Vasilios Grosomanidis

Treatment of Infected Thoracic Aortic Prosthetic Grafts with the In Situ Preservation Strategy: A Review of its History, Surgical Technique, and Results

For cardiothoracic surgeons prosthetic graft infection still represents a difficult diagnostic and treatment problem to manage. An aggressive surgical strategy involving removal and in situ replacement of all the prosthetic material combined with extensive removal of the surrounding mediastinal tissue remains technically challenging in any case. Mortality and morbidity rates following such a major and risky surgical procedure are high due to the nature of the aggressive surgical approach and multi-organ failure typically caused by sepsis. However, removal of the infected prosthetic graft in patients who had an operation to reconstruct the ascending aorta and/or the aortic arch is not always possible or necessary for selected patients according to current alternative treatment options. Rather than following the traditional surgical concept of aggressive graft replacement nowadays a more conservative surgical approach with in situ preservation and coverage of the prosthetic graft by vascular tissue flaps can result in a good outcome. In this article, we review the relevant literature on this specific topic, particularly in terms of graft-sparing surgery for infected ascending/arch prosthetic grafts with special emphasis on staged treatment and the use of omentum transposition.

Haematological effects of minimized compared to conventional extracorporeal circulation after coronary revascularization procedures.

During the last decade, minimized extracorporeal circulation (MECC) systems have shown beneficial effects to the patients over the conventional cardiopulmonary bypass (CECC) circuits. This is a prospective randomized study of 99 patients who underwent coronary artery bypass grafting (CABG) surgery, evaluating the postoperative haematological effects of these systems. Less haemodilution (p=0.001) and markedly less haemolysis (p<0.001), as well as better preservation of the coagulation system integrity (p=0.01), favouring the MECC group, was found. As a clinical result, less bank blood requirements were noted and a quicker recovery, as far as mechanical ventilation support and ICU stay are concerned, was evident with the use of MECC systems. As a conclusion, minimized extracorporeal circulation systems may attenuate the adverse effects of conventional circuits on the haematological profile of patients undergoing CABG surgery.

A Case of Successful Treatment of Neuropathic Pain After a Scapular Fracture Using Subcutaneous Targeted Neuromodulation

Subcutaneous targeted neuromodulation is one part of the wider new peripheral neuromodulation development in the treatment of neuropathic pain. Although it has not received wider acceptance, there are many reports in the literature of successful use of this technique.

Modular minimally invasive extracorporeal circulation systems; can they become the standard practice for performing cardiac surgery?

Minimally invasive extracorporeal circulation (MiECC) has been developed in an attempt to integrate all advances in cardiopulmonary bypass technology in one closed circuit that shows improved biocompatibility and minimizes the systemic detrimental effects of CPB. Despite well-evidenced clinical advantages, penetration of MiECC technology into clinical practice is hampered by concerns raised by perfusionists and surgeons regarding air handling together with blood and volume management during CPB. We designed a modular MiECC circuit, bearing an accessory circuit for immediate transition to an open system that can be used in every adult cardiac surgical procedure, offering enhanced safety features. We challenged this modular circuit in a series of 50 consecutive patients. Our results showed that the modular AHEPA circuit design offers 100% technical success rate in a cohort of random, high-risk patients who underwent complex procedures, including reoperation and valve and aortic surgery, together with emergency cases. This pilot study applies to the real world and prompts for further evaluation of modular MiECC systems through multicentre trials.

Ropivacaine versus bupivacaine for 3-in-1 block during total knee arthroplasty

Purpose. To compare the use of ropivacaine versus bupivacaine for 3-in-1 block during total knee arthroplasty (TKA) in terms of efficacy and safety (lack of toxicity). Methods. 14 men and 26 women aged 58 to 77 (median, 70) years who had the American Society of Anesthesiologists (ASA) grades I to III physical status were randomised to receive ropivacaine (n=20) or bupivacaine (n=20) of a concentration of 0.5% for 3-in-1 block during TKA. The dosage was 0.5 ml/kg. In addition, a sciatic nerve block (20 ml of prilocaine 1%) was used. The onset of the block, duration of postoperative analgesia, level of motor block, and any side-effects were compared. Results. The median time to onset of block was significantly shorter in those receiving ropivacaine than bupivacaine (13 vs. 17.5 minutes, p<0.001), but the levels of motor blockade were not significantly different (p=0.355). Complete analgesia was achieved throughout the procedure. There was no significant difference between the ropivacaine and bupivacaine groups in terms of the mean duration of analgesia (398 vs. 367 minutes, p=0.62), the mean VAS scores at all time points, and the mean total morphine consumption. One patient in the ropivacaine group developed a joint haematoma and 2 patients in the bupivacaine group had excessive wound drainage. Both conditions resolved after antibiotic use. Conclusion. Ropivacaine and bupivacaine showed similar anesthetic and analgesic effects, but the former had a significantly faster onset time.

Successful surgical in situ treatment of prosthetic graft infection by staged procedure after Bentall operation and total aortic arch replacement

We report a case of a 29-year-old Marfan patient who developed prosthetic graft infection 10 months after Bentall operation and successive replacement of the remaining ascending aorta and the entire aortic arch for acute aortic dissection. Instead of an aggressive high-risk aortic redo procedure with removal and replacement of the infected prosthetic graft we elected a staged graft-sparing surgical approach. After 18 months of close follow-up the patient is in good condition and free from infectious sequela. This case and our review of the literature suggest that open extensive disinfection followed by tissue flap coverage is highly effective in controlling thoracic aortic prosthetic graft infection and may be considered as first-line treatment in such high-risk aortic arch redo patients.

Comparison between intubation through ILMA and Airtraq, in different non-conventional patient positions: a manikin study.

Background Tracheal intubation is often difficult in the prehospital setting, especially in trapped casualties, when long extrication time is anticipated and conventional laryngoscopy cannot be achieved. The aim of the present study was the comparison of applicability and efficacy of two alternative techniques: intubation using a laryngeal mask airway (ILMA) or an Airtraq laryngoscope in different patient positions, using an airway management manikin. Methods 20 anaesthetists attempted manikin intubations standing behind the manikin (Sup), standing in front and facing the manikins head (Fac), facing the manikin in the sitting position (Sit) and facing the manikin lying in the lateral decubitus position (Lat), using either Airtraq or ILMA techniques. The intubations were evaluated regarding the success rate, number of attempts and time needed for successful intubation, teeth damage and overall difficulty. Results All intubation attempts were successful for both techniques. Intubations through ILMA were completed with a significantly greater number of attempts and longer time in the Lat position, compared to Fac, Sit and Sup (p<0.05), whereas intubations using Airtraq in the Sup and Fac positions were completed with a significantly greater number of attempts and longer time, compared to Sit and Lat positions (p<0.05). Both ILMA and Airtraq can be used for securing the airway when direct laryngoscopy is impossible due to patient position. ILMA seems to cause greater difficulty in the Lat position, whereas Airtraq intubation is more easily performed in the Sit and Lat positions. Conclusions These preliminary data in manikins could indicate the applicability of the methods to the prehospital setting.

Atrial septostomy and disease targeting therapy in pulmonary hypertension secondary to neurofibromatosis

BackgroundNeurofibromatosis type 1 (NF1) is a rare multisystem genetic disorder. During the course of the disease it can be rarely complicated with pulmonary hypertension (PH) which confers a dismal prognosis.Case presentationWe describe the case of a 57-year-old female patient with NF1 complicated by severe precapillary PH despite dual disease-specific oral combination therapy. The patient was treated with initial atrial septostomy followed by administration of high-dose subcutaneous treprostinil with a favorable medium-term clinical and hemodynamic response.ConclusionsPH secondary to NF1 may be successfully treated with the combination of atrial septostomy and PH targeted therapy in selected patients.

Homografts for the management of graft infections in the ascending aortic position

We read with great interest the article by Khaladj et al. [1] describing their experience with cryopreserved homografts for the management of a severe complication following reconstructive surgery on the ascending aorta and aortic arch, namely prosthetic graft infection. However, we would like to add some comments on the topic. According to their institutional policy, all patients with infected grafts of their ascending aorta, where the aortic arch was also involved, were treated by removal and replacement of the prosthetic material with homografts. Historically, replacement of infected thoracic aortic graft has been reported by individual surgeons, however, with unsatisfactory results. Hospital mortality rates have been as great as 46% [2] typically resulting from the invasiveness and complexity of the procedure, emergency conditions, contaminated field and the difficulties of exposure in the redo aortic setting. Our group, as others [3] too, experienced exceptionally disappointing results following the principle of redo ascending/arch prosthetic graft replacement, due to uncontrollable infective process. We congratulate the outstanding work of Khaladj et al. [1] from Hannover, who reported in their explants series a hospital mortality rate of 24%. This is the largest single-centre experience published so far treating 17 patients with cryopreserved homografts in the ascending/arch and aortic root. However, surgical mortality and morbidity are still a major concern with this aggressive treatment strategy. Moreover, there are no surgical guidelines on proper surgical management for such cases. Other strategies that have been applied in the surgical treatment of ascending/arch prosthetic graft infection are based on the principle of a more conservative, non-resectional, and thus, graftsparing surgical approach [2–6]. It is well documented that many institutions have switched during the last decades to this so-called ‘in situ preservation’ concept performing debridement of perigraft-infected mediastinal tissue, open surgical disinfection and transposition of viable omentum, as suggested by Hargrove and Edmunds [4] and Coselli et al. [5], with excellent clinical results. We were, therefore, surprised to read that ‘the use of omentum has not been evaluated for ascending aortic graft infections’. The literature certainly provides sufficient information concerning the role of this method which is feasible, safe and highly effective in controlling thoracic aortic prosthetic graft infection with superior outcomes when compared with traditional redo ascending/arch prosthetic graft replacement [2–6]. Inspired by a case we treated successfully with open surgical disinfection followed by omentum flap coverage after the Bentall operation and total aortic arch replacement, we reviewed the literature and recognized 77 similar cases for the treatment of infected ascending/arch prosthetic grafts with a collective early survival rate of 95% and a 100% success rate in terms of non-recurrence of graft infection [2–6]. Many of these patients with ascending aortic grafts also received an arch graft, composite valve graft or separate aortic valve prosthesis. We think, as other authors [2–6] too, that the dogma of the need for removal and replacement of the prosthetic graft is unjustified, at least in certain patients with ascending/arch prosthetic graft infection, even after composite aortic root replacement, as long as the infection is not associated with native or prosthetic aortic valve endocarditis or valve dysfunction. The present evidence and knowledge on current preservation strategies has the potential to spare patients high-risk procedures and higher mortality.

Electrodermal Activity during Blood Pooling for Arterial Blood Gases Analysis in Sedated Adult Intensive Care Unit Patients

Electrodermal activity (EDA) is considered a measure of autonomous nervous system activity. This study performed an exploratory analysis of the EDA changes during blood pooling for arterial blood gas analysis in sedated adult critical care patients and correlated the variations to other monitored parameters. EDA, along with other parameters, were monitored during 4 h routine daytime intensive care nursing and treatment in an adult ICU. 4 h measurements were divided into two groups based upon the sedation level. Selected recordings before and after blood pooling for arterial blood gases analysis (stress event) was performed. Nine stress events from Group A and 17 from Group B were included for further analysis. Patients’ demographics, laboratory exams, and severity scores were recorded. For both sedation levels, EDA changes are much greater than any other monitoring parameters used. The changes are noticed in both measurement (15 s and 60 s), even though in the 60 s measurement only selected EDA parameters are significantly changed after the start of the procedure. EDA measurements are more sensitive to a given stress event than cardiovascular or respiratory parameters. However, the present results could only be considered as a pilot study. More studies are needed in order to identify the real stress-load and clinical significance of such stimuli, which are considered otherwise painless in those patients.