Negative Pressure Wound Therapy Becomes the Treatment of Choice of Deep Sternal Wound Infection.

BACKGROUND: Sternal wound infection, especially deep sternal wound infection, is a serious complication after open heart surgery. It leads to a marked increase in hospital stay, financial expenses, and mortality. Treatment is primarily surgical and may be divided into conventional treatment methods and negative pressure wound therapy. MATERIALS AND METHODS: Between 2010 and 2021, 77 patients presenting back after cardiac surgery with deep sternal wound infection were treated surgically. Conventional treatment methods were utilized in 45 patients and included wound revision with primary closure, continuous wound irrigation, and open treatment with secondary closure. Negative-pressure wound therapy (NPWT) was applied in 32 patients. The two treatment arms were compared by two primary outcomes - rate of recurrent infection and hospital mortality. Predictors of mortality and infectious recurrence were identified using multivariate logistic regression. RESULTS: Recurrent infection occurred in 18.2% of cases and mortality was 13% in the whole group. NPWT was more successful in preventing recurrent infection OR: 5.4 (95% CI: 1.1-27.5; P = 0.044) than conventional treatment and more than moderate left ventricular systolic dysfunction (EF<40%) predisposed to infectious recurrence - OR: 4.7 (95% CI: 1.05-22.1; P = 0.049). Recurrent infection itself was the strongest predictor of mortality in the multivariate model OR: 0.14 (95% CI: 0.03 - 0.58; P = 0.007). CONCLUSION: NPWT as an initial method of wound preconditioning followed by definitive wound closure effectively reduces the rate of infectious recurrence and patient mortality. It may become the modality of first choice when dealing with complicated incisional infections following heart surgery.

Direct Cannulation of Ascending Aorta versus Standard Femoral Artery Cannulation in Acute Aortic Dissection Type A.

BACKGROUND: During surgery for ascending aortic dissection, the dissected ascending aorta itself has traditionally been rejected as a cannulation option. The purpose of this study is to prove that direct cannulation of the ascending aorta in patients operated for acute aortic dissection type A (AADA) is at least as effective and safe as classic femoral cannulation. METHODS AND RESULTS: Between September 2008 and January 2015, we operated on 117 patients with AADA through median sternotomy. Cannulation was accomplished in 32 cases (27%) through the femoral artery (group A), and in 85 patients (73%) through the dissected ascending aorta (group B). Moderate hypothermic circulatory arrest with bilateral antegrade cerebral perfusion was used in 108 patients (92%). The mean time of circulatory arrest was 17 minutes (range: 9-52 minutes). The 30-day mortality rate was 22% (7 patients) in group A, and 18% (15 patients) in group B (P = not significant). Temporary neurologic dysfunction (TND) including postoperative confusion, delirium, or agitation occurred in four patients (13%) in group A, and four patients (5%) in group B (P = not significant). The incidence of permanent neurologic dysfunction (stroke) was 9% (3 patients) in group A and 3% (3 patients) in group B. CONCLUSIONS: The direct cannulation of the ascending aorta is a safe alternative for patients with AADA, offering the opportunity for antegrade cerebral perfusion. It is easy to perform, reliable, and associated with acceptable early results.

Can Open Distal Repair Be Safely Used in All Patients with Type A Acute Aortic Dissection?

PURPOSE: The distal suture line during aortic dissection repair can be performed by a closed technique or by an open technique. This study presents a retrospective comparison of both methods regarding their postoperative outcomes. PATIENTS AND METHODS: 120 patients who underwent surgery for acute aortic dissection type A were divided into two groups. In group A (n = 81), open distal anastomosis was performed under hypothermic circulatory arrest and selective cerebral perfusion. In group B (n = 39), distal anastomosis was performed with the aorta cross-clamped under mildly hypothermic cardiopulmonary bypass. Primary outcomes were operative mortality, neurologic morbidity, and long-term survival. RESULTS: Hospital mortality (17.3% for the open group vs. 12.8% for the closed group, p = 0.53), permanent neurologic dysfunction (8.7% vs. 8.3%, p = 1.0), and temporary neurologic dysfunction (31.9% vs. 22.2%, p = 0.298) were not significantly different between groups. No significant difference in actuarial 5- and 10-year survival was observed (88% vs. 86% and 53 vs. 73%, respectively, p = 0.396). After propensity-score adjustment, the technique of distal aortic repair was not found to be a predictor of the primary outcomes. CONCLUSION: We conclude that the open repair can be used in most if not all cases of surgical repair of type A acute aortic dissection.

Cold modified Del Nido cardioplegia in adults undergoing elective cardiac coronary surgery.

INTRODUCTION: The cardioplegic solution of Kirklin (Kn) is frequently used in adult cardiosurgical patients. It requires reinfusion at short intervals, which causes further difficulty during surgery and the quality of myocardial protection is often called into question.

Overestimation of aortic valve replacement risk by EuroSCORE: implications for percutaneous valve replacement.

AIMS: The EuroSCORE has been proposed to identify patients at high risk for surgical aortic valve replacement (AVR) and estimate for them the risk-benefit of percutaneous valve replacement. The aim of our study was to investigate the validity of this proposal. METHODS AND RESULTS: From 1994 to March 2006, 1545 consecutive patients with aortic stenosis underwent isolated surgical AVR at the Department of Cardiac Surgery of Heidelberg. Both additive and logistic EuroSCOREs were calculated for each patient and summed for expected 30-day mortality. Expected and observed mortalities were compared, particularly with respect to 'high-risk' status and era of operation. Overall, 30-day mortality was low (34/1545, 2.2%) and substantially overestimated by both additive (6.1%) and logistic (9.3%) EuroSCOREs. Although both EuroSCOREs stratified patients monotonically with respect to mortality risk, high-risk patients had a 3.6% mortality (29/833), whereas additive and logistic EuroSCOREs predicted 8.3 and 14.8%. Indeed, none of the 71 patients with a EuroSCORE of 11-20 (extremely high risk) died. The more recent the era of operation, the more pronounced was the discrepancy between expected and observed mortalities. CONCLUSION: Although the EuroSCORE still successfully stratifies patients undergoing surgical AVR relative to 30-day mortality, it has become increasingly uncalibrated with absolute risk, resulting in overestimation of 30-day mortality. Inaccurately predicted mortality, especially in 'high-risk' patients, renders it unsuitable for assessing risk reduction of percutaneous valve replacement.

Endovascular iliac vein recanalization for permanent pacemaker implantation in a patient who has long-term haemodialysis: a case report.

BACKGROUND: In chronic haemodialysis patients central veins occlusion occur very often. In such patients, permanent pacemaker placement implantation can be challenging and alternative approaches should be used. CASE SUMMARY: This is a case of 66-year-old male patient with complete atrioventricular block after a mitral valve (MV) surgery for endocarditis. The patient has a permanent surgically inserted haemodialysis catheter in right heart atrium after several unsuccessful attempts of endovascular recanalization of superior vena cava. A lead was implanted in the right ventricle after successful endovascular revascularization of the right iliac vein. The pacemaker was placed in a pouch on the right lower abdominal wall. DISCUSSION: To our knowledge, this is the first reported case where a permanent single-chamber pacemaker was implanted through the right iliac vein after successful endovascular recanalization in chronic haemodialysis patient post-MV replacement.

Therapy with L-thyroxine and Omnadren after Cardiac Surgery. A Case Report.

BACKGROUND: Cardiopulmonary bypass in cardiac surgery produces systemic inflammatory response and catabolic state. Severe stress frequently causes abnormalities in thyroid hormones in the absence of primary thyroid disease, defined as sick euthyroid syndrome (SES). MATERIALS AND METHODS: Supplementation therapy with thyroid and anabolic hormones in combination with an adequate nutritional support has been used to improve outcome in critically ill patient after cardiac surgery. RESULTS: Administration of thyroid and anabolic hormones significantly improved patient's condition. CONCLUSIONS: Supplementation therapy with thyroid and anabolic hormones in combination with an adequate nutritional support could be used to improve hemodynamics, achieve transition to anabolic metabolism and enhance recovery, which could eventually help for a reduction in post-operative morbidity and mortality.

Papillary fibroelastoma of the heart.

BACKGROUND: Fibroelastoma is a rare cardiac tumor that was originally described typically from autopsy findings. Thanks to improved imaging modalities, such tumors are today relatively easy to detect and therefore are actively searched for in patients with unclear embolic events. We present the cases of 2 patients recently treated in our clinic and review the recent literature pertaining to fibroelastomas. METHODS AND RESULTS: An electronic PubMed search revealed 186 cases reported between 1994 and 2003. Ninety-seven percent of the reported fibroelastomas were diagnosed in living patients in their fourth and fifth decades of life. The majority (86%) were symptomatic, with stroke, transient ischemic attack, myocardial infarction, and angina pectoris being the most commonly described. Echocardiography was the typical diagnosis modality. Surgical resection was completed in 95% of the cases. CONCLUSIONS: Although cardiac papillary fibroelastomas are rare and benign tumors, they cannot be considered as harmless endothelial lesions, because related embolic events are frequent and primarily involve adults in their active period of life. Echocardiography must therefore consider fibroelastoma in the differential diagnosis of every unclear systemic embolic event, especially because surgical resection can be considered as curative.