Sternal wound complications in patients undergoing orthotopic heart transplantation.

PURPOSE: The incidence and management of sternal wound complications in patients undergoing orthotopic heart transplantation (OHT) is not well studied. We report outcomes in heart transplant patients who developed sternal infections requiring reoperations. METHODS: From 2004 to 2013, 437 patients underwent OHT at a single institution. In a retrospective review, patients who developed sternal infections (Infection group, n = 27) were compared with those without (Control group, n = 410). RESULTS: Sternal infection rate was 6.2% (n = 27). Demographics were similar (Table 1). Infection group had higher rates of COPD 25% vs 13%, P = 0.03, and previous cardiac surgery via median sternotomy 28% vs 15%, P = 0.03. Infection group had a greater incidence of prolonged ventilation, 44% vs 31%, P = 0.2, renal failure 56% vs 24%, P = 0.001, dialysis requirement 30% vs 10%, P = 0.006, permanent stroke 11% vs 2%, P = 0.02, perioperative myocardial infarction 4% vs 0.2%, P = 0.09. The infection group had a longer ICU stay (524 + 410 vs 187 + 355 hours, P = 0.001) and hospitalization (59 + 28 vs 0.29 + 43 days, P = 0.001). In-hospital/30-day mortality was 30% vs 19%, P = 0.2. The mean time for sternal reoperation at 44 + 50 days. Deep wound infection (41%) and sternal dehiscence (22%) were common presentations. Causative organisms were Enterobacter (22%), Klebsiella (15%), and Pseudomonas (15%). Vancomycin (44%), 4th generation cephalosporin (37%), and fluoroquinolones (30%) were the most commonly used antibiotics. Surgical treatment included sternal debridement with pectoralis muscle flap (52%), primary closure (18%), and omental flap (11%). CONCLUSION: Sternal wound infections impart a significant burden on patients with OHT. Causative organisms are predominantly virulent gram-negative bacteria. Therefore, a high index of suspicion must be maintained for early detection and treatment.

Central Repair With Antegrade TEVAR for Malperfusion Syndromes in Acute Debakey I Aortic Dissection.

BACKGROUND: In acute DeBakey I aortic dissection presenting with malperfusion syndromes, we assessed whether standard open repair with concomitant antegrade stent grafting (thoracic endovascular aneurysm repair; TEVAR) of the descending thoracic aorta (DTA) improves outcomes compared with standard repair alone. METHODS: From 2005 to 2012, 277 patients with acute DeBakey I dissection underwent emergent operation. Of these, 104 patients (37%) presenting with end-organ malperfusion were divided into those undergoing standard distal repair entailing transverse hemiarch replacement (Standard group, n = 65) versus standard repair with concomitant DTA TEVAR during circulatory arrest (TEVAR group, n = 39). Prospectively maintained aortic dissection database was retrospectively reviewed. RESULTS: Demographic characteristics and preoperative comorbidities were similar. Circulatory arrest (56 ± 12 versus 34 ± 14 minutes, p < 0.001) and cross-clamp (176 ± 43 versus 119 ± 80, p = 0.001) times were longer in the TEVAR group. Overall, postoperative stroke rate (5% [n = 2] versus 6% [n = 4], p = 1), paraplegia rate (5% [n = 2] versus 5% [n = 3], p = 1.0), and renal failure rate (10% [n = 4] versus 22% [n = 14], p = 0.2) were similar. In-hospital/30-day mortality rate was lower in the TEVAR group but was not significant (18% (n = 7) versus 34% [n = 22], p = 0.1). In patients presenting with malperfusion involving greater than one end-organ system, the mortality rate was significantly improved in the TEVAR group (28% [n = 6] versus 58% [n = 14], p = 0.05). CONCLUSIONS: Standard repair with antegrade TEVAR of the DTA for acute DeBakey I aortic dissection presenting with malperfusion syndromes can be safely performed. Further, true lumen stabilization achieved through DTA TEVAR may provide a survival benefit in patients with distal multiorgan malperfusion.

The role of holistic processing in judgments of facial attractiveness.

Previous work has demonstrated that facial identity recognition, expression recognition, gender categorisation, and race categorisation rely on a holistic representation. Here we examine whether a holistic representation is also used for judgments of facial attractiveness. Like past studies, we used the composite paradigm to assess holistic processing (Young et al 1987, Perception 16 747-759). Experiment 1 showed that top halves of upright faces are judged to be more attractive when aligned with an attractive bottom half than when aligned with an unattractive bottom half. To assess whether this effect resulted from holistic processing or more general effects, we examined the impact of the attractive and unattractive bottom halves when upright halves were misaligned and when aligned and misaligned halves were presented upside-down. The bottom halves had no effect in either condition. These results demonstrate that the perceptual processes underlying upright facial-attractiveness judgments represent the face holistically. Our findings with attractiveness judgments and previous demonstrations involving other aspects of face processing suggest that a common holistic representation is used for most types of face processing.