[Thoracoscopic, epicardial ablation of atrial fibrillation using the COBRA Fusion system as the first part of hybrid ablation]

INTRODUCTION

Treatment of persistent and long-standing persistent atrial fibrillation is not successfully managed by methods of catheter ablation or pharmacotherapy. Hybrid ablation (i.e. combination of minimally invasive surgical ablation, followed by electrophysiological assessment and subsequent endocardial catheter ablation to complete the entire intended procedure) presents an ever more used and very promising treatment method.

METHOD

Patients underwent thoracoscopic ablation of pulmonary veins and posterior wall of the left atrium (the box-lesion) with use of the COBRA Fusion catheter; thoracoscopic occlusion of the left atrial appendage using the AtriClip system was also done in later patients. After 23 months, electrophysiological assessment and catheter ablation followed. In this article we summarize a strategy of the surgical part of the hybrid procedure performed in our centre. We describe the surgery itself (including possible periprocedural complications) and we also present our short-term results, especially with respect to subsequent electrophysiological findings.

RESULTS

Data of the first 51 patients were analyzed. The first 25 patients underwent unilateral ablation; the mean time of surgery was 102 min. Subsequent 26 patients underwent the bilateral procedure with the mean surgery time of 160 min. Serious complications included 1 stroke, 1 phrenic nerve palsy and 2 surgical re-explorations for bleeding. After 1 month, 65% of patients showed sinus rhythm. The box-lesion was found complete during electrophysiological assessment in 38% of patients and after catheter ablation, 96% of patients were discharged in sinus rhythm.

CONCLUSION

The surgical part of the hybrid procedure with use of the minimally invasive approach and the COBRA Fusion catheter is a well-feasible method with a low number of periprocedural complications. For electrophysiologists, it provides a very good basis for successful completion of the hybrid ablation.Key words: atrial fibrillation hybrid ablation - thoracoscopy catheter ablation electrophysiology assessment.

Increase in plasma free haemoglobin during cardiopulmonary bypass in heart valve surgery: assessment of renal dysfunction by RIFLE classification

Heart valve surgery carries a high risk of renal insufficiency as an independent risk factor due to prolonged cardiopulmonary bypass. Multiple causes of cardiopulmonary bypass-associated renal damage have been described, and haemoglobin-induced renal injury is presently being investigated. Forty-three patients scheduled for heart valve surgery (mostly combined) were enrolled in the prospective study. Plasma free haemoglobin (PFH) levels were evaluated by photocolorimetric measurement at the start of procedures (t(0)) and before the end of extracorporeal circulation (t(1)). A statistically significant increase in PFH levels during cardiopulmonary bypass was detected [median values (interquartile range) - t(0): 62.0 (53.4) mg/L, t(1): 320.4 (352.2) mg/L], P < 0.001. A significant regression relationship between the duration of cardiopulmonary bypass and the increased PFH was found (Spearman's correlation coefficient 0.628, P < 0.001). In some elderly patients, the tendency towards a high release of PFH during cardiopulmonary bypass was more pronounced, but the overall association between age and PFH levels was of borderline significance (P = 0.077). The correlation between PFH and post-operative serum creatinine was low and non-significant, but the latter correlated highly with the pre-operative serum creatinine values (Spearman's correlation coefficient reached values of 0.6-0.7, P < 0.001). Patients were classified according to the Risk of renal failure, Injury to the kidney, Failure of kidney function, Loss of kidney function and End-stage renal failure (RIFLE) classification for acute renal dysfunction during post-operative days 1 - 4; the influence of PFH levels at t(1) on the consequent RIFLE classification was not proven (P=0.648), but 4 patients in the Injury category had shown a higher median value of PFH (433.6 mg/L) in comparison with the others (29 patients with no acute renal dysfunction - 313.7 mg/L, 10 patients at Risk - 330.1 mg/L).

Morphological features of vasa vasorum in pathologically changed human great saphenous vein and its tributaries

BACKGROUND

The question whether the primary increase of vasa vasorum (VV) of venous wall (i) plays an initial role in varicogenesis or (ii) is an expression of impairment of the nutritional conditions in superficial veins of lower extremities is not unambiguously solved yet. The aim of the study was to describe the arrangement of the VV within the wall of the human great saphenous vein (GSV) qualitatively, and of its tributaries at different stages of varicosis and in other pathological states like thrombophlebitis or phlebosclerosis.

MATERIAL AND METHODS

22 patients deserving an aorto-coronary bypass surgery or GSV surgery were subdivided into three groups according to the staging of their varices and other pathology. The harvested GSV were prepared for light and scanning electron microscopy. One cadaverous specimen of GSV was injected with India ink.

RESULTS

In specimens from reticular and primary large varices local intimal hyperplasia was regularly found, partially accompanied with a mild increase of VV. Tortuosities and irregular dilations of adventitial veins were also found. In patients with recurrent primary varices or thrombophlebitis severe intimal and medial hyperplasia, thrombosis and a striking increase of VV were found. The intima remained avascular in all cases.

CONCLUSIONS

Remarkable increase of VV accompanies the most severe forms of varices as well as all cases of the extreme grades of phlebosclerosis, medial hyperplasia and thrombosis. We hypothesize that this increase in VV is rather a secondary vascular reaction to the impaired metabolic conditions within the venous wall than a primary varicogenic factor.

[Huge sinus of Valsalva aneurysm in patient with cystic medial necrosis of the aorta]

In this case we present a patient with unruptured non-coronary sinus of Valsalva aneurysm associated with diverse clinical findings, caused by acquired degenerative changes of the aortic wall. A previously healthy 36-year-old female was admitted to the neurological clinic of our hospital having suffered from an episode of unconsciousness prior to admission, with accompanying seizures. For the preceding two months she had also been suffering from dyspnoea and palpitation. Neurological examination, computed tomography of the head and electroencephalography were with normal findings. Thereafter, due to paroxysm of supraventricular tachycardia she was referred to cardiology clinic. On routine physical examination a diastolic murmur was detected and the patient was referred for transthoracic echocardiography. This examination revealed a large, unruptured noncoronary sinus of Valsalva aneurysm, which was thereafter confirmed by transoesophageal echocardiography a angiography. The patient was indicated for surgical correction with aortic valve and aortic root replacement by Bentall procedure. Histological examination of the part of resected aneurysm found cystic medial degeneration of the aortic wall, also called cystic medial necrosis.

Higher content of 18:1 trans fatty acids in subcutaneous fat of persons with coronarographically documented atherosclerosis of the coronary arteries

AIM

To identify the total content of trans fatty acid (TFA) isomers and C18:1 trans isomers in subcutaneous fat samples from persons with atherosclerosis of the coronary arteries, as an indicator of dietary exposure.

METHODS

Using capillary gas chromatography, the authors determined total content of TFA isomers and C18:1 trans isomers in the subcutaneous fat of 34 patients with ischemic heart disease who had undergone aortocoronary bypass surgery and in 46 patients with no sign of coronary disease.

RESULTS

On average, the total TFAs in cardiac patients were 2.88 +/- 1.19% of all fatty acids, in noncardiac patients 2.56 +/- 0.89%. However, the difference is not statistically significant. The average concentration of C18:1 trans in cardiac patients (2.31 +/- 1.09%) was statistically significantly higher (p = 0.05) than in the noncardiac group (1.95 +/- 0.77%).

CONCLUSIONS

The results obtained indicate a lower TFA load in comparison with previous studies in other countries. A higher concentration of 18:1 TFAs in the subcutaneous fat of patients with coronary disease might be an impulse to correct the dietary habits of this very high-risk population.

Tranexamic acid reduces bleeding after off-pump coronary artery bypass grafting

AIM

To assess the ability of tranexamic acid, compared with an untreated control group, to decrease bleeding and transfusion requirements in patients undergoing coronary artery bypass grafting on the beating heart.

METHODS

Forty-nine randomly selected patients were enrolled to elective coronary artery bypass grafting without the use of cardiopulmonary bypass. Of these, 23 received tranexamic acid (bolus of 1 g before surgical incision, followed by infusion 200 mg/hour during surgery) and 26 patients were enrolled into a control group. Preoperative hematological variables, postoperative blood loss at 4 and 24 hours, transfusion requirements of packed red blood cells,and postoperative thrombotic events such as a myocardial infarction, stroke and pulmonary embolism were recorded.

RESULTS

The two groups were similar in terms of patients' characteristics. Postoperative bleeding was significantly lower in the tranexamic acid group compared with the control group (median [25th-75th percentiles]): 115 [92-148] vs 230 [170-260] mL at 4 hours, p<0.001; 420 [330-523] vs 550 [500-650] mL at 24 hours, p<0.01). Transfusion requirements were lower in the tranexamic acid group compared with the control group (RBC 9% vs 28%), but the difference was not statistically significant. Treatment with tranexamic acid was not associated with a higher incidence of myocardial ischemia or other thrombotic events.

CONCLUSION

Tranexamic acid reduces postoperative blood loss after coronary artery bypass grafting on the beating heart. Evaluation of transfusion requirements warrants further study.

Protracted infection of pacemaker leads with development of large vegetations: three years follow up. Case report

A case history of a patient with permanent pacemaker reports inaccurate diagnosis of inflammation at the site of operation wound and a protracted infection of pacemaker leads. Inadequate therapy led to protracted inflammation with the leads fixed in the superior vena cava and the development of large vegetations in the right heart. Finally, the condition was resolved by surgical explantation and long-term antibiotic therapy. This case history describes infectious complications related to the implantation of a permanent pacemaker and the role of echocardiography in diagnosis of vegetations and points out the surgical treatment as a method of choice.

[Acute abdomen after cardiac surgery]

Acute abdomen after cardiosurgery accounts for a minor group of complications, however, they are associated with a high mortality and morbidity. In 2001 in the authors department 940 cardiac operations were performed. In four patients (0.43%) during the early postoperative period acute abdomen developed which called for urgent surgical intervention. Two patients died. Only early diagnosis and subsequent urgent laparotomy can have a positive impact on the prognosis of this group of patients.

Value of first day angiography/angioplasty in evolving Non-ST segment elevation myocardial infarction: an open multicenter randomized trial. The VINO Study

AIMS

Direct angioplasty is an effective treatment for ST-elevation myocardial infarction. The role of very early angioplasty in non-ST-elevation infarction is not known. Thus, a randomized study of first day angiography/angioplasty vs early conservative therapy of evolving myocardial infarction without persistent ST-elevation was conducted.

METHODS

One hundred and thirty-one patients with confirmed acute myocardial infarction without ST-segment elevations were randomized within 24 h of last rest chest pain: 64 in the first day angiography/angioplasty group and 67 in the early conservative group (coronary angiography only after recurrent or stress induced myocardial ischaemia).

RESULTS

All patients in the invasive group underwent coronary angiography on the day of admission (mean randomization-angiography time 6.2 h). First day angioplasty of the infarct related artery was performed in 47% of the patients and bypass surgery in 35%. In the conservative group, 55% underwent coronary angiography, 10% angioplasty and 30% bypass surgery within 6 months. The primary end-point (death/reinfarction) at 6 months occurred in 6.2% vs 22.3% (P<0.001). Six month mortality in the first day angiography/angioplasty group was 3.1% vs 13.4% in the conservative group (P<0.03). Non-fatal reinfarction occurred in 3.1% vs. 14.9% (P<0.02).

CONCLUSIONS

First day coronary angiography followed by angioplasty whenever possible reduces mortality and reinfarction in evolving myocardial infarction without persistent ST-elevation, in comparison with an early conservative treatment strategy.

Thoracic epidural anesthesia for off-pump coronary artery bypass without intubation

Thoracic epidural anesthesia without intubation was used in 10 patients undergoing off-pump coronary artery reconstruction performed through median sternotomy. Considering the preoperative finding of impaired pulmonary function, all were moderate-risk patients for surgery using conventional general anesthesia with intubation. All patients had an uneventful postoperative course. In indicated cases, we regard thoracic epidural anesthesia as a suitable method again modifying the term "minimally invasive" in cardiac surgery.

[Less invasive approaches in surgical treatment of aortic valve defects]

Longitudinal median sternotomy is even nowadays the standard approach to operations of the aortal valve. The authors summarize in the submitted paper their experience with operations in 60 patients where replacement of the aortal valve was performed either from a small transverse sternotomy in the second intercostal space or from upper ministernotomy from the jugulum to the fourth (third) intercostal space. One patient died. The low incidence of serious postoperative complications, the rapid rehabilitation of patients and short subsequent period of hospitalization indicate the advantages of this approach. The authors use at present upper ministernotomy as the surgical approach in the majority of operations of the aortal valve.

[Emergency myocardial revascularization during a developing myocardial infarct]

In 1996-1998 in our Cardiocentre urgent revascularizations were made in 28 patients with developing acute myocardial infarction (AIM) with manifestations of different grades of acute circulatory failure up to developed cardiogenic shock and cardiac arrest. In all patients complete revascularization with a mean number of 2.9 bypasses per patient was made, in one patient at the same time a rupture of the interventricular septum was closed and in two patients an insufficient mitral valve was replaced. From the whole group two patients died during the early postoperative period, two were revised on account of postoperative haemorrhage and two had signs of low cardiac output. Twenty-two patients had a postoperative course without complications. Urgent surgical revascularization in patients developing AIM and circulatory deterioration is the method of primary and definite treatment when primary PTCA is not suitable.

[Plastic surgery of the thoracic wall as a method of thoracic wall reconstruction after complete surgical wound disintegration after sternotomy]

During the period between January 1996 and July 1998 in our department 1920 patients were operated on account of heart disease from median sternotomy. In 17 patients, i.e. in 0.9% during the early postoperative period the surgical wound disintegrated incl. dehiscence of the sternum and the development of postoperative mediastinitis. In 14 of these patients the authors reconstructed the defect of the thoracic wall by their own modification of Jurkiewicz plastic operation using the pectoral muscles. One patient from this group died, in the remaining 13 patients the wound healed without deformity of the chest and without signs of instability, without restriction of movement and function.

[Direct myocardial revascularization from an upper median laparotomy in a reoperation]

Case-history of a patient with IHD, six months after the first revascularization operation, performed on account of occluded venous grafts and relapse of anginous complaints, successfully reoperated from upper median laparotomy. From this surgical approach an anastomosis of the right gastroepiploic artery on the ramus interventricularis posterior (RIVP) of the right coronary artery was made. Six months after operation the patient is free from angionous complaints and lives a full life. Control coronarograpy indicates patency of the graft.

[Aortocoronary bypass without extracorporeal circulation]

Extracorporeal circulation is nowadays part of the standard technique of aortocoronary reconstruction. The authors summarize in their paper their experience with operations in 45 patients where an aortocoronary bypass was made on the beating heart without the use of extracorporeal circulation. None of the patients died. The incidence of postoperative complications was low. Rapid rehabilitation of the patients and a shorter period of hospitalization makes this method an alternative standard technique of aortocoronary reconstruction.

[100 renal transplantations with intravesical implantation of the ureter]

Transplantation of the kidney is nowadays a common therapeutic method. During the past 30 years in the transplantation centre of IKEM more than 1200 transplantations were performed. The authors present a group of 100 patients where the ureter of the transplanted Kidney was attached to the urinary bladder of the recipient by intravesical technique. With regard to the low incidence of fistulas and the easy solution of complications this technique can be widely used in clinical transplantation programmers.