Therapy options in deep sternal wound infection: Sternal plating versus muscle flap.

BACKGROUND: Management of deep sternal wound infection (DSWI) in cardiac surgical patients still remains challenging. A variety of treatment strategies has been described. Aim of this cohort study was to analyse two different treatment strategies for DSWI: titanium sternal plating system (TSFS) and muscle flap coverage (MFC). METHODS: Between January 2007 and December 2011, from 3122 patients undergoing cardiac surgery 42 were identified with DSWI and treated with one of the above mentioned strategies. In-hospital data were collected, follow-up performed by telephone and assessment of Quality of Life (QoL) using the SF-12 Health Survey Questionnaire. RESULTS: 20 patients with deep sternal wound infection were stabilized with TSFS and 22 patients treated with MFC. Preoperative demographics and risk factors did not reveal any significant differences. Patients treated with TSFS had a significantly shorter operation time (p<0.05) and shorter hospitalization (p<0.05). A tendency towards lower mortality rate (p = n.s.) and less re-interventions were also noted (plating 0.6 vs. flap 1.17 per patient, n.s.). Quality of Life in the TSFS group for the physical-summary-score was significantly elevated compared to the MFC group (p<0.05). Relating to chest stability and cosmetic result the treatment with TSFS showed superior results, but the usage of MFC gave the patients more freedom in breathing and less chest pain. CONCLUSION: Our results demonstrate that the use of TSFS is a feasible and safe alternative in DSWI. However, MFC remains an absolutely essential option for complicated DSWI since the amount of perfused tissue can be the key for infection control.

Modified frozen elephant trunk for acute type A aortic dissection: a comparative study with standard repair technique.

Objectives: We hypothesized that antegrade open stent graft implantation in the descending aorta during acute type A aortic dissection surgery is safe and improves patient outcome compared with the standard repair technique. Methods: Hundred and forty-one consecutive patients underwent surgery for acute type A aortic dissection at our institution from 2010 to 2016. Of those, 104 patients underwent ascending aorta and hemiarch repair under hypothermic circulatory arrest with antegrade cerebral perfusion (standard group). Since 2013, 37 patients have undergone the standard procedure combined with antegrade stent implantation in the descending aorta (stented group). A matched analysis using the logistic EuroSCORE (37 patients per group) was done. All data were collected prospectively. Results: The mean logistic EuroSCORE was 29 in both groups, P = 1. Cardiopulmonary bypass time was 150 ± 57 (standard) vs 157 ± 48 (stented) min, P = 0.6; aortic clamping 99 ± 47 (standard) vs 100 ± 36 (stented) min, P = 1. Stented patients had longer circulatory arrest times with antegrade cerebral perfusion, 23 ± 7 vs 15 ± 7 min, P < 0.001. Stroke occurred in 24.3% (standard) vs 8.1% (stented), P = 0.1; paraplegia developed in 2.7% (standard) vs 0% (stented), P = 1. Abdominal intervention due to suspected visceral ischaemia was needed in 18.9% (standard) vs 5.4% (stented), P = 0.2. 30-day mortality was 13.5% (standard) vs 0% (stented), P = 0.05. Survival at 6-month was 100% and 86.5% in patients with implanted stents and standard repair, respectively, P = 0.02. Conclusions: Antegrade, open stent graft implantation into the descending aorta during acute type A aortic dissection repair is safe and is associated with improved outcomes at 6 months postoperatively compared to the standard repair technique.

Computed Tomography Scan Predicts Abdominal Interventions but Not Stroke after Surgery for Acute Type A Aortic Dissection.

BACKGROUND: We hypothesized that preoperative computed tomography (CT) is a predictor of abdominal intervention for visceral malperfusion and stroke after emergent surgery for acute type A aortic dissection (AAAD). METHODS: A total of 90 patients, mean (± SD [standard deviation]) age 62 (± 12) years, 76% males, undergoing emergent surgery for AAAD at our institution from May 2008 to August 2013 were included. All clinical data were collected prospectively and correlated to CT images. RESULTS: At initial presentation 9 (10%) patients showed preoperative focal neurologic deficit or coma, 10 patients (11%) complained of abdominal pain, and the logistic EuroSCORE was 44 (± 22). Hemiarch replacement was performed in 96%, total arch in 4%. The duration of hypothermic circulatory arrest (HCA) at 28°C bladder temperature was 26 (± 19) minutes. Cross-clamp time was 88 (± 39) minutes, and cardiopulmonary bypass (CPB) time 148 (± 49) minutes. Overall 30-day mortality was 13%. Moreover, 12 (13%) patients required postoperative abdominal interventions for suspected visceral malperfusion; stroke occurred in 25 (28%) patients. Logistic regression revealed that "dissection of the celiac trunk and/or the superior mesenteric artery" in preoperative CT images is a predictor of postoperative abdominal interventions for visceral malperfusion (p = 0.03), but preoperative abdominal pain is not similarly predictive. Postoperative stroke is best predicted by preoperative neurologic symptoms (p = 0.01), but not by supra-aortic vessel dissection in preoperative CT images. CONCLUSION: In patients undergoing surgery for AAAD, analysis of preoperative CT images allows identifying those with a high risk of postoperative abdominal intervention for visceral malperfusion. Postoperative stroke is best predicted by preoperative neurologic symptoms.