Andreas Borowski

Stroke as a first manifestation of ovarian cancer

Background: Gynaecologic neoplasms are reported to have the highest potential for developing of ischemic stroke.Objectives: The history of a female patient, in whom recurrent cerebral embolism was the first clinical sign of occult ovarian neoplasm is described and the casuistic literature to characterise this clinical phenomenon reviewed.Results: Among a large spectrum of neoplasms complicating with ischemic stroke, ovarian carcinoma is one of the most frequently reported in the casuistic literature. The source of systemic microembolisation is endocardits of non-infectious origin; the characteristic diagnostic findings are thrombocytopenia, elevated D-dimers level, and a specific stroke pattern in magnetic resonance imaging.Conclusion: Meticulous diagnosis in female, otherwise ‘healthy’ patients with ischemic stroke, to detect the underlying neoplastic disease is of paramount importance, as early surgical intervention on cancer promises successful therapy for both, cancer and thromboembolism.

Coronary artery disease progression in patients who need repeat surgical revascularisation: the surgeon's point of view.

Objective The purpose of this study was to evaluate changes in native coronary arteries in patients undergoing repeat myocardial revascularisation late (>3 years) after primary coronary artery bypass grafting (CABG). Methods The angiographic images of 30 patients obtained at first and redo CABG were assessed for significant (>75%), short (<1 cm) and long (>1 cm) stenosis or total occlusion in native coronary arteries. Bypass grafts were also evaluated for significant stenosis (>50%) or occlusion. Results At first CABG, a mean number of 3.3 grafts/patient (range 1–5) were implanted. The mean time interval from first CABG to reoperation was 11.4 years (range 3–21 years). All patients showed disease progression in the native coronary arteries. At redo CABG, 3 (3.5%) grafts were non-stenotic, 27 (31%) stenotic, and 57 (65.5%) occluded. In native coronary vessels, five patients developed a new left main coronary artery stenosis, and there was a four-to-six-fold increase in total occlusions. Indications for redo CABG were disease progression in non-bypassed vessels (n = 3), bypass lesions (n = 19), and both bypass lesions and disease progression in the distal segments of native coronary arteries (n = 8). Conclusions Late after CABG, coronary artery disease is highly progressive, mainly affecting the proximal segments of native coronary arteries, with a high incidence of coronary occlusion. Conversely, a low incidence of disease progression is observed in the distal segments of native coronary arteries, except in diabetic patients. Total arterial revascularisation as a primary strategy for CABG should be highly recommended, and more aggressive risk factor management is desirable.

Surgery for severe aortic stenosis with low transvalvular gradient and poor left ventricular function – a single centre experience and review of the literature

BackgroundA retrospective comparative study was designed to determine whether the transvalvular gradient has a predictive value in the assessment of operative outcome in patients with severe aortic stenosis and poor left ventricular function.MethodsFrom a surgical database, a series of 30 consecutive patients, who underwent isolated aortic valve replacement for severe aortic stenosis with depressed left ventricular (LV) function (EF < 40%), were enrolled in the study and divided into two groups according to the mean transvalvular gradient (TVG): LG(low gradient)-Group < 40 mmHg (n = 13), and HG(high gradient)-Group > 40 mmHg (n = 17). Both groups were then comparatively assessed with respect to perioperative organ functions and mortality.ResultsBoth groups were well matched with respect to the preoperative clinical status. LG-Group had a larger aortic valve area, higher LVEDP, larger LVESD and LVEDD, and higher mean pulmonary pressures. The immediate postoperative outcome, hospital morbidity and mortality did not differ significantly among the groups.ConclusionIn patients with severe aortic stenosis and poor LV function, the mean transvalvular gradient, although corresponds to reduced LV performance, has a limited prognostic value in the assessment of surgical outcome. Generally, operating on this select group of patients is safe.

Intermittent Cold-Blood Cardioplegia and Its Impact on Myocardial Acidosis during Coronary Bypass Surgery.

BACKGROUNDnThe purpose of the study was to assess the degree of myocardial acidosis in patients undergoing elective coronary bypass surgery, in whom intermittent cold-blood cardioplegia (ICBC) was used for myocardial protection. The results of this study are presented in comparison to those of a previous trial conducted by the same investigators, using a similar methodology, but with intermittent warm-blood cardioplegia (IWBC).nnnPATIENTS AND METHODSnIn 15 patients undergoing elective myocardial revascularization with ICBC for myocardial protection, metabolic changes of global ischemia indicators, lactate and pH values (measured simultaneously in coronary sinus and arterial blood) were analyzed. Lactate concentrations and pH values were measured at the beginning and the end of each cardioplegia administration, and the change-overtime analysis of the values was performed. For comparison with the results of the previous study (IWBC method) consisting of 12 patients, the analysis of variance with repeated measurements, including tests for a crossover, group, and time effect were used.nnnRESULTSnUsing the ICBC method, as compared with IWBC, no significant difference in the lactate production was observed during the first two successive cardioplegia administrations. During the third and fourth administrations, especially at the end of reperfusions, ICBC patients had a significantly lower lactate release and higher pH values, as compared with IWBC patients.nnnCONCLUSIONnOur results suggest that ICBC has an inhibiting effect on potentially progressive myocardial acidosis during cross-clamp period.

Calcium Pyrophosphate Dihydrate Crystal Deposition Disease of the Sternoclavicular Joint.

Deposition of calcium pyrophosphate dihydrate (CPPD) crystals in the articular structures affects predominantly temporomandibular, knee, hip, spine, and wrist joints, and is a rare condition, often mimicking malignancy. Sternoclavicular joint is extremely rarely involved. We present a patient with swelling of the right upper extremity, in whom on computed tomography a mass posterior to the sternoclavicular joint causing compression of the brachiocephalic vein was detected. A modified resection arthroplasty was performed, and the histopathological findings revealed massive deposits of CPPD in the articular cartilage. To our knowledge, there is only one similar case published in the literature.

Surgical decision making for revascularization of chronically occluded right coronary artery.

ObjectiveChronic totally occluded right coronary artery (CTO-RCA) often poses a problem in decision making for/against bypass grafting due to the lack of standardized indication criteria. The aim of the study was to investigate whether qualitative angiograms can be useful in decision making for/against surgical revascularization of CTO-RCA.MethodsA retrospective cohort study was conducted with 69 patients who underwent elective CABG procedure, including single graft to the RCA. The distal run-off of the bypassed RCA was measured intraoperatively using the ultrasonic transit-time method. As a primary endpoint of the study, the flow values were analysed in regard to diameter of the recipient artery. As a secondary endpoint, the correlations between the regional and global LV function, Rentrop grading, type of collateral pathway, number of donor sources, comorbidity, and the graft flow and the diameter of the recipient artery were investigated using uni- and multi-variate regression analyses.ResultsIn general, the flow values correlated significantly with the diameter of the recipient artery. Significantly lower flow (pxa0<xa00.0001) and diameter values (pxa0<xa00.05) were found in hypo/akinetic and infarcted area reflecting functionality of the CTO-RCA territory.ConclusionsThe qualitative angiograms combined with regional wall motion studies can be useful in decision making for revascularization of CTO-RCA. Revascularization of akinetic/infarcted CTO-RCA territory is associated with lower graft flows even in patients presented with high Rentrop class and high degree of collaterality, suggesting necessity of viability tests prior to bypass surgery.

Intermittent cold-blood vs. warm-blood cardioplegia – a comparative study on myocardial acidosis during coronary bypass surgery

The aim of the study was to assess the impact of the intermittent cold-blood cardioplegia (ICBC) on myocardial acidosis in comparison to the warm-blood cardioplegic administration (IWBC) in patients undergoing coronary bypass surgery. n nIn 15 patients undergoing elective bypass surgery with ICBC for myocardial protection, metabolic changes of global ischemia indicators with lactate and pH values, measured simultaneously in the arterial and coronary sinus blood, were analyzed and compared with those observed when warm-blood method was used. For comparison, the analysis of variance with repeated measurements including tests for a cross-over effect of group and time was used. n nIn patients with ICBC compared to IWBC, the lactate production as well as degree of acidosis were generally lower with a significant group effect for both, lactate and pH values measured at the end of reperfusions. Our results suggest that ICBC has an inhibiting effect on potentially progressive myocardial acidosis during cross clamp period.

Surgery for bacterial endocarditis associated with bacteria of oral/dental origin – characteristics of the “typical host” and implications for prevention

Results Significant differences between the groups were found regarding poor oral health, metabolic syndrome and dental treatment with a higher incidence in Group A. In Group A, majority of cases had left-sided endocarditis (79%); in Group B, 63% of patients were diagnosed with left-sided-, 30% with left-and-right-sided-, and 7% with right-sided-endocarditis. The in-hospital mortality was 0% vs. 26% in Group A and Group B, respectively.