25th anniversary of the Department of Cardiac Surgery at the University Medical Center Maribor: advancing hearts, changing lives : A quarter century of commitment

In 1996, Slovenia witnessed a profound transformation in its cardiac care landscape with the establishment of the Department of Cardiac Surgery at the University Medical Centre Maribor. This momentous milestone heralded the birth of the nation's second heart surgery center revolutionizing cardiovascular care accessibility. Today, the Department of Cardiac Surgery stands as a regional hub, delivering specialized cardiac surgical services to Slovenia's northeastern region and beyond. Its unwavering commitment to excellence, patient-centered care, and adherence to international guidelines reflects its dedication to providing top-tier cardiac care. As the department commemorates its 25th anniversary, this article offers a reflective overview of its establishment, development, growth and future trajectory for further development in an ever-changing era of cardiovascular medicine. The article also highlights the department's active involvement in international collaborations, scientific research, medical education, and innovations in minimally invasive cardiac surgery.

Veno-arterial extracorporeal membrane oxygenation for post-infarction ventricular septal defect in a low-volume center

Managing patients with post-ischaemic ventricular septal defects (VSD) and postcardiotomy cardiogenic shock can be extremely challenging in a low-volume cardiac surgery unit. We present a case of a 68-year-old patient who received veno-arterial extracorporeal membrane oxygenation support due to cardiogenic shock after VSD repair. The patient was successfully weaned off support after 86 h. In the postoperative period, mediastinitis occurred, and negative pressure wound therapy was instituted.

Aortic Valve Repair and Early-Career Surgeons-Nothing Is Impossible

Aortic valve repair with either the reimplantation of the aortic valve or aortic root remodelling with the external annuloplasty procedure is the most effective means of treating aortic regurgitation and/or aortic root aneurysms [...].

Sex related difference in heart failure development in patients after first myocardial infarction; role of galectine-3

 

Cardiac remodeling after the first myocardial infarction (MI) appears to be more successful in women than in men, but more frequently associated with heart failure (HF) development. Galectin-3 expression is upregulated in remodeling and failing myocardium and circulatory level is activated in hypertrophy, fibrosis and inflammation.

This study aimed to investigate the potential role of sex differences in the following: risk factors, structural and functional left ventricle (LV) changes, coronary angiography, expression of Galectin-3 and it's circulating level for HF occurrence during 6 months in patients after first MI.

Material and methods

The prospective study included patients with the first MI treated with the primary percutaneous coronary intervention (p PCI) who underwent Doppler echocardiography within 2±1 days of MI and after 6 months. Relative LGALS-3 mRNA expression in peripheral blood were detected by TaqMan® technology. Expression and concentration of Galectin-3 was obtained by ELISA method. Presence of HF was confirmed by clinical examination and Doppler echocardiography. Assessment of p PCI and description of coronary angiography was performed at the patient's admission time.

Results

The study included 137 men and 44 women, who were significantly older (57.8 vs. 54.4, p=0.034), with higher LDL cholesterol (3.54±0.93 vs. 4.03±1.27, p=0.027) without differences among angiographic characteristics and medications. In the acute phase of MI, the significantly lower indexed LV volumes were found in women compared to men (EDLVI: 58.3 vs. 49.6, p<0.001, ESLVI: 33.84 vs. 26.83, p<0.001), but the grade of LV remodeling (delta LVDVI, delta LVESVI) during 6 months and changes in LV ejection fraction (deltaLVEF) were similar (p=ns). Incidence of LV hypertrophy and HF development was significantly higher in women 70% vs. 44.6%, p=0.034, 37.5% vs.19.3%, p=0.02). Females have had a higher degree of LV diastolic dysfunction (DD) in the early and late phase after MI (p=0.038, p=0.027). There were significant correlations between grade of DD and level of Gal-3 expression (p=0.001). The relative expression of LGALS-3 mRNA in peripheral blood was higher in females (p=0.007) with upregulation of circulating Gal-3 in females (44.66 vs. 16.30, p<0.001) and in HF patients (31.1 vs. 21.2, p=0.025).

Conclusion

Sex specific actions such as LV hypertrophy, diastolic dysfunction, upregulation of Galectin-3 expression and higher circulating level may explain more incidence of HF in female. Difference in model and determinants of HF between men and women can be important for further therapy including Gelectin-3 inhibition.

Funding Acknowledgement

Type of funding sources: None.

Effect of Ascorbic Acid on Cardiac Surgery-Associated Acute Kidney Injury Incidence

Objectives  Acute kidney injury (AKI) is associated with higher perioperative mortality and morbidity. Oxidative stress has been proposed as a cause of postoperative AKI. Ascorbic acid (AA) supplementation was suggested as a novel and promising antioxidant. The aim of this study was to evaluate the capability of AA to reduce the incidence of postoperative AKI in cardiac surgery patients.

Methods  A prospective randomized trial was conducted in patients scheduled for on-pump cardiac surgery. Subjects in the AA group received 2 g of AA intravenously during the induction of anesthesia, 2 g before aortic cross-clamp removal and 1 g every 8 hours for five postoperative days (the JERICA protocol). Postoperatively, the patients were monitored for AKI and other complications. Malondialdehyde levels were monitored in a subpopulation of 100 patients to evaluate the effect of AA on oxidative stress level.

Results  The AA and control group consisted of 163 and 169 patients, respectively. The groups were well matched for baseline demographics and had similar intraoperative characteristics. The incidence of AKI in the AA and control group was 20.9 and 28.4%, respectively ( p  = 0.127). The estimated glomerular filtration rate did not differ between the study groups in the entire postoperative period. There was a trend toward higher malondialdehyde values with statistical significance on postoperative day 1 and lower in-hospital mortality in the AA group (0.6 vs. 4.1%, p  = 0.067).

Conclusion  Our results do not support the effectiveness of AA supplementation in reducing the incidence of postoperative AKI in on-pump cardiac surgery patients.

Clinical Registration Number  This study was registered with the ISRCTN Registry under the trial registration number ISRCTN98572043.

Pacemaker-generated stress fracture of the second rib: a case report

Background

Pocket-related complications following the implantation of cardiovascular implantable electronic devices primarily include pocket hematoma, infection, skin erosion or decubitus, device migration, and Twiddler's syndrome, with other pathologies such as nerve impairment or bone lesions being extremely rarely encountered. We report a case of a 20-year old asthenic, non-athlete female patient presenting with a device-generated fracture of the second rib several months after sub-muscular permanent pacemaker implantation due to repeated bilateral pre-pectoral pocket infections.

Case presentation

A 20-year old female patient was readmitted to our institution 9 months following sub-pectoral implantation of a permanent pacemaker, complaining of severe pocket-related pain, which arose spontaneously in the absence of direct trauma, intense physical activity or vigorous coughing, and was associated with normal day-to-day activity. To rule out a pacemaker re-infection, a native computed tomography and a positron emission tomography—computed tomography of the thorax were performed. Both modalities excluded an infection but showed a healing fracture and a focus of enhanced metabolic activity in the anterolateral part of the right second rib, indicating a non-traumatic or stress fracture of the bone. Consequently, a complete extraction of the pulse generator and both leads was performed and the smallest available single-chamber pulse generator with a single atrial electrode was implanted in the sub-fascial, pre-muscular pocket in the now recovered and uninfected left subclavicular region, alleviating patient’s severe pain symptoms and significantly enhancing her quality of life.

Conclusions

In the absence of direct trauma, intense physical activity or vigorous coughing, we assume that in this asthenic girl a normal day-to-day motion of the right shoulder has persistently forced the sub-muscularly placed pulse generator toward thoracic wall, putting increased repetitive pressure force on the underlying bones, finally causing a fatigue stress fracture of the second rib. In asthenic phenotype patients with small thorax and short subclavicular distance, a sub-muscular pacemaker implantation can potentially cause unique and unexpected pocket-related adverse events necessitating advanced diagnostics and timely treatment.

Left ventricular pseudoaneurysm following atrioventricular groove rupture after mitral valve replacement

Left ventricular pseudoaneurysm is a partial cardiac rupture, contained by the surrounding pericardium that maintains communication with the left ventricular lumen. Whereas most cases of left ventricular pseudoaneurysms are related to myocardial infarction (loss of myocardial integrity), only a handful are associated with valve surgery. We present a female patient, who was admitted for elective mitral valve replacement. After the implantation of the mechanical valve, we encountered a rupture of the atrioventricular groove. After 3 months, a left ventricular pseudoaneurysm was found and the patient was reoperated. The valve was explanted and the inspection of the annulus and previously implanted pericardial patch revealed a loosened stitch on the inferior (ventricular) side. The defect was reinforced with additional stitches and the valve was reimplanted. In conclusion, we report an unusual case with two serious complications after mitral valve replacement - atrioventricular groove rupture and left ventricular pseudoaneurysm.

Migration and invasion is inhibited by silencing ROR1 and ROR2 in chemoresistant ovarian cancer

Ovarian cancer survival remains poor despite recent advances in our understanding of genetic profiles. Unfortunately, the majority of ovarian cancer patients have recurrent disease after chemotherapy and lack other treatment options. Wnt signalling has been extensively implicated in cancer progression and chemoresistance. Therefore, we investigated the previously described Wnt receptors ROR1 and ROR2 as regulators of epithelial-to-mesenchymal transition (EMT) in a clinically relevant cell line model. The parental A2780- and cisplatin-resistant A2780-cis cell lines were used as a model of ovarian cancer chemoresistance. Proliferation, adhesion, migration and invasion were measured after transient overexpression of ROR1 and ROR2 in the parental A2780 cell line, and silencing of ROR1 and ROR2 in the A2780-cis cell line. Here we show that ROR1 and ROR2 expression is increased in A2780-cis cells, alongside β-catenin-independent Wnt targets. Knockdown of ROR1 and ROR2 significantly inhibited cell migration and invasion and simultaneous knockdown of ROR1 and ROR2 significantly sensitised cells to cisplatin, whilereas ROR overexpression in the parental cell line increased cell invasion. Therefore, ROR1 and ROR2 have the potential as novel drug targets in metastatic and recurrent ovarian cancer patients.

Wnt signalling in gynaecological cancers: A future target for personalised medicine?

The three major gynaecological cancers, ovarian, uterine and cervical, contribute a significant burden to global cancer mortality, and affect women in both developed and developing countries. However, unlike other cancer types that have seen rapid advances and incorporation of targeted treatments in recent years, personalised medicine is not yet a reality in the treatment of gynaecological cancers. Advances in sequencing technology and international collaborations and initiatives such as The Cancer Genome Atlas are now revealing the molecular basis of these cancers, and highlighting key signalling pathways involved. One pathway which plays a role in all three cancer types, is the Wnt signalling pathway. This complex developmental pathway is altered in most human malignancies, and members of this pathway, particularly the recently linked ROR receptor tyrosine kinases may be attractive future therapeutic targets. This review provides an up-to-date summary of research into Wnt signalling and ovarian, uterine and cervical cancers, and discusses the potential of the Wnt pathway as a future target for personalised medicine in gynaecological cancers.

Chronic stress differentially affects antioxidant enzymes and modifies the acute stress response in liver of Wistar rats

Clinical reports suggest close interactions between stressors, particularly those of long duration, and liver diseases, such as hepatic inflammation, that is proposed to occur via reactive oxygen species. In the present study we have used 21-day social isolation of male Wistar rats as a model of chronic stress to investigate protein expression/activity of liver antioxidant enzymes: superoxide dismutases (SODs), catalase (CAT), glutathione peroxidase (GPx) and glutathione reductase (GLR), and protein expression of their upstream regulators: glucocorticoid receptor (GR) and nuclear factor kappa B (NFkB). We have also characterized these parameters in either naive or chronically stressed animals that were challenged by 30-min acute immobilization. We found that chronic isolation caused decrease in serum corticosterone (CORT) and blood glucose (GLU), increase in NFkB signaling, and disproportion between CuZnSOD, peroxidases (CAT, GPx) and GLR, thus promoting H2O2 accumulation and prooxidative state in liver. The overall results suggested that chronic stress exaggerated responsiveness to subsequent stressor at the level of CORT and GLU, and potentiated GLR response, but compromised the restoration of oxido-reductive balance due to irreversible alterations in MnSOD and GPx.

Oxidative stress in diabetic pregnancy: SOD, CAT and GSH-Px activity and lipid peroxidation products

Diabetic pregnancy is often complicated by a number of pathological conditions among which is increased oxidative stress. This study was conducted to investigate the parameters of oxidative stress in 90 patients divided into the three groups: pregnant women with Type 1 diabetes mellitus, healthy pregnant women and non-pregnant women. In pregnancy groups all parameters were followed in 1st, 2nd and 3rd trimester. Diabetic control was monitored by fasting blood glucose and glycosylated hemoglobin (HbA(1c)) and these values, as well as measured biochemical parameters (urea, creatinine, total cholesterol and uric acid), were appropriate throughout the study. The concentration of TBARS, as a measure of lipid peroxidation, and activity of antioxidant enzymes superoxide dismutase (Cu, Zn-SOD), glutathione peroxidase (GSH-Px) and catalase (CAT) were investigated in hemolysate of erythrocytes. TBARS concentration increased significantly in pregnant women when compared with control group (non-pregnant women), as well as in pregnant diabetics compared with healthy pregnant women. The SOD activity was gradually increased in the group of normal pregnant women vs. non-pregnant group, but decreased significantly in the group of diabetic pregnant women. Catalase activity was significantly increased only in 3rd trimester diabetic pregnant women. Increased lipid peroxidation and reduced antioxidant status, despite good diabetic control, show that pregnant women are exposed to oxidative stress to a greater degree than controls.

Factors related to the process of seeking and completing treatment for drug abuse (qualitative methods in drug abuse research)

Numerous studies have demonstrated the effectiveness of drug abuse treatment. Yet many drug abusers do not enter treatment, many who do enter leave prematurely, and relapse following treatment is common. Understanding motivation for change and treatment readiness is key to understanding how to induct and engage drug users in treatment. To the extent that treatment programs focus initially on reducing drug use, rather than psychosocial problems that motivate individuals to seek treatment, treatment programs may fail to meet the primary needs of users and thus fail to attract or engage them. Outcomes of substance abuse treatment programs historically have been measured by successful program completion, reduced drug use and illegal activity, and improved social functioning (employment, education etc). There is minimal reference to client expectations of treatment and factors that influenced treatment-seeking behavior. Studies that have assessed client dropout from substance abuse treatment have generally focused upon quantitative measures that attempt to determine what types of clients drop out or stay, or what types of characteristics best predict client dropout. Qualitative methods are the most appropriate to fill these gaps in substance abuse treatment research.

Characteristics of agoraphobia in women and men with panic disorder with agoraphobia

We compared female and male patients with panic disorder with agoraphobia (PDA) in terms of characteristics of agoraphobia (AG). Ninety-five patients (73 women and 22 men) with the SCID-based diagnosis of PDA were administered the National Institute of Mental Health Panic Questionnaire (NIMH PQ), and women and men were compared on the items of the NIMH PQ that pertain to AG and symptoms of panic attacks. Male and female patients did not differ significantly with respect to demographic characteristics, age of onset of panic disorder and AG, duration of PDA, and severity and frequency of symptoms experienced during panic attacks. Women avoided more situations than did men, but this difference was not statistically significant. Women avoided buses and being in unfamiliar places alone significantly more often. The only situation that was avoided more often by men, although not significantly, was staying at home alone. Women were significantly more likely to stay at home to avoid agoraphobic situations and significantly less likely to go outside of home alone. When going outside, women required a companion significantly more often. There were significantly more married women than married men who required a spouse as a companion, and significantly more women with children than men with children who required a child as a companion. Women thought that AG had affected the overall quality of their lives significantly more adversely. Whereas the overall "profile" of agoraphobic situations does not seem to distinguish between female and male patients with AG, females may be more impaired and appear more dependent than men in terms of requiring companions to move outside of the home. Cultural and psychological factors may be most likely to account for these findings.

Protein kinase A regulates Lewis lung carcinoma adherence to extracellular matrix components and spontaneous metastasis

Tumor cell adhesion to and migration through the extracellular matrix (ECM) can influence their capacity to disseminate. Since prior studies with Lewis lung carcinoma (LLC) tumors had shown metastatic clones to have more protein kinase A (PKA) activity than nonmetastatic clones, the present study assessed if PKA regulates the interaction between tumor and the ECM, and how this may be associated with the metastatic capacity of the tumor cells. This was accomplished with the use of metastatic (LLC-LN7) and nonmetastatic (LLC-C8) variants that had been stably transfected to overexpress the PKA Calpha subunit or to have blocked PKA activity. Cells with increased PKA activity were less adherent to vitronectin, laminin, and collagen I, and could more readily migrate through these ECM components than could transfectants with reduced PKA activity. PKA did not regulate adhesion to or migration through fibronectin, and did not appear to be associated with changes in expression of surface integrins. In addition to modulating tumor adhesion and migration in vitro, PKA activation caused an increased formation of metastases from s.c. tumors, but did not regulate formation of experimental metastases by i.v. injected tumor cells. These results suggest that PKA signaling is important for modulating the tumor-ECM interaction and can facilitate tumor transit from the primary tumor site.

Prostaglandin E2-protein kinase A signaling and protein phosphatases-1 and -2A regulate human head and neck squamous cell carcinoma motility, adherence, and cytoskeletal organization

Human head and neck squamous cell carcinoma (HNSCC) cultures were established from cancers of two patients. These cells were used to study if phosphorylation reactions by protein kinase A (PKA) and dephosphorylation reactions by protein phosphatases-1 and -2A (PP-1/2A) regulate tumor motility and adhesion to extracellular matrix components, and if this might be associated with cytoskeletal reorganization. Both cultures were motile and adherent to collagen I, fibronectin, vitronectin and laminin. Motility and adhesiveness was dependent on production of prostaglandin E2 PGE2 and on PKA activation. Blocking PP-1/2A activity with okadaic acid resulted in a PKA-dependent increase in m otility and, in some instances, adhesiveness by the HNSCC cells. The okadaic acid-induced increase in motility and adhesiveness coincided with a reduction in filamentous actin. These data suggest PKA and PP-1/2A have opposing effects in regulating the motility, adherence, and actin polymerization.

Regulation of Lewis lung carcinoma invasion and metastasis by protein kinase A

Metastatic Lewis lung carcinoma (LLC-LN7) cells have increased protein kinase A (PKA) activity and are more invasive in vitro than are non-metastatic (LLC-C8) cells. To determine whether PKA mediates the in vitro invasiveness and in vivo metastatic capabilities of these tumor cells, the LLC variants were stably transfected to over-express the C alpha subunit of PKA, and thus to have increased PKA activity, or to express a mutant cAMP-resistant PKA R1 alpha subunit which blocks PKA activation. Wild-type LLC-LN7 tumor cells were invasive in vitro and in vivo, recurred after tumor excision and metastasized to the lungs. However, they lost these properties after transfection to express the mutant R1 alpha that blocks PKA activation. The non-invasive, non-recurring and non-metastatic LLC-C8 cells gained the capacity to invade, to recur following tumor excision and to metastasize when transfected to express the PKA C alpha subunit.

Regulation of cytoskeletal organization in tumor cells by protein phosphatases-1 and -2A

Non-metastatic Lewis lung carcinoma cells (LLC-C8) become more motile when protein phosphatases (PP-1 and -2A) are inhibited by okadaic acid, attaining the same level of motility as metastatic LLC (LLC-LN7) variants. This stimulation of LLC-C8 motility was tempered when protein kinase A activity was inhibited. We examined whether the okadaic acid-stimulated LLC-C8 motility was associated with alterations in the cytoskeletal organization so that these non-metastatic cells acquire the rounded morphology and diffuse cytoskeletal organization previously described for metastatic LLC-LN7 cells. Non-metastatic LLC-C8 are typically adherent during culture, achieving a spread morphology. Treatment of non-metastatic LLC-C8 cells with okadaic acid resulted in a contraction of most of their extended processes, formation of spikes and membrane blebs within 10 min, and complete cell rounding within 20 min for most of the cells. While the overall level of F-actin was minimally affected by the okadaic acid, its uniform distribution shifted to localization toward the periphery of the rounded cells, often concentrating at a single focus. Immunofluorescent staining for vimentin showed a similar shift to the cell periphery and similar capping. After okadaic acid treatment, the filamentous network of microtubules in non-metastatic LLC-C8 cells disappeared and was replaced with a diffusely staining distribution of beta-tubulin. These results show that PP-1 and -2A maintain cytoskeletal organization and that inhibition of this control reduces cytoskeletal organization and increases tumor cell motility.

Activation of the protein kinase a signal transduction pathway by granulocyte-macrophage colony-stimulating factor or by genetic manipulation reduces cytoskeletal organization in Lewis lung carcinoma variants

Granulocyte-macrophage colony-stimulating factor (GM-CSF) that is produced by metastatic Lewis lung carcinoma (LLC-LN7) cells functions as an autocrine stimulator of tumor-cell motility through protein kinase A (PKA) signal transduction. This GM-CSF-mediated enhancement of LLC-LN7 cell motility coincides with a reduction in the level of polymerized F-actin. In contrast, non-metastatic LLC-C8 tumor cells, which have a diminished level of PKA signaling, do not produce GM-CSF and do not respond to exogenous GM-CSF, since they remain non-motile and retain a high content of filamentous actin. The capacity of PKA to regulate the cytoskeletal organization of tumor cells was further studied with the use of LLC variants that had been stably transfected to over-express the C alpha subunit of PKA (CEV cells) or to express a mutant cAMP-resistant PKA RI alpha subunit resulting in a defective PKA (REV cells). When compared with wild-type metastatic LLC-LN7 cells, in which the F-actin staining was too diffuse to be clearly visualized microscopically, the PKA-defective REV-LN7 transfectants had an increased level of F-actin. In comparison with the wild-type non-metastatic LLC-C8 cells, which had a high content of F-actin, the CEV-C8 transfectants that over-expressed PKA activity had a reduced level of F-actin. The reduced polymerization of actin in these CEV-C8 transfectants was accompanied by reduced levels of the intermediate filament protein vimentin and a shift in the distribution both of F-actin and of vimentin to the periphery of the cells. These results show reduced cytoskeletal organization in metastatic LLC-LN7 cells as compared with that of non-metastatic LLC-C8 cells, and indicate that elevation of PKA activity, either by autologous GM-CSF or by genetic manipulation, diminishes cytoskeletal organization.

Granulocyte-macrophage colony-stimulating factor stimulates the metastatic properties of Lewis lung carcinoma cells through a protein kinase A signal-transduction pathway

Expression of granulocyte-macrophage colony-stimulating factor (GM-CSF) by metastatic Lewis lung carcinoma cells (LLC-LN7) was previously shown to contribute to the maintenance of phenotypic characteristics associated with an increased capacity to metastasize. In the present study, pre-incubation of LLC-LN7 cells with neutralizing anti-GM-CSF antibodies diminished the capacity of the tumor cells to form experimental metastases after i.v. inoculation, while pre-incubation with recombinant GM-CSF (rGM-CSF) increased formation of metastases. In the presence of rGM-CSF, the LLC-LN7 cells exhibited an increased capacity to migrate, invade through a reconstituted basement membrane, and adhere to lung tissue. Studies to identify the signal transduction pathway through which GM-CSF enhanced the in vitro metastatic properties of the LLC-LN7 tumor cells implicated protein kinase A (PKA). Signaling through PKA was suggested by the demonstration that the stimulation of tumor-cell motility by GM-CSF was blocked in the presence of the adenylate cyclase inhibitor nicotinic acid, or the PKA inhibitors A3 or KT5720. In addition, the role of PKA as a signaling mechanism for GM-CSF was assessed by using REV-LN7 cells, which are LLC-LN7 cells that have been stably transfected with an expression vector encoding a mutant PKA RI alpha subunit and which, in turn, express a cAMP-resistant PKA. Adherence and invasion by the PKA-defective REV-LN7 cells were not stimulated by rGM-CSF, contrasting with the stimulation observed for wild-type LLC-LN7 cells. These data suggest that rGM-CSF can further enhance the in vitro metastatic characteristics of LLC-LN7 tumor cells and that this is dependent on signal transduction through PKA.