Surgical site infection with extended-spectrum ß-lactamase-producing Enterobacteriaceae after cardiac surgery: incidence and risk factors.

OBJECTIVE: To determine the incidence, microbiology and risk factors for sternal wound infection (SWI) with extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-PE) following cardiac surgery. METHODS: We performed a retrospective analysis between January 2006 and December 2015 of prospective surveillance of a cohort of patients with cardiac surgery at a single centre (Paris, France). SWI was defined as the need for reoperation due to sternal infection. All patients with an initial surgery under extracorporeal circulation and diagnosed with an SWI caused by Enterobacteriaceae isolates were included. We compared patients infected with at least one ESBL-PE with those with SWI due to other Enterobacteriaceae by logistic regression analysis. RESULTS: Of the 11 167 patients who underwent cardiac surgery, 412 (3.7%) developed SWI, among which Enterobacteriaceae were isolated in 150 patients (36.5%), including 29 ESBL-PE. The main Enterobacteriaceae (n = 171) were Escherichia coli in 49 patients (29%) and Enterobacter cloacae in 26 (15%). Risk factors for SWI with ESBL-PE in the multivariate logistic regression were previous intensive care unit admission during the preceding 6 months (adjusted odds ratio (aOR) 12.2; 95% CI 3.3-44.8), postoperative intensive care unit stay before surgery for SWI longer than 5 days (aOR 4.6; 95% CI 1.7-11.9) and being born outside France (aOR 3.2; 95% CI 1.2-8.3). CONCLUSIONS: Our results suggest that SWI due to ESBL-PE was associated with preoperative and postoperative unstable state, requiring an intensive care unit stay longer than the usual 24 or 48 postoperative hours, whereas being born outside France may indicate ESBL-PE carriage before hospital admission.

Sternal wound infection after cardiac surgery: incidence and risk factors according to clinical presentation.

The incidence of surgical site infection (SSI) after cardiac surgery depends on the definition used. A distinction is generally made between mediastinitis, as defined by the US Centers for Disease Control and Prevention (CDC), and superficial SSI. Our objective was to decipher these entities in terms of presentation and risk factors. We performed a 7-year single centre analysis of prospective surveillance of patients with cardiac surgery via median sternotomy. SSI was defined as the need for reoperation due to infection. Among 7170 patients, 292 (4.1%) developed SSI, including 145 CDC-defined mediastinitis (CDC-positive SSI, 2.0%) and 147 superficial SSI without associated bloodstream infection (CDC-negative SSI, 2.1%). Median time to reoperation for CDC-negative SSI was 18 days (interquartile range, 14-26) and 16 (interquartile range, 11-24) for CDC-positive SSI (p 0.02). Microorganisms associated with CDC-negative SSI were mainly skin commensals (62/147, 41%) or originated in the digestive tract (62/147, 42%); only six were due to Staphylococcus aureus (4%), while CDC-positive SSI were mostly due to S. aureus (52/145, 36%) and germs from the digestive tract (52/145, 36%). Risk factors for SSI were older age, obesity, chronic obstructive bronchopneumonia, diabetes mellitus, critical preoperative state, postoperative vasopressive support, transfusion or prolonged ventilation and coronary artery bypass grafting, especially if using both internal thoracic arteries in female patients. The number of internal thoracic arteries used and factors affecting wound healing were primarily associated with CDC-negative SSI, whereas comorbidities and perioperative complications were mainly associated with CDC-positive SSI. These 2 entities differed in time to revision surgery, bacteriology and risk factors, suggesting a differing pathophysiology.

Thoracoscopic IMA takedown.

In recent years, the field of minimally invasive cardiac surgery has grown rapidly beginning with the MIDCAB operation and evolving toward totally endoscopic coronary artery bypass grafting (CABG). It promotes the goal of decreasing surgical trauma while maintaining surgical efficacy. For MIDCAB, a limited anterior thoracotomy or mediastotomy have been proposed to harvest the internal mammary artery (IMA). However, complete graft harvesting of the IMA is difficult under direct vision in these circumstances and may necessitate costal resection and important chest wall retraction. Additionally, it carries the potential risk of kinking or coronary steal syndrome. Thoracoscopic harvesting of the IMA avoids these hazards. It permits complete dissection from the subclavian artery to the sixth inter-costal space (ICS) with section of all collateral branches issuing from the IMA without any traumatic retraction. The technique of IMA takedown described herein has been used regularly by us since 1995. Our current experience shows that it is safe and reproducible after a reasonable period of training. Furthermore, in the objective of performing a totally endoscopic and/or robotic CABG, thoracoscopic IMA takedown would be a prerequisite.

Effective reduction of a giant left atrium by partial autotransplantation.

Although many surgical procedures have been proposed to reduce the size of a left atrium, their effectiveness is not well established. We present a case of mitral and tricuspid valve insufficiency with a giant left atrium. Partial heart autotransplantation was used in a mitral and tricuspid valve operation with a successful outcome. This procedure can be an effective method to treat giant left atrium.

Advancement flaps to treat superficial wound infections after cardiac operations.

The management of superficial sternal wound infections is not well-codified. In case of large necrosis or tissue defect we use a two-stage approach, consisting of a first surgical debridement, followed a few days later by wound closure by means of two lateral advancement flaps. We have used this technique with good cosmetic results and shorter hospital stays.

[Long-term outcome of infra-inguinal endovascular surgery for critical ischemia]. / Résultats à long-terme de la chirurgie endovasculaire à l'étage infra-inguinal dans le cadre de l'ischémie critique.

STUDY AIM: Endovascular surgery can be proposed as an alternative to infrainguinal conventional surgery in critical ischemia. The aim of this study was to report the latest results of our series of 186 patients. MATERIALS AND METHODS: One hundred and eighty-six patients (100 women and 86 men; mean age 74.5 +/- 13 years) were treated for pain during rest (31.5%), gangrene (58%), or ischemic ulcer (10.5%). The lesions were unilateral (n = 172) or bilateral (n = 14). Two hundred eighty-seven target lesions were treated: for stenosis (n = 168) or occlusion (n = 119): of superficial femoral artery (31.7%), popliteal artery (40%) or tibial arteries (28.3%). RESULTS: Technical success was achieved in 81% (15% amputations). The in-hospital mortality rate was 6.5%. The cumulative patency rate was 61 +/- 3% at 12 months, and 52 +/- 6% at 48 months. The limb salvage rate was 87 +/- 3% at 12 months and 82 +/- 4% at 48 months. Thirteen potential factors of patency were analyzed: the only predictive factors affecting patency were occlusion versus stenosis, and the use of atherectomy (Log rank test: P < 0.001 and P < 0.0001). CONCLUSION: Despite a risk of technical failure and of mid-term restenosis, endovascular surgery for critical ischemia provides a fair long-term limb salvage rate.

[Mitral valvuloplasty for asymptomatic or pauci-symptomatic mitral insufficiency]. / Valvuloplastie mitrale pour insuffisance mitrale asymptomatique ou paucisymptomatique.

The aim of this study was to assess the results of mitral valvuloplasty for chronic asymptomatic or paucisymptomatic mitral regurgitation. Of 584 patients operated for chronic mitral regurgitation between January 1989 and December 1994, 175 were in NYHA Classes I and II and made up the study population. All had chronic grade 3 or 4/4 mitral regurgitation suitable for mitral valvuloplasty. The average follow-up was 34.3 months. Mitral valvuloplasty was performed in 174 patients, the other patient requiring mitral valve replacement. Three patients died (1.7%) and the actuarial 5 year survival was 98.2 +/- 1.0%. The probability of absence of reoperation and absence of thrombo-embolic complications at 5 years were 97 +/- 0.8% and 96.3 +/- 1.7% respectively. The residual regurgitation at Doppler echocardiography was minimal or absent in 94% of patients at the last follow-up control. The mean end-systolic and end-diastolic left ventricular dimensions decreased from 40.0 +/- 6.8 mm and 64.8 +/- 7.0 mm before surgery to 34.6 +/- 6.7 mm (p < 0.001) and 52.7 +/- 7.4 mm (p < 0.001) at the last control. The authors conclude that conservative mitral valve surgery for NYHA Classes I and II patients with chronic mitral regurgitation is feasible with a low risk and is associated with a significant reduction in ventricular volumes and stability of valvular continence at medium-term. When performed by teams trained in techniques of mitral valvuloplasty, these results suggest that surgery should be performed early.

Clinical evaluation of the Physio annuloplasty ring.

STUDY OBJECTIVES: Prospective evaluation of a selectively flexible annuloplasty ring was undertaken to assess its safety and efficacy. PATIENTS: Between December 1992 and November 1996, 190 patients with mitral regurgitation underwent mitral valve repair using an annuloplasty ring (Carpentier-Edwards Physio; Baxter-Edwards CVS Laboratories; Irvine, Calif). Ninety-four were in New York Heart Association class I or II. Etiology was degenerative in 74% of the patients. RESULTS: Four patients died early for a hospital mortality of 2.1%, and one late death occurred. Two patients with systolic anterior motion required early valve replacement. Two transient episodes of hemiparesis occurred during the first postoperative month. There were no late thromboembolic complications, no late reoperation, and no endocarditis. Mean follow up of 23+/-13 months was complete in 99% of the patients. Seventy-seven patients (40.5%) have had Doppler echocardiography > 1 year after surgery: 61 (80%) of them have no residual regurgitation, 15 have grade 1+/4+ mitral regurgitation, while 1 has grade 2+/4+ insufficiency. Left ventricular end-diastolic volume index (mL/lm2) decreased from 107.4+/-35.5 preoperatively to 74.2+/-24.4 at last control (p<0.001). CONCLUSION: The physio annuloplasty ring provided reliable and stable results at medium-term follow-up with a very low incidence of valve-related complications.

Continuous warm blood cardioplegia pitfalls and solutions.

BACKGROUND: Continuous warm blood cardioplegia offers superior preservation in both routine and complicated cardiac cases. Management of continuous perfusion is an important task during each case. METHODS: The authors have developed several specific techniques to ensure stable catheter insertion and placement for continuous coronary sinus or antegrade ostial perfusion. RESULTS: Over 3,800 patients have been operated on with continuous warm blood cardioplegia using catheter techniques as described in this article. The overall 30-day mortality was 3.9%. CONCLUSIONS: Safe application of continuous warm blood cardioplegia has many advantages over prior cold techniques, but surgeons must know certain technical modifications to be able to universally apply continuous techniques safely.

[Initial results of mitral valvuloplasty using the Physio-Carpentier-Edwards ring]. / Résultats préliminaires de la plastie mitrale avec l'anneau physio-carpentier-edwards.

The Physio-Carpentier-Edwards ring is a new prosthetic ring developed to allow mitral annuloplasty associating remodelling and flexibility of the native mitral annulus. The object of this study was to assess the feasibility and reliability of mitral valvuloplasty with the Physio ring. Between December 1992 and October 1995, 100 patients with an average age of 56.8 years suffering from mitral insufficiency underwent mitral valvuloplasty with a Physio ring. The mitral insufficiency was degenerative in 94% of cases. The degree of regurgitation was scored 3+ or 4/+4/+ in 94 patients. Mitral valve prolapse was observed in 83 patients. Mitral reconstruction was undertaken using Carpentier's techniques. One patient died in the immediate postoperative period. Two patients were reoperated for valve replacement because of systolic anterior motion (SAM). One patient had SAM which regressed with medical treatment. There were no deaths after the hospital period. There were no late reoperations of thrombo-embolic complications. The average follow-up period was 19 +/- 8 months; 77 patients were followed up for over 1 year and all underwent control Doppler echocardiography. Sixty-one patients had no residual mitral insufficiency: 15 patients had grade 1/4 regurgitation and one patient had grade 2/4 regurgitation. The average mitral valve surface area was 2.8 +/- 0.3 cm2. The average left ventricular end diastolic volume decreased from 186 +/- 59 cm3 before surgery to 129 +/- 37 cm3 at the last control (p < 0.001). The authors conclude that the Physio ring enables reliable and effective mitral valvuloplasty with excellent short term results. The benefits of the flexibility of the Physio ring remain to be evaluated by a randomised trial.

Surgical treatment of asymptomatic and mildly symptomatic mitral regurgitation.

OBJECTIVE: The purpose of this study was to review the risk-benefit ratio of mitral valve repair in patients with severe mitral regurgitation and no or mild symptoms. METHODS: From January 1989 to December 1994, 584 patients were operated on for mitral regurgitation. Of these, 175 patients were in New York Heart Association class I or II with grade 3 to 4 isolated chronic mitral regurgitation. They comprise our study population. Mean age was 51.3 +/- 14.3 years. Principal causes of mitral regurgitation were degenerative in 128 (73%) and rheumatic in 26 patients (15%). Leaflet prolapse was the mechanism responsible for regurgitation in 152 patients (86%). Mitral valve repair was performed in 174 patients, and one patient required initial valve replacement. Mean follow-up was 34.3 +/- 18.8 months. RESULTS: Three patients died, for an overall mortality of 1.7%. Five patients were reoperated on, for an actuarial freedom from reoperation of 97.0% +/- 0.8% at 5 years. Actuarial freedom from thromboembolism and endocarditis was 96.3% +/- 1.7% and 99.4% +/- 0.6%, respectively, for an event-free survival of 91.0% +/- 2.0% at 5 years. Left atrial diameter decreased from 54.3 +/- 11.6 mm to 43.6 +/- 10.5 mm (p < 0.001). Left ventricular end-systolic and end-diastolic diameters decreased from 40.0 +/- 6.8 mm and 64.8 +/- 7.0 mm to 34.6 +/- 6.7 mm (p < 0.001) and 52.7 +/- 7.4 mm (p < 0.001), respectively. Mean residual mitral regurgitation was 0.44 +/- 0.6. CONCLUSION: Mitral valve repair for chronic mitral regurgitation in patients having mild or no symptoms was performed with low mortality and morbidity, good valve function, and preserved late left ventricular performance. Early repair may be advocated on the basis of severity of regurgitation and valve repairability, regardless of symptoms.

[Coronary artery bypass with 2 internal mammary arteries. Early clinical and angiographic results in 100 patients]. / Pontages coronaries avec les 2 artères mammaires internes. Résultats cliniques et angiographiques précoces chez 100 malades.

One hundred patients underwent coronary revascularisation with both internal mammary arteries between 1987 and 1990. The average age of the patients was 55 years. The left internal mammary was used in 97 of the 100 cases as a pediculated graft to revascularise the left anterior descending (66 cases), left lateral (27 cases) or a bissecting artery (4 cases). The right internal mammary was used as a pediculated graft in 51 cases and as a free graft to revascularise a left lateral (51 cases), left anterior descending (29 cases) or right coronary artery (20 cases). There was one death in the first 30 postoperative days. Morbidity was low with no cases of sternal infection. The average postoperative bleeding was 633 +/- 550 ml per patient. The incidence of phrenic nerve paralysis decreased from 36% in the first 50 patients to 6% in the second 50 patients. Angiography at the 10th postoperative day showed 4 occlusions out of 132 internal mammary arteries opacified (97% patency). Ninety four patients are asymptomatic and have negative exercise stress tests. Mortality and morbidity of coronary surgery using the two internal mammary arteries are therefore the same as those of conventional coronary surgery using saphenous veinar only one internal mammary artery, providing that it is reserved for patients in good general condition, under 65 years of age, without obesity or diabetes. This technique of coronary artery revascularization should provide better long-term results because of the high patency rate of the grafts.