Thomas Syburra

Fatal outcome of recombinant factor VIIa in heart transplantation with extracorporeal membrane oxygenation.

Recombinant activated factor VII (rFVIIa) has been approved for treatment of bleeding episodes in patients with hemophilia and in nonhemophilia patients with acquired antibodies against factor VIII or IX. The application of rFVIIa in nonapproved settings, as in cardiac surgery, has not been established. It raises concerns regarding its safety. We used rFVIIa in a patient with excessive nonsurgical bleeding on extracorporeal membrane oxygenation, which was established for early graft failure after heart transplantation and after 3 months of biventricular assist device support. After rFVIIa administration, cardiac thrombosis developed and caused the patients death.

Gold-coated pacemaker implantation after allergic reactions to pacemaker compounds

An 86-year-old man underwent pacemaker implantation for symptomatic atrio-ventricular block grade 2 Mobitz II. The patient suffered repeated admissions for iterative sterile wound necrosis, leading to two generator re-implantations. No bacterial infection was detected in the microbiological screening tests. The skin patch testing to titanium was negative. Nevertheless, we decided to remove the pacemaker system and to implant a gold-plated generator with polyurethane leads. Since then, there has been no recurrence of wound complications. Gold-plated generator and polyurethane leads are effective in treating allergic reactions to pacemaker system components in selected cases. Negative skin patch testing to titanium does not exclude allergic reaction to this pacemaker component.

Mitral valve surgery in severe congenital factor VII deficiency

Abstract The estimated incidence of congenital factor VII deficiency is 1:500 000. Severe FVII deficiency is associated with spontaneous bleeding such as intraarticular or intracranial haemorrhage. The risk of perioperative bleeding is high during cardiac surgery as a result of the exposure to extracorporeal circulation, systemic anticoagulation, loss of coagulation factors, and postoperative platelet malfunction. Effective treatment of pre-existing coagulopathy is crucial, as increased morbidity and mortality are associated with allogenic blood transfusions. We report a 67-year-old Caucasian male patient with severe congenital FVII deficiency, undergoing successful and uneventful elective mitral valve repair surgery, radiofrequency epicardial atrial fibrillation ablation, and exclusion of the left atrial appendage. He presented with severe symptomatic mitral valve regurgitation, moderate pulmonary artery hypertension, and paroxysmal atrial fibrillation; his left ventricular ejection fraction was 67%. Three years before surgery, during a routine assessment of a grade I renal failure, a spontaneous International Normalised Ratio of 4.1 was observed. He had no history of previous spontaneous bleeding. The diagnosis of a severe FVII deficiency, with an FVII activity below 2% (normal references values in City Hospital Triemli Zurich: 55–170%) was made.

Oxidized regenerated cellulose in cardiac computer tomography imaging

Oxidized regenerated cellulose is widely used as a bioabsorbable topical hemostatic agent. Postoperative visualization of this material through routine chest imaging, such as conventional radiography, computer tomography (CT), magnetic resonance imaging as well as sonography, may prove difficult and, to our knowledge, is not described in the literature. We describe a case where the mediastinal packing with Surgicel™ Nu-Knit™ after a mitral valve repair procedure led to a delayed obstruction of the superior vena cava, necessitating a re-thoracotomy and curettage of the hemostatic material. The hemostatic agent was not prospectively interpreted as the cause of a severe upper inflow restriction, despite repeated imaging. Retrospectively, the hemostatic material as a cause of the upper inflow obstruction could have been identified earlier if its presence would have been known to the radiologist. We strongly recommend that the surgeon inform the radiologist that such materials were used to improve the diagnostic yield of CT interpretation.

Pacemaker lead laceration due to clavicular compression plate screw migration.

Laceration of pacemaker leads as a late complication after clavicular osteosynthesis is rare; however, the consequences can be fatal. We present the case of a 61-year-old gentleman with a history of right clavicular osteosynthesis using a compression plate, who 20 years later received a right pectoral dual-chamber pacemaker. Twenty months after pacemaker implantation, a screw tip migration from the osteosynthesis caused laceration and dysfunction of the atrial lead. The osteosynthesis material was completely removed and atrial lead replaced. This case demonstrates that pacemaker systems in these rare patients should be placed on the contralateral side.

Avoidance of aortic side-clamping for proximal bypass anastomoses: better short-term outcome?

OBJECTIVES The benefit of off-pump coronary artery bypass (OPCAB) surgery may be reduced by strokes caused by microemboli produced after aortic side-clamping for proximal bypass anastomoses. The Heartstring device allows constructing proximal bypass anastomoses without side-clamping of the aorta. METHODS This retrospective study describes 260 consecutive patients who underwent OPCAB surgery; 442 proximal anastomoses were performed with the Heartstring device in this series. Ten percent of the patients were randomly sampled before discharge to undergo a coronary angiogram for assessment of graft patency. RESULTS Intraoperative Doppler measurements confirmed regular bypass function. Early mortality occurred in 4 patients (1.5%), and stroke occurred in 2 patients (0.8%). Device-related bleeding was negligible, and there were no cases of aortic dissection. Perioperative ischemia occurred in 8 patients (3.1%). Predischarge coronary angiography evaluations in 25 of the patients (of 260) showed that all 42 Heartstring-assisted anastomoses (of 442) were patent. CONCLUSIONS Clampless performance of proximal bypass anastomoses combined with OPCAB is associated with a very low incidence of stroke complications. Short-term follow-up has shown excellent results regarding bypass patency and other adverse events. Prospective randomized trials are required to confirm the advantage of this technique.

Aortic posterior wall perforation with automatic aortic cutter during routine off-pump coronary bypass grafting

Aortic complications are very rare during off-pump coronary artery bypass grafting (OPCAB). When they occur, the mortality is high. We report a case of perforation of the posterior aortic wall after punching out the hole in the ascending aorta with an automatic aortic cutter to avoid clamping for the proximal anastomosis during a routine OPCAB procedure. The consequence was a massive hemorrhage, emergency conversion to cardiopulmonary bypass and replacement of the aortic valve and of the ascending aorta.

Motion sickness in pilot trainees: management to keep them flying.

INTRODUCTION Motion sickness is a recurrent problem in pilot schools. Many techniques to overcome motion sickness are used worldwide, mostly including sedative medication and psychotherapy. Motion sickness does not correlate with future pilot skills: it should not be a criterion for selection of candidates. The problem must be controlled from the onset in an objective way. In the Swiss Air Force selection program, time compression does not allow any delay between the selection flights, nor can drugs be used. METHODS We created an after-flight motion sickness checklist. We present a descriptive statistic for motion sickness assessed with our checklist in 2 consecutive years of pilot selection and our recommendations for a management policy without drug use and without interference with the selection schedule. RESULTS Due to the small number of observations, no statistically significant correlations could be verified. Nevertheless, we had no drop out from selection due to motion sickness. DISCUSSION The use of the after-flight motion sickness checklist seems to be effective. Further studies with a greater number of observations are required.

Retracted: right anterior minithoracotomy for minimal access aortic valve replacement.

Background: Controversy surrounds the safety of the use of minimal access aortic valve replacement (AVR). Most studies report on partial sternotomy as the preferred approach. Here we report our experience with a homogenous series of patients undergoing AVR through a right minithoracotomy (MAVR). Methods: Preoperative 64-multislice computer-tomography (64-MSCT) was done to optimize the approach in MAVR patients. One hundred and sixteen patients underwent MAVR by a standardized technique. Results: Guided by 64-MSCT, the second intercostal space was entered in 16 and the third in 100 patients. Anatomical contraindications to this technique were further defined by 64-MSCT: distance from intercostal space to aortic valve ≥12 cm and to aortic cannulation site ≥10 cm, aortic annulus diameter ≤19 mm, distance of the aortic valve annulus to the right coronary ostium ≤12 mm, and to the left coronary ostium ≤8 mm. Despite the prolonged operative, cardiopulmonary bypass and cross-clamp times, early mortality, and morbidity (perioperative myocardial infarction, stroke, reexploration for bleeding) in our patients compared favorably with those reports comparing minimal access and sternotomy approaches. Similarly, patient outcomes (mechanical ventilation time, intensive care stay, transfusion requirements, incidences of new-onset atrial fibrillation and deep wound infection, and need for major pain medication) consistently compared to the results reported by a meta-analysis of reports comparing minimal access and sternotomy techniques. Conclusions: Right anterior minithoracotomy is safe for isolated aortic valve replacement. Preoperative 64MSCT allows a better planning and definition of contraindications to this approach. This is a valuable technique in selected patients for isolated aortic valve replacement. doi: 10.1111/j.1540-8191.2009.00862.x (J Card Surg ****;**:**-**) In view of the growing risk profile of cardiac surgical patients, operative techniques aimed at reduction of the operative burden could potentially help in maintaining the good results obtained with standard approaches. For patients undergoing isolated myocardial revascularization, off-pump coronary artery bypass grafting is a technical option to achieve this goal.1 For patients needing valve procedures, in particular Address for correspondence: Reza Tavakoli, M.D., Ph.D., Department of Cardiac Surgery, Canton Hospital Lucerne, 6000 Lucerne 16, Switzerland. Fax: +41-41-205 45 63; e-mail: reza.tavakoli@ksl.ch aortic valve replacement (AVR), minimal access aortic valve replacement (MAVR) has been developed in order to lower surgical trauma and hence to maintain excellent results obtained through median sternotomy approach.2,3 Since its introduction, MAVR has been adopted by many centers as an alternative to conventional surgery.4 However, almost all these centers perform the MAVR through a ministernotomy or a right parasternal approach.4 Here, we report our experience in a group of patients undergoing AVR with a standardized right minithorcotomy approach5 guided by preoperative 64-multislice computer tomography (64-MSCT). RE TR AC TE D ii WEBER, ET AL. MINITHORACOTOMY AORTIC VALVE REPLACEMENT J CARD SURG ****;**:**-** TABLE 1 Exclusion Criteria for MAVR Chest deformities Previous right hemithorax surgery or irradiation Combined valve and bypass surgery Aneurysm of the ascending aorta METHODS AND PATIENTS All patients underwent routine preoperative assessment including complete blood analysis, electrocardiogram, chest X-ray, lung function test, echocardiography, and coronary angiography for patients older than 45 years. Moreover, a 64-MSCT was performed in preparation for MAVR in patients eligible (Table 1) for this procedure.