Mediastinitis after cardiac surgery

Departamentul Cardiochirurgie SCR, Al XI-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova și cea de-a XXXIII-a Reuniune a Chirurgilor din Moldova „Iacomi-Răzeșu” 27-30 septembrie 2011Scopul lucrării. Mediastenita anterioară după operații pe cord, determină o rată sporită a morbidității, care denotă mărirea costului mediu a cazului tratat a acestui contingent de pacienți. Scopul acestui studiu a fost de a determina cauzele ce condiționează apariția mediastinitei postoperatorie. Metode şi materiale. În perioada anilor 2000 - 2010 au suportat intervenţie chirurgicală pe cord 2634 pacienţi. La 44 (1,67%) de pacienți perioada postoperatorie s-a complicat cu infectarea plăgii. În 22 (50%) cazuri s-a dezvoltat mediastenita anterioară și în 22 (50%) cazuri infectarea plăgii pînă la stern, ulterior s-a dezvoltat mediastinita cu sau fără dehiscența sternului.Grupul de pacienți a fost constituit din 30 (68,1%) bărbați şi 14(31,9%) femei, cu vîrsta medie de 59 de ani. Preoperator 20 (45%) pacienți erau obezi, 6 (13,6%) sufereau de diabet zaharat și 7 (16%) bronhopneumopatie cronică obstructivă. Pentru By-pass aortocoronarian s-a folosit artera toracică internă (ATI) unilateral în 18 (40%) şi bilateral la 1 (2,3%) pacient. Timpul intervenției chirurgicale în mediu a alcătuit 345min. Transfuzii masive postoperator au necesitat 5 (11,3%) pacienți. Diagnosticul de mediastenita a fost stabilit la a 5 - 17 zi postoperator. Restabilirea integrității sternale cu aplicarea procedeului Robicsek s-a efectuat la 14(31,8%) pacienți. A decedat 1 pacient (2,3%) din acest grup, cu mediastinita sero-purulentă la a - 20 zi postoperaror din cauza insuficienței poliorganice. La 4 pacienți s-a dezvoltat osteomielită sternală, care a necesitat tratament de lungă durată (3 - 6 luni). Concluzia: Studiul sugerează că utilizarea ATI uni sau bilaterale, bronhopneumopatie cronica obstructivă, diabetul zaharat, obezitatea, transfuziile masive, timpul îndelungat a operației sunt predictori importanți de mediastinită anterioară.Abstract. Background: Mediastinitis is a serious complication of cardiac surgery. It has a significantsocioeconomic impact and high morbidity. The purpose of this study was to determine perioperative predictors of mediastinitis. Methods and results: From 2634 consecutive pacients, which underwent cardiac surgery in 2000-2010. In forty-four pacients (1.67%) postoperative period was complicated by wound infection. In 22 (50%) cases developed earlier mediastenitis and 22 (50%) cases sternum wound infection subsequently developed mediastinitis with or without dehiscence of the sternum. In this group of pacients 30 were men (68.1%) and 14 women (31.9%) of average age 59 years. Preoperator, 20 (45%) of them had obesity, 6 (13.6%) suffered of diabetes mellitus and 7 (16%) of chronic obstructive pulmonary disease. As a graft for Coronary Artery Bypass (IMA) was used unilaterally 18 (40%) and bilateral 1 (2.3%) pacient. The average time of surgery duration was 345 min. Massive transfusion after surgery was certified on five pacients (11.3%). Diagnosis of Mediastenitis was established at the 5 - 17 days postoperatively. Restoration of sternal integrity with the Robicsek proceeding was performed in 14 (31.8%) pacients.One pacient 1(2.3%) of this group with mediastinitis diet after 20 days postoperative, due to failure Multiple Organ System Dysfunctions. In four pacients developed sternal osteomyelitis, requiring long-term treatment (3-6 months). Conclusion: The present study suggest that uni/bilateral internal mammary artery grafting, chronic obstructive pulmonary disease, obesity, massive transfused units and long surgery duration are important predictors of mediastinitis

Retracted cusps augmentation in corection of relative tricuspid insufficiency

Departamentul Cardiochirurgie, Spitalul Clinic Republican, Chişinău, Republica Moldova, Al XII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova cu participare internațională 23-25 septembrie 2015Introducere: Insuficienţa tricuspidă relativă (ITR) evoluează cu o mortalitate sporită şi deteriorarea în timp a rezultatelor corecţiei valvulopatiilor asociate. Ea este cauzată de alterarea geometriei VD, „tethering”-ul cuspelor valvei tricuspide (TCVT) şi dilatarea inelului ei fibrotic. Scopul studiului a fost aprecierea eficacităţii tehnicilor de corecţie a ITR cauzată de TCVT utilizând procedee noi de augumentare a cuspelor anterioare şi posterioare cu pericard autolog. Material şi metode: Pe parcursul ultimilor 10 ani au fost efectuate 1004 operaţii reconstructive în ITR. Fenomenul TCVT cu regurgitaţii gr.III-IV a fost diagnosticat în 112 cazuri. Ecocardiografic au fost evaluate diametrul cavităţii medii a VD, aria de TCVT, diametrul inelului fibrotic, presiunea sistolică în VD. În 61 cazuri au fost efectuată anuloplastia De Vega, în 17 – a fost aplicat un petic de lărgire în baza cuspelor anterioară şi posterioară a VT cu implantarea unui inel de suport. Ceilalţi pacienţi au beneficiat de protezări valvulare. Rezultate: Postoperator regurgitări reziduale >gr.II au fost diagnosticate în grupul de pacienţi după anuloplastie De Vega în 15 (24,6%) cazuri, cu recidiva patologiei în perioada de durată la 9 pacienţi, 5 dintre ei au necesitat reoperaţie. După augumentare a fost înregistrat un caz de regurgitare până la gr.II, fără cazuri de recurenţă şi reoperaţii. Analiza statistică multivariantă confirmă că diametrul cavităţii medii a VD şi aria de TCVT sunt determinante în apariţia efectelor adverse după corecţia reconstructivă a ITR. Concluzii: Procedeul de augumentare poate înlătura efectiv fenomenul de TCVT şi împreună cu anuloplastia cu inel de suport poate asigura o corecţie adecvată şi durabilă a ITR.Introduction: Relative tricuspid insufficiency (RTI) evolves with significant mortality and deteriorates in time the results of correction of associated valve pathology. It is caused by altering of the RV geometry, tricuspid valve cusps tethering (TVCT) and fibrous ring dilatation. Purpose of study was assessment of effectiveness of RTI correction techniques caused by TVCT using new methods of anterior and posterior cusps augmentation with autologous pericardium. Material and methods: During last 10 years 1004 reconstructive operations for RTI were performed. TVCT with regurgitation of gr.III-IV was diagnosed in 112 cases. The average diameter of the RV, TVCT area, fibrotic ring diameter, RV systolic pressure were assessed by echocardiography. De Vega annuloplasty was performed in 61 cases and a patch for widening the base of the anterior and posterior TV with implantation of a support ring was applied in 17, other patients received valve prosthesis. Results: Postoperative residual regurgitation >gr.II was diagnosed in the group of patients after De Vega annuloplasty in 15 (24.6%) cases, with pathology relapse in the long-term period at 9 patients, 5 of them required reoperation. After augmentation was one case of regurgitation up to gr.II, without recurrence and reoperation. Multivariate statistical analysis confirms that the RV mean diameter and TVCT area determines the appearance of adverse effects after reconstructive correction of RTI. Conclusions: Augmentation procedure can effectively eliminate the phenomenon of TVCT and together with support ring annuloplasty may provide adequate and durable correction of the RTI

Myocardial revascularization on a beating heart

Department of Cardiac Surgery, Republican Hospital, Chisinau, the Republic of MoldovaBackground: Myocardial revascularization on a beating heart in case of the atherosclerotic affection of the coronory arteries. Material and methods: Retrospective analysis of 372 operations (myocardial revascularization without extracorporeal circulation) performed in 2002 October 2013. Results: In our study most patients were extubated within 24 hours. Mechanical ventilation of the lungs for more than 24 hours was required 11 patients (2.9%). Arrhythmias were 63 (17%) patients (atrial fibrillation – 56, atrial flutter – 7), that required additional administration of antiarrhythmic preparations to restore sinus rhythm, but in 11 cases was performed cardioversion. In the early postoperative period died 3 (0.8%) patients: 1 – acute renal failure, 1 – polyorganic failure, 1 – ventricular fibrillation. Conclusion: Off-pump coronary artery bypass (OPCAB) challenges the conventionalon-pump coronary artery bypass grafting (CABG) as the standardof surgical therapy for coronary disease. Conventional coronary bypass surgery is associated with substantialmorbidity caused by cardiopulmonary bypass. Conventional CABG has been performed with reproducible success, but complications cause significant morbidity and mortality. Some complications may be secondary to cardiopulmonary bypass (CPB) and include neurological dysfunction and a systemic inflammatory response syndrome ending in vital organ damage. Although OPCAB on a beating heart is an attractive alternative to conventional CABG on CPB, it also has drawbacks

Tratamentul complicaţiilor infecţioase după sternotomie în chirurgia cardiacă

Departamentul de chirurgie cardiacă, IMSP Spitalul Clinic RepublicanObiectiv: Mediastinita anterioară este una din complicaţiile majore după sternotomie în chirurgia cardiacă. Determinarea factorilor de risc ce pot determina apariţia acestor complicaţii, diagnosticul timpuriu, managementul chirurgical etapizat este de o importanţă majoră în tratamentul acestor pacienţi. Metode: Pe parcursul anilor 2000-2013 în secţia de chirurgie cardiacă cu mediastinită postoperatorie au fost trataţi 63 pacienţi (1,81% cazuri), inclusiv, 33 dintre ei (0,94%) cu infecţii profunde în plaga operatorie, 30 (0,86%) - cu sau fară dehiscenţă de stern. Grupul de studiu a fost format din 45(71,4%) barbaţi şi 18(28,5%) femei, avînd o vîrstă medie de 59 de ani, 30(47,6%) dintre ei sufereau de obezitate, 16(22,2%) sufereau de diabet zaharat, 41 (65%) de boală pulmonară cronică obstructivă. Folosirea unei arterei mamare interne (AMI) a fost la 29(46%), iar a ambelor artere mamare la 3(4,76%) dintre pacienţi. Durata medie de intervenţie chirurgicală a fost de 312 min. Terapie transfuzională au necesitat 19 (30,2%) din pacienţi. Mediastinita a fost diagnostificată la a 5-17 zi postoperator. Rezultate: Aplicarea metodelor deschise, debridarea timpurie, instalarea irigaţiei convenţionale au fost preferabile în etapizarea tramentului chirurgical. Resuturarea sternului prin procedeul Robicsek a fost efectuată la 22(35%) din pacienţi. Un caz de deces (1,58%) la a 20-a zi postoperatori, cauza fiind mediastinita sero-purulentă şi insuficienţă poliorganică. Patru pacienţi care au prezentat osteită sternală şi au necesitat rezecţii de cartilage şi plastia defectelor cu lambou muscular (3), pedicul omental (1). Concluzie: Folosirea uneia sau ambelor artere mamare, boala pulmonară cronică obstructivă, diabet zaharat, obezitatea, terapie transfuzională şi prelungirea timpului operator, sunt factori predictori pentru dezvoltarea mediastinitei poststernotomie. Managementul chirurgical etapizat reduce considerabil complicaţiile majore posibile şi cazurile de deces

Strategies of the treatment of cardiac prosthetic valve thrombosis

Department of Cardiac Surgery, Republican Hospital, Chisinau, the Republic of MoldovaBackground: The article deals with the analysis of principal causes of valve prosthesis thrombosis and “pannus” thrombosis. The diagnosis and contemporary treatment strategy of prosthesis dysfunction have been considered. Material and methods: In our department 1670 patients with extracorporeal circulation were operated on, among them 1260 had valve pathology that made up 74.2%. 1164 heart valves were replaced, 145 of them were biological prostheses and 1019 were mechanical ones of different types. Prosthesis thrombosis took place in 28 patients that represented 60% of the number of patients with prothesis disfunction and 2.2% of the total number of operated patients from which 21 patients, their age ranged from 35 to 63 years old. The surgical treatment was performed to 9 patients, thrombolysis – to 19 patients. Results: During last 6-7 years the thrombolysis treatment with ateplasum and reteplasse has been successfully implemented in the therapy of thrombosis valve prothesis. Thrombolysis was performed to 19 patients. The results are the following: in 17 cases good outcomes (a complete recovery of the prosthesis function with transprosthetic gradient and the normalization of systolic pressure in right ventricle) have been registered, one case has been complicated with transitory ischemic ictus. Out of 19 patients who underwent the thrombolysis treatment, there were 2 lethal cases. Conclusions: The patients that are in a critical state with prosthesis thrombosis (acute pulmonary edema, hypotension, heart insufficiency NYHA IV) should immediately receive EchoCG confirmation of the need of intravenous thrombolitic therapy. The thrombolysis efficacy in prosthesis thrombosis is high; the rate of embolic complications is low, which can be used as the first line treatment for all patients with prothesis thrombosis (in the absence of contraindications). In the case of partial response to the thrombolysis treatment, the patient can be operated on in good hemodynamic conditions and with low surgical risk

Repair surgical techniques in degenerative cardiac valve disease

Obiective: Examinarea posibilităților reconstructive în corecția patologiilor degenerative de valvă mitrală. Metode: Analizând caracterul patologiilor care au determinat mecanismul de dezvoltare a insuficienței valvulare, au fost determinate 136 cazuri de prolaps al cuspei anterioare și 152 – al cuspei posterioare. Ruptura de cordaje s-a stabilit la 79 (58,9%) pacienți, defecte de cuspe („cleft”) s-au apreciat în pozițiile A1, A2, A3 – 15 cazuri (5,9%) și în P1, P2, P3 – în 92 (86,6%) cazuri. Rezultate: Tehnicile chirurgicale efectuate au fost separate în: - Rezecționale – pentru cuspele anterioare și posterioare – 45 cazuri și însoțit de slaiding – în 30 de cazuri. - Cu implantare de neo-cordaj GoreTex – 115 cazuri, cu transfer de cordaje – 30. - Lărgire de cuspe cu pericard autolog – 5 cazuri, procedeul Alfieri – 8. Implantarea unui inel de suport au necesitat 130 (97,0%) pacienți. Corecția valvulopatiilor asociate au necesitat 125 pacienți (De Vega – 89,1%, inel – 8). Bypass coronarian au necesitat – 16 pacienți. Cazuri letale postoperatorii nu s-au înregistrat. Concluzii: În baza datelor obținute putem recomanda operațiile plastice reconstructive la valve de etiologie degenerativă, posttraumatice, ischemice, post-endocardită ca tehnici efective și durabile în timp, fiind o alternativă superioară protezării.Objectives: Examination of reconstructive possibilities in the correction of degenerative mitral valve disease. Methods: Analyzing the nature of the pathologies that determined the development mechanism of valve insufficiency, 136 cases of anterior cusp prolapse and 152 cases of posterior cusp prolapse were determined. Chordae rupture was established in 79 (58.9%) patients, cusp defects ("cleft") were appreciated in positions A1, A2, A3 - 15 cases (5.9%) and in P1, P2, P3 – in 92 (86.6%) cases. Results: The surgical techniques performed were separated into: - Resection - for the anterior and posterior cusps - 45 cases and accompanied by the sliding - in 30 cases. - With GoreTex neo-chordae implantation – 115 cases, with cord transfer – 30. - Cusp enlargement with autologous pericardium – 5 cases, Alfieri procedure – 8. Implantation of a support ring required 130 (97.0%) patients. The correction of the associated valve disease required 125 patients (De Vega – 89.1%, ring – 8). Coronary bypass was required – 16 patients. There were no postoperative fatal cases. Conclusions: Based on the data obtained, we can recommend reconstructive repair surgery for valves of degenerative, post-traumatic, ischemic, post-endocarditis etiology as effective and sustainable techniques over time, being a superior alternative to replacement with prosthetic valves

Left ventricle wall rupture in mitral valve replacement

Departamentul Cardiochirurgie, Spitalul Clinic Republican, Chişinău, Republica Moldova, Al XII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova cu participare internațională 23-25 septembrie 2015Introducere: Rupturile peretelui de ventricul stîng (RPVS) sunt cele mai grave complicaţii în protezarea valvei mitrale şi au o incidenenţă medie de 1,2%. Scopul studiului: de a delimita căile de prevenţie şi tratament chirurgical a RPVS. Material şi metode: Pe parcursul ultimilor 20 ani au fost înregistrate 19 cazuri de RPVS. Au fost analizate variantele anatomice, cauzele apariţiei, divizarea lor în cîteva tipuri (după S.I.Sezar): tipul 1 – în continuitatea atrioventriculară (decalcinări la cuspa posterioară, abcese inelare, iatrogenii) – 11 cazuri; tipul 2 – la originea muşchilor papilari (rezecţii parietale de pilieri, infarct miocardic perioperator) – 4 cazuri; tipul 3 – poziţionare intermediară (implantări forţate de valve cu diametrul mare, perforaţii cu elementele carcasului protezelor biologice, traumatizare la utilizarea ventului) – 4 cazuri. Rezultate: Letalitatea postoperatorie a alcătuit 26,3% (5 cazuri). Tehnicile chirurgicale aplicate s-au împărţit în externe şi interne. În primul grup RPVS au fost lichidate prin aplicarea de suturi profunde pe miocard utilizînd petic de teflon ori pericard. Al doilea grup reoperat în condiţii de CEC, cu aplicarea unui „sandwich” (2 petice ce acoperă ruptura din ambele părţi). Pentru hemostază definitivă a fost utilizat buretele hemostatic şi cleiul biologic. Concluzii: Operaţiile pe valva mitrală trebuie efectuate cu măsuri de profilaxie a RPVS (prezervarea muşchilor papilari, evitarea decalcinărilor masive, limitarea utilizării bioprotezelor de profil înalt la pacienţii cu cavitatea VS mică, alegerea corectă a diametrului protezei implantate, manipulaţii gentile pe suprafaţa ventriculară, protecţia adecvată a miocardului). Tehnicile chirurgicale combinate (interne şi externe) sunt cele mai efective pentru a atinge hemostaza definitivă.Introduction: Left ventricle wall rupture (LVWR) is one of the most serious complications in mitral valve replacement, with an incidence of 1.2%. The purpose of study: to determine the ways of prevention and surgical treatment of LVWR. Material and methods: During last 20 years were registered 19 cases of LVWR. We studied the anatomical features, cause of appearance, classifing them in different types (according to S.I.Sezar): type 1 – in atrioventricular continuity (posterior cusp decalcification, ring abscess, iatrogenic) – 11 cases; type 2 – at the origin of papillary muscle (parietal resection of pillars, perioperatory myocardial infarction) – 4 cases; type 3 – intermediate positioning (forced valve implantation with big diameter, perforation with elements of biological valve, trauma after vent usage) – 4 cases. Results: Postoperative mortality was 26.3% (5 cases). The surgical techniques applied were divided into external and internal. In the first group LVWR were repaired by applying deep sutures to myocardium using Teflon or pericardial patches. The second group underwent redo operation under CPB, applying a „sandwich” technique (2 patches covering the rupture from both parts). For final hemostasis we used hemostatic sponges and biological glue. Conclusion: Surgery for mitral valve must be performed with prophylactic measures for LVWR (papillary muscle preservation, avoiding massive decalcification, limiting the use of high profile biological valve for patients with small LV cavity, proper selection of implanted prosthesis diameter, gentle manipulations of ventricular surface, adequate myocardium protection). Surgical combined techniques (internal and external) are the most effective in order to achieve final hemostasis

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

Aims The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation. Methods and results Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (inhospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, prehospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin. Conclusion The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality