Topical Vancomycin and Risk of Sternal Wound Infections: A Double-Blind Randomized Controlled Trial.

BACKGROUND: The use of topical vancomycin in the reduction of sternal wound infection (SWI) risk has become a point of contention. The earlier literature consists of observational studies and 1 unblinded trial. Hence, the objective of this study was to assess whether vancomycin reduces the incidence of SWI in a double-blind randomized controlled trial. METHODS: Patients were randomized 1:1 to either vancomycin-soaked (vancomycin) or saline-soaked (control) sponges. The sponges were applied once the sternum was opened and were removed just before sternal closure. Patients were followed up at 3 months and at 1 year postoperatively to determine the incidence of SWI in each group. Results were analyzed according to the modified intention-to-treat principle. RESULTS: This study assessed 1038 patients for eligibility and enrolled 1037 patients. There were 517 patients randomized to the vancomycin group and 520 patients randomized to the control group. Analysis was performed on 1021 patients. At 3 months postoperatively, there was no significant difference in the incidence of SWI between the vancomycin and control groups (2.7% vs 4.1%; P = .23). There was also no significant difference between the vancomycin and control groups in the risk of superficial, deep, and organ-space infections. Similar findings were observed 1 year postoperatively. The most common organism isolated was coagulase-negative Staphylococcus. CONCLUSIONS: The use of vancomycin applied to the sternum during cardiac surgery does not reduce the incidence of SWI.

Redo Heart Double-Lung Transplant in a Previous Double-Lung Transplant Recipient With Pneumonectomy: A Case Report.

Placing a new donor lung into a postpneumonectomy pleural space has many potential surgical challenges. We report the technical challenges we faced in a case of a 42-year-old man who had initially undergone a double-lung transplant for idiopathic pulmonary arterial hypertension. Unfortunately, his left transplanted lung failed, which required a left pneumonectomy. Eight years later, his remaining right lung failed. He was evaluated and deemed suitable for retransplant. Our report presents the first successful redo heart double-lung transplant surgery preceded by pneumonectomy. There were significant technical intraoperative challenges; however, the procedure was performed successfully with an uneventful postoperative course and follow-up.

Outcomes of Solo Smart valve in a single-center experience of 270 patients.

BACKGROUND: The Solo Smart pericardial aortic valve has been widely used in Europe as an option for aortic valve replacement (AVR). We are reporting early and midterm clinical outcomes of AVR with the Solo Smart valve in a single North America center. METHODS: This is a retrospective study of 270 consecutive patients who had AVR at Mazankowski Alberta Heart Institute from February 2011 to March 2015. Follow-up and echocardiographic data were collected retrospectively from electronic and paper charts. Univariate and multivariate analysis were performed to evaluate the results. RESULTS: The mean age was 71.2±10.0 years, 67.4% were male, and 79.3% had combined procedures. Mean STS Score was 4.18±3.91. Early mortality was 3.7% for the entire group and 0% for isolated AVR group. Mean cross-clamp time for isolated AVR and AVR with concomitant procedure was 70.8±12.7 min and 117.0±45.0 min, respectively. Permanent pacemaker implantation was necessary in 2.2% of patients. Echocardiography demonstrated a reduction in mean gradients from 40.8±17.4 mmHg to 7.6±3.7 mmHg and peak gradient from 72.5±48.8 mmHg to 15.5±7.5 mmHg. The 1-, 3-, and 5-year overall survival was 93.0%, 86.5% and 75.9%, respectively. At 5 years, freedom from valve-related death was 92.4%, freedom from structural valve deterioration and freedom from aortic valve reoperation were 96.4% and 98%, respectively. CONCLUSIONS: The Solo Smart valve is safe and has excellent hemodynamic performance. Aortic valve reoperation and rates of valve-related adverse events during midterm follow-up were low.

Case series using the ROTAFLOW system as a temporary right ventricular assist device after HeartMate II implantation.

The purpose of this study was to investigate the outcomes of using the ROTAFLOW as a temporary right ventricular assist device (RVAD) support in patients who develop right ventricular dysfunction (RVD) at the time of left ventricular assist device (LVAD) implantation with the HeartMate (HM) II. We conducted a retrospective chart review of patients in whom the ROTAFLOW system was used for RV support during HM II implantation from October 2009 to September 2011. Twelve patients received a ROTAFLOW as an RVAD at the time of HM II implantation; 83% had preoperative echocardiography evidence of either moderate or severe RVD. The most common complications in the postoperative period were the need for tracheostomy because of respiratory failure (45%) and mediastinal bleeding requiring exploration (36%). Ninety-one percent of patients survived to discharge, and all were alive at 1 year follow-up. Our results show that temporary RVAD support with the ROTAFLOW system in the setting of RVD at the time of HM II implantation is feasible and effective.

Use of RotaFlow (MAQUET) for temporary right ventricular support during implantation of HeartMate II left ventricular assist device.

Temporary right ventricular (RV) support is considered during insertion of a left ventricular assist device in patients who are at risk of right ventricular dysfunction. There are several circuits and cannulation strategies available. Here, we report an effective and safe method for achieving RV support using the RotaFlow (Maquet) extracorporeal pump with inflow and outflow grafts placed through small opposing lateral thoracotomy incisions.

Expression of QK/QR/RRRAA or DERAA motifs at the third hypervariable region of HLA-DRB1 and disease severity in rheumatoid arthritis.

OBJECTIVE: To examine the relationship between disease severity in patients with confirmed rheumatoid arthritis (RA) and the carriage of alleles expressing the high risk epitope (HRE) QK/QR/RRRAA or the low risk epitope (LRE) DERAA at positions 70-74 of the third hypervariable region of HLA-DRB1. METHODS: A case-control design to compare allele carriage rates in 204 Caucasian subjects with severe RA and mild RA and healthy controls. Patients had a mean disease duration of 12-18 years and severity of RA was defined using clinical and therapeutic criteria. Molecular typing at the HLA-DRB1 locus was performed using a polymerase chain reaction method. RESULTS: Eighty-seven percent of patients (52/60) with severe RA had one or more of the alleles bearing the QK/QR/RRRAA motif or HRE, compared with 54% (21/39) with mild RA (OR 5.57, p = 0.0007) and 39% (41/105) of controls (OR 10.15, p < 0.0001). Twenty-five percent of patients (15/60) with severe disease expressed 2 disease associated HRE DRB1 alleles, compared with 13% of patients (5/39) with mild disease (OR 2.3, p = NS) and 5% (5/105) of controls (OR 6.67, p = 0.0003). In contrast, only 5% of patients (3/60) with severe RA expressed one of the LRE alleles that carry the DERAA motif at positions 70-74, compared with 31% of patients (12/39) with mild RA (OR 0.12, p = 0.0013) and 22% of controls (23/105) (OR 0.19, p = 0.0082). No patient or control was homozygous for LRE alleles. Eighty-three percent (50/60) of patients with severe RA expressed the HRE without the LRE, compared with 44% (17/39) of those with mild disease (OR 6.47, p < 0.0001) and 35% (37/105) of controls (OR 9.19, p < 0.0001). In contrast, only one patient (2%) with severe disease expressed the LRE without the HRE, compared with 20% (8/39) of those with mild disease (OR 0.07, p = 0.0047) and 16% (17/105) of controls (OR 0.09, p = 0.009). There was no significant difference between the 3 groups in the frequency of patients who expressed both or neither epitope. Logistic regression showed that age at disease onset (p = 0.0009), duration of disease (p = 0.007), positive rheumatoid factor status (p = 0.003), and presence of the HRE or LRE (p = 0.00005) were significantly associated with the presence of severe disease. CONCLUSION: HLA-DRB1 alleles appear to confer an important bidirectional influence on the risk of disease severity in RA, with 20-fold difference in OR between those associated with the highest (HLA-DRB1*0401) and lowest (HLA-DRB1*1301/02) risk. The HRE and LRE exhibit diametrically opposed effects, which may be mutually antagonistic. These data support a multistep pathogenesis in which MHC class II genes are one component of a coordinate genetic and environmental interaction leading to immunological injury and joint destruction.