Faculty Bibliography

Cardiac surgery patients with infected implantable cardioverter defibrillator hardware face high morbidity with both surgical and nonoperative management options. We present a case of infected epicardial patch defibrillator leads in a patient with prohibitively high risk of death with open surgical removal. As a less morbid alternative, an Eloesser flap was used to convert his presenting mediastinal empyema necessitans into a chronic, manageable wound.

PURPOSE: Driveline exit site (DLES) management following left ventricular assist device implantation is important for preventing driveline infection (DLI). While chlorhexidine gluconate (CHG) is generally recommended for DLES antisepsis, CHG intolerance can develop, resulting in a need for alternative antiseptics. We reviewed our institutional experience with DLES antisepsis methods in HeartMate II patients, comparing outcomes of patients with and without CHG intolerance. METHODS: Between October 2011 and March 2016, 44 patients underwent primary HeartMate II implantation. CHG was used for DLES antisepsis and povidone-iodine (PVP-I) was used in patients with CHG intolerance. DLI was defined by Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) criteria. RESULTS: Of 44 patients, 37 (84%) received CHG and 7 (16%) received PVP-I antisepsis due to CHG intolerance. Five patients (11.4%) developed a DLI, with an event per patient-year rate of 0.07. Median length of support was 521 days (interquartile range 202-881 days). Characteristics were similar between patients with and without DLI. However, a larger proportion of patients with DLI had CHG intolerance compared to patients without DLI (60.0% vs. 10.3%, p:0.05). Causative organisms were Staphylococcus aureus in CHG-intolerant patients and Stenotrophomonas and Acinetobacter in CHG-tolerant patients. Kaplan-Meier method and log-rank test demonstrated decreased infection-free days in patients using PVP-I rather than CHG (p:0.01). CONCLUSIONS: While the etiology of DLI is multifactorial, CHG intolerance appears to be a risk factor. Our findings highlight the need for larger studies comparing the efficacy of antiseptics for DLES care, particularly for patients with CHG contraindications.

This monograph outlines the rich history of cardiothoracic surgery at New York University (NYU), beginning with its origins at The Bellevue Hospital in the mid-1800's. Numerous early clinical accomplishments were significant, leading up to the arrival of Dr Frank Spencer in 1966. Under Dr Spencer's leadership, the department progressed with development of a culture of innovation, leadership and education that carries through today. The program encompasses three major hospitals and will soon graduate its 50th class of trainees, many of whom have had outstanding careers and a major impact on the field of cardiothoracic surgery. This culture continues under the direction of our current chair, Dr Aubrey Galloway, whose vision has orchestrated and refined a new period of innovation and excellence.

BACKGROUND: There are limited data in the literature concerning the effect of a blood conservation strategy (BCS) on aortic valve replacement (AVR) patients. METHODS: From 2007 to 2011, 778 patients underwent AVR at a single institution. During this period, a multidisciplinary BCS was initiated with emphasis on limiting intraoperative hemodilution, tolerance of perioperative anemia, and blood management education for the cardiac surgery care providers. RESULTS: Mortality was 3.0% (23 of 778) overall and 1.7% (9 of 522) for isolated first-time AVR. There was no difference in rates of mortality (p = 0.5) or major complications (p = 0.4) between the pre-BCS and post-BCS groups; however, the BCS was associated with a lower risk of major complications (odds ratio, 1.7; p = 0.046) by multivariable analysis. The incidence of red blood cell (RBC) transfusion decreased from 82.9% (324 of 391) to 68.0% (263 of 387; p < 0.01). Of those patients who did not receive any day-of-operation RBC transfusions, 64.5% (191 of 296) did not receive any postoperative RBC transfusions. Lower risk of RBC transfusion was associated with isolated AVR (p < 0.01), a minimally invasive approach (p < 0.01), and BCS (p < 0.01), whereas a greater risk of RBC transfusion was associated with older age (p < 0.01), prior cardiac operation (p = 0.01), female sex (p < 0.01), and smaller body surface area (p < 0.01). Day-of-operation RBC transfusion of 2 units or more was associated with increased deaths (p = 0.01), prolonged intubation (p < 0.01), postoperative renal failure (p = 0.01), and increased incidence of any complication (p < 0.01). CONCLUSIONS: Perioperative BCS reduced RBC transfusion in AVR patients without an increase in mortality or morbidity. Guidelines for BCS in routine cardiac operations should be extended to AVR patients.

OBJECTIVE: Recent Society of Thoracic Surgeons and Society of Cardiovascular Anesthesiologists (STS/SCA) guidelines highlight the safety of blood conservation strategies in routine cardiac surgery. We evaluated the feasibility and impact of such a program in complex aortic surgery. METHODS: Between March 2010 and October 2011, 63 consecutive aortic replacement procedures were performed: aortic root (n = 17; 27%), ascending aorta (n = 15; 23.8%), aortic arch (n = 19; 30.2%), descending aorta (n = 8; 12.7%), and thoracoabdominal aorta (n = 4; 6.3%). Aortic dissections were present in 32 patients. A multidisciplinary approach to blood conservation included minimal perioperative crystalloid, small priming circuits, hemoconcentration, meticulous hemostasis, and tolerance of postoperative anemia (hemoglobin of >/= 7mg/dL). RESULTS: Operative mortality was 11.1%. Multivariate predictors of mortality were low preoperative hematocrit (HCT, P = 0.05) and endocarditis (P = 0.021). Seventy-four percent of patients required no intraoperative packed red blood cell (pRBC) transfusion. For nondissection patients, 80.6% required /= 2 U (P = 0.001). CONCLUSIONS: These findings demonstrate that a perioperative blood conservation management strategy can be extended to complex aortic surgery and is associated with better clinical outcomes.

Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly present in approximately one in 300,000 live births. Here, we present a unique ALCAPA variant identified in a neonate. The left anterior descending artery originated posterolaterally on the main pulmonary artery, and the circumflex originated separately from the distal right pulmonary artery. doi: 10.1111/jocs.12079 (J Card Surg 2013;28:306-308).