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Introduction. If young women with congenital heart disease need heart valve surgery, it is necessary to thoroughly consider the choice of the valve and the risks of serious complications during pregnancy. Case Report. We report a case of a woman who presented with a pregnancy complicated by mechanical aortic valve thrombosis at the end of the first trimester. After a thorough evaluation by a multidisciplinary team, the patient underwent surgical thrombectomy and normal mechanical valve function was restored. At 36 weeks of gestation, planned cesarean section was performed. The mother and the child remained well during the 5-year follow-up. Conclusion. Mechanical heart valves in pregnancy carry a very high risk of complications. An individualized approach is needed in the management of women with mechanical valves, as well as uniform antenatal care in centers that provide complete care from pregnancy planning to delivery.

Objectives Acute kidney injury (AKI) is associated with higher perioperative mortality and morbidity. Oxidative stress has been proposed as a cause of postoperative AKI. Ascorbic acid (AA) supplementation was suggested as a novel and promising antioxidant. The aim of this study was to evaluate the capability of AA to reduce the incidence of postoperative AKI in cardiac surgery patients. Methods A prospective randomized trial was conducted in patients scheduled for on-pump cardiac surgery. Subjects in the AA group received 2 g of AA intravenously during the induction of anesthesia, 2 g before aortic cross-clamp removal and 1 g every 8 hours for five postoperative days (the JERICA protocol). Postoperatively, the patients were monitored for AKI and other complications. Malondialdehyde levels were monitored in a subpopulation of 100 patients to evaluate the effect of AA on oxidative stress level. Results The AA and control group consisted of 163 and 169 patients, respectively. The groups were well matched for baseline demographics and had similar intraoperative characteristics. The incidence of AKI in the AA and control group was 20.9 and 28.4%, respectively (p = 0.127). The estimated glomerular filtration rate did not differ between the study groups in the entire postoperative period. There was a trend toward higher malondialdehyde values with statistical significance on postoperative day 1 and lower in-hospital mortality in the AA group (0.6 vs. 4.1%, p = 0.067). Conclusion Our results do not support the effectiveness of AA supplementation in reducing the incidence of postoperative AKI in on-pump cardiac surgery patients. Clinical Registration Number This study was registered with the ISRCTN Registry under the trial registration number ISRCTN98572043.

SUMMARY Cardiac surgery-associated acute kidney injury (CS-AKI) is a major complication associated with increased morbidity and mortality. There are multiple diagnostic criteria for CS-AKI. Despite many new investigations available for improved AKI diagnostics, creatinine and urea remain the cornerstone of diagnostics in everyday clinical practice. There are three major pathophysiological mechanisms that contribute to kidney injury, i.e. renal hypoperfusion, inflammation with oxidative stress, and use of nephrotoxic agents. Some risk factors have been identified that can be modified during the course of treatment (use of nephrotoxic agents, duration of cardiopulmonary bypass, type of extracorporeal circulation, postoperative low cardiac output or hypotension). The aim of AKI prevention should always be to prevent aggravation of renal failure and, if possible, to avoid progression to renal replacement therapy, which in turn brings worse long-term outcomes.

Introduction/Objective. Stanford type A aortic dissection is a surgical emergency associated with high mortality. The aim of this study was to determine which group of patients and which characteristics were associated with postoperative, in-hospital mortality. Methods. The retrospective study included 116 patients with type A aortic dissection surgically treated over a five-year period. The association between postoperative, in-hospital mortality and patient characteristics was examined. Results. Total postoperative, in-hospital mortality was 22.4% (26 out of 116 patients). The variables that, after a multivariate analysis, showed a direct correlation with mortality were as follows: admission creatinine value [OR 1.026 (1.006?1.046), p = 0.009], C-reactive protein (CRP) > 10 mg/L [OR 4.764 (1.066?21.283), p = 0.041], and stroke [OR 6.097 (1.399?26.570), p = 0.016]. The receiver operating characteristic (ROC) curve showed that creatinine could be a good predictor of mortality (area under the ROC curve = 0.767; p < 0.0005). The cut-off point was 124.5 ?mol/L. The sensitivity was 65% and the specificity was 80%. The cut-off point for CRP was 14.5 mg/L ? sensitivity 71.4%, specificity 75% (area under the ROC curve = 0.702, p = 0.021). Conclusion. Surgery for type A aortic dissection is still associated with relatively high mortality. A lower chance of survival may be indicated by elevated admission creatinine and CRP values, as well as stroke.

Introduction. Coronary embolism can rarely be a cause of myocardial infarction. It is usually associated with atrial fibrillation, dilated cardiomyopathy, bacterial endocarditis and underlying hypercoagulable state, as well as heart surgery. Case report. We reported a case of a patient with severe mitral and tricuspid regurgitation, with no underlying coronary artery disease. The patient underwent heart valve surgery, and the immediate postoperative course was uneventful. Five days after the operation, the patient sustained cardiac arrest, which was followed by a successful cardiopulmonary resuscitation. Electrocardiography showed atrial fibrillation with a significant ST segment elevation in the inferior leads. Urgent coronary angiography revealed a total occlusion of the right coronary artery, thus percutaneous coronary intervention was performed, after which flow restoration through the artery was achieved. The patient was discharged with triple antithrombotic therapy on the 20th postoperative day. Conclusion. Heart surgery could be followed by unexpected and potentially fatal complications, coronary embolism being one of them. In such case, the prompt and adequate reaction by the whole medical team is crucial for a patient's survival and recovery.

Introduction. Partial atrioventricular septal defect (AVSD) is a form of congenital heart disease (CHD) rarely detected in adults. Infective endocarditis represents a severe complication that carries a substantial risk. Case report. We here reported a case of a 43-year-old female with previously diagnosed adult CHD (partial AVSD and bicuspid aortic valve) presented to the hospital with fever and malaise 14 days prior to admission. On the lung computed tomography scan inflammatory consolidations were found and dual antibiotic therapy (ceftazidime and clarithromycin) was administered without significant regression of pulmonary inflammatory consolidations. The antibiotic treatment was continued with amoxicillin/clavulanic acid combined with levofloxacin and metronidazole. Transthoracic and transesophageal echocardiography revealed a large vegetation (dimension, 3.6 x 1.8 cm) attached to the septal leaflet of the tricuspid valve floating between right atrium and right ventricle through tricuspid valve with high embolic potential. Endocarditis team reached a decision for immediate surgical intervention. The operative findings revealed the partial AVSD, common atrioventricular valve with cleft of the anterior mitral leaflet in the A2 segment and detached and cleft septal leaflet of the tricuspid valve. Vegetation (size 4 x 3 cm) was attached to the septal side of the tricuspid annulus, basal segment of the anterior mitral leaflet and edge of the atrial septal defect freely floating between right atrium, right ventricle and left atrium. Excision of the vegetation and AVSD plastics were done, as well as the reconstruction of the mitral and tricuspid annuli and leaflets. The treatment was continued with antibiotics and completed in 18 days with full recovery. Conclusion. Early and precious diagnosis and optimal management that combines both conventional and surgical approaches are crucial for reducing the risk of complications and mortality in patients with infective endocarditis in grown-up congenital heart disease.

BACKGROUND There were gaps between guidelines and practice when surgery was the only treatment for aortic stenosis (AS). OBJECTIVES This study analyzed the decision to intervene in patients with severe AS in the EORP VHD (EURObservational Research Programme Valvular Heart Disease) II survey. METHODS Among 2,152 patients with severe AS, 1,271 patients with high-gradient AS who were symptomatic fulfilled a Class I recommendation for intervention according to the 2012 European Society of Cardiology guidelines; the primary end point was the decision for intervention. RESULTS A decision not to intervene was taken in 262 patients (20.6%). In multivariate analysis, the decision not to intervene was associated with older age (odds ratio [OR]: 1.34 per 10-year increase; 95% CI: 1.11 to 1.61; P = 0.002), New York Heart Association functional classes I and II versus III (OR: 1.63; 95% CI: 1.16 to 2.30; P = 0.005), higher age adjusted Charlson comorbidity index (OR: 1.09 per 1-point increase; 95% CI: 1.01 to 1.17; P = 0.03), and a lower transaortic mean gradient (OR: 0.81 per 10-mm Hg decrease; 95% CI: 0.71 to 0.92; P < 0.001). During the study period, 346 patients (40.2%, median age 84 years, median EuroSCORE II [European System for Cardiac Operative Risk Evaluation II] 3.1%) underwent transcatheter intervention and 515 (59.8%, median age 69 years, median EuroSCORE II 1.5%) underwent surgery. A decision not to intervene versus intervention was associated with lower 6-month survival (87.4%; 95% CI: 82.0 to 91.3 vs 94.6%; 95% CI: 92.8 to 95.9; P < 0.001). CONCLUSIONS A decision not to intervene was taken in 1 in 5 patients with severe symptomatic AS despite a Class I recommendation for intervention and the decision was particularly associated with older age and combined comorbidities. Transcatheter intervention was extensively used in octogenarians. (J Am Coll Cardiol 2021;78:2131-2143) (c) 2021 by the American College of Cardiology Foundation.

Introduction. The incidence of aortic dissection ranges 3?5 cases per 100,000 person-years. In women under the age of 40 who acquire aortic dissection, almost half of the cases happen during pregnancy. Case outline. We report a case of a 22-year-old pregnant woman in the 16th gestational week with a history of arterial hypertension and known aortic dilatation, who was admitted with aortic dissection. She underwent the Bentall procedure, in which her aortic valve, ascending aorta, and proximal part of the aortic arch were replaced using valved composite graft. On the next day, the evacuation abortion was made, since the fetus didn?t survive the operation. Six years later, the patient stopped taking anticoagulation therapy and was admitted for prosthetic valve thrombosis, which was successfully treated with intravenous heparin. One year later, the patient died of a myocardial infarction due to coronary thromboembolism, confirmed on autopsy. Conclusion. Preconceptional counseling in women with a known aortic disease is of the utmost importance. Aortic dissection in pregnant women is an acute life-threatening condition for both mother and fetus that should be managed by a multidisciplinary team. After a mechanical heart valve implantation, lifetime oral anticoagulants are mandatory.

We report the case of a 62-year-old male patient, admitted for aortic valve replacement. Bilateral common carotid artery occlusion and bilateral internal carotid artery occlusion have been reported, as well as right vertebral artery occlusion. Aortic valve replacement was performed in the standard fashion using the cardiopulmonary bypass. No neurological deficit was apparent on emergence from anesthesia. Keywords: bilateral carotid occlusion, the vertebral artery occlusion, cardiac surgery

A persistent left superior vena cava is relatively common venous anomaly. But, the presence of persistent left superior vena cava with the atresia of the right superior vena cava is a much rarer situation. The association of these anomalies with the drainage of the left hepatic vein into the right atrium is an extremely rare situation. Here we present one such case in the situs solitus and normocardia.

The idea of isolated organ perfusion, a precursor of cardiopulmonary bypass, came by Legalois in 1812. First isolated organ perfusion was described by Loebell in 1849. The first closed system for oxygenation and returning the blood through arteries was created by Frey and Gruber in 1885. Gibbon Jr. is considered the father of extracorporeal circulation. In spring of 1934 he began constructing a machine for extracorporeal circulation in Boston. He published the first description of this system in 1937. Gibbon won the grant of the International Business Machines Corporation for developing the machine in 1947. Together they developed Model I in 1949 and Model II in 1951. After a few unsuccessful attempts in 1952, the first successful surgical intervention on the heart (closure of atrial septal defect) using cardiopulmonary bypass was performed on May 6, 1953. In 1945, Kirklin and his working group reported on a series of eight successfully treated patients in a row who underwent surgery with extracorporeal circulation. First successful valve surgery under the direct vision was performed by Dodrill in 1952, using his ?Michigan Heart? machine as a right heart bypass. Using cardiopulmonary bypass, cardiac surgeons can deal with the complex cardiac pathology and save millions of lives.

Introduction. Intramural hematoma of the aorta presents potentially fatal condition developing as a result of a vasa vasorum rupture. It is a major risk factor for developing a frank aortic dissection. Case Outline. A 65-year-old woman was admitted to our clinic for the second time, after her symptoms of chest pain and vertigo (with no electrocardiographic signs of myocardial infarction) hadn?t disappeared after several months of medicament treatment (indicated in the first hospitalization). Computed tomography arteriography of the aorta showed no sign of acute aortic dissection, but revealed a contrast depo in the aortic wall of 8 ? 14 mm dimensions, with no extravasation of contrast. Also, massive pericardial effusion was observed (10-30 mm in thickness). Transesophageal echocardiography confirmed these findings completely. The patient underwent surgery, in which plaque exulceration was detected on the convex side of the ascending aorta, 3 cm above the aortic valve, 1 cm in diameter, with no signs of intimal tear. A resection of the ascending aorta was performed, and the aorta was reconstructed with a 30 mm Dacron tube graft. The patient was discharged on the 14th postoperative day with satisfactory results. Conclusion. Intramural hematoma is not a common event, but it is potentially a fatal one. Open surgery in patients with an intramural hematoma is an effective treatment strategy, although percutaneous endovascular treatment options are being described.

An isolated atrial septal defect (ASD) can occasionally go unrecognized for decades and accounts for 25-30% of congenital heart disease cases diagnosed in adulthood. Pulmonary hypertension often develops as a result of a long-lasting, left-to-right shunt and may ultimately be associated with a fixed increase of pulmonary vascular resistance, sometimes rendering these patients inoperable. To reduce the risk of developing postoperative morbidity and possible mortality, we employed our technique of a unidirectional valved patch for the closure of ASD.

This chapter presents a case study of a toxic Planktothrix rubescens bloom in the Serbian reservoir Vrutci used as the water supply for the city of Užice. Chemical cyanotoxin analyses were supplemented by Artemia salina bioassays, a questionnaire directed to the inhabitants of Užice, and epidemiological work. The overall aim of the studies was to assess the potential human health impacts of the toxic bloom.

Background/Aim. Postoperative nonlethal complications after open heart surgery are a serious clinical problem causing a considerable engagement of health workers, an augmented use of drugs, and prolonged operation incapacity leading to prolonged hospital stay and increased expenses. The aim of the study was to establish whether there is any correlation between the level of expected operative risk and postoperative nonlethal complications. Methods. A consecutive series of 853 patients subjected to the open heart surgery were investigated, 622 (73%) males and 231 (27%) females. The average age of the patients was 57.2 ? 9.9 (16-81) years. The patients were divided into 3 groups according to the additive EuroSCORE model: groups I, II and III with the expected operative risk of 0%-2%, 2%- 5% and over 5%, respectively. The data were collected prospectively and analyzed retrospectively. Statistical methods of correlation and t-test were used. Results. A high degree of correlation between the operative risk level and frequency of postoperative nonlethal complications (R = 0.98) was found. The average rate of complications was 24% for the whole group of 853 patients. It accounted for 21%, 29% and 47% in the groups I, II and III, respectively. According to the expected operative risk level there was a statistically significant difference in respect of heart arrhythmias (p = 0.02), neurologic complications (p = 0.002), and pulmonary complications (p = 0.009). Conclusion. Our results show a high degree of correlation between the expected level of operative risk according to the EuroSCORE model and the frequency of postoperative nonlethal complications. There is a statistically significant difference in respect to frequency of heart rhythm disturbances, pulmonary and neurological complications and expected operative mortality.

During the last several years many authors have found that the European System for Cardiac Operative Risk Evaluation is useful in the prediction of not only postoperative mortality but also of the length of stay in the intensive care unit, complication rate and overall treatment expenses. This study included 329 patients who had undergone isolated surgical myocardial revascularization at our Department during the period from January 1st to June 6th, 2008. For the operative risk evaluation, the additive European System for Cardiac Operative Risk Evaluaion was used. In group I (low risk 0-2%) there were 144 patients (43.7%), whereas group II (medium risk 3-5%) and group III (high risk ? 6%) included 141 (42.8%) and 44 (13.4%) patients, respectively. The length of stay in the intensive care unit was 25.56, 32.43 and 49.59 hours for groups I, II and III, respectively. The difference in the mean length of stay in the intensive care unit between the groups was highly statistically significant (p

Introduction. Quality of life assessment and survival analysis are a "gold standard" in assessing treatment quality in general. In the absence of a universally accepted integral index, we developed our own QOLi-NS (Quality of life index - Novi Sad) as a disease specific index. The aim of this study was to investigate long-term survival and quality of life after myicardial revascularization with respect to sex and age. Material and methods. The study included 563 coronary patients operated on at the University Clinic of Cardiovascular Surgery in Sremska Kamenica, in the period from September 1, 1995 to June 1, 1998. The patients were divided into two groups with respect to sex and age; two age categories were defined: younger and older than 65 years of age. Quality of life was evaluated using Integral quality of life index QOLi - NS. Actuarial life table was used to establish the survival curve. Results. After myocardial revascularization, all investigated patients demonstrated a considerable improvement in quality of life with statistically significant differences with respect to age and sex. The highest postoperative quality of life (QOLi-NS), and the best survival rate were found in male patients and in patients younger than 65 years. Conclusion. The gathered data confirmed a significant improvement in quality of life and survival rate after myocardial revascularization in all groups of patients. A statistically significant difference in survival rate was determined with respect to the patients age. Improved quality of life in patients older than 65 years proved that myocardial revascularization is a good therapeutic option for these patients. .

Coronary artery disease is the leading cause of death worldwide. Hereditary and environmental factors have a strong impact on coronary artery disease development. The exact incidence of this disease and its characteristics among identical twins is unknown. Despite a limited amount of documented cases, several characteristics can be drawn: coronary artery disease is expressed at an early age, the onset of symptoms occurs within a short time span between the twins, the coronary pathology is often very similar and the metabolic and biochemical profiles are generally alike. We present a case of identical male twins with a near simultaneous clinical presentation of coronary artery disease, who initially underwent unsuccessful percutaneous coronary intervention due to chronic total occlusion and finally, coronary artery bypass grafting. In the case of identical twins, it is imperative to aggressively screen the asymptomatic twin of the symptomatic patient irrespective of young age or absence of symptoms.

Quadricuspid aortic valve, a rare congenital anomaly, is often related to severe aortic regurgitation and has a significant morbidity. The first described case was reported in 1862. Quadricuspid aortic valve is, in most cases, an isolated malformation, but it can be associated with other concomitant anomalies. We present here the case of a quadricuspid aortic valve discovered by intraoperative transesophageal echocardiography and successfully replaced with a mechanical aortic valve.

Infective endocarditis (IE) is an endovascular infection of cardiovascular structures – usually valves – but also large intra-thoracic vessels and intra-cardiac foreign bodies. It is typically caused by bacteria or fungi. In contrast, sterile thrombotic lesions are termed non-bacterial thrombotic endocarditis (NBTE). IE is generally characterised by lesions of vegetations composed of platelets, fibrin, microorganisms, and inflammatory cells, as well as leaflet disruption to a various degree. Endocarditis may also produce a wide variety of systemic signs and symptoms due to sterile and infected emboli, as well as various immunological phenomena. IE is a fatal disease if left untreated (Horstkotte et al., 2004). Characterising aspects of IE were first described by Jean Francois Fernel in his book Medicini in 1554. Lazaire Riviere followed suit with gross autopsy findings of the disease in 1723 after which, in 1852, Kirkes described emboli arising from heart valves in cerebral, renal, splenic and other arteries. Although several reports of IE have been published since – some from well-known physicians like Morgagni and Virchow, it was not until 1885 that IE was comprehensively documented when Sir William Osler accumulated various works and presented them to the public in the form of the comprehensive analysis of this disease (Millar & Moore, 2004). Despite substantial improvements in diagnosis and treatment of native valve IE, disease incidence is on an increase currently averaging 3.3 new cases each year per 100,000 population in the United Kingdom, similar figures in the United States, and 1.4 to 4 new cases over the same population in European countries (Bashore et al., 2006). Native valve IE continues to be associated with high morbidity and mortality rate. Even though IE was previously associated with poor dentition and rheumatic heart disease, many factors have altered its epidemiology but have maintained its incidence: an aging population with degenerative valvular disease, injection drug use, increasing number of valve replacements, and medical interventions i.e. invasive vascular procedures (Wang & Bashore, 2009). Several variants to valve endocarditis have also been recognized: nosocomial IE, intravenous drug abuse IE, and prosthetic valve endocarditis (PVE). Nosocomial infective endocarditis is defined as acute IE, occurring 48 to 72 hours or more post-admission to hospital, or endocarditis directly related to a hospital-based procedure performed during a prior hospital visit within eight weeks of admission (Haddad et al., 2004). Intravenous drug abuse IE most commonly affects tricuspid valve and is associated with no previous structural damage of the valve. PVE accounts for 10-20% of cases. Incidence of PVE is reported to be most often between 0.2 and 0.8% for each year of life with an implanted valve (Dominik &

Introduction. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) was developed in order to predict operative risk in cardiac surgery and to assess the quality of the cardio-surgical care. Introduction of the uniform terminology in result evaluation process leads to the significant improvement in measuring and evaluation of surgical treatment quality. Objective. The aim of the study was to evaluate our results in isolated coronary surgery using the EuroSCORE. Methods. The study was done respectively by analyzing predicted mortality according to the EuroSCORE model and observed operative risk in 4,675 coronary patients operated at our Clinic during the period 2001-2008. For statistical analyses, the Pearson, Chisquare and ANOVA tests were used. Results. The total postoperative mortality predicted by the EuroSCORE was 2.9±2.25, while the observed one was 2.2%. When the scoring system and observed results were compared over the years, a considerably lower observed mortality was found during the last 4 years. Overall average number of distal anastomoses was 2.62±0.84. During the period 2004-2008, the average number of coronary anastomoses increased over the years reaching the value of 2.77±0.88. The difference is at the level of statistical significance with the trend of further increase. Percentage of the patients with single or double graft myocardial revascularization decreases, while the number of the patients with triple or more bypasses increases. Conclusion. During the last years, the results in isolated coronary surgery have considerably improved. The EuroSCORE overestimates operative risk. In order to improve its predictive value, the model should be recalibrated.

Background During the last decade many authors find that European Systems for Cardiac Operative Risk Evaluation (EuroSCORE), additive and logistic models, overestimate risk in cardiac surgery. The new EuroSCORE II has been recently introduced as an update to previous versions. The aim of the study: to investigate the prognostic value and discriminatory power of the additive and logistic EuroSCORE, and the EuroSCORE II.