Predictors of Complications After Pectoralis Major Transposition for Sternum Dehiscence.

OBJECTIVES: Mediastinitis and sternum dehiscence are serious complications after open heart surgery, causing an increase in hospital stay, utilization of health care resources, and mortality. The defect that results after sternal wound debridement frequently necessitates tissue-flap coverage, for which pectoralis major transposition currently is the preferred method. In this study, the postoperative outcome and individual characteristics of patients undergoing pectoralis major transposition were analyzed to identify predictors of complications after wound closure. METHODS: A retrospective chart review was conducted, covering a 7-year period, focusing on patient and operation characteristics. All patients with sternum dehiscence, who underwent pectoralis major transposition, were included. All postoperative wound complications were graded according to the Clavien-Dindo classification of surgical complications. Complications were further divided in major and minor. Mortality was defined as death within 30 days after sternal wound repair or during hospital stay. RESULTS: In total, 77 patients underwent a pectoralis major transposition repair of the sternum. Thirty-eight patients (49%) developed a wound complication of which 21 (27%) had a major wound complication. Mortality was 9%. Further analyses of our data showed that smoking and length of operation time were predictors of wound complications (P = 0.018 and P = 0.01). Female sex showed a relation with wound redehiscence (P = 0.014). Postoperative bleeding, for which reoperation was necessary, occurred more often when the humeral insertion of the pectoralis major flap was divided (P = 0.004). CONCLUSIONS: Tissue-flap coverage of the sternum using pectoralis major advancement flaps is a procedure that is still hampered by a high postoperative complication incidence. Female sex, smoking, detachment of the humeral insertion and operation time are associated with postoperative wound complications. These results may contribute in improving operative strategy. Also the use of the Clavien-Dindo classification makes underestimation of the complication rate unlikely in this study. The classification can easily be used in future studies, which will enhance comparability of results.

Quality of life in elder adults one-year after coronary bypass.

BACKGROUND: Survival rates in the elderly after cardiac surgery have improved over the last decades and therewith more attention is directed toward Quality of Life (QoL) as a patient reported outcome measure. OBJECTIVE: The purpose of this study was to explore QoL in patients one year after coronary artery bypass grafting, with special interest in the elderly patients (≥80 years). METHODS: In a quantitative, retrospective single-center study patients with isolated coronary artery bypass grafting (eg, nonvalve) surgery aged 80 years or older and operated in 2013 were included (n = 32). A control group of patients aged younger than 80 years was selected by matching based on gender and a recalculated (for age) logistic European System for Cardiac Operative Risk Evaluation (log EuroSCORE I) during the same period (n = 48). QoL assessment by the EuroQol questionnaire (EQ-5D) and additional questions were performed at one-year follow-up. RESULTS: QoL in elderly patients was 0.79 versus 0.90 in younger patients (P = 0.013). Overall, 54.8% of the elderly experience some or extreme problems in mobility versus 18.8% in the younger group (P = 0.001). Elderly patients also experience more problems in self care (19.3 vs 4.2%, P = 0.029). Nine of the elderly (29%) valued their postoperative health status to be worse than preoperatively versus 5 (10%) in the younger group (P = 0.028). Only patients aged 80 years or older would choose not to have surgery again (12.9%). Hospital mortality was 3.1% in the elderly group (n = 32) and 0% in the younger group (n = 48). CONCLUSION: Not all elderly patients experience benefits in terms of QoL one year after cardiac surgery. Therefore, potential benefits and risks need to be considered and discussed by physicians and patients before making the decision to operate or not.

Pulmonary valve replacement: twenty-six years of experience with mechanical valvar prostheses.

BACKGROUND: Although the thromboembolic risk after pulmonary valve replacement (PVR) with mechanical valves is presumed to be high, recent studies suggest promising short-term and mid-term results. However, large studies reporting long-term mortality and valve-related complications are missing. METHODS: We describe valve-related complications in 66 patients with a mechanical pulmonary valvar prosthesis implanted between 1987 and 2013. RESULTS: Mean follow-up duration was 5.9 ± 4.8 years (median 4.9). Mean age at time of implantation was 35 ± 13 years. The most frequent underlying cardiac diagnosis was tetralogy of Fallot (77%). Valvar thrombosis or pannus was reported in 7 patients (10%) of which 4 in the setting of inadequate anticoagulation or pregnancy. Redo PVR was performed in 6 patients. Freedom from redo PVR in survivors after 5 and 10 years was 96% and 89%, respectively. Survival after 5 and 10 years was 91% and 81%, respectively. Main cause of death was end-stage heart failure. CONCLUSIONS: Success of PVR using mechanical valvar prostheses over 26 years was limited because of valvar thrombosis (often in the setting of pregnancy or incompliance with anticoagulation therapy) or pannus. Performance of mechanical prostheses in the pulmonary position may improve when valvar thrombosis is prevented by patient selection, avoiding mechanical valves in patients at increased risk of valvar thrombosis, and by strict compliance to anticoagulation therapy.

Quantification of ventricular volume load in the context of a bidirectional cavopulmonary shunt: a theoretical treatise.

BACKGROUND: Functional univentricular hearts are currently palliated by a staged procedure of which the bidirectional cavopulmonary shunt is usually the second stage. In addition to this stage, a calibrated amount of additional pulmonary blood flow may be preserved to promote pulmonary artery growth and increase the length of the interval preceding the total cavopulmonary connection. However, additional pulmonary blood flow can be deleterious for ventricular functioning and development as it increases functional ventricular volume load. METHODS: Using the Fick principle we devised a theoretic framework to estimate the ventricular volume loading caused by additional pulmonary and collateral aortopulmonary flow. To use this framework, blood samples need to be taken intraoperatively from the aorta, pulmonary veins, and inferior caval vein to determine oxygen saturations. The oxygen saturation samples have to be taken sequentially with and without additional pulmonary blood flow. RESULTS: The objective of this paper is to provide a theoretic framework to estimate the ventricular volume loading caused by collateral aortopulmonary flow and additional pulmonary blood flow in the context of a bidirectional cavopulmonary shunt in the staged palliation of univentricular hemodynamics. The formulas have not yet systematically been applied in vivo. CONCLUSIONS: The added volume loading of the ventricle caused by additional pulmonary blood flow can theoretically be estimated using the newly devised formulas so as to calibrate ventricular volume loading to a desired level intraoperatively.

The effect of additional pulmonary blood flow on timing of the total cavopulmonary connection.

BACKGROUND: The staged Fontan procedure is used to palliate functionally univentricular hearts. The effect of additional pulmonary blood flow combined with a bidirectional cavopulmonary shunt in these patients remains a controversial subject. METHODS: This retrospective study included all 82 patients with a unilateral or bilateral bidirectional cavopulmonary shunt at our institution between April 1990 and July 2010. Patients with hypoplastic left heart syndrome were excluded. Two groups, based on the presence (n=57) or absence (n=25) of additional pulmonary blood flow after the bidirectional cavopulmonary shunt, were compared. RESULTS: Patients with a bidirectional cavopulmonary shunt combined with additional pulmonary blood flow had higher arterial oxygen saturations postoperatively (86% [interquartile range, 85% to 90%] vs 82% [80% to 85%]; p=0.001) and had a longer median interval before the total cavopulmonary connection (3.42 [2.43 to 4.89] years vs 2.90 [2.08 to 3.32] years; p=0.06). At the total cavopulmonary connection, they were older (4.59 [3.88 to 6.49] years vs 3.94 [3.10 to 4.57] years; p=0.03) and had a larger median body surface area (0.73 [0.65 to 0.87] m2 vs 0.68 [0.59 to 0.73] m2; p=0.04). CONCLUSIONS: Patients with a bidirectional cavopulmonary shunt and additional pulmonary blood flow have a longer interval before the total cavopulmonary connection without evident untoward effects. This may theoretically be advantageous for the pulmonary artery growth needed for a successful Fontan circulation. Furthermore, postponement of the final Fontan may ensure the insertion of a larger extracardiac conduit to avoid prosthesis-patient mismatch.

Prophylactic aortic root surgery in patients with Marfan syndrome: 10 years' experience with a protocol based on body surface area.

BACKGROUND: Current guidelines recommending prophylactic aortic root replacement in Marfan syndrome are based on absolute diameters of the aortic root. However, aortic root diameter is a function of body surface area (BSA). Here, we report our experience with a protocol for prophylactic aortic root replacement based on BSA. METHODS: Patients with established Marfan syndrome (Ghent criteria) and without prior aortic surgery were eligible for our study. Aortic root ratio was defined as the ratio between the observed aortic root diameter (as measured during annual echocardiography) and the maximum predicted aortic root diameter as calculated according to age and BSA. Replacement surgery was performed if dilatation of the aortic root during follow-up resulted in an aortic root ratio >/=1.3. RESULTS: Fifty-three patients fulfilled the entry criteria (24 men/29 women, median age at baseline 27 years, range 18-59 years). During follow-up between 1997 and 2007 (mean 4.7+/-3.2 years) four patients underwent uncomplicated aortic root replacement; two had an aortic root ratio >/=1.3 (aortic root diameters were 4.9 and 5.2 cm, respectively), one had aortic root dilatation of 0.4 cm/year and a positive family history for aortic dissection and one had an aneurysm of the ascending aorta as the primary indication. None of the patients in the whole group suffered from type A aortic dissection and there was no mortality. CONCLUSIONS: Although numbers are small, our protocol for prophylactic aortic root replacement in patients with Marfan syndrome based on BSA was effective in terms of preventing aortic dissection and mortality.

Off-pump connection of the hepatic to the azygos vein through a lateral thoracotomy for relief of arterio-venous fistulas after a Kawashima procedure.

OBJECTIVE: To connect the hepatic veins to the azygos venous system through a lateral thoracotomy, and without the use of extracorporeal circulation, so as to relieve arteriovenous fistulas after a previous Kawashima operation. METHODS: Description of the operative technique by which the hepatic veins are anastomosed to the hepatic venous system. RESULTS: The surgical approach was successfully applied in 3 patients, all of whom showed an excellent rise of saturations of oxygen after redirection of the hepatic venous blood. CONCLUSION: The operative method presented is an elegant means of redirecting the hepatic venous blood to the pulmonary circulation without the disadvantages of extracorporeal circulation and resternotomy.

Persistent pulmonary hypertension of the newborn with transposition of the great arteries.

BACKGROUND: Persistent pulmonary hypertension of the newborn (PPHN) in patients with transposition of the great arteries (TGA) is reported to be a high-risk and often therapy-resistant condition, associated with a high mortality. However, data on its incidence and prognosis are scarce and originate mostly from the era before introduction of inhaled nitric oxide (iNO) therapy for PPHN. METHODS: This is a retrospective study of consecutive newborns with TGA, admitted to a tertiary cardiac and neonatal intensive unit over a 10-year period. In this period, iNO therapy was available. RESULTS: Fourteen out of 112 patients with TGA (12.5%) presented with associated PPHN. The PPHN occurred more frequently in patients with TGA and intact ventricular septum (IVS) compared with those with TGA and ventricular septal defect (13 out of 83 patients versus one out of 29 patients, respectively; p = 0.06, Fisher exact test). Of those newborns, six presented with severe PPHN, whereas eight presented with mild-to-moderate PPHN. Despite currently available treatment modalities, including iNO, four out of 14 patients died before corrective surgical procedures were considered to be an option (TGA/PPHN preoperative mortality 28.6%). These included three out of six patients (50%) with severe PPHN and one out of eight (12.5%) with mild-to-moderate PPHN. CONCLUSIONS: The combination of TGA with PPHN is a serious and often fatal condition. It may jeopardize the usually favorable outcome of newborns with TGA. Despite the introduction of iNO therapy, the combination of TGA and PPHN remains a condition with unacceptable high mortality (in our series). Additional treatment strategies need to be investigated.

Pulmonary valve replacement with a mechanical prosthesis. Promising results of 28 procedures in patients with congenital heart disease.

OBJECTIVE: Pulmonary valve replacement is performed increasingly late after correction of Tetralogy of Fallot. Most reports deal with pulmonary allografts as the valvar substitute of choice, although late deterioration and reoperation(s) are the rule. Mechanical valves are scarcely reported and if so only because of complications. Although life-long anticoagulation therapy is indicated for mechanical prostheses, the chance of subsequent re-operations can be expected to be low. We report the results of 28 mechanical valve replacements in the pulmonary position. METHODS: A mechanical valve was implanted in 27 of 79 patients indicated for pulmonary valve replacement. Tetralogy of Fallot was the most common basic lesion. The results and follow-up were reviewed retrospectively, where death and re-operation were primary end points. Routine outpatient follow-up, including trans-thoracic echocardiography, was performed. RESULTS: Twenty-eight pulmonary valve implantations were done in 27 patients. Thirty-day hospital mortality was 1/28 (3.6%), because of a cerebro-vascular accident. One patient died late (2.8 years postoperatively). Median age was 33 years and the median interval between primary repair and insertion of the prosthesis was 26 years. Freedom from re-operation at 1 year was 100%. One valve had to be replaced 14 years after implantation because of malfunction due to ingrowth of endomyocardial fibrosis. No thrombo-embolic events were observed. CONCLUSIONS: Our series do not confirm the bad reputation of mechanical valvar prostheses in the pulmonary position. On the contrary they perform well and result in a much lower re-operation rate than can be expected and in fact is reported after allograft usage. No thrombo-embolic complications were noted. In our experience pulmonary mechanical valve prostheses do well.

Large common left and right coronary artery to coronary sinus fistula.

Coronary fistulas are vascular anomalies which in rare cases can cause hemodynamic problems with indication for intervention. We report about a 47-year-old man with a large coronary fistula arising from both, the left and right coronary artery. To our knowledge this is the first case described with this anatomy. The main coronary arteries were united at the crux cordis and drained through the coronary sinus into the right atrium. As a consequence of the longstanding volume overload the coronary arteries were extremely dilated. Also, both ventricles were dilated. Therefore, although the patient was asymptomatic, the obvious compromise of the ventricles due to volume overload was regarded as an indication for surgical intervention.