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Objectives: Deep sternal wound infection is a severe complication after cardiac surgery. Insufficient antibiotic target site concentrations may account for variable success of perioperative prophylaxis. Therefore, we measured perioperative penetration of cefazolin and of linezolid into sternal cancellous bone after sternotomy in coronary artery bypass grafting (CABG) patients by in vivo microdialysis., Methods: Nine patients underwent CABG using a skeletonized left internal mammary artery. Standard antibiotic prophylaxis consisted of 4 g cefazolin prior to skin incision and additional 2 g during skin closure. In addition, 600 mg of linezolid were administered prior to skin incision and after 12 h for study purposes. Two microdialysis probes were inserted into the sternal cancellous bone (left and right side) after sternotomy., Results: First mean peak cefazolin and linezolid plasma concentrations were 273 ± 92 µg/ml and 22.1 ± 8.9 µg/ml, respectively. Mean peak concentrations of antibiotics in sternal cancellous bone on the left and right sternal side were 112 ± 59 µg/ml and 159 ± 118 µg/ml for cefazolin and 10.9 ± 4.0 µg/ml and 12.6 ± 6.1 µg/ml for linezolid, respectively. Cefazolin exceeded the required tissue concentrations for relevant pathogens by far, but linezolid did not gain effective tissue concentrations in all patients for some relevant pathogens. Mammary artery harvesting had no significant effect on antibiotic tissue penetration., Conclusions: Direct measurement of antibiotic concentration in sternal cancellous bone with in vivo microdialysis is technically demanding but safe and feasible. We could demonstrate sufficient antibiotic coverage with our standard cefazolin-dosing regimen in the sternal cancellous bone during cardiac surgery. Mammary artery harvesting had no clinically relevant effect on tissue penetration. Linezolid concentrations were not sufficient for some relevant pathogens., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Extracorporeal membrane oxygenation (ECMO) is currently accepted in lung transplantation either to bridge patients to transplantation or to treat postoperatively arising severe primary graft failure. Based on promising initial experiences we have since 2001 implemented ECMO as the standard of intraoperative extracorporeal support in lung transplantation (LuTX) patients with haemodynamic or respiratory instability with the potential to prolong ECMO support into the perioperative period. The aim of this paper is to summarise our total experience with the use of ECMO in LuTX., Methods: We retrospectively reviewed all 306 patients undergoing primary lung transplantation from 1/2001 to 1/2006 with regard to the different forms of ECMO use. Results of all patients requiring ECMO were compared to those without ECMO during the observation period., Results: ECMO was used in 147 patients in total. Two patients were bridged to transplantation. A total of 130 patients received intraoperative ECMO support. In 51 of these patients ECMO was prolonged into the perioperative period. Five of these patients required ECMO support again in the postoperative period due to graft dysfunction. Contrary cardiopulmonary bypass was used in 27 patients mainly with concomitant cardiac defects. Eleven of these patients needed therapeutic ECMO in the further course. A total of 149 patients without relevant risk factors were transplanted without any intraoperative extracorporeal support. Six of these patients required ECMO support in the postoperative period for treatment of primary graft dysfunction. Overall 3-month, 1-year and 3-year survival rates were 88.6%, 82.1% and 74.63%. The mentioned survival rates were 85.4%, 74.2% and 67.6% in the intraoperative+/-prolonged ECMO group; 93.5%, 91.9% and 86.5% in the no support group and 74.0%, 65.9% and 57.7% in the CPB group., Conclusion: ECMO is a valuable tool in lung transplantation providing the potential to bridge patients to transplantation, to replace CPB with at least equal results and to overcome severe postoperative complications. Favourable survival rates can be achieved despite the fact that ECMO is used in the more complex patient population undergoing lung transplantation as well as to overcome already established severe complications.

Objective: Standard lung donor criteria have been established on opinions and individual experiences rather than on existing evidence. Since the scarcity of donor organs is one of the major limitations to lung transplantation, extension of donor lung criteria might considerably increase the donor pool. This study therefore evaluates the outcome, achieved with the use of extended donors versus standard donors and aims to redefine lung donor criteria., Methods: We performed a retrospective analysis of 98 consecutive primary lung transplantations from 94 donors from 1/2001 to 12/2002. Donors were classified as extended if they fulfilled at least one criteria: age >55 years, PaO(2) at FiO(2)/PEEP 5 <300mmHg, tobacco history >20 pack years, inhalative drug abuse, presence of infiltration on chest X-ray or purulent secretions at bronchoscopy. Recipients were stratified in two groups according to whether they received a 'standard' or 'extended' organ. Postoperative complications, extubation time, ICU and hospital stay and survival were compared., Results: Twenty-three (24.5%) donors were extended. Twenty-six recipients (26.55%) received organs from extended donors. Differences in intubation times (12+/-2 days standard vs. 14+/-5 days extended, P=0.70), ICU stay (16+/-2 days standard vs. 18+/-5 days extended, P=0.74) and hospital stay (38+/-4 days standard vs. 40+/-6 days extended, P=0.71) were not statistically significant. Postoperative bleeding rates were comparable (n=14 standard vs. n=3 extended) as well as bronchial anastomotic complications (n=7 standard vs. n=3 extended). Three months survival was 88.89% in the standard group vs. 92.31% in the extended group. One year survival is comparable as well with 81.94 vs. 84.62%, respectively., Conclusions: The use of lung donors who fail to meet standard criteria does not impair short and medium term results compared to standard lung donors. The impact on long term development of BOS has yet to be evaluated. The strict application of standard lung donor criteria excludes a considerable number of lungs potentially suitable for transplantation, thus liberalisation of donor criteria might help to overcome donor shortage.

Objective: To evaluate the influence of two different ablation devices (microwave AFx and radiofrequency Medtronic), designed to create linear lesion lines, with respect to efficacy and restoration of sinus rhythm (SR)., Methods: Between February 2001 and December 2002, 42 patients with chronic, persistent atrial fibrillation (AF) >6 months were submitted to different combinations of valve surgery (mitral+/-tricuspid, n = 30; mitral and aortic+/-tricuspid reconstruction, n = 6 aortic+/-tricuspid, n = 8) and concomitant Maze procedure. The biatrial Maze followed the concept of the Cox III procedure, using either microwave energy (AFx Lynx) (group I: age 65.8+/-11.9 years, mean duration of AF 61.9+/-28.9 months, n = 23) or radiofrequency (Medtronic Cardioblate) (group II: age 64.1+/-11.1 years, mean duration of AF 53.5+/-49 months, n = 19)., Results: There was one death with group I (4%), due to liver failure. Both groups were comparable with regard to Euro Score, ejection fraction, cross clamp time, cardiopulmonary bypass time, ICU (median 1 day in both groups) and hospital stay, and type of indication. The preoperative diameter of the left atrium was 69.7+/-10.8 and 74.0+/-14.3 mm in groups I and II, respectively (P = 0.359). The Maze procedure resulted in 23+/-2 and 17+/-1 min additional cross clamp time in groups I and II, respectively (P = 0.013). At the 12-month follow up, freedom from AF was 81 and 80% in groups I and II, respectively. Twenty percent in group I and 21% in group II needed a pacemaker (PM), due to sick sinus syndrome (2 versus 2 cases), AV bloc (2 versus 1 case) and preoperative bradycardia (0 versus 1 case), respectively., Conclusions: The combination of complex valve surgery and Maze procedure was safe and reproducible. Following the Cox Maze III line concept, microwave and radiofrequency ablation gave similar results even in patients with more complex double or triple valve procedures.

Objectives: The increasing scarcity of donor lungs, especially for small and pediatric recipients has stimulated the development of new operative techniques, which allow larger lungs to be downsized for use in smaller recipients. This approach has only recently gained widespread use-especially for highly urgent recipients-however, it is still not considered a standard procedure., Methods: This report reviews the Vienna University experience with cadaveric split lung transplantation, lobar transplantation and by means of peripheral resection size reduced lung transplantation within the years 2001-2002. Peri-operative complications and outcome of those patients were retrospectively analysed and compared to the patients undergoing standard single or double lung transplantation during the observation period., Results: During the observation period 98 primary lung transplantations were performed, of which 27 (27.6%) were size reduced transplantations. Size reduction was achieved by lobar transplantation (n=9), split lung transplantation (n=2) or peripheral segmental resection (n=16). There was no statistically significant difference between the size reduced and standard lung transplantation group with regard to the rate of bronchial healing problems (n=3/7; P=0.85) and the rate of post-operative bleeding (n=5/12; P=0.85). No other major thoracic surgical complications were observed. Three months survival rate was 85.2% in the size reduced group, compared to 92.9% in the standard group (P=0.13)., Conclusions: Size reduced lung transplantation, including split lung transplantation, lobar transplantation and peripheral segmental resection, is a reliable procedure providing equal results compared to standard lung transplantation.

Objectives: Lung volume reduction surgery (LVRS) is accepted as a potential alternative therapy to lung transplantation (LTX) for selected patients. However, the possible impact of LVRS on a subsequent LTX has not been clearly elucidated so far. We therefore analyzed the course of 27 patients who underwent LVRS followed by LTX in our institution., Methods: Twenty-seven patients (11 male, 16 female, mean age 51.9+/-2.2 years) out of 119 patients who underwent LVRS between 1994 and 1999 underwent LTX 29.7+/-3.2 months (range 2-57 months) after LVRS. Based on the postoperative course of FeV1 after LVRS (best value within the first 6 months postoperatively compared with the preoperative value) patients were divided into two groups: Group A (n=11) without any improvement (FeV1 <20% increase), and Group B (n=16) with FeV1 increase > or = 20% after successful LVRS which declined to preoperative values after 8-42 months. Subsequent LTX was performed 22.9+/-5.6 months after LVRS in Group A and 34.3+/-4.9 months after LVRS in Group B (P<0.05). Patients were analyzed according to the course of their functional improvement and of their body mass index (BMI) after LVRS and to survival after LTX, respectively. Values are given as the mean+/-SEM and significance was calculated by the chi(2)-test whereas continuous values were estimated by Student's t-test., Results: Patients in Group A without improvement in FeV1 after LVRS had no increase in BMI as well and this resulted in a high perioperative mortality of 27.3% after LTX. On the contrary, patients in Group B, who had a clear increase of FeV1 after LVRS, experienced a significant increase of BMI of 23.2+/-4.5% as well (P<0.05). This improvement in BMI remained stable despite a later deterioration of FeV1 prior to LTX. After LTX, these patients had a significantly lower perioperative mortality of 6.3% as compared to Group A (P=0.03)., Conclusions: Successful LVRS delays the need for transplantation, improves nutritional status and brings patients into a better pretransplant condition, which results in decreased perioperative mortality at LTX. Patients after failed LVRS, however, should be considered as poor candidates for later transplantation.

Objective: Lung transplantation for pulmonary hypertension (PH) is usually performed on cardiopulmonary bypass, with the disadvantage of full systemic anticoagulation, uncontrolled allograft reperfusion and aggressive ventilation. These factors can be avoided with intra- and postoperatively prolonged extracorporeal membrane oxygenator (ECMO) support., Patients and Methods: Between February 1999 and March 2001, 17 consecutive patients with PH (systolic pulmonary artery pressure >70 mmHg) of different etiologies underwent bilateral lung transplantation (BLTX). There were 11 females and six males in the age range from 7 to 50 years (mean age, 28.4+/-12.9 years). Six patients were preoperatively hospitalized, four in the intensive care unit (ICU), one was on ECMO for 3 weeks pretransplantation, and one was resuscitated and bridged with ECMO for 1 week until transplantation. Femoral venoarterial ECMO support with heparin-coated circuits was set up after induction of anesthesia and discontinued at the end of surgery (n=3) or extended for 12 h median into the postoperative period (n=14). Postoperative ventilation pressure was kept below 25 mmHg. Allograft function at 2 h after discontinuation of ECMO, outcome and adverse events were monitored in all patients. Mean follow up time was 18+/-11.4 months., Results: The perioperative mortality was 5.9% (n=1). Arterial oxygen pressure measured 2 h after weaning from ECMO, and under standard mechanical ventilation with a peak pressure of 25 mmHg and inspired oxygen fraction of 0.4, was 157+/-28 mmHg. The mean pulmonary artery pressures were reduced to 29+/-3,4 from 66+/-15 mmHg before transplantation. Postoperative complications included rethoracotomy due to bleeding (n=4) and temporary left ventricular failure (n=4). Median ICU stay was 12 days. Incidence of rejection within the first 100 days was 0.4 per patient., Conclusion: BLTX with intraoperative and postoperatively prolonged ECMO support provides excellent initial organ function due to optimal controlled reperfusion and non-aggressive ventilation. This results in improved outcome even in advanced forms of PH.