Clinical and echocardiographic features of two large left atrial parietal thrombi.

A 62-year-old woman with severe mitral stenosis and two large parietal thrombi inside the left atrium is described. The patient was admitted to the hospital because of heart failure. Transthoracic and transesophageal echocardiography showed a severe calcific mitral stenosis and two large (56.9 and 46.2 mm in diameter) parietal thrombi inside the left atrium attached to the interatrial septum and associated with severe spontaneous echo contrast. This severe spontaneous echo contrast was detected in the left atrium and in the left atrial appendage. The patient was referred for cardiac surgery. The two large parietal thrombi were removed, and the valve was replaced with a Sorin-Bicarbon mitral valve prosthesis. Intraoperative transesophageal echocardiography after replacement of the mitral valve prosthesis and removal of the thrombotic mass showed absence of any spontaneous echo contrast in the left atrium and in the left atrial appendage. This report describes the diagnostic approach and successful surgical treatment of two very large parietal thrombi inside the left atrium associated with severe mitral stenosis and atrial fibrillation, which is a rare occurrence.

Cytomegalovirus disease as a possible etiologic factor for early atherosclerosis.

A group of 284 patients who underwent orthotopic heart transplantation between April 1986 to June 1991 and who were followed up for at least five years was analyzed in this paper. Patients were divided into three groups according to the presence or absence of cytomegalovirus infection or disease: patients without infection, patients with serologycaly proven infection and patients with cytomegalovirus disease. The analysis of survival was performed with respect to all major factors that influence survival: age and sex of a donor and a recipient, number of rejection episodes, perioperative ischemic time and pulmonary vascular resistence. A recipient's age was shown to be a significant factor. Patients who experienced at least one episode of cytomegalovirus disease had significantly worse long-term survival compared to those with the infection only or without the infection. That difference was caused by the increased incidence of coronary atherosclerosis, which caused deaths in patients with a previous episode of cytomegalovirus disease. A possible mechanism responsible for this phenomenon is discussed.

Changes in vitamin E concentration after surgery and anesthesia.

UNLABELLED: The aim of this randomized study was to examine changes in vitamin E concentration in female subjects (age 30-60, ASA I) after cholecystectomy and halothane (N = 16) or isoflurane (N = 16) anaesthesia. Vitamin E concentration was measured two days before, and then one, five and twenty-four hours and four days after surgery. High-pressure liquid chromatography was used for its determination. Simultaneously activities of alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma glutamyltransferase (GGT) were determined. STATISTICAL ANALYSIS: ANOVA, Tukay HSD test. The research has been accepted by the Drugs Committee of the Karlovac County Hospital. Preoperative vitamin E concentrations in the halothane group were 8.69 +/- 2.35 micrograms/L, median 8.67 micrograms/L and in the isoflurane group 9.43 +/- 2.4 micrograms/L, median 9.08 micrograms/L. Statistically lower vitamin E concentrations compared with preoperative values were noted one hour (P < 0.05), 5 hours (P < 0.01), 24 hours (P < 0.01), as well as 4 days (P < 0.01) after the operation. The lowest vitamin E concentrations were noted 24 hours after the operation with statistically insignificantly higher values in the isoflurane group (halothane group 5.98 +/- 2.08 micrograms/L, isoflurane group 6.58 +/- 1.51 micrograms/L). Analyzing enzyme (ALT, AST and GGT) pre- and postoperative values, no statistically significant differences between the investigated groups and during the time were observed. Statistically significant differences were found between individual measurement times, with no statistical significance of the differences between the halothane and isoflurane groups. It seems that neither the difference in halothane and isoflurane biotransformation nor their distinct effect on perfusion of some organs are the determining factors in post-operative changes in vitamin E concentration.

Penetrating cardiothoracic war wounds.

OBJECTIVE: Penetrating cardiothoracic war wounds are very common among war casualties. Those injuries require prompt and specific treatment in an aim to decrease mortality and late morbidity. There are a few controversies about the best modality of treatment for such injuries, and there are not many large series of such patients in recent literature. METHODS: We analysed a group of 259 patients with penetrating cardiothoracic war wounds admitted to our institutions between May 1991 and October 1992. RESULTS: There were 235 (90.7%) patients with thoracic wounds, 14 (5.4%) patients with cardiac, wounds and in 10 (3.7%) patients both heart and lungs were injured. The cause of injury was shrapnel in 174 patients (67%), bullets in 25 patients (9.7%), cluster bomb particles in 45 patients (17.3%) and other (blast etc.) in 15 patients (6%). Patients, 69, had concomitant injuries of various organs. The initial treatment in 164 operated patients was chest drainage in 76 (46.3%) patients, thoracotomy and suture of the lung in 71 (43.2%) patients, lobectomy in 12 (7.3%) patients and pneumonectomy in 5 (3%) patients. Complications include pleural empyema and/or lung abscess in 20 patients (8.4%), incomplete reexpansion of the lung in 10 patients (4.2%), osteomyelitis of the rib in 5 patients (2.1%) and bronchopleural fistula in 1 patient (0.4%). Secondary procedures were decortication in 12 patients, rib resection in 5 patients, lobectomy in 2 patients, pneumonectomy in 4 patients, reconstruction of the chest wall in 2 patients and closure of the bronchopleural fistula in 1 patient. The cardiac chamber involved was right ventricle in 12 patients, left ventricular in 6 patients, right atrium in 7 patients, left atrium in 3 patients, ascending aorta in 2 patients and 1 patient which involved descending aorta, right ventricle and coronary artery (left anterior descending) and inferior vena cava, respectively. The primary procedure was suture in 17 patients (in 10 patients with the additional suture of the lung), suture + extraction of the foreign body in 4 patients, 2 of them with cardiopulmonary bypass. Complications were pericardial effusion in 6 patients, arrhythmia in 2 patients, myocardial infraction in 1 patient and migration of the foreign body in 1 patient. Patients, 7, died, five of the group with concomitant injuries, two of thoracic and one of cardiac injuries (5, 1.2 and 4.2%, respectively). CONCLUSIONS: Penetrating cardiothoracic wounds are among the most serious injuries in war, either in combat or among civilians. In spite of their nature, they can be treated successfully with relatively low mortality and morbidity.

Adult respiratory distress syndrome.

In this article the authors present a case of successful treatment of a 54-year old male patient with non-insulin dependent diabetes mellitus (NIDDM) and triple-vessel coronary artery disease who underwent surgical myocardial revascularization and was reoperated on the same day because of excessive bleeding. The patient was given cca 5000 mL of whole blood and cca 3000 mL of blood derivatives. The first postoperative chest X-ray showed radiological signs of ARDS. The therapy was based upon authors' experience and was consisted of controlled mechanical ventilation (respiratory volume 12-15 mL/kg, 10-14 cycles/min, I/E ratio 1:2, FIO2 0.6, PEEP 2-5 cm H2O), daily bronchoscopies with bronchoaspiration, aggressive diuresis, negative fluid balance, specific antibiotic therapy, and last but not least, of prostaglandin E1 (PGE1) 0.5-20 micrograms/kg/min combined with dopamine inotropic support (2-5 micrograms/kg/h). Simple but careful clinical observation still remains a milestone for all therapeutic measures taken in ARDS patients.

[Hemodynamic effects of captopril, an ACE inhibitor, in patients after aortocoronary bypass]. / Hemodinamski ucinak ACE inhibitora captoprila u bolesnika nakon aortokoronarnog premostenja.

During the last few years, the use of angiotensin converting enzyme (ACE) inhibitors in the treatment of patients with cardiovascular diseases has been increasing. Captopril is the earliest oral ACE inhibitor and was marketed in 1977. The adverse effect most undesirable with vasodilators, particularly in patients with heart disease, is a reflex tachycardia. The absence of tachycardia with the possibility of binding free radicals is the comparative advantage of angiotensin converting enzyme inhibitors. Because of their positive hemodynamic effect, ACE inhibitors should be used as a supplement in the treatment of patients who need aortocoronary bypass. Their use does not exclude the intravenous administration of vasodilators, and only decreases the required therapeutic concentration of these drugs.

The importance of glucose-insulin-potassium with cardiopulmonary bypass prior to cardioplegic arrest in open-heart surgery.

The benefit of a high dose glucose-insulin-potassium (33% glucose, 80 mmol KCl, 120 units of insulin - 1 mL/kg) (GIK) with cardiopulmonary bypass support (CPB) prior to cardioplegic arrest in open-heart surgery has been evaluated in this article. Twenty non-diabetic patients (PTS) were selected upon their preoperatively impaired left ventricular ejection fraction (LVEF < 45%) and were divided into two groups. Group 1 was given GIK and 20 minutes of CPB prior to cardioplegic arrest; Group 2 was the control group with no GIK and no CPB support. Hemodynamics was measured prior to surgery, 30 minutes after weaning from CPB, and 12 and 24 hours postoperatively. There were less rhythm disturbances and need for intraoperative defibrillation in Group 1 (2:10 pts VS 8:10 pts in the Group 2). There were significantly higher values of cardiac index (CI) in Group 1 30 minutes after weaning from CPB (2.5 +/- 0.28 VS 2.11 +/- 0.25: p < 0.01), while there was no significant difference in late postoperative course. Left ventricular stroke work index (LVSWI) in Group 2 was significantly higher 12 hours after the surgery (38.35 +/- 8.93 VS 29.76 +/- 8.17:p < 0.05). At 30 minutes and 24 hours postoperatively there was no significant difference, but clinical difference was observed, probably due to necessary inotropic stimulation in Group 2. There was neither clinical nor statistical difference in right ventricular stroke work index (RVSWI) throughout the whole measurement. The authors emphasise the importance of GIK with CPB in myocardial protection in patients undergoing open-heart surgery.

[Hemodynamic effects of amrinone, dobutamine and dopamine in the cardiac low output syndrome following open-heart surgery]. / Hemodinamski ucinak amrinona, dobutamina i dopamina u sindromu niskog minutnog volumena srca nakon kirurskog zahvata na otvorenom srcu.

Low heart stroke volume syndrome is clinically manifested with hypoperfusion of all body systems. Inotropic or mechanical support is applied. Acute heart failure is one of the most important complications after open heart surgery. Catecholamines have been up to non considered as a therapy of choice for the acute heart failure. Effectiveness of catecholamines could be limited with some side effects. Phosphodiesterase inhibitors promise a new therapeutic approach. PDE III primary act through phosphodiesterase inhibition which leads to a rise of aAPM levels. Thus they show positive inotropic and lusitropic effects, which could be monitored by occlusive pulmonary capillary pressure values. Amrinone is obviously superior to inotropic catecholamines.

Inotropic agents in the treatment of postoperative low cardiac output syndrome.

Two basic groups of inotropic drugs that are in the treatment of postcardiotomy low cardiac output syndrome (LCOS) are presented. The authors emphasize the advantages of phosphodiesterase inhibitors (PDE III) as compared to catecholamines.

Treatment of adult respiratory distress syndrome--our way.

From July 1991 to September 1992 the authors treated twenty-eight patients with proven adult respiratory distress syndrome (ARDS). In this paper five patients with ARDS accompanying septicaemia are presented. In this group of patients, elevated pulmonary artery pressure or pulmonary hypertension (PAH) could not have been caused by LV failure, as it was possible in remaining twenty-three patients with ARDS after open heart surgery, so the effect of prostaglandin E1 (PGE1) on pulmonary hypertension could be followed accurately. Moreover, ARDS after septicaemia carries the worst prognosis. All patients were admitted from other hospitals, they were intubated and mechanically ventilated. ARDS was diagnosed 4 to 7 days after the primary injury.

Coronary vascularization in patient maintained on chronic hemodialysis.

A patient, maintained on hemodialysis for 16 years because of chronic renal failure caused by chronic glomerulonephritis, who underwent surgical coronary revascularization, is presented. The authors conclude that preoperative hemodialysis, careful hydration of the patient, right management of cardiopulmonary bypass, use of hemodilution and aprotinin can contribute to escivating of hemofiltration and heterologue blood transfusion in uremic patients who undergo well timed coronary revascularization.

[War injuries of the thorax]. / Ratne ozljede prsnog kosa.

Chest injuries are very common in war circumstances. Chest injury is commonly associated with other injuries of intrathoracic organs and development of shock, which has to be treated immediately. Our patients with war chest injuries are presented, along with our approach to the treatment of these injuries. "The conservative treatment" is stressed, with particularly importance of proper chest drainage, as a corner stone of proper and successful therapy. Shock treatment and prevention of atelectasis does present an unavoidable procedure of this type of therapy.