Quality of life after aortic valve repair is similar to Ross patients and superior to mechanical valve replacement: a cross-sectional study.

BACKGROUND: In patients after aortic valve surgery, the quality of life is hypothesized to be influenced by the type of the valve procedure. A cross-sectional study on the postoperative quality of life was carried out in patients after aortic valve-sparing surgery (with regards to the age of the patient), Ross procedure and mechanical aortic valve replacement. METHODS: Quality of life was studied in 139 patients after aortic valve surgery divided into four study groups (Y - aortic valve-sparing procedure at the age below 50 years, mean age 36.2 years; O - aortic valve-sparing procedure at the age 50 years and over, mean age 59.2 years; R - Ross procedure, mean age 37.8 years and M - mechanical aortic valve replacement at the age below 50 years, mean age 39.2 years). SF-36 Short Form and valve-specific questionnaires were mailed to the patients after 6 months or later following surgery (median 26.9 months). RESULTS: In SF-36, the younger aortic valve repair patients and the Ross patients scored significantly better in 4 of 4 physical subscales and in 2 of 4 mental subscales than the older aortic valve repair and mechanical valve replacement patients. In the valve-specific questionnaire; however, all 3 groups free of anticoagulation (Y, O, and R) displayed greater freedom from negative valve-related concerns. CONCLUSIONS: Postoperative quality of life is influenced by the type of aortic valve procedure and is negatively linked with mechanical prosthesis implantation and long-term anticoagulation. Aortic valve-sparing strategy should be considered in cases with suitable valve morphology due to favorable clinical results and beneficial impact on the long-term quality of life.

[Minimally invasive video-assisted operations for heart disease]. / Miniinvazivní videoasistované operace srdecních vad.

INTRODUCTION: Minimally invasive surgical access for the treatment of mitral and tricuspid valves has become an alternative method to the conventional approach via median sternotomy. The aim of this paper is to evaluate our experience and results with minimally invasive approach in cardiac surgery at our institution. MATERIAL AND METHODS: A total of 52 patients underwent minimally invasive cardiac surgery between November 2011 and March 2013. Right lateral minithoracotomy and femoral vessels cannulation for cardiopulmonary bypass was used. Follow-up data was collected in a prospective database and analysed retrospectively. RESULTS: The mean age of patients was 60.9 ± 11.6 years (female patients accounted for 63.5%). The procedures performed included mitral valve repair in 44 (85%) patients and tricuspid valve repair in 25 (48%). Atrial septal defect closure was performed in 8 (15%) patients and cryoablation of atrial fibrillation in 26 (50%) patients. There were 75% combined procedures. The median duration of the operation was 235 (155-315) minutes. The median length of cardiopulmonary bypass and crossclamp time was 139 (89-225) and 92 (51-168) minutes, respectively. The median duration of postoperative hospital stay was 12.5 (6-34) days. Hospital and 30-day mortality was 0%. At follow-up (121.3 ± 32.72 days), two patients (3.8%) required reoperation (1 for right haemothorax, 1 for aortic valve insufficiency). CONCLUSION: Minimally invasive access has been adopted as a routine method for the therapy of valve disease. The minithoracotomy approach is a safe and feasible technique with comparable mortality and in-hospital morbidity.

[Sonographic diagnostics in neurological emergency and intensive care medicine]. / Sonographische Diagnostik in der neurologischen Notfall- und Intensivmedizin.

BACKGROUND: This article gives an up-to-date overview of neurosonographic emergency and intensive care diagnostics. METHODS: Selective literature research from 1984 with critical appraisal and including national and international guidelines. RESULTS: Fast and valid diagnostics in acute stroke is the main field of application of neurosonography. Specific monitoring methods bear great advantages for intensive care patients, especially "as-often-as-wanted" repetitive imaging under real-time conditions. A number of new developments make neurosonography an interesting area of research. CONCLUSIONS: Neurosonography has played a key role in neurological emergency and intensive care medicine for many years. It remains important to continuously support dissemination of the method.

The potential of neurosonography in neurological emergency and intensive care medicine: monitoring of increased intracranial pressure, brain death diagnostics, and cerebral autoregulation­ part 2.

Transcranial B-mode sonography is an easy to use bedside imaging modality to monitor significant changes of the brain parenchyma such as in malignant middle cerebral infarction or intracerebral hemorrhage. The elevation of intracranial pressure can be followed with various neurosonographical techniques: Measurements of the ventricular width, midline shift, arterial resistance, and optic nerve sheath diameter. They should be viewed as complementary to each other and to other imaging modalities. Repeated cCT and MRI may be avoided in unstable patients by bedside neurosonography in the hands of an experienced physician. Monitoring of evolving hydrocephalus using serial measurements of the third and lateral ventricles can be used to guide therapeutic decisions such as the removal of a ventricular drainage. The cessation of cerebral blood flow in the case of intracranial pressure exceeding systemic arterial pressure is an important part of brain death diagnostics. Early demonstration of a sufficient temporal bone window is needed in patients in whom brain death may be expected. Cerebrovascular autoregulation is an integer component of the brain's blood supply and is compromised in a variety of neurological diseases. In neurological/neurosurgical patients in the intensive care unit, its assessment allows for extended neuromonitoring and control of therapeutic procedures.

Brain tumor imaging with transcranial sonography: state of the art and review of the literature.

Transcranial sonography (TCS) is a widely used non-invasive bedside method to evaluate the brain, its vessels, perfusion and pathologies. Transcranial brain tumor sonography emerged in the early nineties and while B-mode imaging and Color-Doppler have acquired widespread use, especially for intraoperative imaging, other ultrasound modalities such as Perfusion Imaging are applied more in the research field. The aim of this review is to give an overview of the different ultrasound modalities and their respective application in sonographic brain tumor imaging.

Transcranial perfusion sonography using a low mechanical index and pulse inversion harmonic imaging: reliability, inter-/intraobserver variability.

PURPOSE: Transcranial perfusion sonography (TPS) is an emerging noninvasive bedside method for evaluating brain perfusion. The purpose was to assess the feasibility of a low MI/almost real-time frame rate approach and to test its intra-/interobserver variability. MATERIALS AND METHODS: 10 healthy volunteers were investigated 3 times with TPS at a low MI (1.0) and a high frame rate (8.3 Hz). Investigations were performed by 2 sonographers in a cross-over design: 1.) twofold measurements each with 5 volunteers (intraobserver test), and 2.) single measurements of the other 5 volunteers (interobserver test). From 8 established regions of interest (ROI), time-intensity curves (TIC) with the following parameters were calculated: peak intensity (PI), time-to-PI (TTP), area-under-curve (AUC), and cerebral transit time (CTT). The TIC quality was described by the coefficient of determination. TIC parameters were presented descriptively. Intra- and interobserver variability was tested by Spearman's correlation. RESULTS: The overall quality of the TIC was very good (mean r(2) = 0.92, 0.87 - 0.97). TTP (25.7 - 28.1 sec; mean 26.8 sec) and CTT (8.2 - 10.7 sec; mean 9.9 sec) were the most robust parameters. The intraobserver variability was lower with the more experienced sonographer (r = 0.70 vs. r = 0.29). The interobserver reliability was r = 0.34 (p < 0.05). CONCLUSION: Low MI TPS allows for nearly real-time imaging facilitating probe control. Sound sonographer experience allows for a high reliability and makes TPS an interesting tool for the diagnosis and follow-up of perfusion changes, e. g. in stroke or anti-angiogenic brain tumor therapy.

[Surgical treatment of ischemic heart disease and diabetes mellitus]. / Chirurgická lécba isthemické thoroby srdecní a diabetes mellitus.

At present, treatment of IHD is relatively frequently surgical. Approximately every fourth patient undergoing surgery for IHD is a diabetic. The surgery itself does not differ from non-diabetic patients except for the specific preparation of a diabetic patient with respect to glycaemia control and with respect to metabolic demands associated with the surgical intervention. Frequent involvement of more extensive as well as more peripheral regions of the coronary arteries makes the surgical intervention more difficult. The differences with respect to mortality have been diminished mainly due to the continuously improving cardiac surgery and expanding knowledge of pathophysiology of DM, enabling better control and correction of glycaemia. However, the differences with respect to morbidity still remain (higher incidence of wound healing problems, higher incidence of strokes, renal failure, longer mean duration of hospitalization). Furthermore, long-term survival in diabetic patients is shorter, particularly due to more rapidly progressing atherosclerosis. The outcomes of IHD treatment in diabetic patients might improve when these well-known issues are fully acknowledged. The best possible diabetes treatment might contribute to this. Surgical treatment of IHD, particularly arterial grafting and use of as gentle as possible approaches (myocardial revascularization from mini-invasive entry pathways, possibly without extracorporeal circulation) also encompass great potential for outcome improvement.

[Aortic valve sparing operations and reconstruction--from anatomy to the long-term results]. / Záchovné operate a plastiky aortální chlopne--od anatomie chlopne az k dlouhodobým výsledkum.

The implantation of an artificial heart valve (a mechanical valve or a xenograft valve) involves the risk of serious and life-threatening complications for the patient, such as hemorrhagic complications, thromboembolic complications, the risk of endocarditis, the risk of premature degeneration of the xenograft valve, etc. Preserving the patient's own aortic valve eliminates or at least significantly reduces the above complications. On the other hand, it brings about the disadvantage of a technically more demanding surgery and the possible risk of reoperation due to failure of the spared aortic valve. The authors present a comprehensive and up-to-date view ofthe issue of aortic valve sparing surgeries and plastic corrections, beginning with the basics of aortic root anatomy and ending with the indications and principles of cardiosurgical techniques, and long-term results.

[Arthroscopy prior to osteotomy in cases of unicondylar osteoarthritis]. / Die Arthroskopie vor kniegelenknahen Korrekturosteotomien bei unikompartimenteller Gonarthrose.

BACKGROUND: Osteotomy around the knee is an established procedure in orthopaedic surgery. However, there is no consensus regarding whether the patient should have arthroscopy prior to osteotomy in the same operative session. PATIENTS AND METHODS: This prospective study included 300 cases of osteotomy around the knee with routine arthroscopy. During arthroscopy, the indication for osteotomy was checked first. Then the cartilage status was determined to modify the type and degree of osteotomy correction accordingly. Finally, therapeutic procedures were performed in cases of intraarticular pathology. RESULTS: The indication for osteotomy was rejected in 51 cases because of worse cartilage status than expected. Twelve patients received immediate or early endoprosthetic treatment. In 208 cases, the degree of correction was modified, in five cases at the level of the osteotomy. For the 288 nonendoprosthetic sessions, there were 268 arthroscopies with therapeutic treatments. CONCLUSION: This study demonstrated that arthroscopy is indispensable for checking the indications for osteotomy, modifying the type and degree of correction, and performing therapeutic procedures.

[Intra-aortic balloon counterpulsation in cardiac surgery patients--experiences of Department of Cardiac Surgery, Charles University, Faculty of Medicine in Hradec Králove, University Hospital Hradec Králové, Czech Republic]. / Intraaortálna balóniková kontrapulzácia u kardiochirurgických pacientov--skúsenosti na Kardiochirurgickej klinike Lékarské fakulty Univerzity Karlovy v Hradci Králové a Fakultní nemocnice Hradec Králové.

AIM: To evaluate the use of intra-aortic balloon pump (IABP) at the Department of Cardiac Surgery, Charles University, Faculty of Medicine in Hradec Králové, University Hospital Hradec Králové and identifying the complications of this method and their frequency in long-term follow-up. METHOD: Retrospective analysis of the outcome of IABP use. From September 1994 to September 2007, 10,024 cardiosurgery operations were performed at the Department of Cardiac Surgery, University Hospital Hradec Králové, Czech Republic. IABP was applied in 363 cases (3.6%). Therapeutic indication for initiation of IABP at our department was the syndrome of low cardiac output in the postoperative period and during operation (difficulty in weaning from cardio-pulmonary bypass) and severe acute ischemic changes of myocardium refractory to pharmacotherapy. Prophylactic IABP was elective introduction of support before cardiac surgery in hemodynamically stable high risk patients. OUTCOME: From the group of 363 counterpulsated patients 192 were succesfully treated (52.9%), 171 patients (47.1%) died in consequence of cardiogenic shock and multiorgan failure. In 20 cases (5.5%) the IABP was introduced before the operation. Complications were observed in 61 patients (16.8%). Vascular complications were found in 27 cases (7.4%) including ischemic changes of the limb (14 cases 3.9%), significant bleeding occurred at the site of puncture (7 cases 1.9%), dissection of the femoral and iliac arteries (2 cases--0.55%), perforation of the iliac artery (1 case--0.3%). In 1 case (0.3%) the balloon was removed for intramural hematoma of the descending aorta without dissection. In 2 cases (0.55%) the balloon was led into the venous system. Thrombocytopenia occurred in our group in 23 patients (6.3%). Technical complications were observed in 7 cases (1.9%). None from our group of couterpulsated patinets had infectious complication. CONCLUSION: IABP is an effective and clinically verified mechanical cardiac support. Our results are similar to other studies.

[Rupture of the interventricular septum after the blunt trauma of thorax]. / Traumatická ruptura mezikomorového septa jako následek tupého poranení hrudníku--kazuistika.

Authors present the case of little patient with the dissection, pseudoaneurysm and finally a rupture of the interventricular septum after the blunt thracic injury. The patient was smitten as a pedestrian by a car and during the whole period of her stay in the hospital she was showing signs of circulatory instability. Due to the current intraabdominal injuries this circulatory decompensation was first assigned to hemoperitoneum, for which the girl was operated on about 3 hours after admission. Nevertheless, even after the abdminal cavity check, after the treatment of supreficial liver lacerations and intensive volume resuscitation the patient showed signs of insufficiency. Diagnosis was finally determined on the base of the transthoracic echocardiography (TTE), which proved the traumatic rupture of interventricular septum. The operation followed correcting the defect, which was performed with a good result according to the TTE postoperatively. Nevertheless, 27 hours after the admission the patient died due to the electromechanical dissociation. In the discussion the authors then evoke a number of papers concerning the same topic.

Comparison of perfusion harmonic imaging and perfusion mr imaging for the assessment of microvascular characteristics in brain tumors.

PURPOSE: The purpose of this study was to evaluate the potential of perfusion harmonic imaging (pHI) for assessing microvascular characteristics of brain tumors and to compare this ultrasound technique to perfusion MRI (pMRI). MATERIALS AND METHODS: Twenty-five patients with brain tumors underwent transtemporal pHI and fourteen of these patients underwent additional pMRI. Time-intensity curves of two different regions of interest (ROIs; (1) enhancing tumor; (2) healthy brain) were calculated off-line, and the following parameters were compared between the two ROIs and the two methodologies: time-to-peak intensity (TTP [sec]), the ratios of the peak intensities (PI ratio), the ratios of the positive slope gradient (PG ratio) and the ratios of the area under the curve (AUC ratio). p < 0.05 was considered statistically significant. RESULTS: Four of 25 patients were excluded due to bone window insufficiency or unfavorable tumor location. Focal abnormal echogenicity was detected in native B-mode in 86 % of the patients. Contrast agent administration led to remarkable echo enhancement in the tumor in all patients with corresponding time-intensity curves. Both pHI and pMRI showed significant differences with respect to the mean PI, PG and AUC (pHI: p < 0.001 / < 0.001 / < 0.001; pMRI: p < 0.05 / < 0.05 / < 0.001) when comparing tumor to healthy brain. The TTP was not significantly different in tumor and brain tissue. Comparison of pHI and pMRI data did not show any significant differences for three of four parameter ratios between both methodologies. CONCLUSION: PHI provides a new technique for assessing microvascular characteristics of brain tumors reflecting their abnormal perfusion. Overall comparison of this methodology to pMRI demonstrated encouraging results. Further studies should address the clinical potential of pHI especially in view of microvascular response to anti-angiogenic treatment.

Transcranial ultrasound perfusion imaging: implementation of a low MI and a high frame rate.

PURPOSE: Conventional transcranial ultrasound perfusion imaging (UPI) depends on bolus injection and is limited to triggered imaging. To improve our set-ups, we compared two imaging modalities with two different frame rates (FR) and mechanical indices (MI), intending to approach conditions more similar to real time imaging in order to increase parameter precision. MATERIALS AND METHODS: Fifteen healthy volunteers were investigated twice with UPI after i. v. administration of 1 ml of SonoVue(R): first, with a high MI (1.6) and a low FR (0.67 Hz)) and second, with a low MI (1.0) and a high FR (5 Hz). Apart from visual analysis, time-intensity curves were calculated from three regions of interest (ROI) and peak intensity (PI), time to PI (TP), and area-under-the-curve (AUC) were compared between the two imaging modalities. RESULTS: Visually, only scarce contrast enhancement was observed in 10/15 probands, and penetration depth was markedly lower at the low MI/high FR setting, while the high MI/low FR setting lead to very intense enhancement in 13/15 individuals. Signal-to-noise-ratio was higher at the low MI/high FR setting. TP was not significantly different between the two set-ups (p > 0.05). PI and AUC were significantly lower at the low MI/high FR setting (p

[Carotid dissection with cerebri media thrombosis due to a tonsillar lesion]. / Karotisdissektion mit Cerebri-media-Thrombose nach Tonsillenverletzung.

A 7-year-old boy suffered a tonsillar lesion due to trauma and presented to hospital with a GCS of 15. Some hours later he developed hemiparesis with loss of consciousness. Angiography displayed a left-sided carotid dissection associated with thrombosis of the arteria cerebri media. After initial treatment by heparinization, the increase of intracranial pressure was treated by craniectomy. The neurological deficits diminished partially after days and reimplantation of the skull cap was possible. The initial hemiparesis decreased slightly during rehabilitation after 5 weeks.

[Penetrating aortic ulcers--case report on endovascular therapy]. / Penetrující aortální vred: kazuistická sdelení endovaskulární lécby.

We report our experience with two cases of endovascular treatment of penetrating aortic ulcers (PAU). The first patient was a 71-year-old woman with 30 mm width aortic ulcer accompanied by intramural hematoma of the descending thoracic aorta. The second patient was an 80-year-old obese woman with 50 mm pseudoaneurysma of the abdominal aorta, which was result of PAU. Both patients were successfully treated by means of tubular stentgraft, implanted from surgical cut down of the right femoral artery. Penetrating aortic ulcer represents localized, potentially lethal pathology of the aorta. Together with dissection and intramural hematoma belongs among the acute aortic syndromes. During nature course PAU can progress to the acute classic dissection, pseudoaneurysma or rupture of the aorta. It is principally disease of elderly hypertensive patients. Early diagnosis and appropriate therapy improves prognosis of patients with PAU. Open surgical repair with synthetic graft has been the gold standard of treatment but endovascular therapy is an attractive option in risk elderly patients. It seems to be a safe, effective treatment but stability of results of this method should be proved.

Intimal flap in a common carotid artery in a patient with Marfan's syndrome.

Dissection of the common carotid artery is a rare but important complication of Marfan's syndrome. The following case describes a patient with formation of an intimal flap of the common carotid artery who had suffered from an aortic dissection years before.

Stroke recurrence and its prevention in patients with patent foramen ovale.

BACKGROUND: It is unclear whether medical or invasive (surgical or catheter interventional) treatment is preferable to prevent recurrence of cerebral ischemia in patients with patent foramen ovale (PFO) as the suspected cause of stroke and what the role of concomitant risk factors is in stroke recurrence. METHODS: Over a period of ten years, 124 patients (mean age 51 +/- 15 years) with cryptogenic cerebral ischemia and PFO were included into the study and prospectively followed over a mean of 52 +/- 32 months. Of these, 83 were treated medically, 34 underwent transcatheter closure, and seven had surgical closure of the foramen. Of the medically treated patients, 11 stopped medication during follow-up. Recurrent ischemic events and risk factors for recurrence were analyzed. RESULTS: Annual stroke recurrence rates were generally low and comparable in catheter and medically treated patients, and in patients who had stopped medication (2.9%/2.1%2.2%/year). Patients suffering from recurrence after transcatheter closure (n = 2) both had residual shunts. No stroke recurrence was observed in the few surgically treated patients. An atrial septal aneurysm was not a predictor of recurrent or multiple strokes (p > 0.05, OR = 0.31, and OR = 0.74). Large shunts and a history of previous ischemic events were considerably more frequent in patients with recurrent strokes (p < 0.05, OR = 5.0, and OR = 4.4). Pulmonary embolism and case fatality rates were significantly higher in patients with stroke recurrence (p < 0.001, and p < 0.01). CONCLUSIONS: The absolute risk of recurrent cerebrovascular events in patients with PFO receiving medical or catheter interventional therapy is low. The small group of untreated patients had a comparably low rate of stroke recurrences. Previous ischemic events and shunt size were risk factors in this observational study. Given conflicting findings across multiple studies, enrollment into a randomized controlled trial would be the optimal choice.

[The endovascular treatment of the aortic trauma]. / Endovaskulární lécba traumatického poranení aorty.

BACKGROUND: Traumatic injuries of the thoracic aorta are very frequent during motor vehicle accidents with sudden deceleration. Spiral CT has become the modality of choice for evaluating significant blunt trauma and grading system for aortic injury has been developed. Immediate diagnosis, introduction of antihypertensive therapy and endovascular treatment by means of stentgraft give a better chance for patients with blunt aortic injury. AIM: Prospective evaluation of results of endovascularly treated patients with blunt aortic injury. MATERIALS AND METHODS: We prospectively followed patients after endovascular treatment of acute aortic injury. Diagnosis was based on chest x-ray and CT examination. Stentgrafts were placed under fluoroscopic guidance and patients were routinely followed by CT and clinical visit. RESULTS: Between December 1999 and September 2004 we endovascularly treated seven patients (6 men, 1 woman, mean age 41.7 years) for blunt aortic injury of the thoracic aorta. Stentgraft was implanted between 5 hours and 6 days (mean 3.2 days) after injury. Seven stentgrafts were implanted in 7 patients in total. One patient died due to failure of endovascular technique for collapsed stentgraft. A new onset of lower legs paraparesis was detected in one patient. Other five patients are regularly followed (3-55 months, mean 30.7 months) without any complications. CONCLUSION: Endoluminal technique can be used successfully in the immediate repair of aortic trauma. At present time in our center, treatment by means of the stentgraft placement is the first line therapy in injured patients. It allows rapid stabilization of aortic trauma and further treatment of other injuries.

Metyrapone and cocaine: a double-blind, placebo-controlled drug interaction study.

Pre-clinical research suggests that suppression of adrenocorticosteroid synthesis might decrease susceptibility to stress-induced relapse. Metyrapone effectively suppresses cortisol synthesis and thus might have promise as a cocaine dependence treatment. The present inpatient study evaluated the interaction of metyrapone and cocaine to assess the safety of conducting an outpatient trial. Twelve nontreatment-seeking cocaine-dependent individuals completed this double-blind, placebo-controlled, crossover study with two factors: medication (750 mg of metyrapone vs. placebo) and infusion (40 mg of cocaine vs. saline). Safety measures included vital signs, adverse events, and electrocardiogram. Efficacy measures included visual analog scale (VAS) ratings of craving and drug effect. Neuroendocrine measures included cortisol and ACTH. As predicted, metyrapone was well tolerated and did not exacerbate cocaine's physiological effects. Also as predicted, metyrapone did not significantly alter cocaine's subjective effects. The results of the present study suggest that metyrapone at the dose studied can likely be used safely in an outpatient study with active cocaine users.