Bicuspid aortic valve repair: outcomes after 17 years of experience.

OBJECTIVES: This study presents the results of 17 years of experience with bicuspid aortic valve (BAV) repair and the analysis of factors associated with repair failure and early echocardiographic outcome. METHODS: Between 2003 and 2020, a total of 206 patients [mean age: 44.5 ± 15.2 years; 152 males (74%)] with BAV insufficiency with or without aortic dilatation underwent elective aortic valve repair performed by a single surgeon with a mean follow-up of 5 ± 3.5 years. The transthoracic echocardiography examinations were reported. RESULTS: There were no deaths during the hospital stay, and all but 1 patient survived the follow-up period (99.5%). Overall, 10 patients (5%) developed severe insufficiency and 2 (1%) developed aortic dilatation requiring reoperation. Freedom from reoperation at 7 years reached 91.8%. Type 2 BAV configuration [hazard ratio (HR) 3.9; 95% confidence interval (CI): 1.01-60; P = 0.049], no sinotubular junction remodelling (HR 7; 95% CI: 1.7-23; P = 0.005), no circumferential annuloplasty (HR 3.9; 95% CI: 1.01-64; P = 0.047) and leaflet resection (HR 5.7; 95% CI 1.2-13. P = 0.017) have been identified as a risk factor of redo operation. Parameters of the postoperative left ventricle reverse remodelling improved significantly early after the operation and later at 2 years evaluation. CONCLUSIONS: The repair of BAV offers good short- and mid-term results providing a significant reverse left ventricular remodelling. Type 0 BAV preoperative configuration, circumferential annuloplasty and sinotubular junction remodelling are associated with better repair durability.

The evaluation of annuloplasty in bicuspid aortic valve repair using cardiac magnetic resonance.

BACKGROUND: The incompetent bicuspid aortic valve (BAV) can be replaced or repaired using various surgical techniques. This study sought to assess the efficacy of external annuloplasty and postoperative reverse remodelling using cardiac magnetic resonance (CMR) and compare the results of external and subcommissural annuloplasty. METHODS: Out of a total of 200 BAV repair performed between 2004 and 2018, 21 consecutive patients (median age 54 years) with regurgitation requiring valve repair with annuloplasty without concomitant aortic root surgery were prospectively referred for CMR and transthoracic echocardiography (TTE) one year after the operation. Two aortic annulus stabilization techniques were used: external, circumferential annuloplasty (EA), and subcommissural annuloplasty (SCA). RESULTS: 11 patients received EA and 10 patients were treated using SCA. There was no in-hospital mortality and all patients survived the follow-up period (median: 12.6 months (first quartile: 6.6; third quartile: 14.1). CMR showed strong correlation between postoperative aortic recurrent regurgitant fraction and left ventricular end-diastolic volume (r = 0.62; p = 0.003) as well as left ventricular ejection fraction (r = -0.53; p = 0.01). Patients treated with EA as compared with SCA had larger anatomic aortic valve area measured by CMR (3.5 (2.5; 4.0) vs. 2.5 cm2 (2.0; 3.4); p = 0.04). In both EA and SCA group, aortic valve area below 3.5 cm2 correlated with no regurgitation recurrency. EA (vs. SCA) was associated with lower peak transvalvular aortic gradients (10 (6; 17) vs. 21 mmHg (15; 27); p = 0.04). CONCLUSIONS: The repair of the bicuspid aortic valve provides significant postoperative reverse remodelling, provided no recurrent regurgitation and durable reduction annuloplasty can be achieved. EA is associated with lower transvalvular gradients and higher aortic valve area assessed by CMR, compared to SCA.

Upregulated sulfatase and downregulated MMP-3 in thoracic aortic aneurysm.

BACKGROUND: Thoracic aortic aneurysm (TAA) formation is accompanied by degradation of extracellular matrix components (EMC). Numerous matrix metalloproteinases (MMPs) have been implicated in the process, but the involvement of MMP-3 remains unclear. Additionally, the changes in proteoglycan (PG) structure can alter the signal transduction pathways in TAA, though the enzymatic systems which originate them are not fully understood. OBJECTIVES: To measure MMP-3 and sulfatase levels in aneurysmal tissue, comparing them with non-aneurysmal vessels, and to investigate possible correlations with patients' serum levels in order to evaluate their potential usefulness in aiding aneurysm detection and monitoring. MATERIAL AND METHODS: The study included 74 patients (TAA: n = 42; control group: n = 32). Sulfatase activity was measured colometrically and MMP-3 levels were measured immunoenzymatically. RESULTS: Sulfatase activities were higher (p = 0.03) and MMP-3 concentrations lower (p = 0.014) in aneurysmal tissue than in normal aortic tissue. Medium-sized dilatations were associated with lower tissue MMP-3 concentrations than small dilatations (p = 0.033). No differences in sulfatase activity or MMP-3 concentration in the serum of TAA patients were observed in comparison with the controls. The serum and tissue levels of MMP-3 were correlated (r = 0.41; p < 0.001). The serum levels of MMP-3 were significantly lower in the female patients than in the male patients (p = 0.006). CONCLUSIONS: Our studies confirmed the lower MMP-3 levels in aneurysmal tissue, but the lack of a statistically confirmed reduction of MMP-3 in the blood serum seems to preclude its usefulness for diagnostic purposes. Our study points to the differences in MMP-3 behavior between TAA and abdominal aortic aneurysms. Significantly higher sulfatase activity in TAA tissue suggests a possible impact of sulfatase on signal transduction pathways involved in aneurysm formation.

Liver function after transplantation in the assessment of the coagulation system and the concept of antithrombotic therapy.

INTRODUCTION: Thrombotic complications after liver transplantation limit the long-term success of the procedure. Therefore, an early and accurate diagnosis with the appropriate treatment is crucial to sustain the proper functioning of the graft. AIM: To evaluate the return of newly transplanted liver function within the first days of ICU stay after liver transplantation surgery (Ltx) observed in laboratory examination. It is important to understand the physiology of the newly transplanted liver, particularly in terms of its metabolic function and the assessment of easy-to-monitor coagulation parameters and enzyme markers. MATERIAL AND METHODS: We present our observations carried out in 27 patients, transplanted in the period 2015-2017, during their stay in the Department of Anaesthesiology and Intensive Therapy of the University Hospital in Wroclaw. We demonstrated changes in laboratory parameters within 72 h after liver transplantation and the concept of anticoagulant therapy at our institution. RESULTS: The presented results show the characteristics of aspartate transaminase, alanine transaminase, bilirubin, and standard tests evaluating the coagulation system within the first 4 days after surgery. The concept of anticoagulant therapy used in our intensive care unit is also presented. The aim of the work is an observation of physiology of the graft function in the aspect of coagulation disorders. CONCLUSIONS: The early postoperative period is considered prognostic. The characteristics of basic biochemical tests are determined by the function of the transplanted organ. Implementation of anticoagulant therapy in this period is a therapeutic challenge that requires experience.

Platelets function assessment in patients qualified for cardiac surgery - clinical problems and a newer diagnostic possibilities.

BACKGROUND: As the incidence of cardiovascular diseases increases, the use of antiplatelet therapy is widely recognized. This presents clinicians with the challenge of balancing the risk of thrombotic and bleeding complications. Platelet dysfunction is one of the causes of postoperative bleedings and their etiology is not fully understood. Platelets receptors point-of-care investigation is of a remarkable value in assessing patients risk of bleeding. Reliable assessment of platelet function can improve treatment. The aim of this study was to evaluate the activity of platelet receptors in patients qualified for cardiac surgery, taking into account organ dysfunctions and pharmacological therapy applied in these patients. METHODS: Seventy-one cardiac surgical patients were analyzed before surgery using multiple electrode aggregometry with the use of the ADP test and ASPI test. The cut-off values were determined based on the manufacturer's recommendations. Patients were divided into four groups: Group I (33/71 patients, without platelet dysfunctions), Group II (6/71 patients, ADP < 710 AU x min), Group III (13/71 patients, ASPI < 570 AU x min) and Group IV (19 / 71 patients, ADP < 710 AU x min and ASPI < 570 AU x min). Biochemical data defining the efficiency of the liver and kidneys, the list of preoperative drugs used and the requirement for transfusion throughout the study group were collected. RESULTS: The study group included 41 males (57.7%) and 30 females (42.3%), mean age 66 years. The majority of patients (94.4%) had platelet counts within the normal range, but platelet function was impaired in more than half of the studied patients (53.5%). No relationship was found between the biochemical markers of the kidneys and liver and the function of the ADP and ASPI receptors, while receptors activities were related (rs = 0.72, p < 0.001), and both associated with platelet count (rs = 0.55, p < 0.001 and rs = 0.42, p < 0.001, respectively). Platelet receptors activity was not related to the postoperative need for any type of transfusion as well as the applied preoperative pharmacological therapy. CONCLUSIONS: Early identification of patients at high risk of bleeding, using point-of-care platelet function assessment tests, enables a targeted therapeutic pathway. Due to the variety of factors affecting the activity of platelets, finding a specific cause of this pathology is extremely difficult. According to our study, the correlation between platelet receptor disorders and mild to moderate liver and kidney injury has not been demonstrated. However, platelet receptors dysfunction has been shown to be associated with a decreased number of platelets.

Lipomatous hypertrophy of the atrial septum - a benign heart anomaly causing unexpected surgical problems: a case report.

BACKGROUND: Lipomatous hypertrophy of the atrial septum (LHAS) is an anomaly of the heart. It is characterized by an infiltration of adipocytes into myocytes of the interatrial septum, sparing the fossa ovalis, which gives a characteristic hourglass-shaped image. Due to the progress in imaging techniques, it can be recognized more frequently, but it is still often misdiagnosed. CASE PRESENTATION: We present a case of 65-year-old woman with an incidentally discovered lipomatous hypertrophy of the atrial septum during cardiac surgery, which has caused the technical problems for surgeons with bicaval cannulation and visualization of the operated structures of the heart. Due to the unclear shadow in the lung parenchyma, the patient had preoperative computed tomography (CT) done, but the study report focused only on the lung description, neglecting visible changes in the structure of the heart. Based on the standardly performed intra-operative transesophageal echocardiography (TEE), as well as by analyzing the chest X-ray and CT scans, the diagnosis of LHAS was made. It allowed the surgeon to leave the mass intact, thus not increasing the risk of the baseline surgery. CONCLUSIONS: LHAS is a rare but increasingly recognized anomaly of the heart. Contemporary diagnostic methods allow to diagnose and make the right therapeutic decisions. The utility of TEE and analysis of X-ray images, in this case, allowed the surgeon to recognize LHAS, and because of its histologically benign nature and asymptomatic course, to leave this change intact. Surgical treatment should be limited only to cases of patients with life-threatening cardiovascular complications.

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.

Dynamic occlusions in natural permanent dentition.

OBJECTIVES: The problem of occlusion pattern for prosthetic or orthodontic rehabilitation continues to be discussed in the literature. This controversial dilemma may be solved by studying the prevalence of dynamic occlusions in natural permanent dentition. The aim of this study was to assess which schemas of dynamic occlusion are typical of natural dentition in young and older subjects and to determine if any dynamic occlusions are dependent on gender or age. METHOD AND MATERIALS: A total of 834 subjects with natural dentition and no prosthetic replacements were included in the study. The age of the subjects ranged from 20 to 63 years. Dynamic occlusions in all subjects were identified during clinical examination of lateral and protrusive tooth-guided excursions of the mandible. RESULTS: The following dynamic occlusions were found: bilateral and unilateral canine-protected occlusion, group function occlusion, balanced occlusion, and "other occlusions." Occurrences of particular forms of dynamic occlusion were almost the same in men and women; however, some of the occlusions were dependent on age. The frequencies of bilateral and unilateral canine-protected occlusions decreased with age, while the frequency of group function occlusion increased. The frequencies of balanced occlusion and "other occlusions" were very low and remained nearly unchanged in relation to age. CONCLUSION: Bilateral canine-protected and group function occlusions were the most typical occlusions for younger patients, while group function occlusion was more common for older patients. The canine-protected occlusion seems to be the most suitable pattern for orthodontic and prosthetic rehabilitation planned in younger patients, while the group function occlusion may be a good pattern for prosthetic rehabilitation in older patients. Further studies are needed to determine the relationship of the occlusal schemas to periodontitis, bruxism, or temporomandibular disorders.