Search

Background/purpose: Among patients suspected of pectus excavatum, visual examination is a key aspect of diagnosis and, moreover, guides work-up and treatment strategy. This study evaluated the inter observer and intra-observer agreement of visual examination and diagnosis of pectus excavatum among experts. Methods: Three-dimensional surface images of consecutive patients suspected of pectus excavatum were reviewed in a multi-center setting. Interactive three-dimensional images were evaluated for the presence of pectus excavatum, asymmetry, flaring, depth of deformity, cranial onset, overall severity and morphological subtype through a questionnaire. Observers were blinded to all clinical patient information, completing the questionnaire twice per subject. Agreement was analyzed by kappa statistics. Results: Fifty-eight subjects with a median age of 15.5 years (interquartile range: 14.1-18.2) were evaluated by 5 (cardio)thoracic surgeons. Pectus excavatum was visually diagnosed in 55% to 95% of cases by different surgeons, revealing considerable inter-observer differences (kappa: 0.50; 95%-confidence interval [CI]: 0.41-0.58). All other items demonstrated inter-observer kappa's of 0.25-0.37. Intra-observer analyses evaluating the presence of pectus excavatum demonstrated a kappa of 0.81 (95%-CI: 0.72-0.91), while all other items showed intra-observer kappa's of 0.36-0.68. Conclusions: Visual examination and diagnosis of pectus excavatum yields considerable inter-observer and intra-observer disagreements. As this variation in judgement could impact work-up and treatment strategy, objective standardization is urged. Levels of evidence: III. (c) 2021 Elsevier Inc. All rights reserved.

Objectives Aortic valve endocarditis is occasionally complicated by periannular spreading of the infection and abscess formation, leading to a more aggressive course of the disease and life-threatening complications. This retrospective observational study investigated the long-term outcomes of patients with this complication, which was surgically managed with annular reconstruction and aortic valve replacement. Methods Between 1998 and 2018, 69 patients were identified with aortic valve endocarditis complicated by periannular abscess formation. All patients were treated with debridement of the infected tissue, gentamicin filling of abscess cavities, annulus reconstruction with bovine pericardium, and valve replacement. Long-term follow-up was performed to detect the rate of recurrence of endocarditis, aortic valve reoperation and survival. Results Mean age was 58 ± 15 years, 81% of patients were male, and the infected valve was native in 51% of all patients. The overall mortality was 36%, with a 30-day mortality of 13% and 120–day mortality of 16%. Five- and 10-year survival was 69.4 ± 12.0% and 55.7 ± 14.3%, respectively. Ten-year freedom from recurrent endocarditis was 83.5 ± 13.3%. Conclusion Endocarditis with annular abscess remains associated with high morbidity and mortality and aggressive treatment of the infected tissue and abscess cavities is crucial. Compared with earlier literature, long-term outcome of annular reconstruction in this series is comparable to that of aortic root replacement.

Background Following guidelines, aortic valve replacement (AVR) in asymptomatic patients with severe aortic valve stenosis is often postponed until symptoms do occur. Delaying AVR will inevitably lead to progression of left ventricular hypertrophy. We studied the relationship between septum wall thickness indexed for body surface area (SWTI) as a measure for LV hypertrophy and 30-day and late all-cause mortality after AVR. Methods This study included the data of adult patients who underwent isolated AVR between January 2006 and December 2010 and in whom a reliable measurement of the septum wall thickness could be made. The patients were stratified into three groups according to their SWTI. The SWTI was less than 6 mm/m 2 in 136 patients, between 6 and 8 mm/m 2 in 307 patients, and more than 8 mm/m 2 in 126 patients. Results Death occurred in 10 patients within 30 days (1.8%), and 41 patients died during follow-up (7.2%). Univariate logistic regression analysis revealed only endocarditis as predictor of early mortality. Multivariate Cox regression analyses revealed SWTI as a continuous variable as well as a categorical (group) variable to be a predictor of late mortality. Compared with the group SWTI less than 6 mm/m 2 , odds ratio for the group with SWTI 6 to 8 mm/m 2 was 3.4 ( p = 0.046), and for the group with SWTI more than 8 mm/m 2 , it was 6.0 ( p = 0.005). Conclusions In patients undergoing AVR, the SWTI was a strong predictor of late mortality. Whether avoidance of progression of left ventricular hypertrophy by early AVR leads to better outcome remains to be investigated.

Background: Mediastinitis is a serious complication after coronary artery bypass grafting (CABG). We studied the risk factors for the development of postoperative mediastinitis in a large group of patients who underwent isolated CABG at Catharina Hospital, Eindhoven, The Netherlands. Methods: Data of all patients undergoing an isolated CABG between January 1998 and December 2008 were analyzed. Univariate and multivariate logistic regression analyses were performed to investigate the effect of biomedical variables on the development of mediastinitis. Multivariate analyses were used to test for the confounding effect of various risk factors on outcomes. Results: Mediastinitis was present in 100 out of the 11,748 patients. Preoperative atrial fibrillation [odds ratio = 4.26 (2.26 to 8.02)] and an elevated preoperative C-reactive protein level [odds ratio = 1.013 (1.007 to 1.020)] were important independent predictors of the development of mediastinitis. Other significant risk factors were the following: age, chronic obstructive pulmonary disease, diabetes, morbid obesity, use of extracorporeal circulation, use of bilateral internal mammary arteries, reexploration for ischemia, and perioperative myocardial infarction. Conclusions: Apart from previously described risk factors for the development of postoperative mediastinitis, we found preoperative atrial fibrillation and an elevated C-reactive protein level to be significant predictors of mediastinitis in patients undergoing CABG.

Surgical correction of pectus excavatum (PE) has shifted to the modern minimally invasive Nuss procedure, which proved to be safe and effective. In order to restore the dented deformity, custom-curved metal bars provide continuous retrosternal pressure but cross the habitat of the internal mammary arteries (IMAs) directly affecting their patency. In this initial report, we sought to assess the patency of the IMAs in the first 6 patients who underwent Nuss bar removal in our department.In 2010, we started to perform correction of PE using the Nuss bar technique. In 2013, observational analysis was performed on the first 6 patients who underwent removal of the Nuss bar. Computed tomography angiography (CTA) was performed in order to assess the patency of both IMAs directly after removal.In 4 (67%) patients, IMA patency was affected unilaterally (total obstruction or highly decreased flow pattern) corresponding with the lowest retrosternal side.According to our preliminary results, the oppressive force of Nuss bars interferes with IMA patency and thereby compromises future usability in coronary artery bypass grafting (CABG). We recommend that patients undergoing CABG following the Nuss procedure undergo preoperative evaluation of IMA patency. This study will be continued to include a larger number of patients including follow-up CTA one year after removal of the bar.? The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Background:Post-sternotomy pain in the absence of cardiac ischemia and sternal instability is most commonly due to the sternal wire sutures or a protruding wire. We performed a retrospective study to investigate the effect of removal of the steel wires for relief of post-sternotomy pain.Methods:All 206 patients who underwent sternal wire removal in our institution from January 2003 through August 2011 were included in this study. Alive patients were contacted by telephone to inquire about the fate of their pain. Accordingly, patients were classified into 4 groups: group 1 were free of symptoms; group 2 were satisfied, significantly better than before wire removal; group 3 had unchanged symptoms; and group 4 had worsening of pain after wire removal.Results:After excluding patients who died during the follow-up and those who had sternal instability and wound infection, 186 patients were available for the questionnaire. Complete relief of pain occurred in 83% of these patients, and 10% had improvement of their symptoms.Conclusions:We recommend removal of the steel wires in patients with persistent chest pain after median sternotomy, when sternal instability, mediastinitis, and cardiac causes such as ischemia are excluded.

Cardiac herniation after pneumonectomy is recognized as a rare complication. This case report describes two cases. The mortality rate of this complication remains high as reported in the literature; in early-recognized cases 50 % and in late or unrecognized cases 100 %. In the following two cases a pneumonectomy was performed as a treatment for lung cancer. Within 48 h after the initial operative treatment, the clinical situation of the patients got worse and radiographic examinations showed a strongly deviated heart. After suspicion of the diagnosis, the patients were immediately transferred to the operation theatre for emergency thoracotomy. Per-operative the diagnosis was confirmed and the heart was returned into its original position while the defect in the pericardial sac was closed with a bovine pericardial patch. Both patients survived these procedures and did not suffer from any further complication.

Objectives The EuroSCORE as a predictor for midterm survival after isolated aortic valve replacement (AVR) and combined AVR with coronary artery bypass graft (CABG) surgery was tested. Survival in different risk-stratification groups also was compared to the survival of the general Dutch population. Design A retrospective analysis of prospectively collected data. Setting A single-center study performed in an educational hospital. Participants All patients (N = 1,652) who underwent AVR with (n = 711) or without (n = 941) CABG surgery from January 2004 through December 2009. Interventions AVR with or without CABG surgery. Measurements and Main Results Univariate Cox regression analyses were used to identify the additive and the logistic EuroSCOREs as independent predictors of midterm mortality. Kaplan-Meier survival curves were used to compare the survival of different patients' risk subgroups, based on both the additive and the logistic EuroSCOREs, with the normal Dutch population matched for age and sex. Both additive and logistic EuroSCOREs were significant predictors of midterm mortality after isolated AVR and AVR with CABG surgery. This was also true for the different risk-stratification groups. Except for survival after AVR with CABG surgery in the high-risk group based on the additive EuroSCORE, no difference was found between survival after surgery and survival of the age- and sex-matched normal population. Conclusions Both EuroSCORE models can predict midterm survival after isolated AVR and combined AVR with CABG surgery. However, the EuroSCORE is not a predictor for midterm survival when comparing the patient groups with the general Dutch population matched for age and sex. Except for high-risk patients undergoing AVR with CABG surgery, other risk subgroups have similar midterm survival to that of their age- and sex-matched cohorts of the Dutch population.

Several methods have been used in wound closure after coronary artery bypass grafting (CABG). In this study, the safety and efficacy of one of these methods, Steri-Strip S is compared with the traditional intracuticular suture method. Eighty-one patients undergoing CABG were prospectively randomized into two groups according to the method of skin closure: Steri-Strip S group and traditional suture group. Comparison between the two methods was done with regards to the length of the wound and the time needed to close it. The median closure time with Steri-Strip S was 5.45+/-3.35 min vs. 7.53+/-3.41 min in the suture group. A pain score of >or=6 at the first postoperative day was found in 30% of the patients in the suture group vs. 14% of the patients in the Steri-Strip S group (P=0.07). Cosmetic evaluation showed a non-significant difference in the linear visual analogue score in favor of Steri-Strip S group compared to the intracuticular suture group (73.1 vs. 70.1) (P=0.07). Steri-Strip S is a fast, safe alternative for wound closure of the sternotomy incision and graft harvesting site. A larger study is needed to establish the potential beneficial effect of Steri-Strip S on wound infection prevention.

Objective: Postoperative wound infections generally cause considerable extra morbidity, mortality and costs. As nowadays length of hospitalization shortens, post-discharge surveillance is important to get reliable information on the prevalence of postoperative wound infections. In this study, the prevalences of sternal wound (SWI) and donor site infections (DSI) during hospitalization as well as, 30 and 90 days after cardiac surgery were studied paying special attention to the contribution of post-discharge surveillance. Methods: A total of 1885 patients who underwent cardiac surgery were included in the study and were followed for the prevalence of SWI or DSI up to 90 days postoperatively. Infection data during hospitalization were collected using medical records, bacteriological results and systematic observations of infection control nurses. After discharge from the hospital, data were collected with the help of the out-patient clinic and the family physician. Results: After cardiac surgery, SWI and DSI were diagnosed in 4.7 and 1.5% of patients during hospitalization, in 6.8 and 4.6% at 30 days postoperatively, and in 9.0 and 7.3% of patients at 90 days postoperatively. Of the 90-days postoperative infections rates almost half of SWI and 80% of DSI were diagnosed post-discharge, a result predominantly achieved by the active participation of the family physicians. Conclusions: After 30 and 90 days follow-up of patients after cardiac surgery, additional sternal wound and donor site infections were diagnosed compared with the in-hospital infection rate. Post-discharge surveillance is essential for a reliable assessment of surgical wound infections.

Papillary fibroelastomas are uncommon in daily cardiac surgery practice. They typically arise from the valvular endocardium, affecting the atrioventricular and semilunar valves equally [1]. Upon diagnosis, prompt resection should be undertaken because of possible devastating complications such as stroke. A young patient came to the emergency unit with partial left-sided hemiplegia. The patient’s history showed partial loss of sight with spontaneous recovery. Transesophageal echocardiography identified a solitary structure attached to the mitral valve suggestive of fibroelastoma (Fig 1). Intraoperatively, we were confronted with diffusely spread fibroelastomas on the anterior leaflet of the mitral valve (Fig 2), leaving no other option than to replace the valve. Histologic examination confirmed the diagnosis of fibroelastoma (Fig 3; hematoxylin and eosin staining). The patient’s postoperative recovery was uneventful. She was discharged on the eighth postoperative day. Cardiac fibroelastomas are rare tumors, typically involving the heart valves. The preferred therapy is to perform repair of the valve whenever possible. If the tumor has a diffuse character, this is not an acceptable option, and replacement of the valve should be performed.

A 75-year-old man underwent a Bentall procedure and hemi-arch replacement with a Biovalsalva conduit (Vascutek Terumo, Renfrewshire, Scotland) and concomitant coronary re-vascularisation. Three days later, the patient underwent an uneventful re-sternotomy due to cardiac tamponade. During the procedure, blood was drained to release the tamponade; however, no primary area for blood loss was found, though the proximal Biovalsalva appeared dissected (Fig. 1). www.elsevier.com/locate/ejcts European Journal of Cardio-thoracic Surgery 36 (2009) 400