Negative Pressure versus Conventional Sternal Wound Dressing in Coronary Surgery Using Bilateral Internal Mammary Artery Grafts.

BACKGROUND: Sternal wound infection (SWI) is a major complication occurring often after coronary artery bypass grafting (CABG) using bilateral internal mammary artery (BIMA) grafts. The aim of this study is to assess whether such a risk may be reduced by using incision negative pressure wound therapy (INPWT). METHODS: Data on patients undergoing isolated CABG using BIMA grafts at the Reims University Hospital, France, from 2013 to 2016 without or with INPWT was prospectively collected.  Results: INPWT was used in 161 patients and conventional sterile wound dressing was used in 266 patients. Propensity score matching resulted in 128 pairs with similar characteristics. SWIs were similarly distributed between the conventional sterile wound dressing (10.9%) and the INPWT cohorts (10.2%) (P = 1.00). Patients treated with INPWT had a lower rate of deep SWI/mediastinitis than patients who had conventional sterile dressing (5.5% versus 10.2%, P = .210), but the difference did not reach statistical significance. Tests for interaction confirmed these findings in different patient subgroups. CONCLUSION: The routine use of INPWT may not significantly reduce the risk of SWI in patients undergoing BIMA grafting. In view of previous reports showing a benefit with the use of this method, a large randomized study is justified to assess the efficacy of INPWT in patients undergoing cardiac surgery.

Medical and economic interest of the use of cryosurgery in the instrumental treatment of atrial fibrillation.

INTRODUCTION: In order to definitively integrate cryosurgery for the surgical treatment of atrial fibrillation (AF) into the therapeutic armamentarium, the medical and economic impact of its use on a population of patients with a high risk of recurrence of postoperative AF must be evaluated. METHOD: An observational study of patients who benefited from cryosurgery between July 2006 and December 2008 was performed. The cost of consumables and hospitalization was determined and compared to that of a control group of 27 patients with preoperative AF that had not benefited from cryosurgery. RESULTS: Twenty-nine patients benefited from cryosurgery during a mitral (65.5%) or aortic intervention (37.9%) to treat a paroxystic (44.8%) or permanent AF (55.2%). More than half of them (58.6%) had a 12-month follow-up; 82.4% of these patients showed a permanent sinus rhythm and 32.6% had stopped their antiarrhythmic medication. There was no significant difference between the duration and cost of hospitalization for the 2 groups. CONCLUSION: Cryosurgery provides a clear clinical and economic advantage with no recurrence of AF, and it reduces antiarrhythmic medication treatment.

Thrombocytopenia after aortic valve replacement with freedom solo bioprosthesis: a propensity study.

BACKGROUND: The incidence of postoperative thrombocytopenia after aortic valve replacement with the Freedom Solo bioprosthesis remains unclear. This propensity-matched study was carried out to evaluate the incidence and clinical impact of thrombocytopenia in patients receiving the Freedom Solo bioprosthesis. METHODS: Patients who underwent aortic valve replacement with a Freedom Solo or Carpentier-Edwards Perimount pericardial prosthesis at our institution between 2006 and 2008 were screened retrospectively. Exclusion criteria included double valve replacement, redo surgery, and active endocarditis. Two hundred six patients were considered eligible for this analysis. Using propensity scores 36 matched pairs of patients with a Freedom Solo or Perimount bioprosthesis were obtained. The primary end point was the occurrence of postoperative thrombocytopenia. Secondary end points were postoperative thromboembolic or hemorrhagic events and 30-day mortality. RESULTS: Before matching, severe thrombocytopenia (<30 x 10(9) platelets/L) occurred in 22% of patients with a Freedom Solo bioprosthesis and 1% with a Perimount bioprosthesis (p < 0.0001), thromboembolic or hemorrhagic events occurred in 3% and 2%, respectively (p = 0.37), and 30-day mortality was 4% and 6%, respectively (p = 0.48). Multivariate analysis identified preoperative platelet count (p = 0.01) and Freedom Solo (p < 0.0001) as independent risk factors for severe postoperative thrombocytopenia. After matching, severe thrombocytopenia occurred in 25% and 3% of patients with Freedom Solo and Perimount bioprostheses, respectively (p < 0.0001), thromboembolic or hemorrhagic events occurred in 0%, and 30-day mortality was 3% and 6%, respectively (p = 0.99). CONCLUSIONS: The risk of thrombocytopenia was high after Freedom Solo implantation. However, this complication was not related to any deleterious events in our study population.

Septic coronary embolism in aortic valvular endocarditis.

Acute myocardial infarction due to septic coronary emboli in active infective endocarditis is rare, but may be fatal. The case is reported of a 58-year-old man who presented with wrist arthritis, which resulted in acute aortic valvular endocarditis. Echocardiography revealed 3 mm vegetations on the posterior and anterior valve cusps, and aortic regurgitation (grade 3-4). As the patient's clinical status was stable, medical treatment was selected which included antibiotic therapy, but after four weeks the patient reported an acute anterior chest pain. Coronary angiography revealed stenosis of the left anterior descending (LAD) artery, due to septic embolism. The patient was referred for emergency cardiac surgery, at which a surgical thrombectomy and coronary artery bypass grafting with reconstruction of the LAD artery were performed, along with aortic valve replacement using a bioprosthesis. The postoperative course was uneventful and the patient was discharged on postoperative day 15. An adapted oral antibiotherapy was continued for a further six-week period.

Totally normothermic aortic arch replacement without circulatory arrest.

BACKGROUND: Various techniques have been proposed for cerebral protection during the surgical treatment of complex aortic disease. The authors propose a revisited strategy of normothermic replacement of the aortic arch to avoid limitations and complications of profound hypothermic circulatory arrest. MATERIALS AND METHODS: From April 2000 to May 2006, 19 patients with an aneurysm of the aortic arch and 10 patients with an acute (7) or a chronic (3) aortic dissection underwent a totally normothermic, complete replacement of the aortic arch using three pumps: One pump ensured antegrade cerebral perfusion, at a flow rate adapted to obtain a pressure of 70 mmHg in the right radial artery, and required a selective cannulation of the supra-aortic vessels. A second pump ensured body perfusion at a flow rate adapted to obtain a pressure of 55 mmHg in the left femoral artery and was situated between the right femoral artery and the right atrium. A special balloon aortic occlusion catheter was placed in the descending thoracic aorta. A third pump ensured intermittent normothermic myocardial perfusion via the coronary venous sinus. The arch reconstruction was performed with no time limit. RESULTS: There were two operative, in-hospital (6.8%) mortalities. All others patients were rapidly extubated, except one, with no neurological sequelae, and postoperative course was uneventful, without coagulopathy or hepato-renal impairment. CONCLUSIONS: In the light of these results, a normothermic procedure is possible for arch surgery and may ensure a more physiological autoregulation of cerebral blood flow while maintaining body perfusion without high vascular resistances.

Prospective randomized study comparing coronary artery bypass grafting with the new mini-extracorporeal circulation Jostra System or with a standard cardiopulmonary bypass.

BACKGROUND: To assess the potential benefits of a new concept of cardiopulmonary bypass (CPB), the mini-extracorporeal circulation (MECC) Jostra System, we conducted a prospective randomized study among patients who underwent coronary artery bypass grafting (CABG) with a MECC Jostra System or with a standard CPB. METHODS: In a prospective randomized study, 400 patients underwent elective CABG using a standard CPB (200 patients) or a Jostra MECC System (200 patients). The patients were randomly assigned to have preoperative data similar for both groups. RESULTS: The operative mortality rate (< 30 days) was 1.5% for the MECC group and 2.5% for the CPB group (P = NS). Low-cardiac-output syndrome occurred in 0.66% and 4% for the CPB group (P < .001.). The inflammatory response was significantly reduced with the MECC. Likewise, C-reactive protein release was significantly higher in group B at 24 hours (69.6 +/- 38.5 vs 40.8 +/- 21.8 mg/L for the group A, P < .01) and at 48 hours (116.7 +/- 47.0 vs 65.4 +/- 39.5 mg/L, P < .05) postoperatively. In the CPB group, there was a significantly higher decrease of hematocrit and hemoglobin rate. So, the intraoperative transfusion rate amounted to 6% for the MECC group and 12.8% for the CPB group (P < .001). Patients in the CPB group had significantly higher levels of postoperative blood creatinine and urea. CONCLUSION: The MECC system is a new concept of CPB that seems to be reliable and safe. To perform CABG, the MECC provides an excellent surgical exposure like a standard CPB and a better biologic profile like CABG without CPB.

Clinical experience with the mini-extracorporeal circulation system: an evolution or a revolution?

PURPOSE: We studied a cohort of 150 patients operated on with a new cardiopulmonary bypass (CPB) system. This is the mini-extracorporeal circulation (MECC) system. DESCRIPTION: The MECC is a fully heparin coated closed-loop CPB system that includes a centrifugal pump and has a priming volume of 450 mL. Between March 2001 and September 2002, 150 consecutive patients were operated on using the mini-CPB (MECC) method. This includes 105 coronary artery bypass graft and 45 aortic valve replacement patients. The median age was 66.7 +/- 10.7 years with a gender ratio of 3.27 males to 1 female. EVALUATION: The 30-day operative mortality was 1.3%. The hemoglobin concentration was stable and perioperative transfusion was needed in only 6% of all patients. The renal and neuropsychiatric complications were less than 1%. CONCLUSIONS: In our experience, the MECC system is a reliable new concept for CPB with good clinical results.

Totally normothermic aortic arch replacement without circulatory arrest.

The authors propose a new strategy of normothermic perfusion for replacement of the aortic arch to avoid the complications of profound hypothermic circulatory arrest. Six patients underwent complete replacement of the aortic arch under normothermia using two pumps for the body (one for the brain and the thoracoabdominal aortic branches) and one for the heart. The surgical procedure was performed with no time limit. There were no operative or late deaths. No patients had neurologic deficit and all were rapidly extubated with uneventful postoperative courses. The method preserves autoregulation of cerebral blood flow and maintains body perfusion without high vascular resistances.

Purulent pericarditis caused by malignant oesophago-pericardial fistula.

A case of purulent pericarditis with an unusual aetiology and a favourable outcome is reported. This patient presented with purulent pericarditis secondary to an oesophago-pericardial fistula caused by a squamous carcinoma of the oesophagus. A review of the literature revealed only a small number of similar cases. The prognosis can be improved by rapid diagnosis, appropriate antibiotic therapy, surgical drainage and surgical repair of the fistula. An aggressive therapeutic approach should be proposed in order to achieve long-term remission in these frequently young patients.