The combined impact of mechanical factors on the wall stress of the human ascending aorta - a finite elements study.

BACKGROUND: Biomechanical factors influence stress in the aortic wall. The aim of this study was to assess how the diameter and shape of the vessel, blood pressure and longitudinal systolic aortic stretching (SAS) caused by the contraction of the myocardium influence stress in the aortic wall. METHODS: Three computational models of the non-dilated aorta and aneurysms of the ascending aorta and aortic root were created. Then, finite elements analyses were carried out. The models were subjected to blood pressure (120 mmHg and 160 mmHg) and longitudinal systolic aortic stretching (0 mm, 5 mm, 10 mm and 15 mm). The influence of wall elasticity was examined too. RESULTS: Blood pressure had a smaller impact on the stress than the SAS. An increase in blood pressure from120 mmHg to 160 mmHg increased the peak wall stress (PWS) on average by 0.1 MPa in all models. A 5 mm SAS caused a 0.1­0. 2 MPa increase in PWS in all the models. The increase in PWS caused by a 10mm and 15mmSAS was 0.2 MPa and 0. 4 MPa in the non-dilated aorta, 0.2­0.3 MPa and 0.3­0.5 MPa in the aneurysm of the ascending aorta, and 0.1­0.2 MPa and 0.2­0.3 MPa in the aortic root aneurysm model, respectively. The loss of elasticity of the aneurysmal wall resulted in an increase of PWS by 0.1­0.2 MPa. CONCLUSIONS: Aortic geometry, wall stiffness, blood pressure and SAS have an impact on PWS. However, SAS had the biggest impact on wall stress. The results of this study may be useful in future patient-specific computational models used to assess the risk of aortic complications.

Increased content of resistin in epicardial adipose tissue of patients with advanced coronary atherosclerosis and history of myocardial infarction.

OBJECTIVES: The aim of the study was to assess whether the plasma level and content of adipokines, in adipose tissue, is associated with a medical history of myocardial infarction. PATIENTS AND METHODS: The study group consisted of 33 consecutive patients (12 females, 21 males, aged 68.6 ± 6.8 years) who underwent cardiac bypass surgery. Patients were divided into groups; group 1 presented with a history of myocardial infarction and group 2 presented without a history of myocardial infarction. During cardiac surgery, samples of epicardial adipose tissue, adipose tissue located at internal mammary artery, subcutaneous adipose tissue, and blood samples were taken for further assessment.Significantly higher levels of resistin in adipose tissue from the epicardial tissue were found in group 1 than in group 2: median and interquartile range, respectively, 37.2 (8.9-121.5) ng/g versus 15.0 (7.1-24.1) ng/g; p < 0.049. Multivariate analysis found that previous myocardial infarction was associated with male gender, older age, and higher content of resistin in epicardial adipose tissue. CONCLUSION: The resistin content in epicardial adipose tissue in patients with advanced coronary atherosclerosis seems higher in those with a history myocardial infarction. Increased resistin epicardial content seems related to the previous myocardial infarction independent of the other established risk factors such as age and male gender. The importance of paracrine function of adipose pericardial tissue in the occurrence of complications of atherosclerosis merits further investigations.

J. Mikulicz-Radecki, K. H. Bauer, and W. Bross. Three great surgeons, three different epochs, one clinic in Wroclaw.

The city of Wroclaw (Breslau) lies where the cultural and economic influences of the eastern, southern, and western Europe meet. Over a thousand years of history it changed the state affiliation several times. Since 1945, similarly as seven centuries ago, it lies within the borders of Poland. The historical complex of hospital buildings constructed at the end of the 19th century for the medical faculty remained almost untouched, despite catastrophic war destructions in the whole city. The building of surgical clinic witnessed epoch-making events in the discipline of surgery performed by the three great personalities. Jan Mikulicz-Radecki (1850-1905), the first head of the department, world famous physician and scientist, created in Wroclaw a modern surgical center. From among his numerous achievements the most important seems to be the performance of the world's first safe thoracotomy in the low-pressure chamber (1904). Karl Heinrich Bauer (1890-1979) was the next great personality, who had been leading the surgical department since 1933. Genetics, transplantology, traumatology and oncology were the main points of his interest. Because of political reasons he had to leave Wroclaw. He continued his surgical and scientific career in Heidelberg. Wiktor Bross (1903-1994) came to the ruined city directly after the World War II. As an experienced general and thoracic surgeon he created a new surgical school. First in Poland open heart surgery (1958) and renal transplantation (1966) were performed by him and his team in the same building, where Mikulicz-Radecki and Bauer worked in the past. The memory of all three great surgeons has been honored by placing their sculptures among the prominent Wroclaw citizens in the city hall.

Readiness for Discharge from Hospital after Myocardial Infarction: A Cross-Sectional Study.

Myocardial infarction (MI) is a common cause of cardiovascular deaths. Education of patients with myocardial infarctions essential to prevent further cardiovascular events and reduce the risk of mortality. The study aimed to evaluate the associations between patients' readiness for hospital discharge after myocardial infarction, acceptance of illness, social, demographic, and clinical factors. The study used a cross-sectional design and included 102 patients, who were hospitalized for myocardial infarction after percutaneous coronary intervention (PCI). Two questionnaires were used: The Readiness for Hospital Discharge After Myocardial Infarction Scale (RHD-MIS) and Acceptance of Illness Scale (AIS). Low readiness characterized nearly half of patients (47.06%), 27.45% of patients showed an intermediate level of readiness, while 25.49% of patients had high readiness. Readiness for hospital discharge was higher among younger patients, respondents living in relationships, living with a family, with tertiary or secondary education, and professionally active. Acceptance of illness was higher among male patients, respondents living in relationships, and family, with secondary education and professionally active. The AIS score positively correlated with readiness for hospital discharge.

Metastasis of adrenocortical carcinoma to the heart.

Not required for Clinical Vignette.

[Big myxoma of the left atrium suggesting pulmonary embolism]. / Duzy sluzak lewego przedsionka o przebiegu sugerujacym poczatkowo zatorowosc plucna.

Cardiac myxomas are rare. They usually appear as a sporadic isolated mass in the left atrium of women with no other pathology. Our patient had symptoms which may suggest pulmonary embolism (PE)-TTE, D-dimers, ECG, laboratory findings seemed to confirm acute PE. Physical examination was unremarkable. Signs of pulmonary hypertension and shortened acceleration time also suggested PE. However, angio-CT excluded it. The patient was transfered to surgical department. During the operation the big myxoma filling the whole space of the left atrium and blocking the entrance to the left ventricle was found and easily removed. Kardiol Pol 2010; 68, 6: 695-696.

Influence of pressure on the endothelium of the saphenous vein coronary artery bypass graft.

The aim of this study was to evaluate the influence of pressure applied while assessing the graft's tightness on the expression of adhesion molecules. Another goal was to find a correlation between the type of fluid (heparynized blood or saline) used during preparation of the conduit and the expression of the adhesion molecules. Saphenous vein fragments were obtained from 48 patients who had undergone coronary artery surgery. Expression of the following particles was evaluated: CD 31, ICAM 1, VCAM 1 and P-selectin. Expression of the CD 31 molecule was described as a percentage of the inner surface of the vessel showing positive immunocytochemical reaction. Expression of the remaining molecules (ICAM 1, VCAM 1, P-selectin) was assessed as the percentage of the surface, determined by CD 31 positive reaction. The expression of the adhesion molecules (ICAM 1, VCAM 1, P-selectin) was higher in the fragments of the vein exposed to pressure. In reference to VCAM 1 the difference, as compared with the control group, was: 250% in the fragments infused with blood and 270% in the fragments infused with saline, respectively. The differences for the ICAM 1 were approximately 300% in both experimental groups and 450% for the P-selectin with subtle differences between the two experimental groups. The loss of the endothelial surface (determined by the expression of the CD 31 antigen) was similar in the specimens flushed either with blood or saline, which indicates that the major cause of damage of the endothelium is influence of pressure on the conduit's wall. Mechanical widening of vessels results in the increased expression of the adhesion molecules on the surface of the endothelial cells, and, as a consequence, leads to rise in the leukocyte adhesion and loss of the functional properties of the transplanted veins.

[Recent myocardial infarction, cardiogenic shock and unsuccessful coronary angioplasty--the pattern of cooperation between a centre without on-site surgical back-up and a distantly located clinical cardiosurgery centre]. / Ostry zawal miesnia serca, wstrzas kardiogenny i nieskuteczna angioplastyka wiencowa--modelowy przyklad wspólpracy osrodka inwazyjnego bez zaplecza sali operacyjnej z odleglym osrodkiem kardiochirurgicznym.

The case of a 66-year-old male with acute myocardial infarction (AMI) complicated by cardiogenic shock is presented. Because of failed primary PCI, after stabilisation of ischaemia and haemodynamics by medication and IABP he was transferred to a distantly located cardiosurgery unit. This patient underwent successful emergency CABG on the second day after infarction. The problem of transporting a patient with AMI and cardiogenic shock to a distant site and the problem of emergency CABG in such high-risk patients is discussed.

[Pseudoaneurysm of the left ventricle in a 42-year-old patient with chronic viral hepatitis and history of infective endocarditis]. / Tetniak rzekomy lewej komory u 42-letniego chorego z przewleklym wirusowym zapaleniem watroby i przebytym w przeszlosci infekcyjnym zapaleniem wsierdzia.

A case of a 42-year-old male patient with symptoms of chronic heart failure, history of infective endocarditis and drug abuse is presented. Echocardiography revealed the presence of pseudoaneurysm of the left ventricle, probably of post-inflammatory origin. Further course of the disease was complicated by multiorgan dysfunction, inflammatory and intravascular coagulation process, which led finally to acute circulatory and respiratory failure and death soon before planned cardiac surgery. Autopsy confirmed the diagnosis of left ventricular pseudoaneurysm.

[Haemolytic anaemia following implantation of the mitral annuloplasty ring: a case report]. / Niedokrwistosc hemolityczna jako powiklanie po zabiegu wszczepienia pierscienia mitralnego.

Haemolytic anaemia following mitral annuloplasty is uncommon as compared with mitral valve replacement procedures. A 67-year-old woman, who underwent mitral annuloplasty and CABG, developed haemolytic anaemia. Echocardiographic examination revealed mitral regurgitation jet colliding with mitral ring. The management of these cases usually demands redo surgery. In the presented case, the direction of mild mitral regurgitant jet with respectfully high velocity contributed significantly to the early postoperative haemolysis. Redo surgery with implantation of bioprosthesis caused withdrawal of intravascular haemolysis.

[Effect of aprotinin on selected parameters of coagulation and drainage blood loss after cardiac operations in patients without coagulation disorders]. / Wplyw aprotyniny na wybrane parametry ukladu krzepniecia i utrate krwi po operacjach kardiochirurgicznych u chorych bez zaburzen krzepniecia.

THE AIM OF THE STUDY: An estimation of influence of different doses of aprotynin on bleeding, coagulation parameters and safety of its use after coronary artery bypass grafting (CABG) in pts without coagulation disorders. MATERIAL AND METHODS: 91 patients underwent CABG, 73 men, 18 women in age 37 to 76 +/- 56.5 years. Patients were randomly assigned to 3 groups; Group I; 38 pts. 6.5 mln KIU aprotynin. Group II; placebo--30 pts. Group III; 23 pts. 2 mln. KIU. There were 4 measurements 1.--before operation, 2. after discontinuing CPB, 3.--6 h after operation, 4.--24 h after operation. We measured Hb, Ht, PLT Glucose, D-dimers, APTT, TT Fibrynogen, INR, AT3, Ca2+, factor V, VIII, GOT GPT CK, CK-MB, CRP, ACT concentration of Hb in drainage 6 h after operation. There were estimated: renal function profile, drainage loss, perioperative MI, mortality, reoperation rate due to bleeding. RESULTS: The level of blood count and coagulation parameters did not differ between the groups in any test periods. D-dimer levels were significantly higher in the placebo group than in group I and III. The decrease of fibrin degradation was not related to the dose of aprotynin. Drainage was insignificantly higher in placebo group. Renal function was impaired in neither group. Reoperation rate perioperative infarction and mortality did not differ between the groups, however was highest in group I. CONCLUSION: Aprotynin reduces blood loss after operation in CPB and decrease fibrin degradation independently to the dose of the drug. The high-dose of aprotynin may increase the risk of early graft occlusion in patients without coagulation disorders.

Computed tomography angiography of aorta subjected to external wrapping.

BACKGROUND: External wrapping is a surgical technique used in patients with dilated ascending aorta. To date, there is no available data describing the radiographic features of the aorta subjected to external wrapping using a straight corrugated Dacron vascular prosthesis. The aim of this study was to find distinctive radiographic features of an externally constricted aorta. METHODS: Preoperative and early postoperative (7th postoperative day) CT angiography images of ten patients who underwent wrapping procedures were assessed and compared. The images were analyzed in order to find characteristic features of CT angiography images of the ascending aorta subjected to external wrapping. RESULTS: The CT-angiography images showed that the aortic wall deformed significantly (the wall plicated) after the wrapping procedure in one patient, whose aortic diameter was decreased by 47 %. The remaining nine patients did not have significant aortic wall deformations. All patients presented with a periaortic mass. This was a collection of blood clots and pericardial fluid that filled the empty space in the pericardium following a decrease in the diameter of the ascending aorta. A very thin (<1 mm) crescent-shaped uncontrasted layer was noticed between the aorta and the periaortic area in all patients. This, in turn, was an empty space between the aorta and the corrugated vascular prosthesis. CONCLUSIONS: The CT-angiography images of the aorta subjected to external wrapping may have unique features that are not observed after other operations on the ascending aorta. The knowledge about the details of this surgical procedure helps to correctly assess these images.

Single center experience with wrapping of the dilated ascending aorta.

BACKGROUND: External wrapping is a surgical technique performed in patients with a dilated ascending aorta. The aim of this study is to present the mid-term results of wrapping of the dilated ascending aorta. METHODS: 34 patients (mean age: 64.4 ± 10.8 years, 21 males) with a dilated ascending aorta were operated on at a single cardiac surgery center using a wrapping technique. The aortas were wrapped with 32-36 mm straight Dacron vascular prostheses. The aortic wall was not excised in any of the patients. Wrapping was performed concomitant to other cardiac surgery procedures in 30 patients (88 %), which involved surgery on the aortic valve in 28 patients (82 %). RESULTS: The mean follow-up time was 19.5 ± 8.3 months (median: 18 months, range: 12-36 months). None of the patients died or had aortic complications during the hospital stay and the follow-up period. A rethoracotomy had to be performed due to excessive postoperative bleeding in two patients. One patient was diagnosed with a transient ischemic attack on the 4th postoperative day, while another had respiratory failure requiring prolonged intubation. No redilatation of the ascending aorta or dislocation of the wrap was noticed in any of the patients. CONCLUSIONS: According to our study, external wrapping of the ascending aorta has good short-term results and may be regarded as a safe surgical option for patients with a moderately dilated ascending aorta.

First beating-heart valve-sparing aortic root repair: a "corset" technique.

We present our preliminary experience with beating-heart aortic root remodeling using an external "corset," which we performed in 2 patients with aortic insufficiency and aortic root dilatation. Standard extracorporeal circulation (ECC) was used. After a meticulous dissection of the aortic root and ascending aorta, the bespoke vascular prosthesis was placed around the vessel to decrease its diameter and restore aortic valve function. Postoperative angiographic computed tomography (CT) showed a significant decrease in the diameter of the wrapped aorta. Echocardiography performed 12 months after the operation showed normal aortic valve function with trivial regurgitation and stable aortic diameter in both patients.

Biomechanical analysis of wrapping of the moderately dilated ascending aorta.

BACKGROUND: External wrapping is a surgical method performed to prevent the dilatation of the aorta and to decrease the risk of its dissection and rupture. However, it is also believed to cause degeneration of the aortic wall. A biomechanical analysis was thus performed to assess the stress of the aortic wall subjected to external wrapping. METHODS: A stress analysis using the finite elements method was carried out on three models: a non-dilated aorta, a moderately dilated aorta and a wrapped aorta. The models were subjected to a pulsatile flow (120/80 mmHg) and a systolic aortic annulus motion of 11 mm. RESULTS: The finite elements analysis showed that the stress exerted on the outer surface of the ascending aorta in the wrapping model (0.05-0.8 MPa) was similar to that observed in the normal aorta (0.03-0.7 MPa) and was lower than in the model of a moderately dilated aorta (0.06-1.4 MPa). The stress on the inner surface of the ascending aorta ranged from 0.2 MPa to 0.4 MPa in the model of the normal aorta, from 0.3 to 1.3 MPa in the model of the dilated aorta and from 0.05 MPa to 0.4 MPa in the wrapping model. CONCLUSIONS: The results of this study suggest that the aortic wall is subjected to similar stress following a wrapping procedure to the one present in the normal aorta.

Does the Stage of Chronic Kidney Failure Influence the Outcome in Cardiac Surgery?

BACKGROUND: The number of patients with chronic kidney failure requiring cardiac surgery is continuously increasing. Additionally, significant worsening in the overall risk profile of this group of patients is noted. OBJECTIVES: To investigate the effect of chronic renal dysfunction both in non-dialysis-dependent renal failure and end-stage renal failure patients, on early mortality--morbidity and late survival in a series of cardiac surgery patients at our institution. MATERIAL AND METHODS: 1344 patients who had open heart surgery at our university hospital between 2010 and 2013 were retrospectively reviewed. Chronic renal dysfunction was defined according to preoperative glomerular filtration rate. Patients selection (n=80). Group 1 mild--(GRF 59-30 mL/min), Group 2 moderate--(GFR 29-15 mL/min), Group 3 end stage--(GFR<15 mL/min) renal failure. RESULTS: Chronic renal dysfunction was present in 5.95% of all patients studied. Group 1--55 (68.75%), Group 2--16 (20%), Group 3--9 (11.25%). No difference between the groups in the need for heart inotropic support was noted; however the use of these medications was necessary in 60.6% of all studied patients. Forty nine percent in Group 1, 87.5% in Group 2 and 77% in Group 3, respectively. Renal replacement therapy in the early postoperative period was needed in 12 patients, with significance between the groups (p = 0.001). The overall hospital mortality was 2.5%. Follow-up was completed with a mean of 1.4 years (range 2 months to 4 years). There were 6 (7.5%) late deaths. CONCLUSIONS: Our observations do not exhibit large variations in postoperative complications and deaths in patients with chronic renal failure, depending on the degree of preoperative renal function impairment. It seems that renal failure regardless of the degree of impairment is a factor aggravating the intra and post-operative course in cardiac surgery patients.

Presence of Periodontopathic Bacteria DNA in Atheromatous Plaques from Coronary and Carotid Arteries.

OBJECTIVES: Interest in periodontitis as a potential risk factor for atherosclerosis and its complications resulted from the fact that the global prevalence of periodontal diseases is significant and periodontitis may induce a chronic inflammatory response. Many studies have analyzed the potential impact of the Porphyromonas gingivalis, major pathogen of periodontitis, on general health. The purpose of this study was to find the presence of the Porphyromonas gingivalis DNA in the atherosclerotic plaques of coronary and carotid arteries and in the periodontal pockets in patients with chronic periodontitis, who underwent surgery because of vascular diseases. METHODS AND RESULTS: The study population consisted of 91 patients with coronary artery disease or scheduled for carotid endarterectomy. The presence of Porphyromonas gingivalis DNA in atheromatous plaques and in subgingival samples was determined by PCR. Bacterial DNA was found in 21 of 91 (23%) samples taken from vessels and in 47 of 63 (74.6%) samples from periodontal pockets. CONCLUSIONS: Porphyromonas gingivalis DNA is frequently found in atheromatous plaques of patients with periodontitis. That is why more research should be conducted to prove if this periopathogen may have an impact on endothelium of patients at risk of atherosclerosis.

Long-term efficacy of surgical ablation of atrial fibrillation in a low-volume centre.

Surgical ablation is a recommended procedure for patients with atrial fibrillation (AF) undergoing a cardiac surgery operation. However, the procedure is associated with significant risk of late recurrence of AF. The aim of the study was to assess the long-term efficacy of the procedure with respect to the comorbidities. The study group consisted of 22 patients: 9 women and 13 men, who underwent surgical AF ablation in the 2008-2013 period. The patients were interviewed by telephone and were asked to send their recently performed 12-lead electrocardiography (ECG). The semi-structured interview consisted of 25 items regarding the history of AF, concomitant comorbidities, lifelong syncopal history, smoking, family history of premature cardiovascular diseases, and current medical treatment. Furthermore, the Epworth test was performed to measure the daytime sleepiness, which in turn is related to the presence of obstructive sleep apnoea. On the basis of the obtained data, the CHADS2, and Epworth scale scores were calculated for each patient. As a result of the study six patients (27%) had sinus rhythm or paced dual chamber rhythm, and 16 patients had atrial fibrillation. The multivariate analysis revealed that Epworth scale scoring > 9, CHADS2 score > 0, and persistent type of AF were related to poor outcome of surgical ablation procedure. In conclusion, patients with AF treated with surgical ablation have similar prognosis of sinus rhythm maintenance to those treated with radiofrequency ablation. Moreover, the same predisposing factors play a significant role in AF recurrence both in surgical patients and in patients treated with radiofrequency ablation.