[Prospects of cardioprotection by volatile anesthetics].

Myocardial ischaemia is followed by some reversibile or ireversibile changes. The aim of cardioplegia is to protect numerous intracellular processes: to spare the intracellular energy stores, to reduce the free oxygen radicals synthesis, to protect the function of the endothelium and myocardial oxygen balance as well as ionic balance. The crystalloid or blood cardioplegia, with anterograde or retrograde infusion, is a basic procedure of the intraoperative cardiac protection. Glucose-insulin-potassium solution was primarily used in a myocardial infarction. After the first promising results, some surgical teams started to use the high glucose-insulin-potassium solution, as a metabolic modulation approach, during a coronary surgery as addition to cardioplegia. During ischaemia, a number of intracellular mechanisms deteriorate with bioenergy misbalance and decrease of cellular functional reserve. In particular, the regulation of contractility in response to loading, alteration in autocrine or paracrine regulation in metabolically stressed hearts and acquired, "learned" tolerance of muscle to deteriorate perfusion (preconditioning) are examples of a variety of the cardiac adaptation. The further improvement in the metabolic modulation during a coronary surgery was made with fluorine ion halogenated volatile aneasthetics used for anaesthesia. The results of some experimental and first clinical studies induced a new approach to the modulation of the intracellular metabolic mechanisms and announced a new concept of anaesthetic preconditioning in coronary surgery. Large, randomized studies are needed to evaluate anaesthetic preconditioning and dependence of its efficiency on type and dose of volatile anaesthetics as well as the role of gene regulation in cardioprotection.

[Reconstructive surgery of idiopathic hypertrophic subaortic stenosis with dynamic obstruction of the left ventricular outflow tract causing severe mitral insufficiency]. / Rekonstrukciona hirurgija idiopatske hipertroficne subaortne stenoze sa dinamskom opstrukcijom izlaznog trakta leve komore i posledicnom teskom mitralnom insuficijenciom.

Hypertrophic obstructive cardiomyopathy (HOCM) is an idiopathic disease frequently associated with systolic anterior motion (SAM). The anterior leaflet of mitral valve is sucked by Ventury effect into the left ventricle outflow tract making subaortic stenosis more severe and producing mitral insufficiency at the same time. Septal myectomy along with mitral valve replacement has been the treatment of choice for a long time. An understanding of pathoanatomy and hemodynamics of the disease has opened possibility for total reconstructive treatment of both subaortic stenosis and mitral insufficiency in such patients. This is a case report of 50-year-old male with severe subaortic stenosis (136/70 mmHg) due to HOCM and SAM along with grade IV mitral insufficiency. Septal myectomy was performed. Mitral insufficiency was managed by reducing the height of posterior cusp along with remodeling of mitral annulus by Carpentier-Classic ring. In that way, subaortic obstruction was reduced to 30.9/10 mmHg while mitral insufficiency was lowered to negligible level. The patient was discharged from hospital with sinus rhythm eight days after the surgery.

The use of acute normovolemic hemodilution in patients undergoing cardiac surgery.

Avoiding allogeneic blood transfusion during cardiac surgery and during the post-operative period is of great importance. Acute normovolemic hemodilution (ANH) is one of the options for blood salvage. We have prospectively analyzed 310 consecutive patients (pts) after different open heart procedures, operated on during April-May, 2000. ANH was possible in 226 pts (73%) with hemoglobin level over 125 g/l and hematocrit over 36%. Of those, one unit of blood was withdrawn in 128 pts (70%), while two to five units of blood were taken in 68 pts (30%). Total number of autologous blood units taken was 296, for the average of 1.31 units/pt. Predictors of increased intra- and post-operative blood loss were hematocrit (Hct) <39% (76% vs. 24%, p<0.001), age over 65 (p=0.028), female sex (p=0.006), CPB duration over 90 min (63% vs. 37%; p<0.001) and preoperative left ventricular ejection fraction (LVEF) <35% (63% vs. 37%; p<0.001). All pts with the above-mentioned characteristics were in need for allogeneic blood transfusion. During their hospital stay, 142 pts did not get allogeneic blood (142/310, 46%), and all were in the ANH group (142/226, 62%).