Intravascular Ultrasound during Endovascular Intervention for Peripheral Artery Disease, by Severity, Location, Device, and Procedure.

There is limited evidence for the role of intravascular ultrasound (IVUS) in patients who underwent peripheral vascular intervention (PVI). We conducted retrospective cohort study utilizing the Healthcare Cost and Utilization Project-Agency for Healthcare Research and Quality National Readmission database to delineate outcomes in IVUS-guided PVI versus non-IVUS-guided PVI. The present study utilized National Readmission database between January 1, 2016, and December 31, 2019. We identified patients who underwent endovascular intervention for peripheral artery disease using relevant International Classification of Diseases, Tenth Revision, Procedural Coding System. The cohort was divided based on the use of IVUS during the procedure. The primary outcome was major amputation at 6 months after index hospitalization. Measured confounders were matched using propensity score inverse probability of treatment weighing method. We further performed a subgroup analysis based on disease severity, location of intervention, device, and procedure. A total of 434,901 hospitalizations were included in the present analysis. PVI with IVUS compared with no IVUS had similar risk of amputation at 6 months (195 of 8,939 [2.17%] vs 10,404 of 384,003 [2.71%]), hazard ratio 0.98, CI 0.77 to 1.25. Further, there was no difference in the rates of secondary outcomes. On subgroup analysis, amputation rates were significantly lower in patients with rest pain, in iliac intervention, or patients who underwent drug-eluting stent implantation with the use of IVUS compared with no IVUS. This nationwide observational study showed that there was no difference in major amputation rates with the use of IVUS in patients who underwent PVI. However, in subgroup of patients with rest pain, iliac intervention or drug-eluting stent implantation IVUS use was associated with significantly lower major amputation rates.

Restricted cusp motion in newly implanted tricuspid bioprostheses: Incidence, predictors, and impact on survival.

OBJECTIVE: To investigate the occurrence of restricted cusp motion (RCM) at the time of bioprosthetic tricuspid valve replacement (TVR) and analyze associated risk factors and outcomes. METHODS: This study involved adult patients who underwent TVR with a bioprosthesis at our institution between 2012 and 2022. Bioprosthetic cusp motion was analyzed de novo through a detailed review of intraoperative transesophageal echocardiograms (TEE). Two models of porcine valves were implanted: the Medtronic Hancock II bioprosthesis and the St Jude Medical Epic bioprosthesis. RESULTS: Among the 476 patients who met the inclusion criteria, RCM was identified on immediate post-bypass TEE in 150 (31.5%); there was complete immobility of the cusp in 63 patients (13.2%) and limited movement of a cusp in 87 patients (18.3%). In a multivariable logistic regression analysis, the Hancock II model (odds ratio [OR], 6.15; P < .001), a larger orifice area (per IQR increase: OR, 1.58; P = .017), a smaller body surface area (per IQR increase: OR, .68; P = .040), and a lower ejection fraction (per IQR increase: OR, .60; P = .033) were independently associated with having RCM. Cox regression adjusting for 15 covariates revealed that RCM at the time of TVR was independently associated with an increased risk of mortality (hazard ratio, 1.35; P = .049). CONCLUSIONS: This study revealed a high incidence of RCM in bioprosthetic valves in the tricuspid position detected shortly postimplantation, which was associated with increased late mortality. To reduce the probability of RCM, it is important to select the appropriate prosthesis model and size, particularly in small patients.

Hemodynamic Comparison of the On-X and Top Hat Mechanical Aortic Valve Prostheses.

BACKGROUND: There are limited data comparing hemodynamic valve function in mechanical aortic valve prostheses. This study compared the hemodynamic function of 2 commonly used mechanical aortic valve (AV) prostheses, the On-X (Artivion) and Top Hat (CarboMedics Inc) valves. METHODS: This study was a retrospective analysis of 512 patients who underwent AV replacement with the On-X (n = 252; 49%) or Top Hat (n = 260; 51%) mechanical valves between 2011 and 2019. Patients were matched on the basis of selected variables. Echocardiographic data were collected preoperatively and postoperatively over a median follow-up of 1.39 years. RESULTS: A total of 320 patients were matched, 160 patients in each group. Despite being matched for left ventricular outflow tract diameter, patients in the Top Hat group received a greater prevalence of smaller tissue annulus diameter valves (≤21 mm) (83% vs 38%; P < .001). Patients in the On-X group had longer aortic cross-clamp times (78 minutes vs 64 minutes; P < .001) during isolated aortic valve replacement. Discharge echocardiography showed no difference in the AV area index between both groups (1.00 cm2/m2 vs 1.02 cm2/m2; P = .377). During longer-term echocardiographic follow-up, the AV area index remained stable for both valves within their respective tissue annulus diameter groups (P = .060). CONCLUSIONS: There was no difference between the 2 valves with respect to the AV area index at discharge, and hemodynamic function was stable during longer-term follow-up. The longer aortic cross-clamp time observed in the On-X group may indicate increased complexity of implantation compared with the Top Hat group.

A Bayesian meta-analysis of double kissing (DK) crush or provisional stenting for coronary artery bifurcation lesions.

OBJECTIVE: Despite the development of dedicated, two-stent strategies, including the double kissing (DK) crush technique, the ideal technique for coronary artery bifurcation stenting has not been identified. We aimed to compare and determine the absolute risk difference (ARD) of the DK crush technique alone versus provisional stenting approaches for coronary bifurcation lesions, using the Bayesian technique. METHOD: We queried PubMed/MEDLINE to identify randomized controlled trials (RCTs) that compared DK crush technique with provisional stenting for bifurcation lesions, published till January 2023. We used Bayesian methods to calculate the ARD and 95% credible interval (CrI). RESULTS: We included three RCTs, with 916 patients, in the final analysis. The ARD of cardiac death was centered at -0.01 (95% CrI: -0.04 to 0.02; Tau: 0.02, 85% probability of ARD of DK crush vs. provisional stenting <0). ARD for myocardial infarction was centered at -0.03 (95%CrI: -0.9 to 0.03; Tau: 0.05, 87% probability of ARD of DK crush vs. provisional stenting <0). ARD for stent thrombosis was centered at 0.00 (95% CrI: -0.04 to 0.03, Tau: 0.03, 51% probability of ARD for DK crush vs. provisional stenting <0). Finally, ARD for target lesion revascularization was centered at -0.05 (95% CrI: -0.08 to -0.03, Tau: 0.02, 99.97% probability of ARD for DK crush vs. provisional stenting <0). CONCLUSIONS: Bayesian analysis demonstrated a lower probability of cardiac death, myocardial infarction and target lesion revascularization, with DK crush compared with provisional stenting techniques, and a minimal probability of difference in stent thrombosis.

Analysis of Anemia, Transfusions, and CABG Outcomes in The Society of Thoracic Surgeons National Database.

BACKGROUND: This study characterized the association of preoperative anemia and intraoperative red blood cell (RBC) transfusion on outcomes of elective coronary artery bypass grafting (CABG). METHODS: Data from 53,856 patients who underwent CABG included in The Society of Thoracic Surgeons (STS) Adult Cardiac Database in 2019 were used. The primary outcome was operative mortality. Secondary outcomes were postoperative complications. The association of anemia with outcomes was analyzed with multivariable regression models. The influence of intraoperative RBC transfusion on the effect of preoperative anemia on outcomes was studied using mediation analysis. RESULTS: Anemia was present in 25% of patients. Anemic patients had a higher STS Predicted Risk of Operative Mortality (1.2% vs 0.7%; P < .001). Anemia was associated with operative mortality (odds ratio [OR], 1.27; 99.5% CI, 1.00-1.61; P = .047), postoperative RBC transfusion (OR, 2.28; 99.5% CI, 2.12-2.44; P < .001), dialysis (OR, 1.58; 99.5% CI, 1.19-2.11; P < .001), and prolonged intensive care unit and hospital length of stay. Intraoperative RBC transfusion largely mediated the effects of anemia on mortality (76%), intensive care unit stay (99%), and hospital stay, but it only partially mediated the association with dialysis (34.9%). CONCLUSIONS: Preoperative anemia is common in patients who undergo CABG and is associated with increased postoperative risks of mortality, complications, and RBC transfusion. However, most of the effect of anemia on mortality is mediated through intraoperative RBC transfusion.

Association of sleep duration with atrial fibrillation/flutter mortality in the United States: a cross-sectional analysis.

BACKGROUND: The association between sleep duration and atrial fibrillation risk is poorly understood, with inconsistent findings reported by several studies. We sought to assess the association between long sleep duration and mortality due to atrial fibrillation/atrial flutter (AF/AFL). METHODS: The 2016-2020 Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research dataset was used to identify death records secondary to AF/AFL in the United States population. We used the 2018 Behavioral Risk Factor Surveillance System (BRFSS) dataset of sleep duration at the county level. All counties were grouped into quartiles based on the percentage of their population with long sleep duration (i.e., ≥ 7 h), Q1 being the lowest and Q4 the highest quartile. Age-adjusted mortality rates (AAMR) were calculated for each quartile. County Health Rankings for Texas were used to adjust the AAMR for comorbidities using linear regression. RESULTS: Overall, the AAMR for AF/AFL were highest in Q4 (65.9 [95% CI, 65.5-66.2] per 100,000 person-years) and lowest in Q1 (52.3 [95% CI, 52.1-52.5] per 100,000 person-years). The AAMR for AF/AFL increased stepwise from the lowest to highest quartiles of the percentage population with long sleep duration. After adjustment for the county health ranks of Texas, long sleep duration remained associated with a significantly higher AAMR (coefficient 220.6 (95% CI, 21.53-419.72, p-value = 0.03). CONCLUSIONS: Long sleep duration was associated with higher AF/AFL mortality. Increased focus on risk reduction for AF, public awareness about the importance of optimal sleep duration, and further research to elucidate a potential causal relationship between sleep duration and AF are warranted.

Twenty-year United States national, demographic and regional mortality trends from traumatic thoracic aortic injury, 1999 to 2019.

INTRODUCTION: Traumatic Thoracic Aortic Injury (TTAI) is associated with high mortality rates and is the second leading cause of death in traumatic patients. There has been a considerable advancement in the management of TTAI with novel and improved surgical procedures and imaging modalities. The aim of this study was to determine the national demographic and regional trends in mortality associated with TTAI in the United States across twenty years, 1999 to 2019. METHODS: The multiple cause of death data on Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC-WONDER) database was utilized to query death certificates for TTAI from 1999 to 2019, in the United States. The International Classification of the Diseases, Tenth Revision (ICD-10) code S25.0 was used to identify and abstract data for TTAI related deaths. The data was further abstracted based on age, race, gender and Census-Bureau defined regions. The age-adjusted mortality rate (AAMR) per 100,000 population-year and Average Annual Percentage Change (AAPC) with 95 % Confidence Interval were computed. The JoinPoint software was utilized to compute the temporal trends in mortality based on a segmented change and AAPC calculation. RESULTS: A total of 20,842 TTAI associated deaths occurred from 1999 to 2019 corresponding to an AAMR of 0.407(0.401-0.412) per 100,000 population-year. The overall AAMR reduced from 0.759 to 0.223 per 100,000 population-year from 1999 to 2019[average APC -6.5(-7.5; -5.5)]. The reduction was reported in both <45 age group [average APC -6.5(-7.9; -5.1)] and >45 age group [-6.2(-7.3; -5.0)]; among females [average APC -6.1(-7.8; -4.3)] and males [-6.1(-7.2; -5.0)]; among Whites [average APC -6.9(-7.8; -5.9)] and Blacks [-5.0(-7.4; -2.5)]. The reduction in mortality as per the census region was highest in the west followed by Mid-West, North-East and South [average APC -6.8(-8.6; -5.0); -6.2(-8.8; -3.6); -5.7(-7.0; -4.4); -5.5(-7.4; -3.6), respectively]. CONCLUSION: There was a significant decrease in the TTAI associated mortality trends in the United States across 1999-2019 with a consistent decline in all demographic and regional subgroups.

Left Ventricular Assist Device: Review of Antimicrobial Prophylaxis Strategies and Incidence of Infections at a Tertiary Care Center 12-Year Experience.

Background: Left ventricular assist devices (LVAD) have an associated infection rate of 13%-80% postimplant. An optimal strategy for surgical infection prophylaxis (SIP) at the time of implantation has not been well defined. We aimed to evaluate the different LVAD implantation antibiotic prophylaxis regimens as well as the incidence of LVAD infection at our institution. Methods: We performed a single-center, retrospective study of patients who underwent LVAD implantation between February 2007 and June 2019. The primary outcome was the incidence of LVAD infection (LVADI), within 3 months and 1 year of placement, between patients who received expanded or narrow-spectrum regimens for SIP. We assessed outcomes using Kaplan-Meier, time-to-first event. We used a noninferiority analysis, which was established if the narrow-spectrum event rate was no more than 5% greater than the expanded-spectrum event rate. Results: We included 399 patients, 305 (76.4%) patients received narrow-spectrum SIP, whereas the remaining 94 (23.6%) patients received the expanded-spectrum regimen. Statistical noninferiority of the narrow spectrum to the multiple drug regimen was demonstrated at both time points, and statistical superiority of the narrow-spectrum group across 12-month follow up was further evident (P = .037). Conclusions: We report evidence supporting noninferiority, or even superiority, of the narrow-spectrum over expanded-spectrum antimicrobial prophylaxis strategy with respect to LVADI. These findings support data-driven antimicrobial prophylaxis strategies.

Clinical characteristics, management, and outcomes of patients with primary cardiac angiosarcoma: A systematic review.

Primary cardiac angiosarcomas (PCA) are highly aggressive malignant heart tumors. Previous reports have shown a poor prognosis regardless of management, and no consensus or guidelines exist. It is necessary to clarify this information since patients with PCA have a short survival. Therefore, we aimed to systematically review clinical manifestations, management, and outcomes. We systematically searched in PubMed, Scopus, Web of Science, and EMBASE. We intended to include cross-sectional studies, case-control studies, cohort studies, and case series that reported clinical characteristics, management, and outcomes of patients with PCA. As a methodological approach, we used the Joanna Briggs Institute Critical Appraisal Checklist for Case Series and the Newcastle-Ottawa Scale for cohorts. We included six studies (five case series, one cohort). The mean/median age ranged from 39 to 48.9 years. Male sex was predominant. The most frequent manifestations were dyspnea (range: 50%-80%), pericardial effusion (29% & 56%), and chest pain (10%-39%). The mean tumor size ranged from 5.8 to 7.2 cm, with the majority of these localized in the right atrium (70-100%). The most common locations of metastasis were the lung (20%-55.6%), liver (10%-22.2%), and bone (10%-20%). Resection (22.9%-94%), and chemotherapy as neoadjuvant or adjuvant (30%-100%) were the most commonly used methods of treatment. Mortality ranged from 64.7% to 100%. PCA often presents late in its course and usually results in poor prognosis. We strongly recommend performing multi-institutional prospective cohorts to better study disease course and treatments to develop consensus, algorithms, and guidelines for this type of sarcoma.

Analysis of Cardiac Computed Tomography Anatomy in Patients With Severe Tricuspid Regurgitation Considered for Transcatheter Intervention.

Background: Severe tricuspid regurgitation (TR) is associated with considerable morbidity/mortality in an elderly population with multiple comorbidities. There is interest in transcatheter interventions to manage severe TR. Understanding complex right heart (RH) geometry and tricuspid valve shape and size has implications for patient/device selection for transcatheter intervention. We characterized RH anatomy by computed tomography in patients with symptomatic severe TR considered for intervention. Methods: The retrospective Mayo Clinic study included 29 patients with an echocardiogram and cardiac computed tomography angiogram considered for intervention of severe TR from March 01, 2016 to December 15, 2020. Patients were divided into 2 groups: intervention (surgical or transcatheter; n = 17) and medical management alone (n = 12). Results: Mean age was 83 ± 8 (83% female), 100% had atrial fibrillation, and 62% had chronic kidney disease ≥3a. Ninety-seven percent were symptomatic, 93% had been prescribed loop diuretics, and 24% had device leads. Mean tricuspid annular plane systolic excursion was 16.8 ± 4.5 mm, effective regurgitant orifice area was 81 ± 33 mm2, and cardiac index was 2.6 ± 0.6 L/min/m2. Forty-one percent had at least moderate right ventricular (RV) dysfunction with a mean RV systolic pressure of 46 ± 16 mmHg. Patients receiving intervention had significantly larger effective regurgitant orifice area (101 ± 33 vs. 63 ± 22 mm2, p = 0.033), shorter tricuspid leaflet tenting length (6.5 ± 3.0 vs. 8.9 ± 2.7 mm, p = 0.042), and smaller annuloplasty diagnostic perimeter during diastole (120.1 ± 16.6 vs. 131.1 ± 7.4 mm, p = 0.041). Intervention patients tended to have better right ventricular function, smaller RV and inferior vena cava size, and more severe symptoms. The maximal tricuspid annulus diameter in systole and diastole was 51 ± 5 and 53 ± 7 mm, respectively. Conclusions: Severe TR patients referred for transcatheter intervention present with severe RH enlargement with a large proportion having tricuspid annulus dimensions outside the range for current devices available in clinical trials. The presented data have implications for device development/selection and procedural feasibility.

Pulmonary Capillary Recruitment Is Attenuated Post Left Ventricular Assist Device Implantation.

There is limited knowledge of pulmonary physiology and pulmonary function after continuous flow-left ventricular assist device (CF-LVAD) implantation. Therefore, this study investigated whether CF-LVAD influenced pulmonary circulation by assessing pulmonary capillary blood volume and alveolar-capillary conductance in addition to pulmonary function in patients with heart failure. Seventeen patients with severe heart failure who were scheduled for CF-LVAD implantation (HeartMate II, III, Abbott, Abbott Park, IL or Heart Ware, Medtronic, Minneapolis, MN) participated in the study. They underwent pulmonary function testing (measures of lung volumes and flow rates) and unique measures of pulmonary physiology using a rebreathe technique that quantified the diffusing capacity of the lungs for carbon monoxide (DLCO) and diffusing capacity of the lungs for nitric oxide before and 3 months after CF-LVAD implantation. After CF-LVAD, pulmonary function was not significantly changed (p >0.05). For lung diffusing capacity, alveolar volume (VA) was not changed (p = 0.47), but DLCO was significantly reduced (p = 0.04). After correcting for VA, DLCO/VA showed a trend toward reduction (p = 0.08). For the alveolar-capillary component, capillary blood volume (Vc) was significantly reduced (p = 0.04), and alveolar-capillary membrane conductance trended toward a reduction (p = 0.06). However, alveolar-capillary membrane conductance/Vc was not altered (p = 0.92). In conclusion, soon after CF-LVAD implantation, Vc is reduced likely because of pulmonary capillary derecruitment, which contributes to the decrease in lung diffusing capacity.

Impact of concomitant coronary artery bypass grafting on postoperative outcomes in patients undergoing pericardiectomy: A 33-year experience.

Objective: Concomitant coronary artery bypass grafting (CABG) and pericardiectomy (PC) can be a technically challenging operation. We sought to study the outcomes of patients undergoing concomitant PC and CABG. Methods: Between July 1983 and August 2016, 70 patients (median age, 67 years; 88% males) underwent concomitant PC and CABG (PC + CABG group). Multivariable analysis was used to identify predictors of mortality. Matched patients who underwent isolated PC (PC group) were identified, and postoperative outcomes and long-term survival in the 2 groups were compared. Results: Compared with the PC group, cardiopulmonary bypass time was significantly longer in the PC + CABG group (82 minutes vs 61 minutes; P < .001). In-hospital mortality was 4% in the PC group and 7% in the PC + CABG group (P = .380). Multivariable analysis identified peripheral vascular disease (hazard ratio [HR], 2.67; 95% CI, 1.06-6.76; P = .04) as a predictor of increased morbidity or mortality and a borderline association with New York Heart Association functional classes III and IV (HR, 2.41; 95% CI, 0.99-5.86; P = .05) with increased morbidity and mortality in the PC + CABG group. Kaplan-Meier estimates demonstrated similar late mortality rates in the 2 groups at a 15-year follow-up (P = .700). Conclusions: Concomitant PC and CABG is not associated with increased morbidity or mortality compared with isolated PC. Thus, CABG should not be denied at the time of PC.

Artificial Intelligence-Derived Electrocardiogram Assessment of Cardiac Age and Molecular Markers of Senescence in Heart Failure.

OBJECTIVE: To ascertain whether heart failure (HF) itself is a senescent phenomenon independent of age, and how this is reflected at a molecular level in the circulating progenitor cell niche, and at a substrate level using a novel electrocardiogram (ECG)-based artificial intelligence platform. PATIENTS AND METHODS: Between October 14, 2016, and October 29, 2020, CD34+ progenitor cells were analyzed by flow cytometry and isolated by magnetic-activated cell sorting from patients of similar age with New York Heart Association functional classes IV (n = 17) and I-II (n = 10) heart failure with reduced ejection fraction and healthy controls (n = 10). CD34+ cellular senescence was quantitated by human telomerase reverse transcriptase expression and telomerase expression by quantitative polymerase chain reaction, and senescence-associated secretory phenotype (SASP) protein expression assayed in plasma. An ECG-based artificial intelligence (AI) algorithm was used to determine cardiac age and difference from chronological age (AI ECG age gap). RESULTS: CD34+ counts and telomerase expression were significantly reduced and AI ECG age gap and SASP expression increased in all HF groups compared with healthy controls. Expression of SASP protein was closely associated with telomerase activity and severity of HF phenotype and inflammation. Telomerase activity was more closely associated with CD34+ cell counts and AI ECG age gap. CONCLUSION: We conclude from this pilot study that HF may promote a senescent phenotype independent of chronological age. We show for the first time that the AI ECG in HF shows a phenotype of cardiac aging beyond chronological age, and appears to be associated with cellular and molecular evidence of senescence.

A Single-Center Bleeding Comparison of Warfarin Plus Aspirin or Clopidogrel Following Coronary Artery Bypass Grafting and Surgical Valve Replacement.

The optimal antithrombotic therapy following combined coronary artery bypass graft (CABG) and surgical valve replacement (SVR) surgery remains unclear. The aim of this single-center, retrospective cohort study was to assess the safety and effectiveness of a vitamin K antagonist (VKA) plus either aspirin or clopidogrel in patients following combined CABG and SVR. The primary endpoint was the occurrence of bleeding within six months. The secondary endpoint was the occurrence of CV death, stroke, acute coronary syndrome (ACS), or valve dysfunction. Outcomes were identified by pre-specified ICD codes. A total of 629 patients were included in the analysis, with 583 patients receiving aspirin and 46 patients receiving clopidogrel. Bleeding occurred in 1.7% of patients receiving aspirin and in 0% of patients receiving clopidogrel (p = 0.99). CV death, stroke, ACS, or valve dysfunction occurred in 3.1% of patients receiving aspirin and 4.3% of patients receiving clopidogrel (p = 0.65). In this study, there were no differences in the safety or effectiveness of a VKA plus either aspirin or clopidogrel following combined CABG and SVR.

Opioid usage after left ventricular assist device implantation: A single center retrospective analysis.

BACKGROUND: Opioid use disorder is a known national concern and extends across multiple populations; however, opioid use in the left ventricular assist device (LVAD) population and subsequent outcomes is not well described. OBJECTIVES: We sought to understand opioid use and patient characteristics among the LVAD population at a single center and associated outcomes after index LVAD hospitalization in relation to opioid use. METHODS: A single center retrospective review of pre-operative and post-operative opioid use was characterized during the index admission for LVAD implantation. Additionally, we reviewed medical records from patients with opioid prescription at hospital discharge stratified by oral morphine equivalents (OME) and refills of opioid prescriptions with analysis of the outcomes of readmission and death after hospital discharge from the index admission for LVAD implantation. RESULTS: Opioid exposed patients in this cohort increased in frequency from 0% of patients in 2007 to a peak of 25.9% of patients in 2013, and gradually declined thereafter to 12.5% in 2017. CONCLUSIONS: Despite the rate of high dose opioid therapy in this cohort, neither opioid use, opioid history, oral morphine equivalents (OME), or opioid refills portended worse survival after LVAD implantation.

The Utility of the Omentum Flap for Complex Intrathoracic Problems.

Introduction: Omentum flap is a viable reconstructive option for complex chest wall and mediastinal reconstruction. The impact of vasoconstrictors and the laminar pattern of blood flow associated with left ventricular assist devices (LVADs) on the outcomes of reconstructions has not been thoroughly evaluated. Methods: A retrospective review of all patients who underwent chest wall or mediastinal reconstruction using pedicled omentum flaps between 2003 and 2019. Results: Forty patients (60% males) underwent chest wall or mediastinal reconstruction using a pedicled omentum flap at a mean age of 58 years. The median follow-up was 24.3 months. The most common indication was the reconstruction of anterior chest wall/sternal defects (n = 16), followed by coverage of repaired bronchopleural fistula (n = 6), osteoradionecrosis of the anterolateral chest wall (n = 5), reconstruction of anterior/lateral chest wall following oncologic resections (n = 5), coverage of replaced infected LVAD (n = 4), and coverage of exposed/replaced aortic root vascular grafts (n = 4). Vasoconstrictors were used in 26 patients (65%). Eight flaps had partial necrosis, and none of the flaps had complete necrosis. There was no difference in flap complication rates in patients who received vasoconstrictors during the case compared to those who did not (P = 1.0). Thirteen (33%) flaps were skin grafted at a median of 13 days with 100% skin graft viability. Abdominal incisional hernia developed in 8 patients. In patients with LVADs, the omentum remained viable during the follow-up period. Conclusion: The ability of the omentum to easily reach various regions in the chest and the low failure rate make this flap a reliable reconstructive method.

Introduction: Un lambeau péritonéal représente une option reconstructive viable pour les reconstructions complexes de la paroi thoracique et du médiastin. L'impact des vasocontricteurs et l'aspect laminaire du flux sanguin associé aux dispositifs d'assistance du ventricule gauche sur les résultats des reconstructions n'ont pas été pleinement évalués. Méthodes: Une analyse rétrospective a inclus tous les patients ayant subi une reconstruction de la paroi thoracique ou du médiastin au moyen de lambeaux péritonéaux pédiculés entre 2003 et 2019. Résultats: Quarante patients (hommes : 60 %) ont subi une reconstruction de la paroi thoracique ou du médiastin faisant appel à un lambeau péritonéal pédiculé à l'âge moyen de 58 ans. Le suivi médian a été de 24,3 mois. L'indication la plus fréquente était la reconstruction pour manque de la paroi thoracique antérieure/du sternum (n = 16), suivie par la couverture d'une fistule bronchopleurale réparée (n = 6), une ostéoradionécrose de la paroi thoracique antérolatérale (n = 5), une reconstruction de la paroi thoracique antérieure/latérale après résections oncologiques (n = 5), la couverture d'un dispositif d'assistance du ventricule gauche infecté et remplacé (n = 4), la couverture de greffons vasculaires de la racine aortique exposés/remplacés (n = 4). Des vasoconstricteurs ont été utilisés chez 26 patients (65 %). Huit lambeaux ont présenté une nécrose partielle et aucun n'a eu de nécrose complète. Il n'y a pas eu de différence dans les taux de complications des lambeaux chez les patients ayant reçu des vasoconstricteurs pendant l'intervention par rapport à ceux qui n'en ont pas reçu (P = 1,0). Treize lambeaux (33 %) étaient greffés de peau dans un délai médian de 13 jours avec une viabilité de la greffe cutanée de 100 %. Une hernie abdominale post-incision est apparue chez 8 patients. Chez les patients porteurs de dispositif d'assistance du ventricule gauche, le péritoine est resté viable pendant la période de suivi. Conclusion: La capacité du péritoine à atteindre facilement différentes régions thoraciques et le faible taux d'échec font de ce lambeau une méthode reconstructive fiable.

Impact of time to chest closure on early and late survival in adults with delayed sternal closure.

OBJECTIVES: Delayed sternal closure (DSC) after cardiac surgery is a temporizing measure to address coagulopathy or haemodynamic instability after cardiac surgery. We sought to study: (i) indications and temporal trends for DSC, (ii) factors associated with time to chest closure and (iii) its impact on short-term and long-term outcomes. METHODS: From January 2007 to December 2017, 494 patients (median age 67 years, 66% males) required DSC after cardiac surgery. Medical records were reviewed for indications, risk factors, time to DSC and outcomes. Multivariable Cox regression via landmark analysis of 486 5-day survivors was used to investigate the impact of time to chest closure on early and late survival. RESULTS: Coagulopathy and haemodynamic instability were the most common indications. Median time to chest closure was 2 days. Pre-/intraoperative extracorporeal membranous oxygenation, severe right ventricular dysfunction and diabetes mellitus were associated with longer time to chest closure. Longer time to closure was associated with increased risk of operative complications and operative mortality, but did not have a statistically significant association with late mortality. Increasing age, pulmonary hypertension and a greater number of prior sternotomies were also found to be associated with overall mortality. CONCLUSIONS: While longer time to chest closure was associated with increased rates of operative complications and operative mortality, it did not reveal a statistically significant association with long-term survival.