Enterobacter cloacae septicemia in a triple-cannula extracorporeal membrane oxygenation circulatory support treated with Seraph-100 Microbind affinity blood filter.

Bloodstream infections (BSI) are frequently encountered during extracorporeal membrane oxygenation (ECMO) support. Once septicemia is observed, treatment should be rapid, adequate, and multifaceted, particularly in advanced ECMO configurations. We report on a case of a 60-year-old male patient with acute-on-chronic heart failure due to ischemic cardiomyopathy. The treatment was complicated by cardiogenic shock requiring veno-arterial ECMO support, and, due to persistent pulmonary congestion, an upgrade with an additional left-atrial drainage cannula. After seven days of ECMO support, septicemia with shock ensued. Ex iuvantibus antibiotic treatment was started promptly. We wanted to minimize the likelihood of bacterial biofilm build-up requiring an exchange of the ECMO circuit and cannula, which was expected to be challenging. Therefore, we added a Seraph-100 Microbind affinity blood filter (providing blood purification with the potential for rapid bacterial clearance) to the ECMO circuit. Initial blood cultures tested positive for Enterobacter cloacae. Following a course of Seraph-100 treatment, bacteremia, septicemia, and shock resolved. There was no need for a circuit or cannula exchange. The additional eleven days of ECMO support were uneventful. The patient was successfully bridged to long-term mechanical circulatory support. We believe that the synergistic effect of early implementation of both broad-spectrum antibiotic treatment and blood purification with the potential for rapid bacterial clearance (such as the one provided with the Seraph-100 Microbind affinity blood filter) is crucial in BSI in patients receiving advanced ECMO.

Comparison between OPCABG and CABG Surgical Revascularization Using Transit Time Flow Measurement (TTFM).

OBJECTIVE: To compare the intraoperative quality of coronary anastomoses performed with or without cardiopulmonary bypass using transit time flow measurement (TTFM) parameters. METHODS: We collected data from 588 consecutive patients who underwent surgical revascularization. We retrospectively reviewed data from two groups: 411 with cardiopulmonary bypass (CABG group) and 177 off-pump (OPCABG group). Transit time flow measurement parameters: mean graft flow (MGF), pulsatile index (PI), and diastolic filing (DF) were measured for each graft and patient. RESULTS: Patients in the OPCABG group had higher EuroSCORE compared with the CABG group (3.53 ± 2.32 versus 2.84 ± 2.15, P = .002). Overall comparison of TTFM parameters showed no statistical difference between the two surgical techniques except for PI in circumflex artery territory, which was higher in the OPCABG group for all types of grafts 3.0 ± 4.9 versus 2.4 ± 2.0 in, P = .026. CONCLUSION: The comparison between OPCABG and CABG in this study showed comparable results with both surgical techniques. PI was higher in the OPCABG group in harder-to-reach vessel territories. Measurement of transit time may improve the quality, safety, and efficacy of coronary artery bypass grafting and should be considered as a routine procedure.

The epidemiological and clinical features of odontogenic infective endocarditis.

Antibiotic prophylaxis (AP) of infective endocarditis (IE) in dental practice is a controversial topic. We evaluated the characteristics of the odontogenic IE and assessed the practice and sources of information pertaining to the topic utilized by the Croatian dentists. We conducted a retrospective review of consecutive medical charts of adult patients with IE, admitted to the University Hospital for Infectious Diseases in Zagreb, Croatia, between January 2007 and December 2017. In addition, a cross-sectional, self-reporting questionnaire survey was conducted with participation of 348 Croatian dentists. Of the 811 admissions for suspected IE (40.3% of all Croatian and 92.1% of all Zagreb hospitals), 386 patients were confirmed as definite IE: 68 with odontogenic IE and 318 with IE of other origin. Their first hospital admissions were analyzed. Definite odontogenic IE was defined as a positive echocardiographic result in conjunction with two separate positive blood cultures showing exclusive oral cavity pathogen or Streptococcus viridans associated with current or recent (< 1 month) dental, periodontal, or oral cavity infection. The annual number of new odontogenic IE patients appeared constant over time. In 91.2% of the cases, odontogenic IE was not preceded by a dental procedure; poor oral health was found in 51.5% of patients, and 47.1% had no cardiac condition that increases the IE risk. In-hospital mortality was 5.1% with conservative treatment and 4.5% with cardiac surgery and was much lower for odontogenic IE than in non-odontogenic IE (14.6% and 34.4%, respectively). An increasing number of admissions for non-odontogenic IE were observed in parallel with an increasing number of staphylococcal IE. Surveyed dentists (500 invited, 69.6% responded) were aware of the AP recommendations, but were largely reluctant to treat patients at risk. In people with poor oral health, AP should be considered regardless of cardiac risk factors. Improvement of oral health should be the cornerstone of odontogenic IE prevention.

Heart re-transplantation in Eurotransplant.

Internationally 3% of the donor hearts are distributed to re-transplant patients. In Eurotransplant, only patients with a primary graft dysfunction (PGD) within 1 week after heart transplantation (HTX) are indicated for high urgency listing. The aim of this study is to provide evidence for the discussion on whether these patients should still be allocated with priority. All consecutive HTX performed in the period 1981-2015 were included. Multivariate Cox' model was built including: donor and recipient age and gender, ischaemia time, recipient diagnose, urgency status and era. The study population included 18 490 HTX, of these 463 (2.6%) were repeat transplants. The major indications for re-HTX were cardiac allograft vasculopathy (CAV) (50%), PGD (26%) and acute rejection (21%). In a multivariate model, compared with first HTX hazards ratio and 95% confidence interval for repeat HTX were 2.27 (1.83-2.82) for PGD, 2.24 (1.76-2.85) for acute rejection and 1.22 (1.00-1.48) for CAV (P < 0.0001). Outcome after cardiac re-HTX strongly depends on the indication for re-HTX with acceptable outcomes for CAV. In contrast, just 47.5% of all hearts transplanted in patients who were re-transplanted for PGD still functioned at 1-month post-transplant. Alternative options like VA-ECMO should be first offered before opting for acute re-transplantation.

LETTER TO THE EDITOR.

We read with great interest the report by Dr. Colak and coworkers about utilization of omentoplasty in poststernotomy mediastinitis treatment [Colak 2016]. In our opinion, several points need to be addressed.

The Role of Standard Echocardiographic Parameters in Endomyocardial Biopsy Proven Cardiac Amyloidosis.

Primary light-chain (AL) amyloidosis is a plasma cell dyscrasia associated with the deposition of immunoglobulin-derived amyloid in multiple organs. In the heart, this results in an infiltrative cardiomyopathy, with increased left ventricular wall thickness, normal or decreased left ventricular (LV) cavity size and congestive heart failure. Cardiac involvement is a major determinant of prognosis of AL amyloidosis. We report a patient with cardiac amyloidosis proven by cardiac biopsy, and aim to point out at transthoracic echocardiography as the hallmark of diagnostics. Echocardiography revealed increased LV thickness at 20mm, impaired LV ejection fraction (EF) at 35%, enlarged atria, transmitral deceleration time at 156 ms and increased E/A ratio at 4.25. Early diagnosis and intervention can have a significant impact on the patient's response to treatment, especially when the underlying condition involves a malignancy or infiltrative disorder. Standard transthoracic echocardiography as a noninvasive diagnostic tool is valuable and has a significant role in diagnosis and prognosis.

Why pulsatility still matters: a review of current knowledge.

Continuous-flow left ventricular assist devices (LVAD) have become standard therapy option for patients with advanced heart failure. They offer several advantages over previously used pulsatile-flow LVADs, including improved durability, less surgical trauma, higher energy efficiency, and lower thrombogenicity. These benefits translate into better survival, lower frequency of adverse events, improved quality of life, and higher functional capacity of patients. However, mounting evidence shows unanticipated consequences of continuous-flow support, such as acquired aortic valve insufficiency and acquired von Willebrand syndrome. In this review article we discuss current evidence on differences between continuous and pulsatile mechanical circulatory support, with a focus on clinical implications and potential benefits of pulsatile flow.

Aortic Valve Repair with External Annuloplasty in Bicuspid versus Tricuspid Aortic Valve Patients.

Surgical repair for regurgitant bicuspid aortic valve (BAV) is promising but underutilized due to perceived complexities and lack of long-term data. This study evaluated the efficacy of valve-sparing root remodeling (VSRR) or isolated valve repair combined with calibrated external ring annuloplasty in BAV versus tricuspid aortic valve (TAV) patients. All patients operated on for aortic regurgitation and/or aneurysm at our institution between 2014 and 2022 were included and entered into the Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (AVIATOR). Patients with successful repair at index surgery (100% in the BAV group, 93% in the TAV group, p = 0.044) were included in a systemic follow-up with echocardiography at regular intervals. Among 132 patients, 58 were in the BAV (44%) and 74 in the TAV group (56%). There were no inter-group differences in preoperative patient characteristics, except BAV patients being significantly younger (47 ± 18 y vs. 60 ± 14 y, p < 0.001) and having narrower aortic roots at the level of sinuses (41 ± 6 mm vs. 46 ± 13 mm, p < 0.001) and sinotubular junctions (39 ± 10 mm vs. 42 ± 11, p = 0.032). No perioperative deaths were recorded. At four years, there was no significant difference in terms of overall survival (96.3% BAV vs. 97.2% TAV, p = 0.373), freedom from valve reintervention (85.2% BAV vs. 93.4% TAV, p = 0.905), and freedom from severe aortic regurgitation (94.1% BAV vs. 82.9% TAV, p = 0.222). Surgical repair of BAV combined with extra-aortic annuloplasty can be performed with low perioperative morbidity and mortality and excellent mid-term results which are comparable to TAV repair.

[Recovery after long-term pulsatile mechanical circulatory support in patient with chronic heart failure: a case report]. / Oporavak nakon dugotrajne mehanicke cirkulatorne potpore u bolesnika s kronicnim zatajivanjem srca: prikaz bolesnika.

Use of mechanical circulatory support (MCS) is a part of today's standard therapy in the treatment of end-stage heart failure. In this paper we describe characteristics of Thoratec pVAD device for MCS, implantation techniques, as well as the most important advantages and complications of application of the device. We present a 41-year-old patient with dilatated cardiomyopathy, who was the first recipient ofparacorporeal left ventricular assist device (LVAD) in the Republic of Croatia due to end-stage heart failure. After heart function recovery the patient was successfully weaned from MCS after 130 days of support.

Long-term results after reconstructive surgery for aneurysms of the left ventricle.

BACKGROUND: Aneurysms of the left ventricle (LV) present a serious consequence of myocardial infarction, causing mechanical, thromboembolic, and arythmogenic complications. We present our experience in LV remodeling and long-term follow-up results. METHODS: From May 1998 to February 2009, 85 patients with postinfarction LV aneurysm underwent reconstructive procedures. Mean age was 58.7 + or - 8.9 years (range 36-79 years). Average LV ejection fraction was 39.8% + or - 13.1% (range 20%-70%). Mean EuroScore was 6.0 + or - 2.9 (range 3-19) and predictive mortality was 8.2% + or - 11.9% (range 1.6%-85.6%). The majority of patients were in New York Heart Association functional class II (44%) preoperatively and 32% of patients were in New York Heart Association class III or IV. LV reconstruction was performed by using the endoventricular patch technique in 56 patients (66%). In 29 patients (34%) reconstruction was done by linear closure. In 79 patients (93%) concomitant myocardial revascularization was performed. Mitral valve procedures were performed in 11 patients (13%), (repair in 10 patients and replacement in 1). RESULTS: Perioperative mortality was 3.5% (3 patients). Long-term follow-up was completed by means of phone interview with an average duration of 31.6 months (range 3-120 months). There were 9 late deaths (11%) during follow-up. Actuarial survival rates at 1, 5, and 10 years were 91%, 77%, and 68%, respectively. Fifty-nine patients (72%) were in New York Heart Association functional class I and II postoperatively. CONCLUSION: LV remodeling is a safe surgical procedure with low perioperative morbidity and mortality and excellent long-term survival, even in patients with severely reduced systolic function.

The Dark Side of the Heart: Cardiovascular Manifestation of Ochronosis.

Alkaptonuria is rare genetic disorder of tyrosine metabolism manifesting with signs of tissue pigmentation, dark urine, and ochronotic arthropathies. Commonly undiscovered by late adulthood, alkaptonuria can manifest as cardiac ochronosis with cardiovascular disorders such as valvulopathies, but rarely coronary artery disease. This case report describes 2 patients with aortic stenosis and coronary artery disease in whom alkaptonuria was diagnosed during open heart surgery.

Immunoglobulin G4 Inflammatory Aortic Aneurysm Mimicking Acute Aortic Syndrome.

Immunoglobulin-G4-related disease (IgG4RD) is a novel clinical entity characterized by lymphoplasmacytic infiltrates presenting as an excessive fibrosis such as retroperitoneal inflammatory pseudotumor but rarely affecting the heart or the aorta. We describe a case of IgG4RD with multifocal aortic involvement presenting as an acute aortic syndrome.

Topical use of antifibrinolytic agents reduces postoperative bleeding: a double-blind, prospective, randomized study.

OBJECTIVE: Postoperative bleeding is still one of the most common complications of cardiac surgery. Antifibrinolytic agents successfully reduce bleeding, but there are controversies concerning adverse effects after their systemic use. By topical application of antifibrinolytic agents in pericardial cavity, most of these effects are avoided. We compared the effects of topically applied aprotinin, tranexamic acid and placebo on postoperative bleeding and transfusion requirements. METHODS: In this single-center prospective, randomized, double-blind trial, 300 adult cardiac patients were randomized into three groups to receive one million IU of aprotinin (AP group), 2.5g of tranexamic acid (TA group) or placebo (PL group) topically before sternal closure. Groups were comparable with respect to all preoperative and intraoperative variables. Postoperative bleeding, transfusion requirements and hematologic parameters were evaluated. RESULTS: Postoperative bleeding within first 12-h period (AP group 433+/-294 [350; 360]ml, TA group 391+/-255 [350; 305]ml, PL group 613+/-505 [525; 348]ml), as well as cumulative blood loss within 24h (AP group 726+/-432 [640; 525]ml, TA group 633+/-343 [545; 335]ml, PL group 903+/-733 [800; 445]ml), showed statistically significant inter-group differences (both p<0.001). Bleeding rates values were significantly higher in placebo group compared to the groups treated with antifibrinolytic agents (AP and TA groups) concerning both variables. Although TA group showed the lowest values, no statistical differences between TA and AP groups were found. Inter-group difference of blood product requirements was not statistically significant. CONCLUSIONS: Topical use of either tranexamic acid or aprotinin efficiently reduces postoperative bleeding. TA seems to be at least as potent as aprotinin, but potentially safer and with better cost-effectiveness ratio.

Endoscopic radial artery harvesting reduces postoperative pain and neurologic complications.

BACKGROUND: Endoscopic radial artery harvest provides better cosmetic result without compromising the quality of the graft. We sought to compare postoperative harvesting site neurologic and vascular outcome. METHODS: From 10/2002 until 10/2004, 50 patients were randomized to have their radial artery harvested for coronary bypass either endoscopically (group A, n = 25) or conventionally (group B, n = 25). Radial arteries were preoperatively evaluated by Doppler echocardiography. Neurologic and functional status was assessed by a self reporting questionnaire with a semiquantitative (1-5) scale. Vascular status of the forearm was assessed by control echocardiography. RESULTS: At an average follow-up of 37 +/- 7 months, patients undergoing endoscopic radial artery harvesting had less overall neurologic complications (11 versus 17 patients, P = .023) and they were less severe (0.8 +/- 1.1 versus 2.2 +/- 1.2; P < .001). Ulnar flow increase was similar among the groups: 13.1 +/- 5.43 cm/s in group A versus 15.9 +/- 4.9 cm/s in group B (P = .147) as well as ulnar artery diameter increase 0.29 +/- 0.16 mm in group A versus 0.29 +/- 0.26 cm in group B (P = .914). CONCLUSION: Endoscopic radial artery is safe and does not compromise graft quality or forearm and hand circulation postoperatively. Along with providing a better cosmetic result, endoscopic artery harvesting reduces postoperative harvesting site pain and neurologic complications.

Successful treatment of annular rupture during transcatheter aortic valve implantation.

Annular rupture presents a rare but potentially fatal complication of transcatheter aortic valve implantation (TAVI). Although it can be subtle and subclinical in presentation, most severe forms present with hemodynamic instability and represent true emergencies requiring a more invasive treatment, even conventional surgery. We present a case of successful treatment of annular rupture by left ventricular outflow tract patch and surgical aortic valve replacement.

Isolated Tricuspid Valve Libman-Sacks Endocarditis in Systemic Lupus Erythematosus with Secondary Antiphospholipid Syndrome.

Libman-Sacks endocarditis, one of the most prevalent cardiac presentations of systemic lupus erythematosus, typically affects the aortic or mitral valve; tricuspid valve involvement is highly unusual. Secondary antiphospholipid syndrome increases the frequency and severity of cardiac valvular disease in systemic lupus erythematosus. We present the case of a 47-year-old woman with lupus and antiphospholipid syndrome whose massive tricuspid regurgitation was caused by Libman-Sacks endocarditis isolated to the tricuspid valve. In addition, we discuss this rare case in the context of the relevant medical literature.

Neopterin kinetics after cardiac surgery with or without cardiopulmonary bypass.

Cardiac surgery (CS) with cardiopulmonary bypass (CPB) induces systemic inflammatory response by activating plasma proteins and blood cells. Activated monocytes/macrophages produce inflammatory marker neopterin (NP). The aim was to explore the NP kinetics in first 24 hours after CS according to the CPB use. Significant difference between groups was found for NP levels 12 and 24 hrs after CS, being higher in on-pump group. Strong association was found between NP levels 12 hrs after CS and the length of ICU stay for on-pump group (r=0.744, p<0.001). Strong association was found between preoperative NP levels and the length of ICU stay for those on-pump patients with elevated preoperative NP (r=0.855, p=0.001; linear regression equation y=0.50x-5.14, p<0.001). Preoperative NP levels higher than 10 nmol/L in on-pump group could predict prolonged ICU stay and outpoint patients at higher risk for developing postoperative complications and, therefore, help to determine the necessary therapeutic interventions.

[Coronary artery surgery in women]. / Specificnost kirurskog zahvata revaskularizacije miokarda u zena.

Cardiovascular diseases are the leading cause of morbidity and mortality for women in developed countries. Numerous studies have shown that women have higher morbidity and mortality rates than men following coronary artery bypass graft surgery (CABG). Having this evidence as our starting point, we compared the outcomes of CABG procedures in women and men. The analysis included patient preoperative risk factors (age, left ventricular ejection fraction, diabetes mellitus, arterial hypertension, hypercholesterolemia, myocardial infarction and cerebrovascular insult), number of grafts and perioperative complications (reopening for bleeding, perioperative myocardial infarction, sternal wound infections--both superficial and deep, atrial and ventricular fibrillation, cardiac decompensation), and mortality. Women had more risk factors and comorbidities than man, including arterial hypertension and hypercholesterolemia, but less severe atherosclerosis and higher left ventricular ejection fraction. Off-pump myocardial revascularization was done in 48% of women and in 42% of men. There was no statistically significant difference in perioperative complications between women and men. Comparison of the mean values showed the perioperative mortality to be higher in women than in men (3.4% vs. 2.9%), but the difference was not statistically significant (p = 0.724).

[Advanced myocardial ischemia in patients with diabetes mellitus--early results of surgical treatment]. / Uznapredovala ishemija miokarda kod bolesnika sa secernom bolescu-- rani rezultati kirurskog lijecenja.

In this restrospetive study, data on 272 coronary artery disease patients with concomitant diabetes mellitus treated between 12/1997 and 12/2002 were analyzed. Eighty patients inderwent complete arterial revascularization (DM-ART), whereas 192 patients underwent coronary revascularization using arterial-venous grafts (DN-NEART). The following preoperative data and risk factors were analyzed: arterial hypertension, hyperlipoproteinemia, number of vessels involved, left coronary artery stenosis, unstable angina, previous myocardial infarction (MI), previous cardiac surgery, EuroScore. During a 30-day postoperative period, the following complications were analyzed: bleeding, perioperative MI, wound infection, sternal dehiscence, neurologic dysfunction, mortality. DM-ART patients had a higher rate of hyperlipoproteinemia (p=0.004). Difference was only found for the occurrence of perioperative MI in DM-NEART group (p<0.001). Total arterial revascularization without cardiopulmonary bypass is a reliable and safe choice in patients with concomitant diabetes mellitus irrespective of its type. Definitive conclusions can only be made after five- or ten-year evaluation of postoperative mirbidity and mortality.