Co-Management Reduces Mortality in Post-Sternotomy Mediastinitis.

Background: Post-sternotomy mediastinitis (PSM) is one of the most feared complications of cardiac surgery. The impact of a multidisciplinary management approach on this pathology is yet unknown. Patients and Methods: A multidisciplinary approach based on a co-management model (CMM) of care was initiated in January 2018 because of the incorporation of a hospitalist unit on a cardiac surgery department. An observational retrospective cohort study was designed to evaluate the impact of the CMM of care compared to the standard model (SM) of care in patients diagnosed with PSM. Our primary and secondary outcomes were survival time and treatment failure rate (two or more surgical procedures needed to solve PSM or PSM-related death), respectively. Data related to patient death date were collected from the Spanish National Death Index. A multivariable Cox regression model was created using those variables believed to be clinically relevant. Results: Ninety-one patients developed PSM from January 2010 to June 2020. Regarding the pre-operative clinical status, surgical procedure, and PSM severity, both groups had similar baseline characteristics. Patients were followed for a mean of 27.54 ± 30.5 months. A total of 60.3% of the SM group and 11.1% of the CMM group (p < 0.001) died. Treatment failure occurred in 53 patients (72.6%) in the SM group versus 7 (38.6%) in the CMM group (p = 0.007). The CMM independently reduced overall mortality (hazard ratio [HR], 0.11; 95% confidence interval [CI]. 0.01-0.83) and treatment failure rate (HR, 0.01; 95% CI, 0.001-0.183). Gram-positive bacterial infection (HR, 3.73; 95% CI, .6-8.3), and complete osteosynthesis material removal (HR, 0.47; 95% CI, 0.24-0.91) also influenced mortality in our model. Conclusions: A co-management care model reduced overall mortality in patients diagnosed with post-sternotomy mediastinitis.

Transcatheter versus surgical aortic valve replacement in moderate and high-risk patients: a meta-analysis.

Objectives: The evidence of the benefits of transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) for patients of high or intermediate surgical risk is not consistent. We performed a meta-analysis to compare major adverse outcomes after TAVR or SAVR. Methods: We searched propensity score matched studies or randomized clinical trials comparing the risks of mortality, stroke, major bleeding, acute renal injury, pacemaker implantation, vascular complications and prostheses haemodynamic performance between TAVR and SAVR in patients with moderate or high risk. Combined odds ratios (ORs), relative risk or mean differences with corresponding 95% confidence intervals (CIs) were calculated using a random effects model. Analyses of sensitivity and publication bias were also conducted. Results: We included 5 clinical trials and 37 observational studies, enrolling 20 224 patients (TAVR, n = 9099 and SAVR, n = 11 125). The pooled analysis suggested no differences in early (OR = 1.11, 95% CI 0.9-1.39, P = 0.355) or late mortality (relative risk = 0.91, 95% CI 0.78-1.05, P = 0.194). TAVR was associated with a lower risk of major bleeding (OR = 0.42, 95% CI 0.25-0.69, P < 0.001) and acute kidney injury (OR = 0.51, 95% CI 0.34-0.71) but with an increase in the incidence of pacemaker implantation (OR = 2.31, 95% CI 1.73-3.08) and vascular complications (OR = 4.88, 95% CI 2.84-8.39). Residual aortic regurgitation was more frequent after TAVR (OR= 6.83, 95% CI 4.87-9.6). SAVR prostheses were associated with poor trans-prosthetic gradients (mean difference: -2.4 mmHg, 95% CI - 3.27 to - 1.53). Conclusions: TAVR and SAVR have similar short and long-term all-cause mortality and risk of stroke among patients of moderate or high surgical risk. TAVR decreases the risk of major bleeding, acute kidney injury and improves haemodynamic performance compared with SAVR but increases the risk of vascular complications, the need for a pacemaker and residual aortic regurgitation.

Validation of EuroSCORE II on a single-centre 3800 patient cohort.

OBJECTIVES: To compare and validate the new European System for Cardiac Operative Risk Evaluation (EuroSCORE) II with EuroSCORE at our institution. METHODS: The logistic EuroSCORE and EuroSCORE II were calculated on the entire patient cohort undergoing major cardiac surgery at our centre between January 2005 and December 2010. The goodness of fit was compared by means of the Hosmer-Lemeshow (HL) chi-squared test and the area under the curve (AUC) of the receiver operating characteristic curves of both scales applied to the same sample of patients. These analyses were repeated and stratified by the type of surgery. RESULTS: Mortality of 5.66% was observed, with estimated mortalities according to logistic EuroSCORE and EuroSCORE II of 9 and 4.46%, respectively. The AUC for EuroSCORE (0.82, 95% confidence interval [CI] 0.79-0.85) was lower than that for EuroSCORE II (0.85, 95% CI 0.83-0.87) without the differences being statistically significant (P = 0.056). Both scales showed a good discriminative capacity for all the pathologies subgroups. The two scales showed poor calibration in the sample: EuroSCORE (χ(2) = 39.3, P(HL) < 0.001) and EuroSCORE II (χ(2) = 86.69, P(HL) < 0.001). The calibration of EuroSCORE was poor in the groups of patients undergoing coronary (P(HL) = 0.01), valve (P(HL) = 0.01) and combined coronary valve surgery (P(HL) = 0.012); and that of EuroSCORE II in the group of coronary (P(HL) = 0.001) and valve surgery (P(HL) < 0.001) patients. CONCLUSIONS: EuroSCORE II demonstrated good discriminative capacity and poor calibration in the patients undergoing major cardiac surgery at our centre.

Mid-term outcomes after off-pump coronary surgery in patients with prior intracoronary stent.

OBJECTIVE: An increasing number of patients undergoing heart surgery have had a prior coronary stent placement. This study was designed to examine the effect of this situation on the mid-term outcomes of off-pump coronary artery bypass graft (OP-CABG) surgery. METHODS: A comparative retrospective non-randomized comparison was performed as follows: all patients undergoing OP-CABG from January 2005 to December 2009 at our centre were divided into two groups: those who did or did not have stents at the time of surgery. We compared the incidences of the following events: (i) death and (ii) combined major adverse cardiac events (MACEs): death, myocardial infarction (MI) and repeat revascularization. Cox's proportional hazards analysis adjusted by a propensity score (n:m) were performed to determine the effects of prior stent placement on the risks of such events. RESULTS: A total of 1020 patients were included, of which 156 (15.6%) had at least one stent. The median follow-up was 32.32 months (interquartile rank 18.08-48). The overall 1, 3 and 5-year survival rates were 95, 92 and 91% for the without-stent group vs. 82, 77 and 74% for the with-stent group, respectively. The 1, 3 and 5-year survival rates free from MACEs were: 92, 87 and 76% for patients without stent vs. 77, 66 and 56% for those with stents. Patients with stent showed an increased risk of death [hazard ratio (HR) 3.631, 95% confidence interval (CI) 2.29-5.756] and MACEs (HR 2.784, 95% CI 1.962-3.951). When adjusted by the propensity score, prior stent placement continued to increase the risks of death (HR 3.795, 95% CI 2.319-6.21) and MACEs (HR 2.89, 95% CI 2.008-4.158). CONCLUSIONS: Patients with intracoronary stents have a lower survival rate and a greater risk of death, MI or need for repeat revascularization during the mid-term follow-up after OP-CABG.

Right intra-atrial catheter insertion at the end stage of peripheral vascular access for dialysis.

The number of patients with end-stage renal failure requiring dialysis keeps increasing every year. Many of these patients also suffer from peripheral arterial disease. We report the case of a middle age woman receiving dialysis who had undergone amputation of both lower limbs and suffered multiple deep venous thrombosis. Therefore, peripheral accesses for venous dialysis were not available. A catheter had to be implanted right into the right atrium.

Short- and mid-term results for aortic valve replacement in octogenarians.

Population over 80 years who require surgery for degenerative aortic stenosis has largely increased in the past decades. We have compared short- and mid-term results for conventional aortic valve replacement (AVR) for calcific-degenerative aortic stenosis in older and younger than 80 years operated at our institution between April 2004 and December 2008. Predictors of mortality and major adverse cardio and cerebrovascular events (MACCEs) on the postoperative and follow-up period were determined through multivariable analysis. Four hundred and fifty-one patients were included in the study. Ninety-four (20.8%) were >or=80. Previous cardiac surgery [odds ratio (OR)=4.08, P=0.047], renal failure (OR=6.75, P<0.001), concomitant coronary artery bypass grafting (CABG) (OR=2.57, P=0.034), female sex (OR=2.49, P=0.047), and severe pulmonary hypertension (OR=3.68, P=0.024) were independent predictors of in-hospital mortality. In the follow-up, age >or=80 years [Hazard ratio (HR)=2.44, P=0.02], high blood pressure (HBP) (HR=5.2, P=0.025) and peripheral arterial disease (PAD) (HR=5.1, P<0.001) were independent predictors for late mortality. Only PAD (HR=3.55, P=0.014) and HBP (HR=8.24, P=0.04) were independent predictors for late cardiac mortality. Renal failure (OR=2.57, P=0.005), severe pulmonary hypertension (OR=3.49, P=0.005) and concomitant CABG (OR=2.49, P=0.002) were independent predictors for postoperative MACCEs. Diabetes mellitus (HR=2.03, P=0.033) and PAD (HR=2.3, P=0.041) were independent predictors for MACCEs in the follow-up. According to these data, we can conclude that conventional open AVR for degenerative aortic stenosis grants good early- and mid-term outcomes in octogenarians in our experience.

Clinical outcomes with off-pump coronary surgery after angioplasty with stent.

INTRODUCTION AND OBJECTIVES: The aim was to determine whether prior coronary stent implantation affects postoperative outcomes in patients undergoing coronary artery bypass grafting. METHODS: Between January 2005 and April 2008, a retrospective analysis was carried out to evaluate the effect of prior coronary stent implantation in patients undergoing off-pump coronary surgery on the incidence of major cardiovascular events in the postoperative period (i.e. at 30 days or during postoperative hospitalization). RESULTS: In total, 796 consecutive patients underwent coronary artery bypass grafting. Of these, 116 (14.6%) had a coronary stent at the time of surgery. Patients with and without stents had similar levels of risk (i.e. EuroSCORE). Multivariate analysis, adjusted for the presence of confounding variables (i.e. preoperative left ventricular ejection fraction <40%, critical preoperative state, age, history of cerebrovascular accident, recent acute myocardial infarction, number of diseased coronary vessels, incomplete revascularization and on-pump conversion), showed that the presence of a stent was significantly associated with increased risks of postoperative myocardial infarction (relative risk [RR]=3.13; 95% confidence interval [CI], 1.75-5.96), in-hospital cardiac mortality (RR=4.62; 95% CI, 1.76-12.11) and in-hospital all-cause mortality (RR=3.65; 95% CI, 1.60-8.34). CONCLUSIONS: In our experience, coronary artery stent implantation prior to coronary surgery was associated with increased risks of postoperative myocardial infarction, cardiac mortality and all-cause mortality in the postoperative period.

Resultados de la cirugía coronaria sin circulación extracopórea tras angioplastia con stent / Clinical outcomes with off-pump coronary surgery after angioplasty with stent

Introducción y objetivos. Evaluar el impacto de la implantación de stents coronarios previa a la cirugía de revascularización miocárdica en los resultados postoperatorios de ésta. Métodos. Desde enero de 2005 hasta abril de 2008, se evaluó retrospectivamente el impacto de la implantación de stents coronarios previa a la cirugía coronaria sin circulación extracorpórea en la incidencia de eventos cardiovasculares mayores en el postoperatorio (30 días o ingreso hospitalario postoperatorios). Resultados. Se sometió a 796 pacientes consecutivos a revascularización miocárdica quirúrgica; 116 (14,6%) portaban algún stent coronario en el momento de la cirugía. Los grupos con stent y sin stent tenían un perfil de riesgo similar (EuroSCORE). En el análisis multivariable, ajustando el riesgo por las variables de confusión detectadas (fracción de eyección del ventrículo izquierdo preoperatoria < 40%, estado crítico preoperatorio, edad, antecedentes de accidente cerebrovascular agudo, infarto miocárdico agudo previo reciente, número de vasos coronarios enfermos, revascularización quirúrgica incompleta y conversión a circulación extracorpórea) se detectó que el ser portador de stent se asociaba de forma significativa a un mayor riesgo de infarto miocárdico postoperatorio (RR = 3,13; intervalo de confianza [IC] del 95%, 1,75-5,96), mortalidad cardiaca hospitalaria (RR = 4,62; IC del 95%, 1,76-12,11) y mortalidad hospitalaria por todas las causas (RR = 3,65; IC del 95%, 1,6-8,34). Conclusiones. En nuestra experiencia, la implantación previa de stents coronarios se asocia a un mayor riesgo de infarto miocárdico y mortalidad cardiaca y por todas las causas en el postoperatorio de la cirugía coronaria (AU)

Introduction and Objectives. The aim was to determine whether prior coronary stent implantation affects postoperative outcomes in patients undergoing coronary artery bypass grafting. Methods. Between January 2005 and April 2008, a retrospective analysis was carried out to evaluate the effect of prior coronary stent implantation in patients undergoing off-pump coronary surgery on the incidence of major cardiovascular events in the postoperative period (ie, at 30 days or during postoperative hospitalization). Results. In total, 796 consecutive patients underwent coronary artery bypass grafting. Of these, 116 (14.6%) had a coronary stent at the time of surgery. Patients with and without stents had similar levels of risk (ie, EuroSCORE). Multivariate analysis, adjusted for the presence of confounding variables (ie, preoperative left ventricular ejection fraction <40 critical preoperative state age history of cerebrovascular accident recent acute myocardial infarction number diseased coronary vessels incomplete revascularization and on-pump conversion showed that the presence a stent was significantly associated with increased risks postoperative relative risk rr="3.65;" 95 confidence interval ci 1 75-5 96 in-hospital cardiac mortality 76-12 11 all-cause 60-8 34 conclusions in our experience artery implantation prior to surgery period inhospital (AU)