Cardiac tamponade and para-aortic hematoma post elective surgical myocardial revascularization on a beating heart - a possible complication of the Lima-stitch and sequential venous anastomosis.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) surgery can be associated with some intrinsic, but relatively rare complications. A pericardial effusion is a common finding after cardiac surgeries, but the prevalence of a cardiac tamponade does not exceed 2% and is less frequent after myocardial revascularization.Authors believe that in our patient an injury of a nutritional pericardial or descending aorta vessel caused by the Lima stitch resulted in oozing bleeding, which gradually leaded to cardiac tamponade. The bleeding increased after introduction of double antiplatelet therapy and caused life-threatening hemodynamic destabilization. According to our knowledge it is the first report of such a complication after OPCAB. CASE PRESENTATION: We present a case of a 61-year old man, who underwent elective surgical myocardial revascularization on a beating heart. On the 11th postoperative day the patient was readmitted emergently to the intensive care unit for severe chest pain, dyspnoea and hypotension. Coronary angiographic control showed a patency of the bypass grafts and significant narrowing of circumflex artery, treated with angioplasty and stenting. The symptoms and hemodynamic instability exacerbated. A suspicion of dissection of the ascending aorta and para-aortic hematoma was stated on 16-slice cardiac computed tomography. The patient was referred to the Cardiovascular Surgery Clinic. Transthoracic echocardiography revealed cardiac tamponade. On transesophageal echocardiography there were no signs of the ascending aorta dissection, but a possible lesion of the descending aorta with para-aortic hematoma was visualized. Emergent rethoracotomy and cardiac tamponade decompression were performed. 12 days after intervention the control 64-slice computed tomography showed no lesions of the ascending or descending aorta. On one-year follow-up patient is in a good condition, the left ventricular function is preserved and there is no pathology in thoracic aorta on echocardiography. CONCLUSIONS: Mechanical complications of surgical myocardial revascularization on a beating heart should be considered as a cause of the clinical and hemodynamic instability relatively early in the postoperative period. Echocardiographic examination must be the first step in diagnostics process in a patient after cardiac surgery.

A second delivery after heart transplantation - a case study.

Pregnancy after organ transplantation is becoming relatively common. We present the case of a heart transplant recipient who gave birth to a second child. Despite the fact that the transplanted heart seems to adapt well to the changes caused by pregnancy, gestation in patients after heart transplantation may be complicated by hypertension, pre-eclampsia, or preterm labor. In this article, we consider the issues of preterm uterine contractions, anemia, thrombocytopenia, and several other complications in pregnant patients with transplanted hearts. We also present current opinions regarding the use of glucocorticoids as a form of preventing breathing disorders in neonates as well as breast-feeding by mothers receiving immunosuppressive agents. Pregnancies in heart transplant recipients should be considered high-risk. A second successful delivery of a healthy child remains a challenge for such patients and their doctors.

Long-term impact of vertical banded gastroplasty (VBG) on plasma concentration of leptin, soluble leptin receptor, ghrelin, omentin-1, obestatin, and retinol binding protein 4 (RBP4) in patients with severe obesity.

Restrictive type bariatric surgery is an effective therapeutic approach that decreases overall mortality in patients with severe obesity. Several new cytokines, including adipocytokines that control energy metabolism, have been discovered recently, but their role in obesity is not fully recognized. The aim of the study was to evaluate the influence of vertical banded gastroplasty (VBG), one of restrictive type bariatric surgery, on peripheral blood concentrations of some adipocytokines and hormones involved in the control of food intake and energy turnover. The studied group comprised 12 females and 2 males aged from 31 to 59years (46.6±7.4) with simple obesity (BMI: 44.9±7.2) and metabolic syndrome. The patients were examined both before and 3, 6, 12, 24months after bariatric surgery (eight patients were also checked after 36 and six patients after 48months). Measurements of peripheral blood concentration of glucose, insulin, leptin, soluble leptin receptor, obestatin, ghrelin, omentin-1, and retinol binding protein 4 (RBP4) by ELISA method have been performed. After the surgery body weight, BMI and waist circumference significantly decreased. Positive changes considering the components of metabolic syndrome have been noted. Namely glucose, insulin and triglycerides' levels decreased, accompanied by the significantly lower HOMA index. Conversely, HDL cholesterol concentrations increased. Furthermore, peripheral blood concentration of leptin decreased, but the blood levels of soluble leptin receptor and ghrelin gradually increased. The positive correlations between leptin and body weight and BMI were noted as well as between the RBP4 and total cholesterol and LDL cholesterol levels. We did not observe significant differences in levels of obestatin, omentin-1 and RBP4 after surgery. In conclusion, VBG is an effective type of bariatric surgery. Fast decrease of body weight in morbidly obese patients treated by restrictive bariatric surgery leads to significant changes in peripheral blood levels of some adipokines and hormones controlling energy turnover and appetite (leptin and soluble leptin receptor) as well as ghrelin but not omentin-1, obestatin or retinol binding protein (RBP-4).

[Primary pulmonary artery sarcoma in 36-year-old women: 3-years follow-up after partial resection and radiotherapy]. / Pierwotny miesak tetnicy plucnej u 36-letniej pacjentki: obserwacja 3-letnia po czesciowej resekcji i radioterapii.

Intimal sarcoma of the heart and pulmonary artery is a very rare, malignant, primary tumour. The prognosis in patients with primary sarcoma of the pulmonary artery, including intimal sarcoma, is poor. We present the case and 3-years follow-up of 36-year-old woman who was successfully treated with surgical, partial resection of the tumour followed by radiotherapy.

[Tumour in left atrium diagnosed 6 years after ablation of pulmonary vein ostia and inferior right atrial isthmus: thrombus or myxoma?]. / Guz w lewym przedsionku rozpoznany 6 latpo ablacji ujsc zyl plucnych i ciesni dolnejprawego przedsionka: skrzeplina czy sluzak?

We present a case of the left atrial myxoma 6 years after atrial fibrillation ablation. The initial diagnosis of the mass revealed on echocardiography was a thrombus. Failure of anticoagulant treatment and transesophageal echocardiography led to diagnosis of myxoma, confirmed intraoperatively and histologically.

Sources of thromboembolism in patients with correctly functioning mechanical valves: a single-center transesophageal echocardiographic study.

BACKGROUND: In patients with mechanical prostheses (MP), thromboembolism is one of the most serious complications. The study aim was to assess the incidence of sources of thromboembolism in patients with correctly functioning MP with and without a history of thromboembolism. METHODS: Two hundred ninety-seven patients with correctly functioning MP were enrolled in this single-center, transesophageal echocardiographic (TEE), retrospective, observational study. Two groups were analyzed: Group A, 183 patients with a history of thromboembolism, and Group B, 114 patients with no history of thromboembolism. RESULTS: Definite sources of thromboembolism were revealed in 59% of patients in Group A, and sources of potential thromboembolism were revealed in 13% of patients in Group B (P < .001). Multiple sources of thromboembolism were present in 9% of patients in Group A and 1% of patients in Group B. Localization of sources of thromboembolism included MP ring (59% and 53% of patients in Groups A and B, respectively); left atrium/left atrium appendage (24%/21% and 13%/40% of patients in Groups A and B, respectively); and aorta (12% and 13% of patients in Groups A and B, respectively). Patients with multiple sources of thromboembolism were older (P < .001) and in a higher New York Heart Association (NYHA) class (P = .004). Patients with sources of thromboembolism in the aorta were older than the rest of the group (P < .01). CONCLUSIONS: In patients with correctly functioning MP, sources of thromboembolism are observed 4 times more often in case of the positive history of thromboembolism. The most common source of thromboembolism is thrombosis of MP ring. Age and heart failure predispose multiple sources of thromboembolism. One might consider control TEE after mechanical valve implantation, but only in selected group of patients without embolic events but with a higher risk of thromboembolism.

Impact of vertical banded gastroplasty on body weight, insulin resistance, adipocytokine, inflammation and metabolic syndrome markers in morbidly obese patients.

INTRODUCTION: Diet, exercise, and pharmacological therapy have been shown to be unsatisfactory treatments for severe obesity in the long term. Bariatric surgery is the most effective means to achieve weight loss in morbidly obese subjects. The aim of this study was to evaluate the action of a number of adipocytokines, as well as the metabolic syndrome parameters of obese patients, before and after vertical banded gastroplasty (VBG). MATERIAL AND METHODS: The test subjects comprised eight males and 20 females (total 28 patients) aged from 20 to 59 years (43.7 ± 10.0) with simple obesity and the presence of metabolic syndrome, both before and 3, 6, 12, and 24 months after bariatric surgery (six patients were also checked after 36 and 48 months). RESULTS: After surgical treatment (at 24 months), the values of body weight, BMI, waist circumference, blood pressure (RR-S, RR-D), HOMA-IR and blood concentrations of CRP, TG, IRI, AUC-IRI, and AUC-GLU gradually decreased. We did not observe any significant differences of fasting glucose, leptin, total cholesterol and LDL-cholesterol concentrations before or after surgery. The blood levels of HDL, adiponectin, resistin, and ghrelin gradually increased after treatment. CONCLUSIONS: The significant decrease of body weight after vertical banded gastroplasty, as well as improvement of the main metabolic syndrome parameters and some adipocytokine blood levels, indicate the use of bariatric surgery as a valuable method of treating morbidly obese patients.

Systemic blood osteopontin, endostatin, and E-selectin concentrations after vertical banding surgery in severely obese adults.

BACKGROUND: Obesity is associated with endothelial dysfunction and increased inflammation as well as with expansion of the capillary bed in regional adipose deposits, and a balance between these factors is involved in angiogenesis. Osteopontin (OPN) is a proinflammatory cytokine involved in regulating immune processes and mediating chronic inflammation. Its level is usually elevated in the plasma and adipose tissue of obese subjects. E-selectin, an adhesion molecule which is released by dysfunctional endothelial cells, is believed to be a marker of an early atherosclerotic process. Endostatin (END), an angiogenesis inhibitor, is present in the blood of obese subjects. The most effective treatment to achieve weight loss in morbidly obese subjects is bariatric surgery. The aim of the study was to evaluate and compare the circulating concentrations of OPN, E-selectin and END as well as the insulin resistance (HOMA-IR) of severely obese patients with metabolic syndrome before and after vertical banded gastroplasty (VBG). MATERIAL AND METHODS: The test cohorts comprised eight males and 20 females (total 28 patients) aged from 20 to 59 years with simple obesity and the presence of metabolic syndrome, both before and 3, 6, 12, 24 months after bariatric surgery (six patients were also checked after 36 and four after 48 months). RESULTS: Bariatric surgery significantly reduced (over 24 months) body weight, BMI, waist circumference, HOMA-IR and blood concentrations of CRP. Plasma OPN gradually increased after VBG and E-selectin in systemic blood decreased. We did not observe any differences in END concentrations from 12 to 48 months after surgery. CONCLUSION: VBG improves metabolic syndrome parameters, decreases E-selectin and gradually increases OST blood concentrations but it does not have any significant influence on END levels.

Redo surgery risk in patients with cardiac prosthetic valve dysfunction.

INTRODUCTION: The aim of the study was to analyse the risk factors of early and late mortality in patients undergoing the first reoperation for prosthetic valve dysfunction. MATERIAL AND METHODS: A retrospective observational study was performed in 194 consecutive patients (M = 75, F = 119; mean age 53.2 ±11 years) with a mechanical prosthetic valve (n = 103 cases; 53%) or bioprosthesis (91; 47%). Univariate and multivariate Cox statistical analysis was performed to determine risk factors of early and late mortality. RESULTS: The overall early mortality was 18.6%: 31.4% in patients with symptoms of NYHA functional class III-IV and 3.4% in pts in NYHA class I-II. Multivariate analysis identified symptoms of NYHA class III-IV and endocarditis as independent predictors of early mortality. The overall late mortality (> 30 days) was 8.2% (0.62% year/patient). Multivariate analysis identified age at the time of reoperation as a strong independent predictor of late mortality. CONCLUSIONS: Reoperation in patients with prosthetic valves, performed urgently, especially in patients with symptoms of NYHA class III-IV or in the case of endocarditis, bears a high mortality rate. Risk of planned reoperation, mostly in patients with symptoms of NYHA class I-II, does not differ from the risk of the first operation.

Long-lasting durability of Carpentier-Edwards pericardial bovine bioprosthesis in mitral position - a case report of unfavourable post redo valve surgery course.

We describe a 73 year-old patient with mitral valve pericardial bioprosthesis Carpentier-Edwards 29M implanted due to the rheumatic mitral stenosis 21 years ago. Hemodynamic destabilisation had emerged 18 months before the admission. Echocardiography revealed significant bioprosthesis degeneration with calcification of its leaflets, small pannus on the bioprosthetic ring, moderate mitral stenosis, severe mitral and tricuspid regurgitation with high pulmonary hypertension and moderate aortic regurgitation. Redo valve surgery with mechanical Medtronic 27M valve implantation and tricuspid suture annuloplasty was successfully performed. The postoperative course was complicated by bleeding and severe respiratory insufficiency and the patient died 3 weeks after the surgery.

Bifocal pacing in the right ventricle: an alternative to resynchronization when left ventricular access is not possible in end-stage heart failure patients.

BACKGROUND: It has been reported that bifocal pacing (BiF) in the right ventricle might be an alternative to unsuccessful left ventricular lead implantation. This case report presents an assessment of the clinical and hemodynamic parameters during a three month follow-up in patients implanted with right ventricular BiF. METHODS: Eight patients who underwent unsuccessful left ventricular lead implantation were implanted with a bifocal system in the right ventricular. Leads were implanted in the right atrium appendage, the apex and the right ventricular outflow tract and connected to the cardiac resynchronization therapy pacemaker. All patients performed a sixminute walking test and underwent echocardiography after the implantation and after the three month follow-up. RESULTS: We found a significant performance increase in the six minute walking test and reduction in New York Heart Association class and mitral regurgitation in echocardiography study, as well as a significant increase in left ventricular ejection fraction, and cardiac output directly after the implantation, as well as at threemonth follow-up in patients after BiF implantation. CONCLUSIONS: Right ventricular bifocal pacing in patients with cardiac resynchronization therapy indication and unsuccessful left ventricular lead placement seems to be a beneficial treatment for heart failure. Satisfactory hemodynamic and clinical results were observed directly after BiF implantation and during the three month follow-up.

Factors associated with C-reactive protein at the early stage of acute myocardial infarction in men.

BACKGROUND: Elevation of C-reactive protein (CRP) is associated with acute coronary events. CRP is related to cardiovascular risk factors and adipokines. The aim of the study was to reveal the factors associated with elevated CRP levels in patients with ST-segment elevation acute myocardial infarction (STEMI). As there are sex-related differences in plasma levels of CRP and adipokines, our study was designed for males. METHODS: Seventy men admitted within the initial 6 hours of STEMI were categorized into 4 groups according to the quartile of CRP. Clinical data and laboratory measurements were analyzed. RESULTS: Anthropometric measurements, glucose at admission, resistin, and leptin were significantly higher, and adiponectin lower with the increase of CRP quartile. A significant positive correlation between CRP and body mass index, waist circumference, glucose at admission, resistin, and leptin and a negative relation of CRP to HDL-cholesterol and adiponectin were observed. In univariate logistic regression analysis, variables associated with a level of CRP above the fourth quartile were history of angina, obesity, diabetes, glucose at admission, resistin, leptin, and adiponectin, and independent predictors were glucose at admission and resistin. To predict the elevated CRP level the optimal cut-off for glucose at admission was 144 mg/dL (sensitivity 84%, specificity 86%) and for resistin was 21.5 ng/mL (sensitivity 79%, specificity 71%). CONCLUSIONS: Glucose at admission and resistin are independently associated with elevated levels of CRP in men during the early stage of STEMI.

Value of blood adipose tissue hormones concentration--adiponectin, resistin and leptin in the prediction of major adverse cardiac events (MACE) in 1-year follow-up after primary percutaneous coronary intervention in ST-segment elevation acute myocardial infarction.

OBJECTIVES: The objective of the study was to assess the impact of adipokines on the future major adverse cardiac events (MACE) in patients with acute myocardial infarction. METHODS: Subjects were 77 men with first, ST-segment elevation acute myocardial infarction undergoing primary percutaneous coronary intervention in whom data were available after one year follow-up. Baseline clinical and angiographic data were collected, blood level of C-reactive protein, uric acid, fasting glucose, lipid profile, adiponectin, resistin and leptin and left ventricular ejection fraction on echocardiography were assessed. MACE was defined as cardiac death, nonfatal myocardial infarction, hospitalization for angina or heart failure. RESULTS: 12% of patients experienced MACE. As revealed by univariate logistic regression analysis predictors of MACE were diabetes, multivessel disease, ejection fraction, blood C-reactive protein and adiponectin level. In multivariable analysis diabetes (OR=22.19, 95%CI 1.22-402.19; p=0.0360), lower left ventricular ejection fraction (OR=0.78, 95%CI 0.63-0.98; p=0.0298) and lower adiponectin level (OR=0.19, 95%CI 0.04-0.90; p=0.0362) were independent negative predictors of MACE. The optimal value of adiponectin for predicting MACE was 4.23 microg/ml. CONCLUSION. In male patients with myocardial infarction undergoing primary percutaneous coronary intervention, a baseline blood adiponectin but not resistin or leptin is independently predictive of MACE. The other prognostic factors are diabetes mellitus and left ventricular ejection fraction.

Resistin increases with obesity and atherosclerotic risk factors in patients with myocardial infarction.

The objective of the study was to assess the relation of resistin to the anthropometric parameters, metabolic risk factors, and C-reactive protein (CRP) in men with myocardial infarction. Subjects were 40 obese (age, 53.6 +/- 7.39 years; body mass index, > or =30 kg/m2) and 40 lean (age, 54.4 +/- 6.62 years; body mass index, <25 kg/m2) men with first acute myocardial infarction. Waist and hip circumferences, CRP, uric acid, fasting glucose, lipid profile, and blood resistin concentration were measured. In obese patients, triglycerides, fasting glucose, and CRP were significantly higher whereas high-density lipoprotein cholesterol was lower than in lean patients. The range of blood resistin concentration was 6.0 to 70.5 ng/mL: 27.84 +/- 12.15 ng/mL in obese subjects and 17.35 +/- 11.08 ng/mL in lean subjects (P < .0001). Significant positive correlation was revealed between blood resistin concentration and each of the analyzed anthropometric parameter and with fasting glucose, low-density lipoprotein cholesterol, and CRP, whereas negative relation was observed between resistin and high-density lipoprotein cholesterol. As revealed by univariate logistic regression analysis, risk of blood resistin concentration being greater than the median value (19.75 ng/mL) was increased by obesity, high-density lipoprotein cholesterol <40 mg/dL, hypertension, and CRP. In multivariate model, independent variables associated with higher median of resistin were obesity and CRP. Obesity increased 5.5-fold the probability of blood resistin concentration being greater than 19.75 ng/mL, whereas each 1-mg/dL increase in CRP increased this probability by 13%. In patients with acute myocardial infarction, obesity is positively related to blood resistin concentration. Resistin is likely to play a major role in the atherogenesis and its complications, and this action seems to be mostly related to the inflammatory reaction.

[The impact of comprehensive cardiac rehabilitation in patients up to 55 years old after acute myocardial infarction treated with primary coronary intervention]. / Korzystne efekty kompleksowej rehabilitacji kardiologicznej u osób do 55 roku zycia, po zawale miesnia sercowego, leczonych za pomoca pierwotnej angioplastyki.

UNLABELLED: The aim of our study was to evaluate the impact of comprehensive 3-phases cardiac rehabilitation in patients aged up to 55 years after acute myocardial infarction treated with primary coronary intervention (PCI) of the infarction related artery on the cardiovascular status, modification of coronary risk factors, psychological and physical status and exercise tolerance. METHODS: Out of 106 consecutive patients aged up to 55 years with acute myocardial infarction (AMI) with ST-segment elevation, treated with primary coronary intervention (PCI) of the infarction related artery 71 patients entered the study and were randomized either to the Study Group (GB) or to the Control Group (GK). 31 patients of GB underwent 3-phases cardiac rehabilitation program and 40 patients of GK did not participate in phase III of the program. At phase I of the rehabilitation and 6 months after myocardial infarction physical examination, echocardiography and treadmill exercise test were performed. RESULTS: At 6-months follow-up chest pain and symptoms of heart failure were significantly less common (p < 0.001) and a tendency for fewer new cardiac events and re-PCI was noted in GB. Self-evaluated, significantly greater improvement in the emotional and physical status as well as in physical activity (p < 0.001) was achieved in GB. In GB better exercise tolerance on treadmill exercise test, greater improvement in left ventricular ejection fraction (p < 0.05) and contractile index (p < 0.05) on echocardiography were observed. The effects of the secondary prevention in terms of smoking cessation and obesity were not satisfactory in both groups. CONCLUSION: 3-phases comprehensive cardiac rehabilitation in patients with AMI treated with PCI of the infarction related artery improves recovery at 6-month follow-up. It has a favorable impact on the anginal and heart failure symptoms, cardiac risk factors (especially physical activity, restrictive diet), psychological and physical status. It contributes towards maintaining a further event-free period. It improves selected cardiovascular parameters such as exercise tolerance, segmental and global left ventricular function.