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Background: Continuous renal replacement therapy (CRRT) is commonly used for the treatment of acute renal failure in haemodynamically unstable patients after cardiac surgery. The main problem associated with CRRT is the need for systemic anticoagulation that may lead to bleeding complications. As an alternative to heparins, and to avoid systemic anticoagulation, the use of regional citrate infusion has been proposed for patients with a high risk of bleeding., Case Reports: We present the clinical course of three patients with a high risk of bleeding after cardiac surgery in which CRRT, based on regional citrate anticoagulation, was conducted safely. Circuit survival times were over 80 hours and filters were changed on schedule, without any signs of dysfunction. Metabolic alkalosis was observed in one patient, who was treated by reducing the circuit blood flow and increasing the dialisate flow. One patient required chronic dialysis, the other two recovering after short-term CRRT., Conclusion: Regional citrate anticoagulation during CRRT should be used as a method of choice in patients with a high risk of haemorrhage in the postoperative period.

Identification and preparation of a potential organ donor requires careful and meticulous intensive care, so that the organs may be harvested in the best possible condition for transplantation. The protocol consists of three key elements: (1) monitoring and haemodynamicstabilisation, (2) hormonal therapy, and (3) adequate mechanical ventilation and nosocomial pneumonia prophylaxis. Standard haemodynamic monitoring should consist of a 12 lead EGG, and direct monitoring of arterial and central venous pressures. Pulmonary artery catheterisation is indicated in donors with a left ventricular ejection fraction (LVEF) below 45%. PCWP should be kept at around 12 mm Hg, Cl at greater than 2.4 L m(-2), and SVR between 800 and 1200 dyn s(-1) cm(-5). When a vasopressor is necessary, vasopressin should be used as the drug of choice. If vasopressin is not available, noradrenaline or adrenaline may be used. Haemoglobin concentration should be maintained between 5.5-6.2 mmol L(-1). In a potential heart donor, troponin concentration should be checked daily. Neutral thermal conditions should be maintained using a warm air blower. A brain dead patient cannot maintain adequate pituitary function, therefore hormone replacement therapy with methylprednisolone, thyroxin and desmopressin is indicated. Glucose concentrations should be kept within the normal range, using insulin if necessary. The lung harvesting protocol should be similarto ARDS treatment guidelines (optimal PEEP, low tidal volumes). Lung recruitment manoeuvres, and aggressive prevention and treatment of nosocomial infection are essential.

Background: Single lung transplantation, bilateral lung transplantation and combined heart-lung transplantation are the procedures currently being performed in patients with arterial pulmonary hypertension and pulmonary hypertension as a result of end-stage lung disease. In patients with severe pulmonary hypertension, regardless of its aetiology, general anaesthesia and mechanical ventilation could precipitate the onset of cardiac failure and the necessity of extracorporeal circulation employment., Aim: To assess the clinical and prognostic value of the pulmonary artery pressure (PAP) measured during the intra- and early postoperative period in patients undergoing lung transplantation., Methods: We analysed 20 patients undergoing lung transplantation in the Silesian Centre for Heart Disease in Zabrze, of whom 13 suffered from pulmonary hypertension before the operation. The PAP was measured using Swan-Ganz catheters., Results: Pulmonary artery pressure markedly decreased after transplantation (systolic, diastolic and mean PAP values were 31/19/23 mmHg, respectively) but in 3 recipients the mean PAP exceeded 25 mmHg (45/23/30 mmHg). In all 3 cases a cardiopulmonary bypass was required and single-lung transplantation was performed. Pulmonary hypertension immediately after the operation was the potential marker of lung dysfunction (pulmonary oedema, ischaemia-reperfusion injury, infection) - all 3 patients with increased PAP developed complications., Conclusions: Lung transplantation is associated with a significant reduction in pulmonary artery pressures immediately after graft implantation. The persistence of pulmonary hypertension in the early postoperative period suggests temporal allograft dysfunction and affects the post-operative outcome.

Pulmonary hypertension is characterized by a progressive increase in pulmonary arterial pressure in association with dilatation and hypertrophy of the right ventricle, causing gradual reduction in ejection fraction. The increase in mean pulmonary arterial pressure may be passive, due to increased downstream pressure, hyperkinetic due to increased cardiac output, or due to increased pulmonary vascular resistance resulting from changes in the pulmonary vessels. In an advanced stage of pulmonary hypertension there may be right ventricular dilatation and hypertrophy, tricuspid regurgitation and septal deviation, with consequent effects on cardiac function. Clinical symptoms are not specific. Until recently, the treatment of pulmonary hypertension was limited to anticoagulation, supplementary oxygen and high-dose calcium channel blockers, in association with diuretics and digoxin where indicated. Recently approved treatments are nitric oxide, sildenafil--a phosphodiesterase-5 inhibitor, analogs of prostacyclin, and nonselective and selective endothelin receptor inhibitors. Surgery and anaesthesia pose a significant risk for patients with pulmonary hypertension. Right ventricular failure, persistent postoperative hypoxia and coronary ischaemia are among the potential postoperative complications.

Background: New diseases and therapies that lead to marked immunocompromise, have brought to medicine so-called opportunistic infections, caused by pathogens that usually do not cause disease in the presence of a healthy immune system. First diagnosed in AIDS patients, opportunistic infections have appeared in many other situations, including transplant recipients, other immunosuppressed patients, and even in otherwise healthy patients undergoing major elective surgery. Among the most common pathogens causing atypical infections are: Pneumocistis jiroveci, Chlamydia, Mycoplasma and Legionella. The aim of this retrospective study was to assess the incidence of the above mentioned infections in cardiac surgical patients whose early postoperative period was complicated by respiratory distress., Methods: The postoperative course of 5026 cardiac surgical patients was analysed retrospectively. In 196 cases (3.9%), important respiratory complications, defined as prolonged (>24h) requirement for mechanical ventilation, pulmonary oedema, atelectasis, pneumothorax, haemothorax, infiltrations present on chest x-ray, or ARDS, were detected., Results: Positive atypical sputum cultures (Chlamydia pneumoniae, Mycoplasma pneumoniae or Pneumocistis jiroveci) were obtained from 27 patients (16%). Pneumocistis jiroveci was the most common pathogen identified. Legionella pneumoniae was never cultured. The average duration of mechanical ventilation in the study group was 253 h, and the mortality 18.5% (5 patients)., Conclusions: Opportunistic infection with atypical pathogens should be suspected in the postoperative period when complicated by prolonged respiratory distress and difficulties with weaning from mechanical ventilation. Since these infections do not present with obvious symptoms, the diagnostic process should be extended and appropriate treatment introduced.

Background: Coronary artery disease is one of the leading causes of death among women in developed countries all over the world. Coronary artery bypass grafting (CABG) is a well established therapeutic modality to treat diffuse coronary artery atherosclerosis., Aim: In this study we focused on the retrospective assessment of the early results of CABG in women as compared to the results of such treatment in men., Methods: This analysis involved 2881 patients (677 women and 2204 men) who underwent CABG between 2003 and 2005. An operative technique (conventional on-pump or off-pump) was applied in a similar proportion of patients in both groups (on-pump: 59.4% of women and 59.6% of men; NS). Women were older than men and had higher body mass index. Concomitant disorders such as diabetes mellitus, hypertension and hypercholesterolaemia were noted more frequently in female patients., Results: In the perioperative period, left ventricular failure requiring intra-aortic balloon pump insertion and administration of high doses of catecholamines was observed significantly more often in women than in men (22.1 vs. 16.1%, respectively; p <0.001). Perioperative myocardial infarction was diagnosed more frequently in women (5.5 vs. 2.9%; p <0.001). In female patients, the rate of repeat operation was higher (8.9 versus 5.1%; p <0.001) and more subjects required blood transfusions (45.5 vs. 27.5%; p <0.001). Female gender featured a higher rate of postoperative acute renal failure requiring renal replacement therapy (8.5 vs. 0.95%; p <0.001). Mechanical ventilation was longer, and women stayed longer in the postoperative intensive care unit as well as in hospital. Early postoperative mortality among women was 3.6%, i.e. significantly higher than in male patients (1.6%) (p <0.01)., Conclusions: The analysis performed herein suggests that mortality and morbidity after CABG is higher in women than in men.

Lung transplantation is now generally accepted as a modality of care for patients with end-stage lung diseases who demonstrate declining of lung function despite optimal therapy. This paper describe a case of single lung transplantation performed in patient with advanced obstructive pulmonary diseases and pulmonary fibrosis. One year follow-up with special regard to complications after operation is presented.

Background: Despite recent progress in clinical transplantology, coronary artery disease of transplanted heart (TxCAD) remains the main cause of long-term mortality. The role of elective coronary angiography (CAG) and percutaneous coronary interventions (PCI) in these patients has not yet been well established., Aim: To evaluate the incidence of TxCAD based on the results of elective CAG and to assess the role of potential risk factors and treatment options., Methods: We analysed the results of 227 elective CAG procedures performed in 145 patients after orthotopic heart transplantation (OHT) between 1986 and 1998. The result of CAG was considered positive when any lesion was found in coronary arteries regardless of its hemodynamic relevance, including both atherosclerotic plaques and lesions characteristic of vasculopathy. The influence of immunological (rejection of transplanted heart) and non-immunological risk factors on the development of TxCAD was analysed separately for the first 3 years after OHT and for the subsequent period., Results: Positive result of at least one CAG was found in 54 (37%) patients. The overall percentage of positive CAG was 41%, starting from 18% one year after OHT to 55% five years after surgery. Vasculopathic lesions were found in 14% of CAG procedures. Risk factor analysis showed an increasing impact over time of non-immunological factors, however, differences were not statistically significant. Hemodynamically significant lesions were found in 21 patients. In 16 of those PCI was performed. Control CAG was done in 12 patients after PCI revealing indications for another PCI in 8 of them. TxCAD was the cause of death in 3 patients in the PCI group., Conclusions: Based on the results of elective CAG, frequency of TxCAD increases with time and reaches 55% by 5 years after OHT. PCI is an effective method of treating significant coronary lesions after OHT.