Urgent carotid stenting before cardiac surgery in a young male patient with acute ischemic stroke caused by aortic and carotid dissection.

Introduction: Acute aortic dissection (AD) is the most common life-threatening disorder affecting the aorta. Neurological symptoms are present in 17-40% of cases. The management of these patients is controversial. Case report: We presented a 37-year-old man admitted for complaining of left-sided weak-ness. Symptoms appeared two hours before admission. The patient had no headache, neither thoracic pain. Neurological examination showed mild confusion, left-sided hemiplegia, National Institutes of Health Stroke Scale (NIHSS) score was 10. Ischemic stroke was suspected, brain multislice computed tomography (MSCT) and angiography were performed and right intrapetrous internal carotid artery dissection noted. Subsequent color Doppler ultrasound of the carotid arteries showed dissection of the right common carotid artery (CCA). The patient underwent thoracic and abdominal MSCT aortography which showed ascending aortic dissection from the aortic root, propagating in the brachiocephalic artery and the right CCA. Digital subtraction angiography was performed subsequently and two stents were successfully implanted in the brachiocephalic artery and the right CCA prior to cardiac surgery, only 6 hours after admission. The ascending aorta was reconstructed with graft interposition and the aortic valve re-suspended. The patient was hemodynamically stable and with no neurologic deficit after surgery. Unfortinately, at the operative day 6, mediastinitis developed and after intensive treatment the patients died 35 days after admission. Conclusion: In young patients with suspected stroke and oscillatory neurological impairment urgent MSCT angiography of the brain and neck and/or Doppler sonography of the carotid and vertebral artery are mandatory to exclude carotid and aortic dissection. The prompt diagnosis permits urgent carotid stenting and cardiosurgery. To the best of our knowledge, this is the first published case of immediate carotid stenting in acute ischemic stroke after the diagnosis of carotid and aortic dissection and prior to cardiac surgery

Massive right atrial myxoma with dyspnea at rest in an elderly patient: a case report.

INTRODUCTION: Primary heart tumors are extremely rare and myxoma is the most common type of these tumors. Although intra-atrial presentation is a predilection place, right atrial localization is atypical. The symptom triad is characteristic in the clinical presentation of the tumor: embolic complication, intracardiac blood flow obstruction and systemic manifestations like elevated erythrocyte sedimentation rate, fever, anemia, body weight loss. CASE REPORT: We presented an elderly female patient with massive myxoma in the right atrium, 77 x 44 mm in diameter, which filled the entire right atrium and spread into the right ventricle, causing the tricuspid valve obstruction and dyspnea. It was visualized by transthoracic echocardiography and small and insignificant pericardial effusion was also seen. After surgical removal of the tumor, the patient remained without any symptoms and pericardial effusion. CONCLUSION: Tumors of the right heart have to be considered in the differential diagnosis of unexplained dyspnea in elderly patients. Transthoracic echocardiography is certainly necessary and mostly available diagnostic tool that can be of great help in diagnosing heart tumor as well as planning cardiac surgery, as it provides in most cases excellent visualization of the tumor and its relationship with other parts of the heart.

Functional recovery of patients with ischemic cardiomyopathy treated with coronary artery bypass surgery and concomitant intramyocardial bone marrow mononuclear cell implantation--a long-term follow-up study.

BACKGROUND/AIM: Intramyocardial bone marrow mononuclear cells (BMMNC) implantation concomitant to coronary artery bypass grafting (CABG) surgery as an option for regenerative therapy in chronic ischemic heart failure was tested in a very few number of studies, with not consistent conclusions regarding improvement in left ventricular function, and with a follow-up period between 6 months and 1 year. This study was focused on testing of the hypothesis that intramyocardial BMMNC implantation, concomitant to CABG surgery in ischemic cardiomyopathy patients, leads to better postoperative long-term results regarding the primary end-point of conditional status-functional capacity and the secondary endpoint of mortality than CABG surgery alone in a median follow-up period of 5 years. METHODS: A total of 30 patients with ischemic cardiomyopathy and the median left venticular ejection fraction (LVEF) of 35.9 ± 4.7% were prospectively and randomly enrolled in a single center interventional, open labeled clinical trial as two groups: group I of 15 patients designated as the study group to receive CABG surgery and intramyocardial implantation of BMMNC and group II of 15 patients as the control group to receive only the CABG procedure. All the patients in both groups received the average of 3.4 ± 0.7 implanted coronary grafts, and all of them received the left internal mammary artery (LIMA) to the left anterior descending (LAD) and autovenous to other coronaries. RESULTS: The group with BMMNC and CABG had the average of 17.5 ± 3.8 injections of BMMNC suspension with the average number of injected bone marrow mononuclear cells of 70.7 ± 32.4 x 10(6) in the total average volume of 5.7 ± 1.5 mL. In this volume the average count of CD34+ and CD133+ cells was 3.96 ± 2.77 x 10(6) and 2.65 ± 1.71 x 10(6), respectively. All the patients were followed up in 2.5 to 7.5 years (median, 5 years). At the end of the follow-up period, siginificantly more patients from the group that received BMMNC were in the functional class I compared to the CABG only group (14/15 vs 5/15; p = 0.002). After 6 months the results on 6-minute walk test (6-MWT) were significantly different between the groups (435 m in the BMMNC and CABG group and 315 m in the CABG only group; p = 0.001), and continued to be preserved and improved on the final follow-up (520 m in the BMMNC and CABG group vs 343 m in the CABG only group; p < 0.001). Cardiovascular mortality was also significantly reduced in the BMMNC and CABG group (p = 0.049). CONCLUSION: Implanatation of BMMNC concomitant to CABG is a safe and feasible procedure that demonstates not only the improved functional capacity but also a reduced cardiac mortality in a 5-year follow-up in patients with ischemic cardiomyopathy scheduled for CABG surgery.

Myocardial protection during elective coronary artery bypasses grafting by pretreatment with omega-3 polyunsaturated fatty acids.

BACKGROUND/AIM: Despite recent advances in coronary artery bypass grafting (CABG), cardioplegic cardiac arrest and cardiopulmonary bypass (CPB) are still associated with myocardial injury. Accordingly, the efforts have been made lately to improve the outcome of CPB by glucose-insulin-potassium, adenosine, Ca(2+)-channel antagonists, L-arginine, N-acetylcysteine, coenzyme Q10, diazoxide, Na+/H+ exchange inhibitors, but with an unequal results. Since omega-3 polyunsatutated fatty acids (PUFAs) have shown remarkable cardioprotection in preclinical researches, the aim of our study was to check their effects in prevention of ischemia reperfusion injury in patients with CPB. METHODS: This prospective, randomized, placebo-controlled study was performed with parallel groups. The patients undergoing elective CABG were randomized to receive preoperative intravenous omega-3 PUFAs infusion (n = 20) or the same volume of 0.9% saline solution infusion (n = 20). Blood samples were collected simultaneously from the radial artery and the coronary sinus before starting CPB and at 10, 20 and 30 min after the release of the aortic cross clamp. Lactate extraction/excretion and myocardial oxygen extraction were calculated and compared between the two groups. The levels of troponin I (TnT) and creatine kinase-myocardial band (CK-MB) were determined before starting CPB and 4 and 24 h postoperatively. RESULTS: Demographic and operative characteristics, including CPB and aortic cross-clamp time, were similar between the two groups of patients. The level of lactate extraction 10 and 20 min after aortic cross-clamp time has shown negative values in the control group, but positive values in the PUFAs group with statistically significant differences (-19.6% vs 7.9%; p < 0.0001 and -19.9% vs 8.2%; p < 0.0008, respectively). The level of lactate extraction 30 minutes after reperfusion was not statistically different between the two groups (6.9% vs 4.2%; p < 0.54). Oxygen extraction in the PUFAs group was statistically significantly higher compared to the control group after 10, 20 and 30 min of reperfusion (35.5% vs 50.4%, p < 0.0004; 25.8 % vs 48.7%, p < 0.0001 and 25.8% vs 45.6%, p < 0.0002, respectively). The level of TnT, 4 and 24 h after CPB, was significantly higher in the control group compared to PUFAs group, with statistically significant differences (11.4 vs 6.6, p < 0.009 and 12.7 vs 5.9, p < 0.008, respectively). The level of CK-MB, 4 h after CPB, was significantly higher in the control group compared to PUFAs group (61.9 vs 37.7, p < 0.008), but its level, 24 h after CPB, was not statistically different between the two groups (58.9 vs 40.6, p < 0.051). CONCLUSION: Treatment with omega-3 PUFAs administered preoperatively promoted early metabolic recovery of the heart after elective CABG and improved myocardial protection. This study showed that omega-3 emulsion should not be considered only as a nutritional supplement but also as a clinically safe and potent cardioprotective adjunct during CPB.

[Impact of heart myxoma localization upon its clinical course and outcome].

INTRODUCTION: Primary heart tumors are very rare. They can be benign and malignant. Benign ones make about two thirds of all heart tumors. However, they are benign only by their biologic characteristics, but potentially malignant by their localization. About three forths of benign tumors are myxomas. Their growth is usually slow and they can be for a long time silent, particularly if they do not compromise vital functional parts of the heart. Myxomas grow in the atria, mostly in the left one and very rarely in the ventricles. CASE REPORT: We presented two patients with myxomas in the left, and, in the right atrium which are representative samples of the most common localization of heart myxoma considering previous knowledge of these tumors. Analysis of the clinical course in the two presented patients with characteristic localizations showed general characteristics of the clinical course of heart myxoma. The patients did not have characteristic symptoms for a rather long period of time and the findings obtained by standard examinations did not raise suspicion of heart tumor. Pulmonary symptomatology in one patient and cardial in the other, when tumor had already occupied almost the entire atrium, suggested necessity of cardiologic examination. Indication for operation was in both patients confirmed after performed echocardiography, computed tomography of the thorax and angiography with ventriculography. The size of the removed atrial tumors and their localization explained some of the patients' troubles, but it was also amazing that they had not caused more serious problems. Operation as the only method of treatment was successful in both female patients and its effect was permanent. At annual controls neither recurrence of the tumor nor troubles possibly associated with it were observed. CONCLUSION: Patients with heart myxoma usually pass through asymptomatic or oligosymptomatic phase, but when troubles become manifested, they do not much differ from those due to other causes. For this reason this tumor can be diagnosed just when complications caused by its localization and growth develop. Modern cardiologic diagnostics, primarily preventive non-invasive echocardiography, enables timely diagnosis and removal of the tumor because only then it may take a name benign tumor.

[Diagnosis and results of treatment of heart myxoma].

BACKGROUND/AIM: Myxoma is the most common benign primary cardiac neoplasm, and usually originates from the left atrial septum. Early diagnosis of cardiac myxomas depends on a high index of a clinical suspicion. Surgical management must be done as soon as possible after diagnosis. The aim of this retrospective study was to present diagnostics and treatment outcome data of 61 patients with cardiac myxoma treated in the Military Medical Academy, Belgrade during a 49-years period. METHODS: Intra-hospital diagnosis was established in all the patients by the cardiologist. Diagnostic methods were various, in dependence on the examination period and suspected diagnosis. RESULTS: Within a 49-years period (1961-2009) heart myxoma was diagnozed and treated in 61 patients in the Military Medical Academy, Belgrade. Most of the operated patients were females (38 or 62.3%). The operated patients were 19-68 years old. Average age of all the patients was 47.9%. The great majority of them (98.4%) had atrial, and only one operated patient had ventricular myxoma. In 13 (21.3%) of the patients heart myxoma was found out accidentally due to no previous cardiologic symptomatology. In most patients (27.44%) symptomatology was presented as thromboembolic disease. Because of the suspected ventricular myxoma in one patient, the patient was operated on, but Hodgkin's lymphoma was found out which, according to the subsequent course of the disease, could be justifiably recognized as primary heart lymphoma. This study presented brief descriptions of the course of the disease in 4 patients with myxomas in each of the cardiac cavities. CONCLUSION: The only diagnostic difficulty in cardiac myxoma is due to its asymptomatic and oligosymptomatic presence within the longer period of time, namely, its growth period. Echocardiography should be the standard method of cardiologic examination of these patients, which could considerably contribute to early diagnosis and treatment of heart myxoma. Surgical extirpation of myxoma is the only and very successful therapeutic method.

Epidemiology of nosocomial colonization/infection caused by Acinetobacter spp. in patients of six surgical clinics in war and peacetime.

BACKGROUND/AIM: Acinetobacter spp. has emerged as nosocomial pathogen during the past few decades in hospitals all over the world, but it has increasingly been implicated as a serious nosocomial pathogen in military hospitals. The aim of this study was to analyse and compare the surveillance data on Acinetobacter nosocomial colonization/infection (NCI) collected during the wartime with the data collected in peacetime. METHODS: We conducted a prospective study of incidence of Acinetobacter spp. colonization/infection. Also, the two nested case-control studies were conducted. The patients with nosocomial infection (cases) were compared with those with nosocomial colonization (controls) during the two different periods, wartime and peacetime. The patients with NCI by Acinetobacter spp. were identified by the case-based surveillance. The surveillance covered all the patients in 6 surgical clinics. RESULTS: During the study periods a total of 166 patients had cultures that grew Acinetobacter spp. and the pooled rates of Acinetobacter spp. colonization and infection were significantly higher in wartime. When patients with NCI in wartime were compared with those with NCI in peacetime significant differences were observed. In the war year, the patients were more significantly males (p < 0.000). In a period of peace, most of the colonization/infections were reported from patients with certain chronic diseases (p = 0.020) and the survival of patients was more significant (p = 0.049). During the peacetime, proportions of Acinetobacter isolates resistent to ciprofloksacin, imipenem and meropenem were significantly higher (p < 0.001). CONCLUSION: This study provides additional important information about the risk factors of nosocomial Acinetobacter spp. infections in a large cohort of surgical patients. This is also the first study that directly examines epidemiological differences between NCI caused by Acinetobacter spp. during the war and peace period.

A young soldier with syncope, shortness of breath and palpitations.

INTRODUCTION: Coronary artery disease in people under 30 years is relatively uncommon, but once a disease occurs it brings a significant morbidity and psychological effects. CASE REPORT: We reported a 28-year-old patient presenting atypical symptoms after sincopa and non-specific changes on electrocardiogram at admission. After noninvasive and invasive cardiology diagnostic procedures were made, we concluded that he had a subtotal tubular stenosis in proximal segment of the left anterior descending coronary artery. Myocardial revascularization was successfully performed 24-hour after coronarography with the left internal mammary thoracic artery graft on the left anterior descending coronary artery and the patient had a prompt and satisfactory postoperative recovery. CONCLUSION: This case indicates the importance of a careful evaluation of young adults even if they do not experience typical anginal symptoms or do not have multiple risk factors for cardiovascular diseases.

Sexual rehabilitation after myocardial infarction and coronary bypass surgery: why do we not perform our job?

BACKGROUND/AIM: There is a perception that in patients with heart diseases in Serbia sexual rehabilitation does not exist. Why do we not perform our job? A kind of resistance to sexual rehabilitation is common for heart disease patients. Prejudices regarding patients' sexuality, fear and limited knowledge are not rare among the members of medical staff. The aim of this study was to assess knowledge on sexual rehabilitation, inner sense during conversation on sexual rehabilitation and quality of sexual life in patients with myocardial infarction (MI) and bypass surgery (BPS). Also, we wanted to assess an opinion of the medical staff members about that. METHODS: We performed a prospective nonrandomized clinical study, which involved 40 participants: ten patients, six partners and twenty four medical staff members. All participants were tested by the self-created questionnaires. The main issues of observation were: knowledge about sexual rehabilitation, quality of sexual life and inner sense during conversation on sexual rehabilitation. The data were analyzed by the Shapiro-Wilk test, Kolmogorov Smirnov test, Mann Whitney Exact test and Fishers Exact test. Statistical significance was set up to p < 0.05. RESULTS: There was a statistically significant difference among the participants regarding an attitude when sexual activity should be resumed after MI or BPS. The members of medical staff had a significantly different opinion about the most important team members responsible for sexual rehabilitation performance. There was a statistically significant difference (p = 0.01) in quality of patient's sexual life after MI or BPS (score: 14.2 +/- 5.5) in relation to conditions before them (score: 21.3 +/- 3.1). The members of medical staff had significantly (P = 0.05) worse inner sense (score: 3.8 +/- 0.7) during and after fulfilling the questionnaires than the patients (score: 4.6 +/- 0.5). CONCLUSION: Ignorance and prejudices are reasons why we do not perform our job.

[Heyde's syndrome].

BACKGROUND: Heyde's syndrome implies an association of calcified aortic stenosis with the high gradient of pressure and angiodysplasic bleeding from the digestive tract. It has been proven that in patients with this syndrome, acquired form of von Willebrand type II A develops. Replacing of aortic valves by artificial ones brings about the spontaneous retreat of coagulation disorder, and the stoppage of the digestive tract bleeding. CASE REPORT: We reported two patients with the Heyde's syndrome. In one of the patients the aortic valves were replaced by biologic valves, after which the digestive tract bleeding stopped, while the second patient was treated conservatively due to a high operation risk. CONCLUSION: Patients with Heyde's syndrome are a complex multidisciplinary problem, thus their adequate treatment requires a team work in order to provide the most rational type of therapy for each patient separately.

[Innominate artery war injury].

AIM: A case is reported of successfully surgically treated explosive war injury to the innominate artery. CASE REPORT: A 26-year-old soldier was injured in combat by a fragment of mortar shell. In the field hospital, the wound gauze packing was applied, followed by orotracheal intubation and thoracic drainage. The soldier was admitted to MMA six hours later. Physical examination, on admission, revealed huge swelling of the neck, the absence of pulse in the right arm and the right common carotid artery. Chest x-ray revealed hemopneumothorax of the right side and the foreign metal body in the projection of the right sternoclavicular joint. Due to the suspicion of large vessel injury, a median sternotomy was immediately performed. Surgery revealed disrupted bifurcation of the right innominate artery, so the ligation was performed. Aortography was performed postoperatively, followed by the reconstruction of innominate bifurcation with synthetic grafts. Control aortography showed good graft patency, and the patient was discharged from the hospital in good general condition with palpable pulses and mild anisocoria as a sole neurological sequela. CONCLUSION: A rare and life-threatening injury was successfully managed, mainly due to the rational treatment carried out in the field hospital that helped the injured to survive and arrive to the institution capable of performing the most sophisticated diagnostic and therapeutic procedures.

[Superior vena cava syndrome caused by epitheloid hemangioma].

AIM: A case is presented of the surgical treatment of epitheloid hemangioma as a rare cause of superior vena cava syndrome. CASE REPORT: A 53-year old woman was admitted to the clinic with the symptoms and signs of superior vena cava syndrome. After clinical evaluation and diagnostic tests, she was operated on through median stemotomy, and the desobliteration of the superior vena cava through longitudinal cavotomy was done. After the desobliteration b y the removal o f benign tumor from its cavity, vena cava was reconstructed with the continuous prolen suture. Pathohistologicaly, there was the evidence of epitheloid hemangioma that made the subtotal obliteration of the vena cava superior by its expansive growing at the entry in the right atrium. Postoperatively, there was a complete disappearance of the symptoms and signs of superior vena cava syndrome. After an uneventful recovery, the patient was discharged from the hospital.

[Papillary muscle rupture due to acute myocardial infarction followed by cardiogenic shock, pulmonary edema, and acute renal failure].

AIM: The case of successfull surgical treatment of anterolateral papillary muscle rupture due to acute myocardial infarction with cardiogenic shock, pulmonary edema and acute renal failure. CASE REPORT: A 62-year old male from Belgrade with chest pain, hypotension and a new heart murmur refused hospitalization at the Military Medical Academy. On the third day of his illness he was readmitted to MMA as an emergency due to hemoptysis. Examination revealed mitral valve anterolateral papillary muscle rupture. The patient, with signs of cardiogenic shock and acute renal failure, was immediately operated on. The surgery was performed using extracorporeal circulation. An artificial mitral valve was implanted, and myocardial revascularization accomplished with one venous graft of the left anterior descending artery. On the second postoperative day, hemodialysis was carried out due to acute renal failure. On the 28th postoperative day, the patient was discharged from the hospital being hemodynamically stable with normal renal function and balanced anticoagulation. The case is interesting in terms of unrecognized papillary muscle rupture that led to the development of cardiogenic shock, hemoptysis and acute renal failure. CONCLUSION: Papillary muscle rupture is a fatal complication of acute myocardial infarction. Early recognition and urgent surgical intervention were life-saving in the case of complete papillary muscle rupture. Surgical treatment, regardless of high risk, is the procedure of choice.

[Morphological changes in aorto-coronary vein graft--the analysis of autopsy and biopsy material]. / Morfoloske promene u aortokoronarnom venskom graftu--analiza autopsijskog i biopsijskog materijala.

BACKGROUND: Patients with implanted aortic coronary grafts have different survival time, which raises the question why the efficacy of graft implants is so poor. The aim of this study was to present the results of the analysis of morphological changes in the vein grafts taken after the death of patients who died after surgery in different time intervals, as well to present the analysis of the grafts obtained after surgical reintervention. METHODS: The total number of 656 grafts of 308 dead patients was analyzed, as well as 76 grafts from 40 patients who underwent surgical reintervention. According to the duration of the graft since surgical intervention until death, all the analyzed changes were divided into two groups: a) early changes and complications, and b) late changes and complications in aorto-coronary vein grafts. RESULTS: After the autopsy, 518 vein grafts from the first group were evaluated histopathologically. Changes were found in the form of small or large areas with peeled endothelium in 266 grafts, with the insudation of fibrin and thrombocytes in such places, subendothelial edema, and occlusive thrombosis of the graft lumen. Significant stenosis, which occurred distally from the anastomoses, was present in 118 grafts without changes in the walls of the graft, and there was significant narrowing of the graft lumen in 134 vein grafts due to intimal hyperplasia. In the second group, 138 grafts were histopathologically analyzed after autopsy. Significant hyperplasia was present in 117 grafts with the migration of smooth muscle cells from media into intima, and in 21 grafts there were atheromatous plaques. In 120 veins analyzed before the graft implantation, the lesion or the lack of endothelium was found, as well as the penetration of fibrin and blood elements and intimal hyperplasia. In 46 veins analyzed before the graft implantation, significant intimal hyperplasia with the elevated number of smooth muscle cells was found. CONCLUSION: The most frequent lesions in the grafts were the lesions of the endothelium, which caused thrombosis formation and lumen occlusion. Intimal hyperplasia in patients with longer survival time occurred due to the migration of smooth muscle cells from the media, or due to the formation of atherosclerotic plaques, which caused graft lumen stenosis or thrombosis.