Surgical Management and Outcomes of Cardiac and Great Vessels Echinococcosis: A 16-Year Experience.

BACKGROUND: Cardiac involvement is an uncommon presentation of hydatid disease. In this study, we aim to analyze the experience of surgical treatment of cardiac and great vessels echinococcosis in our cardiovascular and thoracic surgery department. METHODS: Through a 16-year period, from 2000 to 2015, 27 patients underwent surgery for cardiac and great vessels hydatid disease. The clinical, operative, and postoperative data were analyzed through this retrospective and descriptive study. RESULTS: Most of our patients came from a rural area. The most common symptom was chest pain. The diagnosis was mainly made by transthoracic echocardiography, which has shown the right ventricle as the most frequent location of the disease. All patients received surgical treatment under cardiopulmonary bypass, and only six surgeries were performed without cross-clamping the aorta. Inhospital mortality rate was 7.4%. CONCLUSIONS: Cardiac hydatidosis is a rare but potentially serious condition whose treatment is mainly surgical even for asymptomatic patients owing to its possible fatal complications. The surgery outcomes are usually satisfactory. Follow-up examinations are highly recommended to detect recurrences.

Xenopericardial roll graft replacement for infectious pseudoaneurysms and graft infections of the aorta.

BACKGROUND: Which graft material is the optimal graft material for the treatment of infected aortic aneurysms and aortic graft infections is still a matter of controversy. Orthotopic aortic reconstruction with intraoperatively prepared xenopericardial roll grafts without omentopexy was performed as the "initial" operation to treat aortic infection or as a "rescue" operation to treat graft infection. Mid-term outcomes were evaluated. METHODS: Between 2009 and 2013, orthotopic xenopericardial roll graft replacement was performed to treat eight patients (male/female: 6/2; mean age: 69.5 [55-80] yr). Graft material: equine/bovine pericardium: 2/6; type of operation: initial 4/rescue 4; omentopexy 0. Additional operation: esophagectomy 2. Mean follow-up period: 2.6 ± 1.6 (1.1-5.1) years. RESULTS: Replacement: ascending 3, arch 1 (reconstruction of neck vessels with small xenopericardial roll grafts), descending 3, and thoracoabdominal 1. Pathogens: MRSA 2, MSSA 1, Candida 1, E. coli 1, oral bacillus 1, and culture negative 2. Postoperative local recurrence of infection: 0. Graft-related complications: stenosis 0, calcification 0, non-infectious pseudoaneurysm of anastomosis 2 (surgical repair: 1/TEVAR 1). In-hospital mortality: 2 (MOF: initial 1/rescue 1); Survival rate exclusive of in-hospital deaths (~3 y): 100 %, but one patient died of lung cancer (3.6 yr). CONCLUSIONS: Because xenopericardial roll grafts are not composed of synthetic material, the replacement procedure is simpler and less invasive than the standard procedure. Based on the favorable results obtained, this procedure may have the possibility to serve as an option for the treatment of aortic infections and aortic graft infections not only as a "rescue" treatment but as an "initial" treatment as well.

Long-term temporary pacing with an active fixation lead.

BACKGROUND: Ensuring a haemodynamically effective cardiac rhythm is a challenge in patients waiting for pacemaker reimplantation after transcutaneous lead extraction due to an infection of the implanted system. AIM: The authors report a retrospective analysis of temporary pacing with an active fixation lead (AFTP) connected to an externalised pacemaker in patients after transvenous lead extraction (TLE) due to an infection. METHODS: AFTP was used in 34 patients (12 women) aged from 38 to 88 years (mean 67.5 years). This represented 24.5% of the population of patients undergoing TLE due to infective indications. In 32 cases, the indication for temporary pacing was atrioventricular block, and in 2 patients sick sinus syndrome. The lead was implanted via the internal jugular vein puncture into the right ventricle in 33 cases and into the right atrium in 1 case. Leads were secured to the skin and attached to externalized pacemakers. RESULTS: AFTP was used for 4 to 26 days (average 14.5 days). Re-implantation was performed in 29 patients (85.3% of the study group). There was no early infection recurrence. Three patients died during AFTP (8.8% of the study group), including two due to septic shock, and a cardiac arrest due to pulseless electrical activity in another patient. CONCLUSIONS: Temporary pacing with an active fixation lead is an effective and safe method to ensure a hemodynamically stable heart rhythm for a period ranging from a few to several days after the surgery in patients after transcutaneous lead extraction due to infective indications.

Surgery for coincidental infected distal arch and abdominal aortic aneurysms.

A 63-year old man was admitted to hospital for the treatment of coincidental infected distal arch and abdominal aortic aneurysms. His haemodynamic state was unstable and uncontrollable because of septic shock. Group A beta-haemolytic Streptococcus pyogenes was the responsible microorganism. An emergent extra-anatomical bypass and complete aneurysm excisions were performed without extracorporeal circulation.

Equine pericardial roll graft replacement of infected pseudoaneurysm of the ascending aorta.

The standard procedure for treating infected aortic aneurysms is to resect the infected aorta, debridement of the surrounding tissue, in situ graft replacement, and omentopexy. However, the question of which graft material is optimal is still a matter of controversy. We recently treated a patient with an infected ascending aortic aneurysm. Because of previous abdominal surgery, the omentum was unavailable. The ascending aorta was replaced in situ with equine pericardial roll grafts. The patient is alive and well 29 months after the operation.

Equine pericardial roll graft replacement of infected pseudoaneurysm of the aortic arch.

Resection of the infected aorta, debridement of the surrounding tissue, in situ graft replacement, and omentopexy is the standard procedure for treating infected aortic aneurysms, but the question of which graft material is optimal is still a matter of controversy. We recently treated a patient with an infected thoracic aortic aneurysm. The aneurysm was located in the proximal aortic arch. Because the patients had previously undergone abdominal surgery, the aortic arch were replaced in situ with a branched equine pericardial roll grafts. The patient is alive and well 23 months after the operation.

Impact of timing of device removal on mortality in patients with cardiovascular implantable electronic device infections.

BACKGROUND: Cardiovascular implantable electronic device (CIED) infections are associated with increased mortality. However, detailed analyses of the impact of device removal on mortality have been limited. OBJECTIVE: This study sought to evaluate the impact of timing device removal on mortality in patients with CIED infections. METHODS: We retrospectively reviewed all cases of CIED infections seen at Mayo Clinic Rochester between 1991 and 2008. The impact of device removal on 30-day and 1-year mortality was evaluated using Cox proportional hazards models. RESULTS: Of 416 patients with CIED infection, 23 (5.5%) died by 30 days and 61 (14.6%) died by 1 year. Forty-four (12.0%) developed complications related to device removal, and 3 (0.8%) died. Complete procedural success was achieved in 341 (81.9%) and clinical success in 391 (93.9%) cases. In multivariate analysis, antimicrobial therapy without device removal was associated with a 7-fold increase in 30-day mortality (hazard ratio [HR] 6.97, 95% confidence interval [CI] 1.36 to 35.60). Although device removal complications were associated with increased mortality at 30 days (HR 4.33, 95% CI 1.47 to 12.70) and at 1 year (HR 3.77, 95% CI 1.88 to 7.55), immediate device removal, when compared to delay in device removal in favor of initial conservative therapy with antimicrobials alone, and no device removal, was associated with a 3-fold decrease in 1-year mortality (HR 0.35, 95% CI 0.16 to 0.75). CONCLUSION: Although device removal resulted in fatal complications in a few patients, the mortality associated with a delay in device removal was significantly higher. Therefore, early and complete device removal was associated with improved outcomes.