[Penetrating Injuries of the Heart and Great Vessels - Fifteen Years of Experience of the Cardiac Surgery Service as a Part of the Major Trauma Centre]. / Penetrující poranení srdce a velkých cév ­ patnáctiletá zkusenost kardiochirurgického servisu v rámci primárního traumacentra.

PURPOSE OF THE STUDY Outcome analysis of penetrating cardiac and great vessels injury within the 15-year existence of the cardiac surgery service as a part of the major trauma centre of the University Hospital Olomouc MATERIAL AND METHODS Retrospective analysis of a group of a total of 16 patients who underwent a surgery for penetrating cardiac and great vessels injury since II/2002 to XI/2016. The dominant causes of penetrating trauma were stab injuries (15 patients, 94%), in one patient only (6%) it was a gunshot injury. The mean age of the patients included in the group was 42.9 ± 16.1 years, with men significantly prevailing (13 patients, 81%). A total of 7 injured persons (44%) were haemodynamically stable when admitted, 9 injured persons (56%) were unstable or in critical condition. The average transfer distance was 48.8 ± 34.5 km; the injured were admitted on average 115.9 ± 154.8 minutes after being injured. Preoperatively, all the injured suffered from pericardial effusion (>5 mm) confirmed by TTE (81%) or CTA (19%). In 4 patients (25%) pericardial drainage for cardiac tamponade was performed before surgery. RESULTS All the penetrating cardiac and great vessels injuries were repaired by cardiac surgeon, in one case only (6%) the extracorporeal circulation support was used. The injury of coronary arteries was in one case managed by CABG and in the other case by ligation of the peripheral part of the coronary artery. In 4 patients (25%) also a penetrating injury of other organs was simultaneously managed. The mean ICU stay reached 85.8 ± 91.9 hours, on average 5.6 ± 9.3 units of red blood cells were administered during the in-hospital stay which lasted on average 7.1 ± 2.4 days. In the group a nonsignificant increase of left ventricular ejection fraction (44.1 ± 4.7 vs. 49.3 ± 3.2, p = 0.882) was reported at discharge of the injured patients. One patient died on the 78 th day of hypoxic brain damage (6% three-month mortality). The long-term survival analysis showed 94% one-year and 88% five-year cumulative survival in the group. DISCUSSION The incidence of the penetrating cardiac and great vessels injury is directly dependent on the crime level in the respective countries and regions. A cardiac arrest, severe hemodynamic instability, unconsciousness, serious concomitant injury, gunshot injury, multiple or atrial injury represent independent predictors of death in these injuries. The total three-month mortality in penetrating cardiac and great vessels injury ranges from 18 to 42%, the presence of vital signs at the time of hospital admission is associated with 78-92% probability of survival. The surviving patients show excellent long-term results with the exception of those who suffered a severe damage to valve apparatus or with significantly depressed left ventricular function. CONCLUSIONS Our experience proves a high survival rate of patients with penetrating cardiac and great vessels injury. The centralisation of the care into the major trauma centre with a cardiac surgery background, a unified treatment algorithm, and a vital interdisciplinary cooperation are the key goal of successful management of these injuries. Key words:penetrating injury, cardiac injury, great vessel injury, outcome. Práce byla podporena programem institucionální podpor.

Complex gunshot injury to the heart as a consequence of suicide attempt in a schizophrenic patient.

INTRODUCTION: Self-inflicted gunshot injury to the heart is uncommon in Western Europe countries. However it is considered to have a high mortality through cardiac tamponade or exsanguination and concomitant chest or abdominal cavity injury. CASE PRESENTATION: We present a 39-year-old schizophrenic woman who attempted suicide with the aid of a 6.35mm caliber handgun, after self-discontinuing of antipsychotic treatment. Lower third of sternum, right heart atrium and ventricle and inferior caval vein were hit by the bullet which consequently got lodged in the right paravertebral muscle mass at the lower thoracic vertebral level. As she was hemodynamically unstable due to hemopericardium and a huge right hemothorax, she underwent emergent surgery. Heart and inferior vena caval injuries were repaired on extracorporeal circulation. The postoperative course was uneventful and she was transferred to a psychiatric facility on the 7th postoperative day. One year after the surgery she is well, compliant to antipsychotic medications and on periodic follow-up by psychiatrists. CONCLUSION: This case represents management of complex self-inflicted gunshot cardiac injury in a schizophrenic patient who discontinued antipsychotic medication. Liaison between themedical rescue service and high level trauma center essentially reduced injury-to-surgery time. Complex heart injury was successfully repaired on extracorporeal circulation.

Impact of methylprednisolone in priming solution of cardiopulmonary bypass on anti-inflammatory CD163 receptor during cardiac surgery.

We evaluated the influence of methylprednisolone in cardiopulmonary bypass fluid on scavenger receptor for hemoglobin CD163 molecule expression on monocytes of patients who underwent elective coronary artery bypass grafting with cardiopulmonary bypass with either exposure to methylprednisolone present in the cardiopulmonary bypass fluid (20 patients), or without methylprednisolone in the cardiopulmonary bypass fluid (22 patients) and operated on without cardiopulmonary bypass (42 patients). The dynamics of CD163 expression was also followed in patients operated on without cardiopulmonary bypass. This study was a retrospective analysis of a comparison of two studies. The expression of CD163 was determined quantitatively by standardized flow cytometry technique. The similarities in the dynamics of CD163 monocyte expression, comparing the patients operated on with or without cardiopulmonary bypass, were found. Compared to the preoperative level, CD163 monocyte expression was significantly elevated on the 1(st) postoperative day. Monocyte CD163 expression on the 1(st) postoperative day was evidently similar in both groups of patients operated without cardiopulmonary bypass (median value of mean fluorescence intensity (MFI) 18,896; interquartile range from 27,538 to 57,711; median value of MFI 18,863; interquartile range from 16,514 to 26,559; n.s.), suggesting high reproducibility of our flow cytometric method; the monocyte CD163 expression was significantly higher (median value of MFI 37,902; interquartile range from 27,538 to 57,711) on the 1(st) postoperative day in patients exposed to methylprednisolone compared to patients without this exposure (median value of MFI 20,995; interquartile range from 16,321 to 29,623) (p<0.001). We concluded that the expression of hemoglobin scavenger receptor CD163 on monocytes of cardiac surgical patients is induced by methylprednisolone present in cardiopulmonary bypass fluid.

Superiority of topical negative pressure over closed irrigation therapy of deep sternal wound infection in cardiac surgery.

AIM: We sought to compare clinical outcomes, in-hospital mortality and 1-year survival of two different treatment modalities of deep sternal wound infection, topical negative pressure and the closed irrigation therapy. METHODS: Retrospective analysis of 66 consecutive patients treated for deep sternal infection at our institution. A total of 28 patients (February 2002 through September 2004) underwent primarily closed irrigation therapy, and 34 patients (November 2004 through December 2007) had the application of topical negative pressure. Four patients (July 2004 through December 2004) who underwent a combination of both strategies were excluded from the study. Clinical and wound care outcomes were compared, focusing on therapeutic failure rate, in-hospital stay and the 1-year mortality of both treatment strategies. RESULTS: Topical negative pressure was associated with a significantly lower failure rate of the primary therapy (P<0.05), shortening of the intensive care unit stay (P<0.001), a particular decrease in the in-hospital stay (P<0.05) and the 1-year mortality (P<0.05) in comparison with closed irrigation therapy. Comparable overall length of the therapy, in-hospital stay and the risk of wire-related fistulas after chest reconstruction were found. CONCLUSION: Topical negative pressure is a superior method of treatment for deep sternal wound infection, which is based on lower therapeutic failure rate, significant decrease in-hospital stay, and the decrease of the 1-year mortality rate, compared with primarily applied closed irrigation.

Direct oxymetric peripheral tissue perfusion monitoring during open heart surgery with the use of cardiopulmonary bypass: preliminary experience.

BACKGROUND: Regional hypoperfusion has been associated with the development of postoperative organ dysfunction in cardiac surgery involving cardiopulmonary bypass (CPB). Direct tissue oxymetry is a potentially new method for monitoring the quality of the peripheral tissue perfusion during CPB. The aim of this study was to assess the effects of CPB in skeletal muscle oxygenation when measured in the deltoid muscle by direct oxymetry during perioperative period. METHOD: Seven patients underwent on-pump coronary artery bypass grafting. Direct oxymetry was performed by an optical cathether introduced into the deltoid muscle. Continuous measurement was made during the surgical procedure and the postoperative period. Mean arterial blood pressure, blood flow during CPB, laboratory markers of tissue hypoperfusion, blood gases and body temperature were also recorded. RESULTS: Interstitial muscle tissue oxygen tension (pO(2)) decreased after the introduction to anaesthesia and, more significantly, during CPB. After the disconnection from CPB at the end of the operation, the pO(2) returned to pre-anaesthetic values. During the first hours after admission of the patients to the intensive care unit, the pO(2) progressively decreased, reached a minimum value after four hours, and increased slowly thereafter. There was a significant correlation of pO(2) with mean arterial blood pressure and blood flow during that time. CONCLUSION: The result of this first measurement seems to demonstrate that the standard technique of conducting cardiopulmonary bypass produces low muscle oxygen tension and, thus, little perfusion of skeletal muscle. The data also indicate that both high mean arterial blood pressure and high flow are necessary during CPB to ensure skeletal muscle perfusion. The investigation is continuing.

The effect of a cardiopulmonary bypass system with biocompatible coating on fibrinogen levels determined by the TEG--functional fibrinogen method: preliminary results.

When cardiopulmonary bypass (CPB) is used, the blood comes into contact with foreign surfaces. To diminish this impact, various types of biocompatibly coated surfaces have been developed. The study assessed the effects of heparin-coated CPB systems on the level and function of fibrinogen as measured by thromboelastography (TEG), as compared with non-coated systems. No statistically significant differences between both groups were revealed by comparing paired data. In our study, heparin-coated CPB circuits had no significant effect on either fibrinogen level or its function.

[The effect of preoperative administration of heparin on the heparin resistance development]. / Vliv predoperacního podání heparinu na vznik heparinové rezistence.

BACKGROUND: Heparin resistance is relatively frequent problem in cardio surgery. We were try to determine real occurrence heparin resistance before operation. AIM OF THE STUDY: Purpose of the project--to find the real frequency of heparin resistance in patients who will undergo a cardio surgical operation. To find out the dependence between the pre-operational application of heparin and the development of heparin resistance. METHODS: We recorded pre-operative administration heparin in patients. If the dose of heparin was 5 mg/kg and more then we insert patients to the group heparin resistant. RESULTS: In our collection was heparin resistance in 203 patients from 624, it was 32.5%. Test agreement relative frequency with 22% was throw out--p < 0.001--heparin resistance in our group statistically different from 22% heparin resistance was higher than hypothesis. Heparin before operation was administrate 181 patients, which make to 29%. For administration of heparin was hypothesis of independence thrown (p < 0.001). CONCLUSION: Results of our works confirmed statistically significant occurrence of heparin resistance in patients that was administration heparin pre-operative. Heparin resistance occurred against presumption 22% in 32.5% in our group. It is statistic significant difference.

Endoscopic versus minimally invasive vein harvesting. Impact on leg-related morbidity in coronary artery bypass surgery: one-year follow-up of a prospective trial.

AIM: We sought to compare the impact of endoscopic and minimally invasive great saphenous vein harvesting on leg-related patient morbidity after coronary artery bypass grafting. METHODS: From February 2004 to July 2006, 120 patients underwent minimally invasive vein harvesting, and 180 patients underwent endoscopic vein harvesting for coronary artery bypass grafting. Patients were evaluated prospectively for wound-healing disturbances, residual leg edema, pain intensity and saphenous neuropathy at seven days, three months and one year after surgery. RESULTS: Both harvesting techniques were associated with a low incidence of wound-healing disturbances; nevertheless, endoscopic vein harvesting was associated with a significantly lower incidence of residual edema (12% vs 28%, P<0.05 seven days postoperative; 6% vs 19%, P<0.001 three months postoperative), pain (9% vs 20%, P<0.05; 6% vs 10%, P<0.05) and saphenous neuropathy (6% vs 23%, P<0.001; 3% vs 14%, P<0.05) during follow-ups. Endoscopic vein harvesting was also associated with a significantly lower incidence of neurological disturbances at one-year follow-up (2% vs 8%, P<0.05). Mean harvesting time (43.9+/-10.2 vs 40.6+/-15.5 min, P=0.09), conversion rate (2% vs 3%, P=0.71) and injury per conduit (0.3+/-0.1 vs 0.3+/-0.2, P=0.91) were comparable for both groups. CONCLUSION: EVH is superior to MIVH in terms of reduction in pain intensity, residual leg edema and saphenous neuropathy at seven days and again at three months postoperative. A significantly lower incidence of neurological disturbances is still presented one year after surgery.

Impact of cardiopulmonary bypass on peripheral tissue metabolism and microvascular blood flow.

The aim of this study was to monitor and compare the changes in metabolism and blood flow in the skeletal muscles during cardiac operations performed with cardiopulmonary bypass (CPB) and operations without CPB (off-pump) by means of interstitial microdialysis (Figure 1). Surgical revascularization, coronary artery bypass grafting (CABG), was performed in 40 patients randomized to two groups. Twenty patients (On-Pump Group) were operated on using CPB, 20 patients (Off-Pump Group) were operated on without CPB. Interstitial microdialysis was performed by 2 probes of a CMA 60 (CMA Microdialysis AB, Solna, Sweden) inserted into the patient's deltoid muscle. Microdialysis measurements were performed at 30-minute intervals. Glucose, lactate, pyruvate and glycerol as markers of basic metabolism and tissue perfusion were measured in samples from the first probe, using a CMA 600 Analyzer (CMA Microdialysis AB). Blood flow through the interstitium was monitored by means of dynamic microdialysis of ethanol as a flow-marker in the dialysates taken from the second probe (ethanol dilution technique). Results in both the groups were statistically processed and compared. Both the groups were similar in respect of preoperative characteristics. Dynamic changes of interstitial concentrations of the measured analytes were found in both the patient groups (on-pump vs. off-pump) during the operation. There was no significant difference in dialysate concentrations of glucose and lactate between the groups. Significant differences were detected in pyruvate and glycerol interstitial concentrations, lactate/pyruvate ratio and lactate/glucose ratio between the on-pump vs. off-pump patients. In the Off-Pump Group, pyruvate concentrations were higher and the values of concentrations of glycerol lower. The lactate/pyruvate ratio and the lactate/glucose ratio, indicating the aerobic and anaerobic tissue metabolism status, were lower in the Off-Pump Group. There was no significant difference in dialysate concentrations of ethanol as a flow-marker during the surgery in either of the groups. There was no statistically significant difference between the groups (On-Pump Group vs. Off-Pump Group) comparing the postoperative clinical outcome (ICU stay, ventilation duration, length of hospital stay). The dynamic changes in the interstitial concentrations of the glucose, glycerol, pyruvate and lactate were found in both the groups of patients (On-Pump Group and Off-Pump Group), but there was no difference in local blood flow when the ethanol dilution technique was used. These results showed significantly higher aerobic metabolic activity of the peripheral tissue of patients in the Off-Pump Group vs. the On-Pump Group during the course of cardiac revascularization surgery. Results suggest that extracorporeal circulation, cardiopulmonary bypass, compromises peripheral tissue (skeletal muscles) energy metabolism. These changes have no impact on the postoperative clinical outcome; no significant difference between the groups was found.

Cardiac amyloidosis in the cardiosurgical operating room--a rare but fatal trap.

Coronary artery bypass grafting resulted in a fatal outcome in two patients with unsuspected cardiac amyloidosis. Despite preoperative symptoms of myocardial ischemia, each case represented a different pathophysiological combination of cardiac amyloidosis and coronary artery disease. Pitfalls preventing correct diagnosis and possible patterns of treatment are discussed.

[Cardiac surgery operations and their influence on serum level of antiinflammatory cytokine interleukin-10]. / Kardiochirurgické operace a jejich vliv na sérovou hladinu protizánetového cytokinu interleukinu-10.

BACKGROUND: Cardiac surgical operation is followed by the development of inflammatory reaction. This reaction is regulated in many ways including the production of antiinflammatory cytokines such as IL-10 to avoid potentially harmful effects of inflammation. METHODS AND RESULTS: We compared serum levels of cytokines IL-10, IL-6, and IL-13 in the group of patients undergoing cardiac surgical operation using either cardiopulmonary bypass (CPB, n=17) or surged on the beating heart (n=17). We found significant elevation in the serum level of IL-10 during surgery with the peak immediately after finishing surgery in CPB patients and at the first postoperative day in non-CPB patients, respectively. There is statistically significantly higher level of IL-10 in CPB patients in comparison with non-CPB patients at the end of surgery. Serum level of IL-6 is elevated in both groups during surgery reaching maximum immediately after surgery in CPB patients and at the first postoperative day in patients without CPB, respectively. The serum levels of IL-13 are only nonsignificantly changed during operation and in postoperative period in both groups. CONCLUSIONS: The intensity of inflammatory response in CPB patients which is enhanced by massive contact activation of blood and extensive ischemia-reperfusion injury is regulated by the production of antiiflammatory IL- 10 cytokine.

[Transcription factor KLF2 (Krüppel-like factor 2) and natural defence of vascular endothelium]. / Transkripcní faktor KLF2 (Krüppel-like factor 2) a prirozená ochrana cévního endotelu.

Vascular endothelium, monocytes and T-lymphocytes belong to the key cellular populations, which take an active part in the host's defence reactions. A successful course of these reactions is determined by a meticulous control of all phases since the very first steps until final healing of all incurred wounds. Any failure of the control mechanisms may lead to the development of chronic inflammatory diseases with an autoimmune component, such as the rheumatoid arthritis or atherosclerosis. An inflammatory reaction which is already under way is regulated by anti-inflammatory cytokines. However, of equal importance is the maintenance of cellular participants of inflammatory reactions in a quiescent state while no pro-inflammatory stimuli are present. One of the most important endogenous mediators, which prevent a self-initiated activation of endothelial cells, monocytes and T-lymphocytes, is represented by the transcription factor Krüppel-like factor 2. Its impact on the mentioned cells is almost identical with the so-called pleiotropic effects of inhibitors of the enzyme HMG CoA reductase or statins. This review article offers an insight into basic preventive mechanisms exerted by KLF2, notably those related to atherosclerosis.

[Shared pathogenesis of infectious and cardiovascular diseases--year 2005's view]. / Spolecné patogenetické mechanizmy infekcních a kardiovaskulárních chorob: pohled roku 2005.

Entry of microorganisms into the blood stream provokes a decline in the contractile function of the cardiac muscle. Lipopolysaccharide of Gram-negative bacteria sets off production of pro-inflammatory cytokines including bactericidal concentrations of nitric oxide which set up the first defence line against bacteremia. At the same time, however, the performance of the cardiovascular system is negatively affected. The immediate menace resides in the occurrence of septic shock, while chronic infectious diseases that are accompanied by low-grade inflammation have been suspected to take an active part in the initiation and progression of atherosclerosis. This hypothesis, as attractive as it may appear, has not yet been accepted unequivocally. The article offers an up-to-date review of the signalling cascades which permit activation by lipopolysaccharide of the target cells. The same holds true for cellular activation by non-infectious stimuli. An emerging paradigm seems plausible that the same biologic events which serve to combat acute infection might be in the long run involved in the pathogenesis of atherosclerosis.

Changes in metabolism and blood flow in peripheral tissue (skeletal muscle) during cardiac surgery with cardiopulmonary bypass: the biochemical microdialysis study.

The aim of this study was to monitor the metabolism and blood flow in the interstitium of the skeletal muscle during cardiac surgery with cardiopulmonary bypass (CPB) and in the early postoperative period by means of microdialysis and to compare metabolic changes during CPB at normothermia (NT) and hypothermia (HT). Surgical revascularization using CPB was performed in 50 patients, 25 patients (group HT) were operated using hypothermic CPB, 25 (group NT) using normothermic CPB. Interstitial microdialysis was performed by two CMA 60 probes (CMA Microdialysis AB, Solna, Sweden) inserted into the patient's deltoid muscle. Constituents analysed in the obtained dialysates, collected at intervals, were glucose, urea, glycerol and lactate. Tissue blood flow was monitored by dynamic microdialysis with gentamicin as a marker. In both groups, NT versus HT, similar dynamics of concentrations were found. Low initial concentrations were followed by gradual increases during CPB and in the following phase of the operation. Concentrations were higher in the NT group. Immediately after the operation, the decrease in values continued, with a gradual increase in the succeeding postoperative period in both groups. Similar dynamic changes in the lactate concentration were found in both groups. The gentamicin concentrations were lower in the NT group (versus the HT group). The results showed dynamic changes in the interstitial concentrations of glucose, urea, glycerol and lactate, which depend on the phase of the surgery in the CPB and early postoperative phase in the both groups of patients. Higher tissue perfusion of the skeletal muscle was noted in those patients operated on in normothermia. The dynamics of the concentration changes of these substances in the interstitium of the skeletal muscle has been proven to be caused by both the metabolic activity of the tissue and by the blood flow through the interstitium of the muscle.

[Interstitial microdialysis study of changes in metabolism and blood flow in skeletal muscles during cardiac surgery with normothermic and hypothermic extracorporeal circulation]. / Sledování zmen metabolismu a krevního prutoku v kosterním svalu behem srdecní operace v mimotelním obehu v normotermii a hypotermii pomocí intersticiální mikrodialýzy.

AIM: Hypoperfusion of peripheral tissues and splanchnic organs during cardiac surgery in extracorporeal circulation may lead to the origin of serious complications. The aim of the study was to monitor metabolism and blood pressure in interstital peripheral tissue, skeletal muscle, during the operation on the patient with extracorporeal circulation (ECC) in an early post-operation period by means of microdialysis. METHODS: The interstitial microdialysis is a minimally invasive method for the biochemical monitoring of metabolic changes and blood pressure in extracellular space of tissue. The substances in interstitium pass across a semipermeable membrane of the inserted microdialysis probe and may be analyzed. Microdialysis in this study was performed by means of two microdialysis probes CMA (CMA Microdialysis AB, Sweden) inserted into the deltoid muscle of the surgically treated patient. The probes were perfused by the Ringer solution at the rate of 0.3 ml/hour. The dialysates were sampled in the following intervals: beginning of the operation, beginning of ECC, end of ECC, end of the operation, two hours during the post-operation period. Standard biochemical methods were to evaluate, in the dialysates, glucose, urea, glycerol and lactate. The blood flow in the interstitium was monitored by means of dynamic microdialysis of gentamycine as a marker. Microdialysis was performed in 40 patients with ischemic heart disease, operated on in the extracorporeal circulation. In 20 patients the ECC was performed in normothermia (NT), while in the other 20 patients it was made in hypothermia (HT). RESULTS: In both groups, NT versus HT, a similar dynamism of interstitial concentration of the observed substances in relation to the operation phase and in early post-operation period. Low initial concentrations were gradually increasing during the extracorporeal circulation and increased further after the end of extracorporeal circulation and also in the subsequent phase of the operation. The concentration values of the analytes under observation were higher in the groups operated on under normothermia, apparently due to normal cellular activity during normothermia (versus values in hypothermia). Immediately after the operation the observed values decreased in the both groups and subsequently gradually increased in the post-operation period in the both groups. The trend of dynamic changes of the observed analytes, selected as compounds indicating metabolic activity of skeletal muscles during hypothermia documents a lower metabolic activity of the cells during hypothermia and its marked increase (against NT) in the phase of subsequent normalization of the tissue temperature. Analysis of the concentrations of lactate, as a compounds mapping anaerobic metabolism of skeletal muscle, revealed similar dynamic changes in the both groups (NT vs. HT). There were no significant differences, related to the phase of the operation or the phase of immediate post-operation course when the both groups were compared. The analysis of gentamycine concentrations as a flow marker revealed lower gentamycine concentrations in dialysate during the operation, ECC and the early post-operation course in the group operated on in normotheramia (vs. HT), indicating a higher tissue flow in skeletal muscle against the group of patients operated on under hypothermia. CONCLUSION: The results of the microdialysis study demonstrated dynamic changes in interstitial concentrations of the observed compounds (glucose, urea, glycerol and lactate) related to the phase of operation on the heart in extracorporeal circulation and in early post-operation period. A higher perfusion of skeletal muscle was documented in patients operated on under normothermia. It became obvious that the dynamism in the changes of the compounds observed in the interstitium of skeletal muscle was determined by metabolic activity of the tissue as well as by blood flow in the muscle interstitium.

[Surgical myocardial revascularization in a female patient with bilateral occlusion of the common carotid arteries]. / Chirurgická revaskularizace myokardu u nemocné s oboustranným uzáverem spolecných krkavic (kazuistika).

Concurrent stenosis of the coronary and carotid circulation is one of the most serious disease. The authors describe the case of a 74-year old female patient with ischaemic heart disease with concurrent bilateral occlusion of the common carotid arteries. Surgical revascularization of the myocardium was made using extracorporeal circulation under general normothermia with protection of the heart muscle from ischaemia by the method of warm blood cardioplegia. In the discussion the authors analyze contemporary possibilities of surgical treatment of ischaemic disease (MIDCAB, OPCAB, operations with extracorporeal circulation) and emphasize the advantages and risks of different procedures.

[Frequency of occurrence of traumatic aortic rupture in automobile passengers involved in a frontal crash with a static or dynamic obstacle]. / Cetnost výskytu úrazové ruptury aorty u posádek automobilu pri celním stretu se statickou ci dynamickou protijedoucí prekázkou.

There is a lesion of aortic thoracic complex in car-passengers during the frontal clash to a static or to a dynamic antipodal obstacle is described in this study. It is a retrospective analysis. Facts were noted especially from dissectional documents. All from 298 men died. The main cause of car-passengers death was a weighty traumatic lesion of cardiovascular system in 58.7%. The aortic rupture was noted in 98 (32.9%) people, the death was in 90.8% directly on the road and 9.2% at hospital. From the whole people who were accepted to a hospital were 9 (8.9%) with a traumatic aortic rupture. But nobody of them was transported to a special center and everyone died due to traumatic lesion of cardiovascular system. Statistical significant cofactors of aortic rupture were atherosclerosis of aortic wall and intensity of clash. Therefore we can expect an aortic rupture in every third dead frontal car crash participant on a dynamic or static obstacle. Nearly 10% from men with traumatic aortic rupture were transported to a hospital. No aortic rupture was diagnosed.

[Gastric perforation as an early complication of surgical myocardial revascularization using extracorporeal circulation]. / Perforace zaludku jako casná komplikace chirurgické revaskularizace myokardu v mimotelním obehu.

The authors describe the case of a man with ischaemic heart disease after revascularization of the myocardium by an aortocoronary bypass using extracorporeal circulation. The early postoperative course was complicated by perforation of a gastric ulcer. The condition was successfully resolved by an urgent operation, suture of the perforated stomach with toilet of the abdominal cavity. In the discussion the authors analyze the causes of the possible development of gastrointestinal complications after cardiac surgery, in particular the influence of extracorporeal circulation and other specific effects during cardiac surgery and during the immediate postoperative period.

Morbidity and mortality in patients 70 years of age and over undergoing isolated coronary artery bypass surgery.

BACKGROUND AND AIM: Due to the constantly improving results of surgical revascularization for coronary heart disease even the elderly patients are offered more frequently this type of treatment. Since older age is a harbinger of reduced vital capacity and increased morbidity the results of coronary artery bypass grafting (CABG) in elderly as well as long-term benefit deserve a careful examination. MATERIALS AND METHODS: 1475 isolated CABG procedures performed between 1995 and 1997 in a university hospital cardiac surgery unit, divided in group I (age below 70, n = 1324) and group II (age 70 and over, n = 151). A retrospective analysis of pre-operative, peri-operative and post-operative data. RESULTS: Significant differences (lower BMI and BSA, advanced NYHA and CCS stage, higher prevalence of diabetes, renal dysfunction and extracardial atherosclerotic lesions) were found in elderly. CABG was performed in both groups with no differences in technique of procedure (only slightly longer duration of CPB in group II). However, there was markedly higher mortality (2.3 vs. 7.3%, p < 0.005), incidence of NearMiss+ (18.4 vs. 36.4%, p < 0.005) and post-operative morbidity (34.6 vs. 56.3%, p < 0.005) in the older group, which was also expressed in a longer ICU stay and postoperative hospitalization. CONCLUSION: Coronary revascularization can be performed in elderly with higher but still acceptable risk. Higher mortality and associated morbidity is caused by higher preoperative prevalence of known risk factors as well as generally reduced vital capacity. Surgical procedure should not be denied to elderly population because of the age alone but a careful evaluation of an individual patient is required.

Sternobronchial fistula--uncommon complication after coronary surgery (a case report).

The authors describe a case of a 46-year-old man with ischemic heart disease who underwent coronary surgery. After some time span an inflamed wound, several skin fistulae and the system of substernal fistulae appeared. One of these fistulae communicated with the left bronchial tree.