Extended cardiopulmonary resuscitation: from high fidelity simulation scenario to the first clinical applications in Poznan out-of-hospital cardiac arrest program.

BACKGROUND: The outcomes of out-of-hospital cardiac arrest (OHCA) patients are poor. In some OHCA cases, the reason is potentially reversible cardiac or aortic disease. It was suggested previously that high-quality cardiopulmonary resuscitation (CPR) followed by extracorporeal membrane oxygenation (ECMO) support may improve the grave prognosis of OHCA. However, extended CPR (ECPR) with ECMO application is an extremely invasive and cutting-edge procedure. The purpose of this article is to describe how high-fidelity medical simulation as a safe tool enabled implementation of the complex, multi-stage ECPR procedure. METHOD: A high fidelity simulation of OHCA in street conditions was prepared and carried out as part of a ECPR procedure implemented in an in-hospital area. The simulation tested communication and collaboration of several medical teams from the pre-hospital to in-hospital phases along with optimal use of equipment in management of a sudden cardiac arrest (SCA) patient. RESULTS: The critical and weak points of an earlier created scenario were collected into a simulation scenario checklist of ECPR algorithm architecture. A few days later, two ECPR procedures followed by cardiologic interventions for OHCA patients (one pulmonary artery embolectomy for acute pulmonary thrombosis and one percutaneous coronary artery angioplasty with drug eluting stent implantation for acute occlusion of the left anterior descending artery), were performed for the first time in Poland. The protocol was activated five times in the first 2 months of the POHCA Program. CONCLUSION: High fidelity medical simulation in real-life conditions was confirmed to be a safe, useful tool to test and then implement the novel and complex medical procedures. It enabled to find, analyze and solve the weakest points of the earlier developed theoretical protocol and eventually succeed in clinical application of complete ECPR procedure.

Managing patients on extracorporeal membrane oxygenation support during the COVID-19 pandemic - a proposal for a nursing standard operating procedure.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is effective in a selected critically ill patient population with promising results in refractory hypoxemia related to the novel coronavirus disease (COVID-19). However, it requires specialized clinicians and resources in advanced technology. Moreover, the COVID-19 remains an ongoing global emergency, and there is no evidence-based practice in preparedness. This article proposes an innovative and optimized nursing care protocol, the Standard Operating Procedure (SOP), that regulates safety and efficiency in using personal protective equipment (PPE) during ECMO-relevant procedures while providing ECMO therapy for patients with COVID-19. METHODS: After performing a narrative literature search, we developed a high-fidelity translational simulation scenario. It included practicing appropriate donning and doffing PPE during work organization, ECMO-related procedures, and routine daily nursing care and management of ECMO over nine hours. In addition, we held supplementary constructive debrief meetings to consult international expert in the field. RESULTS: A proposal for nursing standardized operating procedures was created, divided into categories. They included work organization, workload references, competences, infrastructural conditions, cannulation equipment, daily routine nursing care, and procedures during ECMO. CONCLUSIONS: High-fidelity medical simulation can play an important role in staff training, improvement in previously gained proficiency, and development of optimal SOP for nursing care and management during ECMO in patients with COVID-19. Optimal SOPs may further guide multidisciplinary teams, including intensive care units and interventional departments.

Development of regional extracorporeal life support system: The importance of innovative simulation training.

BACKGROUND: Despite advances in mechanical ventilation, severe acute respiratory distress syndrome (ARDS) is associated with high morbidity and mortality rates ranging from 30% to 60%. Extracorporeal Membrane Oxygenation (ECMO) can be used as a "bridge to recovery". ECMO is a complex network that provides oxygenation and ventilation and allows the lungs to rest and recover from respiratory failure, while minimizing iatrogenic ventilator-induced lung injury. In the critical care settings, ECMO is shown to improve survival rates and outcomes in patients with severe ARDS. The primary objective was to present an innovative approach for using high-fidelity medical simulation before setting ECMO program for reversible respiratory failure (RRF) in Poland's first unique regional program "ECMO for Greater Poland", covering a total population of 3.5 million inhabitants in the Greater Poland region (Wielkopolska). AIM AND METHODS: Because this organizational model is complex and expensive, we use advanced high-fidelity medical simulation to prepare for the real-life implementation. The algorithm was proposed for respiratory treatment by veno-venous (VV) Extracorporeal Membrane Oxygenation (ECMO). The scenario includes all critical stages: hospital identification (Regional Department of Intensive Care) - inclusion and exclusion criteria matching using an authorship protocol; ECMO team transport; therapy confirmation; veno-venous cannulation of mannequin's artificial vessels and implementation of perfusion therapy and transport with ECMO to another hospital in a provincial city (Clinical Department of Intensive Care), where the VV ECMO therapy was performed in the next 48 h, as training platform. RESULTS: The total time, by definition, means the time from the first contact with the mannequin to the cannulation of artificial vessels and starting VV perfusion on ECMO, did not exceed 3 h - including 75 min of transport (the total time of simulation with first call from provincial hospital to admission to the Clinical Intensive Care department was 5 h). The next 48 h for perfusion simulation "in situ" generated a specific learning platform for intensive care personnel. Shortly after this simulation, we performed, the first in the region: ECMO used for RRF treatment. The transport was successful and exceeded 120 km. During first year of Program duration we performed 6 successful ECMO transports (5 adult and 1 paediatric) with 60% of adult patient survival of ECMO therapies. Three patients in good condition were discharged to home. Two years old patient was successfully disconnected from ECMO and in stabile condition is treated in Paediatric Department. CONCLUSIONS: We discovered the important role of medical simulation, not only as an examination for testing the medical professional's skills, but also as a mechanism for creating non-existent procedures. During debriefing, it was found that the previous simulation-based training allowed to build a successful procedural chain, to eliminate errors at the stage of identification, notification, transportation and providing ECMO perfusion therapy.

BEST Life-"Bringing ECMO Simulation To Life"-How Medical Simulation Improved a Regional ECMO Program.

The implemented "ECMO for Greater Poland" program takes full advantage of the ECMO (extracorporeal membrane oxygenation) perfusion therapy to promote health for 3.5 million inhabitants in the region. The predominant subjects of implementation are patients with hypothermia, with severe reversible respiratory failure (RRF), and treatment of other critical states leading to heart failure such as sudden cardiac arrest, cardiogenic shock or acute intoxication. Finally, it promotes donation after circulatory death (DCD) strategy in selected organ donor cases. ECMO enables recovery of organs' function after unsuccessful lifesaving treatment. Because this organizational model is complex and expensive, we use advanced high-fidelity medical simulation to prepare for real-life implementation. During the first four months, we performed scenarios mimicking "ECMO for DCD," "ECMO for ECPR (extended cardiopulmonary resuscitation)," "ECMO for RRF" and "ECMO in hypothermia." It helped to create algorithms for aforementioned program arms. In the following months, three ECMO courses for five departments in Poznan (capitol city of Greater Poland) were organized and standardized operating procedures for road ECMO transportation within Medical Emergency System were created. Soon after simulation program, 38 procedures with ECMO perfusion therapy including five road transportations on ECMO were performed. The Maastricht category II DCD procedures were done four times on real patients and in two cases double successful kidney transplantations were carried out for the first time in Poland. ECMO was applied in two patients with hypothermia, nine adult patients with heart failure, and five with RRF, for the first time in the region. In the pediatric group, ECMO was applied in four patients with RRF and 14 with heart failure after cardiac surgery procedures. Additionally, one child was treated successfully following 200 km-long road transport on ECMO. We achieved good and promising results especially in VV ECMO therapy. Simulation-based training enabled us to build a successful procedural chain, and to eliminate errors at the stage of identification, notification, transportation, and providing ECMO perfusion therapy. We discovered the important role of medical simulation, not only to test the medical professional's skills, but also to promote ECMO therapy in patients with critical/life-threatening states. Moreover, it also resulted in increase of the potential organ pool from DCD in the Greater Poland region.

The role of simulation to support donation after circulatory death with extracorporeal membrane oxygenation (DCD-ECMO).

Maintaining the viability of organs from donors after circulatory death (DCD) for transplantation is a complicated procedure, from a time perspective in the absence of appropriate organizational capabilities, that makes such transplantation cases difficult and not yet widespread in Poland. We present the procedural preparation for Poland's first case of organ (kidney) transplantation from a DCD donor in which perfusion was supported by extracorporeal membrane oxygenation (ECMO). Because this organizational model is complex and expensive, we used advanced high-fidelity medical simulation to prepare for the real-life implementation. The real time scenario included all crucial steps: prehospital identification, cardiopulmonary resuscitation (CPR), advanced life support (ALS); perfusion therapy (CPR-ECMO or DCD-ECMO); inclusion and exclusion criteria matching, suitability for automated chest compression; DCD confirmation and donor authorization, ECMO organs recovery; kidney harvesting. The success of our first simulated DCD-ECMO procedure in Poland is reassuring. Soon after this simulation, Maastricht category II DCD procedures were performed, involving real patients and resulting in two successful double kidney transplantations. During debriefing, it was found that the previous simulation-based training provided the experience to build a successful procedural chain, to eliminate errors at the stage of identification, notification, transportation, donor qualifications and ECMO organ perfusion to create DCD-ECMO algorithm architecture.

The importance of the development of extracorporeal life support simulation centres for improving skills and knowledge during the COVID-19 pandemic.

Introduction: Despite increasing implementation of sophisticated and logistically challenging techniques to support patients in life-threatening conditions in the last years, there were no devoted education centres, especially in coronavirus pandemic. Aim: To assess the value of gaining evidence-based knowledge and improving the skills of physicians by means of simulation techniques in the safe use of extracorporeal technologies to support patients in the life-threatening conditions. Material and methods: In 2019, the National Education Centre for Artificial Life Support and Patient Safety and the frame program of the course of "Artificial Life Support with ECMO". was created. In years 2019-2023, we managed to organise 34 such courses for 405 physicians, which were additionally endorsed by ELSO (Extracorporeal Life Support Organisation). The physicians' cognitive, behavioural, and technical skills were evaluated before and after the courses. Results: The participants' gender was well balanced (54% men and 46% women). Most of them (mainly at the age between 31-40 years) presented more than 5 years of clinical experience, predominantly in anaesthesiology and intensive care (63%). Of note, 54% of them had no experience with ECMO application. In all detailed aspects of cognitive, behavioural, and technical assessment and knowledge scores, significant improvement was observed after the course. Conclusions: The development of a simulation-based education centre was found to be an invaluable achievement that enabled not only successful standardised training and testing of novel or previously accepted procedures, but also the upgrading of technical skills, even in the challenging COVID-19 pandemic period.

Emergency Endovascular Interventions on Descending Thoracic Aorta: A Single-Center Experience.

Background: Implementation of emergency endovascular aortic repair provides an attractive opportunity in the treatment of complicated acute aortic syndromes involving descending aorta. Aim: The aim of this study was to analyze the effectiveness of thoracic endovascular aortic repair (TEVAR) for the treatment of acute surgical emergencies involving the descending thoracic aorta. Methods: A retrospective review of the medical records of all patients undergoing TEVAR in a single center since 2007 was undertaken. Patients with the aortic disease treated on emergency inclusion criteria were complicated spontaneous acute aortic syndrome (csAAS), traumatic aortic acute injuries (TAIs), and other indications requiring emergent intervention. Technical and clinical success with patient mortality, survival, and reoperation rate was evaluated according to Society for Vascular Surgery reporting standards for thoracic endovascular aortic repair (TEVAR). Results: The emergency interventions were necessary in 74 cases (51.0%), including patients with the complicated spontaneous acute aortic syndrome (csAAS) (64.8%; n = 48) and traumatic aortic acute injuries (TAIs) (31.1%). In addition, in one case aortic iatrogenic dissection (AID) and in 2 other fistulas after the previous stent graft, implantations were diagnosed. All procedures were done through surgically exposed femoral arteries while 2 hybrid procedures required additional approaches. The primary technical success rate was 95.9%, in 3 cases endoleak was reported. The primary clinical success occurred in 94.5%. All patients survived the endovascular interventions, whereas during in-hospital stay one of them died due to multiorgan failure (early mortality 1.3%). During the follow-up period, lasting 6 through 164 months (median 67), 11 patients died. Annual, five- and ten-year probability of survival was 86.4 ± 0.04%, 80.0 ± 0.05%, and 76.6 ± 0.06%, respectively. However, the rate of 5-year survivors was significantly higher after TAI (95.2%) than scAAS (63.4%) (p=0.008). Early after the procedure, one individual developed transient paraparesis (1.3%). No other serious stent-graft-related adverse events were noted within the postdischarge follow-up period. Conclusions: Descending aortic pathologies requiring emergent interventions can be treated by endovascular techniques with optimal results and low morbidity and mortality in an experienced and dedicated team.

Extracorporeal Life Support in Accidental Hypothermia with Cardiac Arrest-A Narrative Review.

Severely hypothermic patients, especially suffering cardiac arrest, require highly specialized treatment. The most common problems affecting the recognition and treatment seem to be awareness, logistics, and proper planning. In severe hypothermia, pathophysiologic changes occur in the cardiovascular system leading to dysrhythmias, decreased cardiac output, decreased central nervous system electrical activity, cold diuresis, and noncardiogenic pulmonary edema. Cardiac arrest, multiple organ dysfunction, and refractory vasoplegia are indicative of profound hypothermia. The aim of these narrative reviews is to describe the peculiar pathophysiology of patients suffering cardiac arrest from accidental hypothermia. We describe the good chances of neurologic recovery in certain circumstances, even in patients presenting with unwitnessed cardiac arrest, asystole, and the absence of bystander cardiopulmonary resuscitation. Guidance on patient selection, prognostication, and treatment, including extracorporeal life support, is given.

Unfractionated Heparin Versus Subcutaneous Nadroparin in Adults Supported With Venovenous Extracorporeal Membrane Oxygenation: a Retrospective, Multicenter Study.

Extracorporeal membrane oxygenation (ECMO) requires constant management of coagulation. Whereas unfractionated heparin remains the anticoagulant of choice, experienced centers report high bleeding rates. Biocompatibility of the extracorporeal circuit enables management of anticoagulation with subcutaneous low-molecular-weight heparins only. The aim of this study was to evaluate the safety and feasibility of anticoagulation with subcutaneous nadroparin compared with unfractionated heparin during respiratory ECMO in patients. We assessed for thrombotic complications and number of bleeding and life-threatening bleeding events. Additionally, we evaluated the change in resistance to flow in the oxygenator and the number of transfused blood products. Nadroparin and unfractionated heparin were comparable in terms of number of bleeding (34 vs. 53%; p = 0.12), life-threatening bleeding (2.8 vs. 9.3%; p = 0.26) events, and daily red blood cell transfusion rates (0.79 units/patient/day vs. 0.71 units/patient/day in nadroparin group; p = 0.87) during respiratory ECMO. The relative change in resistance to flow in the oxygenator was similar between groups (8.03 vs. 11.6%; p = 0.27). Nadroparin seemed equivalent to unfractionated heparin in the number of thrombotic and hemorrhagic events as well as in the daily red blood cell transfusion rates during venovenus-ECMO.

Patient Safety during ECMO Transportation: Single Center Experience and Literature Review.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has been proven to support in lifesaving rescue therapy. The best outcomes can be achieved in high-volume ECMO centers with dedicated emergency transport teams. AIM: The aim of this study was to analyze the safety of ECMO support during medical transfer on the basis of our experience developed on innovation cooperation and review of literature. METHODS: A retrospective analysis of our experience of all ECMO-supported patients transferred from regional hospital of the referential ECMO center between 2015 and 2020 was carried out. Special attention was paid to transportation-related mortality and morbidity. Moreover, a systematic review of the Medline, Embase, Cochrane, and Google Scholar databases was performed. It included the original papers published before the end of 2019. RESULTS: Twelve (5 women and 7 men) critically ill ECMO-supported patients with the median age of 33 years (2-63 years) were transferred to our ECMO center. In 92% (n = 11) of the cases venovenous and in 1 case, venoarterial supports were applied. The median transfer length was 45 km (5-200). There was no mortality during transfer and no serious adverse events occurred. Of note, the first ECMO-supported transfer had been proceeded by high-fidelity simulations. For our systematic review, 68 articles were found and 22 of them satisfied the search criteria. A total number of 2647 transfers were reported, mainly primary (90%) and as ground transportations (91.6%). A rate of adverse events ranged from 1% through 20% but notably only major complications were mentioned. The 4 deaths occurred during transport (mortality 0.15%). CONCLUSIONS: Our experiences and literature review showed that transportation for ECMO patients done by experienced staff was associated with low mortality rate but life-threatening adverse events might occur. Translational simulation is an excellent probing technique to improve transportation safety.

Mechanical circulatory support. An expert opinion of the Association of Intensive Cardiac Care and the Association of Cardiovascular Interventions of the Polish Cardiac Society.

Mechanical circulatory support (MCS) methods are used in patients with both acute and chronic heart failure, who have exhausted other options for pharmacological or surgical treatments. The purpose of their use is to support, partially or completely, the failed ventricles and ensure adequate organ perfusion, which allows patients to restore full cardiovascular capacity, prolonging their life and effectively improving its quality. The three most popular devices include an intra-aortic balloon pump (IABP), percutaneous assist devices (including Impella, TandemHeart), and venoarterial extracorporeal membrane oxygenation (VA-ECMO). A multidisciplinary approach with the special participation of the Heart Team is required to determine the proper MCS strategy, the choice of the supporting method, and the time of its use. The studies published so far do not allow us to determine which MCS method is the safest and the most effective. Thus, the site experience and accessibility of the method seem to matter most today. MCS finds particular application in patients with acute coronary syndromes complicated by refractory cardiogenic shock, as well as in patients with acute heart failure of the high potential for reversibility. It can also serve as a backup for percutaneous coronary interventions of high risk (complex and high-risk indicated percutaneous coronary intervention [PCI], complex and high-risk indicated PCI [CHIP]). The use of appropriate supportive drugs, precise hemodynamic and echocardiographic monitoring, as well as optimal non-invasive or mechanical ventilation, are extremely important in the management of a patient with MCS. The most serious complications of MCS include bleeding, thromboembolic events, as well as infections, and hemolysis.

Comprehensive assessment of a nationwide simulation-based course for artificial life support.

BACKGROUND: Successful implementation of medical technologies applied in life-threatening conditions, including extracorporeal membrane oxygenation (ECMO) requires appropriate preparation and training of medical personnel. The pandemic has accelerated the creation of new ECMO centers and has highlighted continuous training in adapting to new pandemic standards. To reach high standards of patients' care, we created the first of its kind, National Education Centre for Artificial Life Support (NEC-ALS) in 40 million inhabitants' country in the Central and Eastern Europe (CEE). The role of the Center is to test and promote the novel or commonly used procedures as well as to develop staff skills on management of patients needing ECMO. METHOD: In 2020, nine approved and endorsed by ELSO courses of "Artificial Life Support with ECMO" were organized. Physicians participated in the three-day high-fidelity simulation-based training that was adapted to abide by the social distancing norms of the COVID-19 pandemic. Knowledge as well as crucial cognitive, behavioral and technical aspects (on a 5-point Likert scale) of management on ECMO were assessed before and after course completion. Moreover, the results of training in mechanical chest compression were also evaluated. RESULTS: There were 115 participants (60% men) predominantly in the age of 30-40 years. Majority of them (63%) were anesthesiologists or intensivists with more than 5-year clinical experience, but 54% had no previous ECMO experience. There was significant improvement after the course in all cognitive, behavioral, and technical self-assessments. Among aspects of management with ECMO that all increased significantly following the course, the most pronounced was related to the technical one (from approximately 1.0 to more 4.0 points). Knowledge scores significantly increased post-course from 11.4 ± SD to 13 ± SD (out of 15 points). The quality of manual chest compression relatively poor before course improved significantly after training. CONCLUSIONS: Our course confirmed that simulation as an educational approach is invaluable not only in training and testing of novel or commonly used procedures, skills upgrading, but also in practicing very rare cases. The implementation of the education program during COVID-19 pandemic may be helpful in founding specialized Advanced Life Support centers and teams including mobile ones. The dedicated R&D Innovation Ecosystem established in the "ECMO for Greater Poland" program, with developed National Education Center can play a crucial role in the knowledge and know-how transfer but future research is needed.

Long-term biventricular circulatory support with POLVAD-MEV paracorporeal pulsatile pumps. Single-centre experience.

INTRODUCTION: Severe heart failure decompensation requires circulatory mechanical support in emergency situations. Polish paracorporeal pulsatile pumps, POLVAD-MEV, are designed for biventricular end-stage heart dysfunction. AIM: To evaluate long-term POLVAD-MEV therapy by multiple pump exchange in patients on a transplant list. MATERIAL AND METHODS: There were 3 patients in INTERMACS level 1 referred for emergency POLVAD-MED implantation due to acute heart failure deterioration. The paracorporeal pulsatile mechanical support was applied due to severe biventricular dysfunction. RESULTS: They were supported by paracorporeal biventricular POLVAD-MEV pumps for 438, 473 and 394 days until heart transplantation. During the hospitalisation the pumps required multiple pumps exchanges within 29 ±10 (4-49) day intervals. CONCLUSIONS: POLVAD-MEV paracorporeal pulsatile pumps present a safe option for long-term circulatory support in a selected group of patients. Therapy requires pump exchange but enables survival while awaiting a heart transplant.

A concept for the development of a pioneer regional Out-of-Hospital Cardiac Arrest Program to improve patient outcomes.

BACKGROUND: Immediate initiation of cardiopulmonary resuscitation (CPR) increases chances of restoring spontaneous circulation and survival after out­of­hospital cardiac arrest (OHCA). For some refractory cases, extended cardiopulmonary resuscitation (ECPR) may be a promising option. AIMS: The aim of the study was to estimate the possibility of implementation of ECPR procedure to improve current early outcomes of patients after OHCA. METHODS: The medicalcharts of the Province Emergency Station in Poznan from a 12­month periodwere assessed retrospectively. All OHCA cases were identified and the following potential inclusion criteria for ECPR were analyzed: initial defibrillation rhythm, age between 18 and 65 years, CPR conducted by bystanders, and time to hospital arrival less than 40 minutes. RESULTS: In 576 (46.7%) of 1233 identified OHCA cases, CPR wasinitiated by bystanders and automated external defibrillatorwas applied only 17 times. An initial defibrillation rhythm was noted in 138 individuals (11.2%). Out of 65 patients who met the ECPR age criterion, 55 underwent CPR by bystanders which lead to a no­flow time that did not exceed 10 minutes. The additional 9 of them would be excluded due to time to hospital arrival. This means that ECPR would be applicable in 46 patients after OHCA. CONCLUSIONS: Our analysis showed that in some patients after sudden cardiac arrest, it would have been possible to implement ECPR as a crucial part of the Regional Out-of-Hospital Cardiac Arrest (OHCA) Program, and in consequence, probably to improve early outcomes of patients with refractory and potentially reversible cardiac arrest.

Introducing of the First DCD Kidney Transplantation Program in Poland.

In many countries, including Poland, the main problem with transplantation is the insufficiency of organ donors in relation to the demand for organs. Hence, the common aim globally is to increase the pool of donors. The prolonged survival of patients after transplantation, with respect to the survival time of patients on dialysis, makes the search much more intense. After the recourse of expanded criteria donors (ECD), the next step was obtaining kidneys from donors after irreversible cardiac death (DCD). Therefore, based on Dutch, British, and Spanish experience, it can be hypothesized that the introduction of DCD procedures in countries that have not launched these programs and the improvement of DCD procedures may shorten the waiting time for organ transplantation globally. The legal basis for the procurement of organs after irreversible cardiac arrest came into existence in Poland in 2010. Previously, such organ procurements were not in practice. Since 1984, when Poland published irreversible cardiac arrest as a criterion of brain death, it became the only way to determine death prior to the procurement of organs. The aim of this report was to evaluate the results of the first 19 transplantation cases involving harvested kidneys from donors after cardiac arrest, which was irreversible and clinically confirmed, without any doubt as per the ethical protocol of DCD. Understanding, support, and public perception are essential for this program's initiation and maintenance.

Endovascular treatment of complex diseases of the thoracic aorta-10 years single centre experience.

BACKGROUND: Introduction of invasive endovascular techniques constituted a real a breakthrough in the treatment of aortic aneurysm dissection and rupture. We assessed the effectiveness and safety of thoracic endovascular aortic repair (TEVAR) in patients with thoracic aortic pathologies. METHODS: Between 2007 and 2017, 118 patients with thoracic aortic pathology underwent TEVAR. Among them, 20 (16.9%) patients required hybrid procedures. Stent grafts indication were thoracic aortic aneurysm in 46 (39.0%) patients, type B dissection in 68 (57.6%) patients and other indications in 4 (3.3%). Procedural success rate, in-hospital and late mortality and morbidity were evaluated. RESULTS: The patients were followed-up for a mean of 55 months (range, 6-118 months). The technical success rate was 96%. Five patients died during the first 30 days after procedure (mortality 4.2%), four due to ischemic stroke followed by multi-organ failure and another one hemodynamically significant type I endoleak. Most of them were noted in the first years of our study. Five others died during post-discharged period. Four patients developed neurological complications, including stroke (n=2; 1.7%) and paraparesis (n=2; 1.7%). There were 6 (5.1%) primary (5 type I and 1 type II) and 3 (2.5%) secondary endoleaks (1 type I and 2 type III). Secondary interventions were required in 8 subjects. There was one case of stent collapse and two retrograde aortic dissection. CONCLUSIONS: Treatment of descending aortic diseases by using stent graft implantation has become the method of choice, decreasing the risk of open surgery, especially in patients with severe clinical state and comorbidities. However, effectiveness and safety may be achieved by experience team.

Off pump hybrid extra-anatomic techniques for aortic arch repair-own experience.

BACKGROUND: Treatment of the aortic arch pathologies is technically challenging. In this study we assess early and late outcomes of hybrid aortic arch repairs that comprise extra-anatomic surgical procedures completed by thoracic endovascular interventions [thoracic endovascular aortic repair (TEVAR)]. METHODS: Since 2007, 21 patients (8 women and 13 men) with a median age of 48 years have undergone hybrid procedures for aortic arch pathologies. All of them were treated without cardio-pulmonary bypass. All survivors were followed up regularly and imaging examination were performed. A technical success, procedural complications as well as the early and late mortality and morbidity rates were evaluated. RESULTS: All patients survived surgery and TEVAR was technically successful in all of them. However, 2 individuals died (in-hospital mortality rate 9.5%) during in-hospital stay, both due to multi-organ failure (MOF). Additionally, one patient developed symptoms of cerebral stroke, another one of spinal cord ischemia. During the follow-up that ranged from 6 to 118 months and was completed by 100% of the survivors, one patient died 3 years after procedure because of sepsis (aorto-oesophageal fistula prior to intervention) and late vascular graft occlusions were noted in three cases. CONCLUSIONS: Hybrid procedures on the aortic arch that comprise surgical and endovascular interventions has become an attractive and safe therapeutic option with acceptable mortality and morbidity rate. They may be considered as a method of choice in treatment of the elderly and high-risk patients.

Fluid therapy in non-septic, refractory acute decompensated heart failure patients - The cautious role of central venous pressure.

PURPOSE: Fluid therapy in congestive acute decompensated heart failure (ADHF) patients might be inappropriate and worsening the prognosis. The aim of our study was to analyze the effect of fluid administration on mortality in non-septic, ADHF patients with reduced ejection fraction. MATERIAL AND METHODS: We analyzed 41 ADHF consecutive 'cold-wet' patients (mean age 69.3 ± 14.9 years, 27 men, LVEF 22.8 ± 11.1%, lactates 2.2 ± 1.6 mmol/L) without sepsis. At admission central venous pressure (CVP) was measured (17.6 ± 7.2 cm H2O), and ultrasound examination of inferior vena cava (IVC) was performed (IVC min. 18.6 ± 7.3 mm and IVC max. 24.6 ± 4.3 mm). Moreover, the groups were compared (survivors vs. non-survivors as well as 1st and 4th quartile of CVP). RESULTS: Altogether 17 (41%) patients died: 16 (39%) during a mean of 11.2 ± 7.8 days of hospitalization and 1 during a 30-day follow up. Patients in the lowest CVP quartile (<13 cm H2O) had significantly worse in-hospital survival as compared to patients in the highest quartile (>24 cm H2O), P = 0.012. Higher intravenous fluid volumes within the first 24 h were infused in patients in the lowest CVP quartile as compared to the highest CVP quartile (1791.7 ± 1357.8 mL vs. 754.5 ± 631.4 mL, P = 0.046). Moreover, more fluids were infused in a group of patients who died during a hospital stay and at 30-day follow up (1362.8 ± 752.7 mL vs. 722.7 ± 1046.5 mL, P = 0.004; 1348.8 ± 731.0 mL vs. 703.6 ± 1068.4 mL, P = 0.002, respectively). CONCLUSIONS: CVP-guided intravenous fluid therapy is a common practice which in high risk ADHF 'cold-wet' patients might be harmful and should rather be avoided. Lower CVP seems to be related with worse prognosis.

Preoperative blood morphology and incidence of acute kidney injury after on-pump coronary artery bypass grafting - a single-center preliminary report.

INTRODUCTION: Acute kidney injury (AKI) after coronary artery bypass grafting (CABG) performed in cardiopulmonary bypass (CPB) may complicate the postoperative course and has a negative impact on outcome. In some cases, postoperative AKI develops in spite of normal baseline creatinine concentration and estimated glomerular filtration rate (eGFR). AIM: To examine whether there is any association between the preoperative blood morphology and incidence of post-operative AKI. MATERIAL AND METHODS: The study involved 62 consecutive patients with the mean age of 64.0 ±7.4 years who underwent CABG in CPB. Before surgery, blood morphology and biochemistry were analyzed. Patients with eGFR below 60 ml/min/1.73 m2 were excluded. After the operation, parameters of renal function were checked systematically. Acute kidney injury was defined according to the Acute Kidney Injury Network (AKIN) classification. RESULTS: Twenty-one (33.9%) patients presented AKI (group AKI), although in the majority of them (n = 16) it was temporary and medical management was enough to cure AKI. Only in 1 (1.6%) case was renal replacement therapy necessary. In group AKI, patients' preoperative hemoglobin concentration (8.46 ±0.72 mM/l), red blood cell count (4.51 ±0.39 × 1012/l) and hematocrit (0.40 ±0.04) were significantly lower (p < 0.05) than in group C (9.07 ±0.57 mM/l; 4.78 ±0.36 × 1012/l; 0.43 ±0.03, respectively). Interestingly, the baseline parameters of renal function were comparable between groups. CONCLUSIONS: Hemoglobin concentration and red blood cell counts close to the lower limit of the normal range may enable identification of patients at risk of AKI early after CABG in CPB among individuals with normal preoperative biochemical parameters of renal function.