A. Zientara

Xenopericardial self-made tube grafts in infectious vascular reconstructions: Preliminary results of an easy and ready to use surgical approach.

Purpose Infections are a major setback of vascular reconstruction and associated with considerable morbidity and mortality. We evaluated retrospectively our results with self-made bovine pericardial grafts in infected vessel revascularization versus standard graft material. Basic methods Retrospective analysis of 9 patients with bovine reconstruction and 10 patients with miscellaneous grafts (vein, homograft) for vascular infections. Principal findings Infection-free rate of the pericardial group was 100% in 17 months. For patients after reconstructions with miscellaneous grafts, the infection-free rate was 82% in 45 months. Overall in-hospital mortality was 10.5%. There were no in-hospital deaths in the pericardial group. Graft patency of the whole cohort was 100%. The median follow up was 11.74 months. Conclusion Self-made bovine pericardial tube grafts can be crafted to almost any size and adjusted to complex anatomic requirements. The use was feasible in various situations and was associated with good preliminary results concerning patency and reinfection.

Evaluation of a New Sonoclot Device for Heparin Management in Cardiac Surgery

Background: Sonoclot is used to measure kaolin-based activated clotting time (kACT) for heparin management. Apart from measuring kACT, the device assesses the patient’s coagulation status by glass bead–activated tests (gbACTs; measuring also clot rate [CR] and platelet function [PF]). Recently, a new version of the Sonoclot has been released, and the redesign may result in performance changes. The aim of this study was to evaluate and compare the performance of the new (S2) and the previous (S1) Sonoclot. Methods: The S1 was used in the routine management of 30 patients undergoing elective cardiac surgery. Blood samples were taken at baseline (T1), after heparin administration (200 U/kg, 100 U/kg; T2 and T3), during cardiopulmonary bypass (T4), after protamine infusion (T5), and before intensive care unit transfer (T6). Kaolin-based activated clotting time and gbACTs were measured in duplicate by both the old and the new device and performance compared by Bland-Altman analysis and percentage error calculation. Results: A total of 300 kACT and 180 gbACTs were available. Bland-Altman analysis for kACT revealed that S2 consistently reported results in shorter time compared to S1 (overall = −14.7%). Comparing S2 and S1, the glass bead–activated tests showed mean percentage differences of −18.9% (gbACTs), +37.4% (CR), and −3.7% (PF). Conclusion: Since clotting is faster in the new S2 compared to S1, shorter clotting times have to be considered in clinical practice. The use of S2 kACT in heparin management will result in higher heparin and protamine dosing unless heparin kACT target values are adjusted to correct for the differences in results between S1 and S2.

Type B dissection reveals a rare anomaly of left cervical arch of Haughton D type.

Figure 1: Computed tomography; arrow points to the left subclavian artery arising from the arch aneurysm (*greatest extent of 41 mm). Figure 2: (A and B) Computed tomography reconstruction of the aortic arch; arrows show the course of the dissecting membrane, which starts from the aneurysm. LACC: left common carotid artery; RACC: right common carotid artery; TB: truncus brachiocephalicus; RSA: right subclavian artery.

Uncommon cause of ventricular tachycardia in a patient with a giant pseudoaneurysm of the ascending aorta

Ventricular arrhythmias occur predominantly in patients with structural heart disease. The most common substrate is scarring due to ischemic heart disease. We present an uncommon cause of ventricular tachycardia due to excessive right coronary artery stretch in a patient with a giant pseudoaneurysm of the ascending aorta years after aortic root repair.

Fast-Track Management in Off-Pump Coronary Artery Bypass Grafting: Dexmedetomidine Provides Rapid Extubation and Effective Pain Modulation

BACKGROUND  Dexmedetomidine (DEX) is a highly selective α-2 agonist with many desirable effects including analgesia, improvement of hemodynamic stability, and potential myocardial and renal protection. The aim of this study was to investigate the effect of DEX on patients undergoing off-pump coronary artery bypass (OPCAB) grafting with regard to less pain medication, earlier extubation, faster transfer to normal ward, and cardiac protection. PATIENTS AND METHODS  From January 2012 to March 2015, 464 patients receiving OPCAB were included for retrospective analysis. After propensity matching (1:1), two groups (DEX vs. propofol, n = 129) could be compared. Continuous and categorical variables were reported as mean ± standard deviation or percentages, and compared with the chi-square test and the Mann-Whitneys test, respectively. RESULTS  In the DEX group, less use of pain medication in the initial phase at intensive care unit was observed. During the first 2 hours, DEX patients received more nicomorphine (DEX 8 ± 3.2 mg vs. propofol 6 ± 4 mg, p < 0.001), while in the following 2 hours, the pain medication was significantly reduced (DEX 3.2 ± 2.8 mg vs. propofol 4.7 ± 3.3 mg, p < 0.001). Remifentanil was stopped considerably earlier (DEX 238 ± 209 minutes vs. propofol 353 ± 266 minutes, p < 0.001). DEX led to earlier extubation (DEX 208 ± 106 minutes vs. propofol 307 ± 230 minutes, p < 0.001) and less postoperative atrial fibrillation (AF) (p = 0.01). CONCLUSION  Early postoperative DEX application supports the fast-track strategy in patients after OPCAB through enabling rapid extubation, effective pain control, and reduced occurrence of new-onset AF. We are confident to give precedence to DEX over propofol as the new routine medication during postoperative patient transfer.

Tricuspid Valve Repair for the Poor Right Ventricle: Tricuspid Valve Repair in Patients with Mild-to-Moderate Tricuspid Regurgitation Undergoing Mitral Valve Repair Improves In-Hospital Outcome.

Background Tricuspid regurgitation (TR) in patients undergoing surgery for mitral valve (MV) increases morbidity and mortality, especially in case of a poor right ventricle. Does repair of mild‐to‐moderate insufficiency of the tricuspid valve (TV) in patients undergoing MV surgery lead to a benefit in early postoperative outcome? Methods A total of 22 patients with mild‐to‐moderate TR underwent MV repair and concomitant TV repair with Tri‐Ad (Medtronic ATS Medical Inc., Minneapolis, Minnesota, United States) and Edwards Cosgrove (Edwards Lifesciences Irvine, California, United States) rings. The severity of TR was assessed echocardiographically by using color‐Doppler flow images. The tricuspid annular plane systolic excursion (TAPSE) was under 1.7 cm. Additional procedures included coronary artery bypass (n = 9) and maze procedure (n = 15). The following parameters were compared: postoperative and peak dose of noradrenaline (NA), pre/postoperative systolic pulmonary pressure (sPAP), extubation time, operation time, cross‐clamp time, cardiopulmonary bypass (CPB) time, pre/postoperative ejection fraction (EF), intensive care unit (ICU)‐stay, hospital stay, cell saver blood transfusion, intra/postoperative blood transfusion, and postoperative TR. Results The mean age was 67 ± 14.8 years, 45% were male. Mean EF was 47 ± 16.2%, postoperative 52 ± 12.4%. sPAP was 46 ± 20.1 mm Hg preoperatively, sPAP was 40.6 ± 9.4 mm Hg postoperatively, NA postoperatively was 12 ± 10 &mgr;g/min, NA peak was 18 ± 11 &mgr;g/min, operation time was 275 ± 92 minutes, CPB was 145 ± 49 minutes, ICU stay was 2.4 ± 2.4 days, hospital stay was 10.8 ± 3.5 days, cell saver blood transfusion was 736 ± 346 mL, intraoperative transfusions were 2.5 ± 1.6. Two patients needed postoperative transfusions. A total of 19 patients were extubated at the 1st postoperative day, 2 patients at the 2nd day, and 1 at the 4th postoperative day. Two patients required a pacemaker. No reintubation, no in‐hospital mortality, and one reoperation because of bleeding complications. Conclusion Correction of mild‐to‐moderate TR at the time of MV repair does maintain TV function and avoid right ventricular dysfunction in the early postoperative period improving the clinical outcome.

New clip remover device to prepare saphenous vein graft for coronary bypass grafting

Objective: The accurate prepare of the saphenous vein (SV) is elementary to have good patency rates in myocardial revascularisation. To avoid intimal hyperplasia we use the eSVS Mesh (Kipps Bay Medical™, Minneapolis, USA). Caused by endoscopic harvesting technique of SV all side branches are clipped in situ. All Clips have to be removed and replaced by fine sutures (Prolene 6-0) in order to enable the covering the SV with the eSVS. How to remove the Clips without tearing the SV and its intima? Methods: We use a new designed clip remover in 40 patients. After harvesting the SV the distal end is intubated by a cannula with outlet. Into the SV a solution of sodium chloride 0.9% is applicated with a maximum pressure of 150 cm H2O. So the clips are exposed in a good position and they can be reopened and removed without sheer stress to the tissue by the clip remover device. Intraoperative graft patency was verified by MediStim. Result: All clips could be removed from vein. No tear that had to be repaired. Graft patency was 95% for eSVS treated with the new device. Histologic findings showed no intima lesions. Conclusion: This new tool is very feasible and save. Wrong placed clips on mammarian artery or veins are now easy and safely removable and a new can be applicated in correct position considering the potential intima lesion of the graft by clipping.