[Successful surgical removal of a cardiac myxoma from the left ventricular outflow tract]. / Uspesno hirurski odstranjen miksom srca u izlaznom trakty leve komore.

The precondition for successful, exclusively surgical treatment in the extracorporeal circulation, is the precise diagnosis of heart myxoma, particularly in rare locations such as the left ventricle. We present a case of myxoma in the outflow tract of the left ventricle as the exceptionally rare location, successfully diagnosed and surgically treated at the Clinic for Cardiac and Thoracic Surgery of the Military Medical Academy. A female patient, aged 46 years, was sent from another hospital with misdiagnosis of idiopathic hypertrophic subaortic stenosis. The patient was successfully operated after transthoracic and transesophageal echocardiography as the main diagnostic procedures. Myxoma that completely obstructed the aortic opening if pulled, was completely removed through aortic valve in the extracorporeal circulation. Its pedicle was arising from the ventricular side of the great mitral cusp. Postoperative course was uneventful and the patient was released from the hospital on the tenth postoperative day.

[Successful surgical treatment of a massive pulmonary embolism in the organized thromboembolic phase]. / Masivna plucna embolija uspesno operisana u fazi orgnizovanog tromboembolusa.

A patient, male, aged 36, clinically presented as an unstable angina pectoris following myocardial infarction, who came from general hospital of Banja Luka for further examination is presented. According to the medical report, he was treated for acute myocardial infarction in 1994 at Banja Luka's general hospital, when he was resusciated due to of cardiac arrest. The anginous pain was still present regardless of prescribed therapy. Following the clinical examination at the Military Medical Academy we have established a diagnosis of thromboembolism of the main pulmonary artery with a high pressure in the right ventricle. He underwent surgery under the extracorporeal circulation, when an organized old thrombus the main pulmonary artery and partially in arterial branches. The main pulmonary artery was almost completely obliterated. Thrombectomy was done. Following the operation, the patient was in a good condition and the repeated echocardiographic examinations showed no signs of recurrent thrombosis while the pressure in the right ventricle was significantly decreased. Afterwards, he was treated by heparine and oral anticoagulants and then by antiagregants. This case is very instructive because the massive pulmonary thromboembolism which was wrongly recognized and treated as an acute myocardial infarction.

[Coronarography in the diagnosis of left atrial thrombosis]. / Koronarografija u dijagnostici tromboze leve pretkomore.

Thrombosis of left atrium is frequent in the patients with mitral defect. Systemic embolism that generates by separated thrombus parts is a possible complication during the disease. Echocardiography is routinely used in the diagnosis of left atrial thrombosis. On the basis of angiographic experience, we have set the hypothesis: coronary angiography has a great sensitivity, but small specificity in the diagnosis of left atrial thrombosis. The presence of thrombus in left atrium was analyzed in 60 operated patients with mitral valve disease. During the surgery, thrombus was found in 13, and not found in 47 patients. Coronary angiography was preoperatively performed in all patients. In 9 out of 13 patients with intraoperatively observed left atrial thrombus, thrombus was also found by angiography. In 47 patients thrombus was found neither intraoperatively, and in 45 nor by angiography. The sensitivity of angiography in the diagnosis of left atrial thrombosis is 69%, specificity is 97%, and the accuracy is 90%. Positive index of anticipation is 81%, and negative index of anticipation is 91%.

[Rigid osteosynthesis with the AO plate and Phemister's spongioplasty in secondary treatment of diaphyseal gunshot fractures]. / Rigidna osteosinteza AO plocicom i spongioplastika po Phemisteru u sekundarnom lecenju dijafiznih strelnih preloma.

In prospective study, in 160 injured with diaphyseal gunshot fractures (DGF), in secondary treatment phase, there were applied rigid osteosynthesis by AO plate and spongioplasty with iliac graft by Phemister assuming that this method would provide good functional results. The average age of injured was 32.25 years, and average postsurgical follow-up period was 32.5 months. The fracture healing was achieved in 93.7% injured while pseudoarthrosis developed in 6.25%. Osteomyelitis, as the second significant complication, appeared in 8.12% cases. Good functional results were achieved in 55.62%, satisfying in 36.25% while the poor result was noticed only in 8.12% cases. The applied method in DGF treatment proved to be very successful, it led to faster fracture healing, shortening of hospitalization time of the injured with better functional results and less complications compared to the other treatment methods in the secondary phase.

Glucose as an adjunct triage tool to the Red Cross Wound Classification.

The plasma concentrations of glucose, adrenaline, noradrenaline, insulin, and cortisol were measured in 59 patients within 18 hours of military gunshot/missile (MG/M) wound. The wounds were categorized by the Red Cross Wound Classification (RCWC) and assessed by the Injury Severity Score (ISS) method. The majority of the measured biochemical parameters, except insulin, were significantly increased after MG/M wounds, compared with control values. Plasma glucose concentration in wounded patients was positively related to ISS over the whole severity range. Plasma insulin concentration increased with glucose. Noradrenaline and cortisol were positively related to glucose. Because hemorrhage is the most common cause of general response to MG/M wound, we concluded that glucose measurement could be a useful adjunct tool to the RCWC in rapid and accurate assessment of severely wounded patients, especially those with occult thoraco-abdominal wounds.

Morphological analysis of saphenous vein used for aortocoronary graft.

Histological, histochemical, immunohistochemical and ultrastructural analyses of 120 saphenous veins (of 120 patients) prepared for aortocoronary graft, revealed in 57 cases lesser or larger morphological changes, such as endothelial damage, hyperplasia of t. intima, or t. media, and fibrosis of t. adventitia that could be the result of postoperative complications (thrombosis of the graft lumen, or its occlusion due to progressive hyperplasia of t. intima). The analyses have proved significantly increased number of smooth muscle cells and fibroblasts in t. intima of the damaged veins in relation to t. media, contrary to the findings in normal veins, and it was suggested that these smooth muscle cells in the damaged veins migrated from t. media to t. intima causing hyperplasia, as was confirmed by histochemical, immunohistochemical and ultrastructural findings. Since in 57 of 120 analyzed veins morphological changes were found which developed before the implantation of vein and which could compromise the vein function as the aortocoronary graft and cause severe postoperative complications, forming of vein banks is recommended from the chosen donors to avoid vein implantation with the already existent morphological changes, that could be proven by their immediate histological examination.

[Immediate results of surgical treatment of intracardiac myxomas in 45 patients]. / Neposredni rezultati hirurskog lecenja intrakardijalnih miksoma u 45 bolesnika.

Between 1961 and 1992, 45 patients with intracardiac myxomas localised in the left ventricle--40 (89%) and in the right ventricle--5 (11%) were operated on. There were 27 women and 18 men, aged 15-63, mean age, 46.5 years. Three patients were asymptomatic while in other dominated different degree of malfunction of the corresponding atrioventricular valve, mainly with dominant symptoms and signs of stenosis. In 5 patients (11%) myxoma of the left atrium was in question together with systemic embolization. The diagnosis was established both by invasive and noninvasive methods and the method of choice, very reliable and easy, has proved to be echocardiography. All patients were operated on with the use of the total cardiopulmonary bypass and induced heart arrest. The histologic verification of all excised myxomas was performed. Three early deaths occurred (6.6%), while in other patients no postoperative complications developed. It has been concluded that echocardiography is very safe diagnostic procedure and results of surgical treatment are very good.

[Infections of the sternum after cardiac surgery]. / Infekcije sternuma posle kardiohirurskih operacija.

Methods of treatment of suppurative mediastinitis in cardiosurgical operations applied at the clinic are analysed. These methods are: debridment with closure of the sternum with irrigation of the substernal space, debridment with bandage of open wound and healing per secundam, debridment with bandage of open wound and its closure by myocutaneous layers. It has been concluded that these infections are very complex etiopathogenetically because of which it is very important to know all relevant risk factors aiming to prevent development of this complication in cardiosurgical operations. Its early recognition is necessary.

[Similarities in morphologic changes in heart valves in acquired heart defects of noninflammatory etiology and in damaged menisci without a history of trauma]. / Slicnosti u morfoloskim promenama u zaliscima srca kod stecenih srcanih mana nezapaljenjske etiologije i u ostecenim meniskusima bez anamneze o traumi.

Histologic, histochemical and ultrastructural analyses were performed of the leaflets of all four heart valves in 50 subjects with acquired heart defects of noninflammatory etiology and 88 surgically removed damaged menisci without trauma anamnesis. On the basis of the detailed analysis some morphologic similarities were found in the heart valves and menisci such as myxomatous degeneration as the main pathologic lesion, lack of blood vessels in the altered tissues which point to noninflammatory nature of the lesion, similarity in nourishment by diffusion, degradation of the collagenous fibres which present the main histologic structure and the increased accumulation of acid mucopolysacharrides at the site of their degradation as well as the increased number of fibroblasts, that is, chondroid cells which are considered to excrete acid mucopolysacharrides. Sometimes these changes are hardly identify clinically, especially in meniscal diseases which could simulate rheumatic disease.