Surgical treatment of aortic dissection in a patient with metastatic prostate cancer.

Acute aortic dissection bears all the stigmata of a true clinical emergency. The natural history of this acute aortic syndrome warrants prompt surgical intervention, with only a few absolute contraindications to this line of treatment. We present a 74-year-old man with documented metastatic prostate cancer who underwent emergent surgery for acute Stanford A aortic dissection. Having acknowledged the relatively favorable evolution of our patient's malignant disease, we were not deterred by its presence from pursuing surgical treatment of his aortic dissection.

Off-pump coronary bypass surgery adversely affects alveolar gas exchange.

While the introduction of off-pump myocardial revascularization (OPCAB) has initially shown promise in reducing respiratory complications inherent to conventional coronary surgery, it has failed to eradicate them. Our study focused on quantifying the lactate release from the lungs and the dysfunction at the level of the alveolar-capillary membrane precipitated by OPCAB at different time points after the insult. Furthermore, we aimed to determine the impact of pulmonary lactate production on systemic lactic acid concentrations. The study was conducted in a prospective observational fashion. Forty consecutive patients undergoing OPCAB were analyzed. The mean patient age was 60 +/- 10 years. The mean EUROScore was 3.8 +/- 2.9. The alveolar-arterial O2 gradient increased from 19 [range 9 to 30] to 26 [range 20 to 34] kPa (P < 0.001) and remained elevated up to 6 hours after surgery. It rapidly declined again by 18 hours postoperatively. The observed increase in the pulmonary lactate release (PLR) from a baseline value of 0.022 [range -0.074 to 0.066] to 0.089 [range 0.016 to 0.209] mmol/min/m2 at six hours postoperatively did not reach statistical significance (P = 0.105). The systemic arterial lactate (Ls) concentration increased from 0.94 [range 0.78 to 1.06] to 1.39 [range 0.97 to 2.81] mmol/L (P < 0.001). The venoarterial pCO2 difference showed no significant change in comparison to baseline values. The mortality in the studied group was 2.5% (1/40). The pulmonary lactate production showed a statistically significant correlation with the systemic lactate concentration (R = 0.46; P = 0.003). Pulmonary injury following off pump myocardial revascularization was evidenced by a prompt increase in the alveolar-arterial oxygen gradient. The alveolar-arterial O2 gradient correlated with the duration of mechanical ventilation.

Pulmonary lactate release following cardiopulmonary bypass.

OBJECTIVE: The etiology of lung injury following cardiopulmonary bypass (CPB) is multifactorial. Our study focused on quantifying the lactate release from the lungs precipitated by extracorporeal circulation at different time points after the insult. This was complemented by an evaluation of the gas exchange at the level of the alveolar-capillary membrane. METHODS: Forty consecutive patients (age 61+/-11 years, EuroScore 4.7+/-2.7) undergoing CABG were prospectively analyzed. The data are presented as medians and the interquartile range. RESULTS: The pulmonary lactate release (PLR) increased from a baseline value of 0.033 (range -0.077 to 0.170) to 0.465 mmol/min/m2 (range 0.113-0.922), which was seen 6h postoperatively (P<0.001). The A-a O2 gradient increased from 12.7 (range 8.8-15) to 39.1 kPa (range 30.3-46.5) upon discontinuation of CPB (P<0.001). The systemic arterial lactate (LS) concentration increased from 1.22 (range 1-1.44) to 3.03 mmol/l (range 2.29-4.76) 6h after surgery (P<0.001). The veno-arterial pCO2 difference (V-A dpCO2) rose from 0.6 (range 0.5-0.9) to 0.9 kPa (range 0.7-1) (P=0.014). The mortality in the studied group was 5% (2/40). CONCLUSIONS: The lungs were found to be a significant source of lactate, and this pulmonary lactate flux was accentuated by CPB. The PLR correlated with systemic hyperlactatemia as well as the A-a O2 gradient, and was found to be higher in patients requiring prolonged mechanical ventilatory support. The duration of CPB had a significant impact on the systemic lactate concentrations, V-A dpCO2 and the A-a O2 gradient, but not on the PLR.

Aortic valve replacement in a patient with severe hemophilia.

Hemophilia A is an inherited bleeding disorder characterized by factor VIII deficiency. The basis for insufficient hemostasis lies within inadequate amplification of factor Xa production with the undersupplied factor VIII. We report on a young patient with critical aortic stenosis bearing all the clinical stigmata of severe hemophilia, in whom aortic valve replacement was performed with a tissue valve in order to avoid the need for long term anticoagulation.

Eighteen years of heart transplantation--a single center experience.

The best option for the treatment of a failing heart is heart transplantation. The transplantation program at the University Hospital Center Rebro Zagreb started in 1988. To the best of our knowledge this is the first retrospective study on cardiac transplantation in Croatia looking into survival following heart transplantation. Between 1988 and 2006, we performed 81 heart transplantations at the University Hospital Center Rebro Zagreb. Our study focused on the last ten years after establishment of the Department of cardiac surgery as a separate institution. There were thirteen different hospitals throughout Croatia, which contributed to the donor network. Average age of the heart recipient was 48+/-11.8 years (range 14-72), and average age of the heart donor was 34+/-10.7 years (range 14-56). There were more women among the heart donors (34%) then among the heart recipients (18%). During the first ten years, from 1988-1998, the average number of cardiac transplantations was 3 per year In the period from 1998-2006, average number of cardiac transplantations increased to 6 per year. The average thirty-day mortality for the last nine years was 27%. It declined from 30% and 40% in 1998 and 1999, respectively down to 0% in the last two years. Average age of the patients who died was 50+/-6.5years (range 44-62) and did not significantly differ from those who survived. The donor network has grown up to fourteen different hospitals throughout Croatia. The limiting factor in cardiac transplant surgery is the number of available donors. Therefore in attempt to form a good transplant program it is crucial to form an efficient donor network. The number of performed cardiac transplantations is expected to rise until it reaches the number of available donors. With advances in operative technique and postoperative management--immunosuppressive therapy we have observed a remarkable drop in the early operative mortality in the studied period.

Intracardiac shrapnel in a polytraumatized child.

Penetrating cardiac trauma is a life-threatening condition and presents a therapeutic challenge for the surgeon. Additional multiple organ-system injuries, as are common in the setting of war, further complicate the management of such patients. We present the case of a 9-year-old girl who sustained multiple injuries from an unexploded artillery shell, resulting in a retained intracardiac shrapnel. Her cardiac pathology consisted of a shrapnel located in the interventricular septum accompanied by a pneumopericardium and a right-sided hemopneumothorax. The presentation and management of this patient are the subjects of this report.

Surgical excision of a hemangioendothelioma of the left ventricle.

Primary intracardiac neoplasms are most commonly histologically benign with only 30% exhibiting signs of malignancy. Metastatic tumors of the heart are 30 times more common than primary cardiac tumors. Patients with intracardiac masses may present with dyspnea on exertion, thromboembolic events, pericarditis, arrhythmias, or congestive heart failure. In many, however, the diagnosis is made upon discovering a murmur in an otherwise asymptomatic patient. Hemangioendotheliomas are very rare tumors of the heart characterized by capillary-sized vessels lined by rounded and often multilayered endothelial cells. Cardiac muscle cells are found compressed between proliferating vascular channels. We present a patient with this unusual cardiac tumor with no previous cardiac history and a new systolic murmur.

[Endocarditis associated with atrial and ventricular cardiac pacing leads. Case report]. / Endokarditis na atrijskoj i ventrikulskoj elektrodi trajnog elektrostimulatora srca. Prikaz bolesnika.

The infection of a transvenous lead implanted for cardiac stimulation is a rare, but serious complication. We report observation of a 25-year old man whose Staphylococcus epidermidis sepsis linked to endocarditis was related to atrial and ventricular pacing leads, and was diagnosed after two months of medical treatment. The most important role during the diagnostic process was played by the echocardiographic examination, especially transoesophageal, which revealed the large vegetations on atrial as well as ventricular pacing lead. The diagnosed condition was treated by complete removal of pacing system using open chest surgery and cardiopulmonary pump. After four weeks of vigorous antibiotic treatment, a new DDDR pacing system was implanted, but with epicardial leads.

NT-pro-BNP, but not C-reactive protein, is predictive of atrial fibrillation in patients undergoing coronary artery bypass surgery.

OBJECTIVE: Atrial fibrillation (AF) remains the most commonly observed complication following myocardial revascularisation surgery. We aimed to evaluate the clinical utility of N-terminal fragment of the brain natriuretic peptide (NT-pro-BNP), troponin T, transcoronary lactate gradient (TCLG) and C-reactive protein (CRP) as predictors of AF in patients undergoing isolated coronary artery bypass surgery (CABG). METHODS: This study included 215 consecutive patients in sinus rhythm (SR) undergoing elective CABG between May 2007 and May 2008. The patients were grouped according to their respective postoperative rhythm into SR and AF groups. The data are presented as mean values+/-standard deviation, or medians with quartiles. RESULTS: Fifty-five patients developed AF (26%). The preoperative NT-pro-BNP values were 273+/-347 and 469+/-629 pg ml(-1) in the SR and AF groups, respectively (p<0.0001). The postoperative NT-pro-BNP values were 3110+/-3600 pg ml(-1) in the SR and 4625+/-5640 pg ml(-1) in the AF groups (p=0.027). The transcoronary lactate gradient rose from the pre-cardiopulmonary bypass values to those observed 5 min after revascularisation in both groups (-0.05+/-0.37 to 0.39+/-0.46 mmol l(-1) (p<0.0001) in the SR group and -0.01+/-0.27 to 0.43+/-0.46 mmol l(-1) (p<0.0001) in the AF group). The CRP values increased from 6+/-13 to 163+/-88 mg l(-1) (p<0.0001) in the SR group, and from 6+/-16 to 163+/-104 mg l(-1) (p<0.0001) in the AF group. The dynamics of TCLG and CRP did not differ between the groups (p=0.71, p=0.44, respectively). The troponin T values on postoperative day 1 were significantly higher in the AF than the SR group (0.86 (0.49-2.1) ng ml(-1) vs 0.67 (0.37-1.16) ng ml(-1), p=0.046). The duration of cardiopulmonary bypass (CPB) was 85+/-24 min in the SR and 93+/-30 min in the AF group (p=0.05). Patients who developed AF were older (66+/-7 years vs 60+/-9 years, p<0.0001) and had a higher EuroSCORE (3.9+/-2.7 vs 2.9+/-2.2, p=0.009). Multivariate analysis identified age (p=0.0043), preoperative NT-pro-BNP (p=0.019) and duration of CPB (p=0.035) as independent predictors of AF. CONCLUSIONS: Preoperative and postoperative NT-pro-BNP as well as TnT values were significantly higher in patients who subsequently developed AF. TCLG and CRP were not useful in identifying patients at higher risk for AF. Multivariate analysis identified age, preoperative NT-pro-BNP and duration of CPB as independent correlates of AF.

Primary malignant fibrous histiocytoma of the heart with skeletal muscles metastases.

Malignant fibrous histiocytoma is an extremely rare primary malignant tumor of the heart. It is usually diagnosed when it is locally aggressive or has already metastasized. The prognosis is poor with an average survival time of one year. We report a case of recurrent left atrial malignant fibrous histiocytoma initially misdiagnosed as myxoma. The patient underwent repeated surgical resections followed by chemotherapy. Despite adjuvant chemotherapy, 18 months after initial diagnosis, definitive tumor relapse in left atrium was diagnosed. This is the 48th case of primary cardiac fibrous malignant histiocytoma reported in the literature.