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Understanding the mechanisms of augmented bacterial pathogenicity in post-viral infections is the first step in the development of an effective therapy. This study assessed the effect of human coronavirus NL63 (HCoV-NL63) on the adherence of bacterial pathogens associated with respiratory tract illnesses. It was shown that HCoV-NL63 infection resulted in an increased adherence of Streptococcus pneumoniae to virus-infected cell lines and fully differentiated primary human airway epithelium cultures. The enhanced binding of bacteria correlated with an increased expression level of the platelet-activating factor receptor (PAF-R), but detailed evaluation of the bacterium-PAF-R interaction revealed a limited relevance of this process.

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

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

Background: Systemic inflammatory response syndrome (SIRS) may be associated with critically decreased vascular resistance (vasoplegia syndrome) and become resistant to noradrenaline. Such a condition may be successfully treated with intravenous methylene blue., Case Report: A 73-year-old patient with acute myocardial infarction and cardiogenic shock was admitted to our centre after failed percutaneous coronary interventions to the left anterior descending coronary artery and underwent emergency coronary revascularisation. After surgery, his ejection fraction was 25%. X-ray revealed pulmonary oedema. The patient became severely hypotensive with marked vasoplegia and metabolic acidosis, despite incremental doses of adrenaline and noradrenaline. 2 mg kg(-1) of methylene blue was administered, which quickly stabilized the patient's general condition., Conclusion: Methylene blue applied to vasoplegic patients can effectively increase systemic vascular resistance and restore satisfactory organ perfusion.

Transoesophageal echocardiography is an effective tool in visualisation of intrathoracic aorta. It is highly sensitive in diagnosis of aneurysms, atheromas, posttraumatic ruptures, abnormalities of aortic valve, and complications of bacterial endocarditis. It is superior to other methods in diagnosis of aortic dissection. It is rapid, cheap and can be done at the bedside. TEE is especially helpful in patients undergoing cardiac operations. It makes possible the detection of atheromatosis and assessment of plaque morphology in thoracic aorta. In cases with high risk of peripheral embolisation the surgical strategy is changed.

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

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

Background: It has been shown that leukocytes play one of the key roles in the myocardial reperfusion injury., Aim: To examine the effects of cardiac protection with leukocyte-depleted blood cardioplegia on the early outcome of patients with preserved left ventricular function who undergo surgical revascularisation., Methods: The study group consisted of 58 patients with coronary artery disease (CAD) undergoing coronary artery bypass grafting (CABG) who were randomised to receive leukocyte-depleted blood cardioplegia (leukocyte filter Pall BC1B) (group A, n=29) or to receive standard blood cardioplegia (group B, n=29). Peri-operative mortality and morbidity as well as haemodynamical and biochemical parameters were compared between these two groups., Results: No early death occurred. There were no statistical differences in clinical data between the groups. Only cardiac index measured 24 hours after declamping of aorta was significantly higher in group A than in group B (3.6+/-0.6 l/min/m(2) vs 2.95+/-0.45 l/min/m(2), p<0.05). Group B showed significant higher release of creatine kinase (CK) 6 and 12 hours, and CK-MB 6, 12, and 24 hours after unclumping the aorta whereas troponin I level was similar in both groups., Conclusions: The use of leukocyte-depleted blood cardioplegia during elective CABG did not improve the early outcome.

The investigation of etiopathology of arteriosclerosis shows close relationship between inflammatory processes and evolution of sclerotic lesions. In many patients acute coronary syndromes are caused by the rupture of hemodynamically insignificant sclerotic lesion and consequently thrombosis of coronary artery. The reason of instability of sclerotic plaque may be on going inflammation inside it. This paper reviews literature on the subject of relationship of atheromatosis, inflammation and infection.

2-3% of patients after cardiac procedures with the use of cardiopulmonary by-pass develop neurological complications with focal symptoms. Also to there may be mental, emotional and intellectual disturbances. This kind of complications occurs in 33-83% of patients. The post-cardiopulmonary by-pass delirium is a syndrome with diverse symptoms. Confusion, hallucinations, paranoid illusions, psycho-motoric excitation, fear may also occur. A high level of serotonin and overstimulation of 5-HT2 receptors in the central nervous system are the reason of delirium. The relief of symptoms may be achieved by intravenous administration of Ondansetron, an antagonist of 5-HT2 receptors.

The risk of blood loss in open heart surgery procedures is related to a high level of homologous blood transfusion. Due to numerous possible complications connected with transfusion, as well as the increase in prices of blood preparations, methods of blood saving are of great interest. The aim of the study was to assess acute normovolemic hemo-dilution (ANH) efficacy and aprotinin administration in homologous blood usage limitations. The study was conducted in the group of 265 patients operated on during the period of 12 months. The control group consisted of patients operated on during the period 6 months. The scheme of ANH with the administration of aprotinin was applied in the second half-year period. A statistically significant reduction in the percentage of patients who required blood transfusions was observed (77.2%/53%). The scheme applied enabled to reduce procedure costs in regard to blood preparation purchase. The results have shown that ANH together with antifibrinolytic drug administration is not only an efficient but also profitable strategy of blood saving.

A key component in the development of ischemic functional and structural myocardial injury during cardiosurgical procedures is an inadequate cellular energy supply which occurs as a consequence of the cessation of oxidative metabolism. In such conditions high energy phosphates are rapidly depleted. As they play a critical role in the maintenance of cell viability and postischemic recovery of contractile function, their conservation is therefore a primary objective in any procedure designed to reduce ischemic injury. Exogenous administration of phosphocreatine (CP) has been suggested as being beneficial to the ischemic heart. The aim of present study was to evaluate the possible cardioprotective effect of exogenous CP during coronary artery surgery (CABG). Forty patients undergoing CABG procedure were randomly assigned to receive creatine phosphate-enriched (group I) or standard-St. Thomas' Hospital (group II) cardioplegic solution; each group comprised 20 patients. Group I received: 6.0 g of exogenous CP (Neoton) daily in two 20-min intravenous infusions during 3 days preoperatively; during surgical procedure they were administered standard cardioplegic solution enriched in CP at the concentration of 10 mmol/l and -- 2 days postoperatively -- 4.0 g CP daily in two intravenous injections. Group II did not receive CP at all In both groups were analysed. Haemodynamic parameters. Continuous 48-h ECG recording (Holter monitoring) outcome. Laboratory values of serum CK and CK-MB. Inotropic support required (drugs, mechanical support). Ultrastructural findings (biopsy data). Statistical analysis was carried out using Student's "t"-test and the chi2 test. Values of p<0.05 were taken as the criterion of significant difference. The results of the study were: Significantly lower average number and energy of DC-shocks needed to restore cardiac function after cardiopulmonary bypass procedure in group 1. Statistically significant beneficial effect on the presence of ventricular arrhythmias during surgery and in early postoperative period in group I. Significantly lower requirements for inotropic drugs postoperatively in group I. Statistically significant lower degree of sarcolemmal damages in myocardial biopsies in group I. Concluding, the authors wish to state that: Exogenous phosphocreatine (Neoton) perioperative administration in coronary artery bypass patients reduced the need for inotropic drugs, which is clinically manifested in lower frequency of low cardiac output syndrome. Perioperative administration of exogenous CP improves electrophysiological stability of the myocardium. Advantageous clinical and electrophysiological effect of exogenous CP may result from its properties to protect sarcolemma of the cardiomyocytes.

An unusual case of cyanotic heart disease in a 20-year-old male has been presented. Cyanosis was due to right to left shunt through direct right pulmonary artery--left atrium fistula. After successful operative ligation of the fistula, the patient got rid of cyanosis and is doing well.

Emergency coronary bypass for cardiogenic shock has been associated with a high operative mortality. From February 1986 through October 1989, 40 patients with acute myocardial infarction were operated. Ten pts (25%) were in shock despite intensive treatment (intra-aortic balloon pump in 4, catecholamines in 10). Seven pts. required cardiopulmonary resuscitation before operations. After operations 66% of the patients required catecholamine support and 60% were treated with intra-aortic balloon pump. There were three (30%) hospital deaths (one in the operating room due to acute cardiac failure). Follow-up (100%),(mean 26 months) revealed one late death--39 months after operations. In functional class I were 2 patients, II--one, and III--two pts. One pt is in group IV (transplant candidate). Myocardial infarction complicated by cardiogenic shock can produce a mortality rate in excess of 85%. Contemporary medical management has had little effect on mortality, hence effective surgical therapy has evolved for this lesion.