Aspergillus mediastinitis after cardiac surgery.

BACKGROUND: Mediastinitis is a serious complication after cardiac surgery. While bacteria are the more common pathogens, fungal infections are rare. In particular, several cases of postoperative Aspergillus mediastinitis have been reported, the majority of which had an extremely poor outcome. METHODS: A case of mediastinitis in a 42-year-old patient due to Aspergillus fumigatus after cardiac surgery is described. Two main risk factors were found: cardiogenic shock requiring veno-arterial extracorporeal life support and failure of primary closure of the sternum. A full recovery was attained after surgical drainage and antifungal therapy with liposomal amphotericin B, followed by a combination of voriconazole and caspofungin. The patient was followed for 18 months without relapse. RESULTS: This is an extremely rare case of postoperative Aspergillus mediastinitis exhibiting a favourable outcome. Based on a systematic review of the literature, previous cases were examined with a focus on risk factors, antifungal therapies, and outcomes. CONCLUSION: The clinical features of postoperative Aspergillus mediastinitis may be paucisymptomatic, emphasizing the need for a low index of suspicion in cases of culture-negative mediastinitis or in indolent wound infections. In addition to surgical debridement, the central component of antifungal therapy should include amphotericin B or voriconazole.

Colder is better during hypothermic circulatory arrest for acute type A aortic dissection.

OBJECTIVES: To evaluate the influence, on early postoperative outcomes, of temperature during hypothermic circulatory arrest in emergent surgery for acute type A aortic dissection. DESIGN: Hypothermic circulatory arrest (HCA) with antegrade cerebral perfusion was performed in 63 patients who underwent emergent surgery for acute type A aortic dissection between 2000 and 2009. Patients were retrospectively separated in two groups: ( 1 ) deep HCA, lowest nasopharyngeal temperature < 17 °C (n = 29; 46%) and ( 2 ) moderate HCA, lowest nasopharyngeal temperature ≥ 17 °C (n = 34; 54%). RESULTS: Hospital mortality reached 27%. The nasopharyngeal temperature did not influence postoperative mortality or neurological outcome. Patients with deep HCA had significantly lower rate of infection (33% vs. 69%; p = 0.009) and shorter median intensive care unit length of stay (4 days ( 17 ) vs. 15.5 days ( 26 ) p = 0.017). Multiple regression analysis revealed that the lowest nasopharyngeal temperature was the only significant variable associated with intensive care unit length of stay (p = 0.005). CONCLUSIONS: Patients suffering from acute type A aortic dissection might benefit from colder hypothermia during circulatory arrest.

Risk factors for hospital death after surgery for type A aortic dissection.

This study was undertaken to identify perioperative risk factors for hospital death in patients undergoing surgery for acute type A aortic dissection. Between 2000 and 2009, 101 consecutive patients underwent emergency surgery for acute type A aortic dissection. Four patients died before institution of cardiopulmonary bypass or completion of the procedure. In the remaining 97 (68 men; mean age, 63.4±16.7 years), proximal repair was performed using ascending aortic replacement with valve re-suspension in 52 (53.6%) and composite valve graft replacement in 44 (45.4%). Distal repair required hemi- or total arch replacement in 42 (43.3%) patients. Overall hospital mortality reached 25.8% (25/97 patients). Logistic regression analysis revealed that advanced age, location of an intimal tear in the arch or more distally, and preoperative coronary malperfusion were significant independent risk factors for hospital death. No procedure-related variables were significant risk factors. Current hospital mortality in patients undergoing emergency surgery for acute type A aortic dissection remains high, but seems to be mainly determined by preoperative variables. More aggressive proximal or distal repairs were not associated with increased mortality.

Resolution of sleep-disordered breathing with a biventricular assist device and recurrence after heart transplantation.

Sleep-disordered breathing (SDB) is common in chronic heart failure. Both obstructive sleep apnea syndrome (OSAS) and central sleep apnea with periodic Cheyne-Stokes respiration (CSA-CSR) can occur. CSA-CSR is believed to correlate with heart function. Little information exists about the impact of mechanical assist devices and heart transplantation on SDB in patients with end-stage heart failure. Here, we describe, for the first time, the effects on SDB of a biventricular external assist device and of heart transplantation used successively in the same patient.

Aortic root replacement after previous surgical intervention on the aortic valve, aortic root, or ascending aorta.

BACKGROUND: Aortic root replacement after a previous operation on the aortic valve, aortic root, or ascending aorta remains a major challenge. METHODS: Records of 56 consecutive patients (44 men; mean age, 56.4 +/- 13.6 years) undergoing reoperative aortic root replacement between June 1994 and June 2005 were reviewed retrospectively. RESULTS: Reoperation was performed 9.4 +/- 6.7 years after the last cardiac operation. Indications for reoperation were true aneurysm (n = 14 [25%]), false aneurysm (n = 10 [18%]), dissection or redissection (n = 9 [16%]), structural or nonstructural valve dysfunction (n = 10 [18%]), prosthetic valve-graft infection (n = 12 [21%]), and miscellaneous (n = 1 [2%]). Procedures performed were aortic root replacement (n = 47 [84%]), aortic root replacement plus mitral valve procedure (n = 5 [9%]), and aortic root replacement plus arch replacement (n = 4 [7%]). In 14 (25%) patients coronary artery bypass grafting had to be performed unexpectedly during the same procedure or immediately after the procedure to re-establish coronary perfusion. Hospital mortality reached 17.9% (n = 10). Multivariate logistic regression analysis revealed the need for unplanned perioperative coronary artery bypass grafting as the sole independent risk factor for hospital death (P = .005). Actuarial survival was 83.8% +/- 4.9% at 1 month, 73.0% +/- 6.3% at 1 year, and 65.7% +/- 9.0% at 5 years after the operation. One patient had recurrence of endocarditis 6.7 months after the operation and required repeated homograft aortic root replacement. CONCLUSION: Reoperative aortic root replacement remains associated with a high postoperative mortality. The need to perform unplanned coronary artery bypass grafting during reoperative aortic root replacement is a major risk factor for hospital death. The optimal technique for coronary reconstruction in this setting remains to be debated.

The risk of reoperative heart valve procedures in Octogenarian patients.

BACKGROUND AND AIM OF THE STUDY: The authors' experience is reported of cardiac reoperations for valvular heart disease in octogenarian patients. METHODS: The records of 22 consecutive patients (10 men, 12 women) aged > or =80 years (mean age 82.4+/-2.3 years) who underwent cardiac reoperation for aortic and/or mitral valvular heart disease at the authors' institution between 1991 and 2001 were retrospectively reviewed. RESULTS: Indications for reoperation were structural dysfunction of a previously implanted bioprosthetic valve in 11 patients (50%), new valvular heart disease in six (27%), progression of rheumatic valvular heart disease in four (18%), and prosthetic valve infective endocarditis in one patient (5%). Fourteen patients (64%) underwent isolated aortic valve replacement (AVR), two (9%) had AVR plus coronary artery bypass grafting (CABG), one patient (5%) had aortic root replacement plus CABG, three patients (14%) had isolated mitral valve replacement (MVR), one patient (5%) had MVR plus ascending aorta replacement, and one (5%) had AVR plus MVR. Postoperative complications occurred in 18 patients (82%). The hospital mortality rate was 32%. Actuarial survival estimates at one year, and at three and five years were 62.6%, 56.3% and 40.2%, respectively. CONCLUSION: Cardiac reoperations for valvular heart disease in octogenarians carry a high postoperative morbidity and mortality. These findings must be taken into account in the management of associated mild or moderate valvular heart disease, and in the choice of heart valve prosthesis at the initial operation in younger patients.

Long-term results of the bentall operation versus separate replacement of the ascending aorta and aortic valve.

BACKGROUND AND AIMS OF THE STUDY: Aortic valve disease associated with ascending aorta dilatation can be treated either by separate replacement of the aortic valve and ascending aorta, or by a composite valved graft. METHODS: Between 1974 and 1999, 117 patients underwent a Bentall operation (BP), and 63 a separate replacement procedure (SP) of the ascending aorta and aortic valve. Anatomic lesions were dystrophic aneurysm in 79 patients, annuloectasia in 65, chronic dissection in 14, acute dissection in 18, and other etiology in four. Mean follow up was 3.45+/-3.47 and 8.75+/-6.8 years in the BP and SP groups, respectively. RESULTS: Early mortality was 7.7% in the BP group versus 11% in the SP group (p = NS). Actuarial survival at 10 years postoperatively in these groups was respectively 77.7+/-5.6% versus 75.8+/-6.9% (p = NS). However, freedom from late complication of the ascending aorta was significantly different (97.3+/-1.9% versus 68.3+/-9.0% at 10 years postoperatively). SP was identified as a risk factor for late complication of the ascending aorta by multivariate analysis (p = 0.01; odds ratio = 9). No statistical difference was observed on late reoperation rates. CONCLUSION: Separate replacement of the ascending aorta and aortic valve carries a higher complication rate for the remaining ascending aorta on long-term follow up when compared with the Bentall procedure. However, there were no differences in terms of late mortality.

Risk factor analysis for proximal and distal reoperations after surgery for acute type A aortic dissection.

OBJECTIVE: This study was undertaken to determine significant risk factors for proximal or distal reoperations after surgical correction of acute type A aortic dissection. METHODS: Between 1980 and 2000, a total of 160 consecutive patients (mean age 57.5 +/- 13.3 years, 126 men) underwent surgery for acute type A aortic dissection. Proximal repair was performed by means of ascending aorta replacement with valve resuspension in 130 cases (81.3%), composite graft replacement in 19 cases (11.9%), separate aortic valve and ascending aorta replacement in 7 cases (4.4%), and aortic repair in 1 case (0.6%). Distal repair required arch replacement in 23 cases. Follow-up time averaged 4.51 +/- 5.6 years per patient. RESULTS: Survival estimates after initial operation were 66.1% +/- 3.8%, 57.7% +/- 4.2%, 52.2% +/- 4.6%, and 42.5% +/- 5.8% at 1, 5, 10, and 15 years, respectively. Thirty patients required 37 reoperations at a mean interval of 5.7 +/- 4.5 years after the initial operation. Freedoms from reoperation were 96.9% +/- 1.8%, 74.7% +/- 5.3%, 60.8% +/- 6.8%, and 39.3% +/- 9.1% at 1, 5, 10, and 15 years, respectively. Reoperations included procedures on the proximal aorta (aortic root or valve) in 21 cases and on the distal aorta or its side branches in 19 cases. Cox regression analysis distinguished severe preoperative aortic valve insufficiency as the only significant risk factors for proximal reoperation; younger patient age, more distal extent of dissection, and more recent operative date were found to be significant risk factors for distal reoperation. CONCLUSION: Patients with acute type A aortic dissection who have severe aortic valve insufficiency are at increased risk for proximal reoperation. These patients should benefit from a more aggressive proximal repair at initial operation. Distal extent of aortic resection at initial operation did not significantly influence the risk of distal reoperation.