Cardiac Surgery in Patients with Parkinson's Disease: A Retrospective Analysis of a High-Risk Cohort.

BACKGROUND: Little is known about the perioperative course of patients with Parkinson's disease (PD) undergoing cardiac surgery. The objective of this study was to identify the influence of PD on the perioperative course and to improve treatment. METHODS: Perioperative data were analyzed retrospectively from 130 patients undergoing cardiac surgery between September 2001 and April 2013 who had PD and were compared using 1:1 matched-pair analysis with 130 controls not affected by PD. RESULTS: The 30-day all-cause mortality (4.6 vs. 9.2%; p = 0.21; odds ratio [OR] = 0.45; 95% confidence interval [CI]: 0.16, 1.31) and the overall all-cause mortality (27.7 vs. 28.5%; hazard ratio [HR] = 0.96 [0.56, 1.66]; p = 1.00) were not significantly different between PD patients and the control group. Emergency surgery (p = 0.04; OR = 3.20; 95% CI: 1.06, 9.66) and postoperative pneumonia (p < 0.001; OR = 11.3; 95% CI: 3.06, 41.6) were associated with 30-day mortality. Independent predictors of all-cause mortality were age at surgery (p = 0.01; OR = 3.58; 95% CI: 1.38, 9.30), NYHA (New York Heart Association) classification stage IV (p = 0.02; OR = 17.3; 95% CI: 1.52, 198), and postoperative pneumonia (p = 0.05; OR = 46.4; 95% CI: 0.97, 2219). We did not observe an association of PD with short- or long-term all-cause mortality after adjustment for associated covariates. CONCLUSIONS: We found that PD is not a significant risk factor for perioperative morbidity and mortality in our cohort. Our study showed that patients with PD had outcomes that were similar to those of non-PD patients.

Minimally invasive isolated tricuspid valve surgery.

BACKGROUND AND AIM OF THE STUDY: Outcomes after minimally invasive isolated tricuspid valve (TV) surgery have not been well described. Hence, an assessment was made of the authors' results for minimally invasive, isolated TV surgery. METHODS: Between September 2000 and January 2008, at the authors' institution, a total of 35 patients (15 males, 20 females; mean age 59.2 +/- 14.9 years) underwent isolated TV surgery for TV regurgitation, using a right lateral mini-thoracotomy. The preoperative left ventricular ejection fraction was 57 +/- 11%. The TV pathology included annular dilatation (n = 22), recurrent regurgitation after previous repair (n = 4), ruptured chordae (n = 4), endocarditis (n = 2), intracardiac tumor (n = 2), and blunt chest trauma (n = 1). Twenty patients had previously undergone a total of 30 cardiac operations, eight of which involved the TV. RESULTS: A TV repair was performed in 27 patients (77%), and involved the implantation of an annuloplasty ring in all cases. A leaflet repair was performed in addition to an annuloplasty in two patients, and eight patients underwent TV replacement. The hospital mortality was 5.7%, with two deaths due to low cardiac output syndrome on days 1 and 9 after surgery. The latter patient underwent reoperation on day 7 for recurrent TV regurgitation and a ventricular septal defect. Early and mid-term echocardiographic follow up revealed no TV regurgitation in 19 patients, but trivial and mild regurgitation each in eight patients. The mean follow up time was 35 +/- 40 months, and was 100% complete. A Kaplan-Meier analysis revealed an estimated five-year survival of 90% (95% CI: 73-97). CONCLUSION: Isolated TV surgery can be performed through a minimally invasive approach, with good results. A high repair rate can be achieved, and the procedure has been particularly valuable in redo surgery.

Rapid detection of the R389G polymorphism of ADRB1 by real time PCR using fluorescence resonance energy transfer.

The beta1-adrenoceptor plays a crucial role in the regulation of myocardial contractility and heart rate. A functionally important polymorphism at codon 389 has been associated with heart failure and hypertension. The conventional method of detecting this polymorphism is a PCR-assay followed by digestion with specific restriction enzyme (PCR-RFLP) polymorphism. We aimed to establish an alternative, fast genotyping method by real time PCR, which combines high speed DNA-amplification and real time fluorescence monitoring using fluorescence resonance energy transfer. Venous blood of 50 healthy volunteers was examined for the Arg389Gly polymorphism using both methods. The results from PCR-RFLP were compared to those obtained with real time fluorescence PCR and showed a 100% correlation. DNA sequencing confirmed a 100% concordance. This alternative technique is significantly less time consuming than traditional PCR-RFLP and facilitates the analysis of a large numbers of samples.

Effects of ß-Adrenoceptor and Catechol-O-Methyl-Transferase (COMT) Polymorphism on Postoperative Outcome in Cardiac Surgery Patients.

BACKGROUND There is a long-standing debate about the role of beta-adrenoceptor polymorphisms in the cardiovascular system. We wanted to elucidate whether ß1-adrenoceptor-polymorphisms affects the postoperative catecholamine consumption and the length of intermediate care unit stay in patients undergoing cardiac surgery, and whether this might be enhanced or attenuated by catechol-O-methyl-transferase (COMT) polymorphism. MATERIAL AND METHODS We included 116 patients (63±1.2 years; 34% females; 81±1 kg) undergoing cardiac surgery. We assessed Arg389Gly and Ser49Gly-ß1-adrenoceptor (B1AR) polymorphism together with Val158Met-COMT polymorphism by real-time PCR using fluorescence resonance energy transfer (PCR-FRET). The preoperative risk was assessed by EuroSCORE. In addition, we measured the endogenous preoperative epinephrine and norepinephrine plasma concentrations using an electrochemical HPLC method. RESULTS 84.6% were homozygous for Ser49Ser, 52.1% homozygous for Arg389Arg B1AR, and 32.5% for Val158Val-COMT, while 15.4% showed Ser49Gly B1AR, 38.5% Arg389Gly-B1AR, and 35.6% Val158Met-COMT. We found that the Gly49-variant, the Gly389-variant, and the Val158-COMT-variant were associated with higher postoperative norepinephrine consumption. All patients carrying the Val158-COMT allele exhibited higher preoperative norepinephrine concentrations. Moreover, we found that both ß1-adrenoceptor polymorphisms were associated with a longer stay in hospital, which was modulated by the COMT polymorphism. CONCLUSIONS These data show that the ß1-adrenoceptor polymorphisms, together with the COMT polymorphism, affect norepinephrine consumption and stay in hospital in a situation of enhanced cardiovascular stress, reflected here by the postoperative period after cardiac surgery. Moreover, we conclude that patients with the Val158-COMT genotype exhibit higher endogenous resting plasma norepinephrine levels.

Fistula Formation 6 Years after Removal of Infected Pacemaker Leads.

We describe a case of a male patient who presented with a chronic ulcer below the left clavicle. Six years before the present admission a permanent pacemaker, including leads, was explanted related to endocarditis. The initial working hypothesis suspected an infected sebaceous gland as the cause of ulceration. After two periods of unsuccessful surgical treatment of the gland, further examination identified a small pacemaker lead fragment underneath the articulation between sternum and clavicle as a possible reason.

Coronary Artery Fistula: Two Rare Cases.

Coronary artery fistula (CAF) is an incidental finding in up to 0.2% of cardiac catheterization studies and is a rare pathologic condition affecting up to 1% of the general population. We report two cases of CAF diagnosed by coronary angiography and managed by surgical ligation, with excellent postoperative outcome. Anatomic location, clinical presentation, investigation, and treatment of CAF are discussed.

Rescue surgery 19 years after composite root and hemiarch replacement.

A 59-year-old male patient with Marfan's syndrome was referred to our clinic due to acute chest pain. His medical history contains complex surgery for type A aortic dissection 19 years ago including composite root replacement using a mechanical aortic valve. Immediate computed tomography indicated perforation at the distal ascending aortic anastomosis plus complete avulsion of both coronary ostia. The patient underwent successful rescue surgery with ascending aortic and arch replacement using a modified Cabrol technique.

Successful surgical treatment of atrial fibrillation, mitral regurgitation, and aortic root aneurysm in a patient with classical type Ehlers-Danlos syndrome.

Herein, we present an unusual case of a 48-year-old patient with Ehlers-Danlos syndrome (classic type) with multiple cardiovascular pathologies, including mitral regurgitation, a dilated aortic root, and chronic atrial fibrillation. A complex mitral valve repair, modified cryo-Maze procedure, and aortic valve-sparing operation (reimplantation) were performed, which were further complicated by the patient's fragile tissues. The patient was discharged on postoperative day 10 in good health with normal mitral and aortic valve function. We believe that this is the first report of such an extensive cardiac procedure in a patient with Ehlers-Danlos syndrome.