Clemente Barriuso

Delayed sternal closure for life-threatening complications in cardiac operations: An update

Over a 7-year-period, 25 patients had delayed sternal closure after open heart operations out of 34 patients whose sternum was not closed. The indications were extreme cardiac dilatation and uncontrollable mediastinal hemorrhage. This represented a 1.79% incidence in the overall open heart surgical experience at our unit. Sternal closure was performed at a mean of 2.64 days after the initial operation. Eighteen patients (52.9%) left the hospital alive and well, representing a 72% survival rate among patients undergoing delayed sternal closure. No mediastinal or fatal infection developed and only 1 patient had late superficial wound infection after delayed sternal closure. We conclude that delayed sternal closure is an effective method to treat severe complications after cardiac operations.

Eyes wide shut - unusual two stage repair of pectus excavatum and annuloaortic ectasia in a 37 year old marfan patient: case report

We report about a 37 year old male patient with a pectus excavatum. The patient was in NYHA functional class III. After performed computed tomography the symptoms were thought to be related to the severity of chest deformation. A Ravitch-procedure had been accomplished in a district hospital in 2009. The crack of a metal bar led to a reevaluation 2010, in which surprisingly the presence of an annuloaortic ectasia (root 73 × 74 mm) in direct neighborhood of the formerly implanted metal-bars was diagnosed. Echocardiography revealed a severe aortic valve regurgitation, the left ventricle was massively dilated presenting a reduced ejection fraction of 45%. A marfan syndrome was suspected and the patient underwent a valve sparing aortic root replacement (David procedure) in our institution with an uneventful postoperative course. A review of the literature in combination with discussion of our case suggests the application of stronger recommendations towards preoperative cardiovascular assessment in patients with pectus excavatum.

Reintervenciones en una Unidad de Cuidados Intensivos de Cirugía Cardiovascular

BACKGROUND To analyze the indications, actions and results of the operations performed in the Cardiovascular Surgery Intensive Care Unit. METHODS Retrospective analysis of consecutive non-selected adult patients operated in the ICU. All operations were included. Descriptive statistics were used. RESULTS Between 2008 and 2013, 3379 consecutive adult patients were operated upon. A total of 124 operations were performed in the ICU in 109 patients, 70 male (64.2%) and 39 female (35.8%) with a mean age of 61.6 years (12-80). This represented 3.2% of all operations. During the study period, 185 patients (5.5%) were reoperated for postoperative bleeding/tamponade in the operating room. The index interventions were for valvular heart disease (34.9%), aortic disease (22.9%), ischemic heart disease (15.6%), combined valvular/ischemic (12%), valvular/aorta (11%) and miscellaneous (3.6%). The indications for reoperation were persistent bleeding 54 (43.5%), pericardial tamponade 41 (33%), low cardiac output 13 (10.5%), cardiac arrest/arrhythmia 8 (6.5%), respiratory insufficiency 6 (4.8%) and acute ischemic limb 2 (1.7%). Operations performed were: mediastinal exploration 73 (58.9%), implant/removal of ECMO 17 (13.7%), sternal closure 16 (12.9%), open resuscitation 9 (7.3%), subxyphoid drainage 7 (5.6%) and femoral embolectomy 2 (1.6%). Overall mortality was 33%. There was one case of mediastinitis (0,9%), with no difference from patients operated in the regular operating room. CONCLUSIONS Operations in the ICU represent a safe, life-saving alternative in specific subgroups of patients. The risk of wound infection is not increased, unstable patients are not transferred and there is time savings.

How does an apico-aortic conduit look after death?

A65-year-old man, with insulin dependency, peripheral vascular disease, hypertension, a body mass index of 37.1, and ischemic heart disease, underwent on-pump left internal mammary-to-left anterior descending coronary artery and saphenous vein to posterior descending coronary artery bypass grafting in March 2004. Methycillin-sensitive Staphylococcus aureus mediastinitis required debridement and antibiotics. The patient was discharged 68 days later. The patient had aortic stenosis that was diagnosed in 2008, with a transaortic gradient of 83/46 mm Hg and a 0.7-cm valve area. An apico-aortic conduit containing a 22-mm porcine Hancock xenobioprosthesis (Medtronic Inc, Minneapolis, MN) was implanted on January 12, 2009. The need for a patent conduit was confirmed by computed tomography. Nine months later, the patient was seen because of angina, and his troponin I was 7.76 ng/dL. Emergency catheterization confirmed patent coronary grafts. Eight hours later, he suddenly collapsed and eventually died. Postmortem examination showed a patent apico-aortic conduit (Fig 1). Partial loss of ventricular apical tissue was seen (Fig 2) with no leak on a pressure water test. A midventricular view confirmed healing of the apical connector (Fig 3) and signs of recent infarction. Apico-aortic conduits have been

Empleo de las prótesis compuestas en el tratamiento del arco aórtico distal

La cirugia de la aorta intratoracica sigue siendo un reto quirurgico. La diseccion aguda y los aneurismas del cayado aortico y la aorta toracoab-dominal tienen riesgos relacionados con la presentacion clinica y la tecnica quirurgica, la cual exige tiempos prolongados y la necesidad de modificar temporalmente la circulacion cerebral y medular. El tratamiento del arco aortico exige con frecuencia un abordaje en dos tiempos con las ventajas e inconvenientes que ello representa. La introduccion en clinica de endoprotesis integradas que persiguen el tratamiento simultaneo en un solo tiempo de la aorta intratoracica puede representar un cambio conceptual en ciertas situaciones, como la diseccion aguda de aorta. La acumulacion de experiencia clinica y el analisis cuidadoso de los datos disponibles pueden aportar informacion critica en un futuro no lejano.

The Gore-Tex Surgical Membrane for Temporary Skin Closure after Complicated Cardiac Operations

Between April 1986 and March 1989, 12 patients, 7 male and 5 female with a mean age of 50.0 years underwent temporary skin closure after complicated cardiac operations with the Gore-Tex Surgical Membrane and the indications to delay primary closure of the sternume were myocardial edema, uncontrollable hemorrhage and additional cannulations needed for mechanical circulatory support. Seven patients (58%) finally underwent sternal closure. Five patients survived and left the hospital (42%). No superficial nor deep infection developed in survivors. The analysis of 3 explanted membranes showed no bacterial growth.