Starting Pediatric VAD Program: Transforming Challenges into Opportunities; A Case Series of a Single Center.

BACKGROUND: The prevalence of heart failure is constantly increasing in both children and adults. End-stage heart failure in children unresponsive to medical therapy has limited treatment options. Surgical options include heart transplantation or implantation of durable ventricular assist devices (VADs). To start the VAD program, it was necessary to train core team members, invite experienced proctors and adjust the organizational approach. METHODS: We present our first seven pediatric patients who underwent a VAD implantation with primary indication end-stage dilated cardiomyopathy. RESULTS: The median age on implant was four and a half years and the median duration of VAD support was 39 days with long term survival achieved in three patients. The causes of death were multiorgan failure, thromboembolic events, sepsis, and low cardiac output syndrome. Ischemic stroke was the reason for successful neurointervention during VAD support in two patients. CONCLUSIONS: To establish a VAD program, numerous specialties must be included with adequate training and learning for all team members.

Supracardiac Total Anomalous Pulmonary Venous Return Repair in a 7-Month-Old Infant.

Total anomalous pulmonary venous return is a congenital heart malformation characterized by anomalous pulmonary venous inflow to the right atrium. Surgical repair typically occurs during the first month of life, and survival beyond that age in untreated patients is unlikely. We report an extreme case of supracardiac total anomalous pulmonary venous return in an infant who survived 7 months despite atypical anomalous inflow without atrial-level communication and with right-to-left shunting only through a patent ductus arteriosus. We stabilized the patient's left-sided heart function before surgically repairing the anomalous venous return 2 months later. Three years postoperatively, the patient was well.

Resveratrol as antioxidant in cardiac surgery: is there potential for clinical application?

Cardiopulmonary bypass (CPB) is an essential technique in cardiac surgery but is also associated with adverse effects, including the systemic inflammatory response syndrome that manifests itself as ischaemia-reperfusion injury and multi-organ dysfunction. The aim of this mini review is to take a look at the current knowledge of resveratrol, a stilbenoid and natural antioxidant believed to have many cardioprotective effects including vasodilation, lowering of blood pressure and reactive oxygen species levels, suppression of low-density lipoprotein peroxidation, and mitigation of ischaemia/-reperfusion injury. We mostly focus on its cardioprotective potential in patients undergoing cardiac surgery supported by CPB. Current findings, however, are still inconclusive and call for further research, including clinical trials.

The Dark Side of the Heart: Cardiovascular Manifestation of Ochronosis.

Alkaptonuria is rare genetic disorder of tyrosine metabolism manifesting with signs of tissue pigmentation, dark urine, and ochronotic arthropathies. Commonly undiscovered by late adulthood, alkaptonuria can manifest as cardiac ochronosis with cardiovascular disorders such as valvulopathies, but rarely coronary artery disease. This case report describes 2 patients with aortic stenosis and coronary artery disease in whom alkaptonuria was diagnosed during open heart surgery.

Immunoglobulin G4 Inflammatory Aortic Aneurysm Mimicking Acute Aortic Syndrome.

Immunoglobulin-G4-related disease (IgG4RD) is a novel clinical entity characterized by lymphoplasmacytic infiltrates presenting as an excessive fibrosis such as retroperitoneal inflammatory pseudotumor but rarely affecting the heart or the aorta. We describe a case of IgG4RD with multifocal aortic involvement presenting as an acute aortic syndrome.

Quadruple-valve infective endocarditis caused by Abiotrophia defectiva.

Quadruple-valve endocarditis is a challenging condition, for which there is limited treatment experience and poor overall survival. We report the first case caused by Abiotrophia defectiva that has been surgically treated both with the replacement of the aortic and pulmonary valves and the repair of the mitral and tricuspid valves with a good outcome. The patient's clinical course is described and a review of literature on this rare causative agent is given.

Isolated Tricuspid Valve Libman-Sacks Endocarditis in Systemic Lupus Erythematosus with Secondary Antiphospholipid Syndrome.

Libman-Sacks endocarditis, one of the most prevalent cardiac presentations of systemic lupus erythematosus, typically affects the aortic or mitral valve; tricuspid valve involvement is highly unusual. Secondary antiphospholipid syndrome increases the frequency and severity of cardiac valvular disease in systemic lupus erythematosus. We present the case of a 47-year-old woman with lupus and antiphospholipid syndrome whose massive tricuspid regurgitation was caused by Libman-Sacks endocarditis isolated to the tricuspid valve. In addition, we discuss this rare case in the context of the relevant medical literature.

Off-pump myocardial revascularization attenuates endothelin-1 expression in systemic, pulmonary, and coronary circulation.

OBJECTIVE: The objective of this study was to evaluate the influence of cardiopulmonary bypass (CPB) on endothelin-1 (ET-1) expression in various circulation compartments in patients undergoing myocardial revascularization. METHODS: A total of 30 patients were randomized to undergo myocardial revascularization with (CABG, n = 15) or without (OPCAB, n = 15) CPB. Samples were taken preoperatively, after establishing CPB and after CPB (CABG group), prior to and after revascularization (OPCAB group), and 6 and 24 h postoperatively. Values of ET-1 were compared between groups at all time points and correlated with postoperative cardioselective enzyme values and clinical parameters. RESULTS: In OPCAB group, ET-1 levels did not significantly vary between time points. In CABG group, ET-1 levels were significantly elevated vs. baseline in arterial: ART-T2 vs. ART-T0 (1.83 ± 1.81 vs. 0.76 ± 1.07 fmol/mL, p = 0.05), pulmonary: SG-T2 vs. SG-T0 (2.70 ± 2.75 vs. 0.39 ± 0.28 fmol/mL, p < 0.001) and SG-T3 vs. SG-T0 (1.56 ± 0.28 vs. 0.39 ± 0.28 fmol/mL, p < 0.001), and coronary circulation CS-T2 vs. CS-T1 (1.12 ± 0.49 vs. 0.27 ± 0.09 fmol/mL, p = 0.01). ET-1 levels were significantly higher in CABG group in all vascular compartments: ART-T2 (1.83 ± 1.81 vs. 0.17 ± 0.16 fmol/mL, p = 0.02), ART-T4 (0.99 ± 0.56 vs. 0.24 ± 0.12 fmol/mL, p = 0.01), SG-T1 (0.59 ± 0.15 vs. 0.25 ± 0.13 fmol/mL, p = 0.01), SG-T2 (2.70 ± 2.75 vs. 0.30 ± 0.24 fmol/mL, p = 0.004), SG-T3 (1.56 ± 0.28 vs. 0.35 ± 0.31 fmol/mL, p < 0.001), SG-T4 (1.34 ± 0.11 vs. 0.34 ± 0.16 fmol/mL, p < 0.001), and CS-T2 (1.12 ± 0.49 vs. 0.12 ± 0.12 fmol/mL, p = 0.004). Coronary sinus ET-1 level after CPB (CS-T2) in CABG group correlated positively with troponin-I level 24 h postoperatively (r(2) = 0.802, p = 0.02) CONCLUSION: Off-pump myocardial revascularization attenuates ET-1 expression in all investigated vascular compartments. Elevated coronary ET-1 levels after CPB in CABG group correlate with troponin-I levels 24 h postoperatively.

Less invasive versus conventional heart valve surgery in patients with severe heart failure.

OBJECTIVE: Patients with severe heart failure might benefit from reduced operative trauma, but rarely undergo less-invasive valve surgery. The present study compared the outcomes of less-invasive heart valve surgery with those of complete sternotomy in such patients. METHODS: From January 1995 to July 2010, 871 patients in New York Heart Association class III or IV underwent valve surgery (aortic or mitral, or both). A less-invasive approach was used in 205. Propensity score matching yielded 185 matched pairs for outcomes comparison adjusted for patient characteristics and 139 pairs adjusted further for individual surgeon. RESULTS: Without considering surgeons, myocardial ischemic times (59 ± 27 vs 64 ± 26 minutes, P = .04), cardiopulmonary bypass times (75 ± 35 vs 86 ± 34 minutes, P < .0001), and intensive care unit stays (median, 24 vs 43 hours; P = .007) were shorter for less-invasive surgery. Hospital morbidity, mortality (1.6% [3 of 185] vs 2.7% [5 of 185]; P = .5), and long-term survival (53% and 48% at 12 years; P = .3) were similar. After considering the surgeon, these benefits were not apparent; rather, efficiency, safety, and effectiveness were equivalent to those of complete sternotomy. Thus, myocardial ischemic (63 ± 30 vs 62 ± 25 minutes, P = .8) and cardiopulmonary bypass (80 ± 40 vs 81 ± 31 minutes, P = .5) times were similar, as were intensive care unit stay (median, 28 vs 30 hours; P = .09), postoperative complications, in-hospital mortality (2.2% [3 of 139] vs 3.6% [5 of 139]; P = .5), and long-term survival (57% and 53% at 12 years; P = .5). CONCLUSIONS: In selected patients with severe heart failure, less-invasive valve surgery is a viable option, yielding at least equivalent efficiency, safety, and effectiveness to complete sternotomy. However, achieving these outcomes requires surgeons experienced in less-invasive surgery.

Robotic posterior mitral leaflet repair: neochordal versus resectional techniques.

BACKGROUND: Resectional techniques are the established method of posterior mitral valve leaflet repair for degenerative disease; however, use of neochordae in a robotically assisted approach is gaining acceptance because of its versatility for difficult multisegment disease. The purposes of this study were to compare the versatility, safety, and effectiveness of neochordal versus resectional techniques for robotic posterior mitral leaflet repair. METHODS: From December 2007 to July 2010, 334 patients underwent robotic posterior mitral leaflet repair for degenerative disease by a resectional (n = 248) or neochordal (n = 86) technique. Outcomes were compared both unadjusted and after propensity score matching. RESULTS: Neochordae were more likely to be used than resection in patients with two (28% versus 13%; p = 0.002) or three (3.7% versus 0.87%; p = 0.08) diseased posterior leaflet segments. Three resection patients (0.98%) but no neochordal patient required reoperation for hemodynamically significant systolic anterior motion. Residual mitral regurgitation (MR) at hospital discharge was similar for matched neochordal versus resection patients (MR 0+, 82% versus 89%; MR 1+, 14% versus 8.2%; MR 2+, 2.3% versus 2.6%; 1 neochordal patient had 4+ MR and underwent reoperation; p = 0.14). Among matched patients, postoperative mortality and morbidity were similarly low. CONCLUSIONS: Compared with a resectional technique, robotic posterior mitral leaflet repair with neochordae is associated with shorter operative times and no occurrence of systolic anterior motion. The versatility, effectiveness, and safety of this repair make it a good choice for patients with advanced multisegment disease.

Quality of life after the Sweedish adjustable gastric band procedure.

The term "quality of life" usually describes factors that have an impact on living conditions within the society or on an individual. Generally, the term quality of life refers to the level of the welfare of individuals or group of people. Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health and as such is one of the most common pathological conditions of modern society. Almost 10-25% of adult population in Europe, 1/3 population in the USA and 20% of population in Croatia are affected by obesity. In this prospective study we included 30 patients who underwent Sweedish adjustable gastric band procedure (SAGB) (Johnson & Johnson) procedures without complications during the first year of the postoperative period. Body mass index (BMI) was in female patients 40,52174 kg/m2 and in male patients 46,71429 kg/m2. Prior to the surgical procedures 13 patients (43.33%) experienced worse health conditions. Health conditions were equl in 17 patients. The treatment was ineffective in 5 patients (16.67%). In 5 patients health conditions were equal. 6 patients (20%) had good quality of life, 11 patients (36.67%) very good and only 3 patients (10%) had excellent quality of life after the procedure. We noticed body weight reduction in all patients. The quality of life was improved in all patients, except for one 28 years old woman. Body weight loss and quality of life after the procedure are in positive correlation which means that significant body weight loss leads to improved quality of life. Our conclusion is that SAGB is a quality method in obesity treatment which improves quality of life.

One heart in 3 patients.

In this report, we present a successful reuse of a transplanted heart under complex clinical conditions. Our patient was the second recipient, a 63-year-old man with end-stage heart failure due to amyloid-induced cardiomyopathy. After an uneventful postoperative course, he was diagnosed with acute myelogenous leukemia 6 months after transplantation and died 10 months after transplantation. This outcome was determined by a malignancy in an immunosuppressed patient. Reuse of a transplanted heart in carefully selected patients is a possible alternative in an era of donor organ shortage.

[Recovery after long-term pulsatile mechanical circulatory support in patient with chronic heart failure: a case report]. / Oporavak nakon dugotrajne mehanicke cirkulatorne potpore u bolesnika s kronicnim zatajivanjem srca: prikaz bolesnika.

Use of mechanical circulatory support (MCS) is a part of today's standard therapy in the treatment of end-stage heart failure. In this paper we describe characteristics of Thoratec pVAD device for MCS, implantation techniques, as well as the most important advantages and complications of application of the device. We present a 41-year-old patient with dilatated cardiomyopathy, who was the first recipient ofparacorporeal left ventricular assist device (LVAD) in the Republic of Croatia due to end-stage heart failure. After heart function recovery the patient was successfully weaned from MCS after 130 days of support.

Long-term results after reconstructive surgery for aneurysms of the left ventricle.

BACKGROUND: Aneurysms of the left ventricle (LV) present a serious consequence of myocardial infarction, causing mechanical, thromboembolic, and arythmogenic complications. We present our experience in LV remodeling and long-term follow-up results. METHODS: From May 1998 to February 2009, 85 patients with postinfarction LV aneurysm underwent reconstructive procedures. Mean age was 58.7 + or - 8.9 years (range 36-79 years). Average LV ejection fraction was 39.8% + or - 13.1% (range 20%-70%). Mean EuroScore was 6.0 + or - 2.9 (range 3-19) and predictive mortality was 8.2% + or - 11.9% (range 1.6%-85.6%). The majority of patients were in New York Heart Association functional class II (44%) preoperatively and 32% of patients were in New York Heart Association class III or IV. LV reconstruction was performed by using the endoventricular patch technique in 56 patients (66%). In 29 patients (34%) reconstruction was done by linear closure. In 79 patients (93%) concomitant myocardial revascularization was performed. Mitral valve procedures were performed in 11 patients (13%), (repair in 10 patients and replacement in 1). RESULTS: Perioperative mortality was 3.5% (3 patients). Long-term follow-up was completed by means of phone interview with an average duration of 31.6 months (range 3-120 months). There were 9 late deaths (11%) during follow-up. Actuarial survival rates at 1, 5, and 10 years were 91%, 77%, and 68%, respectively. Fifty-nine patients (72%) were in New York Heart Association functional class I and II postoperatively. CONCLUSION: LV remodeling is a safe surgical procedure with low perioperative morbidity and mortality and excellent long-term survival, even in patients with severely reduced systolic function.

Medical teachers' attitudes towards science and motivational orientation for medical research.

BACKGROUND: Research is an important motivating factor for pursuing a career in academic medicine, but the relation between motivation and other factors involved in scientific research are not clear. PURPOSE: To explore the motivational orientation for doing research and its relation with attitudes towards science and publication practice among members of faculty at a medical school. METHODS: We used a Science Attitude Survey and the Work Preference Inventory (intrinsic and extrinsic motivational orientation using 4 Likert-type scales of motivation, possible range 1-5) to survey two groups of teachers at the Zagreb University School of Medicine (n = 327, 66% response rate): professors, elected to tenure-track positions (n = 150), and instructor/research fellows working on or just completing their thesis (n = 177). RESULTS: Overall, teachers scored highest on the Enjoyment subscale of intrinsic motivational orientation (mean score +/- standard deviation 4.3 +/- 0.42 for professors vs 4.1 +/- 0.42 for instructors/research fellows, P = 0.001, t-test). Professors also scored higher than instructors/research fellows on the Challenge subscale of intrinsic motivational orientation (3.8 +/- 0.55 vs. 3.5 +/- 0.64, P < 0.001, t-test), whereas instructors/research fellows scored higher on the Compensation subscale of extrinsic motivational orientation (3.5 +/- 0.74 vs. 3.1 +/- 0.71, P < 0.001, t-test). Multiple linear regression analysis showed that the number of publications was positively associated with scores on the Science Attitude Survey and the Challenge subscale of intrinsic motivation, and negatively associated with scores on the Compensation subscale of extrinsic motivation. CONCLUSIONS: Members of the medical faculty differ in motivational orientation for research depending on their academic status, and their motivation is associated more with requirements for academic advancement than with research. These findings have important implications for developing strategies for enhancing academic research production.