Impact of COVID-19 on cardiac surgery outcomes.

AIM: This study aimed to assess the impact of COVID-19 infection on cardiac surgery outcomes in patients who contracted COVID-19 peri-operatively or had recently recovered from COVID-19. METHODS: The study prospectively enrolled 95 patients scheduled for cardiac surgery who had recently recovered from COVID-19. This formed the post-COVID-19 group. The other group consisted of 25 patients who contracted COVID-19 peri-operatively. Patients were followed for all-cause mortality as the primary endpoint and postoperative course complications as the secondary endpoint. Data were compared to a historical cohort of 280 non-COVID-19 patients. RESULTS: The peri-operative COVID-19 group exhibited a significantly higher prevalence of primary outcome all-cause mortality (28%), compared with 4.3% in the controls (p < 0.01), as well as the secondary composite endpoint (stroke, peri-operative myocardial infarction and pneumonia) (52 vs 13.9%, p < 0.01). The post-COVID-19 group had a higher incidence of acute pulmonary embolism (3.2 vs 0%, p < 0.01) and atrial fibrillation (23.4 vs 11.4%, p < 0.01). CONCLUSION: Patients who contracted COVID-19 peri-operatively had an increased rate of mortality and postoperative complications, while cardiac surgery in the recently recovered COVID-19 group was associated with a higher incidence of pulmonary embolism and atrial fibrillation.

Characteristics and Outcomes of Patients with Acute Coronary Syndrome and COVID-19.

Acute coronary syndrome (ACS) in patients with COVID-19 is triggered by various mechanisms and can significantly affect the patient's further treatment and prognosis. The study aimed to investigate the characteristics, major complications, and predictors of mortality in COVID-19 patients with ACS. All consecutive patients hospitalized from 5 July 2020 to 5 May 2021 for ACS with confirmed SARS-Co-2 were prospectively enrolled and tracked for mortality until 5 June 2021. Data from the electronic records for age and diagnosis, matched non-COVID-19 and COVID-19 ACS group, were extracted and compared. Overall, 83 COVID-19 ACS patients, when compared to 166 non-COVID ACS patients, had significantly more prevalent comorbidities, unfavorable clinical characteristics on admission (acute heart failure 21.7% vs. 6.6%, p < 0.01) and higher rates of major complications, 33.7% vs. 16.8%, p < 0.01, and intrahospital 30-day mortality, 6.7% vs. 26.5%, p < 0.01. The strongest predictors of mortality were aortic regurgitation, HR 9.98, 95% CI 1.88; 52.98, p < 0.01, serum creatinine levels, HR 1.03, 95% CI 1.01; 1.04, p < 0.01, and respiratory failure therapy, HR 13.05, 95% CI 3.62; 47.01, p < 0.01. Concomitant ACS and COVID-19 is linked to underlying comorbidities, adverse presenting features, and poor outcomes. Urgent strategies are needed to improve the outcomes of these patients.

Unusual non-valvular left ventricular endocarditis presenting as multiple brain embolism.

INTRODUCTION: Masses inside the heart can cause serious and life-threatening effects to the cardiovascular system, mainly because of hemodynamic obstruction of the blood flow, either in the heart cavities themselves or remotely due to embolization. In this paper, we report a case of left ventricular tumor mass which presented with neurological symptoms due to multiple brain embolism. CASE REPORT: A 35-year-old female patient presented with right hemiparesis and dysarthria. Seven days prior to admission she had elevated body temperature and started taking antibiotics. Inflammatory markers were not elevated, and blood cultures were negative. Computerized tomography (CT) and magnetic resonance imaging (MRI) of the brain revealed multiple acute ischemic lesions. Echocardiography showed the presence of a lobular mass inside the left ventricle, which was attached to the basal segment of the lateral left ventricular wall. Based on the laboratory results and additional heart imaging (CT and MRI) the mass was primarily suspected to be a tumor. It was surgically removed. Microscopic analysis of the removed tissue revealed a non-specific endocardial inflammation with formed fresh fibrin thrombi on the surface. During the postoperative recovery intense physical rehabilitation was being performed, so the initial neurological deficit was completely withdrawn. CONCLUSION: Intracardiac masses can cause serious and potentially fatal complications that often present with dramatic clinical symptoms. Despite the comprehensive clinical, laboratory, and imaging investigations, intracardiac masses can be hard to distinguish until the definite microscopic analysis. However, with the right approach and multidisciplinary collaboration, they can be successfully managed.

Asymptomatic Giant Aneurysm of the Left Anterior Descending Coronary Artery: A Case Report and Review of the Literature.

The most common cause of coronary artery aneurysms is atherosclerosis, which is associated with over 50% of all aneurysms diagnosed in adults. Although patients can be asymptomatic throughout their lives, giant coronary artery aneurysms can manifest themselves as myocardial infarction, aneurysmal rupture, and sudden cardiac death as well. Herein, we describe an asymptomatic patient with numerous risk factors and a positive cardiopulmonary exercise test who was admitted to the cardiology clinic for coronary angiography. A giant coronary artery aneurysm (3.0×2.0 cm in diameter) in the left anterior descending coronary artery and significant stenosis in both left and right coronary arteries were found. After discussing possible treatment options, the hospital's heart team recommended the surgical resection of the aneurysm and double coronary artery bypass graft. Four years after the cardiac surgery, at the time of writing the current manuscript, the patient is still in good condition and with no symptoms.

Surgical treatment of intramural hematoma of the ascending aorta.

INTRODUCTION: Intramural hematoma of the aorta presents potentially fatal condition developing as a result of a vasa vasorum rupture. It is a major risk factor for developing a frank aortic dissection. CASE OUTLINE: A 65-year-old woman was admitted to our clinic for the second time, after her symptoms of chest pain and vertigo (with no electrocardiographic signs of myocardial infarction) hadn't disappeared after several months of medicament treatment (indicated in the first hospitalization). Computed tomography arteriography of the aorta showed no sign of acute aortic dissection, but revealed a contrast depo in the aortic wall of 8 x 14 mm dimensions, with no extravasation of contrast. Also, massive pericardial effusion was observed (10-30 mm in thickness). Transesophageal echocardiography confirmed these findings completely. The patient underwent surgery, in which plaque exulceration was detected on the convex side of the ascending aorta, 3 cm above the aortic valve, 1 cm in diameter, with no signs of intimal tear. A resection of the ascending aorta was performed, and the aorta was reconstructed with a 30 mm Dacron tube graft. The patient was discharged on the 14th postoperative day with satisfactory results. CONCLUSION: Intramural hematoma is not a common event, but it is potentially a fatal one. Open surgery in patients with an intramural hematoma is an effective treatment strategy, although percutaneous endovascular treatment options are being described.

Closure of an atrial septal defect with a one-way flap patch in a patient with severe pulmonary hypertension.

An isolated atrial septal defect (ASD) can occasionally go unrecognized for decades and accounts for 25-30% of congenital heart disease cases diagnosed in adulthood. Pulmonary hypertension often develops as a result of a long-lasting, left-to-right shunt and may ultimately be associated with a fixed increase of pulmonary vascular resistance, sometimes rendering these patients inoperable. To reduce the risk of developing postoperative morbidity and possible mortality, we employed our technique of a unidirectional valved patch for the closure of ASD.

Development of cardiopulmonary bypass ­ A historical review.

The idea of isolated organ perfusion, a precursor of cardiopulmonary bypass, came by Legalois in 1812. First isolated organ perfusion was described by Loebell in 1849. The first closed system for oxygenation and returning the blood through arteries was created by Frey and Gruber in 1885. Gibbon Jr. is considered the father of extracorporeal circulation. In spring of 1934 he began constructing a machine for extracorporeal circulation in Boston. He published the first description of this system in 1937. Gibbon won the grant of the International Business Machines Corporation for developing the machine in 1947. Together they developed Model I in 1949 and Model II in 1951. After a few unsuccessful attempts in 1952, the first successful surgical intervention on the heart (closure of atrial septal defect) using cardiopulmonary bypass was performed on May 6, 1953. In 1945, Kirklin and his working group reported on a series of eight successfully treated patients in a row who underwent surgery with extracorporeal circulation. First successful valve surgery under the direct vision was performed by Dodrill in 1952, using his "Michigan Heart" machine as a right heart bypass. Using cardiopulmonary bypass, cardiac surgeons can deal with the complex cardiac pathology and save millions of lives.

Predictors for hospital readmission after cardiac surgery.

BACKGROUND AND AIM OF THE STUDY: Unplanned hospital readmissions are responsible for increased health care costs and have direct influence on patient quality of life. The aim of the study was to determine the predictors for hospital readmission after open-heart surgery. METHODS: Prospective study analyzed all patients who underwent cardiac surgery in the year 2012. Follow-up period was one year from the date of operation. Patients were divided in two groups based on their readmission status. RESULTS: In the study period of one year, 1268 patients who underwent cardiac surgery were included. A total of 121 patients (9.54%) were readmitted within one year after the operation. The main reasons for readmission were congestive heart failure (17.3%), sternal dehiscence (14.9%), rhythm and conduction disturbances (14.9%), wound infection (11.6%), recurrent angina pectoris (11.6%), and pericardial effusion (10.7%). Independent predictors for hospital readmission were previous stroke (p = 0.002), chronic heart failure (p < 0.0005), and postoperative pericardial effusion (p = 0.006). CONCLUSIONS: Our study determined risk factors and predictors for hospital readmission after cardiac surgery. This may help to reduce readmission rates.

Syncope as initial symptom of ostial lesion of the left main coronary artery with cardiogenic shock.

INTRODUCTION: Syncope represents a relatively atypical symptom of acute coronary syndrome. Syncope itself does not provide enough information to indicate an acute coronary event, especially a lesion of the left main coronary artery, without malignant rhythm and conduction disorders. CASE REPORT: A male patient, aged 63, was admitted to the intensive cardiac care unit because of a short loss of consciousness, in sinus tachycardia, with signs of acute heart failure and being hypotensive. Electrocardiogram showed a possible acute anterior myocardial infarction, followed by cardiogenic shock and emergency coronary angiography (subocclusive ostial lesion of the left main coronary artery) and primary percutaneous coronary intervention with intra-aortic balloon pump therapy was performed. A direct drug eluting stent was implanted with the optimal primary result. CONCLUSION: The prompt diagnosis, especially in such relatively atypical clinical presentation, reperfusion therapy with primary percutaneous coronary intervention in acute myocardial infarction complicated by cardiogenic shock, contribute to the improvement in the survival rate and patient's quality of life. This case report is clinically educative due to relatively atypical presentation and performed interventions.

Necessity for introducing the procedure of percutaneous aortic valve implantation in the province of Vojvodina.

INTRODUCTION: Percutaneous aortic valve implantation is an alternative that offers hope to patients who are too old or sick to undergo the conventional surgical aortic valve replacement. The aim of this study was to determine the number of high-risk patients with severe aortic stenosis, hospitalized at the Institute for Cardiovascular Diseases, who are the candidates for percutaneous aortic valve implantation. MATERIAL AND METHODS: The paper prospectively analyzed all patients diagnosed to have severe aortic stenosis who had been hospitalized at the Institute for Cardiovascular Diseases from April 1st, 2011 to October 31st, 2012. Each of these patients was analyzed in relation to the inclusive criteria for percutaneous aortic valve implantation. We analyzed the distribution of these risk factors in relation to age and gender, and the presence of aortic valve replacement surgery by age groups. RESULTS: In the period from April 1st, 2011 to October 31st, 2012, 374 patients diagnosed to have severe aortic stenosis were hospitalized at the Institute for Cardiovascular Diseases. The group of patients older than 80 years had a higher percentage of those patients with low ejection fraction of the heart, chronic pulmonary hypertension and mitral regurgitation. On the other hand, when the total number of surgical aortic valve replacement was taken into consideration with respect to age, there was a significant decrease in their number in the group of patients older than 75 years (41.6%), especially in the age group over 80 years (90.2%). CONCLUSION: The data obtained in this study indicate a high percentage of conservatively treated patients with severe aortic stenosis and high operative risk in patients over 75 years. These data confirm the necessity for the implementation of percutaneous aortic valve replacement in the Province of Vojvodina.

CABG mortality is not influenced by prior PCI in low risk patients.

BACKGROUND AND AIMS: An increasing number of patients referred for coronary artery bypass grafting (CABG) have had prior percutaneous coronary intervention (PCI). We sought to determine whether a relationship exists between increased postoperative mortality and morbidity following CABG procedure in patients with prior PCI. METHODS: Over an 18-month period, 950 patients having first-time isolated CABG were divided into two groups based on absence (Group A, 819 patients--86.21%) or presence of a prior PCI (Group B, 131 patients--13.79%). RESULTS: In the prior PCI population, 74 patients (56.4%) had only one stent, and only 6.8% had multiple admissions for PCI. The overall incidence of three vessel disease in the entire patient population was only 65% and the average ejection fraction was 52%. Multivariate analysis demonstrated age (OR 1.080; 95% CI: 1.020 to 1.145; p = 0.009), left ventricular ejection fraction (OR 0.939; 95% CI: 0.901 to 0.978; p = 0.002), and emergency surgery (OR 0.138; 95% CI: 0.0.045 to 0.424; p = 0.001) as risk factors for 30-day mortality, while age (OR 1.059; 95% CI: 1.016 to 1.104; p = 0.007) and emergency surgery (OR 0.205; 95% CI: 0.078 to 0.537; p = 0.001) predicted major adverse cardiac events (MACE). Prior PCI did not influence mortality or MACE at 30 days. CONCLUSION: In this study involving low risk patients, a PCI prior to CABG did not increase morbidity or mortality.

An unusual origin of proximal coronary bypass anastomosis in a patient with porcelain aorta: how we solved the problem.

Severe calcification of the ascending aorta (porcelain aorta) is a very difficult condition in cardiac surgery because of a high embolization potential during the process of cannulation, aortic cross-clamping and a particular difficulty to suture the proximal anastomosis. We described a case of a 68-year-old female referred to our Institute due to unstable angina. Further diagnostics revealed a severe high grade, multilevel fibrolipid symptomatic carotid stenosis and ostial left main coronary artery stenosis and a highly calcified ascending aorta and aortic arch. We performed simultaneous carotid segment replacement with the Dacron prosthesis and revascularisation of the left anterior descending coronary artery. Proximal venous anastomosis was created in the Dacron prosthesis of the right carotid artery. Perfusion of the patient was achieved via the graft sutured at the right subclavian artery due to impossibility of direct aortic cannulation.

Patency of internal thoracic artery and vein grafts according to revascularized coronary artery properties.

Long-term results of surgical myocardial revascularization are determined by the quality of grafts and the progression of atherosclerosis in coronary arteries. The aim of the study was to evaluate the patency rate of internal thoracic artery and great saphenous vein grafts in relation to the hemodynamic properties of revascularized coronary artery. The patency of internal thoracic artery and great saphenous vein grafts was analyzed in relation to the degree of coronary stenosis estimated by angiography and the diameter of distal portion of coronary artery assessed intra-operatively. The long-term patency of great saphenous grafts depends on the distal coronary artery diameter but not on the degree of coronary artery stenosis. The patency of internal thoracic artery graft depends on the degree of coronary artery stenosis but not on the distal coronary artery diameter. The internal thoracic artery is the superior graft in coronary surgery, but the low patency rate in case of moderate coronary artery stenosis emphasizes the importance of selective approach.