Expanded Petticoat technique to promote the reduction of contrasted false lumen volume in patients with chronic type B aortic dissection.

OBJECTIVE: This study examined the outcomes of our novel concept of expanded provisional extension to induce complete attachment strategy (Petticoat) for safety, durability, and remodeling of chronic type B dissections. METHODS: Twenty patients with chronic type B aortic dissection with aneurysmal degeneration qualified for an expanded Petticoat strategy (stent graft in the thoracic, plus additional distal bare stent into the abdominal and infrarenal aorta, followed by parallel stent grafts into common iliac arteries). Computed tomography was performed preoperatively and at 1, 6, and 12 months after surgery. RESULTS: The primary technical success was 100%. The 30-day mortality rate was 0%. At 12 months, favorable aortic remodeling and complete false lumen (FL) thrombosis were noted as 100% in the thoracic and infrarenal aorta. The volume of contrast-enhanced FL decreased from 186 ± 75.4 mL all along the dissection preoperatively (range, 70-360 mL), to 6.32 ± 5.4 mL postoperatively (range, 0.0-19.6 mL) and was only observed in the visceral aorta (P = .000089). Despite persistent flow in a small area of the FL, the maximal aortic size was stable in follow-up. Neither paraplegia nor visceral branch occlusion were noted in the follow-up. CONCLUSIONS: The treatment of aortic dissections with an expanded Petticoat strategy seems to be safe and offers good early results. It significantly reduced the volume of contrast enhanced FL. Further investigation of any subsequent results will be necessary.

The association between blood pressure and long-term outcomes of patients with ischaemic cardiomyopathy with and without surgical revascularization: an analysis of the STICH trial.

Aims: Hypertension (HTN) is a well-known contributor to cardiovascular disease, including heart failure (HF) and coronary artery disease, and is the leading risk factor for premature death world-wide. A J- or U-shaped relationship has been suggested between blood pressure (BP) and clinical outcomes in different studies. However, there is little information about the significance of BP on the outcomes of patients with coronary artery disease and left ventricular dysfunction. This study aimed to determine the relationship between BP and mortality outcomes in patients with ischaemic cardiomyopathy. Methods and results: The influence of BP during a median follow-up of 9.8 years was studied in a total of 1212 patients with ejection fraction ≤35% and coronary disease amenable to coronary artery bypass grafting (CABG) who were randomized to CABG or medical therapy alone (MED) in the STICH (Surgical Treatment for Ischaemic Heart Failure) trial. Landmark analyses were performed starting at 1, 2, 3, 4, and 5 years after randomization, in which previous systolic BP values were averaged and related to subsequent mortality through the end of follow-up with a median of 9.8 years. Neither a previous history of HTN nor baseline BP had any significant influence on long-term mortality outcomes, nor did they have a significant interaction with MED or CABG treatment. The landmark analyses showed a progressive U-shaped relationship that became strongest at 5 years (χ2 and P-values: 7.08, P = 0.069; 8.72, P = 0.033; 9.86; P = 0.020; 8.31, P = 0.040; 14.52, P = 0.002; at 1, 2, 3, 4, and 5-year landmark analyses, respectively). The relationship between diastolic BP (DBP) and outcomes was similar. The most favourable outcomes were observed in the SBP range 120-130, and DBP 75-85 mmHg, whereas lower and higher BP were associated with worse outcomes. There were no differences in BP-lowering medications between groups. Conclusion: A strong U-shaped relationship between BP and mortality outcomes was evident in ischaemic HF patients. The results imply that the optimal SBP might be in the range 120-130 mmHg after intervention, and possibly be subject to pharmacologic action regarding high BP. Further, low BP was a marker of poor outcomes that might require other interactions and treatment strategies. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.

Influence of mitral regurgitation repair on survival in the surgical treatment for ischemic heart failure trial.

BACKGROUND: Whether mitral valve repair during coronary artery bypass grafting (CABG) improves survival in patients with ischemic mitral regurgitation (MR) remains unknown. METHODS AND RESULTS: Patients with ejection fraction ≤35% and coronary artery disease amenable to CABG were randomized at 99 sites worldwide to medical therapy with or without CABG. The decision to treat the mitral valve during CABG was left to the surgeon. The primary end point was mortality. Of 1212 randomized patients, 435 (36%) had none/trace MR, 554 (46%) had mild MR, 181 (15%) had moderate MR, and 39 (3%) had severe MR. In the medical arm, 70 deaths (32%) occurred in patients with none/trace MR, 114 (44%) in those with mild MR, and 58 (50%) in those with moderate to severe MR. In patients with moderate to severe MR, there were 29 deaths (53%) among 55 patients randomized to CABG who did not receive mitral surgery (hazard ratio versus medical therapy, 1.20; 95% confidence interval, 0.77-1.87) and 21 deaths (43%) among 49 patients who received mitral surgery (hazard ratio versus medical therapy, 0.62; 95% confidence interval, 0.35-1.08). After adjustment for baseline prognostic variables, the hazard ratio for CABG with mitral surgery versus CABG alone was 0.41 (95% confidence interval, 0.22-0.77; P=0.006). CONCLUSION: Although these observational data suggest that adding mitral valve repair to CABG in patients with left ventricular dysfunction and moderate to severe MR may improve survival compared with CABG alone or medical therapy alone, a prospective randomized trial is necessary to confirm the validity of these observations. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.

Complications in cardiac surgery: An analysis of factors contributing to sternal dehiscence in patients who underwent surgery between 2010 and 2014 and a comparison with the 1990-2009 cohort.

BACKGROUND: Sternal dehiscence is a serious postoperative complication of cardiac surgery observed in 0.2-5% of procedures performed by median sternotomy. OBJECTIVES: Assessment of factors, including the method of sternum closure, which may affect the incidence of this complication. MATERIAL AND METHODS: A total of 5,152 consecutive patients undergoing surgery with median sternotomy access in the Cardiac Surgery Department of the Pomeranian Medical University between 2010 and 2014 were included in the study. The analysis centered on cases of sternal dehiscence, which occurred in 45 patients (0.9%). RESULTS: Factors such as age (p < 0.05), body mass (p < 0.005) and coronary artery bypass surgery (CABG) (p < 0.005) were found to be significant risk factors. Diabetes and chronic obstructive pulmonary disease (COPD) also had an impact on an increased risk of sternal dehiscence (p < 0.006 and p < 0.015). However, the differences were only significant in the whole study group. Apart from CABG, the type of operation did not affect the incidence of dehiscence. Logistic regression analysis found independent risk factors for the development of sternal dehiscence: body mass index (BMI) (odds ratio (OR): 2.1; p < 0.019), diabetes (OR: 2.4; p < 0.004), COPD (OR: 2.7; p < 0.016), and redo procedure (OR: 3.0; p < 0.014). There were no significant differences in postoperative mortality between these groups - 6.7% in the group with sternal dehiscence and 3.9% in the group without dehiscence. CONCLUSIONS: Introducing a more durable sternum stabilization method with 8+ loops helped to improve conditions for bone union and reduced the risk of dehiscence. Therefore, we suggest that centers which still use 6-loop sternal closure should consider shifting to a stronger technique.

The influence of carbon dioxide field flooding in mitral valve operations with cardiopulmonary bypass on S100ß level in blood plasma in the aging brain.

INTRODUCTION: The risk of air microembolism during cardiopulmonary bypass (CPB) is high and influences the postoperative outcome, especially in elderly patients. The use of carbon dioxide (CO2) atmosphere during cardiac surgery may reduce the risk of cerebral air microembolism. The aim of our study was to assess the influence of CO2 field flooding on microembolism-induced brain damage assessed by the level of S100ß protein, regarded as a marker of brain damage. MATERIALS AND METHODS: A group of 100 patients undergoing planned mitral valve operation through median sternotomy using standard CPB was recruited for the study. Echocardiography was performed prior to and after the CPB. CO2 insufflation at 6 L/minute was conducted in the study group. Blood samples for S100ß protein analysis were collected after induction of anesthesia, 2 hours after aorta de-clamping, and 24 hours after operation. RESULTS: The S100ß level in blood plasma did not differ significantly between the study and the control group (0.13±0.08 µg/L, 1.12±0.59 µg/L, and 0.26±0.23 µg/L and 0.18±0.19 µg/L, 1.31±0.62 µg/L, and 0.23±0.12 µg/L, P=0.7, 0.14, and 0.78). The mean increase of the S100ß concentration was 13% lower in the group with CO2 protection than in the control group (0.988 µg/L vs 1.125 µg/L), although statistically insignificant. Tricuspid valve annuloplasties (TVAs) had significant impact on the increase in S100ß concentration in the treatment group after 24 hours (TVA [-] 0.21±0.09 vs TVA [+] 0.42±0.42, P=0.05). In patients <60 years, there were significant differences in the S100ß level 2 and 24 hours after the procedure (1.59±0.682 µg/L vs 1.223±0.571 µg/L, P=0.048, and 0.363±0.318 µg/L vs 0.229±0.105 µg/L, P=0.036) as compared with younger patients. CONCLUSION: The increase in S100ß concentration was lower in the group with CO2 protection than in the control group. Age and an addition of TVA significantly influenced the level of S100ß concentration in the tests performed 2 hours after aortic clamp release.

The Efficacy of Inpatient vs. Home-Based Physiotherapy Following Coronary Artery Bypass Grafting.

Background: Intensive post-operative physiotherapy after cardiac surgery helps to reduce the number of complications, accelerating convalescence and decreasing peri-operative mortality. Cardiac rehabilitation is aimed at regaining lost function and sustaining the effect of cardiac surgery. The aim of this study was to compare the efficacy of inpatient and home-based phase II physiotherapy following coronary artery bypass grafting, and inpatient phase II post-operative physiotherapy based on the analysis of the spirometry results. Methods: A prospective observational study included 104 adult patients of both sexes undergoing planned coronary artery bypass grafting and were randomized to one of the two groups-inpatients (InPhysio) and home-based (HomePhysio) at a 1:1 ratio. All patients had undergone spirometry testing prior to surgery (S1) and on the fifth day after the operation (S2), i.e., on the day of completion of the first phase (PI) of physiotherapy. Both the study group (InPhysio) and the control group (HomePhysio) performed the same set of exercises in the second phase (PII) of cardiac physiotherapy, either in the hospital or at home, respectively, according to the program obtained in the hospital. Both groups have undergone spirometry testing (S3) at 30 days after the operation. Results: The demographic and peri-operative data for both groups were comparable and showed no statistically significant differences. An analysis of gradients between the results of spirometry tests before surgery and at 30 days after the surgery showed a smaller decrease in forced vital capacity (FVC) in the study group than in the control group (p < 0.001). The results at five and 30 days after the surgery showed a greater increase in FVC in the study group than in the control group (680 mL vs. 450 mL, p = 0.009). There were no statistically significant differences in other parameters studied. Conclusions: The advantage of inpatient over home-based physiotherapy was evidenced by much smaller decreases in FVC between the initial and final tests, and greater increases between the fifth day after surgery and the final test. Our analysis showed greater efficacy of inpatient physiotherapy as compared with home-based exercises and raises concerns about patient adherence.

[Cardiovascular abnormalities in systemic lupus erythematosus patients in echocardiographic assessment]. / Zmiany w ukladzie sercowo-naczyniowym u chorych na toczen rumieniowaty ukladowy w oparciu o badania echokardiograficzne.

UNLABELLED: Cardiovascular system involvement is the third most common reason of death in patients with systemic lupus erythematosus (SLE). The aim of this study was to assess the cardiac involvement in the SLE patients with a regard to clinical, serological and environmental risk factors. MATERIAL AND METHODS: 103 patients were included into the study, 91 women and 12 men, aged 16-74 yrs, the control group included 25 subjects. Physical examination, two-dimensional guided M-mode and Doppler echocardiographic recordings were performed. The tests for the presence of ANA, ENA, antiphospholipid antibodies (aCL, LA, anti-beta2GPI and antiprothrombin antibodies), ANCA (anti-neutrophil cytoplasm antibodies), AECA (anti endothelial cell antibodies) were carried out. RESULTS: The following pathologies were significantly more common in the SLE patients: pericardial involvement (58%), organic changes of the mitral valve cusps (54%), organic changes of the aortic valve cusps (36%), widening of the aortal lumen (35%), enlargement of the left atrium (18%), hypokinesis of the left ventricle myocardial muscle (15%). Ultrasound cardiac pathologies were associated with presence of antiphospholipid antibodies, ANCA, anti-hitone antibodies and AECA. High activity of SLE increased risk of pericarditis and ascending aortic wall thickening. Cardiovascular manifestations occurred most frequently in patients with short time duration of SLE. CONCLUSION: Cardiac involvement is a frequent and early systemic complication of SLE and it is the most commonly related to pericardium and valvular apparatus. Cardiovascular manifestations in SLE patients are the most frequently related to the presence of serological risk factors, mainly antiphospholipid antibodies. It suggests their major role in the pathogenesis of the cardiovascular involvement in SLE. Pericarditis are markers of high activity of SLE.

Postponed surgery of an acute aortic dissection (type A) in a Jehovah's Witness with significant hemostatic disorders.

In this case report, we present the treatment of an acute type A aortic dissection in a Jehovah's Witness patient. In accordance with the will of the patient, blood products were not used. Additionally, the patient had significant hemostatic disorders due to the use of antiplatelet drugs.

Effect of quercetin on experimental hyperlipidemia and atherosclerosis in rabbits.

Cardiovascular disease is currently the leading cause of death in the West, and a search for factors limiting its occurrence is ongoing. Accumulated data indicate that quercetin, the major flavonol in the plant kingdom, may possess beneficial effects in atherosclerosis. The present study aimed at determination of effects of quercetin on hyperlipidemia and development of atherosclerotic lesions in two animal models, i.e. diet induced hyperlipidemia and aortic atherosclerosis, and in injured carotid artery in rabbits fed high-fat diet for 12 and 4 weeks, respectively. It was demonstrated that quercetin was effective in reducing serum triglycerides and cholesterol levels elevated by high-fat diet, after 12 weeks of the experiment. This activity was less prominent in the 4-week study in injured carotid artery rabbit model. Hypolipemic properties of the flavonoid were associated with the reduced formation of atherosclerotic plaques, both in the aorta (12-week study) as well as within injured carotid artery (4-week study) in high-fat diet-fed animals. The surface of the intima covered with atherosclerotic plaques in high-fat diet-fed rabbits was 24.6 +/- 33.1% in comparison to 0.7 +/- 1.3% (p < 0.05) in quercetin and high-fat diet supplemented animals. It is evident from the present study that quercetin possesses both hypolipemic and antiatherogenic properties.

[Complications of cardiac surgery: sternal dehiscence after median sternotomy. Analysis of 14,171 cases operated on in years 1990­2009].

Introduction: Dehiscence of the sternum is one of the most serious complications following cardiac surgery. It occurs after 0.2­5% of interventions with sternotomy access. The aim of the study was the evaluation of factors that may influence the frequency of this complication. Material and methods: A retrospective review of 14,171 patients undergoing median sternotomy for cardiac surgery between 1990 and 2009 at the Cardiac Surgery Department of the Pomeranian Medical University in Szczecin (Poland) was performed. The studied group consisted of 3,999 women (28.2%) and 10,172 men (71.8%) aged 11­87 years (59.8 years on average). We analysed cases with sternal dehiscence (SD), which occurred in 298 (2.1%) of the patients. Results: The significant risk factors were: male sex (p = 0.0003), age (p < 0.00006), body mass (p < 0.00007), and use of both internal thoracic arteries (p < 0.00001). The risk of SD was also increased by coexisting diabetes and chronic obstructive lung disease (p < 0.012 and p < 0.02 respectively); however, discriminant analysis revealed that these variables were only linked to age. Apart from CABG, the type of surgical intervention had no influence on the frequency of SD. The total length of hospital stay in patients with SD was more than two times longer than in the rest of the patients (p < 0.00001). However, there were no significant differences in postoperative mortality between these two groups ­ 4.4% in the group with SD and 4.2% in the group without it. Conclusions: Not being able to eliminate the influence of risk factors, since 2010 we decided to introduce changes in the method of sternum closure by increasing the number of wire loops from 6 to at least 8. For patients heavier than 80 kg, we assumed a ratio of one additional loop per every 10 kg of body mass, which should result in improved sternum stabilisation and reduce the risk of dehiscence.

The Use of Vacuum-Assisted Closure in Purulent Complications and Difficult-To-Heal Wounds in Cardiac Surgery.

BACKGROUND: Sternal wound infections are a serious and potentially fatal complication of cardiac surgery. OBJECTIVES: The aim of the study was to analyze the results of using the vacuum-assisted closure (VAC) system over a 4-year period. MATERIAL AND METHODS: Quantitative VAC performance data from a retrospective review of a consecutive cohort of 47 patients treated with VAC for post-cardiac surgery wound complications were collected and statistically analyzed. In the study group 35 patients developed infections of the post-operative chest wound. In 12 other patients wound dehiscence was observed, but repeated cultures did not reveal the presence of any bacteria. RESULTS: The statistical analysis identified the following as significant risk factors: age, female sex, being overweight, a high total logistic EuroScore, the use of both internal thoracic arteries for bypass grafting, and diabetes. In the wound negative culture group the total length of hospital stay was significantly shorter than in the wound positive culture group. Mortality in this group was 0.0% vs. 5.7% in the wound positive culture group. In the study material, Gram-negative bacteria were responsible for 77% of the post-operative wound infections, with only 14% Gram-positive wound cultures. No complications were related to VAC use. CONCLUSIONS: The use of negative-pressure wound therapy with other concomitant surgical procedures is a good method of treating infected wounds as well as non-contaminated dehiscence of the wound and sternum. Considering that most of the infections within the authors' department are caused by Gram-negative bacteria, it would be beneficial to consider modifying the model of preventive antibiotic treatment to cover the Gram-negative spectrum in addition to the Gram-positive bacteria currently targeted.

Comparison of Transesophageal and Transthoracic Echocardiographic Measurements of Mechanism and Severity of Mitral Regurgitation in Ischemic Cardiomyopathy (from the Surgical Treatment of Ischemic Heart Failure Trial).

Mitral regurgitation (MR) is common in ischemic heart disease and contributes to symptoms and mortality. This report compares the results of baseline transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) imaging of the mechanism and severity of functional MR in patients with ischemic cardiomyopathy in the Surgical Treatment for Ischemic Heart Failure (STICH) trial. Independent core laboratories measured both TTE and TEE images on 196 STICH participants. Common measurements to both models included MR grade, mitral valve tenting height and tenting area, and mitral annular diameter. For each parameter, correlations were assessed using Spearman rank correlation coefficients. A modest correlation was present between TEE and TTE for overall MR grade (n = 176, r = 0.52). For mechanism of MR, modest correlations were present for long-axis tenting height (n = 152, r = 0.35), tenting area (n = 128, r = 0.27), and long-axis mitral annulus diameter (n = 123, r = 0.41). For each measurement, there was significant scatter. Potential explanations for the scatter include different orientation of the imaging planes between TEE and TTE, a mean temporal delay of 6 days between TEE and TTE, and statistically significant differences in heart rate and blood pressure and weight between studies. In conclusion, TEE and TTE measurements of MR mechanism and severity correlate only modestly with enough scatter in the data that they are not interchangeable.

[Use of minimally invasive direct coronary bypass (MIDCAB) in reoperative coronary surgery]. / Wykorzystanie technik maloinwazyjnych (MIDCAB) podczas powtórnych operacji tetnic wiencowych.

The authors presented the method and early results of minimally invasive direct coronary arteries reoperation in 5 patients, approximately 7, 5 years after the first CABG operation. In all patients venous grafts were occluded. there was a different approach used in every patient: small left or right anterior thoracotomy through IV or V intercostal space, laparotomy with partial low sternotomy or simultaneous combined approach through thoracotomy and sternotomy/laparotomy. The following arteries were grafted: left anterior descending, right posterior descending, LAD with right coronary artery and LAD with marginal branch. All patients were extubated in the operating room. There were no serious perioperative complications observed. Patients were transferred to cardiology department on the 5th-7th postoperative day.

Thoracic aorta aneurysm successfully operated on during pregnancy.

We present the case of an asymptomatic 26-year-old female patient with a huge thoracic aneurysm discovered at a routine echo screening. The patient had previously been operated on for coarctation of the aorta in childhood and also had diagnosed bicuspid aortic valve. The operation was carried out in extracorporeal circulation at the 22(nd) week of gestation without any complications. A few months later in the 38(th) week of pregnancy a baby girl was delivered by cesarean section with an Apgar score of 10. The patient is scheduled for implantation of a stent graft to the descending aorta, because the CT of the chest done a few months after delivery confirmed presence of a significant aneurysm located just below the left subclavian artery.

Mechanisms of functional mitral regurgitation in ischemic cardiomyopathy determined by transesophageal echocardiography (from the Surgical Treatment for Ischemic Heart Failure Trial).

The mechanisms underlying functional mitral regurgitation (MR) and the relation between mechanism and severity of MR have not been evaluated in a large, multicenter, randomized controlled trial. Transesophageal echocardiography (TEE) was performed in 215 patients at 17 centers in the Surgical Treatment for Ischemic Heart Failure (STICH) trial. Both 2-dimensional (n = 215) and 3-dimensional (n = 81) TEEs were used to assess multiple quantitative measurements of the mechanism and severity of MR. By 2-dimensional TEE, leaflet tenting area, anterior and posterior leaflet angles, mitral annulus diameter, left ventricular (LV) end-systolic volume index, LV ejection fraction (LVEF), and sphericity index (p <0.05 for all) were significantly different across MR grades. By 3-dimensional TEE, mitral annulus area, leaflet tenting area, LV end-systolic volume index, LVEF, and sphericity index (p <0.05 for all) were significantly different across MR grades. A multivariate analysis showed a trend for annulus area (p = 0.069) and LV end-systolic volume index (p = 0.071) to predict effective regurgitant orifice area and for annulus area (p = 0.018) and LV end-systolic volume index (p = 0.073) to predict vena contracta area. In the STICH trial, multiple quantitative parameters of the mechanism of functional MR are related to MR severity. The mechanism of functional MR in ischemic cardiomyopathy is heterogeneous, but no single variable stands out as a strong predictor of quantitative severity of MR.

The Gerbode defect - a frequent echocardiographic pitfall.

We present a case of Gerbode type defect (left ventricular to right atrial communication) discovered in a 52 year-old man with atrial and ventricular septal defects. The patient was diagnosed using two-dimensional colour Doppler and transoesophageal echocardiography. We describe the echocardiographic features and review the anatomical consequences of such defects. Our aim was to remind readers about this rare organic heart disease that an inexperienced echocardiography specialist might easily mistake for a recoil wave of tricuspid valve incompetence and thus diagnose pulmonary hypertension.

Evaluation of the level of antibodies against Chlamydophila (Chlamydia) pneumoniae in post-surgery heart ischaemia patients and their clinical conditions - a six-year study.

INTRODUCTION: Inflammatory conditions modulated by Chlamydophila (Chlamydia) pneumoniae are considered to play an important role in the onset of atherosclerosis. In this paper we present the results of progressive observation of C. pneumoniae antibody titres in patients who underwent coronary artery bypass graft (CABG). MATERIAL AND METHODS: The objective of our research was a prospective observation of antibody titres in IgA and IgG class antibodies against C. pneumoniae using indirect immunofluorescence in a group of 155 post-surgery CABG patients suffering from heart ischaemia. The microbiological test results were compared with patients' present coronary complaints evaluated on the CCS scale during a six-year period. RESULTS: Six years after CABG, 128 patients (82.6%) are still alive. During the study a positive serological conversion of antibody titres was observed in 36 patients in the IgA class antibodies, and in 26 patients in the IgG class. The group of patients with no antibodies against C. pneumoniae decreased from 23.2 to 3.4%, while the group of patients with antibodies in both IgG and IgA classes increased from 52.3 to 83.9%. The average CCS degree decreased from 3.18 before CABG to 1.65 in the present study. CONCLUSIONS: These results show no connection between the serological symptoms of chronic C. pneumoniae infection and coronary complaints evaluated on the CCS scale during a six-year study on post-CABG patients suffering from heart ischaemia. The surgical treatment of heart ischaemia brought about long-term improvement in the coronary condition of the observed group of patients.