Komplikationen nach Sternotomie – eine interdisziplinäre Herausforderung

A mediastinitis is a rare complication (incidence 1–4%) following cardiac surgery with a mortality of up to 50%. Treatment is somewhat difficult since no standardized treatment options are established. Thus, every German clinic proceeds differently. It is thus the paper’s intention to describe an optimal treatment plan that guarantees higher patient safety, as well as determining whether the occurrence of postoperative infections can be diminished by raising awareness of involved risk factors.Backed up by first-hand experiences in the treatment of mediastinitis patients a therapy algorithm correlating to the amount of infection was developed. The treatment consists of radical surgical debridement, sternal restabilization (depending on the elapsed time between procedure and cardiac operation) and vacuum therapy (as short as possible). Plastic reconstruction (usually via M. pectoralis plasty) may be performed as soon as supporting condition is attained. If treatment fails, the reconstruction of defects of the anterior chest wall is achievable by different muscle flaps. Based on the results of early interdisciplinary cooperation, a therapy concept was developed, which is adaptable to the patient’s individual condition in order to ensure the best possible treatment concept concerning the patient’s recovery and safety

The history of the management of sternal osteomyelitis and mediastinitis – from Hippocrates until today

Even during the time of Hippocrates, Galen and their colleagues recognized mediastinal affections. However, they were not considered with the surgical treatment. First progress in the treatment options of this severe disease, still denoted as ‘terra incognita’, over to today’s gold standard are pictured.The mediastinitis-registry which was founded by the German Society for Thoracic and Cardiovascular Surgery (DGTHG) in 2011 and the recent establishment of the study group to adopt a guideline ‘diagnosis and therapy of postoperative mediastinitis/sternal osteomyelitis following cardiac surgery’ are attempts to a standardization of the treatment. Substantial advancement in the treatment of postoperative mediastinitis could be achieved in the past. The mortality dropped as low as less than 10%. With these implementations more benefit for the patients’ outcome can be expected

Intraoperative transit time flow measurement: off-pump versus on-pump coronary artery bypass

Hassanein W, Albert AA, Arnrich B, et al. Intraoperative transit time flow measurement: off-pump versus on-pump coronary artery bypass. The annals of thoracic surgery. 2005;80(6):2155-2161.Background Off-pump coronary artery bypass grafting (OPCAB) has attracted increasing attention. Performing the anastomosis off-pump is technically more demanding. The objective of the study is to assess the quality of anastomosis in OPCAB in comparison with conventional on-pump coronary artery bypass grafting using the transit time flow measurement. Methods Four hundred forty-five patients operated on using OPCAB technique were included in the study. For each patient in this group a similar patient from the on-pump coronary artery bypass grafting population was selected according to the number of grafts, bypass material, and target coronary arteries. The mean flow and the pulsatile index were measured in every bypass graft in both groups. Results The average pulsatile index in OPCAB was 2.09 ± 1.03 (mean flow, 39 ± 22.63 mL/min), whereas with on-pump coronary artery bypass grafting it was 1.9 ± 0.98 (mean flow, 44.19 ± 23.58 mL/min); p = 0.005. Subgroup analysis showed significantly lower mean flows and higher pulsatile index with OPCAB in grafts to the obtuse marginal, diagonal, and right coronary artery, but not to the left anterior descending territory. Conclusions The quality of the anastomosis performed using the OPCAB technique might be jeopardized by less accessibility as in the case of lateral and posterior wall coronary arteries. Techniques to optimize the accessibility of the coronary artery like combining sling support with cup stabilizers, together with systematic training, should be strongly considered in OPCAB. Whenever there is good accessibility of the coronary artery as in the case of the left anterior descending, the anastomosis performed under OPCAB has a quality as good as that performed using the conventional technique

What range of pace-sense-compensation should be provided in biventricular pacing systems for heart failure?

In cardiac resynchronization therapy (CRT) for heart failure, individualization of the AV delay is essential to improve hemodynamics and to minimize non-responder rate. In patients in sinus rhythm having additional disposition to bradycardia, optimization is necessary for both situations, atrial sensing and pacing. Therefore, echo-optimization is the goldstandard but time consuming. Unfortunately, it depends on the particular CRT systems parameter set if the resulting individually optimal AV delays can be programmed or not. Some CRT systems provide a set of AV delays for DDD operation combined with a set of the pace-sense-compensation to optimize the AV delay in DDD and VDD operation. The pace-sense-compensation (PSC) can be defined by the difference of implant-related interatrial conduction intervals in DDD and VDD operation measured in the esophageal left atrial electrogram. In a cohort of 96 CRT patients we found mean PSC of 59-35ms ranging between 0-143ms. As a consequence, allowing 10ms tolerance, AVD optimization is completely impossible in one of the two modes, VDD or DDD operation, in 34 (35%) or 5 (5%) patients with implants restricting the PSC range to 60ms or 100ms, respectively. Thus, we propose companies to provide CRT systems with programmable pace-sense- compensation between 0ms and 150ms

Aortic valve replacement in octogenarians: identification of high-risk patients

Objective: This study identifies high-risk octogenarians for surgical aortic valve replacement (AVR) because with the current advances in transcatheter valve therapy, a definition of patient selection criteria is essential. Methods: Between 1996 and 2006, 493 consecutive octogenarians with symptomatic aortic stenosis underwent AVR with and without (51%) concomitant coronary artery bypass grafting (CABG). To identify high-risk patient groups, risk factors of 6-month mortality were determined using multivariable logistic regression. Results: The 30-day mortality rate was 8.4% and it increased up to 15.2% until 6 months after AVR. Independent risk factors of 6-month mortality were patients older than 84 years (odds ratio (OR): 2.2 (1.29-3.61)), left ventricular ejection fraction <60% (OR: 2.5 (1.35-4.61)), body mass index (BMI) <24 (OR: 2.0 (1.22-3.36)), creatinine (OR: 1.6 (1.04-2.53)) and blood glucose (OR: 1.01 (1.001-1.009)). High-risk groups were patients older than 84 years with an ejection fraction <60% (6-month mortality 28%) and patients younger than 84 years with an ejection fraction <60% and a BMI <24 (6-month mortality 23.2%). These high-risk groups comprised 37% of the patient population. After isolated AVR, the 30-day mortality and survival at 1 and 5 years was 11.6%, 69% and 35% in this high-risk group, respectively. In octogenarians with an STS score >10 and an EuroScore >20, the 30-day mortality and survival at 1 year was 10.5% and 80%, 11.6% and 77%, respectively. Conclusions: In most octogenarians, AVR is a safe and beneficial procedure. In high-risk octogenarians, identified by STS score >10, EuroScore >20 and by simple three risk factors (age >84 years, ejection fraction <60% and BMI <24), the mortality after surgical AVR was no different from the currently reported outcome after transcatheter AVI. © 2009 European Association for Cardio-Thoracic Surgery