Sven M. Almdahl

Mediastinitis After Coronary Artery Bypass Grafting Risk Factors and Long-Term Survival

BACKGROUND Mediastinitis is a severe complication of coronary artery bypass grafting. The aim of the present study was to determine incidence of mediastinitis, its risk factors, and its effect on early and long-term survival. METHODS The study has a dual design, a case-control, and a retrospective cohort, using a source population of 18,532 consecutive patients who underwent coronary artery bypass grafting from January 1989 to December 2000. The closing date was February 1, 2008. Median follow-up was 10.3 (range 8.1 to 18.9) years. Patients with mediastinitis were compared with a random control group without mediastinitis issued from the same source population in a ratio 1:4. The crude effect of mediastinitis was estimated using rate ratio and 95% confidence limits. Adjustment for multiconfounders was done with the Cox model. A logistic model was used to pinpoint risk factors of mediastinitis. Calibration and discrimination of a prognostic model was done. RESULTS One hundred seven patients (0.6%) developed mediastinitis. Diagnosis was made 12 (9 to 19) days postoperatively. Independent risk factors of mediastinitis using the logistic model were advanced age, male gender, left main stenosis, body mass index 30 kg/m(2) or greater, chronic obstructive pulmonary disease, diabetes, and increased amount of blood transfusion. There was no increased risk of early mortality (odds ratio = 0.58; 95% confidence interval 0.13 to 2.61) (p = 0.48) but there was increased risk of morbidity (intraaortic balloon pump, ventricular and supraventricular arrhythmia, stroke, inotrope, and myocardial infarction). Follow-up had a median observation time of 10.3 years. Survival for patients with mediastinitis was 49.5 +/- 5.0% versus 71.0 +/- 2.2% for controls (p < 0.01). Analysis of specific death causes documented that cardiac deaths were significantly more frequent in mediastinitis patients than in control patients. When controlling for the confounding effect of the other variables (age, cardiopulmonary bypass time, body mass index, chronic obstructive pulmonary disease), the hazard ratio associated with mediastinitis on long-term mortality was 1.59, 95% confidence limits (1.16 and 2.70) (p = 0.003). CONCLUSIONS The incidence of mediastinitis in 18,532 patients undergoing coronary artery bypass grafting surgery was low. The major preventable risk factor of mediastinitis was amount of blood transfusion. Mediastinitis had an excess risk of early morbidity and was associated with a significant reduced long-term survival. Most deaths were considered to be cardiac.

The effect of dexamethasone on side effects after coronary revascularization procedures.

Corticosteroids decrease side effects after noncardiac elective surgery. We designed this randomized, double-blinded, placebo-controlled study to test the hypothesis that standard doses of dexamethasone (4 mg ×2) would reduce postoperative nausea, vomiting, and pain, decrease the incidence of atrial fibrillation (AF), and improve appetite after cardiac surgery, thereby facilitating the recovery process. A total of 300 patients undergoing coronary revascularization surgery were enrolled in this clinical study. The anesthetic management was standardized in all patients. Dexamethasone (4 mg/mL) or saline (1 mL) was administered after the induction of anesthesia and a second dose of the same study drug was given on the morning after surgery. The incidence of AF was determined by analyzing the first 72 h of continuously recorded electrocardiogram records after cardiac surgery. The patients were assessed at 24- and 48-h intervals after surgery, as well as at the time of hospital discharge, to determine the incidence and severity of postoperative side effects (e.g., nausea, vomiting, pain) and patient satisfaction scores. Dexamethasone significantly reduced the need for antiemetic rescue medication on the first postoperative day (30% versus 42%), and the incidences of nausea (15% versus 26%) and vomiting (5% versus 16%) on the second postoperative day (P < 0.05). In addition, dexamethasone significantly reduced the percentage of patients with a depressed appetite on the second postoperative day. However, the corticosteroid failed to decrease the incidence of AF (27% versus 32%) or the total dosage of opioid analgesic medication administered in the postoperative period. We conclude that dexamethasone (8 mg in divided doses) was beneficial in reducing emetic symptoms and improving appetite after cardiac surgery. However, this dose of the corticosteroid does not seem to have antiarrhythmic or analgesic-sparing properties. IMPLICATIONS: Dexamethasone (8 mg IV) was beneficial in reducing emetic symptoms and increasing appetite after cardiac surgery. However, this dose of the corticosteroid failed to decrease postoperative pain or the incidence of new-onset atrial fibrillation.

Increased levels of serum pentraxin 3, a novel cardiovascular biomarker, in patients with inflammatory rheumatic disease.

Pentraxin 3 (PTX3), a key component of innate immunity, is a strong marker of disease severity in coronary artery disease (CAD). The aim of this study was to compare levels of serum PTX3 in CAD patients with and without inflammatory rheumatic disease (IRD) and in healthy controls.

Multiply Beta-lactam Resistant Enterobacter cloacae Infections Linked to the Environmental Flora in a Unit for Cardiothoracic and Vascular Surgery

During the period March 1987-May 1988, postoperative infection or colonization with Enterobacter cloacae occurred in 9/379 (2.4%) patients who underwent cardiovascular surgery. Five of the patients were infected with multiply beta-lactam resistant E. cloacae, of whom 4 had been infected with an identical, resistant strain during intervals of months. This strain was also found in the environmental flora of the cardiovascular operating suite and in a sink reservoir in the surgery department. All 4 patients with the identical resistant strain had serious complications during the postoperative period with symptoms of septicaemia in 3, multiorgan failure and shock in 2, and mediastinitis in 3. The single resistant strain of a different serotype was also associated with severe postoperative complications. The 4 sensitive strains were all different serotypes. None caused septicaemia, one was associated with mediastinitis, another with an uncomplicated sternum infection, and 2 were from sputum. In the 3 latter patients with sensitive strains and few postoperative complications, cephalosporins had not been used during the pre- or postoperative period.

Randomized prospective trial of saphenous vein harvest site infection after wound closure with and without topical application of autologous platelet-rich plasma.

OBJECTIVE Wound infection is still a common problem after open long saphenous vein harvesting. Platelets are important for the healing process. The hypothesis was that spraying of the wounds with platelet-rich plasma might reduce the frequency of harvest site infections. METHODS From January to October 2008, 140 patients undergoing first-time coronary artery bypass grafting were randomized into two groups of 70 patients. Both groups had standard surgical leg wound closure and care except topical application of platelet-rich plasma as adjunctive treatment in the active treatment group. End points were wound infection and cosmetic result at 6 weeks. RESULTS The follow-up was 100% complete. Nine patients (13%) in the treatment group and eight (11%) in the control group experienced harvest site infection (p=0.80). The overall cosmetic result was also similar between the groups (p=0.34), but the top score was borderline and more frequent in the treatment group (p=0.050). CONCLUSION Topical application of autologous platelet-rich plasma on vein harvest wounds did not reduce the rate of surgical site infection.

Inflammatory markers in patients with coronary artery disease with and without inflammatory rheumatic disease

OBJECTIVES Patients with inflammatory rheumatic diseases (IRDs) have a higher morbidity and mortality from accelerated atherosclerosis than the general population. We hypothesized that patients with the combination of IRD and coronary artery disease (CAD) would have a certain inflammatory phenotype compared with CAD patients without this comorbidity. METHODS Four groups of patients were included: patients with IRD, referred to coronary artery bypass grafting (CABG) (CAD-IRD, n = 67), patients without IRD, referred to CABG (CAD, n = 52), patients with IRD without CAD (IRD, n = 32) and healthy controls (n = 30). Plasma levels of several inflammatory markers were analysed by enzyme immunoassays. RESULTS (i) Plasma levels of markers of endothelial cell activation [i.e. vascular cell adhesion molecule-1 (VCAM-1) and von Willebrand factor] and osteoprotegerin (OPG) were significantly increased and plasma levels of CCL21 significantly decreased in CAD-IRD patients as compared with CAD patients without IRD. (ii) Within the CAD-IRD group, acute coronary syndrome was a significant predictor of OPG, suggesting an enhanced inflammatory response during plaque destabilization in CAD-IRD patients. (iii) Plasma levels of VCAM-1, OPG and CCL21, but not lipid parameters, IRD characteristics and several other inflammatory markers (e.g. CRP), were significant predictors of CAD-IRD as opposed to CAD in two logistic regression models. CONCLUSION Our findings further support a role for inflammation in the accelerated form of atherosclerosis in IRD patients, and suggest that certain inflammatory pathways, such as the enhanced endothelial cell activation and the RANK ligand/RANK/OPG system, may be of particular importance.

Perioperative cardiac function and predictors for adverse events after transmyocardial laser treatment

BACKGROUND Previous studies have reported that mortality and morbidity after transmyocardial laser treatment (TML) mainly occur perioperatively. The present study was designed to evaluate left-ventricular function and identify risk factors for cardiac-related adverse events in this phase. METHODS Forty-nine patients were studied. The inclusion criteria were angina pectoris Canadian Cardiovascular Society Angina Score (CCSAS) class III and IV refractory to medical therapy and untreatable by coronary artery bypass graft or percutaneous transluminal coronary angioplasty, age less than 75 years, left ventricular ejection fraction greater than or equal to 30%, and myocardial regions with reversible ischemia. Hemodynamic data and cardiac adverse events were registered. The follow-up time was 30 days. RESULTS A transient decrease in mean cardiac index (CI) was observed, reaching its minimum immediately after end of the surgical procedure (1.8+/-0.4, p<0.01 vs. baseline). Two patients (4%) died during the postoperative period (30 days). Seventeen patients (35%) experienced adverse cardiac-related events, where CCSAS class IV, unprotected left main stem stenosis, and diabetes mellitus were identified as risk factors in a multivariate analysis. CONCLUSIONS A transient impairment of left ventricular function was observed after TML. The morbidity and mortality after TML were almost exclusively cardiac-related, identifying CCSAS class IV, unprotected left main stem stenosis, and diabetes as risk factors.

Pentraxin 3, a novel cardiovascular biomarker, is expressed in aortic specimens of patients with coronary artery disease with and without rheumatoid arthritis.

BACKGROUND The aims were to evaluate the presence and extent of pentraxin 3 depositions in specimens from the outer layers of the aorta and from the internal thoracic artery of patients with coronary artery disease with and without rheumatoid arthritis and to search for relationships between pentraxin 3 and vascular inflammation. METHODS Using histochemistry and immunohistochemistry, we examined biopsies from the aortic adventitia and from the internal thoracic artery (both with adjacent perivascular tissue), removed during coronary artery bypass grafting in 19 rheumatoid arthritis and 20 non-rheumatoid-arthritis patients, for presence/extent of pentraxin 3 depositions, inflammatory cell infiltrates, and fibrosis. RESULTS In the aorta, pentraxin 3 deposition occurred in all specimens, mostly at sites with inflammatory cell infiltrates or fibrosis, and their extent was related to the extent of inflammatory cell infiltrates (rho=0.43, 95% confidence interval: 0.13-0.66, P=.007). The extent of pentraxin 3 and inflammatory cell infiltrates in the aorta was similar in rheumatoid arthritis and non-rheumatoid-arthritis patients, but rheumatoid arthritis patients had more fibrosis and a lower proportion of T-cells in inflammatory cell infiltrates. In the internal thoracic artery, pentraxin 3 occurred only in 36% patients, and inflammatory cell infiltrates and fibrosis occurred in none. CONCLUSIONS Pentraxin 3 depositions in the outer aortic layers are common and are related to the local inflammation. On the other hand, they occur less frequently in the internal thoracic artery, i.e., a vessel highly resistant to atherosclerosis. Rheumatoid arthritis patients had more pronounced fibrosis in the aortic specimens and a different leukocytic response than non-rheumatoid-arthritis patients. In theory, pentraxin 3 might modulate the inflammatory process involved in the pathogenesis of cardiovascular disease and represent a target for new therapies.

Postinfarction Rupture of Left Ventricular Free Wall Repaired With a Glued-on Pericardial Patch

In a 68-year-old man admitted in deep shock, prompt echocardiographic diagnosis of postinfarction left ventricular free wall rupture was followed by probably life-saving pericardiocentesis. At emergency surgery a 2 cm linear tear in the anterolateral wall of the left ventricle was successfully repaired with a glued-on pericardial patch, without infarctectomy or placement of sutures in the infarcted area.

Rheumatoid arthritis patients have a pro‐atherogenic cytokine microenvironment in the aortic adventitia

Patients with rheumatoid arthritis (RA) are at increased risk of developing cardiovascular disease (CVD) via mechanisms that have not yet been defined. Inflammatory pathways, in particular within the vascular adventitia, are implicated in the pathogenesis of primary CVD but could be amplified in RA at the local tissue level. The aim of this study was to examine the aortic adventitia of coronary artery disease (CAD) patients with or without RA to determine the cytokine profile contained therein.