Thomas Claus

The use of Tachosil surgical patch or fibrin glue in coronary artery surgery does not affect quality of anastomosis or provoke postoperative adhesions in pigs.

OBJECTIVE Fibrin glue products and collagen surgical patches (TachoSil) coated with coagulation factors I and IIa are increasingly being used to prevent oozing from distal or proximal coronary anastomosis. Furthermore, an increasing number of patients are being operated upon anti-platelet therapy. These patients often exhibit diffuse bleeding. Especially in an off-pump scenario surgeons refrain from placing additional stitches in order to avoid an impairment of the graft. In these situations, a biological glue can help resolve this dilemma. It is, however, assumed that these products may exert negative effects on the anastomosis. For obvious reasons a systematic histological assessment in humans is impossible. Therefore, a chronic, large animal model was developed to study the fate of these products on a coronary anastomosis. METHODS In 15 pigs receiving off-pump coronary artery bypass graft of the left mammary artery to the left anterior descending coronary artery, three groups were defined. Group A served as control. In group B the anastomosis was covered with 1 ml fibrin glue; in group C TachoSil coverage was performed. Bypass flow (BF) was measured using a Doppler probe. After 3 months the pigs were sacrificed and the anastomoses were evaluated macroscopically and by means of light microscopy regarding patency and fibrosis. RESULTS In group A, all five animals survived, three of the five anastomoses were patent and the mean BF was 26 ml min(-1). In group B, three of the five animals survived, all anastomoses were patent. The BF was 21 ml min(-1). In group C, all five animals survived, four of the five anastomoses were patent and BF was 21 ml min(-1). Macroscopic and histological evaluation showed no differences between the groups. Remnants of Tachosil or fibrin glue were not observed. CONCLUSIONS In the chronic course, no evidence of adverse effects of TachoSil or fibrin glue was noted. Both agents can therefore be used safely in clinical practice for haemostyptic or positioning purposes.

Surgeon performance index: tool for assessment of individual surgical quality in total quality management

BACKGROUND The surgeons individual performance is a key component of total quality management (TQM) in cardiac surgery. Early mortality as well as postoperative complications can be stratified in order to develop a surgeon performance index (SPI). MATERIAL AND METHODS In three consecutive annual periods (3703 patients) data of board-certified cardiac surgeons were compared. Risk-adjustment of early mortality and postoperative complications was performed by logistical EuroSCORE (logES). Early mortality (EM), early rethoracotomy for bleeding (ReTh), sternal rewiring for instability (ReWr), and mediastinitis (Med) were assessed. ReTh, ReWr, and Med were weighted according to empiric data: (ReThx2; ReWrx1; Medx3). Surgeon performance index was computed as follows: SPI=(EM/logES+[((ReTh/logES)x2)+((ReWr/logES)x1)+((Med/logES)x3)]/6)/2. Ideal SPI was considered <or=1. SPI of the respective previous period was handed out to each surgeon and discussed by means of a structured dialogue. RESULTS Patients from each period were allocated to 11 cardiac surgeons. Overall logES of the three periods were 6.6%, 9.1%, and 11.2% respectively; EM 5.7%, 6.6%, 5.6%; ReTh 5.8%, 7.3%, 10.9%; ReWr 2.4%, 1.9%, 1.4%; and Med 0.9%, 1.8%, 1.8%. SPI showed a mean of 0.71, 0.56, and 0.49. CONCLUSION Comorbidity increased between periods 1 and 3 significantly whereas early mortality remained rather stable. SPI indicated improvement of the performance of the individual surgeon and a decrease of range and mean of the overall performance. SPI is therefore an effective tool to assess individual surgical quality and serves as an instrument for human resource management and development. Sustainable positive effects on overall performance can be expected.

How Do Transcatheter Heart Valves Fit in Mitral Annuloplasty Rings and Which Combination Can be Recommended

BACKGROUND  Transcatheter heart valve (THV) as valve-in-ring is increasingly used in the mitral position. Semi-rigid rings may serve as a more appropriate scaffold for proper anchoring of a THV as they may change from their oval to a round shape thereby fitting to the implanted THV. METHODS  One rigid and five semi-rigid rings of four manufacturers, Edwards Physio I and II, Sorin 3D Memo, Medtronic Simulus, and St. Jude Medical (SJM) Saddle and SJM Sequin, with sizes 28 to 36 mm and Edwards Sapien III THV 23, 26, and 29 mm were used. Preevaluation comprised insertion/inflation of the THV into the ring and visual inspection for the paravalvular gap ≥ 4 mm2. Only valves not showing paravalvular gap were then submitted to hemodynamic evaluation with a pulse duplicator. Cusp movement was assessed with a high-speed-camera. Mean transvalvular gradients (TVGs) were measured. RESULTS  SJM Saddle ring of all sizes and SJM Sequin ring 34 showed marked gaps combined with all THV sizes, thus not undergoing hemodynamic testing. It was further shown that ring sizes ≥ 36 mm did not allow for a proper fit of even the largest THV into the ring of all the manufacturers and were consequently not hemodynamically evaluated. The 23 mm THV was too small for any ring size. The lowest gradients were achieved with the 26 mm THV in 30 and 32 mm and the 29 mm THV in 32 and 34 mm rings. CONCLUSION  Not all currently available annuloplasty rings are ideal scaffolds for THV placement. It appears that a more proper fit can be achieved with semi-rigid rings than with rigid ones. Note that 23 mm THV appeared to be too small for an adequate anchoring in even the smallest available ring. Thus, 26 mm as well as 29 mm THV fit properly in ring sizes between 28 and 34 mm. Surgeons may consider to choose from those ring brands and sizes which allow for good placement of a THV in view of possible valve degeneration in the later course.

Double-Wire versus Single-Wire Sternal Closure in Obese Patients: a Randomized Prospective Study

Background Sternal instability after coronary artery bypass grafting (CABG) is a serious complication. Obese patients are at high risk for sternal instability after CABG. This study was conducted to assess the positive impact of double‐wire sternal closure on sternal instability. Methods A total of 200 obese patients with a body mass index ≥ 30 kg/m2 undergoing isolated CABG with left internal mammary artery (LIMA) graft were randomly assigned to sternal closure either by eight single wires (n = 100) or by a combination of four double wires and four single wires. Results There was a total of 21 cases with sternal instability: 5 cases (i.e., 5%) in the double‐wire group versus 16 cases (16%) in the single‐wire group (p = 0.019). Logistic regression analysis showed sternal closure via double wires as an independent protection factor (odds ratio [OR]: 0.276; p = 0.029). Smoking (OR: 5.5; p = 0.006) and postoperative delirium (OR: 3.5; p = 0.033) turned out to be independent risk factors for the development of sternal instability. Conclusion Double‐wire sternal closure significantly reduces postoperative sternal instability in obese patients undergoing isolated CABG with LIMA graft.