Background
Delayed sternal closure (DSC) is a useful option for patients with intractable bleeding and hemodynamic instability due to prolonged cardiopulmonary bypass and a preoperative bleeding tendency. Vacuum-assisted closure (VAC) has been widely used for sternal wound problems, but only rarely for DSC, and its efficacy for mediastinal drainage immediately after cardiac surgery has not been well established. Therefore, we evaluated the usefulness of DSC using VAC in adult cardiac surgery.
Methods
We analyzed 33 patients who underwent DSC using VAC from January 2017 to July 2022. After packing sterile gauze around the heart surface and great vessels, VAC was applied directly without sternal self-retaining retractors and mediastinal drain tubes.
Results
Twenty-one patients (63.6%) underwent emergency surgery for conditions including type A acute aortic dissection (n=13), and 8 patients (24.2%) received postoperative extracorporeal membrane oxygenation support. Intractable bleeding (n=25) was the most common reason for an open sternum. The median duration of open sternum was 2 days (interquartile range [25th–75th pertentiles], 2–3.25 days) and 9 patients underwent VAC application more than once. The overall in-hospital mortality rate was 27.3%. Superficial wound problems occurred in 10 patients (30.3%), and there were no deep sternal wound infections.
Conclusion
For patients with an open sternum, VAC alone, which is effective for mediastinal drainage and cardiac decompression, had an acceptable superficial wound infection rate and no deep sternal wound infections. In adult cardiac surgery, DSC using VAC may be useful in patients with intractable bleeding or unstable hemodynamics with myocardial edema.
Introduction Although thrombolytic therapy is the standard treatment for massive pulmonary thromboembolism (PTE), it is often ineffective in patients with circulatory collapse. Surgical embolectomy is another treatment option, but whether it is absolutely necessary is controversial. We sought to evaluate the outcomes of patients with massive PTE treated with intensive critical care including extracorporeal membrane oxygenation (ECMO) without thrombolytic therapy or surgical embolectomy. Methods We analyzed 39 patients who were treated for massive PTE from January 2011 to June 2019. Massive PTE was treated with anticoagulation and hemodynamic support at an intensive care unit. ECMO was applied in patients with circulatory collapse. The computed tomography (CT) obstruction index and the ratio of the right ventricle to left ventricle short-axis diameters (RV/LV) were measured using serial CT angiography to confirm changes in pulmonary emboli and RV strain. Results Twenty-one patients were in cardiogenic shock, and 15 of them needed cardiopulmonary resuscitation (CPR). Fifteen patients were treated with ECMO and nine of them were weaned successfully. The overall in-hospital mortality was 23% (9/39). On the follow-up CT scan after 6 months, residual PTE was observed in 10 patients and their median CT obstruction index was 6.25 % (range 2.5–35). The initial mean RV/LV ratio was 1.8 ± 0.47 and the value measured at follow-up CT decreased to less than 1 (0.9 ± 0.1). Conclusions Intensive critical care with heparin alone and timely ECMO support without thrombolytic therapy could be an effective treatment option in patients with acute massive PTE.
Coronary arterial involvement in Takayasu arteritis (TA) is not uncommon. Herein, we describe a case of TA with celiac trunk and superior mesenteric artery occlusion combined with coronary artery disease. Bilateral huge internal thoracic arteries (ITAs) and the inferior mesenteric artery provided the major visceral collateral circulation. After percutaneous intervention to the right coronary artery, off-pump coronary artery bypass grafting for the left coronary territory was done using a right ITA graft and its large side branch because of its relatively minor contribution to the visceral collateral circulation.
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