Prevention of deep sternal wound infection in cardiac surgery: a literature review.

BACKGROUND: Deep sternal wound infection (DSWI) is a dreaded complication of cardiac surgery with considerable consequences in terms of mortality, morbidity and treatment costs. In addition to standard surgical site infection prevention guidelines, multiple specific measures in the prevention of DSWI have been developed and evaluated in the past decades. This review focuses on these specific measures to prevent DSWI. METHODS: An extensive literature search was performed to assess interventions in the prevention of DSWI. Articles describing results of a randomized controlled trial were categorized by type of intervention. Results were yielded and, if possible, pooled. RESULTS: From a total of 743 articles found, 48 randomized controlled trials were selected. Studies were divided into 12 categories, containing pre-, peri- and postoperative preventive measures. Specific measures shown to be effective were: antibiotic prophylaxis with a first-generation cephalosporin for at least 24 h, application of local gentamicin before chest closure, sternal closure with figure-of-eight steel wires, and postoperative chest support using a corset or vest. CONCLUSION: This study identified several measures that prevent DSWI after cardiac surgery that are not frequently applied in current practice. It is recommended that the guidelines on prevention of surgical site infection in cardiac surgery should be updated.

Is there an alternative treatment for patients intolerant to antiplatelet therapy if percutaneous left atrial appendage closure is considered?

INTRODUCTION: Left atrial appendage (LAA) closure has become of major interest for patients with atrial fibrillation intolerant to oral anticoagulation therapy (OAC). Patients with a contraindication to both OAC and antiplatelet therapy are not eligible for percutaneous LAA closure. We aimed to find an alternative treatment for these specific patients. METHODS: From March 2014 until December 2015 five patients were referred for percutaneous LAA closure. Alternative treatment was necessary due to an absolute contraindication to OAC and antiplatelet therapy (n = 4) or after previous failed percutaneous device implantation (n = 1). A stand-alone full thoracoscopic closure of the LAA using the Atriclip PRO device (AtriCure Inc., Dayton, OH, USA) was performed under guidance of transoesophageal echocardiography (TEE). After three months all patients underwent a computed tomography scan. Mean follow-up was 7.2 months [range 4.5-9.8 months]. RESULTS: All procedures were achieved without the occurrence of complications. Complete LAA closure was obtained in all patients without any residual flow confirmed by TEE. Postoperative computed tomography confirmed persisting adequate clip positioning with complete LAA closure and absence of intracardial thrombi. During follow-up no thromboembolic events occurred. CONCLUSION: For atrial fibrillation patients with an absolute contraindication to OAC and antiplatelet therapy a stand-alone, minimally invasive thoracoscopic closure of the LAA is a safe and feasible alternative treatment. This might be a solution to avoid serious bleeding complications while eliminating the thromboembolic risk originating from the LAA in patients who are not eligible for percutaneous LAA closure.

Ascending-descending aortic bypass for the treatment of concomitant severe co-arctation, aortic valve disease and hypoplastic aortic arch.

This report describes a one-stage treatment of a 30-year-old patient suffering from severe aortic valve insufficiency, aortic co-arctation, dilatation of the ascending aorta and arcus hypoplasia. The patient underwent aortic valve, ascending aorta and arch replacement through median sternotomy. The aorta was ligated at the level of the co-arctation, which was located in the proximal part of the descending aorta, and an ascending-descending bypass was created using a transhiatic approach. The postoperative course was complicated by a cerebrovascular accident.

Selective pulmonary artery perfusion: a novel method for the treatment of pulmonary malignancies.

Selective pulmonary artery perfusion (SPAP) is a modality of regional chemotherapy first investigated in the 1950's. A number of studies in animal models documented pharmacokinetic superiority with high-dose local cytostatic drug concentrations when compared to intravenous administration. Blood flow occlusion of the pulmonary artery before or after drug injection results in further increase in local drug concentrations. Animal tumor models with sarcoma and coloncarcinoma confirm anti-tumour efficacy in cytostatic SPAP. In human investigations, feasibility and safety of chemotherapeutic SPAP in humans has been documented. Recent encouraging investigations of SPAP with gemcitabine and blood flow occlusion in a porcine model emphasize the need for further investigations in humans with pulmonary malignancies for safety and efficacy assessments.

Selective antegrade cardioplegic perfusion complicated by left main stem dissection.

Selective antegrade coronary artery perfusion is a commonly used procedure to obtain myocardial preservation during cardiac surgery. This report describes a patient operated for severe aortic valve stenosis and insufficiency, mitral valve and tricuspid insufficiency. Cardioplegia was administered by selective antegrade coronary artery blood perfusion. Antegrade blood cardioplegia was complicated by dissection of the left coronary main stem. The dissection induced a myocardial infaction and the patient finally died due to heart failure.

Toxicity and efficacy of isolated lung perfusion with gemcitabine in a rat model of pulmonary metastases.

BACKGROUND: Long-term toxicity and efficacy of isolated left lung perfusion (ILuP) with gemcitabine (GCB) were studied in a rat model of metastatic pulmonary adenocarcinoma. TOXICITY: Forty rats were randomized into six groups and administered 160 or 320 mg/kg GCB or buffered starch, received either via intravenous injection (i.v.) or via ILuP. Efficacy experiment: Rats with unilateral metastases had ILuP with 320 mg/kg GCB (maximally tolerated dose administered by ILuP), while rats with bilateral metastases had an i.v. injection of 160 mg/kg GCB (maximally tolerated dose given by i.v.). RESULTS: TOXICITY experiment: After i.v. treatments, all rats receiving 320 mg/kg GCB died within one week, while rats who had received 160 mg/kg GCB had a survival rate of 60%. After ILuP with 160 mg/kg GCB and 320 mg/kg GCB, survival rates were 83% in both groups. A significant increase in collagen deposits was observed for ILuP with 320 mg/kg GCB compared to rats treated i.v. with 160 mg/kg GCB. Efficacy experiment: Median survival of ILuP rats treated with 320 mg/kg (38 +/- 4 days) was significantly longer compared to i.v. rats treated with 160 mg/kg (27 +/- 2 days; p = 0.02). CONCLUSIONS: ILuP with GCB prolongs survival in experimental metastatic adenocarcinoma while no major acute or long term toxicity is observed.

Isolated lung perfusion for the treatment of pulmonary metastatic disease: a review.

Isolated lung perfusion with chemotherapeutic agents is an experimental technique for the treatment of lung metastatic disease from certain solid tumours. The technique had already been developed in the late 1950s but underwent a revival in the early 1980s. By that time, experimental work in large and small animals induced extensive clinical work with different agents such as doxorubicin, tumour necrosis factor, melphalan and cisplatin for which safety profiles and maximal tolerated doses were defined. A review of current work is presented in this article.

Variations in flow, duration, and concentration do not change the final lung concentration of melphalan after isolated lung perfusion in rats.

OBJECTIVE: The influences of flow, perfusion time, and concentration on melphalan (MN) lung levels in a rat model of isolated lung perfusion (ILuP) were studied. METHODS: ILuP was performed in WAG/Rij rats by using a single-pass system with 0.5, 0.05, 0.01, and 0.005 mg of MN. Subsequently ILuP with 0.05 mg MN was performed during 30 min with a flow rate of 0.5 ml/min, during 60 min with a flow rate of 0.5 ml/min, and during 30 min with a flow rate of 1.0 ml/min. RESULTS: The lung MN levels of 0.05 mg were significantly lower as compared with 0.5 mg (p = 0.02). In the second experiment, no significant differences were seen in lung levels of MN between the different groups. CONCLUSION: The final lung MN levels were only determined by the absolute amount administered.

Pneumonectomy for lung metastases: report of ten cases.

Today, pulmonary resection for lung metastases is a widely accepted treatment if complete resection can be achieved. However, 5-year survival is only 40 %. Many patients develop recurrences, but some reports have demonstrated that salvage operations can result in a long-term survival. A resection of a complete lung or a resection of more than a lung is still controversial since procedure-related morbidity or mortality does not outweigh the survival benefit. We report on a series of 10 consecutive patients who underwent a primary pneumonectomy or an operation on the residual lung after pneumonectomy with curative intent for pulmonary metastases. 5 year survival rates for the 10 patients after pneumonectomy alone or with additional resection was 45 %, which was not significantly different from those who underwent a more minor resection with a 5-year survival of 39 % (p = 0.40). Since there is currently no alternative proven therapy for patients with isolated pulmonary metastases, a primary or completion pneumonectomy may be offered to selected patients as long as sufficient pulmonary reserve is present, and a complete resection can be achieved.

Long-term results of surgical resection of lung metastases.

Between 1990 and 2000, 56 consecutive patients underwent lung resection for removal of metastatic disease. Mortality, disease-free interval, and overall survival were studied. Only patients with a complete follow-up were included and data were collected conform the protocol of the International Registry of Lung Metastases. The primary tumour in our series was an epithelial tumour in 25 patients (45%), sarcoma in 15 (27%), germ cell tumours in 11 (19%) and melanoma in 5. Operative mortality was 1.4% (1 out of 73 procedures). Germ cell tumours had the best survival (76% at 5 years), and melanoma the worst (0% at 5 years). Multivariate analysis showed that survival for patients who underwent 2 or more metastasectomies was surprisingly good with a 5-year survival rate of 46%. Survival was not related to disease-free interval, multiple lung metastases, or pneumonectomy. It is in accordance with some reports that a short disease-free interval, numerous lung metastases, or recurrence after the first metastasectomy should not preclude patients from operation.