Does the anthropometric profile influence infection morbidity after coronary artery bypass grafting?

BACKGROUND: Infection after cardiovascular surgery is multifactorial. We sought to determine whether the anthropometric profile influences the occurrence of infection after isolated coronary artery bypass grafting (CABG). METHODS: Between January 2011 and June 2016, 1777 consecutive adult patients were submitted to isolated coronary artery bypass grafting. Mean age was 61.7 ± 9.8 years and 1193 (67.1%) were males. Patients were divided into four groups according to the body mass index (BMI) classification: underweight (BMI < 18.5 kg/m2 ; N = 17, 0.9%), normal range (BMI: 18.5-24.99 kg/m2 ; N = 522, 29.4%), overweight (BMI: 25-29.99 kg/m2 ; N = 796, 44.8%), and obese (BMI > 30 kg/m2 ; N = 430, 24.2%). In-hospital outcomes were compared and independent predictors of infection were obtained through multiple Poisson regression with a robust variation. RESULTS: Independent predictors of any infection morbidity were female sex (relative ratio [RR], 1.47; p = .002), age > 60 years (RR, 1.85; p < .0001), cardiopulmonary bypass > 120 min (RR, 1.89; p = .0007), preoperative myocardial infarction < 30 days (RR, 1.37; p = .01), diabetes mellitus (RR, 1.59; p = .0003), ejection fraction < 48% (RR, 2.12; p < .0001), and blood transfusion (RR, 1.55; p = .0008). Among other variables, obesity, as well as diabetes mellitus, were independent predictors of superficial and deep sternal wound infection. CONCLUSIONS: Other factors rather than the anthropometric profile are more important in determining the occurrence of any infection after CABG. However, surgical site infection has occurred more frequently in obese patients. Appropriate patient selection, control of modifiable factors, and application of surgical bundles would minimize this important complication.

Is shortage of heart donors a real problem? Insights from a Brazilian Mid-West heart transplant program.

BACKGROUND AND AIM OF THE STUDY: In developed countries, the shortage of viable donors is the main limiting factor of heart transplantation. The aim of this study is to determine whether the same reality applies to Brazil. METHODS: Between January 2012 and December 2014, 299 adult heart donor offers were studied in terms of donor profiles and reasons for refusal. The European donor scoring system was calculated, being high-risk donors defined as more than 17 points. The donor scoring system was used to objectively determine the donor profile and correlate with donor acceptance and posttransplant primary graft dysfunction and recipient survival. Cox proportional hazard model was used in determining the predictors of long-term mortality. RESULTS: The rates of donor acceptance and heart transplants performed were 45.8% and 19.3%, respectively. Reasons for refusal were mostly nonmedical (53.7%). The majority of donors were classified as high-risk (65.5%). Hearts from high-risk donors did not impact primary graft dysfunction (14.3% vs 10%; P = .6), neither long-term survival (P = .4 by logrank test). Recipient's age was greater than 50 years (hazard ratio, 6.02; 95% confidence interval, 2.41-16.08; P < .0001) and was the only predictor of long-term mortality. CONCLUSIONS: The shortage of donors is not the main limiting factor of heart transplantation in the Mid-West of Brazil. Nonmedical issues represent the main reason for organ discard. Most of the donors are classified as high risk which indicates that an expanded donor pool is a routine practice in our region, and donor scoring does not seem to influence to proceed with the transplant.

Penetrated inferior vena cava filter retrieved by open surgery with deep hypothermic circulatory arrest.

BACKGROUND AND AIM: Complications of inferior vena cava filters are relatively common, and they vary according to different filter types and designs. We aim to present a case of penetrated inferior vena cava filter into the liver. METHODS: Case report. RESULTS: A 42-year old man with thrombophilia (prothrombin gene mutation) required the insertion of an inferior vena cava filter because of recurrent gastrointestinal bleeding associated with oral anticoagulation. However, it penetrated through the retro-hepatic vena cava into the liver, being manifested by constant, blunt abdominal pain. Endovascular retrieval was considered of extreme risk, though a surgical approach was performed under cardiopulmonary bypass with deep hypothermic circulatory arrest. The patient has recovered uneventfully with complete symptom relief. CONCLUSIONS: In symptomatic penetrated vena cava filters in which endovascular retrieval is not feasible, a surgical approach with appropriate planning is a safe and effective treatment.

Is It Conceivable to Still Perform the Cut and Sew Cox Maze III Procedure in the Current Era?

To determine whether cut and sew Cox maze III procedure is still associated with adequate safety endpoints when performed in conjunction with other open-heart procedures. Between January 2008 and January 2015, 113 consecutive adult patients were submitted to cut and sew Cox maze III procedure in association with other operations for structural heart disease. Mean age was 49 years and 80 (70.8%) were females. Longstanding or persistent atrial fibrillation has occurred in 87.6% and rheumatic heart disease in 80.7%. Valve surgery was performed in 98.2%. The number of associated procedures was correlated with morbidity and hospital mortality. Overall mean cardiopulmonary bypass and aortic cross-clamping times were 129 ±â€¯26 and 105 ±â€¯23 minutes, respectively. Hospital mortality was 1.77%, re-exploration for bleeding 0.9%, cerebrovascular accident 1.8%, and acute renal failure requiring hemodialysis 2.6%. The greater number of associated procedures did not correlate with poorer safety outcomes. Permanent pacemaker was required in 18.2% of those with three associated procedures, as opposed to 4% with two procedures and no requirement with one procedure (P = .01). Frequency of sinus rhythm was 88%, 88%, and 85% at 6, 12, and 24 months, respectively. In a contemporary single-center cohort of predominantly rheumatic patients, the surgical treatment of atrial fibrillation associated with structural heart disease by means of cut and sew Cox maze III procedure is safe, with low morbidity and mortality rates. Surgical complexity, defined by number of associated procedures, did not translate into poorer safety endpoints, except for greater need of permanent pacemaker.

Unusual mechanism of myocardial infarction in prosthetic valve endocarditis.

A 46-year-old man with bicuspid aortic valve and severe calcific aortic stenosis was submitted to aortic valve replacement with a stented bioprosthesis. He developed Staphylococcus epidermidis prosthetic valve endocarditis a month later, presenting in the emergency room with acute myocardial infarction. The mechanism of myocardial ischemia was a large aortic root abscess causing left main extrinsic compression. He was urgently taken to the operating room, and an aortic root replacement with cryopreserved homograft was performed, associated with autologous pericardium patch closure of aortic to right atrium fistula and coronary artery bypass grafting of the left anterior descending. After a difficult postoperative period with multiple problems, he was eventually discharged home. At 36-month follow-up, he is asymptomatic with no recurrent infection, and the left main coronary artery is widely patent on control chest computed tomography.

Long-term results of correction of tetralogy of Fallot in adulthood.

OBJECTIVES: The natural history of tetralogy of Fallot (TOF) allows that a minority of patients reach adulthood without any treatment, representing mild forms of the disease. The aim of this study is the long-term evaluation of patients with TOF surgically treated in adulthood, in order to define its real benefit. METHODS: Between November 1982 and January 2001, 39 patients older than 18 years of age with tetralogy of Fallot underwent total correction. Mean age was 26.6 years (range 18-67) and 21 patients (53.8%) were females. A previous modified Blalock-Taussig shunt was performed in four patients (10.3%). Fifteen patients (38.5%) were in NYHA functional class III or IV. Mean hematocrit was 53.6+/-10% and the mean gradient across the right-ventricular outflow tract was 93.9+/-24.8 mmHg. The operation was performed via transatrial/transpulmonary approach in 16 patients (41%) and six patients (15.4%) required transannular patch. Pulmonary valvotomy was necessary in 13 patients (33.3%) and pulmonary valve replacement with bioprosthesis in 3 patients (7.7%). RESULTS: Hospital and late mortality were 5.1 and 7.7%, respectively. The mean follow-up was 45.1 months (range 1-194 months). Actuarial survival was 91.2+/-4.9%, 85.5+/-7.2% and 68.4+/-16.3% at 3, 7 and 15 years, respectively. In the latest follow-up, 27 (79.4%) of the survivals are presently in NYHA functional class I (P<0.001). Echocardiography has shown moderate/severe pulmonary insufficiency in 9 patients (26.5%), moderate pulmonary stenosis in 3 patients (8.8%) and residual ventricular septal defect in 4 patients (11.8%). Arrhythmias were identified in 38.9% of patients with symptoms suspicious of rhythm disturbances. There was impairment of right-ventricular function in 13 patients (38.2%). Three patients were reoperated on to close residual ventricular septal defects in two patients and for pulmonary valve replacement in one patient. CONCLUSIONS: The overall survival of surgically treated adult patients with TOF is acceptable. The great benefit of the complete repair at this age is the functional improvement. On the other hand, late complications closely related to chronic hypoxia, such as arrhythmia and ventricular dysfunction might direct for a more careful follow-up after the surgical correction.