Early postoperative rupture of Heartware outflow graft: A case report.

We know that new generation left ventricular assist devices (LVAD), significantly reduce the mortality of patients in the treatment of advanced heart failure disease, compared to optimal medical therapy. Day by day, we treat more heart failure patients with LVADs. Patients that can be cured are on the rise. But this also causes us to struggle with more complications. In this article, we present a case of cardiac tamponade due to rupture that occurred in the outflow graft of HeartWare left ventricular assist device (HVAD), a complication encountered for the first time as far as we know.

Endovenous laser with miniphlebectomy for treatment of varicose veins and effect of different levels of laser energy on recanalization. A single center experience.

Varicose veins, associated with great saphenous vein (GSV) incompetence, are traditionally treated with conventional surgery. In recent years, minimally invasive alternatives to surgical treatment such as the endovenous laser ablation (EVLA) and radiofrequency (RF) ablation have been developed with promising results. Residual varicose veins following EVLA, regress untouched, or phlebectomy or foam sclerotherapy can be concomitantly performed. The aim of the present study was to investigate the safety and efficacy of EVLA with different levels of laser energy in patients with varicose veins secondary to saphenous vein reflux. From February 2006 to August 2011, 740 EVLA, usually with concomitant miniphlebectomies, were performed in 552 patients. A total of 665 GSV, 53 small saphenous veins (SSV), and 22 both GSV and SSV were treated with EVLA under duplex USG. At 84 patients, bilateral intervention is made. In addition, miniphlebectomy was performed in 540 patients. A duplex ultrasound (US) is performed to patients preoccupying chronic venous insufficiency (with visible varicose veins, ankle edema, skin changes, or ulcer). Saphenous vein incompetence was diagnosed with saphenofemoral, saphenopopliteal, or truncal vein reflux in response to manual compression and release with patient standing. The procedures were performed under local anesthesia with light sedation or spinal anesthesia. Endovenous 980-nm diode laser source was used at a continuous mode. The mean energy applied per length of GSV during the treatment was 77.5 ± 17.0 J (range 60-100 J/cm). An US evaluation was performed at first week of the procedure. Follow-up evaluation and duplex US scanning were performed at 1 and 6 months, and at 1 and 2 years to assess treatment efficacy and adverse reactions. Average follow-up period was 32 ± 4 months (3-55 months). There were one patient with infection and two patients with thrombus extension into the femoral vein after EVLA. Overall occlusion rate was 95%. No post-procedural deep venous thrombosis or pulmonary embolism occurred. Laser energy, less than 80 J/cm, was significantly associated with increased recanalization of saphenous vein, among the other energy levels. EVLA seems a good alternative to surgery by the application of energy of not less than 80 J/cm. It is both safe and effective. It is a well-tolerated procedure with rare and relatively minor complications.

THE effect of P2X7 receptor activation on functional responses of human left internal mammary artery.

The Purinoreceptor 7 (P2X7R) has become a promising drug target in many cardiovascular diseases, including coronary artery disease, since prolonged activation of P2X7R could promote vascular dysfunction, atherosclerosis, and thrombosis. Thus, we aimed to study the effects of P2X7R activation on vascular relaxation responses of the human left internal mammary artery (LIMA). Sections of redundant human LIMA were cut into 3-mm wide rings,, suspended in 20-mL organ baths containing physiologic salt solution, and attached to an isometric force transducer connected to a computer-based data acquisition system. Long-term (60 min) incubation with specific P2X7R agonist Bz-ATP caused significant reductions in relaxation responses of LIMA to ATP and acetylcholine, which were reversed by selective P2X7R antagonists Brilliant Blue G or AZ11645373, whereas there were no changes in relaxation responses to endothelium-independent vasodilators isoprenaline, cAMP analog 8-Br-cAMP, and nitric oxide donor sodium nitroprusside. The impairment in relaxant responses of LIMA to endothelium-dependent vasodilators following activation of P2X7R for the long-term may contribute to postoperative LIMA vasospasm and hypertension. Modulation of P2X7R activity with selective agents may represent a new potential therapeutic approach in patients undergoing coronary artery bypass grafting surgery.

Surgical treatment of left ventricular aneurysms: a comparison of long-term follow-up of left ventricular function for classic aneurysmectomy and endoaneurysmorrhaphy techniques.

OBJECTIVE: Myocardial infarction may be complicated by the formation of a left ventricular (LV) aneurysm that distorts the normal elliptical geometry of the ventricle to produce a dilated spherical ventricle with limited contractile and filling capacities. One of the consequences is congestive heart failure, which may be refractory to medical therapy and require surgical treatment. The aim of this study was to evaluate LV function in the late term following repair of LV aneurysm. METHODS: Ninety-seven patients underwent repair of postinfarctional LV aneurysms. Sixty-one patients (62.9%) underwent classic aneurysmectomy, and 36 patients (37.1%) had endoaneurysmorrhaphy. The mean age (+/-SD) of the 87 men (89.7%) and 10 women was 55.98 +/- 8.59 years. Coronary surgery was performed in 82 patients (84.5%), with a mean of 1.34 +/- 0.77 grafts/patient. The mean preoperative ejection fraction (EF) was 39.74% +/- 8.79% (classic, 39.92% +/- 8.90%; endoaneurysmorrhaphy, 39.43% +/- 8.61%; difference not statistically significant [NS]). Fifty-five patients (56.7%) had angina of Canadian Cardiovascular Society class III to IV (classic, 55.7%; endoaneurysmorrhaphy, 58.3%; NS), 31 patients (31.9%) were in New York Heart Association (NYHA) class III to IV (classic, 31.1%; endoaneurysmorrhaphy, 33.3%; NS), and the mean preoperative NYHA functional class was 2.88 +/- 0.74 (classic, 2.83 +/- 0.77; endoaneurysmorrhaphy, 2.97 +/- 0.71; NS). RESULTS: The mortality rate at <30 days was 9.8% (n = 6) in the classic aneurysmectomy group and 2.7% (n = 1) in the endoaneurysmorrhaphy group. Long-term follow-up was available for 80 of these patients. During a mean follow-up of 79.3 +/- 37.6 months (range, 6-156 months), 14 patients (17.5%) died of a cardiac-related cause (classic, 8 patients [16.6%]; endoaneurysmorrhaphy, 6 patients [18.7%]; NS). The cardiac-related survival rate was 82.5%. In the first year, at 5 years, and at 10 years, the survival rates of the patients who underwent classical aneurysmectomy were 98.8%, 93.5%, and 76.1%, respectively, and the rates for patients who underwent endoaneurysmorrhaphy were 100%, 93.0%, 71.2%, respectively (P = .2). In the follow-up patient population, the mean preoperative EF was 40.21% +/- 9.44% in the classic aneurysmectomy group and 39.34% +/- 8.61% in the endoaneurysmorrhaphy group. Postoperatively, mean EFs increased to 44.24% +/- 9.50% and 43.80% +/- 8.81%, respectively, at the last follow-up. NYHA functional class changed from 2.79 +/- 0.77 preoperatively to 1.60 +/- 0.73 postoperatively in the classic aneurysmectomy group and from 2.97 +/- 0.71 preoperatively to 1.34 +/- 0.54 postoperatively in the endoaneurysmorrhaphy group. There was no significant difference in hospital readmissions for cardiac causes (classic, 27.1%; endoaneurysmorrhaphy, 31.2%). CONCLUSION: LV aneurysm can be repaired with acceptable surgical risk. Surgical treatment of LV aneurysm is associated with an improvement in long-term survival and symptoms.

Extracorporeal Membrane Oxygenation Therapy-Assisted Cardiopulmonary Resuscitation and Successful Bridging to Cardiac Retransplant for Cardiac Allograft Vasculopathy.

Extracorporeal membrane oxygenation therapy is being used increasingly in different areas. It has become an indispensable assistant to clinicians for hypoxic pulmonary disorders, cardiogenic shock, resuscitation, and during cardiac surgery. In this case report, we describe a patient who is bridged to successful cardiac retransplant under extracorporeal membrane oxygenation therapy support after extracorporeal membrane oxygenation therapy-assisted cardiopulmonary resuscitation.

The effect of pentoxifylline on haemolysis during cardiopulmonary bypass in open-heart surgery.

OBJECTIVE: Haemolysis has long been recognized as one of the responses to cardiopulmonary bypass (CPB). Pentoxifylline (PTX), a methylxanthine derivative, has been known for many years for its haemorrheological properties. In this prospective, randomized study, we investigated whether a PTX treatment would reduce the haemolysis during CPB. METHODS: The effect of PTX treatment on haemolysis during CPB was studied in 25 patients (PTX group). Oral PTX (1200 mg/day in 3 divided doses) treatment for 3 days was followed by 300 mg i.v. PTX administration after anaesthesia induction. The control group consisted of 25 patients with equivalent surgery but no PTX treatment. Blood samples were collected at seven time points: prior to CPB, at 5 and 10 min of CPB and 5, 10 and 15 min after removal of cross clamping and 10 min after weaning from bypass in order to measure the haemolysis parameters, which included free haemoglobin and haptoglobin. RESULTS: PTX-treatment caused statistically significant decrements in plasma free haemoglobin levels during CPB. On the other hand, plasma haptoglobin levels stayed higher in PTX-medicated patients during the CPB as compared to control subjects. CONCLUSIONS: These findings suggested that PTX may be an effective agent in reducing the haemolysis during CPB.

A modified infarct exclusion technique for repair of anteroapical postinfarction ventricular septal defect.

Ventricular septal defects complicate approximately 1% to 2% of cases of acute myocardial infarction. Such postinfarction defects require urgent surgical treatment because, on medical treatment alone, 60% to 70% of patients die within the first 2 weeks. Despite the development of various surgical techniques for repair of postinfarction ventricular septal defect, the condition carries a high risk of recurrence and subsequent death. We describe a modification of the infarct exclusion technique in which the septal portion of the patch is reinforced by the right ventricular free wall. This modification appears to prevent leaks to the right ventricle through the ventricular septal defect, from anywhere around the patch. We applied this modified technique to 4 patients with anteroapical postinfarction ventricular septal defect. There was 1 early death, due to mesenteric artery occlusion secondary to embolus. No residual shunt was found during the postoperative period. We believe that our modification to the infarct exclusion technique might reduce both operative mortality and recurrence, by supporting friable endocardial tissue with right ventricular wall. We suggest that it be considered for use in patients with anteroapical ventricular septal defect and no severe right ventricular dysfunction.

A functional and histopathological comparison of proximal and distal saphenous vein contractility and morphology.

Variations in vascular reactivity and morphology of proximal and distal saphenous vein might affect its performance as a bypass conduit. Because peri- or postoperative graft spasm or intimal hyperplasia reduces patency, we compared the reactivity and morphology of human proximal and distal saphenous vein conduits. Isometric tension studies were performed in response to potassium chloride (80 mM), phenylephrine (10(-8) - 10(-5) M), norepinephrine (10(-8) - 10(-5) M), and angiotensin II (10(-11) - 10(-7) M). Relaxant responses were tested with acetylcholine (10(-9) - 10(-5) M), sodium nitroprusside (10(-10) - 10(-6) M), and diltiazem (10(-10) - 10(-4) M). Also, vein segments from proximal and distal leg saphenous vein grafts were collected for histopathologic investigation. In proximal and distal saphenous vein segments, we also examined the structure of intima, media, and adventitia, and we evaluated the smooth muscle cell/extracellular matrix ratio in the media. There was no significant difference (P > 0.05) between proximal and distal venous segments in response to vasoconstrictors or vasodilators. Similarly, investigation by light microscopy was unable to show any significant difference between proximal and distal conduits in vascular structure. The smooth muscle cell/extracellular matrix ratio was also similar in these graft materials. Our failure to find functional or morphologic differences between proximal and distal saphenous vein segments suggests that there is no advantage in using one of these preparations over the other as a conduit in coronary artery bypass operations.

Aorta-right atrial tunnel.

Aorta-right atrial tunnel is rare. We report a case of aorta-right atrial tunnel in which the right coronary artery arose from the tunnel. Successful surgical treatment was performed.

Cardiac relapse of squamous cell carcinoma of the maxillary sinus.

An unusual case of maxillary sinus carcinoma presenting with heart metastasis is reported. The epicardium, myocardium and endocardium were infiltrated with the tumor, but no evidence of recurrent maxillary sinus carcinoma and other organ metastasis was found. Surgical excision was not possible due to massive invasion of the heart by the tumor mass. The right ventricular inflow tract obstruction was relieved by surgical dilatation.

The inhibitory action of protamine on human internal thoracic artery contractions: the effect of free hemoglobin.

OBJECTIVE: We investigated the mechanism of the protamine action and the effects of free hemoglobin on protamine-induced responses in endothelium-denuded and-intact human internal thoracic artery (ITA) rings precontracted with phenylephrine (PE) or high KCl. METHODS: Samples of redundant ITA obtained from patients undergoing a coronary artery bypass graft surgery were cut into 3 mm wide rings and suspended in 20 ml organ baths. Isometric tension was continuously measured with an isometric force transducer connected to a computer-based data acquisition system. RESULTS: Acetylcholine (Ach, 10(-8)-10(-5) M) caused a concentration-dependent relaxation of PE-precontracted ITA rings. Free hemoglobin (0.1 and 0.5 microM) produced a concentration-dependent and significant decrease in sensitivity (pD(2)) and maximal contractility (E(max)) in response to Ach in PE-precontracted ITA rings (P<0.0001). Protamine (50-800 microg/ml), free hemoglobin (0.1 and 0.5 microM), nitric oxide (NO) blocker N(omega)-nitro-L-arginine methyl ester (L-NAME, 100 microM) or soluble guanylate cyclase inhibitor methylene blue (10 microM) administration did not cause a significant alteration on basal tonus of endothelium-intact or -denuded ITA rings. Protamine (50-800 microg/ml) induced concentration-dependent relaxation responses in ITA rings precontracted by either PE or high KCl. There was no difference in sensitivity or maximal response to protamine between the endothelium-intact and -denuded rings. Incubation of endothelium-intact or -denuded ITA rings with L-NAME or free hemoglobin or methylene blue did not cause a significant inhibition on relaxation responses to protamine. ITA ring contractions induced by stepwise addition of calcium to high KCl solution with no calcium were almost completely inhibited by protamine (P<0.0001). CONCLUSIONS: It was suggested that protamine induced relaxation responses in human ITA rings is not NO- or endothelium-dependent but seems to depend on the interactions of protamine with calcium influxes and/or calcium release from intracellular stores in this tissue.

A single coronary artery from the right sinus of valsalva associated with atherosclerosis.

Anomalous origin of the main coronary arteries from the aorta is rare. We report a case with a single coronary artery from the right sinus of Valsalva associated with atherosclerosis. The patient was treated with a coronary artery bypass procedure: left internal mammary artery (LIMA) to the left anterior descending artery (LAD), right internal mammary artery (RIMA) to the right coronary artery (RCA). The postoperative course was uneventful.

The effect of pentoxifylline on haemolysis in patients with double cardiac prosthetic valves.

OBJECTIVE: Intravascular haemolysis frequently occurs in patients with mechanical heart valve prostheses. In this prospective study, we investigated whether pentoxifylline (PTX) has an effect on haemolysis following prosthetic valvular replacement in 40 patients who underwent double valve (mitral and aortic) replacement. METHODS AND RESULTS: The patients were randomly assigned to two groups as control (n = 20) and PTX group (n = 20). PTX was given in a daily oral dose of 1200 mg (3 times 400 mg) for 120 days. Laboratory tests for evidence of haemolysis namely, haemoglobin (Hb), haematocrit (Hct), plasma total bilirubin, indirect bilirubin and haptoglobin levels, corrected reticulocyte percent and serum lactic dehydrogenase activity (SLDH) were performed before and after the PTX treatment. PTX treatment caused significant increases in Hb, Htc, and haptoglobin levels (P < 0.05, P < 0.05 and P < 0.01, respectively). Additionally, there were significant decreases in SLDH, total and indirect bilirubin levels, and corrected reticulocyte percent in patients receiving PTX as compared with their respective control values (P < 0.01, for all). PTX treatment caused a significant improvement, to different extents, in signs of haemolysis in 60% of the patients. On the other hand, the response rate was 5% in the placebo-treated control group (P < 0.05). CONCLUSIONS: These findings suggest that PTX may be an effective agent in the management of haemolysis in patients with prosthetic heart valves.

Effects of vitamin K1 supplementation on vascular responsiveness and oxidative stress in a rat femoral osteotomy model.

The main function of vitamin K1 is to act a co-factor for gamma-glutamyl carboxylase. However, it has also been shown to lessen oxidative stress. This study was aimed to evaluate the effect of vitamin K1 supplementation on vascular responsiveness and oxidative status in rats that underwent femoral osteotomy. Twenty-four male rats were divided into three groups to serve as sham, osteotomy and vitamin K1 groups. Indices of oxidative stress (catalase), and oxidative damage (malondialdehyde) were analysed in erythrocytes. In order to evaluate vascular reactivity, concentration-response curves to phenylephrine, angiotensin II, 5-hydroxytryptamine, bradykinin and histamine were constructed. The findings of this study clearly show that oxidative stress clearly increases after femoral osteotomy in rats. Also, this operation causes a significant depression in vascular responsiveness to contracting agents and endothelium-dependent vasodilators. However, vitamin K1 supplementation prevents vascular hyporeactivity by reducing oxidative stress and may represent a novel approach during osteotomy healing.

The effects of recurrent Pseudomonas aeruginosa infection on pulmonary parenchyma and vasculature in rats fed on a cholesterol-rich diet.

It has been demonstrated that both hypercholesterolemia and infectious agents are contributing factors in atherosclerosis but their combined effect on the pulmonary vascular bed is not known. To answer this question, the authors tried to demonstrate the effects of recurrent infection on pulmonary parenchyma and vascular system in cholesterol-fed rats. Sixty-six rats were randomly divided into 4 groups: Groups I (control), II (cholesterol-rich diet), III (recurrent pulmonary Pseudomonas aeruginosa infection), IV (cholesterol-rich diet + recurrent infection). After 6 months serum cholesterol levels didn't increase in any of the groups. Central pulmonary artery wall thickness was increased in group IV (P < .0001). Although not significant, peripheral pulmonary artery wall thickness was increased in group IV. In rats fed on a cholesterol-rich diet, recurrent infection caused a significant increase in atherosclerosis, although serum cholesterol levels didn't increase. Infection and cholesterol-rich diet have a synergistic effect on atherosclerosis in the pulmonary vascular system in rats even in the absence of hypercholesterolemia.

Aortoiliac kissing stents: long-term results and analysis of risk factors affecting patency.

PURPOSE: To present the early and long-term results of aortoiliac kissing stents implantation and evaluate the risk factors affecting patency. METHODS: The data were retrospectively reviewed on 68 patients (64 men; mean age 55+/-11, range 32-77) who underwent kissing stents implantation during a 12-year period. The majority of patients (64, 94%) had claudication; 4 patients had rest pain. All were smokers. There were bilateral or unilateral stenoses in 42 (62%) patients, and unilateral occlusion and contralateral stenosis in 26 (38%). Lesions were treated with simultaneous implantation of self-expanding (n=52) or balloon-expandable (n=16) stents. After the procedure, patency was determined with Doppler ultrasonography or angiography at 1, 3, 6, and 12 months and annually thereafter. Primary, assisted primary, and secondary patency rates were calculated with Kaplan-Meier analysis on an intention-to-treat basis, and risk factors affecting the patency rates were determined with the Cox regression analysis. RESULTS: All procedures were technically and clinically successful. Complications occurred in 12%, but none required surgery. The follow-up period was 35+/-31 months. Primary, assisted primary, and secondary patency rates, respectively, were 76%, 90%, and 94% at 1 year; 63%, 86%, and 92% at 3 years; and 63%, 64%, and 81% at 5 years. In multivariate analysis, age <50 years and presence of iliac occlusion were identified as risk factors for reduced primary and assisted primary patency; a crossed configuration of kissing stents was identified as a risk factor for reduced primary patency. CONCLUSION: Implantation of kissing stents is a safe and effective alternative in the treatment of aortoiliac obstructions. However, overall primary and assisted primary patency rates are inferior to those reported for surgery. Long-term patency comparable to surgery may be obtained in patients >50 years and in those without an iliac occlusion, particularly if a favorable stent configuration is achieved.

Effects of short-term exposure to homocysteine on vascular responsiveness of human internal mammary artery.

The aim of this study was to investigate the acute direct effects of homocysteine (Hcy) on the vascular responsiveness of human internal mammary artery (IMA) and to define the possible underlying mechanisms. The contractile response to both phenylephrine (Phe) (-36%) and KCl (-18%) was significantly reduced in arteries that were incubated with Hcy (10 (-4)M, 30 minutes), compared with controls (P < 0.05). Removal of endothelium did not significantly alter the responses of human IMA to Phe. Hcy (10 (-6)M) also caused a relaxation response in human IMA rings precontracted with Phe (10 (-4) M) and this effect was not inhibited by N-nitro-L-arginine methyl ester (L-NAME, 10(-4) M), by l-NAME (10 (-4)M) + indomethacin (10 (-4)M), or by intimal rubbing. In addition, contractions induced by stepwise addition to calcium (Ca2+) to high KCl solution with no Ca(2+) were significantly inhibited by Hcy incubation as well as contractions induced by Phe in the absence of extracellular Ca (2+) (P < 0.05). On the other hand, Hcy (10 M, 30 minutes) did not significantly inhibit the relaxation responses to either acetylcholine (ACh) or sodium nitroprusside (SNP) (P > 0.05). These results demonstrated that short-term exposure to Hcy significantly decreased vascular responsiveness in human IMA without affecting endothelium-dependent and -independent vasorelaxation. This effect is not NO-, prostaglandin- or endothelium-dependent. The mechanism is uncertain but seems to depend on the interactions of Hcy with Ca(2+) influxes and/or other undefined direct effects in this tissue.