Chiara Comoglio

Major sternal wound infection after open-heart surgery: a multivariate analysis of risk factors in 2,579 consecutive operative procedures

From January, 1979, to December, 1984, at the Cardiac Surgery Department of the University of Torino Medical School, major sternal wound infections developed in 48 (1.86%) of 2,579 consecutive patients. These patients underwent open-heart procedures through a midline sternotomy and survived long enough for infection to appear. Possible risk factors were evaluated by means of a multivariate analysis. For the group of patients, we considered age, sex, hospital environment (different locations of our surgical facilities over the years), interval between hospital admission and operation, antibiotic prophylaxis, type of surgical procedure, elective or emergency surgical procedure, reoperation, duration of surgical procedures, duration of cardiopulmonary bypass, amount of blood transfused, postoperative blood loss, chest reexploration, rewiring of a sterile sternal dehiscence, duration of mechanical ventilation, and days of treatment in the intensive care unit. Univariate analysis indicated that age, sex, type and mode of surgical procedure, antibiotic prophylaxis, and duration of mechanical ventilation were not significantly associated with wound infection. For all other predisposing factors, a p value of less than .05 was demonstrated. These variables were entered in a multiple stepwise logistic regression. Six emerged as significant: hospital environment (p = .0001), interval between admission and surgery (p = .041), reoperation (p less than .0001), blood transfusions (p = .031), early chest reexploration (p less than .0001), and sternal rewiring (p less than .0001). Contamination of patients may occur before, during, and after operation, and any kind of reintervention may predispose to wound infection.

The Use of CO2 Removal Devices in Patients Awaiting Lung Transplantation: An Initial Experience

BACKGROUND Lung transplantation is the treatment of choice for patients with end-stage lung failure. Limitations are presented by the shortage of donors and the long waiting list periods. New techniques, such as extracorporeal membrane ventilator devices with or without pump support, have been developed as bridges to transplantation for patients with severe, unresponsive respiratory insufficiency. METHODS Between November 2005 and September 2009, 12 patients (7 males and 5 females), of overall mean age of 43.3 +/- 15.5 years underwent decapneization with extracorporeal devices. In 6 cases, a NovaLung system was used; in the remaining 6 patients, it was a Decap device. Causes of respiratory failure that led to implantation of such devices were cystic fibrosis (n = 6), pulmonary emphysema (n = 5), and chronic rejection of a previous double lung transplant (n = 1). RESULTS Mean time on extracorporeal decapneization was 13.5 +/- 14.2 days. Eight patients died on the device. Three patients were bridged to lung transplantation; 1 recovered and was weaned from the device after 11 days. Mean PaCO(2) on the extracorporeal gas exchanger was significantly lower for both the devices at 24, 48, and 72 hours after implantation (P < .05). No significant difference was observed for the 2 systems. CONCLUSION In our initial experience, decapneization devices have been simple, efficient methods to support patients with mild hypoxia and severe hypercapnia that is refractory to mechanical ventilation. This could represent a valid bridge to lung transplantation in these patients.

Human cardiac progenitor cell grafts as unrestricted source of supernumerary cardiac cells in healthy murine hearts.

Human heart harbors a population of resident progenitor cells that can be isolated by stem cell antigen‐1 antibody and expanded in culture. These cells can differentiate into cardiomyocytes in vitro and contribute to cardiac regeneration in vivo. However, when directly injected as single cell suspension, less than 1%‐5% survive and differentiate. Among the major causes of this failure are the distressing protocols used to culture in vitro and implant progenitor cells into damaged hearts. Human cardiac progenitors obtained from the auricles of patients were cultured as scaffoldless engineered tissues fabricated using temperature‐responsive surfaces. In the engineered tissue, progenitor cells established proper three‐dimensional intercellular relationships and were embedded in self‐produced extracellular matrix preserving their phenotype and multipotency in the absence of significant apoptosis. After engineered tissues were leant on visceral pericardium, a number of cells migrated into the murine myocardium and in the vascular walls, where they integrated in the respective textures.

Bacteriology of infected extracted pacemaker and ICD leads.

Introduction Pacemaker and implantable cardioverter defibrillator infections, when not treated, lead to serious consequences. The aim is to identify the prevalent strains of the responsible bacteria to guide an effective therapy. Methods Between May 2003 and April 2008, 118 leads were extracted from 61 patients, with chronic draining sinus, pocket infection, pacemaker endocarditis, or sepsis. Following extraction, samples of the leads underwent cultural and antibiogram examination. Results Staphylococcus epidermidis was the most frequently isolated bacterial strain (37.7%), followed by Gram-positive flora (16.1%), Staphylococcus aureus (14.3%), Candida parapsilosis (5.4%), Staphylococcus schleiferi (5.4%), Corynebacterium species, and Staphylococcus hominis (3.6%). Cultures were negative in 14.3% of the samples. Retained sensitivity to antibiotics were reported as follows: teicoplanin/vancomycin 100%, doxicyclin 96%, amikacin 94%, piperacillin-tazobactam 58%, cotrimoxazole 78%, gentamycin 65%, quinolones 47%, rifampicin 44%, cephalosporins 25%, and oxacillin 25%. Within staphylococci, involved in about 60% of the infections, S. hominis and S. epidermidis showed the highest antibiotic resistance. In case of sepsis, sensitivity was retained for glycopeptides and amikacin (about 100%), and to a lower degree for doxicyclin (80%). Arbitrarily stratifying into recent (<3 months) and chronic (>3 months) infections, an increase in time prior to referral for lead extraction was associated with a significant increase in antibiotic resistance. Conclusion Bacteria associated with pacemaker and implantable cardioverter defibrillator-related infections, staphylococci in about 60% of the cases, show poor susceptibility to antibiotics, presenting three out of four methicillin-resistant features. Therefore, systemic antibiotics, mainly glycopeptides, must not be delayed awaiting the complete removal of the implanted system.

Two cases of aneurysm of the anterior mitral valve leaflet associated with transcatheter aortic valve endocarditis: A mere coincidence?

From the Division of Cardiology, Erasmus MC, Thoraxcenter, Rotterdam, The Netherlands; the Division of Cardiology, University of Turin, San Giovanni Battista Hospital, Turin, Italy; the Division of Cardiology, St Paul’s Hospital, Vancouver, British Columbia, Canada; the Division of Cardiac Surgery, University of Turin, San Giovanni Battista Hospital, Turin, Italy; and the Division of Cardiac Surgery, Erasmus MC, Thoraxcenter, Rotterdam, The Netherlands. Disclosures: None. Received for publication Nov 1, 2009; accepted for publication Nov 6, 2009; available ahead of print Feb 18, 2010. Address for reprints: Patrick W. Serruys, MD, PhD, FACC, Ba 583, Thoraxcenter, Erasmus Medical Center, Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands (E-mail: p.w.j.c.serruys@erasmusmc.nl). J Thorac Cardiovasc Surg 2010;140:e36-8 0022-5223/

Role of Oral Sildenafil in the Treatment of Right Ventricular Dysfunction After Heart Transplantation

36.00 Copyright 2010 by The American Association for Thoracic Surgery doi:10.1016/j.jtcvs.2009.11.012

Aortic valve replacement and mitral valve repair as treatment of complications after percutaneous core valve implantation.

OBJECTIVE Right ventricular dysfunction (RVD) after heart transplantation is a major complication, especially in patients with pulmonary hypertension (PH). Herein we have presented our initial experience with oral sildenafil for RVD following heart transplantation. MATERIALS AND METHODS From February 2006 to February 2008, 10 patients (7 males and 3 females) of overall mean age of 56.7 +/- 9.5 years suffered from acute RVD immediately after heart transplantation. Preoperative hemodynamic data before and after a vasodilatation test (sodium nitroprusside; NTP) showed: systolic pulmonary arterial pressure (SPAP) 59.5 +/- 12.9 and 44.2 +/- 12.4 mm Hg; cardiac output (CO) 3.3 +/- 0.9 and 3.7 +/- 0.8 L/min; transpulmonary gradient (TPG) 11.7 +/- 3.9 and 8.7 +/- 3.6 mm Hg; and pulmonary vascular resistance (PVR) 3.9 +/- 2.1 and 2.4 +/- 1.3 wood units (WU), respectively. All patients required inotropes and inhaled nitric oxide (iNO) to be weaned from cardiopulmonary bypass (CPB). RESULTS Intravenous (IV) or inhaled vasodilators could be weaned using oral sildenafil in all patients. The hemodynamic data obtained during IV or inhaled drugs (between postoperative days 5 and 10) compared with those obtained on sildenafil therapy alone (about 1 month after transplantation) showed a significant decrease in SPAP (39.0 +/- 8.2 vs 32.0 +/- 6.5 mm Hg; P = .049). CONCLUSION These data suggested that oral sildenafil may have a role in the treatment of RVD after heart transplantation.

Accuracy of Swabs, Tissue Specimens, and Lead Samples in Diagnosis of Cardiac Rhythm Management Device Infections

CLINICAL SUMMARY We describe the case of a 66-year-old man who had surgical intervention for a core valve malfunction 3 months after transfemoral implantation. The patient was scheduled for percutaneous aortic valve implantation (PAVI) because of the presence of numerous risk factors, such as obesity (body mass index, 35%) and myelodysplasia. The main concern about elective standard aortic valve replacement was related to the patient’s pulmonary function. As a result of a history of smoking and obesity, he had severe chronic pulmonary disease (forced expiratory volume in 1 second, <35%) and obstructive sleep apnea syndrome requiring noninvasive mechanical ventilation. The patient presented with rapid worsening of dyspnea. An echocardiogram showed a severely calcified aortic stenosis with left ventricular hypertrophy and good ejection fraction (60%). For this reason, he was evaluated for aortic valve replacement. Preoperative coronary angiographic analysis revealed normal coronary arteries. Despite a relative low EuroSCORE, PAVI was indicated because of multiple comorbidities and requested by the patient. PAVI with a core valve bioprosthesis was performed without procedural complications. Only a second balloon dilatation was required for a moderate paraprosthetic aortic regurgitation detected immediately after the procedure, and a mild-to-moderate paraprosthetic aortic regurgitation re-

Does Everolimus Associated With a Low Dose of Cyclosporine in Long-Term Cardiac Transplant Recipients Improve Renal Function? Initial Experience

Aims: Pacemaker and implantable‐cardioverter defibrillator lead infections widely increased with consequent need to accurately recognize responsible bacteria.

C4d Analysis in Endomyocardial Biopsies of Heart Transplant Patients: Is There a Correlation with Hemodynamic Data?

BACKGROUND Cyclosporine (CsA) renal toxicity is a well-known side effect. Various immunosuppressive strategies have been developed to minimize renal insufficiency. The use of everolimus associated with low levels of CsA can be an alternative strategy. METHODS From October 2007 to April 2008, everolimus was started with a lower dose of cyclosporine (trough levels from 109.3 +/- 27.5 to 93.7 +/- 30.1 ng/mL after 45 days) in 21 cardiac transplant recipients (18 male and 3 female patients, mean age 56.4 +/- 10.7 years). Pre-everolimus therapy creatinine levels, creatinine clearances, and glomerular filtration rates were 1.9 +/- 0.9 mg/dL, 54.2 +/- 18.1 mL/mins and 44.3 +/- 16.5 mL/min/m(2), respectively. RESULTS We observed a significant reduction in creatinine levels (from 1.9 +/- 0.9 to 1.4 +/- 0.3 mg/dL, P = .022) as well as a significant improvement in creatinine clearances (from 54.2 +/- 18.1 to 69.0 +/- 19.0 mL/min, P = .020) and glomerular filtration rates (from 44.3 +/- 16.5 to 57.1 +/- 16.3 mL/min/m(2), P = .010) after 7 days of everolimus therapy. Upon univariate analysis patient age, pretransplantation creatinine clearance, creatinine clearance after everolimus introduction, glomerular filtration rate at 45 days, and time from transplantation were associated with renal improvement. Upon multivariate analysis, only creatinine clearance at 7 days was related to the renal improvement. CONCLUSIONS These preliminary data suggested that everolimus with a low dose of CsA may be safe and effective to reduce CsA-related renal insufficiency among selected, heart transplant patients.