P Schurr

Vacuum-assisted wound closure is superior to primary rewiring in patients with deep sternal wound infection.

OBJECTIVE Deep sternal wound infections are serious complications after cardiac surgery. The aim of the present study is to compare the outcome after vacuum-assisted wound closure to that after primary rewiring with disinfectant irrigation. The study additionally focuses on defining predictors for the failure of primary rewiring and its impact on postoperative outcome. METHODS Retrospective analysis was performed in 5232 patients who underwent cardiac surgery with a median sternotomy. 192 patients postoperatively developed deep sternal wound infections and were distributed into 2 therapy groups: a vacuum-assisted wound closure (= VAC) group and a primary rewiring (= RW) group, which was subdivided into healing after rewiring (= RW-h) and failure of rewiring (= RW-f). These groups were compared statistically to reveal coincidental pre-, intra- and postoperative parameters. RESULTS Compared to the VAC group, the RW group showed a poorer outcome, although RW baseline characteristics were apparently beneficial. Primary rewiring failed in 45.8 % of all cases, which led to even worse outcomes. Important predictors for failure of primary rewiring were morbid obesity, diabetes mellitus type II, chronic obstructive pulmonary disease, preoperatively impaired left ventricular function, postoperatively positive blood and wound cultures, bilateral harvesting of internal thoracic arteries and the need for surgical reexploration. CONCLUSIONS In spite of patients being in a worse condition, vacuum-assisted wound closure therapy resulted in improved outcomes and thus should be preferred to primary rewiring. Moreover we report on predictors which may indicate whether there is a high risk of rewiring failure.

Early reintubation after cardiac operations: impact of nasal continuous positive airway pressure (nCPAP) and noninvasive positive pressure ventilation (NPPV).

BACKGROUND Due to an increasing number of comorbidities there is still a significant incidence of respiratory failure after primary postoperative extubation in patients who undergo cardiosurgery. We wanted to study whether nCPAP could improve pulmonary oxygen transfer and avoid the necessity for reintubation after cardiac surgery. Additionally, we compared this protocol to noninvasive positive pressure ventilation (NPPV). PATIENTS AND METHODS Over a period of 3 years we analyzed all patients who were extubated within 12 hours after cardiac surgery, and in whom pulmonary oxygen transfer (PaO₂/FIO₂) deteriorated without hypercapnia so that all these patients met predefined criteria for reintubation. There were three groups of patients: A = patients required immediate reintubation (n = 125); B = patients had nCPAP with intermittent mask CPAP (n = 264); and C = patients had NPPV (n = 36). RESULTS 25.8 % of patients in Group B and 22.2 % of patients in Group C were also intubated after a period of CPAP or NPPV. All other patients of Groups B and C could be weaned from these devices (B: 33.4 ± 5.8 hours, C: 26.2 ± 4.2 h; P < 0.05) and were well oxygenated using a face mask at ambient pressures (PaO₂/FIO₂: B: 136 ± 12, C: 141 ± 12). In Group A, we found a higher mortality (8.8 %) than in Group B (4.2 %) and Group C (5.6 %). The ICU stay and in-hospital stay were significantly prolonged in Group A. The incidence of pulmonary infections (A: 24 %, B: 10.6 %, C: 13.8 %; P < 0.05) and the need for catecholamines were significantly increased in Group A, whereas nCPAP patients suffered significantly more often from impaired sternal wound healing (A: 4.8 %, B: 8.3 %; P < 0.05). CONCLUSIONS We conclude that reintubation after cardiac operations should be avoided since nCPAP and NPPV are safe and effectively improve arterial oxygenation in the majority of patients with nonhypercapnic oxygenation failure. However, it is of great importance to pay special care to sternal wound complications in these patients.

Heparin-induced thrombocytopenia type II after cardiac surgery: predictors and outcome.

BACKGROUND Heparin-induced thrombocytopenia (HIT) is a serious complication after cardiac surgery. The aim of the present study was to identify pre- and intraoperative predictors for the postoperative occurrence of HIT. The study additionally focused on the impact of HIT on postoperative outcome. METHODS Retrospective analysis was performed for 5073 patients who had required extracorporeal circulation during cardiac surgery. Patients were divided into 3 groups: 1) patients who had postoperative HIT (HIT+); 2) patients with postoperative thrombocytopenia but without HIT (HIT-); and 3) patients with normal platelet count (C). The groups were statistically compared with regard to pre-, intra- and postoperative parameters. RESULTS Statistically significant predictors were renal insufficiency, intravenous application of heparin for more than 3 days, previous percutaneous coronary intervention within the last 4 weeks, urgency/emergency operation, combined surgery, prolonged extracorporeal circulation or cross-clamping time, and low cardiac output syndrome. Postoperative HIT was associated with an enhanced risk of renal failure, infectious and thromboembolic complications and in-hospital mortality. CONCLUSION Postoperative HIT increases morbidity and mortality. The predictors presented in this study can be used to identify patients at risk of developing HIT.

Impact of mitral valve repair in patients with mitral regurgitation undergoing coronary artery bypass grafting.

Background — The benefit of concomitant mitral valve correction (replacement or reconstruction, MVR) and coronary artery bypass grafting (CABG) in patients with coronary artery disease and mitral regurgitation (MR) remains unclear.Patients and methods — 298 consecutive patients underwent CABG alone (n = 196) or CABG+ MVR (n = 102) between January 2003 and April 2008. Clinical data were collected and MR graded according to preoperative echocardiographic studies. Four severity grades of MR were determined and patients assigned accordingly. Echocardiographic follow-up was performed postoperatively to assess heart and valve function. Multivariate logistic regression analysis was performed for perioperative morbidity and mortality.Results — Patients were comparable within the groups regarding age, gender, NYHA-class, ejection fraction and number of graft vessels. Perioperative mortality (10.8% vs.5.1%, P < 0.05) and degree of MR were higher among CABG+MVR patients. Among patients with moderate to severe or sev...

Rescue operation after ascending thoracic endovascular aortic repair in a patient with thrombosis of the left main coronary ostium

Transfemoral stent graft implantation in the ascending aorta has been performed in patients with aortic abnormalities and particularly in the case of an existing symptomatic thrombus. We report on a 68-year old male patient who presented to our clinic with angina-pectoris-like chest pain after having been treated with an aortic stent graft. A computed tomography scan revealed a thrombus in the left main stem that could be successfully removed. The aortic stent graft was removed and the supracoronary ascending aorta replaced.

Role of primary bacterial contamination of a pulmonary homograft for Ross operation: report of a case and review of the literature.

In a 43-year-old female, Ross operation was performed with annular reinforcement of the autograft and a cryo-fixed homograft that proved to be contaminated with enterobacter cloacae and klebsiella pneumoniae at the time of operation. Clinical course was unremarkable, perhaps due to effective antibiotic prophylaxis and treatment. In the literature, little is known about intraoperative bacterial contamination and early endocarditis. The authors report what they believe is the second reported case. Particular resistibilities of homograft and autograft might make early endocarditis unlikely.

Mechanische Herz-Kreislauf-Unterstützung mittels intraaortaler Ballongegenpulsation

ZusammenfassungIn der kardiovaskulären Medizin und insbesondere im Rahmen der invasiven Behandlung der koronaren Herzkrankheit stellt die intraaortale Ballongegenpulsation (IABP) ein vielfach bewährtes Verfahren dar, welches auch heute im Zeitalter der mechanischen Herz-Kreislauf-Unterstützung noch immer eine wichtige Rolle im klinischen Alltag spielt. Sie kommt hierbei sowohl periinterventionell im Herzkatheterlabor als auch perioperativ im Rahmen einer chirurgischen Revaskularisation zunehmend zum Einsatz. Die Ballonpumpe unterstützt invasiv die Hämodynamik des Patienten durch eine Steigerung von diastolischer Perfusion und diastolischem Blutdruck. Diese Mechanismen bewirken eine Verbesserung der Koronarperfusion während der Diastole und eine Reduzierung der Nachlast des Herzens. Die Wirksamkeit der IABP konnte in einer Vielzahl klinischer Situationen bewiesen werden. Als klassische Indikationen gelten: akutes Koronarsyndrom, sog. High-risk-Koronarinterventionen im Rahmen einer Herzkatheteruntersuchung, kardiogener Schock und der gesamte perioperative Bereich innerhalb der Herzchirurgie. Die möglichen Komplikationen der intraaortalen Gegenpulsation können durchaus schwerwiegend sein, obwohl sie in ihrer Inzidenz deutlich abgenommen haben. Bei sorgfältiger Patientenselektion und Implantationstechnik stellt die IABP eine effektive Therapieoption in der Behandlung von Patienten mit kardiovaskulären Erkrankungen dar. Die folgende Arbeit fasst die hämodynamischen Veränderungen, Indikationen, Komplikationen und Ergebnisse bei der Verwendung der IABP zusammen.AbstractIn cardiovascular medicine and coronary intervention, the intraaortic balloon pump (IABP) is a proven technology that plays an important role in circulatory support. The balloon pump invasively supports patient hemodynamics by augmenting diastolic perfusion and increasing diastolic blood pressure, thereby increasing coronary perfusion and reducing afterload. Its efficacy has been demonstrated in a multitude of clinical situations, including acute coronary syndromes, high-risk coronary interventions, cardiogenic shock, and cardiovascular surgery. The potential complications of aortic counterpulsation are serious, although much lower than in former times. With proper patient selection, insertion technique, and management, the IABP is a powerful device to assist in the treatment of patients with cardiovascular disease. Hemodynamics, indications, complications, and results associated with IABP use are reviewed.