSIONS: MECC does not adversely affect cognitive brain function after CABG. Additionally, these patients experience a substantial significant cognitive improvement after 3 months, evidentiary proving that the concept of MECC ensures safety and outcome in terms of brain function.

Mid-term results of aortic root replacement using a self-assembled biological composite graft.

OBJECTIVES: To report the mid-term results of aortic root replacement using a self-assembled biological composite graft, consisting of a vascular tube graft and a stented tissue valve. METHODS: Between January 2005 and December 2011, 201 consecutive patients [median age 66 (interquartile range, IQR, 55-77) years, 31 female patients (15.4%), median logistic EuroSCORE 10 (IQR 6.8-23.2)] underwent aortic root replacement using a stented tissue valve for the following indications: annulo-aortic ectasia or ascending aortic aneurysm with aortic valve disease in 162 (76.8%) patients, active infective endocarditis in 18 (9.0%) and acute aortic dissection Stanford type A in 21 (10.4%). All patients underwent clinical and echocardiographic follow-up. We analysed survival and valve-related events. RESULTS: The overall in-hospital mortality rate was 4.5%. One- and 5-year cardiac-related mortality rates were 3 and 6%, and overall survival was 95 ± 1.5 and 75 ± 3.6%, respectively. The rate of freedom from structural valve failure was 99% and 97 ± 0.4% at the 1- and 5-year follow-up, respectively. The incidence rates of prosthetic valve endocarditis were 3 and 4%, respectively. During a median follow-up of 28 (IQR 14-51) months, only 2 (1%) patients required valve-related redo surgery due to prosthetic valvular endocarditis and none suffered from thromboembolic events. One percent of patients showed structural valve deterioration without any clinical symptoms; none of the patients suffered greater than mild aortic regurgitation. CONCLUSIONS: Aortic root replacement using a self-assembled biological composite graft is an interesting option. Haemodynamic results are excellent, with freedom from structured valve failure. Need for reoperation is extremely low, but long-term results are necessary to prove the durability of this concept.

Cor triatriatum sinister.

The cor triatriatum sinister is an uncommon congenital cardiac anomaly and reports in the literature are limited. It is often associated with other cardiac malformations, such as atrial septal defect, transposition of the great arteries, tetralogy of Fallot or atrioventricular septal defect. We present here a 6-year old boy who was diagnosed with cor triatriatum sinister, initially showing symptoms similar to mitral valve stenosis and congestive heart failure, and who underwent subsequent surgical correction using a left atrial approach. The fibromuscular membrane, separating the pulmonary veins from the mitral valve, was completely resected and postoperative echocardiography showed unobstructed pulmonary venous flow.

Long-term results after proximal thoracic aortic redo surgery.

OBJECTIVE: To evaluate early and mid-term results in patients undergoing proximal thoracic aortic redo surgery. METHODS: We analyzed 60 patients (median age 60 years, median logistic EuroSCORE 40) who underwent proximal thoracic aortic redo surgery between January 2005 and April 2012. Outcome and risk factors were analyzed. RESULTS: In hospital mortality was 13%, perioperative neurologic injury was 7%. Fifty percent of patients underwent redo surgery in an urgent or emergency setting. In 65%, partial or total arch replacement with or without conventional or frozen elephant trunk extension was performed. The preoperative logistic EuroSCORE I confirmed to be a reliable predictor of adverse outcome- (ROC 0.786, 95%CI 0.64-0.93) as did the new EuroSCORE II model: ROC 0.882 95%CI 0.78-0.98. Extensive individual logistic EuroSCORE I levels more than 67 showed an OR of 7.01, 95%CI 1.43-34.27. A EuroSCORE II larger than 28 showed an OR of 4.44 (95%CI 1.4-14.06). Multivariate logistic regression analysis identified a critical preoperative state (OR 7.96, 95%CI 1.51-38.79) but not advanced age (OR 2.46, 95%CI 0.48-12.66) as the strongest independent predictor of in-hospital mortality. Median follow-up was 23 months (1-52 months). One year and five year actuarial survival rates were 83% and 69% respectively. Freedom from reoperation during follow-up was 100%. CONCLUSIONS: Despite a substantial early attrition rate in patients presenting with a critical preoperative state, proximal thoracic aortic redo surgery provides excellent early and mid-term results. Higher EuroSCORE I and II levels and a critical preoperative state but not advanced age are independent predictors of in-hospital mortality. As a consequence, age alone should no longer be regarded as a contraindication for surgical treatment in this particular group of patients.

Should aortic arch replacement be performed during initial surgery for aortic root aneurysm in patients with Marfan syndrome?

OBJECTIVES: The aim of this study was to investigate whether total arch replacement (TAR) during initial surgery for root aneurysm should be routinely performed in patients with Marfan syndrome (MFS). METHODS: Retrospective analysis of 94 consecutive MFS patients fulfilling Ghent criteria who underwent 148 aortic surgeries and were followed at this institution during the past 16 years. RESULTS: The mean follow-up interval was 8.8 ± 7 years. Initial presentation was acute aortic dissection (AAD) in 35% of patients (76% Type A and 24% Type B) and aneurysmal disease in 65%. TAR was performed in 8% of patients during initial surgery for AAD (otherwise a hemi-arch replacement was performed) and 1.6% in elective root repair. Secondary TAR had to be performed in only 3% of patients without, but in 33% following AAD (33% Type A and 33% Type B; P = 0.0001). Thirty-day, 6-month, 1-year and overall mortalities were 3.2, 5.3, 6.4 and 11.7%, respectively. Operative and 30-day mortalities in secondary aortic arch replacement were zero. Secondary TAR after AAD did not increase the need for the replacement of the entire thoracoabdominal aorta during follow-up compared with patients without secondary TAR (37 vs 40%, P = 1.0). CONCLUSIONS: MFS patients undergoing elective root repair have small risk of reinterventions on the aortic arch, and primary prophylactic replacement does not seem to be justified. In patients with AAD, the need for reinterventions is precipitated by the dissection itself and not by limiting the procedure to the hemi-arch replacement in the emergency setting. Limiting surgery to the aortic root, ascending aorta and proximal aortic arch is associated with low mortality in MFS patients presenting with AAD.

Long-term results after operations for active infective endocarditis in native and prosthetic valves.

BACKGROUND: The objective of this study was to evaluate the midterm results of patients who underwent operations for active infective endocarditis. METHODS: Within a 10-year period, 141 patients with active infective endocarditis received surgical therapy. We assessed outcome, freedom from reinfection, and freedom from reintervention. Prosthetic valve endocarditis was included in this series. RESULTS: Surgical strategies included valve replacement with a tissue valve in 62% of patients and valve repair in 29% of patients. In 29% of patients, reconstruction of the aortomitral continuity, left ventricular outflow tract, or sinus of Valsalva was preferably performed with 1 or more bovine pericardial patches. In-hospital mortality was 11% and postoperative stroke rate was 7%. Multivariate logistic regression revealed multivalve involvement (p=0.052; odds ratio [OR], 5.84; 95% confidence interval [CI], 0.98-34.57), preoperative neurologic impairment (p=0.006; OR, 9.71; 95% CI, 1.92-49.09), and European system for cardiac operative risk evaluation (EuroSCORE) in quartiles (p=0.023; OR, 2.88; 95% CI, 1.15-7.17) to be independent predictors for in-hospital death. One-year and 5-year actuarial survival was 77% and 69%, respectively. One-year and 5-year actuarial freedom from reinfection was 100% and 90%, respectively. Freedom from reoperation at 5 years was 100%. Five-year survival was 74% for single-valve endocarditis and 46% for multivalve endocarditis (p<0.001). One-year freedom from reinfection was 100% for both single-valve and multivalve endocarditis; 5-year freedom from reinfection was 95% for single-valve endocarditis versus 67% for multivalve endocarditis (p=0.049). CONCLUSIONS: Despite a high early mortality during the first year, surgical intervention for active infective endocarditis provided excellent results with regard to freedom from reinfection and reoperation. A strategy of extensive debridement, reconstruction of destroyed cardiac structures using xenopericardium, followed by valve replacement or repair is highly effective and shows favorable long-term outcomes.

Forty-one-month follow-up of the Symmetry aortic connector system for proximal venous anastomosis.

OBJECTIVE: Results of short- and midterm follow-up studies of the patency rate of the Symmetry aortic connector systems (St Jude Medical, Inc, Minneapolis, Minn) are controversial. Long-term follow-up studies are still lacking (so far, the longest mean follow-up period was 19 months). The aim of our study was (1) to evaluate the patency rate of this device over a longer time-period and (2) to analyze risk factors for graft occlusion. METHODS: Between November 2000 and July 2003, 76 Symmetry aortic connector systems were implanted in 42 patients. At follow-up, 24 patients with 44 mechanical connectors were studied with 64-slice cardiac computed tomography. Eight patients had died previously, 6 patients refused to undergo a computed tomographic scan, and 4 patients had to be excluded because of impaired renal function. RESULTS: From a total of 44 mechanical connectors studied, 24 (55%) were occluded, 20 (45%; confidence intervals 31%-61%) were patent, and 7 of these grafts showed stenosis in the area of the connector. Mean follow-up was 41 +/- 10 months (18-52 months). Sex, age, left main stenosis, hyperlipidemia, hypertension, renal failure, target vessel, stenosis of the target vessel, diameter of the target vessel, type of surgical intervention, diabetes, ejection fraction, postoperative anticoagulation regimen, and the connector size showed no significant influence on the bypass graft patency (P > .05). The bypass graft flow was recognized to be the only risk factor for bypass graft occlusion (P = .0256). CONCLUSION: Midterm follow-up data show a high number of occluded Symmetry aortic connector system vein grafts. On the basis of these observations, the use of the connector was abandoned at our institution.