Frequency, characteristics, and predictors of microbiologically documented nosocomial infections after cardiac surgery.

OBJECTIVE: Nosocomial infections still remain a serious problem in patients undergoing open heart surgery. The objective of this study was to evaluate frequency, characteristics, and predictors of nosocomial infections after cardiac surgery. METHODS: This prospective case-control study was conducted in adult patients who underwent open heart surgery with use of extracorporeal circulation over a period of 16 months. Cases were patients who developed microbiologically documented nosocomial infection. Controls were patients who had open heart surgery within a randomly selected two-month period of the study (defined before the start of the study) and did not develop nosocomial infection. Various variables, available before, during or within the first two days after operation, were examined as possible risk factors of nosocomial infections in bi-variable analysis. Then, variables that were found to be statistically associated with nosocomial infections in the bi-variable analysis were included in a multivariable logistic regression model to identify independent risk factors associated with nosocomial infections after open heart surgery. RESULTS: One hundred and seven of 2122 (5.0%) patients developed microbiologically documented nosocomial infection after open cardiac surgery. The majority of nosocomial infections were respiratory tract infections (45.7%) and central venous catheter-related infections (25.2%). All cause hospital mortality was 16.8% in patients with nosocomial infection and 3.5% in the control group (p=0.005). Out of 20 variables studied as possible risk factors, 12 had a statistically significant association with postoperative infection. History of immunosuppression (OR=3.6, 95% CI 1.2-11.0%), transfusion of more than five red blood cell units in both the operating room and during the first ICU postoperative day (OR=21.2, 95% CI 11.9-37.8%), and development of acute renal failure within the first two days after operation (OR=49.9, 95% CI 22.4-111.0%), were found to be independent predictors of nosocomial infections after cardiac surgery in a multivariable logistic regression model. CONCLUSIONS: Postoperative nosocomial infections are a considerable problem in cardiac surgery patients. The identified independent predictors of nosocomial infection may be useful in identifying those at high risk for development of such infection in cardiac surgery patients.     

Direct epiaortic ultrasound scanning for the rapid confirmation of intraoperative aortic dissection

We present a case of an intraoperative acute aortic type A dissection (AADA) extending from the distal ascending aorta to the distal aortic arch, initially not visible on the transesophageal echocardiography (TEE). The rapid confirmation of the diagnosis by means of direct epiaortic ultrasound scanning facilitated decision-making and the subsequent successful surgical treatment.     

Trans‐carotid access for TAVR allows safe and rapid exchange for bailout valve‐in‐valve procedures

Trans‐carotid access for trans‐catheter aortic valve replacement is a valid alternative in patients with aortic valve dysfunction, severe peripheral vascular disease, and high‐risk for surgery. However, in the event of the need for a bailout valve‐in‐valve procedure, the safety of this access site is uncertain. We report a patient with aortic regurgitation, previous coronary surgery, peripheral vascular disease, and impaired ventricular function who underwent a CoreValve Evolut‐R (Medtronic Inc, Minneapolis, MN) implantation through the left carotid artery followed by a successful valve‐in‐valve procedure with a 26‐mm Edwards Sapien3 valve (Edwards Lifesciences, Irvine, CA) through the same carotid access site.     

Is oxidative stress an issue in peritoneal dialysis?

During the last two decades, oxidative stress (OS) has emerged as a novel risk factor for a variety of adverse events, including atherosclerosis and mortality in chronic kidney disease (CKD) patients. Increased OS occurs even in early stages of the disease, progresses with deterioration of renal function and is further aggravated by hemodialysis (HD), due to the bioincompatibility of the method. Compared to HD, peritoneal dialysis (PD) is a more biocompatible dialysis modality, characterized by a significantly reduced, but still high, OS status. The culprit for OS in PD is mainly the composition of PD solutions (low pH, lactate buffer, increased osmolarity and high glucose concentration). After heat sterilization of PD solutions, formation of glucose degradation products (GDPs) and advanced glycation end‐products (AGEs) trigger inflammation and enhance OS. Chronic exposure of the peritoneum to this toxic, hyperglycemic environment leads to OS‐derived morphologic damage of peritoneal cells, loss of ultrafiltration capacity and decreased technique survival. Moreover, OS is linked with peritonitis, loss of residual renal function, inflammation, atherosclerosis, cardiovascular (CV) disease, and increased mortality. To ameliorate OS status in PD, a multitargeted approach is necessary that includes use of neutral pH, low GDP, low lactate and iso‐ismolar PD solutions, strict glycemic control, optimal volume management and, probably supplementation with antioxidants, N‐acetylcysteine being the most promising among them.