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Accidental hypothermia, defined as an unintentional drop of the body core temperature below 35 °C, is one of the causes of cardiocirculatory instability and reversible cardiac arrest. Currently, extracorporeal life support (ECLS) rewarming is recommended as a first-line treatment for hypothermic cardiac arrest patients. The aim of the ECLS rewarming is not only rapid normalization of core temperature but also maintenance of adequate organ perfusion. Veno-arterial extracorporeal membrane oxygenation (ECMO) is a preferred technique due to its lower anticoagulation requirements and potential to prolong circulatory support. Although highly efficient, ECMO is acknowledged as an invasive treatment option, requiring experienced medical personnel and is associated with the risk of serious complications. In this review, we aimed to discuss the clinical aspects of ECMO management in severely hypothermic cardiac arrest patients.

Prehabilitation is a comprehensive preparation of a patient for primarily surgical treatments. Its aim is to improve the patient'sgeneral condition so as to reduce the risk of complications and ensure the fastest possible recovery to full health. Thebasic components of prehabilitation include: improvement of nutritional status, appropriate exercises to improve functioning,psychological support, and help in eliminating addictions. Other important aspects of prehabilitation are: increasinghemoglobin levels in patients with anemia, achieving good glycemic control in patients with diabetes, treatment or stabilizationof any concurrent disorders, or specialist treatment associated with a specific procedure (endoprostheses, ostomyprocedure). This article organizes and outlines the indications for prehabilitation, its scope, duration, and the method to conductit. Experts of various specialties related to prehabilitation agree that it should be an element of surgery preparationwhenever possible, especially in patients with co-existing medical conditions who have been qualified for major procedures.Prehabilitation should be carried out by interdisciplinary teams, including family physicians and various specialists in thetreatment of comorbidities. Prehabilitation requires urgent systemic and reimbursement solutions.

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Background: Primary graft dysfunction (PGD) is the main cause of death in the first 30 days after heart transplantation (HTX), accounting for approximately 40% of mortality. The study's primary aim was to assess the incidence of PGD, following the International Society for Heart and Lung Transplantation consensus, and to compare it with the incidence of significant postoperative hypotension despite administration of high-dose inotropes and vasoconstrictors. The secondary aim of the study was to determine changes in biochemical markers that accompany the phenomenon., Methods: Forty-five patients who underwent HTX between 2010 and 2015 were enrolled in this study, and detailed hemodynamic and metabolic data from the first 48 postoperative hours were collected and analyzed. Hemodynamic instability was defined as significant postoperative hypotension (mean arterial pressure (MAP) < 60 mmHg) combined with a high inotrope score (> 10). Data for long-term mortality were obtained from the population registration office., Results: PGD incidence was relatively low (17.8%); however, hemodynamic instability was common (40%). Among unstable patients, MAP was insufficient for end-organ perfusion (51.4 ± 9.5 mmHg) but no decrease in left ventricular function was observed (cardiac index, 2.65 ± 0.6 l/min/m2; left ventricular ejection fraction, 52.9 ± 15.5%). Within this group, mean systemic vascular resistance index (961 ± 288 dyn*s*m2/cm5) was low despite receiving high doses of vasoactive agent (norepinephrine 0.21 (0.06-0.27) μg/kg/min during first 24 h postoperatively and 0.21 (0.01-0.27) μg/kg/min during next 24 h postoperatively). After HTX, serum lactate levels were initially significantly higher in patients with hemodynamic instability (p = 0.002); however, impaired lactate clearance was not observed (p = 0.366), and lactate levels normalized within the first 24 h postoperatively. Postoperative hemodynamic instability altered the long-term outcome and increased 5-year mortality after HTX (p = 0.034)., Conclusions: Hemodynamic instability is a more common phenomenon than PGD. Only early postoperative serum lactate levels correspond with hemodynamic instability following HTX. Postoperative hemodynamic instability is associated with poor long-term survival among HTX recipients., (© 2021. The Author(s).)

Background: It is unclear whether acid-base balance disturbances during the perioperative period may impact Clostridium difficile infection (CDI), which is the third most common major infection following cardiac surgery. We hypothesized that perioperative acid-base abnormalities including lactate disturbances may predict the probability of incidence of CDI in patients after cardiac procedures., Methods: Of the 12,235 analyzed patients following cardiac surgery, 143 (1.2%) developed CDI. The control group included 200 consecutive patients without diarrhea, who underwent cardiac procedure within the same period of observation. Pre-, intra and post-operative levels of blood gases, as well as lactate and glucose concentrations were determined. Postoperatively, arterial blood was drawn four times: immediately after surgery and successively; 4, 8 and 12 h following the procedure., Results: Baseline pH was lower and PaO2 was higher in CDI patients (p < 0.001 and p = 0.001, respectively). Additionally, these patients had greater base deficiency at each of the analyzed time points (p < 0.001, p = 0.004, p = 0.012, p = 0.001, p = 0.016 and p = 0.001, respectively). Severe hyperlactatemia was also more common in CDI patients; during the cardiac procedure, 4 h and 12 h after surgery (p = 0.027, p = 0.004 and p = 0.001, respectively). Multivariate logistic regression analysis revealed that independent risk factors for CDI following cardiac surgery were as follows: intraoperative severe hyperlactatemia (OR 2.387, 95% CI 1.155-4.933, p = 0.019), decreased lactate clearance between values immediately and 12 h after procedure (OR 0.996, 95% CI 0.994-0.999, p = 0.013), increased age (OR 1.045, 95% CI 1.020-1.070, p < 0.001), emergent surgery (OR 2.755, 95% CI 1.565-4.848, p < 0.001) and use of antibiotics other than periprocedural prophylaxis (OR 2.778, 95% CI 1.690-4.565, p < 0.001)., Conclusion: This study is the first to show that perioperative hyperlactatemia and decreased lactate clearance may be predictors for occurrence of CDI after cardiac surgery., Competing Interests: The authors have declared that no competing interests exist.

Background: Clostridioides difficile infection (CDI) is the most common cause of hospital-acquired diarrhea. There is little available data regarding risk factors of CDI for patients who undergo cardiac surgery. The study evaluated the course of CDI in patients after cardiac surgery., Methods: Of 6,198 patients studied, 70 (1.1%) developed CDI. The control group consisted of 73 patients in whom CDI was excluded. Perioperative data and clinical outcomes were analyzed., Results: Patients with CDI were significantly older in comparison to the control group (median age 73.0 vs 67.0, P  = 0.005) and more frequently received proton pump inhibitors, statins, β -blockers and acetylsalicylic acid before surgery ( P  = 0.008,  P  = 0.012,  P  = 0.004, and P  = 0.001, respectively). In addition, the presence of atherosclerosis, coronary disease and history of malignant neoplasms correlated positively with the development of CDI ( P  = 0.012,  P  = 0.036 and P  = 0.05, respectively). There were no differences in the type or timing of surgery, aortic cross-clamp and cardiopulmonary bypass time, volume of postoperative drainage and administration of blood products between the studied groups. Relapse was more common among overweight patients with high postoperative plasma glucose or patients with higher C-reactive protein during the first episode of CDI, as well as those with a history of coronary disease or diabetes mellitus ( P  = 0.005, P  = 0.030,  P  = 0.009,  P  = 0.049, and P  = 0.025, respectively). Fifteen patients died (21.4%) from the CDI group and 7 (9.6%) from the control group ( P  = 0.050). Emergent procedures, prolonged stay in the intensive care unit, longer mechanical ventilation and high white blood cell count during the diarrhea were associated with higher mortality among patients with CDI ( P  = 0.05,  P  = 0.041,  P  = 0.004 and P  = 0.007, respectively)., Conclusions: The study did not reveal any specific cardiac surgery-related risk factors for development of CDI., Competing Interests: The authors declare there are no competing interests., (©2020 Rzucidło-Hymczak et al.)

Both the temperature at which defibrillation can be effectively used and how often it should be repeated in severe accidental hypothermia have not been definitely established. Current recommendations are based mainly on expert opinion and suggest withholding defibrillation after 3 shocks when the core temperature is below 30°C (86°F). However, growing evidence supports the effectiveness of defibrillation in patients with a core temperature below 30°C (86°F). We present a case of successful defibrillation of a 54-y-old, severely hypothermic patient with a core temperature of 18.2°C (64.8°F). The shock was delivered automatically by an implanted cardioverter-defibrillator shortly after the implementation of extracorporeal rewarming. The patient survived and was discharged from the hospital neurologically intact. It might be reasonable to consider defibrillation attempts in severely hypothermic patients despite current guidelines to the contrary. Increasing coronary perfusion using extracorporeal circulation may result in a better response to defibrillation., (Copyright © 2020 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

BACKGROUND Hyperlactatemia is a common phenomenon following cardiac surgeries and is associated with prolonged ICU stay and higher morbidity and mortality rates, but such analyses have never focused on patients undergoing heart transplantation (HTX), in whom hyperlactatemia defined with the traditional threshold is observed in nearly every individual. The present study aimed to assess the prognostic value and clinical usefulness of postoperative serum lactate level measurements for in-hospital mortality prediction following HTX. MATERIAL AND METHODS Forty-six consecutive patients who underwent HTX in the Department of Cardiovascular Surgery and Transplantology between 2010 and 2015 were enrolled into a retrospective analysis. Serum lactate level measurements within the first 48 h after HTX were obtained from arterial blood gas analyses, that were routinely conducted every 6 h. Lactate clearance was determined for each patient individually throughout 3 different time frames: the first 24-h (Lac clear 0-24) and second 24-h period (Lac clear 24-48), and the first 48 h after surgery (Lac clear 0-48). RESULTS The ICU admission serum lactate levels differed between the deceased and survivors (7.6 vs. 4.3 mmol/L; p=0.000). Among all tested postoperative lactate level measurements, only the measurement taken upon ICU admission predicted in-hospital mortality (OR 1.94 95% CI [1.09-3.43]; p=0.024). The receiving operating characteristic (ROC) curve for in-hospital mortality was constructed for ICU admission measurement, with the optimal cut-off point estimated at 7.0 mmol/L. CONCLUSIONS Serum lactate level measurement upon ICU admission can be used as a predictive parameter for in-hospital mortality among heart transplant recipients. Values greater than 7.0 mmol/L can predict in-hospital mortality with 90% accuracy.

Objective: Extracorporeal rewarming is the treatment of choice for patients who had hypothermic cardiac arrest, allowing for best neurologic outcome. The authors' goal was to identify factors associated with survival in nonasphyxia-related hypothermic cardiac arrest patients undergoing extracorporeal rewarming., Design: All 38 cardiac surgery departments in Poland were encouraged to report consecutive hypothermic cardiac arrest patients treated with extracorporeal life support. All variables collected were analyzed in order to compare survivor and nonsurvivor groups. The parameters available at the initiation of extracorporeal rewarming were considered as potential predictors of survival in a logistic regression model. The primary outcome was survival to discharge from the intensive care unit. The secondary outcome was neurologic status., Setting: Multicenter retrospective study., Participants: Ninety-eight cases in the final analysis., Interventions: All patients in nonasphyxia-related hypothermic cardiac arrest rewarmed with extracorporeal life support., Measurements and Main Results: The survival rate was 53.1%, and 94.2% of survivors had favorable neurologic outcome. The lowest reported core temperature with cerebral performance category scale 1 was 11.8°C. A univariate analysis identified 3 variables associated with survival, namely: age, initial arterial pH, and lactate concentration. In a multivariate analysis, 2 independent predictors of survival were age (0.957; 95% confidence interval [CI] 0.924-0.991) and lactates (0.871; 95% CI 0.789-0.961). The area under the receiver operating characteristics curve for this fitted model was 0.71; 95% CI 0.602-0.817., Conclusions: Favorable survival with good neurologic outcome in nonasphyxiated hypothermic patients treated with extracorporeal life support was reported. Age and initial lactate level are independently associated with survival., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Introduction: The paper covers the problem of pre-hospital hypothermia recognition and management among lifeguards, board guards and policemen, who took part in e-learning course Academy of Hypothermia., Patients and Methods: Materials and methods: The subject of analysis were the results of pre-test, post-test and lesson revision tests of Academy of Hypothermia e-learning course, taken by lifeguards (WOPR), board guards (SG) and policemen (POL)., Results: Results: 221 participants were enrolled in a study. Lifeguards were significantly younger than other groups (mean age respectively: 34,13 years SG; 32,95 years POL and 23,31 years WOPR; p< 0,001) and median work experience (respectively: 10 years SG, 8 years POL and 2 years WOPR; p< 0,001). Pre-test analysis showed significant difference in results of board guards and lifeguards (median and q1-q3 values respectively: 61%; 43%-92% for SG and 53%; 46%-69% for WOPR, p = 0,02). Post-test analysis proved significantly better results of board guards (median and q1-q3 values: 92%; 77%-100%) in comparison to policemen (median and q1-q3 values: 85%; 69%-92%) and lifeguards (median and q1-q3 values: 85%; 69%-92%). Extra analysis was performed for lesson revision tests. The least correct answers were noted in lessons covering the topic of post trauma hypothermia and the algorithm of hypothermia casualty management., Conclusion: Conclusions: Lifeguards have least knowledge on accidental hypothermia than board guards and policemen. E-learning course is an effective tool for improving knowledge of hypothermia recognition and treatment.

Fast and accurate measurement of core body temperature is crucial for accidental hypothermia treatment. We have developed a novel light and small adapter to the headset jack of a mobile phone based on Android. It has been applied to measure temperature and set up automatic notifications (e.g. Global Positioning System coordinates to emergency services dispatcher, ECMO coordinator). Its validity was confirmed in comparison with Vital Signs Monitor Spacelabs Healthcare Elance 93300 as a reference method, in a series of 260 measurements in the temperature range of 10-42 °C. Measurement repeatability was verified in a battery of 600 measurements (i.e. 100 readings at three points of 10, 25, 42 °C for both esophageal and tympanic catheters). Inter-method difference of ≤0.5 °C was found for 98.5% for esophageal catheter and 100% for tympanic catheter measurements, with concordance correlation coefficient of 0.99 for both. The readings were almost completely repeatable with water bath measurements (difference of ≤0.5 °C in 10 °C: 100% for both catheters; in 25 °C: 99% for esophageal catheter and 100% tympanic catheter; in 42 °C: 100% for both catheters). This lightweight adapter attached to smartphone and standard disposable probes is a promising tool to be applied on-site for temperature measurement in patients at risk of hypothermia.

Direct oral anticoagulants (DOACs) such as apixaban, dabigatran, edoxaban, and rivaroxaban are mainly used in the prevention of thromboembolic complications in patients with atrial fibrillation (AF) and in the treatment of venous thromboembolism. As compared with vitamin K antagonists (VKAs), they are characterized by at least similar efficacy and better safety profiles, especially with respect to intracranial hemorrhages. Moreover, they are more convenient therapeutic agents. The 2016 European Society of Cardiology guidelines clearly favor DOACs over VKAs in patients with AF. However, DOAC therapy is also associated with the risk of bleeding complications. The aim of this review was to provide recommendations for the management of bleeding complications during DOAC therapy in the Polish setting. The recommendations were based on the most important documents concerning this issue and were developed by representatives of different medical specialties. Experience in managing cases of bleeding on DOAC therapy is still limited. Therefore, we hope that this publication will be helpful in everyday clinical practice and that it will be useful for developing in‑hospital recommendations for the management of patients with DOAC‑related bleeding.

Background: Recently, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has become the rewarming treatment of choice in hypothermic cardiac arrest. The detailed indications for extracorporeal rewarming in non-arrested, severely hypothermic patients with circulatory instability have not been established yet. The primary purpose of the study was a preliminary analysis of all aspects of the treatment process, as well as initial identification of mortality risk factors within the group of severely hypothermic patients, treated with arteriovenous extracorporeal membrane oxygenation (VA-ECMO). The secondary aim of the study was to evaluate efficacy of VA-ECMO in initial 6-h period of treatment METHODS: From July 2013 to June 2016, thirty one hypothermic patients were accepted for extracorporeal rewarming at Severe Accidental Hypothermia Center, Cracow. Thirteen patients were identified with circulatory instability and were enrolled in the study. The evaluation took into account patients' condition on admission, the course of therapy, and changes in laboratory and hemodynamic parameters., Results: Nine out of 13 analyzed patients survived (69%). Patients who died were older, had lower both systolic and diastolic pressure, and had increased creatinine an potassium levels on admission. In surviving patients, arterial blood gases parameters (pH, BE, HCO 3 ) and lactates would normalize more quickly. Their potassium level was lower on admission as well. The values of the core temperature on admission were comparable. Although normothermia was achieved in 92% of patients, none of them had been weaned-off VA-ECMO in the first 6 h of treatment., Discussion and Conclusions: In our preliminary study more pronounced markers of cardiocirculatory instability and organ hypoperfusion were observed in non-survivors. Future studies on indications to extracorporeal rewarming in severely hypothermic, non-arrested patients should focus on the extent of hemodynamic disturbances. Short term (<6 h) treatment in severe hypothermic, non-arrested patients seems to be not clinically appropriate.

We sought to organize a functional system of recognition and advanced treatment of hypothermic patients with extracorporeal rewarming as a treatment option. All patients with suspected hypothermia are consulted with the hypothermia coordinator (HC), whose role is to provide expertise on hypothermia recognition and treatment to all rescue and medical services. Patients with Swiss staging system of hypothermia class III and IV are subjected to extracorporeal rewarming. Patients with class I and II are managed in local hospitals, after the HC provides instructions. From program initiation (July 29, 2013) to November 1, 2015, HC consulted 104 hypothermic patients; 21 in hypothermia class III and IV were subjected to extracorporeal rewarming in the John Paul II Hospital in Cracow, Poland. The remaining people were rewarmed in the referring hospitals. Cardiac arrest upon referral was present in 10 cases (resuscitation times from arrest to extracorporeal membrane oxygenation implantation ranged 107-345 minutes). Seven patients died, and the remaining 14 have been rewarmed with the restoration of hemodynamic stability. Systematic approach to active recognition and treatment of profound accidental hypothermia patients, on the basis of HC cooperation with emergency medical services, enables advanced management with good outcomes, especially in patients with cardiac arrest.

Non-vitamin K antagonist oral anticoagulants (NOACs) have a favorable benefit-risk profile compared with vitamin K antagonists. However, the lack of specific reversal agents has made the management of some patients receiving long-term treatment with NOACs problematic in emergency situations such as major bleeding events or urgent procedures. Idarucizumab, a fully humanized Fab antibody fragment that binds specifically and with high affinity to dabigatran, was recently approved for use in adult patients treated with dabigatran when rapid reversal of its anticoagulant effect is required. Clinical experience with idarucizumab is currently limited. We report 11 real-life clinical cases in which idarucizumab was used after multidisciplinary consultation in a variety of emergency situations including severe postoperative bleeding, emergency high-bleeding-risk surgery (hip/spine surgery and neurosurgery), invasive diagnostic testing (lumbar puncture), intracranial bleeding (pre-pontine subarachnoid hemorrhage and lobar intracerebral hemorrhage) and thrombolysis with recombinant tissue plasminogen activator for acute ischemic stroke. This case series illustrates the role of idarucizumab in improving patient safety in rare emergency situations requiring rapid reversal of the anticoagulant effect of dabigatran, while highlighting the importance of information and education about the availability and appropriate use of this recently approved specific reversal agent.

Introduction: The authors present their personal experience in qualifying and treating adult patients using veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) in postcardiotomy cardiogenic shock., Aim: The aim of this study was to analyze the results of VA ECMO in patients with postcardiotomy cardiogenic shock. An analysis of the risk factors of postoperative mortality was also performed., Material and Methods: We analyzed the perioperative results of survivors and non-survivors of treatment using VA ECMO. We compared the number of days on VA ECMO therapy, types of cardiac surgical procedures, and the frequency of VA ECMO complications such as coagulation disorders, lower limb ischemia, cardiac tamponade, and renal replacement therapy., Results: There were 27 patients treated with VA ECMO during the study period. The mean patient age was 45 ±16 years. The hospital mortality rate of patients treated with VA ECMO therapy was 70% (19/27). There were no significant differences between the groups of survivors and non-survivors regarding age, gender, admission type and coexisting diseases. Type of cardiac surgical procedure had no influence on mortality or complications of therapy using VA ECMO., Conclusions: The VA ECMO can be an effective form of therapy in some patients in postcardiotomy cardiogenic shock.

Background: Severe accidental hypothermia can cause circulatory disturbances ranging from cardiac arrhythmias through circulatory shock to cardiac arrest. Severity of shock, pulmonary hypoperfusion and ventilation-perfusion mismatch are reflected by a discrepancy between measurements of CO 2 levels in end-tidal air (EtCO 2 ) and partial CO 2 pressure in arterial blood (PaCO 2 ). This disparity can pose a problem in the choice of an optimal ventilation strategy for accidental hypothermia victims, particularly in the prehospital period. We hypothesized that in severely hypothermic patients capnometry should not be used as a reliable guide to choose optimal ventilatory parameters., Methods: We undertook a pilot, observational case-series study, in which we included all consecutive patients admitted to the Severe Hypothermia Treatment Centre in Cracow, Poland for VA-ECMO in stage III hypothermia and with signs of circulatory shock. We performed serial measurements of arterial blood gases and EtCO 2 , core temperature, and calculated a PaCO 2 /EtCO 2 quotient., Results: The study population consisted of 13 consecutive patients (ten males, three females, median 60 years old). The core temperature measured in esophagus was 20.7-29.0 °C, median 25.7 °C. In extreme cases we have observed a Pa-EtCO 2 gradient of 35-36 mmHg. Median PaCO 2 /EtCO 2 quotient was 2.15., Discussion and Conclusion: Severe hypothermia seems to present an example of extremely large Pa-EtCO 2 gradient. EtCO 2 monitoring does not seem to be a reliable guide to ventilation parameters in severe hypothermia.

Background: Severe accidental hypothermia is defined as a core temperature below 28 Celsius degrees. Within the last years, the issue of accidental hypothermia and accompanying cardiac arrest has been broadly discussed and European Resuscitation Council (ERC) Guidelines underline the importance of Extracorporeal Rewarming (ECR) in treatment of severely hypothermic victims. The study aimed to evaluate the actual costs of ECR with VA-ECMO and of further management in the Intensive Care Unit of patients admitted to the Severe Accidental Hypothermia Centre in Cracow, Poland., Methods: We carried out the economic analysis of 31 hypothermic adults in stage III-IV (Swiss Staging) treated with VA ECMO. Twenty-nine individuals were further managed in the Intensive Care Unit. The actual treatment costs were evaluated based on current medication, equipment, and dressing pricing. The costs incurred by the John Paul II Hospital were then collated with the National Health Service (NHS) funding, assessed based on current financial contract., Results: In most of the cases, the actual treatment cost was greater than the funding received by around 10000 PLN per patient. The positive financial balance was achieved in only 4 (14%) individuals; other 25 cases (86%) showed a financial loss., Conclusion: Performed analysis clearly shows that hospitals undertaking ECR may experience financial loss due to implementation of effective treatment recommended by international guidelines. Thanks to new NHS funding policy since January 2017 such loss can be avoided, what shall encourage hospitals to perform this expensive, yet effective method of treatment.

Background: Coronary artery disease is a major cause of death worldwide. Despite different standard revascularization options, significant number of patients remains not suitable for any treatment. The aim of the study was to evaluate long-term outcome of patients with diffuse coronary artery disease, treated with autologous stem cells injections combined with transmyocardial laser revascularization., Material and Methods: 9 patients underwent Holmium:YAG laser revascularization and autologous bone marrow derived stem cells implantation between 2007 and 2009 in the Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Kraków and were subsequently followed up in 2015., Results: The mean follow-up period was 73 months. The mean CCS class significantly improved (1.4±0.5 vs 3.3±1.0; p<0.001) and cardiac related hospitalizations significantly decreased (1.1±0.8 vs 3.1±2.1; p<0.001). One death due to heart failure was observed. The mean LVEF increased from 38% to 42% (p>0.05)., Conclusions: Clinical status improvement was observed with low mortality rate in the long-term follow-up. No new regional wall motion abnormalities were observed, and the increase of global ejection fraction was noted.

Background: The authors present their own experience of the treatment of patients qualified for transcatheter aortic valve implantation (TAVI) carried out in a modern hybrid operating room. The objective of the present study was to demonstrate the initial results of conducting anaesthesia in high-risk patients qualified for the TAVI procedure (transcatheter aortic valve implantation). In addition, the authors' aim was also to point out to the special challenges of an anaesthesiologist conducting local anaesthesia in such a type of procedures and to evaluate the safety and efficacy of the TAVI procedure conducted under remifentanil analgosedation., Methods: A retrospective analysis included patients treated during the period from September 2015, when local anaesthesia for the transcatheter aortic valve implantation was used for the first time at our centre, up to February 2016. The studied population consisted of 11 patients treated for severe aortic valve stenosis. The mean age of patients was 80 ± 7 years. Three patients were men (27%) and eight were women (73%). The study included all subsequent patients (n = 11), treated in our centre, for whom it was decided to perform TAVI under local anaesthesia., Results: The total hospital mortality rate was 0%. All procedures were performed in a hybrid operating room. Despite the complications observed in the described group, the hospital mortality rate during TAVI was 0%. All patients, after 12 ± 5 days of treatment, left the hospital in a good neurological condition, which was assessed based on the CPC-1 (Cerebra Performance Categories Scale) and GCS-15 (Glasgow Coma Scale) scales. With an ejection fraction of the left ventricle of 53 ± 11%, the transcatheter aortic valve was successfully implanted., Conclusions: Percutaneous aortic valve implantation can be successfully conducted under remifentanil analgosedation. TAVI procedures should be performed in the conditions of a modern, well-equipped hybrid room. The aim of the anaesthesiologist should consist of conducting the least invasive anaesthesia/analgesia, bearing in mind the safety and comfort of the patient.

Background: Application of appropriate method of rewarming is the key issue in the management of hypothermia. Severely hypothermic, life-threatened patients require advanced extracorporeal rewarming. Such procedure is not free of possible complications, yet, if the qualification for extracorporeal rewarming is correct, it guarantees restoration of hemodynamic stability, and what is the most important, leads to full neurologic recovery, even with long resuscitation times., The Aim: The summary of complications observed during extracorporeal rewarming with ECMO in severely hypothermic patients and analysis of their prevalence in managed group. Presentation of possible etiology and means of prevention of anticipated complications and suggested strategies of their treatment., Materials and Methods: Retrospective analysis of medical records of all 33 patients with severe accidental hypothermia, accepted for extracorporeal rewarming with venoarterial ECMO., Conclusions: Based on reviewed medical records of severely hypothermic patients subjected to extracorporeal rewarming it was possible to identify these complications of management, that are hypothermia related, and which are not to be seen in patients treated with ECMO for other reasons.

Objective: The impact of systemic inflammation on clinical outcomes after CABG surgery is still controversial. In this study, we evaluated the impact of the markers of inflammation, endothelial damage and platelet activation on clinical outcomes after on- and off-pump CABG., Methods: A group of 191 consecutive on- and off-pump CABG patients were prospectively studied. Blood samples were drawn before surgery, 18-36h after the procedure and 5-7 days postoperatively and analyzed for 8-iso-prostaglandin F 2α (8-iso-PGF 2α ), asymmetric dimethylarginine (ADMA) and β-thromboglobulin (β-TG). White blood count and C-reactive protein were measured twice, first before and then during the first 18-36h after CABG. The primary clinical end-points were: low cardiac output syndrome (LCOS), postoperative myocardial infarction (PMI) and in-hospital cardiovascular death., Results: Elevation of 8-iso-PGF 2α , ADMA and β-TG before surgery was associated with an increased risk of morbidity and mortality after CABG. There were no differences in analyzed markers and clinical outcomes between the on- and off-pump groups. Even during the uncomplicated postoperative course the inflammatory response was enhanced and still remained higher than baseline 5-7 days after surgery., Conclusion: Links between preoperative 8-iso-PGF 2α , ADMA and β-TG and unfavorable early post-CABG outcomes suggest that these markers could be useful in identifying patients with increased risk of LCOS, PMI and in-hospital cardiovascular death following elective CABG., (Copyright © 2016. Published by Elsevier B.V.)

Objectives: When establishing the Severe Hypothermia Treatment Centre, certain problems and pitfalls regarding the qualification for extracorporeal rewarming were encountered. The authors shared their experience and opened a discussion with other centers that deal with severe, accidental hypothermia., Design: Retrospective analysis of medical records of all patients examined by the hypothermia coordinator., Setting: Patients consulted and treated by the Severe Hypothermia Treatment Centre., Participants: Patients who underwent accidental hypothermia., Interventions: From July 2013 until January 2016, hypothermia coordinators at the Severe Hypothermia Treatment Centre examined the cases of 152 hypothermic patients. Of those cases, 127 patients were subjected to noninvasive rewarming in referral hospitals and 25 were accepted to the center for extracorporeal rewarming., Measurements and Main Results: Difficulties that deferred or delayed the implementation of extracorporeal membrane oxygen rewarming were identified and addressed, including low platelet/red blood count, intraperitoneal fluid of unknown origin, abnormal results of head computed tomography, extremes of age, bleeding from the external auditory meatus, inaccuracy of infrared-based thermometers, iatrogenic trauma to the femoral vessels, chronic/terminal comorbidities, poisonings, pregnancy, hypoglycemia, hemodynamic stability despite severe hypothermia, and decontamination protocol., Conclusions: The problems discussed may delay the use of extracorporeal membrane oxygen rewarming in hypothermic patients but should not discourage medical teams from the implementation of extracorporeal rewarming. The prognosis for severe hypothermia is favorable, even with a long resuscitation time and low core temperatures., (Copyright © 2016 Elsevier Inc. All rights reserved.)

BACKGROUND Orthotopic heart transplantation (HTX) remains the ultimate treatment option in patients with end-stage heart failure, endorsed by the European Society of Cardiology guidelines. The aim of the study is a complex evaluation of the postoperative bleeding after HTX and its influence on short-term outcome. MATERIAL AND METHODS A retrospective cohort study consisted of 53 patients (4 females and 49 males, median age 52.5 years, IQR 17 years) who underwent HTX in the Department of Cardiovascular Surgery and Transplantology of John Paul II Hospital in Krakow between 2007 and 2014. RESULTS The median chest tube output within first 24 hours after the surgery was 695 (550-870) mL. Bleeding decreased throughout the observation (p=0.000). The first postoperative hemoglobin level was a significant predictor of excessive blood loss (p=0.017). The volume of chest tube output increased the duration of mechanical ventilation (p=0.046) and the incidence of re-exploration after first 24 hours of observation (p=0.049). In patients with higher chest tube output, more packed red blood cells (PRBC), fresh frozen plasma (FFP), and platelet (PLT) transfusions were required (p=0.000, p=0.019, and p=0.000, respectively). Early rethoracotomy (within the first 24 hours post-surgery) increased the in-hospital mortality (p=0.021; OR 7.43 [1.36-40.64]). CONCLUSIONS The study demonstrates the importance of postoperative bleeding and bleeding complications for short-term outcome in our post-HTX cohort. Throughout the analysis, the first postoperative hemoglobin level was detected to be a significant predictor of postoperative blood loss.

Background: The prognosis in hypothermic cardiac arrest is frequently good despite prolonged period of hypoperfusion and cardiopulmonary resuscitation. Apart from protective effect of hypothermia itself established protocols of treatment and novel rewarming techniques may influence on outcome. The purpose of the study was to assess the outcome of patients with hypothermic circulatory arrest treated by means of arterio-venous extracorporeal membrane oxygenation (ECMO) according to locally elaborated protocol in Severe Accidental Hypothermia Center in Cracow, Poland., Methods: Prospective observational case-series study - all patients with confirmed hypothermic cardiac arrest consulted with hypothermia coordinator were accepted for extracorporeal rewarming, unless contraindications for ECMO were observed (active bleeding)., Results: The study population consisted of 10 patients (7 male, median age 48.5 years). The core temperature measured esophageally was 16.9-28.4 °C, median 22 °C. On admission 5 patients presented with asystole and 5 with ventricular fibrillation. Duration of circulatory arrest before ECMO implantation was 107 to 345 min (median 156 min). The duration of ECMO support was 1.5 to 91 h (median 22 h). Cardiorespiratory stability and full neurologic recovery was achieved in 7 patients. The duration of mechanical ventilation was 88-437 h (median 177 h) and the length of stay in the ICU was 8-26 days (median 15 days). All survivors had mildly impaired (1 patient, LVEF 40 %) or preserved (6 patients, LVEF 55-65 %) left ventricular systolic function at the time of discharge from ICU. The cause of death of non-survivors (three patients) was acute myocarditis, massive retroperitoneal bleeding, and massive gastrointestinal bleeding., Discussion and Conclusions: Our data confirm the high survival rate (70 %) and excellent neurologic outcome in hypothermic cardiac arrest. The following key elements seem to impact the final prognosis: the appropriate coordination of the rescue operation, immediate high-quality CPR (preferably using mechanical chest compression system) and application of ECMO for rewarming and cardiorespiratory support.

Background: Patients suffering from cardiogenic shock, with no response to conventional therapy, may significantly improve when put on support devices such as extracorporeal membrane oxygenation (ECMO), which maintains systemic and pulmonary circulation, and decongests the heart. This publication presents authors' own experience in qualifying and treating patients with cardiogenic shock, with the use of veno-arterial (VA) ECMO modality., Aim: The main goal of the study was to analyse factors influencing outcome of VA ECMO therapy in patients with cardiogenic shock. Survival data were compared for patients surviving treatment (n = 12, 41%), and for patients who died while VA ECMO., Methods: Retrospective study included all patients treated between February 2009, when ECMO was first used in the clinic, and March 2015. Of those, 29 patients were treated with VA ECMO for respiratory support. Mean patient age was 42 years; 19 (66%) patients were male, and 10 (34%) patients were female., Results: Total in-hospital mortality rate was 59% (17/29). No difference was observed as to patient age, sex, body height, mode of hospital admission, comorbidities or left ventricular ejection fraction at hospital admission, when comparing survivors and patients who died despite treatment. The following parameters were analysed: number of days on VA ECMO, troponin levels during first days from treatment onset, platelet transfusions, and duration of mechanical ventilation. No significant differences were observed between the groups. Surviving patients were significantly longer hospitalised (p = 0.016), including a longer stay in the intensive care unit (p = 0.03)., Conclusions: VA ECMO is an acceptable therapy for patients in a severe state of cardiogenic shock. In-hospital mortality rate was 59%, and 41% patients (12 subjects) were successfully treated with VA ECMO in course of cardiogenic shock.

Introduction: Patients scheduled for coronary artery bypass graft surgery (CABG) are commonly treated with clopidogrel. We sought to assess the relation between preoperative platelet aggregation and bleeds in CABG patients on clopidogrel., Material and Methods: In a case-control study, we compared 52 consecutive patients undergoing isolated CABG on aspirin and clopidogrel 75mg/d versus 50 controls on aspirin monotherapy. Platelet aggregation induced by 10μmol/l adenosine di-phosphate (ADP) in platelet-rich plasma was measured in subjects on clopidogrel within 5days prior to surgery. ADP-induced aggregation of ≥50% was used to define subjects with satisfactory inhibition of platelet reactivity., Results: In 29 patients with preoperative ADP-induced aggregation ≥50%, compared with 23 subjects with aggregation <50%, lower chest-tube drainage volumes (after 6h, p=0.002; and 12h, p=0.001) and fewer rethoracotomies were observed (p=0.03). The former group was characterized with lower transfusion rates of packed red blood cells (p=0.009), platelet concentrate (p=0.04) and fresh frozen plasma (p=0.001). Patients with ADP-induced aggregation ≥50% did not differ from untreated controls regarding the postoperative drainage, transfusions and rethoracotomy. The incidence of thromboembolic events and death during perioperative period were similar in all groups. Multivariate logistic regression identified ADP-induced aggregation <50% as the only independent predictor of rethoracotomy (OR=2.94 [1.12-7.75], p=0.029)., Conclusions: Patients on aspirin and clopidogrel <5days before CABG who had preoperative ADP-induced platelet aggregation ≥50% have bleeding risk similar to those receiving aspirin monotherapy. Reduced platelet reactivity to ADP can predict postoperative bleeding in CABG patients on dual antiplatelet therapy., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Hypothermic patients may be rewarmed using passive or active techniques. In case of severe accidental hypothermia (temperature<28°C) and stage III/IV according to the Swiss Staging System, standard methods might not be effective and aggressive treatment is needed. Extracorporeal membrane oxygenation (ECMO) has proved to be both effective and safe in such cases. The Department of Anesthesiology and Intensive Care, John Paul II Hospital, Cracow, Poland, established the Severe Accidental Hypothermia Center, which provides 24 h on-call to consult and accept patients who need ECMO implantation for profound hypothermia rewarming. Our center is so far the only one in Poland and can accept patients from south-east Poland. Most importantly, it collaborates with all prehospital medical services, namely, with 115 Ambulances, Polish Medical Air Rescue, Mountain Rescue Services, and all 28 Emergency Departments in the area. Severe Accidental Hypothermia Center is a solution for advanced treatment of patients with accidental hypothermia requiring ECMO implantation.

Introduction: Accidental hypothermia is a condition associated with significant morbidity and mortality. Hypothermia has been reported to affect left ventricular systolic and diastolic function. However, most of the data come from animal experimental studies., Aim of the Study: The purpose of the present study was to assess the impact of severe accidental hypothermia on systolic and diastolic ventricular function in patients treated using veno-arterial extracorporeal membrane oxygenation (ECMO)., Methods: We prospectively assessed nine hypothermic patients (8 male, age 25-78 years) who were transferred to the Severe Accidental Hypothermia Center and treated with ECMO. Transthoracic echocardiography was performed on admission (in patients without cardiac arrest) and on discharge from ICU after achieving cardiovascular stability. Cardiorespiratory stability and full neurologic recovery was achieved in all patients., Results: Biomarkers of myocardial damage (CK, CKMB, hsTnT) were significantly elevated in all study patients. Admission echocardiography performed in patients in sinus rhythm, revealed moderate-severe bi-ventricular systolic dysfunction and moderate bi-ventricular diastolic dysfunction. Discharge echocardiography showed persistent mild bi-ventricular diastolic dysfunction, although systolic function of both ventricles returned to normal. Discharge echocardiography in patients admitted with cardiac arrest showed normal (5 patients) or moderately impaired (1 patient) global LV systolic function on discharge. However, mild or moderate LV diastolic dysfunction was observed in all 6 patients. Discharge RV systolic function was normal, whereas mild RV diastolic dysfunction was present in these patients., Conclusion: After severe accidental hypothermia bi-ventricular diastolic dysfunction persists despite systolic function recovery in survivors treated with ECMO.

Background: The incidence of hypothermia is difficult to evaluate, and the data concerning the morbidity and mortality rates do not seem to fully represent the problem. The aim of the study was to estimate the actual prevalence of accidental hypothermia in Poland, as well as the methods of diagnosis and management procedures used in emergency rooms (ERs)., Methods: A specially designed questionnaire, consisting of 14 questions, was mailed to all the 223 emergency rooms (ER) in Poland. The questions concerned the incidence, methods of diagnosis and risk factors, as well as the rewarming methods used and available measurement instruments., Results: The analysis involved data from 42 ERs providing emergency healthcare for the population of 5,305,000. The prevalence of accidental hypothermia may have been 5.05 cases per 100.000 residents per year. Among the 268 cases listed 25% were diagnosed with codes T68, T69 or X31, and in 75% hypothermia was neither included nor assigned a code in the final diagnosis. The most frequent cause of hypothermia was exposure to cold air alongside ethanol abuse (68%). Peripheral temperature was measured in 57%, core temperature measurement was taken in 29% of the patients. Peripheral temperature was measured most often at the axilla, while core temperature measurement was predominantly taken rectally. Mild hypothermia was diagnosed in 75.5% of the patients, moderate (32-28°C) in 16.5%, while severe hypothermia (less than 28°C) in 8% of the cases. Cardiopulmonary resuscitation was carried out in 7.5% of the patients. The treatment involved mainly warmed intravenous fluids (83.5%) and active external rewarming measures (70%). In no case was extracorporeal rewarming put to use., Conclusions: The actual incidence of accidental hypothermia in Polish emergency departments may exceed up to four times the official data. Core temperature is taken only in one third of the patients, the treatment of hypothermic patients is rarely conducted in intensive care wards and extracorporeal rewarming techniques are not used. It may be expected that personnel education and the development of management procedures will brighten the prognosis and increase the survival rate in accidental hypothermia.