Rising incidence, progression and changing patterns of liver disease in Wales 1999-2019.

BACKGROUND: Liver disease incidence and hence demand on hepatology services is increasing. AIM: To describe trends in incidence and natural history of liver diseases in Wales to inform effective provision of hepatology services. METHODS: The registry is populated by International Classification of Diseases-10 (ICD-10) code diagnoses for residents derived from mortality data and inpatient/day case activity between 1999-2019. Pseudo-anonymised linkage of: (1) Causative diagnoses; (2) Cirrhosis; (3) Portal hypertension; (4) Decompensation; and (5) Liver cancer diagnoses enabled tracking liver disease progression. RESULTS: The population of Wales in 2019 was 3.1 million. Between 1999 and 2019 73054 individuals were diagnosed with a hepatic disorder, including 18633 diagnosed with cirrhosis, 10965 with liver decompensation and 2316 with hepatocellular carcinoma (HCC). Over 21 years the incidence of liver diseases increased 3.6 fold, predominantly driven by a 10 fold increase in non-alcoholic fatty liver disease (NAFLD); the leading cause of liver disease from 2014. The incidence of cirrhosis, decompensation, HCC, and all-cause mortality tripled. Liver-related mortality doubled. Alcohol-related liver disease (ArLD), autoimmune liver disease and congestive hepatopathy were associated with the highest rates of decompensation and all-cause mortality. CONCLUSION: A 10 fold increase in NAFLD incidence is driving a 3.6 fold increase in liver disease in Wales over 21 years. Liver-related morbidity and mortality rose more slowly reflecting the lower progression rate in NAFLD. Incidence of ArLD remained stable but was associated with the highest rates of liver-related and all-cause mortality.

To grade or not to grade safety requirements for transvenous lead extraction: Experience with 2216 procedures.

BACKGROUND: Transvenous lead extraction (TLE) procedures are now increasingly safe, but there is still a risk of major complications (MC). AIMS: We aimed to assess the impact of TLE organization on the safety of procedures. METHODS: We analyzed 2216 TLE procedures performed in two centers in the years 2006-2021 and compared three organizational procedural models: (1) TLE in an electrophysiology laboratory (EP-LAB) with intravenous analgesia/sedation; (2) TLE with grading of safety requirements (high-risk patients in the cardiac surgery operating theatre, others in EP-LAB); (3) TLE in the hybrid room in all patients under general anesthesia with transesophageal echocardiographic (TEE) monitoring. The safety of procedures and mortality after TLE in three-year follow-up were assessed. RESULTS: The rate of MC in the EP-LAB group was 1.55%, and the rate of procedure-related deaths (PRD) was 0.33%. While using the graded approach to safety requirements, the percentage of MC was 2.61% and PRD 0.29%. When performing TLE procedures in the hybrid room, the MC percentage was 1.33% and PRD 0.00%. Long-term survival after TLE was comparable in all study groups. CONCLUSIONS: A key factor in preventing TLE-related deaths is procedure organization that enables emergency cardiac surgery. TLE performed in a hybrid room with a collaborating cardiac surgeon and vital signs monitoring appears to be the safest possible option for the patient. A graded safety approach is associated with the risk of unexpected MC and PRD. Any newly established TLE center can achieve satisfactory results if the optimal organizational model of the procedure is used.

Assessment of the impact of organisational model of transvenous lead extraction on the effectiveness and safety of procedure: an observational study.

OBJECTIVES: To estimate the impact of the organisational model of transvenous lead extraction (TLE) on effectiveness and safety of procedures. DESIGN: Post hoc analysis of patient data entered prospectively into a computer database. SETTING: Data of all patients undergoing TLE in three centres in Poland between 2006 and 2021 were analysed. PARTICIPANTS: 3462 patients including: 985 patients undergoing TLE in a hybrid room (HR), with cardiac surgeon (CS) as co-operator, under general anaesthesia (GA), with arterial line (AL) and with transoesophageal echocardiography (TEE) monitoring (group 1), 68 patients-TLE in HR with CS, under GA, without TEE (group 2), 406 patients-TLE in operating theatre (OT) using 'arm-C' X-ray machine with CS under GA and with TEE (group 3), 154 patients-TLE in OT with CS under GA, without TEE (group 4), 113 patients-TLE in OT with anaesthesia team, using the 'arm-C' X-ray machine, without CS (group 5), 122 patients-TLE in electrophysiology lab (EPL), with CS under intravenous analgesia without TEE and AL (group 6), 1614 patients-TLE in EPL, without CS, under intravenous analgesia without TEE and AL (group 7). KEY OUTCOME MEASURE: Effectiveness and safety of TLE depending on organisational model. RESULTS: The rate of major complications (MC) was higher in OT/HR than in EPL (2.66% vs 1.38%), but all MCs were treated successfully and there was no MC-related death. The use of TEE during TLE increased probability of complete procedural succemss achieving about 1.5 times (OR=1.482; p<0.034) and were connected with reduction of minor complications occurrence (OR=0.751; p=0.046). CONCLUSIONS: The most important condition to avoid death due to MC is close co-operation with cardiac surgery team, which permits for urgent rescue cardiac surgery. Continuous TEE monitoring plays predominant role in immediate decision on rescue sternotomy and improves the effectiveness of procedure.

Outcomes of Transvenous Extraction of Leads Older Than 20 and 30 Years-A Large Cohort Study.

BACKGROUND: There is limited knowledge on outcome of transvenous lead extraction (TLE) of leads being 20 and 30 years old. METHODS: Retrospective single center large database analysis containing 3673 TLE procedures performed from 2006 to 2020 was analysed. We aimed to compare procedure complexity and the incidence of the TLE major complications (MC) in groups where extracted leads were under 10 years, 10-20 years, 20-30 years (old) and over 30 years (very old). RESULTS: Rate of removal of old and very old leads almost doubles with successive five-year periods (3-6-10%). In patients with old and very old leads there is an accumulation of risk factors for major complications of TLE (young age, female, multiple and/or abandoned leads, multiple previous procedures). The removal of old and very old leads was more labour-consuming, more difficult, and much more often required second-line (advanced) tools and complex techniques. Incidence of all MC grew parallel to age of removed leads from 0.6 to 18.2%; haemopericardium-from 0.3 to 12.1%, severe tricuspid valve damage-from 0.2 to 2.1%, need for rescue cardiac surgery-from 0.4 to 9.1%. Notably, there was no procedure-related death when old or very old lead was extracted. The percentages of clinical and procedural success decreased with increasing age of the removed leads from 99.2 and 97.8% to 90.9 and 81.8%. The risk of MC during extraction of leads aged 10-20 years increases 6.7 times, aged 20-30 years-14.3 times (amounting to 8.4%), and aged 30 and more years-20.4 times, amounting to 18.2%. Removal of ventricular leads is associated with a greater complexity of the procedure but not with more frequent MC. Removal of the atrial leads is associated with a higher incidence of MC, especially haemopericardium, regardless of the age of the leads, although the tendency becomes less pronounced with the oldest leads. CONCLUSIONS: 1. Extraction of old and very old leads is a rising challenge, since the rate of removal of leads aged 20-and-more years almost doubles with successive five-year periods. 2. Procedure difficulty, complexity and the risk of major complications increases along with the age of extracted lead. TLE is more time-consuming, difficult and much more often requires advanced tools and complex techniques. 3. TLE of old (≥20 years) or very old (≥30 years) leads can be performed with satisfactory success rate and safety profile when conducted at high-volume centre by an experienced operator under optimal safety conditions.

The role of cardiac surgery in transvenous lead extraction. A high-volume center experience with 3207 procedures.

Introduction: The guidelines stress the importance of cardiac surgery in the management of life-threatening complications arising from lead removal. Aim: To delineate the roles of the cardiac surgeon during transvenous lead extraction (TLE). Material and methods: 3207 patients (38.7% F), average age 65.7 years, underwent the extraction of PM/ICD leads using standard non-powered mechanical systems within the last 14 years. Results: Procedural success 96.1%, clinical success 97.8%, procedure-related death 0.18%, major complications 1.9% (cardiac tamponade 1.2%, hemothorax 0.2%, tricuspid valve damage 0.3%, stroke and pulmonary embolism < 1%). The roles for cardiac surgery in TLE have been categorized into five areas: 1. Emergency cardiac surgery (1.18% of all patients), 2. Late surgical intervention (TLE-related tricuspid valve dysfunction) (0.44%), 3. Cardiac surgery complementing partially successful TLE (0.68%: removal of lead fragments), 4. Epicardial pacemaker implantation through sternotomy for the above-mentioned reasons (0.65%), 5. Delayed surgical intervention after TLE to place epicardial LV leads (0.53%). Additionally, surgical experience can help in prevention and treatment of wound infection after TLE. Conclusions: Emergency cardiac surgery (mainly due to severe bleeding) is still the most frequent reason for intervention (33.63% (38/113) of all surgical procedures). The other areas of surgical interventions in lead management are: cardiac surgery complementing partially successful TLE, repair or replacement of the malfunctioning tricuspid valve secondary to lead extraction and implantation of permanent epicardial pacing leads after sternotomy or epicardial left ventricle lead to optimize cardiac resynchronization. Experience of a single high-volume lead extraction center confirms the need for close collaboration between the cardiologist and the cardiac surgeon, whose role goes far beyond mere surgical standby.

The role of cardiac surgeon in transvenous lead extraction: Experience from 3462 procedures.

INTRODUCTION: The professional society guidelines recommend that transvenous lead extraction (TLE) operating teams collaborate closely with cardiac surgeons in the management of life-threatening complications. METHODS: We assessed the role of cardiac surgeons participating in 3462 TLE procedures at a high-volume center between 2006 and 2021. The roles for cardiac surgery in TLE can be categorized into five areas: emergency surgical interventions for the management of cardiac laceration and severe bleeding (1.184%), cardiac surgery complementing partially successful TLE or vegetation removal (0.693%), delayed surgical treatment of TLE-related tricuspid valve dysfunction (0.751%), epicardial pacemaker implantation through sternotomy during emergency, complementing or delayed surgical interventions (0.607%), and delayed epicardial lead implantation (0.491%). RESULTS: Isolated damage to the wall of the right atrium was the most common cause of cardiac tamponade (53.66% of emergency surgeries) followed by injury to the right ventricle and vena cava (both 7.317%). CONCLUSIONS: Emergency cardiac surgery for the management of severe hemorrhagic complications is still the most common treatment option. The remaining areas include surgery complementing partially successful TLE: repair of tricuspid valve or epicardial ventricular lead placement to achieve permanent cardiac resynchronization. The experience at a single high-volume TLE center indicates the necessity of close collaboration with the cardiac surgeons whose roles appear broader than the mere surgical standby. Mortality in patients who survived cardiac surgery during TLE does not differ from the survival of other patients after TLE without complications requiring surgical intervention.

Exposure to Ti4Al4V Titanium Alloy Leads to Redox Abnormalities, Oxidative Stress, and Oxidative Damage in Patients Treated for Mandible Fractures.

Due to the high biotolerance, favourable mechanical properties, and osseointegration ability, titanium is the basic biomaterial used in maxillofacial surgery. The passive layer of titanium dioxide on the surface of the implant effectively provides anticorrosive properties, but it can be damaged, resulting in the release of titanium ions to the surrounding tissues. The aim of our work was to evaluate the influence of Ti6Al4V titanium alloy on redox balance and oxidative damage in the periosteum surrounding the titanium miniplates and screws as well as in plasma and erythrocytes of patients with mandibular fractures. The study included 31 previously implanted patients (aged 21-29) treated for mandibular fractures and 31 healthy controls. We have demonstrated increased activity/concentration of antioxidants both in the mandibular periosteum and plasma/erythrocytes of patients with titanium mandibular fixations. However, increased concentrations of the products of oxidative protein and lipid modifications were only observed in the periosteum of the study group patients. The correlation between the products of oxidative modification of the mandible and antioxidants in plasma/erythrocytes suggests a relationship between the increase of oxidative damage at the implantation site and central redox disorders in patients with titanium miniplates and screws.

Effectiveness, safety, and long-term outcomes of non-powered mechanical sheaths for transvenous lead extraction.

Aims: To analyse the effectiveness, safety and long-term outcomes of conventional non-powered mechanical systems for transvenous lead extraction (TLE) performed by experienced first operators. Outcomes were assessed according to lead location and type of operating room in which the procedure was performed. Methods and results: Data from 2049 patients (mean age: 65 years), with infectious (40%) or non-infectious (60%) indications, were analysed over a mean of 3.37 (±2.29) years. A total of 3426 leads were extracted; and, overall, 95% full procedural, 4% partial procedural, and 98% clinical success were demonstrated. Within the patient cohort, 1.8% (37/2049) experienced major complications, with cardiac tamponade being predominant (30/37). Cardiac tamponade was identified as the main cause of mortality, as well as the cause of all procedure-related deaths (6/2049; 0.3%). Cardiac tamponade occurred in 1.8% of atrial and 0.3% of right ventricular lead extractions, with fatal tamponade reported in 9% of atrial, 40% of ventricular, and 67% of coronary sinus lead extractions. No association between lead location and cardiac tamponade-related mortality was observed; however, lead location did affect the success of pericardiocentesis. The cardiac tamponade-related mortality rate was 37% when TLE was performed in an electrophysiology laboratory. No deaths were reported when the procedure was performed in a cardiac surgery or hybrid operating room. Long-term survival was improved when TLE was performed due to non-infectious indications, rather than pocket infection or lead-related endocarditis (P < 0.001). Conclusion: Using conventional non-powered mechanical sheaths, TLE was effective even in patients at high risk of complications.

Plasma magnesium concentration in patients undergoing coronary artery bypass grafting.

[b]Introduction[/b]. Magnesium (Mg) plays a crucial role in cell physiology and its deficiency may cause many disorders which often require intensive treatment. The aim of this study was to analyse some factors affecting preoperative plasma Mg concentration in patients undergoing coronary artery bypass grafting (CABG). [b]Materials and method[/b]. Adult patients scheduled for elective CABG with cardio-pulmonary bypass (CPB) under general anaesthesia were studied. Plasma Mg concentration was analysed before surgery in accordance with age, domicile, profession, tobacco smoking and preoperative Mg supplementation. Blood samples were obtained from the radial artery just before the administration of anaesthesia. [b]Results. [/b]150 patients were studied. Mean preoperative plasma Mg concentration was 0.93 ± 0.17 mmol/L; mean concentration in patients - 1.02 ± 0.16; preoperative Mg supplementation was significantly higher than in patients without such supplementation. Moreover, intellectual workers supplemented Mg more frequently and had higher plasma Mg concentration than physical workers. Plasma Mg concentration decreases in elderly patients. Patients living in cities, on average, had the highest plasma Mg concentration. Smokers had significantly lower plasma Mg concentration than non-smokers. [b]Conclusions. [/b]1. Preoperative magnesium supplementation increases its plasma concentration. 2. Intellectual workers frequently supplement magnesium. 3. Smoking cigarettes decreases plasma magnesium concentration.

[Sternal wound complications after cardiac surgery--a case report]. / Powiklania w gojeniu rany mostka po operacji kardiochirurgicznej--opis przypadku.

The authors presents case report of a 59-years-old man with triple vessel coronary artery disease, hypertension after myocardial infarction of the inferior wall with sternal wound complcations after coronary bypass grafting (CABG). On the fourth postoperative day the patient developed sternal dehiscence with wound infection. Infection was caused by Staphylococcus haemolyticus--coagulase-negative methicillin-resistant strain, MRCNS. An antimicrobial therapy and negative pressure wound therapy were used for complete wound healing.

Disturbance in venous outflow from the cerebral circulation intensifies the release of blood-brain barrier injury biomarkers in patients undergoing cardiac surgery.

OBJECTIVE: Disturbances in venous outflow from the cerebral circulation may result in brain injury. Severe increases in brain venous pressure lead to brain ischemia and, subsequently, brain edema and intracranial hemorrhages. The purpose of this study was to determine the effect of changes in jugular venous bulb pressure (JVBP) on plasma blood brain-barrier biomarkers concentration and disturbances in arteriovenous total and ionized magnesium (a-vtMg and a-viMg) in brain circulation in patients undergoing coronary artery bypass grafting surgery (CABG) with cardiopulmonary bypass (CPB). DESIGN: Prospective observational study. SETTING: Department of Cardiac Surgery at a Medical University Hospital. PARTICIPANTS: Ninety-two adult patients undergoing elective CABG with CPB under general anaesthesia were studied. METHODS: Central venous pressure (CVP) was measured using a pulmonary artery catheter. The right jugular vein was cannulized retrogradely for jugular venous bulb pressure (JVBP) measurement. Concentrations of plasma S100ß protein, matrix metalloproteinase 9 (MMP-9), creatine kinase isoenzyme BB (CK-BB) a-vtMg and a-viMg were measured as the markers of blood-brain barrier dysfunction. All of them were analyzed in comparison with JVBP during surgery and the early postoperative period. RESULTS: Elevated JVBP was noted after CPB and after surgery. Its increase above 12 mmHg intensified release of S100ß, MMP-9 and CK-BB as well as disorders in a-vtMg and a-viMg. CVP correlated with JVBP, S100ß, and MMP-9. Moreover, JVBP correlated with S100ß and MMP-9. CONCLUSIONS: Cardiac surgery increased JVBP, and JVBP elevated above 12 mmHg intensified an increase in biomarkers of plasma blood-brain barrier disruption.

Lead dependent tricuspid dysfunction: Analysis of the mechanism and management in patients referred for transvenous lead extraction.

BACKGROUND: Lead-dependent tricuspid dysfunction (LDTD) is one of important complications in patients with cardiac implantable electronic devices. However, this phenomenon is probably underestimated because of an improper interpretation of its clinical symptoms. The aim of this study was to identify LDTD mechanisms and management in patients referred for transvenous lead extraction (TLE) due to lead-dependent complications. METHODS: Data of 940 patients undergoing TLE in a single center from 2009 to 2011 were assessed and 24 patients with LDTD were identifi ed. The general indications for TLE, pacing system types and lead dwell time in both study groups were comparatively analyzed. The radiological and clinical effi cacy of TLE procedure was also assessed in both groups with precision estimation of clinical status patients with LDTD (before and after TLE). Additionally, mechanisms, concomitant lead-dependent complications and degree (severity) of LDTD before and after the procedure were evaluated. Telephone follow-up of LDTD patients was performed at the mean time 1.5 years after TLE/replacement procedure. RESULTS: The main indications for TLE in both groups were similar (apart from isolated LDTD in 45.83% patients from group I). Patients with LDTD had more complex pacing systems with more leads (2.04 in the LDTD group vs. 1.69 in the control group; p = 0.04). There were more unnecessary loops of lead in LDTD patients than in the control group (41.7% vs. 5.24%; p = 0.001). There were no signifi cant differences in average time from implantation to extraction and the number of preceding procedures. Signifi cant tricuspid regurgitation (TR-grade III-IV) was found in 96% of LDTD patients, whereas stenosis with regurgitation in 4%. The 10% frequency of severe TR (not lead dependent) in the control group patients was observed. The main mechanism of LDTD was abnormal leafl et coaptation caused by: loop of the lead (42%), septal leafl et pulled toward the interventricular septum (37%) or too intensive lead impingement of the leafl ets (21%). LDTD patients were treated with TLE and reimplantation of the lead to the right ventricle (87.5%) or to the cardiac vein (4.2%), or surgery procedure with epicardial lead placement following ineffective TLE (8.3%). The radiological and clinical effi cacy of TLE procedure was very high and comparable between the groups I and II (91.7% vs. 94.2%; p = 0.6 and 100% vs. 98.4%; p = 0.46, respectively). Repeated echocardiography showed reduced severity of tricuspid valve dysfunction in 62.5% of LDTD patients. The follow- -up interview confi rmed clinical improvement in 75% of patients (further improvement after cardiosurgery in 2 patients was observed). CONCLUSIONS: LDTD is a diagnostic and therapeutic challenge. The main reason for LDTD was abnormal leafl et coaptation caused by lead loop presence, or propping, or impingement the leafl ets by the lead. Probably, TLE with lead reimplantation is a safe and effective option in LDTD management. An alternative option is TLE with omitted tricuspid valve reimplantation. Cardiac surgery with epicardial lead placement should be reserved for patients with ineffective previous procedures.

Transvenous extraction of an eight-year-old ventricular lead accidentally implanted into the left ventricle.

Incorrect implantation of a ventricular pacemaker (PM) lead into the left ventricle (LV) is a known problem associated with permanent pacing. The optimal management of such cases identified late has not been clearly established. Generally acceptable management options are: open-chest cardiac surgery using cardio-pulmonary bypass, chronic anticoagulation and antiplatelet-drugs therapy. Rarely, the problem is solved by percutaneous LV lead extraction. We present a case of a patient with DDD pacing and ventricular lead implanted incorrectly into the LV apex region via an atrial septal defect eight years ago. Chronic PM pocket infection developed after replacement of the device. Both leads were extracted percutaneously, and the embolic protection system (Filter-Wire EZ, Boston Scientific) was used to reduce cerebral circulation embolism. The hardest connective tissue adhesions affecting the lead and the anodal ring were found in the LV. Less dense surrounding fibrous tissue around the lead was present at all levels of the venous course of the lead and in the right atrium. Very small fragments of apparently connective tissue remnants were found in cerebral circulation protection filters, and had been removed after the procedure. We conclude that old, permanently implanted LV leads may be extracted percutaneously, especially when there is an increased risk of cardiac surgery, or where the patient's consent for surgical treatment is lacking. In order to perform the procedure it is recommended to establish a cerebral protection system and intraoperative transoesophageal echocardiography which are mandatory for successful lead removal.

Raised jugular venous pressure intensifies release of brain injury biomarkers in patients undergoing cardiac surgery.

OBJECTIVES: Neurologic damage after cardiac surgery with extracorporeal circulation is multifactorial. Despite several studies, its pathophysiology is poorly understood. The purpose of this study was to determine the changes in jugular venous pressure and to analyze their effect on perioperative brain injury measured by biomarkers in patients undergoing coronary artery bypass grafting. DESIGN: Observational study. SETTING: Department of cardiac surgery in a medical university hospital. PARTICIPANTS: Adult patients undergoing elective coronary artery bypass grafting with extracorporeal circulation under general anesthesia. INTERVENTIONS: The right jugular vein was cannulated in retrograde fashion. Jugular venous pressure was measured in the jugular vein bulb (JVBP). Concentrations of plasma glial fibrillary acidic protein, tau protein, arteriovenous lactate, and jugular vein saturation were measured as the markers of brain injury during the surgery and early postoperative period. All were analyzed in relation to JVBP. MEASUREMENTS AND MAIN RESULTS: Increased JVBP was noted after extracorporeal circulation and after surgery. A significant increase >12 mmHg for JVBP, increased plasma glial fibrillary acidic protein, tau protein, arteriovenous lactate concentrations, and decreased jugular vein saturation were observed. CONCLUSIONS: Cardiac surgery increased JVBP and an increased JVBP > 12 mmHg intensified an increase in brain injury biomarker concentrations.

Brain damage in cardiac surgery patients.

Neuropsychological disorders and brain injury are still a serious problem in cardiac surgery patients. Owing to multifactorial mechanism of brain injury during extracorporeal circulation, the effective and safe protection is extremely difficult. Despite several studies, the ideal neuroprotective treatment has not been found. Based on literature we analysed the main mechanisms of brain injury and new methods of brain protection.

Volatile anesthetics reduce biochemical markers of brain injury and brain magnesium disorders in patients undergoing coronary artery bypass graft surgery.

OBJECTIVES: Neuropsychological disorders are some of the most common complications of coronary artery bypass graft (CABG) surgery. The early diagnosis of postoperative brain damage is difficult and mainly based on the observation of specific brain injury markers. The aim of this study was to analyze the effects of volatile anesthesia (VA) on plasma total and ionized arteriovenous magnesium concentrations in the brain circulation (a-vtMg and a-viMg), plasma matrix metalloproteinase-9 (MMP-9), and glial fibrillary acidic protein (GFAP) in adult patients undergoing CABG surgery. DESIGN: An observational study. SETTING: The Department of Cardiac Surgery in a Medical University Hospital. PATIENTS AND METHODS: Studied parameters were measured during surgery and in the early postoperative period. Patients were assigned to 3 groups: group O, patients who did not receive VA; group ISO, patients who received isoflurane; and group SEV, patients who received sevoflurane. RESULTS: Ninety-two patients were examined. CABG surgery increased MMP-9 and GFAP. The highest MMP-9, GFAP, and the most dramatic disorders in a-vtMg and a-viMg were noted in group O. CONCLUSIONS: Cardiac surgery increased plasma MMP-9 and GFAP concentrations. Changes in MMP-9, GFAP, and arteriovenous tMg and iMg were significantly higher in group O. Volatile anesthetics, such as ISO or SEV, reduced plasma MMP-9, GFAP concentrations, and disturbances in a-vtMg and a-viMg.

Plasma matrix metalloproteinase 9 correlates with disorders of brain magnesium homeostasis in patients undergoing coronary artery bypass surgery.

BACKGROUND: Changes in plasma matrix metalloproteinase 9 (MMP-9) concentrations and parallel changes in brain magnesium homeostasis have not been examined in cardiac surgery patients. The purpose of the present study was to analyse these relationships in patients undergoing coronary artery bypass surgery (CABG) with extracorporeal circulation (ECC). Additionally, the effect of volatile anaesthetics was considered. PATIENTS AND METHODS: Adult patients undergoing CABG with ECC under general anaesthesia were studied. Plasma MMP-9 and total (tMg) and ionized (iMg) magnesium concentrations were measured during surgery and during the early postoperative period. The plasma arteriovenous (a-v) tMg and iMg differences in the brain circulation were considered to be markers for brain magnesium homeostasis. The Mini-Mental State Examination test and computer tomography were used to diagnose postoperative neuropsychological disorders (PNPDs). RESULTS: In total, 92 patients were examined. PNPDs were noted in 17 cases. Cardiac surgery resulted in increased plasma levels of MMP-9. The highest MMP-9 concentrations were observed in patients with PNPDs. MMP-9 concentrations strongly correlated with a-v tMg and a-v iMg differences. Compared with arterial measurements, venous tMg and iMg concentrations were higher during and immediately after surgery and lower during the early postoperative period. The most severe differences in a-v tMg and iMg were noted in patients with PNPDs. CONCLUSION: 1. Cardiac surgery resulted in an increase in plasma MMP-9 concentrations. 2. This increase in MMP-9 was significantly greater in patients with PNPDs. 3. The plasma MMP-9 concentration was correlated with disorders of brain Mg homeostasis.

Changes in intra-abdominal pressure during CABG with normovolemic hemodilution.

BACKGROUND: The measurement of intra-abdominal pressure (JAP) is an important examination in the diagnostics of multiorgan failure. Elevated IAP adversely impacts renal, splanchnic, pulmonary, cardiovascular, and central nervous system physiology. Therefore the measurement of IAP may be important in patients after CABG. The study analyzes LAP changes in patients undergoing surgical revascularization of the myocardium with extracorporeal circulation and normovolemic hemodilution. MATERIAL/METHODS: The study encompassed 21 men. The degree of NH caused by a constant volume of priming (1800 ml) was determined on the basis of hematocrit measurements and in relation to body weight. The patients were divided into two groups according to body weight: < or =75 kg (group A) and >75 kg (group B). The observations were made in 10 stages: 1) after the induction of anesthesia, 2) during the internal thoracic artery preparation, 3) after the initiation of ECC, 4) during aorta clamping, 5) directly before the disconnection of ECC, 6) 10 minutes after ECC disconnection, 7) directly after surgery, 8) one hour after the procedure, 9) 6 hours after the procedure, and 10) 18 hours after the procedure. RESULTS: Extracorporeal circulation caused a decrease in hematocrit in each patient. The CABG resulted in increased IAP in both groups, but higher in group A. A significant correlation between degree of NH and IAP in group A was noted. CONCLUSIONS: 1. The extracorporeal circulation procedures cause an increase in intra-abdominal pressure. 2. The increase in intra-abdominal pressure depends on the degree of hemodilution.

Cardiac arrest in the early stage of cardiosurgical procedure.

Cardiosurgical operations remain one of the most demanding and complicated surgical procedures. Cardiac arrest before extra corporeal circulation (ECC) is one of severe intraoperative complications which can occur in any moment of operation. We have tried to evaluate possible risk factors of intraoperative, pre-ECC cardiac arrest in cardiac surgical patients and also have tried to estimate, if such an incident itself can be a risk factor for further post-operative complications. Pre-ECC intraoperative cardiac arrest (ICA) has occurred in 28 (aged 34-9) of 1,288 cardiac surgical patients operated on in our institution between July 1998 and December 2001. In 20 of these patients (71%) CABG was a planned procedure and in the remaining eight heart valve prostheses implantation were planned. In all 28 cases ventricular fibrillation was a cause of ICA and all patients required indirect and/or direct cardiac massage up to the moment of ECC start. In the subgroup with coronary artery disease (CAD) eight patients (35%) had left main stenosis, 13 (46.4%) had myocardial infarction in medical history. In the group of valve patients mitro-aortis valve disease was diagnosed in three cases and mitro-aorto-tricuspid valve disease with CAD or mitral valve disease or aortic valve disease in single patients. ICA was the most frequent during sternotomy (eight cases), pericardium opening (seven cases) and harvesting of left internal mammary artery (LIMA). In 16 cases prolonged reperfusion was necessary after declamping of the aorta, and in two of these cases ECC re-entry was needed. Eight patients (28.6%) have died, in 14 cases (50%) low output syndrome has been diagnosed, in five cases (18%) myocardial infarction has occurred and, in nine cases (32%) different neurological complications have been found postoperatively and five patients required resternotomy. All these complications were significantly more frequent in the investigated group than in the whole population of patients. We conclude that pre-ECC ICA contributes to noticeable post-operative complications rate increase. Sternotomy and opening of pericardium are the most frequent moments when pre-ECC ICA appears. We have not found any significant preoperative risk factors for pre-ECC ICA.