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Sukhavasi A, Ahmad D, Austin M, Rame JE, Entwistle JW, Massey HT, Tchantchaleishvili V. Utility of Recipient Cardiothoracic Ratio in Predicting Delayed Chest Closure after Heart Transplantation. Thorac Cardiovasc Surg 2024; 72:253-260. [PMID: 36652964 DOI: 10.1055/a-2015-1507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Predicted cardiac mass (PCM) has been well validated for size matching donor hearts to heart transplantation recipients. We hypothesized that cardiothoracic ratio (CTR) could be reflective of recipient-specific limits of oversizing, and sought to determine the utility of donor to recipient PCM ratio (PCMR) and CTR in predicting delayed chest closure after heart transplantation. METHODS A retrospective review of prospectively collected data on 38 consecutive heart transplantations performed at our institution from 2017 to 2020 was performed. Donor and recipient PCM were estimated using Multi-Ethnic Study of Atherosclerosis predictive models. Receiver operating characteristic analysis was performed to determine the discriminatory power of the ratio of PCMR to CTR in predicting delayed sternal closure. RESULTS Of the 38 patients, 71.1% (27/38) were male and the median age at transplantation was 58 (interquartile range [IQR]: 47-62) years. Ischemic cardiomyopathy was present in 31.6% of recipients (12/38). Median recipient CTR was 0.63 [IQR: 0.59-0.66]. Median donor to recipient PCMR was 1.07 [IQR: 0.96-1.19], which indicated 7% oversizing. Thirteen out of 38 (34.2%) underwent delayed sternal closure. Primary graft dysfunction occurred in 15.8% (6/38). PCMR/CTR showed good discriminatory power in predicting delayed sternal closure [area under the curve: 80.4% (65.3-95.6%)]. PCMR/CTR cut-off of 1.7 offered the best trade-off between the sensitivity (69.6%) and specificity (91.7%). CONCLUSION CTR could be helpful in guiding the recipient-specific extent of oversizing donor hearts. Maintaining the ratio of PCMR to CTR below 1.7 could avoid excessive oversizing of the donor heart.
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Affiliation(s)
- Amrita Sukhavasi
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Danial Ahmad
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Melissa Austin
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - J Eduardo Rame
- Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - John W Entwistle
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Howard T Massey
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
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Abdelrehim AA, Stephens EH, Pochettino A, Wittwer ED, Ashikhmina EA, Todd AL, Daly RC, Crestanello JA, Schaff HV, Dearani JA. Delayed Sternal Closure vs Emergency Sternal Reopening in Adults With Congenital Heart Disease. Ann Thorac Surg 2024:S0003-4975(24)00373-4. [PMID: 38763220 DOI: 10.1016/j.athoracsur.2024.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 04/17/2024] [Accepted: 04/22/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Limited data exist regarding outcomes of delayed sternal closure (DSC) in adults with congenital heart disease (ACHD). METHODS We reviewed 159 ACHD patients undergoing cardiac operation from 1993 to 2023 who required DSC (open sternum at the end of operation, n = 112) or sternum emergently reopened (n = 47). Regression models were performed to determine factors associated with outcomes. RESULTS Of 112 patients undergoing DSC, 87 patients (77.6%) underwent DSC ≤4 days and 25 patients (22.3%) >4 days. The most common operations were valve (n = 35 [31.2%]), aortic (n = 33 [29.4%]), and right ventricular outflow tract procedures (n = 23 [20.5%]). Median time to chest closure was 2 days (interquartile range, 1-5 days). Apart from sex, baseline characteristics were similar between DSC groups. A stepwise increase in early mortality was observed from DSC ≤4 days to DSC >4 days (6.8% vs 32%), as well as the incidence of early complications, except sternal infection. Risk factors associated with early mortality were age (P = .02), DSC >4 days (P < .001), hemodynamic indication (P = .03), and single ventricle (P = .02). On multivariable analysis, lower ejection fraction (P = .04), hemodynamic indication (P = .02), single ventricle (P = .004), and diabetes mellitus (P = .03) were predictors of prolonged time to chest closure. Among hospital survivors, late survival was similar between patients undergoing DSC ≤4 days vs >4 days (P = .48). CONCLUSIONS A brief duration of DSC in ACHD patients is associated with low morbidity and mortality. Higher early mortality and complications were observed among patients who did not achieve chest closure within 4 days.
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Affiliation(s)
| | | | | | - Erica D Wittwer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Elena A Ashikhmina
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Austin L Todd
- Department of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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Quintana E, Ranchordas S, Ibáñez C, Danchenko P, Smit FE, Mestres CA. Perioperative care in infective endocarditis. Indian J Thorac Cardiovasc Surg 2024; 40:115-125. [PMID: 38827544 PMCID: PMC11139830 DOI: 10.1007/s12055-024-01740-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/10/2024] [Accepted: 04/12/2024] [Indexed: 06/04/2024] Open
Abstract
Patients undergoing surgery for acute infective endocarditis are among those with the highest risk. Their preoperative condition has significant impact on outcomes. There are specific issues related with the preoperative situation, intraoperative findings, and postoperative management. In this narrative review, focus is placed on the most critical aspects in the perioperative period including the management and weaning from mechanical ventilation, the management of vasoplegia, the management of the chest open, antithrombotic therapy, transfusion, coagulopathy, management of atrial fibrillation, the duration of antibiotic therapy, and pacemaker implantation.
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Affiliation(s)
- Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clínic, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Sara Ranchordas
- Cardiac Surgery Department, Hospital Santa Cruz, Carnaxide, Portugal
| | - Cristina Ibáñez
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Polina Danchenko
- Department of Myocardial Pathology, Transplantation and Mechanical Circulatory Support, Amosov National Institute of Cardiovascular Surgery, Kiev, Ukraine
| | - Francis Edwin Smit
- Department of Cardiothoracic Surgery and The Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Carlos - Alberto Mestres
- Department of Cardiothoracic Surgery and The Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
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Kopanczyk R, Lester J, Long MT, Kossbiel BJ, Hess AS, Rozycki A, Nunley DR, Habib A, Taylor A, Awad H, Bhatt AM. The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action. MEDICINA (KAUNAS, LITHUANIA) 2022; 59:47. [PMID: 36676669 PMCID: PMC9867461 DOI: 10.3390/medicina59010047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
Cardiothoracic surgical critical care medicine (CT-CCM) is a medical discipline centered on the perioperative care of diverse groups of patients. With an aging demographic and an increase in burden of chronic diseases the utilization of cardiothoracic surgical critical care units is likely to escalate in the coming decades. Given these projections, it is important to assess the state of cardiothoracic surgical intensive care, to develop goals and objectives for the future, and to identify knowledge gaps in need of scientific inquiry. This two-part review concentrates on CT-CCM as its own subspeciality of critical care and cardiothoracic surgery and provides aspirational goals for its practitioners and scientists. In part one, a list of guiding principles and a call-to-action agenda geared towards growth and promotion of CT-CCM are offered. In part two, an evaluation of selected scientific data is performed, identifying gaps in CT-CCM knowledge, and recommending direction to future scientific endeavors.
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Affiliation(s)
- Rafal Kopanczyk
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Jesse Lester
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Micah T. Long
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, Madison, WI 53792, USA
| | - Briana J. Kossbiel
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Aaron S. Hess
- Department of Anesthesiology and Pathology & Laboratory Medicine, University of Wisconsin Hospitals & Clinics, Madison, WI 53792, USA
| | - Alan Rozycki
- Department of Pharmacology, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - David R. Nunley
- Department of Pulmonary, Critical Care & Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Alim Habib
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Ashley Taylor
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Hamdy Awad
- Department of Anesthesiology, Division of Cardiothoracic and Vascular Anesthesia, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Amar M. Bhatt
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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Pilot MA, Lutchman A, Hennet J, Anderson D, Robinson W, Rossanese M, Chrysopoulos A, Demetriou J, De la Puerta B, Mullins RA, Brissot H, Jeffery N, Chanoit G. Comparison of median sternotomy closure-related complication rates using orthopedic wire or suture in dogs: A multi-institutional observational treatment effect analysis. Vet Surg 2022; 51:990-1001. [PMID: 35765719 PMCID: PMC9543654 DOI: 10.1111/vsu.13846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 05/08/2022] [Accepted: 06/03/2022] [Indexed: 12/24/2022]
Abstract
Objective To determine and compare median sternotomy (MS) closure‐related complication rates using orthopedic wire or suture in dogs. Study design Multi‐institutional, retrospective observational study with treatment effect analysis. Animals 331 client‐owned dogs, of which 68 were excluded. Methods Medical records of dogs with MS were examined across nine referral centers (2004–2020). Signalment, weight, clinical presentation, surgical details, complications, and outcomes were recorded. Follow‐up was performed using patient records and email/telephone contact. Descriptive statistics, treatment effect analysis and logistic regression were performed. Results Median sternotomy closure was performed with wire in 115 dogs and suture in 148. Thirty‐seven dogs experienced closure‐related complications (14.1%), 20 in the wire group and 17 in the suture group. Twenty‐three were listed as mild, four as moderate and 10 as severe. Treatment effect analysis showed a mean of 2.3% reduction in closure‐related complications associated with using suture versus wire (95% CI: −9.1% to +4.5%). In multivariable logistic regression, the only factor associated with increased risk of closure‐related complications was dog size (p = .01). This effect was not modified by the type of closure used (interaction term: OR = 0.99 [95% CI: 0.96/1.01]). Conclusion The incidence of closure‐related complication after MS was low compared to previous reports. The likelihood of developing a closure‐related complication was equivalent between sutures and wires, independent of dog size, despite a higher proportion of complications seen in larger dogs (≥20 kg). Clinical significance Use of either orthopedic wire or suture appear to be an appropriate closure method for sternotomy in dogs of any size.
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Affiliation(s)
- Mariette A Pilot
- Small Animal Referral Hospital Langford Vets, University of Bristol, Bristol, UK
| | - Aaron Lutchman
- The Royal Veterinary College, Queen Mother Hospital for Animals, Hatfield, UK
| | - Julie Hennet
- Anderson Moores Veterinary Specialists, Hursley, UK
| | | | | | - Matteo Rossanese
- Small Animal Teaching Hospital of the University of Liverpool, Neston, UK
| | | | | | | | - Ronan A Mullins
- Section of Small Animal Clinical Sciences, University College Dublin, Dublin, Ireland
| | | | - Nicholas Jeffery
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Guillaume Chanoit
- Small Animal Referral Hospital Langford Vets, University of Bristol, Bristol, UK
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Kusne S, Irish W, Arabia F. Extended systemic antibiotic prophylaxis in ventricular assist device recipients, an infectious disease perspective. J Card Surg 2022; 37:1819-1823. [PMID: 35655403 DOI: 10.1111/jocs.16487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/28/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate whether mediastinitis/deep sternal wound infection (Med/DSWI) is more common in ventricular assist device (VAD) with delayed sternal closure (DSC) compared to VAD with primary sternal closure (PSC). METHODS A literature search was done over the last four decades for studies that addressed this comparison. RESULTS Two studies met our inclusion criteria, and their results are contradictory. The first study compared 184 VAD recipients with PSC to 180 VAD recipients with DSC. There was no difference in VAD-related infections between DSC and PSC (15% vs. 16%, respectively; odds ratio = 0.965, 95% confidence interval [CI] = 0.525-1.635). The second study compared 464 VAD recipients with PSC to 94 VAD recipients with DSC. The rate of surgical site infection was higher in the DSC patients (12.5% vs. 1.4%, respectively; odds ratio = 10.1; 95% CI = 3.8-27.0). DSC was identified as an independent risk factor for postoperative mortality, but no detailed infection information was given. CONCLUSIONS There is no clear evidence of the association between DSC, compared to PSC, and Med/DSWI. Therefore, DSC is not an absolute indication for extended systemic antibiotic prophylaxis. The decision to extend the duration of systemic antibiotic prophylaxis should be made on a case-by-case basis, in collaboration with an infectious disease specialist.
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Affiliation(s)
- Shimon Kusne
- Division of Infectious Diseases, Mayo Clinic, Scottsdale, Arizona, USA
| | - William Irish
- Department of Surgery, The Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Francisco Arabia
- Departments of Surgery and Medicine, Banner-University Medical Center Phoenix, Phoenix, Arizona, USA
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Chen C, Zheng Q, Wu D, Song Y, Xu G. Review of outcomes of delayed chest closure following lung transplantation: a meta-analysis. J Cardiothorac Surg 2022; 17:122. [PMID: 35590331 PMCID: PMC9118833 DOI: 10.1186/s13019-022-01868-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 04/29/2022] [Indexed: 02/08/2023] Open
Abstract
Purpose The clinical outcomes of delayed chest closure (DCC) compared with primary chest closure (PCC) following lung transplantation, including perioperative outcomes and long-term survival, remained controversial. This was the first systematic review and meta-analysis aimed to identify the short- and long-term outcomes of DCC following lung transplantation. Methods We comprehensively searched electronic literature from 4 databases up to April 1st, 2022. Dichotomous data and continuous data were pooled with odds ratio and weighted mean difference, respectively. The quality of included studies was assessed with the Newcastle–Ottawa Scale. Results Ten studies were included in the systematic review and 4 studies were included in the meta-analysis. Pooled analysis showed that DCC was associated with an increased risk of surgical site infection, prolonged hospital stays, and higher risk of primary graft dysfunction compared to PCC. The 30 day and 5 year survival were higher in PCC cohort compared with DCC cohort while differences in survival at 6 months was insignificant. Conclusion Our findings do not support the aggressive application of DCC. DCC should be cautiously applied since its association with worse perioperative outcomes and higher mortality. But it remains the life-saving steps under dangerous circumstances.
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Affiliation(s)
- Cheng Chen
- Department of Thoracic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, China.,Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Quan Zheng
- West China School of Medicine, Sichuan University, Chengdu, 610041, China
| | - Dongsheng Wu
- West China School of Medicine, Sichuan University, Chengdu, 610041, China
| | - Yongxiang Song
- Department of Thoracic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, China
| | - Gang Xu
- Department of Thoracic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, China.
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Takami Y, Amano K, Sakurai Y, Akita K, Hayashi R, Maekawa A, Takagi Y. Impact of preoperative nasopharyngeal cultures on surgical site infection after open heart surgery. JTCVS OPEN 2021; 8:478-486. [PMID: 36004050 PMCID: PMC9390427 DOI: 10.1016/j.xjon.2021.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/13/2021] [Indexed: 11/16/2022]
Abstract
Objectives Despite advances in surgical techniques and management, surgical site infection (SSI) is still important after cardiovascular surgery. We investigated to determine whether or not preoperative nasopharyngeal cultures (NCx) can predict SSI and its microbial spectrum. Methods A retrospective review was done in 1226 consecutive patients undergoing NCx and cardiac and thoracic aortic surgery via median sternotomy who were cared for with the standard SSI bundle between 2013 and 2018. Microorganisms isolated from the NCx and SSI pathogens were counted to explore the microbial pattern and associated variables in patients with and without postoperative SSI. Perioperative management was not changed by collection of preoperative NCx. Results There were 1281 and 127 microorganisms, including coagulase-negative Staphylococcus as the most prevalent, isolated from 784 nasal and 111 pharyngeal specimens, respectively. Postoperative SSI occurred in 31 patients (2.47%), including chest, groin, and leg SSI. Significant coincidence of the SSI pathogens with the NCx microorganisms was not observed. However, the patients with SSI showed significantly higher positive rates of preoperative NCx than those without SSI. The sensitivity/specificity of NCx for SSI were 81%/37% for nasal and 45%/92% for pharyngeal, respectively. The negative predictive value of NCx for ruling out SSI was 98.6% for nasal and 98.4% for pharyngeal, respectively. Independent risk factors for postoperative SSI included female sex, diabetes mellitus, positive preoperative NCx, and postoperative use of Portex Mini-Trach (Smiths Medical, Minneapolis, Minn) or tracheostomy on multivariate analysis. Conclusions Preoperative NCx may be useful to predict SSI after open heart surgery via median sternotomy, as well as screening for methicillin-resistant Staphylococcus aureus.
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