Joachim Sirch

Active clearance of chest drainage catheters reduces retained blood

OBJECTIVE Chest tubes are used to clear blood from around the heart and lungs after heart surgery, but they can be obstructed by a blood clot, leading to retained blood syndrome (RBS). We sought to examine the frequency of RBS and associated morbidity, and to determine the influence of a preventative active chest tube clearance (ATC) protocol on these outcomes. METHODS A multidisciplinary team developed a simple protocol to institute ATC to preventatively clear chest tubes of clot during the first 24 hours after heart surgery. An extensive educational in-service was performed before universal implementation (phase 1). We retrospectively compared data collected prospectively from 1849 patients before universal implementation (phase 0) with data from 256 patients collected prospectively after universal implementation (phase 2), and then used propensity matching for outcomes assessment. RESULTS In propensity-matched patients, 19.9% of patients had interventions for RBS (phase 0). After the implementation of ATC (phase 2), the percent of patients with interventions for RBS was reduced to 11.3%, representing a 43% reduction in RBS (P = .0087). These patients had a 33% reduced incidence of postoperative atrial fibrillation from 30% (78 out of 256) in phase 0 to 20% (52 out of 256) in phase 2. (P = .013). CONCLUSIONS ATC is associated with a reduced need for interventions for RBS and postoperative atrial fibrillation. Our findings underscore the importance of maintaining chest tube patency in the early hours after cardiac surgery.

Sutureless Valve Implantation via Mini J-Sternotomy: A Single Center Experience with 2 Years Mean Follow-up.

INTRODUCTION Despite increased operative time, minimally invasive cardiac surgery is associated with a lower morbidity than conventional aortic valve replacement (AVR). On the other hand, sutureless aortic bioprostheses have the potential of simplifying implantation, as it reduces the ischemic time. Our aim was to investigate the outcome of a sutureless AVR through a mini-sternotomy. MATERIALS AND METHODS Since March 2010, a total of 262 patients affected by aortic valve stenosis underwent AVR with a sutureless bioprosthesis (Perceval, Sorin Group, Saluggia, Italy). Of these, 145 patients (mean age 77.8 ± 4.7 years, 80 women) underwent surgical AVR through a mini J-sternotomy. Clinical and echocardiographic data were evaluated. RESULTS Patients received a size: S(12), M(49), L(67), or XL(17) prostheses, either as isolated (131) or combined procedures (14) including 2 redo patients who had undergone coronary artery bypass grafting via full sternotomy previously. Mean logistic EuroSCORE (I) was 9.9 ± 5.9%, and mean aortic cross-clamp time was 38 ± 12 minutes (35 ± 11 minutes in isolated procedures). Two conversions to full sternotomy were necessary because of bleeding. Thirty-day mortality was 2.1% (all noncardiac deaths); mean hospital stay was 11.6 ± 4.9 days. We recorded 11 pacemaker implantations (7.6%). At follow-up (23.5 ± 14.4 months), five patients were dead (three noncardiac and two cardiac deaths). At echocardiographic control, mean transprosthetic gradients were as follows: 12.8 ± 4.9, 12.5 ± 4.5, 11.8 ± 4.7 mm Hg, postoperatively at 6 months, 1 year, and 2 years, respectively. No paravalvular leaks were recorded. CONCLUSION The sutureless bioprosthesis shows satisfactory clinical and hemodynamic results. Owing to its simple implantation technique, it represents a good support for minimally invasive access surgery via J-sternotomy.

Minimally invasive aortic valve replacement with Perceval valves: first clinical experience.

Aim Although minimally invasive aortic valve replacement (MIAVR) has been shown to cause less morbidity than conventional surgery, it has not yet received broad application. The purpose of this study was to evaluate sutureless implantation using the Perceval S aortic valve bioprosthesis (Sorin Group, Saluggia, Italy) via ministernotomy. Methods Seventy-two patients (43 women, 29 men; mean age 77.4 ± 5.3 years) with isolated aortic valve stenosis (mean gradient of 52 ± 14 mmHg) underwent aortic valve implantation with the sutureless Perceval S bioprosthesis, following cardiopulmonary bypass (CPB), aortic cross-clamping (ACC), cardioplegic arrest and removal of the calcified native valve. The mean logistic EuroSCORE was 9.7 ± 6.2%. Results The prosthetic valve was successfully deployed in all patients. Thirty-day mortality was 1.4% (n = 1). Mean CBP, ACC, and implantation times were 68 ± 18, 40 ± 13 and 8.9 ± 4 min, respectively. Perioperative echocardiography revealed significant paravalvular leakage in one patient. Postoperative mean gradient was 11.6 ± 5.1 mmHg. At a mean follow-up of 13 ± 6.7 months, no significant paravalvular leakage or valvular regurgitation was observed, and no migration or dislodgement of the prosthesis occurred. Conclusion This study shows that sutureless implantation of the Perceval S aortic valve bioprosthesis provides a simple and reproducible alternative for MIAVR. As the valve does not need to be sutured, it may also result in reduced ACC and CPB times. This self-anchoring valve may also allow the application of MIAVR to a broader spectrum of patients. This new technology needs a long-term follow-up.

Does prophylactic intra-aortic balloon pumping really fail to improve perioperative outcomes in patients with poor left ventricular function?

e728 www.ccmjournal.org November 2014 • Volume 42 • Number 11 First, after publication of the Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) trial data (3), is there still a role for the IABP in cardiogenic shock or should use of the IABP be replaced by percutaneous left ventricular assist devices (pLVADs)? After all, pLVADs are able to provide better hemodynamic support (4), however, without final proof of benefit on clinical endpoints (5). Second, in which patients, and when, should we escalate to VA-ECMO support? And finally, should VA-ECMO support be combined with either IABP or pLVAD? I strongly encourage all investigators involved in cardiogenic shock to join our forces and test these questions in adequately powered multicenter randomized controlled trials. The author has disclosed that he does not have any potential conflicts of interest.

Frühtracheotomie nach medianer Sternotomie

ZusammenfassungDie Tracheotomie, insbesondere die Dilatationstracheotomie bietet Vorteile bei der Therapie langzeitbeatmeter Patienten. Trotzdem gibt es bei herzchirurgischen Patienten Vorbehalte gegen diese Therapie aufgrund der Befürchtungen, das Risiko einer Mediastinitis dadurch zu erhöhen.Wir untersuchten die Daten unserer Patienten über einen 3–Jahreszeitraum hinsichtlich durchgeführter Tracheotomien und gegebenenfalls daraus entstandenen Komplikationen.Von Januar 2002 bis Dezember 2004 wurden 2556 Patienten mittels medianer Sternotomie operiert. 62 (2,8%) davon wurden in den ersten 14 Tagen nach der Operation tracheotomiert (58 Dilatationstracheotomie, 4 konventionell).Eine Mediastinitis trat bei den tracheotomierten Patienten einmal (1,6%) gegenüber 32 (1,25%) bei den nichttracheotomierten Patienten auf (p = n.s.).Somit kommt es auch bei herzchirurgischen Patienten, die in den ersten 2 Wochen nach Sternotomie tracheotomiert werden, zu keiner höheren Inzidenz an Sternuminfektionen.SummaryObjectiveTracheotomy offers significant advantages in patients requiring long–term assisted ventilation. Percutaneous tracheotomy offers advantages since it can be easily performed in the ICU. There is still concern, whether patients after median sternotomy are at increased risk for developing mediastinitis, especially if tracheotomy is performed early (within 14 days) after the sternotomy.MethodsWe reviewed the charts from patients operated at our institution with median sternotomy between January 2002 and December 2004. Patients requiring tracheotomy, the day of tracheotomy after median sternotomy and the patients developing mediastinitis were identified and analyzed.ResultsDuring this time period, we operated upon 2556 patients through a median sternotomy. From 72 patients (2.8%) receiving tracheotomy due to prolonged or expected prolonged assisted ventilation, 62 patients (2.4%) had the procedure performed within 14 days (mean 8.2 ± 2.7) after median sternotomy. In 58 patients (93.6%), tracheotomy was performed percutaneously with no major complication. Four patients (6.4%), who were not suited for the percutaneous approach (anatomical reasons), underwent surgical tracheotomy in the OR. Deep sternal wound infection devel oped in 1 patient, but the identified microbes (Staph. aureus) were different to those cultured from the trachea, excluding cross–contamination. Survivors (52/62, 83.9%) were successfully weaned after 10.4 ± 7.4 days (2–30).ConclusionsOur data show that percutaneous tracheotomy can be performed safely with a very low periprocedural complication rate and without increased incidence of mediastinitis during the first 14 days after median sternotomy. It is therefore well suited for patients who are long–term dependent on assisted ventilation after median sternotomy.

Sutureless Aortic Valves in combined procedures: a useful tool in the armamentarium of cardiac surgeons

Following the encouraging preliminary results, sutureless aortic valve implantation is performed in a growing number of patients as it makes minimally invasive surgery easier.