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Diaddigo SE, LaValley MN, Kuonqui K, Janhofer DE, Ascherman JA. Flap management following orthotopic heart transplantation: A single institution's review of 66 sternal wound complications. J Plast Reconstr Aesthet Surg 2024; 90:266-272. [PMID: 38401198 DOI: 10.1016/j.bjps.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/14/2024] [Accepted: 02/01/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Sternotomy wound complications are more frequent after orthotopic heart transplantation (OHT) compared to other cardiac surgeries, primarily due to additional risk factors, including immunosuppression. Flap closure often becomes necessary for definitive treatment, although there is a scarcity of data on the outcomes of sternal wound reconstruction in this specific population. METHODS A retrospective analysis was conducted on 604 sternal wound reconstructions performed by a single surgeon between 1996 and 2023. Inclusion criteria comprised patients who underwent OHT as their primary cardiac procedure. Surgical interventions involved sternal hardware removal, debridement, and muscle flap closure. RESULTS The study included 66 patients, with culture-positive wound infection being the most common indication for reconstruction (51.5%). The median duration between transplantation and sternal wound reconstruction was 25 days. Bilateral pectoralis major myocutaneous advancement flaps (n = 63), rectus abdominis flaps (n = 2), or pectoralis major turnover flaps (n = 1) were used. Intraoperative wound cultures revealed positivity in 48 patients (72.7%), with Staphylococcus epidermidis being the most frequently cultured organism (25.0%). The overall complication rate was 31.8%, and two patient deaths were related to sternal wounds, resulting from multiorgan failure following septic shock. The majority of the patients reported excellent long-term functional and esthetic outcomes. CONCLUSIONS Sternal wounds following OHT pose a significant morbidity risk. Our strategy focuses on immediate and aggressive antibiotic therapy, thorough debridement, and definitive closure with bilateral pectoralis myocutaneous advancement flaps. This approach has demonstrated complication and mortality rates comparable to the general cardiac surgery population, as well as excellent functional and esthetic results.
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Affiliation(s)
- Sarah E Diaddigo
- Division of Plastic Surgery, Department of Surgery, Columbia University Irving Medical Center, Herbert Irving Pavilion, 5th Floor, 161 Fort Washington Avenue, New York, NY 10032, USA
| | - Myles N LaValley
- Division of Plastic Surgery, Department of Surgery, Columbia University Irving Medical Center, Herbert Irving Pavilion, 5th Floor, 161 Fort Washington Avenue, New York, NY 10032, USA
| | - Kevin Kuonqui
- Division of Plastic Surgery, Department of Surgery, Columbia University Irving Medical Center, Herbert Irving Pavilion, 5th Floor, 161 Fort Washington Avenue, New York, NY 10032, USA
| | - David E Janhofer
- Division of Plastic Surgery, Department of Surgery, Columbia University Irving Medical Center, Herbert Irving Pavilion, 5th Floor, 161 Fort Washington Avenue, New York, NY 10032, USA
| | - Jeffrey A Ascherman
- Division of Plastic Surgery, Department of Surgery, Columbia University Irving Medical Center, Herbert Irving Pavilion, 5th Floor, 161 Fort Washington Avenue, New York, NY 10032, USA.
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2
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Li Q, Zhan M, Liao Y, Wang X, Chen Y. Ultrasound-Guided Bilateral Continuous Superficial Parasternal Intercostal Plane Block Relieves Postoperative Pain After Pediatric Heart Transplantation. J Cardiothorac Vasc Anesth 2023; 37:2314-2317. [PMID: 37596101 DOI: 10.1053/j.jvca.2023.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/16/2023] [Accepted: 07/17/2023] [Indexed: 08/20/2023]
Affiliation(s)
- Qi Li
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Mingying Zhan
- Department of Anesthesiology, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Yi Liao
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaoe Wang
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yu Chen
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
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3
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Perezgrovas-Olaria R, Audisio K, Cancelli G, Rahouma M, Ibrahim M, Soletti GJ, Chadow D, Demetres M, Girardi LN, Gaudino M. Deep Sternal Wound Infection and Mortality in Cardiac Surgery: A Meta-analysis. Ann Thorac Surg 2023; 115:272-280. [PMID: 35618048 DOI: 10.1016/j.athoracsur.2022.04.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/20/2022] [Accepted: 04/23/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Deep sternal wound infection (DSWI) is a rare but severe complication after cardiac surgical procedures and has been associated with increased early morbidity and mortality. Studies reporting long-term outcomes in patients with DSWI have shown contradictory results. We performed a study-level meta-analysis evaluating the impact of DSWI on short- and long-term clinical outcomes. METHODS A systematic literature search was conducted to identify studies comparing short- and long-term outcomes of patients submitted to cardiac surgical procedures who developed DSWI and patients who did not. The primary outcome was overall mortality. Secondary outcomes were in-hospital mortality, follow-up mortality, major adverse cardiovascular events, myocardial infarction, and repeat revascularization. Postoperative outcomes were also investigated. RESULTS Twenty-four studies totaling 407 829 patients were included. Overall, 6437 (1.6%) patients developed DSWI. Mean follow-up was 3.5 years. DSWI was associated with higher overall mortality (incidence rate ratio [IRR], 1.99; 95% CI, 1.66-2.38; P < .001), in-hospital mortality (odds ratio, 3.30; 95% CI, 1.88-5.81; P < .001), follow-up mortality (IRR, 2.02; 95% CI, 1.39-2.94; P = .001), and major adverse cardiovascular events (IRR, 2.04; 95% CI, 1.60-2.59; P < .001). No differences in myocardial infarction and repeat revascularization were found, but limited studies reported those outcomes. DSWI was associated with longer postoperative hospitalization, stroke, myocardial infarction, and respiratory and renal failure. Sensitivity analyses on isolated coronary artery bypass grafting studies and by adjustment method were consistent with the main analysis. CONCLUSIONS Compared with patients who did not develop DSWI, patients with DSWI after cardiac surgical procedures had increased risk of death as well as short- and long-term adverse clinical outcomes.
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Affiliation(s)
| | - Katia Audisio
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mudathir Ibrahim
- Department of General Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Giovanni Jr Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - David Chadow
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Michelle Demetres
- Samuel J. Wood Library and C.V. Starr Biomedical Information Centre, Weill Cornell Medicine, New York, New York
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York.
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Tedesco-Silva H, Saliba F, Barten MJ, De Simone P, Potena L, Gottlieb J, Gawai A, Bernhardt P, Pascual J. An overview of the efficacy and safety of everolimus in adult solid organ transplant recipients. Transplant Rev (Orlando) 2021; 36:100655. [PMID: 34696930 DOI: 10.1016/j.trre.2021.100655] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/17/2021] [Accepted: 09/17/2021] [Indexed: 12/15/2022]
Abstract
As the risk of graft loss due to acute rejection has declined, the goal of post-transplant management has switched to long-term preservation of organ function. Minimizing calcineurin inhibitor (CNI)-related nephrotoxicity is a key component of this objective. Everolimus is a mammalian target of rapamycin inhibitor/proliferation-signal inhibitor with potent immunosuppressive and anti-proliferative effects. It has been widely investigated in large randomized clinical studies that have shown it to have similar anti-rejection efficacy compared with standard-of-care regimens across organ transplant indications. With demonstrated potential to facilitate the reduction of CNI therapy and preserve renal function, everolimus is an alternative to the current standard-of-care CNI-based regimens used in de novo and maintenance solid organ transplantation recipients. Here, we provide an overview of the evidence from the everolimus clinical study program across kidney, liver, heart, and lung transplants, as well as other key data associated with its use in CNI reduction strategies in adult transplant recipients.
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Affiliation(s)
| | - Faouzi Saliba
- AP-HP_Hôpital Paul Brousse, Hepato-Biliary Centre, Villejuif, France; Université Paris-Saclay, INSERM Unit 1193, France
| | - Markus J Barten
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | | | - Luciano Potena
- Heart Failure and Transplant Program, Cardiology Unit, IRCCS Policlinico di Sant'Orsola, Bologna, Italy
| | - Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | | | | | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain.
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5
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Abbo LM, Grossi PA. Surgical site infections: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13589. [PMID: 31077619 DOI: 10.1111/ctr.13589] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 05/06/2019] [Indexed: 02/06/2023]
Abstract
These guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of post-operative surgical site infections (SSIs) in solid organ transplantation. SSIs are a significant cause of morbidity and mortality in SOT recipients. Depending on the organ transplanted, SSIs occur in 3%-53% of patients, with the highest rates observed in small bowel/multivisceral, liver, and pancreas transplant recipients. These infections are classified by increasing invasiveness as superficial incisional, deep incisional, or organ/space SSIs. The spectrum of organisms implicated in SSIs in SOT recipients is more diverse than the general population due to other important factors such as the underlying end-stage organ failure, immunosuppression, prolonged hospitalizations, organ transportation/preservation, and previous exposures to antibiotics in donors and recipients that could predispose to infections with multidrug-resistant organisms. In this guideline, we describe the epidemiology, clinical presentation, differential diagnosis, potential pathogens, and management. We also provide recommendations for the selection, dosing, and duration of peri-operative antibiotic prophylaxis to minimize post-operative SSIs.
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Affiliation(s)
- Lilian M Abbo
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine and Jackson Health System, Miami, Florida
| | - Paolo Antonio Grossi
- Infectious Diseases Section, Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Wallen TJ, Habertheuer A, Gottret JP, Kramer M, Abbas Z, Siki M, Hobbs R, Vasquez C, Molina M, Kanchwala S, Low D, Acker M, Vallabhajosyula P. Sternal wound complications in patients undergoing orthotopic heart transplantation. J Card Surg 2019; 34:186-189. [DOI: 10.1111/jocs.14003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 02/05/2019] [Accepted: 02/07/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Tyler J. Wallen
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
- The University of Florida Health SystemGainesville Florida
| | | | - Jean P. Gottret
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - Matthew Kramer
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - Zara Abbas
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - Mary Siki
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - Reilly Hobbs
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - Charlie Vasquez
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - Maria Molina
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - Suhail Kanchwala
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - David Low
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - Michael Acker
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
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7
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Perioperative Antibiotic Prophylaxis to Prevent Surgical Site Infections in Solid Organ Transplantation. Transplantation 2018; 102:21-34. [DOI: 10.1097/tp.0000000000001848] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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8
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Recent Advances in Mammalian Target of Rapamycin Inhibitor Use in Heart and Lung Transplantation. Transplantation 2016; 100:2558-2568. [DOI: 10.1097/tp.0000000000001432] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Rashidi M, Esmaily S, Fiane AE, Gude E, A Tønseth K, Ueland T, Gustafsson F, Eiskjær H, Rådegran G, Dellgren G. Wound complications and surgical events in de novo heart transplant patients treated with everolimus: Post-hoc analysis of the SCHEDULE trial. Int J Cardiol 2016; 210:80-4. [PMID: 26938682 DOI: 10.1016/j.ijcard.2016.02.075] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/05/2016] [Accepted: 02/07/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The use of mammalian target of rapamycin (mTOR) inhibitors have been limited by adverse events (AE), including delayed wound healing. We retrospectively reviewed all AE and serious AE (SAE) in The Scandinavian heart transplant (HTx) everolimus (EVE) de novo trial with early calcineurin (CNI) avoidance (SCHEDULE). The aim of the study was to compare wound complications between EVE and CNI based regimen. MATERIALS AND METHODS A total of 115 patients (mean age 51 ± 13 years, 73% men) were randomized within five days post-HTx to low dose EVE and reduced dose Cyclosporine (CyA) followed by early CyA withdrawal (EVE group; n=56) or standard CyA regimen (CyA group; n=59). All AE/SAEs were prospectively recorded according to the SCHEDULE study protocol, and re-assessed retrospectively by two independent reviewers. Wound complication as primary endpoint was defined as any complication associated with failure of tissue healing. Secondary endpoint was total number of events involving surgical intervention. RESULTS There were no significant differences between the groups with regards to wound complications (EVE=20, CyA=12)(p=0.08) or total surgical events (EVE=38, CyA=34) (p=0.44). Age>54.5 years (median) was an overall risk factor for surgical wound complications regardless of treatment group (p=0.025). There was no difference in the EVE versus CyA group with regards to other surgical events. Majority of events were in 1/3 of the patients. CONCLUSION De novo initiation of EVE and early CyA withdrawal in HTx patients did not show any significant differences in wound complications or in total surgical events. Majority of complications were seen in a small number of patients.
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Affiliation(s)
- Mitra Rashidi
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway; Department of Plastic and Reconstructive Surgery, Oslo University Hospital, Oslo, Norway.
| | - Sorosh Esmaily
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Arnt E Fiane
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Norway
| | - Einar Gude
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Kim A Tønseth
- Department of Plastic and Reconstructive Surgery, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Norway
| | - Thor Ueland
- Faculty of Medicine, University of Oslo, Norway; Research Institute of Internal Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway; K.G. Jebsen Inflammatory Research Center, University of Oslo, Oslo, Norway; K.G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø, Norway
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Hans Eiskjær
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Göran Rådegran
- The Clinic for Heart Failure and Valvular Disease, Skåne University Hospital and Department of Clinical Sciences Lund, Cardiology, Lund University, Lund, Sweden
| | - Göran Dellgren
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
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10
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Novel Method of Infection Prophylaxis in Heart Transplantation by Retrosternal Gentamycin Sponge Application. Transplant Proc 2015; 47:1954-7. [PMID: 26293080 DOI: 10.1016/j.transproceed.2015.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 02/02/2015] [Accepted: 02/10/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND Surgical wound infections are more frequent in patients undergoing heart transplantation than in other heart surgery patients. There is a wide spread of sternal wound infection incidence in transplant patients ranging from 4% to 40%. It is first study describing local gentamicin sponge application during heart transplantation procedure. MATERIALS AND METHODS We enrolled 75 patients in a retrospective, single-center study, including 25 patients who underwent orthotopic heart transplantation (heart transplant group) and 50 in the cardiac surgery group. They were in mean age of 49 ± 12 years and 51 ± 13 years in heart transplantation and cardiac surgery group, respectively. A gentamicin sponge was inserted intraoperatively between sternal borders before chest closure in all heart transplantation patients. RESULTS There was 1 early death (4%) on postoperative day 7 owing to Clostridium difficile infection in the heart transplant group. There was 1 death (2%) in the cardiac surgery group owing to multiorgan failure secondary to perioperative heart ischemia. There was neither bacterial sternal wound infection nor sternal instability in the heart transplant group. None of the patients who had gentamicin sponge applied had wound healing problems. Two patients (4%) had a deep sternal wound infection in the cardiac surgery group, who had no sponge application; 1 (2%) was treated by surgical debridement and active drainage and 1 (2%) by vacuum therapy. There were 11 patients (44%) discharged on insulin therapy in the heart transplant group and 21 (21%) in the cardiac surgery group. Mean overall postoperative hospital stay was 35 ± 19 days in the heart transplant group and 10 ± 4 days in the cardiac surgery group. CONCLUSIONS Gentamicin sponge is an effective local infection prophylaxis in heart transplant patients.
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Dorschner P, McElroy LM, Ison MG. Nosocomial infections within the first month of solid organ transplantation. Transpl Infect Dis 2014; 16:171-87. [PMID: 24661423 DOI: 10.1111/tid.12203] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 10/24/2013] [Accepted: 11/26/2013] [Indexed: 12/11/2022]
Abstract
Infections remain a common complication of solid organ transplantation. Early postoperative infections remain a significant cause of morbidity and mortality in solid organ transplant (SOT) recipients. Although significant effort has been made to understand the epidemiology and risk factors for early nosocomial infections in other surgical populations, data in SOT recipients are limited. A literature review was performed to summarize the current understanding of pneumonia, urinary tract infection, surgical-site infection, bloodstream infection, and Clostridium difficult colitis, occurring within the first 30 days after transplantation.
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Affiliation(s)
- P Dorschner
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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12
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Kim HJ, Jung SH, Kim JJ, Kim JB, Choo SJ, Yun TJ, Chung CH, Lee JW. Early postoperative complications after heart transplantation in adult recipients: asan medical center experience. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2013; 46:426-32. [PMID: 24368968 PMCID: PMC3868689 DOI: 10.5090/kjtcs.2013.46.6.426] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 06/30/2013] [Accepted: 08/05/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND Heart transplantation has become a widely accepted surgical option for end-stage heart failure in Korea since its first success in 1992. We reviewed early postoperative complications and mortality in 239 patients who underwent heart transplantation using bicaval technique in Asan Medical Center. METHODS Between January 1999 and December 2011, a total of 247 patients aged over 17 received heart transplantation using bicaval technique in Asan Medical Center. After excluding four patients with concomitant kidney transplantation and four with heart-lung transplantation, 239 patients were enrolled in this study. We evaluated their early postoperative complications and mortality. Postoperative complications included primary graft failure, cerebrovascular accident, mediastinal bleeding, renal failure, low cardiac output syndrome requiring intra-aortic balloon pump or extracorporeal membrane oxygenation insertion, pericardial effusion, and inguinal lymphocele. Follow-up was 100% complete with a mean follow-up duration of 58.4±43.6 months. RESULTS Early death occurred in three patients (1.3%). The most common complications were pericardial effusion (61.5%) followed by arrhythmia (41.8%) and mediastinal bleeding (8.4%). Among the patients complicated with pericardial effusion, only 13 (5.4%) required window operation. The incidence of other significant complications was less than 5%: stroke (1.3%), low cardiac output syndrome (2.5%), renal failure requiring renal replacement (3.8%), sternal wound infection (2.0%), and inguinal lymphocele (4.6%). Most of complications did not result in the extended length of hospital stay except mediastinal bleeding (p=0.034). CONCLUSION Heart transplantation is a widely accepted option of surgical treatment for end-stage heart failure with good early outcomes and relatively low catastrophic complications.
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Affiliation(s)
- Ho Jin Kim
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Sung-Ho Jung
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Jae Joong Kim
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Joon Bum Kim
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Suk Jung Choo
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Tae-Jin Yun
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Cheol Hyun Chung
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Jae Won Lee
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
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Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013; 14:73-156. [PMID: 23461695 DOI: 10.1089/sur.2013.9999] [Citation(s) in RCA: 705] [Impact Index Per Article: 64.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Dale W Bratzler
- College of Public Health, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma 73126-0901, USA.
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Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283. [DOI: 10.2146/ajhp120568] [Citation(s) in RCA: 1364] [Impact Index Per Article: 124.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Ensor CR, Doligalski CT. Proliferation signal inhibitor toxicities after thoracic transplantation. Expert Opin Drug Metab Toxicol 2012; 9:63-77. [DOI: 10.1517/17425255.2012.726219] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Impact of De Novo Everolimus-Based Immunosuppression on Incisional Complications in Heart Transplantation. Transplantation 2011; 92:594-600. [DOI: 10.1097/tp.0b013e3182279133] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Abstract
Surgical wound complications are more frequent in patients undergoing heart transplantation than in other heart surgery patients. This is probably attributed to the presence of additional risk factors in these patients, such as immunosuppression, mechanical support through assist devices and generally poor health. Analyses of wound infections in heart transplantation are based on smaller patient population than those for general heart surgery, and the reported incidences vary largely. The identification of specific risk factors in heart transplant recipients to date is mainly based on retrospective case-control studies in small patient cohorts, the results are controversial, and the comparability of data is limited because of the lack of application of consistent definitions. The impact of immunosuppression and especially immunosuppression with mammalian target of rapamycin (mTOR) inhibitors on the development of surgical wound complications has been widely discussed following reports of increased occurrence with sirolimus. However, nonheart-transplant specific risk factors should also be considered to develop risk profiles and treatment algorithms for individual patients. Data on surgical wound complications in general heart surgery patients and in heart transplant recipients are compared, the impact of modern immunosuppression reviewed, and areas for further investigation discussed.
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Affiliation(s)
- Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.
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18
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Muñoz P, Giannella M, Michaels MG, Bouza E. Heart, lung and heart–lung transplantation. Infect Dis (Lond) 2010. [DOI: 10.1016/b978-0-323-04579-7.00076-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Chou N, Wang J, Chi N, Wu I, Huang S, Chen Y, Yu H, Tsao C, Ko W, Su H, Chang S, Chu S, Wang S. Surgical Treatment of Mediastinitis After Cardiac Transplantation. Transplant Proc 2008; 40:2629-30. [DOI: 10.1016/j.transproceed.2008.08.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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20
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Mauermann WJ, Sampathkumar P, Thompson RL. Sternal wound infections. Best Pract Res Clin Anaesthesiol 2008; 22:423-36. [DOI: 10.1016/j.bpa.2008.04.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Incidence, Treatment Strategies and Outcome of Deep Sternal Wound Infection After Orthotopic Heart Transplantation. J Heart Lung Transplant 2007; 26:1084-90. [DOI: 10.1016/j.healun.2007.07.036] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2007] [Revised: 06/12/2007] [Accepted: 07/23/2007] [Indexed: 11/17/2022] Open
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22
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Poghosyan T, Ackerman SJ, Ravenel JG. Infectious complications of solid organ transplantation. Semin Roentgenol 2007; 42:11-22. [PMID: 17174171 DOI: 10.1053/j.ro.2006.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Tereza Poghosyan
- Department of Radiology, Medical University of South Carolina, 169 Ashley Avenue, Charleston, SC 29425, USA
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23
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Miller LW. Heart Transplantation: Indications, Outcome, and Long-Term Complications. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_67] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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24
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Son HS, Sun K, Hwang CM, Fang YH, Lim CH, Lee HW, Park SM, Shin JS, Kim KT, Kim HM. Ventricular Assist Device Implantation Using a Right Thoracotomy. ASAIO J 2006; 52:386-90. [PMID: 16883117 DOI: 10.1097/01.mat.0000227692.75032.86] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Most patients needing implantation of a ventricular assist device (VAD) require repeated sternotomy; some after cardiac surgery, and others later for heart transplantation. The purpose of this study was to establish the right thoracotomy technique as an alternative for VAD implantation to reduce repeated sternotomy-related morbidity and mortality. We performed a right thoracotomy in animals, preclinical cadaver fitting tests, and a clinical case. A total of 20 various animals underwent right thoracotomy for implantation of bi-VAD (BVAD, n = 17) and left VAD (LVAD, n = 3). The right chest cavity was entered through the fourth intercostal space with partial resection of the fifth rib. There was no procedure-related morbidity or mortality, except for one calf with right anterior leg paralysis. Preclinical fitting tests were performed on 7 human cadavers to observe the anatomical feasibility of BVAD cannulation from the right side of the heart. In humans, the ascending aorta, interatrial groove, right atrium, and main pulmonary artery were identified as optimal cannula insertion sites for BVAD implantation. A patient with cardiogenic shock underwent a right thoracotomy for implantation of an external LVAD. Cardiac function recovered after 3 weeks, and the device was successfully explanted through a repeat right thoracotomy. In conclusion, a right thoracotomy can be an alternative method to the standard median sternotomy for patients who need repeated sternotomy because of previous cardiac surgery, transplantation at a later date, or those with mediastinal infections.
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Affiliation(s)
- Ho Sung Son
- Department of Thoracic and Cardiovascular Surgery, Korea University, Seoul, Korea
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25
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Routledge T, Saeb-Parsy K, Murphy F, Ritchie AJ. The Use of Vacuum-Assisted Closure in the Treatment of Post-transplant Wound Infections: A Case Series. J Heart Lung Transplant 2005; 24:1444. [PMID: 16143271 DOI: 10.1016/j.healun.2004.12.111] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2004] [Revised: 11/28/2004] [Accepted: 12/14/2004] [Indexed: 11/25/2022] Open
Abstract
We present 6 cases of the successful use of vacuum-assisted closure dressings as the primary treatment of wound infection after thoracic organ transplantation. In a series of 160 successive transplant operations, deep wound infections developed in 6 patients (3.7%). These all fully resolved over 3 to 29 days with the use of vacuum dressings. We believe vacuum-assisted closure therapy in the context of heart and lung transplantation is effective, well tolerated, and avoids the need for repeated surgical debridement and reconstruction.
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Affiliation(s)
- Tom Routledge
- Transplant Unit, Papworth Hospital, Papworth Everard, Cambridgeshire, United Kingdom.
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26
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Zucker MJ, Baran DA, Arroyo LH, Goldstein DJ, Neacy C, Mele L, Weinberg AD, Prendergast TW, Ribner HS. De Novo Immunosuppression With Sirolimus and Tacrolimus in Heart Transplant Recipients Compared With Cyclosporine and Mycophenolate Mofetil: A One-Year Follow-Up Analysis. Transplant Proc 2005; 37:2231-9. [PMID: 15964386 DOI: 10.1016/j.transproceed.2005.03.086] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2005] [Indexed: 02/07/2023]
Abstract
BACKGROUND Limited data exist regarding the safety and efficacy of sirolimus in combination with a calcineurin inhibitor in heart transplant recipients. METHODS From January 2001 to June 2002, 31 de novo heart transplant recipients (treatment group) received a combination of sirolimus, tacrolimus, low-dose rabbit antithymocyte globulin, and glucocorticoids. Outcomes, such as actuarial survival, rate of rejection, incidence of infection, probability of developing diabetes mellitus, renal function, platelet and white blood cell counts, and incidence of coronary artery disease at 1 year, were compared with a cohort of 25 patients (control group) who underwent transplantation primarily in 2000 and in early 2002 treated with cyclosporine, mycophenolate mofetil, and glucocorticoids. All patients were followed up for at least 12 months. RESULTS Kaplan-Meier actuarial 1-year survival rates were equivalent between groups (97% for the treatment group and 88% for the control group), as was freedom from allograft rejection (48% and 42% for treatment and control groups, respectively). No cases of transplant arteriopathy were noted within the first posttransplantation year. Renal function was not significantly affected in either group. There was a striking increased incidence of mediastinitis in the treatment group (19%) versus 0% in the control group (P = .02). Tacrolimus-sirolimus therapy was associated with a nearly 11-fold increased incidence of new-onset diabetes mellitus as well (P = .004). CONCLUSION Tacrolimus, sirolimus, and steroids (following low-dose rabbit antithymocyte globulin) were associated with an increased incidence of mediastinitis and posttransplantation diabetes mellitus. No obvious long-term benefit on survival, arteriopathy, or renal function was noted.
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Affiliation(s)
- M J Zucker
- Cardiothoracic Transplantation Program, Newark Beth Israel Medical Center, 201 Lyons Avenue, Newark, NJ 07112, USA.
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27
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Long CB, Shah SS, Lautenbach E, Coffin SE, Tabbutt S, Gaynor JW, Bell LM. Postoperative mediastinitis in children: epidemiology, microbiology and risk factors for Gram-negative pathogens. Pediatr Infect Dis J 2005; 24:315-9. [PMID: 15818290 DOI: 10.1097/01.inf.0000157205.31624.ed] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Mediastinitis, although an infrequent complication of median sternotomy, represents a significant source of morbidity and mortality. OBJECTIVE To determine the incidence and describe the epidemiology and microbiology of mediastinitis in children after cardiac surgery and to identify risk factors for the development of Gram-negative mediastinitis. STUDY DESIGN This was a retrospective case-control study nested within the cohort of children, birth to 18 years of age, undergoing median sternotomy between January 1, 1995 and December 31, 2003. RESULTS Forty-three cases of mediastinitis were identified. The incidence of mediastinitis was 1.4%. Median patient age at time of inciting sternotomy was 32 days (interquartile range, 5 days-9 months). Twenty-three (54%) cases occurred in girls. Median time to onset of infection after surgery was 11 days (range, 4-34 days). Overall Gram-positive organisms were present in 29 (67%) cases, and Gram-negative organisms were present in 13 (30%) cases. The organisms most commonly isolated from mediastinal culture were Staphylococcus aureus (46%), coagulase-negative staphylococci (17%) and Pseudomonas aeruginosa (17%). The rate of concurrent bacteremia was 53% (95% confidence interval, 38-69%). In multivariable analysis, delayed sternal closure was an independent risk factor for the development of Gram-negative mediastinitis (odds ratio, 9.3; 95% confidence interval, 1.5-56.8; P = 0.016). CONCLUSIONS Although Gram-positive organisms were the most common cause of infection, Gram-negative organisms accounted for one-third of all isolates. More than one-half of patients with mediastinitis had concurrent bacteremia. Delayed sternal closure was an independent risk factor for Gram-negative mediastinitis.
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Affiliation(s)
- Caroline B Long
- Divisions of General Pediatrics, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA
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28
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Dumont E, Carrier M, Cartier R, Pellerin M, Poirier N, Bouchard D, Perrault LP. Repair of aortic false aneurysm using deep hypothermia and circulatory arrest. Ann Thorac Surg 2004; 78:117-20; discussion 120-1. [PMID: 15223414 DOI: 10.1016/j.athoracsur.2004.01.028] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2004] [Indexed: 11/18/2022]
Abstract
BACKGROUND Aortic false aneurysms are a rare complication of surgery of the aorta that can occur several months to years after the initial operation. We reviewed our results with false aneurysm repair using deep hypothermia and circulatory arrest. METHODS Eleven patients were reoperated on for false aneurysm of either the ascending or descending thoracic aorta. Femorofemoral cardiopulmonary bypass with full-dose aprotinin and a heparinized system was used in all patients. Hypothermic circulatory arrest at an average of 20 degrees C was instituted in all patients for repair. Six patients had a patch repair with either polyethylene terephthalate fiber (Dacron) or bovine pericardium, 4 had tube replacement of the aorta, and 1 had primary repair of the defect. RESULTS Three patients had false aneurysm formation at a site of coarctation repair in the descending aorta, and the 8 others had false aneurysms in the ascending aorta at the site of a previous aortotomy. Six patients had proven infection as the cause; the causative agent was Staphylococcus species in all cases. Mean cardiopulmonary bypass time was 178 +/- 51 minutes, and circulatory arrest time averaged 39 +/- 18 minutes. Operative mortality was 18% (2 of 11); the cause of death was cardiogenic shock in both patients. The mean time to extubation in survivors was 5 days, and the average time to discharge was 16 days. CONCLUSIONS Although mediastinal infection is a common cause, aortic false aneurysms can be safely approached using femorofemoral cardiopulmonary bypass, hypothermic circulatory arrest, and patch repair with acceptable operative mortality and long-term survival.
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Affiliation(s)
- Eric Dumont
- Department of Surgery, Research Center of the Montreal Heart Institute and the University of Montreal, Montreal, Quebec, Canada
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29
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Sjögren J, Gustafsson R, Dobre M, Koul B, Ingemansson R, Algotsson L. Vacuum-assisted closure therapy in mediastinitis after heart transplantation. J Heart Lung Transplant 2004; 23:506-7. [PMID: 15063416 DOI: 10.1016/s1053-2498(03)00224-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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30
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Affiliation(s)
- David H Song
- Sections of Plastic and Reconstructive Surgery, University of Chicago Hospitals, 5841 S. Maryland Avenue, MC 6035, Chicago, IL 60637, USA.
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31
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Abid Q, Nkere UU, Hasan A, Gould K, Forty J, Corris P, Hilton CJ, Dark JH. Mediastinitis in heart and lung transplantation: 15 years experience. Ann Thorac Surg 2003; 75:1565-71. [PMID: 12735580 DOI: 10.1016/s0003-4975(02)04905-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Mediastinitis after sternotomy carries a very high mortality, especially in patients receiving immunosuppressive treatment. METHODS A retrospective analysis of the data for patients who had undergone cardiopulmonary transplantation between May 1985 and December 2000 was undertaken. A total of 776 patients had either a median sternotomy or a transverse sternotomy through a clam-shell incision. Transplantations were as follows: 591 heart (3 simultaneous heart and renal, and 1 heart and liver), 126 bilateral sequential lung, 57 heart-lung, 1 en bloc double-lung, and 1 heart and single-lung. RESULTS In all, 21 (2.7%) recipients had mediastinitis. Of these, 14 had heart, 3 heart-lung, and 4 bilateral lung transplantation. There were 18 median and 3 transverse sternotomies. There were 6 deaths (28.6%). Treatment consisted of antibiotics alone in 2 patients and subxiphisternal drainage in another 2 patients. The sternum was reopened in 17 (80.95%) patients, with debridement and primary closure alone in 5 of these 17 patients and additional irrigation in the other 12. Those who had resternotomy, debridement, and substernal irrigation had a better outcome when compared with the outcomes of other modes of treatment (1 death among 12 patients) (p = 0.06). Age, cardiopulmonary bypass time, body mass index, time to diagnosis, and treatment did not differ between those who survived and those who did not. CONCLUSIONS Early aggressive debridement with substernal irrigation is the best mode of treatment for patients with posttransplantation mediastinitis.
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Affiliation(s)
- Qamar Abid
- Department of Cardiopulmonary Transplantation, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom.
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32
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Stojicić M, Birovljev S, Jovanović M, Colić M. [Treatment of defects of soft tissue and sternum, as postoperative complications of A-C bypass, case report]. ACTA CHIRURGICA IUGOSLAVICA 2003; 50:147-50. [PMID: 15307513 DOI: 10.2298/aci0304147s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
Medial sternotomy is optimal approach for great number of heart surgery. Deep infection of sternum and mediastinis are very rear, but very dangerous complications followed by high rate of morbidity and mortality. Factors which can be responsible for these complications are numerous: post operation bleedings, surgery reinterventions, extended mechanical ventilation, liver chronic diseases, older age, diabetes, previous irradiation therapy, respiratory obstructions and use of steroids. Clinical signs for these complications are: red skin around the surgical wound, leaking, dehiscence, increased body temperature and instability of sternum. Early diagnosis, adequate antimicrobial therapy, and aggressive surgical and multidisciplinary approach in initial phase, are base for successful treatment. Surgical treatment most often assumes use of flaps. Our main objective in this work was to present treatment of defect of sternum and soft tissues, after triple aorto-coronary bypass. After the surgery patients got slack of sternum's ficsation and reficsation. With satisfactory respiratory function, corrections of defect was achieved by omentum and bipedicular myocutan flaps. (m. pectoralis major flap). There was no complications.
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Affiliation(s)
- M Stojicić
- Centar za opekotine, plasticnu i rekonstruktivnu hirurgiju KCS, Beograd
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