Newly developed cardiovascular risk factors in rheumatoid arthritis patients initiating biologic treatment.

Introduction: Rheumatoid arthritis (RA) is a risk factor (RF) for cardiovascular (CV) disease, a leading cause of mortality in RA patients. Material and methods: Consecutive records of RA patients with high disease activity screened upon biologic therapy initiation were reviewed between January 2001 and 2018. Patients with at least 6-month follow-up and baseline disease activity scores were enrolled (n = 353) and stratified into manifest CV disorder ("overt CVD"), any traditional CV risk factor ("atCVrisk") and no CV risk factor ("vlCVrisk") groups. Results: Overall, mean (SD) patient age was 51.4 (±12.2) years, and 291 (82.4%) subjects were female. Median follow-up was 41.9 (IQR 18.6, 80) months. Overall, 89 (25.2%) individuals developed at least one new CV RF, of which 65 (18.4%) acquired one and 24 (6.8%) two or more. Incident lipid disorders (42, 11.9%), followed by hypertension (14, 4%), atrial fibrillation (17, 4.8%) and venous thromboembolism (VTE) (16, 4.5%), were common. Incident major adverse cardiac events (MACE) were not reported in the vlCVrisk group, in contrast to atCVrisk (n = 8, 4.2%) or overt CVD (n = 4, 18.2%). Age was a significant predictor of incident CV risk factor (HR 1.04, 95% CI: 1.02-1.07; p < 0.01). In age-adjusted analyses, only baseline body mass index (BMI) (HR 1.11, 95% CI: 1.04-1.18; p < 0.01), but not ever smoking (p = 0.93), male sex (p = 0.26), positive RF (p = 0.24), positive ACPA (p = 0.90), or baseline disease activity (p = 0.19), were independent predictor of incident CV risk factors. Conclusions: Patients with RA initiating biologics should be screened for cardiometabolic risk factors, especially at an older age. The presence of at least one risk factor may be linked to a worse long-term prognosis.

Impaired fibrin clot lysis is associated with increased mortality in patients after coronary artery bypass grafting: A long-term follow-up study.

BACKGROUND: Mortality after coronary artery bypass grafting (CABG) is primarily thromboembolic by nature. We investigated whether impaired fibrinolysis observed in cardiovascular diseases is associated with long-term mortality following CABG. METHODS: The study population comprised 292 consecutive patients (aged 64.6 ± 8.1 years) who underwent scheduled CABG. We measured plasma clot lysis time (CLT) preoperatively as a measure of fibrinolysis capacity. Cardiovascular and all-cause deaths were recorded during a median follow-up of 13.8 years. RESULT: CLT positively correlated with age (r = .56, p < .001), fibrinogen (r = .25, p = .002) and EuroSCORE I (r = .32, p < .001). The cardiovascular and overall mortality rates were 3.0 and 4.9 per 100 patient-years (32.4% vs 52.8%) respectively. In patients who died from cardiovascular and all causes, CLT was prolonged compared with survivors (both p < .050). Multivariable Cox regression analysis adjusted for potential confounders showed that long-term cardiovascular and all-cause deaths were associated with CLT (HR per 10 min 1.206; 95% CI 1.037-1.402, p = .015 and HR 1.164; 96% CI 1.032-1.309, p = .012), low-density lipoprotein cholesterol (HR per 1 mmol/L 1.556; 95% CI 1.205-2.010, p < .001 and HR 1.388; 96% CI 1.125-1.703, p = .002), C-reactive protein (HR per 10 mg/L 1.171; 95% CI 1.046-1.312, p = .006 and HR 1.127; 95% CI 1.005-1.237, p = .022) and EuroSCORE I (HR 1.173; 95% CI 1.016-1.355, p = .030 and HR 1.183; 95% CI 1.059-1.317, p = .003 respectively). Type 2 diabetes was solely associated with overall mortality (HR 1.594; 96% CI 1.088-2.334, p = .017). CONCLUSIONS: In this study, we showed that reduced fibrin clot susceptibility to fibrinolysis is weekly associated with long-term mortality in advanced CAD.

Plasma fibrin clot properties and cardiovascular mortality in patients with type 2 diabetes: a long-term follow-up study.

BACKGROUND: Patients with type 2 diabetes mellitus (T2DM) are at high risk of cardiovascular mortality, but the mechanisms behind this remain unclear. Prothrombotic fibrin clot properties have been shown in T2DM and cardiovascular disease. We hypothesized that formation of denser clots, which are resistant to fibrinolysis, has a negative impact on cardiovascular mortality in T2DM. METHODS: We studied 133 T2DM patients aged 43-83 years. Plasma fibrin clot turbidity, permeation, compaction, and efficiency of clot lysis using 3 assays including the determination of maximum concentration (D-Dmax) and rate of increase in D-dimer concentration (D-Drate) released during tissue plasminogen activator-induced degradation, were evaluated at the time of enrollment, along with thrombin generation and fibrinolytic proteins. During a median follow-up period of 72 months, cardiovascular mortality was recorded. RESULTS: Cardiovascular deaths (n = 16, 12%) occurred more frequently in patients with increased D-Dmax (> 4.26 mg/l, hazard ratio [HR] 5.43, 95% confidence interval [CI] 1.99-14.79), or decreased D-Drate (< 0.07 mg/l/min, HR 2.97, 95% CI 1.07-8.23), or increased peak thrombin (> 283.5 nM, HR 5.65, 95% CI 2.07-15.51). These predictors had an even more potent impact on cardiovascular mortality in patients with prior cardiovascular disease (64.7%) and with corresponding risks as follows: HR 6.18, 95% CI 2.02-18.96; HR 8.98, 95% CI 2.99-26.96; and HR 5.35, 95% CI 1.62-17.72, respectively. Other investigated fibrin variables and fibrinolytic proteins did not associate with cardiovascular mortality. In multivariable analysis, cardiovascular mortality was predicted by D-Dmax > 4.26 mg/l, age > 65 years, prior cardiovascular disease, and C-reactive protein > 3 mg/l. CONCLUSIONS: This study is the first to show that formation of denser fibrin clots resistant to fibrinolysis could be a risk factor for long-term cardiovascular mortality in T2DM.

Impaired fibrinolysis in degenerative mitral and aortic valve stenosis.

Valvular heart disease is associated with an increased thromboembolic risk. Impaired fibrinolysis was reported in severe aortic stenosis (AS). Little is known about fibrinolysis in mitral stenosis (MS). We sought to compare fibrinolysis impairment in AS and MS. We studied 121 individuals scheduled for elective aortic valve (AV) or mitral valve (MV) surgery for AS (n = 76) or MS (n = 45), in order to compare fibrinolysis impairment. Fibrinolytic capacity was assessed by determination of clot lysis time (t50%) and fibrinolysis inhibitors, including plasma plasminogen activator inhibitor-1 (PAI-1) antigen (PAI-1:Ag) and activity, thrombin-activatable fibrinolysis inhibitor (TAFI) antigen and activity. Prolonged t50% (+ 29%), elevated TAFI activity (+ 12%), TAFI:Ag (+ 21%), and PAI-1:Ag (+ 84%) were observed in patients with MS, compared with those with AS. t50% Correlated with mean and maximal MV gradients (r = 0.43, p < 0.0001 and r = 0.39, p < 0.0001, respectively), but not with AV gradients. Mean and maximal MV gradients correlated with TAFI activity and PAI:Ag. Patients with permanent atrial fibrillation (AF; 35 with MS and 5 with AS) had longer t50% (by 22%, p = 0.0002) and higher PAI-1:Ag (by 74%, p < 0.0001) than the remainder. In the whole group, postoperative drainage volumes correlated inversely with PAI-1:Ag (r = - 0.22, p = 0.02). MS is associated with more pronounced impairment of global fibrinolytic capacity than AS at the stage of surgical intervention, which is in part driven by AF. Our findings suggest that hypofibrinolysis might be implicated in the progression of MS and its thromboembolic complications.

Epidemiologic characteristics and clinical course of children with acute gastroenteritis hospitalized in the Department of Pediatric Infectious Diseases and Hepatology at John Paul II Hospital in Krakow

INTRODUCTION: Acute gastroenteritis (AGE) is considered one of the most common reasons for hospitalization and the third leading cause of death related to infectious diseases in children. The incidence and prevalence of campylobacteriosis is lower in Poland than in other parts of the European Union. THE AIM OF THE STUDY: The aim of the study was to investigate the epidemiology and clinical features of AGE in hospitalized children. MATERIALS AND METHODS: The study population comprised 462 consecutive patients with AGE, hospitalized in the Department of Pediatric Infectious Diseases and Hepatology at John Paul II Hospital in Krakow during 2016. After admission in the hospital, the patients' stool samples were collected and tested for viral or bacterial pathogens. The specimens were analyzed using classical cultural methods and qualitative immunochromatographic assays for pathogens screening. The patients' age, sex, etiological factor, seasonal distribution, hospital length of stay and symptoms of disease were collected retrospectively. RESULTS: The median age of AGE patients was 3.0 years [1.5-5.5]. Eighty percent of all AGE cases occurred in patients under 5 years of age (p<0.001). Rotavirus was the leading cause of AGE and Campylobacter was the most common bacterial pathogen (p=0.001, p=0.05 respectively). The average length of hospital stay was 3.1 ± 1.6 days. The longest hospitalization stays were related to patients with enteropathogenic Escherichia coli and Salmonella (p<0.001 for all). A seasonal pattern was observed for etiological factors of AGE (p<0.001). Fever, diarrhea and pathological stool contaminations occurred more frequently in patients with bacterial AGE (p<0.001 for all). SUMMARY AND CONCLUSIONS: This study showed that routine diagnosis of Campylobacter in all children with AGE is associated with a higher than reported prevalence of campylobacteriosis.

Respiratory System Function in Patients after Aortic Valve Replacement through Right Anterior Minithoracotomy.

Background The aim of the study was to analyze respiratory system function after minimally invasive aortic valve replacement through right anterior minithoracotomy (RAT-AVR). Methods An observational study of 187 patients electively scheduled for RAT-AVR between January 2010 and December 2013. Pulmonary complications were analyzed and spirometry examinations were performed preoperatively, 1 week, 1 month, and 3 months after surgery. Results Hospital mortality was 1.1%. A double-lumen intratracheal tube was used in 88.2% and single-lumen intratracheal tube was used in 11.8% of patients. Pulmonary complications occurred in 10.8% of the patients. Prolonged (>24 hours) mechanical ventilation time was present in five patients (2.7%). The reasons were stroke (n = 1), perioperative myocardial infarction (n = 2), and pneumothorax (n = 2). Right pleural effusion, which occurred in 7.7% (n = 14) of patients, was the most frequent respiratory system complication. One week after surgery, the spirometry parameters decreased in comparison to the preoperative period, then after 3 months statistically significant improvement occurred; however, the spirometry parameters still had not returned to preoperative values. Multivariable median regression analysis shows that the presence of chronic obstructive pulmonary disease and pulmonary complications were associated with lower values of forced expiratory volume in 1 second after surgery. There was no statistically significant difference regarding spirometry values or incidence of pulmonary complications after surgery between patients in whom single-lung or double-lung ventilation was applied. Conclusion Pulmonary functional status measured with spirometry parameters was diminished after RAT-AVR surgery. Single-lung ventilation did not result in a higher rate of respiratory complications after RAT-AVR surgery.

[Percutaneous coronary intervention and minimally invasive aortic valve replacement for patients with aortic valve disease and coronary artery disease].

Objectives: To report the results of hybrid approach combining percutaneous coronary intervention (PCI) and minimally invasive aortic valve replacement through right anterior minithoracotomy (RT-AVR) for patients with aortic valve disease and coronary artery disease. Materials and Methods: Retrospective analysis of 53 hybrid RT-AVR/ PCI procedures where RT-AVR was performed first in the operating room and followed immediately by PCI performed in the catheterization laboratory. Results: Predicted with Euro- SCORE II and observed hospital mortality was 8.7±2.9% and 1.9% respectively. Hospital and intensive care unit length of stay were 5.6±2.4 and 1.8±1.4 days respectively. Biological aortic valve prosthesis was implanted in 40 (75.5%) patients. PCI of LAD was performed in 5 patients (9.4%), of Dg in 10 (18.9%) patients, of Mg or Cx in 21 (39.6%) patients, of PDA or RCA in 25 (47.2%) patients. Two vessels and three vessels PCI were performed in 5 (9.4%) and 3 (5.7%) patients respectively. DES were used during PCI in 42 (79.2%) patients. Dual antiplatelet therapy with 75 mg of Aspirin and 75 mg of Clopidogrel started after RTAVR/ PCI. Complications occurred in 16 (30.2%) patients after hybrid RT-AVR/PCI procedure. Prolonged above 24 hours mechanical ventilation time was necessary in 3 patients (5.7%). Renal insufficiency occurred in 4 (7.5%), stroke in 1 (1.9%) patient. Pacemaker was implanted in 2 (3.8%) patients after surgery. Conversion to conventional surgery through median sternotomy was performed in 1 patient (1.9%), surgical revision due to postoperative bleeding in 2 patients (3.8%). No perioperative myocardial infarction and no mediastinitis was diagnosed after RT-AVR/PCI procedure. Postoperative chest blood drainage was 245.0±181.0 ml. Red blood cells transfusion was required in 10 (18.9%) patients. Conclusions: The hybrid RT-AVR/PCI procedure for these high risk patients with aortic valve disease and coronary artery disease presented in our series favourable mortality results compared to predicted with EuroSCORE II mortality for conventional cardiac surgery.

[Surgical treatment results of chronic pericardial tamponade].

Objective: To report the efficacy of chronic pericardial effusion treatment with pericardial window creation through video-assisted thoracoscopic surgery and pericardial drainage through a small subxiphoid incision. Material and Methods: Retrospective analysis of 31 patients after pericardial window creation through video-assisted thoracoscopic surgery (PW group) and 77 patients where pericardial drainage through small subxiphoid incision (PD group) was performed. Echocardiography examinations were performed to document pericardial tamponade and pericardial effusion recurrence. Results: Length of surgery was 20.5±5.4 minutes in the PD group and 25.8±6.4 minutes in the PW group, p<0.001. Amount of fluid evacuated from pericardium during surgery was 483±191 ml and 521±253 ml in PD and PW groups respectively, p=0.654. Postoperative drainage was maintained longer (4.3±1.4 days vs. 3.2±1.0, p<0.001) and the amount of fluid drained after surgery was higher (497±351 ml vs. 309±231 ml, p=0.031) in the PW group. The amount of pericardial fluid at the end of hospitalization was statistically significantly higher in the PD group compared with the PW group (8.9±4.9 mm vs. 4.9±3.2 mm, p<0.001). Hospital stay was 5.7±2.7 days in the PD group and 6.1±3.4 in the PW group, p=0.112. No patient died during hospitalization period in either group. Mortality within 30 days after surgery was 2.6% in the PD and 3.2% in the PW group (p=0.642). In the PW group there were 4 conversions to right minithoracotomy due to dense pleural adhesions. Pericardial effusion recurrence occurred in 9 patients (12.0%) in the PD group and none was observed (0.0%) in the PW group (p=0.042) within 30 days after surgery. Conclusion: Pericardial window creation through video-assisted thoracoscopic surgery should be considered the preferred method over pericardial drainage through a small subxiphoid incision for chronic pericardial effusion and pericardial tamponade treatment to reduce the frequency of pericardial effusion reoccurrence.

[Pulmonary complications after minimally invasive aortic valve replacement surgery - a propensity score matching analysis].

Instruction: To answer the question if minimally invasive aortic valve replacement surgery through a right anterior minithoracotomy (RT-AVR) may result in increased incidence of postoperative pulmonary complications compared to conventional aortic valve replacement through a median sternotomy (AVR). Material and Methods: It was retrospective analysis of 212 patients scheduled for RT-AVR and 212 for AVR between January 2011 and December 2014 selected with propensity score matching. Respiratory system complications are analysed. Results: Postoperative blood drainage was 353±249 and 524±325 ml in RT-AVR and AVR groups respectively (p<0.001). Hospital stay was 5.7±1.6 and 8.5±4.3 days (p<0.001), ICU stay was 1.3±1.2 and 2.6±2.8 days (p<0.001) in RT-AVR and AVR patients respectively. Respiratory system complications occurred in 13.7% of RT-AVR patients and 17.0% of AVR patients (p=0.364). Pneumonia was diagnosed in 2.4% and 0.5% of patients (p=0.129), pneumothorax in 2.0% and 1.3% of patients (p=0.515), pleural effusion in 8.5% and 7.5% of patients (p =0.732) and thoracentesis was performed in 7.1% and 7.5% of patients from RT-AVR and AVR groups respectively. Mediastinitis was diagnosed in 0.0% of RT-AVR and 2.8% of AVR patients (p=0.020). Phrenic nerve dysfunction was present in 3.8% of RT-AVR and in 0.0% of AVR patients (p=0.006). COPD (OR=5.5; p<0.001) and increased postoperative blood loss (OR=3.5; p<0.001) were risk factors of postoperative pulmonary complications. Conclusion: Minimally invasive RT-AVR surgery did not result in increased rate of postoperative pulmonary complications compared to conventional AVR surgery through a median sternotomy.

Perioperative Outcomes of Minimally Invasive Aortic Valve Replacement through Right Anterior Minithoracotomy.

Background The aim of the study was to analyze perioperative outcomes after minimally invasive aortic valve replacement through right anterior minithoracotomy (RAT-AVR). Patient selection criteria, anesthesia protocol, and surgical technique are presented. Methods A retrospective analysis of 194 patients electively scheduled for RAT-AVR was performed between January 2009 and June 2013. For preoperative planning, computed tomography was performed. Results Among studied patients, there were 48.5% females and 51.5% males with a mean age of 69.9 ± 9.2 years. The predicted mortality calculated with EuroSCORE II was 3.2 ± 0.9%, and observed mortality of RAT-AVR patients was 1.5%. Finally, RAT-AVR surgery was performed on 97.9% of patients (n = 190). Reasons for conversions to median sternotomy were bleeding from aortotomy site (n = 4) and from the right ventricle after epicardial pacing wire placement (n = 1), pleural adhesions (n = 2), and ascending aorta hidden under the sternum (n = 2). The second intercostal space was chosen for surgical access in 97.9% of patients.There were 3.6% reoperations for bleeding: aortotomy place (n = 1), epicardial pacing wire placement (n = 3), right lung tear (n = 2), and intercostal vessels (n = 1). The intensive care unit and hospital length of stays were 1.3 ± 1.2 and 5.7 ± 1.4 days, respectively. Strokes were present in 1.5% of patients. The perioperative complications rate diminished with time, occurring in 44.9% of the patients between 2009 and 2010 and in 15.6% of patients in 2013. Conclusions RAT-AVR can be safely performed without increased morbidity and mortality. Reduced complication rates over time reflect a learning curve.

Function of the Respiratory System in Elderly Patients After Aortic Valve Replacement.

OBJECTIVE: To compare the function of the respiratory system after aortic valve replacement through median sternotomy (AVR) or the minimally invasive right anterior minithoracotomy (RAT-AVR) approach among elderly (aged≥75 years) patients. DESIGN: Observational cohort study. SETTINGS: University hospital. PARTICIPANTS: The study included 65 elderly patients scheduled for RAT-AVR and 82 for standard AVR. INTERVENTIONS: Pulmonary function tests (PFT) were performed preoperatively, 1 week, 1 month, and 3 months after surgery. In addition, respiratory complications were analyzed. MEASUREMENTS AND MAIN RESULTS: Respiratory complications occurred in 12.3% of patients in the RAT-AVR group and 18.3% of patients in the AVR group (p = 0.445). Mechanical ventilation time in the intensive care unit was 7.7±3.6 hours for RAT-AVR patients and 9.7±5.4 hours for AVR patients (p = 0.003). Most PFT were worse in the AVR group than in the RAT-AVR group when performed 1 week after surgery. After 1 month, forced expiratory volume in the first second, vital capacity, and total lung capacity differed significantly in favor of the RAT-AVR group (p = 0.002, p<0.001, and p = 0.001, respectively). After 3 months, the PFT parameters still had not returned to preoperative values, but the differences were no longer significant between the RAT-AVR and AVR groups. The multivariable median regression analysis demonstrated that RAT-AVR surgery was a key factor in a patient's higher postoperative PFT parameter values. CONCLUSIONS: RAT-AVR surgery resulted in shorter postoperative mechanical ventilation time and improved the recovery of pulmonary function in elderly patients, but it did not reduce the incidence of pulmonary complications when compared with surgery performed through a median sternotomy.

Beta-thromboglobulin as a marker of perioperative myocardial infarction in patients undergoing coronary artery bypass grafting following aspirin discontinuation.

Perioperative myocardial infarction (PMI) following coronary artery bypass grafting (CABG) is associated with significant morbidity and mortality. The aim of this study was to assess platelet activation and oxidative stress in the setting of PMI in patients undergoing CABG. We studied 108 consecutive patients who stopped taking low-dose aspirin 7-10 days prior to elective isolated on- or off-pump CABG. ß-thromboglobulin (ß-TG), thromboxane B2 (TXB2) and 8-iso-prostaglandin F2α (8-iso-PGF2α), a marker of oxidative stress, were measured at the baseline and 5-7 days postoperatively. Aspirin (150 mg/d) was administered every morning since 12 hours after CABG. Mean baseline ß-TG was 58.5 ± 10.3 IU/ml, TXB2 was 143.6 ± 28.5 ng/ml and 8-iso-PGF2α was 355.2 ± 40.7 pg/ml. Postoperatively, after administration of 4-6 doses of aspirin, ß-TG increased by 16.7% and 8-iso-PGF2α increased by 17.2% 5-7 days after surgery (p = 0.005 and p < 0.001, respectively). TXB2 decreased by 99.7% to 410.3 ± 52.1 pg/ml (p < 0.001). Nine patients (8.3%) developed PMI. Baseline ß-TG and TXB2, together with postoperative ß-TG and 8-iso-PGF2α were higher in PMI patients than in the remaining subjects (all, p < 0.05). Multivariate analysis showed that baseline ß-TG (OR: 1.28; 95% CI: 1.05-1.57, p = 0.015) was the only independent predictor of PMI. In conclusion, we demonstrated that increased platelet activation and thromboxane production, observed in patients not taking aspirin till the day of CABG, contribute to the occurrence of PMI in early postoperative period.

Poor patients' knowledge about venous thromboembolism and its therapy is associated with increased risk of major bleeding and discontinuation of anticoagulation: A cohort study.

It has been shown that patients' knowledge about venous thromboembolism (VTE) and its therapy is suboptimal, which might reduce compliance and worsen prognosis. We investigated whether low VTE patients' knowledge affects their clinical outcomes during long-term follow-up. We evaluated 151 consecutive patients (51.8 ±â€…15.7 years) after unprovoked VTE, who were recruited from the outpatient clinic (Krakow, Poland). All patients received anticoagulant treatment, mostly with direct oral anticoagulants (n = 113, 74.8%). The modified Jessa Atrial fibrillation Knowledge Questionnaire (JAKQ-VTE; 16 questions) was used to assess the knowledge of VTE and anticoagulant therapy. During a median follow-up of 58.0 months, VTE recurrence, major bleeding, and anticoagulation withdrawal were recorded. The median percentage of correct responses was 62.5% (12.5-100%) and was inversely correlated with age (P < .01). Diabetic patients and those with positive family history of VTE had lower overall scoring compared to the remainder (both P < .05). Major bleeding (n = 10, 6.6%) and anticoagulation withdrawal (n = 28, 18.5%), but not VTE recurrence (n = 12, 7.9%), were associated with lower overall scoring compared to the remainder (48.8% ±â€…12.5% vs 63.8% ±â€…16.3%, P = .003 and 55.3% ±â€…14.7% vs 64.4% ±â€…16.3%, P = .040, respectively). Major bleeding was independently associated with the female sex (hazard ratio [HR] 6.18; 95% confidence interval [CI] 1.15-33.19, P = .034), younger age (HR per 10 years 0.55; 95% CI 0.34-0.90, P = .016), OAC therapy discontinuation (HR 6.69; 95% CI 1.62-27.70), and lower overall scoring of JAKQ-VTE (HR 0.60 per 10 percentage points; 95% CI 0.40-0.92, P = .019). Insufficient knowledge about VTE and anticoagulant treatment predisposes to a higher risk of major bleeding and therapy discontinuation, but not VTE recurrence in unprovoked VTE patients during long-term follow-up.

Patients with aortic valve disease and coronary artery disease can benefit from a hybrid approach combining aortic valve replacement through right minithoracotomy and percutaneous coronary intervention.

Introduction: Minimally invasive and hybrid procedures for patients with aortic valve pathology and coronary artery disease are innovative solutions. Aim: To report the results of hybrid aortic valve replacement through right anterior minithoracotomy (RT-AVR)/percutaneous coronary intervention (PCI) and conventional aortic valve replacement (AVR)/coronary artery bypass grafting (CABG) surgery for patients with aortic valve and coronary artery disease. Material and methods: Analysis of prospectively gathered data of 187 patients - 86 hybrid and 101 conventional procedures. For 21 patients, RT-AVR was followed by PCI during the same session, and for 65 patients RT-AVR was performed within 90 days of PCI. Results: Hospital mortality in the AVR/CABG and RT-AVR/PCI groups was 3.0% and 1.2%, respectively (p = 0.237). Complications occurred in 18.6% of patients in the RT-AVR/PCI group and 33.7% in the AVR/CABG group (p = 0.020). Two-stage RT-AVR/PCI was performed due to ACS (100%); one-stage was due to the intention to perform a minimally invasive procedure instead of AVR/CABG (71.4%) or due to replacing CABG with PCI because of a lack of vascular grafts for CABG (19.1%). In 38.5% of patients from the two-stage subgroup, antiplatelet therapy was stopped before RT-AVR, 32.3% of patients from the two-stage subgroup were on single, and 29.2% on dual antiplatelet therapy until RT-AVR, which had no influence on postoperative blood requirements or postoperative myocardial infarction (p = 0.410 and p = 0.077, respectively). Conclusions: The hybrid procedure presented in our series showed similar mortality and morbidity results and may be an alternative to conventional AVR and CABG through full sternotomy in selected patients.

The Role of Extracorporeal Membrane Oxygenation ECMO in Accidental Hypothermia and Rewarming in Out-of-Hospital Cardiac Arrest Patients-A Literature Review.

Accidental hypothermia, defined as an unintentional drop of the body core temperature below 35 °C, is one of the causes of cardiocirculatory instability and reversible cardiac arrest. Currently, extracorporeal life support (ECLS) rewarming is recommended as a first-line treatment for hypothermic cardiac arrest patients. The aim of the ECLS rewarming is not only rapid normalization of core temperature but also maintenance of adequate organ perfusion. Veno-arterial extracorporeal membrane oxygenation (ECMO) is a preferred technique due to its lower anticoagulation requirements and potential to prolong circulatory support. Although highly efficient, ECMO is acknowledged as an invasive treatment option, requiring experienced medical personnel and is associated with the risk of serious complications. In this review, we aimed to discuss the clinical aspects of ECMO management in severely hypothermic cardiac arrest patients.

Thromboembolic Complications in Adult Patients Following Fontan Procedure-A Multicenter Study.

BACKGROUND: Morbidity and mortality following Fontan (FO) surgery are primarily thromboembolic in nature. However, follow-up data regarding thromboembolic complications (TECs) in adult patients after FO procedure are inconsistent. In this multicenter study, we investigated the incidence of TECs in FO patients. METHODS: We studied 91 patients who underwent FO procedure. Clinical data, laboratory, and imaging investigations were collected prospectively during the scheduled medical appointments in 3 Adult Congenital Heart Disease Departments in Poland. TECs were recorded during a median follow-up of 31 months. RESULTS: Four patients (4.4%) were lost to follow-up. The mean age of patients was 25.3 (±6.0) years at enrollment, and the mean time between FO operation and investigation was 22.1 (±5.1) years. A total of 21 out of 91 patients (23.1%) had a history of 24 TECs since an FO procedure, mainly pulmonary embolism (PE; n = 12, 13.2%), including 4 (33.3%) silent PE. The mean time since FO operation to the first TEC was 17.8 (±5.1) years. During follow-up, we documented 9 TECs in 7 (8.0%) patients, mainly PE (n = 5, 5.5%). Most patients with TEC had a left type of systemic ventricle (57.1%). Three patients (42.9%) were treated with aspirin, 3 (3.4%) with Vitamin K antagonists or novel oral anticoagulants, and 1 patient had no antithrombotic treatment at the time of TEC occurrence. Supraventricular tachyarrhythmias were present in 3 patients (42.9%). CONCLUSIONS: This prospective study shows that TECs are common in FO patients, and a significant number of these events occur during adolescence and young adulthood. We also indicated how much TECs are underestimated in the growing adult FO population. The complexity of the problem requires more studies, especially to standardize the prevention of TECs in the whole FO population.

8-Isoprostanes and Asymmetric Dimethylarginine as Predictors of Mortality in Patients Following Coronary Bypass Surgery: A Long-Term Follow-Up Study.

BACKGROUND: We previously demonstrated that enhanced oxidative stress and reduced nitric oxide bioavailability are associated with unfavorable outcomes early after coronary artery bypass grafting. It is not known whether these processes may impact long-term results. We sought to assess whether during long-term follow-up, markers of oxidative stress and nitric oxide bioavailability may predict cardiovascular mortality following bypass surgery. METHODS: We studied 152 consecutive patients (118 men, age 65.2 ± 8.3 years) who underwent elective, primary, isolated on-pump bypass surgery. We measured plasma 8-iso-prostaglandin F2α and asymmetric dimethylarginine before surgery and twice after surgery (18-36 h and 5-7 days). We assessed all-cause and cardiovascular death in relation to these two biomarkers during a mean follow-up time of 11.7 years. RESULTS: The overall mortality was 44.7% (4.7 per 100 patient-years) and cardiovascular mortality was 21.0% (2.2 per 100 patient-years). Baseline 8-iso-prostaglandin F2α was associated with cardiovascular mortality (HR 1 pg/mL 1.010, 95% CI 1.001-1.021, p = 0.036) with the optimal cut-off ≤ 364 pg/mL for higher survival rate (HR 0.460, 95% CI 0.224-0.942, p = 0.030). Asymmetric dimethylarginine > 1.01 µmol/L measured 18-36 h after surgery also predicted cardiovascular death (HR 2.467, 95% CI 1.140-5.340, p = 0.020). Additionally, elevated 8-iso-prostaglandin F2α measured at the same time point associated with all-cause mortality (HR 1 pg/mL 1.007, 95% CI 1.000-1.014, p = 0.048). CONCLUSIONS: Our findings indicate that in advanced coronary disease, increased oxidative stress, reflected by 8-iso-prostaglandin F2α before bypass surgery and enhanced asymmetric dimethylarginine accumulation just after the surgery are associated with cardiovascular death during long-term follow-up.

Prognostic role of perioperative acid-base disturbances on the risk of Clostridioides difficile infection in patients undergoing cardiac surgery.

BACKGROUND: It is unclear whether acid-base balance disturbances during the perioperative period may impact Clostridium difficile infection (CDI), which is the third most common major infection following cardiac surgery. We hypothesized that perioperative acid-base abnormalities including lactate disturbances may predict the probability of incidence of CDI in patients after cardiac procedures. METHODS: Of the 12,235 analyzed patients following cardiac surgery, 143 (1.2%) developed CDI. The control group included 200 consecutive patients without diarrhea, who underwent cardiac procedure within the same period of observation. Pre-, intra and post-operative levels of blood gases, as well as lactate and glucose concentrations were determined. Postoperatively, arterial blood was drawn four times: immediately after surgery and successively; 4, 8 and 12 h following the procedure. RESULTS: Baseline pH was lower and PaO2 was higher in CDI patients (p < 0.001 and p = 0.001, respectively). Additionally, these patients had greater base deficiency at each of the analyzed time points (p < 0.001, p = 0.004, p = 0.012, p = 0.001, p = 0.016 and p = 0.001, respectively). Severe hyperlactatemia was also more common in CDI patients; during the cardiac procedure, 4 h and 12 h after surgery (p = 0.027, p = 0.004 and p = 0.001, respectively). Multivariate logistic regression analysis revealed that independent risk factors for CDI following cardiac surgery were as follows: intraoperative severe hyperlactatemia (OR 2.387, 95% CI 1.155-4.933, p = 0.019), decreased lactate clearance between values immediately and 12 h after procedure (OR 0.996, 95% CI 0.994-0.999, p = 0.013), increased age (OR 1.045, 95% CI 1.020-1.070, p < 0.001), emergent surgery (OR 2.755, 95% CI 1.565-4.848, p < 0.001) and use of antibiotics other than periprocedural prophylaxis (OR 2.778, 95% CI 1.690-4.565, p < 0.001). CONCLUSION: This study is the first to show that perioperative hyperlactatemia and decreased lactate clearance may be predictors for occurrence of CDI after cardiac surgery.

Core Temperature Measurement-Principles of Correct Measurement, Problems, and Complications.

Core temperature reflects the temperature of the internal organs. Proper temperature measurement is essential to diagnose and treat temperature impairment in patients. However, an accurate approach has yet to be established. Depending on the method used, the obtained values may vary and differ from the actual core temperature. There is an ongoing debate regarding the most appropriate anatomical site for core temperature measurement. Although the measurement of body core temperature through a pulmonary artery catheter is commonly cited as the gold standard, the esophageal temperature measurement appears to be a reasonable and functional alternative in the clinical setting. This article provides an integrative review of invasive and noninvasive body temperature measurements and their relations to core temperature.

Prognosis of Hypothermic Patients Undergoing ECLS Rewarming-Do Alterations in Biochemical Parameters Matter?

BACKGROUND: While ECLS is a highly invasive procedure, the identification of patients with a potentially good prognosis is of high importance. The aim of this study was to analyse changes in the acid-base balance parameters and lactate kinetics during the early stages of ECLS rewarming to determine predictors of clinical outcome. METHODS: This single-centre retrospective study was conducted at the Severe Hypothermia Treatment Centre at John Paul II Hospital in Krakow, Poland. Patients ≥18 years old who had a core temperature (Tc) < 30 °C and were rewarmed with ECLS between December 2013 and August 2018 were included. Acid-base balance parameters were measured at ECLS implantation, at Tc 30 °C, and at 2 and 4 h after Tc 30 °C. The alteration in blood lactate kinetics was calculated as the percent change in serum lactate concentration relative to the baseline. RESULTS: We included 50 patients, of which 36 (72%) were in cardiac arrest. The mean age was 56 ± 15 years old, and the mean Tc was 24.5 ± 12.6 °C. Twenty-one patients (42%) died. Lactate concentrations in the survivors group were significantly lower than in the non-survivors at all time points. In the survivors group, the mean lactate concentration decreased -2.42 ± 4.49 mmol/L from time of ECLS implantation until 4 h after reaching Tc 30 °C, while in the non-survivors' group (p = 0.024), it increased 1.44 ± 6.41 mmol/L. CONCLUSIONS: Our results indicate that high lactate concentration is associated with a poor prognosis for hypothermic patients undergoing ECLS rewarming. A decreased value of lactate kinetics at 4 h after reaching 30 °C is also associated with a poor prognosis.