Virulence of Staphylococcus Infection in Surgically Treated Patients With Endocarditis : A Multicenter Analysis.

OBJECTIVE: Infective endocarditis (IE) caused by Staphylococcus species (spp.) is believed to be associated with higher morbidity and mortality rates. We hypothesize that Staphylococcus spp. are more virulent compared with other commonly causative bacteria of IE with regard to short-term and long-term mortality. BACKGROUND: It remains unclear if patients suffering from IE due to Staphylococcus spp. should be referred for surgical treatment earlier than other IE patients to avoid septic embolism and to optimize perioperative outcomes. MATERIALS AND METHODS: The database of the CAMPAIGN registry, comprising 4917 consecutive patients undergoing heart valve surgery, was retrospectively analyzed. Patients were divided into 2 groups with regard to the identified microorganisms: Staphylococcus group and the non- Staphylococcus group. The non- Staphylococcus group was subdivided for further analyses: Streptococcus group, Enterococcus group, and all other bacteria groups. RESULTS: The respective mortality rates at 30 days (18.7% vs 11.8%; P <0.001), 1 year (24.7% vs 17.7%; P <0.001), and 5 years (32.2% vs 24.5%; P <0.001) were significantly higher in Staphylococcus patients (n=1260) compared with the non- Staphylococcus group (n=1787). Multivariate regression identified left ventricular ejection fraction <30% ( P <0.001), chronic obstructive pulmonary disease ( P =0.045), renal insufficiency ( P =0.002), Staphylococcus spp. ( P =0.032), and Streptococcus spp. ( P =0.013) as independent risk factors for 30-day mortality. Independent risk factors for 1-year mortality were identified as: age ( P <0.001), female sex ( P =0.018), diabetes ( P =0.018), preoperative stroke ( P =0.039), chronic obstructive pulmonary disease ( P =0.001), preoperative dialysis ( P <0.001), and valve vegetations ( P =0.004). CONCLUSIONS: Staphylococcus endocarditis is associated with an almost twice as high 30-day mortality and significantly inferior long-term outcome compared with IE by other commonly causative bacteria. Patients with Staphylococcus infection are more often female and critically ill, with >50% of these patients suffering from clinically relevant septic embolism. Early diagnosis and referral to a specialized center for surgical treatment are strongly recommended to reduce the incidence of preoperative deterioration and stroke due to septic embolism.

Pacemaker after Sutureless and Rapid-Deployment Prostheses: A Progress Report from the SURD-IR.

OBJECTIVES: The aim of this study was to investigate the need for postoperative permanent pacemaker implantation (PPI) following sutureless and rapid-deployment aortic valve replacement (SuRD-AVR) in the context of a progress report from a large multicenter international registry (SURD-IR). METHODS: We retrospectively analyzed 4,166 patients who underwent SuRD-AVR between 2008 and 2019. The primary outcome was the need for PPI before discharge. The study population was analyzed separately according to the implanted prostheses (Su cohort and RD cohort). Each cohort was divided into two groups based on the operation date: an early group ("EG" = 2008-2016) and a late group ("LG" = 2017-2019). RESULTS: The rate of PPI decreased significantly in the Su cohort over time (EG = 10.8% vs LG = 6.3%, p < 0.001). In the Su cohort, a decrease in age, risk profile, and incidence of bicuspid aortic valve, increased use of anterior right thoracotomy, reduction of cardiopulmonary bypass time and of associated procedures, and more frequent use of smaller prostheses were observed over time. In the RD cohort, the rate of PPI was stable over time (EG = 8.8% vs LG = 9.3%, p = 0.8). In this cohort, a younger age, lower risk profile, and higher incidence of concomitant septal myectomy were observed over time. CONCLUSION: Our analysis showed a significant decrease in the PPI rate in patients who underwent Su-AVR over time. Patient selection as well as surgical improvements and a more accurate sizing could be correlated with this phenomenon. The RD cohort revealed no significant differences either in patient's characteristics or in PPI rate between the two time periods.

Blood versus crystalloid cardioplegia during triple valve surgery: A single center experience.

BACKGROUND: The efficacy of different cardioplegia solutions on outcomes of complex cardiac operations such as triple valve surgery (TVS) is scarce. Here we compared the outcomes in TVS patients receiving either crystalloid (Bretschneider) or blood (Calafiore) cardioplegia. METHODS: Screening of our institutional database with prospectively entered data identified 471 consecutive patients (mean age 70.3 ± 9.2 years; 50.9% male), who underwent TVS (replacement or repair of aortic, mitral and tricuspid valve) between December 1994 and January 2013. In 277 patients, cardiac arrest was induced with HTK-Bretschneider solution (HTK, n = 277, 58.8%), whereas 194 received cold blood cardioplegia (BCP) according to Calafiore (n = 194, 41.2%). Comparisons of perioperative and follow up outcomes were made between cardioplegia groups. RESULTS: Preoperative patient characteristics and comorbidities were equally balanced between groups. 30-days mortality was similar between groups (HTK: 16.2%; BCP: 18.2%; p = 0.619). Incidence of the cumulative endpoint (30days mortality, myocardial infarction (MI), arrhythmia, low cardiac output syndrome or need for permanent pacemaker implantation) was also comparable (HTK: 47.6%; BCP: 54.8%, p = 0.149). In patients with reduced left ventricular ejection fraction (LVEF <40%), 30days mortality was higher in the HTK group (HTK 18/71 22.5%; BCP 5/50 10%; p = 0.037). Five-year survival was similar between groups (52 ± 6% for HTK and 55 ± 5% for BCP patients). In-Hospital mortality was best predicted by length of surgery and reperfusion ratio. Decreased age, shorter bypass time, preserved LVEF and concomitant surgical procedures have been found to be protective from long-term mortality. CONCLUSIONS: Myocardial protection with HTK shows equivalent outcomes compared to BCP during TVS. Patients with reduced left ventricular function may benefit from BCP during TVS.

Coronary artery bypass surgery for acute coronary syndrome: A network meta-analysis of on-pump cardioplegic arrest, off-pump, and on-pump beating heart strategies.

BACKGROUND: Coronary artery bypass grafting (CABG) in the setting of an acute coronary syndrome is a high-risk procedure, and the best strategy for myocardial revascularisation remains debated. This study compares the 30-day mortality benefit of on-pump CABG (ONCAB), off-pump CABG (OPCAB), and on-pump beating heart CABG (OnBHCAB) strategies. METHODS: A systematic search of three electronic databases was conducted for studies comparing ONCAB with OPCAB or OnBHCAB in patients with acute coronary syndrome (ACS). The primary outcome, 30-day mortality, was compared using a Bayesian hierarchical network meta-analysis (NMA). A random effects consistency model was applied, and direct and indirect comparisons were made to determine the relative effectiveness of each strategy on postoperative outcomes. RESULTS: One randomised controlled trial and eighteen observational studies fulfilling the inclusion criteria were identified. A total of 4320, 5559, and 1962 patients underwent ONCAB, OPCAB, and OnBHCAB respectively. NMA showed that OPCAB had the highest probability of ranking as the most effective treatment in terms of 30-day mortality (odds ratio [OR], 0.50; 95% credible interval [CrI], 0.23-1.00), followed by OnBHCAB (OR, 0.62; 95% CrI, 0.20-1.57), however the 95% CrI crossed or included unity. A subgroup NMA of nine studies assessing only acute myocardial infarction (AMI) patients demonstrated a 72% reduction in likelihood of 30-day mortality after OPCAB (CrI, 0.07-0.83). No significant increase in rate of stroke, renal dysfunction or length of intensive care unit stay was found for either strategy. CONCLUSIONS: Although no single best surgical revascularisation approach in ACS patients was identified, the significant mortality benefit with OPCAB seen with AMI suggests high acuity patients may benefit most from avoiding further myocardial injury associated with cardiopulmonary bypass and cardioplegic arrest.

Management of aortic root in type A dissection: Bentall approach.

BACKGROUND: We analyzed the results of the modified Bentall procedure in a high-risk group of patients presenting with acute type A aortic dissection (ATAAD). METHODS: ATAAD patients undergoing a modified Bentall between 1996 and 2018 (n = 314) were analyzed. Mechanical composite conduits were used in 45%, and biological ones using either a bioprosthesis implanted into an aortic graft (33%) or xeno-/homograft root conduits (22%) in the rest. Preoperative malperfusion was present in 34% of patients and cardiopulmonary resuscitation required in 9%. RESULTS: Concomitant arch procedures consisted of hemiarch in 56% and total arch/elephant trunk in 34%, while concomitant coronary artery surgery was required in 20%. The average cross-clamp and cardiopulmonary bypass times were 126 ± 43 and 210 ± 76 min, respectively, while the average circulatory arrest times were 29 ± 17 min. A total of 69 patients (22%) suffered permanent neurologic deficit, while myocardial infarction occurred in 18 cases (6%) and low cardiac output syndrome in 47 (15%). The in-hospital mortality rate was 17% due to intractable low cardiac output syndrome (n = 29), major brain injury (n = 16), multiorgan failure (n = 6), and sepsis (n = 2). The independent predictors of in-hospital mortality were critical preoperative state (odds ratio [OR], 5.6; p < .001), coronary malperfusion (OR, 3.6; p = .002), coronary artery disease (OR, 2.6; p = .033), and prior cerebrovascular accident (OR, 5.6; p = .002). CONCLUSIONS: The modified Bentall operation, along with necessary concomitant procedures, can be performed with good early results in high-risk ATAAD patients presenting.

Concomitant Tricuspid Valve Repair during Minimally Invasive Mitral Valve Repair.

BACKGROUND: Concomitant use of tricuspid valve (TV) surgery and minimally invasive mitral valve (MV) repair is debatable due to a prolonged time of surgery with presumably elevated operative risk. Herein, we examined cardiopulmonary bypass times and 30-day mortality in patients who underwent MV repair with and without concomitant TV surgery. METHODS: We retrospectively evaluated 3,962 patients with MV regurgitation who underwent minimally invasive MV repair without (n = 3,463; MVr group) and with (n = 499; MVr + TVr group) concomitant TV surgery between 1999 and 2014. Preoperative parameters between the groups were significantly different; therefore, propensity score matching was performed. RESULTS: Mean cardiopulmonary bypass time for all patients was 125.5 ± 55.8 minutes in MVr and 162.0 ± 58.0 minutes in MVr + TVr (p < 0.001). Overall 30-day mortality was significantly different between these groups (4.8 vs. 2.1%; p < 0.001); however, after adjustment, there was no significant difference (3.3 vs. 1.2%; p = 0.07). Backward logistic regression revealed that cardiopulmonary bypass time was not a significant predictor for early mortality within the MVr + TVr cohort. CONCLUSION: Concomitant TV repair using prosthetic rings through a minimally invasive approach is safe and does not lead to elevated early mortality in our patient cohort. Therefore, prolonged cardiopulmonary bypass time should not be the sole reason to rule out MV repair with concomitant TV repair and to prefer the use of suture techniques, which saves only a few minutes compared with prosthetic ring implantation.

Midterm results after St Jude Medical Epic porcine xenograft for aortic, mitral, and double valve replacement.

BACKGROUND: The aim of this study was to evaluate the results after stented porcine xenograft implantation (Epic, SJM, St Paul, MN) with Linx anticalcification treatment in elderly patients at our high-volume tertiary care center. METHODS: A total of 3825 patients undergoing aortic (AVR = 2441), mitral (MVR = 892), or double valve (DVR = 492) replacement between 11/2001 and 12/2017 with Epic xenografts were evaluated. Outcomes were assessed by reviewing the prospectively acquired hospital database results, and regular annual follow-up information was acquired from questionnaires or telephone interviews. RESULTS: For patients undergoing AVR, MVR, DVR, age at surgery were 76.4 ± 6, 71.2 ± 9, 72.9 ± 8 years; active endocarditis was an indication for valve surgery in 4.5%, 20.7%, 19.7%; and the predicted median (interquartile range [IQR]) mortality risk (EuroSCORE II) was 5.2% (3.1%-9.4%), 7.5% (3.9%-16.2%), 9.9% (6.0%-19.6%), respectively. Median follow-up was 3.04 (IQR: 0.18-5.21). Thirty-day survival was 91.2% ± 0.6%, 87.6% ± 0.1.1%, 84.7% ± 1.6%; and 10-year survival was 56.7% ± 1.0%, 59.4% ± 2.5%, 50.45% ± 3.1%, respectively. Patients who underwent MVR versus AVR were at significant increased risk for reoperation for endocarditis (adjusted odds ratio; 2.2, 95% confidence interval; 1.29-3.7; P = .003). There was no significant difference in all-cause mortality at midterm in AVR vs MVR in the matched cohort (P = .85). CONCLUSIONS: Implantation of the Epic stented porcine xenograft is associated with acceptable survival and freedom from valve-related complications or reoperation due to structural valve disease at midterm follow-up.

Randomized trial of ticagrelor vs. aspirin in patients after coronary artery bypass grafting: the TiCAB trial.

AIMS: The antiplatelet treatment strategy providing optimal balance between thrombotic and bleeding risks in patients undergoing coronary artery bypass grafting (CABG) is unclear. We prospectively compared the efficacy of ticagrelor and aspirin after CABG. METHODS AND RESULTS: We randomly assigned in double-blind fashion patients scheduled for CABG to either ticagrelor 90 mg twice daily or 100 mg aspirin (1:1) once daily. The primary outcome was the composite of cardiovascular death, myocardial infarction (MI), repeat revascularization, and stroke 12 months after CABG. The main safety endpoint was based on the Bleeding Academic Research Consortium classification, defined as BARC ≥4 for periprocedural and hospital stay-related bleedings and BARC ≥3 for post-discharge bleedings. The study was prematurely halted after recruitment of 1859 out of 3850 planned patients. Twelve months after CABG, the primary endpoint occurred in 86 out of 931 patients (9.7%) in the ticagrelor group and in 73 out of 928 patients (8.2%) in the aspirin group [hazard ratio 1.19; 95% confidence interval (CI) 0.87-1.62; P = 0.28]. All-cause mortality (ticagrelor 2.5% vs. aspirin 2.6%, hazard ratio 0.96, CI 0.53-1.72; P = 0.89), cardiovascular death (ticagrelor 1.2% vs. aspirin 1.4%, hazard ratio 0.85, CI 0.38-1.89; P = 0.68), MI (ticagrelor 2.1% vs. aspirin 3.4%, hazard ratio 0.63, CI 0.36-1.12, P = 0.12), and stroke (ticagrelor 3.1% vs. 2.6%, hazard ratio 1.21, CI 0.70-2.08; P = 0.49), showed no significant difference between the ticagrelor and aspirin group. The main safety endpoint was also not significantly different (ticagrelor 3.7% vs. aspirin 3.2%, hazard ratio 1.17, CI 0.71-1.92; P = 0.53). CONCLUSION: In this prematurely terminated and thus underpowered randomized trial of ticagrelor vs. aspirin in patients after CABG no significant differences in major cardiovascular events or major bleeding could be demonstrated. CLINICALTRIALS.GOV IDENTIFIER: NCT01755520.

Complex cases of acquired pulmonary vein stenosis after radiofrequency ablation: is surgical repair an option?

AIMS: Results of catheter based interventional treatment for pulmonary vein stenosis (PVS) following radiofrequency ablation (RFA) for atrial fibrillation remain suboptimal. Surgical repair may represent an alternative therapy, though long-term results have not been thoroughly investigated. METHODS AND RESULTS: We retrospectively assessed all patients in our centre undergoing surgical repair for radiofrequency-induced PVS. Data regarding surgical technique, clinical outcome, and rate of pulmonary vein (PV) restenosis were collected and analysed. Between 2004 and 2016, the rate for PVS resulting from RFA for atrial fibrillation in our institution was 0.79% (76/9633). During this period, five male patients with multiple PVS (3 ± 1) underwent surgical repair of a total of 13 symptomatic PVS. Surgery was performed in a standard setting under cardiopulmonary bypass. Stenotic veins were incised longitudinally followed by a patch augmentation plasty using either bovine pericard (n = 7) or polytetrafluoroethylene (PTFE) patches (n = 5). Localization of incision was on the anterior side of the PV only (n = 8) or on both the anterior and posterior sides (n = 4). In one PVS lesion, mechanical dilatation was sufficient. Long-term follow-up after 60 ± 69 months revealed an average restenosis rate of 38%. Restenosis was defined as narrowing >70%. All patients reported clinical improvement of symptoms at follow-up. CONCLUSION: Even in the era of wide circumferential lesions, PVS still occurs. While surgical PV patch plasty represents a valuable treatment option, restenosis remains an issue during follow-up. Nevertheless, surgical repair achieves highly acceptable long-term results for RFA-acquired PVS. Hence, it should be routinely discussed as a therapeutic option in cases with multiple PVS.

Evaluation of Strategies in the Management of Infective Aortic Valve Endocarditis at German Cardiac Surgical Departments.

BACKGROUND: Surgical treatment of infective aortic valve endocarditis (AVE) remains a therapeutic challenge, necessitating interdisciplinary approach to limit morbidity and mortality in this high-risk cohort. With a considerable spectrum of available laboratory testings, imaging techniques, as well as operative strategies developed in recent years, there is a lack of standardization across cardiac surgical departments in Germany. Thus, the optimal treatment strategy of AVE has yet to be defined. METHODS: A nationwide survey on infective AVE was conducted, including 64 cardiac surgical departments responding to a 41-item questionnaire. The evaluation included common surgical practice, routine diagnostic steps, surgical techniques, perioperative medical treatment, as well as postoperative management. RESULTS: Remarkable differences were observed among the participating institutions, including the following components of the treatment: (1) standardization and extent of the use of imaging techniques and (2) success rate in identification AVE-causing germs, (3) timing of operation in case of cerebral embolization, and (4) choice of valve prosthesis for aortic valve replacement for infective AVE. CONCLUSION: The findings of this survey underline the need for a nationwide registry to further elucidate the nature and course of AVE in Germany, as well as to serve as a solid basis for prospective trials, addressing the most important clinical purposes in the diagnosis and treatment of AVE.

Acute Effect of Mitral Valve Repair on Mitral Valve Geometry.

BACKGROUND: The aim of this study was to quantify acute mitral valve (MV) geometry dynamic changes throughout the cardiac cycle using three-dimensional transesophageal echocardiography (3D TEE) in patients undergoing surgical MV repair (MVR) with ring annuloplasty and optional neochord implantation. METHODS: Twenty-nine patients (63 ± 10 years) with severe primary mitral regurgitation underwent surgical MVR using ring annuloplasty with or without neochord implantation. We recorded 3D TEE data throughout the cardiac cycle before and after MVR. Dynamic changes (4D) in the MV annulus geometry and anatomical MV orifice area (AMVOA) were measured using a novel semiautomated software (Auto Valve, Siemens Healthcare). RESULTS: MVR significantly reduces the anteroposterior diameter by up to 38% at end-systole (36.8-22.7 mm; p < 0.001) and the lateromedial diameter by up to 31% (42.7-30.3 mm; p < 0.001). Moreover, the annular circumference was reduced by up to 31% at end-systole (129.6-87.6 mm, p < 0.001), and the annular area was significantly decreased by up to 52% (12.8-5.7 cm2; p < 0.001). Finally, the AMVOA experienced the largest change, decreasing from 1.1 to 0.2 cm2 during systole (at midsystole; p < 0.001) and from 4.1 to 3.2 cm2 (p < 0.001) during diastole. CONCLUSIONS: MVR reduces the annular dimension and the AMVOA, contributing to mitral competency, but the use of annuloplasty rings reduces annular contractility after the procedure. Surgeons can use 4D imaging technology to assess MV function dynamically, detecting the acute morphological changes of the mitral annulus and leaflets before and after the procedure.

Deep sternal wound infection - latissimus dorsi flap is a reliable option for reconstruction of the thoracic wall.

BACKGROUND: At present, data describing patients' long-term outcomes, quality of life, and survival after deep sternal wound infection are rarely available. The purpose of our study was to evaluate functional outcome and patient well-being after debridement and reconstruction of the sternal defect using a pedicled latissimus dorsi flap following deep sternal wound infection (DSWI). METHODS: This retrospective analysis reviewed 106 cases of DSWI after open-heart surgery treated between May 1, 2012, and May 31, 2015. The parameters of interest were demographic and medical data, including comorbidity and mortality. Follow-up consisted of physical examination of the patients using a specific shoulder assessment, including strength tests and measurements of pulmonary function. RESULTS: The population consisted of 69 (65%) male and 37 (35%) female patients. Their average age at the time of plastic surgery was 69 years (range: 35-85). The 30-day mortality was 20% (n = 21); after one-year, mortality was 47% (n = 50), and at follow-up, it was 54% (n = 58). Heart surgery was elective in 45 cases (42%), urgent in 31 cases (29%) and for emergency reasons in 30 cases (28%). The preoperative European System for Cardiac Operative Risk Evaluation (EuroSCORE) averaged 16.3 (range: 0.88-76.76). On the dynamometer assessment, a value of 181 Newton (N) (±97) could be achieved on the donor side, in contrast to 205 N (±91) on the contralateral side. The inspiratory vital capacity of the lung was reduced to an average of 70.58% (range: 26-118), and the forced expiratory volume in 1 s was decreased to an average of 69.85% (range: 38.2-118). CONCLUSIONS: Given that only small adverse effects in shoulder function, strength, and pulmonary function were observed, the latissimus dorsi flap appears to be a safe and reliable option for the reconstruction of the sternal region after DSWI.

Minimally Invasive Mitral Valve Surgery for Mitral Valve Infective Endocarditis.

BACKGROUND: The feasibility of minimally invasive mitral valve (MV) surgery in infective endocarditis (IE) has not been reported in detail. We assessed the safety, efficacy, and durability of the minimally invasive approach through a right anterolateral minithoracotomy for surgical treatment of MV IE. METHODS: A review of the Leipzig Heart Center database revealed 92 eligible patients operated on between 2002 and 2013. All patients had undergone minimally invasive surgery for IE. The indication for surgery was isolated IE of the MV in all patients. Baseline and intraoperative data, as well as clinical outcomes and short-term follow-up were analyzed retrospectively. RESULTS: The patients' mean age was 60.9 ± 15.3 years, the logistic EuroSCORE II was 19.6 ± 19.1%, and 64.1% (59) were male. MV repair was feasible in 23.9% (22/92) of patients. Repair techniques included annuloplasty ring implantation, anterior mitral leaflet resection, posterior mitral leaflet resection, and implantation of neochordae. MV replacement was performed in 69 patients (75%), a mitral annulus patch in 1 patient, and concomitant tricuspid valve surgery for tricuspid regurgitation in 5 patients. Bacteriological analysis showed staphylococcus infection in 45.5%, streptococcus in 36.4%, enterococcus in 13.6%, and others in 4.5%. The 30-day-mortality rate was 9.8% (9 patients). The 1-year follow-up showed a 1-year survival rate of 77.7 ± 4.4% and freedom from reoperation within 1 year due to reendocarditis of 93.3 ± 2.1%. CONCLUSIONS: The minimally invasive approach is suitable for the treatment of IE of the MV. It is a good technique in IE in selected patients.

Indication-specific immunomodulatory effects of extracorporeal photopheresis: A pilot study in heart transplanted patients.

BACKGROUND: The clinical use of extracorporeal photopheresis (ECP) is based on its ability to induce cell-mediated immune tolerance towards foreign and self-antigens. Up-to-date, no clear consensus consists on how to use ECP after heart transplantation (HTx). In this pilot study, we evaluated the stimulatory effects of ECP on immune cells in HTx patients. METHODS: HTx patients received ECP therapy as prophylaxis of rejection (PRX, n = 15), to treat acute cellular rejection (ACR, n = 13) or cardiac allograft vasculopathy (CAV, n = 5). Three ECP cycles with monthly frequency were performed. Blood samples were taken before every ECP cycle and 2 months after the last ECP cycle and were analyzed for cytokines and the tolerance-inducing cell subsets regulatory T cells (Tregs ), myeloid (mDCs), and plasmacytoid dendritic cells (pDCs). RESULTS: While ECP treatment induced first an increase of pDCs in the CAV group (baseline: 22.0% ± 9.6%, prior third ECP cycle: 8.6% ± 3.2%, follow-up: 31.5% ± 8.4%, P = .009), no significant changes of DC subsets and Tregs were observed in the ACR- and in the PRX group. Furthermore, analysis of the immune balance showed different response profiles of pro- and anti-inflammatory cytokines among prophylactically ECP-treated patients and ECP-treated patients suffering from CAV or ACR. CONCLUSIONS: In our pilot study, we showed different stimulatory effects of ECP on pDCs and cytokines among prophylactic and therapeutic ECP therapy after HTx. Immunological monitoring should be included in a larger clinical study of ECP treatment following HTx and to identify predictable parameters for ECP efficacy.

[Pedicled Omentum Flaps in the Management of Deep Sternal Wound Infections]. / Der gefäßgestielte Omentumlappen zur Behandlung tiefer sternaler Wundinfekte.

AIM: Coverage of a deep sternal wound infection with a greater omentum flap. Due to a persistent infection caused by an infected aortic prosthesis, the primarily performed reconstruction with a latissimus dorsi flap had to be revised, and an alternative solution had to be found. INDICATION: A deep sternal wound infection is a rare but devastating complication following median sternotomy. If the commonly used muscle flap is not sufficient and artificial material is still present in the wound, for instant drivelines or a vascular prosthesis, the greater omentum flap is a useful option due to its immunologic capacity. METHOD: After an exploration of the persisting infected deep sternal wound, a radical debridement is performed followed by a jet lavage. The soft tissue from the greater omentum is prepared via median laparotomy and transferred through a tunnel created in the diaphragm. Then it is pulled into the wound cavity and can be used for tension-free sheathing of the aortic prosthesis. The previously used muscle flap can additionally be used for superficial soft tissue coverage. CONCLUSION: Due to its immunologic competence, the greater omentum flap is a good treatment alternative to the commonly used muscle flaps in defects with infected artificial material.

Temporal Trends in Predictors of Early and Late Mortality After Emergency Coronary Artery Bypass Grafting for Cardiogenic Shock Complicating Acute Myocardial Infarction.

BACKGROUND: Cardiogenic shock after acute myocardial infarction is an indication for emergent coronary artery bypass grafting in patients not amenable to percutaneous coronary intervention. Our study aimed to evaluate and identify risk factors for early and long-term outcomes in such patients. METHODS: A total of 508 patients who underwent coronary artery bypass grafting for cardiogenic shock complicating acute myocardial infarction between January 2000 and June 2014 were divided into 3 time cohorts: 2000 to 2004 (n=204), 2005 to 2009 (n=166), and 2010 to 2014 (n=138). Predictors of in-hospital mortality for each time cohort and long-term mortality for all patients were identified by logistic and Cox regression analyses, respectively. RESULTS: Mean age was 68.3±9.8 years. Of the 508 patients, 78.5% had 3-vessel and 47.1% had left main disease. Left ventricular function <30% was observed in 44.1% of patients, with 30.4%, 37.9%, 52.9%, and 3.1% requiring preoperative resuscitation, ventilation, intra-aortic balloon pump, and extracorporeal membrane oxygenation support, respectively. Overall in-hospital mortality was 33.7%; declined from 42.2% to 30.7% to 24.6%, respectively, for the 3 time cohorts (P=0.02); and was independently predicted by serum lactate >4 mmol/L (odds ratio [OR], 4.78; 95% confidence interval, 2.88-7.95; P<0.0001), ST-segment-elevation myocardial infarction (OR, 2.10; 95% confidence interval, 1.36-3.26; P=0.001), age >75 years (OR, 2.01; 95% confidence interval, 1.06-3.85; P=0.03), and left ventricular ejection fraction <30% (OR, 1.83; 95% confidence interval, 1.15-2.91; P=0.01). Cumulative survival was 42.6±2.0% and 33.4±2.0% at 5 and 10 years, respectively, and correspondingly improved to 64.3±3.0% and 49.8±3.0% in hospital survivors. Serum lactate >4 mmol/L (OR, 2.2; P<0.0001), incremental age (OR, 1.05; P<0.0001), New York Heart Association class IV (OR, 1.33; P=0.02), diabetes mellitus (OR, 1.39; P=0.005), and preoperative inotropic (OR, 2.61; P=0.001) and extracorporeal membrane oxygenation (OR, 1.68; P=0.05) support predicted late mortality. CONCLUSIONS: Emergency coronary artery bypass grafting in patients with acute myocardial infarction complicated by cardiogenic shock is associated with a high in-hospital mortality, which showed a significant decline with time. Hospital survivors have good long-term outcomes, which demonstrate the beneficial effect of surgical revascularization. Preoperative serum lactate >4 mmol/L is a strong predictor of both early and late mortality.

Tricuspid Valve Repair after Previous Mitral Valve Surgery.

Tricuspid valve (TV) regurgitation in patients after previous mitral valve surgery is usually a secondary failure and conditioned by a long-lasting left-sided valve failure. TV surgery in these patients represents a high-risk procedure regarding the operative strategy and perioperative management. This article will discuss the indication for TV surgery in patients with secondary TV regurgitation and previous mitral valve surgery, the choice of surgical access, as well as TV repair techniques and their postoperative results.

Tricuspid Valve Surgery in Patients with Isolated Tricuspid Valve Endocarditis: Analysis of Perioperative Parameters and Long-Term Outcomes.

Background The aim of this study was to evaluate the perioperative characteristics and the short- and mid-term outcomes in patients undergoing tricuspid valve (TV) surgery for isolated TV endocarditis. Patients and Methods A total of 56 patients with isolated TV endocarditis underwent TV surgery at a single center between June 1995 and February 2012. Mean age of patients was 53.8 ± 17.1 years, 39 (69.6%) being male. The mean left ventricular ejection fraction was 60.4 ± 13.6% and 13 (23.2%) patients had diabetes mellitus. Average logistic EuroSCORE was 19.4 ± 17.0%. Mean follow-up was 4.7 ± 3.8 years. Results Microbiological investigations revealed positive blood cultures in 89.1% of patients and positive intraoperative swabs in 51.9%. The most common pathogen (42.9%) isolated was Staphylococcus aureus, followed by coagulase-negative staphylococcus (17.9%). Discussion A history of intravenous drug abuse (IVDA) was recorded in 11 patients (19.6%), of which 8 patients additionally had hepatitis C. A total of 15 patients (26.8%) had a permanent pacemaker/implantable cardioverter-defibrillator in situ. TV replacement was performed in 22 patients (39.3%) and TV repair was performed in 34 patients (60.7%). Overall 30-day mortality was 12.5%. Five-year survival was 63.9 ± 7.2% (95% confidence interval [CI]: 64.0-137.5 months). Freedom from reoperation for recurrent TV endocarditis was 91.7 ± 4.0% (95% CI: 152.3-179.3 months) at 5 years. Conclusion Blood culture is the most important tool to detect the causative pathogen causing IE of TV. The high risk of hepatitis C in patients with IVDA and IE of the TV should be mentioned.

Preoperative Predictors and Outcome of Triple Valve Surgery in 487 Consecutive Patients.

Background Triple valve surgery (TVS) is associated with an elevated risk for operative mortality and thus remains a surgical challenge. We report our experience and results of TVS procedures, especially with respect to identification of preoperative risk factors, to improve patient selection. Methods Between December 1994 and January 2013, 487 consecutive patients (240 male, 247 female) underwent TVS at the Heart Center Leipzig, University of Leipzig. The data were prospectively collected and retrospectively analyzed. Univariate and multivariable regression analyses were performed to identify risk factors. Results The 30-day mortality was 16.1% and the long-term survival at 1 year and 5 years was 71.8% and 54.6%, respectively. Multivariable logistic regression analysis identified previous myocardial infarction to be the only significant predictor for early mortality. Age, New York Heart Association functional class IV, previous myocardial infarction, dialysis, and liver dysfunction were identified as preoperative predictors for late mortality. Furthermore, an increase of operative risk, given for each year, was observed during the study period. In contrast, 30-day mortality decreased during the observation time. Conclusion TVS is associated with a high surgical risk. Long-term survival is decreased, but acceptable for these high-risk patients. The series demonstrates that increasing surgical risk, age, and comorbidities are the future challenges in TVS.

Postoperative Changes in the Distal Residual Aorta after Surgery for Acute Type A Aortic Dissection: Impact of False Lumen Patency and Size of Descending Aorta.

Objective In the present study, we retrospectively identified and analyzed the factors that influenced progressive dilatation of the residual distal aorta after surgical repair for acute type A aortic dissection (acute type A). Methods A total of 477 patients underwent surgical repair for acute type A aortic dissection between 1995 and 2012. Postoperative and follow-up computed tomography (CT) scans of the descending aorta were available in 105 patients. We analyzed the maximum aortic diameter, total luminal area, and true luminal area of the descending thoracic and abdominal aorta. Results The mean follow-up time was 4.5 ± 3 years, and the mean time interval between CT scan investigations was 2.0 ± 2.3 years. A residual dissection membrane was observed in 80 (76%) patients, with presence of a patent false lumen (FL) in 52 patients (50%) and a thrombosed FL in 28 patients (26%).Progression of aortic disease with an increase in aortic diameter greater than 10 mm was observed in 14.3% (n = 15) of patients during follow-up. The independent predictors that influenced progressive dilation of the descending aorta by 10 mm or more were postoperative descending aortic diameter greater than 40 mm (p = 0.006; odds ratio [OR], 5.6; 95% confidence interval [CI], 1.6-19) and postoperative patent FL (p = 0.002; OR, 8.5; 95% CI, 2.2-32.3).The unadjusted 1- and 5-year freedom from reoperation was 96.9 ± 2 and 80.1 ± 5%, respectively. Marfan syndrome (p = 0.006; OR, 5.2; 95% CI, 1.6-16.9) and postoperative descending aortic diameter greater than 40 mm (p = 0.07; OR, 4.1; 95% CI, 1.4-11.6) were independent predictors of aorta-related reoperations.The mean survival at 1, 5, and 8 years was 90.7 ± 3, 82.5 ± 4, and 70 ± 6%, respectively. Previous cardiac surgery was independent predictor of midterm survival (hazard ratio, 3.6; 95% CI, 1.03-2.8; p = 0.04). Conclusions A regular follow-up CT scan is mandatory to assess progressive dilatation of the distal residual aortic arch, descending thoracic, and abdominal aorta after surgical repair of acute type A dissection, particularly in patients with a patent FL, descending aortic diameter greater than 40 mm, and/or Marfan syndrome.