Colchicine for prevention of postpericardiotomy syndrome and postoperative atrial fibrillation: the COPPS-2 randomized clinical trial.

IMPORTANCE: Postpericardiotomy syndrome, postoperative atrial fibrillation (AF), and postoperative effusions may be responsible for increased morbidity and health care costs after cardiac surgery. Postoperative use of colchicine prevented these complications in a single trial. OBJECTIVE: To determine the efficacy and safety of perioperative use of oral colchicine in reducing postpericardiotomy syndrome, postoperative AF, and postoperative pericardial or pleural effusions. DESIGN, SETTING, AND PARTICIPANTS: Investigator-initiated, double-blind, placebo-controlled, randomized clinical trial among 360 consecutive candidates for cardiac surgery enrolled in 11 Italian centers between March 2012 and March 2014. At enrollment, mean age of the trial participants was 67.5 years (SD, 10.6 years), 69% were men, and 36% had planned valvular surgery. Main exclusion criteria were absence of sinus rhythm at enrollment, cardiac transplantation, and contraindications to colchicine. INTERVENTIONS: Patients were randomized to receive placebo (n=180) or colchicine (0.5 mg twice daily in patients ≥70 kg or 0.5 mg once daily in patients <70 kg; n=180) starting between 48 and 72 hours before surgery and continued for 1 month after surgery. MAIN OUTCOMES AND MEASURES: Occurrence of postpericardiotomy syndrome within 3 months; main secondary study end points were postoperative AF and pericardial or pleural effusion. RESULTS: The primary end point of postpericardiotomy syndrome occurred in 35 patients (19.4%) assigned to colchicine and in 53 (29.4%) assigned to placebo (absolute difference, 10.0%; 95% CI, 1.1%-18.7%; number needed to treat = 10). There were no significant differences between the colchicine and placebo groups for the secondary end points of postoperative AF (colchicine, 61 patients [33.9%]; placebo, 75 patients [41.7%]; absolute difference, 7.8%; 95% CI, -2.2% to 17.6%) or postoperative pericardial/pleural effusion (colchicine, 103 patients [57.2%]; placebo, 106 patients [58.9%]; absolute difference, 1.7%; 95% CI, -8.5% to 11.7%), although there was a reduction in postoperative AF in the prespecified on-treatment analysis (placebo, 61/148 patients [41.2%]; colchicine, 38/141 patients [27.0%]; absolute difference, 14.2%; 95% CI, 3.3%-24.7%). Adverse events occurred in 21 patients (11.7%) in the placebo group vs 36 (20.0%) in the colchicine group (absolute difference, 8.3%; 95% CI; 0.76%-15.9%; number needed to harm = 12), but discontinuation rates were similar. No serious adverse events were observed. CONCLUSIONS AND RELEVANCE: Among patients undergoing cardiac surgery, perioperative use of colchicine compared with placebo reduced the incidence of postpericardiotomy syndrome but not of postoperative AF or postoperative pericardial/pleural effusion. The increased risk of gastrointestinal adverse effects reduced the potential benefits of colchicine in this setting. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01552187.

Right minithoracotomy versus full sternotomy for the aortic valve replacement: preliminary results.

BACKGROUND: Minimally invasive surgery (MIS) for aortic valve replacement (AVR) is going to increase with different techniques described so far. We hereby report the results of AVR through a right minithoracotomy (RM) compared to a median sternotomy (MS). MATERIALS AND METHODS: One hundred patients operated for isolated AVR by the same surgeon (chief of the department) were enrolled and allocated to: MS (group A, 50 patients, 26 females, mean age 69.9 ± 12.4 years). RM (group B, 50 patients, 27 females, mean age 71.6 ± 11.2 years). Mean logistic Euroscores were, respectively, 6.5 ± 4.0 and 8.0 ± 5.9 (p=ns). RESULTS: Mean duration of cardiopulmonary by-pass (CPB) was 62.8 ± 18.3 min in group A and 101.4 ± 35.2 min in group B (p<0.05); cross-clamp was 44.8 ± 13.4 min in group A and 74.6 ± 26.7 min in group B (p<0.05). Thirty-day mortality was 2 (4%) in group A and 0 in group B (p=ns). ICU stay and hospital stay did not significantly differ amongst two groups. The incidence of bleeding was lower in group B, showing a slight reduction of blood transfusions and re-explorations (p=ns). CONCLUSIONS: Our experience shows that RM offers a good 30-day survival and a lower incidence of mediastinitis or osteomyelitis. The risk of insufficient vision or sudden complications is safely managed by enlarging the surgical incision through a transverse sternotomy.

Transomental titanium plates for sternal osteomyelitis in cardiac surgery.

INTRODUCTION: Wound infection is a devastating complication resulting in a high mortality rate from 7% to 80%. The risk of recurrences depends on the depth and the extension of the infection. We present our experience of omentoplasty using transomental sternal plates. MATERIAL AND METHODS: Five patients (two females, mean age 61.2 ± 8.3 years) had severe osteomyelitis requiring radical sternectomy and omental flap transposition. In three cases (60%), the sternal manubrium was completely removed: in case of upper sternectomy, chest wall stability was achieved without metallic bars; in two cases chest wall stability required the use of three metallic plates for each patient (STRATOS SYSTEM) fixed on the second, third, and fourth ribs. The plates were passed through the omental flap to obtain a partial cover of the devices. RESULTS: No patient had abdominal complications. One patient had postoperative dehiscence of the superficial wound that was treated by VAC therapy for 30 days. The length of hospital stay was 65.2 ± 45.2 days. All patients had complete wound healing and are alive after 24.0 ± 21.4 months. CONCLUSIONS: Omental flap transposition represents a good option in the treatment of sternal osteomyelitis. Partial or total sternal manubrium preservation and fixation are essential for the restoration of sternal stability. The use of transomental titanium plates provides chest wall stabilization when extensive sternal resection is required.

Hypothermic cardiac arrest in the homeless: what can we do?

Accidental deep hypothermia with body temperature < 28 degrees C induces high mortality rates for neurological and cardiac complications. Although several reports described successful treatment of hypothermic arrest by extracorporeal membrane oxygenation (ECMO), the field of warming in the homeless is almost completely unquestioned although the malnutrition and the co-morbidities are usually believed as relevant risk factors for poor outcome. This article describes the experience of successful warming by ECMO in two homeless victims of unwitnessed cardiac arrest, who survived without neurological or cardiac complications. In conclusion, this is an initial experience and further research is required, although our results are appreciable in this high risk subset of population.

Aortic valve replacement using a stentless bioprosthesis through right minithoracotomy: an initial experience.

OBJECTIVE: Aortic valve replacement (AVR) is nowadays a safe procedure with low rates of mortality and morbidity, but the necessity for a less invasive approach is going to increase. The use of a stentless prosthesis through right mini-thoracotomy has not yet been described and our experience could be useful for other surgeons. METHODS: From June 2009 until March 2010, seven female patients (mean age 79.9 ± 5.7 years) underwent stentless-AVR for aortic stenosis through a right mini-thoracotomy (RM). The logistic Euroscore was 11.3 ± 6.1, and left ventricular ejection fraction was 60.7 ± 4.5%. In five cases RM was performed through the second intercostal space (ICS); in two cases through the third ICS. The cannulation was in most cases between ascending aorta and femoral vein (5/7). When transverse sternotomy was required (two patients), the right mammary artery was clipped and cut. RESULTS: Extracorporeal circulation time (ECC) was 110 ± 41min and aortic cross clamp was 80 ± 35min. Two patients required transverse sternotomy. The mean bleeding was 484 ± 469ml and the duration of mechanical ventilation was 22.0 ± 12.5h. The ICU stay was 3.3 ± 2.2 days. No in-hospital death was observed. The mean hospital stay was 11.6 ± 5.4 days. CONCLUSION: Right mini-thoracotomy is a safe and applicable approach even in case of AVR using stentless prosthesis. The risk of insufficient surgical exposure or complication may be safely managed, by enlarging the thoracotomy through transverse sternotomy. However, valve implantation could be more difficult than the standard approach and it requires an expert and confident surgeon with a large experience in standard stentless implantation.

External stenting of vein grafts in coronary artery bypass grating: interim results from a two centers prospective study.

BACKGROUND: previous studies evaluating external stents for saphenous vein grafts (SVG) in CABG were limited to on-pump isolated CABG and single grafting technique with one external stent per patient. The objective of this prospective study was to evaluate the safety and the short-term performance of external stents in a heterogeneous group of patients who underwent on- and off-pump CABG, single and sequential grafting. METHODS: 102 patients undergoing CABG were enrolled in two centers. All patients received internal mammary artery to the left anterior descending artery and additional arterial and/or venous grafts. In each patient, at least one SVG was supported with an external stent. Grafts' patency and SVG lumen uniformity were assessed using CT angiography at a pre-defined time window of 6-12 months post procedure. All patients were prospectively followed-up via phone call and/or visit every 6 months for Major Adverse Cardiac and Cerebrovascular Events. RESULTS: 51 patients (50%) underwent off-pump CABG and 23 patients (23%) were grafted with bilateral internal mammary arteries. Each patient received one or more SVG grafted in a sequential technique (44%) or as a single graft (56%). All SVG were externally stented in 84% of patients and in 16% (n = 16) one SVG was stented and one remained unsupported. At 6-12 months, patency rates of LIMA, RIMA, externally stented SVG and none-stented SVG were 100, 100, 98 and 87.5% respectively. 90% of the externally stented SVG had uniform lumen compared to 37% of the non-stented SVG. Clinical follow-up was completed for all patients with a mean duration of 20 months (range 6-54 months). During follow up period, one patient experienced myocardial infarction due to occlusion of the LIMA-LAD graft and one patient experienced a transient ischemic attack. CONCLUSIONS: External stenting of SVG is feasible and safe in CABG setting which includes off pump CABG and sequential SVG grafting and associated with acceptable early patency rates. TRIAL REGISTRATION: Study was registered at ClinicalTrials.gov. NCT01860274 (initial release 20.05.2013).

Nuss procedure in adult pectus excavatum: a simple artifice to reduce sternal tension.

Nowadays the Nuss operation represents the standard surgical choice for pectus excavatum repair in children and teenagers. Some concerns have been raised regarding its applicability in adults, as compared with younger patients, in view of the higher rate of complications after surgery. We describe an easy trick that has been performed on a 36-year old man with a moderate pectus excavatum after an unsatisfactory Nuss procedure. It consisted of a T-shaped partial anterior sternotomy, performed after positioning of the stainless steel bar, in order to promote a hinge mechanism of the sternum to reduce the tension over the reinforcement. This procedure was successful with well-controlled postoperative pain and great patient satisfaction. No complications were recorded at 1-year follow-up. In our opinion, this simple trick could represent a valid surgical option for pectus excavatum repair in late adolescents and adults to obviate the occurrence of major sternal tension.

The 37-year durability of a Björk-Shiley Delrin-disc aortic valve prosthesis.

We report the exceptional longevity of a Björk-Shiley Delrin-disc prosthetic aortic valve that had been implanted in a man who underwent surgical correction of an ascending aortic aneurysm 37 years later. Upon explantation of the valve, the Delrin disc had only shallow abrasion on the ventricular surface, and none on the aortic surface. We discuss the soundness and durability of this valve in our patient, in contrast with its short functional prosthetic life in other patients. The 37-year lifespan of this patient's Björk-Shiley Delrin-disc valve is among the longest reported.

Preoperative mobilization of bone marrow-derived cells followed by revascularization surgery: early and long-term outcome.

INTRODUCTION: Coronary artery disease (CAD), along with its main complications such as acute myocardial infarction (AMI) and congestive heart failure (CHF), remains a serious worldwide problem and affects many patients despite the improvement of medical treatment. The possibility of the replacement of the infarcted areas by the re-generation of the myocardial cells has been long discussed and the mobilization of the stem cells from bone marrow (BMCs) to the peripheral blood (PB) induced by cytokines, represents a potential pathway to activate the regenerative process. PATIENTS AND METHODS: We describe BMC mobilization and direct/indirect revascularization in 15 patients operated on for coronary artery bypass grafting (CABG) and/or mitral valve surgery and/or ventricular remodeling combined to multiple trans-myocardial punctures (Sen technique) in ungraftable non-viable fibrotic areas. RESULTS: Peak values of circulating BMCs were recorded between day +4 and day +6. We had no in-hospital (0-30 days) mortality. All the patients were discharged from the ICU after a median period of 2 days while the in-hospital length of stay was 10.5+4.2 days (range 7-21) and all patients were discharged in good clinical condition. There were two sudden deaths over the mid-term, at postoperative day (POD) 32 and 45 respectively. CONCLUSIONS: Our study suggests that the combination of BMC mobilization and CABG may be safely performed. However, considering the small series, final conclusions about the benefit of this procedure must await a larger prospective study comparing the role of cytokines alone, myocardial perforation, and the combination of both.

Pulsed or continuous flow in long-term assist devices: a debated topic.

The end-stage cardiomyopathy is an increasing worldwide problem. Cardiac transplantation lacks sufficient donors to treat all patients, and there is thus debate about alternative strategies. The use of left ventricular assist devices for long-term support is increasing with a positive impact on patient survival. Although there is an ongoing debate regarding the risks and benefits of maintaining pulsatile flow during long-term ventricular assist device support, there has been a significant move towards implantation of continuous flow devices due to the lower surgical morbidity and better long-term reliability of these pumps. The following is a review of the literature on continuous and pulsatile flow for long-term support. Starting from the definition of flow, we analyze the current evidence and consider gastrointestinal complications.

Late angiograms ten years after transmyocardial laser revascularization.

We present the angiograms of a patient after transmyocardial laser revascularization (TMR), which were performed 10 years before by the application of holmium laser pulses. Thirteen years before the TMR procedure, the patient underwent coronary artery bypass graftings complicated by graft occlusion with no longer possibility of direct revascularization. Then, refractive angina required an alternative approach for symptom relief as the indirect revascularization by the application of the holmium laser pulses. Interestingly, the late angiograms, taken when the patient suffered from effort dyspnea for ongoing left ventricular dysfunction, showed a network of small vessels (absent before the TMR procedure) that supplies blood to the heart with no flow through the coronary arteries because of their complete occlusion. This is a historical presentation of the results of TMR to understand the effects of the indirect revascularization on the blood circulation through the heart over the long-term follow-up.

The role of psychological support in cardiac surgery: initial experience.

The scientific literature has pointed out several predictors of negative outcome after surgery such as pain and depression, negatively affecting the postoperative outcome in cardiac surgery. From January 2009 until June 2010, 15 patients scheduled for cardiac surgery were enrolled. The patients were assessed by psychological evaluation either in the hospital stay either in the rehabilitation period with the aim of identifying their emotional condition (sentiments about the onset of the disease, support received from family and friends) even by means of preformed tests for anxiety and depression (tests of Stay and Back). Thus, in our preliminary experience, the psychological evaluation failed to detect the occurrence of postoperative complications. Conversely, the psychological evaluation is very effective in detecting a poor emotional state and the psychological support decreases the degree of anxiety and depression with positive effects on postoperative outcome. In conclusion, a standardize test for anxiety and depression should be used for patients at hospital admission to detect who may benefits by psychological support.

Is surgery always mandatory for type A aortic dissection?

BACKGROUND: The International Registry of Aortic Dissections showed that 42% of the unoperated patients with type A acute aortic dissection were discharged from the hospital after intensive medical treatment. We analyzed our experience to identify a preoperative score for in-hospital mortality to propose an alternative strategy for type A acute aortic dissection. METHODS: From 1980 to 2004, 616 consecutive patients with type A acute aortic dissection underwent surgery in our center. The preoperative univariate risk factors with a probability value less than 0.05 were entered into multivariate analysis. A risk equation was developed: predicted mortality = exp(beta 0 + sigma beta i X i)/[1 + exp(beta 0 + sigma beta i X i)]. RESULTS: Early mortality was 25.1% (154 of 616 patients). Five risk factors were identified: age, coma, acute renal failure, shock, and redo operation. The beta i values are age 0.023, shock 0.771, reoperation 0.595, coma 1.162, acute renal failure 0.778; the constant (beta 0) is -2.986. CONCLUSIONS: Our large, single-center experience allowed us to develop a mathematical model to predict 30-day mortality for type A acute aortic dissection. When the expected mortality is 58% or less, surgery is always indicated. When the predicted mortality is greater than 58%, the possibility of survival is similar, according to International Registry of Aortic Dissections data, for surgery and medical treatment. In such cases surgery can no longer be considered mandatory, and a careful evaluation of the individual patient is recommended to choose the more suitable strategy.