Massimiliano Carrozzini

Italian multicentre study on type A acute aortic dissection: a 33-year follow-up

OBJECTIVES Despite substantial progress in surgical techniques and perioperative management, the treatment and long-term follow-up of type A acute aortic dissection (AAD) still remain a major challenge. The objective of this retrospective, multicentre study was to assess in a large series of patients the early and long-term results after surgery for type A AAD. METHODS We analysed the preoperative, intraoperative and postoperative conditions of 1.148 consecutive patients surgically treated in seven large referral centres from 1981 to 2013. We applied to each patient three different multi-parameter risk profiles (preadmission risk, admission risk and post-surgery risk) in order to compare risk factors and outcome. Long-term Kaplan-Meier survival was evaluated. RESULTS The median age was 64 years and the male population was predominant (66%). Identified diagnosis of collagen disease was present in 9%, and Marfan syndrome in 5%. Bicuspid aortic valve was present in 69 patients (6%). Previous cardiac surgery was identified in 10% of the patients. During surgery, the native aortic valve was preserved in 72% of the cases, including leaflet resuspension in 23% and David operation in 1.2%. Considering aortic valve replacement (AVR: 28%), bioprosthesis implantation was performed in 14.7% of the subjects. Neurological impairment at discharge was shown in 23% of the cases among which 21% of patients had new neurological impairment versus preoperative conditions. The overall 30-day mortality rate was 25.7%. All risk profiles remained independently associated with in-hospital mortality. During the available follow-up of hospital survivors (median: 70 months, interquartile range: 34-113, maximum: 396), cardiac-related death occurred in 7.9% of the subjects. The cumulative survival rate for cardiac death was 95.3% at 5 years, 92.8% at 10 years and 52.8% at 20 years. Severe aortic regurgitation (AR) (grade 3-4) at the time of surgery showed to be a significant risk factor for reintervention during the follow-up (P < 0.001). Among risk profiles, only the preadmission risk was independently associated with late mortality after multivariate analysis. Unexpectedly, there was no difference in freedom from cardiac death between patients with and without AVR. CONCLUSIONS Although surgery for type A has remained challenging over more than three decades, there is a positive trend in terms of hospital mortality and long-term follow-up. About 90% of patients were free from reoperation in the long term, although late AR remains a critical issue, suggesting that a thorough debate on surgical options, assessment and results of a conservative approach should be considered.

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.

Vacuum-Assisted Closure Therapy for the Treatment of Poststernotomy Wound Dehiscence in Neonates and Infants

We sought to analyze effectiveness and results of a vacuum-assisted closure system for the treatment of sternal wound dehiscence in newborns and children after cardiac surgery in our institution. Six patients with poststernotomy wound problems (large defects of epithelialization or mediastinitis) were treated with a vacuum-assisted closure (VAC) therapy. Median age was 5 months (range: 1-144); VAC therapy was started with negative pressure -75 mm Hg, continuously. All children achieved healing of the sternal wound and a subsequent closure after a median length of treatment of 8.3 days (range: 4-14). In conclusion, VAC therapy with high negative pressure is safe, effective, and is a well-tolerated therapy in pediatric patients with either early- or late poststernotomy wound dehiscence.

Surgical Treatment of Congenital Mitral Valve Dysplasia

Congenital mitral valve (MV) dysplasia is a relatively rare and highly complex cardiac disease. We present our results and illustrate the techniques used to repair these valves.

One‐and‐a‐Half Ventricle Repair in Adult Patients: A Word of Caution

The “one‐and‐a‐half ventricle repair” (1.5 VR) is applied to several congenital heart diseases with hypoplastic right ventricle (RV), with good functional and clinical results in infants and children, but feasibility in adult population is being explored.

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