Safety and feasibility of minimally invasive coronary artery bypass surgery early after drug-eluting stent implantation due to acute coronary syndrome.

BACKGROUND: The evidence on performing minimally invasive coronary artery surgery early after drug-eluting stent (DES) implantation due to acute coronary syndrome (ACS) is limited. AIM: The study aimed to determine the safety and feasibility of this approach. METHODS: This registry included 115 (78% male) patients treated from 2013 to 2018, who underwent non-left anterior descending (LAD) percutaneous coronary intervention (PCI) due to ACS with contemporary DES implantation (39% diagnosed with myocardial infarction at baseline), followed by endoscopic atraumatic coronary artery bypass (EACAB) surgery within 180 days, after temporary P2Y12 inhibitor discontinuation. Primary composite endpoint of MACCE (major adverse cardiac and cerebrovascular events), defined as death, myocardial infarction (MI), cerebrovascular incident, and repeat revascularization was evaluated in long-term follow-up. The follow-up was collected via a telephone survey and in line with National Registry for Cardiac Surgery Procedures. RESULTS: The median (interquartile range [IQR]) time interval separating both procedures was 100.0 (62.0-136.0) days. Median (IQR) follow-up duration was 1338.5 (753.0-2093.0) days and was completed for all patients with regard to mortality. Eight patients (7%) died; 2 (1.7%) had a stroke; 6 (5.2%) suffered from MI, and 12 (10.4%) required repeat revascularization. Overall, the incidence of MACCE was 20 (17.4%). CONCLUSIONS: EACAB is a safe and feasible method of LAD revascularization in patients who received DES for ACS within 180 days before surgery despite early dual antiplatelet therapy discontinuation. The adverse event rate is low and acceptable.

One-shot cardioplegia for minimally invasive mitral valve repair-a comparison of del Nido and Bretschneider Histidine-Tryptophan-Ketoglutarate solutions.

BACKGROUND: Minimally invasive procedures are demanding in terms of cardioprotection. In many leading centres Bretschneider HTK solution is used for mitral valve surgery. The study was designed to provide comparison of the del Nido and Bretschneider HTK protocol. METHODS: Patients who underwent minimally invasive mitral valve repair for primary mitral regurgitation and received single delivery of either del Nido (Group 1) or Bretschneider HTK cardioplegia (Group 2) were matched on basis of age, gender and length of the cross-clamp time. The groups were compared in terms of major adverse cardiac and cerebrovascular events (death, myocardial infarction, stroke), high sensitivity troponin T (hs-TnT) and creatine kinase- MB isoenzyme (CK-MB) release at 12 h and 24 h following the surgery, incidence of low cardiac output syndrome (LCOS), postoperative arrhythmia, transfusions and postoperative renal function. RESULTS: Case control matching selected 38 pairs of patients. None of patients died, nor suffered from myocardial infarction or stroke. Troponin values did not differ at 12 h (median: 281.0 pg/mL vs 313.0 pg/mL; p = .38) and 24 h (median: 261.0 pg/mL vs 299.0 pg/mL; p = .54), as well as CK-MB at 12 h (median: 25.0 ng/mL vs 29.0 ng/mL; p = .31) and 24 h (median: 11.0 ng/mL versus 9.6 ng/mL; p = .46). Difference in occurrence of LCOS was insignificant (2 vs 7; 5.2% vs 18.4%; p =.15). No difference was shown in incidence of postoperative arrhythmia, transfusions and renal function. CONCLUSIONS: Del Nido cardioplegia can be used safely as an alternative for Bretschneider HTK for minimally invasive mitral valve surgery.

The impact of del Nido cardioplegia solution on blood morphology parameters.

BACKGROUND: Crystalloid cardioplegic solutions are believed to reduce hemoglobin significantly and increase the transfusion rate. However, recent reports indicate that the del Nido cardioplegia may preserve blood morphology parameters. METHODS: In "The del Nido versus cold blood cardioplegia in aortic valve Replacement" trial patients undergoing aortic valve replacement were randomized into the del Nido (DN) or cold blood cardioplegia (CB) group. For the subanalysis, patients who underwent blood transfusions were excluded from the study. Red blood cell (RBC) count, hemoglobin, white blood cell (WBC) count and platelet (PLT) count were measured before the surgery, 24-, 48-, and 96 hours postoperatively. Furthermore, percental variation in first-last measure was compared in groups. In addition, indexed normalized ratio (INR) and activated partial thromboplastin time (aPTT) were compared preoperatively and 24 hours after the surgery. RESULTS: Eighteen (24%) patients from the del Nido group and 22 (29.3%) patients from the CB group received blood product transfusions (p = 0.560) and were excluded from further analysis. As such, 57 patients remained in DN group and 53 patients remained in CB group. No difference was found in RBC, hemoglobin, WBC, and platelet count in time intervals. Percental variation in first-last measure revealed higher fall in RBC (p = 0.0024) and hemoglobin (p = 0.0028) in the CB group. No difference was shown in preoperative and 24-hour postoperative INR and aPTT. CONCLUSIONS: The del Nido cardioplegia does not decrease blood morphology parameters when compared to cold blood cardioplegia and may be used alternatively regardless of bleeding and coagulopathy risk.

Del Nido versus Bretschneider cardioplegic solution in valve replacement for severe aortic stenosis - a case-control pilot study.

Introduction: The adequate protection provided by the del Nido cardioplegia has already been proven in trials comparing the solution with blood cardioplegia. However, evidence regarding comparison to the Bretschneider HTK solution is limited. Aim: To determine the efficacy of the del Nido cardioplegia when compared to Bretschneider HTK solution in patients undergoing aortic valve replacement for severe aortic stenosis. Material and methods: Ten patients undergoing isolated aortic valve replacement for severe aortic stenosis using the del Nido solution (group 1) were case-control matched to patients undergoing aortic valve replacement (AVR) using the Bretschneider solution (group 2). The observation included: cardioplegia dosage, time to cardiac arrest, cross-clamp and extracorporeal circulation time, ventricular fibrillation (VF) after removing the cross-clamp, gasometry parameters, creatinine kinase (MB isoenzyme - CK-MB) at 24 and 48 h following the surgery and troponin (highsensitivity troponin T - hsTnT) at 24 and 48 h. Results: Patients were no different in terms of comorbidities. Higher incidence of VF occurred in group 2 (3 vs. 9, 30% vs. 90%; p = 0.02). Blood sodium measurements after removing the cross-clamp were significantly higher in group 1 (median 137.0 vs. 130.0; p = 0.0004). Biomarker release trended toward lower values in group 1, but not significantly (median troponin at 24 h: 223.1 pg/ml vs. 294.8 pg/ml; p = 0.4 and 48 h: 208.0 pg/ml vs. 242.5 pg/ml; p = 0.7, median CK-MB at 24 h: 16.6 ng/ml vs. 17.3 ng/ml; p = 0.6, and 48 h: 6.7 ng/ml vs. 5.08 ng/ml; p = 0.3). Peak creatinine trended towards lower values in group 2, but not significantly (1.35 mg/dl vs. 1.05 mg/dl; p = 0.09). Conclusions: Both del Nido and Bretschneider cardioplegia provide satisfactory myocardial protection. However, del Nido cardioplegia reduces the incidence of VF after declamping the aorta. Further studies are required.

Age- and gender-related differences in the del Nido cardioprotection protocol.

BACKGROUND: The evidence regarding the impact of patient's age and gender on del Nido cardioplegia cadio-protection capability in adults is strongly limited. METHODS: A group of 75 patients undergoing aortic valve replacement (AVR) with del Nido cardioplegia was divided into Group 1 (male) and Group 2 (female). Creatine kinase (CK-MB isoenzyme) and high sensitivity troponin T (hs-TnT) values at 24 hours and 48 hours, occurrence of cardiac activity during crossclamp and ventricular fibrillation (VF) during reperfusion were compared. The impact of age on hs-TnT,CK-MB, VF during reperfusion and cardiac activity during crossclamp was investigated using regression models. RESULTS: No difference between the groups was reported in 24-hour CK-MB (median 15.57 ng/mL; IQR 12.13-22.82 ng/mL vs. 13.97; 12.09-17.147 ng/mL; P=0.168), 48-hour CK-MB (6.19; 4.22-7.71 ng/mL vs. 6.07;4.56-7.06 ng/mL; P=0.707), 24-hour hs-TnT (259.2; 172.0-376.9 pg/mL vs. 193.0; 167.8-351 pg/mL.1; P=0.339), 48-hour hs-TnT (169.1; 124.9-293.0 pg/mL vs. 159.2; 123.12-211.77 pg/mL; P=0.673), VF during reperfusion (25% vs. 18,5%; P=0.774) and cardiac activity during arrest (39.6% vs. 37.1%; p= 1.0). Values of CK-MB at 24 hours, hs-TnT at 24 hours and hs-TnT at 48 hours were not dependent on age. The CK-MB at 48 hours was dependent on age (P=0.039). Probit regression failed to reveal the impact of patients' age on postclamp VF occurrence (P=0.11) or electrical activity during arrest (P=0.57). CONCLUSIONS: Considering our study results, it can be hypothesized that the del Nido cardioplegia provides adequate myocardial protection in AVR patients regardless of age and gender.

Six-year single-centre experience in minimally invasive mitral valve repair - impact of the team learning curve on in-hospital clinical outcome.

INTRODUCTION: Minimally invasive mitral repair is less traumatic and more acceptable for the patient than traditional surgery. However, it is a challenging procedure that requires effort from all the personnel involved. AIM: To investigate the results of the minimally invasive mitral valve repair learning curve at the institution. MATERIAL AND METHODS: The indication for the surgery was severe mitral regurgitation. Patients with other valvular insufficiency, body mass index (BMI) > 30 kg/m2, ejection fraction (EF) < 45%, aortic dilatation, reoperation, pleural adhesions, coronary artery disease requiring invasive treatment, and pregnant women were disqualified. The patients were assigned to one of three groups regarding their surgery date - group 1 (2012-2013), group 2 (2014-2015) and group 3 (2016-2017). The primary endpoints were death, myocardial infarction, stroke, an reoperation for mitral dysfunction. The investigation was performed to determine preoperative parameters (EuroSCORE, age, sex, BMI, arrhythmias, EF), intraoperative parameters (procedure, cross-clamp, extracorporeal circulation), and postoperative parameters (chest revision, transfusion, drainage, ventilation time, pleurocentesis, hospitalization time). RESULTS: There were 173 patients in total. One patient from group 1 (0.6% overall) died. No myocardial infarction or stroke was observed in any of the three groups. Chest revision count (5 vs. 1 vs. 1; p = 0.0004), total drainage (797.20 vs. 517.92 vs. 449.69; p = 0.0018) and hospitalization time (7.89 vs. 7.18 vs. 6.73; p = 0.0005) were significantly different among the groups. The ventilation time, transfusion number and pleurocentesis count did not differ significantly. CONCLUSIONS: The procedure is safe and ensures optimal perioperative results. The number of complications is low and acceptable.

Left main disease management strategy: indications and revascularization methods in particular groups of subjects.

Surgical revascularization with coronary artery by-pass grafting is still recommended in vast majority of patients with unprotected left main disease. The aim of the paper was to analyze optimal treatment of left main disease in selected groups of patients, on the basis of current guidelines and information gained from literature data. We focused on data in relation to treatment of elderly patients, diabetics and those hemodynamically unstable. Additionally we discussed the issue of anti-platelet therapy and informed consent. As far as efficacy of treatment is concerned, not only method of revascularization but also general condition of the patient, the factors influencing peri-operative risk and optimal pharmacotherapy should be taken into account. Therefore establishment of the heart team is crucial when choosing the most suitable method of invasive treatment of left main disease.

Perioperative blood pressure variability in patients undergoing coronary artery bypass grafting: its magnitude and determinants.

OBJECTIVES: The study aimed to assess the magnitude and determinants of perioperative blood pressure (BP) variability in patients undergoing coronary artery bypass grafting (CABG) with the use of extracorporeal circulation (ECC). METHODS: Two hundred patients were enrolled, 41 women (21%) and 159 men (79%), aged 6 1± 8 years. A direct method of intraoperative BP measurement was used with a cannula placed in the radial artery, and BP was recorded at intervals of 5 min at three stages of the CABG: from cannula placement to the start of ECC, during ECC, and post-ECC until the transfer of patient to the postoperative room. BP variability was assessed using coefficient of variation (in percentage) for systolic, diastolic, mean, and pulse pressures. Impact of sex, age, and comorbidities was determined. RESULTS: Greater changes in BP during CABG were observed in diastolic BP (4/19%) than in systolic BP (11/15%) and the greatest BP variability was associated with pulse pressure (20/72%). The greatest variability of BP parameters was found during ECC (15/72%). Higher BP lability was found in women (13/83%), younger patients (11/78%), and those without diabetes (11/78%), hypertension (11/82%), or obesity (11/71%), and smoking habit increased the variability during CABG (11/89%). All trends were similar for all types of BP. CONCLUSION: Special attention in perioperative anesthetic management should be given not only to elder patients with many comorbid conditions, but also to younger and healthier participants because the latter are characterized by greater variations of BP during CABG.

[Delirium in cardiac surgery patients - a multi-disciplinary approach]. / Majaczenie u chorych kardiochirurgicznych - problem wielodyscyplinarny.

We describe a case of a 86 year-old male who underwent urgent cardiac surgery and developed post-operative delirium. The treatment and prevention of this condition are discussed.

Outside stenting of the vein graft decreases VEGF-A expression and induces significant down-regulation of VEGFR-1 in the intimal and medial layers after the re-endothelialization period.

BACKGROUND: Neointimal hyperplasia (NIH) in vein grafts implanted into the arterial system develops after re-endothelialization and is considered a significant risk factor of occlusion. Evidence suggests that VEGF-A expression with VEGFR-2 activation and/or VEGFR-1 down-regulation might be involved in inhibiting NIH formation. The aim was to assess whether a stented vein graft (SV) has an impact on VEGF-A and VEGFR-1 expression compared with non-stented vein grafts. MATERIAL/METHODS: Twelve sheep received a radial vein with an outside stent (SV) and a radial vein (RV) transplanted into their carotid arteries. The covering of the luminal surface of the SV and RV grafts by endothelium was 98.3% and 96.3%, respectively, at 6 weeks. From the 6th to 12th weeks after transplantation, the time course of total VEGF-A expression and VEGFR-1 expression were evaluated separately for the intima and media. RESULTS: VEGF-A and VEGFR-1 expression were significantly lower in the SV than in the RV group in the intima. In the media the SV grafts were associated with higher VEGF-A and VEGFR-1 expression at 6 and 8 weeks, but lower values were observed at weeks 10 and 12 compared with the RV grafts. Comparing the time courses of VEGF-A and VEGFR-1 expression in the intima and media with intimal/medial thickening in the SV and RV groups, negative correlations for the SV grafts were found. CONCLUSIONS: These findings indicate that outside stenting of the vein graft decreases VEGF-A expression and induces significant down-regulation of VEGFR-1 in the intima and media after the re-endothelialization.

[Application of HPLC to meropenem determination in plasma samples of patients with infections treated after coronary artery bypass graft surgery]. / Zastosowanie HPLC do oznaczania meropenemu w osoczu krwi pacjentów leczonych z powodu infekcji po przebytym zabiegu pomostowania aortalno-wiencowego.

In performed study the effectiveness of meropenem administration was estimated after therapeutic using in infections treatment after coronary artery bypass graft surgery on the base of antibiotic concentrations determined by HPLC method in the plasma samples of patients. The aim of the present study was to determine pharmacokinetic parameters of meropenem in patients' plasma samples after multiple intravenous antibiotic administration and the estimation of meropenem concentrations to MIC of bacterial pathogens. The biological material to our study was taken in 2; 4; 5 and 6 day of the antibiotic therapy. The solid phase extraction was used to the isolation of meropenem from the plasma samples. Applied chromatographic conditions of antibiotic included the column LiChrisopher 100 RP-18 (5 microm, 250 mm x 4 mm); the mobile phase comprised phosphate buffer pH 7,0/acetonitrile (92:8); DAD with detection at 296 nm. The maximal meropenem concentration in the steady state (Css(max)) in 2 day of treatment 0.25 h after administration of the next dose of antibiotic was 17.58 microg/ml. In the plasma samples which were taken in the end of the dosage regimen (8 h) in subsequent days the antibiotic was not fund. Only in one patient the minimal concentration in the steady state (Css(min)) was 0.87-0.89 microg/ml and exceeded MIC for Staphylococcus aureus, Enterobacter Escherichia coli i Serratia. The shorter frequency of drug administration has to be consider to assure the therapeutic range of antibiotic concentrations.

[Surgical correction of the Bland-White-Garland syndrome with anomalous origin of right coronary artery - a case report]. / Korekcja chirurgiczna zespolu Blanda-White'a-Garlanda z nieprawidlowym odejsciem prawej tetnicy wiencowej - opis przypadku.

The main cause of the Bland-White-Garland (BWG) syndrome is usually an anomalous origin of the left coronary artery, however, the right coronary artery can be affected as well. We report on the surgical treatment of an adult type BWG syndrome in a 59-year-old male patient. The reason for angiography was anginal pain which occurred 7 years prior to the operation. At that time patient did not agree to undergo surgery, however, symptom aggravation brought him to the hospital again. Because of the vessel anatomy the operator decided to implant a vein graft.

Epitope-targeted proteome analysis: towards a large-scale automated protein-protein-interaction mapping utilizing synthetic peptide arrays.

We describe the development of a process for the genome-wide mapping of interactions between protein domains and peptide ligands entirely based on high-throughput biochip technologies. A phage library displaying protein domains from a randomly fragmented and cloned cDNA library will be "panned" on an array of synthetic peptide ligands. After multiplexed affinity enrichment, peptide-specific phage populations will be automatically eluted, propagated, labelled and identified by hybridisation to a DNA microarray. Peptide arrays are synthesized in situ by SPOT synthesis on a planar substrate. By utilizing a commercially available library of human brain cDNA plus a set of distinct model domains cloned into T7-phage, we could show that a single panning round on an array of known peptide ligands for these model domains synthesized on a cellulose membrane can yield an enrichment of better than a factor of 1,000. This is sufficient to detect peptide-specific enrichment of Cy3(post-panning) against Cy5(pre-panning)-labelled phage DNA inserts on a cDNA microarray. Thus, the proof-of-principle of our approach could be successfully demonstrated and first interaction data are being collected.