Single Low-Volume Center Experience with Frozen Elephant Trunk in Acute Type A Aortic Dissections.

BACKGROUND: Acute Type A aortic dissection (AAAD) is a surgical emergency. In patients with arch and descending aorta involvement (DeBakey Type I), a total aortic arch replacement with frozen elephant trunk (FET) could favor false lumen thrombosis and improve long-term results. The authors hereby present their experience with this technique in a single low-volume center, to assess whether the technique is feasible to treat such disease. METHODS: From January 2011 to December 2016, 43 patients with AAAD were operated on in the authors' institution, which carries out 300 to 350 annual procedures. Among these, 12 patients with an intimal tear in the aortic arch and/or proximal descending aorta received a FET procedure (10 males, age 57 years). Concomitant procedures were aortic valve replacement (42%), Bentall (25%), and aortic valve repair (17%). RESULTS: Cardiopulmonary bypass, cardiac arrest, and circulatory arrest times were 235 ± 43, 171 ± 33, and 75 ± 20 minutes, respectively. The operative mortality was 16.7% (n = 2). Stroke and re-thoracotomy for bleeding occurred in 8% (n = 1) and 8% (n = 1), respectively. There was no spinal cord injury. Follow-up was 36.1 months. During follow-up, no patients died or required a reoperation on the downstream aorta. CONCLUSION: Although all patients were operated on in a low-volume center, the results with FET in AAAD are acceptable. Even though this technique demands high technical skills, it is a promising approach in patients with acute aortic dissection.

Profilaxis de la dehiscencia esternal en obesos mediante la aplicación sistemática del cerclaje de tipo Robicsek / Prophylaxis of sternal dehiscence in obese patients through systematic application of robicsek closure

Introducción. La dehiscencia esternal es una complicación relativamente frecuente de la esternotomía media y que causa gran morbimortalidad en cirugía cardiotorácica. La obesidad se considera uno de los factores de riesgo más importantes de dehiscencia e infección esternal, y su prevalencia cada vez mayor en la población sometida a cirugía cardíaca. En el presente estudio se evalúa el beneficio clínico del uso profiláctico del refuerzo esternal de tipo Robicsek en los pacientes de alto riesgo que son intervenidos de cirugía cardíaca mayor. Pacientes y método. Se analiza a 290 pacientes consecutivos intervenidos mediante esternotomía media en nuestro centro. La indicación de refuerzo profiláctico esternal se estableció en casos de osteoporosis esternal severa o índice de masa corporal (IMC) >= 30, empleándose la técnica en 105 pacientes, 54 varones y 51 mujeres, cuya edad media era de 67,7 ± 9,1 años y con un IMC medio de 31,8 ± 4,1. Resultados. No hubo dehiscencias no infecciosas en el grupo con refuerzo de tipo Robicsek; sólo se produjo un caso (1,7%) de dehiscencia esternal debida a osteomielitis en el grupo reforzado, con buena respuesta a desbridamiento quirúrgico asociado con antibioterapia por vía intravenosa. Conclusión. El refuerzo de tipo Robicsek reduce la incidencia de dehiscencia esternal en los pacientes de alto riesgo y su indicación profiláctica debe ser considerada en casos de osteroporosis severa o IMC >= 30 (AU)

Introduction. Sternal deshidence is a relatively frequent complication in median sternotomy and causes high morbidity and mortality in cardiothoracic surgery. Obesity is one of the most important risk factors for sternal infection and deshidence and its prevalence is increasingly frequent in patients undergoing cardiac surgery. The aim of the present study was to assess the clinical benefit of the prophylactic use of robicsek sternal reinforcement in high-risk patients undergoing cardiac surgery. Patient and method. Two hundred ninety ninety consecutive patients who underwent median sternotomy in our center were analysed. The indications for prophylactic sternal reinforcement were severe sternal osteoporosis or a body mass indez (BMI) of >= 30. The technique was used in 105 patients, 54 men and 51 women, with a mean age of 67.7 +/- 9.1 years and a mean BMI of 31.8+/-4.1. Results. None of the patients in the reinforcement group developed non-infectious dehiscence; only one patient (1.7%) in this group showed sternal dehiscence due to osteomyelitis with good response to surgical debridement and intravenous antibiotics. Conclusion. Robicsek reinforcement reduces the incidence of sternal dehiscence in high-risk patients and its prophylactic use should be considered in patients with severe osteoporosis or a BMI of >=30 (AU)

Endothelium histological integrity after skeletonized dissection of the left internal mammary artery with ultrasonic scalpel.

Evaluate the endothelium histological changes produced in the left internal mammary artery (LIMA) after its dissection in a skeletonized manner with an ultrasonic scalpel. Two study groups were created in a prospective and randomized way: group A, 14 LIMA fragments skeletonized with a high frequency ultrasonic scalpel and group B (control group) with 14 specimens dissected with scissors and clips. The endothelium was studied in all 28 fragments fixing the segments with 10% formaldehyde, and paraffin inclusion. The arteries were sliced in 4 microm sections and stained with hematoxilin-eosin, and then evaluated by one single pathologist. In group A (ultrasonic scalpel) none of the specimens showed any endothelial damage, as did the samples in group B (control group). In both groups the endothelial wall was intact. There were chronic lesions in the form of intimal hyperplasia that might be in relation to the advanced age of both groups of patients. The left IMA dissection in a skeletonized fashion with an ultrasonic scalpel does not produce endothelial structural damage in it being similar to the one dissected with conventional methods. This permits its safe use, allowing us to benefit from the numerous advantages of arterial grafts usage in modern era coronary surgery.

Vacuum-assisted therapy with a handcrafted system for the treatment of wound infection after median sternotomy.

The VAC (vacuum-assisted closure) system is a non-invasive therapy based on the application of negative pressure by controlled suction to the wound surface. This method has been proved to be effective on the promotion of granulation tissue proliferation. The aim of the study was to evaluate the effectiveness of the vacuum-assisted therapy with a handcrafted system, because the commercialized one was not available in our institution. Since July 2004, seven patients with sternal wound infection after median sternotomy were treated with vacuum-assisted therapy. All patients underwent surgical debridement under aseptic conditions. Thereafter, the patients received vacuum-assisted therapy with a handcrafted system. Complete healing with a tension-free wound direct closure was achieved in all patients, without morbidity. Removal of the system was done after a median of 15 days after surgery (range 8-47 days). All patients received intravenous antibiotics during the treatment. The cultures became negative after a median of 7 days (range 2-21 days). We suggest that our method, based on the negative pressure principle, is a valuable and effective tool in the management of patients with wound infection after median sternotomy when the commercialized one is not available.

[Prophylaxis of sternal dehiscence in obese patients through systematic application of Robicsek closure]. / Profilaxis de la dehiscencia esternal en obesos mediante la aplicación sistemática del cerclaje de tipo Robicsek.

INTRODUCTION: Sternal dehiscence is a relatively frequent complication in median sternotomy and causes high morbidity and mortality in cardiothoracic surgery. Obesity is one of the most important risk factors for sternal infection and dehiscence and its prevalence is increasingly frequent in patients undergoing cardiac surgery. The aim of the present study was to assess the clinical benefit of the prophylactic use of Robicsek sternal reinforcement in high-risk patients undergoing cardiac surgery. PATIENTS AND METHOD: Two hundred ninety consecutive patients who underwent median sternotomy in our center were analyzed. The indications for prophylactic sternal reinforcement were severe sternal osteoporosis or a body mass index (BMI) of > or = 30. The technique was used in 105 patients, 54 men and 51 women, with a mean age of 67.7 +/- 9.1 years and a mean BMI of 31.8 +/- 4.1. RESULTS: None of the patients in the reinforcement group developed noninfectious dehiscence; only one patient (1.7%) in this group showed sternal dehiscence due to osteomyelitis with good response to surgical debridement and intravenous antibiotics. CONCLUSION: Robicsek reinforcement reduces the incidence of sternal dehiscence in high-risk patients and its prophylactic use should be considered in patients with severe osteoporosis or a BMI of > or = 30.