Surgical Treatment of Infective Endocarditis in Pulmonary Position-15 Years Single Centre Experience.

Background and Objectives: Infective endocarditis in the pulmonary position is a rare disease. Isolated pulmonary valve endocarditis is extremely rare. The aim of our study was to assess patients who were treated surgically for pulmonary endocarditis at our institution from January 2003 to December 2017. Materials and Methods: We analyze eight cases of infectious endocarditis in pulmonary position out of 293 patients who were operated for infective endocarditis (2.7%, 8/293). Only two of these eight patients were not related to congenital heart malformation. They were followed for early and late mortality, long-term survival, postoperative morbidity and reoperations. Results: Among six patients suffering from congenital heart disease, four patients underwent corrections of pulmonary valve malformation previously, and their infected grafts were replaced by two allografts and two xenografts. The two other patients had replaced their infected pulmonary valves with allografts. Two non-congenital patients with pulmonary valve endocarditis underwent valve replacement with biological prosthesis. All patients survived the early postoperative course. The mean follow-up time was 9.1 (interquartile range (IQR), 5.3-12.6) years. The long-term follow-up included seven patients. One patient (12.5%, 1/8) died more than 4 years after the surgery due to sepsis. Pulmonary endocarditis was the rarest endocarditis treated surgically (p < 0.001). Conclusion: Surgery for infective endocarditis in the pulmonary position (IEPP) is an effective method of treatment with excellent early outcome and good late results despite a very uncommon pathology and few operations being performed. Surgery performed earlier may make the procedure less radical.

Efficacy of Antiseptic Solutions in Treatment of Staphylococcus Aureus Infected Surgical Wounds with Patches of Vascular Graft: An Experimental Study in Rats.

Background and objectives: Treatment of a prosthetic vascular graft infection (PVGI) remains a challenging problem in vascular surgery. The aim of this study was to design a novel rat model for treatment of peripheral vascular prosthesis infection caused by Staphylococcus aureus (S. aureus) and to determine the efficacy of different antiseptic solutions in suppressing or eradicating infection from the wound and the graft material itself. Materials and methods: A piece of Dacron vascular prosthesis was surgically implanted at the dorsum of 48 Wistar rats and the wounds were infected with 5 McFarland standard inoculum of S. aureus. Suppurating wounds were daily irrigated with different antiseptic solutions: octenidine dihydrochloride, povidone-iodine, chlorhexidine digluconate, and sterile saline. The antimicrobial action of antiseptics was defined according to their capability to eradicate bacteria from the graft surroundings and bacteriological examination of the graft itself. Extended studies on wound microbiology, cytology, and histopathology were performed with an additional group of 10 rats, treated with the most effective antiseptic-octenidine dihydrochloride. Results: Four-day treatment course with octenidine, povidone-iodine, and chlorhexidine resulted in 99.98% (p = 0.0005), 90.73% (p = 0.002), and 65.97% (p = 0.004) decrease in S. aureus colonies in wound washouts, respectively. The number of S. aureus colonies increased insignificantly by 19.72% (p = 0.765) in control group. Seven-day treatment course with octenidine eradicated viable bacteria from nine out of 10 wound washouts and sterilized one vascular graft. Conclusions: A reproducible rat model of PVGI with a thriving S. aureus infection was designed. It is a first PVGI animal model where different antiseptic solutions were applied as daily irrigations to treat peripheral PVGI. Seven-day treatment with octenidine eradicated bacteria from the wound washouts for 90% of rats and one vascular graft. Further studies are needed to investigate if irrigations with octenidine could properly cure vascular bed from infection to assure a successful implantation of a new synthetic vascular substitute.

Fontan Completion for Younger than 3 Years of Age: Outcome in Patients with Functional Single Ventricle.

Most single ventricle patients undergo Fontan procedure earlier in current era. However, optimal timing of Fontan completion after an intermediate staging surgery is controversial. We present children who had Fontan surgeries younger than 3 years of age comparing the data with older patients. Between 2000 and 2013, 45 patients with functional single ventricle underwent extracardiac total cavopulmonary connection (TCPC) using GORE-TEX(®) conduit at a single institution. Children were divided into group A (age < 36 months; n = 15) and group B (age ≥ 36 months; n = 30), and retrospectively reviewed. Median follow-up was 2.9 [interquartile range (IQR) 2-4.4] years. There were two hospital deaths and one late death (all in group B, p = 0.286). One TCPC was taken down in group A. The median intensive care unit and hospital stay were 90 (IQR 46-140) h and 21 (IQR 16-33) days for group A versus 65 (IQR 45-115) h and 29 (IQR 20.8-38.5) days for group B, respectively (p = 0.322 and p = 0.057). Ventricular ejection fraction and GORE-TEX(®) conduit size were similar in both groups. The time of chest drain stay was significantly lower in group A (median 12 days, IQR 7-22) than in group B (22 days, IQR 16-32.5) (p = 0.014). Extracardiac TCPC can be performed earlier with good intermediate results. Earlier Fontan procedure might be advantageous for reducing chest drains stay.

[Survival rate of patients with ascending aorta aneurysm and aortic valve regurgitation in the late postoperative period]. / Pacientu, operuotu esant letinei kylanciosios aortos aneurizmai ir aortos voztuvo nesandarumui, isgyvenamumas velyvuoju pooperaciniu laikotarpiu.

UNLABELLED: The aim of the study was to evaluate the long-term survival in patients undergoing surgical treatment for chronic aortic aneurysms with aortic regurgitation. MATERIAL AND METHODS: We analyzed survival data of 188 patients during follow-up period of 1 month to 20 years postoperatively. The patients were divided into the following groups according to the clinical course: Group 1--chronic dissecting aneurysm of ascending aorta with aortic regurgitation (42 patients, 22.3%); Group 2--chronic nondissecting aneurysm of ascending aorta with aortic regurgitation (146 patients, 77.7%). Mean NYHA functional class of the patients was 3.5+/-0.06. In the Group 1, 64.3% of the patients were in NYHA functional class IV; 35.7% of the patients were in NYHA class III. In the Group 2, the majority of the patients (58.2%) were in class III; in class IV - 41.8%. The most common etiological factors in both groups were atherosclerosis, arterial hypertension, and Marfan's syndrome. RESULTS: No differences in overall and long-term survival rates between the groups were found. However, the patients who were in class III before the operation showed significantly higher overall and long-term survival rates in comparison with the survival rate of the patients who were in NYHA class IV preoperatively (overall survival rate, 91.4+/-3.0% vs 62.9+/-6.9%; and long-term survival rate, 93.2+/-2.7% vs 72.9+/-5.6; respectively). There were 24 deaths (12.8%) during the late postoperative period. The main causes of death were progressive heart failure and infective prosthetic endocarditis (Group 2), chronic heart failure and dysfunction of the conduit (Group 1). CONCLUSIONS: The analysis of patients' long-term survival demonstrated the efficacy of surgical treatment of such a complex pathology as chronic aneurysm of the ascending aorta with aortic valve regurgitation. The survival rate in the late postoperative period was higher in NYHA class III patients. The main causes of death were chronic heart failure and infective prosthetic endocarditis.

[Results of surgical treatment of aortic root infection]. / Aortos saknies infekcijos chirurginio gydymo rezultatai.

AIM OF THE STUDY: To investigate preoperative status and results of surgery of patients with confirmed diagnosis of aortic root infection. MATERIALS AND METHODS: We have analyzed data of 21 patients who were operated on at the Heart Surgery Center, Vilnius University, since January 1, 1997, till December 31, 2006. All these patients underwent surgery because of aortic root infection. The patients were aged 25-72 years (mean age, 53+/-14 years). There were 17 (80.9%) male patients. Sixteen patients (76%) preoperatively were in NYHA class IV. The abscesses of aortic root were confirmed preoperatively by means of esophageal echocardiography in 18 patients (86%). Blood cultures positive for Staphylococcus aureus were found in four patients (19.9%). All the patients underwent replacement of the aortic valve by mechanic prosthesis; one of these patients was reoperated because of persistent sepsis, and replacement of the aortic root with homograft was performed. The duration of follow-up of the patients was 1 to 10 years. RESULTS: Inhospital mortality rate was 14.3%. The causes of death included sustained heart failure and sepsis. All these patients were in NYHA functional class IV preoperatively; one of these patients had culture positive for Staphylococcus aureus. Inhospital survival was 85.7%, one-year postoperative survival - 80.9%, and both five-year and ten-year survivals were 76.0%. The long-term survival was negatively influenced by recurrent infective endocarditis, heart failure, and age. Death occurred in 1 patient (11.1%) of the 9 patients who at the time of surgery were younger than 50 years and 4 patients (33.3%) of the 12 who were older than 50 years at the time of operation. CONCLUSIONS: The infection of aortic root is not common pathology; however, it is a complicated disease. Esophageal echocardiography is an informative method while diagnosing aortic root abscesses. The inhospital mortality is increased by the heart failure persisting after the operation and sepsis. The long-term survival is decreased by preoperative infective endocarditis of the prosthesis and heart failure. The mortality rate of patients older than 50 years is 3-fold higher than mortality rate of younger ones.

[Extra-anatomic thoracic aortic bypass operations]. / Krutines aortos apeinamuju jungciu suformavimo operacijos.

OBJECTIVE: When the patient condition contraindicates major surgery for descending thoracic aneurysms, the surgeon should consider using an ascending aorta to abdominal aorta bypass graft, leaving the diseased segment undisturbed. Our experience with eight patients is presented. MATERIAL AND METHODS: Between 1988 and 2008, eight patients were treated for the following indications: reoperation for coarctation (two patients), complicated descending aortic aneurysms (five patients), and posttraumatic descending aorta dissection (one patient). The mean age of the patients was 44+/-8 years (range, 27-53 years). There were 6 (75%) males and 2 (25%) females. Emergency operations were performed in three patients (two with aortic recoarctation, one with posttraumatic aortic dissection). Two cases were reoperations (both after recoarctation). Descending aorta was ligated in seven cases. Distal anastomosis was connected with abdominal aorta in four cases and with iliac arteries in four patients. RESULTS: Three early deaths occurred. Two patients died after emergency operation after recoarctation and posttraumatic aortic dissection, and one patient died after descending aorta aneurysm correction because of bleeding. CONCLUSIONS: In complex aortic coarctation, extra-anatomic bypass operation remains an effective procedure. The usage of these procedures in patients with descending aortic aneurysms remains complicated.

Primary cardiac lymphoma: two cases and a review of literature.

BACKGROUND: Primary cardiac lymphoma is one of the rarest tumours of the heart. It belongs to the extra-nodal non-Hodgkin's lymphomas. The most common type of this tumour is diffuse large B cell lymphoma. Usually, right atrium and right ventricle are involved. This tumour is fatal unless diagnosed and treated in time. In this article two female patients who were diagnosed with primary cardiac lymphoma and treated at our clinic are described. The first patient went to remission after the treatment, while the second patient died. The goals of this article are to show the difficulties of diagnosing and treating this disease, the role of cardiac surgery in its treatment and to raise awareness of this disease. CASE REPORTS: In this article two female patients who were diagnosed with primary cardiac lymphoma and treated at our clinic are described. The first patient went to remission after the treatment, while the second patient died. CONCLUSIONS: Primary cardiac lymphoma is a very rare disease. At the moment the most effective treatment is chemotherapy. Palliative surgery may be necessary to correct hemodynamics when venous blood flow to the lungs is disturbed.

[Heart assist (Vilnius University experience)]. / Pagalbine kraujotaka (Vilniaus universiteto patirtis).

Over the last three decades, the results of heart surgery have significantly improved. However, the number of patients at the last stages of heart deficiency has increased. Prevention provided to the patients suffering from heart diseases has improved the quality of their life and increased their lifetime. In spite of that, most of these patients sooner or later need a surgical treatment: heart surgery operation or heart transplantation. The visible damage to haemodynamics of the patients waiting for heart operations and particularly heart transplantations or after them has drawn the focus of heart surgeons to the mechanical systems of heart assist. In many cases they help to cure patients after post-cardiotomic or post-transplant cardiogenic progressive circulation and poly-organic deficiency. They also are regarded effective as a bridge to heart transplantation. In the Heart Surgery Center of Vilnius University, heart assist has been applied since 1976. Contrapulsation with intraaortic balloon pump has been applied to 856 patients, which after heart operations have developed progressive heart deficiency. Four methods of balloon insertion into aorta were used: through the a. iliaca incision (337 cases); through the a. femoralis punction (287 cases); through the ascending aorta (171 cases) and through the ascending aorta using tourniquets (61 cases). The best results were achieved employing intraaortic balloon pump after aorta-coronary bypass surgery: 67% patients were discharged from hospital. The worst results follow heart transplants, as intraaortic balloon pump was successful only to 28% of patients. In general, the total number of patients to whom the heart assist method was successful is 454 (53%). The second heart assist method that has been applied in our centre is the use of extracorporeal membranous oxigenator. It has been employed since 1998 to the patients with the critical respiration and heart deficiency. Extracorporeal membranous oxigenator has been used to 8 patients, to whom pharmaceutical treatment and intraaortic balloon pump were inefficient. Unfortunately, only one of the patients after 105 days was successfully disconnected from the extracorporeal membranous oxigenator, while maintaining his good haemodynamics. The third method of heart assist is the employment of artificial Berlin Heart ventricles. From 1999 up to 2003, 15 artificial Berlin Heart ventricles have been connected to thirteen patients, 7 of them as a bridge to heart transplant. One of the patients has already lived for over 2 years, while 6 patients had heart transplantation. There have been 8 post-cardiotomic patients with incorporated artificial Berlin Heart ventricles. The most experience has been accumulated in the use of intraaortic balloon pump. The fact that 53% of patients were discharged from hospital after such treatment indicates its efficiency. We have little experience in the employment of extracorporeal membranous oxigenator, therefore it is difficult to make conclusions. Whereas the application of Berlin Heart artificial ventricles is an effective method of assist circulation (heart assist), being a bridge to heart transplantation and effective in a long-term treatment.

[Myocardial revascularization combined with mitral valve surgery in case of ischemic mitral valve insufficiency]. / Miokardo revaskulizacija ir mitralinio voztuvo operacija esant iseminiam mitralinio voztuvo nesandarumui.

BACKGROUND: The aim of the study was to evaluate the possibility of mitral valve surgery in patients with mitral valve insufficiency and short time outcomes following mitral valve correction combined with coronary artery bypass grafting. METHODS: Thirty one combined coronary artery bypass grafting with mitral valve correction procedures were performed from 1994 to 2002. Mean age was 65.4+/-6 years. 29 pts were in NYHA IV-V functional class. 84% of pts were with impaired left ventricle function. RESULTS: Mitral valve replacement was performed in 16 patients and correction of mitral valve in 15 cases. Mitral valve replacement was performed in cases with significant lesions of the papillary muscles. The mean of 3.05+/-1.8 graft per patient was performed and total coronary revascularisation for 84% of patients. Hospital mortality was 32.2% (10/31). CONCLUSION: In cases of coronary artery bypass grafting for patients with moderate and significant mitral insufficiency after myocardial infarction, mitral valve correction must be performed.

[Radiofrequency modified maze procedure with mitral valve surgery: mid-term follow-up results]. / Modifikuota radiodaznine labirinto procedura ir mitralinio voztuvo ydos korekcija: vidutines trukmes pooperacinio stebejimo rezultatai.

OBJECTIVE: The Cox-maze procedure is an effective established surgical method for elimination of atrial fibrillation. The aim of this study was to evaluate the efficacy and safety of radiofrequency ablation as a surgical adjunct in treating atrial fibrillation and to adapt maze principles to mitral valve surgery using transseptal approaches. MATERIAL AND METHODS: Thirty-six patients underwent radiofrequency modified maze procedure using standard and cooled ablation electrodes in combination with surgery for hemodynamically significant mitral valve disease and chronic, persistent or paroxysmal atrial fibrillation. Fourteen (39%) patients had mitral valve repair and 22 (61%) patients had mitral valve replacement; 33 (91.6%) patients underwent concomitant surgical procedures. RESULTS: The cardiopulmonary bypass time was 162+/-38 min, the aortic cross-clamp time - 98+/-22 min. The additional aortic cross-clamp time required for the radiofrequency modified maze procedure was 21+/-3 min. Postoperative mortality was 2.8%. In 7 of 36 pts (19.4% ) significant bradycardia requiring permanent pacing (six - AAI, one - DDD) was seen after the operation. Patients were followed up for 4 months to 2.5 years after surgery (mean 11.2+/-7.4 months). There were no deaths, no thromboembolic complications during follow-up. Freedom from atrial fibrillation or flutter was 100% at the end of operation, but during 0.5-3 months after operation atrial fibrillation or flutter were observed in 41.6% (15/36) patients. In 2 (5%) patients chronic atrial fibrillation developed. Freedom from atrial fibrillation/flutter was 86% (12/14) at 1 year postoperatively. CONCLUSIONS: The radiofrequency modified maze as an adjunctive procedure is safe and effective in eliminating atrial fibrillation using standard and cooling-tip ablation electrodes in combination with surgery for mitral valve disease.

[Surgical treatment of critical aorta coarctation in neonates]. / Naujagimiu aortos koarktaciju chirurginis gydymas.

UNLABELLED: Coarctation of the aorta is relatively common defect accounting for 5-8% of all congenital heart defects. Newborns very often, about in 50% of cases, are in cardiogenic shock. From 1991 to 2003, 26 neonates with coarctation of the aorta underwent surgical repair at Heart Surgery Center of Vilnius University: 12 with isolated coarctation of the aorta and 14 with leading heart pathology. Age of patients was from 2 to 30 days. Weight was from 2.8 to 4.7 kg. Fifty percent of neonates were on ventilatory and inotropic support. All neonates were operated using surgical technique "end-to-end" or extended "end-to-end" in case of aortic arch hypoplasia. All neonates with isolated coarctation of the aorta survived; with leading heart pathology mortality was 14.3%. From 26 operated neonates 2 had recoarctation, 1 - reoperation and 2 - balloon aortoplasty. Our patients were free from spinal chord ischemia and brain damage. CONCLUSIONS: Neonatal coarctation of the aorta needs an urgent surgical treatment. Surgery remains a gold standard for the treatment of aorta coarctation. Preferable technique is "end-to-end" anastomosis or extended coarctation resection with "end-to-end" anastomosis for hypoplastic aortic arch. Associated cardiac pathology increases risk of operation.

[Risk of second and third reoperation on prosthetic heart valves]. / Trecioji ir ketvirtoji sirdies voztuvu operacija tam paciam ligoniui. Ar didele operaciju rizika?

As the volume of heart valve replacements increases, more patients are undergoing repeated operations. There are many reasons for reoperations that include incomplete or imperfectly executed primary operation, infection on valve prostheses, valve related complications. Repeated operations have their own specific technical problems, and from them depends mortality and complications rate. At Vilnius University Heart Surgery Clinic from 1967 we performed 6200 heart valve replacement operations. At the same time we performed 428 reoperations for 394 patients. Two reoperations were performed for 28 patients and 3 reoperations for 3 patients (65 reoperations for 31 patient). Main course of reoperation - sepsis and periprosthetic leaks (50%). Half of patients at the time of last reoperation were in functional class V (NYHA). Mortality rate after second reoperation was 28%, after third reoperation all three patients died. Main course of operative mortality - sepsis, heart failure, hemorrhage.

[Congenital heart surgery in neonates]. / Naujagimiu igimtu sirdies ydu chirurgija.

From January 1974 trough August 2002 184 neonates with congenital heart disease underwent surgical repair in Heart Surgery Clinic of Vilnius University. It came to 3.8% of all 4813 procedures of congenital heart diseases performed. Number of neonates operations considerably increased in the latter's years, because special Department with proper technique was established. One hundred and seven neonates were operated without cardiopulmonary bypass with 36.4% postoperative mortality rate. Seventy seven neonates underwent surgery repair with cardiopulmonary bypass. Postoperative mortality rate was 67.5% in this group. Mean age of patients was 11.96+/-0.28 days. Unsatisfactory results of neonates operations with cardiopulmonary bypass, especially such as left heart hypoplasia syndrome is the main problems. The group of specialists performing repair of congenital heart diseases is working actively in the heart Surgery Clinic of Vilnius University. Improvement of surgery methods and results, following the best Heart Surgery Clinics of the world, is the main purpose of this group.

[Closure of atrial septal defect via small lateral thoracotomies, partial and full length sternotomies]. / Priesirdziu pertvaros defekto pasalinimas per nedideles sonines torakotomijas, daline bei pilnutine sternotomijas.

Surgical closure of atrial septal defect is considered a low risk procedure. Various minimally invasive surgical techniques spread over the conventional full-length sternotomy. But the risk profile and complication rates of the minimally invasive closure of atrial septal defect are not revealed sufficiently. We present the results of atrial septal defect surgery via small thoracotomies: right anterolateral, right posterolateral, partial sternotomies and full-length median sternotomies. Ninety four patients underwent surgical closure of atrial septal defect via minimal approaches through the period from February 1999 to December 2001. Via median sternotomies were operated 85 patients. Right anterolateral group consisted of 17 patients, right posterolateral - 68, partial sternotomies - 9. The intracardiac period of operation was performed on electrical fibrillation under mild hypothermia. Median bypass time was 33 min. in right anterolateral, 31 min. - right posterolateral, 32 min. - partial sternotomies, 37 min. - median sternotomies. Median fibrillation time was 21 min. in right anterolateral, 18 min. - right posterolateral, 15 min. - partial sternotomies, 21 min. - median sternotomies. There were no technical procedure related complications in minimally invasive group. Intrahospital morbidity consisted of 6 pneumonias, 4 pleural effusions. There were 3 pneumonias, 2 pleural and 2 pericardial effusions in median sternotomies group.

A double-orifice tricuspid valve associated with a divided right atrium.

Right atrioventricular valve duplication is a rare congenital anomaly with only isolated cases of a double-orifice tricuspid valve having been described. This article presents a case of the surgical repair of a double-orifice tricuspid valve associated with a divided right atrium, a ventricular septal defect, and Wolff-Parkinson-White syndrome.

Sustainable knowledge transfer in pediatric cardiac surgery: a team approach to shared learning.

The study assesses the impact of a program using a model of knowledge transfer on the long-term development of a pediatric cardiac service in Lithuania. A team from the United Kingdom evaluated Lithuanian pediatric cardiac services and provided support in areas targeted for improvement. The total number of infant operations performed in Lithuania from 1990 to 2008, together with in-hospital mortality rates, was broken down into 3 time periods and analyzed to estimate the efficacy of the program: (1) 1990-1998, before the program; (2) 1999-2002, during the program; (3) 2003-2008, following the end of the program. Lithuanian results in children older than 1 year were comparable with other European centers. However, only 315 infant and neonatal cardiac procedures were performed between 1990 and 1998, and there was an in-hospital mortality of 34.2%. Between 1999 and 2002, the UK team performed 23 highly complex demonstration procedures (in-hospital mortality, 13%). During the same period the Lithuanian team performed 305 additional operations in neonates and infants, and in-hospital mortality decreased to 18.7%. From 2003 to 2008 results continued to improve-559 infant operations were performed, with in-hospital mortality of 11.3% (P < .0001). Knowledge transfer has led to substantial and sustainable long-term improvement in the results of infant cardiac surgery in Lithuania. Demonstrating techniques and care on a limited number of more complex cases is an efficient way of transferring knowledge and skills to the developing pediatric cardiac centers.

Characterisation and validity of inflammatory biomarkers in the prediction of post-operative atrial fibrillation in coronary artery disease patients.

Atrial fibrillation (AF) is a common complication of coronary artery bypass grafting (CABG). We sought to determine the diagnostic validity of plasma biomarkers of i) inflammation (marked by interleukin-6 [IL-6] and high-sensitivity C-reactive protein [hs-CRP]), ii) extracellular matrix remodelling (matrix metalloproteinase [MMP-9], tissue inhibitor of matrix metalloproteinase [TIMP-1]) and iii) the prothrombotic state (tissue factor and von Willebrand factor [vWF]) in the risk prediction of post-operative AF. Samples were obtained preoperatively from peripheral/femoral vein and from intracardiac chambers (right atrium [RA], the right atrial appendage [RAA], the left atrium [LA] and the left atrial appendage [LAA]) amongst 100 consecutive patients free of AF and inflammatory disease undergoing elective CABG. Biomarker concentrations were related to incident AF (30 days). At 30 days post CABG, 30 patients were proven to have had AF. Concentrations of tissue factor (TF) and vWF were unrelated to postoperative AF. Peripheral (p=0.018), and intracardiac levels (RAA (p=0.029) and LA (p=0.026)) of hs-CRP were associated with the presence of AF after CABG. Intracardiac levels of IL-6 in samples from the RAA (p=0.031), LA (p=0.042) and LAA (p=0.006), and MMP-9 in the LAA sample were also associated with AF (p=0.007). Our data suggest that an intra-cardiac inflammatory environment that is manifest peri-operatively may predispose to the development of post-operative AF. This intracardiac inflammatory state was reflected by increased peripheral hs-CRP levels. These differences may indicate local substrate abnormalities contributing to the development of AF post-operatively.

Sensitisation and post-transplant course after the implantation of ventricular assist device.

The purpose of this study was to evaluate sensitisation, occurring because of bridging with VAD, and development of rejection episodes after transplantation in selected groups of patients using triple drug immunosuppression, without induction or desensitisation therapy. Sensitisation using standard complement dependent cytotoxicity was tested in 16 patients awaiting cardiac transplantation before VAD placement, one month post-implantation and on a six-monthly basis later on. Long-term (955+/-998 days) post-transplant course of six transplanted post-VAD patients was compared with 19 non-bridged recipients (follow-up time 1425+/-1273 days) of the same age. One-third of VAD recipients had developed anti-HLA antibodies one month post-implantation; 4/16 patients were sensitised six months after implantation. No de novo sensitisation development was revealed in VAD group post-transplantation. All sensitised patients independent of VAD placement underwent graft rejection episodes. Only 1 of 6 VAD recipient was treated because of grade 2R rejection, compared to 6/19 in the non-bridged group, P=0.63. None of the patients had failed because of early graft rejection. In conclusion, VAD devices used in our centre cause low level risk for anti-HLA antibodies development. There were no differences in survival due to immunologic reasons between VAD bridged and non-bridged patients.

Influence of inflow cannula length in axial-flow pumps on neurologic adverse event rate: results from a multi-center analysis.

BACKGROUND: The application of axial-flow pumps in patients with end-stage heart failure reveals a significantly reduced infectious complication rate as compared with rates observed with pulsatile devices. The remaining adverse event rate relates mainly to thromboembolic complications with neurologic consequences. We investigated the dependence of the neurologic adverse event rate on the length of the inflow cannula. METHODS: A total of 216 consecutive patients with an axial-flow pump (INCOR; Berlin Heart GmbH, Berlin, Germany) were included in a retrospective multi-center analysis. In 138 patients, a short inflow cannula (24-mm tip length into the left ventricle), and in 78 patients a long inflow cannula (tip length 34 mm) was applied. RESULTS: Patients with a long inflow cannula (LC) demonstrated a better survival rate than those with a short inflow cannula (SC) at the end of the observation period (LC, 63.4%; SC, 52.9%; p = 0.05). The thromboembolic adverse event rate was also significantly lower. Only 3 of the 78 patients (3.8%) with an LC had a thromboembolic adverse event (thromboembolic events per patient-year = 0.11) as compared with 32 (23.2%) of SC patients (thromboembolic events per patient-year = 0.50, p < 0.001). CONCLUSIONS: Patients with a long inflow cannula had a better survival rate and a lower incidence of cerebrovascular adverse events than patients with a short inflow cannula.

Intra-aortic balloon counterpulsation in decompensated cardiomyopathy patients: bridge to transplantation or assist device.

OBJECTIVES: The crucial decision to progress from pharmacological treatment of acute decompensated heart failure to institution of assist device or transplantation begins with evaluation of the chances for a successful recovery. We tested whether the intra-aortic balloon counterpulsation (IABP) could give us the necessary time for clinical decision-making and preserve adequate circulation until it is made. METHODS: We assessed 11 dilated cardiomyopathy patients of NYHA class IV, listed for heart transplantation or a ventricular assist device (VAD), who had conventional IABP placed. Heart function prior to and after IABP insertion as well as hemodynamics, end-organ function (renal and hepatic), frequency of complications and clinical outcomes were assessed. RESULTS: The duration of intra-aortic balloon pump insertion ranged from 72 to 360 h (mean 181.54+/-81.65). After 48 h of intra-aortic balloon pump support, there was a significant increase of mean systemic arterial pressure from 74.5+/-9.6 to 82.3+/-4.7 mmHg (P=0.02), and ejection fraction from 14.7+/-6.4 to 21.0+/-8.6 (P=0.014). Meanwhile improvement of cardiac index, pulmonary wedge pressure and end-organ perfusion markers did not reach statistical significance. Three patients were successfully weaned off the balloon and recovered without additional interventions, two patients were transplanted and three were supported with counterpulsation until the implantation of assist device. Three patients died due to progressive heart failure, two after IABP removal and one after VAD implantation. There was no incidence of infection, limb ischemia, thrombus, or embolic complications. CONCLUSIONS: Our data showed that intra-aortic balloon pump support may be successfully and safely used in the acute decompensated dilated cardiomyopathy patients, as an urgent measure of cardiac support, to stabilize the patient and maintain organ perfusion until transplant is available, VAD is placed or patient is weaned from IABP.