Search

Reoperation for bleeding (ROB) after emergency coronary artery bypass grafting (eCABG) has been identified as an independent risk factor for mortality. Consecutively, the influence of fluid intake, fluid output, fluid balance, blood loss, and inotropic demand on ROB were analyzed. This retrospective single-center study included 265 patients undergoing eCABG between 2011 and 2020. From 2018, postoperative hemodynamic management was performed with lower volume administration and higher vasoactive support. The primary outcome measure was the incidence of ROB within 48 h according to altered fluid resuscitation strategy. Consecutively, the influence of fluid intake, fluid output, fluid balance, blood loss, and inotropic demand on ROB were analyzed. Incidence of ROB was independent from the volume resuscitation protocol (P = .3). The ROB group had a higher perioperative risk, which was observed in EuroSCORE II. Fluid intake (P = .021), fluid balance (P = .001), and norepinephrine administration (P = .004) were associated with ROB. Fluid output and blood loss were not associated with ROB (P = .22). Post-test probability was low among all variables. Although fluid management might have an impact on specific postoperative complications, different fluid resuscitation protocols did not alter the incidence of ROB after emergency CABG., Trial Registration: www., Clinicaltrials: gov registration number NCT04533698; date of registration: August 31, 2020 (retrospectively registered due to nature of the study); URL: https://classic., Clinicaltrials: gov/ct2/show/NCT04533698., (© 2024. The Author(s).)

Importance: Preoperative skin antisepsis is an established procedure to prevent surgical site infections (SSIs). The choice of antiseptic agent, povidone iodine or chlorhexidine gluconate, remains debated., Objective: To determine whether povidone iodine in alcohol is noninferior to chlorhexidine gluconate in alcohol to prevent SSIs after cardiac or abdominal surgery., Design, Setting, and Participants: Multicenter, cluster-randomized, investigator-masked, crossover, noninferiority trial; 4403 patients undergoing cardiac or abdominal surgery in 3 tertiary care hospitals in Switzerland between September 2018 and March 2020 were assessed and 3360 patients were enrolled (cardiac, n = 2187 [65%]; abdominal, n = 1173 [35%]). The last follow-up was on July 1, 2020., Interventions: Over 18 consecutive months, study sites were randomly assigned each month to either use povidone iodine or chlorhexidine gluconate, each formulated in alcohol. Disinfectants and skin application processes were standardized and followed published protocols., Main Outcomes and Measures: Primary outcome was SSI within 30 days after abdominal surgery and within 1 year after cardiac surgery, using definitions from the US Centers for Disease Control and Prevention's National Healthcare Safety Network. A noninferiority margin of 2.5% was used. Secondary outcomes included SSIs stratified by depth of infection and type of surgery., Results: A total of 1598 patients (26 cluster periods) were randomly assigned to receive povidone iodine vs 1762 patients (26 cluster periods) to chlorhexidine gluconate. Mean (SD) age of patients was 65.0 years (39.0-79.0) in the povidone iodine group and 65.0 years (41.0-78.0) in the chlorhexidine gluconate group. Patients were 32.7% and 33.9% female in the povidone iodine and chlorhexidine gluconate groups, respectively. SSIs were identified in 80 patients (5.1%) in the povidone iodine group vs 97 (5.5%) in the chlorhexidine gluconate group, a difference of 0.4% (95% CI, -1.1% to 2.0%) with the lower limit of the CI not exceeding the predefined noninferiority margin of -2.5%; results were similar when corrected for clustering. The unadjusted relative risk for povidone iodine vs chlorhexidine gluconate was 0.92 (95% CI, 0.69-1.23). Nonsignificant differences were observed following stratification by type of surgical procedure. In cardiac surgery, SSIs were present in 4.2% of patients with povidone iodine vs 3.3% with chlorhexidine gluconate (relative risk, 1.26 [95% CI, 0.82-1.94]); in abdominal surgery, SSIs were present in 6.8% with povidone iodine vs 9.9% with chlorhexidine gluconate (relative risk, 0.69 [95% CI, 0.46-1.02])., Conclusions and Relevance: Povidone iodine in alcohol as preoperative skin antisepsis was noninferior to chlorhexidine gluconate in alcohol in preventing SSIs after cardiac or abdominal surgery., Trial Registration: ClinicalTrials.gov Identifier: NCT03685604.

Introduction: The impact of sex on hospital readmission rate after cardiac surgery is unclear. Therefore, we aimed to analyse sex-specific differences and underlying factors in 30-day readmission rate after cardiac surgery., Methods: We conducted a single center study including all patients after major cardiac surgery (excluding aortic dissection and left ventricular assist device implantation) from January 2012 to September 2020. Reasons for readmission were adjudicated according to all available medical records. We calculated incidence rate ratios (IRR) with 95% confidence intervals (CI) for female sex with re-admission crude and adjusted for plausible confounding factors using negative binomial regression., Results: 4,868 patients were included in the analysis. The median [Interquartile range] age was 68 [60 to 74] years and 24% ( n  = 1,149) of the patients were female. Female patients were significantly older (median [IQR] age 70 (63 to 76) vs. 67 (59 to 74), p  < 0.001) and had lower body mass index and fewer cardiovascular risk factors compared to men. Isolated valve surgery was more frequent in female while coronary artery bypass grafting was more often in men. 30-day readmission was comparable between both sexes (7.0% [ n  = 81] in female vs. 8.7% [ n  = 322] in men; p  = 0.078). Cardiac related readmissions and infections were the most common reasons for readmission in both groups. The overall incidence rate ratios of female sex with readmission (0.80, 95% CI 0.63 to 1.03, p  = 0.078) remained robust after adjustment for EuroSCORE 2 (0.78, CI 0.61 to 1.0, p  = 0.051)., Conclusion: Readmission rate and reasons for 30-day readmission after major cardiac surgery were similar between men and women., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (© 2023 Koechlin, Miazza, Gahl, Santer, Vöhringer, Berdajs, Eckstein and Reuthebuch.)

Study Objective: The diagnostic performance of T-wave amplitudes for the detection of myocardial infarction is largely unknown. We aimed to address this knowledge gap., Methods: T-wave amplitudes were automatically measured in 12-lead ECGs of patients presenting with acute chest discomfort to the emergency department within a prospective diagnostic multicenter study. The final diagnosis was centrally adjudicated by 2 independent cardiologists. Patients with left ventricular hypertrophy, complete left bundle branch block, or paced ventricular depolarization were excluded. The performance for lead-specific 95th-percentile thresholds were reported as likelihood ratios (lr), specificity, and sensitivity., Results: Myocardial infarction was the final diagnosis in 445 (18%) of 2457 patients. In most leads, T-wave amplitudes tended to be greater in patients without myocardial infarction than those with myocardial infarction, and T-wave amplitude exceeding the 95th percentile had positive and negative lr close to 1 or with confidence intervals (CIs) crossing 1. The exceptions were leads III, aVR, and V1, which had positive lrs of 3.8 (95% CI, 2.7 to 5.3), 4.3 (95% CI, 3.1 to 6.0) and 2.0 (95% CI, 1.4 to 2.9), respectively. These leads normally have inverted T waves, so T-wave amplitude exceeding the 95th percentile reflects upright rather than increased-amplitude hyperacute T waves., Conclusion: Hyperacute T waves, when defined as increased T-wave amplitude exceeding the 95th percentile, did not provide useful information in diagnosing myocardial infarction in this sample., (Copyright © 2022 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Due to the advent of interventional therapies for low- and intermediate-risk patients, case complexity has increased in cardiac surgery over the last decades. Despite the surgical progress achieved to keep up with the increase in the number of high-risk patients, the prevention of sternal complications remains a challenge requiring new, individualized sternal closure techniques. The aim of this study was to evaluate the safety and feasibility, as well as the in-hospital and long-term outcomes, of enhanced sternal closure with combined band and plate fixation using the new SternaLock ® 360 (SL360) system as an alternative to sternal wiring. From 2020 to 2022, 17 patients underwent enhanced sternal closure using the SL360 at our institution. We analyzed perioperative data, as well as clinical and radiologic follow-up data. The results were as follows: In total, 82% of the patients were treated with the SL360 based on perioperative risk factors, while in 18% of cases, the SL360 was used for secondary closure due to sternal instability. No perioperative complications were observed. We obtained the follow-up data of 82% of the patients (median follow-up time: 141 (47.8 to 511.5) days), showing no surgical revision, no sternal instability, no deep wound infections, and no sternal pain at the follow-up. In one case, a superficial wound infection was treated with antibiotics. In conclusion, enhanced sternal closure with the SL360 is easy to perform, effective, and safe. This system might be considered for both primary and secondary sternal closure in patients at risk of sternal complications.

Engineering functional tissues of clinically relevant size (in mm-scale) in vitro is still a challenge in tissue engineering due to low oxygen diffusion and lack of vascularization. To address these limitations, a perfusion bioreactor was used to generate contractile engineered muscles of a 3 mm-thickness and a 8 mm-diameter. This study aimed to upscale the process to 50 mm in diameter by combining murine skeletal myoblasts (SkMbs) with human adipose-derived stromal vascular fraction (SVF) cells, providing high neuro-vascular potential in vivo. SkMbs were cultured on a type-I-collagen scaffold with (co-culture) or without (monoculture) SVF. Large-scale muscle-like tissue showed an increase in the maturation index over time (49.18 ± 1.63% and 76.63 ± 1.22%, at 9 and 11 days, respectively) and a similar force of contraction in mono- (43.4 ± 2.28 µN) or co-cultured (47.6 ± 4.7 µN) tissues. Four weeks after implantation in subcutaneous pockets of nude rats, the vessel length density within the constructs was significantly higher in SVF co-cultured tissues (5.03 ± 0.29 mm/mm 2 ) compared to monocultured tissues (3.68 ± 0.32 mm/mm 2 ) ( p < 0.005). Although no mature neuromuscular junctions were present, nerve-like structures were predominantly observed in the engineered tissues co-cultured with SVF cells. This study demonstrates that SVF cells can support both in vivo vascularization and innervation of contractile muscle-like tissues, making significant progress towards clinical translation.

Background: Disseminated Mycobacterium chimaera ( M . chimaera ) infection following cardiac surgery has been associated with a high mortality. The long-term impact of surgery and the appropriate surgical approach are still matters of debate., Methods: From 2015 to 2019, seven patients with M. chimaera infection following cardiac surgery were isolated., Results: The median incubation time was 30 months (IQR 18-38). Echocardiography was unremarkable in three patients (43%). We decided to redo cardiac surgery in all patients and explanted all previously implanted prosthetic material. All explant cultures yielded M. chimaera. One patient (14%) died in-hospital seven months after the redo surgery. After a median follow-up of 59.6 months (IQR 39.1-69.6), we observed three infection relapses among the survivors (43%), presumably due to concomitant extracardiac infection and recurrent cardiac implant infection., Conclusions: M. chimaera infection following cardiac surgery is associated with a delayed and unspecific clinical presentation. Echocardiogaphy has a limited sensitivity for prosthetic valve infection with M. chimaera , and negative findings should not preclude the surgical decision. The extraction of all previously implanted material is crucial to achieving the source control, as the re-implantation of prosthetic material as well as uncontrolled extracardiac infection at the time of the redo cardiac surgery appear to be key factors for persisting/relapsing infection.

Background: TAVI via the left subclavian artery is considered a bail-out strategy in cases where a transfemoral approach is not feasible. However, since this route is only scarcely used, major complications can arise. We describe such an adverse course and present our proceeding., Case Presentation: A 65-year-old man with severe aortic valve stenosis (AS) was referred for transcatheter aortic valve implantation (TAVI) via left subclavian artery. After uneventful deployment of the TAVI prosthesis, consequent valve assessment with transeosophageal echocardiography and angiography showed a highly mobile and tubular structure shifting within the valve. We went for a surgical extraction via sternotomy on cardiopulmonary bypass (CPB). A 6 cm longish intimal cylinder was hassle-free extracted. 4 days postoperatively the left sided radial pulse was missing. In a subsequent computed tomography angiography (CTA) scan a proximal dissection as well as an intimal flap, causing a subtotal stenosis of the left subclavian artery, was detected. Consecutively the intimal cylinder was removed using a Fogarty-balloon. Pre-discharge control revealed recurrence of peripheral radial pulse and an unimpeded function of the TAVI prosthesis. The patient presented no sequela at discharge., Conclusion: Though TAVI is a well-advanced technique complications are not completely avertable. It is thus advisable to have patients discussed in the heart team encompassing all potentially involved specialties., (© 2023. The Author(s).)

Background: We aimed to analyse the performance of minimal invasive extracorporeal circulation (MiECC) concomitantly with Microplegia, in patients with recent myocardial infarction (MI) undergoing urgent coronary artery bypass grafting (CABG) surgery. Methods: We included patients with a recent MI (≤7 days) undergoing isolated CABG surgery using MiECC. The primary endpoint was a major cardiovascular or cerebrovascular event (MACCE). In a secondary analysis, we compared our institutional Microplegia concept with the use of a crystalloid single-shot cardioplegic solution. Results: In total, 139 patients (mean ± standard deviation (SD) age 66 ± 10 years) underwent urgent CABG surgery using Microplegia; 55% (n = 77) of the patients had an acute MI within 1−7 days preoperatively; 20% (n = 28) had an acute MI within 6−24 h; and 24% (n = 34) had an acute MI within <6 h preoperatively. The number of distal anastomoses was a geometric mean of 4 (95% confidence interval 3−4). The MACCE and in-hospital mortality were 7% (n = 10) and 1% (n = 2), respectively. The results were confirmed in a secondary analysis comparing Microplegia with crystalloid cardioplegic solution (n = 271). Conclusion: The use of MiECC with Microplegia in urgent CABG surgery is feasible and safe and provides a straight-forward intraoperative setting. Therefore, it can also be considered to retain the benefits of MiECC in urgent CABG surgery., Competing Interests: The authors declare no conflicts of interest.

Background: Aortic valve replacement is the traditional surgical treatment for aortic valve diseases, yet standardized aortic valve neocuspidization (AVNeo) is a promising alternative that is gaining popularity. The purpose of this article is to review the available published literature of AVNeo using glutaraldehyde-treated autologous pericardium, also known as the Ozaki procedure, including indications, outcomes, potential benefits, and modes of failure for the reconstructed valve., Methods: A comprehensive literature search was performed using keywords related to aortic valve repair, AVNeo, or Ozaki procedure. All articles describing performance of AVNeo were reviewed., Results: Reported early mortality after AVNeo varies from 0% to 5.88%. The largest cohort of patients in the literature includes 850 patients with an inhospital mortality rate of 1.88%. Cumulative incidence of aortic valve reoperation was 4.2% in the largest series. Reoperation was uncommon and mainly due to infective endocarditis or degeneration of the reconstructed valve (most commonly due to aortic valve regurgitation, rather than stenosis)., Conclusions: Aortic valve neocuspidization is a versatile and standardized alternative to aortic valve replacement with a biological prosthesis. Early to midterm outcomes from a number of centers are excellent and demonstrate the safety and durability of the procedure. Long-term outcomes and clinical trial data are necessary to determine which patients benefit the most from this procedure., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: In isolated mitral valve regurgitation general consensus on surgery is to favor repair over replacement excluding rheumatic etiology or endocarditis. If concomitant aortic valve replacement is performed however, clinical evidence is more ambiguous and no explicit guidelines exist on the choice of mitral valve treatment. Both, double valve replacement (DVR) and aortic valve replacement in combination with concomitant mitral valve repair (AVR + MVP) have been proven to be feasible procedures. In our single-center, retrospective, observational cohort study, we compared the outcome of these two surgical techniques focusing on mortality and morbidity., Methods: 89 patients underwent DVR (n = 41) or AVR + MVP (n = 48) in our institution between 2009 and 2018. Follow-up data was collected using electronic patient records, by contacting treating physicians and by telephone interviews. We used the Kaplan-Meier method to analyze mortality during follow-up and Cox regression to investigate potential predictors of mortality., Results: During a median follow-up duration of 4.5 [IQR 2.9 to 6.1] years, there was no significant difference in mortality between both cohorts. Thirty days mortality was 6.3% in the DVR and 7% in the AVR + MVP cohort. Overall mortality amounted to 17% for DVR and 23% for AVR + MVP. DVR was the preferred procedure for valve disease of rheumatic etiology and for endocarditis, while in degenerative valves AVR + MVP was predominant. More biological valves were used in the AVR + MVP cohort (p < 0.001) and more mechanical valves were implanted in the DVR cohort. The rate of rehospitalization, deterioration of left ventricular ejection fraction and postoperative complications were equally distributed among the two cohorts., Conclusion: Our data analysis showed that both DVR and AVR + MVP are safe and feasible options for double valve surgery. Based on our findings we could not prove superiority of one surgical technique over the other. Choosing the appropriate procedure for the patient should be influenced by valve etiology, patients' comorbidities and the surgeons' experience., Trial Registration: This was a retrospectively registered trial, registered on April 1st 2018, ClinicalTrials.gov Identifier: NCT03667274., (© 2022. The Author(s).)

Background: High-sensitivity cardiac troponin T (hs-cTnT) and the ESC 0/1h-hs-cTnT-algorithm have worse performance in the early diagnosis of myocardial infarction (MI) in patients with prior coronary artery bypass grafting (CABG). It is unknown, whether this concern applies also to hs-cTnI, the most widely used analyte worldwide., Methods: In an international multicenter diagnostic study, two cardiologists centrally adjudicated the final diagnosis in patients presenting to the emergency department with symptoms suggestive of MI according to the Third Universal Definition of MI. The objective was to compare the diagnostic accuracy of hs-cTnI assays and their performance within the ESC hs-cTnI 0/1h-algorithms in patients with versus without prior CABG. Findings were externally validated in an U.S. multicenter diagnostic study., Results: A total of 392/5'200 patients (8%) had prior coronary artery bypass grafting (CABG). Diagnostic accuracy of hs-cTnI as quantified by the area under the receiver-operating characteristics-curve (AUC) in these patients was high, but lower versus patients without prior CABG (e.g. hs-cTnI-Architect 0.91 versus 0.95; p = 0.016). Sensitivity/specificity of rule-out/in by the European Society of Cardiology (ESC) 0/1h-hs-cTnI-algorithms remained very high [e.g. hs-cTnI-Architect 100% and 93.5%], but efficacy was lower (52% versus 74%, p < 0.01). External validation (n = 2113) confirmed these findings in 192 patients with prior CABG using hs-cTnI-Atellica, with 52% versus 36% (p < 0.001) remaining in the observe zone., Conclusions: Diagnostic accuracy of hs-cTnI and efficacy of the ESC 0/1h-hs-cTnI-algorithms are lower in patients with prior CABG, but sensitivity/specificity remain very high., Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT00470587, number NCT00470587., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Aims: Diagnosis of acute myocardial infarction (AMI) can be challenging in patients with prior coronary artery bypass grafting (CABG)., Methods and Results: Final diagnoses were adjudicated by two independent cardiologists using the universal definition of AMI among patients presenting to the emergency department (ED) with suspected AMI. Diagnostic accuracy of 34 chest pain characteristics (CPCs) and four electrocardiogram (ECG) signatures stratified according to the presence or absence of prior CABG were prospectively quantified. Among 4015 patients (no prior CABG: n = 3686; prior CABG: n = 329), prevalence of AMI and unstable angina were higher in patients with prior CABG (35% vs. 18%; 26% vs. 8%; both P < 0.001). Three CPCs (9%) and two electrocardiographic findings (50%) showed a different diagnostic performance (interaction P < 0.05) with loss of diagnostic value in patients with prior CABG. The diagnostic accuracy as quantified by the area under the curve (AUC) of the integrated clinical judgement was moderate to good in patients with prior CABG, and significantly lower compared to patients without prior CABG [AUC 0.80 (95% confidence interval (CI) 0.75-0.84) vs. AUC 0.87 (95% CI 0.86-0.89); P = 0.004]. Time to discharge from the ED was significantly longer in patients with prior CABG [359 (215-525) min vs. 300 (192-435) min; P < 0.001]. Key findings were confirmed in a large independent external validation cohort (n = 13 653)., Conclusions: Patients with prior CABG presenting with suspected AMI have a high prevalence of AMI and unstable angina and lower diagnostic accuracy of CPCs and the ECG, possibly justifying liberal use of early coronary angiography in these vulnerable patients., Clinicaltrials.gov Registry: Number NCT00470587., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Purpose: The aim of this study was to analyze the effects of 10-minute (standard term) versus 20-minute treatment with glutaraldehyde (GA) on mechanical stability and physical strength of human pericardium in the setting of the OZAKI procedure., Methods: Leftover pericardium (6 patients) was bisected directly after the operation, and one-half was further fixed for 10 additional minutes. Uniaxial tensile tests were performed and ultimate tensile strength (UTS), ultimate tensile strain (uts), and collagen elastic modulus were evaluated., Results: Both treatments resulted in similar values of uniaxial stretching-generated elongations at rupture (10 minutes 25 ± 7 % vs. 20 minutes: 22 ± 5 %; p = 0.05), UTS (5.16 ± 2 MPa vs. 6.54 ± 3 MPa; p = 0.59), and collagen fiber stiffness (elastic modulus: 31.80 ± 15.05 MPa vs. 37.35 ± 15.78 MPa; p = 0.25)., Conclusion: Prolongation of the fixation time of autologous pericardium has no significant effect on its mechanical stability; thus, extending the intraoperative treatment cannot be recommended.