Simple adaptations of surgical technique to critically reduce the risk of postoperative sternal complications in patients receiving bilateral internal thoracic arteries.

OBJECTIVES: Limited blood supply to the thoracic chest wall is a known risk factor for sternal wound complications after CABG. Therefore, bilateral internal thoracic arteries are still rarely utilized despite their proven superior graft patency. The aim of our study was to analyse whether modification of the surgical technique is able to limit the risk of sternal wound complications in patients receiving bilateral internal thoracic artery grafting. METHODS: All 418 non-emergent CABG patients receiving bilateral internal thoracic artery CABG procedures (BITA) from January 2001 to January 2012 were analysed for sternal wound complications. Surgical technique together with known risk factors and relevant comorbidity were analysed for their effect on the occurrence of sternal wound complications by means of multivariate logistic regression analysis. RESULTS: Sternal wound complications occurred in 25 patients (5.9%), with a sternal dehiscence rate of 2.4% (10 patients). In multivariate analysis, diabetes (odds ratio [OR]: 4.8, 95% CI: 1.9-11.7, P=0.001), but not obesity (OR: 1.6, 95% CI: 0.7-4.2, P=0.28) or chronic obstructive pulmonary disease (OR: 2.2, 95% CI: 0.87-5.6, P=0.1) was a relevant comorbid condition for sternal complications. Skeletonization of ITA grafts (OR: 0.17, 95% CI: 0.06-0.5, P=0.001) and the augmented use of sternal wires (OR: 0.24, 95% CI: 0.06-0.95, P=0.04) were highly effective in preventing sternal complications. The use of platelet-enriched-fibrin glue (PRF) sealant, however, was associated with more superficial sternal infections (OR: 3.7, 95% CI: 1.3-10.5, P=0.02). CONCLUSIONS: Adjusted for common risk factors, skeletonization of BITA grafts together with augmented sternal wires is effective in preventing sternal complications. The use of PRF sealant, however, increased the risk for superficial wound complications.

Propensity score-matched analysis of aortic valve replacement by mini-thoracotomy.

BACKGROUND AND AIM OF THE STUDY: Although minimally invasive aortic valve replacement (MIAVR) through an anterolateral mini-thoracotomy has been shown to reduce surgical trauma, the technique is utilized only at a few selected heart surgery centers. The study aim was to demonstrate the implementation of a MIAVR program at the Innsbruck Medical University, Austria. METHODS: Between October 2006 and January 2009, a total of 315 patients underwent elective isolated aortic valve replacement (AVR). Of these patients, 87 (27.6%) received MIAVR, while the remainder (n = 228) underwent 'conventional' AVR by full sternotomy. In the MIAVR group, 76 patients (87%) were cannulated via the femoral artery. The mean EuroSCORE was 5.7 +/- 2.2 in the MIAVR group, and 6.7 +/- 2.9 in the AVR group (p < 0.001). Propensity score matching was used to reduce the impact of treatment selection in the comparison of MIAVR with conventional AVR. The propensity score was used to yield two matched groups by means of a 1:1 sample matching. RESULTS: The total operative, cardiopulmonary bypass and aortic cross-clamp times were significantly longer in the MIAVR group compared to the matched AVR group. The actuarial one-year survival was 96% in the MIAVR group, and 98% in the propensity-matched AVR group (p = 0.57). Reoperation due to bleeding was necessary in 4.6% of the MIAVR group (four patients, three by mini-thoracotomy) compared to 5.7% in the matched AVR group (n = 5; p = 0.38). A total of six MIAVR patients (6.9%) had complications from the cannulated groin, predominantly lymphatic fistula formation. Additionally, there was a trend towards a higher rate of renal insufficiency in the MIAVR group (p = 0.07). CONCLUSION: MIAVR can be safely implemented as routine cardiac surgery procedure, although the operative times are significantly longer. The early postoperative outcome was equal to that of the sternotomy approach, but postoperative complications were predominantly associated with femoral cannulation.

Single time point measurement by C2 or C3 is highly predictive in cyclosporine area under the curve estimation immediately after lung transplantation.

BACKGROUND: The two h post-dose cyclosporine (CsA) concentration has been advocated as the optimal time point measurement for CsA area under the curve (AUC) estimation after solid organ transplantation. The aim of the study was to investigate whether intensified CsA monitoring is necessary, or if a single time point measurement is accurate to estimate the AUC in the very early period following lung transplantation (LuTX). METHODS: Within the first two wk following transplantation, daily AUCs were calculated by serial CsA measurements at zero, one, two, three, four, and six h (C0-C6) in 12 consecutive lung transplant recipients. Correlation of single CsA measurements and AUC as well as linear regression analysis was performed to evaluate the most predictive single CsA blood level regarding the AUC. RESULTS: A total of 606 CsA concentration measurements were performed and the 101 corresponding AUCs were calculated for each patient. Mean AUC was 3443 +/- 1451 microg/L. C0: 361 +/- 118 microg/L, C1: 481 +/- 231 microg/L, C2: 682 +/- 314 microg/L, C3: 715 +/- 347 microg/L, C4: 658 +/- 271 microg/L, C6: 571 +/- 260 microg/L. The correlation of CsA serum levels with AUC was the lowest at trough levels (C0) with a correlation coefficient (r = 0.31) and highest at three h (C3: r = 0.89) and two h (C2: r = 0.88). CONCLUSIONS: Similar to a stable post-transplant period, CsA trough levels turned out to have poor correlation with the corresponding AUC early after LuTX. The highest correlation of C3 with the AUC may be explained by delayed intestinal resorption immediately post-operative, however C2 is a peer parameter. Optimum AUCs and corresponding C2 or C3 levels in the immediate post-operative phase however remain to be determined.

Mitral valve repair provides improved outcome over replacement in active infective endocarditis.

OBJECTIVES: Mitral repair in active infective endocarditis still remains controversial. Several studies demonstrate the feasibility of mitral repair in infective endocarditis; however, superiority of repair has never been shown. The aim of the investigation was to compare valve repair and valve replacement in respect to the extent of destruction and to analyze survival, recurrent endocarditis, and reoperation (event-free survival). METHODS: Sixty-eight consecutive patients underwent surgical intervention for mitral endocarditis. Thirty-four (50%) patients had valve repair, and 34 (50%) patients had valve replacement. Leaflet destruction involving at least one mitral leaflet was present in 15 (44.1%) patients of the repair group and 11 (32.4%) patients of the replacement group. Repair of the mitral annulus with pericardium was performed in 4 (11.8%) patients in the repair group and 3 (8.8%) patients in the replacement group. Patients in both groups were similar concerning the progression of valvular destructions and comorbidities. RESULTS: Hospital mortality was 11.8% (8 patients). No significant differences were found in all baseline parameters, with the exception of a higher incidence of previous septic embolism and sepsis in the repair group. Actuarial event-free survival at 1 year was 88.2% in the repair group compared with 67.7% in the replacement group, and 5-year event-free survival was 80.4% in the repair group and 54.6% in the replacement group (P = .015). Mitral valve repair remained the superior treatment regarding event-free survival in the multivariate analysis (hazard ratio, 0.33; 95% confidence interval, 0.12-0.93; P = .02). CONCLUSIONS: Mitral valve repair offers excellent early and late results and is the preferable treatment option in the surgical therapy of native infective endocarditis.

Cardiac transplantation complicated by acute thrombotic occlusion of the right coronary artery.

We report the case of a 63-year-old male patient undergoing cardiac transplantation due to fourth time aortic valve endocarditis. The postoperative course was complicated by thrombotic occlusion of the right coronary artery (RCA) causing acute right ventricular myocardial infarction, which required extracorporeal membrane oxygenation. The RCA could be reopened by catheter-based intervention and the patient stabilized. In order to avoid further immobilization, a right ventricular assist device was implanted and an aortocoronary bypass to the RCA was performed. After that, the patient stabilized progressively, could be weaned from the assist device, and was discharged home 6 weeks after transplantation. On coronary angiography, which is routinely performed 4 to 6 weeks after transplantation, a fistula from the RCA to the right ventricle was detected which was treated conservatively. Five months after transplantation, the patient is in good clinical condition without signs of recurrent endocarditis. This case shows that intense interdisciplinary cooperation of cardiac specialists allows the successful management of very complex patients in serious clinical conditions.

Severe endocarditis in transplant recipients--an epidemiologic study.

Infective endocarditis (IE) is reported with an incidence of 6/100,000 inhabitants in the general population. Even though immunosuppression predisposes to systemic infection, reports regarding IE after solid organ transplantation (SOT) are sparse. From 1989 to 2004, 2556 patients underwent SOT at the University Hospital Innsbruck. During this period, 27 transplant recipients were diagnosed IE. Nine patients (33.3%) were diagnosed at autopsy, eight patients (29.6%) were cured by antibiotic treatment and 10 patients (37.1%) underwent surgery. Overall mortality was 44.4% (12 patients). Staphylococcus was the predominant microorganism in 16 cases (59.3%), fungal infection was present in four patients (14.8%). Incidence of IE was 1% (95% CI: 0.67-1.49), indicating a 171-fold risk compared with the overall population. IE after SOT constitutes a significant problem and is associated with an excessive high mortality. Alertness to this condition is indicated, as we might diagnose more cases of IE in the future.

Evaluation of factors damaging the bronchial wall in lung transplantation.

BACKGROUND: Lung transplantation has become important in treating end-stage lung disease; however, bronchial complications are common. Lack of bronchial arterial circulation, ischemic time, and acute rejection episodes may damage the bronchial wall. In this study, we analyzed factors that may hamper bronchial airway healing, requiring intervention after lung transplantation. METHODS: We collected data from a consecutive series of 81 transplantations performed between 1993 and 2002 and evaluated recipients for bronchial complications. In 30 single and 51 sequential bilateral lung transplantations, a total of 132 anastomoses were performed. Four patients (3 bilateral and 1 single lung transplant recipients who died within the first 14 post-operative days were excluded from the analysis. Finally, 125 lung grafts remained for statistical analysis of factors influencing bronchial complications. RESULTS: Peri-operative mortality was 8.9%. Eleven patients (14.7%) experienced severe bronchial complications in 16 of 125 evaluated bronchial anastomoses (12.8%) and required surgical treatment or bronchoscopic interventional therapy. In a multivariate logistic regression model, severe reperfusion edema (adjusted odds ratio, 8.3; p = 0.002) and rejection episode within the 1st post-operative month (adjusted odds ratio, 4.1; p = 0.036) were associated with bronchial complications. Using the univariate model, we found that factors such as interleukin-2-antibody induction therapy, immunosuppression, or bronchial anastomotic technique had significant influence on bronchial healing, whereas we could not confirm this when using multivariate anasysis. CONCLUSIONS: Preventing reperfusion edema with optimized lung preservation and with early and aggressive medical treatment or mechanical hemodynamical support (e.g., veno-arterial extra corporal membrane oxygenation are necessary to avoid prolonged ventilation dependence, which may result in bronchial complications. Furthermore, avoiding early rejection episodes promotes uncomplicated bronchial healing.