The aim of this study was to investigate the overall outcome of adult patients undergoing redo-mitral valve replacement (redo-MVR) at our institution. Forty-nine patients (24 males) underwent redo-MVR with either bioprosthetic (n = 24) or mechanical valves (n = 25) between January 2000 and 2010. Median age of patients was 63 years (range 21-80 years), and the mean additive EuroSCORE was 12 ± 4. Median time to re-operation was 8.2 ± 6.6 years for first time redo-MVR and 6.4 ± 5.6 years for second-time redo-MVR. Indications included prosthetic endocarditis (n = 22), para-prosthetic leak (n = 12), structural valve degeneration (n = 8), prosthetic valve thrombosis (n = 6) and malignancy (n = 1). The mean follow-up was 47.5 ± 37.0 months (range 0.1-112.3 months). In-hospital mortality was 12% (n = 6). Mean hospital stay was 17 ± 11 days (range 8-50 days). Actuarial survival at 1 and 5 years was 81 ± 5% and 72 ± 6%, respectively. Three patients required re-intervention: two for prosthetic valve endocarditis and one for para-prosthetic leak. Multivariate analysis showed that overall survival was associated with the LVEF < 50% (P < 0.001), concomitant AVR (P < 0.001) and urgent surgery (P = 0.03).

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Emergency surgical repair of ATAAD in elderly patients resulted in an acceptable early mortality rate and satisfactory intermediate survival. Preoperative acute neurological deficit predicts a worse outcome. Advanced age alone should not be considered as a contraindication to AAD repair.

BackgroudTo assess the feasibility and efficacy of PuraStat®, a novel haemostatic agent, in achieving suture line haemostasis in a wide range of cardiac surgical procedures and surgery of the thoracic aorta.MethodsA prospective, non-randomised study was conducted at our institution. Operative data on fifty consecutive patients undergoing cardiac surgery where PuraStat® was utilised in cases of intraoperative suture line bleeding was prospectively collected. Questionnaires encompassing multiple aspects of the ease of use and efficacy of PuraStat® were completed by ten surgeons (five consultants and five senior registrars) and analysed to gauge the performance of the product.ResultsNo major adverse cardiac events were reported in this cohort. Complications such as atrial fibrillation, pacemaker requirement and pleural effusions were comparable to the national average. Mean blood product use of packed red cells, platelets, fresh-frozen plasma (FFP) and cryoprecipitate was below the national average. There was one incidence of re-exploration, however this was due to pericardial constriction rather than bleeding. Analysis of questionnaire responses revealed that surgeons consistently rated PuraStat® highly (between a score of 7 and 10 in the various subcategories). The transparent nature or PuraStat® allowed unobscured visualisation of suture sites and possessed excellent qualities in terms of adherence to site of application. The application of PuraStat® did not interfere with the use of other haemostatic agents or manipulation of the suture site by the surgeon.ConclusionPuraStat® is an easy-to-use and effective haemostatic agent in a wide range of cardiac and aortic surgical procedures.

Purpose: Deep sternal wound complications after cardiac surgery have an incidence of 2 to 8% and carry a significant mortality. The aim of this study was to evaluate the effect of thermo-reactive Nitinol clips on the incidence of postoperative deep sternal wound complications. Methods: We retrospectively reviewed 1119 consecutive patients that underwent major cardiac surgery via median sternotomy in our centre. Sternal closure was performed using Nitinol clips in 235 patients (Group I) and standard stainless steel wires in 884 patients (Group II). The risk factors that were identified between the two groups were age, EuroSCORE, body mass index, diabetes and pulmonary comorbidity. Results: The overall incidence of deep sternal wound complications was 2.2% (25/1119). The incidence was higher in Group II (2.3%) compared to Group I (1.7%) (p = 0�8). Mechanical sternal dehiscence occurred in 2 patients in Group II. Mortality related to sternal wound complications was 8% (2/21) in Group II whereas in Group I was 0%. Conclusion: The incidence of sternal wound complications and the mortality related to them were lower in patients undergoing sternal closure with Nitinol clips. A randomized study to further evaluate the possible advantages of Nitinol clips is warranted.Keywords: wound closure, mediastinal infection, wound infection, wound dehiscence, sternum IntroductionMedian sternotomy is the standard approach in cardiothoracic surgery. Closure of this incision is simple and the method of choice worldwide is the use of standard steel wires placed either parasternally or directly through the bone. Healing complications such as osteomyelitis, mediastinitis, dehiscence, sinuses formation and superficial wound infection may occur and have a significant impact on postoperative recovery. The incidence of deep sternal wound complications (DSWC) after cardiac surgery varies from 0.5% to 5% 1-3� but is associated with a significant mortality in all studies. The surgical management of these complications has evolved over recent decades from closed mediastinal antibiotic irrigation, by Mandelbaum and Schumaker in 1963, to the primary use of pectoralis muscle flaps in 1980, by Jurkiewicz and associates. 3�Today, established treatment protocols include aggressive surgical debridement, the application of vacuumassisted closure (VAC) devices, delayed rewiring or plastic reconstruction with muscle and omental flaps, depending on the severity of infection. Apart from well described inherent patient risks, we believe the technique of primary sternal closure is an important risk factor for the subsequent incidence of dehiscence and wound infection. The aim of this study was to evaluate the effect of thermo-reactive Nitinol clips (Praesidia, Bologna, Italy) on the incidence of postoperative DSWC (Fig. 1). Purpose: Deep sternal wound complications after cardiac surgery have an incidence of 2 to 8% and carry a significant mortality. The aim of this study was to evaluate the effect of thermo-reactive Nitinol clips on the incidence of postoper...

Aim To compare the clinical characteristics, at the time of admission and after coronary revascularization by bypass surgery, among British patients of Indo-Asian and white Caucasian descent.Method One hundred and ninety-four pairs of patients admitted between November 1994 and January 1997 were matched for age (within 3 years), sex and date of admission (within 3 months). Their clinical characteristics at the time of admission for coronary artery bypass grafting surgery, and the incidence of hospital morbidity, hospital mortality and length of stay in the intensive therapy unit or hospital following coronary artery bypass grafting were determined.Results A higher proportion of Indo-Asian patients underwent coronary revascularization on a non-elective basis (43% vs 32% white Caucasian patients, P=0·018), had a higher prevalence of diabetes (39% vs 12%, P=0·0001), a lower prevalence of smoking (36% vs 80%, P=0·0001) and a lower rate of previous myocardial infarction (47% vs 62%, P=0·012). As regards revascularization, although there was no significant difference in the number of vessels revascularized, there was a lower use of the arterial conduit (internal mammary artery) in the Indo-Asian patients (72% vs 81%, P=0·028) particularly for those undergoing emergency/urgent surgery (59% vs 72%, P=0·001) and with a previous myocardial infarction (65% vs 81%; P=0·01) when compared with their white Caucasian counterparts. Following surgery there were no differences in the types of support required for vital functions. There was no significant difference in the proportion of major post-operative complications, that is, haemorrhage, cerebrovascular accident, renal failure requiring dialysis or respiratory failure. Similarly, there were no differences in the length of intensive therapy unit stay (median stay 1 day vs 1 day, P=0·4) and hospital stay following surgery (median stay 6 days vs 6 days, P=0·5) between the two groups. Although there was a trend towards a higher in-hospital (30 day) mortality (6·7% [95% confidence intervals CI 3·18-10·21] vs 2·6% [CI 0·35-4·9; P=0·0618]), in Indo-Asians compared to white Caucasians this trend disappeared when patients in the two groups undergoing non-elective surgery only were compared (9% vs 7%; P=0·7).Conclusions A higher proportion of Indo-Asians underwent non-elective coronary revascularization, with a significantly lower use of the arterial conduit and a relatively higher in-hospital mortality. Following coronary revascularization the medical management, length of stay and hospital morbidity in Indo-Asian patients was no different from that of their white Caucasian counterparts. This is despite a perceived poorer outcome in Indo-Asians compared to white Caucasians.

AVR post-CABG with patent grafts can be performed in high-risk patients with excellent short- and long-term outcomes and appears to be superior to published catheter-based interventions. In the absence of randomized trial data, we believe that open AVR remains the treatment of choice for aortic valve disease following prior CABG.

41 surgeons said that they would routinely do computed tomography, 68 indicated that they would do a mediastinoscopy if the computed tomography showed enlarged nodes. This suggests that some surgeons will undertake mediastinal exploration if