Effect of donor cardiac arrest and arrest duration on outcomes of lung transplantation.

BACKGROUND: Limited data are available about lung transplantation (LTx) from donors suffering cardiac arrest (CA) prior to actual donation. METHODS: A retrospective analysis of LTx performed between January 2007 and September 2012 was done with the focus on CA in donors. The recipients were grouped depending on the history of donor CA and CA duration (downtime) as: No cardiac arrest ("NoCA"), CA downtime less than 20 min ("CA < 20"), and CA downtime equal to or more than 20 min ("CA > 20"). Early and mid-term outcomes after LTx were compared among the three groups. RESULTS: A total of 237 LTx were performed during the study period. One hundred eighty-eight patients received organs from "NoCA" donors, 25 from "CA < 20" donors, and 24 patients from "CA > 20" donors. There was a trend toward better overall cumulative survival in both CA groups (log rank p = 0.076) whereas the survival in the "CA > 20" group was significantly better than in the "NoCA" group in the subgroup analysis (log rank p = 0.045). Freedom from bronchiolitis obliterans syndrome (BOS) also increased with increase in CA duration, although it did not reach statistical significance. CONCLUSIONS: Transplantation of lungs from donors with a history of CA is safe and feasible. Longer duration of cardiac arrest may improve the outcomes after the LTx in terms of survival and freedom from BOS.

The role of cardiopulmonary bypass in lung transplantation.

BACKGROUND: The risk-benefit for utilizing cardio-pulmonary bypass (CPB) in lung transplantation (LTx) remains debatable. This study compares outcomes after LTx utilizing different CPB strategies - elective CPB vs. off-pump vs. off-pump with unplanned conversion to CPB. METHODS: A total of 302 LTx performed over seven yr were divided into three groups: "off-pump" group (n = 86), "elective on-pump" group (n = 162), and "conversion" group (n = 54). The preoperative donor and recipient demographics and baseline characteristics and the postoperative outcomes were analyzed; 1:1 propensity score matching was used to identify patients operated upon using elective CPB who had risk profiles similar to those operated upon off-pump (propensity-matching 1) as well as those emergently converted from off-pump to CPB (propensity-matching 2). RESULTS: Preoperative group demographic characteristics were comparable; however, the "off-pump" patient group was significantly older. The "conversion" group had a significantly greater number of patients with primary pulmonary hypertension, pulmonary fibrosis, preoperative mechanical ventilation, and preoperative extracorporeal life support (ECLS). Postoperatively, patients from the "conversion" group had significantly poorer PaO2 /FiO2 ratios upon arrival in intensive care unit (ICU) and at 24, 48, and 72 h postoperatively, and they required more prolonged ventilation, longer ICU admission, and they experienced an increased need for ECLS than the other groups. Overall, cumulative survival at one, two, and three yr was significantly worse in patients from the "conversion" group compared to the "off-pump" and "elective on-pump" groups - 61.9% vs. 94.4% vs. 86.9%, 54.4% vs. 90.6% vs. 79.5% and 39.8% vs. 78.1% vs. 74.3%, respectively (p < 0.001). The "off-pump" group had significantly better PaO2 /FiO2 ratios, and a significantly shorter duration of ventilation, ICU stay, and hospital length of stay when compared to the propensity-matched "elective on-pump" group. There were no statistically significant differences in postoperative outcomes and overall survival between the "converted" group and the propensity-matched "elective on-pump" group. CONCLUSIONS: Despite segregation of unplanned CPB conversion cases from elective on-pump cases, patients with comparable preoperative demographic/risk profiles demonstrated better early postoperative outcomes and, possibly, an improved early survival with an off-pump strategy. A considerable proportion of high-risk patients require intraoperative conversion from off-pump to CPB, and this seems associated with suboptimal outcomes; however, there is no significant benefit to employing an elective on-pump strategy over emergent conversion in the high-risk group.

Chiral ligands derived from monoterpenes: application in the synthesis of optically pure secondary alcohols via asymmetric catalysis.

The preparation of optically pure secondary alcohols in the presence of catalysts based on chiral ligands derived from monoterpenes, such as pinenes, limonenes and carenes, is reviewed. A wide variety of these ligands has been synthesized and used in several catalytic reactions, including hydrogen transfer, C-C bond formation via addition of organozinc compounds to aldehydes, hydrosilylation, and oxazaborolidine reduction, leading to high activities and enantioselectivities.

Gender differences in continuous-flow left ventricular assist device therapy as a bridge to transplantation: a risk-adjusted comparison using a propensity score-matching analysis.

The purpose of this study was to evaluate gender differences regarding outcome after continuous-flow left ventricular assist device (cfLVAD) implantation. The study was a retrospective review of prospectively collected data. Included were 24 consecutive female cfLVAD recipients and 24 male recipients (62.5% HeartMate II, 37.5% HeartWare) who received their devices between July 2007 and May 2013. Subjects were matched using propensity score analysis based on age, diagnosis, body surface area, preoperative mechanical circulatory support, heart failure severity score (INTERMACS class), and comorbidities. Female patients were significantly sicker before operation. After propensity score matching, there were no statistically significant differences in demographics or clinical baseline characteristics between male and female LVAD recipients. Also, there was a trend towards a longer postoperative intensive care unit stay in the female group (median 9 days [interquartile range 5-17] versus 15 days [interquartile range 8-33]; P < 0.061) and higher postoperative bilirubin values (median 14 mmol/L [interquartile range 10-17] versus 21 mmol/L [interquartile range 13-30]). However, there were no significant differences between the two groups in terms of outcome (P < 0.569). The overall survival was comparable between the two groups (log rank P < 0.389). Half (50%) of female patients required inotropic support for more than 7 days compared with 21.7% in the male group (P < 0.048). Half (50%) of female recipients required short-term postoperative right ventricular assist device implantation compared with 16.7% in the male group (P < 0.014). In conclusion, cfLVAD implantation as a bridge to transplantation is associated with longer duration of inotropic support and higher requirement for postoperative mechanical right ventricular support in women with similar survival rates. Further studies are required to identify additional demographic and clinical factors that modulate outcomes and will enhance the ability to risk-stratify cfLVAD recipients.

Continuous-flow left ventricular assist device therapy in patients with preoperative hepatic failure: are we pushing the limits too far?

The purpose of this study was to evaluate the effects and outcome of continuous-flow left ventricular assist device (cf-LVAD) therapy in patients with preoperative acute hepatic failure. The study design was a retrospective review of prospectively collected data. Included were 42 patients who underwent cf-LVAD implantation (64.3% HeartMate II, 35.7% HeartWare) between July 2007 and May 2013 with preoperative hepatic failure defined as elevation of greater than or equal to two liver function parameters above twice the upper normal range. Mean patient age was 35 ± 12.5 years, comprising 23.8% females. Dilated cardiomyopathy was present in 92.9% of patients (left ventricular ejection fraction 17.3 ± 5.9%). Mean support duration was 511 ± 512 days (range: 2-1996 days). Mean preoperative laboratory parameters for blood urea nitrogen, serum creatinine, total bilirubin, and alanine aminotransferase were 9.5 ± 5.4 mg/dL, 110.3 ± 42.8 µmol/L, 51.7 ± 38.3 mmol/L, and 242.1 ± 268.6 U/L, respectively. All parameters decreased significantly 1 month postoperatively. The mean preoperative modified Model for Endstage Liver Disease excluding international normalized ratio score was 16.03 ± 5.57, which improved significantly after cf-LVAD implantation to 10.62 ± 5.66 (P < 0.001) at 7 days and 5.83 ± 4.98 (P < 0.001) at 30 days postoperatively. One-year and 5-year survival was 75.9 and 48.1%, respectively. 21.4% of the patients underwent LVAD explantation for myocardial recovery, 16.7% were successfully transplanted, and 7.1% underwent LVAD exchange for device failure over the follow-up period. Patients with preexisting acute hepatic failure are reasonable candidates for cf-LVAD implantation, with excellent rates of recovery and survival, suggesting that cf-LVAD therapy should not be denied to patients merely on grounds of "preoperative elevated liver enzymes/hepatopathy."

First experience with the Synergy Micro-Pump in patients in INTERMACS class 1-2 as a bridge to transplantation: pushing the limits?

The Synergy Micro-pump is the smallest implantable left ventricular assist device (LVAD) and provides partial flow support up to 4.25 L/min. It was shown that early intervention with this device can provide substantial benefits to patients with severe heart failure not yet sick enough for a full-support LVAD. However, as it can be inserted via small incisions with no need for sternotomy or cardiopulmonary bypass, it might be beneficial for selected high-risk patients. The aim of this study was to evaluate the efficacy of the Synergy Micro-pump in patients in INTERMACS class 1-2. From February 2012 to August 2013, 13 patients with severe heart failure were supported with the Synergy Pocket Micro-pump. Patients were divided into two groups according to INTERMACS class: the high-risk group (INTERMACS class 1-2) and the low-risk group (INTERMACS class 3-4). There were seven patients in INTERMACS class 1-2 and six in INTERMACS class 3-4. Patient demographics, perioperative characteristics, and postoperative outcomes were compared. There were no statistically significant differences in patient demographics, and mean support time was 108 ± 114 days in the high-risk group and 238 ± 198 days in the low-risk group. Also, there were no significant differences in perioperative characteristics or in the rate of postoperative adverse events. The overall survival was comparable between the two groups (one late death in each group, log-rank P = 0.608). Two patients from the high-risk group were upgraded to a full-support LVAD (P = 0.462) after 65 ± 84.9 days of mean support. One patient from the high-risk group and two patients from the low-risk group were successfully transplanted (P = 0.559). The use of the Synergy Micro-pump in INTERMACS 1-2 patients is feasible and is associated with similar postoperative outcome as in patients in INTERMACS 3-4. Carefully selected patients with severe heart failure could benefit due to the small size of the pump; however, further studies and medium-term follow-up are required.

Extracorporeal Life Support in "Awake" Patients as a Bridge to Lung Transplant.

BACKGROUND: Traditionally, patients on extracorporeal membrane oxygenation (ECMO) are sedated and mechanically ventilated, which increases risk of complications related to immobility and mechanical ventilation. The purpose of this study was to assess the feasibility and highlight the benefits of a bridge to lung transplant (LTx) using "awake ECMO" support. METHODS: The peripheral venovenous or venoarterial ECMO was implanted at a bedside. A retrospective study of patients undergoing LTx between January 2007 and March 2013 was performed. Outcomes in patients supported on ECMO as a bridge to LTx and kept "awake" (Group 1) were compared with the rest of the LTx patients (Group 2). RESULTS: In this period, 249 LTx were performed and in them 7 patients were bridged to LTx using "awake ECMO" strategy. Two patients were awake at ECMO implantation and throughout the therapy, and two patients were on ventilator support at the time of ECMO implantation who were extubated later and maintained awake until LTx. The remaining three patients were awake for some time during the ECMO. There was no statistically significant difference in most donor characteristics and recipient baseline characteristics as well as post-LTx parameters between the two groups. One-year survival estimate was not different between the groups: Group 1, 85.7% vs. Group 2, 86.3% (log rank p = 0.99). CONCLUSION: In end-stage lung disease, the ECMO can be commenced in "awake" patients and patients can be awakened on ECMO. The "awake ECMO" strategy may avoid complications related to mechanical ventilation, sedation, and immobilization and provide comparable outcomes in the high-risk LTx patients.

Lung transplantation from donors outside standard acceptability criteria--are they really marginal?

Lung transplantation (LTx) from "extended donor criteria" donors may reduce significantly organ shortage. However, its influence on results remains unclear. In this study, we evaluate retrospectively the results of LTx from donors outside standard criteria: PaO2/FiO2 ratio < 300 mmHg, age over 55 years, and history of smoking > 20 pack-years. Two hundred and forty-eight patients underwent first time LTx in our institution between January 2007 and January 2013. Seventy-nine patients (Group I) received organs from "extended donor criteria" and 169 patients (Group II) from "standard donor criteria." Recipients' and donors' demographics, perioperative variables, and outcome were compared. Donors from Group I were significantly older [median (interquartile range)]: 52.5 (44;58) vs. 42 (28.5;48.5) years (P < 0.001) with lower PaO2/FiO2 ratio: 366 ± 116.1 455 ± 80.5 mmHg (P < 0.001), higher incidence of smoking history: 57.7% vs. 41.8% (P = 0.013), and more extensive smoking history: 24(15;30) vs. 10(3.75;14) pack-years (P < 0.001). Other parameters were comparable. Recipients' gender, diagnosis, percentage of patients operated on pump and receiving double LTx were also comparable. Recipients from Group I were significantly older: 50 (42;57) vs. 44 (29.5;53.5) years (P = 001). There were no differences observed in recipients' prevalence of primary graft dysfunction (PGD) grade 3 over first three postoperative days, duration of mechanical ventilation, intensive care and hospital length of stay, prevalence of rejection, and bronchiolitis obliterans syndrome (BOS). 90-day, 1-year, and 5-year survival (Group I vs. II) were also similar: 88.6% vs. 91.7%, 83.2% vs. 84.6%, and 59% vs. 68.2% (log rank P = 0.367). Carefully selected donor lungs from outside the standard acceptability criteria may expand existing donor pool with no detrimental effect on LTx outcome.

The management of concomitant renal oncocytoma and giant coronary and bilateral common iliac artery aneurysms.

We present the rare case of a 66-year-old Caucasian male patient presenting with intermittent left-side abdominal pain. He underwent a kidneys, ureters, and bladder computed tomography scan on which an incidental 45-mm giant aneurysm of the left anterior descending coronary artery was discovered along with 55-mm right-sided and 62-mm left-sided common iliac artery aneurysms and a 100-mm benign renal oncocytoma. He underwent on-pump coronary artery bypass grafting of the left anterior descending, left circumflex and right coronary arteries using internal mammary artery and saphenous vein grafts. He subsequently underwent simultaneous open left nephrectomy and bilateral common iliac aneurysm repair using a bifurcated tube graft. He made a full recovery postoperatively. Giant coronary artery aneurysms are rare. In the pediatric population, they are predominantly secondary to Kawasaki disease. In adults, atheromatous disease is the leading cause. The coexistence of giant coronary artery aneurysms with extracoronary artery aneurysms is extremely unusual. We propose that the identification of giant coronary artery aneurysms necessitates further imaging investigations to identify the presence of extracoronary aneurysms. To our knowledge, this is the first description of such a case in the literature.

Distal limb perfusion: Achilles' heel in peripheral venoarterial extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) is a temporary mechanical circulatory assist method that offers circulatory as well as respiratory support efficiently via peripheral access; however, it is liable to complications. Limb ischemia is one of the notorious complications of ECMO but can be avoided utilizing a proper distal limb perfusion method. A retrospective study of patients undergoing peripheral venoarterial (VA) ECMO for various reasons between June 2010 and December 2012 was performed. All patients were evaluated by our multidisciplinary team for suitability as candidates for ECMO. A peripheral VA-ECMO circuit was implanted via groin: inflow cannula in the femoral vein, an outflow cannula and distal-perfusion cannula, or an introducer sheath in the femoral artery. During the study period, 83 patients underwent various types of ECMO; 45 received peripheral VA-ECMO. Distal limb perfusion was achieved with an introducer sheath (6-8 Fr) in 13 cases and with a distal-perfusion cannula (10-12 Fr) in 32 cases. Nine (20%) patients developed signs of ischemia; five (11.2%) were treated conservatively, while four (8.8%) required surgical intervention. One patient required a below-knee amputation. The incidences of limb ischemia and limb ischemia requiring surgical intervention were significantly higher for the introducer sheath compared with the cannula (30.6 vs. 15.6% and 15.4 vs. 6.25%, respectively). Moreover, the patients supported on ECMO with a distal-perfusion cannula spent a significantly longer time on ECMO compared with the ones in whom an introducer sheath was used (11.9 ± 9.1 vs. 7.7 ± 4.3 days). The mean cannula size was significantly greater than the mean introducer sheath size (11.1 ± 1.3 vs. 7.0 ± 1.1 Fr). Use of a distal-perfusion cannula is a most reliable method of limb perfusion in peripheral VA-ECMO. The cannula can ensure adequate and smooth perfusion of the limb owing to its large caliber, its less turbulent flow, the ability it provides to monitor the flow, and the option to attach a side port.

Short-term ventricular assist device in post-cardiotomy cardiogenic shock: factors influencing survival.

Post-cardiotomy cardiogenic shock (PCCS) results in substantial morbidity and mortality, whereas refractory cases require mechanical circulatory support. The aim of this study was to evaluate factors influencing survival during short-term ventricular assist support in PCCS. In total, 154 CentriMag(®) (Thoratec; CA, USA) devices were implanted for cardiogenic shock between 2004 and 2011 out of which 31 were for PCCS. A retrospective review was performed in 31 PCCS patients who required the CentriMag short-term VAD as a bridge to decision. Survivors and non-survivors were compared with respect to pre- and intra-operative characteristics as well as duration of short-term VAD support. Mean duration of support was 11.7 ± 15.4 days (range 1-65 days). Seventeen (54.83 %) patients died on support, 14 (45.16 %) were weaned off or upgraded to long-term device, while 11 (35.5 %) were discharged home. The overall survival to myocardial recovery and device explantation, or upgrade to a long-term VAD, was 41.9 % (n = 13) at the study cutoff. EuroSCORE II was significantly higher in non-survivors as compared to survivors (p = 0.047). The duration of short-term VAD support was significantly longer in survivors (p < 0.001). The CentriMag is a versatile, safe and effective short-term circulatory support for patients with PCCS as a bridge to decision which enables longer support and better recovery of both heart and end-organ function and thus may improve the survival of PCCS patients. Lower EuroSCORE may be essential for myocardial recovery in PCCS.

Impact of concomitant coronary artery bypass grafting on in-hospital outcome in octogenarians undergoing aortic valve replacement.

BACKGROUND AND AIM OF THE STUDY: Abundant data are available reporting excellent in-hospital outcomes after surgical aortic valve replacement (AVR) in octogenarians. However, there is a paucity of studies reporting the in-hospital outcome of concomitant AVR and coronary artery bypass grafting (CABG) in this group of patients. Hence, a comparison was made of the impact of concomitant AVR and CABG versus isolated AVR on in-hospital outcome in octogenarians. METHODS: Between January 2001 and October 2011, a total of 114 consecutive octogenarians undergoing combined AVR and CABG were compared with a control group of octogenarians (n = 68) undergoing isolated AVR. A retrospective analysis was performed of a prospectively collected cardiac surgery database. In addition, the medical notes and charts of all study patients were reviewed. RESULTS: The two groups had a similar mean age (AVR 82.3 +/- 2.4 years versus AVR + CABG 82.6 +/- 2.1 years; p = 0.91), demographics and EuroSCORE (AVR 11.4 versus AVR + CABG 13.2; p = 0.12). The aortic cross-clamp and cardiopulmonary bypass times were longer for AVR + CABG patients (p < 0.001). In-hospital mortality (7.4% after isolated AVR, 9.6% after AVR + CABG; p = 0.35 between groups) and major clinical outcomes for the two groups were found to be similar except for an increased need for hemofiltration in AVR + CABG patients (p = 0.02). CONCLUSION: In-hospital outcomes for concomitant AVR and CABG in octogenarians are comparable to those of isolated AVR, justifying the performance of combined AVR and CABG in this high-risk group of carefully selected patients.

In-hospital outcomes of pedicled bilateral internal mammary artery use in diabetic and nondiabetic patients undergoing off-pump coronary artery bypass grafting: single-surgeon, single-center experience.

OBJECTIVE: A common perception is that use of pedicled bilateral internal mammary arteries (BIMA) increases the risk of sternal wound complications in diabetic patients undergoing coronary artery bypass grafting (CABG). The purpose of this study was to compare the in-hospital outcomes of CABG using pedicled BIMA in diabetic and nondiabetic patients. METHODS: From September 1998 to September 2010, 390 consecutive diabetic patients and 519 nondiabetic patients underwent isolated off-pump CABG using pedicled BIMA. The 2 groups had comparable preoperative demographics except for a higher prevalence of acute myocardial infarction (18.9% versus 6.1%, P = .01), peripheral vascular disease (17.2% versus 2.7%, P = .001), an ejection fraction <30% (17.7% versus 8.5%, P = .02), and chronic renal failure (4.5% versus 0.9%, P = .01) in the diabetic patients. RESULTS: The operative mortality rate of the diabetic patients was comparable to that of the nondiabetic patients (2.8% versus 2.1%, P = .87). The in-hospital outcomes, including occurrence of superficial and deep sternal wound infections, were similar except for an increased occurrence of wound infection at the vein harvest site (6.6% versus 1.1%, P = .04) and a need for hemofiltration (11.8% versus 2.1%, P = .02) in the diabetic patients. CONCLUSIONS: Pedicled BIMA use is associated with comparable incidences of sternal wound complications and other outcomes in diabetic patients and nondiabetic patients. Strict perioperative glycemic control, adherence to meticulous closure technique, and postoperative management of surgical wounds can make pedicled BIMA use a default strategy for diabetic patients.

Concomitant off-pump coronary artery bypass grafting results in improved in-hospital outcomes for patients with ischemic mitral regurgitation undergoing surgery.

OBJECTIVE: Surgical management of ischemic mitral regurgitation (IMR) has primarily consisted of revascularization with or without the addition of mitral valve repair or replacement. We hypothesize that performing off-pump coronary artery bypass (OPCAB) grafting before fixing MR improves in-hospital outcomes for patients with IMR undergoing surgery. METHODS: From January 2000 through December 2010, a total of 96 consecutive patients with moderate or severe IMR, as determined by preoperative echocardiography, underwent on-pump coronary artery bypass grafting (CABG) (n = 66) or OPCAB (n = 30) revascularization with concomitant mitral valve repair or replacement. A retrospective analysis of a prospectively collected cardiac surgery database (PATS; Dendrite Clinical Systems, Oxford, UK) was performed. In addition, medical notes and charts were reviewed for all study patients. RESULTS: The 2 groups had similar preoperative demographic and EuroSCORE risk-stratification characteristics. The operative mortality rate for the entire cohort was 9.4%. Patients who underwent OPCAB grafting had a lower operative mortality than those who underwent CABG (3.3% versus 12.1%; P = .006). The mean ±SD cardiopulmonary bypass time (82.7 ± 34.7 minutes versus 160.7 ± 45.2 minutes; P < .001) and cross-clamp time (49.0 ± 22.4 minutes versus 103.4 ± 39.5 minutes; P < .001) were significantly shorter in the off-pump group than in the on-pump group. The OPCAB group also had significantly less in-hospital morbidity and shorter stays in the intensive care unit and the hospital. CONCLUSION: Our analysis shows that OPCAB grafting (compared with conventional CABG) before repairing MR is associated with favorable in-hospital outcomes for patients undergoing surgery for IMR.

α-Amino-oximes based on optically pure limonene: a new ligands family for ruthenium-catalyzed asymmetric transfer hydrogenation.

A new family of bifunctional, optically pure α-amino-oxime ligands based on (R)-limonene has been synthesized and used as chiral inducers for enantioselective hydrogen transfer reactions on various ketones in the presence of ruthenium catalysts. The X-ray structures of Ru-amino-oxime complexes are also described.

A hydrological modeling framework for defining achievable performance standards for pesticides.

This paper proposes a hydrological modeling framework to define achievable performance standards (APSs) for pesticides that could be attained after implementation of recommended management actions, agricultural practices, and available technologies (i.e., beneficial management practices [BMPs]). An integrated hydrological modeling system, Gestion Intégrée des Bassins versants à l'aide d'un Système Informatisé, was used to quantify APSs for six Canadian watersheds for eight pesticides: atrazine, carbofuran, dicamba, glyphosate, MCPB, MCPA, metolachlor, and 2,4-D. Outputs from simulation runs to predict pesticide concentration under current conditions and in response to implementation of two types of beneficial management practices (reduced pesticide application rate and 1- to 10-m-wide edge-of-field and/or riparian buffer strips, implemented singly or in combination) showed that APS values for scenarios with BMPs were less than those for current conditions. Moreover, APS values at the outlet of watersheds were usually less than ecological thresholds of good condition, when available. Upstream river reaches were at greater risk of having concentrations above a given ecological thresholds because of limited stream flows and overland loads of pesticides. Our integrated approach of "hydrological modeling-APS estimation-ecotoxicological significance" provides the most effective interpretation possible, for management and education purposes, of the potential biological impact of predicted pesticide concentrations in rivers.

Impact of gentamicin-collagen sponge (Collatamp) on the incidence of sternal wound infection in high-risk cardiac surgery patients: a propensity score analysis.

OBJECTIVE: Local delivery of prophylactic antibiotic to the wound site with an implanted, reabsorbable, gentamicin-containing collagen sponge (Collatamp) is a strategy that has been claimed to prevent sternal wound infection after cardiac surgery. The purpose of this study was to review our experience with Collatamp in cardiac surgery patients deemed at high risk for sternal wound infection. METHODS: From January 2007 to December 2010, Collatamp was used in 107 patients deemed at high risk for sternal wound infection. Applying the propensity score, we matched 97 patients with Collatamp (group I) with 97 patients who did not receive Collatamp (group II). All individuals received routine intravenous antimicrobial prophylaxis. Postoperative wound-infection rates as well as routine outcomes were compared. Information for the study was obtained from the cardiac surgical Patients Analysis and Tracking System (PATS) database and from hospital records. RESULTS: The superficial sternal wound infection rate was 2.1% (2/97) in group I and 6.2% (6/97) in group II (P = .01). The rates of deep sternal wound infection rate were similar (2.1% versus 3.1%, P = .87). There was no mediastinitis in the study population. In addition, more patients in group II received an intra-aortic balloon pump (5.2% versus 2.1%, P = .04) and underwent hemofiltration (7.2% versus 3.1%, P = .02). No side effects were noted. CONCLUSION: Gentamicin-containing collagen sponge (Collatamp) is a useful adjunct to meticulous surgical technique and postoperative wound care in reducing the incidence of sternal wound infection in high-risk cardiac surgery patients. An adequately powered study is needed, however, to validate the safety and efficacy of this strategy.

Ten-year outcome analysis of off-pump sequential grafting: single surgeon, single center experience.

OBJECTIVES: Despite increasing recognition that off-pump coronary artery bypass surgery and sequential grafting strategy individually are associated with improved outcomes, concerns persist regarding the safety and efficacy of combining these 2 techniques. We compared in-hospital and midterm outcomes for off-pump multivessel sequential and conventional coronary artery bypass grafting. METHODS: From September 1998 to September 2008, 689 consecutive patients received off-pump multivessel sequential coronary artery bypass grafting performed by a single surgeon. These patients were propensity matched to 689 patients who underwent off-pump coronary artery bypass grafting without sequential anastomoses. A retrospective analysis of prospectively collected perioperative data was performed. In addition, medical notes and charts of all the study patients were reviewed. The mean duration of follow-up was 5.1 ± 2.0 years. RESULTS: The major in-hospital clinical outcomes in the sequential and control groups were found to be similar. After adjusting for clinical covariates, sequential grafting was not an independent predictor of in-hospital adverse events (odds ratio [OR], 1.18; 95% confidence interval [CI], 0.86-1.50; P = .31), medium-term mortality (hazard ratio [HR], 1.26; 95% CI, 1.06-1.32; P = .92), and readmission to hospital (HR, 1.12; 95% CI, 0.96-1.20; P = .80). Sequential grafting was an independent predictor of receiving more than 3 distal anastomoses (OR, 7.46; 95% CI, 4.27-11.45; P < .0001). Risk-adjusted survival was 89% for sequential grafting patients and 88% for conventional grafting patients (P = .96) during the medium-term follow-up. CONCLUSION: Our analysis confirms the short- and midterm safety and efficacy of off-pump sequential coronary artery bypass grafting.

Traction suture modification of the Cosgrove hemisternotomy technique.

BACKGROUND AND AIM OF THE STUDY: Minimal access is an integral part of cardiac surgery. A personal customization is presented of the Cosgrove technique of hemisternotomy for aortic valve surgery. METHODS: The procedure involves an additional 2 cm right anterior intercostal incision, through which a Roberts clamp is used to tension a suture from the right pericardial flap, thus optimizing exposure of the right atrium. The incision is used later to insert a pericardial drain. RESULTS: The modified Cosgrove technique was applied to 66 patients (43 men, 23 women; mean age 60.47 years; median age 64 years; range: 29-85 years) between January 2005 and March 2010. During the postoperative period, no conversion, tamponade or fatality has been observed among patients. CONCLUSION: This traction suture represents a simple and safe means of optimizing exposure of the right atrium, which is problematic in this type of operation.

Mini-sternotomy aortic valve replacement: is it safe and effective? Comparison with standard techniques.

BACKGROUND AND AIM OF THE STUDY: Mini-sternotomy aortic valve replacement (MSAVR) has been increasingly performed at the authors' institution since October 2003. The study aim was to compare results obtained with MSAVR to those following AVR with conventional sternotomy (SAVR). METHODS: Between 1998 and 2008, a total of 143 consecutive patients (mean age: 67 +/- 12.5 years) underwent AVR at the authors' institution. Of these patients, 82 underwent SAVR, and 61 underwent MSAVR performed through a reversed-L-shaped median sternotomy with a transverse limb at the right fourth intercostal space. Ascending aortic and right atrial cannulation through the mini-sternotomy were employed for cardiopulmonary bypass (CPB). RESULTS: Typically, the MSAVR patients were slightly younger than SAVR patients (mean age: 67 +/- 16 years and 70 +/- 15 years, respectively; p = 0.037), had a lower incidence of diabetes (3% versus 18%, p = 0.008), and a slightly higher left ventricular ejection fraction (74.5 +/- 12% versus 71 +/- 12%, p = 0.019). There were no other inter-group preoperative differences. As expected, MSAVR required a slightly longer aortic cross-clamp time (49 +/- 19 min) compared to SAVR (44.5 +/- 16 min; p = 0.019), and longer CPB times (77 +/- 31 min versus 60 +/- 26 min; p <0.0001), though the overall operating times were similar (p = 0.38). Postoperatively, MSAVR patients were extubated at 3 +/- 5 h, similar to SAVR patients (4 +/- 5 h) (p = 0.13). The median intensive therapy unit stay was 1 +/- 1 days in both groups. The median hospital stay was comparable between groups (MSAVR, 7 +/- 5 days; SAVR, 8 +/- 4 days; p = 0.48). The MSAVR patients had a higher incidence of delayed pericardial effusions requiring pericardiocentesis (n = 4; p = 0.031), but this did not affect survival. The 30-day mortality was similar in both groups (MSAVR group, n = 1 (1.6%); SAVR group, n = 3 (3.7%); p = 0.64). At five years after surgery, freedom from cardiac-related death was 96 +/- 2.6% in MSAVR patients, and 89 +/- 4.9% in SAVR patients (p = 0.32). CONCLUSION: Mini-sternotomy AVR is technically challenging with longer CPB and aortic cross-clamp times. However, with increasing surgical experience, it offers results comparable to those achieved with conventional AVR, and with acceptable cosmetic results.