A Patient in Their 70s With Bright Red Blood in the Pericardiocentesis Catheter.

This case report discusses a finding of blood in the pericardiocentesis catheter of a patient with a recent history of aortic valve replacement and recurrent postsurgical pericardial and pleural effusions.

Propensity-score matched comparison between minimally invasive and conventional aortic valve replacement.

AIM: To evaluate the impact of minimally invasive aortic valve replacement (mini-AVR) on clinical outcomes in comparison with the gold standard. METHODS: We retrospectively reviewed the records of all patients who underwent isolated AVR at the University Hospital Center Zagreb from 2010 to 2020. Patients undergoing mini-AVR were compared with patients undergoing conventional AVR (fs-AVR). The primary outcome measure was blood product consumption. Propensity score matching was used to create a balanced covariate distribution across treatment groups. Additionally, we compared the contemporary outcomes with a historical control. RESULTS: The final sample consisted of 1088 patients. In the unmatched cohorts, mini-AVR patients were younger (65±12 vs 68±10 years, P<0.001) and had lower risk profiles (EuroSCORE2 2.8±2.0 vs 3.5±3.1, P=0.003). After matching, mini-AVR patients required less blood transfusion than fs-AVR patients (270 [0-790] vs 510 [0-970] mL, P=0.029). The incidences of stroke, dialysis, new AV block, and mortality were comparable. Cross-clamp times were longer in the mini-AVR group (71 [60-87] vs 66 [53-83] minutes, P=0.013). Outcomes were improved in the contemporary mini-AVR era compared with our early mini-AVR experience across multiple metrics. Blood product consumption was reduced in the latter tercile of experience (0 [0-520] vs 500 [0-1018] mL, P<0.001), and the operation was performed more expeditiously (cross-clamp times: 63 [54,80] vs 74 [62,88] minutes, P<0.001) in comparison with earlier periods. CONCLUSIONS: We showed that mini-AVR was associated with less blood product requirement than conventional surgery. Our data supports wider adoption of minimally invasive techniques in dedicated centers of excellence.

Definition of acetylsalicylic acid resistance using whole blood impedance aggregometry in patients undergoing coronary artery surgery.

A beneficial effect of acetylsalicylic acid (ASA) on vein graft patency has been described, but some patients experience adverse cardiac events despite appropriate ASA treatment. Study aim was to define ASA resistance using Multiple electrode aggregometry (MEA) preoperatively in group of patients undergoing coronary artery bypass grafting (CABG). Prospective observational trial at University Hospital Center Zagreb enrolled 131 patients scheduled for CABG, and divided them into 4 groups with respect to preoperative antiplatelet therapy (APT). Group 1 received 100 mg ASA per day, Group 2 100 mg ASA + 75 mg clopidogrel per day, Group 3 75 mg clopidogrel per day, and Group 4 did not receive any APT. MEA with ASPI test (sensitive to ASA) and ADP test (sensitive to clopidogrel) was performed prior to surgery. In Group 1, patients were characterized as ASA resistant if their ASPI test value exceeded the 75th percentile distribution. Study enrolled 131 patients. Significant differences both in the ASPI (p < 0.001) and the ADP test (p = 0.038) were observed between patients in different APT groups. In Group (1) ASPI test value of 30 AUC presented 75th percentile of distribution, thus indicating ASA resistance. Group 2 patients had slightly lower ADP test values, but no significant difference occurred (mean 60.05 vs. 63.32 AUC, p = 0.469). In Group 1 and 2, significant correlations between the ADP test and both, platelet count (r = 0.347, p < 0.001) and fibrinogen level (r = 0.364, p < 0.001) were observed. Association between low response to ASA and post-CABG major adverse ischemic events risk increase has been described thus indicating need for ASA resistant patients detection. In patients with preoperative ASPI test exceeding 30 AUC postoperative, ASA dose adjustment or clopidogrel addition according to MEA results should be considered.

Bleeding risk assessment using whole blood impedance aggregometry and rotational thromboelastometry in patients following cardiac surgery.

Excessive bleeding after cardiopulmonary bypass (CPB) is risk factor for adverse outcomes after elective cardiac surgery (ECS). Differentiating between patients who bleed due to surgical issues and those whose excessive chest tube output (CTO) is due to coagulopathy, remains challenging. Bedside suitable tests to identify hemostatic disturbances and predict excessive bleeding are desirable. The study sought to evaluate prediction of excessive bleeding after ECS using two bedside suitable devices for platelet function and viscoelastic blood clot properties assessment. We enrolled 148 patients (105 male and 43 female) undergoing ECS in a prospective observational study. Patients were characterized as bleeders if their 24 h CTO exceeded the 75th percentile of distribution. Multiple electrode aggregometry (MEA, with ASPI, ADP and the TRAP test) and rotational thromboelastometry (TEM, with ExTEM, HepTEM and FibTEM test), were performed at three time points: preoperatively (T1), during CPB (T2), and after protamine administration (T3). The primary endpoint was CTO and the secondary endpoint was administration of blood products, 30-day and 1 year mortality. The best predictors of increased bleeding tendency were the tests performed after protamine administration (T3). At T3, patients characterized as bleeders had significantly lower MEA ASPI (median, 14 vs. 27 AUC, p = 0.004) and ADP test values (median, 22 vs. 41 AUC, p = 0.002) as well as TEM values expressed in maximum clot firmness after 30 min (MCF 30) for ExTEM (53 vs. 56 mm, p = 0.005), HepTEM (48 vs. 52 mm, p = 0.003) and FibTEM (8 vs. 11 mm, p < 0.001) test. 24 h CTO inversely correlated with both the MEA (ASPI test: r = -0.236, p = 0.004; ADP test: r = -0.299, p < 0.001), and TEM MCF 30 (ExTEM: r = -0.295, p < 0.001; HepTEM: -0.329, p < 0.001; FibTEM: -0.377, p < 0.001) test values. Our study showed that MEA and TEM are useful methods for prediction of excessive bleeding after ECS. In order to prevent excessive postoperative CTO, hemostatic interventions with timely and targeted blood component therapy according to MEA and TEM results should be considered.

Bleeding risk assessment using multiple electrode aggregometry in patients following coronary artery bypass surgery.

Individual variability in the response to antiplatelet therapy (APT), frequently administered preoperatively, has been established by various platelet function assays and could reflect bleeding tendency after coronary artery bypass surgery (CABG). Our hypothesis is that multiple electrode whole-blood aggregometry (MEA) can identify patients at risk for excessive bleeding. We enrolled 211 patients (155 male and 56 female) undergoing isolated CABG in a prospective observational study. Patients were divided into four groups with respect to their preoperative APT management. MEA, using the ASPI and the ADP test, was performed prior to surgery. The primary endpoint was chest tube output (CTO) and the secondary endpoint was perioperative packed red blood cell concentrate (PRBC) administration. Patients were characterized as bleeders if their 24 h CTO exceeded the 75th percentile of distribution. 24 h CTO value of 11.33 ml/kg presented 75th percentile of distribution, thus cut-off value for "bleeder category". The proportion of patients characterized as bleeders was significantly different among the groups in regard to preoperative APT (p = 0.039). Significant differences in both ASPI (p < 0.001) and ADP (p = 0.038) tests were observed between different preoperative APT groups. Significant correlations between the ASPI test (r = -0.170, p = 0.014) and ADP test (r = -0.206, p = 0.003) with 24 h CTO were found. The receiver operating curve revealed an ASPI test value of <20 area under curve (AUC) units (AUC 0.603, p = 0.023) and an ADP test <73 AUC (AUC 0.611, p = 0.009) as a "bleeder" determinant. The proportion of patients transfused with PRBC did not significantly differ among the groups in regard to preoperative APT (p = 0.636). Comparison of the ASPI test values between patients with respect to PRBC administration revealed lower values in the ASPI test in a group of patients transfused with PRBC (mean, 27.88 vs. 40.32 AUC, p = 0.002). Our study showed that MEA is a useful method of predicting CABG patients with excessive postoperative bleeding.

Surgical treatment of aortic dissection in a patient with metastatic prostate cancer.

Acute aortic dissection bears all the stigmata of a true clinical emergency. The natural history of this acute aortic syndrome warrants prompt surgical intervention, with only a few absolute contraindications to this line of treatment. We present a 74-year-old man with documented metastatic prostate cancer who underwent emergent surgery for acute Stanford A aortic dissection. Having acknowledged the relatively favorable evolution of our patient's malignant disease, we were not deterred by its presence from pursuing surgical treatment of his aortic dissection.

[Guidelines for prevention, control and treatment of infections caused by methicillin-resistant Staphylococcus aureus (MRSA): changes and updates of chapter 7.0: treatment of patients with MRSA infection]. / Smjernice za prevenciju, kontrolu i lijecenje infekcija koje uzrokuje meticilin-rezistentni Staphylococcus aureus (MRSA): izmjena i dopuna poglavlja 7.0.: lijecenje bolesnika s MRSA - infekcijom.

Methicillin-resistant Staphylococcus aureus (MRSA) is an important pathogen throughout the world, and as well in Croatia. Therefore it was decided to develop guidelines with the aim to reduce the number of patients infected/colonized with MRSA in healthcare facilities and in nursing homes in Croatia, consequently reducing MRSA-related morbidity and mortality. An interdisciplinary team of experts developed these guidelines using existing international guidelines from different countries, and literature reviews about prevention, control, treatment and laboratory diagnosis of MRSA infections. Grades of evidence for specific recommendations were determined using CDC/HICPAC grading system. Categorization is based on existing data, theoretical basis, applicability and economic impact. After a broad discussion in different professional societies, Guidelines were accepted. In the meantime, several new possibilities appeared in the treatment of patients with MRSA infections in Croatia, so the Chapter 7.0 Treatment of patients with MRSA infections is changed and updated according to the new treatment possibilities. The rest of the Guidelines was not changed.

NT-pro-BNP, but not C-reactive protein, is predictive of atrial fibrillation in patients undergoing coronary artery bypass surgery.

OBJECTIVE: Atrial fibrillation (AF) remains the most commonly observed complication following myocardial revascularisation surgery. We aimed to evaluate the clinical utility of N-terminal fragment of the brain natriuretic peptide (NT-pro-BNP), troponin T, transcoronary lactate gradient (TCLG) and C-reactive protein (CRP) as predictors of AF in patients undergoing isolated coronary artery bypass surgery (CABG). METHODS: This study included 215 consecutive patients in sinus rhythm (SR) undergoing elective CABG between May 2007 and May 2008. The patients were grouped according to their respective postoperative rhythm into SR and AF groups. The data are presented as mean values+/-standard deviation, or medians with quartiles. RESULTS: Fifty-five patients developed AF (26%). The preoperative NT-pro-BNP values were 273+/-347 and 469+/-629 pg ml(-1) in the SR and AF groups, respectively (p<0.0001). The postoperative NT-pro-BNP values were 3110+/-3600 pg ml(-1) in the SR and 4625+/-5640 pg ml(-1) in the AF groups (p=0.027). The transcoronary lactate gradient rose from the pre-cardiopulmonary bypass values to those observed 5 min after revascularisation in both groups (-0.05+/-0.37 to 0.39+/-0.46 mmol l(-1) (p<0.0001) in the SR group and -0.01+/-0.27 to 0.43+/-0.46 mmol l(-1) (p<0.0001) in the AF group). The CRP values increased from 6+/-13 to 163+/-88 mg l(-1) (p<0.0001) in the SR group, and from 6+/-16 to 163+/-104 mg l(-1) (p<0.0001) in the AF group. The dynamics of TCLG and CRP did not differ between the groups (p=0.71, p=0.44, respectively). The troponin T values on postoperative day 1 were significantly higher in the AF than the SR group (0.86 (0.49-2.1) ng ml(-1) vs 0.67 (0.37-1.16) ng ml(-1), p=0.046). The duration of cardiopulmonary bypass (CPB) was 85+/-24 min in the SR and 93+/-30 min in the AF group (p=0.05). Patients who developed AF were older (66+/-7 years vs 60+/-9 years, p<0.0001) and had a higher EuroSCORE (3.9+/-2.7 vs 2.9+/-2.2, p=0.009). Multivariate analysis identified age (p=0.0043), preoperative NT-pro-BNP (p=0.019) and duration of CPB (p=0.035) as independent predictors of AF. CONCLUSIONS: Preoperative and postoperative NT-pro-BNP as well as TnT values were significantly higher in patients who subsequently developed AF. TCLG and CRP were not useful in identifying patients at higher risk for AF. Multivariate analysis identified age, preoperative NT-pro-BNP and duration of CPB as independent correlates of AF.

[Guidelines for prevention, control and treatment of infections caused by methicillin-resistant Staphylococcus aureus (MRSA)]. / Smjernice za prevenciju, kontrolu i lijecenje infekcija koje uzrokuje meticilin-rezistentni Staphylococcus aureus (MRSA).

Methicillin-resistant Staphylococcus aureus (MRSA) is an important pathogen throughout the world, and in Croatia as well. Therefore it was decided to develop guidelines with the aim to reduce the number of patients infected/colonized with MRSA in healthcare facilities and in nursing homes in Croatia, consequently reducing MRSA-related morbidity and mortality. An interdisciplinary team of experts developed these guidelines using existing international guidelines from different countries, and literature reviews about prevention, control, treatment and laboratory diagnosis of MRSA infections. Grades of evidence for specific recommendations were determined using CDC/HICPAC grading system. Categorization is based on existing data, theoretical basis, applicability and economic impact. After a broad discussion in different professional societies, Guidelines were accepted. Guidelines include recommendations for measures in prevention of MRSA spread, role of hospital management, rational use of antibiotics, measures in a case of outbreak, treatment of infections and brief review of community-acquired MRSA. At the end, appendices concerning hospital audit, algorithms of laboratory diagnosis, patient information and form for national MRSA surveillance were added.

Endomedullary radiofrequency ablation of metastatic lesion of the right femur 5 years after primary breast carcinoma: a case report.

Metastatic tumors of the long bones usually present with severe pain refractory to analgesic therapy. Pathologic fractures of the bone may lead to the significant decrease of patient's quality of life and necessitate further surgical therapy. We present 66 year old female with metastatic left breast carcinoma (T2N0M0) diagnosed 5 years before presentation of the metastatic lesion of the right femur causing severe pain in the middle of the right upper leg. Pain persisted after palliative irradiation therapy. We performed radiofrequency ablation of the metastatic lesion of the right femur using R.I.TA. Medical System Generator. This resulted in total necrosis of the tumor mass that caused osteolysis of the internal part of the femoral cortex. First three months after RFA procedure, the pain and tenderness were absent and normal daily activities were performed without restrictions.

Left ventricular fibroma mimicking an acute coronary syndrome.

Cardiac fibromas are exceedingly rare neoplasms. We report the case of a 21-year-old woman who presented with symptoms that were initially misinterpreted as an acute coronary syndrome. Radical surgical resection was undertaken and was considered curative, as the mass histology was consistent with a benign fibroma.