Paraoxonase 1 low activity and SYNTAX score may predict postoperative complications after coronary artery surgery.

OBJECTIVE: Coronary artery bypass grafting (CABG) seems to present a powerful trigger of oxidative stress (OS) and acute inflammatory response. This study aimed to estimate the effects of off-pump coronary artery bypass (OPCAB) grafting on the OS that is commonly observed in patients undergoing operation under cardiopulmonary bypass (CPB). Additionally, we aimed to examine the relationship between and paraoxonase 1 (PON1) activity and the degree of stenosis, severity and complexity of the atherosclerotic lesions, estimated by SYNTAX score (SS). PATIENTS AND METHODS: Study group of 107 patients scheduled for CABG were divided into CPB and OPCAB group. Blood samples for OS markers measurement were collected at six-time intervals: before skin incision (t1), immediately after surgery (t2), 6h (t3), 24h (t4), 48h (t5) and 96h after cessation of the operation and surgical trauma (t6). SS was calculated. RESULTS: A significant decrease in lipid hydroperoxides (LOOH) and advanced oxidation protein products (AOPP) levels after both types of surgeries were observed, whereas PON1 reduction was observed higher in the CPB than in the OPCAB group. A significant inverse correlation between SS values and PON1 activity, preoperatively and during the early postoperative hours after surgery [in t2, t3 time intervals (p<0.05 for all)] was found. ROC analysis showed that for CPB patients, Model with all OS parameters showed excellent accuracy (AUC=0.957, p<0.001) for prediction postoperative complications. CONCLUSIONS: Decrease in PON1 activity during the early post-operative phases was related to higher SS. This relationship was more convincing in CPB, compared with OPCAB patients. Moreover, integrated models of OS status parameters have the capability to predict the development of postoperative complications.

Surgical Technique: Laparoscopic Gastric Sleeve Resection in Super-Obese Patients.

Laparoscopic gastric sleeve (LGS) resection in super-obese patients (BMI > 50 kg/m2) is a challenging procedure. We have developed a unique approach and technique for LGS with no buttress stapling and without oversewing. After 102 operations there have been no leaks and late complications.

[Functional status of patients after surgical myocardial revascularization].

UNLABELLED: Determination of patient's functional status in early postoperative period is a delicate task, because of its general health status. Measures that can be used for that purpose are walk tests and functional status questionnaires. OBJECTIVE: To determine correlation of different functional tests administered preoperatively and two minute walk test (2MWT) done postoperatively. To detect predictors of early functional recovery measured with two minute walk test. METHOD: We examined ninety eight patients hospitalized for an elective coronary artery bypass graft surgery in February and March 2008. Functional status was assessed preoperatively using Duke Activity Status Index questionnaire (DASI), generic health related quality of life questionnaire and two minute walk test. Prior to discharge from the hospital, two minute walk test was repeated along with VAS for intensity of pain. Statistical analyze was done using Pearson's correlation coefficient, T test and multivariate regression analysis. RESULTS: Distance walked in 2 minutes decreased significantly postoperatively (p < 0.001). There was significant correlation between DASI and SF -12 preoperatively (r = 0.6 p < 0.001) and DASI preoperatively with 2MWT postoperatively (r = 0.4 p < 0.001). 2MWT postoperatively showed good correlation with intensity of pain (r = -0.42 p < 0.001) and age (r = -0.35 p < 0.001). There were no significant correlation with comorbidity, number of bypasses or postoperative complications. Multivariate regression analysis showed that the age was the strongest independent predictor of functional recovery (beta = - 0.33 < 0.05p) and that values of DASI preoperatively had moderate importance in prediction of functional status(beta = 0.238 p < 0.06). CONCLUSION: 2MWT was sensitive to change postoperatively. Significant correlation of 2MWT postoperatively with DASI preoperatively, age and VAS, as well as prediction capacity of age and DASI, gives us possibility to utilize those parameters in early rehabilitation program in order to achieve maximal functional recovery of patients.

Simultaneous surgical treatment of ruptured abdominal aortic aneurysm and acute carotid occlusive disease.

Combined rupture of abdominal aortic aneurysm and acute thrombosis of internal carotid artery is extremely rare but fatal combination resulting in high mortality rate. Presented case, shows successfully performed simultaneous surgery of ruptured abdominal aortic aneurysm and acute cerebrovascular insult caused by thrombosis of carotid artery in 81 year-old male. Post operative course was uneventfull. At 24 months follow up patient was in good condition, with full neurological recovery. Simultaneous surgical treatment of acute occlusive carotid disease and ruptured abdominal aortic aneurysm (RAAA) seems to be the only life saving procedure for this rare, but very complicated condition. To our knowledge, this is the first reported successful simultaneous surgical treatment of RAAA and acute thrombosis of internal carotid artery.

[Off-pump myocardial revascularization (OPCAB) in patients with post-infarction unstabile angina, low ejection fraction and renal disfunction].

UNLABELLED: The purpose of this study is to present our experience in off-pump myocardial revascularization in patients with post-infarction unstable angina, left ventricular low ejection fraction and renal dysfunction. MATERIAL AND METHODS: From January 1998. until march 2002, at the Institute for Cardiovascular Diseases in Clinical Centre of Serbia, we have operated 20 patients with post infarction unstable angina, echocardiographicaly proved low ejection fraction (less than 30%) and renal dysfunction (Serum Creatinin 150 micrograms per liter) using this method. All patients were male and they were between 52 and 79 years old. Preoperative characteristics, surgical treatment and postoperative course are presented. RESULTS: There was no hospital mortality, as well as important morbidity. There was no worsening of the renal and myocardial function. Postoperative ICU stay was from 1 to 2 days. Postoperative hospital stay was between 3 and 7 days. CONCLUSION: Off-pump myocardial revascularization is safe and effective procedure in all patients with left ventricular low ejection fraction and renal dysfunction.

[Differential diagnosis of deep vein thrombosis]. / Diferencijalna dijagnostika tromboze dubokih vena.

UNLABELLED: The incidence of deep venous thrombosis (DVT) is high in numerous surgical and medical diseases [1]. There are increasing data on higher incidence of DVT in patients with malignant and other diseases [2]. The diagnosis of DVT is not always simple since there are subclinical and asymptomatic forms of the disease [3]. Besides, there are numerous pathological conditions that imitate deep venous thrombosis [4]. METHODS: We present the results of a retrospective study over the period of January 1, 1996--June 30, 1998 at the Department of Vascular Surgery. Over that period we treated 113 patients (64 females, 49 males, average aged 60.3 +/- 7.5 years) with clinical picture of deep venous thrombosis. All patients underwent duplex scanning examinations (Toschiba SSA-100 A, 3.5 MHz and 8 MHz probes) [5, 6]. Special examinations such as angiography (8 patients), computerised tomography or nuclear magnetic resonance (27 patients) were performed in cases with unclear findings. RESULTS: True DVT was established in 91 (80.3%) patients (Fig. 1). Seven of these patients had asymptomatic phlebothrombosis. Of 12 (10.6%) patients in 9 other pathologic conditions were found (Fig. 2). This symptomatic DVT was caused by malignant diseases (5 sarcomas, 2 metastatic carcinomas, 1 lymphoma); aneurysms of common femoral artery (2) and popliteal artery (2 patients). Ten patients (8.9%) with clinical picture of DVT established by special examinations had no evidence of the presence of intravenous thrombs (Fig. 3). This pseudo DVT was caused by calf haemathoma (3), Baker's cyst (2), popliteal artery aneurysm (1), lipoma of thigh (1), psoas abscess (1), gluteal abscess (1) and acute arthritis of the knee (1). The treatment of these groups of patients was different: surgical thrombectomy, use of streptokinase or heparine (true deep vein thrombosis), tumour extraction (Fig. 4) or another surgical treatment (symptomatic phlebothrombosis) and special decompression measures (Fig. 5) (pseudophlebothrombosis). DISCUSSION: Aetiopathogenesis of true DVT is determined by Virchov's triad [3, 4, 7, 8]. The incidence of DVT in medical and surgical patients is high (30-75%). Initially true DVT may be asymptomatic in 35-70% of patients [1, 3, 8] and depended on detection methods [1, 6, 7, 9, 10]. DVT may be only a symptom of other pathological conditions [2, 3, 7]. This symptomatic DVT is mostly caused by malignant diseases [2]. Pseudo DVT or primary deep vein obstruction may be caused by external abnormalities (right common iliac artery; compression of the left common iliac vein, malignant disease, retroperitoneal fibrosis, internal iliac compression of the external iliac vein, latent femoral hernia compression of the femoral vein, masses in the thigh (large tumours, true or false aneurysms, popliteal masses/aneurysms, large Baker's cysts), changes in the wall or within the lumen of a vein as aplasia, primary tumours, intraluminal spurs [7].

[Analysis of programmed pacing rate levels in patients with the carotid sinus hypersensitivity syndrome and implanted Clarity pacemakers]. / Analiza nivoa programisane frekvencije impulsa pejsmejkera kod bolesnika sa sindromom preosetljivosti karotidnog sinusa u ugradjenim pejsmejkerom "Klariti".

New Clarity DDDR pacemaker system (Vitatron Medical B.V.) Clarity DDDR, provides an option for recognizing sudden rate drop and responding by intervention pacing until it detects the recovering. In patients in whom syncopal episodes are mainly caused by occasional drops in heart rate, Sudden Rate Drop Intervention feature intends to provide high rate intervention pacing. We have implanted 10 of these devices in our Centre, 2 of which in patients with hypersensitive carotid sinus syndrome. In patients with carotid sinus syndrome it is possible to provoke this situation by sinus caroticus massage. In both patients, we activated Sudden Rate Drop Intervention on DDD mode pacing and used protocol for testing the necessary level of sudden Rate Drop Intervention Rate. Both patients gave their informed consent to be submitted to this testing. Pacemaker software assumes rate intervention level of 110 bpm. We tested our patients for rate levels of 90 and 110 bpm. Massaging the carotid sinus during 5 seconds, we provoked sudden Rate Drop Intervention 10 times, in each patient, 5 times at intervention rate of 90 and 5 times at 110 bpm. Patients were unaware of the programmed intervention rate and were merely expected to report any different sensations experienced during the testing. In all 20 tests, pacemaker responded to sudden rate drop elicited by carotid sinus massage (100%), that was verified by selected event recordings. After the massage, no patient experienced any sensation at sudden rate drop intervention rate level of 90 bpm in a total od 10 tests (100%), while 8 of 10 messages at 110 bpm intervention rate provoked palpitations (80%). We concluded that lowering of Sudden Rate Drop Intervention Rate Level from 110 BPM to 90 BPM did not affect the reliability of system reaction, but changes of patient's awareness of heart beats. As a final conclusion, it should be said that basic prerogatives of a pacing system are: safety and efficacy with minimal energy consumption, and in this case, quality of life option that a patient practically does not feel intervention when it occurs, are all met.

Permanent endocardial pacing by cephalic vein access in new-borns and infants--surgical techniques.

Most centers worldwide use permanent endovenous cardiac electrostimulation in children requiring pacing whose body mass is over 10kg. The normal implantation route is via a subclavian vein puncture. In our Center, we have implanted permanent endovenous pacing systems for complete AV block in nine children with a mean body mass 7.4kg (range 2.45-10kg). The endovenous lead was placed using cephalic vein cutdown procedure. To allow 'sliding' during the child's growth, the lead was secured by absorbable sutures.