Aortic root replacement with the stentless Freestyle bioprosthesis.

In this video tutorial, the technical details for the implantation of the Freestyle stentless bioprosthesis are outlined based on the case of a 76-year-old male patient with symptomatic stenosis of a bicuspid aortic valve and aortic root dilatation.

Application of local gentamicin in the treatment of deep sternal wound infection: a randomized controlled trial.

OBJECTIVES: In patients with deep sternal wound infection (DSWI), primary closure of the sternal bone over high negative pressure Redon drains has shown to be a safe and feasible treatment method. Addition of local gentamicin could accelerate healing and improve clinical outcomes. METHODS: We conducted a randomized controlled trial to evaluate the effectiveness of local gentamicin in the treatment of DSWI. In the treatment group, collagenous carriers containing gentamicin were left between the sternal halves during sternal refixation. In the control group, no local antibiotics were used. Primary outcome was hospital stay. Secondary outcomes were mortality, reoperation, wound sterilization time, time till removal of all drains and duration of intravenous antibiotic treatment. RESULTS: Forty-one patients were included in the trial of which 20 were allocated to the treatment group. Baseline characteristics were similar in both groups. Drains could be removed after a median of 8.5 days in the treatment group and 14.5 days in the control group (P-value: 0.343). Intravenous antibiotics were administered for a median of 23.5 days in the treatment group and 38.5 days in the control group (P-value: 0.343). The median hospital stay was 27 days in the treatment group and 28 days in the control group (P-value: 0.873). Mortality rate was 10% in the treatment group and 9.5% in the control group (P-value: 0,959). No side effects were observed. CONCLUSIONS: This randomized controlled trial showed that addition of local gentamicin in the treatment of DSWI did not result in shorter length of stay. CLINICAL TRIAL REGISTRATION NUMBER: 2014-001170-33.

Bartonella quintana as a cause for prosthetic valve endocarditis and post-sternotomy mediastinitis.

An otherwise healthy patient, with minimal clinical, biochemical and peroperative signs of infection, was diagnosed with Bartonella quintana prosthetic valve endocarditis by 16S PCR. The patient subsequently developed a post-sternotomy mediastinitis and Bartonella quintana was the only detected pathogen. Bartonella quintana can cause severe infections in individuals not classically at risk, and may be missed in the routine diagnostic work-up of endocarditis.

Titanium Plate Fixation versus Conventional Closure for Sternal Dehiscence after Cardiac Surgery.

Background Postoperative sternal dehiscence with or without mediastinitis is a complication of cardiac surgery leading to considerable disability. Titanium plate fixation can provide sternal stability in patients with a dehiscent sternum. The aim of this study is to compare clinical outcomes of titanium plate fixation with conventional treatment methods such as steel wire cerclage and pectoralis muscle reconstruction. Patients and Methods A retrospective analysis was performed on 42 patients who underwent sternal refixation after dehiscence or secondary wound closure after poststernotomy mediastinitis. Clinical outcomes during hospital stay and follow-up were determined. Results Twenty patients were closed using sternal plates. Twenty-two patients were closed conventionally: 8 using pectoral muscle reconstruction and 14 using cerclage steel wires. There were no differences in baseline characteristics between the two groups. Indications of sternal closure were similar. Sternal stability at hospital discharge was achieved more often using sternal plating (90 vs. 50%, p = 0.005), mainly in patients closed after treatment of poststernotomy mediastinitis (100 vs. 22%, p = 0.002). Hospital stay was similar in both groups (10 [5-23] vs. 12 (5-21) days, p = 0.527). There was no inhospital mortality. Conclusion Titanium plate fixation is superior in stabilizing the sternal bone when compared with conventional refixation methods, especially in secondary closure after poststernotomy mediastinitis.

Primary closure using Redon drains for the treatment of post-sternotomy mediastinitis.

OBJECTIVES: Post-sternotomy mediastinitis is a severe complication of open heart surgery resulting in prolonged hospital stay and increased mortality. Vacuum-assisted closure is commonly used as treatment for post-sternotomy mediastinitis, but has some disadvantages. Primary closure over high vacuum suction Redon drains previously has shown to be an alternative approach with promising results. We report our short- and long-term results of Redon therapy-treated mediastinitis. METHODS: We performed a retrospective analysis of 124 patients who underwent primary closure of the sternum over Redon drains as treatment for post-sternotomy mediastinitis in Amphia Hospital (Breda, Netherlands) and St. Antonius Hospital (Nieuwegein, Netherlands). Patient characteristics, preoperative risk factors and procedure-related variables were analysed. Duration of therapy, hospital stay, treatment failure and mortality as well as C-reactive protein and blood leucocyte counts on admission and at various time intervals during hospital stay were determined. RESULTS: Mean age of patients was 68.7 ± 11.0 years. In 77.4%, the primary surgery was coronary artery bypass grafting. Presentation of mediastinitis was 15.2 ± 9.8 days after surgery. Duration of Redon therapy was 25.9 ± 18.4 days. Hospital stay was 32.8 ± 20.7 days. Treatment failure occurred in 8.1% of patients. In-hospital mortality was 8.9%. No risk factors were found for mortality or treatment failure. The median follow-up time was 6.6 years. One- and 5-year survivals were 86 and 70%, respectively. CONCLUSIONS: Primary closure using Redon drains is a feasible, simple and efficient treatment modality for post-sternotomy mediastinitis.

Acute mediastinal bleeding during vacuum-assisted closure.

Vacuum-assisted closure is commonly used to treat post-sternotomy mediastinitis. Several studies show improved outcome using vacuum-assisted therapy; however, risks using negative pressure should not be underestimated. We describe two cases of acute mediastinal bleeding during vacuum treatment for post-sternotomy mediastinitis and discuss preventative measurements.

Primary closure using Redon drains vs vacuum-assisted closure in post-sternotomy mediastinitis.

OBJECTIVES: Vacuum-assisted closure (VAC) is a commonly used therapy for the treatment of post-sternotomy mediastinitis. Primary closure of the sternum with high vacuum suction using Redon drains is an alternative that may reduce hospital stay. The aim of this study was to describe for the first time, the results of VAC compared with Redon drainage. METHODS: We performed a retrospective analysis of 132 patients undergoing VAC (n = 89) or primary closure of the sternum with Redon drains (n = 43) as treatment for post-sternotomy mediastinitis between January 2000 and January 2011. Patient characteristics, risk factors and procedure-related variables were analysed. Duration of therapy, treatment failure, hospital stay and mortality as well as C-reactive protein and blood leucocyte counts on admission and at various time intervals during hospital stay were determined. RESULTS: In-hospital mortality was 12.5% in the VAC group compared with 14% in the Redon group (P = 0.96). Treatment failure in the VAC and Redon groups occurred in 28 and 23% of the patients, respectively (P = 0.68). Intensive-care stay in the VAC group was 6.8 ± 14.4 days, and 4.8 ± 10.1 days in the Redon group (P = 0.99). Hospitalization in the VAC group was 74 ± 61 days and in the Redon group, 45 ± 38 days (P = 0.0001). CONCLUSIONS: Primary closure using high vacuum suction drains is a safe and feasible treatment modality for post-sternotomy mediastinitis. It reduces hospital stay when compared with VAC therapy, without compromising mortality.

Vacuum-assisted closure of post-sternotomy mediastinitis as compared to open packing.

Post-sternotomy mediastinitis is a rare but serious complication of cardiac surgery leading to prolonged hospital stay and higher mortality. In the last decades several treatment modalities have been described, of which vacuum-assisted closure (VAC) shows the most promising results. The aim of this study is to describe clinical outcomes of VAC as compared to open packing and to predict risk factors for mortality. We performed a retrospective analysis of 113 patients with mediastinitis undergoing VAC (n = 89) or open packing (n = 24) between January 2000 and July 2010. Patient characteristics, risk factors and procedure-related variables were analysed. C-reactive protein and leukocyte counts were determined on admission and at regular intervals during hospital stay. We compared length of treatment, treatment failure, hospital stay and mortality. We also analysed risk factors predicting mortality. In-hospital mortality in the VAC group was 12.4% compared to 41.7% in the conventional group (P = 0.0032). Intensive care stay was 6.8 ± 14.4 days with VAC therapy compared to 18.5 ± 21.0 days with open packing (P = 0.0081). Significant risk factors for mortality were pre-operative renal failure and obesity. Our findings indicate that VAC therapy is superior to open packing, resulting in shorter intensive care stay and improved survival.