Abiotrophia defectiva endocarditis - Diagnostic and therapeutic challenge: Case report.

Belonging to the normal oral, gastrointestinal, and urogenital flora, Abiotrophia defectiva is responsible for 1-2 % of all infective endocarditis (IE) cases. The manifestation of A.defectiva endocarditis may by atypical, without fever. Difficult to isolate pathogen requires special culture media. A 45-year-old female was admitted due to anemia and progressive weight loss (8 kg in 6 months). She had a history of benign mitral valve (MV) prolapse and non-stenotic bicuspid aortic valve (BAV). In echocardiography, large vegetations on MV and small vegetation on BAV were found. An enriched medium for fastidious pathogens was used. A. defectiva was identified using biochemical analysis with VITEK-2 Compact. In the fourth week of antibiotic therapy, she required urgent MV replacement due to MV regurgitation progression while vegetation on BAV disappeared. Although patient's frailty and underweight caused prolonged postoperative wound healing, she was transferred to rehabilitation in good conditions. No relapse of IE was observed during five-month follow-up.

Relationship between stress and alexithymia, emotional processing and negative/positive affect in medical staff working amid the COVID-19 pandemic.

The psychological burden of the COVID-19 pandemic may have a lasting effect on emotional well-being of healthcare workers. Medical personnel working at the time of the pandemic may experience elevated occupational stress due to the uncontrollability of the virus, high perceived risk of infection, poor understanding of the novel virus transmission routes and unavailability of effective antiviral agents. This study used path analysis to analyze the relationship between stress and alexithymia, emotional processing and negative/positive affect in healthcare workers. The sample included 167 nurses, 65 physicians and 53 paramedics. Sixty-two (21.75 %) respondents worked in COVID-19-designated hospitals. Respondents were administered the Toronto Alexithymia Scale-20, Cohen's Perceived Stress Scale, Emotional Processing Scale, and the Positive and Negative Affect Schedule. The model showed excellent fit indices (χ2 (2)=2.642, p=0.267; CFI=0.999, RMSEA=0.034, SRMR=0.015). Multiple group path analysis demonstrated physicians differed from nurses and paramedics at the model level (X2diff (7)=14.155, p<0.05 and X2diff (7)=18.642, p<0.01, respectively). The relationship between alexithymia and emotional processing was stronger in nurses than in physicians (difference in beta=0.27; p<0.05). Individual path χ2 tests also revealed significantly different paths across these groups. The results of the study may be used to develop evidence-based intervention programs promoting healthcare workers' mental health and well-being.

Exceptional life-threatening complication 19 years after Ravitch correction of pectus excavatum.

BACKGROUND: Ravitch technique of chest correction has been considered, although invasive, as a safe and efficacious surgical method. CASE: We describe a case of a 35-year-old woman with cardiac tamponade and in cardiogenic shock due to exceptional late complication after pectus excavatum reconstruction by means of classic Ravitch technique 19 years earlier. This very late adverse event was caused by a broken metal sternal wire that injured the wall of the ascending aorta. The patient underwent salvage repair of this segment of the aorta in cardiopulmonary bypass. Postoperative course and postdischarge 3-year follow-up have been uneventful. CONCLUSION: Therefore, life-threatening cardiovascular complications may occur even many years after reconstructive surgery for chest deformity.

Autologous fibrin sealant application in cardiac surgery - a single-centre observational study.

INTRODUCTION: To minimize the risk of blood loss and post-transfusion complications in patients undergoing cardiovascular surgery, different strategies are used. AIM: To analyse the efficacy of the intraoperative use of autologous fibrin glue to seal suture lines of cardiac and vascular structures. MATERIAL AND METHODS: The early results of 62 patients who underwent complex cardiac operations in extracorporeal circulation were analysed. In a half of them Vivostat autologous fibrin sealant in addition to the routine haemostatic agents was applied (study group), whereas in the second group (matched-pair control group) only standard haemostatics were used. Among many other factors, special attention was paid to postoperative drainage and blood products used. RESULTS: The mean age of the patients and prevalence of comorbidities did not differ between groups. Generally, in the study group fewer haemostatic agents were used. For example, Preveleak tissue glue was applied in 3.2% of studied cases compared to one third of control patients (p = 0.008). The thoracic drainage on either day 0 or day 1 was also similar. The number of patients who received blood products did not differ between groups. More importantly, there were no significant differences in in-hospital mortality and prevalence of other postoperative complications. CONCLUSIONS: In this study it was found that application of autologous fibrin glue was safe and might limit use of standard haemostatic agents. Taking into account the lack of potential threats related to the transmission of infections and immune responses, it may be an interesting alternative to the previously used local haemostatics.

Dysfunctional Coping Mediates the Relationship between Stress and Mental Health in Health-Care Staff Working amid the COVID-19 Pandemic.

OBJECTIVE: This cross-sectional study aimed to assess the stress outcomes in health-care staff working during the COVID-19 pandemic and to explore the role of coping in the relationship between stress outcomes and mental health dimensions with Preacher & Hayes's mediation analysis. SUBJECTS AND METHODS: One hundred seventy participants including physicians (n = 41; 24.1%), nurses (n = 114, 67.1%), and paramedics (n = 15, 8.8%) with a mean age of 37.69 ± 12.23 years and an average seniority of 14.40 ± 12.32 years were administered the Toronto Alexithymia Scale-20, Cohen's Perceived Stress Scale (PSS-10), the Emotional Processing Scale, and Positive and Negative Affect Schedule. The data were analyzed by estimation of simple correlation coefficients and a Preacher and Hayes's mediation procedure. RESULTS: Participants reported elevated levels of stress (7-8 sten on the sten scale developed for the PSS-10 questionnaire). Statistically significant differences in the stress levels between nurses, paramedics, and physicians could not be determined. In contrast, significant association between mental health outcomes and the occupational category could not be found. CONCLUSION: Our observations support the assumption about a controlling role of coping in the relationship between work-related stress, alexithymia, emotional processing loneliness and positive/negative affect in medical staff working amid pandemic.

[Progressive cardiac tamponade and right ventricular free wall perforation as complications after dual-chamber pacemaker implantation - a case report]. / Perforacja wolnej sciany prawej komory i postepujaca tamponada serca jako powiklanie po implantacji dwujamowego ukladu stymulujacego - opis przypadku.

In recent years the number of complications related to implantation of cardiac stimulating systems is increasing. Life-threatening myocardial perforation leading to cardiac tamponade is one of the rarest complications. In that case it is necessary to take the immediate lifesaving procedures. A CASE REPORT: 61-year-old woman ended up in the cardiac surgery department with progressive cardiac tamponade and cardiogenic shock symptoms. Three weeks earlier due to the tachycardia-bradycardia syndrome with second-degree atrioventricular block diagnosis, the cardiac stimulating system was implanted into the heart at the cardiology department. Two days after the discharge from hospital the patient appeared in the emergency department with non-specific chest symptoms, which disappeared after analgesic drugs. After another two weeks the patient returned to the emergency department in general poor condition. Echocardiographic examination showed fluid in both pleural cavities, a dense layer around heart and fluid out wards from the layer in the pericardial space. Furthermore, CT scan showed unobvious shape crossing the heart muscle. Firstly, the patient was admitted to the cardiology department and next transferred to the cardio surgery where on account of deteriorating condition was made a decision urgent sternotomy and revision pericardial sac. Intraoperatively were found perforation of right ventricular free wall caused by stimulation electrode and hole communicating pericardial space with left pleural cavity. The operation went well, without any complications. The patient was discharged from hospital 12 days after surgery. CONCLUSIONS: In the case of suspected complications related to the implantation of electrostimulation equipment, it is necessary to perform appropriate diagnostics and implement urgent procedures, including surgery.

[Lyell's syndrome complicated with multi-organ failure and patient's death after complex cardiac surgery - a case report]. / Zespól Lyella powiklany niewydolnoscia wielonarzadowa i zgonem chorego po zlozonej operacji kardiochirurgicznej ­ opis przypadku.

A complex cardiac surgery may be associated with a number of complications. The occurrence of toxic epidermal necrolysis (TEN) in the postoperative period in a patient who has already experienced other complications contributes to the worsening of his prognosis. Despite the regression of necrotic skin lesions TEN can lead to tragic complications. A CASE REPORT: A 48-year-old patient was admitted as scheduled to a cardiac surgery ward for a complex cardiac surgery. During the procedure, a mechanical aortic valve prosthesis, an ascending aorta prosthesis were implanted, and the left internal thoracic artery (LIMA) was grafted to the left anterior descending coronary artery (LAD). The intraoperative course was not complicated. In the postoperative period, some fluid was found in the left pleural cavity, which was decompressed. In the following days of the postoperative period an instability of the sternum and a serous-bloody discharge from the wound ocurred, these resulted in the reoperation and use of vacuum-assisted closure (VAC) therapy. Later, there were also haemorrhagic complications requiring surgical intervention and numerous transfusions of blood components. The patient was diagnosed with a very rare complication in the form of toxic epidermal necrolysis. Despite the therapy and regression of skin lesions an irreversible multi-organ failure developed in the patient which resulted in his death. CONCLUSIONS: Toxic epidermal necrolysis turned out to be a complication significantly contributing to the patient's death.

[Cardiosurgical treatment of pneumomediastinum caused by polytrauma]. / Kardiochirurgiczne leczenie odmy sródpiersiowej po urazie wielonarzadowym.

Pneumomediastinum (also known as mediastinal emphysema) is defined as the presence of gas in the mediastinum. It can be spontaneous or arise as a result of trauma. Most cases can be effectively treated conservatively, however, if severe symptoms occur, cardiosurgical intervention is necessary. A CASE REPORT: A man 20 years old, a victim of a traffic accident resulting in polytrauma, was transported to the Municipal Hospital of Jozef Strus in Poznan. Rapid tests performed at the Hospital's Emergency Room speeded up the diagnosis of a life-threatening pneumomediastinum. The patient was transferred to the Operating Room of the Cardiosurgical Department, where during an urgent surgery, the pericardial sac was decompressed. Subsequently, the patient underwent another surgery in the Thoracic surgery Department of the Wielkopolskie Center of Pulmonology and Thoracic Surgery. Afterwards, the patient had to spend a couple of weeks at the Intensive Care Department of Municipal Hospital of Jozef. Ultimately, after 6 weeks of hospitalization, the patient was discharged from the hospital in a good condition. CONCLUSIONS: The therapeutic success was an outcome of a quick diagnostic process, cooperation of doctors of various specialties and implementation of urgent surgical treatment. Mediastinal emphysema, which even though usually treated conservatively, may require lifesaving surgery in cardiothoracic surgery wards.

Takotsubo syndrome following mitral valve replacement and left anterior descending coronary artery bypass grafting.

Takotsubo syndrome (TTS) is rarely diagnosed following valvular and nonvalvular cardiac surgery. Only several such cases, including 12 after mitral valve replacement (MVR) or plasty (MVP) and 2 after coronary artery bypass grafting (CABG) have been reported so far. A CASE REPORT: The authors describe a case of a 75-year-old female in whom TTS occurred on the first postoperative day after elective combined surgery: MVR (with bioprosthesis) and CABG (of the left anterior descending coronary artery). Echocardiography revealed left ventricular (LV) dysfunction in the form of apical ballooning with markedly decreased ejection fraction (EF) and global longitudinal strain (GLS): 28 % and -9.3 %, respectively; there were no signs of prosthesis dysfunction. Due to circulatory and concomitant respiratory failure, she was transferred to the intensive care unit; however, an intra-aortic balloon pump was not necessary. Normalization of LV function (EF 60%, GLS -18.5%) was observed after 2 weeks. The authors compare the clinical data of the case presented with those of the remaining 14 TTS patients after MVR, MVP or CABG described in the literature and emphasize the coexistence of multiple triggering factors (e.g. additional procedures, catecholamines use, protamine use, pleural or pericardial drainage, blood transfusion, rapid heart rate). The authors suggest that TTS should be routinely included in differential diagnosis of post-cardiac surgery heart failure decompensation.

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.

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.

[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.