Adverse events in the postoperative period of cardiac surgery in a pediatric intensive care unit: the contribution of the VIS score and the RACHS-1 / Eventos adversos em pós-operatório cardíaco em uma unidade de terapia intensiva pediátrica: a contribuição do escore VIS e do RACHS-1

ABSTRACT Objective: To evaluate the occurrence of adverse events in the postoperative period of cardiac surgery in a pediatric intensive care unit and to find any patient characteristics that can predict such events. Methods: This was a historical cohort study of patients recovering in the pediatric intensive care unit for the first 7 days after cardiac surgery between April and December 2019, by reviewing the medical records. The following were reviewed: demographic, clinical, and laboratory characteristics; patient severity scores; and selected adverse events, grouped into device-related, surgical, and nonsurgical. Results: A total of 238 medical records were included. At least one adverse event occurred in 110 postoperative patients (46.2%). The total number of adverse events was 193 (81%). Vascular catheters were the most common cause, followed by cardiac arrest, bleeding, and surgical reexploration. In the univariate analysis, the vasoactive-inotropic score (VIS), Risk Adjustment in Congenital Heart Surgery (RACHS-1) score, age, Pediatric Index of Mortality (PIM-2), cardiopulmonary bypass and aortic clamping duration were significantly associated with adverse events. In the multivariate analysis, VIS ≥ 20 (OR 2.90; p = 0.004) and RACHS-1 ≥ 3 (OR 2.11; p = 0.019) were significant predictors, while age and delayed sternal closure showed only trends toward significance. To predict the occurrence of adverse events from VIS and RACHS-1, the area under the curve was 0.73 (95%CI 0.66 - 0.79). Conclusion: Adverse events were quite frequent in children after cardiac surgery, especially those related to devices. The VIS and RACHS-1, used together, predicted the occurrence of adverse events well in this pediatric sample.

RESUMO Objetivo: Avaliar a ocorrência de eventos adversos em pós-operatório cardíaco em uma unidade de terapia intensiva pediátrica e estabelecer eventuais associações das características dos pacientes e a possibilidade de predizer tais eventos. Métodos: Coorte histórica de 7 dias de pós-operatório cardíaco, de abril a dezembro de 2019, por revisão de prontuários de pacientes com recuperação em unidade de terapia intensiva pediátrica. Foram revisados: características demográficas e clínico-laboratoriais, escores de gravidade dos pacientes e eventos adversos selecionados agrupados em: relacionados a dispositivos, a aspectos cirúrgicos e a aspectos não cirúrgicos. Resultados: Foram incluídos 238 prontuários. Ocorreu pelo menos um evento adverso em 110 pós-operatórios (46,2 %). O número total de eventos adversos foi 193 (81%), sendo mais frequente a complicação com cateteres vasculares, seguida de parada cardíaca, sangramento e reexploração cirúrgica. Na análise univariada, escore vasoativo-inotrópico (VIS- vasoactive-inotropic score), Risk Adjustment in Congenital Heart Surgery (RACHS-1) score, idade, Pediatric Index of Mortality (PIM-2), tempo de circulação extracorpórea e de clampeamento aórtico foram estatisticamente significantes com eventos adversos. Na análise multivariável, VIS ≥ 20 (OR 2,90; p = 0,004) e RACHS-1 ≥ 3 (OR 2,11; p = 0,019) mostraram-se relevantes e com significância estatística, enquanto idade e fechamento tardio do esterno possuíam apenas tendência a essa associação. Considerando a previsão de ocorrência de eventos adversos a partir dos valores de escore vasoativo-inotrópico e de RACHS-1, a área sob a curva mostrou valor de 0,73 (IC95% 0,66 - 0,79). Conclusão: A frequência de eventos adversos foi expressiva e aqueles relacionados a dispositivos foram os mais frequentes. O VIS e o RACHS-1, utilizados em conjunto, foram capazes de predizer a ocorrência de eventos adversos nesta amostra pediátrica.

Coronary ostial stenosis after coronary artery bypass graft and combined aortic valve replacement: case report.

A 65-year-old patient with the left anterior descending artery (LAD) ostial stenosis proved by coronary angiography is presented. LAD ostial stenosis is an uncommon condition whose etiology is unknown. The patient also had a coronary artery bypass graft combined with aortic valve replacement 13 years ago. The clinical and angiographic profiles of the patient are discussed here, supported by the literature. Case Presentation: A 65-year-old female patient with a medical history of hypertension and dyslipidemia came to the outpatient department with a complaint of chest pain and shortness of breath. Coronary angiography was carried out in 2008, which revealed triple vessel coronary artery disease, valvular heart disease, and ostial stenosis. In 2009, the patient underwent coronary artery bypass graft surgery combined with aortic valve replacement and remained asymptomatic thereafter. In 2022, transthoracic echocardiography and a Doppler study were conducted, which revealed normal size left ventricle, an ejection fraction of 55%, and diastolic dysfunction grade I. A graft study was done, which revealed left main and right coronary artery were normal, and the left circumflex artery with mild stenosis and obtuse marginal with subtotal stenosis and severe ostial stenosis of the LAD was observed. Clinical Discussion: Recognizing this complication early can prevent life-threatening complications and is then of the utmost importance. Coronary ostial stenosis is an uncommon but potentially dangerous consequence of aortic valve replacement whose etiology is not well understood in the literature. Rapid clinical identification is therefore essential. Coronary angiography needs to be done right away if coronary ostial stenosis is suspected. The mainstay of treatment for ostial stenosis is coronary artery bypass surgery or percutaneous coronary angioplasty. Since the patient has already undergone a coronary artery bypass graft (CABG) surgery, there is a significant risk of redoing CABG, as it is associated with considerable morbidity, which has a negative effect on long-term quality of life. Conclusion: Despite the fact that CABG is the most common form of therapy, percutaneous coronary intervention has demonstrated good short-term outcomes. To assess the effectiveness of CABG with drug-eluting stents for the treatment of coronary ostial stenosis, further information on long-term outcomes is required.

Kidney Injury after Cardiac Surgery: Prevention-Associated Cost Reduction.

INTRODUCTION: Cardiac surgery may induce acute kidney injury and the need for renal replacement therapy. It is also associated with higher hospital costs, morbidity and mortality. The aims of this study were to investigate predictors of cardiac surgery associated acute kidney injury in our population and to determine the burden of acute kidney injury in elective cardiac surgery, evaluating the potential cost effectiveness of preventing it through the application of the Kidney Disease: Improving Global Outcomes bundle of care to high-risk patient groups identified by the [TIMP-2]x[IGFBP7] used as a screening test. MATERIAL AND METHODS: In a University Hospital single-center retrospective cohort study we analyzed a consecutive sample of adults who underwent elective cardiac surgery between January and March 2015. A total of 276 patients were admitted during the study period. Data from all patients was analyzed until hospital discharge or the patient's death. The economic analysis was performed from the hospital costs' perspective. RESULTS: Cardiac surgery associated acute kidney injury occurred in 86 patients (31%). After adjustment, higher preoperative serum creatinine (mg/L, ORadj = 1.09; 95% CI: 1.01 - 1.17), lower preoperative hemoglobin (g/dL, ORadj = 0.79; 95% CI: 0.67 - 0.94), chronic systemic hypertension (ORadj = 5.00; 95% CI: 1.67 - 15.02), an increase in cardiopulmonary bypass time (min, ORadj = 1.01; 95% CI: 1.00 - 1.01) and perioperative use of sodium nitroprusside (ORadj = 6.33; 95% CI: 1.80 - 22.28) remained significantly associated with cardiac surgery related acute kidney injury. The expected cumulative surplus cost for the hospital linked with cardiac surgery associated acute kidney injury (86 patients) was €120 695.84. Based on a median absolute risk reduction of 16.6%, by dosing kidney damage biomarkers in every patient and using preventive measures in high-risk patients, we would expect a break-even point upon screening 78 patients, which would translate, in our patient cohort, into an overall cost benefit of €7145. CONCLUSION: Preoperative hemoglobin, serum creatinine, systemic hypertension, cardiopulmonary bypass time and perioperative use of sodium nitroprusside were independent predictors of cardiac surgery associated acute kidney injury. Our cost-effectiveness modelling suggests that the use of kidney structural damage biomarkers combined with an early prevention strategy could be associated with potential cost savings.

Management of Atrial Fibrillation Following Cardiac Surgery: Observational Study and Development of a Standardized Protocol.

BACKGROUND: Postoperative atrial fibrillation (POAF) is the most common complication occurring after cardiac surgery. Guidelines for the management of this complication are scarce, often resulting in differences in treatment strategy use among patients. OBJECTIVE: To evaluate the management of POAF in a cardiac surgery department, characterize the extent of its variability, and develop a standardized protocol. METHODS: This was an observational retrospective study with data from patients who underwent cardiac surgeries with subsequent POAF between January 1, 2017, and June 1, 2018. We assessed the difference in the proportions of patients whose first POAF episodes were treated with a rate control (RaC) strategy, a rhythm control (RhC) strategy, and both among different hospital units. We also assessed the mean duration of POAF episodes, POAF recurrences, and the management of anticoagulation. RESULTS: Data from 97 patients were included in this study. The POAF management strategy differed significantly among the 3 types of hospital units (P = 0.001). Considering all POAF episodes (including all recurrences), 83 of the 97 patients (85.6%) received amiodarone as part of the RhC strategy. Anticoagulation was used in 58 (59.8%) patients and was suboptimal according to the study criteria in 29.5% of the patients included. Based on these results, a hospital working group developed a standardized protocol for POAF management. CONCLUSIONS AND RELEVANCE: POAF management was heterogeneous at our institution. This article highlights the need for clear practice guidelines based on large prospective studies to provide care according to best practices.

Desarrollo y validación externa de un puntaje predictivo de mediastinitis posoperatoria en cirugía cardíaca derivado del registro multicéntrico CONAREC XVI / Development and External Validation of a Predictive Score of Postoperative Mediastinitis in Cardiovascular Surgery Derived from the CONAREC XVI Multicenter Registry

RESUMEN Objetivos: El objetivo de este análisis fue definir variables predictoras independientes para la aparición de mediastinitis pos-cirugía cardíaca, y desarrollar un puntaje validado para estratificar el riesgo de manifestación de mediastinitis. Materiales y métodos: Se analizaron datos el estudio CONAREC XVI de adultos sometidos a cirugía cardíaca entre 2007 y 2008, en 49 centros de 16 provincias argentinas. Se definió mediastinitis como la presencia de signos clínicos o cultivos positivos. Se evaluaron variables epidemiológicas, clínicas, tipo de cirugía, variables intraoperatorias y posoperatorias, estudios complementarios. Se realizó un análisis de regresión logística múltiple para identificar variables independientemente asociadas a la manifestación de mediastinitis posoperatoria. Se consideró como significativa un error alfa menor del 5% a dos colas. Se construyó un score y se realizó una validación externa con pacientes de otros centros quirúrgicos. Resultados: Se analizaron 2553 pacientes: 1465 (57,4%) sometidos a cirugía coronaria, 359 (14,1%) a reemplazo valvular aórtico, 169 (6,6%) a cirugía valvular mitral, 312 (12,2%) a cirugía combinada y 248 (9,7%) a otras. La incidencia de mediastinitis fue 1,88% en la población global. Las variables asociadas al desarrollo de mediastinitis fueron: antecedente de tabaquismo, OR: 2,3 (IC 95% 1,1-5,1) p = 0,02, disfunción ventricular grave, OR: 2,8 (IC 95% 1,3-6,2) p = 0,001, reoperación, OR: 4,6 (IC 95% 1,8-11,3) p = 0,001, e insuficiencia renal posoperatoria, OR: 4,3 (IC 95% 1,9-9,6) p = 0,0001. Se construyó un score de riesgo adjudicando los siguientes puntajes según la presencia o ausencia de cada una de los cuatros variables del modelo resultante: 1 punto en caso de disfunción ventricular grave, 1 punto para el antecedente de tabaquismo, 2 puntos para el desarrollo de insuficiencia renal y 2 puntos para la necesidad de reoperación. El área ROC para mortalidad fue 0,72 (IC 95% 0,64-0,81) (Hosmer Lemeshow p = 0,9). El grupo de validación incluyó 1657 pacientes con edad media fue de 62,8 ± 13 años. Se observó una incidencia de mediastinitis de 1,6%. El área ROC para desarrollo de mediastinitis fue 0,70 (IC 95% 0,58-0,80), p = 0,001. Conclusiones: La construcción de un score de riesgo predictivo del desarrollo de mediastinitis en el posoperatorio de cirugía cardíaca resulta relevante para su aplicación en la práctica diaria, tanto para la prevención como para la detección temprana de esta grave complicación.

ABSTRACT Objective: The aim of this analysis was to define independent predictive variables for the development of mediastinitis after cardiovascular surgery and develop a validated score to stratify the risk for mediastinitis. Methods: Data were retrieved from the CONAREC XVI study comprising adults undergoing cardiovascular surgery between September 2007 and October 2008 in 49 centers of 16 provinces in Argentina. Mediastinitis was defined as the presence of clinical signs attributable to the condition or positive cultures. Epidemiological and clinical variables, type of surgery, intraoperative and postoperative variables and complementary tests were evaluated. A logistic regression model was used to identify the independent variables associated with perioperative mediastinitis. A two-tailed alpha error < 0.05 was considered statistically significant. A score was constructed and was externally validated in patients from other surgical centers. Results: A total of 2553 patients were analyzed: coronary artery bypass graft surgery, 1465 patients (57.4%); aortic valve replacement, 359 (14.1%); mitral valve surgery, 169 (6.6%); combined procedure (revascularization-valve surgery), 312 (12.2%); other procedures, 248 (9.7%). The overall incidence of medistinitis was 1.88%. The variables associated with the development of mediastinitis were: smoking habits (OR, 2.3; 95% CI,1.1-5,1; p=0.02), severe left ventricular dysfunction (OR, 2.8; 95% CI, 1.3-6.2; p=0.001), reoperation (OR, 4,6; 95% CI,1.8-11.3; p=0.01) and postoperative renal failure (OR, 4.3; 95% CI, 1.9-9,6; p=0.0001). A risk score was constructed assigning 1 point for severe left ventricular dysfunction, 1 point for the history of smoking habits, 2 points for the development of renal failure and 2 points for need for reoperation. The area under the ROC curve for mortality was 0.72 (95% CI, 0.64-0,81; Hosmer Lemeshow test p=0.9). The external validation was performed on 1657 patients, mean age 62.8±13.3 years. The incidence of mediastinitis was 1.6%. The area under the ROC curve for the development of mediastinitis was 0.70 (95% CI, 0.58-0.80; p=0.001). Conclusions: The construction of a predictive score for the development of postoperative mediastinitis after cardiovascular surgery is relevant for daily practice for the prevention and early detection of this severe complication.

Influence of Body Mass Index on Outcomes of Patients Undergoing Surgery for Acute Aortic Dissection: A Propensity-Matched Analysis.

To determine whether body mass index ≥30 kg/m2 affects morbidity and mortality rates in patients undergoing surgery for type A acute aortic dissection, we conducted a retrospective study of 201 patients with type A dissection. Patients were divided into 2 groups according to body mass index (BMI): nonobese (BMI, <30 kg/m2; 158 patients) and obese (BMI, ≥30 kg/m2; 43 patients). Propensity score matching was used to reduce selection bias. The overall mortality rate was 19% (38/201 patients). The perioperative mortality rate was higher in the obese group, both in the overall cohort (33% vs 15%; P=0.01) and in the propensity-matched cohort (32% vs 12%; P=0.039). In the propensity-matched cohort, patients with obesity had higher rates of low cardiac output syndrome (26% vs 6%; P=0.045) and pulmonary complications (32% vs 9%; P=0.033) than those without obesity. The overall 5-year survival rates were 52.5% ± 7.8% in the obese group and 70.3% ± 4.4% in the nonobese group (P=0.036). In the propensity-matched cohort, the 5-year survival rates were 54.3% ± 8.9% in the obese group and 81.6% ± 6.8% in the nonobese group (P=0.018). Patients with obesity (BMI, ≥30 kg/m2) who underwent surgery for type A acute aortic dissection had higher operative mortality rates and an increased risk of low cardiac output syndrome, pulmonary complications, and other postoperative morbidities than did patients without obesity. Additional extensive studies are needed to confirm our findings.

Modified internal mammary artery perforator flap in treatment of sternal wound complications.

OBJECTIVES: There are multiple treatment strategies and flap options to cover defects after deep sternal wound infections and other similar sternal defects. The choice of flap is made according to surgeons' preferences and the size and location of the defect. Our aim is to introduce a new option to cover these kinds of defects with an internal mammary artery perforator flap combined with a pectoralis major muscle flap mostly raised with a muscle-sparing technique. DESIGN: We treated 13 patients with a sternal defect after cardiothoracic operations with this technique between 2010-2016. Ten patients had a deep sternal wound infection, two had an infection of the prosthesis after carotico-subclavian bypass and one had a fragmented sternum. Nine patients were treated with an internal mammary artery perforator fasciocutaneous flap with a muscle-sparing pectoralis major muscle flap and four patients with an internal mammary artery perforator fasciocutaneous flap combined with a right pectoralis major muscle flap. RESULTS: Three patients (23%) experienced major complications and four patients (31%) had conservatively treated minor complications. There were no flap losses. CONCLUSION: This combination of flaps is a suitable option for patients with large defects in whom direct skin closure is not possible. It can be utilized for defects comprising the entire vertical length of the sternum. These are local flaps with a short operation time and are therefore most suitable for patients with comorbidities in whom major surgery is not an option.

Aortic Coarctation 28 Days after an Arterial Switch Operation in a Neonate.

Aortic coarctation rarely occurs after an arterial switch operation for D-transposition of the great arteries with intact ventricular septum. We report the case of a neonate patient in whom aortic coarctation developed 28 days after an uncomplicated arterial switch operation. Preoperatively, the aorta was noted to have an irregular shape, but there was no pressure gradient across the lesion. The patient underwent successful reoperation to correct the coarctation. We hope that our report raises awareness of a rare early complication after arterial switch operation with intact ventricular septum, and the need to carefully monitor the aortic isthmus in patients who have aortic irregularities, even in the absence of a pressure gradient.

Comparison of Sutureless and Conventional Techniques to Repair Total Anomalous Pulmonary Venous Connection.

Surgical repair of total anomalous pulmonary venous connection (TAPVC) is challenging. This study aimed to compare the outcomes of the sutureless and conventional techniques for primary repair. From October 2007 to December 2013, 179 consecutive patients underwent repair of TAPVC (sutureless, n = 81; conventional, n = 98). Propensity score matching was used to submit 140 patients to stratified analysis by the presence or absence of preoperative pulmonary venous obstruction (pre-PVO). Surgeons׳ performance differences were assessed with multilevel mixture survival analysis. Freedom from death and postoperative PVO (post-PVO) were evaluated with Kaplan-Meier curves. Risk factors for death and post-PVO were explored using Cox proportional hazard model. Surgeons׳ multilevel effects did not exist in this study. Following matching, Kaplan-Meier curves showed that for patients with pre-PVO (totally 38 cases), rates of freedom from death and post-PVO at 1 year were 80.0% (59.8%-100.0%) in the sutureless group, which was significantly better than that in the conventional group (38.3% [15.2%-61.4%], P = 0.02). For patients without pre-PVO (totally 102 cases), rates of freedom from death and post-PVO at 1 year were 96.1% [95% CI: 90.8%-100.0%] and 86.7% [76.5%-96.9%] in the sutureless and conventional groups, respectively (P = 0.15). Conventional technique was a risk factor for death (hazard ratio = 4.14, 95% CI: 1.29-13.28) and post-PVO (hazard ratio = 5.56, 95% CI: 1.18-26.27) adjusting for type of TAPVC, pre-PVO, and other confounders. In conclusions, the sutureless strategy for primary repair of TAPVC is safe and effective. For patients with pre-PVO, this strategy may associate with decreased mortality and post-PVO with statistical significance.

Selective Vulnerability of Cortical Border Zone to Microembolic Infarct.

BACKGROUND AND PURPOSE: Endovascular procedures, including atrial fibrillation transcatheter ablation, may cause microembolization of brain arteries. Microemboli often cause small sized and clinically silent cerebral ischemias (SCI). These lesions are clearly visible on early postoperative magnetic resonance diffusion-weighted images. We analyzed SCI distribution in a population of patients submitted to atrial fibrillation transcatheter ablation. METHODS: Seventy-eight of 927 consecutive patients submitted to atrial fibrillation transcatheter ablation were found positive for acute SCI on a postoperative magnetic resonance. SCI were identified and marked, and their coordinates were transformed from native space into the International Consortium for Brain Mapping/Montreal Neurological Institute space. We then computed the voxel-wise probability distribution map of the SCI using the activation likelihood estimation approach. RESULTS: SCI were more commonly found in the cortex. In supratentorial regions, SCI selectively involved cortical border zone between anterior, middle, and posterior cerebral arteries; in infratentorial regions, distal territory of posteroinferior cerebellar artery. Possible explanations include selective embolization, linked to the vascular anatomy of pial arteries supplying those territories, reduced clearance of emboli in a relatively hypoperfused zone, or a combination of both. This particular distribution of lesions has been reported in both animal models and in patients with microemboli of different sources. CONCLUSIONS: A selective vulnerability of cortical border zone to microemboli occurring during atrial fibrillation transcatheter ablation was observed. We hypothesize that such selectivity may apply to microemboli of different sources.

Improved systemic saturation after ventricular assist device implantation in a patient with decompensated dextro-transposition of the great arteries after the Fontan procedure.

We report the successful implantation of a HeartMate II left ventricular assist device after a failed Fontan procedure in a patient with dextro-transposition of the great arteries. The patient had developed significant intrapulmonary arteriovenous shunting. Despite the theoretical risk of worsening intrapulmonary shunting due to the decrease in systemic vascular resistance after device implantation, our patient did well. He was discharged from the hospital in stable condition and had better oxygen saturation than before the device was implanted. To our knowledge, ours is the 2nd report of the use of a ventricular assist device after the failure of a Fontan procedure, and the first report concerning the effect of ventricular assist device implantation on intrapulmonary shunting.

Perioperative outcomes after on- and off-pump coronary artery bypass grafting.

Although numerous reports describe the results of off-pump coronary artery bypass grafting (CABG) at specialized centers and in select patient populations, it remains unclear how off-pump CABG affects real-world patient outcomes. We conducted a large, multicenter observational cohort study of perioperative death and morbidity in on-pump (ON) versus off-pump (OFF) CABG. We reviewed Veterans Affairs Surgical Quality Improvement Program data for all patients (N=65,097) who underwent isolated CABG from October 1997 through April 2011 (intention-to-treat data were available from 2005 onward). The primary outcome was perioperative (30-day or in-hospital) death; the secondary outcomes were perioperative stroke, dialysis dependence, reoperation for bleeding, mechanical circulatory support, myocardial infarction, ventilator support ≥ 48 hr, and mediastinitis. Propensity scores calculated from age, 17 preoperative risk factors, and year of surgery were used to match 8,911 OFF with 26,733 ON patients. In the complete cohort, compared with the ON patients (n=53,468), the OFF patients (n=11,629) had less perioperative death (2.02% vs 2.53%, P=0.0012) and lower incidences of all morbidities except perioperative myocardial infarction. In the matched cohort, perioperative death did not differ significantly between OFF and ON patients (1.94% vs 2.28%, P=0.06), but the OFF group had lower incidences of all morbidities except for perioperative myocardial infarction and mediastinitis. A subgroup intention-to-treat analysis yielded similar but smaller outcome differences between the ON and OFF groups. Off-pump CABG might be associated with decreased operative morbidity but did not affect operative death, compared with on-pump CABG. Future studies should examine the effect of off-pump CABG on long-term outcomes.

Use of a sandwich technique to repair a left ventricular rupture after mitral valve replacement.

One difficulty with external repair of left ventricular rupture after mitral valve replacement is collateral bleeding in friable myocardium adjacent to the rupture. The bleeding is caused by tension on the closing sutures, whether or not pledgets have been used. We report the case of a 69-year-old woman who underwent an uneventful mitral valve replacement. After cardiopulmonary bypass was terminated, brisk bleeding started from high in the posterior left ventricular wall, typical of a type III defect. We undertook external repair, placing a plug of Teflon felt into the cavity of the rupture and sandwiching it into place with pledgeted mattress and figure-of-8 sutures. The space occupied by the plug decreased the distance needed to obliterate the defect and thereby reduced the tension on the sutures necessary to achieve hemostasis. This simple technique enabled closure of the defect and avoided collateral tears that would have compromised an otherwise successful repair. Two years postoperatively, the patient had normal mitral valve function and no left ventricular aneurysm. In addition to reporting the patient's case, we review the types of left ventricular rupture that can occur during mitral valve replacement and discuss the various repair options.

Analysis of postsurgical aortic false aneurysm in 27 patients.

Aortic false aneurysm is a rare complication after cardiac surgery. In recent years, improved results have been reported in regard to the surgical management of these high-risk lesions. We retrospectively examined 28 consecutive cases (in 27 patients) of postsurgical aortic false aneurysm diagnosed at our institution from May 1999 through December 2011. Twenty-four patients underwent reoperation. Cardiopulmonary bypass was instituted before sternotomy in 15 patients (63%). Isolated repair of the aortic false aneurysm was performed in 15 patients. Four patients (including one who had already undergone repeat false-aneurysm repair) declined surgery in favor of clinical monitoring. Eleven patients were asymptomatic at the time of diagnosis. In the other 16, the main cause was infection in 7, and previous operation for acute aortic dissection in 9. The in-hospital mortality rate was 16.6% (4 patients, 3 of whom had infective false aneurysms). Relevant postoperative sequelae were noted in 7 patients (29%). The cumulative 1-year and 5-year survival rates were 83% and 62%, respectively. The 4 patients who did not undergo reoperation were alive at a median interval of 23 months (range, 9-37 mo). Two underwent imaging evaluations; in one, computed tomography revealed an 8-mm increase of the false aneurysm's maximal diameter at 34 months. Aortic false aneurysm can develop silently. Surgical procedures should be proposed even to asymptomatic patients because of the unpredictable evolution of the condition. Radical aortic-graft replacement should be chosen rather than simple repair, because recurrent false aneurysm is possible.

Is post-sternotomy mediastinitis still devastating after the advent of negative-pressure wound therapy?

In this study, we reviewed a 15-year experience with the treatment of a severe sequela of cardiac surgery: post-sternotomy mediastinitis. We compared the outcomes of conventional treatment with those of negative-pressure wound therapy, focusing on mortality rate, sternal reinfection, and length of hospital stay.We reviewed data on 157 consecutive patients who were treated at our institution from 1995 through 2010 for post-sternotomy mediastinitis after cardiac surgery. Of these patients, 74 had undergone extensive wound débridement followed by negative-pressure wound therapy, and 83 had undergone conventional treatment, including primary wound reopening, débridement, closed-chest irrigation without rewiring, topical application of granulated sugar for recurrent cases, and final plastic reconstruction with pectoral muscle flap in most cases.The 2 study groups were homogeneous in terms of preoperative data and operative variables (the primary cardiac surgery was predominantly coronary artery bypass grafting). Negative-pressure wound therapy was associated with lower early mortality rates (1.4% vs 3.6%; P = 0.35) and significantly lower reinfection rates (1.4% vs 16.9%; P = 0.001). Significantly shorter hospital stays were also observed with negative pressure in comparison with conventional treatment (mean durations, 27.3 ± 9 vs 30.5 ± 3 d; P = 0.02), consequent to the accelerated process of wound healing with negative-pressure therapy.Lower mortality and reinfection rates and shorter hospital stays can result from using negative pressure rather than conventional treatment. Therefore, negative-pressure wound therapy is advisable as first-choice therapy for deep sternal wound infection after cardiac surgery.

Delayed chylous pericardial effusion after aortic valve replacement.

Chylopericardium after cardiac surgery is rare, and there are few reports of its occurrence after aortic valve surgery. Chylous pericardial effusion 4 months after aortic valve replacement for endocarditis is highly unusual.Herein, we report the case of a 54-year-old man who had undergone bioprosthetic aortic valve replacement because of endocarditis and valvular dysfunction. Two months later, he underwent pericardiocentesis twice because of large pericardial effusions consisting of pinkish white fluid with predominant lymphocytes. Four months after valve replacement, he presented with recurrent effusion consistent with early tamponade, and a pericardial window was created. At surgery, 1,500 cc of milky white fluid was recovered, and the diagnosis of chylopericardium was made. Postoperative high-volume drainage prompted thoracic duct ligation, which was curative.

Coronary ostial stenosis after aortic valve replacement: successful treatment of 2 patients with drug-eluting stents.

Coronary ostial stenosis is a rare but potentially serious sequela after aortic valve replacement. It occurs in the left main or right coronary artery after 1% to 5% of aortic valve replacement procedures. The clinical symptoms are usually severe and may appear from 1 to 6 months postoperatively. Although the typical treatment is coronary artery bypass grafting, patients have been successfully treated by means of percutaneous coronary intervention.Herein, we present the cases of 2 patients in whom coronary ostial stenosis developed after aortic valve replacement. In the 1st case, a 72-year-old man underwent aortic valve replacement and bypass grafting of the saphenous vein to the left anterior descending coronary artery. Six months later, he experienced a non-ST-segment-elevation myocardial infarction. Coronary angiography revealed a critical stenosis of the right coronary artery ostium. In the 2nd case, a 78-year-old woman underwent aortic valve replacement and grafting of the saphenous vein to an occluded right coronary artery. Four months later, she experienced unstable angina. Coronary angiography showed a critical left main coronary artery ostial stenosis and occlusion of the right coronary artery venous graft. In each patient, we performed percutaneous coronary intervention and deployed a drug-eluting stent. Both patients were asymptomatic on 6-to 12-month follow-up. We attribute the coronary ostial stenosis to the selective ostial administration of cardioplegic solution during surgery. We conclude that retrograde administration of cardioplegic solution through the coronary sinus may reduce the incidence of postoperative coronary ostial stenosis, and that stenting may be an efficient treatment option.