The evaluation of annuloplasty in bicuspid aortic valve repair using cardiac magnetic resonance.

BACKGROUND: The incompetent bicuspid aortic valve (BAV) can be replaced or repaired using various surgical techniques. This study sought to assess the efficacy of external annuloplasty and postoperative reverse remodelling using cardiac magnetic resonance (CMR) and compare the results of external and subcommissural annuloplasty. METHODS: Out of a total of 200 BAV repair performed between 2004 and 2018, 21 consecutive patients (median age 54 years) with regurgitation requiring valve repair with annuloplasty without concomitant aortic root surgery were prospectively referred for CMR and transthoracic echocardiography (TTE) one year after the operation. Two aortic annulus stabilization techniques were used: external, circumferential annuloplasty (EA), and subcommissural annuloplasty (SCA). RESULTS: 11 patients received EA and 10 patients were treated using SCA. There was no in-hospital mortality and all patients survived the follow-up period (median: 12.6 months (first quartile: 6.6; third quartile: 14.1). CMR showed strong correlation between postoperative aortic recurrent regurgitant fraction and left ventricular end-diastolic volume (r = 0.62; p = 0.003) as well as left ventricular ejection fraction (r = -0.53; p = 0.01). Patients treated with EA as compared with SCA had larger anatomic aortic valve area measured by CMR (3.5 (2.5; 4.0) vs. 2.5 cm2 (2.0; 3.4); p = 0.04). In both EA and SCA group, aortic valve area below 3.5 cm2 correlated with no regurgitation recurrency. EA (vs. SCA) was associated with lower peak transvalvular aortic gradients (10 (6; 17) vs. 21 mmHg (15; 27); p = 0.04). CONCLUSIONS: The repair of the bicuspid aortic valve provides significant postoperative reverse remodelling, provided no recurrent regurgitation and durable reduction annuloplasty can be achieved. EA is associated with lower transvalvular gradients and higher aortic valve area assessed by CMR, compared to SCA.

The use of data science to analyse physiology of oxygen delivery in the extracorporeal circulation.

BACKGROUND: Recent scientific reports have brought into light a new concept of goal-directed perfusion (GDP) that aims to recreate physiological conditions in which the risk of end-organ malperfusion is minimalized. The aim of our study was to analyse patients' interim physiology while on cardiopulmonary bypass based on the haemodynamic and tissue oxygen delivery measurements. We also aimed to create a universal formula that may help in further implementation of the GDP concept. METHODS: We retrospectively analysed patients operated on at the Wroclaw University Hospital between June 2017 and December 2018. Since our observations provided an extensive amount of data, including the patients' demographics, surgery details and the perfusion-related data, the Data Science methodology was applied. RESULTS: A total of 272 (mean age 62.5 ± 12.4, 74% male) cardiac surgery patients were included in the study. To study the relationship between haemodynamic and tissue oxygen parameters, the data for three different values of DO2i (280 ml/min/m2, 330 ml/min/m2 and 380 ml/min/m2), were evaluated. Each set of those lines showed a descending function of CI in Hb concentration for the set DO2i. CONCLUSIONS: Modern calculation tools make it possible to create a common data platform from a very large database. Using that methodology we created models of haemodynamic compounds describing tissue oxygen delivery. The obtained unique patterns may both allow the adaptation of the flow in relation to the patient's unique morphology that changes in time and contribute to wider and safer implementation of perfusion strategy which has been tailored to every patient's individual needs.

Lipomatous hypertrophy of the atrial septum - a benign heart anomaly causing unexpected surgical problems: a case report.

BACKGROUND: Lipomatous hypertrophy of the atrial septum (LHAS) is an anomaly of the heart. It is characterized by an infiltration of adipocytes into myocytes of the interatrial septum, sparing the fossa ovalis, which gives a characteristic hourglass-shaped image. Due to the progress in imaging techniques, it can be recognized more frequently, but it is still often misdiagnosed. CASE PRESENTATION: We present a case of 65-year-old woman with an incidentally discovered lipomatous hypertrophy of the atrial septum during cardiac surgery, which has caused the technical problems for surgeons with bicaval cannulation and visualization of the operated structures of the heart. Due to the unclear shadow in the lung parenchyma, the patient had preoperative computed tomography (CT) done, but the study report focused only on the lung description, neglecting visible changes in the structure of the heart. Based on the standardly performed intra-operative transesophageal echocardiography (TEE), as well as by analyzing the chest X-ray and CT scans, the diagnosis of LHAS was made. It allowed the surgeon to leave the mass intact, thus not increasing the risk of the baseline surgery. CONCLUSIONS: LHAS is a rare but increasingly recognized anomaly of the heart. Contemporary diagnostic methods allow to diagnose and make the right therapeutic decisions. The utility of TEE and analysis of X-ray images, in this case, allowed the surgeon to recognize LHAS, and because of its histologically benign nature and asymptomatic course, to leave this change intact. Surgical treatment should be limited only to cases of patients with life-threatening cardiovascular complications.

Myocardial remodeling after kidney transplantation: a case report.

BACKGROUND: Lupus nephritis (LN) is one of the most common manifestations of systemic lupus erythematosus (SLE) and is often the most serious organ complication and the cause of premature death of such a patient. Most of other organs and systems can be also affected. A typical complication is a cardiovascular involvement leading to the development of heart failure. According to current therapeutic standards, kidney transplantation is the treatment of choice in patients with renal failure in course of LN. On the contrary, a kidney transplantation in a patient with an additional heart disease poses a serious clinical challenge. CASE PRESENTATION: We present a case of a 49-year-old woman with renal and heart failure following a long-term SLE prepared for kidney transplantation. During the SLE course, the function of the heart and kidneys gradually deteriorated. The patient required the initiation of renal replacement therapy and was dialyzed until a kidney transplantation for 4 years. In the preparation of the patient for the surgical procedure, due to the extremely low ejection fraction, it was decided to include cardioprotective treatment with Levosimendan. The postoperative period was not straightforward but successful. In the monthly and five-month follow-up, a continuous improvement of heart function with normal renal function was noted. CONCLUSIONS: Kidney transplantation in patients with lupus suffering from heart failure requires the involvement of a team of specialists. Patients with extremely low ejection fraction in the perioperative period should undergo careful hemodynamic supervision in the intensive care unit. Cardioprotective and thus nephroprotective Levosimendan therapy together with optimal fluid and hemodynamic therapy in the peri-transplant period may be a bridge for heart remodeling after kidney transplantation.

Internal aortic annuloplasty remodeling ring in bicuspid aortic valve repair: different phenotypes.

We describe our approach, which is based on using an internal bicuspid annuloplasty ring not only to provide annular reduction but also to routinely achieve 180° valve symmetry. The HAART 200 ring has a circular base geometry with 180° subcommissural posts. It is sized according to the intercommissural diameter and keeps that dimension unchanged. The non-fused leaflet serves as a reference, and its free-edge length is measured with a ball sizer that predicts the required ring diameter (D): D =free-edge diameter/1.5 with transannular suturing. The ring brings the sinus-to-sinus dimension centrally to improve leaflet coaptation. More importantly, the ring remodels the fused and nonfused sinuses into equal annular segments, thereby increasing the mobility of the fused segment, facilitating its later plication. In this way, the ring establishes 180° valve geometry.

Mature mediastinal teratoma with somatic type malignancy including neuroblastoma and intestinal type of adenocarcinoma: A Case Report.

INTRODUCTION AND IMPORTANCE: The majority of mediastinal tumours develop asymptomatically and are often detected incidentally on a chest X-ray performed for another reason. Mediastinal tumours, although mostly asymptomatic, may cause non-specific symptoms associated with advanced tumour growth. CASE PRESENTATION: We present a case of a 30-year-old woman who presented with exhaustion and lower back pain accompanied by severe headaches with symptoms of visual disturbances, followed by the typical Horner syndrome. Computed tomography revealed a tumour measuring 12 × 11 × 10 cm in the right cavity with features suggestive of teratoma. The patient underwent mediastinal tumour resection and thymectomy. The pathomorphological examination confirmed the primary diagnosis of mediastinal teratoma, but rare somatic type malignancy was detected. Therefore, the patient was referred for further oncological treatment. DISCUSSION: Mediastinal teratoma is an uncommon finding and usually asymptomatic. Despite its slow growth, it can grow enough to compress adjacent structures, causing symptoms similar to those presented in our patient. CONCLUSION: Radiologic imaging proves diagnostic in most cases. Despite the somatic type malignancy, surgical excision of the tumour using the en-bloc technique seems to be a sufficient option for the patient, and further oncological treatment is not always obligatory.

Bicuspid aortic valve repair: outcomes after 17 years of experience.

OBJECTIVES: This study presents the results of 17 years of experience with bicuspid aortic valve (BAV) repair and the analysis of factors associated with repair failure and early echocardiographic outcome. METHODS: Between 2003 and 2020, a total of 206 patients [mean age: 44.5 ± 15.2 years; 152 males (74%)] with BAV insufficiency with or without aortic dilatation underwent elective aortic valve repair performed by a single surgeon with a mean follow-up of 5 ± 3.5 years. The transthoracic echocardiography examinations were reported. RESULTS: There were no deaths during the hospital stay, and all but 1 patient survived the follow-up period (99.5%). Overall, 10 patients (5%) developed severe insufficiency and 2 (1%) developed aortic dilatation requiring reoperation. Freedom from reoperation at 7 years reached 91.8%. Type 2 BAV configuration [hazard ratio (HR) 3.9; 95% confidence interval (CI): 1.01-60; P = 0.049], no sinotubular junction remodelling (HR 7; 95% CI: 1.7-23; P = 0.005), no circumferential annuloplasty (HR 3.9; 95% CI: 1.01-64; P = 0.047) and leaflet resection (HR 5.7; 95% CI 1.2-13. P = 0.017) have been identified as a risk factor of redo operation. Parameters of the postoperative left ventricle reverse remodelling improved significantly early after the operation and later at 2 years evaluation. CONCLUSIONS: The repair of BAV offers good short- and mid-term results providing a significant reverse left ventricular remodelling. Type 0 BAV preoperative configuration, circumferential annuloplasty and sinotubular junction remodelling are associated with better repair durability.

Effect of Perioperative Optimization of Arterial Oxygen Content and Perfusion Pressure on the Function of the Transplanted Kidney in the Retrospective Study of Excretory Function and Assessment of New Markers of Kidney Damage: IL-18, Neutrophil Gelatinase-Associated Lipocalin, and Clusterin.

INTRODUCTION: The concept of anesthesia, in which kidney perfusion is optimized, the use of nephrotoxic drugs is avoided, and general anesthesia with protective and preconditioning properties of the graft is applied, is a key element of the therapeutic strategy in kidney transplantation (KTx). MATERIAL AND METHOD: A total of 86 patients (mean age: 49.4 ± 14.0 years, 66% men) with end-stage renal disease who underwent KTx between 2012 and 2015 were included in this retrospective study. Our aim was to assess the effect of oxygen content in arterial blood and selected hemodynamic parameters on the graft function and the occurrence of delayed graft failure. RESULTS: No differences were found in baseline characteristics, indication for transplantation, and surgical technique used among study population. No correlation was found between oxygen delivery exponents and both standard markers of renal function and new biochemical markers (eg, IL-18, clusterin, and neutrophil gelatinase-associated lipocalin [NGAL]). DISCUSSION: In our study, hemodynamic parameters measured at scheduled intervals did not exceed the physiological range, which might have been the reason for the lack of correlation between the function of graft and the described hemodynamic conditions. At the same time, in the observed ranges of perfusion pressure during optimization of the oxygen content, no correlations were found with the postoperative function of the transplanted kidney. That observation could be a valuable conclusion for reducing the tendency of maintaining high blood pressure with the abuse of catecholamines, especially vasoconstrictors, and volume therapy, whose negative effect on tissue perfusion is unequivocal.

Liver function after transplantation in the assessment of the coagulation system and the concept of antithrombotic therapy.

INTRODUCTION: Thrombotic complications after liver transplantation limit the long-term success of the procedure. Therefore, an early and accurate diagnosis with the appropriate treatment is crucial to sustain the proper functioning of the graft. AIM: To evaluate the return of newly transplanted liver function within the first days of ICU stay after liver transplantation surgery (Ltx) observed in laboratory examination. It is important to understand the physiology of the newly transplanted liver, particularly in terms of its metabolic function and the assessment of easy-to-monitor coagulation parameters and enzyme markers. MATERIAL AND METHODS: We present our observations carried out in 27 patients, transplanted in the period 2015-2017, during their stay in the Department of Anaesthesiology and Intensive Therapy of the University Hospital in Wroclaw. We demonstrated changes in laboratory parameters within 72 h after liver transplantation and the concept of anticoagulant therapy at our institution. RESULTS: The presented results show the characteristics of aspartate transaminase, alanine transaminase, bilirubin, and standard tests evaluating the coagulation system within the first 4 days after surgery. The concept of anticoagulant therapy used in our intensive care unit is also presented. The aim of the work is an observation of physiology of the graft function in the aspect of coagulation disorders. CONCLUSIONS: The early postoperative period is considered prognostic. The characteristics of basic biochemical tests are determined by the function of the transplanted organ. Implementation of anticoagulant therapy in this period is a therapeutic challenge that requires experience.

Assessment of Hemoglobin Levels in Patients Qualified for Kidney Transplantation in the Perioperative Period and Its Impact on the Occurrence of Delayed Graft Function.

BACKGROUND: Anesthesia in patients undergoing kidney transplantation (KTx) should be aimed at creating optimal hemodynamic conditions for the newly implanted kidney. Changes in of blood count, caused mainly by intraoperative hemodilution, may adversely affect the perioperative course by strengthening the pathologic mechanisms of ischemia-reperfusion syndrome. METHODS: A total of 86 patients (mean age: 49.4 ± 14.0 years, 66% men) with end-stage renal disease who underwent KTx between 2012 and 2015 were included in this retrospective study. Our aim was to assess the hemoglobin level and the effect of fluctuations caused by the implemented fluid therapy on graft function and the occurrence of delayed graft failure. RESULTS: There was no difference in baseline characteristics, indication for transplantation, and surgical technique used among study population. Among the whole observation group, no correlation was found between fluid therapy causing hemodilution with a decrease in hemoglobin concentration and the occurrence of delayed graft failure. CONCLUSIONS: In our observations, we paid special attention to the problem of hemodilution in patients undergoing KTx. It is important to emphasize the importance of proper preparation of the patient for KTx by earlier implementation of anemia therapy, thus preventing exacerbation of anemia in the postoperative period, especially because the perioperative use of blood products is associated with numerous complications and a worse prognosis for the newly implanted kidney.

Can a trainee perform endovascular aortic repair as effectively and safely as an experienced specialist?

OBJECTIVES: Endovascular aortic repair (EVAR) is a technically demanding procedure usually carried out by highly experienced surgeons. However, in this era of modern endovascular surgery with growing numbers of patients qualifying for the procedure, the need to enhance surgical training has emerged. Our aim was to compare the technical results of EVAR in patients operated on by trainees to that of those operated on by an endovascular expert. METHODS: Between 2016 and 2018, a total of 119 patients diagnosed with an abdominal aorta disease requiring EVAR were admitted to our clinic. Overall, we included 96 patients who underwent preoperative and postoperative computed tomography angiography and EVAR performed either by an endovascular expert (N = 51) or a trainee (N = 45). RESULTS: We detected no difference in the baseline characteristics, indication for EVAR and preoperative anatomy between patients operated on by trainees and our endovascular expert. We noted the same incidence of endoleak type Ia occurrence (n = 2 vs n = 2, P = 1.00), reintervention rate (n = 0 vs n = 0, P = 1.00) and in-hospital mortality (n = 0 vs n = 1, P = 1.00) for operations done by trainees and the expert, respectively. There was no difference in X-ray doses or time between the 2 groups. Despite longer median operation times [112 (first quartile: 84; third quartile: 129) vs 89 (75-104) min; P = 0.03] and in-hospital stays [10 (8-13) vs 8 (7-10) days, P = 0.007] of the patients operated on by trainees, the overall clinical success of EVAR was satisfactory in both groups. CONCLUSIONS: An EVAR planned and performed by a trainee need not raise the cumulative risk of the procedure. Trainees who have undergone both mind and hand skills training can therefore carry out EVAR under the supervision of an experienced specialist as effectively and safely as experts do.

Evaluating the diagnostic accuracy of maximal aortic diameter, length and volume for prediction of aortic dissection.

OBJECTIVE: Management of thoracic aortic aneurysms (TAAs) comprises regular diameter follow-up until the indication criterion for prophylactic surgery is reached. However, this approach is unable to predict the majority of acute type A aortic dissections (ATAADs). The current study aims to evaluate the diagnostic accuracy of ascending aortic diameter, length and volume for occurrence of ATAAD. METHODS: This two-centre observational cohort study retrospectively screened 477 consecutive patients who presented with ATAAD between 2009 and 2018. Of those, 25 (5.2%) underwent CT angiography (CTA) within 2 years before dissection onset. Aortic diameter, length and volume of these patients ('pre-ATAAD') were compared with those of TAA controls (n=75). Receiver operating curve analysis was performed to evaluate the predictive accuracy of the three different measurements. RESULTS: 96% of patients with pre-ATAAD did not meet the surgical diameter threshold of 55 mm before dissection onset. Maximal aortic diameters (45 (40-49) mm vs 46 (44-49) mm, p=0.075) and volume (126 (95-157) cm3 vs 124 (102-136) cm3, p=0.909) were comparable between patients with pre-ATAAD and TAA controls. Conversely, ascending aortic length (84±9 mm vs 90±16 mm, p=0.031) was significantly larger in patients with pre-ATAAD. All three parameters had an area under the curve of >0.800. At the 55 mm cut-off point, the maximal diameter yielded a positive predictive value (PPV) of 20%. While maintaining same specificity levels, measurements of aortic volume and length showed superior diagnostic accuracy (PPV 55% and 70%, respectively). CONCLUSION: Measurements of aortic volume and length have superior diagnostic accuracy compared with the maximal diameter and could improve the timely identification of patients at risk for ATAAD.

Modelling of predissection aortic size in acute descending aortic dissection.

OBJECTIVES: Large aortic diameter is considered the most frequent cause of aortic dissection. However, this assumption relies on postdissection imaging of the aorta. We recently showed that acute dissection leads to a 23% increase in the descending aortic diameter. Our aim was to model the diameter of the aorta before the acute descending aortic dissection occurred. METHODS: Between 2003 and 2017, a total of 190 patients developed acute descending aortic dissection. In total, 165 non-Marfan patients were included, whose computed tomography angiography scans were available and taken within 6 h after the occurrence of acute descending aortic dissection [67 (first quartile 58-third quartile 75) years, 69% males]. The maximum postdissection aortic diameter was measured at the level of the mid-descending aorta. Modelling was performed by dividing the postdissection aortic diameter by the factor 1.23. RESULTS: The median modelled predissection descending diameter measured in the mid-descending aorta was 30.5 (27.3-35.4) mm. The median predissection descending diameter was higher in men (P = 0.021) and associated with age (P < 0.001) but not with body surface area. The modelled diameter of the predissected descending aorta revealed that 98.8% (163/165) of patients had an aortic diameter measuring <55 mm and 84.8% (140/165) <40 mm. In other words, 50% of these patients had a non-dilated descending aorta prior to dissection onset. CONCLUSIONS: Modelling indicated that more than 80% of patients who suffered an acute descending aortic dissection had a descending aorta <40 mm before dissection onset. Only 1% of them would have met the guideline criteria (aortic diameter ≥55 mm) for elective descending aortic repair. The role of an excessively large aortic diameter as a predictor of descending aortic dissection might be overrated.