A rare care of Lomentospora prolificans sternal wound infection post aortic valve replacement-an approach to surgical management.

A 77-year-old woman underwent surgical aortic valve replacement via hemisternotomy. Her post-operative course was unremarkable. Owing to travel and contact restrictions during the COVID pandemic, she was unable to attend routine follow up. She continued review with her local medical officer in regional New South Wales. Post 6 months following her index surgery, she was referred to the Infectious Disease Clinic of her local hospital with a non-healing lesion at the base of her hemi-sternotomy wound. Computed tomography revealed a deep sternal wound infection which extended deep to bone. She was admitted to hospital for treatment. The primary pathogen identified was Lomentospora prolificans-a dangerous fungus that affects immunosuppressed patients. Strong antifungal and adjunctive antibiotics did not contribute much to clearance of infection. Radical surgical debridement was required to obtain clean tissue margins.

Culture-negative polymicrobial chronic Q fever prosthetic valve infective endocarditis utilizing 16S ribosomal RNA polymerase chain reaction on explanted valvular tissue.

Coxiella burnetti is the causative organism of the zoonotic infection Q fever, of which endocarditis is one of the most common manifestations of the chronic form. Polymicrobial endocarditis with Q fever is extremely rare and is yet to be described among an Australasian cohort. SUMMARY: We present the case of a 32-year-old gardener with culture-negative chronic Q fever prosthetic valve endocarditis concomitant with another bacterial pathogen, leading to aortic root abscess formation, requiring a Bentall procedure, extracorporeal membrane oxygenation, and prolonged antimicrobial therapy, with a fatal outcome. Unique to our case, Q fever was identified early, and the second pathogen was only detected on 16S ribosomal RNA (rRNA) polymerase chain reaction of explanted valvular tissue. Given the high risk for morbidity, we recommend that screening for Q fever in endemic areas among patients with infective endocarditis from other etiologies be considered. In addition, this case highlights the role for Q fever vaccination of the at-risk population with underlying valvulopathy. Furthermore, clinicians should be aware of polymicrobial infective endocarditis and suspicious in case of patients with atypical clinical features.

Octogenarians and aortic valve surgery: surgical outcomes in the geriatric population.

BACKGROUND: The era of percutaneous aortic valve intervention has challenged the continuing indication for surgical aortic valve replacement (SAVR). AIM: The aim of this study is to evaluate clinical outcomes of the elderly patients who underwent surgical aortic valve replacement via median sternotomy, in order to assess the impact of surgery on patient outcomes and discharge destination. METHODS: The study involves a retrospective observational analysis in a single centre, including all octogenarian patients who underwent aortic valve surgery between January of 2011 and July of 2016. The study assessed pre-operative co-morbidities and post-operative outcomes, including long-term mortality and discharge destination following on from surgery. RESULTS: The mean age of patients was 82.7 years (± 2.9), 67% of whom were male. The mean EuroSCORE II was 8.1 (± 7.6). The most common pre-operative co-morbidities were dyslipidaemia (82%), hypertension (80%), and ischaemic heart disease (78.8%). The median length of stay was 10 days (± 6.9 days). Discharge home occurred in 71.8% of patients, with 21.2% of patients requiring transfer to a rehabilitation facility, and 1.2% of patients required placement into an aged care facility. There were five peri-operative deaths, equating to 5.9% of the cohort. CONCLUSION: Despite high EuroSCORE II values for the majority of our patients, our data adds to overall suggestions that the octogenarian population can be considered eligible for SAVR and should not be excluded due to age alone. The use of the EuroSCORE II index more accurately predicts adequacy for treatment however does not entirely predict overall course of events, and proceduralist discretion should still be used.

A systematic review and meta-analysis of the clinical outcomes of TAVI versus SAVR in the octogenarian population.

BACKGROUND: Surgical aortic valve replacement (SAVR) has shown safe, robust results in elderly populations, and up until recently, was the gold standard for management of severe aortic stenosis. The approach to severe aortic stenosis in high-risk populations, such as octogenarians, has been challenged with the development of transcatheter-based strategies. We sought to systematically analyse outcomes between surgical and transcatheter aortic valve replacement (TAVI) in octogenarians. METHOD: Electronic databases were searched from their inception until November 2018 for studies comparing SAVR to TAVI in octogenarians, according to a predefined search criterion. The primary end point was mortality, and secondary end points included post-procedural complications. RESULTS: The review yielded four observational studies. The total number of patients included was 1221 including 395 who underwent TAVI and 826 SAVR. On average, patients from both subgroups carried a high number of cardiac risk factors, and STS-PROM scoring yielded mean values equating to high-risk population groups, with significantly higher values for TAVI patients across the board. The presence of post-procedural moderate aortic regurgitation was noted only in the TAVI population (OR = 8.88; 95% CI (1.47-53.64), χ2 = 1.22; p = 0.02; I 2 = 0%). Otherwise, there were no significant differences when accounting for mortality (OR = 0.68; 95% CI (0.44-1.05), χ2 = 1.88; p = 0.60; I 2 = 0%), permanent pacemaker implantation groups (OR = 0.45; 95% CI (0.44-1.49), χ2 = 0.11; p = 0.19; I 2 = 0%), and neurological events (OR = 0.72; 95% CI (0.42-1.23), χ2 = 2.57; p = 0.23; I 2 = 22%). DISCUSSION: The analysed data on TAVI versus SAVR in the octogenarian population show that TAVI shows similar outcomes with relation to mortality and inpatient admission times, in a population with significantly higher risk profiles than their SAVR counterparts. TAVI has higher occurrences of post-procedural AR. TAVI still does not have robust long-term data to ensure its efficacy and rate of complications, but is showing promising results nonetheless.

Safety and efficacy of aerobic exercise commenced early after cardiac surgery: A systematic review and meta-analysis.

BACKGROUND: Aerobic exercise is a critical component of cardiac rehabilitation following cardiac surgery. Aerobic exercise is traditionally commenced 2-6 weeks following hospital discharge and most commonly includes stationary cycling or treadmill walking. The initiation of aerobic exercise within this early postoperative period not only introduces the benefits associated with aerobic activity sooner, but also ameliorates the negative effects of immobilization associated with the early postoperative period. METHODS: A systematic review identified all studies reporting safety and efficacy outcomes of aerobic exercise commenced within two weeks of cardiac surgery. A meta-analysis was performed comparing functional, aerobic and safety outcomes in patients receiving early postoperative aerobic exercise compared with usual postoperative care. RESULTS: Six-minute walk test distance at hospital discharge was 419 ± 88 m in early aerobic exercise patients versus 341 ± 81 m in those receiving usual care (mean difference 69.5 m, 95% confidence interval (CI) 39.2-99.7 m, p < 0.00001). Peak aerobic power was 18.6 ± 3.8 ml·kg-1·min-1 in those receiving early exercise versus 15.0 ± 2.1 ml·kg-1·min-1 in usual care (mean difference 3.20 ml·kg-1·min-1, 95% CI 1.45-4.95, p = 0.0003). There was no significant difference in adverse events rates between the two groups (odds ratio 0.41, 95% CI 0.12-1.42, p = 0.16). CONCLUSION: Aerobic exercise commenced early after cardiac surgery significantly improves functional and aerobic capacity following cardiac surgery. While adverse event rates did not differ significantly, patients included were very low risk. Further studies are required to adequately assess safety outcomes of aerobic exercise commenced early after cardiac surgery.

Treatment of Intravenous Leiomyomatosis with Cardiac Extension following Incomplete Resection.

Aim. Intravenous leiomyomatosis (IVL) with cardiac extension (CE) is a rare variant of benign uterine leiomyoma. Incomplete resection has a recurrence rate of over 30%. Different hormonal treatments have been described following incomplete resection; however no standard therapy currently exists. We review the literature for medical treatments options following incomplete resection of IVL with CE. Methods. Electronic databases were searched for all studies reporting IVL with CE. These studies were then searched for reports of patients with inoperable or incomplete resection and any further medical treatments. Our database was searched for patients with medical therapy following incomplete resection of IVL with CE and their results were included. Results. All studies were either case reports or case series. Five literature reviews confirm that surgery is the only treatment to achieve cure. The uses of progesterone, estrogen modulation, gonadotropin-releasing hormone antagonism, and aromatase inhibition have been described following incomplete resection. Currently no studies have reviewed the outcomes of these treatments. Conclusions. Complete surgical resection is the only means of cure for IVL with CE, while multiple hormonal therapies have been used with varying results following incomplete resection. Aromatase inhibitors are the only reported treatment to prevent tumor progression or recurrence in patients with incompletely resected IVL with CE.

A meta-analysis of endoscopic versus conventional open radial artery harvesting for coronary artery bypass graft surgery.

OBJECTIVE: The radial artery has been demonstrated to provide superior long-term patency outcomes compared with saphenous veins for selected patients who undergo coronary artery bypass graft surgery. Recently, endoscopic radial artery harvesting has been popularized to improve cosmetic and perioperative outcomes. However, concerns have been raised regarding the effects on long-term survival and graft patency of this relatively novel technique. The present meta-analysis aimed to assess the safety and the efficacy of endoscopic radial artery harvesting versus the conventional open approach. METHODS: A systematic review of the current literature was performed on five electronic databases. All comparative studies on endoscopic versus open radial artery harvesting were included for analysis. Primary endpoints included mortality and recurrent myocardial infarction. Secondary endpoints included graft patency, wound infection, hematoma formation, and paresthesia. RESULTS: Twelve studies involving 3314 patients were included for meta-analysis according to predefined selection criteria. There were no statistically significant differences in overall mortality, recurrent myocardial infarction, or graft patency between the two surgical techniques. However, patients who underwent endoscopic harvesting were found to have significantly lower incidences of wound infection, hematoma formation, and paresthesia. CONCLUSIONS: Current literature on endoscopic harvesting of the radial artery for coronary artery bypass graft surgery is limited by relatively short follow-up periods as well as differences in patient selection and surgical techniques. In addition, there are currently no randomized controlled trials to provide robust clinical data. However, the available evidence suggests that the endoscopic approach is associated with superior perioperative outcomes without clear evidence demonstrating compromised patency or survival outcomes.

Right ventricular loop indicating malposition of J-wire introducer for double lumen bicaval venovenous extracorporeal membrane oxygenation (VV ECMO) cannula.

The key to safe placement of a bicaval double lumen cannula for Venovenous Extracorporeal Membrane Oxygenation (VV ECMO) is to visualise correct guide wire placement in the inferior vena cava (IVC), thus aiding subsequent correct advancement of the cannula. Transoesophageal (TOE) and transthoracic (TTE) echocardiography, as well as fluoroscopy, have been described as aiding imaging techniques. We report a case of guide wire malposition into the right ventricle, despite echocardiographic confirmation of guide wire position deep into the IVC. This malposition, if undetected, may have resulted in potential life threatening complications.

A meta-analysis of randomized controlled trials on mid-term angiographic outcomes for radial artery versus saphenous vein in coronary artery bypass graft surgery.

BACKGROUND: Currently, saphenous vein (SV) and radial artery (RA) are the most commonly used conduits in combination with the left internal mammary artery for conventional coronary artery bypass graft surgery (CABG). The present meta-analysis aimed to assess the existing evidence from randomized controlled trials (RCTs) to compare the angiographic outcomes of these two conduits at mid-term follow-up. METHODS: Four relevant and updated RCTs with follow-up beyond 3 years were identified using five electronic databases. Angiographic endpoints included complete occlusion, 'string sign', graft failure and complete patency. RESULTS: The incidence of complete occlusion was significantly lower after using RA compared to SV [6.7% vs. 17.2%; odd ratio (OR), 0.36; 95% confidence interval (CI), 0.23-0.58; P<0.0001]. The angiographic 'string sign' was significantly more likely to be identified after using RA compared to SV (3.1% vs. 0%; OR, 5.65; 95% CI, 1.21-26.39; P=0.03). Graft failure was significantly lower after RA compared to SV (9.6% vs. 18.8%; OR, 0.47; 95% CI, 0.30-0.72; P=0.0005). Complete graft patency was found to be significantly higher after RA compared to SV (88.6% vs. 75.8%; OR, 3.19; 95% CI, 1.42-7.16; P=0.005). CONCLUSIONS: Results of the present meta-analysis suggest that selected patients with severe, proximal stenosis may have superior angiographic outcomes at mid-term follow-up after using RA compared to SV for CABG. However, RA is associated with a significantly higher incidence of the 'string sign'. Future studies should aim to collect additional data on symptomatic outcomes.

Video-assisted thoracic surgery versus open thoracotomy for non-small cell lung cancer: a meta-analysis of propensity score-matched patients.

OBJECTIVES: This meta-analysis aimed to compare the perioperative outcomes of video-assisted thoracic surgery (VATS) with open thoracotomy for propensity score-matched patients with early-stage non-small cell lung cancer (NSCLC). METHODS: Four relevant studies with propensity score-matched patients were identified from six electronic databases. Endpoints included perioperative mortality and morbidity, individual postoperative complications and duration of hospitalization. RESULTS: Results indicate that all-cause perioperative mortality was similar between VATS and open thoracotomy. However, patients who underwent VATS were found to have significantly fewer overall complications, and significantly lower rates of prolonged air leak, pneumonia, atrial arrhythmias and renal failure. In addition, patients who underwent VATS had a significantly shorter length of hospitalization compared with those who underwent open thoracotomy. CONCLUSIONS: In view of a paucity of high-level clinical evidence in the form of large, well-designed randomized controlled trials, propensity score matching may provide the highest level of evidence to compare VATS with open thoracotomy for patients with NSCLC. The present meta-analysis demonstrated superior perioperative outcomes for patients who underwent VATS, including overall complication rates and duration of hospitalization.