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Aortic valve surgery in non-elderly patients represents a very challenging patient population. The younger the patient is at the point of aortic valve intervention, the longer their anticipated life expectancy will be, with longer exposure to valve-related complications and risk for re-operation. Although the latest international guidelines recommend aortic valve repair in patients with aortic valve insufficiency, what we see in the real world is that the vast majority of these aortic valves are replaced. However, current prosthetic valves has now been shown to lead to significant loss of life expectancy for non-elderly patients up to 50% for patients in their 40s undergoing mechanical aortic valve replacement. Bioprostheses carry an even worse long-term survival, with higher rates of re-intervention. The promise of trans-catheter valve-in-valve technology is accentuating the trend of bioprosthetic implantation in younger patients, without yet the appropriate evidence. In contrast, aortic valve repair has shown excellent outcomes in terms of quality of life, freedom from re-operation and freedom from major adverse valve-related events with similar life expectancy to general population as it is also found for the Ross procedure, the only available living valve substitute. We are at a time when the paradigm of aortic valve surgery needs to change for the better. To better serve our patients, we must acquire high quality real-world evidence from multiple centers globally - this is the vision of the AVIATOR registry and our common responsibility.

Aim: To report a case of a patient with undiagnosed endocarditis that presented as COVID-19 pneumonia Case report: 62-year-old woman with a history of arterial hypertension, presented to the Emergency Department of General Hospital Koprivnica with fever and cough lasting for 7 days and general fatigue lasting for 3 weeks Her vital signs were in physiologic range, while auscultatory she had a systolic murmur over the whole precordium with diffuse pulmonary crackles Chest radiograph showed bilateral interstitial pneumonia whilst laboratory results displayed elevated inflammatory markers, cardiac troponin and D-dimers combined with mild partial respiratory insufficiency She was admitted to an isolated COVID-19 ward where empiric antibiotic therapy with ceftriaxone began in parallel with dexamethasone, dalteparin and oxygen therapy via nasal cannula During the night of admission, she became hemodynamically unstable and fluid resuscitation in conjunction with inotropes was initiated Emergency pulmonary CT angiography ruled out pulmonary embolism and showed bilateral ground-glass changes with pleural effusion as well as signs of venous congestion Subsequently, COVID-19 was confirmed with the RT-PCR test After a 10-day isolation period, she was transferred to the Cardiology Department where transthoracic echocardiography was performed Massive vegetation on the anterior mitral leaflet that caused obstruction of the left ventricular outflow tract and moderate mitral regurgitation with filiform vegetation on the aortic valve were shown Initial antibiotic therapy was swapped to amikacin and gentamicin Further hospital stay was complicated with paroxysmal atrial fibrillation, worsening of heart failure and psychological disturbance Indication for emergency valve replacement and transfer to the University Hospital Dubrava was indicated Intraoperatively, massive vegetation on A1/A2 section of mitral leaflet and a smaller vegetation on ventricular side of left and noncoronary cusps of the aortic valve were visible Both valves were replaced with mechanical valves with satisfying results and the patient was returned to the parent hospital Coagulase-negative S aureus susceptible to vancomycin was later verified on the mitral leaflet specimen Conclusion: Despite our focus on SARS-CoV-2 pandemic, it is important not to neglect other diagnosis and usefulness of echocardiography as a powerful diagnostic tool in everyday clinical practice [ABSTRACT FROM AUTHOR] Copyright of Cardiologia Croatica is the property of Croatian Cardiac Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission However, users may print, download, or email articles for individual use This abstract may be abridged No warranty is given about the accuracy of the copy Users should refer to the original published version of the material for the full abstract (Copyright applies to all Abstracts )

Alkaptonuria is rare genetic disorder of tyrosine metabolism manifesting with signs of tissue pigmentation, dark urine, and ochronotic arthropathies. Commonly undiscovered by late adulthood, alkaptonuria can manifest as cardiac ochronosis with cardiovascular disorders such as valvulopathies, but rarely coronary artery disease. This case report describes 2 patients with aortic stenosis and coronary artery disease in whom alkaptonuria was diagnosed during open heart surgery.

Objective: Aortic valve replacement (AVR) is still the most commonly used therapeutic option for patients suffering from AR. Aortic valve repair (AVRep) is an attractive alternative method, since it avoids the risks of prosthesis-related complications.1-3 We would like to present our experience with the Yacoub root remodeling, valve sparing technique with the extraaortic expansible ring. Patients and Methods: Between November 2014 and July 2019, a total of 79 patients (52.6±13.3 years; 15.2% female, EuroScore II of 3.15%±2) underwent AVRep, 12 due to isolated cusp malcoaptation and 67 associated with aortic root dilatation. Reconstruction was done with the Coroneo Extraaortic Ring (27 (25-31)), and the Gelweave graft (28 (26-32)). 44 patients had a tricuspid valve, 33 patients had a bicuspid valve, and 2 patients had an unicuspid valve. Concomitant procedures included Mvrep and TVrep in 4 patients, CABG in two patents. Aortic arch was replaced in two patients, two patients underwent hemiarch replacement, and two patients had aortic arch replacement with stented conduit and placement of stent in descending thoracic aorta (EVITA stent graft Jotec GmbH). Echocardiography was used to determine AR severity grade preoperatively, during immediate post-operative period (within 7 days from operation) and at early follow-up. Results: In postoperative follow-up no patients died. Freedom from reoperation was 88% (10/79) and there were 2 patients reoperated due to early postoperative regurgitation, one patient was reoperated due to AI after two years, and one was operated due to pseudoaneurysm formation after 2.5 years. A significant decrease in LV end-diastolic diameter was observed (LVEDD) (60mm preoperatively, 53 mm postoperatively) with further decrease at early follow-up. At follow up none of the patients had major AR (AR0=61, AR1+=14, AR2+=4). Conclusions: We have proved that AVRep is a good alternative for patients with aortic insufficiency and leads to LV reverse remodeling with comparable results in terms of LVEDD and LVEF immediately post-operatively and at early follow up. It is feasible to use this technique in tricuspid, bicuspid, as well as unicuspid valves with excellent results.

Objective: Valve-sparing aortic root replacement has gained popularity in the last decade. This report provides short-term outcome and differences between patients after valve-sparing versus valve-...

Internationally 3% of the donor hearts are distributed to re-transplant patients. In Eurotransplant, only patients with a primary graft dysfunction (PGD) within 1 week after heart transplantation (HTX) are indicated for high urgency listing. The aim of this study is to provide evidence for the discussion on whether these patients should still be allocated with priority. All consecutive HTX performed in the period 1981-2015 were included. Multivariate Cox' model was built including: donor and recipient age and gender, ischaemia time, recipient diagnose, urgency status and era. The study population included 18 490 HTX, of these 463 (2.6%) were repeat transplants. The major indications for re-HTX were cardiac allograft vasculopathy (CAV) (50%), PGD (26%) and acute rejection (21%). In a multivariate model, compared with first HTX hazards ratio and 95% confidence interval for repeat HTX were 2.27 (1.83-2.82) for PGD, 2.24 (1.76-2.85) for acute rejection and 1.22 (1.00-1.48) for CAV (P < 0.0001). Outcome after cardiac re-HTX strongly depends on the indication for re-HTX with acceptable outcomes for CAV. In contrast, just 47.5% of all hearts transplanted in patients who were re-transplanted for PGD still functioned at 1-month post-transplant. Alternative options like VA-ECMO should be first offered before opting for acute re-transplantation. ispartof: TRANSPLANT INTERNATIONAL vol:31 issue:11 pages:1223-1232 ispartof: location:Switzerland status: published

Immunoglobulin-G4-related disease (IgG4RD) is a novel clinical entity characterized by lymphoplasmacytic infiltrates presenting as an excessive fibrosis such as retroperitoneal inflammatory pseudotumor but rarely affecting the heart or the aorta. We describe a case of IgG4RD with multifocal aortic involvement presenting as an acute aortic syndrome.

Case report: 29-year-old m ale u nderwent aortic root reconstruction w ith root remodeling technique and external ring annuloplasty (Corneo Extra Aortic Ring A 29, Gelweave graft 30 mm) in 2015 due to bicuspid aortic valve with significant aortic regurgitation and aortic root dilatation. In 2017 due to pseudoaneurysm of aortic root and severe aortic regurgitation, the patient was reoperated and mechanical aortic valve was implanted (Carbomedics Mechanical A 25) with patch plastic of the pseudoaneurysm. A year later he was admitted again, now due to fever and high inflammatory markers. Multimodality imaging, transthoracic echocardiography, transesophageal echocardiography, MSCT aortography and abdominal CT described aortic /perivalvular root abscess with significant paravalvular leak in terms of hemodynamically significant regurgitation with high flow velocity over the mechanical valve, peak velocity > 4 m/s. TEE (2D+3D) showed the septate hyperechogenic formation with hypoechogenic cavities which seemed to touch a part of trigonum, approximately 15 mm thick, extending from annulus ascending to the entire visible part of the aortic root, ascending more than 4 cm. It appeared to affect > 50% of the annulus, with visible paraannular leak and massive aortic regurgitation. Previously implanted patch plastic on aortic root was hypermobile depending on heart cycle. Left ventricle showed normal contractility. MSCT of thorax and aortography confirmed the finding (Figure 1). The patient was diagnosed with endocarditis of the mechanical aortic valve and aortic root abscess, thus the antimicrobial therapy was started. Patient had to undergo urgent surgical reoperation. Aortic root replacement with coronary artery reimplantation was performed (sec Bentall, BioIntegral Surgical A 23). There were no signs of paravalvular leak on the control MSCT aortography, with proper flow through graft, coronary artery and supra-aortal branches. Control echocardiography showed a good function of the mechanical valve. Patient recovered successfully and was sent home after antimicrobial therapy protocol was finished. Conclusion: Cooperation of the heart team (cardiologist, heart surgeon, radiologist) and multimodality imaging is a paramount for accurate diagnosis and management of patients with complex aortic pathology1,2.

Libman-Sacks endocarditis, one of the most prevalent cardiac presentations of systemic lupus erythematosus, typically affects the aortic or mitral valve; tricuspid valve involvement is highly unusual. Secondary antiphospholipid syndrome increases the frequency and severity of cardiac valvular disease in systemic lupus erythematosus. We present the case of a 47-year-old woman with lupus and antiphospholipid syndrome whose massive tricuspid regurgitation was caused by Libman-Sacks endocarditis isolated to the tricuspid valve. In addition, we discuss this rare case in the context of the relevant medical literature.

Annular rupture presents a rare but potentially fatal complication of transcatheter aortic valve implantation (TAVI). Although it can be subtle and subclinical in presentation, most severe forms present with hemodynamic instability and represent true emergencies requiring a more invasive treatment, even conventional surgery. We present a case of successful treatment of annular rupture by left ventricular outflow tract patch and surgical aortic valve replacement.

Objective: Aortic valve replacement (AVR) is still the most commonly used therapeutic option for patients suffering from AR. Aortic valve repair (AVRep) is an attractive alternative method, since it avoids the risks of prosthesis-related complications. We would like to present our experience with the Yacoub root remodeling, valve sparing technique with the extraaortic expansible ring. Patients and Methods: Between November 2014 and August 2017, a total of 49 patients (52.1±12.5) years ; 18.9% female, EuroScore II of (2.4%±1%) underwent AVRep, 6 due to isolated cusp malcoaptation and 43 with associated with aortic root dilatation. Recontruction was done with the Coroneo Extraaortic Ring (27 (25-31)) and the Gelweave graft (28 (26-32)). Concomitant procedures included MVRep in three patients with TVrep in two of them, CABG in two patents and replacement of aortic arch and placement of EVITA stent graft in two patients. Echocardiography was used to determine AR severity grade pre- operatively, during immediate post-operative period (within 7 days from operation) and at early follow-up. Results: In postoperative follow up no patients died. Freedom from reoperation was 94% (3/37) and there were 2 patients reoperated due to early postoperative regurgitation, and one because of early cardiac tamponade. A significant decrease in LV end-diastolic diameter was observed (LVEDD) (61.3/53.5mm) with further decrease at early follow-up. At follow up none of the patients had major AR (AR 0=40, AR 1+=7, AR 2+=2). Conclusions: We have proved that AVRep is a good alternative for patients with aortic insufficiency and leads to LV reverse remodeling with comparable results in terms of LVEDD and LVEF immediately post- operatively and at early follow.

The objective of this study was to evaluate the influence of cardiopulmonary bypass (CPB) on endothelin-1 (ET-1) expression in various circulation compartments in patients undergoing myocardial revascularization. A total of 30 patients were randomized to undergo myocardial revascularization with (CABG, n = 15) or without (OPCAB, n = 15) CPB. Samples were taken preoperatively, after establishing CPB and after CPB (CABG group), prior to and after revascularization (OPCAB group), and 6 and 24 h postoperatively. Values of ET-1 were compared between groups at all time points and correlated with postoperative cardioselective enzyme values and clinical parameters. In OPCAB group, ET-1 levels did not significantly vary between time points. In CABG group, ET-1 levels were significantly elevated vs. baseline in arterial: ART-T2 vs. ART-T0 (1.83 ± 1.81 vs. 0.76 ± 1.07 fmol/mL, p = 0.05), pulmonary: SG-T2 vs. SG-T0 (2.70 ± 2.75 vs. 0.39 ± 0.28 fmol/mL, p

OBJECTIVES: Cardiac surgery-associated acute kidney injury (AKI) is a well-known factor influencing patients' long-term morbidity and mortality. Several prediction models of AKI requiring dialysis (AKI-D) have been developed. Only a few direct comparisons of these models have been done. Recently, a new, more uniform and objective definition of AKI has been proposed [Kidney Disease: Improve Global Outcomes (KDIGO)-AKI]. The performance of these prediction models has not yet been tested. ----- METHODS: Preoperative demographic and clinical characteristics of 1056 consecutive adult patients undergoing cardiac surgery were collected retrospectively for the period 2012-2014. Multivariable logistic regression analysis was used to determine the independent predictors of AKI-D and the KDIGO-AKI stages. Risk scores of five prediction models were calculated using corresponding subgroups of patients. The discrimination of these models was calculated by the c-statistics (area under curve, AUC) and the calibration was evaluated for the model with the highest AUC by calibration plots. ----- RESULTS: The incidence of AKI-D was 3.5% and for KDIGO-AKI 23% (17.3% for Stage 1, 2.1% for Stage 2 and 3.6% for Stage 3). Older age, atrial fibrillation, NYHA class III or IV heart failure, previous cardiac surgery, higher preoperative serum creatinine and endocarditis were independently associated with the development of AKI-D. For KDIGO-AKI, higher body mass index, older age, female gender, chronic obstructive pulmonary disease, previous cardiac surgery, atrial fibrillation, NYHA class III or IV heart failure, higher preoperative serum creatinine and the use of cardiopulmonary bypass were independent predictors. The model by Thakar et al. showed the best performance in the prediction of AKI-D (AUC 0.837; 95% CI = 0.810-0.862) and also in the prediction of KDIGO-AKI stage 1 and higher (AUC = 0.731; 95% CI = 0.639-0.761), KDIGO-AKI stage 2 and higher (AUC = 0.811; 95% CI = 0.783-0.838) and for KDIGO-AKI stage 3 (AUC = 0.842; 95% CI = 0.816-0.867). ----- CONCLUSIONS: The performance of known prediction models for AKI-D was found reasonably well in the prediction of KDIGO-AKI, with the model by Thakar having the highest predictive value in the discrimination of patients with risk for all KDIGO-AKI stages.

Primary light-chain (AL) amyloidosis is a plasma cell dyscrasia associated with the deposition of immunoglobulin-derived amyloid in multiple organs. In the heart, this results in an infiltrative cardiomyopathy, with increased left ventricular wall thickness, normal or decreased left ventricular (LV) cavity size and congestive heart failure. Cardiac involvement is a major determinant of prognosis of AL amyloidosis. We report a patient with cardiac amyloidosis proven by cardiac biopsy, and aim to point out at transthoracic echocardiography as the hallmark of diagnostics. Echocardiography revealed increased LV thickness at 20mm, impaired LV ejection fraction (EF) at 35%, enlarged atria, transmitral deceleration time at 156 ms and increased E/A ratio at 4.25. Early diagnosis and intervention can have a significant impact on the patient's response to treatment, especially when the underlying condition involves a malignancy or infiltrative disorder. Standard transthoracic echocardiography as a noninvasive diagnostic tool is valuable and has a significant role in diagnosis and prognosis.

Calcifying fibrous pseudotumor is a rare benign lesion composed mostly of dense hyalinized colagen with multiple dystrophic or psammomatous calcifications and variable lymphoplasmacytic infiltrate. Children and young adults are most commonly affected by this tumor of uncertain pathogenesis. This is a case of an asymptomatic young woman with calcifying fibrous pseudotumor of the pericardium compressing heart cavities. Partial resection and marsupialization of the mass was performed.

Continuous-flow left ventricular assist devices (LVAD) have become standard therapy option for patients with advanced heart failure. They offer several advantages over previously used pulsatile-flow LVADs, including improved durability, less surgical trauma, higher energy efficiency, and lower thrombogenicity. These benefits translate into better survival, lower frequency of adverse events, improved quality of life, and higher functional capacity of patients. However, mounting evidence shows unanticipated consequences of continuous-flow support, such as acquired aortic valve insufficiency and acquired von Willebrand syndrome. In this review article we discuss current evidence on differences between continuous and pulsatile mechanical circulatory support, with a focus on clinical implications and potential benefits of pulsatile flow.

Background. Endoscopic radial artery harvest provides better cosmetic result without compromising the quality of the graft. We sought to compare postoperative harvesting site neurologic and vascular outcome. Methods. From 10/2002 until 10/2004, 50 patients were randomized to have their radial artery harvested for coronary bypass either endoscopically (group A, n = 25) or conventionally (group B, n = 25). Radial arteries were preoperatively evaluated by Doppler echocardiography. Neurologic and functional status was assessed by a self reporting questionnaire with a semiquantitative (1-5) scale. Vascular status of the forearm was assessed by control echocardiography. Results. At an average follow-up of 37 +/- 7 months, patients undergoing endoscopic radial artery harvesting had less overall neurologic complications (11 versus 17 patients, P = .023) and they were less severe (0.8 +/- 1.1 versus 2.2 +/- 1.2 ; P < .001). Ulnar flow increase was similar among the groups: 13.1 +/- 5.43 cm/s in group A versus 15.9 +/- 4.9 cm/s in group B (P = .147) as well as ulnar artery diameter increase 0.29 +/- 0.16 mm in group A versus 0.29 +/- 0.26 cm in group B (P = .914) Conclusion. Endoscopic radial artery is safe and does not compromise graft quality or forearm and hand circulation postoperatively. Along with providing a better cosmetic result, endoscopic artery harvesting reduces postoperative harvesting site pain and neurologic complications.

Background Despite advances in medical treatment, development of new surgical procedures and the availability of mechanical circulatory support heart transplantation (HTx) remains the treatment of choice for end-stage heart failure. Objective of this study is to report single center experience and outcomes of patients undergoing HTx. Methods We retrospectively examined the outcomes from ninetyfive HTx recipients between September 1995 and May 2013. The mean recipient age was 55±8 years, and 85% were male. Dilated cardiomyopathy was present in 40%, ischemic in 30% and 30% were other causes. Ten patients (10%) that were heart recipients from our cohort were on high urgent list of Eurotransplant. As an induction of immunosuppressive therapy we were using antithymocyte globulin, and for maintenance a combination of cyclosporine, prednisone and mycophenolate. Survival was studied using Kaplan- Meier curves. Results In-hospital mortality was 12%. The median follow- up was 20 months. The global survival rates at 1, 5, and 10 years were 82%, 77%, and 62% respectively. The mean survival is 105 months (95% CI, 93.4-118.3). Early main causes of death were sepsis (41%) and primary graft failure (29%) and late causes were late rejection (20%), malignant disease and other causes (10%). Conclusion In our center, post-HTx survival rates at 1, 5, and 10 years were even better than those reported by the International Society of Heart and Lung Transplantation as a result of combined effort of all medical personnel involved in perioperative and postoperative management.

Mehanička potpora cirkulaciji danas je dio standardne terapije u liječenju završne faze zatajivanja sistoličke funkcije srca. U radu opisujemo karakteristike uređaja Thoratec pVAD za mehaničku potporu cirkulaciji, tehniku ugradnje, kao i najvažnije prednosti i komplikacije primjene uređaja. Prikazujemo slučaj 41-godišnjeg bolesnika s dilatacijskom kardiomiopatijom, kojemu je prvi put u Republici Hrvatskoj zbog zatajivanja srca ugrađen uređaj za parakorporalnu mehaničku potporu lijevom srcu (LVAD), koji je nakon 130 dana potpore odstranjen zbog poboljšanja srčane funkcije., Use of mechanical circulatory support (MCS) is a part of today’s standard therapy in the treatment of end-stage heart failure. In this paper we describe characteristics of Thoratec pVAD device for MCS, implantation techniques, as well as the most important advantages and complications of application of the device. We present a 41-year-old patient with dilatated cardiomyopathy, who was the first recipient of paracorporeal left ventricular assist device (LVAD) in the Republic of Croatia due to end-stage heart failure. After heart function recovery the patient was successfully weaned from MCS after 130 days of support.

Long-term mechanical circulatory support has become a valid treatment option for end stage heart failure. In selected patients’ cases, this therapeutic option has been proven to improve survival, both as a bridge to transplant and as a destination therapy. In this article, we address implantation technique, strategies to prevent excessive bleeding, right heart failure, and driveline and pocket infection., Dugotrajna mehanička potpora cirkulaciji postala je provjerena metoda u liječenju završne faze srčanog zatajenja. Kod odabranih bolesnika, dokazano je da poboljšava preživljenje, bilo kao potpora do transplantacije ili destinacijske terapije. U članku opisujemo tehnike ugradnje, strategije u cilju smanjenja prekomjernog krvarenja, zatajenja desnog srca te infekcije oko mjesta izlaska kabela za napajanje.

Left ventricular assist systems (LVAS) are widely accepted nowadays as a successful tool for bridging the patients with end-stage heart failure to heart transplantation (BTT). The second generations of axial-flow devices, such as the HeartMate II, provide a safe and reliable, as well as an effective hemodynamic support in such patients, offering them an improved quality of life; they are furthermore associated with a very low rate of device malfunction or infection requiring device change. We report here of our first three patients with the implanted HM II LVAS as a BTT ., Uređaji za potporu lijevom srcu (LVAS – left ventricular assist system) su danas prihvaćeni kao uspiješno sredstvo za premoštenje bolesnika u završnom stadiju zatajivanja srca do transplantacije. Druga generacija aksijalnih pumpi, kao što je HeartMate II , pruža sigurnu i učinkovitu hemodinamsku potporu takvim bolesnicima, poboljšavajući kvalitetu života. Danas su ti uređaji povezani sa niskom inicidencijom malfunkcije ili infekcije koje bi zahtijevale zamjenu. Prikazujemo naša tri bolesnika kojima je ugrađen HeartMate II LVAS kao premoštenje do transplantacije.

Continuous-flow left-ventricular assist devices (LVADs) have emerged as the standard of care for advanced heart failure patients, who require long-term mechanical circulatory support. In this review, we describe in brief the basics of the development of various devices, both the old (pulsatile-flow) and the new (continuous-flow) devices. A clinical review of modern devices and their today’s relevance are given in a brief outline., Uređaji za asisitirano srce i asistiranu cirkulaciju postali su standard u liječenju pacijenata s kroničnim zatajenjem srca, kojima je neophodna dugoročna mehanička potpora srcu i cirkulaciji. U ovom članku ukratko su opisane povijest razvoja različitih starijih (pulsatilnih) i novijih (kontinuirani tok) uređaja te važnost kliničke primjene ovih modernih uređaja.

Despite recent advances in treatment, the number of people with heart failure continues to grow; this is associated with high mortality and morbidity rates. Heart transplantation is very limited due to the lack of the adequate number of heart donors, and medical therapy remains palliative. He use of ventricular assist devices (VADs) has led to improved survival rates for patients with severe heart failure. Originally introduced as a temporary bridge-to-recovery, and later as a bridge-to-transplantation, VADs have evolved to permanent or destination therapy for patients with terminal stage of congestive heart failure1. In this paper, we report of our patient with dilatative cardiomyopathy, to whom – due to the end-stage heart failure, and for the first time in Croatia – a device for paracorporeal long-term mechanical left ventricular support (pVAD) was implanted., Unatoč novijim dostignućima u liječenju kongestivnog zatajivanja srca, broj ljudi sa srčanim popuštanjem kontinuirano raste što dovodi do povećane stope mortaliteta i morbiditeta. Transplantacija srca je često ograničena zbog nedostatka broja adekvatnih donora, a medikamentozna terapija ostaje palijativna. Korištenje mehaničke cirkulacijske potpore (LVAD-left ventricular assist device), kao standardne terapije u liječenju završne faze zatajivanja srca značajno je poboljšalo ishod liječenja. Mehanička potpora lijevom ventriklu, prvotno primjenjena kao metoda privremenog premoštenja prema ozdravljenju (bridge-to-recovery), zatim kao premoštenja do transplantacije (bridge– to-transplantation), danas se primjenjuje kao trajna opcija liječenja bolesnika s terminalnom fazom srčanog zatajivanja. U ovom radu prikazan je slučaj bolesnika s dilatativnom kardiomiopatijom, kojem je po prvi puta, u Republici Hrvatskoj, zbog zatajivanja srca ugrađena parakorporalna mehanička potpora lijevom srcu.

Background: Aneurysms of the left ventricle (LV) present a serious consequence of myocardial infarction, causing mechanical, thromboembolic, and arythmogenic complications. We present our experience in LV remodeling and long-term follow-up results.Methods: From May 1998 to February 2009, 85 patients with postinfarction LV aneurysm underwent reconstructive procedures. Mean age was 58.7 ± 8.9 years (range 36-79 years). Average LV ejection fraction was 39.8% ± 13.1% (range 20%-70%). Mean EuroScore was 6.0 ± 2.9 (range 3-19) and predictive mortality was 8.2% ± 11.9% (range 1.6%-85.6%). The majority of patients were in New York Heart Association functional class II (44%) preoperatively and 32% of patients were in New York Heart Association class III or IV. LV reconstruction was performed by using the endoventricular patch technique in 56 patients (66%). In 29 patients (34%) reconstruction was done by linear closure. In 79 patients (93%) concomitant myocardial revascularization was performed. Mitral valve procedures were performed in 11 patients (13%), (repair in 10 patients and replacement in 1).Results: Perioperative mortality was 3.5% (3 patients). Long-term follow-up was completed by means of phone interview with an average duration of 31.6 months (range 3-120 months). There were 9 late deaths (11%) during follow-up. Actuarial survival rates at 1, 5, and 10 years were 91%, 77%, and 68%, respectively. Fifty-nine patients (72%) were in New York Heart Association functional class I and II postoperatively.Conclusion: LV remodeling is a safe surgical procedure with low perioperative morbidity and mortality and excellent long-term survival, even in patients with severely reduced systolic function.

The need for quality management system (QMS) at cardiac surgery department has been recognized for some time. QMS should help in management of all processes prevent organizational mistakes and provide a tool for unbiased outcome analysis. Comprehensive process analysis of surgical treatment of cardiac patient has been carried out. Requirements of the ISO 9001:2000 standard: quality management system, management responsibility, resource management, product realization, measurement analysis and improvement, were customized to specifics of cardiac patient treatment. All documentation was written in plain language to serve as practice manual. QMS emphasis is routine investigation of all adverse events and statistical analysis of trends in treatment. After 22 months, QMS has been certified according to ISO 9001:2000 standard for scope of cardiac surgery, cardiac anaesthesia, intensive care and perfusion. The implemented QMS has ensured consistency and improvement of working practice, which in turn provided better control over achieved medical results and higher patient satisfaction., Potreba za sustavom upravljanja kvalitetom na Odjelu za kardijalnu kirurgiju je postojala neko vrijeme. Sustav upravljanja kvalitetom je iskorišten da bi pomogao u upravljanju procesima i sprječavanju organizacijskih pogrešaka te kao sredstvo za nepristranu analizu rezultata. Napravljena je sveobuhvatna analiza procesa kirurške obrade pacijenata na Odjelu za kardijalnu kirurgiju. Zahtjevi norme ISO 9001:2000: sustav upravljanja kvalitetom, odgovornost upravljanja, upravljanje sredstvima, ostvarivanje proizvoda, analiza mjerenja te poboljšanja su prilagođeni posebnostima liječenja pacijenata sa srčanim tegobama. Sva je dokumentacija napisana jednostavnim jezikom kako bi služila kao praktični priručnik. Naglasak na sustavu upravljanja kvalitetom uključuje rutinsko istraživanje svih nepovoljnih događaja i statističkih analiza trendova u liječenju. Nakon 22 mjeseca, sustav upravljanja kvalitetom je certificiran prema normi ISO 9001:2000 tako da obuhvaća kardijalnu kirurgiju, kardijalnu anesteziologiju, intenzivnu njegu te perfuziju. Uvedeni sustav upravljanja kvalitetom je osigurao dosljednost i poboljšanje prakse, što je zauzvrat osiguralo bolju kontrolu nad postignutim medicinskim rezultatima te veće zadovoljstvo pacijenata.

Objective: Postoperative bleeding is still one of the most common complications of cardiac surgery. Antifibrinolytic agents successfully reduce bleeding, but there are controversies concerning adverse effects after their systemic use. By topical application of antifibrinolytic agents in pericardial cavity, most of these effects are avoided. We compared the effects of topically applied aprotinin, tranexamic acid and placebo on postoperative bleeding and transfusion requirements. - - - - - Methods: In this single-center prospective, randomized, double-blind trial, 300 adult cardiac patients were randomized into three groups to receive one million IU of aprotinin (AP group), 2.5g of tranexamic acid (TA group) or placebo (PL group) topically before sternal closure. Groups were comparable with respect to all preoperative and intraoperative variables. Postoperative bleeding, transfusion requirements and hematologic parameters were evaluated. - - - - - Results: Postoperative bleeding within first 12-h period (AP group 433+/-294 [350; 360]ml, TA group 391+/-255 [350; 305]ml, PL group 613+/-505 [525; 348]ml), as well as cumulative blood loss within 24h (AP group 726+/-432 [640; 525]ml, TA group 633+/-343 [545; 335]ml, PL group 903+/-733 [800; 445]ml), showed statistically significant inter-group differences (both p

Cardiovascular diseases are the leading cause of morbidity and mortality for women in developed countries. Numerous studies have shown that women have higher morbidity and mortality rates than men following coronary artery bypass graft surgery (CABG). Having this evidence as our starting point, we compared the outcomes of CABG procedures in women and men. The analysis included patient preoperative risk factors (age, left ventricular ejection fraction, diabetes mellitus, arterial hypertension, hypercholesterolemia, myocardial infarction and cerebrovascular insult), number of grafts and perioperative complications (reopening for bleeding, perioperative myocardial infarction, sternal wound infections--both superficial and deep, atrial and ventricular fibrillation, cardiac decompensation), and mortality. Women had more risk factors and comorbidities than man, including arterial hypertension and hypercholesterolemia, but less severe atherosclerosis and higher left ventricular ejection fraction. Off-pump myocardial revascularization was done in 48% of women and in 42% of men. There was no statistically significant difference in perioperative complications between women and men. Comparison of the mean values showed the perioperative mortality to be higher in women than in men (3.4% vs. 2.9%), but the difference was not statistically significant (p = 0.724).

In this restrospetive study, data on 272 coronary artery disease patients with concomitant diabetes mellitus treated between 12/1997 and 12/2002 were analyzed. Eighty patients inderwent complete arterial revascularization (DM-ART), whereas 192 patients underwent coronary revascularization using arterial-venous grafts (DN-NEART). The following preoperative data and risk factors were analyzed: arterial hypertension, hyperlipoproteinemia, number of vessels involved, left coronary artery stenosis, unstable angina, previous myocardial infarction (MI), previous cardiac surgery, EuroScore. During a 30-day postoperative period, the following complications were analyzed: bleeding, perioperative MI, wound infection, sternal dehiscence, neurologic dysfunction, mortality. DM-ART patients had a higher rate of hyperlipoproteinemia (p=0.004). Difference was only found for the occurrence of perioperative MI in DM-NEART group (p0.001). Total arterial revascularization without cardiopulmonary bypass is a reliable and safe choice in patients with concomitant diabetes mellitus irrespective of its type. Definitive conclusions can only be made after five- or ten-year evaluation of postoperative mirbidity and mortality.

Endocarditis represents a rare but life-threatening condition after heart transplantation. Recent American Heart Association guidelines recognize cardiac transplant patients with valvulopathy as high risk for endocarditis, but acknowledge that there were not sufficient data to make a recommendation for prophylaxis. Also, genitourinary procedures were no longer considered a risk factor for endocarditis in the most recent guidelines. We present a patient who acquired aortic valve endocarditis of the intact valve, after multiple urethral instrumentation 2 years after heart transplantation, who was successfully treated by aortic valve replacement and prolonged antibiotic therapy.

Ectopic parathyroid adenoma is a frequent cause of persistent or recurrent hyperparathyroidism after parathyroidectomy in patients with chronic renal failure on dialysis. An unusual anatomic localization of parathyroid adenoma may make the diagnosis and surgery difficult. In a 41-year-old woman with chronic renal failure, increased serum level of parathyroid hormone and symptoms of progressive renal osteodystrophy, mediastinal parathyroid adenoma was detected in the aorticopulmonary window by 99m Tc sesta MIBI scintigraphy and transmission computed tomography. Extirpation of adenoma, sized 3 x 2 cm, was performed through a left thoracotomy. Serum parathormone level returned to normal and the patient steadily recovered.

To present our preliminary results with stentless aortic valve bioprostheses.From November 2001 to February 2002, 15 patients (8 men and 7 women) underwent aortic valve replacement with aortic stentless bioprosthesis. The patients age ranged from 50 to 79 years (mean+/-SD, 63.3+/-5.7 years). Three patients had aortic stenosis, 3 aortic regurgitation, and 9 combined aortic pathology. Mean+/-SD left ventricle ejection fraction was 53.0+/-13.9%. Median EuroSCORE was 4 (range, 3-10). Mean+/-SD sinotubular junction diameter measured by transesophageal echo (TEE) was 22.9+/-1.97 mm preoperatively, and the diameter of implanted prostheses was 25.9+/-2.4 mm. All valves were implanted using subcoronary technique. In 5 patients, concomitant myocardial revascularization was performed.Mean+/-SD total bypass time was 126.7+/-45.9 min (range, 96-180) and cross-clamp time was 88.7+/-15.6 min (range, 69-118). There were no in-hospital deaths or neurological complications. All patients were discharged with only antiagregation agents in therapy. TEE control was performed 1 week after the surgery. The mean systolic gradient across the prosthesis was 25.6+/-5.6 mm Hg and maximum 25.9+/-7.3 mm Hg. No aortic insufficiency was observed in 6 and only minor in 9 patients in postoperative TEE.Although the implantation of aortic stentless bioprosthesis is technically challenging and time-consuming, early postoperative hemodynamic results are satisfactory.