Reimplantation and long-term mortality after transvenous lead extraction in a high-risk, single-center cohort.

PURPOSE: The use of cardiac implantable electronic devices (CIEDs) has increased significantly over the last decades. With the development of transvenous lead extraction (TLE), procedural success rates also improved; however, data regarding long-term outcomes are still limited. The aim of our study was to analyze the outcomes after TLE, including reimplantation data, all-cause and cause-specific mortality. METHODS: Data from consecutive patients undergoing TLE in our institution between 2012 and 2020 were retrospectively analyzed. Periprocedural, 30-day, long-term, and cause-specific mortalities were calculated. We examined the original and the revised CIED indications and survival rate of patients with or without reimplantation. RESULTS: A total of 150 patients (age 66 ± 14 years) with 308 leads (dwelling time 7.8 ± 6.3 years) underwent TLE due to pocket infection (n = 105, 70%), endocarditis (n = 35, 23%), or non-infectious indications (n = 10, 7%). All-cause mortality data were available for all patients, detailed reimplantation data in 98 cases. Procedural death rate was 2% (n = 3), 30-day mortality rate 2.6% (n = 4). During the 3.5 ± 2.4 years of follow-up, 44 patients died. Arrhythmia, as the direct cause of death, was absent. Cardiovascular cause was responsible for mortality in 25%. There was no significant survival difference between groups with or without reimplantation (p = 0.136). CONCLUSIONS: Despite the high number of pocket and systemic infection and long dwelling times in our cohort, the short- and long-term mortality after TLE proved to be favorable. Moreover, survival without a new device was not worse compared to patients who underwent a reimplantation procedure. Our study underlines the importance of individual reassessment of the original CIED indication, to avoid unnecessary reimplantation.

Case report: Urgent surgical management of pediatric clear cell sarcoma of the kidney with atrial obstruction.

Clear cell sarcoma of the kidney (CCSK) is an uncommon renal neoplasm of childhood. Progression of intracaval or cavoatrial thrombosis is extremely rare and mostly asymptomatic, treated with neoadjuvant therapy followed by surgery. However, in an unstable patient, acute radical surgical intervention is the treatment of choice. We present a 2-year-old girl diagnosed as having a large left kidney tumor and acute cardiac decompensation via cavoatrial thrombotic progression. Urgent radical nephrectomy and removal of tumor thrombus were performed using atriotomy and inferior vena cava (IVC) endarterectomy under cardiopulmonary bypass. Histopathology revealed CCSK. The patient is tumor-free at 9-year follow-up.

Changes in the care of peripheral vascular disease at the University of Szeged / A perifériás érbetegség ellátásának változásai a Szegedi Tudományegyetemen

Introduction and aims. In recent decades health care changes have accelerated enormously. Previously, by learning an effective procedure, the doctor could guarantee his patients the highest level of care for many years. Nowadays, due to the dynamics of development, the renewal cycles of the methods have been shortened, without continuous learning and training, it is already inconceivable to provide the up-to-date care required by patients. Patients and methods. Instead of vascular replacements with prosthetic grafts, which played an important role in vascular reconstructions, the primacy of endovascular techniques has become decisive. It can be significant for aortic aneurysms that can be operated with high invasiveness. The learning of catheter techniques by vascular surgeons made it possible to treat more successfully those limb-threatening cases, which are often associated with extensive vascular involvement, through the so-called hybrid operations. In addition to the increasing prevalence of diabetes worldwide, the higher proportion of critical limb ischemia and the highlighted pathogenic role of multi-resistant bacteria in the disease caused the marginaliation of the use of previously preferred prosthetic grafts. The effectiveness of the treatment of graft infections, which thus become less frequent, is improved by the use of homografts and negative pressure therapy. An effective method of preventing stroke is carotid endarterectomy, the morbidity of which is reduced by the introduction of locoregional anaesthesia allowing direct neuromonitoring. Results/conclusions. Although the acquisition and implementation of new methods has posed a continuous challenge for our specialists and doctors over the past 10 years, our achievements have made our department one of the leading vascular surgery centres in the country.

Clinical significance of the aortic arch and its malformations from fetus to adulthood / Az aortaív-anomáliák klinikai jelentosége a magzattól a felnottkorig.

Összefoglaló. Az intrauterin echokardiográfiás és MR-diagnosztika fejlodése napjainkban jelentos szerepet tulajdonít már az elso trimeszter idejében kimutatható aortaív-fejlodési rendellenességeknek. Célunk volt részletezni a vascularis gyuruk megjelenési formáit, ezek különbözo életkorokban jelentkezo tüneteit, sebészi kezelését, hogy hozzájárulhassunk a helyes felvilágosításhoz, mely alapveto lehet a szülés helyének megválasztásában, így meghatározhassák a magzat sorsát, perinatalis ellátását. A situs inversustól eltekintve a jobb oldali aortaív jelenléte mindig felhívja a figyelmet vascularis gyuru, társuló szívhibák, genetikai betegségek, kromoszómaanomáliák jelenlétére, tehát a magzat további vizsgálata szükséges. Kettos aortaív esetén jelentkezhetnek olyan súlyos tünetek, melyek a megszületés után, kora csecsemokorban sebészi beavatkozást igényelhetnek (szükséges lehet a szülés helyének megválasztása!). Az aberráns jobb arteria subclavia önállóan nem alkot érgyurut, a ritkán társuló truncus caroticusszal csak késobbi életkorban okozhat sebészi beavatkozást igényló enyhe tüneteket. Orv Hetil. 2021; 162(48): 1920-1923. Summary. Nowadays, the development of intrauterine echocardiography and MR diagnostics plays a significant role in aortic arch malformations detected during the first trimester. Our aim was to detail the manifestations of vascular rings, their symptoms at different ages and their surgical treatment options in order to determine the fate of the fetus and its perinatal care. Apart from situs inversus, the presence of the right aortic arch always draws the attention to the possible presence of vascular rings, associated heart defects, genetic diseases, or chromosomal abnormalities, therefore further examinations of the fetus are necessary. In the case of a double aortic arch, severe symptoms may occur, which may require surgery after birth and in early infancy (it may be necessary to choose the place of birth!). The right aberrant subclavian artery does not form a ring and may cause mild symptoms requiring surgery at a later age with rarely associated truncus carotid. Orv Hetil. 2021; 162(48): 1920-1923.

Mitral valve surgery in the treatment of atrioventricular septal defect / A mitralis billentyu sebészete atrioventricularis septumdefektusban.

Összefoglaló. A veleszületett szívbetegségek egyik gyakori formáját jelento atrioventricularis septumdefektus korrekciós mutétjének kritikus pontja a közös atrioventricularis szájadék elválasztásával a mitralis billentyu kialakítása. A korrekció sikere számos anatómiai variáns függvénye, ezért nem lehet minden esetben a tökéletes anatómiai viszonyokat kialakítani. A fennmaradó billentyustenosisok, regurgitatiók a késobbi életkorban progressziót mutatva olyan hemodinamikai kórképeket, keringési elégtelenséget okozhatnak, melyek további beavatkozásokat igényelhetnek. A mitralis billentyunek az atrioventricularis septumdefektushoz társuló betegsége koraszülöttkortól aggkorig minden életkorban elofordul, más-más mutéti megoldást igényelve. A szerzok részletezik a különbözo életkorokra vonatkozóan a napjainkban lehetséges és szükséges mutéti megoldásokat, sebészi kihívásokat. A mitralis billentyu mubillentyure történo cseréjében a klasszikus sebészi megoldások mellett napjainkban új beavatkozásokként jelentos számban jelentkeznek a katéteres intervenciós és hibrid megoldások. A felnottkort egyre nagyobb számban megélo betegek fokozott odafigyelést, speciális ellátást igényelnek a kardiológusoktól, szívsebészektol. Orv Hetil. 2021; 162(35): 1397-1401. Summary. The critical point of the atrioventricular septal defect correction is to separate the common atrioventricular orifice, which results in the reconstruction of the mitral valve. The success of the correction depends on many anatomical aspects, therefore a perfect anatomical outcome is not always possible. The remaining valvular stenoses and regurgitations, showing progression at a later age, may result in hemodynamic disorders and circulatory insufficiency that may require further interventions. Mitral valve disease associated with atrioventricular septal defect occurs at all ages from preterm to adulthood, requiring different surgical solutions. The authors detail the possible and necessary surgical solutions and surgical challenges at different ages. In addition to the classic surgical solutions, a significant number of catheter interventional and hybrid solutions are emerging as new interventions in the replacement of the mitral valve with an artificial valve. An increasing number of patients living in adulthood require increased attention and special care from cardiologists and cardiac surgeons. Orv Hetil. 2021; 162(35): 1397-1401.

Left ventricular rotational abnormalities in adult patients with corrected tetralogy of Fallot following different surgical procedures (Results from the CSONGRAD Registry and MAGYAR-Path Study).

BACKGROUND: Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease (CHD). Abnormal aortic dimensions and elasticity parameters have been long described for corrected TOF (cTOF) together with left ventricular (LV) rotational abnormalities, but results are conflicting. The present study focuses on investigating LV rotational mechanics in cTOF, and possible correlation of these parameters with aortic elasticity. It was also aimed to be examined whether different surgical strategies have any effect on these results. METHODS: The study involved 26 adult cTOF patients, from which 14 had palliative surgery first and a late total correction (pcTOF), while early total correction was the treatment of choice in 12 patients (etrTOF). Their results were compared to those of 37 age- and gender-matched healthy adults. Routine transthoracic two-dimensional Doppler echocardiography extended with assessment of aortic elastic properties and three-dimensional speckle-tracking echocardiography (3DSTE) was performed in all cTOF patients and controls. RESULTS: Sixteen out of 26 cTOF patients showed normally directed LV rotational mechanics, while apical or basal LV rotations were in the same clockwise or counterclockwise directions in 7 and 3 cTOF cases, respectively (LV 'rigid body rotation', RBR). Significantly reduced LV apical rotation and twist could be demonstrated in all cTOF patients with preserved LV basal rotation regardless of previous procedure. pcTOF patients showed significantly reduced LV apical rotation as compared to that of etrTOF cases. Significant correlations could be demonstrated between LV apical rotation and aortic stiffness index (r=-0.55, P=0.03) and aortic distensibility (r=0.52, P=0.04). CONCLUSIONS: Significant LV rotational abnormalities could be demonstrated in cTOF with the high prevalence of LV-RBR. pcTOF patients showed significantly reduced LV apical rotation as compared to that of etrTOF cases. Unexpected abnormal physiologic response of LV rotational mechanics to increased aortic stiffness can be detected in cTOF patients without LV-RBR.

Left ventricular strains correlate with aortic elastic properties in adult patients with corrected tetralogy of Fallot (Results from the CSONGRAD Registry and MAGYAR-Path Study).

BACKGROUND: Aortopathy is a common phenomenon in tetralogy of Fallot (TOF). The current study was designed to detect left ventricular (LV) deformation abnormalities and its relation to aortic stiffness in corrected TOF (cTOF) using the novel three-dimensional (3D) speckle-tracking echocardiography (3DSTE). Detailed comparative analysis between patients with early palliation-late correction (pcTOF) and early total reconstruction (etrTOF) was also performed. METHODS: The present study consisted of 28 cTOF patients (35.0±15.7 years, 11 males) from which 15 and 13 proved to be pcTOF and etrTOF, respectively. Their clinical parameters were compared to those of 39 matched healthy adults (35.5±6.0 years, 16 males). RESULTS: cTOF patients showed significantly lower global LV longitudinal, circumferential and area strains as compared to controls. In etrTOF patients, global LV 3D strain was higher than in controls. In pcTOF patients, all LV strains proved to be significantly lower as compared to those of etrTOF patients and controls. In all cTOF patients, several moderate correlations could be detected between LV strain parameters and aortic elastic properties. CONCLUSIONS: Significant LV deformational abnormalities could be demonstrated in cTOF patients. etrTOF patients have beneficial LV strain parameters as compared to those of pcTOF patients. LV strains show correlations with aortic elastic properties.

Surgical treatment of heart failure due to giant coronary artery fistula: a case report.

Coronary artery fistula is a rare congenital cardiac anomaly that is often found incidentally during computed tomography angiography. Coronary fistula between the left circumflex coronary artery and the coronary sinus is among the less common forms of coronary artery fistula. A 60-yea\r-old female patient presented to our outpatient cardiology department with symptoms of severe, de novo heart failure. Echocardiogram revealed severe mitral regurgitation and a dilated duct that turbulently accelerated colour Doppler flow behind the left ventricle with significant left-to-right shunt. Cardiac magnetic resonance imaging and computed tomography angiography revealed a massively dilated fistula between the left circumflex coronary artery and the coronary sinus with a diameter of 3-4 cm. The patient underwent combined heart surgery involving mitral ring annuloplasty and fistula ligation and was discharged in stable condition on guideline-based medical therapy. At 18 months of follow-up, minimal residual shunt flow and mild-to-moderate mitral regurgitation were found. We report a rare case of congenital coronary disorder resulting in heart failure and highlight the importance of complex non-invasive cardiac diagnostic procedures before planning and performing heart surgery.

Coarctatio aortae: management from infancy to adulthood. / A coarctatio aortae kezelése újszülöttkortól a felnottkorig.

The surgical management of congenital heart defects is changing continuously due to technical development. Aortic coarctation is one of the most frequent congenital heart diseases often with serious symptoms. The authors review the different surgical techniques (end-to-end anastomosis, pathplasty, interposition) and present the up-to-date procedures from infancy to adulthood. We assess the results, the benefits and disadvantages of the different procedures based on our and international experiences. The greatest surgical challenges are the management of the serious hypoplastic aortic arch in infancy and later evolving restenosis and complications (aneurysm, dissection). Nowadays, the management of aortic coarctation is very difficult because the surgical procedures are different in infancy, childhood and adult age. In the latter two cases, it is necessary to apply catheter interventions, too, the correct timing of which also present great challenges nowadays. Orv Hetil. 2020; 161(21): 861-866.

Left Atrial Volumetric and Deformation Analysis in Adult Patients with Dextro-Transposition of the Great Arteries (Insights from the CSONGRAD Registry and MAGYAR-Path Study).

BACKGROUND: In complete or dextro-transposition of the great arteries (dTGA), the aorta and the pulmonary artery are transposed. The present study was designed to examine dTGAassociated left atrial (LA) volumetric and functional abnormalities in adult patients late after repair and to compare their results to those of healthy controls. METHODS: The present study consisted of 15 dTGA patients (30.3 ± 8.1 years, 9 males), the patients had Mustard (n = 8) or Senning (n = 7) procedure performed. Their results were compared to those of 36 age- and gender-matched healthy subjects (28.7 ± 1.5 years, 24 males). RESULTS: Increased maximum LA volume and reduced LA emptying fractions respecting the cardiac cycle could be demonstrated in our dTGA patients. LA stroke volumes representing all LA functions were significantly reduced. Peak LA circumferential, longitudinal, and area strains and LA circumferential, longitudinal, and area strains measured at atrial contraction were reduced in our dTGA patients. Most LA strains were reduced in patients having Mustard surgery compared to controls and patients undergoing Senning operation. CONCLUSIONS: Significant LA volumetric and functional abnormalities could be demonstrated in adult patients with dTGA late after repair. Senning procedure seems to have more beneficial long-term effects on LA volumetric and functional features as compared to the Mustard procedure.

Agricultural systems as potential sources of emerging human mycoses caused by Trichoderma: a successful, common phylotype of Trichoderma longibrachiatum in the frontline.

Trichoderma species are abundant in different agricultural habitats, but some representatives of this genus, mainly clade Longibrachiatum members are also emerging as causative agents of various human diseases with even fatal outcome. Strains of these species frequently show resistance to commonly used azole antifungals. Based on previous data it is hypothesized that Trichoderma isolates identified in human infections derive from environmental-including agricultural-origins. We examined Trichoderma longibrachiatum Rifai and Trichoderma bissettii Sandoval-Denis & Guarro strains recovered from four novel cases of human mycoses, along with isolates from previous case reports and different agricultural habitats, using multilocus phylogenetic analysis, BIOLOG Phenotype Microarrays and Etest. Strains attributed to T. bissettii were more abundant in both clinical and agricultural specimens compared to T. longibrachiatum. The majority of the isolates of both taxa could tolerate >256, >32 and >32 µg/ml fluconazole, itraconazole and posaconazole, respectively. None of the obtained results revealed characteristic differences between strains of clinical and agricultural origin, nor between the two taxa, supporting that agricultural environments may be significant sources of infections caused by these emerging human fungal pathogens. Furthermore, based on our findings we propose the re-classification of T. bissettii as T. longibrachiatum f. sp. bissettii.

[Pediatric coronary artery surgery. A new area in cardiac surgery?] / Coronariasebészet csecsemo- és gyermekkorban. A szívsebészet új ága?

Introduction and aim: Pediatric coronary artery surgery for congenital heart disease has become increasingly important in newborns and infants. It is life-saving in unsuccessful coronary transfer surgery, injury of coronary artery during surgery, in pediatric coronary artery bypass surgery (PCABS) due to acquired Kawasaki disease. Method: We review the current surgical role of congenital and acquired coronary artery diseases in newborns and infants. Results: The 7 main challenges are: 1) anomalous origin of the left coronary artery from the pulmonary artery; 2) different variations of the origins of the coronary arteries in transposition of the great arteries (TGA); 3) acute and late coronary events in the arterial switch operation for TGA; 4) complications after coronary transfer procedures: Ross-, Nikaidoh operation; 5) inadvertent coronary artery injury during heart surgery; 6) Kawasaki disease; 7) coronary artery procedures in premature infants. Direct coronary reimplantation in most, surgical angioplastic procedures in selected patients is the first choice; however, PCABS with internal thoracic artery (ITA) grafts can be life-saving in emergency or severe myocardial hypoperfusion conditions. Since the patency of saphenous vein grafts is poorer than that of ITA grafts, their use should be avoided in growing children. The procedures can be performed safely in neonates and infants, using high-power magnifying glasses or a surgical microscope. Conclusion: Pediatric coronary artery surgery technique is now established as the standard safety surgical choice, as a new area in cardiac surgery. Congenital heart surgeons after proper training are able to use coronary transfer and bypass surgery safely even in premature babies. Orv Hetil. 2019; 160(49): 1935-1940.

Five-Year Outcomes after PCI or CABG for Left Main Coronary Disease.

BACKGROUND: Long-term outcomes after percutaneous coronary intervention (PCI) with contemporary drug-eluting stents, as compared with coronary-artery bypass grafting (CABG), in patients with left main coronary artery disease are not clearly established. METHODS: We randomly assigned 1905 patients with left main coronary artery disease of low or intermediate anatomical complexity (according to assessment at the participating centers) to undergo either PCI with fluoropolymer-based cobalt-chromium everolimus-eluting stents (PCI group, 948 patients) or CABG (CABG group, 957 patients). The primary outcome was a composite of death, stroke, or myocardial infarction. RESULTS: At 5 years, a primary outcome event had occurred in 22.0% of the patients in the PCI group and in 19.2% of the patients in the CABG group (difference, 2.8 percentage points; 95% confidence interval [CI], -0.9 to 6.5; P = 0.13). Death from any cause occurred more frequently in the PCI group than in the CABG group (in 13.0% vs. 9.9%; difference, 3.1 percentage points; 95% CI, 0.2 to 6.1). In the PCI and CABG groups, the incidences of definite cardiovascular death (5.0% and 4.5%, respectively; difference, 0.5 percentage points; 95% CI, -1.4 to 2.5) and myocardial infarction (10.6% and 9.1%; difference, 1.4 percentage points; 95% CI, -1.3 to 4.2) were not significantly different. All cerebrovascular events were less frequent after PCI than after CABG (3.3% vs. 5.2%; difference, -1.9 percentage points; 95% CI, -3.8 to 0), although the incidence of stroke was not significantly different between the two groups (2.9% and 3.7%; difference, -0.8 percentage points; 95% CI, -2.4 to 0.9). Ischemia-driven revascularization was more frequent after PCI than after CABG (16.9% vs. 10.0%; difference, 6.9 percentage points; 95% CI, 3.7 to 10.0). CONCLUSIONS: In patients with left main coronary artery disease of low or intermediate anatomical complexity, there was no significant difference between PCI and CABG with respect to the rate of the composite outcome of death, stroke, or myocardial infarction at 5 years. (Funded by Abbott Vascular; EXCEL ClinicalTrials.gov number, NCT01205776.).

Off-Pump Versus On-Pump Bypass Surgery for Left Main Coronary Artery Disease.

BACKGROUND: Concerns remain for a greater risk of incomplete revascularization and reduced survival with off-pump coronary artery bypass grafting (CABG) surgery compared with on-pump surgery particularly in patients with left main disease and extensive underlying myocardial ischemia. OBJECTIVES: This study sought to compare outcomes following off-pump versus on-pump surgery for left main disease by performing a post hoc analysis from the multicenter, randomized EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial. METHODS: The EXCEL trial was designed to compare percutaneous coronary intervention with everolimus-eluting stents versus CABG in patients with left main disease. CABG was performed with or without cardiopulmonary bypass (on-pump vs. off-pump surgery) according to the discretion of the operator. The 3-year outcomes in the off-pump and on-pump groups were compared using inverse probability of treatment weighting (IPTW) for treatment effect estimation. RESULTS: Among 923 CABG patients, 652 and 271 patients underwent on-pump and off-pump surgery, respectively. Despite a similar extent of disease, off-pump surgery was associated with a lower rate of revascularization of the left circumflex coronary artery (84.1% vs. 90.0%; p = 0.01) and right coronary artery (31.1% vs. 40.6%; p = 0.007). After IPTW adjustment for baseline differences, off-pump surgery was associated with a significantly increased risk of 3-year all-cause death (8.8% vs. 4.5%; hazard ratio: 1.94; 95% confidence interval: 1.10 to 3.41; p = 0.02) and a nonsignificant difference in the risk for the composite endpoint of death, myocardial infarction, or stroke (11.8% vs. 9.2%; hazard ratio: 1.28; 95% confidence interval: 0.82 to 2.00; p = 0.28). CONCLUSIONS: Among patients with left main disease treated with CABG in the EXCEL trial, off-pump surgery was associated with a lower rate of revascularization of the coronary arteries supplying the inferolateral wall and an increased risk of 3-year all-cause death compared with on-pump surgery.

Neuronal Nitric Oxide Mediates the Anti-inflammatory Effects of Intestinal Ischemic Preconditioning.

BACKGROUND: Ischemic preconditioning (IPC) can provide a defense against ischemia-reperfusion (IR)-induced acute inflammation and barrier dysfunction in many organs. Because nitric oxide (NO) has been implicated as a trigger or mediator in the IPC mechanism and because neuronal NO synthase (nNOS) is a dominant isoform of NOS in the gastrointestinal tract, our aim was to investigate the role of nNOS in IPC-induced protection after mesenteric IR. MATERIALS AND METHODS: Intestinal IR was induced in sodium pentobarbital-anesthetized dogs by clamping the superior mesenteric artery for 60 min followed by 2 h of reperfusion (IR group; n = 7). In further groups, IPC was used (three cycles of 5-min ischemia/5-min reperfusion periods) before IR in the presence or absence of selective inhibition of nNOS with 7-nitroindazole (5 mg/kg, intravenously, in a bolus 15 min before IPC, n = 6 each). Changes in mesenteric vascular resistance, intramucosal pH (pHi), and small bowel motility were monitored. Plasma nitrite/nitrate levels, intestinal NO synthase activity, leukocyte accumulation, mast cell degranulation, and histologic injury were also determined. RESULTS: Ischemia significantly decreased mesenteric vascular resistance and pHi, whereas IR induced a temporary bowel hypermotility and acute inflammatory reaction. IPC facilitated pHi recovery, attenuated motility dysfunction, elevated NOS-dependent NO production, and reduced leukocyte accumulation, mast cell degranulation, and mucosal injury. Pretreatment with 7-nitroindazole halted the IPC-induced increase in NO availability, pHi recovery, and the anti-inflammatory and morphologic effects. CONCLUSIONS: Our data demonstrate that NO generated by intestinal nNOS plays a pivotal role in IPC-linked tissue protection by inhibiting an IR-related acute inflammatory response.

Methane inhalation reduces the systemic inflammatory response in a large animal model of extracorporeal circulation.

OBJECTIVES: Extracorporeal circulation induces cellular and humoral inflammatory reactions, thus possibly leading to detrimental secondary inflammatory responses. Previous data have demonstrated the bioactive potential of methane and confirmed its anti-inflammatory effects in model experiments. Our goal was to investigate the in vivo consequences of exogenous methane administration on extracorporeal circulation-induced inflammation. METHODS: Two groups of anaesthetized Vietnamese minipigs (non-treated and methane treated, n = 5 each) were included. Standard central cannulation was performed, and extracorporeal circulation was maintained for 120 min without cardiac arrest or ischaemia, followed by an additional 120-min observation period with haemodynamic monitoring. In the methane-treated group, 2.5% v/v methane-normoxic air mixture was added to the oxygenator sweep gas. Blood samples through the central venous line and tissue biopsies from the heart, ileum and kidney were taken at the end point to determine the whole blood superoxide production (chemiluminometry) and the activity of xanthine-oxidoreductase and myeloperoxidase, with substrate-specific reactions. RESULTS: Methane treatment resulted in significantly higher renal blood flow during the extracorporeal circulation period compared to the non-treated group (63.9 ± 16.4 vs 29.0 ± 9.3 ml/min). Whole blood superoxide production (548 ± 179 vs 1283 ± 193 Relative Light Unit (RLU)), ileal myeloperoxidase (2.23 ± 0.2 vs 3.26 ± 0.6 mU/(mg protein)) and cardiac (1.5 ± 0.6 vs 4.7 ± 2.5 pmol/min/mg), ileal (2.2 ± 0.6 vs 7.0 ± 3.4 pmol/min/mg) and renal (1.2 ± 0.8 vs 13.3 ± 8.0 pmol/min/mg) xanthine-oxidoreductase activity were significantly lower in the treated group. CONCLUSIONS: The addition of bioactive gases, such as methane, through the oxygenator of the extracorporeal circuit represents a novel strategy to influence the inflammatory effects of extracorporeal perfusion in cardiac surgical procedures.

Outcomes following surgical revascularization with single versus bilateral internal thoracic arterial grafts in patients with left main coronary artery disease undergoing coronary artery bypass grafting: insights from the EXCEL trial†.

OBJECTIVES: Observational data suggest that the use of a single internal thoracic artery (SITA) may result in inferior outcomes compared with bilateral internal thoracic artery (BITA) use for coronary artery bypass grafting (CABG)-a finding not yet supported by randomized trial outcomes. However, the optimal number of internal thoracic artery grafts in patients with left main coronary artery disease has not been investigated. METHODS: The EXCEL trial randomized 1905 patients with left main coronary artery disease to percutaneous coronary intervention with everolimus-eluting stents versus CABG. Among the 905 patients undergoing CABG, 688 (76.0%) received SITA and 217 (24.0%) received BITA. Differences in clinical event rates were estimated using the Kaplan-Meier method and compared with the log-rank test. Multivariable Cox regression was used to adjust for differences in baseline covariates. RESULTS: Compared to SITA, patients treated with BITA were younger (66.1 ± 9.5 vs 64.5 ± 9.3 years, P = 0.020), were less likely female (24.3% vs 14.3%, P = 0.002) and diabetic (28.8% vs 15.2%, P < 0.001), and had a lower prevalence of peripheral vessel disease (10.2% vs 5.5%, P = 0.040). The unadjusted 3-year composite primary endpoint of death, stroke or myocardial infarction (MI) occurred in 15.6% of SITA vs 11.6% of BITA patients (P = 0.17). The SITA group tended to have a higher 3-year rate of all-cause death compared with the BITA group (6.7% vs 3.3%; P = 0.070). Stroke, MI and ischaemia-driven revascularization outcomes were not significantly different between groups. After adjusting for baseline differences, neither the composite of death, stroke or MI [hazard ratio (HR) 1.12, 95% confidence interval (CI) 0.71-1.78; P = 0.62] nor mortality (HR 1.36, 95% CI 0.60-3.12; P = 0.46) was significantly higher with SITA. The rehospitalization rate after 3 years was higher in the SITA group (35.8% vs 26.0%, P = 0.008), a difference which was no longer present after multivariable adjustment (HR 1.27, 95% CI 0.93-1.74; P = 0.13). Sternal wound dehiscence within 30 days did not occur more often in the BITA group compared to the SITA group (1.8% vs 2.2%, P > 0.99). CONCLUSIONS: In the EXCEL trial, there were no clinical differences at 3 years between SITA or BITA revascularization in patients with left main coronary artery disease.

[Perioperative use of levosimendan in cardiac surgery. Hungarian recommendation]. / A levoszimendán perioperatív alkalmazása a szívsebészetben. Magyar ajánlás.

Low output syndrome significantly increases morbidity and mortality of cardiac surgery and lengthens the durations of intensive care unit and hospital stays. Its treatment by catecholamines can lead to undesirable systemic and cardiac complications. Levosimendan is a calcium sensitiser and adenosine triphosphate (ATP)-sensitive potassium channel (IK,ATP) opener agent. Due to these effects, it improves myocardium performance, does not influence adversely the balance between O2 supply and demand, and possesses cardioprotective and organ protective properties as well. Based on the scientific literature and experts' opinions, a European recommendation was published on the perioperative use of levosimendan in cardiac surgery in 2015. Along this line, and also taking into consideration cardiac surgeon, anaesthesiologist and cardiologist representatives of the seven Hungarian heart centres and the children heart centre, the Hungarian recommendation has been formulated that is based on two pillars: literature evidence and Hungarian expert opinions. The reviewed fields are: coronary and valvular surgery, assist device implantation, heart transplantation both in adult and pediatric cardiologic practice. Orv Hetil. 2018; 159(22): 870-877.

[Pathophysiology, clinical and experimental possibilities of pericardial tamponade]. / A pericardialis tamponád kórélettana, klinikuma és állatkísérletes vizsgálati lehetoségei.

Acute pericardial tamponade is one of the most emergent clinical scenarios in cardiac surgery. With numerous causes in the background, pericardial tamponade can lead to cardiogenic shock and death. In modern diagnostic era, the recognition of pericardial tamponade is simple, but its management and the long-term effects can still be challenging. Without the detailed understanding of the pathophysiological pathways diagnostic and therapeutic management plans of pericardial tamponade is very difficult. The aim of this review was to give a complex picture of pericardial tamponade, from its role in medical history to pathophysiology and its significance in surgical experimental models. Orv Hetil. 2018; 159(5): 163-167.

[The significance of N-terminal pro-B natriuretic peptide in the management of adult patients with congenital heart disease - Results from the CSONGRAD Registry]. / Az N-terminális pro-B natriureticus peptid jelentosége a felnott korú congenitalis szívbetegek gondozásában ­ Eredmények a CSONGRAD Regiszterbol.

INTRODUCTION: The prognostic role of B-type natriuretic peptide (BNP) level was confirmed in chronic heart failure and congenital heart diseases irrespective of the aetiology. AIM: The aim of this study was to compare NT­proBNP measured in the clinical practice and important clinical and echocardiographic parameters in patients with adult congenital heart diseases under our care. METHOD: Data of a total of 70 patients were analysed; 34 patients had corrected tetralogy of Fallot and 19 patients had corrected transposition of the great arteries. In 17 further cases, patients with other congenital vitiums have been involved in the study. In all cases, out-patient examination was performed with electrocardiography, echocardiography and NT-proBNP measurement. The New York Heart Association (NYHA) stages of the patients were determined and the patients filled in a questionnaire regarding their quality of life. RESULTS: Elevated NT-proBNP level resulted in a worse quality of life (visual analogue scale, VAS) and an increased right ventricular end diastolic diameter; the incidence of arrhythmia increased as well. Negative correlation was found between the NT-proBNP level and the VAS value (r = -0.45, p = 0.0001) and the left ventricular ejection fraction (LV-EF) (r = -0.67, p = <0.0001). ROC analysis showed that NT­proBNP≥668.1 pg/ml was the cut-off value that most accurately predicted NYHA class III-IV (sensitivity 93%, specificity 63%, area under the curve 80%, p = 0.001). Similarly, NT-proBNP≥184.7 pg/ml was found to be the cut-off value most accurately predicting LV-EF below 55% (sensitivity 66%, specificity 67%, area under the curve 77%, p = 0.02). CONCLUSIONS: NT-proBNP has a role in the evaluation of adult patients with congenital heart diseases and in determining the prognosis of these patients, and in addition to other examinations used in the follow-up of these patients, NT-proBNP may help in determining the time of reoperation or potential heart transplantation. Orv Hetil. 2018; 159(4): 141-148.