Rapid serodiagnosis of Staphylococcus aureus surgical site infection following median sternotomy

Objectives: To determine the sensitivity and specificity of a novel ELISA for the serodiagnosis of surgical site infection (SSI) due to staphylococci following median sternotomy. Methods: Twelve patients with a superficial sternal SSI and 19 with a deep sternal SSI due to Staphylococcus aureus were compared with 37 control patients who also underwent median sternotomy for cardiac surgery but exhibited no microbiological or clinical symptoms of infection. A further five patients with sternal SSI due to coagulase-negative (CoNS) staphylococci were studied. An ELISA incorporating a recently recognised exocellular short chain form of lipoteichoic acid (lipid S) recovered from CoNS, was used to determine serum levels of anti-lipid S IgG in all patient groups. Results: Serum anti-lipid S IgG titres of patients with sternal SSI due to S. aureus were significantly higher than the control patients (P<0.0001). In addition, patients with deep sternal SSI had significantly higher serum anti-lipid S IgG titres than patients with superficial sternal SSI (P=0.03). Serum anti-lipid S IgG titres of patients with sternal SSI due to CoNS were significantly higher than the control patients (P=0.001). Conclusion: The lipid S ELISA may facilitate the diagnosis of sternal SSI due to S. aureus and could also be of value with infection due to CoNS. © 2005 Published by Elsevier Ltd. on behalf of The Bristish Infection Society

Failure of retrograde cerebral perfusion to attenuate metabolic changes associated with hypothermic circulatory arrest

AbstractObjectives: Although retrograde cerebral perfusion has become a popular adjunctive technique and may improve cerebral ischemic tolerance during hypothermic circulatory arrest, direct cerebral metabolic benefit has yet to be demonstrated in human subjects. We investigated the post-arrest metabolic phenomena with and without retrograde cerebral perfusion in patients. Methods: In a prospective randomized trial, 42 patients undergoing aortic surgery requiring hypothermic circulatory arrest were allocated to receive hypothermic circulatory arrest alone (n = 21) or hypothermic circulatory arrest with additional retrograde cerebral perfusion (n = 21). Circulatory arrest was commenced at 15°C, and retrograde perfusion was instituted through the superior vena cava at a maximum jugular bulb pressure of 25 mm Hg. Transcranial, paired, repeated samples of the arterial and jugular bulb blood were analyzed for oxygen and glucose. Velocity in the right middle cerebral artery was also measured simultaneously. Results: There were 3 (7.1%) deaths and 3 (7.1%) episodes of neurologic deficit. Mean bypass and circulatory arrest duration (in minutes) were similar between groups (P = .4 and .14). The mean retrograde perfusion duration was 23 minutes. Post-arrest nasopharyngeal temperature was similar (15.3°C vs 15.3°C). Retrograde perfusion did not affect post-arrest oxygen extraction, glucose extraction, or jugular bulb Po2. There was no immediate lactate release immediately after hypothermic circulatory arrest. Conclusions: Retrograde cerebral perfusion did not influence immediate post-arrest nasopharyngeal temperature or cerebral metabolic recovery. The low jugular bulb Po2 suggests equivalent ischemia. These findings cast doubt on the effectiveness of retrograde cerebral perfusion as a metabolic adjunct to hypothermic circulatory arrest.J Thorac Cardiovasc Surg. 2002;123:943-50

One-stage repair in complex multisegmental thoracic aneurysmal disease: Results of a multicentre study

Objectives: Patients with thoracic aneurysmal disease involving the arch and the descending or thoracoabdominal aorta may require more than one surgical intervention. The results of one-stage repair using a hybrid stent-graft in the frozen elephant trunk manner are presented. Methods: Between January 2005 and March 2012, 113 (age 67 \ub1 10 years) of 358 registered patients in the International E-Vita Open\uae Registry were operated on for combined arch and descending and thoracoabdominal aortic aneurysm. Thirty-one (27%) patients had a previous cardiothoracic, abdominal aortic surgery or endovascular repair. The E-Vita Open\uae hybrid stent-graft was used in all cases. Postoperatively and during the follow-up (100%), aortic image examinations were performed. Results: Combined arch replacement and antegrade stent-grafting distally (graft diameter 34 \ub1 4 mm) were performed under selective cerebral perfusion (72 \ub1 27 min) and hypothermic visceral ischaemia (65 \ub1 27 min). Postoperatively, aneurysm exclusion was completely and partially achieved in 80% and 20%, respectively. In-hospital mortality and survival rate after 5 years were 12% (13 of 113) and 78%, respectively. Latest aortic imaging demonstrated 93% complete aneurysm exclusion. Freedom from secondary endovascular intervention and open surgery were 88 and 90%, respectively. CONCLUSIONS: In multisegmental thoracic aneurysmal disease, combined arch replacement with distal repair by a hybrid stent-graft enables one-stage treatment with acceptable mortality. Aneurysm exclusion by the stent-graft seems to be primarily curative and allows easier access for distal open or endovascular reintervention. \ua9 The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved

The Frozen Elephant Trunk for the treatment of chronic dissection of the thoracic aorta: a multicenter experience.

A-Link(opens in a new window)|Entitled full text(opens in a new window)|View at Publisher| Export | Download | Add to List | More... Annals of Thoracic Surgery Volume 92, Issue 5, November 2011, Pages 1663-1670 The frozen elephant trunk for the treatment of chronic dissection of the thoracic aorta: A multicenter experience (Article) Pacini, D.a , Tsagakis, K.b, Jakob, H.b, Mestres, C.-A.c, Armaro, A.a, Weiss, G.d, Grabenwoger, M.d, Borger, M.A.e, Mohr, F.W.e, Bonser, R.S.f, Di Bartolomeo, R.a a Department of Cardiac Surgery, Sant' Orsola-Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy b Department of Thoracic and Cardiovascular Surgery, West German Heart Center Essen, Essen, Germany c Department of Cardiovascular Surgery, Hospital Cl\uednico, University of Barcelona, Barcelona, Spain View additional affiliations View references (24) Abstract Background: Because of the extensive involvement of the aorta, surgical treatment of its chronic dissection continues to represent a surgical challenge. We conducted a study of a multicenter experience to describe a multicenter experience in the treatment of this complex pathology, using the frozen elephant trunk (FET) technique. Methods: Between January 2005 and May 2010, 240 patients underwent treatment with the FET technique and had their clinical data collected in the International E-vita Open Registry. Ninety of the patients, who were the population in the present study, underwent operations for chronic dissection of the aorta (type A, 77%). The mean age of these 90 patients was 57 \ub1 12 years, and 72 (80%) of the patients were male. Sixty-two patients (69%) had undergone a previous aortic operation. All of the procedures in the study were performed with the aid of antegrade selective cerebral perfusion. Results: Total replacement of the aortic arch was done in 84 patients (93%). Cardiopulmonary bypass, myocardial ischemia, cerebral perfusion, and visceral ischemia times were 243 \ub1 65, 145 \ub1 48, 86 \ub1 24, and 75 \ub1 22 minutes, respectively. In-hospital mortality was 12% (11 patients). One patient died from a stroke and 8 patients (9%) died from ischemic spinal cord injury. The false lumen (FL) in the patients' aortae was evaluated with computed tomography after operation and during follow up. The rates of complete thrombosis of the FL around the elephant trunk were 69% and 79% at the first and last postoperative examinations, respectively. The rates of 4-year survival and freedom from aortic reoperation were 78% \ub1 5% and 96% \ub1 3%, respectively. Conclusions: The treatment of chronic aortic dissection (AD) with the FET technique is feasible, with respectable results. The rate of aortic reoperation with the use of this technique appears to be lower than that with a conventional approach to the repair of chronic AD. Ischemic spinal cord injury represents a concerning complication of the FET technique but seems to be unrelated to thrombosis of the FL

Should intentional endovascular stent-graft coverage of the left subclavian artery be preceded by prophylactic revascularisation?

Thoracic endovascular aortic repair (TEVAR) has emerged as a promising therapeutic alternative to conventional open aortic replacement but it requires suitable proximal and distal landing zones for stent-graft anchoring. Many aortic pathologies affect in the immediate proximity of the left subclavian artery (LSA) limiting the proximal landing zone site without proximal vessel coverage. In patients in whom the distance between the LSA and aortic lesion is too short, extension of the landing zone can be obtained by covering the LSA's origin with the endovascular stent graft (ESG). This manoeuvre has the potential for immediate and delayed neurological and vascular symptoms. Some authors, therefore, propose prophylactic revascularisation of the LSA by transposition or bypass, while others suggest prophylactic revascularisation only under certain conditions, and still others see no requirement for prophylactic revascularisation in anticipation of LSA ostium coverage. In this review about LSA revascularisation in TEVAR patients with coverage of the LSA, we searched the electronic databases MEDLINE and EMBASE historically until the end date of May 2010 with the search terms left subclavian artery, covering, endovascular, revascularisation and thoracic aorta. We have gathered the most complete scientific evidence available used to support the various concepts to deal with this issue. After a review of the current available literature, 23 relevant articles were found, where we have identified and analysed three basic treatment concepts for LSA revascularisation in TEVAR patients (prophylactic, conditional prophylactic and no prophylactic LSA revascularisation). The available evidence supports prophylactic revascularisation of the LSA before ESG LSA coverage when preoperative imaging reveals abnormal supra-aortic vascular anatomy or pathology. We further conclude that elective patients undergoing planned coverage of the LSA during TEVAR should receive prophylactic LSA transposition or LSA-to-left-common-carotid-artery (LCCA) bypass surgery to prevent severe neurological complications, such as paraplegia or brain stem infarctio

Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection

Acute type A aortic dissection is a lethal condition requiring emergency surgery. It has diverse presentations, and the diagnosis can be missed or delayed. Once diagnosed, decisions with regard to initial management, transfer, appropriateness of surgery, timing of operation, and intervention for malperfusion complications are necessary. The goals of surgery are to save life by prevention of pericardial tamponade or intra-pericardial aortic rupture, to resect the primary entry tear, to correct or prevent any malperfusion and aortic valve regurgitation, and if possible to prevent late dissection-related complications in the proximal and downstream aorta. No randomized trials of treatment or techniques have ever been performed, and novel therapies-particularly with regard to extent of surgery-are being devised and implemented, but their role needs to be defined. Overall, except in highly specialized centers, surgical outcomes might be static, and there is abundant room for improvement. By highlighting difficulties and controversies in diagnosis, patient selection, and surgical therapy, our over-arching goal should be to enfranchise more patients for treatment and improve surgical outcomes