Background: "Type A" acute aortic dissection (AAAD) is the most challenging among the emergency operations in cardiac surgery. The aim of this study was the evaluation of the role of acute renal failure (ARF) in postoperative survival of patients operated for AAAD. Methods: From February 2010 to April 2012, 37 consecutive patients were operated at our department for AAAD. We studied our population by subdividing the patients within groups according to the presence of ARF requiring continuous veno-venous hemofiltration (CVVH) and according to hypothermic circulatory arrest (HCA) times and degrees. Results: The overall 30-day mortality was 27% (50% group A with ARF, 13% group B no ARF). Acute renal failure requiring CVVH was 37.8%. Multivariate analysis revealed a significant association with 30-day mortality (odds ratio 6.6 and p = 0.020). Preoperative oliguria [urine output less than 30 ml/h (odds ratio 4.7 p = 0.039)], CPB greater than 180 minutes (odds ratio 6.5 p = 0.023) and postoperative bleeding requiring a surgical reopening (odds ratio 12.2 and p = 0.021) were the variables significantly associated with acute kidney injury. Conclusions: The data obtained from our analysis bring out the high incidence of renal injuries after surgery for AAAD, and indicate a negative impact on renal injuries of a preoperative oliguria, longer Cardiopulmonary bypass (CBP)/HCA times, and postoperative bleeding requiring a surgical revision. Our data also suggest a better 30-day survival and better renal outcomes in case of shorter HCA and lesser degree of hypothermia.The option of lesser and shorter hypothermia may be very useful, especially for the elderly patients and octogenarians.

Sternal Wound Infections (SWI) represent a dangerous complication after cardiac surgery entailing significantly longer hospital stays and worse short-term survival, especially in case of deep infections (DSWI) with the onset of osteomielitis or mediastinitis. In the literature, the real incidence of SWI 1 is estimated between 0.25% and 10%, while we can gain an insight into the prognostic impact of mediastinitis thinking about the high mortality rate between 14-47% related to this complication, that usually presents an incidence between 1-2.4%. Hereafter we describe a case in which a plastic surgical approach associated to the adoption of a VAC-therapy instill after specific antibiotic-therapy has integrated and optimized the trend of a very complex clinical circumstance. Case reportA 65-year old female was admitted at our division to undergo coronary artery bypass grafting procedure; about her medical history, the patient suffered from essential arterial hypertension, diabetes mellitus in insulin-therapy and mild obesity. Transthoracic echocardiography revealed an ejection fraction about 50% with inferior wall and posterior septum medio-basal acynesia, whereas the coronarography pointed out a three-vessel disease with involvement of the left main coronary artery. Thus, the patient underwent CABG through LIMA-LAD and SVG-OM-PDA according to the sequential technique; after surgery our conventional broad-spectrum antibiotic prophylaxis, relied on the administration of cefotaxime, was started.The post-operative course was characterized by an early psychomotor agitation, a severe glycemic decompensation and the presence of mild serosity at the third infe-

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Despite not included in the traditional risk scores before surgery, liver cirrhosis, especially in advanced stages, has always influenced strongly final outcome both on short and mid-term in patients undergoing cardiac surgery. Growing incidence of non-alcoholic fatty liver disease interlinked with metabolic syndrome and significant advancements in medical therapy have actually increased the likelihood of cardiac surgery in cirrhotic patients. To date, Child-Pugh and MELD scores have been commonly used to predict mortality and postoperative hepatic decompensation, but on the other hand, both traditional risk scores show some limitations for evaluation of hepatopathic patients undergoing specifically cardiac surgery. In this context, a specific Heart-Liver score hasn't been developed yet in the attempt to outline a patient profile able to face surgery, therefore addressing us to adopt the best strategy possible for each case. If CP class A or low MELD score (<11) patients tolerate cardiac surgery with a mild increase in mortality and morbidity, currently state of art recommends particular caution towards surgery idea in presence of advanced hepatic disease. As far as cardiac surgery represents the unique therapeutic strategy in several life-threatening cases, anyway surgical correction of cardiac pathology won't guarantee an increased life expectancy in accordance with the persistent liver dysfunction. Hereby, this paper will focus on preoperative parameters that should be considered in the future realization of a Heart-Liver prognostic score for overcoming limitations and difficulties related to the impact of liver disease on final clinical outcome.

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