A review of a newly established ECMO program in a university affiliated cardiac center.

Extracorporeal membrane oxygenation (ECMO) is an established rescue treatment option for severe respiratory and cardiac failure in infants and neonates and has recently become widely utilised in adults. ECMO support can be initiated rapidly in an emergency setting both by percutanous implantation and surgically; it allows transportation of patients in cardio-pulmonary collapse and bridging of critically ill patients to be recovered, other support measures or transplantation. The aim of this study was to report authors' initial experience after starting an ECMO program in a university-based cardiac center. The institutionally approved ECMO team bears responsibility for adjudication regarding indication and implementation of ECMO in all patients. Since the establishment of the ECMO team in October 2007, one elective and nine urgent patients in deep cardiogenic and/or ventilatory collapse were treated by ECMO support up to December 2008. Three patients suffered severe acute right heart dysfunction, two patients suffered postcardiotomy refractory cardiogenic shock, two patients had a cardiogenic shock due to postinfarction interventricular septal rupture, two patients experienced severe respiratory failure and one had elective ECMO implantation as a back-up support during high-risk percutaneous coronary intervention. Veno-arterial ECMO was used in eight cases and veno-venous in two cases of isolated respiratory failure. In nine patients, ECMO circuit was instituted by peripheral cannulation, in eight out of nine cases by percutaneous puncture. On one occasion central surgical cannulation was used. In urgent patients, immediate hemodynamic and oxygenation improvement was observed. Average support duration was 6.8 days (range 1-16 days). Five (50 %) patients were successfully weaned from ECMO and survived to hospital discharge. The illness severity in urgent patients defined by SOFA score ranged from 10 to 17, patients dying while on ECMO had higher SOFA scores (14.8±1.6 vs. 10.8±1.5; P=0.0065). Complications included mainly bleeding. ECMO support allows treatment of severely ill patients in imminent cardiovascular and/or ventilatory collapse. Therefore, establishment of an ECMO program in university affiliated cardiac center is fully justified. A multidisciplinary approach is essential. Despite adequate training and education of ECMO team members, this highly invasive therapeutic modality bears an inherent risk of complications.

[Multiple sequence revascularization of infrapopliteal arteries in the management of critically ischemic extremity]. / Vícenásobná sekvencní revaskularizace infrapopliteálních tepen pri záchrane kriticky ischemick koncetiny.

AIM OF THE STUDY: Most cases of distal bypasses closures are caused by reduced blood flow within the affected peripheral vasculature, resulting in corresponding reduction in the graft's blood supply. The authors use multiple, sequence, Y grafting and bridge grafting procedures on crural and pedal arteries, in order to improve the above hemodynamic features. Furthermore, the techniques facilitate better circulation within larger extremity regions. METHODS: From April 2007 to January 2009, the authors completed a total of 38 sequence bypass procedures. The procedures included 30 Y graft procedures with peripheral anastomoses with crural arteries, 4 Y graft procedures with peripheral anastomoses with pedal arteries and 4 bridge graft procedures. Y grafting is a technique, in which a classical distal bypass is formed, to which another bypass is attached end-to-side in an acute angle. The composite bypasses form a reversed letter Y. Its distal branches anastomose with crural or pedal arteries. Bridge grafting is a technique, where a short bypass between crural arteries is formed, using a venous graft with removed valves, allowing for a two-way flow. The distal anastomosis is attached end-to-side. All the above vascular reconstructions were indicated for critical extremity ischemia, some patients had a history of endovascular reinterventions. In the patient group, autologous veins were used in 20 reconstructions, while PTFE prostheses were used in 10 reconstructions. Clinical and sonographic examinations were performed on discharge, followed by check ups at 1,3, 6 and 12 months. RESULTS: The follow up period in patients with Y graft reconstructions was 6-20 months (mean duration of 12 months). Two patients underwent major amputation, required for bypass closures, 3 subjects exited with patent vascular reconstructions, their deaths were not related to the procedure. The authors recorded 4 bypass closures, with the main trunk patency. Primary/secondary 30-day patency rate was 90%/97%, the long-term patency rate was 93%. CONCLUSION: The vascular reconstructions results are similar to those presented in literature. In order to perform more accurate assessment of individual revascularization variants, long- term follow up studies, including randomized studies, are required.

[Outcomes of combined surgical and endovascular treatment of the venous thoracic outlet syndrome during 2000-2007 in the IInd Surgical Clinic of the VFN (General Faculty Hospital) and 1. LF UK (First Medical Faculty, Charles University) in Prague]. / Výsledky kombinované chirurgické a endovaskulární lécby zilního thoracic outlet syndromu v letech 2000-2007 na II. chirurgické klinice VFN a 1. LF UK v Praze.

OBJECTIVES: Between 2000-2007 we performed 31 surgical procedures for thoracic outlet syndrome, two patients underwent bilateral procedure. METHODS AND RESULTS: 26 patients had venous TOS, 4 neurovascular and 1 arterial TOS. Rib resection and scalenotomy were performed at 23 patients, rib resection, scalenotomy and deliberation at 9 patients, in one case re-operation. CONCLUSION: 76% patients were without difficulties after combined endovascular and surgical procedures.

[Contribution to diagnostics of vascular prosthesis infections]. / Príspevek k diagnostice infekce cévní protézy.

Vascular prosthesis infection is a life-threatening complication in 0.5-5% of cases. Early and reliable diagnosis is a necessity for adequate treatment. Computed tomography (CT) is the gold standard diagnostic method used world-wide with excellent results, but in cases of advanced graft infection. Low grade infections in non-acute patients are a diagnostic challenge requiring a new method with good diagnostic accuracy. The authors describe diagnostic accuracy of currently available methods.

[Bilateral leg compartment syndrome due to severe myonecrosis caused by inappropriate use of simvastatin]. / Syndrome de compression des loges bilatéral des membres inférieurs et myonécrose sévère due à l'usage inapproprié de la simvastatine.

Bilateral leg compartment syndrome due to myonecrosis caused by inappropriate use of statins is a rare but potentially fatal complication of this lipid lowering medication. We report a case of a 39-year-old woman who presented with suspicious critical lower limb ischemia. Subsequently, bilateral leg compartment syndrome and myonecrosis developed. The primary cause of myonecrosis was due to misuse of simvastatin mistaken by the patient for a weight-reducing drug. Urgent fasciotomies were performed and the patient underwent urgent renal replacement therapy with continuous hemodialysis for acute renal failure due to myoglobinuria. After this complex treatment, the patient was discharged. She almost fully recovered with only a residual paresis of the left fibular nerve. According to literature, this is a unique case of bilateral compartment syndrome and myonecrosis with acute renal failure due to statin overdose leading to acute renal failure and bilateral fasciotomy.

[Postcatheterization pseudoaneurysm of the radial artery]. / Postkatetrizacní pseudoaneuryzma arteria radialis.

A postcatheterization pseudoaneurysm of the radial artery remains a rare complication, considering frequencies of its punction. The radial artery is easily accessible for the punction site management after the catheter removal. We present pathogenesis of their origin, their prevention and options for surgical management of the radial artery pseudoaneurysms.

[Main clinical and surgical determinants of in-hospital mortality after surgical revascularization of left main coronary artery stenosis: 2 year retrospective study (1998-1999)]. / Les facteurs cliniques et opératoires associés à la mortalité hospitalière après chirurgie d'une sténose du tronc commun de l'artère coronaire gauche. Analyse rétrospective de janvier 1998 à décembre 1999.

UNLABELLED: Stenosis of left main coronary artery (LMCA) is a common finding on coronary angiographies (7 to 10%). Mortality is very high for conservative therapy in comparison with surgery, which provides very good long-term outcome and is accepted as the standard therapy of this condition. Over the last few years, percutaneous coronary intervention (PCI) has become a new alternative in selected patients. AIM OF THE STUDY: To assess in hospital mortality in subjects referred to our surgical unit for coronary artery bypass grafting (CABG) and to identify the main clinical and surgical determinants of in-hospital mortality. METHODS: Two year retrospective analysis (1998-1999) of in-hospital mortality and morbidity of patients having left main stenosis referred for CABG. RESULTS: Among a group of 1443 patients operated for coronary heart disease, LMCA stenosis was found in 330 patients (22.9%). The mean age was 63 +/- 8.6 years. Elective surgery was done in 173 patients (52.4%), and acute operation (i.e. urgent, emergent or desperate) in 157 patients (47.6%). The total in-hospital mortality was 4.2% (14/330). Elective surgery in-hospital mortality was 1.7% (3/173) and urgent surgery in-hospital mortality was 7% (11/157). The main risk factors of in-hospital mortality were age > 68 years, low ejection fraction (LVEF<0.4), history of myocardial infarction, gender (female) and urgency of the operation. CONCLUSION: The proportion of patients undergoing CABG for left main stenosis is relatively high in our center and their mortality is quite low especially for elective operations. As the mortality of patients treated by PCI for LMCA stenosis is similar to surgery in high-risk patients, we postulate that this approach can be a real alternative treatment for such patients. Because of its potential benefit, combined revascularisation is also an alternative that should be considered in some cases. Furthermore, as a new generation of coated stents has emerged in the treatment of restenosis after PCI, we hypothesize that this method can in the near future be accepted as equivalent to surgery. However several randomized clinical trials must first be conduced prove this point.

On-pump cardiac surgery in a conscious patient using a thoracic epidural anesthesia--an ultra fast track method.

OBJECTIVE: To demonstrate the applicability and efficacy of spontaneous ventilation during cardiac surgery. METHODS: From March 1999 through December 2002, 129 awake patients were operated on; 90 on-pump and 39 off-pump. A thoracic epidural space blockage was performed one hour prior to an incision being made at the Th 2-Th 4 level. Medial approach was used and the hanging drop method was routinely employed for epidural space detection. RESULTS: There were 82 male and 47 female patients with a mean age of 64.5 years. Forty two cases were aortic valve replacement, 32 patients underwent on-pump coronary artery bypass grafting (CABG), 12 underwent mitral valve replacement, 27 patients were indicated for sternal wound reexploration, 12 for off-pump CABG, one for aortic valve replacement with aortic arch reconstruction and aortic valve replacement together with CABG was performed three times. There were ten conversions to general anesthesia and there was no death. Mean duration of the stay in the intensive care unit was 7.2 hours and in the hospital 5.1 days. We did not observe low cardiac output syndrome, stroke, renal insufficiency or pulmonary dysfunction in patients who sufficiently underwent thoracic epidural anesthesia. Less pain at assessments was demonstrated (Visual Analgetic Score=3.3). CONCLUSION: The recent interest in rapid recovery and early out-patient care of patients after cardiac surgery has prompted investigations into the use of neuraxial analgesia for these procedures. The above mentioned technique would be beneficial for patients with preoperative pulmonary dysfunction and may be particularly useful in endoscopic cardiac surgery. (Tab. 1, Fig. 2, Ref. 18.)

[Comparison of short-term and long-term results after aortocoronary bypass in ischemic heart disease in diabetics and non-diabetics]. / Porovnání krátkodobých a dlouhodobých výsledku po aortokoronárním bypassu pro ischemickou chorobu srdecní u diabetiku a nediabetiku.

In the presented study we have evaluated short-term and long-term results of the multiple aortocoronary bypass surgery in the patients with ischemic heart disease. We have compared the incidence of the preoperative and postoperative complications, short-term and long-term mortality in the group of diabetics in comparison to nondiabetics as well as the entry characteristics of both groups. Among 2518 patients who were treated with aortocoronary bypass surgery there were 773 (30.6%) diabetics. The diabetic patients were significantly elder, we have found more women among them, more frequent presence of hypertension, chronic heart failure and peripheral vascular disease. Contrary in the incidence of the previous myocardial infarction we have not found any significant difference between both groups. The patients with diabetes mellitus had lower ejection fraction of the left ventricle and significantly more extensive coronary artery disease which explains that in this group of patients the number of coronary bypasses was significantly higher. Comparing the incidence of preoperative complications we have not seen any significant difference between the patients with and without diabetes mellitus. Out of the postoperative complications we have noticed significantly more renal failure, infectious complications, low cardiac output syndrome and bleeding disorders in the diabetic patients. The duration of hospitalisation in the intensive care unit was significantly longer in diabetics (55.11 +/- 89.09 hours to 47.84 +/- 65.18 hours in nondiabetics, p < 0.05). 30 days mortality in diabetics was 3.75% and 2.4% in nondiabetics (p < 0.05). This difference was mainly due to the significantly higher incidence of multiorgans failure as a cause of death among diabetics (1.3% in diabetics, 0.5% in nondiabetics, p < 0.05). 89.1% of nondiabetics and 86.9% of diabetics lived 2-6 years after aortocoronary bypass surgery (n.s.). We have found the significantly higher long-term cardiovascular mortality (2-6 years) in diabetics (10.3%) then in nondiabetics (7.6%, p < 0.05).

[Surgery of infectious complications in prostheses in the abdominal aorta]. / Chirurgické resení infekcních komplikací náhrady brisní aorty.

The authors describe the successful solution of a serious and feared complication, i.e. infection of a vascular prosthesis. A hitherto not used procedure was adopted-concurrent removal of the infected prosthesis and restoration of the blood flow into both extremities by an extra-anatomical axillobiiliac bypass. The authors draw attention to the advantages of this method in context with possible future solutions; and with regard to the hitherto not complicated postoperative course they assume that this type of treatment could be final. At the same time they draw attention to the complexity of the problem from the diagnostic and therapeutic aspect.

[The in situ saphenous vein--more possibilities for vascular reconstruction?]. / Saféna in situ--rozsírení mozností zilních rekonstrukcí?

A clinical study of 47 patients with reconstruction of the large saphenous vein by the in situ technique indicates a statistically insignificant difference in the patency for venous grafts from 3 to 4 mm as compared with those above 4 mm. This confirms that the in situ technique extends the possibilities of venous reconstructions. In the author's group it extended the possibility to use a venous graft by 12.8%. The study confirms also the fundamental importance of patency of the pedal arch for long-term patency. Secondary patency of reconstructions in situ and reverse reconstructions in our department is comparable during the five-year period: 82 and 84%.

[Early results of mitral valve surgery]. / Casné výsledky operací mitrálních chlopní.

The authors submit a retrospective group of 245 patients operated in the course of 6 years at the Second Surgical Clinic of Cardiovascular Surgery of the General Faculty Hospital and First Medical Faculty Charles University on account of mitral valve disease. The early results of mitral valve prostheses are comparable or in some combined operations better than reported in world statistics. In the etiology the authors found a relative decrease of rheumatic defects and higher incidence of ischaemic affections. The general mortality in mitral valve prostheses was 7.1%, combined operations incl. acute ones being predominant. In mitral plastic operations the authors lost 4 patients, i.e. 19%. In all instances acute combined operations were involved and the result is consistent with the predicted mortality according to the Merged Cardiac Registry. The mean hospitalization period was 7.52 days. A postoperative QIM was recorded in one patient, i.e. in 0.46%, revision after mediastinitis also in one patient (0.41%) and revision after haemorrhage in 14 patients, i.e. in 5.7%. Neurological complications were recorded in 10 patients i.e. 4%. The work emphasizes the trend of improving results in this important area of cardiosurgery and indicates further possibilities and ways of development in the treatment of mitral valve diseases.

[Video-assisted myocardial revascularization and left-sided minithoracotomy using the Symmetry automatic connector]. / Videoasistovaná revaskularizace myokardu z levostranné minitorakotomie s pouzitím automatického konektoru Symmetry.

OBJECTIVE: Introduction of the new method of videoassisted multiple direct revascularization of the heart muscle from left-sided minithoracotomy (LAST--Left Anterior Small Thoracotomy) using an automatic connector of central anastomoses Symmetry (St. Jude Medical ATG, Inc., St. Paul, MN) in patients indicated for re-operation of bypasses of the coronary arteries or with pathological conditions of the sternum and for the cosmetic effect of submammary incisions in women. METHOD: From September 2001 to the end of February 2002 15 patients with affections of three arteries had an operation from a LAST approach with videoscopic construction of central anastomoses by means of a Symmetry connector with portal entries and the use of extracorporeal circulation introduced from the groin without cardioplegic arrest. Nine men and six women were operated with a mean age of 68.7 years and a mean ejection fraction (EF) of 58.2%. In seven instances reoperation of aortocoronary bypasses was involved; two patients with multiple myelomas (morbus Kahler) had a brittle and cavernously altered sternum, all six women wanted a small skin incision below the breast. The criterion for ruling out the mentioned procedure was marked atherosclerotic affection of the ascendent aorta, affection of the arteries in the aortoiliac area and affection of one or two coronary arteries suitable for miniinvasive revascularization without extracorporeal circulation. Fourteen patients had an angiographic check up examination of the patency of grafts before they were discharged. RESULTS: The total number of distal anastomoses per patient was 3.13 +/- 0.6, the median period of extracorporeal circulation was 112 +/- 34 minutes and the mean time of operation 186 +/- 52 minutes. Blood losses were on average 425 ml/24 h without necessity of revision on account of haemorrhage. Eleven (73%) patients were subjected to an ultra fast track protocol with extubation on the operating table. The mean time spent in the postoperative department was 8.6 hours and the total hospitalization period 5.5 days. None of the operated patients died. Peroperative ischaemia of the heart muscle was not observed, in one instance the authors observed a newly developed atrial fibrillation. During an angiographic check-up the authors detected 6 (13.6%) stenoses and occlusions in 44 checked bridged vessels. CONCLUSION: The alternative approach reduces the risk of cardiac injury during reoperation and the danger of impaired healing of the sternotomical wound in patients with pathological conditions of the sternum, with contamination of the surrounding tissue (e.g. in tracheostomy) or malignant disease. The cosmetic effect of the submammary incision, the small inguinal incision and endoscopic saphenous vein harvesting should be considered in elective direct revascularization of the heart muscle in women. Bridging of the coronary arteries with optical assistance from minithoracotomy and with an automatic connector of central anastomoses seems to be a safe alternative of standard sternotomy only with methodological but not anatomical or functional restriction.

[Myocardial revascularization via a median sternotomy without cardiopulmonary bypass in 250 patients--midterm results and study of graft patency]. / Revaskularizace myokardu ze strední sternotomie bez pouzití mimotelního obehu u 250 nemocných--strednedobé výsledky a studie pruchodnosti stepu.

OBJECTIVES: To evaluate mid-term results and one-year graft patency of less invasive coronary artery bypass grafting through a median sternotomy. METHODS: From January 1, 1998, to December 31, 1999, 250 patients had coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) through a median sternotomy. The patient base of 188 men and 62 women averaged 61.7 years, mean ejection fraction (EF) was 55.1%. An average of 2.7 (range 1 to 5) distal anastomoses per patient was achieved. Results are compared with a CPB subgroup of patients operated on through a median sternotomy in the same time (N = 1126). In a random subgroup of 100 patients (50 per group) an angiographic control of graft patency was done. RESULTS: A non-CPB group showed lesser occurrence of postoperative acute myocardial infarction (p = 0.038), atrial fibrillation (p = 0.029) and lower incidence of renal (p = 0.033) complications. We observed lower operative mortality (p = 0.019), as well as the occurrence of low cardiac output syndrome (p < 0.001) in the off pump group. The follow-up is 36 +/- 12 months and the number of patients with recurrent angina (5.4%), late AMI (0%) and late death (0.4%) is acceptable. We did not find an inordinate number of vein grafts occlusions (2.2%) and stenoses (7.8%) at anastomotic sites. None of the arterial grafts in both groups were occluded. CONCLUSIONS: We detected lower incidence of postoperative complications and decreased operative mortality in a non-CPB group. Angiographic assessment displayed an excellent run-off in both groups of patients. Off-pump coronary bypass grafting is associated with sufficient short-term graft patency and mid-term clinical outcomes.

[Late complication of surgical repair of aortic coarctation: ruptured pseudoaneurysm of the aorta treated by thoracic endovascular aortic repair]. / Complication tardive d'un traitement chirurgical par interposition prothétique d'une coartation aortique: rupture d'un faux anévrisme anastomotique traitée par implantation endoluminale d'endoprothèse couverte.

Aortic coarctation is a frequent congenital defect requiring early surgical treatment. Late complications of these surgical procedures can be fatal as in the case of a ruptured anastomotic pseudoaneurysm. We present a case of a 49-year-old man presenting with hemorrhagic shock due to this complication who was successfully treated by endovascular techniques with implantation of two stent grafts. This case illustrates the fact that endovascular aortic repair is feasible, certainly less invasive and very efficient for this type of complication when used in an experienced center.

[Thrombectomy and embolectomy using the adherent clot catheter]. / Trombektomie a embolektomie Adherent Cloth katetrem.

The efficacy of the Adherent Cloth Catheter is demonstrated on the three above described cases. The different mechanism of function on contrary to the classic Fogarty Catheter enables us to remove the older, strongly adherent thrombus from prothesis, artery or vein. The catheter is a functional instrument not only for vascular surgery, but also for invasive angiology.

[Aneurysm of the descending aorta causing destruction of vertebral bodies. Case report]. / Výdut sestupné aorty jako prícina destrukce obratlových tel. Kazuistika.

A case report of 59-year-old woman with combined lesion of the aneurysm of the descending thoracic aorta and the destruction of vertebral bodies is presented. Considering the infectious aetiology of the whole lesion and the possibility of the future orthopaedic intervention we use the less usual operative approach and technique in this case. Only indirect method to prevent the spinal cord injury was used and the aneurysm was repaired with bypass and exclusion. The only postoperative complication requiring future surgery was the dissection and thrombosis of the right superficial femoral artery used for blood pressure monitoring. We perform, in local heparinization, the proximal femoropopliteal prosthetic bypass. The latter postoperative course was uneventful. Follow-up digital angiography of the aorta 12 month later showed good filling of the prostheses and normal anastomosis, X-ray film and CT scans one, three and five years after operation showed almost complete reconstruction of the vertebral bodies. This article also discusses the technical and tactical aspects of the thoracic aortic aneurysm repair and also analyses the diagnostic and therapeutic chance to influence the spinal cord ischaemia.

[Contribution to the theory of venous grafting using the great saphenous vein. An experimental study]. / Príspevek k teorii zilních náhrad velkou safenou. Experimentální studie.

The experimental study took interest in measurement of the flow through great saphenous vein graft. This study compared the flow through reversed vein graft and nonreversed vein graft with cutting vein valvules in the similar conditions. The flow in nonreversed graft lenght of 65 cm was Q = 697 +/- 26 ml/min, in reversed graft lenght of 65 cm Q = 836 +/- 8.61 ml/min. The flow in nonreversed graft lenght of 55 cm was Q = 1002.5 +/- 12.9 ml/min in reversed graft 55 cm Q = 1059 +/- 7.36 ml/min. The results of measurements show higher flow the shorter the graft as well as higher flow through the reversed graft. The statistically significant difference in values of the flow was also confirmed by Wilcoxon-Mann-Whitney test. The conclusion of our study can be applied on usage of allogenous vein grafts and autogenous vein grafts that could be transferred on the other leg. In these indications we can recommend the usage of reversed technique, because the measured flow through the reversed graft is statistically higher than through the nonreversed graft.

[A nontraditional method of surgical treatment of an aortocaval fistula. Case report]. / Netradicní zpusob chirurgické lécby aortokavální pístele. Kazuistika.

Unusual method of aortocaval fistula and venous aneurysm repair is discussed and possible advantages of this type of surgery are cleared up. The aortoiliac prosthetic substitution and exclusion of the region, where aorta and inferior vena cava communicate without direct suture of the fistula makes the operation safer and lowers the risk of postoperative bleeding. In authors' opinion, this method is effective even in acutely rising aortocaval fistulas.

[Comparison of the effectiveness of crystalloid and warm blood cardioplegia in patients with significant left ventricular dysfunction]. / Srovnání úcinnosti krystaloidní a krevní teplé kardioplegie u pacientu s významnou dysfunkcí levé komory srdecní.

UNLABELLED: In a group of 84 patients undergoing elective coronary artery bypass surgery and with the ejection fraction lower than 40% two types of myocardial protection were studied. Group I (41 cases) was given intermittent cold crystalloid cardioplegia and group II (43 patients) was given intermittent warm blood cardioplegia followed by normothermic reperfusion. Preoperative, intraoperative and postoperative data were retrospectively collected. There were no differences between the two groups except more rhythm disturbances in group I and higher incidence of neurological complications in group II. CONCLUSIONS: Warm blood cardioplegia is an effective, cheap and practical myocardial protection technique.