Ic Ennker

The concept of negative pressure wound therapy (NPWT) after poststernotomy mediastinitis – a single center experience with 54 patients

Deep sternal infections, also known as poststernotomy mediastinitis, are a rare but often fatal complication in cardiac surgery. They are a cause of increased morbidity and mortality and have a significant socioeconomic aspect concerning the health system. Negative pressure wound therapy (NPWT) followed by muscular pectoralis plasty is a quite new technique for the treatment of mediastinitis after sternotomy. Although it could be demonstrated that this technique is at least as safe and reliable as other techniques for the therapy of deep sternal infections, complications are not absent. We report about our experiences and complications using this therapy in a set of 54 patients out of 3668 patients undergoing cardiac surgery in our institution between January 2005 and April 2007.

In Search of a Standardized Treatment for Poststernotomy Mediastinitis

Poststernotomy mediastinitis following median sternotomy procedures such as open heart surgery is a rare complication which nevertheless has a mortality rate of up to 50 %. Several treatment options are currently available; however, none of them are standardized. Based on the experience gained from open heart surgery performed at the MediClin Heart Institute Lahr/Baden, a therapeutic algorithm was developed. The treatment steps consist of repeated radical surgical debridement, sternal restabilization, vacuum-assisted closure therapy (VAC) as well as a surgical reconstruction via M. pectoralis plasty (MPP). This approach had a 30-day mortality of 0 % and a hospital mortality of 10.4 %. The approach proved to be safe and advantageous for specific patient groups operated on at the MediClin Heart Institute Lahr/Baden.

Are Aortic Valve Reoperations after Primary Replacement with Stentless Heart Valve Prostheses More Demanding than after Stented Biological Prostheses

OBJECTIVE Reoperations after aortic valve replacement (AVR) with stentless valve prostheses are believed to be surgically more difficult than after stented prostheses. METHODS Between January 1996 and December 2006, 1,340 of 3,785 patients with AVR in a single institution received a stentless valve prosthesis in aortic position (Medtronic Freestyle, Medtronic GmbH, Meerbusch, Germany). Reoperations after stentless AVR occurred in 27 patients (2.0%). Twenty-four of these patients were compared with another 24 patients having redo surgery after a primary stented bioprosthesis after carrying out propensity score matching. RESULTS After matching, stentless valve redo patients had a similar preoperative risk profile regarding EuroSCORE (stentless 10 ± 3 points/stented 11 ± 3 points; p = 0.37), preoperative active endocarditis (stentless 37.5%/stented 16.7%; p = 0.081), and amount of concomitant procedures (stentless 37.5%/stented 16.7%; p = 0.222). Thirty-day mortality after reoperation was 20.8% (5 patients) in the stentless and 4.2% (1 patient) in the stented group (p = 0.081), and reintubation rate was 16.7% in the stentless and 0% in the stented group (p = 0.037). Aortic clamping time (stentless 90 ± 25 min/stented 86 ± 34 min; p = 0.208) and extracorporeal circulation time (stentless 151 ± 59 min/stented 132 ± 52 min; p = 0.55) were similar in both groups. CONCLUSION Our data do not show that the technical difficulty of reoperations after stentless AVR is higher than that of reoperations after stented AVR. The clinically visible, but not statistically significant, higher early mortality rate of our stentless group is mainly due to more active valve prosthesis endocarditis cases and a higher amount of concomitant procedures.

Female gender does not increase perioperative risk in coronary bypass surgery.

INTRODUCTION Female gender has been identified as an independent risk factor for perioperative mortality in several risk scores for cardiac surgery. Since no explanation has been given for this, this study aimed to evaluate potential differences in the distribution of other risk factors between the genders. PATIENTS AND METHODS 10 714 consecutive coronary bypass patients were analyzed retrospectively. The distribution of the risk factors as used in the EuroSCORE was evaluated. Diabetes mellitus was added to the analysis as an additional risk factor. Patients aged between 60 and 70 years without any additional risk factors were directly compared in a subgroup analysis. Statistical analysis was done using the T-test or chi-square test where appropriate. RESULTS Female patients were significantly older compared to male ones (69.1 ± 8.5 vs. 65.4 ± 4 years, P < 0.05). The distribution of the analyzed risk factors did not differ except for diabetes mellitus: female patients were more likely to present with diabetes (42 % vs. 29 %, P < 0.05) and in diabetic patients, the incidence of insulin dependency was higher in female patients (50 % vs. 33 %, P < 0.05). Overall perioperative mortality was higher in female patients (2.7 % vs. 1.8 %, P < 0.05). This difference increased when diabetes was present (3.9 % vs. 1.8 %, P < 0.05) and was even higher in insulin-dependent patients (4.9 % vs. 1.9 %, P < 0.05). However, when adjusting for age and diabetes, the differences were reduced. This was most evident when subgroups of age-adjusted patients without any additional risk factors were analyzed: no gender-specific difference in perioperative mortality was observed. CONCLUSIONS Female gender itself did not present as an independent risk factor. The presence of diabetes mellitus increased the risk in female patients significantly more than in male patients. The higher prevalence of diabetes in female patients in combination with the older age at presentation might result in the higher overall mortality observed in female patients compared to men.

[Experiences collected in more than 2,300 diabetics undergoing coronary artery bypass grafting: patients with a specific risk profile].

SummaryBackgroundThe objective of this paper was to analyze demographic and clinical characteristics of diabetic patients undergoing coronary artery bypass grafting on the basis of a significant number of cases.MethodsThe data of 8,195 patients who have undergone coronary bypass operations between 1996 and 2003 were analyzed. Non-diabetic patients (no DM), oral treated diabetics (DM oral) and insulin-treated diabetics (DM insulin) were compared in terms of their pre-operative, intra-operative and post-operative characteristics. The statistical analyses were performed with the support of SPSS 11.5 under application of chi-square and student-t tests.ResultsIn cardiosurgery, diabetics differ in various ways from non-diabetic patients. They show a significantly higher prevalence of the known cardiovascular risk factors such as raised body mass index, age and hypertension. Furthermore they present a higher prevalence of vascular comorbidity such as peripheral vascular disease and carotid disease. At the postoperative stage, cerebral dysfunction occurred more often among the diabetic patients (no DM 5.2% vs. DM oral 7.3% vs. DM insulin 10.5%; p<0.05), they suffered from apoplexies more frequently (no DM 1.9% vs. DM oral 2.1% vs. DM insulin 3.2%; p<0.05), and they required re-intubation more frequently (no DM 2.6% vs. DM oral 3.1% vs. DM insulin 5.6%; p<0.05). Peri-operative mortality was highest in the group of insulin-treated diabetics (no DM 1.1% vs. DM oral 1.6% vs. DM insulin 1.8%; p<0.05).ConclusionIn coronary surgery, diabetic patients represent an especially challenging patient group with an independent risk profile, who require specific consideration as far as the selection of the operative approach, on, one hand, and the post-operative follow-up, on the other hand, are concerned.ZusammenfassungEinleitungAnhand eines aussagekräftigen Patientenkollektivs sollten die demographischen, klinischen, operativen und postoperativen Daten diabetischer Koronarpatienten mit nichtdiabetischen Patienten verglichen werden.Methoden und ErgebnisseEs wurden die Daten von 8 195 Patienten untersucht, die sich im Zeitraumvon 1996 bis 2002 koronaren Bypassoperationen unterzogen. Nichtdiabetische Patienten (kein DM), mit oralen Antidiabetika therapierte Diabetiker (DM oral) und mit Insulin therapierte Diabetiker (DM Insulin) wurden hinsichtlich ihrer präoperativen Charakteristika und Risikofaktoren und hinsichtlich der Ergebnisse des postoperativen Verlaufs miteinander verglichen. Es zeigte sich, dass diabetische Koronarpatienten signifikant häufiger zahlreiche kardiovaskuläre Risikofaktoren und eine höhere vaskuläre Komorbidität aufwiesen als nichtdiabetische Patienten. Postoperativ litten Diabetiker häufiger unter Verwirrtheitszuständen (kein DM 5,2% vs. DM oral 7,3% vs. DM Insulin 10,5%; p<0,05), erlitten häufiger Schlaganfälle (kein DM 1,9% vs. DM oral 2,1% vs. DM Insulin 3,2%; p<0,05) und mussten häufiger reintubiert werden (kein DM 2,6% vs. DM oral 3,1% vs. DM Insulin 5,6%; p<0,05). Die 30-Tage-Mortalität war unter den Diabetikern signifikant erhöht (kein DM 1,1% vs. DM oral 1,6% vs. DM Insulin 1,8%; p<0,05).SchlussfolgerungDie Ergebnisse der vorliegenden Studie zeigen, dass diabetische Koronarpatienten in der Herzchirurgie ein eigenständiges Risikoprofil aufweisen, das in der Wahl der operativen Strategien und im postoperativen Verlauf eine besondere Herausforderung darstellt.

Implementation of the aortic no-touch technique to reduce stroke after off-pump coronary surgery

Objectives Despite substantial scientific effort, the relationship between stroke after coronary artery bypass grafting and the use of the aortic no‐touch off‐pump technique (anOPCAB) remains incompletely understood. The present study aimed to define the effect of anOPCAB on the occurrence and time point of stroke. Methods A total cohort of 15,042 consecutive patients underwent surgical myocardial revascularization at a single institution. After establishing anOPCAB as routine procedure, 4695 patients received surgery by 18 different surgeons using the anaortic approach. After the exclusion of all patients with cardiogenic shock and “side‐clamp” off‐pump coronary artery bypass grafting, 13,279 patients (4485 with anOPCAB) were included in the study. Perioperative strokes were classified as strokes occurring during the hospital stay, with early strokes observed immediately after emergence from anesthesia (vs delayed strokes). Results The anOPCAB technique reduced the postoperative stroke rate to 0.49% versus 1.31% in on‐pump patients (P < .0001). The overall stroke rate after adoption of anOPCAB (0.64%) decreased compared with before its adoption (1.40%; P < .0001). With anOPCAB, the risk of early strokes virtually disappeared to 4 of 4485 patients (0.09%; 95% confidence interval, 0.00‐0.18% vs 0.83% in on‐pump patients; P < .0001), whereas the incidence of delayed strokes was not affected (0.40% vs 0.48%; P = .5181). The key results were confirmed after adjustment using propensity score–based analyses. Conclusions The anOPCAB technique with avoidance of any aortic manipulation is an effective tool to minimize the risk of early strokes during coronary artery bypass grafting, and thus, should be considered as a routine approach. In contrast, additional preventive strategies against delayed strokes remain to be elaborated.

Freestyle stentless bioprosthesis for aortic valve therapy: 17-year clinical results

Background Aortic valve replacement with stentless bioprostheses has been shown to produce lower aortic gradients than stented bioprostheses, thus facilitating left ventricular mass regression and preventing heart failure. We sought to determine the long-term results of stentless biological aortic valve replacement over a 17-year follow-up. Methods Between 1996 and 2012, 2551 patients underwent isolated aortic valve replacement with a stentless prosthesis (Medtronic Freestyle) at a single center. The mean patient age was 72 ± 10 years, 55% were male, 24.1% were in New York Heart Association class I and II, 9.6% had undergone previous surgery, 18.1% had coronary artery disease, and 23.1% had diabetes. For the long-term follow-up, patients were contacted in writing and by telephone; follow-up was 96.3% complete, resulting in 11,546 patient-years. Results At 30 days, mortality (5.4%), renal failure (3.9%), myocardial infarction (0.7%), and stroke (1.4%) rates were acceptable. During long-term follow-up of 1–17 years, the bleeding rate (2.9%) was higher than the thromboembolic event rate (0.7%) despite 18.1% of patients being on oral anticoagulants. New pacemaker implantation (4.5%; 0.87 events/100 patient-years), neurological disorders (5%; 0.52 events/100 patient-years), valve insufficiency (0.7%; 0.16 events/100 patient-years), paravalvular leakage (0.4%; 0.09 events/100 patient-years) and reoperation due to valvular complications (0.7%; 0.38 events/100 patient-years) were rare. Long-term survival was 41.8% ± 1.6 after 10 years, 21.3% ± 2.3 after 15 years, and 12.1% ± 3.9 after 17 years. Conclusion Long-term results after aortic valve replacement with stentless biological prostheses compare favorably with those obtained with stented bioprostheses.

Current indications for stentless aortic bioprostheses

The best aortic prostheses have been debated for decades. The introduction of stentless aortic bioprostheses was aimed at improving hemodynamics and potentially the durability of aortic bioprostheses. Despite the good short- and long-term outcomes after implantation of stentless aortic bioprostheses, their use remains limited owing to the technically demanding implantation techniques. Nevertheless, stentless aortic bioprostheses might be of special benefit in certain indications, where they could be a valuable addition to the surgical armamentarium.

Continuation of preoperative aspirine therapy does not increase blood loss in coronary bypass patients

Introduction: Platelet inhibition is thought to increase perioperative blood loss in patients with planned coronary artery bypass grafting (CABG). This retrospective study reviews the results of over 10000 patients with CABG comparing continued platelet inhibition with preoperative sessation of this therapy. Patients and methods: From 1995 to 2007, 11976 patients had isolated CABG and were included in this study. Data were evaluated with regards to preoperative aspirin-therapy, Euro-Score relevant risk factors, and operative results. Parameters of the operative outcome were in-hospital mortality, perioperative infarctions, re-explorations rate, strokes, pericardial tamponade, blood transfusions, and perioperative drainage loss. Results: Group 1: Continuous aspirin therapy till surgery (n=2523). Group 2: Patients with preoperative interruption of their aspirin therapy for at least five days (n=9453). There was no difference between the groups concerning age, Euro-Score (4.3±2.8 vs. 4.2±2.9), emergencies (8.2% vs. 8.8%), left main stenoses (17.6% vs. 17.9%), duration of surgery (198±53 vs. 198±52min.), and sex distribution. The postoperative drainage loss did not differ between the groups (745±686ml vs. 780±775ml), as did the number of administered red cell packages (0.84±2.7 vs. 0.85±2.8). Analysing the subgroups on-pump primary CABG, OPCAB-procedures, and redo-CABG, no difference in the main outcome parameters was found. Only redo-CABGs of group 2 had a higher reexploration rate compared to group 1 (5% vs. 3.3%, p<0.05). Conclusion: The preoperative aspirin therapy does not seem to influence the operative outcome of isolated CABG.

Erfahrungen mit Diabetikern in der Koronarchirurgie—@@@Experiences collected in more than 2,300 diabetics undergoing coronary artery bypass grafting: patients with a specific risk profile: Patienten mit einem besonderen Risikoprofil

SummaryBackgroundThe objective of this paper was to analyze demographic and clinical characteristics of diabetic patients undergoing coronary artery bypass grafting on the basis of a significant number of cases.MethodsThe data of 8,195 patients who have undergone coronary bypass operations between 1996 and 2003 were analyzed. Non-diabetic patients (no DM), oral treated diabetics (DM oral) and insulin-treated diabetics (DM insulin) were compared in terms of their pre-operative, intra-operative and post-operative characteristics. The statistical analyses were performed with the support of SPSS 11.5 under application of chi-square and student-t tests.ResultsIn cardiosurgery, diabetics differ in various ways from non-diabetic patients. They show a significantly higher prevalence of the known cardiovascular risk factors such as raised body mass index, age and hypertension. Furthermore they present a higher prevalence of vascular comorbidity such as peripheral vascular disease and carotid disease. At the postoperative stage, cerebral dysfunction occurred more often among the diabetic patients (no DM 5.2% vs. DM oral 7.3% vs. DM insulin 10.5%; p<0.05), they suffered from apoplexies more frequently (no DM 1.9% vs. DM oral 2.1% vs. DM insulin 3.2%; p<0.05), and they required re-intubation more frequently (no DM 2.6% vs. DM oral 3.1% vs. DM insulin 5.6%; p<0.05). Peri-operative mortality was highest in the group of insulin-treated diabetics (no DM 1.1% vs. DM oral 1.6% vs. DM insulin 1.8%; p<0.05).ConclusionIn coronary surgery, diabetic patients represent an especially challenging patient group with an independent risk profile, who require specific consideration as far as the selection of the operative approach, on, one hand, and the post-operative follow-up, on the other hand, are concerned.ZusammenfassungEinleitungAnhand eines aussagekräftigen Patientenkollektivs sollten die demographischen, klinischen, operativen und postoperativen Daten diabetischer Koronarpatienten mit nichtdiabetischen Patienten verglichen werden.Methoden und ErgebnisseEs wurden die Daten von 8 195 Patienten untersucht, die sich im Zeitraumvon 1996 bis 2002 koronaren Bypassoperationen unterzogen. Nichtdiabetische Patienten (kein DM), mit oralen Antidiabetika therapierte Diabetiker (DM oral) und mit Insulin therapierte Diabetiker (DM Insulin) wurden hinsichtlich ihrer präoperativen Charakteristika und Risikofaktoren und hinsichtlich der Ergebnisse des postoperativen Verlaufs miteinander verglichen. Es zeigte sich, dass diabetische Koronarpatienten signifikant häufiger zahlreiche kardiovaskuläre Risikofaktoren und eine höhere vaskuläre Komorbidität aufwiesen als nichtdiabetische Patienten. Postoperativ litten Diabetiker häufiger unter Verwirrtheitszuständen (kein DM 5,2% vs. DM oral 7,3% vs. DM Insulin 10,5%; p<0,05), erlitten häufiger Schlaganfälle (kein DM 1,9% vs. DM oral 2,1% vs. DM Insulin 3,2%; p<0,05) und mussten häufiger reintubiert werden (kein DM 2,6% vs. DM oral 3,1% vs. DM Insulin 5,6%; p<0,05). Die 30-Tage-Mortalität war unter den Diabetikern signifikant erhöht (kein DM 1,1% vs. DM oral 1,6% vs. DM Insulin 1,8%; p<0,05).SchlussfolgerungDie Ergebnisse der vorliegenden Studie zeigen, dass diabetische Koronarpatienten in der Herzchirurgie ein eigenständiges Risikoprofil aufweisen, das in der Wahl der operativen Strategien und im postoperativen Verlauf eine besondere Herausforderung darstellt.