[Late results of coronary revascularization with saphenous vein and internal thoracic artery grafts]. / Veniniu ir arteriniu jungciu, suformuotu su skirtingomis vainikinemis arterijomis, isgyvenimas.

OBJECTIVE: To evaluate the patency of saphenous vein and internal thoracic artery grafts by coronary system using angiographies performed in symptomatic patients after coronary artery bypass grafting. MATERIAL AND METHODS: From 1999 to 2006, 685 patients (mean age, 59.1+/-11.8 years) had angiography of 538 internal thoracic and gastroepiploic artery and 1644 saphenous vein grafts. There were 580 (84.7%) males. The mean period from operation to the performance of reangiogram was 73.3+/-53.5 months. Graft failure was defined as >95% stenosis. The saphenous vein was grafted to the left anterior descending artery in 106 (6.4%), to the diagonal artery in 364 (22.1%), to the obtuse marginal artery in 629 (38.3%), and to the right coronary artery in 545 (33.1%) cases. RESULTS: During the study, 1496 (68.97%) grafts were patent, and 686 (31.0%) had failed. Unadjusted 1-, 5-, 10-, and >10-year patency was 91.0%, 89.9%, 90.1%, and 75% for internal thoracic arteries and 79.9%, 68.6%, 57.4%, and 51.0% for saphenous veins, respectively. CONCLUSIONS: Internal thoracic arteries demonstrate better patency than saphenous veins except when grafting moderately stenosed coronary arteries. When bypassing coronary arteries with less than 70% stenosis, saphenous veins may be a better choice.

[Surgical treatment of acute type A aortic dissection]. / Uminio A tipo aortos atsisluoksniavimo gydymas.

UNLABELLED: The objective of this study was to evaluate the short-term results of surgical treatment in patients with acute aortic dissection. PATIENTS AND METHODS: A retrospective analysis of 38 patients with acute type A aortic dissection who were surgically treated at the Clinic of Cardiac, Thoracic, and Vascular Surgery, Hospital of Kaunas University of Medicine, from January 2004 to December 2007 was conducted. The diagnosis of aortic dissection was confirmed by employing special techniques. Two-dimensional transthoracic echocardiography was performed in 34 (89.5%) patients; transesophageal echocardiography, in 24 (63.1%); computed tomography, in 29 (76.3%); coronagraphy and angiography, in 20 (52.6%). Preoperative shock was reported in 3 (7.9%) and cardiac tamponade in 18 (47.4%) cases. More than half (57.9%) of patients were operated on within the first 24 hours after admission. In the majority of cases (73.7%), the diameter of the aorta exceeded 4 cm. In the presence of type A aortic dissection, all patients underwent surgery on cardiopulmonary bypass; its duration varied from 20 to 485 min, with a mean of 214.6+/-102.9 min. The mean aortic cross-clamp time was 114.5+/-62.7 min. Complete circulatory arrest was needed in the majority of cases (86.8%), and it lasted 2 to 97 min (mean, 27.4+/-18.6 min). During cardiopulmonary bypass, body temperature was decreased to 17-28 degrees C (mean, 18.9+/-1.95 degrees C). The duration of surgery ranged from 1 to 14 hours, with a mean of 6.1+/-2.49 hours. During the early postoperative period, 12 (31.6%) patients died. Postoperative bleeding was seen in 16 (42.1%) patients, and 6 of them died later. Due to prolonged bleeding, 4 (10.5%) patients were left with an open sternum after surgery. Resternotomy was performed in 9 patients; 3 of them died due to multiorgan injury. During postoperative period, cardiogenic shock of various degrees was seen in 7 (18.4%) patients. Central nervous system injury occurred in 9 (23.7%) patients. CONCLUSION: The main risk factor for acute aortic dissection is the diameter of the aorta exceeding 4 cm (diagnosed in 73.7% of cases). The main postoperative complications are bleeding (42.1%), injuries of central nervous system (23.7%), and cardiogenic shock (18.4%).

[Aortic root surgery: early postoperative results of different surgical techniques]. / Aortos saknies operacijos: skirtingu operaciniu metodiku ankstyvieji rezultatai.

UNLABELLED: The aim of the study was to evaluate early postoperative results of different surgical techniques of aortic root surgery. MATERIAL AND METHODS: Between January 2004 and November 2007, a cohort of 83 patients underwent aortic root surgery in the Heart Center, Hospital of Kaunas University of Medicine. Patients were divided into three groups: Group 1 (18 patients) - reimplantation of the aortic valve within a vascular graft (David operation), Group 2 (48 patients) - replacement of the ascending aorta and aortic valve using a valved conduit (Bentall de Bono operation), and Group 3 (17 patients) - biological aortic root replacement. Study protocol included clinical data, operative data, and postoperative major adverse effects: reoperations for bleeding, stroke and lethal outcomes. RESULTS: Patients undergoing biological aortic root replacement were older as compared with other groups. The mean age in the Group 1 was 50.3+/-3.5 years vs. 57+/-2.0 years in the Group 2 and 67.8+/-3.3 years in the Group 3 (P<0.05). The main indication for the aortic root surgery was the aneurysm of the aortic root and ascending aorta in the Group 1 and 2 patients (64.7% and 72%), while in the Group 3, the main indication was fibrocalcinosis of aortic valve, aortic annulus, and ascending aorta (61.1%). The 30-day hospital mortality rates were as follows: 5.8% (n=1), in the Group 1; 10.4% (n=5), in the Group 2; 5.5% (n=1), in the Group 3. In the early postoperative period, 11 reoperations were performed due to bleeding events: in the Group 1, after planned/emergency surgery (n=2/2), and in the Group 2 (n=1/6), respectively. The function of aortic valve improved significantly in all groups of patients early after surgery. In the Group 1, the degree of aortic regurgitation decreased from 2.5+/-0.8 to 1.1+/-0.6 (P<0.05); in the Groups 2 and 3, the mean gradient through the aortic valve decreased from 39.9+/-7.5 to 17.1+/-5.3 mm Hg and from 48.8+/-18.0 to 20.1+/-11.0 mm Hg, respectively (P<0.05). No reoperation for aortic valve failure before the discharge was required in all groups of patients, and neither thromboembolic complications nor stroke events were noted in any group. CONCLUSIONS: Different aortic root surgery techniques showed similar postoperative results. New aortic root surgery methods such as aortic root-preserving/sparing procedures and concurrent aortic valve leaflet repair or aortic root replacement with the bioprosthesis can be selected for a diverse class of aortic root pathology with low perioperative mortality rates and good early postoperative results.

Matrix metalloproteinase-3 gene polymorphism and dilatative pathology of ascending thoracic aorta.

Matrix metalloproteinase-3 (MMP-3) degrades extracellular matrix and may lead to development of dilatative pathology of ascending thoracic aorta. Expression of MMP-3 depends upon the 5A/6A polymorphism in the promoter region. An increased number of 5A alleles leads to high expression of MMP-3. Thus, objective of the study was to determine whether the 5A/6A polymorphism in the promoter region of MMP-3 gene is associated with the development of dilatative pathology of ascending thoracic aorta. We studied 76 patients (age ranged from 31 to 81 years; median age, 64 years) who underwent aortic reconstruction surgery due to dilatative pathology of ascending thoracic aorta and a random sample of the population (n=604) aged 25-64 years, all from Lithuania. DNA was analyzed by using real-time polymerase chain reaction to genotype polymorphism 5A/6A at a position -1171 of the MMP3 gene promoter. The prevalence of MMP-3 genotypes was similar in the group of dilatative pathology of ascending thoracic aorta and random sample of population. The frequency of 5A allele did not differ significantly between both groups and was 0.506 and 0.514, respectively. Male carriers of 5A/5A genotype were significantly younger compared with those with the 6A/6A genotype. In conclusion, the frequency of MMP-3 promoter 5A/6A genotypes did not differ between the group of patients with dilatative pathology of ascending thoracic aorta and the random sample of population, but the males with dilatative pathology of ascending thoracic aorta and 5A/5A genotype required aortic reconstruction surgery at the younger age than the males carrying 6A/6A genotype in the MMP-3 promoter region.

[Myocardial revascularization and mitral insufficiency correction in case of acute myocardial infarction]. / Miokardo revaskulizacija ir mitralinio voztuvo korekcija umaus miokardo infarkto metu.

UNLABELLED: The aim of our study was to evaluate patients survival, changes of functional status after repair of ischemic mitral insufficiency and coronary artery bypass grafting in acute period of myocardial infarction. In the Clinic of Cardiosurgery of Kaunas University of Medicine (since January 2001 till July 2003) 82 patients with acute myocardial infarction underwent surgery. Patients were operated on the 1(st)-21(st) day after myocardial infarction. Among 82 operated patients with acute myocardial infarction, 64 (78%) underwent coronary artery bypass grafting and 18 (22%) - coronary artery bypass grafting with mitral valve repair. Ten patients (55.6%) were in NYHA functional class II and 44.4% - in NYHA functional class III. Before myocardial infarction ischemic heart disease was diagnosed in 12 (66.7%) patients; 8 (44.4%) patients had a history of myocardial infarction. Patients were not operated during the first 24 hours of myocardial infarction. All patients were evaluated by means of 2 Doppler-echocardiography and transesophageal echocardiography before, during and a few days after operation. Eighteen patients underwent mitral valve repair: in 9 (50%) - annulocompression (original technique), in 7 (39%) - annulocompression with shortening of papillary muscles, in 1 case - Kay valvuloplasty was performed. One patient needed mechanical mitral valve prosthesis due to rheumatic mitral valve disease. After correction of ischemic mitral incompetence improvement of left ventricular function was observed. Medial-lateral mitral valve ring diameter was reduced from 36.8+/-2.6 mm to 23.9+/-0.56 mm (p<0.01) resulting in decrease of degree of mitral incompetence - 2.9+/-0.2 to 0.7+/-0.8, mean LVEDD - 53.3+/-6 to 50+/-4.1 mm, improvement of LVEF - 35.9+/-6.3 to 38.4+/-9.5, LVWSI from 2.61+/-0.22 to 1.81+/-0.43. CONCLUSIONS: 1. Patients suffering acute myocardial infarction with >II degrees mitral valve incompetence, should receive coronary artery bypass grafting with mitral valve repair. 2. Repair of ischemic mitral incompetence should consist of annulocompression with/without papillary muscle shortening. 3. Early results surgery in patients with acute myocardial infarction and mitral valve incompetence are similar to the results of surgery on stable ischemic heart disease with mitral valve incompetence if operation is performed on the 3(rd) day of acute myocardial infarction.

[Myocardial revascularization of acute coronary syndromes in Clinic of Cardiac Surgery at Kaunas University of Medicine Hospital (experience of 5 years)]. / Uminio vainikinio sindromo chirurginis gydymas (penkeriu metu Kauno medicinos universiteto kliniku patirtis).

UNLABELLED: A retrospective study of patients undergoing emergent and urgent coronary artery bypass grafting for acute coronary insufficiency was performed to identify the risk factors for hospital death specifically associated with the clinical severity of the acute coronary insufficiency syndrome. MATERIAL AND METHODS: The 104 patients were divided into three groups - emergent, urgent A, urgent B - on the basis of the evaluation of the clinical pattern of the acute coronary insufficiency syndrome on full medical treatment. The three groups were defined as follows: emergent (26 patients), prompt myocardial revascularization was required because medical treatment achieved only transient regression of myocardial ischemia; urgent A (29 patients), myocardial revascularization could be delayed for 24 to 72 hours after beginning of chest pain because of adequate control of ischemia; urgent B (49 patients), these patients had operation after 72 hours after beginning of chest pain because mild episodes of recurrent ischemia not required urgent revascularization. RESULTS: Hospital mortality 14 patients. Mortality rates were 30.8% for the emergent group, 13.8% for the urgent A group, and 4.1% for the urgent B group. Death resulted from cardiac-related causes in 10 patients. Surgery performed at a later stage has good results if performed in a non emergency situation, specially after the first 72 hours. CONCLUSIONS: Including patients undergoing semielective revascularization procedures would lead to better results, thus giving the impression of low mortality rates in a acute coronary syndromes category of patients. Employment of a more exact definition of patients risk and the identification of new risk factors make the interpretation of the outcome data clearer.