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3. Surgery for Bentall endocarditis: short- and midterm outcomes from a multicentre registry

Author

Francesco Santini, Giovanni Troise, Ugolino Livi, Sandro Sponga, Michele Danilo Pierri, Antonio Salsano, Antonio Messina, Roberto Lorusso, Marco Picichè, Marco Di Eusanio, Daniele Maselli, Diego Cugola, Giuseppe Cagnoni, Uberto Bortolotti, Michele De Bonis, Michele Di Mauro, Domenico Paparella, Ruggero De Paulis, Cesare Beghi, Pietro Giorgio Malvindi, Guglielmo Mario Actis Dato, Carlo Antona, Giangiuseppe Cappabianca, Paolo Centofanti, Mauro Rinaldi, Davide Pacini, Carlo De Vincentiis, Samuel Mancuso, Alberto Pozzoli, Luca Weltert, Lorenzo Galletti, Alessandro Parolari, Loris Salvador, Giacomo Murana, CTC, MUMC+: MA Med Staf Spec CTC (9), RS: Carim - V04 Surgical intervention, Sponga S., Mauro M.D., Malvindi P.G., Paparella D., Murana G., Pacini D., Weltert L., De Paulis R., Cappabianca G., Beghi C., De Vincentiis C., Parolari A., Messina A., Troise G., Salsano A., Santini F., Pierri M.D., Eusanio M.D., Maselli D., Dato G.A., Centofanti P., Mancuso S., Rinaldi M., Cagnoni G., Antona C., Marco Piciche, Salvador L., Cugola D., Galletti L., Pozzoli A., De Bonis M., Lorusso R., Bortolotti U., Livia U., Sponga, S., Di Mauro, M., Malvindi, P. G., Paparella, D., Murana, G., Pacini, D., Weltert, L., De Paulis, R., Cappabianca, G., Beghi, C., De Vincentiis, C., Parolari, A., Messina, A., Troise, G., Salsano, A., Santini, F., Pierri, M. D., Di Eusanio, M., Maselli, D., Actis Dato, G., Centofanti, P., Mancuso, S., Rinaldi, M., Cagnoni, G., Antona, C., Piciche, M., Salvador, L., Cugola, D., Galletti, L., Pozzoli, A., De Bonis, M., Lorusso, R., Bortolotti, U., and Livi, U.

Subjects
Aortic valve, Male, Bentall procedure, 030204 cardiovascular system & hematology, AORTIC ROOT REPLACEMENT, 0302 clinical medicine, Mitral valve, Aortic root, Registries, Heart Valve Prosthesis Implantation, Endocarditis, Hazard ratio, General Medicine, Middle Aged, Mediastinitis, medicine.anatomical_structure, Treatment Outcome, Heart Valve Prosthesis, SURGICAL-TREATMENT, Female, Cardiology and Cardiovascular Medicine, Aortic surgery, Adult, Aged, Aortic Valve, Humans, Reoperation, Pulmonary and Respiratory Medicine, medicine.medical_specialty, Preoperative care, 03 medical and health sciences, medicine, MANAGEMENT, INFECTIVE ENDOCARDITIS, TERM-FOLLOW-UP, business.industry, GRAFT, Perioperative, medicine.disease, Surgery, 030228 respiratory system, PROSTHETIC VALVE ENDOCARDITIS, ASCENDING AORTA, business
Abstract

OBJECTIVES Endocarditis after the Bentall procedure is a severe disease often complicated by a pseudoaneurysm or mediastinitis. Reoperation is challenging but conservative therapy is not effective. The aim of this study was to assess short- and midterm outcomes of patients reoperated on for Bentall-related endocarditis. METHODS Seventy-three patients with Bentall procedure-related endocarditis were recorded in the Italian registry. The mean age was 57 ± 14 years and 92% were men; preoperative comorbidities included hypertension (45%), diabetes (12%) and renal failure (11%). The logistic EuroSCORE was 25%; the EuroSCORE II was 8%. RESULTS Preoperatively, 12% of the patients were in septic shock; left ventricular-aortic discontinuity was present in 63% and mitral valve involvement occurred in 12%. The most common pathogens were Staphylococcus aureus (22%) and Streptococci (14%). Reoperations after a median interval of 30 months (1–221 months) included a repeat Bentall with a bioconduit (41%), a composite mechanical (33%) or biological valved conduit (19%) and a homograft (6%). In 1 patient, a heart transplant was required (1%); in 12%, a mitral valve procedure was needed. The hospital mortality rate was 15%. The postoperative course was complicated by renal failure (19%), major bleeding (14%), pulmonary failure (14%), sepsis (11%) and multiorgan failure (8%). At multivariate analysis, urgent surgery was a risk factor for early death [hazard ratio 20.5 (1.9–219)]. Survival at 5 and 8 years was 75 ± 6% and 71 ± 7%, with 3 cases of endocarditis relapse. CONCLUSIONS Surgery is effective in treating endocarditis following the Bentall procedure although it is associated with high perioperative mortality and morbidity rates. Endocarditis relapse seems to be uncommon.

Published
2020

4. Intraoperative antifibrinolysis and blood-saving techniques in cardiac surgery. Prospective trial of 3 antifibrinolytic drugs.

Author

Penta de Peppo A, Pierri MD, Scafuri A, De Paulis R, Colantuono G, Caprara E, Tomai F, and Chiariello L

Subjects
Adult, Aged, Aminocaproic Acid administration & dosage, Aminocaproic Acid adverse effects, Antifibrinolytic Agents adverse effects, Aprotinin administration & dosage, Aprotinin adverse effects, Blood Coagulation Tests, Blood Loss, Surgical physiopathology, Cardiopulmonary Bypass, Coronary Artery Bypass, Dose-Response Relationship, Drug, Drug Administration Schedule, Female, Heart Diseases blood, Heart Valve Prosthesis, Humans, Male, Middle Aged, Postoperative Hemorrhage blood, Prospective Studies, Tranexamic Acid administration & dosage, Tranexamic Acid adverse effects, Antifibrinolytic Agents administration & dosage, Blood Loss, Surgical prevention & control, Blood Transfusion, Autologous, Heart Diseases surgery, Postoperative Hemorrhage prevention & control
Abstract

Sixty consecutive patients undergoing elective open-heart surgery were prospectively enrolled in a study to compare the efficacy of 3 different antifibrinolytic drugs to reduce postoperative bleeding and to reduce homologous blood requirements in combination with blood-saving techniques and restrictive indications for blood transfusion. The patients were randomized to 1 of 4 intraoperative treatment regimens: 1) control (no antifibrinolytic therapy); 2) epsilon-aminocaproic acid (10 g IV at induction of anesthesia, followed by infusion of 2 g/h for 5 hours); 3) tranexamic acid (10 mg/kg IV within 30 minutes after induction of anesthesia, followed by infusion of 1 mg/kg per hour for 10 hours); or 4) high-dose aprotinin (2 million KIU IV at induction of anesthesia and 2 million KIU added to the extracorporeal circuit, followed by infusion of 500 thousand KIU/h during surgery). Hemoconcentration and reinfusion of blood drained from the operative field and the extracorporeal circuit after operation were used in all patients. Indications for blood transfusion were hypotension, tachycardia, or both, with hemoglobin values < 8.5 g/dL; or severe anemia with hemoglobin values < 7 g/dL. Compared with the blood loss in the control group, patients receiving aprotinin and epsilon-aminocaproic acid showed significantly less postoperative blood loss at 1 hour (control, 128 +/- 94 mL; aprotinin, 54 +/- 47 mL, p = 0.01; and epsilon-aminocaproic acid, 69 +/- 35 mL, p = 0.03); this trend continued at 24 hours after operation (control, 724 +/- 280 mL; aprotinin, 344 +/- 106 mL, p < 0.0001; and epsilon-aminocaproic acid, 509 +/- 148 mL, p = 0.01). Aprotinin was significantly more efficient than epsilon-aminocaproic acid (p=0.002). Tranexamic acid did not have a statistically significant effect on blood loss. Homologous blood requirements were not significantly different among the groups; postoperative hematologic values and coagulation times were also comparable. Despite the efficacy of aprotinin and epsilon-aminocaproic acid shown in the present study, the blood requirements were not significantly different from those that are found when transfusions are restricted, autotransfusions are used, and blood from the operative field and extracorporeal circuit is concentrated and reinfused. Therefore, intraoperative antifibrinolysis may not be indicated in routine cardiac surgery when other blood-saving techniques are adopted.

Published
1995

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