Thirteen-year experience with universal Staphylococcus aureus nasal decolonization prior to cardiac surgery: a quasi-experimental study.

INTRODUCTION: Sternal wound infection (SWI) after cardiac surgery is a severe complication. Among preventive measures, pre-operative decolonization of nasal carriage of Staphylococcus aureus has recently been shown to be beneficial. This quasi-experimental study assessed the effect of decolonization on the incidence of S. aureus-associated SWI based on 19 years of prospective surveillance. METHODS: Segmented negative binomial regression was used to analyse the change over time in the incidence of S. aureus mediastinitis requiring re-operation after cardiac surgery in a French university hospital between 1996 and 2014. Universal nasal decolonization with mupirocin was introduced in December 2001. The association between pre-operative nasal carriage and SWI due to S. aureus was analysed between 2006 and 2012. RESULTS: Among 17,261 patients who underwent a cardiac surgical procedure, 565 developed SWI (3.3%), which was caused by S. aureus in 181 cases (1%). The incidence of mediastinitis caused by S. aureus decreased significantly over the study period (1.43% in 1996-2001 vs 0.61% and 0.64% in 2002-2005 and 2006-2014, respectively; P<0.001). In segmented analysis, there was a significant break in 2002, corresponding to the introduction of decolonization. Despite this intervention, pre-operative nasal carriage remained a significant risk factor for S. aureus mediastinitis (adjusted odds ratio 2.2; 95% confidence interval 1.2-4.2), as were obesity, critical pre-operative status, coronary artery bypass grafting (CABG), and combined surgery with valve replacement and CABG. CONCLUSION: Universal nasal decolonization before cardiac surgery was effective in decreasing the incidence of mediastinitis caused by S. aureus. Nasal carriage of S. aureus remained a risk factor for S. aureus-associated SWI.

Surgical site infection with extended-spectrum ß-lactamase-producing Enterobacteriaceae after cardiac surgery: incidence and risk factors.

OBJECTIVE: To determine the incidence, microbiology and risk factors for sternal wound infection (SWI) with extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-PE) following cardiac surgery. METHODS: We performed a retrospective analysis between January 2006 and December 2015 of prospective surveillance of a cohort of patients with cardiac surgery at a single centre (Paris, France). SWI was defined as the need for reoperation due to sternal infection. All patients with an initial surgery under extracorporeal circulation and diagnosed with an SWI caused by Enterobacteriaceae isolates were included. We compared patients infected with at least one ESBL-PE with those with SWI due to other Enterobacteriaceae by logistic regression analysis. RESULTS: Of the 11 167 patients who underwent cardiac surgery, 412 (3.7%) developed SWI, among which Enterobacteriaceae were isolated in 150 patients (36.5%), including 29 ESBL-PE. The main Enterobacteriaceae (n = 171) were Escherichia coli in 49 patients (29%) and Enterobacter cloacae in 26 (15%). Risk factors for SWI with ESBL-PE in the multivariate logistic regression were previous intensive care unit admission during the preceding 6 months (adjusted odds ratio (aOR) 12.2; 95% CI 3.3-44.8), postoperative intensive care unit stay before surgery for SWI longer than 5 days (aOR 4.6; 95% CI 1.7-11.9) and being born outside France (aOR 3.2; 95% CI 1.2-8.3). CONCLUSIONS: Our results suggest that SWI due to ESBL-PE was associated with preoperative and postoperative unstable state, requiring an intensive care unit stay longer than the usual 24 or 48 postoperative hours, whereas being born outside France may indicate ESBL-PE carriage before hospital admission.

Thymic function is a major determinant of onset of antibody-mediated rejection in heart transplantation.

Thymic function decreases progressively with age but may be boosted in certain circumstances. We questioned whether heart transplantation was such a situation and whether thymic function was related to the onset of rejection. Twenty-eight antithymocyte globulin-treated heart transplant recipients were included. Patients diagnosed for an antibody-mediated rejection on endomyocardial biopsy had a higher proportion of circulating recent thymic emigrant CD4+ T cells and T cell receptor excision circle levels than other transplanted subjects. Thymus volume and density, assessed by computed tomography in a subset of patients, was also higher in patients experiencing antibody-mediated rejection. We demonstrate that thymic function is a major determinant of onset of antibody-mediated rejection and question whether thymectomy could be a prophylactic strategy to prevent alloimmune humoral responses.

[Combined heart and kidney transplantation in Fabry's disease: Long-term outcomes in two patients]. / Transplantation combinée cœur­rein au cours de la maladie de Fabry : suivi à long terme de deux patients.

INTRODUCTION: Fabry disease is a lysosomal storage disorder linked to an alpha-galactosidase A deficiency that can lead to heart and kidney failure. There is little data about the prognosis of patients who undergo a combined heart and kidney transplantation. CASE REPORTS: Two brothers who were diagnosed with Fabry disease after the age of 30 years underwent a combined heart and kidney transplantation at respectively 49 and 42 years of age because of a severe hypertrophic cardiomyopathy with end stage renal failure. They are alive respectively 4 and 9 years after the transplantation. No recurrence of the disease in the transplanted organs has been found. CONCLUSION: Combined heart and kidney transplantation in Fabry disease is an efficient therapy for the cardiomyopathy and kidney failure. Its prognosis can be good when the patients are carefully selected. However, an early diagnosis is critical in order to avoid a procedure associated with a high perioperative mortality.

Eclipsed mitral regurgitation: an unusual cause of acute heart failure.

AIMS: So far, a total of five patients with eclipsed mitral regurgitation (MR) have been reported in the literature by three different teams. The aim of this article was to detail clinical and echocardiographic characteristics, and outcome of patients presenting eclipsed MR. METHODS AND RESULTS: We defined eclipsed MR as spontaneous appearance, at rest, from 1 min to the next of an acute restriction in the motion of mitral leaflets preventing coaptation and leading to massive MR in patients with normal left ventricular end-diastolic diameter, left ventricular ejection fraction >45%, and baseline MR ≤2. Spontaneous regression occurred within 30 min, and no obvious trigger such as acute hypertension, new-onset arrhythmia, or myocardial ischaemia is present. Clinical data, ECG, echocardiographic data, surgery report, and follow-up status of six patients with eclipsed MR are reported: all were post-menopausal women with median age of 74 [57-80] years presenting hypertension (4/6), chronic kidney disease (5/6), or chronic anaemia (4/6). Five out of six patients experienced acute pulmonary oedema requiring hospitalization and underwent mitral valve replacement because of heart failure recurrence. Two patients died in the first days after surgery while the three others are free of symptoms at, respectively, 56, 18, and 10 months follow-up. CONCLUSION: Eclipsed MR is a clinical and echocardiographic syndrome responsible for heart failure with preserved EF. It is presently underdiagnosed and should be evoked in cases of recurrent acute pulmonary oedema without obvious trigger, in particular in patients presenting discordant evaluation of MR severity over time.

Sternal wound infection after cardiac surgery: incidence and risk factors according to clinical presentation.

The incidence of surgical site infection (SSI) after cardiac surgery depends on the definition used. A distinction is generally made between mediastinitis, as defined by the US Centers for Disease Control and Prevention (CDC), and superficial SSI. Our objective was to decipher these entities in terms of presentation and risk factors. We performed a 7-year single centre analysis of prospective surveillance of patients with cardiac surgery via median sternotomy. SSI was defined as the need for reoperation due to infection. Among 7170 patients, 292 (4.1%) developed SSI, including 145 CDC-defined mediastinitis (CDC-positive SSI, 2.0%) and 147 superficial SSI without associated bloodstream infection (CDC-negative SSI, 2.1%). Median time to reoperation for CDC-negative SSI was 18 days (interquartile range, 14-26) and 16 (interquartile range, 11-24) for CDC-positive SSI (p 0.02). Microorganisms associated with CDC-negative SSI were mainly skin commensals (62/147, 41%) or originated in the digestive tract (62/147, 42%); only six were due to Staphylococcus aureus (4%), while CDC-positive SSI were mostly due to S. aureus (52/145, 36%) and germs from the digestive tract (52/145, 36%). Risk factors for SSI were older age, obesity, chronic obstructive bronchopneumonia, diabetes mellitus, critical preoperative state, postoperative vasopressive support, transfusion or prolonged ventilation and coronary artery bypass grafting, especially if using both internal thoracic arteries in female patients. The number of internal thoracic arteries used and factors affecting wound healing were primarily associated with CDC-negative SSI, whereas comorbidities and perioperative complications were mainly associated with CDC-positive SSI. These 2 entities differed in time to revision surgery, bacteriology and risk factors, suggesting a differing pathophysiology.

Less invasive radial artery harvest.

BACKGROUND: Recent studies have sparked a renewed interest in the use of autogenous radial arteries in coronary operations. Some concerns have been found about sequelae of conventional harvesting. A less invasive technique for radial artery harvesting has been proposed by others using endoscopic devices. This technique is time consuming, needs expensive instrumentation and an important learning curve. METHODS: A new less invasive approach for radial harvesting has been developed with a light assisted retractor under direct vision. A small skin incision, median in the forearm, is followed by dissection of the proper plane of the artery. A subcutaneous tunnel is created around the vessel and all the branches are ligated or clipped. The dissection of the pedicle under the skin is completed with the aid of a modified light assisted retractor, originally designed for the saphenous vein harvesting. The incision is closed after heparin reversal with a small redon as drainage. RESULTS: A preliminary serie of 15 patients have been operated with this technique. In all patients the radial artery was patent and functional at the postoperative angiography. Morbidity included only a light hematoma at the beginning of our experience. CONCLUSION: This less invasive technique for the radial artery harvesting appears to be an excellent surgical compromise between the open technique and the endoscopic procedure; it is easy to perform, the learning curve is acceptable and it offers an excellent aesthetic result.

Retrocaval in situ RIMA for distal marginal arteries grafting.

The length of the in situ right internal mammary artery (RIMA) often restricts its use as a graft to distal marginal arteries. We describe herein a retrocaval supra-azygous extra-pleural passage of the RIMA that allows a significant gain in length. We report our experience in 30 patients with distal marginal lesions or with large hearts.

A multicenter initial clinical experience with right heart support and beating heart coronary surgery.

BACKGROUND: During coronary surgery without CPB, exposure of posterior vessel via sternotomy can cause deterioration of cardiac hemodynamics requiring inotrope drugs support. Recent animal experiments demonstrate hemodynamic benefit of right heart support (RHS) with the AMED system. The purpose of this study was to evaluate the hemodynamic effects during cardiac manipulation to expose the posterior coronary arteries, and determine the effect of RHS in restoring hemodynamics, increasing anastomotic exposure and reducing inotropic requirements. MATERIAL AND METHODS: From July 28 to December 29, 32 patients (25 men/7 women), mean age of 63.4 (+/- 6.2 years, ages: 49-78) received coronary revascularization with the A-Med RHS device. They were divided into two groups of 16 patients, A and B. Group A patients had at least one circumflex branch bypassed. The anterior wall was systematically bypassed off-pump without RHS. The right coronary artery (RCA) and the obtuse coronary artery (OM) were completed utilizing RHS. In group B patients, all vessels including anterior vessels were bypassed with the RHS. Mean arterial pressure (MAP), mean pulmonary arterial pressure (PAP), cardiac output (CO) and the average pump flow (APF) were recorded during the OM and RCA bypass for group A, and for group B LAD data was also recorded. RESULTS: Elective beating heart coronary artery bypass graft (CABG) was successfully accomplished in 32 patients with RHS. Data measurements recorded in Group A showed the improved hemodynamic recovery for OM and RCA bypass with RHS. The MAP increased from 44 to 68 mmHg (OM) and from 63 to 81 mmHg (RCA); the CO from 2.1 to 4.4 L/min (OM) and from 3.3 to 4.7 L/min (RCA). In group B, the data recorded showed the stability of the MAP in all vessels bypassed (LAD, OM and RCA). No device-related patient incidents occurred. All 32 patients were discharged to their homes. CONCLUSIONS: The AMED system, as RHS support, facilitated coronary bypass without CPB to posterior vessels, restoring hemodynamics, providing better exposure to anastomotic sites and apparently reducing inotropes need. Prospective randomize trials are necessary to confirm this initial experience.

Pressure-adjusted antegrade brain perfusion for surgery of the aortic aneurysm.

Determining cerebral blood flow during circulatory arrest in patients undergoing surgery for aortic aneurysms has been traditionally based on body weight. We report the use of per-aortic antegrade cerebral perfusion regulated by perfusion pressure using a triple lumen cardioplegia catheter thus optimising cerebral flow.

Combined left pneumonectomy and off-pump coronary artery bypass through left thoracotomy.

Concomitant pneumonectomy and coronary artery bypass grafting (CABG) carry a high morbidity and mortality rate. We present the case of a patient operated on for left pneumonectomy and off pump CABG through a left thoracotomy incision in a one-stage procedure with a 1-year disease-free follow-up. To the best of our knowledge, simultaneous surgical management as presented in this patient has not been previously reported.

[Rupture of a sinus of Valsalva aneurysm in the left atrium]. / Rupture d'un anévrisme des sinus de Valsalva dans l'oreillette gauche.

Ruptures of sinus of Valsalva aneurysms are a rare complication, and very few cases of rupture in the left atrium have been described. In this clinical case we report the case of a patient hospitalised with a scenario of cardiac insufficiency revealing a very large posterior sinus of Valsalva aneurysm, associated with a bicuspid aortic valve, and rupture in the left atrium. The diagnosis was by transthoracic and transoesophageal multiplan echocardiography, and the treatment surgical, with a good result.

Pericardial patch for rapid and effective hemostasis of cardioplegia injection site.

Cardioplegia injection site may be the source of serious haemorrhagic complications either intraoperatively or during the early postoperative period. Here we describe a simple technique that allows a rapid control of hemostasis at this site. An autologous pericardial patch is used to repair and strengthen the aortic wall.

[Aortic dissection at 6 months gestation in a women with Marfan's syndrome. Simultaneous Bentall intervention and cesarean section]. / Dissection aortique au 6e mois d'une grossesse chez une femme atteinte d'un syndrome de Marfan. Intervention de Bentall et césarienne simultanées.

A 31 year old woman with Marfan's syndrome had a dilatation of the aortic root (55-60 mm at the beginning of pregnancy). Pregnancy was continued with beta-blocker therapy and with regular echocardiographic follow-up. The aortic dilatation increased (62-65 mm) at the last control and, at the 34th week of pregnancy, the patient suffered a dissection of the ascending aorta. A caesarean section was performed with a Bentall procedure during the same operative session. The mother and baby girl are well two years later. The problems of pregnancy in patients with Marfan's syndrome are discussed.

Effect of cryopreservation on endothelin-1 productions of human mammary artery.

The aim of this study was to determine the ability of human mammary artery cells to maintain a metabolic activity by measuring the artery concentration of two vasoactive substances, endothelin-1 (ET-1) and cyclic guanosyl monophosphate (cGMP), and a neurohumoral substance-neuropeptide Y (NPY)-prior to and following cryostorage. Ten distal segments of internal mammary arteries were obtained at the time of surgery in patients who had undergone coronary artery bypass grafting. One ring of each vessel served as a fresh control for the other ring that was used in cryopreservation experiments. The arteries were frozen with liquid nitrogen at a controlled rate down to -130 degrees C with an automatic freezing machine and were then stored in a liquid nitrogen vapor at -150 degrees C. After mammary artery extraction, ET-1, cGMP, and NPY concentrations were studied before and after cryopreservation. Cryopreserved, compared to fresh arteries, exhibited an increase in ET-1 (11.11+/-1.61 vs. 3. 09+/-0.06 pg/mg; p=0.004) and a decrease in cGMP (9.88+/-2.04 vs. 8. 55+/-2.07 p moles/mg; p<0.02), whereas there was no significant NPY variation. An increase in ET-1 and decrease in cGMP was found in 10 out of 10 and 6 out of 10 of cryopreserved artery specimen, respectively. There was no significant correlation between ET-1 and cGMP production in fresh or in cryopreserved arteries. The present method of cryostorage is effective in preserving "hormonal" mammary artery activity. However, the particularly high ET-1 concentration without associated cGMP concentration may be deleterious by increasing smooth-muscle cell proliferation and vascular tone of cryopreserved arteries.

Thoracoscopic IMA takedown.

In recent years, the field of minimally invasive cardiac surgery has grown rapidly beginning with the MIDCAB operation and evolving toward totally endoscopic coronary artery bypass grafting (CABG). It promotes the goal of decreasing surgical trauma while maintaining surgical efficacy. For MIDCAB, a limited anterior thoracotomy or mediastotomy have been proposed to harvest the internal mammary artery (IMA). However, complete graft harvesting of the IMA is difficult under direct vision in these circumstances and may necessitate costal resection and important chest wall retraction. Additionally, it carries the potential risk of kinking or coronary steal syndrome. Thoracoscopic harvesting of the IMA avoids these hazards. It permits complete dissection from the subclavian artery to the sixth inter-costal space (ICS) with section of all collateral branches issuing from the IMA without any traumatic retraction. The technique of IMA takedown described herein has been used regularly by us since 1995. Our current experience shows that it is safe and reproducible after a reasonable period of training. Furthermore, in the objective of performing a totally endoscopic and/or robotic CABG, thoracoscopic IMA takedown would be a prerequisite.