Marina Comisso

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.

Acute DeBakey Type I aortic dissection without intimal tear in the arch: is total arch replacement the right choice?

OBJECTIVES Surgical management of acute DeBakey Type I aortic dissection without intimal tear in the aortic arch is controversial. This study compared short- and long-term outcomes of total arch replacement (TAR) versus limited ascending aorta/hemiarch replacement (no-TAR) in a consecutive series of patients. METHODS Between January 1998 and December 2015, 220 consecutive patients were operated for DeBakey Type I acute aortic dissection; 135 cases did not exhibit an intimal entry tear in the aortic arch and were subsequently selected to comprise the primary study cohort. A secondary subgroup analysis was made within these 135 cases, which comprised patients who received antegrade cerebral perfusion as the neuroprotective strategy of choice (n = 45). RESULTS Mean follow-up period was 5 ± 4 years. Among the patients selected, 21 (16%) underwent TAR. Thirty-day mortality was higher in the TAR group (38% vs 21%, P = 0.04). Postoperative complication rates were similar between the groups (61% vs 73%, P = 0.31). Long-term mortality and late aortic reintervention rates were also similar (7% vs 30%, P = 0.36 and 27% vs 14%, P = 0.32, respectively). From the subgroup of patients with antegrade cerebral perfusion, 14 (31%) underwent TAR and 31 (69%) had no-TAR. Mean follow-up-time was 3 ± 2 years. Thirty-day mortality was higher in the TAR group (50% vs 16%, P < 0.01), postoperative complications, long-term mortality and late aortic reintervention rates were similar (64% vs 69%, P = 0.73; 0% vs 19%, P = 0.22; 29% vs 8%, P = 0.17, respectively). CONCLUSIONS TAR was associated with higher 30-day mortality compared with the less extensive hemiarch replacement. In the long term, TAR showed a trend of improved survival and higher reintervention rate.

Early and late outcomes after surgical repair of congenital supravalvular aortic stenosis: a European Congenital Heart Surgeons Association multicentric study

OBJECTIVES Our goal was to evaluate the early and late results of the surgical management of congenital supravalvular aortic stenosis (SVAS). METHODS We performed a retrospective, multicentre study using data from the European Congenital Heart Surgeons Association. Exclusion criteria were age >18 years, operation before 1990 and redo supravalvular aortic stenosis operations. Multivariate Cox regression analysis was performed to detect independent predictors of adverse events. RESULTS Of a total of 301 patients (male/female = 194/107; median age 3.9 years, range 13 days‐17.9 years), 17.6% had a prior surgical or interventional procedure. Pulmonary artery stenosis was present in 41.5% and coronary anomalies in 13.6%. The operation consisted of a single patch repair in 36.7%, a pantaloon‐shaped patch in 36.7%, a 3‐patch technique in 14.3% and other techniques in 11.7%. Postoperative complications occurred in 14.9%, and the early mortality rate was 5%. At a median follow‐up of 13 years (interquartile range 3.5‐7.8; follow‐up completed 79.1%), there were 10 late deaths (4.2%). A surgical reoperation or an interventional cardiology procedure occurred in 12.6% and 7.2%, respectively. No significant differences in outcomes between the techniques were found. Age at repair <12 months and pulmonary artery stenosis were associated with an increased risk of early (P = 0.0001) and overall mortality (P = 0.025), respectively. Having an operation after 2005 and co‐existing pulmonary artery stenosis were significant predictors of late reintervention (P = 0.0110 and P = 0.001, respectively). CONCLUSIONS Surgical repair of congenital stenosis is an effective procedure with acceptable surgical risk and good late survival, but late morbidity is not negligible, especially in infants and when associated pulmonary artery stenosis is present.

Twenty Year Patient Survival and 17 Year Complications of Isolated Mitral Biocor Standard Porcine Valve

Objective: Performance of the prostheses must be verified in the time domain. We report the 20-year survival of 230 patients operated of mitral replacement with Biocor Standard prosthesis in Padova and Verona and the 17 year prosthetic failure and complications of the series of Padova. Methods: 230 patients, 150 females and 80 males, aged 71 ± 6.3 received 235 isolated mitral Prostheses in Verona (67) and Padova (168), between June 1989 and August 2004. Twenty-year survival including 1698 patient-years was complete. Prosthesis survival was evaluated in the patients of Padova with a 90% goodness of follow-up and included 905 patient-years. Results: Twenty-seven operations were done in the eighties, 168 in the nineties, 52 in this century. Three operations were emergent, 20 urgent. The indication was prosthetic malfunction in 50 cases (21.7%), regurgitation in 114 (49.6%), stenosis in 22 (9.7%), mixed lesion in 44 (19.1%), concomitant CABG (Coronary Artery Bypass Graft) was performed in 23%. Overall survival was 6% (2-13%), Thirty day mortality was 8.9% (5.6-13.3%). The early hazard phase extended to 2.5 years with a linearized rate 1.4%/patient-years vs. a late rate of 7.2%/patient-years. Seventeen years freedom from reoperation was 80.5% (55.3-92.3%), actual 92% (86.4-94.5%), from SVD (Structural Valve Degeneration) 85.2% (52.6-96.1%) actual 94% (88.2-96.7%), from perivalvular leak 92.6% (86.5- 96%), from embolism 83.1% (73-89.7%), from haemorrhage 83.8% (71.5-91.1%), from endocarditis 90.9% (82.4- 95.4%), from pacemaker 77% (60.2-87.5%). Conclusion: Mitral Biocor has optimal durability and average complications. Premature mortality (6% vs. 30% survival of US (United States) matched population) is unrelated to prosthesis performance and suggest failure of our surgical strategy of the past century. Ultra mini abstract: 20 year Survival of patients is disappointing (6%) when compared to the matched US population (30%). The 17 year performance of the Biocor standard device compares with the best available prostheses. This therefore suggests an overall failure of our surgical strategy of the past century.

Use of Freedom SOLO bioprosthesis in aortic valve endocarditis involving the annulus.

Implantation technique for the Freedom SOLO valve in the setting of aortic endocarditis with annular destruction. The annulus is compacted with a circumferential running suture (a). The valve is lowered in supraannular position with the aid of three sutures and subsequently secured with a single-line running suture (b). To the Editor We read with interest the recent article by Pfeiffer et al. reporting encouraging results with the use of Freedom SOLO (Sorin Group, Milan, Italy) stentless bioprosthesis for the treatment of aortic endocarditis associated with annular destruction. We agree with the authors on the advantages of the SOLO valve in this clinical setting, and we present our centre’s experience.

Different Impact on the Coagulation System of Two Continuous Flow LVADs: Axial Versus Centrifugal Flow

Purpose Antithrombotic therapy is essential in LVAD recipients and must be carefully titrated in each patient. Different devices might influence the coagulation system differently. An awareness of this may allow early planning of the most appropriate antithrombotic approach according to LVAD type. We studied the impact of two different continuous flow LVADs on the coagulation system: Jarvik 2000, an axial flow pump, versus HeartWare HVAD, a magnetically levitating centrifugal pump. Methods and Materials Results of platelet count, thromboelastometric and aggregometric tests were compared between 13 patients with Jarvik and 8 patients with HeartWare, all implanted in our center between 2008 and 2012. Results At 7, 14, 21 and 28 days HeartWare patients showed significantly higher levels of platelets, Intem-Extem MCF, TRAP and COL tests. After 2 months we observed a remarkable reduction of the markers of coagulation activation in HeartWare patients. Conclusions The two pumps have markedly different effects on hemostasis. The HeartWare causes hyperactivation of the coagulation system compared to the Jarvik. Accordingly, HeartWare patients usually need both anticoagulant and antiplatelet drugs, while Jarvik patients are usually managed only with anticoagulation. TEST POSTOP. DAY HVAD JARVIK P PLATELETS 7 241,4±113,9 114,4±53,5 0,01 14 457,7±109,1 119,2±70,14 21 385,2±75,8 140,7±83,9 0,0002 28 326,5±7,8 168,9±81,3 0,03 60 353±102,6 166,1±77,9 0,002 135 292±99 180,1±90 0,17 INTEM MCF 7 68,1±5,2 61,2±2 0,007 14 73,8±7,3 64,4±3,2 0,0104 21 77,5±3,2 58,2±6,4 0,0004 28 76,1± 5,2 53,4±8,7 EXTEM MCF 7 67,8±4,9 60±3,2 0,004 14 71,9±5,5 63,4±6 0,02 21 78±4 60,4±2,4 28 75,5±6,9 54,2±4,2 0,0001 FIBTEM MCF 7 32,5±4,5 28±2,4 0,03 14 36,9±8,1 28±4,1 0,02 21 41,5±13,1 30,6±6,8 0,09 28 35,4±26,2 19,8±10,4 0,25 TRAP 7 68,2±16,7 30,3±17,2 0,005 14 86±20,7 53,2±28,6 0,05 21 99,9±37,7 53±1,2 0,04 28 108,1 ± 21,4 51,2±1,5 0,01 COL 7 37±9,6 16,6±9,6 0,004 14 35,8±18 29,3±20,8 0,64 21 34,8±3,9 17±8,5 0,01 28 40,2±12,3 15±0,8 0,02