Candida tropicalis endocarditis on the aortic valve with coexisting meningitis in a patient with multiple risk factors - What to do?

A 65-year-old female patient with Candida tropicalis infective endocarditis on the aortic valve underwent aortic valve replacement. In the postoperative period a head computer tomography revealed a left temporal arachnoid cyst, diagnosed as fungal meningitis. We outline a successful treatment approach for this high-risk patient.

Single versus multiple arterial coronary artery bypass grafting in men and women: results from Polish National Registry of Cardiac Surgery Procedures.

BACKGROUND: The objective of this multicenter study aimed to investigate the impact of sex on long-term survival among patients with multivessel coronary artery disease undergoing coronary artery bypass grafting (CABG) using multiple arterial grafting (MAG) or a single artery with saphenous vein grafts. MATERIALS AND METHODS: Data were obtained from the Polish National Registry of Cardiac Surgery Procedures database. This study included 81 136 patients who underwent CABG for multivessel disease between January 2012 and December 2020 (22.9 were women and 77.1% were men). MAG was performed in 8.3 and 11.7% of female and male patients, respectively. A 1:1 propensity score (PS)-matching was performed. Long-term mortality was compared between matched groups of men and women. Subgroup analyses of patients aged <70 and ≥70 years, with an ejection fraction (EF) >40% and ≤40%, and with and without diabetes, obesity, peripheral artery disease (PAD), or chronic lung disease (CLD) were performed separately in women and men. RESULTS: MAG was associated with lower long-term mortality than saphenous vein grafts in 1528 PS-matched female pairs [hazard ratio (HR): 0.74; 95% CI: 0.59-0.92; P =0.007) and 7283 PS-matched male pairs (HR: 0.80; 95% CI: 0.72-0.88; P <0.001). Subgroup analyses confirmed the results among female patients aged <70 years, with diabetes and EF >40%, and without PAD or CLD, and of male patients aged <70 and ≥70 years; with EF >40%; with or without diabetes, obesity, or PAD; and without CLD. CONCLUSIONS: In patients undergoing CABG, MAG was associated with significantly improved survival in both sexes. The long-term benefits of MAG observed across subgroups of men and women support the consideration of a multiarterial revascularization strategy for a broader spectrum of patients.

Comparison of Repair vs Replacement in Calcific and Rheumatic Mitral Disease.

BACKGROUND: The benefit of repair over replacement of rheumatic or calcified mitral valve (MV) is debatable. METHODS: Patients who underwent MV repair or replacement for rheumatic or calcified MV disease between 2006 and 2020 were identified in the Polish National Registry of Cardiac Surgery Procedures. Patients who underwent additional procedures other than coronary artery bypass grafting or tricuspid valve surgery, as well as redo or emergency cases, were excluded. The long-term survival was verified based on National Health Fund registry data. The survival was compared between MV repair and replacement in the whole cohort and after propensity score matching. RESULTS: We included 4338 patients: 1859 (43%) with pure mitral regurgitation and 2479 (57%) with mitral stenosis. MV was repaired in 543 patients (29%) with pure regurgitation and 126 (5.1%) with stenosis (P < .001). In total, 984 (23%) patients underwent concomitant coronary artery bypass grafting and 1358 (32%) tricuspid valve surgery. MV repair improved survival (hazard ratio 0.81; 95% CI 0.68-0.97; P = .022) in patients with no mitral stenosis, and had no effect in mitral stenosis (hazard ratio 1.17; 95% CI 0.85-1.59; P = .332). The results were confirmed in propensity-matched cohorts. The freedom from MV reoperation at 10 years was 95.5% ± 1.2% after repair and 96.0% ± 0.7% after MV replacement (P = .416) in the absence of stenosis and 91.8% ± 3.4% after repair vs 95.9% ± 0.5% after replacement in patients with mitral stenosis (P = .065). CONCLUSIONS: Repair of rheumatic/calcified mitral valve should be a preferred option in patients with no mitral stenosis, but confers no benefit if mitral stenosis is present.

Infective endocarditis of the tricuspid valve. Surgical treatment with pericardial cylinder implantation.

Introduction: Infective endocarditis (IE) on the tricuspid valve usually requires the complete resection of the infected tissue and implantation of a valve prosthesis. Aim: We assumed that total elimination of artificial material and implantation of the entirely patient-derived biological material would reduce the recurrence of IE. Material and methods: The group consisted of 7 consecutive patients who underwent implantation of a cylindrical valve created from the patient's own pericardium in the tricuspid orifice. There were only men aged 43 to 73 years. Isolated tricuspid valve reimplantation with a pericardial cylinder was performed in 2 patients. Five (71%) patients needed additional procedures. The postoperative follow-up ranged from 2 to 32 months (median: 17 months). Results: In patients who underwent isolated tissue cylinder implantation, the average extracorporeal circulation (ECC) time was 77.5 minutes and aortic cross-clamp time was 58 minutes. In cases where additional procedures were performed the ECC and X-clamp times were 197.4 and 156.2 minutes, respectively. The function of the implanted valve was examined after weaning from the ECC by transesophageal echocardiogram, followed by transthoracic echocardiogram on day 5-7 after surgery revealed normal function of the prosthesis in all patients. There was no operative mortality. Two late deaths were observed. Conclusions: In the follow-up period none of the patients had a recurrence of IE within the pericardial cylinder. Degeneration with subsequent stenosis of the pericardial cylinder occurred in 3 patients. One patient was reoperated on; one had a transcatheter valve-in-valve cylinder implantation.

Beneficial and harmful effects of CB1 and CB2 receptor antagonists on chronotropic and inotropic effects related to atrial ß-adrenoceptor activation in humans and in rats with primary hypertension.

We have previously shown that cannabinoid CB1 and CB2 receptor antagonists, AM251 and AM630, respectively, modulate cardiostimulatory effects of isoprenaline in atria of Wistar rats. The aim of the present study was to examine whether such modulatory effects can also be observed (a) in the human atrium and (b) in spontaneously hypertensive rats (SHR) and normotensive Wistar Kyoto rats (WKY). Inotropic effects of isoprenaline and/or CGP12177 (that activate the high- and low-affinity site of ß1 -adrenoceptors, respectively) were examined in paced human atrial trabeculae and rat left atria; chronotropic effects were studied in spontaneously beating right rat atria. AM251 modified cardiostimulatory effects more strongly than AM630. Therefore, AM251 (1 µM) enhanced the chronotropic effect of isoprenaline in WKY and SHR as well as inotropic action of isoprenaline in WKY and in human atria. It also increased the inotropic influence of CGP12177 in SHR. AM630 (1 µM) decreased the inotropic effect of isoprenaline and CGP12177 in WKY, but enhanced the isoprenaline-induced inotropic effect in SHR and human atria. Furthermore, AM251 (0.1 and 3 µM) and AM630 (0.1 µM) reduced the inotropic action of isoprenaline in human atria. In conclusion, cannabinoid receptor antagonists have potentially harmful and beneficial effects through their amplificatory effects on ß-adrenoceptor-mediated positive chronotropic and inotropic actions, respectively.

Off-pump versus on-pump coronary artery surgery in octogenarians (from the KROK Registry).

BACKGROUND: According to the medical literature, both on-pump and off-pump coronary artery surgery is safe and effective in octogenarians. OBJECTIVES: The aim of our study was to examine the epidemiology, in-hospital outcomes and long-term follow-up results in octogenarians undergoing off-pump and on-pump coronary artery surgery utilizing nationwide registry data. METHODS: All octogenarians (≥ 80 years) enrolled in the Polish National Registry of Cardiac Surgical Procedures (KROK Registry), who underwent isolated coronary surgery between January 2006 and September 2017 were identified. Preoperative data, perioperative complications, hospital mortality and long-term mortality were analyzed. Unadjusted and propensity-matched comparisons were performed between octogenarians undergoing off-pump and on-pump coronary artery bypass surgery. RESULTS: Octogenarians accounted for 4.1% of the total population undergoing coronary artery surgery in Poland during the analyzed period (n = 152,631) and this percentage is increasing. Among 6,006 analyzed patients, 2,744 (45.7%) were operated on-pump and 3,262 (54.3%) were operated off-pump. Propensity-matched analysis revealed that patients operated on-pump were more often reoperated due to postoperative bleeding and their in-hospital mortality was higher (6.6% vs 4.5%, p = 0.006 and 8.7% vs 5.8%, p = 0.001, respectively). Long-term all-cause mortality was lower among patients operated off-pump (p = 0.013). CONCLUSION: On the basis of our findings we suggest that off pump technique should be considered as perfectly acceptable in octogenarians.

Effectiveness of surgical closure of left atrial appendage during minimally invasive mitral valve surgery.

BACKGROUND: Left atrial appendage closure (LAAC) reduces the risk of stroke in patients with atrialfibrillation. It can be performed surgically from the inside of the left atrium or from the outside. Stapling or clipping devices can also be used from the outside. Despite providing an excellent interior view of the appendage, those techniques cannot be implemented during minimally invasive mitral valve surgery conducted through right­sided minithoracotomy. AIMS: This study aimed to assess the effectiveness of surgical closure of the left atrial appendage from the inside during minimally invasive mitral valve surgery. METHODS: A total of 50 patients with mitral valve disease and atrial fibrillation who underwent minimallyinvasive mitral valve surgery and LAACbetween 2012 and 2017 were included in this study. The appendagewas closed from the inside using a continuous suture. After a median follow­up of 1.6 years after surgery, 19 patients were examined by transthoracic and transesophageal echocardiography (TEE). Transesophageal echocardiography was performed to assess whether the appendage had been effectively closed. When any leakage was suspected, cardiac computed tomography was performed. RESULTS: In 19 patients, TEE was performed at 0.5 to 5 years after the surgery. A single patient did not tolerate TEE, and minimal leakage was suspected in 2 patients. All 3 individuals underwent computed tomography examination, which confirmed leakage in a single patient. CONCLUSIONS: Surgical LAACduring minimally invasive mitral valve surgery through right minithoracotomyis an effective technique that provides durable results.

Impact of diabetes mellitus on the contractile properties of the left and right atrial myofilaments.

OBJECTIVES: The incidence of diabetes mellitus in patients with ischaemic cardiomyopathy is increasing. To evaluate the impact of diabetes mellitus on contractility, we examined the calcium-induced force in left and right atrial myofilaments of patients with and without diabetes. METHODS: We included 149 patients (106 without diabetes, 43 with diabetes), scheduled for elective coronary artery bypass grafting from August 2016 to June 2017. The left and right atria were excised and prepared for skinned fibre measurements (pCa-force curve). The unit for the force measurements is Millinewton (mN). Comprehensive demographic data as well as echocardiographic findings of the patients were collected. RESULTS: We observed a significant decrease of left atrial force values in patients with diabetes, averaged over all calcium concentrations (patients with diabetes 0.50 ± 0.19 mN vs 0.68 ± 0.23 mN in patients without diabetes, P = 0.002) as well as in right atrial fibres (patients with diabetes 0.35 ± 0.17 mN vs 0.47 ± 0.21 mN in patients without diabetes, P = 0.005). There was a significant influence of repeated measurements (of the calcium concentrations) on force in left atrial myofilaments (P < 0.001). There was also a significant impact of diabetes on the force values of the different calcium concentrations in left atrial myofilaments (P 0.002). In right atrial myofilaments we also found a significant influence of repeated measurements (of the calcium concentrations) on force (P < 0.001). Additionally the impact of diabetes on the force values was significant (P = 0.005). CONCLUSIONS: We demonstrated that diabetes mellitus has a significantly negative impact on calcium-induced force development in left and right atrial myofilaments.

Single-centre experience in surgery of acute aortic type A dissection and true aortic arch aneurysm.

BACKGROUND: Surgery of the aortic arch is challenging. AIM: To assess the results of aortic arch surgery. METHODS: Analysis of 172 patients operated on arch dissection (emergency group: 97 patients) or aneurysm (elective group: 75 patients) between 2007 and 2014. Arch surgery was defined as a procedure requiring circumferential anastomosis at the level of the aortic arch or the descending aorta with the use of techniques of brain protection (deep hypothermic circulatory arrest [DHCA] or selective antegrade cerebral perfusion [SACP]) and/or debranching of at least one supra-aortic vessel. RESULTS: Men predominated in both groups (> 70%). Men were younger in the emergency group (55 vs. 66 years; p < 0.008). The operative risk was higher in the emergency group (19.2% vs. 12.5%; p < 0.001). Forty-nine per cent of the patients from the emergency group and 5% from the elective group were operated with antiplatelet therapy (p < 0.001). Extended hemiarch procedure was performed in 79% (n = 77) in the emergency and 76% (n = 57) in the elective group. Total arch replacement was performed in 19 (21%) patients from the emergency and 18 (24%) patients from the elective group. In these patients debranching was performed in 68% of the emergency patients group and in 67% of the elective group. Elephant trunk procedure (classic/frozen) was performed in 53% (n = 10) from the emergency and in 78% (n = 14) of patients from the elective group. Aortic valve sparing surgery was performed in 20% of patients from the emergency and 9% from the elective group (p = 0.063). DHCA was performed in 58% (n = 43) of patients from the elective group and 39% (n = 37) from the emergency group. SACP was performed in 61% (n = 58) of patients from the emergency and 42% (n = 31) from the elective group. Thirty-day mortality in the emergency group reached 33% (n = 32), and in the elective group 15% (n = 11; p = 0.007). In multivariate analysis, predictors of death in the emergency group were: Logistic EuroSCORE above 19.5%, extracorporeal circulation time above 228 min, and postoperative acute renal failure (ARF); and in the elective group: DHCA time above 26 min, rethoracotomy due to bleeding, and ARF. Follow-up was completed in 100% of patients in terms of vital status. The mean follow-up time of the patients from the emergency group was 24.3 ± 27.10 (min 0, max 92) months, and from the elective group 30.3 ± 24.5 (min 0, max 99) months. During the follow-up period all-cause mortality in the emergency group was 43% (n = 42/97), and in the elective group it was 36% (n = 27/75). CONCLUSIONS: Early mortality in the emergency group was higher, while long-term mortality did not differ among the groups. Postoperative ARF is a critical predictor of mortality in both groups.

Thrombocytopenia and perioperative complications after stentless Freedom Solo valve implantation.

BACKGROUND: Freedom Solo (FS) stentless bioprostheses have superior haemodynamic performance compared to stented valves; however, the data of thrombocytopenia after FS implantations is disturbing. AIM: To compare platelet count and perioperative complications between stentless and stented biological valves in patients undergoing aortic valve replacement. METHODS: In 29 patients, FS bovine valves (Sorin Group, Saluggia, Italy) were implanted. Platelet counts were analysed before surgery, on the day of operation, on four consecutive postoperative days (POD) as well as at discharge, and compared to 29 control patients with biological stented porcine valves (Labcor Laboratorios TLBP-A Supra). The analysis of the perioperative variables extracorporeal circulation (ECC), aortic cross clamping (XC) and mechanical ventilation times, as well as blood supply, was performed. RESULTS: Initial platelet counts were comparable in both groups. In the FS group, platelet levels on the four consecutive POD were significantly lower. The lowest platelet value (13 × 10³/µL), related to fatal thrombotic thrombocytopenic purpura, was found in one patient from the FS group. ECC as well as XC and mechanical ventilation times, were significantly longer in the FS group, and more blood transfusions in these patients were required. In multiple regression analysis, ECC and XC times did not correlate with platelet count. CONCLUSIONS: Implantations of FS stentless bioprostheses are related to significantly lower platelet counts. Severe perioperative complications and their relation to thrombocytopenia need further evaluation.

Infective mitral valve endocarditis after transapical aortic valve implantation.

An 80-year old patient underwent a transapical aortic valve implantation. On the 28th postoperative day, the patient developed acute mitral valve endocarditis. Initially, the patient was unsuccessfully treated conservatively. After 71 days, the patient was operated on with mitral valve replacement. In this report, we discuss the potentially growing problem of complications related to transcatheter valve implantation.

[Apicoaortic valved conduit as an alternative method of surgical treatment of aortic stenosis - a case report]. / Wszczepienie protezy zaopatrzonej w zastawke pomiedzy koniuszkiem lewej komory a aorta zstepujaca jako alternatywna metoda operacji zwezenia zastawki aortalnej - opis przypadku.

A case of a 73-year-old patient with critical aortic stenosis, porcelain aorta and occluded femoral arteries is presented. We performed apico-aortic valved conduit (A-AVC) without cardiopulmonary bypass (CPB). Hegar dilator inserted through the apex into the left ventricle allowed anastomosis of dacron tube to the apex. Valved conduit was anastomosed to the descending aorta. Both tubes were connected. Before the operation, maximal gradient through the valve was 95, after operation dropped to 33 mmHg. This method of apical anastomosis allowed to perform A-AVC without CPB in a patient with extremely high peri-operative risk while using CPB.

[The analysis of risk factors for fetal macrosomia and the complications in the course of pregnancy and delivery of macrosomic baby]. / Analiza czynników predysponujacych do makrosomii plodu oraz przebieg ciazy i porodu w przypadkach ciaz powiklanych duza masa plodu.

UNLABELLED: Newborns weighing 4000g or heavier, are defined as macrosomic. OBJECTIVES: The purpose of this study was to present the risk factors of macrosomia, the course of pregnancy and the frequency of maternal outcomes associated with the delivery of macrosomic fetuses. MATERIALS AND METHODS: The retrospective analysis included 670 gravidas hospitalized at The Department of Reproduction and Obstetrics, Medical University of Wroclaw, between 1999 and 2004, who delivered babies weighing at least 4000g. RESULTS: The majority of macrosomic neonates (80%) were given birth to by women over the age of 25, who gained over 15 kilos in the course of the pregnancy. Macrosomy tends to affect primiparas most frequently. The medium duration of macrosomic pregnancy was 40.61 +/- 1.15 weeks. The percentage of deliveries by cesarean section amounts to 38.5%. Vaginal deliveries are burdened with significant risk of maternal complications. CONCLUSIONS: Women over 30, medium height or tall, who gain over 15 kilos during the pregnancy, tend to deliver macrosomic babies. Multiparas who had given birth to the marosomic babies once before, are predisposed to deliver macrosomic neonate in the following pregnancy. On the basis of our studies, we have determined 4kg as a borderline birth weight for increased frequency of parturient canal injuries.

[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.

[Surgical restoration of left ventricle after myocardial infarction]. / Chirurgiczna rekonstrukcja pozawalwo uszkodzonej lewej komory serca.

Heart failure is currently one of the biggest problems of all heath care systems in the world and will become even more important. In about 50% of the patients, heart failure is a consequence of myocardial infarction. The surgical reconstruction of the left ventricle after anterior myocardial infarction became the first effective method of treatment which can be applied in many patients. After anterior myocardial infarction the apical part of the ventricle dilates, becomes more spherical with thinned wall. Dilated, spherical apex results in rise of wall tension of the transition zone between the apex and the proximal part of the left ventricle. This increases oxygen demand and reduces coronary blood flow. This phenomenon is responsible for severe angina pectoris and explains why myocardial infarction is the most common cause of death of patients with LV aneurysm. Increased wall tension of the transition zone leads to fibrosis, further dilatation and decrease of contractility of the left ventricle. Only surgical reconstruction of the left ventricle can stop this progressive process. The aim of surgery is to decrease the wall tension by restoring the normal elliptical shape, geometry and volume of the left ventricle. Results of this operation are very promising. Perioperative mortality is about 5% and 5-year survival 80%.

[Early results of coronary artery bypass reoperations in own experience]. / Wczesne wyniki reoperacji wiencowych w materiale wlasnym.

UNLABELLED: Coronary Artery Bypass Grafting (CABG) is widely accepted as an effective and durable method of treatment of Coronary Artery Disease. In some patients however, recurrent angina and the necessity of reoperation (RE-CABG) occurs. AIM: The aim of the study is the estimation of the results of RE-CABG in own material. MATERIAL AND METHODS: In years 1995-2002 CABG operations were performed in 3452 patients (CABG group) and RE-CABG in 37 pts (1.07%) (RE-CABG group). Patients were considered for operation on condition of the presence of symptomatic CAD confirmed by coronarography in standard projections. Operations were performed using Cardiopulmonary Bypass. RESULTS: The CABG group consisted of 3452 pts in mean age 57.9 years, including 2693 men (78%) and 759 (22%) women. The RE-CABG group was composed of 37 pts in mean age 60.7 years, comprising 22 (59.5%) men and 15 (40.5%) women. The percentage of women in CABG group was significantly higher than in CABG group. The mean age in RE-CABG group was insignificantly higher than in CABG group. In the CABG group 3.1 anastomosis/pt were performed, including anastomosis IMA to LAD in 2779 pts (80.5%). From this group only in 2 pts (0.07%) coronary reoperations were performed. In the remaining 673 pts from CABG group during the first operation, only saphenous vein graft were performed and in 35 (5.2%) coronary reoperation was necessary. This difference is statistically significant. In-hospital mortality in CABG group was 5%, the IABP was used in 7.8% of pts. Mortality in the RE-CABG group reached 8.1% (3/37), the IABP was used in 16.2% (6/37). CONCLUSIONS: 1. The use of arterial grafts during the first coronary operation decreases the reoperation rate. 2. RE-CABG are performed in the older patient rather than CABG. 3. RE-CABG are performed more frequently in women than in men as compared to CABG. 4. RE-CABG are burdened with twice as high mortality rate and the necessity of use of IABP than CABG.