Incidence and predictors of sternal surgical wound infection in cardiac surgery: A prospective study.

Sternal surgical wound infection (SSWI) in cardiac surgery is associated with increased morbidity. We investigated the incidence of SSWI, the main germs implicated and predictors of SSWI. Prospective study including patients undergoing full median sternotomy between January 2017 and December 2019. Patients were followed-up for 3 months after hospital discharge. All sternal wound infections up to 90 days after discharge were considered SSWI. 1004 patients were included. During follow-up, 68 (6.8%) patients presented SSWI. Patients with SSWI had a higher incidence of postoperative renal failure (29.4% vs 17.1%, P = .007), a higher incidence of early postoperative reoperation for non-infectious causes (42.6% vs 9.1%, P < .001), longer ICU stay (3 [2-9] days vs 2 [2-4] days, P = .006), and longer hospital stay (24.5 [14.8-38.3] days vs 10 [7-18] days, P < .001). Gram-positive germs were presented in 49% of the cultures, and gram-negative bacteria in 35%. Early reoperation for non-infectious causes (OR 4.90, 95% CI 1.03-23.7), and a longer ICU stay (OR 1.37 95% CI 1.10-1.72) were independent predictors of SSWI. SSWI is rare but leads to more postoperative complications. The need for early reoperation because of non-infectious cause and a longer ICU stay were independently associated with SSWI.

Randomized controlled trial between conventional versus sutureless bioprostheses for aortic valve replacement: Impact of mini and full sternotomy access at 1-year follow-up.

BACKGROUND: The present study is a sub-analysis of the multicenter, randomized PERSIST-AVR trial (PERceval Sutureless Implant versus Standard Aortic Valve Replacement) comparing the in-hospital and 1-year results of sutureless versus conventional stented bioprostheses in isolated surgical aortic valve replacement (SAVR) within two different surgical approaches: mini-sternotomy (MS) and full-sternotomy (FS). METHODS: A total of 819 patients (per-protocol population) underwent preoperative randomization to sutureless or stented biological valve at 47 centers worldwide. Sub-analysis on isolated SAVR was performed. Results were compared between sutureless and stented within the two different surgical approaches. RESULTS: 285 patients were implanted with Perceval (67% in MS) and 293 with stented valves (65% in MS). Sutureless group showed significantly reduced surgical times both in FS and MS. In-hospital results show no differences between Perceval and stented valves in FS, while a lower incidence of new-onset of atrial fibrillation (3.7% vs 10.8%) with Perceval in MS. After 1-year, use of sutureless valve showed a significant reduction of MACCE (5.2% vs 10.8%), stroke rate (1.0% vs 5.4%), new-onset of atrial fibrillation (4.2% vs 11.4%) and re-hospitalizations (21.8 days vs 47.6 days), compared to stented valves but presented higher rate of pacemaker implantation (11% vs 1.6%). CONCLUSIONS: Sutureless bioprosthesis showed significantly reduced procedural times during isolated SAVR in both surgical approaches. Patients with sutureless valves and MS access showed also better 1-year outcome regarding MACCEs, stroke, re-hospitalization and new-onset atrial fibrillation, but presented a higher rate of permanent pacemaker implantation compared to patients with stented bioprosthesis.

Hemodynamic Performance of Sutureless vs. Conventional Bioprostheses for Aortic Valve Replacement: The 1-Year Core-Lab Results of the Randomized PERSIST-AVR Trial.

OBJECTIVE: Sutureless aortic valves are an effective option for aortic valve replacement (AVR) showing non-inferiority to standard stented aortic valves for major cardiovascular and cerebral events at 1-year. We report the 1-year hemodynamic performance of the sutureless prostheses compared with standard aortic valves, assessed by a dedicated echocardiographic core lab. METHODS: Perceval Sutureless Implant vs. Standard Aortic Valve Replacement (PERSIST-AVR) is a prospective, randomized, adaptive, open-label trial. Patients undergoing AVR, as an isolated or combined procedure, were randomized to receive a sutureless [sutureless aortic valve replacement (Su-AVR)] (n = 407) or a stented sutured [surgical AVR (SAVR)] (n = 412) bioprostheses. Site-reported echocardiographic examinations were collected at 1 year. In addition, a subgroup of the trial population (Su-AVR n = 71, SAVR = 82) had a complete echocardiographic examination independently assessed by a Core Lab (MedStar Health Research Institute, Washington D.C., USA) for the evaluation of the hemodynamic performance. RESULTS: The site-reported hemodynamic data of stented valves and sutureless valves are stable and comparable during follow-up, showing stable reduction of mean and peak pressure gradients through one-year follow-up (mean: 12.1 ± 6.2 vs. 11.5 ± 4.6 mmHg; peak: 21.3 ± 11.4 vs. 22.0 ± 8.9 mmHg). These results at 1-year are confirmed in the subgroup by the core-lab assessed echocardiogram with an average mean and peak gradient of 12.8 ± 5.7 and 21.5 ± 9.1 mmHg for Su-AVR, and 13.4 ± 7.7 and 23.0 ± 13.0 mmHg for SAVR. The valve effective orifice area was 1.3 ± 0.4 and 1.4 ± 0.4 cm2 at 1-year for Su-AVR and SAVR. These improvements are observed across all valve sizes. At 1-year evaluation, 91.3% (n = 42) of patients in Su-AVR and 82.3% in SAVR (n = 51) groups were free from paravalvular leak (PVL). The rate of mild PVL was 4.3% (n = 2) in Su-AVR and 12.9% (n = 8) in the SAVR group. A similar trend is observed for central leak occurrence in both core-lab assessed echo groups. CONCLUSION: At 1-year of follow-up of a PERSIST-AVR patient sub-group, the study showed comparable hemodynamic performance in the sutureless and the stented-valve groups, confirmed by independent echo core lab. Perceval sutureless prosthesis provides optimal sealing at the annulus with equivalent PVL and central regurgitation extent rates compared to sutured valves. Sutureless valves are therefore a reliable and essential technology within the modern therapeutic possibilities to treat aortic valve disease.

Pacemaker implantation after sutureless or stented valve: results from a controlled randomized trial.

OBJECTIVES: Sutureless aortic valves demonstrated non-inferiority to standard stented valves for major cardiovascular and cerebral events at 1 year after aortic valve replacement. We aim to assess the factors correlating with permanent pacemaker implantation (PPI) in both cohorts. METHODS: PERSIST-AVR is a prospective, randomized, open-label trial. Patients undergoing aortic valve replacement were randomized to receive a sutureless aortic valve replacement (Su-AVR) or stented sutured bioprosthesis (SAVR). Multivariable analysis was performed to identify possible independent risk factors associated with PPI. A logistic regression analysis was performed to estimate the risk of PPI associated to different valve size. RESULTS: The 2 groups (Su-AVR; n = 450, SAVR n = 446) were well balanced in terms of preoperative risk factors. Early PPI rates were 10.4% in the Su-AVR group and 3.1% in the SAVR. PPI prevalence correlated with valve size XL (P = 0.0119) and preoperative conduction disturbances (P = 0.0079) in the Su-AVR group. No predictors were found in the SAVR cohort. Logistic regression analysis showed a significantly higher risk for PPI with size XL compared to each individual sutureless valve sizes [odds ratio (OR) 0.272 vs size S (95%confidence interval 0.07-0.95), 0.334 vs size M (95% CI 0,16-0; 68), 0.408 vs size L (95% CI 0,21-0.81)] but equivalent risk of PPI rates for all other combination of valve sizes. CONCLUSIONS: Su-AVR is associated with higher PPI rate as compared to SAVR. However, the increased PPI rate appears to be size-dependent with significant higher rate only for size XL. The combination of preoperative conduction disorder and a size XL can lead to a higher probability of early PPI in Su-AVR. CLINICAL TRIAL REGISTRATION NUMBER: NCT02673697.

Incidence and causes of pacemaker implantation during postoperative period of aortic valve replacement with rapid deployment prosthesis.

BACKGROUND: Aortic stenosis is currently the most frequently occurring valve pathology. Developments, such as transcatheter prostheses and rapid deployment prostheses, allow for the offer of a valve replacement to higher risk patients, but these techniques are linked with a higher need for a permanent pacemaker during the immediate postoperative period. METHODS: We studied the incidence and the factors associated with permanent pacemaker implantation after aortic valve replacement with Edwards Intuity rapid deployment prosthesis. RESULTS: Between October 2012 and December 2016, the Edwards Intuity prosthesis was implanted in 71 patients (68% male, 75.3 ± 5 years old). Six patients (8%) required a permanent pacemaker during immediate postoperative period. Univariate analysis showed that a history of acute myocardial infarction (AMI) (P = .046, B = 7.5, 95% CI [1.039-54.1]) and preoperative amiodarone (P = .009, B = 31.5; 95% CI [2.32-426]) were associated with a higher need for a pacemaker during the postoperative period. CONCLUSIONS: The incidence of permanent pacemaker implantation during the immediate postoperative period of aortic valve replacement with Edwards Intuity prosthesis was 8%, a value which is within the limits reported for conventional aortic prostheses. Preoperative amiodarone treatment and previous AMI may increase the need for a pacemaker during the postoperative period of these aortic prostheses.

Tratamiento percutáneo de una prótesis aórtica sin sutura degenerada precozmente / Percutaneous treatment of early denegeration of a sutureless bioprosthesis

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Perceval Less Invasive Aortic Replacement Register: multicentric Spanish experience with the Perceval S bioprosthesis in moderate-high-risk aortic surgery.

OBJECTIVES: The development of new percutaneous and surgical techniques has reduced the risk associated with aortic valve replacement procedures. We present the results of a Spanish register after initiating a programme for sutureless prostheses in moderate-high-risk patients. METHODS: This prospective multicentre study was carried out from November 2013 to November 2016. Data were obtained from 448 patients in whom a Perceval S prosthesis was implanted. RESULTS: The mean age was 79.24 (standard deviation [SD] 4.1) years, and 61.2% were women. The estimated EuroSCORE I log risk was 11.15% (SD 7.6), with an observed mortality of 4.4% (20 patients). Isolated aortic valve replacement was performed on 69.26% of patients, with 64% involving ministernotomy. The incidence of neurological events was 2%, with 2 permanent cerebrovascular accidents, and 41 (9.2%) patients were implanted with a permanent endocavitary pacemaker. At discharge, 12 (2.6%) patients presented minimal periprosthetic leakage, and 4 (0.89%) patients had moderate leakage. There were 3 reinterventions during follow-up (2 endocarditis and 1 dysfunction due to periprosthetic leak progression). The mean gradient at discharge, 6 months and 1 year was 12.94 (SD 5.3) mmHg, 12.19 (SD 4.7) mmHg and 11.77 (SD 4.7) mmHg, respectively; 59.4% of the patients were octogenarians, with a survival rate of 98% at both 6 months and 1 year at discharge. There was neither valve migration nor early structural degeneration. The mean follow-up was 12 ± 3 months. The 6-month and 1-year mortality was 1.4% and 2.1%, respectively. CONCLUSIONS: This is a prospective multicentric study on the largest cohort of patients with sutureless valves conducted in Spain to date. It is a reproducible procedure that has enabled surgery on patients with a moderate-high risk with low morbidity and mortality, providing good haemodynamic results.

Treatment of right heart thromboemboli: the need of a randomized multicentre trial.

Currently, there are not solid evidence-based recommendations on the treatment of in-transit right heart thromboemboli. We present a case of acute pulmonary embolism with right ventricular entrapped thrombus detected by echocardiography. Surgical thrombectomy was successfully carried out. Treatment options are discussed and the need of a randomized trial is stressed.

[Initial experience with the Impella left ventricular assist device for postcardiotomy cardiogenic shock and unprotected left coronary artery angioplasty in patients with a low left ventricular ejection fraction]. / Experiencia inicial con la asistencia ventricular izquierda tipo "Impella" para el shock cardiogénico poscardiotomía y la angioplastia de tronco coronario izquierdo no protegido con baja fracción de eyección ventricular izquierda.

Low-output syndrome is one of the leading causes of death following open-heart surgery or high-risk angioplasty. Ventricular assist devices have been used to treat patients who suffer from postoperative cardiogenic shock despite use of an intraaortic balloon pump and maximum inotropic support. The Impella pump (Impella Cardiosystems AG, Aachen, Germany) is a newly introduced left ventricular assist device that has been shown to reduce infarct size and to accelerate recovery of stunned myocardium. We report our initial experience using the Impella device for the treatment of cardiogenic shock following cardiopulmonary bypass and for maintaining hemodynamic stability in high-surgical-risk patients undergoing unprotected left coronary artery angioplasty.

Experiencia inicial con la asistencia ventricular izquierda tipo «Impella» para el shock cardiogénico poscardiotomía y la angioplastia de tronco coronario izquierdo no protegido con baja fracción de eyección ventricular izquierda / Initial experience with the impella left ventricular assist device for postcardiotomy cardiogenic shock and unprotected left coronary artery angioplasty in patients with a low left ventricular ejection fraction

El síndrome de bajo gasto es una de las principales causas de muerte tras la cirugía cardiaca y la angioplastia de alto riesgo. Los dispositivos de asistencia ventricular se han utilizado para tratar a pacientes con bajo gasto postoperatorio a pesar del balón de contrapulsación intraaórtico y el apoyo inotrópico máximo. El Impella (Impella Cardiosystems AG, Aachen, Alemania) es un dispositivo de asistencia ventricular de reciente introducción que ha demostrado reducir el tamaño del infarto, así como acelerar la recuperación del miocardio aturdido. Describimos nuestra experiencia inicial con el Impella para el tratamiento del shock cardiogénico tras el bypass cardiopulmonar y para el mantenimiento de la estabilidad hemodinámica en pacientes con tronco coronario izquierdo no protegido de alto riesgo quirúrgico tratados con angioplastia (AU)

Low-output syndrome is one of the leading causes of death following open-heart surgery or high-risk angioplasty. Ventricular assist devices have been used to treat patients who suffer from postoperative cardiogenic shock despite use of an intraaortic balloon pump and maximum inotropic support. The Impella pump (Impella Cardiosystems AG, Aachen, Germany) is a newly introduced left ventricular assist device that has been shown to reduce infarct size and to accelerate recovery of stunned myocardium. We report our initial experience using the Impella device for the treatment of cardiogenic shock following cardiopulmonary bypass and for maintaining hemodynamic stability in high-surgical-risk patients undergoing unprotected left coronary artery angioplasty (AU)

Constrictive pericarditis due to Coxiella burnetii.

Q fever is characterized by its clinical polymorphism. Cardiac involvement in acute Q fever is rare. We report a case of pleuro-pericarditis that rapidly evolved to pericardial constriction during an acute episode of Coxiella burnetii infection. Constrictive pericarditis was confirmed by hemodynamic measurements, echocardiography, and magnetic resonance. Indirect immunofluorescence assay revealed positive serology for acute Q fever. The patient underwent a successful pericardiectomy and was given antibiotics. The histopathologic study of the excised pericardium showed C. burnetii in a large cluster of organisms. After a 6-month follow-up period, the individual was asymptomatic.

Endovascular repair of concomitant celiac trunk and abdominal aortic aneurysms in a patient with Behçet's disease.

PURPOSE: To report endovascular repair of dual aneurysms in a patient with Behçet's disease. CASE REPORT: A 37-year-old man diagnosed 6 months prior with Behçet's disease presented with a pulsating abdominal mass. Computed tomography revealed a 70-mm-diameter pseudoaneurysm in the abdominal aorta and another (20 mm) in the celiac trunk 5 mm from the aorta. Staged endovascular repair began with the aortic aneurysm, which was excluded with a bifurcated 23 x 140-mm Excluder stent-graft. Three days later, 2 Jostent stent-grafts were placed in the celiac trunk, successfully excluding the lesion. Fifteen days later, the patient was discharged on a regimen of clopidogrel, cyclosporine, and warfarin. At 6 months, the CT scan showed good perfusion of the stent-grafts. CONCLUSIONS: Aneurysmal involvement of the celiac trunk in a patient with Behçet's disease is a rare pathology that appears amenable to stent-graft repair.

Successful biventricular assistance after heart transplantation.

We present a successful use of biventricular pneumatic assistance during seven days allowing the recovery from a severe primary graft failure that occurred in the operating room. Suboptimal donors are associated with higher rates of immediate graft failure; however proper use of mechanical assistance can help to recover graft function.

Recambio valvular por insuficiencia aórtica severa tras cirugía conservadora según técnica de David / Valve replacemente in severe aortic regurgitation produced after a valve sparing operation with David's technique

La reconstrucción valvular aórtica tiene gran interés en el tratamiento de la insuficiencia aórtica severa causada por dilatación del anillo valvular asociada a anuloectasia aórtica. Si la válvula es normal y queremos evitar problemas derivados de las prótesis y la anticoagulación de por vida, utilizaremos técnicas como la descrita por David para preservación valvular aórtica. Aunque los resultados a largo plazo suelen ser buenos, en algunos casos como en el que aquí nos ocupa se produce una intensa fibrosis en la válvula nativa que evoluciona hacia una insuficiencia aórtica severa que precisa reoperación. Describimos aquí la evolución cronológica del deterioro valvular, el momento en que se indicó la reintervención y la cirugía que se hizo (AU)