Impact of previous percutaneous coronary interventions on the course and clinical outcomes of coronary artery bypass grafting.

BACKGROUND: Despite the increasing number of patients after percutaneous coronary intervention (PCI) requiring coronary artery bypass grafting (CABG), studies on the impact of these procedures on surgical revascularisation outcomes are sparse. Furthermore, advances in cardiology require reassessment of their potential prognostic significance. AIM: We sought to assess the influence of previous PCI on CABG outcomes. METHODS: A total of 211 consecutive patients scheduled for CABG were enrolled into this prospective study. Patients after PCI (group 1, n = 99) were compared with subjects with no history of PCI (group 2, n = 112) in terms of preoperative, operative, and postoperative data. All the patients were followed-up for the incidence of in-hospital (cardiogenic shock, myocardial infarction, stroke, acute renal failure, reoperation, death) and long-term (overall mortality, occlusion of at least one graft in 64-row computed tomography) clinical endpoints. RESULTS: Group 1 had more advanced heart failure and coronary artery disease as reflected by New York Heart Association (2.43 ± 0.57 vs. 2.17 ± 0.68; p < 0.001) and Canadian Cardiovascular Society (2.44 ± 0.59 vs. 2.03 ± 0.65; p < 0.001) scales, respectively. Compared with group 2, longer aortic cross-clamp (33.5 ± 9.9 vs. 29.5 ± 8.4; p < 0.05) and cardiopul-monary bypass (67.5 ± 28.2 vs. 56.5 ± 17.9; p < 0.001) times were observed as well as a higher number of implanted grafts (3.0 ± 0.7 vs. 2.8 ± 0.70; p < 0.05). No significant differences were observed in terms of in-hospital clinical endpoints. During 12 ± 3.41 months of follow-up group 1 had higher mortality (5.05% vs. 0%; p < 0.05) but similar graft patency. CONCLUSIONS: "Stent-loaded" patients undergo more time-consuming CABG with a higher number of grafts. Furthermore, they have higher long-term mortality but similar graft patency and in-hospital mortality/morbidity.

Implantation of mitral, aortic, and tricuspid bioprostheses due to infective endocarditis with necessary reimplantation of the bioprosthetic aortic valve.

The patient was admitted to the Department of Cardiac Surgery of the J. Strus City Hospital in Poznan due to infective endocarditis involving the aortic, mitral, and tricuspid valves. Implantation of three biological valve prostheses proceeded without complications. Starting on day 23, the patient's general condition deteriorated, with high fever. Despite postoperative antibiotic therapy, transesophageal echocardiography revealed the presence of vegetation on the bioprosthetic aortic valve. On the 46th day after the initial surgery, the patient required replacement of the aortic bioprosthesis, which exhibited the presence of numerous vegetations. The bioprosthetic mitral and tricuspid valves were not affected by the degenerative process. On the 12th day after the reimplantation of the bioprosthetic aortic valve, the patient was discharged from the hospital in good general condition.

Penetrating thoracic injuries - treatment of two patients after suicide attempts.

Thoracic injuries are usually caused by penetrating or blunt trauma. The primary method of treatment is surgery. This study describes two cases of male patients with stab wounds of the chest resulting from suicide attempts. The first case involved a 29-year-old patient transported and admitted to the hospital with a knife still in his chest; its blade extended from the jugular notch to the 5(th) thoracic vertebra but did not damage any important structures. The applied treatment, limited to evacuating the knife, resulted in a satisfactory outcome, and the patient was discharged from the intensive care unit (ICU) in good condition. The second patient reached the hospital on his own. On admission, he did not reveal the real cause of the wound; however, in view of his deteriorating condition, he admitted that the knife penetrated deeply into the mediastinum. In this case, sternotomy was necessary to stop the bleeding of the pulmonary trunk and internal thoracic artery. After completion of treatment, the patient was discharged in good condition. The described management of life-threatening situations conducted by a multidisciplinary team of consultants enabled the choice of optimal treatment methods and resulted in successful outcomes.

[Septic shock in 23 year old female patient after surgical correction of the nasal septum effectively treated in the intensive care unit]. / Wstrzas septyczny u 23-letniej pacjentki po operacji korekcji przegrody nosa leczony skutecznie w oddziale intensywnej terapii.

A female patient 23 years old was admitted to the medical intensive care unit due to sudden loss of consciousness and seizures. At the time of admition observed lack of consciousness, seizures and severe critical condition was observed. Meningitis and septic shock were diagnosed. Based on computed tomography performed on the first day--inflammation of the sinuses soft tissues was diagnosed. Suspected cause of infection was performed 6 weeks earlier surgical correction of the nasal septum. In the next stage of treatment on the seventh day after admission the functional endoscopic sinus surgery was performed. Due to massive tissue hypoperfusion the necrosis in the skin of the lower limbs occurred. Due to the lack of effectiveness antimicrobial therapy use of intravenous ceftaroline was administrated. Effective treatment allowed in day 11 to wean the patient from the ventilator. At the day 26 the patient was transferred to a hospital in the place of residence.

[Isolated tricuspid valve infective endocarditis in a patient with a urological history]. / Izolowane infekcyjne zapalenle wsierdzia na zastawce trójdzielnej u chorego z wywiadem urologicznym.

Infective endocardits of the tricuspid valve (TVIE) occurs mainly in addicted-intravenous drug users, in the presence of intracardiac electrodes or central venous catheters, and in some congenital heart diseases; rarely, in other conditions. The authors present a case of a 61-year-old male with TVIE as a result of complicated transurethral resection of bladder papilloma. The onset of TVIE was insidious, with low back pain, followed by pulmonary symptoms. Echocardiography showed large vegetations on the tricuspid valve; blood culture was positive for methycylin-resistant, coagulase-negative staphylococcus. Fever remission and negative bacteriological blood examination results were achieved following treatment with linezolid; however, because of advanced tricuspid valve destruction, valve replacement was necessary.

Readmission to an intensive care unit after cardiac surgery: reasons and outcomes.

BACKGROUND: Intensive care unit (ICU) readmission after cardiac surgery is believed to be associated with higher in-hospital mortality and may predict poor outcomes. ICU readmissions use resources and increase treatment costs. AIM: To determine reasons for readmission to ICU, evaluate outcomes in these patients, and identify factors predisposing to the need for readmission to ICU. METHODS: We retrospectively investigated a total of 2076 consecutive adult patients who underwent either isolated coronary artery bypass grafting or a valve procedure or combination of both and were discharged from our ICU between January 2008 and December 2010. To identify the factors that increase the risk of readmission to ICU, we used the dominance-based rough set approach (DRSA) which is a methodology of knowledge discovery from data. The knowledge has the form of "if... then..." decision rules relating patient characteristics to the risk of readmission to ICU. RESULTS: Of 2076 patients discharged from ICU, 56 (2.7%) required a second stay in the ICU (study group) while 2020 patients needed no readmission to ICU (control group). The main causes of readmission were haemodynamic instability (28.6%, n = 16), respiratory failure (23.2%, n = 13), and cardiac tamponade or bleeding (23.2%, n = 13). The mean length of stay (LOS) in the general cardiac ward after primary discharge from ICU until readmission was 3.5 ± 4.2 days. The mean LOS in ICU after readmission was 12.5 ± 21.2 days. Postoperative complications occurred more frequently in readmitted patients (10.2% vs. 48.2%, p < 0.0001). In-hospital mortality was significantly higher in the study group (15 [26.8%] vs. 23 [1.1%] patients, p < 0.0001). As a result of applying the DRSA methodology, the algorithm generated decision rules categorizing patients into high and low ICU readmission risk. Advanced age, non-elective surgery and the length of initial ICU stay after the surgery were the factors of greatest importance for the correct categorisation of patients in the study group. CONCLUSIONS: The most common cause of readmission to ICU is haemodynamic instability. Postoperative complication and in-hospital mortality rates are significantly higher in patients readmitted to ICU. Factors most commonly predisposing to readmission to ICU after cardiac surgery included advanced patient age, non-elective surgery, and longer initial stay in ICU after the surgery.

Gigantic aneurysm of a venous bypass graft causing superior vena cava syndrome.

A case of a 66-year-old patient 13 years after coronary artery bypass grafting (CABG) admitted to hospital with typical ischemic chest pain and symptoms of superior vena cava syndrome (SVCS) is described. Non-invasive diagnostics confirmed acute coronary syndrome: non-ST-elevated myocardial infarction (ACS NSTEMI). Trans-thoracic echocardiography (TTE) revealed a gigantic tumor mass modeling the right atrium, causing chronic cardiac tamponade. Angiography showed that the tumor mass was in fact the aneurysmatically changed venous bypass graft to the right coronary artery (RCA). Computed tomography angiography (CT-angio) confirmed venous aneurysm size (the longest diameters were 10.2 cm × 8.7 cm). We also present treatment planning and the aneurysmal surgical removal procedure of this very rare case.

The effect of leukocyte reduction filters on inflammatory mediator release during coronary artery bypass grafting.

BACKGROUND: Extracorporeal circulation used during coronary artery bypass grafting triggers systemic inflammatory response with neutrophil activation which adversely affects ischaemic/reperfused myocardium. One method of myocardial protection during cardiac surgery is the use of blood cardioplegia. Its protective effect is related to cardiac cooling and metabolism reduction, oxygen supply from erythrocytes, and reactive oxygen species scavenging. However, blood cardioplegia is also associated with myocardial damage induced by undesirable morphotic blood elements. AIM: To evaluate the effect of the use of leukocyte reduction filters on the activity of polymorphonuclear neutrophils (PMN) in patients undergoing surgical myocardial revascularisation. PMN activity was evaluated based on measurements of plasma activity of granulocyte enzymes, lysozyme and beta-glucuronidase. METHODS: We studied 40 patients who underwent myocardial revascularisation using extracorporeal circulation. Patients were randomly assigned to two equal groups: in Group I, blood cardioplegia was administered using leukocyte reduction filters, and in Group II, leukocyte reduction filters were not used for blood cardioplegia. Measurements were performed in plasma of arterial and coronary sinus blood samples collected before aortic clamping, immediately after unclamping, and after 25 min of reperfusion. In addition, blood cardioplegic solution samples were collected in Group I from the lines proximal and distal to the filter during first and last administration. Plasma levels of lysozyme and beta-glucuronidase were determined using previously described methods. RESULTS: We found a significant decrease in PMN count in filtered blood cardioplegic solution during its first administration (0.27 ± 0.07 G/L) compared to samples collected before filter passage (1.73 ± 0.049 G/L). Also during last administration, PMN count in filtered blood cardioplegic solution was decreased compared to samples collected before filter passage (0.66 ± 0.35 G/L vs. 3.64 ± 1.14 G/L, respectively). Significantly lower (p < 0.02) plasma beta-glucuronidase levels were found in arterial blood samples in Group I compared to Group II (5.59 ± 1.63 µg/mL immediately after aortic unclamping and 6.59 ± 1.98 µg/mL after 25 min of reperfusion in Group I vs. 10.19 ± 2.66 and 12.83 ± 1.88 µg/mL, respectively, in Group II). Beta-glucuronidase levels in coronary sinus blood samples collected after aortic unclamping and at the end of reperfusion were significantly higher in Group II compared to Group I (p < 0.04). In Group I, plasma lysozyme levels in arterial and venous blood samples did not show significant changes during the surgery. In contrast, plasma lysozyme level in coronary sinus blood samples at the end of reperfusion in Group II was significantly higher compared to that in pre-clamping samples (p < 0.014). CONCLUSIONS: With the use of leukocyte reduction filters, we found significantly lower beta-glucuronidase levels in arterial and coronary sinus blood samples. These findings seem to confirm reduced PMN activation and/or reduced myocardial infiltration by activated PMN. Plasma levels of lysozyme, a characteristic product of PMN degranulation, did not show significant differences between the study groups.

[Debranching of aortic arch as part of a complex cardiac surgery]. / Debranching luku aorty jako element zlozonego zabiegu kardiochirurgicznego.

We present 54 year-old man diagnosed with an aneurysm of the ascending aorta and arch with aortic regurgitation and coronary artery disease. Surgery consisted of removing an aneurysm of the ascending aorta and arch of subtraction (debranching)cephalic brachiocephalic trunk and the common carotid artery and anastomosis of the descending aorta with vascular prosthesis and coronary artery bypass grafting. Postoperative course was uneventful. In 14 days after surgery the patient was discharged from the unit. Debranching method allowed avoiding hypothermia during surgery and shortening the time of cardio pulmonary bypass.

[Severe tricuspid valve injury following blunt chest trauma--case report]. / Ciezkie uszkodzenie zastawki trójdzielnej po tepym urazie klatki piersiowe--opis przypadku.

Tricuspid valve (TV) injury is a rare complication of blunt chest trauma, most commonly as a result of a traffic collision. The authors describe a case of massive TV regurgitation due to a rupture of the chorde tendinae to the anterior and septal leaflets in a 21-year-old man, the victim of a car crash. Concomitant organ injuries included, among others, multiple rib fractures, pulmonary contusion, open femoral fracture. TV annuloplasty with Medtronic Duran ring implantation was performed one year after the accident because of right ventricular function worsening and occurrence of right heart failure symptoms. Three years after surgery only trivial TV regurgitation is detectable. The patient manifest good physical efficiency and continues occupational activity.

[Asymptomatic myxoma of the tricuspid valve septal leaflet]. / Bezobjawowy sluzak platka przegrodowegozastawki trójdzielnej.

We presented a case of asymptomatic myxoma of the tricuspid valve septal leaflet. The tumour was diagnosed accidentally during rutine transthoracic echocardiography and confirmed by transesophageal echocardiography. It was resected and the septal leaflet repaired during surgery.

[Co-existence of severe aortic valve stenosis and recoarctation of the aorta treated surgically in childhood]. / Wspolistnienie ciezkiej stenozy aortalnej i restenozy skorygowanej w dziecinstwie koarktacji aorty.

Coarctation of the aorta is treated surgically in most of patients during childhood. However, some of them experience recoarctation in future. A 57 year-old woman suffering from chest pain and decreased activity tolerance was admitted to the cardiac department. Physical examinations, lab tests and cardiovascular imaging revealed severe aortic valve stenosis and insignificant narrowing of the aorta. The patient underwent a surgical replacement of the aortic valve without recoarctation repair.

[Fungal endocarditis of mitral and aortic biological prosthetic valves]. / Grzybicze zapalenie wsierdzia na protezie biologicznej w ujsciu mitralnym i aortalnym.

We present a rare case of fungal (Candida albicans) endocarditis on the two (mitral and aortic) biological prosthetic valves. Vegetations were detected by transthoracic echocardiography and confirmed by transesophageal echocardiography.

[Severe tricuspid regurgitation due to ventricular pacing lead - a case report]. / Ciezka niedomykalnosc zastawki trójdzielnej spowodowana zbyt krótka elektroda komorowa ukladu stymulujacego.

We present a case of severe symptomatic tricuspid valve regurgitation due to shifting of the septal leaflet of the valve toward the interventricular septum by a permanent ventricular pacemaker lead, making coaptation of the tricuspid leflats in systole impossible.

[Quadricuspid aortic valve]. / Czteroplatkowa zastawka aortalna.

We reported a case of a 45 year-old woman who had a quadricuspid aortic valve associated with moderate aortic regurgitation. The valve abnormality was detected by transthoracic echocardiography. Transesophageal echocardiography showed mild thickening of 4 symmetric aortic valve cusps, a small rectangular central regurgitant orifice, and moderate aortic insufficiency. In addition visualised this anomaly in 3D transesophageal echocardiography too.