[Perioperative use of levosimendan in cardiac surgery. Hungarian recommendation]. / A levoszimendán perioperatív alkalmazása a szívsebészetben. Magyar ajánlás.

Low output syndrome significantly increases morbidity and mortality of cardiac surgery and lengthens the durations of intensive care unit and hospital stays. Its treatment by catecholamines can lead to undesirable systemic and cardiac complications. Levosimendan is a calcium sensitiser and adenosine triphosphate (ATP)-sensitive potassium channel (IK,ATP) opener agent. Due to these effects, it improves myocardium performance, does not influence adversely the balance between O2 supply and demand, and possesses cardioprotective and organ protective properties as well. Based on the scientific literature and experts' opinions, a European recommendation was published on the perioperative use of levosimendan in cardiac surgery in 2015. Along this line, and also taking into consideration cardiac surgeon, anaesthesiologist and cardiologist representatives of the seven Hungarian heart centres and the children heart centre, the Hungarian recommendation has been formulated that is based on two pillars: literature evidence and Hungarian expert opinions. The reviewed fields are: coronary and valvular surgery, assist device implantation, heart transplantation both in adult and pediatric cardiologic practice. Orv Hetil. 2018; 159(22): 870-877.

[Visceral complications of the aortic dissections - indications and technique of the thoracoabdominal refenestration]. / Aortadissectiók zsigeri szövodményei ­ a thoracoabdominalis refenestratio javallata és technikája.

Aortic dissection is a life threatening cardiovascular catastrophy. Its incidence estimated to 5-6 cases per 100,000 patients/year. The intimal tear happens at the ascending aorta in Type A, meanwhile at the aortic isthmus in Type B, but entry point may develop anywhere alongside the entire aorta. All types may affect a short aortic segment resulting in a localized false aneurysm, others separate the intimal layer at longer extension down to the visceral segment and far beyond to the femoral arteries. Dissection of orifices of side branches may lead to cerebral, upper extremity, spinal, visceral, renal and lower extremity malperfusion. These complications beyond the aortic rupture contribute significantly to high mortality of dissection. Today, first line treatment option in Type A dissection is surgery, but it can be endovascular or medical in Type B dissection. However, awareness of surgical procedures in this field remains inevitable. In this paper we summarize the surgical options for distal malperfusion affecting spinal, visceral, renal and lower extremity circulation.

Minimalinvaziv aortabillentyu-beultetes soran nyert kezdeti tapasztalataink / Minimálinvazív aortabillentyu-beültetés során nyert kezdeti tapasztalataink

Introduction: Due to the aging population, aortic valve stenosis is the most frequently diagnosed acquired cardiac disease amongst adults. Various surgical techniques have been developed and median sternotomy has become the standard practice for exploration. Improvements in cardiological intervention techniques allow surgery to provide the same quality with less invasiveness.Objective: Our aim was to compare the results of the isolated aortic valve surgeries (AVR) performed as either full or partial sternotomy during the study period in terms of pre-, intra-, and postoperative variables.Patients and methods: We examined the results of the isolated AVR performed at Gottsegen National Cardiovascular Center between January 2019 and March 2020 (99 AVR and 151 mini-AVR). During mini-AVR we opened the sternum with J shape ministernotomy up to the 3rd or 4th intercostal space while in median sternotomy we separated the sternum in its total length.Results: Blood consumption (unit) (AVR: 2.90 [2.90]; mini-AVR: 1.85 [2.12]; p<0,05), days of hospitalization (AVR: 9.75 [2.99]; mini-AVR: 8.85 [2.85]; p<0,05) and length of surgery (minutes) (AVR:148.49 [34.4]; mini-AVR: 134.6 [34.8]; p<0,05) were significantly better in the mini-AVR group. In terms of preoperative variables, the two groups were not homogeneous therefore we corrected the strong predictive variables. As a result, levels of bio-statistical significance have disappeared but there is still a trend in favour of minimally invasive surgery.Conclusions: Mini-AVR surgery is considered a more cost-effective intervention compared to standard surgery in terms of less surgical trauma, reduced blood consumption, and shorter operative time.

Surgical repositioning of Jarvik 2000 LVAD power supply pedestal following fall trauma.

Advanced heart failure (HF) is one of the leading causes of mortality and morbidity. With an aging population, its prevalence is expected to rise further. Although orthotopic heart transplantation (HTX) remains the gold standard in therapy, there is a significant deficiency in the ratio of donor organs to recipient patients. Left ventricular assist devices (LVAD) could relieve this problem either as a bridge-to-transplant (BTT) or as a destination therapy (DT). Despite the widespread implantation of ventricular assist devices, their efficacy may be limited by some serious adverse events, while infection is a major issue. A longer period of LVAD support significantly increases the risk of driveline infections (DLI). The Jarvik 2000® ventricular assist device (Jarvik Heart, New York, NY, USA) offers prolonged infection-free survival. In our report, we present the case of a 61-year-old female patient with a driveline pedestal that has become fully detached from the skull following a fall trauma. We describe how the traumatized pedestal was surgically replaced by removing the previous, damaged unit and inserting a repositioned new one. The surgical procedure presented in our case has not been performed before and we have not found any similar one in the literature. It requires individual surgical planning and a multidisciplinary surgeon's team to ensure the procedure is safe and feasible.

Treatment of three-vessel disease in light of the results of the FAME-3 study / A háromér-betegség kezelése a FAME-3 vizsgálat eredményeinek tükrében

Previous randomized clinical studies have shown the superiority of coronary artery bypass grafting over percutaneous coronary intervention in the treatment of severe multivessel disease mainly because of a reduced need for repeat revascularization but, in some, a mortality benefit and reduced rate of myocardial infarction were shown among those undergoing surgery. The late breaker multicentric, randomized FAME (Fractional Flow Reserve Versus Angiography in Multivessel Evaluation)-3 study, involving 1500 patients, sought to determine whether fractional flow reserve guided percutaneous coronary intervention with implantation of new-generation drug-eluting stents was non -inferior to present-day coronary bypass surgery with respect to the composite of all-cause death, myocardial infarction, stroke and repeat revascularization at one year. The authors who were particularly active in the FAME-3 trial describe the study setting, the characteristics of the patient population, the procedures, and the results. The FAME-3 study failed to show the non-inferiority of percutaneous coronary intervention to bypass surgery in the treatment of three vessel disease using the predetermined margin. The authors present a detailed analysis of the possible reasons and some important secondary results. These include a lack of significant difference between the two arms with respect to `hard end points' and the significantly higher perioperative morbidity of the surgical group. Albeit our clinical practice should be based on the analysis of the primary end point, informing patients and shared decision making must include these secondary results when individual revascularization strategies are planned.

Vasorelaxing effect of levosimendan against 5-hydroxytryptamine-induced contractions in isolated human conduit bypass grafts.

Levosimendan is a novel inodilator drug developed for the treatment of heart failure. The possible vasodilating property of the drug in human coronary artery bypass grafts was investigated. Isometric tensions of the left internal thoracic artery (LITA, n = 8) as well as the proximal and distal segments of the radial artery (RA, n = 8 and 8) were measured in isolated organ baths. Concentration-relaxation curves for levosimendan (0.009-1.14 micromol L(-1)) were obtained against 5-hydroxytryptamine (5-HT; serotonin, 0.002-9.3 micromol L(-1))-induced contractions. 5-HT-induced contraction of LITA was considerably smaller than that of the proximal and distal RAs. Levosimendan relaxed the grafts in the following order of calculated maximum efficacies (E(max)): LITA > proximal RA > distal RA (LITA 100.3+/-16.2% of 5-HT-induced maximum tension, proximal RA 86.9+/-8.6%, distal RA 59.4+/-17.5%, P < 0.05 LITA vs distal RA). The potency values of levosimendan, expressed as the negative logarithm of 50% effective concentrations (pD(2)), were comparable in the three bypass grafts (LITA -6.52+/-0.44 log mol L(-1), proximal RA -6.60+/-0.49 log mol L(-1), distal RA -6.85+/-0.45 log mol L(-1)). The results suggest that levosimendan is an effective vasorelaxant of conduit bypass grafts and may serve as a new therapeutic tool, especially in the case of LITA and proximal RA grafts, for relieving perioperative spasm and subsequent graft failure.

Prolonged antispasmodic effect in isolated radial artery graft and pronounced platelet inhibition induced by the inodilator drug, levosimendan.

Radial artery frequently develops spasm and requires vasodilator therapy during coronary artery bypass graft surgery (CABG). Levosimendan was recently shown to oppose 5-hydroxytryptamine-induced contraction of radial artery (RA) grafts. The aim of the present study was to explore whether levosimendan retains its vasodilatory capacity following in vitro pre-incubation of RA segments with the inodilator. A possible cumulative effect of the drug in human platelets was also studied. Human isolated RA segments were pre-incubated in 0.16 µmol/L levosimendan containing solution or in 0.9% NaCl, Bretschneider, 5% albumin and a 5% human serum protein solution (Biseko) as controls for 45 min. Contractions were induced by three consecutive administrations of 5-hydroxytryptamine (0.31 µM) 45, 90 and 120 min. after exchanging the pre-incubation solutions with Krebs-Henseleit solution, uniformly. Receptor-independent contractions (KCl, 80 mmol/L), endothelium-dependent (acetylcholine, 1 µmol/L) and independent relaxations (papaverine, 100 µmol/L) were also investigated. Washed human platelets were pre-incubated with levosimendan (0.06 µmol/L) for 2 or 15 min. and aggregated with thrombin (0.1 IU/mL). Contractions of RA grafts induced by 5-hydroxytryptamine were significantly smaller 45 min. and 90 min. after the replacement of levosimendan with Krebs-Henseleit solution. Biseko solution also decreased the contraction of the graft at 45 min. Contractions did not change in time following the pre-incubations of radial arteries with 0.9% NaCl, Bretschneider and 5% albumin solutions. The grafts remained intact as assessed by their maximum contractions and endothelium-dependent and endothelium-independent relaxations at the end of the investigations. Platelets revealed larger anti-aggregatory effect to levosimendan following the enhancement of the incubation time. Results indicate that the antispasmodic and anti-aggregatory effects of levosimendan cumulate in the vascular tissue and in platelets. The storage of RA with the inodilator before implantation may help to prevent the intraoperative spasm of the graft and also thrombotic occlusion during CABG surgery.

Biseko colloidal solution diminishes the vasoreactivity of human isolated radial arteries.

OBJECTIVE: Radial arteries are increasingly used as grafts in coronary artery bypass surgery. The surgical preparation and intraoperative management of this conduit artery may affect its early and long-term patencies. We investigated the effects of the colloidal Biseko and 5% albumin solutions as well as the crystalloid physiological saline (0.9% NaCl) and Bretschneider solutions on the contractile and relaxing capacities of isolated human radial artery grafts. METHOD: Radial artery segments were harvested using the technique with an ultrasonic scalpel, and 2.5-3mm rings were obtained from the proximal part of the artery. Arterial rings were stored in Biseko or 5% albumin solutions and in 0.9% NaCl or Bretschneider solutions for 45 min. Isometric tensions of radial arteries obtained from 26 patients were measured in isolated organ baths. Contractions were induced by 0.31 micromolL(-1) 5-hydroxytryptamine and 10 micromol L(-1) noradrenaline. Endothelium-dependent relaxations were induced by 10 micromol L(-1) acetylcholine and 1 micromol L(-1) bradykinin as well as the endothelium-independent relaxations by 10 micromol L(-1) glyceryl trinitrate and 100 micromol/l papaverine. RESULTS: Contractions of radial arteries induced by 5-hydroxytryptamine were significantly lower following storage in Biseko solution (12.6+/-4.4 mN) than in 5% albumin (37.9+/-13.0 mN, p=0.03) or in 0.9% NaCl solution (35.9+/-11.9 mN, p=0.04). Noradrenaline-induced contractions of the arteries were also diminished in Biseko solution compared to those stored in 5% albumin (32.9+/-6.2 mN vs 49.2+/-6.4 mN, p=0.01). No significant differences in relaxations were obtained between the two crystalloid and the two colloidal solutions using endothelium-dependent and independent vasorelaxants. CONCLUSION: Our results suggest that storage of radial artery in Biseko colloidal solution before coronary artery bypass grafting decreases the sensitivity of the graft to vasoconstriction, thereby decreasing the risk of intra/perioperative graft failure.