Confirmation of Safety of Titanium Wire in Sternotomy Closure, A Randomized Prospective Study.

BACKGROUND: There are many factors that are known to increase the risk of sternal wound infection (SWI); some studies have reported that nickel is a risk factor for SWI. Titanium wires have only been used as an alternative to steel wires in patients with known allergy to nickel. However, there is a paucity of literature regarding the safety of using titanium wires compared to that on the safety of steel wires for sternum closure after cardiac surgery. Therefore, this study aimed to demonstrate the noninferiority of titanium wires, even in patients without a known allergy. METHODS: A total of 322 patients who underwent elective full median sternotomy were randomly assigned to sternal closure either by titanium wires (n = 161) or by stainless steel wires. RESULTS: Fourteen patients had sternal instability, six (3.7%) patients in the titanium group and eight (5%) patients in the stainless steel group (p = 0.585). There was no statistically significant difference between both groups in terms of postoperative wound infection (p = 0.147). Patients in the titanium group experienced statistically significant lower postoperative pain than those in the stainless steel group (p = 0.024). The wire type was not an independent risk factor for SI, as shown by univariate and logistic regression analyses. CONCLUSION: Titanium wires are a good alternative and have been proven to be safe and effective for sternal closure. The surgeon should be aware of the possibility of developing an allergic reaction to the wires, especially in patients with previous multiple allergic histories.

Quality of Life after Surgery for Stanford Type A Aortic Dissection: Influences of Different Operative Strategies.

BACKGROUND: Outcome of surgery for acute Stanford type A aortic dissection extends beyond mortality and morbidity. More than one operative strategy is available but little is known regarding their influence on quality of life. This study analyzes the influence of defensive and aggressive operative strategies on the patients' midterm quality of life (QoL). METHODS: From July 2007 to July 2010, 95 patients underwent surgery for acute Stanford type A aortic dissection in our institution. Patients who survived the procedure, gave consent to inclusion in the institution prospective registry, completed at least 2-years of follow-up protocol, and answered two quality of life questionnaires (SF-36 and WHO-QOL-BREF) were included in the study. Patients were divided into two groups according to operative strategy: defensive (DS) with replacement of the ascending aorta only, and aggressive (AS) with replacement of the ascending aorta, aortic arch with/out a frozen elephant trunk procedure. The preoperative, operative, postoperative and the midterm QoL were analyzed and compared. RESULTS: 39 patients were included in the study. The DS group had a shorter operative time (184 ± 54 versus 276 ± 110 minutes respectively, P = .001). The AS group had higher incidence of dialysis (31% versus 4% respectively, P = .038). The midterm QoL analysis showed a collective lower value than the normal population. In the SF-36, DS performed better in all categories but with no statistical significance. In the WHO-QOL-BREF, DS performed significantly better in the global life quality and psychological health categories (P = .038 and .049 respectively). CONCLUSION: In Stanford type A aortic dissection, adopting an aggressive surgical strategy does not improve the quality of life in midterm follow-up compared to a defensive strategy. Unless the clinical setting dictates an aggressive management strategy, a defensive strategy can be safely adopted.

Legitimacy of Entry-Oriented Strategy in DeBakey I Dissection in the Era of Endovascular Therapy.

BACKGROUND: Legitimacy of entry-oriented therapy for DeBakey I aortic dissection is of eminent importance in the era of emerging ascending aorta endovascular therapy. This study aims to evaluate early, midterm, and reintervention results of entry-oriented operative strategy compared to more aggressive strategies for treatment of DeBakey type I aortic dissection with an isolated intimal tear in the ascending aorta. METHODS: This study prospectively followed 98 consecutive patients who received an operation for DeBakey type I aortic dissection with the intimal tear in the ascending aorta between 2007 and 2013 for up to 6 years. Follow-up included survival, medical therapy, CT-imaging results, and reinterventions. Patients were grouped into entry-oriented (group I) receiving an isolated replacement of the ascending aorta and/or hemiarch (65 patients); and aggressive therapy (group II) receiving a replacement of the ascending aorta and complete aortic arch (33 patients). Results: The in-hospital mortality was 19% and 23% respectively. The 3-year survival was 52% and 47% respectively (P = .193). Group II showed no advantage regarding persistence or progression of the dissection, thrombosis of false lumen, increase in aortic diameter, peripheral organ malperfusion (as assessed by follow-up computed tomography imaging) or freedom from reintervention. Conclusion: In treating DeBakey I aortic dissection with an entry tear in the ascending aorta, it might be legitimate to adopt an entry-oriented operative strategy. Further research is also needed to clearly describe the indication of extending the operative strategy in such cases.

Anastomotic leak after surgical repair of type A aortic dissection - prevalence and consequences in midterm follow-up.

BACKGROUND: This study reports the mid-term prevalence and therapeutic consequences of anastomotic leaks after surgery for Stanford type A aortic dissections. PATIENTS AND METHODS: From July 2007 to July 2013, 93 patients survived surgery for acute type A dissections at our center and underwent a standardized follow-up. The pre-, peri-, and postoperative as well as the midterm results were collected prospectively. Follow-up computed tomography (CT) imaging was performed 7 days, 3, and 12 months after surgery, and yearly thereafter, to assess the presence or progression of anastomotic leaks at the aorto-prosthesis anastomotic sites. RESULTS: The mean follow-up was 4 years (1534 ± 724 days). Follow-up CT revealed anastomotic leaks in 4 patients (4.3 %). All leaks developed during midterm follow-up and half of them did not increase with time. Two patients required redo surgery for an increase in periaortic extravasation and compression of neighboring structures. Further analysis was not able to reveal independent risk factors for development or deterioration of leaks. CONCLUSIONS: Anastomotic leaks after surgery for Stanford Type A aortic dissection can develop in midterm follow-up, even after initially excellent results. Meticulous follow-up is mandatory to detect possible deterioration and a need for redo surgery.

Evaluation of the Value of Histological Examination for the Prediction of Genetic Thoracic Proximal Aortopathies.

Background: Heritable connective tissue disorders are often accompanied by an increased risk for thoracic aortic aneurysm and dissection (TAAD). Profound knowledge of the underlying pathology may have an impact on individual treatment, systematic follow-up, and early detection by the screening of offspring. The aim of this study, based in a single high-volume tertiary center, was an analysis of the diagnostic validity of histopathologic findings in patients with TAAD due to these findings' accuracy in diagnosing heritable connective tissue disorders. Methods: Therefore, genetic testing by next-generation sequencing (NGS) was performed to evaluate the correlations. In total, 65 patients with TAAD undergoing surgical treatment before the age of 60 years or with age up to 80 years if they had offspring at the time of the procedure were included in the analysis. Results: In our cohort, no certain correlation of histological findings to the results of genetic diagnostics in patients with clinically relevant aortic pathology could be shown. Patients with histopathologic findings for heritable connective tissue disorder and a positive gene variant were 11.6 years younger than patients without mutation and without histological evidence for connective tissue disorder. Conclusions: Genetic clarification is useful to define the specific genotype of the disease of the aortic wall in the case of non-specific histological characteristics.