Aleksandar Redzek

Aortic Valve Endocarditis

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 &

CABG Mortality is Not Influenced by Prior PCI in Low Risk Patients

An increasing number of patients referred for coronary artery bypass grafting (CABG) have had prior percutaneous coronary intervention (PCI). We sought to determine whether a relationship exists between increased postoperative mortality and morbidity following CABG procedure in patients with prior PCI.

Closure of an atrial septal defect with a one-way flap patch in a patient with severe pulmonary hypertension

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.

An unusual origin of proximal coronary bypass anastomosis in a patient with porcelain aorta: how we solved the problem.

Severe calcification of the ascending aorta (porcelain aorta) is a very difficult condition in cardiac surgery because of a high embolization potential during the process of cannulation, aortic cross-clamping and a particular difficulty to suture the proximal anastomosis. We described a case of a 68-year-old female referred to our Institute due to unstable angina. Further diagnostics revealed a severe high grade, multilevel fibrolipid symptomatic carotid stenosis and ostial left main coronary artery stenosis and a highly calcified ascending aorta and aortic arch. We performed simultaneous carotid segment replacement with the Dacron prosthesis and revascularisation of the left anterior descending coronary artery. Proximal venous anastomosis was created in the Dacron prosthesis of the right carotid artery. Perfusion of the patient was achieved via the graft sutured at the right subclavian artery due to impossibility of direct aortic cannulation.

Cardiac surgery in patients with chronic renal failure

Introduction/Objective Patients with chronic renal failure (CRF) undergoing cardiac surgery are believed to have more postoperative complications and significantly higher mortality rate. The aim of the paper was to determine preoperative predictors of exacerbation of CRF and the outcome in patients with CRF submitted to cardiac surgery. Methods A retrospective study included 169 patients hospitalized from 2012 to 2015 (age 67.71 ± 8.46 years, 72.3% male). The analysis included numerous perioperative characteristics. Results Preoperative stage I CRF was present in 62 (37%), stage II in 77 (46%), and stage III–V in 30 (17%) patients. Exacerbation of CRF was registered in 37 (21.9%), and the lethal outcome in 16 (9.5%) patients. Stage II of CRF (odds ratio [OR] 4.76; 95% confidence interval [CI] 1.31–17.28; p = 0.018) and stage III–V of CRF (OR 11.39; 95% CI 2.87–45.14; p = 0.001) were designated as predictors for exacerbation of CRF following cardiac surgery. In patients with CRF stage I and II, multivariate analysis designated previous cerebrovascular insult (OR 3.36; 95% CI 1.04–10.93; p = 0.044) and ejection fraction ≤ 35% (OR 5.35; 95% CI 1.83–15.64; p = 0.02) as predictors for the exacerbation of CRF. The only predictor of postoperative dialysis requirement was higher stage of CRF (OR 5.81; 95% CI 1.22–27.81; p = 0.028). CRF stage III–V was a predictor of lethal outcome (OR 7.64; 95% CI 1.49–39.27; p = 0.015). Conclusion Higher stage of CRF in patients submitted to cardiac surgery is a predictor of exacerbation of renal failure and the lethal outcome.

eReply re: Atrial septal defect closure with a composite check-valved patch in pulmonary hypertensive patients

pulmonary arterial hypertension associated with congenital heart disease. Circ J 2014;78:4–11. [3] Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2008;52:e143–263. [4] Baumgartner H, Bonhoeffer P, De Groot NM, de Haan F, Deanfield JE, Galie N et al. ESC Guidelines for the management of grown-up congenital heart disease (new version 2010). Eur Heart J 2010;31:2915–57. [5] Robicsek F. Flap-valve closure of ventricular septal defects. Ann Thorac Surg 2006;81:788.

Necessity for introducing the procedure of percutaneous aortic valve implantation in the province of Vojvodina.

INTRODUCTION Percutaneous aortic valve implantation is an alternative that offers hope to patients who are too old or sick to undergo the conventional surgical aortic valve replacement. The aim of this study was to determine the number of high-risk patients with severe aortic stenosis, hospitalized at the Institute for Cardiovascular Diseases, who are the candidates for percutaneous aortic valve implantation. MATERIAL AND METHODS The paper prospectively analyzed all patients diagnosed to have severe aortic stenosis who had been hospitalized at the Institute for Cardiovascular Diseases from April 1st, 2011 to October 31st, 2012. Each of these patients was analyzed in relation to the inclusive criteria for percutaneous aortic valve implantation. We analyzed the distribution of these risk factors in relation to age and gender, and the presence of aortic valve replacement surgery by age groups. RESULTS In the period from April 1st, 2011 to October 31st, 2012, 374 patients diagnosed to have severe aortic stenosis were hospitalized at the Institute for Cardiovascular Diseases. The group of patients older than 80 years had a higher percentage of those patients with low ejection fraction of the heart, chronic pulmonary hypertension and mitral regurgitation. On the other hand, when the total number of surgical aortic valve replacement was taken into consideration with respect to age, there was a significant decrease in their number in the group of patients older than 75 years (41.6%), especially in the age group over 80 years (90.2%). CONCLUSION The data obtained in this study indicate a high percentage of conservatively treated patients with severe aortic stenosis and high operative risk in patients over 75 years. These data confirm the necessity for the implementation of percutaneous aortic valve replacement in the Province of Vojvodina.