Marco Franceschi

Pediatric Coronary Artery Revascularization: A European Multicenter Study

BACKGROUND We sought to evaluate the hospital and midterm results of different surgical revascularization techniques in pediatric patients within the European Congenital Heart Surgeons Association. METHODS From 1973 to 2011, 80 patients from 13 European Congenital Heart Surgeons Association centers underwent 65 pediatric coronary artery bypass grafting (PCABG) and 27 other coronary artery procedures (OCAP; 12 patients had combined PCABG and other coronary artery procedures). Excluded were patients with Kawasaki disease. Median age at the time of coronary procedure was 2.3 years (range, 2 days to 16.9 years); 33 patients (41.2%) were younger then 12 months. An emergency procedure was necessary in 34 patients (42.5%). RESULTS Twelve patients (15%) died in the hospital; age at surgery (p=0.02) and the need for an emergent procedure (p=0.0004) were related to hospital mortality. Median follow-up time was 7.6 years (range, 0.9 to 23 years). There were 3 late cardiac deaths, all after a median time of 4 years (range, 9 months to 8.8 years) after PCABG. Fourteen patients (20.5%) presented with symptoms, including congestive heart failure (n=10) and angina (n=4), that were significantly associated with a low ejection fraction (p<0.001) and the presence of moderate or severe mitral valve regurgitation (p=0.0003). Six patients underwent a reintervention for impaired myocardial perfusion; all of them had a stenotic or atretic PCABG (p=0.001), and the majority were symptomatic (5 of 6 patients; 83.3%; p=0.001). CONCLUSIONS Both PCABG and other coronary artery procedures are suitable surgical options in pediatric patients with impaired myocardial perfusion, which increases operative and midterm survival. Such population of patients needs to be followed for life to prevent and treat any possible cause of further myocardial ischemia.

Impact of vacuum-assisted closure therapy on outcomes of sternal wound dehiscence †

OBJECTIVES Sternal wound dehiscence (SWD) after cardiac surgery is a rare but serious condition associated with considerable costs and morbidity. We sought to evaluate the results of the introduction of vacuum-assisted closure (VAC) therapy in the management of sternal wound dehiscence, compared with those of previous conventional treatments. METHODS We retrospectively collected 7148 patients who underwent cardiac surgery at our institution between January 2002 and June 2012. A total of 152 (2.1%) patients had a sternal wound dehiscence: 107 were treated with conventional treatments (Group A) and 45 were managed with VAC therapy (Group B). Patients were stratified according to preoperative risk factors and type of sternal wound dehiscence (superficial or deep; infected or not) and compared by means of a propensity-matched analysis. A cost analysis was also performed. RESULTS Forty-five patients of each group matched for all preoperative risk factors and type of sternal wound dehiscence. SWD-related mortality rate was significantly lower in Group B (11 vs 0%; P = 0.05). Incidence of mediastinitis (P < 0.0001), sepsis (P = 0.04), delayed SWD infection (P = 0.05), other complication (P = 0.05), surgical sternal revision (P = 0.04) and surgical superficial revision (P < 0.0001) were all significantly lower in Group B. Mean patient cost was 31 106€ in Group A and 24 383€ in Group B, thus achieving a mean saving of 6723€ per patient. CONCLUSIONS In our experience, the use of VAC therapy for the management of SWD was considerably effective in decreasing mortality (SWD related), incidence of complications and need for surgical procedures; thus, leading to a significant reduction of costs.

Nitinol Flexigrip Sternal Closure System and Chest Wound Infections: Insight From a Comparative Analysis of Complications and Costs

BACKGROUND We sought to assess the efficiency of two different sternal closure techniques in preventing sternal wound complications (SWC). A cost analysis was also considered. METHODS Between January 2008 and April 2010, 1,644 consecutive cardiac surgery patients who underwent cardiac surgery in our institute were prospectively collected. A total of 1,072 patients received a standard parasternal wiring technique (group A), and 572 patients received a new method of sternal closure based on the use of thermoreactive nitillium clips (Flexigrip; Praesidia SRL, Bologna, Italy [group B]). We investigated, by a propensity matched analysis, whether the use of standard or nitinol clip closure would impact on sternal wound outcome. RESULTS In all, 464 patients of each group were matched for 17 available risk factors. Overall incidence of SWC was significantly higher in group A (4.1% versus 1.7%; p=0.03). Sternal surgical revision to treat a thoracic instability was required in a significantly higher number of patients in group A (9 patients, 1.9%) and in none of group B (p=0.004). The incidence of sternal instability, secondary to wound infection, was significantly lower in group B (p=0.05). Overall costs were €7,407,296 and €6,896,432 in group A and group B, respectively. Thus, nitinol clip closure technique offered a €510,864 cost saving compared with standard steel wiring technique. CONCLUSIONS The Flexigrip assured a lower incidence of SWC. The use of the nitinol clip favored an improved sternal closure technique preventing mediastinitis. Additionally, the nitinol clip system proved to be cost effective in cardiac surgery.

Discrete fracture network of the Latemar carbonate platform

The Latemar massif represents a good analogue of a carbonate fractured reservoir. Fractures are widely exposed all over the mountain and the stratigraphic relationships among carbonate platform units, such as the platform margin and slope, are very well preserved. Having escaped pervasive dolomitization, the Latemar is renowned for the study of Triassic stratigraphy and of the evolution of Triassic carbonate build-ups of Western Tethys. In this paper we present the results of fracture modelling performed at Latemar, by the construction of a discrete fracture network in the lower part of the stratigraphic sequence. The modelling methodology consists in using field data for generating fracture network models that can be used to represent the fracture density variability and to estimate permeability distribution on at a regional scale. These models can also be useful in the study of other petrophysical parameters, for instance generating synthetic seismic datasets for comparison with reservoirs in the subsurface.

Geological map of the Middle Triassic Latemar platform (Western Dolomites, Northern Italy)

The Latemar is a Middle Triassic isolated carbonate buildup with a diameter of approximately 3 km, that crops out in the western Dolomites, northern Italy. The platform is an important case study and potential analogue for carbonate hydrocarbon reservoirs. Detailed field mapping of the platform has been carried out on a high-resolution topographic base extracted from airborne LIDAR to produce a geological map at 1:5000 scale. Remote sensing was used for the recognition of structural features and then validated in the field. In addition, high-resolution digital photographs were used to interpret the geology of inaccessible rock walls. This work represents a up-to-date detailed geologic map of the Middle Triassic Latemar platform that enhances its internal units subdivision and highlights its complex shape, characterized by gulfs and internal basins and strongly controlled by synsedimentary tectonics.

Integration of 3D modeling, aerial LiDAR and photogrammetry to study a synsedimentary structure in the Early Jurassic Calcari Grigi (Southern Alps, Italy)

Abstract LiDAR and photogrammetry data are integrated to study an Early Jurassic extensional synsedimentary structure in the Italian Southern Alps. Airborne LiDAR data helped in getting geologic information in areas covered by vegetation, photogrammetry was applied to produce a high-resolution 3D textured model of the inaccessible parts of the outcrop. LiDAR and photgrammetric data were merged together producing a multi-resolution model. Key geologic boundaries and faults bounding the synsedimentary structure were digitized in a 3D geomodeling environment. The reconstruction yielded information about the structure kinematics and accumulated displacements.

Nitinol flexigrip sternal closure system and standard sternal steel wiring: insight from a matched comparative analysis.

Objective We sought to assess the efficiency of two different sternal closure techniques in preventing sternal wound instability in high-risk patients. Materials and methods Between January 2009 and February 2012, 2068 consecutive cardiac patients were prospectively collected in our database. The 561 patients in whom the thermoreactive nitilium clips (Flexigrip) have been used (group A) were matched 1 : 1 with 561 patients who received a standard parasternal wiring technique (group B) on 10 available risk factors known to affect sternal wound healing (age, age >75 years, sex, diabetes mellitus, cardiac procedure, obesity, re-intervention, cross-clamp, and total operative times). The study was completed with a cost analysis. Results The two groups were well matched, although different for bilateral internal thoracic harvesting, chronic obstructive pulmonary disease, renal insufficiency, and congestive heart failure, which were significantly more frequent in group A. At 30 days of follow-up, the association of wound complication and sternal instability was significantly less frequent in group A versus group B (0.2 versus 1.6%) (P = 0.04). Overall incidence of sternal wound complication was lower in group A (2 versus 3.5%) (P = 0.28). In the presence of wound infection, a sternal wound instability was never observed in group A (P = 0.06). Overall costs were &OV0556;8 701 854 and &OV0556;9 243 702 in groups A and B, respectively; thus the Flexigrip closure technique offered a &OV0556;541 848 cost saving. Conclusions Flexigrip use in high-risk patients showed a lower incidence of sternal wound instability with no need for sternal re-wiring in any case, even in the presence of wound infection.

FISH FEEDING TRACES FROM MIDDLE EOCENE LIMESTONES (GARGANO PROMONTORY, APULIA, SOUTHERN ITALY)

ABSTRACT More than two hundred subcircular to crescent-shaped depressions, often with radiating markings, were discovered on a 120 m2 bedding plane interpreted as base-of-slope carbonate deposits and belonging to the Lutetian–Bartonian Peschici Formation at San Lorenzo (Vieste, Gargano Promontory, Italy). The area was mapped using a high-resolution aerial camera (mounted on a kite) and a terrestrial laser scanner. The survey allowed detailed morphologic analysis and topographic mapping of the traces, in order to analyze the very regular distribution pattern. The ichnological study, combined with sedimentologic and stratigraphic analyses, identifies the depressions as fish feeding traces. Although the tracemaker cannot be definitely identified, the comparison with modern and fossil fish excavations suggests a higher affinity with bony fishes (e.g., sturgeons) than with rays. The trace fossils are here attributed to the ichnogenus Piscichnus and constitute the first discovery of this ichnotaxon in the middle Eocene of the Apulia Carbonate Platform and of Italy.

A Single Institution Evaluation of the Performance of Two Different Chest Drainage Systems in Pediatric Patients after Surgery for Congenital Heart Disease

BACKGROUND The study compares the efficacy and advantages of two different drainage systems in pediatric patients during surgery for congenital heart disease (CHD). METHODS A total of 200 consecutive pediatric patients (< 16 years) were enrolled; in 100 patients we used a polyvinyl chloride drain (PVCD) and in the other 100 we used a silicone drain (SD). Demographics, drains technical data, and postoperative complications and costs were evaluated. A pain score was calculated in patients older than 6 years. RESULTS The SDs were significantly smaller when compared with PVCDs (median of 1.63 vs. 3.09 French/kg, p = 0.0006), were kept in site for a median shorter period (23 vs. 40 hours, p = 0.002), drained more thoracic spaces (median of 2 vs. 1, p < 0.0001), and were associated to a lower pain score (p = 0.01). The overall drain-related complication rate was lower for the SD group than for the PVCD group (3 vs. 9%, p = 0.1) as well as the drain-related adverse event required additional interventional maneuvers (0 vs. 6%, p = 0.04). Patients who were treated with a PVCD reported a higher perceived pain score than patients treated with a SD, both at the time when the drain was in site (p = 0.016) and during the drains removal (p = 0.0001). CONCLUSION SDs can be used safely in pediatric patients during surgery for CHD. Sizes required are smaller than other conventional drains and multiple cavities can be drained with a single tube. The use of SD is associated to a lower complication rate, lower requirement of additional procedures, and lesser perceived pain from the patient, when compared with other more traditional drains.