Background
Del Nido cardioplegia was recently introduced to adult cardiac surgery with encouraging results. The effect of Del Nido cardioplegia in patients with low ejection fraction (EF) has not ...been thoroughly evaluated. The objective of this study was to assess the safety of Del Nido cardioplegia in adult patients with low EF compared to intermittent warm blood cardioplegia.
Results
During 2018 and 2019, 73 adult patients with an EF of ≤ 40% underwent cardiac surgery using Del Nido cardioplegia. The patients were compared to a historical cohort of consecutive patients with low EF who had intermitted warm blood cardioplegia (
n
= 81). Patients who had Del Nido cardioplegia had significantly lower EuroSCORE II (2.73 (1.7–4.1) vs. 4.5 (2.4–7.4),
P
= 0.004). There were no differences in creatinine clearance and preoperative echocardiographic data between the groups. Cardiopulmonary bypass and cross-clamp times were non-significantly lower with Del Nido cardioplegia. There were no differences in stroke and postoperative echocardiographic data between the groups. No hospital mortality was reported in both groups. Peak troponin levels were significantly higher in patients who had Del Nido cardioplegia (0.88 (0.58–1.47) vs. 0.7 (0.44–1.01) ng/dL;
P
= 0.01); however, after multivariable regression analysis, cardiopulmonary bypass time was the only predictor of postoperative troponin level (coefficient 0.005 (95% CI: 0.003–0.008);
P
< 0.001). ICU stay was significantly longer in patients who had Del Nido cardioplegia (4 (3–6) vs. 2(1–4) days,
P
< 0.001), while postoperative hospital stay did not differ between the groups. After multivariable regression, the use of intermittent warm blood cardioplegia was significantly associated with shorter ICU stay (coefficient − 1.80 (95% CI − 3.06 – -0.55);
P
= 0.01).
Conclusions
Prolonged ICU was reported with Del Nido cardioplegia; however, there were no differences in the duration of hospital stay and the clinical outcomes between the groups. Despite the proven efficacy of intermittent warm blood cardioplegia, the use of Del Nido cardioplegia might be safe in patients with low EF.
A 56-year old male with ischemic heart disease and an unremarkable preoperative echocardiogram underwent surgical coronary revascularization. An intraoperative post pump trans-esophageal ...echocardiogram (TOE) performed while the patient was being ventilated at a positive end expiratory pressure (PEEP) of 8 cm H2O demonstrated a right to left interatrial shunt across a patent foramen ovale (PFO). Whereas oxygen saturation was normal, a reduction of the PEEP to 3 cm H2O led to the complete resolution of the shunt with no change in arterial blood gases. Attempts to increase the PEEP level above 3 mmHg resulted in recurrence of the interatrial shunt. The remaining of the TEE was unremarkable. Mechanical ventilation, particularly with PEEP, causes an increase in intrathoracic pressure. The resulting rise in right atrial pressure, mostly during inspiration, may unveil and pop open an unrecognized PFO, thus provoking a right to left shunt across a seemingly intact interatrial septum. This phenomenon increases the risk of paradoxical embolism and can lead to hypoxemia. The immediate management would be to adjust the ventilatory settings to a lower PEEP level. A routine search for a PFO should be performed in ventilated patients who undergo a TEE.
Full text
Available for:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Endothelial nitric oxide synthase type III is the key enzyme of the nitric oxide production in the vessel wall. In this study the localization of endothelial nitric oxide synthase type III within the ...wall of the human internal thoracic and radial arteries and the great saphenous vein was investigated.
Specimens were harvested from 23 patients undergoing surgical myocardial revascularization and submitted to light and electron microscope analysis using histochemical stainings and immunohistochemistry with specific antibodies anti-endothelial nitric oxide synthase type III, Factor VIII, and α-smooth muscle actin.
Endothelial nitric oxide synthase type III was evident in the intima of all conduits and, unexpectedly, in the muscle cells of the media of muscular internal thoracic arteries and radial arteries. No endothelial nitric oxide synthase type III expression was found in the media of great saphenous veins. Semiquantitative analysis revealed a higher endothelial nitric oxide synthase type III expression in the wall of internal thoracic artery, particularly at the level of the media.
Endothelial nitric oxide synthase type III is expressed in the intima of the internal thoracic and radial artery and the great saphenous vein and in the muscle cells of the media of the internal thoracic and radial arteries. However, the internal thoracic artery shows a higher intensity of endothelial nitric oxide synthase type III expression, particularly within the media. The present study provides the first demonstration of the endothelial nitric oxide synthase type III expression at the level of the smooth muscle cells of the tunica media of systemic human arteries and can provide an histologic explanation for the better results of the internal thoracic artery when used for coronary artery bypass grafting.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objectives This study was conceived to describe the evolution of aortic dimensions in patients with moderate post-stenotic ascending aorta dilation (50 to 59 mm) submitted to aortic valve replacement ...(AVR) alone. Background The appropriate treatment of post-stenotic ascending aorta dilation has been poorly investigated. Methods Ninety-three patients affected by severe isolated calcific aortic valve stenosis in the tricuspid aortic valve accompanied by moderate dilation of the ascending aorta (50 to 59 mm) were submitted to AVR only. All patients were followed for a mean of 14.7 ± 4.8 years by means of periodic clinical evaluations and echocardiography and tomography scans of the thorax. Results Operative mortality was 1.0% (1 patient). During the follow-up, 16 patients died and 2 had to be reoperated for valve dysfunction. No patients experienced acute aortic events (rupture, dissection, pseudoaneurysm), and no patient had to be reoperated on the aorta. There was not a substantial increase in aortic dimensions: mean aortic diameter was 57 ± 11 mm at the end of the follow-up versus 56 ± 02 mm pre-operatively (p = NS). The mean ascending aorta expansion rate was 0.3 ± 0.2 mm/year. Conclusion In the absence of connective tissue disorders, AVR alone is sufficient to prevent further aortic expansion in patients with moderate post-stenotic dilation of the ascending aorta. Aortic replacement can probably be reserved for patients with a long life expectancy.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract Background Munchausen syndrome is a psychiatric disease characterized by pathological lying and malingering. Patients who are affected can set up such complex and compelling clinical ...scenarios that they can lead to a bias in the diagnostic process and even to unnecessary surgery. Case Reports Two cases of Munchausen syndrome misrepresenting acute aortic dissection are reported. The two cases occurred at two different institutions where there was considerable expertise in the management of aortic pathology. In both patients, a wrong diagnosis of acute aortic syndrome was made, leading to unnecessary surgery. Conclusions Retrospective analysis of the clinical events and the diagnostic process suggests that a confirmation bias played a major role in determining the misdiagnosis. The same mistake is likely to have occurred in the only other case reported in the literature.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
There is no consensus regarding mitral valve management during surgical ventricular restoration (SVR) for ischemic cardiomyopathy. We compared the impact of SVR with mitral valve repair (MVr) vs ...replacement (MVR) on postoperative outcomes and long-term survival in ischemic cardiomyopathy and mitral regurgitation patients. This study included 112 patients who underwent SVR from 2009 to 2018 with MVr (n = 75) or MVR (n = 37). Patients who had MVR had higher Euro SCORE II, dyspnea class, a lower ejection fraction, higher pulmonary artery systolic pressure, higher grade of preoperative mitral and tricuspid regurgitation, and higher end-diastolic and end-systolic diameters. Intra-aortic balloon pump was more commonly used in patients with MVR. Hospital mortality occurred in 7 (9.33%) patients in the MVr group vs 3 (8.11%) in the MVR group (P > .99). Freedom from rehospitalization at 1, 5, and 7 years was 87%, 76%, and 70% in the MVr group and 83%, 61%, and 52% in the MVR group (P = .191). Survival at 1, 5, and 7 years was 88%, 78%, and 74% in the MVr group and 88%, 56%, and 56% in the MVR group (P = .027). Adjusted survival did not differ between groups.
MVr or MVR are valid options in patients undergoing SVR, with good long-term outcomes.
Full text
Available for:
NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
Background
The influence of the etiology of mitral valve (MV) lesion on outcomes of concomitant repair for functional tricuspid regurgitation (TR) is not well studied. Our objectives were to compare ...long‐term survival and TR recurrence after tricuspid valve (TV) repair concomitant with surgery for rheumatic versus degenerative MV disease.
Methods
We included 480 patients who had concomitant MV and TV surgery from 2009 to 2019. We grouped the patients into Group 1 (n = 345; rheumatic MV) and Group 2 (n = 135; degenerative MV). Propensity score matching identified 104 matched pairs.
Results
There was no significant difference in survival between groups before (p = .46) or after matching (p = .09). There was no difference in the recurrence of moderate TR (subdistributional hazard ratio SHR: 1.22 0.77−1.95, p = .40). Recurrent TR was significantly associated with the preoperative TR grade (SHR: 1.8 1.5−2.16, p < .001); body mass index (SHR: 1.05 1.03−1.08, p < .001), and the use of flexible versus rigid TV prosthesis (SHR: 0.64 0.41−0.99, p = .042). Recurrence of TR was higher with MV replacement compared with repair (SHR: 1.69 1.03−2.78, p = .038). The change in the degree of TR did not differ between groups before matching (OR: 0.77 0.56−1.04, p = .09) or after matching (OR: 0.98 0.67−1.44; p = .93).
Conclusion
Outcomes of concomitant TR repair were comparable in rheumatic and degenerative mitral pathology. Type of the TV prosthesis and TR grade affected TR recurrence. MV repair could be associated with a lower recurrence of TR compared with replacement.
Full text
Available for:
BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
This study was conceived to describe the evolution of aortic dimensions in patients with moderate post-stenotic ascending aorta dilation (50 to 59 mm) submitted to aortic valve replacement (AVR) ...alone.
The appropriate treatment of post-stenotic ascending aorta dilation has been poorly investigated.
Ninety-three patients affected by severe isolated calcific aortic valve stenosis in the tricuspid aortic valve accompanied by moderate dilation of the ascending aorta (50 to 59 mm) were submitted to AVR only. All patients were followed for a mean of 14.7 ± 4.8 years by means of periodic clinical evaluations and echocardiography and tomography scans of the thorax.
Operative mortality was 1.0% (1 patient). During the follow-up, 16 patients died and 2 had to be reoperated for valve dysfunction. No patients experienced acute aortic events (rupture, dissection, pseudoaneurysm), and no patient had to be reoperated on the aorta. There was not a substantial increase in aortic dimensions: mean aortic diameter was 57 ± 11 mm at the end of the follow-up versus 56 ± 02 mm pre-operatively (p = NS). The mean ascending aorta expansion rate was 0.3 ± 0.2 mm/year.
In the absence of connective tissue disorders, AVR alone is sufficient to prevent further aortic expansion in patients with moderate post-stenotic dilation of the ascending aorta. Aortic replacement can probably be reserved for patients with a long life expectancy.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Female gender is a risk factor in several cardiac surgery risk stratification systems. This study explored the differences in the outcomes following triple heart valve surgery in men vs women. The ...study included 250 patients (males
= 101; females
= 149) who underwent triple valve surgery from 2009 to 2020. BMI (body mass index) was higher in females (29.6 vs 26.5 kg/m
,
< .001), and diabetes was more common in males (44 vs 42%,
= .012). The ejection fraction was higher in females (55 vs 50%,
< .001). The severity of mitral valve stenosis and tricuspid valve regurgitation was significantly greater in females (33.11 vs 27.72%,
= .003 and 44.30 vs 19.8%,
< .001, respectively). Mitral valve replacement was more common in females (
< .001), and they had lower concomitant coronary artery bypass grafting (
= .001). Bleeding and renal failure were lower in females (
= .021 and <0.001, respectively). Hospital mortality, readmission, and reintervention were not significantly different between genders. By multivariable analysis, male gender was a risk factor for lower survival HR (hazard ratio): 2.18;
= .024. Triple valve surgery can be performed safely in both genders, with better long-term survival in females. Female gender was not a risk factor in patients undergoing triple valve surgery.
Full text
Available for:
NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
We report a case of coronary spasm soon after aortic valve replacement associated with hemodynamic and arrhythmic instability. The spasm was demonstrated at coronary angiography and was resolved with ...the intracoronary infusion of nitrates and antiarrhythmics.
PDF
