Closed incision negative pressure therapy: international multidisciplinary consensus recommendations.

Surgical site occurrences (SSOs) affect up to or over 25% of patients undergoing operative procedures, with the subset of surgical site infections (SSIs) being the most common. Commercially available closed incision negative pressure therapy (ciNPT) may offer surgeons an additional option to manage clean, closed surgical incisions. We conducted an extensive literature search for studies describing ciNPT use and assembled a diverse panel of experts to create consensus recommendations for when using ciNPT may be appropriate. A literature search of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials using key words 'prevention', 'negative pressure wound therapy (NPWT)', 'active incisional management', 'incisional vacuum therapy', 'incisional NPWT', 'incisional wound VAC', 'closed incisional NPWT', 'wound infection', and 'SSIs' identified peer-reviewed studies published from 2000 to 2015. During a multidisciplinary consensus meeting, the 12 experts reviewed the literature, presented their own ciNPT experiences, identified risk factors for SSOs and developed comprehensive consensus recommendations. A total of 100 publications satisfied the search requirements for ciNPT use. A majority presented data supporting ciNPT use. Numerous publications reported SSI risk factors, with the most common including obesity (body mass index ≥30 kg/m2 ); diabetes mellitus; tobacco use; or prolonged surgical time. We recommend that the surgeon assess the individual patient's risk factors and surgical risks. Surgeons should consider using ciNPT for patients at high risk for developing SSOs or who are undergoing a high-risk procedure or a procedure that would have highly morbid consequences if an SSI occurred.

The impact of surgical site occurrences and the role of closed incision negative pressure therapy.

Surgical site occurrences are observed in up to 60% of inpatient surgical procedures in industrialised countries. The most relevant postoperative complication is surgical site infection (SSI) because of its impact on patient outcomes and enormous treatment costs. Literature reviews ('SSI', 'deep sternal wound infections' (DSWI), 'closed incision negative pressure wound therapy' (ciNPT) were performed by electronically searching MEDLINE (PubMed) and subsequently using a 'snowball' method of continued searches of the references in the identified publications. Search criteria included publications in all languages, various study types and publication in a peer-reviewed journal. The SSI literature search identified 1325, the DSWI search 590 and the ciNPT search 103 publications that fulfilled the search criteria. Patient-related SSI risk factors (diabetes mellitus, obesity, smoking, hypertension, female gender) and operation-related SSI risk factors (re-exploration, emergency operations, prolonged ventilation, prolonged operation duration) exist. We found that patient- and operation-related SSI risk factors were often different for each speciality and/or operative procedure. Based on the evidence, we found that high-risk incisions (sternotomy and incisions in extremities after high-energy open trauma) are principally recommended for ciNPT use. In 'lower'-risk incisions, the addition of patient-related or operation-related risk factors justifies the application of ciNPT.

Effect of surgical incision management on wound infections in a poststernotomy patient population.

Skin breakdown and infiltration of skin flora are key causative elements in poststernotomy wound infections. We hypothesised that surgical incision management (SIM) using negative pressure wound therapy over closed surgical incisions for 6-7 days would reduce wound infections in a comprehensive poststernotomy patient population. 'All comers' undergoing median sternotomy at our institution were analysed prospectively from 1 September to 15 October 2013 (study group, n = 237) and retrospectively from January 2008 to December 2009 (historical control group, n = 3508). The study group had SIM (Prevena™ Therapy) placed immediately after skin suturing and applied at -125 mmHg for 6-7 days, whereas control group received conventional sterile wound tape dressings. Primary endpoint was wound infection within 30 days. Study group had a significantly lower infection rate than control group: 1·3% (3 patients) versus 3·4% (119 patients), respectively (P < 0·05; odds ratio 2·74). In the study group, when the foam dressing was removed after 6-7 days, the incision was primarily closed in 234 of 237 patients (98·7%). SIM over clean, closed incisions for the first 6-7 postoperative days significantly reduced the incidence of wound infection after median sternotomy. Based on these data SIM may be cost-effective in patients undergoing cardiac surgery.

Coronary atherosclerosis of the donor heart--impact on early graft failure.

OBJECTIVE: Due to the shortage of donor hearts, the criteria for organ acceptability have been considerably extended and donor grafts with coronary atherosclerosis are among those offered. This study evaluated whether and to what degree pre-existing coronary atherosclerosis may be acceptable. METHODS: A total of 1253 consecutive HTx recipients were investigated retrospectively for donor-transmitted coronary atherosclerosis (DCAS). Donor-transmitted coronary atherosclerosis was defined as focal atherosclerosis with stenosis of at least 50%. Inclusion criteria were absence of pre-HTx angiogram but performance of angiogram or autopsy within 6 months after heart transplantation. Kaplan-Meier analysis and log-rank test were used. RESULTS: Eighty-five out of 1253 (6.8%) cases were excluded, since coronary evaluation was not performed within 6 months (n=45) or hearts had undergone pre-transplant angiography (n=40). In 1086 patients no donor-transmitted coronary atherosclerosis was found (NDCAS group) and in 82 patients (7%) donor-transmitted coronary atherosclerosis was diagnosed by angiography (n=49) or autopsy (n=33). Single-vessel donor-transmitted coronary atherosclerosis was found in 53/82 patients (DCAS1 group) and double- or triple-vessel donor-transmitted coronary atherosclerosis in 26/82 patients (DCAS2/3 group). Three of the 82 patients with donor-transmitted coronary atherosclerosis were excluded since the autopsy report was unclear regarding degree of atherosclerosis. Early after heart transplantation the 30-day mortality in the NDCAS and DCAS1 groups was 12.2% versus 13.2% whereas in the DCAS2/3 group it was 61.5%. Beyond the first year the annual decrease with and without donor-transmitted coronary atherosclerosis (single-vessel disease) is comparable. CONCLUSIONS: Donor screening without coronary angiogram overlooks significant atherosclerotic lesions in a considerable number of cases (7.0%). Therefore, angiographic donor screening should be performed. Donor grafts with single-vessel coronary atherosclerosis may be accepted as marginal hearts; however, in our opinion, revascularisation (CABG, PTCA) should be considered. Grafts with two- or even three-vessel coronary atherosclerosis seem to have a serious risk for early graft failure. Beyond the first year the outcome of healthy grafts and grafts with donor-transmitted coronary atherosclerosis seems to be comparable.

Surgical treatment of right-sided active infective endocarditis with or without involvement of the left heart: 20-year single center experience.

OBJECTIVE: The aim of this paper is to review the 20-year experience of surgical treatment of right-sided infective endocarditis at our institution, and in particular to compare the outcome of isolated right-sided endocarditis to right-sided endocarditis with involvement of the left heart. METHODS: Between April 1986 and April 2006, 84 operations had to be performed in 79 patients (49 men, median age 43.5 years). There were 72 (85.7%) cases of native and 12 (14.3%) of prosthetic valve endocarditis. In 57 (67.9%) cases, operation was for isolated right-sided endocarditis (RSE) and in 27 (32.1%) cases for combined right and left-sided endocarditis (RLSE). Follow-up was completed in all 91% of survivors. The median follow-up time at 448 patient years was 3.59 years (range 6 months-19.27 years). RESULTS: There was a highly significant difference between the survival rates of patients operated on due to RSE compared to RLSE: the 30-day, 1-, 5-, 10- and 20-year survival rate after RSE operation was 96.2%, 88.4%, 73.5%, 70.4% and 70.4%, respectively, compared to 72.0%, 67.8%, 50.8%, 35.6% and 35.6% after operation for RLSE (p=0.0093). Patients with RLSE more often underwent emergency operations (p<0.001), preoperatively were more often on high-dose catecholamines (p<0.006) and intraoperatively showed more abscess formation (p<0.001). Freedom from reoperation at 30 days, 1-, 5-, 10- and 20-year was 97.4%, 95.9%, 92.2%, 88.6% and 88.6%, respectively. Risk factors for early mortality were priority of surgery with an odds ratio (OR) of 5.13, age over 40 years (OR 1.04 and 3.24) and left heart involvement (or 2.54). CONCLUSIONS: Our surgical strategy for right-sided infective endocarditis is based on three principles: (1) debridement of the infected area or vegetectomy; (2) valve repair whenever possible, avoiding artificial material; (3) if valve replacement is unavoidable, use of a biological substitute without any artificial material that might become infected. Following these strategies surgery of right-sided infective endocarditis with or without left-side involvement can be performed with good early, mid-term and long-term results. Patients with involvement of the left side showed not only worse preoperative conditions but also a significantly poorer clinical outcome than those with isolated right-sided infective endocarditis.

Aortic root abscess and secondary infective mitral valve disease: results of surgical endocarditis treatment.

OBJECTIVE: Mortality in active infective endocarditis (AIE) is substantial and reinfection can strongly influence outcome. Assessment of factors influencing mortality is important. We studied 108 (33%) patients suffering from root abscess out of a total of 327 AIE patients admitted to the Deutsches Herzzentrum Berlin for surgical treatment between 1996 and 2003. Among them were 53 (25.5% of all patients) who were diagnosed as having secondary infective mitral valve disease (SMVD). Mean age was 53+/-14.2 years; there were 37 men and 16 women. METHODS: Risk factors were assessed on the basis of clinical, hemodynamic, echocardiographic and surgical information. Mean follow-up was 325+/-251 days with complete echocardiographic examination performed in patients with double valve surgery. The differences between groups were analyzed using Student's t-test. Multivariate analysis for the whole group suffering from abscess was performed to identify independent factors influencing mortality. RESULTS: In 19 (35.8%) patients suffering from SMVD mitral valve reconstruction was undertaken and mitral valve replacement was performed in 34 (64.2%) patients. There were 27 patients treated with a Shelhigh prosthesis: 18 with double valve replacement (both Shelhigh) and nine with an aortic Shelhigh prosthesis and concomitant mitral valve reconstruction. Homografts were used in 17 patients, with mitral reconstruction in 10 and a stented mitral prosthesis in seven. In nine cases two stented valve prostheses were used. The calculated mean Doppler gradient for homografts and Shelhigh in aortic position was 12 (+/-5.7) and 15 (+/-4.6), respectively (NS). The following predisposing factors for mortality were assessed: severe damage of aortic annulus (OR 4.65, CI 1.22-17.1, P=0.0159); septic shock (OR 3.44, CI 0.85-13.9, P=0.07) and poor ejection fraction (<40%), and dilated LV. CONCLUSIONS: Excessive mortality reaching 29% was noted in patients suffering from AIE with aortic ring abscess and SMVD requiring double valve surgery. Double valve surgery with semi-stented Dacron-free valve prostheses is associated with a low rate of reinfection and good function of the implants. The most potent independent risk factors for death were septic shock and severe aortic root destruction.

Impact of donor-transmitted coronary atherosclerosis.

Because of the shortage of donor hearts, the criteria of an acceptable organ have been extended considerably over the past few years. This has increased the probability of the transmission of atherosclerotic lesions by means of transplantation. This study evaluated the extent to which pre-existing coronary atherosclerosis boosts the cumulative injury caused by brain death, ischemia, and reperfusion, and thus additionally impairs the outcome of transplantation.

Donor-transmitted coronary atherosclerosis.

BACKGROUND: Autopsies show that coronary atherosclerosis is present frequently in the young and healthy. However, according to our former guideline, we performed pre-transplant evaluation without coronary angiogram in donors <60 years. The purpose of this study is to evaluate to what extent native coronary atherosclerosis is transmitted through heart transplantation. METHODS: Between April 1986 and December 2000, a total of 1253 patients underwent heart transplantation at our institution. If coronary evaluation with coronary angiogram or autopsy had been performed within 6 months after transplantation, we regarded focal and non-circumferential atherosclerosis with >or=50% stenosis in proximal segments of at least 1 coronary vessel of the donor heart as transmitted, native coronary atherosclerosis, rather than newly developed transplant vasculopathy. RESULTS: We excluded 85 of 1253 (6.8%) cases because coronary evaluation was not performed within 6 months (n = 45) or because hearts underwent angiography during pre-transplant evaluation (n = 40). Of these, 2 patients with significant coronary atherosclerosis underwent transplantation and concurrent coronary artery bypass grafting. The prevalence of significant (stenosis >or=50%) and inadvertently transmitted coronary atherosclerosis was 7.0% (82/1168). CONCLUSION: The prevalence of coronary atherosclerosis in patients who underwent angiography within 6 months after transplantation was 5.2% (49/950). Among subjects who had autopsies within the first 6 months after heart transplantation, we found significant coronary atherosclerosis (stenosis >or=50%) 15.1% (33/218), and among those with early graft failure (<10 days after transplantation), the prevalence was 22.8% (26/114). The prevalence of coronary atherosclerosis in the donor pool is high, and donor screening without coronary angiogram overlooks significant coronary atherosclerotic lesions (stenosis >or=50%) in a considerable number of cases (7.0%). Because donor-transmitted coronary atherosclerosis is a risk factor in short-term (early graft failure) survival after heart transplantation, we have now changed our policy to include coronary angiography as a standard in screening donors >or=40 years. However, to what extent donor coronary atherosclerosis is accepted undoubtedly must be made arbitrarily until an evidence-based algorithm becomes available.

Dislocated wrap after previous reduction aortoplasty causes erosion of the ascending aorta.

We report a patient with bicuspid aortic valve and dilatation of the ascending aorta who had previous aortic valve replacement and reduction aortoplasty with wrapping. After 4 years, reoperation because of coronary artery disease and paravalvular leakage revealed an erosion of the aortic wall due to dislocation of the wrap. This complication confirms the need for secure anchoring and good fitting of the Dacron wrap to avoid alterations of the underlying aortic wall.

Factors influencing the results of double-valve surgery in patients with fulminant endocarditis: the importance of valve selection.

BACKGROUND: Extension of infection below the aortic valve is a serious complication, especially with mitral valve involvement. Mortality is substantial and reinfection can strongly influence outcome. PATIENTS: Of 327 surgical patients with active infective aortic valve endocarditis admitted to the Deutsches Herzzentrum Berlin for surgical treatment between December 1996 and December 2003, 108 had root abscess, and 53 (25.5%) had diagnoses of secondary infective mitral valve disease (SMVD). The mean age (+/-SD) was 53 +/- 14.2 years; there were 37 men and 16 women. METHODS: The secondary lesion on the mitral valve was classified as SMVD requiring double-valve surgery (DVS). This prospective clinical and echocardiographic study revealed 2 paths of infection extension into the mitral valve. In the DVS group, 38 patients (71.7%) had tissue metastatic lesions, and 15 patients (28.3%) had a jet lesion on the mitral valve. Most patients (42) with SMVD had an aortic ring abscess as the primary lesion. RESULTS: All patients with destructive endocarditic doublevalve disease received aortic and mitral valve surgery. In 19 cases (35.8%), mitral valve reconstruction was undertaken; in 4 cases, mitral valve replacement had to be carried out after attempted mitral valve reconstruction. Concomitant mitral valve replacement because of severe damage to the valvular and subvalvular apparatus was performed in 30 patients (56.6%). Other types of surgery performed in 11 cases (20.8%) were 8 closures of a septic ventricular septal defect and 3 closures of a fistula to the right ventricle or right atrium. Twenty-seven patients were treated with a Shelhigh prosthesis, 18 were treated with double-valve replacement (both Shelhigh), and 9 were treated with an aortic Shelhigh prosthesis and concomitant mitral valve reconstruction. Homografts were used in 17 patients, with mitral valve reconstruction carried out in 10 patients and a stented mitral prosthesis in 7. In 9 cases, 2 stented valve prostheses were used. There were 14 early (60 days) deaths (26.4%). Septic shock, severe annular and subannular destruction, and poor left ventricular function (end-diastolic dimension >65 mm, ejection fraction <40%) were the significant risk factors determined in the multivariate analysis. Function of Implants: Continuous and Color Doppler Investigation: Comparative studies of 2 different implants in the aortic position were performed late postoperatively (325 +/- 251 days) for homografts and the Shelhigh stentless prosthesis. The calculated instantaneous (maximal Doppler) gradient and the mean pressure gradient through the aortic implants were 19 +/- 10.4 mm Hg and 12 +/- 5.7 mm Hg, respectively, for the homografts and 24 +/- 8.4 mm Hg and 15 +/- 4.6 mm Hg, respectively, for the Shelhigh stentless prosthesis (not significantly different for the 2 groups). There was no mitral or aortic valve dysfunction. A trivial paravalvular leakage in the mitral position in 1 patient and a pseudoaneurysm of the left ventricular out- flow tract without leakage or valvular dysfunction in another were diagnosed by postoperative Doppler investigation. CONCLUSIONS: The mortality in patients with destructive endocarditis requiring DVS depends mostly on the patients' preoperative hemodynamic situation. The risk of reinfection can be minimized if valve substitutes are properly selected (homografts, Shelhigh No-React SuperStentless and No-React BioConduit in the aortic position, or Shelhigh BioMitral in the mitral position). Concomitant mitral valve reconstruction procedures do not increase the risk of mitral reinfection.

Prevention of poststernotomy wound infections in obese patients by negative pressure wound therapy.

OBJECTIVE: The majority of wound infections after median sternotomy in obese patients are triggered by the breakdown of skin sutures and subsequent seepage of skin flora. The purpose of this study was to evaluate negative pressure wound dressing treatment for the prevention of infection. We hypothesized that negative pressure wound dressing treatment for 6 to 7 days applied immediately after skin closure reduces the numbers of wound infections. METHODS: In a prospective study, 150 consecutive obese patients (body mass index ≥ 30) with cardiac surgery performed via median sternotomy were analyzed. In the negative pressure wound dressing treatment group (n = 75), a foam dressing (Prevena, KCI, Wiesbaden, Germany) was placed immediately after skin suturing, and negative pressure of -125 mm Hg was applied for 6 to 7 days. In the control group (n = 75), conventional wound dressings were used. The primary end point was wound infection within 90 days. Mann-Whitney U test and Fisher exact test were used. Freedom from infection was estimated by Kaplan-Meier analysis. RESULTS: Three of 75 patients (4%) with continuous negative pressure wound dressing treatment had wound infections compared with 12 of 75 patients (16%) with conventional sterile wound dressing (P = .0266; odds ratio, 4.57; 95% confidence interval, 1.23-16.94). Wound infections with Gram-positive skin flora were found in only 1 patient in the negative pressure wound dressing treatment group compared with 10 patients in the control group (P = .0090; odds ratio, 11.39; 95% confidence interval, 1.42-91.36). CONCLUSIONS: Negative pressure wound dressing treatment over clean, closed incisions for the first 6 to 7 postoperative days significantly reduces the incidence of wound infection after median sternotomy in a high-risk group of obese patients.

Simultaneous aortic valve replacement in left ventricular assist device recipients: single-center experience.

INTRODUCTION: Aortic valve regurgitation or the presence of a mechanical aortic valve prosthesis is a relative contraindication for implantation of left ventricular assist devices (LVAD). However, concomitant aortic valve replacement by a biological prosthesis is one of the options in this situation. We analyzed our recent experience with left ventricular assist device implantation and concomitant aortic valve replacement. METHODS: Between January 1, 2008 and January 15, 2012, 318 adult patients (>18 years old) were supported with a long-term implantable LVAD in our institution. In 19, simultaneous aortic valve replacement (6 redo and 13 primary procedures) was performed. Patients were divided into 2 groups according to INTERMACS (IM) level: Group 1 (n = 7) consisted of patients with IM level 1-2 and Group 2 (n = 12) of IM level 3-4 patients. As a control cohort we analyzed all LVAD recipients during the study period (n = 299, study group excluded). The control cohort was similarly divided into two groups according to the IM level: Group 3 (n = 162) consisted of patients with IM level 1-2 and Group 4 (n = 137) of those with IM level 3-5. Perioperative data and outcomes in all groups were retrospectively analyzed and compared (Group 1 compared to Group 3; and Group 2 to Group 4). RESULTS: In study Groups 1 and 2 all patients were male; in Groups 3 and 4, 80% and 88% respectively were male. Median age distribution in Groups was 55, 61, 54, and 57 years respectively. Patients from Group 2 were significantly older than those from Group 4 (p = 0.039). Body mass index was significantly lower in Group 1 than in Group 3 (p = 0.033). Cardio-pulmonary bypass time was significantly longer in Groups 1 and 2 compared with Groups 3 and 4 respectively (p=0.001). Patients from Group 1 had a trend more often to develop right ventricular failure requiring a right ventricular assist device (RVAD) than those in Group 3 (p = 0.09). Intensive care unit stay duration of mechanical ventilation and in-hospital mortality in Group 1 were significantly higher than in Group 3 (p = 0.025, p = 0.005, p = 0.038). Patients from Group 2 had similar outcomes compared to those from Group 4. CONCLUSIONS: In stable patients, simultaneous aortic valve replacement and LVAD implantation are not associated with an impaired outcome. In patients with cardiogenic shock an additional aortic valve replacement may impair outcome; therefore alternative techniques should be considered.

Infectious erosion of aorta ascendens during vacuum-assisted therapy of mediastinitis.

Sternal wound infection is a potentially life-threatening complication after cardiac surgery. With the vacuum-assisted closure (VAC) system a relatively new treatment option is available, with encouraging results and few complications. However, fatal right ventricular rupture for mechanical reasons has been reported. We report the case of a 34-year-old patient with life-threatening bleeding due to infectious erosion of the aorta ascendens during VAC therapy of mediastinitis after cardiac surgery. To the best of our knowledge, this is the first reported case of infectious erosion (i.e. not VAC-related) of cardiovascular structures during running vacuum-assisted therapy.

Cyanoacrylate-sealed Donati suture for wound closure after cardiac surgery in obese patients.

The majority of wound infections after median sternotomy in obese patients are triggered by the breakdown of skin suture and subsequent seepage of skin flora into the deeper tissue layers. In a prospective study, 90 patients (body mass index ≥30) who had cardiac surgery via median sternotomy were enrolled. In 45 patients, skin closure was performed according to the Donati technique (vertical interrupted mattress suture) and sealed with octylcyanoacrylate (group A). In 45 patients, intracutaneous running technique without sealed was performed (group B). The endpoint was wound infection within 90 days. Degree of obesity and other risk factors for wound infection were equally distributed between groups A and B (all P>0.05). In group A only two superficial infections occurred, whereas in group B there were nine wound infections including two deep infections (P=0.026). In 10 of 11 infections (both groups) coagulase-negative staphylococci were isolated. In eight of 11 wound infections the caudal third of the incision was affected. Intertrigo in inframammary skin folds was found in 20.0% (18/90) of all patients but in 63.6% (seven of 11) of cases with infection. We conclude, that cyanoacrylate-sealed Donati suture is superior to intracutaneous suture technique since it offers tension-resistant closure with immediate microbial barrier properties.

Survival of patients with idiopathic pulmonary arterial hypertension after listing for transplantation: impact of iloprost and bosentan treatment.

BACKGROUND: Survival after idiopathic pulmonary arterial hypertension (IPAH) diagnosis is often shorter than the waiting time for grafts. Iloprost and bosentan improve outcome in advanced IPAH (New York Heart Association Functional Class III), but there is controversy about the limits of their efficacy in end-stage (Class IV) IPAH. METHODS: We investigated the impact of iloprost (prostacyclin analog) and bosentan (endothelin-receptor antagonist) therapy on the outcome of patients with IPAH after listing for transplantation (Tx) to answer the following questions: (1) How efficient is this treatment in reducing mortality on waiting lists? (2) Is Tx still most promising for survival once recurrent right heart failure emerges, or can this treatment improve survival to an extent that exceeds post-Tx survival? We assessed the outcome of our IPAH patients listed for Tx between September 1996 and September 2005 in relation to kind and duration of medical treatment. RESULTS: Among 59 listed patients, 24 (40.7%) died before Tx, after 2.9 months (median). With iloprost and/or bosentan treatment the mortality on Tx lists was 33.3%, whereas with calcium-channel blockers it reached 64.3% (p < 0.05). Patients with iloprost and/or bosentan therapy showed similar survival, regardless of whether they responded to vasodilator testing. Survival after listing was better for patients who were transplanted than for those who received iloprost and/or bosentan but not Tx (p = 0.017). Iloprost and bosentan treatment allowed the withdrawal of 3 patients from Tx lists. CONCLUSIONS: Iloprost and bosentan allowed the effective bridge-to-transplant treatment in IPAH. However, with this treatment the mortality rate on Tx lists remained high and survival benefit was lower than from transplantation.

Orthotopic heart transplantation in patients with Marfan syndrome.

BACKGROUND: Due to the risk of vascular complications, the indication for heart transplantation (HTx) in patients with Marfan syndrome and end-stage heart disease remains controversial. We analyzed the results of such patients who underwent HTx at our institution. METHODS: Ten patients with Marfan syndrome (median age 36, range 19 to 56 years) underwent HTx between March 1986 and December 2005. The primary vascular manifestation of Marfan syndrome was type-A aortic dissection in three patients and ascending aortic aneurysm in seven patients. All patients had undergone cardiovascular operations prior to transplantation. All had refractory heart failure (New York Heart Association class IV) before transplantation. Three patients underwent transplantation after ventricular assist device (VAD) support (left VAD, n = 2; biventricular assist device, n = 1). RESULTS: There were no perioperative deaths. Two patients died of causes unrelated to Marfan disease (pneumonia on day 27, n = 1; stroke on day 102, n = 1). One patient died due to type-B dissection 3.8 years posttransplantation and one due to rupture of an aortic arch aneurysm after 12.1 years. Two patients underwent thoracoabdominal aortic replacement for chronic dissection 14 and 20 months posttransplantation, respectively. Kaplan-Meier survival rate was 80% at 1 year and 64% at 10 years. The Kaplan-Meier freedom from reoperation was 100% at 1 year and 62.5% at 10 years. CONCLUSIONS: Heart transplantation in patients with Marfan syndrome results in good long-term survival, similar to that of patients without Marfan syndrome. Close follow-up and timely operation of aortic pathologies is mandatory. Reluctance to place these patients on a heart transplant waiting list appears not to be justified.

Observational study with everolimus (Certican) in combination with low-dose cyclosporine in de novo heart transplant recipients.

BACKGROUND/METHODS: This observational study reports on immunosuppression with cyclosporine (CsA) in 38 de novo heart transplant recipients receiving everolimus compared with 14 patients receiving mycophenolate mofetil (MMF). RESULTS: Mean (+/- SD) everolimus C0 blood levels remained stable within 5 to 7 ng/ml. Mean CsA C0 blood levels were reduced by 47%, from 240 +/- 57 ng/ml at 2 weeks post-transplant to 128 +/- 38 ng/ml at Month 6 and by 58% to 101 +/- 26 ng/ml at Month 12 in the everolimus group, compared to 18% from 246 +/- 54 ng/ml at 2 weeks post-transplant to 201 +/- 48 ng/ml at Month 6 and by 35% to 160 +/- 41 ng/ml in MMF patients. Efficacy was high with a rejection rate of 23.6% (everolimus) vs 28.5% (MMF) by Month 12. Mean pre-transplant serum creatinine levels of 1.67 +/- 0.59 mg/dl decreased to 1.53 +/- 0.57 mg/dl under everolimus and increased from 1.22 +/- 0.36 to 1.99 +/- 0.75 mg/dl in the MMF group by Month 12 post-transplant. However, calculated GFR declined in both groups by Month 12 (everolimus: from 71 +/- 29 to 57 +/- 27 ml/min/1.73 m2; MMF: from 73 +/- 22 to 44 +/- 24 ml/min/1.73 m2), with stabilization after 3 to 6 months in everolimus-treated patients and after 6 to 9 months in MMF-treated patients. CONCLUSIONS: Everolimus allows marked reduction of CsA exposure without significant loss of efficacy and also provides early protection of renal function.

Prevalence of graft vessel disease after paediatric heart transplantation: a single centre study of 54 patients.

The study tested the prevalence of graft vessel disease (GVD) in 54 paediatric heart transplant (HTx) patients (32 male, age 0-17 years) who underwent coronary angiographic investigations (N=117). These were evaluated according to the Stanford classification and additional criteria (peripheral obliterations, diameter fluctuations, pathologic tapering) were applied for risk assessment (no GVD/minimal lesions, GVD without Stanford lesions, accelerated GVD). In H&E stainings from right ventricular endomyocardial biopsies (EMB=169) diagnosis of acute cellular rejection (ACR, ISHLT) and microvasculopathy were performed. Mild rejection was found in 43% (N=44) and severe rejection in 7% (N=7) of EMB early (1st year) and mild rejection in 31% (N=32) and severe in 8% (N=9) late (>3 years) after HTx. Microvasculopathy was present in 22% of EMB. Risk assessment of coronary angiographies showed no GVD/minimal disease in 25% (N=29), GVD without Stanford lesions in 12% (N=14) and different grades of accelerated GVD in 74% (N=74) of studies. All patients dying due to cardiac related causes of death (N=6, 3-12 years after HTx) had evidence of GVD. The data show GVD to be an important cause of late cardiac related deaths in this population.

An assessment of different filter systems for extracorporeal elimination of bivalirudin: an in vitro study.

IMPLICATIONS: Bivalirudin is a new, direct thrombin inhibitor. We investigated the extracorporeal elimination rate of different hemofilters and one plasmapheresis filter for bivalirudin. Our data show that bivalirudin can be effectively eliminated via hemofiltration and plasmapheresis, although there were significant differences in the elimination rates among the filter systems investigated.