Readiness for Discharge from Hospital after Myocardial Infarction: A Cross-Sectional Study.

Myocardial infarction (MI) is a common cause of cardiovascular deaths. Education of patients with myocardial infarctions essential to prevent further cardiovascular events and reduce the risk of mortality. The study aimed to evaluate the associations between patients' readiness for hospital discharge after myocardial infarction, acceptance of illness, social, demographic, and clinical factors. The study used a cross-sectional design and included 102 patients, who were hospitalized for myocardial infarction after percutaneous coronary intervention (PCI). Two questionnaires were used: The Readiness for Hospital Discharge After Myocardial Infarction Scale (RHD-MIS) and Acceptance of Illness Scale (AIS). Low readiness characterized nearly half of patients (47.06%), 27.45% of patients showed an intermediate level of readiness, while 25.49% of patients had high readiness. Readiness for hospital discharge was higher among younger patients, respondents living in relationships, living with a family, with tertiary or secondary education, and professionally active. Acceptance of illness was higher among male patients, respondents living in relationships, and family, with secondary education and professionally active. The AIS score positively correlated with readiness for hospital discharge.

Metastasis of adrenocortical carcinoma to the heart.

Not required for Clinical Vignette.

The combined impact of mechanical factors on the wall stress of the human ascending aorta - a finite elements study.

BACKGROUND: Biomechanical factors influence stress in the aortic wall. The aim of this study was to assess how the diameter and shape of the vessel, blood pressure and longitudinal systolic aortic stretching (SAS) caused by the contraction of the myocardium influence stress in the aortic wall. METHODS: Three computational models of the non-dilated aorta and aneurysms of the ascending aorta and aortic root were created. Then, finite elements analyses were carried out. The models were subjected to blood pressure (120 mmHg and 160 mmHg) and longitudinal systolic aortic stretching (0 mm, 5 mm, 10 mm and 15 mm). The influence of wall elasticity was examined too. RESULTS: Blood pressure had a smaller impact on the stress than the SAS. An increase in blood pressure from120 mmHg to 160 mmHg increased the peak wall stress (PWS) on average by 0.1 MPa in all models. A 5 mm SAS caused a 0.1­0. 2 MPa increase in PWS in all the models. The increase in PWS caused by a 10mm and 15mmSAS was 0.2 MPa and 0. 4 MPa in the non-dilated aorta, 0.2­0.3 MPa and 0.3­0.5 MPa in the aneurysm of the ascending aorta, and 0.1­0.2 MPa and 0.2­0.3 MPa in the aortic root aneurysm model, respectively. The loss of elasticity of the aneurysmal wall resulted in an increase of PWS by 0.1­0.2 MPa. CONCLUSIONS: Aortic geometry, wall stiffness, blood pressure and SAS have an impact on PWS. However, SAS had the biggest impact on wall stress. The results of this study may be useful in future patient-specific computational models used to assess the risk of aortic complications.

Computed tomography angiography of aorta subjected to external wrapping.

BACKGROUND: External wrapping is a surgical technique used in patients with dilated ascending aorta. To date, there is no available data describing the radiographic features of the aorta subjected to external wrapping using a straight corrugated Dacron vascular prosthesis. The aim of this study was to find distinctive radiographic features of an externally constricted aorta. METHODS: Preoperative and early postoperative (7th postoperative day) CT angiography images of ten patients who underwent wrapping procedures were assessed and compared. The images were analyzed in order to find characteristic features of CT angiography images of the ascending aorta subjected to external wrapping. RESULTS: The CT-angiography images showed that the aortic wall deformed significantly (the wall plicated) after the wrapping procedure in one patient, whose aortic diameter was decreased by 47 %. The remaining nine patients did not have significant aortic wall deformations. All patients presented with a periaortic mass. This was a collection of blood clots and pericardial fluid that filled the empty space in the pericardium following a decrease in the diameter of the ascending aorta. A very thin (<1 mm) crescent-shaped uncontrasted layer was noticed between the aorta and the periaortic area in all patients. This, in turn, was an empty space between the aorta and the corrugated vascular prosthesis. CONCLUSIONS: The CT-angiography images of the aorta subjected to external wrapping may have unique features that are not observed after other operations on the ascending aorta. The knowledge about the details of this surgical procedure helps to correctly assess these images.

Single center experience with wrapping of the dilated ascending aorta.

BACKGROUND: External wrapping is a surgical technique performed in patients with a dilated ascending aorta. The aim of this study is to present the mid-term results of wrapping of the dilated ascending aorta. METHODS: 34 patients (mean age: 64.4 ± 10.8 years, 21 males) with a dilated ascending aorta were operated on at a single cardiac surgery center using a wrapping technique. The aortas were wrapped with 32-36 mm straight Dacron vascular prostheses. The aortic wall was not excised in any of the patients. Wrapping was performed concomitant to other cardiac surgery procedures in 30 patients (88 %), which involved surgery on the aortic valve in 28 patients (82 %). RESULTS: The mean follow-up time was 19.5 ± 8.3 months (median: 18 months, range: 12-36 months). None of the patients died or had aortic complications during the hospital stay and the follow-up period. A rethoracotomy had to be performed due to excessive postoperative bleeding in two patients. One patient was diagnosed with a transient ischemic attack on the 4th postoperative day, while another had respiratory failure requiring prolonged intubation. No redilatation of the ascending aorta or dislocation of the wrap was noticed in any of the patients. CONCLUSIONS: According to our study, external wrapping of the ascending aorta has good short-term results and may be regarded as a safe surgical option for patients with a moderately dilated ascending aorta.

Presence of Periodontopathic Bacteria DNA in Atheromatous Plaques from Coronary and Carotid Arteries.

OBJECTIVES: Interest in periodontitis as a potential risk factor for atherosclerosis and its complications resulted from the fact that the global prevalence of periodontal diseases is significant and periodontitis may induce a chronic inflammatory response. Many studies have analyzed the potential impact of the Porphyromonas gingivalis, major pathogen of periodontitis, on general health. The purpose of this study was to find the presence of the Porphyromonas gingivalis DNA in the atherosclerotic plaques of coronary and carotid arteries and in the periodontal pockets in patients with chronic periodontitis, who underwent surgery because of vascular diseases. METHODS AND RESULTS: The study population consisted of 91 patients with coronary artery disease or scheduled for carotid endarterectomy. The presence of Porphyromonas gingivalis DNA in atheromatous plaques and in subgingival samples was determined by PCR. Bacterial DNA was found in 21 of 91 (23%) samples taken from vessels and in 47 of 63 (74.6%) samples from periodontal pockets. CONCLUSIONS: Porphyromonas gingivalis DNA is frequently found in atheromatous plaques of patients with periodontitis. That is why more research should be conducted to prove if this periopathogen may have an impact on endothelium of patients at risk of atherosclerosis.

Biomechanical analysis of wrapping of the moderately dilated ascending aorta.

BACKGROUND: External wrapping is a surgical method performed to prevent the dilatation of the aorta and to decrease the risk of its dissection and rupture. However, it is also believed to cause degeneration of the aortic wall. A biomechanical analysis was thus performed to assess the stress of the aortic wall subjected to external wrapping. METHODS: A stress analysis using the finite elements method was carried out on three models: a non-dilated aorta, a moderately dilated aorta and a wrapped aorta. The models were subjected to a pulsatile flow (120/80 mmHg) and a systolic aortic annulus motion of 11 mm. RESULTS: The finite elements analysis showed that the stress exerted on the outer surface of the ascending aorta in the wrapping model (0.05-0.8 MPa) was similar to that observed in the normal aorta (0.03-0.7 MPa) and was lower than in the model of a moderately dilated aorta (0.06-1.4 MPa). The stress on the inner surface of the ascending aorta ranged from 0.2 MPa to 0.4 MPa in the model of the normal aorta, from 0.3 to 1.3 MPa in the model of the dilated aorta and from 0.05 MPa to 0.4 MPa in the wrapping model. CONCLUSIONS: The results of this study suggest that the aortic wall is subjected to similar stress following a wrapping procedure to the one present in the normal aorta.

First beating-heart valve-sparing aortic root repair: a "corset" technique.

We present our preliminary experience with beating-heart aortic root remodeling using an external "corset," which we performed in 2 patients with aortic insufficiency and aortic root dilatation. Standard extracorporeal circulation (ECC) was used. After a meticulous dissection of the aortic root and ascending aorta, the bespoke vascular prosthesis was placed around the vessel to decrease its diameter and restore aortic valve function. Postoperative angiographic computed tomography (CT) showed a significant decrease in the diameter of the wrapped aorta. Echocardiography performed 12 months after the operation showed normal aortic valve function with trivial regurgitation and stable aortic diameter in both patients.

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.

Does the Stage of Chronic Kidney Failure Influence the Outcome in Cardiac Surgery?

BACKGROUND: The number of patients with chronic kidney failure requiring cardiac surgery is continuously increasing. Additionally, significant worsening in the overall risk profile of this group of patients is noted. OBJECTIVES: To investigate the effect of chronic renal dysfunction both in non-dialysis-dependent renal failure and end-stage renal failure patients, on early mortality--morbidity and late survival in a series of cardiac surgery patients at our institution. MATERIAL AND METHODS: 1344 patients who had open heart surgery at our university hospital between 2010 and 2013 were retrospectively reviewed. Chronic renal dysfunction was defined according to preoperative glomerular filtration rate. Patients selection (n=80). Group 1 mild--(GRF 59-30 mL/min), Group 2 moderate--(GFR 29-15 mL/min), Group 3 end stage--(GFR<15 mL/min) renal failure. RESULTS: Chronic renal dysfunction was present in 5.95% of all patients studied. Group 1--55 (68.75%), Group 2--16 (20%), Group 3--9 (11.25%). No difference between the groups in the need for heart inotropic support was noted; however the use of these medications was necessary in 60.6% of all studied patients. Forty nine percent in Group 1, 87.5% in Group 2 and 77% in Group 3, respectively. Renal replacement therapy in the early postoperative period was needed in 12 patients, with significance between the groups (p = 0.001). The overall hospital mortality was 2.5%. Follow-up was completed with a mean of 1.4 years (range 2 months to 4 years). There were 6 (7.5%) late deaths. CONCLUSIONS: Our observations do not exhibit large variations in postoperative complications and deaths in patients with chronic renal failure, depending on the degree of preoperative renal function impairment. It seems that renal failure regardless of the degree of impairment is a factor aggravating the intra and post-operative course in cardiac surgery patients.

Unchanged plasma levels of the soluble urokinase plasminogen activator receptor in elective coronary artery bypass graft surgery patients and cardiopulmonary bypass use.

OBJECTIVE AND DESIGN: The soluble urokinase plasminogen activator receptor (suPAR) has been recently recognized as a potential biological marker of various disease states, but the impact of a major surgical intervention on the suPAR level has not yet been established. The aim of our study was to investigate if the induction of a systemic inflammatory reaction in response to cardiopulmonary bypass would be accompanied by an increase in the plasma suPAR level. METHODS AND SUBJECTS: Patients undergoing coronary artery bypass grafting under cardiopulmonary bypass (CPB) were added. Based on the baseline suPAR level, patients were divided into group 1 (suPAR within normal range) or group 2 (suPAR above range). Blood was collected before the induction of anesthesia and 6 and 24 hours after surgery. Plasma suPAR, IL-6, IL-8, TNF-α, troponin I, NT-proBNP, and NGAL were quantified to assess the impact of surgical trauma on these markers. RESULTS: The baseline suPAR level was within the normal range in 31 patients (3.3 ng/mL), and elevated in 29 (5.1 ng/mL) (p<0.001). Baseline mediators of systemic inflammatory reaction concentrations (IL-6, TNF-α, and IL-8) and organ injury indices (troponin I, NT-proBNP, and NGAL) were low and increased after surgery in all patients (p<0.05). The surgery did not cause significant changes in the suPAR level either at 6 or 24 hours after, however the difference between groups observed at baseline remained substantial during the postoperative period. CONCLUSIONS: There was no change in the suPAR level observed in patients subjected to elective cardiac coronary artery bypass surgery and CPB, despite activation of a systemic inflammatory reaction.

Increased content of resistin in epicardial adipose tissue of patients with advanced coronary atherosclerosis and history of myocardial infarction.

OBJECTIVES: The aim of the study was to assess whether the plasma level and content of adipokines, in adipose tissue, is associated with a medical history of myocardial infarction. PATIENTS AND METHODS: The study group consisted of 33 consecutive patients (12 females, 21 males, aged 68.6 ± 6.8 years) who underwent cardiac bypass surgery. Patients were divided into groups; group 1 presented with a history of myocardial infarction and group 2 presented without a history of myocardial infarction. During cardiac surgery, samples of epicardial adipose tissue, adipose tissue located at internal mammary artery, subcutaneous adipose tissue, and blood samples were taken for further assessment.Significantly higher levels of resistin in adipose tissue from the epicardial tissue were found in group 1 than in group 2: median and interquartile range, respectively, 37.2 (8.9-121.5) ng/g versus 15.0 (7.1-24.1) ng/g; p < 0.049. Multivariate analysis found that previous myocardial infarction was associated with male gender, older age, and higher content of resistin in epicardial adipose tissue. CONCLUSION: The resistin content in epicardial adipose tissue in patients with advanced coronary atherosclerosis seems higher in those with a history myocardial infarction. Increased resistin epicardial content seems related to the previous myocardial infarction independent of the other established risk factors such as age and male gender. The importance of paracrine function of adipose pericardial tissue in the occurrence of complications of atherosclerosis merits further investigations.

Porphyromonas gingivalis in periodontal pockets and heart valves.

BACKGROUND: There is evidence that advanced infectious chronic periodontal inflammatory disease may have an impact on general health including cardiovascular diseases. The aim of this clinical study was to evaluate the ability of Porphyromonas gingivalis to colonize heart valves and, subsequently, to assess whether there is an association between the presence of the DNA of Porphyromonas gingivalis in periodontal pockets and in degenerated heart valves. MATERIALS AND METHODS: Thirty patients were enrolled in the study and 31 valve specimens harvested during cardiac surgery operations were examined. All patients underwent a periodontal examination. To evaluate the periodontal status of the patients the following clinical parameters were recorded: the pocket depth, bleeding on probing (BOP) and aproximal plaque index (API). The presence of P. gingivalis in heart valve specimens and samples from periodontal pockets was analyzed using a single-step PCR method. RESULTS: P. gingivalis DNA was detected in periodontal pockets of 15 patients (50%). However, the DNA of this periopathogen was found neither in the aortic nor in the mitral valve specimens. CONCLUSIONS: This study suggests that P. gingivalis may not have an influence on the development of the degeneration of aortic and mitral valves.

A successful cesarean section in a pregnant woman with A (H1N1) influenza requiring ECMO support.

A 24-year-old pregnant woman (29.4 weeks of gestation) with A (H1N1) influenza-associated adult respiratory distress syndrome was admitted to the intensive care unit. The patient was connected to femoral-jugular veno-venous extracorporeal membrane oxygenation (ECMO) 8 hours after admission. On the 7(th) day of ECMO support, due to the increasing threat to the life of the mother and the fetus, a decision was made to carry out a cesarean section (CS) without discontinuing the ECMO support. The CS was performed uneventfully under general anesthesia, 5 hours after the discontinuation of heparin infusion. A live, premature 1200 g female neonate was delivered. No complications occurred in the perioperative period. On the 17(th) day, the patient was successfully weaned off the ECMO and discharged 10 days later. The newborn was discharged from the hospital in good health 41 days after the delivery.

Temporary resolution of chronic atrial fibrillation after cardiac surgery and the prolongation of ventricular repolarization.

BACKGROUND: Chronic atrial fibrillation may temporarily resolve after cardiac surgery. Prolongation of the ventricular repolarization period may be the electrophysiological background for this phenomenon. OBJECTIVES: The aim of the study was to assess the association between resolution of atrial fibrillation and changes in the duration of the ventricular repolarization period in patients with pre-operative chronic atrial fibrillation who underwent cardiac surgery. MATERIAL AND METHODS: A retrospective analysis of the medical recordings of patients with chronic atrial fibrillation who underwent cardiac surgery was performed. After exclusions the study group comprised 51 patients with chronic atrial fibrillation who underwent surgery in the Cardiac Surgery Department of Wroclaw Medical University in 2008 and 2009. The 12-lead EKGs performed before and after the surgery were assessed and the QT and R-R intervals were measured. The patients were divided into Group 1, in whom atrial fibrillation persisted after the cardiac surgery, and Group 2, whose atrial fibrillation resolved after the surgery. RESULTS: In 31 patients (60.8%) atrial fibrillation disappeared during the first 24 hours after cardiac surgery. A significant prolongation of the QT interval after the surgery was found in Group 2 that was not observed in Group 1. Multiple regression analysis revealed that QT interval duration after surgery is related to the resolution of atrial fibrillation independently from the duration of the R-R interval duration and the need for cardiac pacing. CONCLUSIONS: Spontaneous temporary resolution of atrial fibrillation is a common finding after cardiac surgery in patients with chronic atrial fibrillation. This phenomenon is related to a prolonged QT interval, therefore it may have an electrophysiological basis rather than a hemodynamic background. Further studies are required to assess the clinical importance of the prolongation of the QT interval after cardiac surgery.

The use of minimally invasive videoscopic technique in large vessel and cardiac surgery. Does the potentially increased difficulty bring benefits to the patient?

We present the clinical case of a 63-year-old patient who underwent in the Department of Cardiac Surgery implantation of an aorto-bifemoral graft prosthesis and coronary artery bypass revascularization with application of less invasive off-pump technique. Graft selection (arterial grafts, venous grafts) is very important during qualification for coronary artery bypass revascularization. Minimally invasive saphenous vein harvesting was performed during the presented case. The endoscopic technique of vein harvesting is a relatively rarely applied technique during myocardial revascularization surgery. The concept of minimally invasive videoscopic technique is presented. There is a discussion on why the team decided to prolong duration of the case consisting of two major operations performed simultaneously. Minimally invasive videoscopic technique may have a significant positive impact on postoperative outcome in a selected group of patients.

[Lack of left main and the operation of aortic valve replacement]. / Brak pnia lewej tetnicy wiencowej a operacja korekcji wady zastawki aortalnej.

Heart valve surgery demands cardiac arrest with concomitant cardiac protection against ischaemia and reperfusion. Anomalous origin of left coronary artery (LCA) system require different approach to the infusion of cardioplegia into coronary ostia. We present a case of a patient suffering from severe aortic stenosis with concomitant aortic insufficiency and double ostium LCA with left artery descending and circumflex arteries originating separately from the left sinus of Valslava. During the procedure a retrograde, intermittent, cold-crystalloid cardioplegia was applied with moderate hypothermic arrest of 32°C. Antegrade cardioplegia in patients presenting with anomalous origin of left coronary system when direct coronary intubation is required remains controversial. In such cases retrograde cardioplegia serves a valid option for the operating surgeon.

J. Mikulicz-Radecki, K. H. Bauer, and W. Bross. Three great surgeons, three different epochs, one clinic in Wroclaw.

The city of Wroclaw (Breslau) lies where the cultural and economic influences of the eastern, southern, and western Europe meet. Over a thousand years of history it changed the state affiliation several times. Since 1945, similarly as seven centuries ago, it lies within the borders of Poland. The historical complex of hospital buildings constructed at the end of the 19th century for the medical faculty remained almost untouched, despite catastrophic war destructions in the whole city. The building of surgical clinic witnessed epoch-making events in the discipline of surgery performed by the three great personalities. Jan Mikulicz-Radecki (1850-1905), the first head of the department, world famous physician and scientist, created in Wroclaw a modern surgical center. From among his numerous achievements the most important seems to be the performance of the world's first safe thoracotomy in the low-pressure chamber (1904). Karl Heinrich Bauer (1890-1979) was the next great personality, who had been leading the surgical department since 1933. Genetics, transplantology, traumatology and oncology were the main points of his interest. Because of political reasons he had to leave Wroclaw. He continued his surgical and scientific career in Heidelberg. Wiktor Bross (1903-1994) came to the ruined city directly after the World War II. As an experienced general and thoracic surgeon he created a new surgical school. First in Poland open heart surgery (1958) and renal transplantation (1966) were performed by him and his team in the same building, where Mikulicz-Radecki and Bauer worked in the past. The memory of all three great surgeons has been honored by placing their sculptures among the prominent Wroclaw citizens in the city hall.