Search

Inzulinska rezistenca oziroma stanje zmanjšanega biološkega odziva na fiziološke ravni inzulina je ključni dejavnik tveganja za srčnožilne bolezni, zato je pogosto prisotna pri bolnikih v srčnožilni kirurgiji. Vnetni procesi, poškodba tkiva in hormonski odziv v perioperativnem obdobju dodatno prispevajo k inzulinski rezistenci, ki vodi v različne biokemične spremembe. Le-te negativno vplivajo na delovanje organov, na zaplete po operaciji in na okrevanje po njej. Inzulinska rezistenca se kaže kot širok nabor kliničnih stanj, ki se postopno razvijajo od hiperinzulinemije do motene tolerance za glukozo in končno hiperglikemije, ko se normoglikemija ne more več vzdrževati kljub povečanemu izločanju inzulina. Priporočila različnih strokovnih združenj glede ciljnih vrednosti krvnega sladkorja v perioperativnem obdobju niso enoznačna. Prelomne raziskave so sprva dokazale, da strog glikemični nadzor vodi do boljših izidov, vendar je pojavnost hipoglikemij pomemben varnostni zadržek. Zato se v danes uveljavljenih protokolih za perioperativno odmerjanje inzulina cilja na vrednosti glikemije med 7,8 in 10 mmol/l. Hkrati pa je nejasno, ali na obolevnost in smrtnost vpliva stopnja hiperglikemije ali že zgolj prisotnost sladkorne bolezni oziroma sama inzulinska rezistenca. Procesom inzulinske rezistence v perioperativnem obdobju se lahko izognemo z minimalno invazivnim kiruškim pristopom, ustrezno anestezijo ter analgezijo in skrajšanjem obdobij stradanja. Prispevek obravnava patofiziologijo in klinične posledice odpornosti na inzulin oziroma hiperglikemije ter opiše perioperativne strategije za zmanjševanje inzulinske rezistence, izbiro najbolj primernega načina zdravljenja in pristope za hitrejše okrevanje po posegu na srcu in po kompleksnih operacijah aorte.

Background Recently adopted mini-thoracotomy approach for surgical aortic valve replacement has shown benefits such as reduced pain and shorter recovery, compared to more conventional mini-sternotomy access. However, whether limited exposure of the heart and ascending aorta resulting from an incision in the second intercostal space may lead to increased intraoperative cerebral embolization and more prominent postoperative neurologic decline, remains inconclusive. The aim of our study was to assess potential neurological complications after two different minimal invasive surgical techniques for aortic valve replacement by measuring cerebral microembolic signal during surgery and by follow-up cognitive evaluation. Methods Trans-cranial Doppler was used for microembolic signal detection during aortic valve replacement performed via mini-sternotomy and mini-thoracotomy. Patients were evaluated using Addenbrooke’s Cognitive Examination Revised Test before and 30 days after surgical procedure. Results A total of 60 patients were recruited in the study. In 52 patients, transcranial Doppler was feasible. Of those, 25 underwent mini-sternotomy and 27 had mini-thoracotomy. There were no differences between groups with respect to sex, NYHA class distribution, Euroscore II or aortic valve area. Patients in mini-sternotomy group were younger (60.8 ± 14.4 vs.72 ± 5.84, p = 0.003), heavier (85.2 ± 12.4 vs.72.5 ± 12.9, p = 0.002) and had higher body surface area (1.98 ± 0.167 vs. 1.83 ± 0.178, p = 0.006). Surgery duration was longer in mini-sternotomy group compared to mini-thoracotomy (158 ± 24 vs. 134 ± 30 min, p p = 0.027). Addenbrooke’s Cognitive Examination Revised Test score decreased equivalently in both groups (p = 0.630) (MS: 85.2 ± 9.6 vs. 82.9 ± 11.4, p = 0.012; MT: 85.2 ± 9.6 vs. 81.3 ± 8.8, p = 0.001). Conclusion There is no difference in microembolic load between the groups. Total intraoperative microembolic signals count was associated with cardiopulmonary bypass duration. Age, but not micorembolic signals load, was associated with postoperative neurologic decline. Trial registry number clinicaltrials.gov, NCT02697786 14.

Cardiac tumors are rare, and their treatment differs interindividually regarding the histopathological proprieties and the stage of disease. Authors present a case of symptomatic cardiac melanoma metastasis that expressed an ERBB2 (HER2) gene amplification in a course of the disease that has not yet been reported. The frail patient with a history of pulmonary and renal carcinoma, was admitted to the hospital due to a symptomatic left atrial tumor mass. The patient underwent a tumor-resecting cardiac surgery. At first mistaken for myxoma on echocardiography, the histopathological examination of the tumor revealed a melanoma of acral or mucosal origin. The melanoma metastasis was negative for common genetic mutations in BRAF, NRAS or KIT genes, and for the presence of NTRK genes fusions, but carried ERBB2 (HER2) gene amplification. The absence of standard gene mutations rendered it unresponsive to treatment with BRAF and MEK inhibitors. This molecular finding is rare in melanomas and represented a therapeutic target for off-label systemic treatment with drugs, primarily aimed at ERBB2 positive breast, gastric, and gastroesophageal junction cancers. A rare finding like this justifies molecular genetic analysis of unusual tumor specimen and guarantees optimal treatment for uncommon types of cardiac metastatic tumors.

Background: Recently adopted mini-thoracotomy approach for surgical aortic valve replacement has shown benefits such as reduced pain and shorter recovery, compared to more conventional mini-sternotomy access. However, whether limited exposure of the heart and ascending aorta resulting from an incision in the second intercostal space may lead to increased intraoperative cerebral embolization and more prominent postoperative neurologic decline, remains inconclusive. The aim of our study was to assess potential neurological complications after two different minimal invasive surgical techniques for aortic valve replacement by measuring cerebral microembolic signal during surgery and by follow-up cognitive evaluation.Methods: Trans-cranial Doppler was used for microembolic signal detection during aortic valve replacement performed via mini-sternotomy and mini-thoracotomy. Patients were evaluated using Addenbrooke’s Cognitive Examination Revised Test before and 30 days after surgical procedure.Results: A total of 60 patients were recruited in the study. In 52 patients, transcranial Doppler was feasible. Of those, 25 underwent mini-sternotomy and 27 had mini-thoracotomy. There were no differences between groups with respect to sex, NYHA class distribution, Euroscore II or aortic valve area. Patients in mini-sternotomy group were younger (60.8±14.4 vs.72±5.84, p=0.003), heavier (85.2 ± 12.4 vs.72.5 ± 12.9, p= 0.002) and had higher body surface area (1.98 ±0.167 vs. 1.83±0.178, p=0.006).Surgery duration was longer in mini-sternotomy group compared to mini-thoracotomy (158 ±24 vs. 134±30 min, pConclusion: There is no difference in microembolic load between the groups. Total intraoperative microembolic signals count was associated with cardiopulmonary bypass duration. Age, but not micorembolic signals load, was associated with postoperative neurologic decline.

OBJECTIVES Extraction of cardiovascular implantable electronic devices in low-volume medical centres with limited clinical experience and an evolving lead extraction programme may be challenging. We aimed to evaluate the safety and efficacy of stepwise transvenous lead extraction (TLE) using a novel type of hand-powered rotational sheath as a first-line tool for extraction of chronically implanted devices in a single, low-volume centre. METHODS Sixty-seven consecutive patients undergoing a TLE procedure using the novel Evolution® RL rotational sheath as the first-line extraction tool between 2015 and 2019 at our institution were enrolled in the study. Their short-term and 30-day outcomes were observed. RESULTS Sixty-nine devices and 131 leads were explanted. Procedural and clinical success rates were 92.4% and 98.5%, respectively. Two procedures were classified as failures due to lead remnants >4 cm remaining in patients’ vascular systems. One major (1.5%) and 3 minor (4.4%) adverse events and no deaths were observed. CONCLUSIONS TLE procedures, performed in a stepwise manner, using the Evolution RL sheath as a first-line extraction device and conducted by an experienced, surgically well-trained operator, offer excellent results with clinical and procedural success rates comparable to those, achieved in dedicated, high-volume institutions. Opting for optimal lead extraction approach in low-volume centres or institutions with evolving TLE programmes, a stepwise extraction strategy using the Evolution RL sheath by skilled operator may provide the optimal scheme with an excellent ratio between clinical and/or procedural success and complications.

Aims We investigated the spectrum of emergency veno-arterial extracorporeal membrane oxygenation (VA ECMO)-supported interventions including percutaneous coronary intervention (PCI), transcatheter aortic valve implantation (TAVI) and invasive electrophysiology (EP). Methods and results Between June 2010 and February 2020, 52 consecutive patients underwent VA ECMO implantation for refractory cardiac arrest (E-CPR) and 78 for profound cardiogenic shock. Percutaneous interventions on VA ECMO included PCI (n = 29), TAVI (n = 4) and EP (n = 1). Surgical interventions were cardiac (n = 36) or non-cardiac (n = 5). During PCI, ECMO flow was maintained at 2.7 ± 1.0 L/min. Of the 40 treated lesions, 48% were located on left anterior descending and 20% on the left main artery. An average 2.0 ± 1.8 DES/patient with diameter 3.2 ± 0.5 mm and stented length 41 ± 35 mm were implanted. PCI success was 83%. TAVI was performed in 4 patients with left ventricular ejection fraction 21 ± 10% and mean aortic valve gradient 41 ± 5 mmHg. After successful valve implantation supported by 1.4 ± 0.1 L/min ECMO flow, mean gradient decreased to 11 ± 5 mmHg without significant aortic regurgitation. In one patient radiofrequency ablation of His bundle followed by permanent pacemaker implantation was performed under ECMO flow of 2.8 L/min. Overall survival to hospital discharge with good neurological recovery was 29% in E-CPR and 44% in profound cardiogenic shock. Conclusions Our study showed feasibility and effectiveness of VA ECMO-supported percutaneous interventions in patients with profound hemodynamic collapse.

Background. Heart failure (HF) is characterized by unfavorable prognosis. Disease trajectory of HF, however, may vary, and risk assessment of patients remains elusive. In our study, we sought to determine the prognostic impact of endocan—a novel biomarker of endothelial dysfunction and low-grade inflammation—in patients with heart failure. Methods. In outpatients with chronic HF, baseline values of endocan were determined and clinical follow-up for a minimum of 18 months obtained. A multivariate Cox proportional hazard model was built for HF-related death or hospitalization requiring inotropic support. Results. A total of 120 patients (mean age 71 years, 64% male, mean LVEF 36%) were included. During a mean follow-up of 656±109 days, 50 patients (41.6%) experienced an event. On Cox multivariate analysis, endocan values emerged as an independent predictor of HF prognosis (HR, 1.471 CI 95% 1.183-1.829, p=0.001, for each 1 ng/mL increase) even after adjustment for age, gender, HF etiology, LVEF, NYHA class, NT-proBNP, and exercise tolerance. Conclusions. Endocan is an independent predictor of HF-related events in chronic HF individuals and represents a promising tool for risk assessment of HF patients.

Background. Galectin-3 plasma levels (gal-3) were shown to correlate with the scar burden in chronic heart failure (CHF) setting. As scar burden predicts response to stem cell therapy, we sought to explore a correlation between gal-3 and response to CD34+ cell transplantation in patients with CHF. Methods. We performed a post hoc analysis of patients, enrolled in 2 prospective trials investigating the clinical effects of CD34+ cell therapy in patients with ischemic cardiomyopathy (ICMP) and nonischemic dilated cardiomyopathy (DCMP). CD34+ cells were mobilized by G-CSF, collected via apheresis, and injected transendocardially using NOGA system. Patients were followed for 3 months and demographic, echocardiographic, and biochemical parameters and gal-3 were analyzed at baseline and at follow-up. Response to cell therapy was defined as an LVEF increase of ≥5%. Results. 61 patients were included in the analysis. The mean age of patients was 52 years and 83% were male. DCMP and ICMP were present in 69% and 31% of patients, respectively. The average serum creatinine was 86±23 μmol/L, NT-proBNP 1132 (IQR 350-2279) pg/mL, and LVEF 30±6%. Gal-3 at baseline and at 3 months did not differ significantly (13.4±5.5 ng/mL vs. 13.1±5.8 ng/mL; p=0.72), and there were no differences in baseline gal-3 with respect to heart failure etiology (15.1±7.2 ng/mL in ICMP vs. 12.7±4.3 ng/mL in DCMP; p=0.12). Comparing responders (N=49) to nonresponders (N=18), we found no differences in baseline gal-3 (13.6±5.7 ng/mL vs. 13.2±4.9 ng/mL; p=0.80). However, responders had significantly lower gal-3 at 3-month follow-up (12.1±4.0 ng/mL vs. 15.7±8.4 ng/mL; p<0.05). Also, responders demonstrated a significant decrease in gal-3 over 3 months, while in nonresponders, an increase in gal-3 occurred (−1.5±5.4 ng/mL vs. +2.7±4.3 ng/mL; p=0.01). Conclusions. In patients with chronic heart failure undergoing CD34+ cell therapy, a decrease in galectin-3 plasma levels is associated with beneficial response to this treatment modality. Further prospective data is warranted to confirm our findings and to deepen our understanding of the role of gal-3 in the field of stem cell therapy.

Swallow syncope is a rare dysautonomic syndrome characterized by temporary loss of consciousness upon swallowing solid foods or liquids, displaying primarily in individuals with an underlying structural or functional esophageal or cardiac pathology. However, the evidence also suggests that isolated vagal dysfunction or abnormal reactions of esophageal mechanoreceptors after mechanical irritation, demyelination, or trauma can potentially evoke a cardioinhibitory response or vasodepression upon swallowing. We present a case of a 49-year-old otherwise healthy female patient who developed swallow syncope two weeks after whiplash neck injury acquired in a rear-end collision. After no evident anatomical and/or functional cardiac or esophageal pathology was diagnosed using several diagnostic procedures, the final diagnosis was confirmed by a provocative tilt-table test while ingesting solid food. Subsequently, a dual-chamber pacemaker was implanted, relieving the patient from troublesome symptoms. Abnormal reactions of esophageal mechanoreceptors to stimuli associated with food ingestion and/or dysfunction of afferent and efferent vagal fibers due to stretch injury and related neck trauma (acquired during the car accident) may be the leading pathophysiological mechanisms of swallow syncope in our patient.

Cardiac perforation after an ICD implantation is a rare complication, with a reported incidence between 0.6-5.2%. Its manifestation might be acute, subacute, or delayed, with an acute perforation occurring within the first 24 hours after implantation, frequently accompanied by severe clinical signs, while subacute and delayed perforations have a more benign progression. Here, we report a case of a 69-year old patient with an acute right ventricular perforation by a defibrillator lead migrating all the way through the pericardium and thoracic wall into the left breast, with an unusually mild and benign clinical course, delaying prompt diagnosis and postponing subsequent surgical treatment. Heart perforation with a defibrillator electrode is a rare but dangerous complication, which may lead to pacing failure, cardiac tamponade, cardiogenic shock, and even death. Even with a benign clinical course, one must think of cardiac wall perforation at any time after device implantation, and a contrast enhanced computer tomography (CTA) must be performed if perforation is suspected. At re-implantation, the lead should be located at a different anatomical position within the RV, preferably at the interventricular septal site, and manipulation of the injury site within the RV avoided.

BackgroundThe multifractal approach of HRV analysis offers new insight into the mechanisms of autonomic modulation of the diseased hearts and has a potential to depict subtle changes in cardiac autonomic nervous control not revealed by conventional linear and non-linear analyses in various conditions like heart failure or stable angina pectoris. The aim of this study was to employ the multifractality approach in cardiac surgery patients and evaluate the multifractality before and after beating-heart myocardial revascularization (off-pump CABG). MethodsTwenty-four hour Holter recordings were performed pre- and postoperatively in 60 patients undergoing off-pump CABG. Selected conventional time- and frequency-domain linear HRV indices were calculated from the 24h and 5min ECG segments, and preselected multifractal parameters ?(q=2), ?(q=3), h_top and Δh were determined for daytime (12:00-18:00) and nighttime (00:00-06:00) periods of the ECG recordings using Ivanov?s method. Mean differences over time were tested using paired-samples t-test and exact Wilcoxon matched-pairs test. The results are reported as mean?SD and median with interquartile range. A p value of

Left ventricular noncompaction cardiomyopathy (LVNC) is a rare hereditary cardiomyopathy characterized by the formation of an outer compacted and inner noncompacted layer of the myocardium. The latter is characterized by prominent trabeculations and deep intertrabecular recesses and is functionally inferior to the compacted myocardium. As there is no specific treatment for patients with LVNC who develop heart failure, the management of these patients is limited and many patients progress to advanced stages of the disease. For LVNC patients with advanced heart failure, the data regarding the use of mechanical circulatory support are scarce. We report a case of a 29-year-old patient with LVNC and advanced refractory heart failure, who was successfully bridged to heart transplantation using a long-term continuous-flow left ventricular assist device.

Introduction: The underlying mechanisms of CD34+ cell therapy in patients with non-ischemic dilated cardiomyopathy (DCM) remain poorly defined Hypothesis: We sought to evaluate the effects of CD34+ cell therapy on extracellular matrix. Methods: We performed a cohort analysis of 23 consecutive patients with DCM who underwent transendocardial CD34+ cell transplantation between January and December 2013. All patients received 5-day stimulation with G-CSF; CD34+ cells were selected with apheresis and injected transendocardially guided by electroantomical mapping. Patients were followed for 6 months and good clinical response was defined as an increase of left ventricular ejection fraction (LVEF) ≥5%. Extracellular matrix turnover was evaluated by measuring changes in galectin-3 serum levels. Results: Within 6 months after cell therapy galectin-3 levels decreased in 9 (39%) patients (Group A) and increased in 14 (61%, Group B). The two groups did not differ with regards to gender (male: 100% in Group A vs. 78% in Group B; P=0.15), age (51±10 years vs. 52±11 years; P=0.79), serum creatinine (86±22 μmol/L vs. 82±17 μmol/L, P=0.62), bilirubine (20±11 μmol/L vs. 17±9 μmol/L, P=0.51), or NT-proBNP levels (1465±1448 pg/mL vs. 1380±1626 pg/mL, P=0.72). Baseline LVEF (28±9% vs. 33±7%, P=0.10) and left ventricular end-diastolic diameter (7.1±0.8 cm vs. 6.5±0.7 cm, P=0.22) were also comparable in the two groups. Both groups received comparable doses of CD34+ cells (84±51 million cells in Group A vs. 132±96 million cells in Group B, P=0.21). At 6 months LVEF increased significantly more in Group A than in Group B (9.2±5.1% vs. 3.4±5.2%, P=0.01) and the same was true for 6-minute walk test distance (83±47 m vs. 37±27 m, P=0.03). NT-proBNP decreased in Group A (-356±684 pg/mL), but not in Group B (+449±1040 pg/mL, P=0.07) and overall clinical response was significantly better in Group A than in Group B (responders: 88% vs. 33%, P=0.008). Conclusions: In non-ischemic DCM, clinical response to CD34+ cell therapy appears to correlate with changes in galectin-3 serum levels. This suggests that the effects of CD34+ cell therapy may be partially mediated through remodelling of the extracellular matrix.

BACKGROUND: De-novo ventricular arrhythmias are potentially life-threatening complications after beating-heart revascularization (off-pump CABG). Whether pulmonary hypertension can influence initiation of ventricular arrhythmias through increased sympathetic activity is controversial. In order to determine the influence of pulmonary hypertension on its relative contribution to ventricular arrhythmia, we first had to define the role of cardiac autonomic modulation in patients with pulmonary normotension. We aimed to observe how parameters of linear and nonlinear heart rate variability are changed pre- and postoperatively in patients with pulmonary normotension undergoing off-pump CABG. METHODS: Fifteen-minute ECG recordings were collected before and after off-pump CABG in 54 patients with multivessel coronary artery disease and pulmonary normotension to determine linear (TP, HF, LF, LF:HF ratio) and nonlinear detrended fluctuation analysis (α1, α2) and fractal dimension (average, high and low) parameters of heart rate variability. Arrhythmia was monitored preoperatively in 24-hour Holter recordings and postoperatively by continuous monitoring and clinical assessment. RESULTS: Deterioration from simple (Lown I–II) to complex (Lown III–V) ventricular arrhythmia was observed in 19 patients, and improvement from complex to simple arrhythmia in five patients (P = 0.022). Patients with postoperative deterioration of ventricular arrhythmia had preoperatively significantly lower values of TP, HF and LF (P = 0.024–0.043) and postoperatively significantly higher values on the low fractal dimension index (P = 0.031) than patients with postoperative improvement of arrhythmia. CONCLUSION: Patients experiencing postoperative deterioration of ventricular arrhythmia already have impaired autonomic regulation before surgery. Higher postoperative values on the low fractal dimension index indicate that sympathetic predominance with or without concomitant vagal withdrawal is the underlying neurogenic mechanism contributing to ventricular arrhythmia.

BACKGROUND Advanced nonlinear methods of measuring heart rate variability (HRV) derived from the mathematics of complex dynamics and fractal geometry have provided new insights into the abnormalities of heart rate behavior in various pathologic conditions. These methods have provided additional prognostic information compared with traditional HRV measures and clearly have complemented the conventional linear methods. Knowledge about the behavior of complex cardiac dynamics indices after different cardiac procedures is very limited, however. We aimed to clarify how nonlinear heart rate dynamics are affected by beating-heart revascularization (off-pump coronary artery bypass graft [CABG] surgery) within the first week after the procedure. METHODS Included in the study were 66 patients who had isolated stable multivessel coronary artery disease and were in normal sinus rhythm. The patients were on chronic beta-blocker therapy and were scheduled for off-pump CABG. We performed 15-minute high-resolution electrocardiographic recordings preoperatively and on the third and seventh postoperative days to assess linear and nonlinear heart rate dynamics. Frequency-domain measurements, detrended fluctuation analysis (DFA) with short-term ( 11 beats, alpha2) correlation properties of RR-intervals, and fractal dimension (FD) measurements (average, high, and low) were made. Arrhythmia was monitored preoperatively with 24-hour Holter recordings, postoperatively by continuous monitoring for the first 4 days after the procedure, and subsequently by clinical monitoring; 24-hour Holter recordings were obtained again on the seventh postoperative day. We used the paired-samples Student t test, the Mann-Whitney U test, and the Fisher exact test for statistical analyses. Differences in arrhythmia occurrence before and after the procedure were tested with the Wilcoxon signed rank test and the McNemar test. A P level < .05 was considered statistically significant. RESULTS Values for all frequency-domain parameters decreased significantly after off-pump CABG (P< .001). Values for the alpha1 and high FD parameters decreased significantly after the procedure (P= .028 and .001, respectively), whereas alpha2 increased significantly (P= .023). DFA alpha1 was significantly lower in patients with postoperative atrial fibrillation than in patients remaining in sinus rhythm (mean +/- SD, 0.79+/-0.32 versus 1.13+/-0.45 [P= .003] on the third postoperative day; 0.89+/-0.31 versus 1.22+/-0.34 [P< .001] on the seventh postoperative day), whereas low and average FDs were significantly higher (1.84+/-0.16 versus 1.68+/-0.19 [P= .003] on the third postoperative day and 1.77+/-0.18 versus 1.66+/-0.17 [P= .01] on the seventh postoperative day for the low FD; 1.83+/-0.09 versus 1.76+/-0.10 [P= .011] on the third postoperative day and 1.80+/-0.11 versus 1.73+/-0.10 [P= .014] on the seventh postoperative day for the average FD). The low FD was significantly higher on the third postoperative day in patients with postoperative deterioration of ventricular ectopy than in patients with improved ventricular ectopy (1.74+/-0.17 versus 1.48+/-0.08, [P= .03]). CONCLUSION The decreases in alpha1, average FD, and high FD indicate that a profound decay of cardiac complexity and fractal correlation can be observed after off-pump CABG. Furthermore, a more extensive impairment of nonlinear indices was observed in patients who developed postoperative arrhythmias than in those who remained in stable sinus rhythm. Our findings suggest that the postoperative hyperadrenergic setting acts as a preliminary condition in which both reduced and enhanced vagal activity may predispose patients to arrhythmia, indicating that postoperative rhythm disturbances are an end point associated with divergent autonomic substrates.

Non-linear analyses of heart rate dynamics reveal subtle changes not evident from conventional heart rate variability measures. Traditionally, the information was inferred from 24-hour ECG recordings, making it less suitable for clinical application. Moreover, only few studies have attempted to evaluate the reliability of non-linear analyses in relation to varying proportion of artifacts in tracings. In 67 patients revascularized with beating-heart technique, fractal dimension and detrended fluctuation analyses were obtained from 24-hour Holter and 15-minute high-resolution ECG recordings pre and postoperatively. We found strong correlations of non-linear indices between 24-hour and 15-minute recordings (0.54-0.77, p

Interpretation and evaluation of images obtained by different contrast-enhanced diagnostic tools in patients on extracorporeal membrane oxygenation (ECMO) support can be extremely challenging due to profound pump-related alterations in haemodynamics and contrast media enhancement patterns. We present a case of a 65-year old patient on veno-arterial ECMO with a pseudo-filling defect of the arterial system on contrast-enhanced computed tomography scan, resembling aortic dissection.

Objective Elective minilaparotomy abdominal aortic aneurysm (AAA) repair is associated with a significant number of complications involving respiratory, cardiovascular, gastrointestinal, and central nervous systems, with mortality ranging up to 5%. In our study, we tested the hypothesis that intra- and postoperative intravenous restrictive fluid regimen reduces postoperative morbidity and mortality, and improves the outcome of minilaparotomy AAA repair. Methods From March 2009 to July 2013, 60 patients operated due to AAA were included in a prospective randomized controlled trial (RCT). About the administration of fluid during the operation and in the early postoperative period, all the patients were randomized into two groups: the group of standard fluid administration (S-group, 30 patients) and the group of reduced fluid administration (R-group, 30 patients). The verification of the treatment success was measured by the length of intensive care unit (ICU) stay, duration of hospitalization after the procedure, as well as the number and type of postoperative complications and mortality. This prospective RCT was registered in a publicly accessible database ClinicalTrials.gov with unique Identifier ID: NTC01939652. Results Total fluid administration and administration of blood products were significantly lower in R-group as compared with S-group (2,445.5 mL vs. 3308.7 mL, p = 0.004). Though the number of nonlethal complications was significantly lower in R-group (2 vs. 9 patients, p = 0.042), the difference in lethal complications remained nonsignificant (0 vs. 1 patient, p = ns). The average ICU stay (1.2 vs. 1.97 days, p = 0.003) and duration of postoperative hospital stay (4.33 vs. 6.20 days, p = 0.035 for R-group and S-group, respectively) were found to be significantly shorter in R-group. Conclusion Intra- and postoperative restrictive intravenous fluid regimen in patients undergoing minilaparotomy AAA repair significantly reduces postoperative morbidity, and shortens ICU and overall hospital stay. Even though incidence of lethal complication was lower in R-group, the difference did not reach statistical significance. Therefore, we may assume that this study was probably underpowered to estimate the differences in mortality between R- and S-groups. Further multicentric, sufficiently powered RCTs are needed to confirm these findings and to clarify effect of restrictive fluid management on mortality.

s S61 and at one year follow-up was 5.78 L/min vs. 6.38 vs. 5.88 (p= 0.063), respectively. Despite body size mismatch, recipient-to-donor LVEDD ratio was similar between groups (1.66 in-range vs. 1.86 undersized vs. 1.70 oversized, p= 0.057). Conclusion: We did not detect any difference in outcomes of patients transplanted with undersized or oversized donors. LVEDD was similar between the groups, despite the body size mismatch. Matching recipients and donors by LVEDD may allow expansion of the donor pool for OHT, and reduce OHT wait time.

The incidence of cardiac rupture complicating myocardial infarction has declined since the introduction of thrombolytic therapy. Despite the advances in the management of myocardial infarction, cardiac rupture remains an important cause of death among infarction-related fatalities. We discuss a patient who presented to our hospital with myocardial infarction and who subsequently developed a complex ventricular septal rupture, for which surgical repair was not feasible. Implantation of a CardioWest Total Artificial Heart (SynCardia Systems) allowed for immediate hemodynamic stabilization and served as a bridge to transplantation.

s S181 (‘Culture-graft’); blood samples were obtained for regular blood work, serum VCM concentration measurements and blood culture (‘Culture-blood’). The pocket tissue was also submitted to measurement of local VCM concentration. Results: There was a remarkable infectious response in the group without vancomycin; however, no other groups developed any sign of infection. ‘Culturegraft’ showed MRSA growth only with V0. ‘Culture-blood’ was negative in all groups, and only minimal serum concentrations of vancomycin were detected. Conclusion: One-dose topical administration of VCM via FG was effective against localized MRSA graft infection without systemic VCM administration. Topical administration of antibiotics may help treat difficult graft infections and reduce systemic use of potent antibiotics.

Background Several studies have shown that percutaneous dilational tracheostomy (PDT) is safe and cost-effective for patients recovering from surgery that requires a median sternotomy. We report our experience with PDT in patients receiving mechanical cardiac assistance. Methods We reviewed the medical records of all patients who underwent ventricular assist device implantation at our institution between July 2000 and July 2003, and who subsequently required long-term ventilatory support during the same hospital admission. Data obtained from the records included demographic and biometric information, primary diagnosis, early (≤30days) and late (>30days) complications, date and cause of death, type of anti-coagulation used at the time of tracheostomy, and various coagulation measures. Results Thirty-one consecutive patients (29 men, 2 women; mean age, 56 years) had PDT after ventricular assist device implantation. Four minor complications occurred among 3 of the patients (10%), including 3 early complications (2 peristomal oozing and 1 peristomal cellulitis) and 1 late complication (recurrent peristomal cellulitis), none of which affected long-term outcome. No major adverse events, long-term complications, or deaths resulted from the PDT procedure. Conclusions PDT is feasible for patients with mechanical support devices who require long-term ventilatory support. Although some of these patients are coagulopathic, our results indicate that PDT is safe and effective in this challenging patient population.