Mild cognitive impairment with associated inflammatory and cortisol alterations as independent risk factor for postoperative delirium.

AIMS: The present study aimed to determine the impact of mild cognitive impairment (MCI) on the development of postoperative delirium and, secondly, to assess the association between MCI and raised perioperative cortisol, cytokine, cobalamin and homocysteine levels. METHODS: The study recruited 113 consecutive adult patients scheduled for cardiac surgery with cardiopulmonary bypass. The patients were examined preoperatively with the Montreal Cognitive Assessment and Trail Making Test. A diagnosis of MCI was established based upon the criteria of the National Institute on Aging and Alzheimer's Association. Patients were screened for delirium within the first 5 days postoperatively. RESULTS: MCI was diagnosed in 24.8% of the patients, whereas the frequency of delirium was 36%. A multivariate analysis demonstrated that individuals with MCI were at a significantly higher risk of postoperative delirium (OR = 6.33, p = 0.002). Preoperative cortisol, postoperative cortisol and IL-2 plasma levels were higher in the MCI group as compared to non-MCI subjects. CONCLUSION: MCI is associated with a higher risk of postoperative delirium. Perioperative cortisol and inflammatory alterations observed in MCI may provide a physiological explanation for this increased risk.

Cardiac tamponade and para-aortic hematoma post elective surgical myocardial revascularization on a beating heart - a possible complication of the Lima-stitch and sequential venous anastomosis.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) surgery can be associated with some intrinsic, but relatively rare complications. A pericardial effusion is a common finding after cardiac surgeries, but the prevalence of a cardiac tamponade does not exceed 2% and is less frequent after myocardial revascularization.Authors believe that in our patient an injury of a nutritional pericardial or descending aorta vessel caused by the Lima stitch resulted in oozing bleeding, which gradually leaded to cardiac tamponade. The bleeding increased after introduction of double antiplatelet therapy and caused life-threatening hemodynamic destabilization. According to our knowledge it is the first report of such a complication after OPCAB. CASE PRESENTATION: We present a case of a 61-year old man, who underwent elective surgical myocardial revascularization on a beating heart. On the 11th postoperative day the patient was readmitted emergently to the intensive care unit for severe chest pain, dyspnoea and hypotension. Coronary angiographic control showed a patency of the bypass grafts and significant narrowing of circumflex artery, treated with angioplasty and stenting. The symptoms and hemodynamic instability exacerbated. A suspicion of dissection of the ascending aorta and para-aortic hematoma was stated on 16-slice cardiac computed tomography. The patient was referred to the Cardiovascular Surgery Clinic. Transthoracic echocardiography revealed cardiac tamponade. On transesophageal echocardiography there were no signs of the ascending aorta dissection, but a possible lesion of the descending aorta with para-aortic hematoma was visualized. Emergent rethoracotomy and cardiac tamponade decompression were performed. 12 days after intervention the control 64-slice computed tomography showed no lesions of the ascending or descending aorta. On one-year follow-up patient is in a good condition, the left ventricular function is preserved and there is no pathology in thoracic aorta on echocardiography. CONCLUSIONS: Mechanical complications of surgical myocardial revascularization on a beating heart should be considered as a cause of the clinical and hemodynamic instability relatively early in the postoperative period. Echocardiographic examination must be the first step in diagnostics process in a patient after cardiac surgery.

Raised IL-2 and TNF-α concentrations are associated with postoperative delirium in patients undergoing coronary-artery bypass graft surgery.

BACKGROUND: The knowledge base regarding the pathogenesis of postoperative delirium is limited. The primary aim of this study is to investigate whether increased levels of IL-2 and TNF-α are associated with delirium in patients who underwent coronary-artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB). The secondary aim is to establish whether any association between raised cytokine levels and delirium is related to surgical and anesthetic procedures or mediated by pre-existing conditions associated with raised cytokine levels, such as major depressive disorder (MDD), cognitive impairment, or aging. METHODS: Patients were examined and screened for MDD and cognitive impairment one day preoperatively, using the Mini International Neuropsychiatric Interview and The Montreal Cognitive Assessment and Trail Making Test Part B. Blood samples were collected postoperatively for cytokine levels. RESULTS: Postoperative delirium screening was found positive in 36% (41 of 113) of patients. A multivariate logistic regression revealed that an increased concentration of pro-inflammatory cytokines is associated with delirium, and related to advancing age, preoperative cognitive decline of participants, and duration of CPB. According to receiver operating characteristic analysis, the most optimal cut-off for IL-2 and TNF-α concentrations in predicting the development of delirium were 907.5 U/ml and 10.95 pg/ml, respectively. CONCLUSIONS: The present study suggests that raised postoperative cytokine concentrations are associated with delirium after CABG surgery. Postoperative monitoring of pro-inflammatory markers combined with regular surveillance may be helpful in the early detection of postoperative delirium in this patient group.

Cortisol levels and neuropsychiatric diagnosis as markers of postoperative delirium: a prospective cohort study.

INTRODUCTION: The pathophysiology of delirium after cardiac surgery is largely unknown. The purpose of this study was to investigate whether increased concentration of preoperative and postoperative plasma cortisol predicts the development of delirium after coronary artery bypass graft surgery. A second aim was to assess whether the association between cortisol and delirium is stress related or mediated by other pathologies, such as major depressive disorder (MDD) or cognitive impairment. METHODS: The patients were examined 1 day preoperatively with the Mini International Neuropsychiatric Interview and the Montreal Cognitive Assessment and the Trail Making Test to screen for depression and for cognitive impairment, respectively. Blood samples for cortisol levels were collected both preoperatively and postoperatively. The Confusion Assessment Method for the Intensive Care Unit was used within the first 5 days postoperatively to screen for a diagnosis of delirium. RESULTS: Postoperative delirium developed in 36% (41 of 113) of participants. Multivariate logistic regression analysis revealed two groups independently associated with an increased risk of developing delirium: those with preoperatively raised cortisol levels; and those with a preoperative diagnosis of MDD associated with raised levels of cortisol postoperatively. According to receiver operating characteristic analysis, the most optimal cutoff values of the preoperative and postoperative cortisol concentration that predict the development of delirium were 353.55 nmol/l and 994.10 nmol/l, respectively. CONCLUSION: Raised perioperative plasma cortisol concentrations are associated with delirium after coronary artery bypass graft surgery. This may be an important pathophysiological consideration in the increased risk of postoperative delirium seen in patients with a preoperative diagnosis of MDD.

Sources of thromboembolism in patients with correctly functioning mechanical valves: a single-center transesophageal echocardiographic study.

BACKGROUND: In patients with mechanical prostheses (MP), thromboembolism is one of the most serious complications. The study aim was to assess the incidence of sources of thromboembolism in patients with correctly functioning MP with and without a history of thromboembolism. METHODS: Two hundred ninety-seven patients with correctly functioning MP were enrolled in this single-center, transesophageal echocardiographic (TEE), retrospective, observational study. Two groups were analyzed: Group A, 183 patients with a history of thromboembolism, and Group B, 114 patients with no history of thromboembolism. RESULTS: Definite sources of thromboembolism were revealed in 59% of patients in Group A, and sources of potential thromboembolism were revealed in 13% of patients in Group B (P < .001). Multiple sources of thromboembolism were present in 9% of patients in Group A and 1% of patients in Group B. Localization of sources of thromboembolism included MP ring (59% and 53% of patients in Groups A and B, respectively); left atrium/left atrium appendage (24%/21% and 13%/40% of patients in Groups A and B, respectively); and aorta (12% and 13% of patients in Groups A and B, respectively). Patients with multiple sources of thromboembolism were older (P < .001) and in a higher New York Heart Association (NYHA) class (P = .004). Patients with sources of thromboembolism in the aorta were older than the rest of the group (P < .01). CONCLUSIONS: In patients with correctly functioning MP, sources of thromboembolism are observed 4 times more often in case of the positive history of thromboembolism. The most common source of thromboembolism is thrombosis of MP ring. Age and heart failure predispose multiple sources of thromboembolism. One might consider control TEE after mechanical valve implantation, but only in selected group of patients without embolic events but with a higher risk of thromboembolism.

Does the additional usage of a local hemostatic patch reduce bleeding after aortic reimplantation?

INTRODUCTION: Our study aimed to assess the efficacy of a local hemostatic, consisting of human thrombin and fibrinogen, which was applied on the aortotomy suture line. MATERIAL AND METHODS: The study involved 93 patients undergoing elective aortic valve replacement. Patients were randomized to two groups. Group 1 comprised 41 patients, in whom a hemostatic patch (Tachosil) was used additionally. Group 2 comprised 52 patients in whom Tachosil was not applied. RESULTS: The postoperative drainage after 48 h was significantly lower in the group of patients where the local hemostatic patch (Tachosil) was additionally used, compared to the control group (p = 0.0335). The prevalence of rethoracotomies was twice as high in the control group compared to the Tachosil group (5% vs. 10%), but the statistical analysis did not show a significant difference. As a consequence, both measurements of hemoglobin concentration revealed significantly higher hemoglobin in Tachosil-treated patients than the control group (p < 0.001, p = 0.0002). Red blood cell count (RBC) was also significantly higher in the Tachosil group. The difference in perioperative blood loss between the two groups resulted in a difference in postoperative acute renal injury or renal failure. The rate of infection within the early postoperative period was also comparable between the groups, although it was slightly higher in the Tachosil group (23% vs. 18%). The perioperative mortality was higher in group 2 but the difference was not statistically significant (3% in the Tachosil group vs. 5% in the control group). CONCLUSIONS: Tachosil use reduced postoperative drainage considerably, which had an important influence on renal complications after aortic valve replacement.

Mycotic DNA in non-atherosclerotic aortic wall of coronary patients is associated with sICAM-1 expression.

BACKGROUND: Atherosclerosis is currently being investigated as a chronic inflammatory process and the role of infectious agents is unclear. The presence of mycotic DNA in the wall of the non-atherosclerotic aorta of patients with coronary artery disease (CAD) and its association with levels of soluble intercellular adhesion molecule (sICAM)-1 expression was examined in the present study. METHODS AND RESULTS: In 40 patients with CAD and a comparative group of 20 patients with aortic valve stenosis (AS) without CAD, specimens of the aortic wall were obtained during cardiac surgery. Mycotic DNA was analyzed by polymerase chain reaction (PCR) using a fungus-specific universal primer pair, ITS3 and ITS4, to amplify a portion of the 5.8S rDNA region, the entire ITS2 region and a portion of the 28S rDNA region, and using a species-specific primer pair, CALB1 and CALB2, to specifically amplify Candida (C.) albicans. The nested PCR method was performed to amplify the intergenic transcribed spacer regions of the rRNAs of Candida species. Before surgery the serum level of sICAM-1 was estimated. Mycotic DNA was detected in 48% of the CAD patients and in 40% of the AS patients, with C. albicans DNA in 58% and 100%, respectively (P>0.05). In CAD patients with a high level of sICAM-1, C. albicans DNA was found more frequently than in patients without elevated levels of sICAM-1 (P<0.05). CONCLUSIONS: Mycotic DNA was found in the non-atherosclerotic aortic wall of CAD patients as well as in patients with AS. In the CAD patients C. albicans DNA was related to sICAM-1 expression.

The use of DSM-IV and ICD-10 criteria and diagnostic scales for delirium among cardiac surgery patients: results from the IPDACS study.

Diagnostic accuracy of different diagnostic systems in estimating the incidence of delirium among surgery patients has not been investigated to date. Therefore, the authors evaluated the frequency of delirium according to DSM-IV and ICD-10 criteria and the cutoff values of the Memorial Delirium Assessment Scale (MDAS) and Delirium Index in 563 patients undergoing cardiac surgery. DSM-IV criteria were found as more inclusive, while ICD-10 criteria were more restrictive in establishing a diagnosis of postoperative delirium. The cutoff scores of 10 on the MDAS and 7 on the Delirium Index were optimal to the presence or absence of delirium.

Long-lasting durability of Carpentier-Edwards pericardial bovine bioprosthesis in mitral position - a case report of unfavourable post redo valve surgery course.

We describe a 73 year-old patient with mitral valve pericardial bioprosthesis Carpentier-Edwards 29M implanted due to the rheumatic mitral stenosis 21 years ago. Hemodynamic destabilisation had emerged 18 months before the admission. Echocardiography revealed significant bioprosthesis degeneration with calcification of its leaflets, small pannus on the bioprosthetic ring, moderate mitral stenosis, severe mitral and tricuspid regurgitation with high pulmonary hypertension and moderate aortic regurgitation. Redo valve surgery with mechanical Medtronic 27M valve implantation and tricuspid suture annuloplasty was successfully performed. The postoperative course was complicated by bleeding and severe respiratory insufficiency and the patient died 3 weeks after the surgery.

Detection of infectious agents by polymerase chain reaction in human aortic wall.

INTRODUCTION: Several studies have been suggested that infectious agents may induce or progress the process of atherosclerosis in humans. In the present study, the samples of visually healthy human aortic wall were examined for the presence of Chlamydia pneumoniae, Mycoplasma pneumoniae, Helicobacter pylori, herpes simplex virus (HSV), and cytomegalovirus (CMV). METHODS: Bacterial DNA of C. pneumoniae, M. pneumoniae, and H. pylori and viral DNA of HSV and CMV were analyzed by polymerase chain reaction. The specimens were obtained from 40 patients with atherosclerotic three-vessel stable coronary artery disease referred to surgical revascularization (coronary group) and 20 controls referred to aortic valve replacement (valve group). RESULTS: C. pneumoniae was detected in 11 of 40 samples of aorta in coronary group (27.5%) and 5 of 20 in valve group (25%). M. pneumoniae was found in 6 of 40 (15%) and 5 of 20 (25%) samples, and CMV was found in 22 of 40 (55%) and 10 of 20 (50%) samples. The most frequent detected pathogens were H. pylori and HSV. H. pylori was found in 32 of 40 samples of aortic wall in coronary group (80%) and 17 of 20 samples in valve group (85%), whereas HSV was found in 27 of 40 (67.5%) and 17 of 20 (85%) aortic wall specimens. CONCLUSION: Results demonstrate that C. pneumoniae, M. pneumoniae, H. pylori, CMV, and HSV can be detected in macroscopically healthy aortic wall of coronary and valve patients in similar frequency, which do not support hypothesis concerning the role of microorganisms in atherosclerosis etiology.

The role of elective coronary surgery early after acute myocardial infarction in the era of primary percutaneous coronary intervention.

AIMS: There is a group of patients with acute myocardial infarction (AMI), who, according to results of emergency coronary angiography and regardless of performed or not performed primary percutaneous coronary intervention (PCI), are qualified for elective coronary artery bypass grafting (CABG). The authors have not found a publication that focuses on this problem. They tried to determine the base-line characteristic of this subgroup as well as appreciate its operative surgical risk. METHODS AND RESULTS: Emergency coronary angiography - followed by primary PCI when appropriate - was performed in 1867 consecutive patients with AMI. Of all these patients, 85 (4.6%) were qualified at the further stage of treatment for elective CABG. Compared with patients requiring only PCI (n = 1771), those undergoing elective CABG were the same age (61.9 +/- 9.4 vs. 61.8 +/- 12.8 years) and gender, but more frequently suffered from hypertension, diabetes mellitus, lipid disorders and multi-vessel disease. The majority of CABG patients (56.5%) belonged to the medium risk group according to the calculated EuroSCORE ratio. The mean value of the logistic EuroSCORE was 5.26 +/- 8.07. CONCLUSIONS: The elective CABG in patients early after AMI, who underwent emergency coronary angiography to perform primary PCI, is an integral part of treatment. However, this procedure usually regards only few patients. Numerous risk factors of coronary artery disease are present in those patients, who belong, however, to the medium operative risk group.

Computed tomography angiography for imaging results of neochordal mitral valve repair.

INTRODUCTION: Degenerative mitral regurgitation is currently the most frequent indication for mitral valve repair. AIM: To visualize and assess the mid-term results of mitral valve repair with neochordae implantation, using computed tomography angiography (CTA) imaging. MATERIAL AND METHODS: The CTA with ECG gating and without modulation was applied in 10 patients to assess the results of a mitral valve sparing procedure. The results of 3 patients are presented. The patients were operated on for severe symptomatic degenerative mitral regurgitation, defined according to a modified Carpentier's functional classification. RESULTS: Neochordal repair, by placing expanded polytetrafluoroethylene sutures between the leading edge of the prolapsing segment and the corresponding papillary muscle, was conducted. From 1 to 3 double Gore-Tex loops were used. Leaflet clefts, if present, were sutured. All repairs included mitral valve ring annuloplasty. The CTA was performed at 20-24 months after the surgery. Long-axis views, reconstructed during mid-systole, seemed to be the most valuable. Good quality cardiac images, precisely presenting the mitral valve complex with its constituents, were obtained in the case of patients without obesity, with a relatively small anterior-posterior thorax dimension, with sinus, slow heart rhythm and quite good left ventricle contractility. The evaluation of the mitral valve included presence of calcifications, fibrosis or thickening, chordal insertion and coaptation points, and papillary muscle locations. Primary and secondary native chordae tendineae and artificial chordae were visualized. CONCLUSIONS: Contrast material-enhanced ECG-gated CTA applied after mitral valve repair with Gore-Tex neochordae allows one to obtain satisfactory mitral valve images, especially during mid-systole, and evaluate mid-term results of the surgery in chosen patients.

EuroSCORE II does not show better accuracy nor predictive power in comparison to original EuroSCORE: a single-centre study.

BACKGROUND: EuroSCORE is used to predict postoperative mortality in patients undergoing cardiac surgery. Its updated version was published in 2011. AIM: To assess whether EuroSCORE II (ESII) predicts more accurately postoperative mortality after cardiac surgery in comparison with additive (addES) and logistic EuroSCORE (logES). METHODS: A total of 461 patients (aged 21-88 years, 63.4% of men) who underwent cardiac surgery (December 2010 - June 2011) were included into the prospective research. For each patient ESII, addES and logES were calculated. Accuracy, calibration, and clinical performance of these models were assessed with receiver operating characteristics analyses using the area under the curve and the Hosmer-Lemeshow test. Out of this population, a group of 300 coronary artery bypass grafting (CABG) patients (aged 42-85 years, 73% of men) was selected and statistically analysed using the same methods. RESULTS: The mortality rate was 5.21%. Predicted mortality rates were as follows: addES 4.68%, logES 4.57%, and ESII 1.89%; the accuracy was: 0.589, 0.728, and 0.726, respectively. Only logES presented good predictive power (Hosmer-Lemeshow test: c2 = 12.79, p = 0.12). In the CABG patients, the postoperative mortality rate was 5.33%. Predicted mortality rates were as follows: addES 4.69%, logES 4.59%, and ESII 1.88%; the accuracy was: 0.512, 0.691, and 0.687, respectively. In the Hosmer-Lemeshow test also logES presented good predictive power (c2 = 10.72, p = 0.218). CONCLUSIONS: EuroSCORE II did not estimate mortality risk better in comparison to its previous versions, in the entire studied population or in the CABG patients. On the basis of the analysed data, it seems that the closest to the actual risk of death for the Polish population is the EuroSCORE logistic model.

Iatrogenic left main-stem dissection extending to the circumflex artery and retrogradely involving the left and non-coronary sinuses of Valsalva: iatrogenic aortocoronary dissection.

We present the case of a 57-year-old female who experienced iatrogenic left main-stem (LMS) dissection during elective coronary angiography. The dissection immediately affected the circumflex artery (Cx), causing its total distal occlusion, and the left anterior descending artery (LAD), in which a metal stent, implanted six months earlier, provided blood flow. The dissection spread retrogradely to the left and non-coronary sinuses of Valsalva (SV). Ventricular fibrillation (VF) occurred but the patient was successfully defibrillated. The subsequent introduction of a catheter resulted in recurrent VF, again successfully defibrillated. Total arterial myocardial revascularisation with double skeletonised internal thoracic arteries was performed without complications and SV repair was avoided. At the one-year follow up, a control multi-slice CT (MSCT) angiography was conducted, revealing complete healing of the SV and LMS dissections. It also showed native blood flow, the left internal thoracic artery (LITA) graft to the Cx occlusion, and a patent right internal thoracic artery (RITA) graft implanted to the LAD.

Independent predictors of early mortality after coronary artery bypass grafting in a single centre experience--does gender matter?

BACKGROUND: It is commonly believed that women undergoing isolated coronary artery bypass graft surgery (CABG) are subject to a higher risk of perioperative complications and death. AIM: To evaluate the effect of sex as a risk factor on early complications and mortality after isolated CABG performed with cardiopulmonary bypass, and to evaluate the profile of the risk determined by the patient's sex. METHODS: Data derived from 2,194 surgical procedures performed in the Department of Cardiac Surgery at the Medical University of Lodz between January 2009 and March 2011 was analysed. The database was constructed on the basis of retrospective analysis of variables contained in a form of the National Registry of Cardiac Surgery. RESULTS: Isolated CABG with cardiopulmonary bypass was carried out in 1,303 patients (59.4% of all procedures). Women constituted the minority of patients (24.2%), and were significantly older (mean age 67.3 vs. 62.8 years, p < 0.001). They more often suffered from concomitant diabetes (43.1% vs. 33.41%, p = 0.003), had impaired renal function (median eGFR 88.5 vs. 95.0 mL/min1/1.73 m2, p < 0.001), and had a history of smoking in fewer cases (54.1% vs. 83.0%, p < 0.001). Internal mammary artery was more rarely used as arterial graft in the group of women (84.8% vs. 95.0%, p < 0.001). Women were subject to a higher risk of recent postoperative myocardial infarction (5.5% vs. 2.9%, p = 0.03) and required reoperation more rarely than men (4.5% vs. 8.1%, p = 0.04). Higher 30-day mortality was observed among women (7.6% vs. 2.8%, p < 0.001) and female sex appeared to be an independent predictor of death in the multiple logistic regression analysis (OR = 1.8; 95% CI 1.2-2.7). CONCLUSIONS: Women undergoing isolated CABG are subject to higher 30-day mortality. Female sex is an independent risk factor for death after isolated CABG. Further studies are necessary to identify causes of differences in prognoses among women.

Artificial aortic valve dysfunction due to pannus and thrombus - different methods of cardiac surgical management.

INTRODUCTION: Approximately 60 000 prosthetic valves are implanted annually in the USA. The risk of prosthesis dysfunction ranges from 0.1% to 4% per year. Prosthesis valve dysfunction is usually caused by a thrombus obstructing the prosthetic discs. However, 10% of prosthetic valves are dysfunctional due to pannus formation, and 12% of prostheses are damaged by both fibrinous and thrombotic components. The authors present two patients with dysfunctional aortic prostheses who were referred for cardiac surgery. Different surgical solutions were used in the treatment of each case. CASE STUDY 1: The first patient was a 71-year-old woman whose medical history included arterial hypertension, stable coronary artery disease, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and hypercholesterolemia; she had previously undergone left-sided mastectomy and radiotherapy. The patient was admitted to the Cardiac Surgery Department due to aortic prosthesis dysfunction. Transthoracic echocardiography revealed complete obstruction of one disc and a severe reduction in the mobility of the second. The mean transvalvular gradient was very high. During the operation, pannus covering the discs' surface was found. A biological aortic prosthesis was reimplanted without complications. CASE STUDY 2: The second patient was an 87-year-old woman with arterial hypertension, persistent atrial fibrillation, and COPD, whose past medical history included gastric ulcer disease and ischemic stroke. As in the case of the first patient, she was admitted due to valvular prosthesis dysfunction. Preoperative transthoracic echocardiography revealed an obstruction of the posterior prosthetic disc and significant aortic regurgitation. Transesophageal echocardiography and fluoroscopy confirmed the prosthetic dysfunction. During the operation, a thrombus growing around a minor pannus was found. The thrombus and pannus were removed, and normal functionality of the prosthetic valve was restored. CONCLUSIONS: Precise and modern diagnostic methods facilitated selection of the treatment method. However, the intraoperative view also seems to be crucial in individualizing the surgical approach.

Influence of coronary artery bypass grafting on heart rate turbulence parameters.

This study evaluated the influence of coronary artery bypass grafting on heart rate turbulence (HRT) parameters assessed during 1-year follow-up in patients with coronary artery disease. HRT and heart rate variability (HRV) parameters significantly worsened 3 months after surgery. After 1 year, HRV parameters and turbulence onset returned to preoperative values, whereas turbulence slope remained significantly attenuated. Our results show that there is a marked attenuation of HRT parameters in the early postoperative period, indicating an impairment of baroreflex sensitivity after coronary artery bypass grafting. Concomitant depression of HRV parameters points to dysfunction of the autonomic nervous system, provoked by perioperative attenuation, as a potential underlying cause of impaired baroreflex response.

Early and long-term results of surgical treatment of type A aortic dissection.

BACKGROUND: Acute aortic dissection is one of the most serious life-threatening conditions, with mortality during the first 48 hours reaching 50%. AIM: To assess short and long-term effects as well as safety of surgical treatment of aortic dissection combined with aortic valve repair. METHODS: The study group consisted of 57 patients (38 males, 19 females, mean age 47.9 +/- 13 years) with dissection of the ascending part of the aorta (type A aortic dissection) who underwent surgery in our institution between 1985 and 1999. Follow-up duration ranged from 2 to 16 years -- mean 6 years. Control transthoracic or transesophageal echocardiography was performed in 37 patients. RESULTS: Early mortality was 21%. There were 12 perioperative deaths and 3 late non-cardiovascular deaths. Three patients underwent repeated surgery due to (1) aortic valve insufficiency, (2) pseudoaneurysm at the site of the anastomosis between proximal part of the vascular prosthesis and the aorta, and (3) fistula between aorta and right atrium. CONCLUSIONS: Aortic dissection type A is more frequent in males than females. The main causative factor is hypertension. Early mortality is significantly higher in patients undergoing emergency surgery compared with elective procedures. Heart failure symptoms (NYHA class) improve postoperatively in the majority of patients. Aortic valve repair is effective and relatively safe, and is an alternative to the aortic valve replacement with coronary arteries reimplantation.

[Cold retrograde brain perfusion in repair of aortic arch dissection or aneurysm]. / Wsteczna zimna perfuzja mózgu w operacjach rozwarstwienia lub tetniaka luku aorty.

UNLABELLED: We have used hypothermic retrograde brain perfusion (RBP) as a cerebral protection concurrently with hypothermic circulatory arrest (HCA) since September 1994. Till January 2000, 59 patients with ascending and arch aortic aneurysms were operated on (32 emergency cases with acute aortic dissection, 27 elective, including 5 with the chronic dissection). Cardio-pulmonary bypass (CPB) was established, using a common femoral artery and two venous caval cannulae, general hypothermia, aorta cross-clamping, and cold crystalloid intermittent cardioplegia via the coronary orifices. In 10 patients with De Bakey type I dissection, in whom the intimal tear was localised either in the arch or high in the ascending aorta near the orifice of the brachiocephalic trunk, and in 1 patient without dissection, after implementing HCA, continuous RBP was carried on with cold oxygenated blood via the superior caval cannula from its additional connection with the arterial line. After accomplishing the distal anastomosis (in 6 cases with the top of the arch containing the orifices of the brachiocephalic arteries and upper descending thoracic aorta, in 1 case using artificial arch, in 4 cases before the orifice of the brachiocephalic trunk) RBP was finished and CPB re-established. The incompetent aortic valve was repaired by suspension of its commissures and the prosthesis was anastomosed proximally above the coronary orifices. Seven patients died, one (with megaaorta syndrome) during the operation, 2 of myocardial failure on the 2nd postoperative day, and 3 of multiple organ disorder (including stroke with hemiparesis in 2) in the 2nd postoperative week (all but one after regaining consciousness). One patient died suddenly at home six weeks after the operation. Four patients are alive, without any neurological damage. CONCLUSION: This simple and economical method effectively protects the brain against ischaemia and emboli, without technically prolonging or complicating the operation.