Anna Marcinkiewicz

Sarcomas of the heart as a difficult interdisciplinary problem.

Cardiac tumors are assumed to be a rare entity. Metastases to the heart are more frequent than primary lesions. Sarcomas make up the majority of cardiac malignant neoplasms. Among them angiosarcoma is the most common and associated with the worst prognosis. Malignant fibrous histiocytoma comprises the minority of cardiac sarcomas and has uncertain etiology as well as pathogenesis. Transthoracic echocardiography remains the widely available screening examination for the initial diagnosis of a cardiac tumor. The clinical presentation is non-specific and the diagnosis is established usually at an advanced stage of the disease. Sarcomas spread preferentially through blood due to their immature vessels without endothelial lining. Surgery remains the method of choice for treatment. Radicalness of the excision is still the most valuable prognostic factor. Adjuvant therapy is unlikely to be effective. The management of cardiac sarcomas must be individualized due to their rarity and significant differences in the course of disease.

23-year experience on diagnosis and surgical treatment of benign and malignant cardiac tumors.

Introduction Although myxoma is the most frequent cardiac tumor, other conditions should be taken into consideration in the differential diagnosis. Transthoracic echocardiography (TTE), followed by transesophageal echocardiography (TEE) remain the principal methods for cardiac tumor screening and visualizing. The aim of the study was to compare the diagnostics, surgical treatment and prognosis of malignant and benign cardiac tumors. Material and methods From 1986 to 2009 there were 121 patients with cardiac tumors operated on in the Cardiac Surgery Clinic of the Medical University in Lodz. Patients were referred to surgery mainly on the basis of the TTE and TEE image. In 4 cases valvular prosthesis implantation or valve repair were carried out. Patients remained under long-term observation in the Cardiac Surgery Outpatient Clinic. Results Myxoma was diagnosed in 114 cases. Malignancies were discovered in 7 cases. The left atrium was the most frequent localization. The echocardiographic image differed significantly in benign and malignant tumors. The postoperative period was complicated by embolic events or myocardial infarctions. Only malignant tumors were associated with mortality due to cardiovascular events. The survival for malignant tumors was significantly shorter. Conclusions Short and long-term results of operative treatment are very good for benign tumors in contrast to cardiac malignancies. The TTE and TEE image can be very significant in the final diagnosis.

Comparison of the clinical application of reactive oxygen species and inflammatory markers in patients with endocarditis.

Introduction Infective endocarditis (IE) is still connected with high operative mortality. Inflammatory markers are commonly used in monitoring patient clinical condition. Respiratory burst and reactive oxygen species (ROS) are the main way of pathogen elimination. Specificity of this process in the aspect of bacterial infection is the key for correlation assessment between ROS and inflammatory markers in patients with IE. In the study, assessment of ROS as a clinical indicator in IE was conducted. Material and methods During 2007/2008 in the Cardiosurgical Clinic of the Medical University in Lodz there were 20 patients operated on for IE. The examined population consisted of 13 men and 7 women, aged from 23 to 74 years. Inflammatory markers – leukocytosis (WBC), C-reactive protein (CRP), procalcitonin (PCT) and erythrocyte sedimentation rate (ESR) – were assessed preoperatively, on the 3rd, 7th, 12th and 21st day. Simultaneously, with the second venous blood sample chemiluminescence (luminal enhanced whole blood chemiluminescence) was carried out and used to assess ROS production. The results were analyzed statistically. Results Positive correlation between ESR, CRP and ROS in the preoperative period was confirmed. An increase in ROS and a statistically significant increase in inflammatory markers on the 3rd day were observed. The ROS normalized on the 12th day. Marked individual variability was specific for the inflammatory markers. Despite the significant decrease, not all of them achieved a normal level at the last control point. Conclusions Assessment of ROS seems to be a universal parameter with possible application in patients with IE.

Progression of coronary artery disease in a HIV-infected patient previously treated for ascending aorta aneurysm

The pathophysiology of increased cardiovascular risk in HIV infection is complex and multifactorial but chronic inflammation and immune activation seem to play a crucial role. Direct effects of HIV, leakage of bacteria from the gut, damage of lymphoid tissues as well as co-infections are responsible for the activation of the immune system [1], resulting in proinflammatory and pro-thrombotic status [2]. Pro-inflammatory high density lipoprotein (HDL) is dysfunctional with high redox activity and easy non-calcified coronary atherosclerotic plaque rupture [3]. Endothelial and macrophage cell function is significantly impaired. Some antiretroviral agents (either directly or via associated dyslipidemia and insulin resistance) may also contribute to the increased rate of cardiovascular disease in HIV and therefore require careful selection according to the underlying cardiovascular risk factors. A 35-year-old man was diagnosed (02.09.2009) with syphilis and HIV infection classified as stage A3. The patient was a cigarette smoker and had arterial hypertension and a family history of coronary artery disease (CAD). Combined antiretroviral therapy (cART) was composed of lamivudine, abacavir atazanavir and ritonavir. One year later atazanavir was replaced with darunavir due to potential drug-to-drug interaction with protein pump inhibitor (PPI). The patient remained asymptomatic and HIV RNA was undetectable. The CD4 T lymphocyte count was 386 cells/μl. Due to exercise capacity impairment control transthoracic echocardiography (TTE) was performed and revealed: aneurysm of the ascending aorta with maximal diameter 60 mm, aortic bulb 50 mm, aortic annulus 26 mm with good left ventricular ejection fraction (LVEF) – 66%. The aortic valve function was preserved. Preoperative coronarography revealed no significant atherosclerosis in coronary vessels. Initial lipid profile revealed hypertriglyceridemia (LDL 130 mg/dl, HDL 41 mg/dl, TG 240 mg/dl). Lipid-lowering therapy was initiated (atorvastatin 40 mg, fenofibrate 267 mg). Supracoronary ascending aorta replacement with a vascular prosthesis (Vascutek 28) and aortic commissure suspension were performed (25.03.2011) without complications. The patient was discharged on the 5th day after the surgery. The patient had outpatient check-ups regularly. Eighteen months later (22.08.2012) the patient had lateral ST elevation myocardial infarction (STEMI). Coronary angiography revealed narrowing of the circumflex artery (Cx), treated with bare metal stent (BMS) implantation. At that moment 50% de novo stenosis in the proximal segment of the left anterior descending artery (LAD) was also diagnosed (Fig. 1). Double antiplatelet therapy was introduced and continuation of antihypertensive and lipid-lowering medication was recommended. HIV RNA remained undetectable and the CD4 T lymphocyte count was 200– 300 cells/μl. Combined antiretroviral therapy was modified to tenofovir, emtricitabine, darunavir and ritonavir, due to the suspected adverse impact of abacavir on the cardiovascular risk. Six months later (1.03.2013) the patient was admitted again to the cardiology department with diagnosis of NSTEMI. Coronary angiography revealed de novo 95% narrowing in the 3rd segment of the right coronary artery (RCA) (without progression in the proximal LAD), treated with BMS implantation. The lipid profile showed a good response to cholesterol-lowering treatment (LDL 49 mg/dl, HDL 41 mg/dl). Due to hypertriglyceridemia (TG 249 mg/dl) lipid-lowering therapy was changed (rosuvastatin 40 mg and fenofibrate 267 mg, BioCardine Omega-3). Lifestyle modifications (cigarette and alcohol cessation) were once again recommended to the patient. At that time the CD4 T lymphocyte count increased to 660 cells/μl. In a 10-month follow-up the deterioration of angina pectoris (to CCS class III) was observed, and was confirmed with non-invasive tests. Coronary angiography revealed progression of proximal LAD stenosis (90%), and elec-

Computed tomography angiography for imaging results of neochordal mitral valve repair

Introduction Degenerative mitral regurgitation is currently the most frequent indication for mitral valve repair. Aim To visualize and assess the mid-term results of mitral valve repair with neochordae implantation, using computed tomography angiography (CTA) imaging. Material and methods The CTA with ECG gating and without modulation was applied in 10 patients to assess the results of a mitral valve sparing procedure. The results of 3 patients are presented. The patients were operated on for severe symptomatic degenerative mitral regurgitation, defined according to a modified Carpentier’s functional classification. Results Neochordal repair, by placing expanded polytetrafluoroethylene sutures between the leading edge of the prolapsing segment and the corresponding papillary muscle, was conducted. From 1 to 3 double Gore-Tex loops were used. Leaflet clefts, if present, were sutured. All repairs included mitral valve ring annuloplasty. The CTA was performed at 20–24 months after the surgery. Long-axis views, reconstructed during mid-systole, seemed to be the most valuable. Good quality cardiac images, precisely presenting the mitral valve complex with its constituents, were obtained in the case of patients without obesity, with a relatively small anterior-posterior thorax dimension, with sinus, slow heart rhythm and quite good left ventricle contractility. The evaluation of the mitral valve included presence of calcifications, fibrosis or thickening, chordal insertion and coaptation points, and papillary muscle locations. Primary and secondary native chordae tendineae and artificial chordae were visualized. Conclusions Contrast material-enhanced ECG-gated CTA applied after mitral valve repair with Gore-Tex neochordae allows one to obtain satisfactory mitral valve images, especially during mid-systole, and evaluate mid-term results of the surgery in chosen patients.

Artificial aortic valve dysfunction due to pannus and thrombus – different methods of cardiac surgical management

Introduction Approximately 60 000 prosthetic valves are implanted annually in the USA. The risk of prosthesis dysfunction ranges from 0.1% to 4% per year. Prosthesis valve dysfunction is usually caused by a thrombus obstructing the prosthetic discs. However, 10% of prosthetic valves are dysfunctional due to pannus formation, and 12% of prostheses are damaged by both fibrinous and thrombotic components. The authors present two patients with dysfunctional aortic prostheses who were referred for cardiac surgery. Different surgical solutions were used in the treatment of each case. Case study 1 The first patient was a 71-year-old woman whose medical history included arterial hypertension, stable coronary artery disease, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and hypercholesterolemia; she had previously undergone left-sided mastectomy and radiotherapy. The patient was admitted to the Cardiac Surgery Department due to aortic prosthesis dysfunction. Transthoracic echocardiography revealed complete obstruction of one disc and a severe reduction in the mobility of the second. The mean transvalvular gradient was very high. During the operation, pannus covering the discs’ surface was found. A biological aortic prosthesis was reimplanted without complications. Case study 2 The second patient was an 87-year-old woman with arterial hypertension, persistent atrial fibrillation, and COPD, whose past medical history included gastric ulcer disease and ischemic stroke. As in the case of the first patient, she was admitted due to valvular prosthesis dysfunction. Preoperative transthoracic echocardiography revealed an obstruction of the posterior prosthetic disc and significant aortic regurgitation. Transesophageal echocardiography and fluoroscopy confirmed the prosthetic dysfunction. During the operation, a thrombus growing around a minor pannus was found. The thrombus and pannus were removed, and normal functionality of the prosthetic valve was restored. Conclusions Precise and modern diagnostic methods facilitated selection of the treatment method. However, the intraoperative view also seems to be crucial in individualizing the surgical approach.

Urgent splenectomy in the course of prosthetic valve endocarditis.

We present a case of a 51-year-old male patient hospitalized due to acute coronary syndrome requiring stent implantation to the left main stem. Double antiplatelet therapy was commenced. After 2-3 days, the patient presented with high fever, dyspnea on exertion, pain in the chest, myalgia, and general weakness. Transthoracic (TTE) and transesophageal (TEE) echocardiography revealed abnormal, turbulent flow across the aortic prosthesis, which was probably caused by the presence of a pathological smooth and mobile structure (10 × 9 × 5 mm) in front of the aortic annulus. Blood cultures were positive and staphylococcal prosthetic valve endocarditis (PVE) was diagnosed. Despite antibiotic treatment, the patients condition deteriorated, and he was referred for prosthesis reimplantation. After being transferred to the Cardiac Surgery Clinic, he presented with nausea, vomiting, and abdominal pain. The results of imaging examinations suggested spleen hematoma. The patient underwent an urgent splenectomy. Histopathological examination revealed a spleen infarction consequent to an embolic event and subscapular hematoma. On the 10th day after the laparotomy, cardiac surgery was performed. No large vegetations were found on the aortic prosthesis. The mechanical valve, implanted 20 years earlier, was functioning properly; it was intact and well healed. Several fragments of a thrombus and fibrous tissue, resembling a pannus and covered with minor calcifications, were removed from the ventricular surface of the discs. A decision was reached to leave the aortic prosthesis in situ. The valvular material culture revealed the presence of Streptococcus anginosus, and the antibiotic scheme was modified. The postoperative period was uneventful.

Removal of the left atrium and left ventricle tumour: a

The heart is the rarest site for neoplasms to be localized. Despite modern diagnostic techniques, cardiac tumours continue to among those discovered latest and with the worst prognoses. We present the case of a 62-year-old woman with a heart tumour and mediastinal lymphadenopathy, who was admitted to the Department of Cardiac Surgery. The patient underwent surgical removal of the tumour with extracorporeal circulation. The left atrium, mitral valve and the left ventricle were occupied by the infiltration. A radical resection appeared to be impossible. A valvular prosthesis was not implanted. The perioperative period was uncomplicated. On the 9th day a local recurrence was confirmed in the transthoracic echocardiography. Further oncological diagnostics revealed the spread of the malignant neoplasm to bones of the pelvis and spine. Chemotherapy was initiated. The authors discuss the most appropriate diagnostic and treatment procedures employed in the above case.

Removal of the left atrium and left ventricle tumour: a case report.

The heart is the rarest site for neoplasms to be localized. Despite modern diagnostic techniques, cardiac tumours continue to among those discovered latest and with the worst prognoses. We present the case of a 62-year-old woman with a heart tumour and mediastinal lymphadenopathy, who was admitted to the Department of Cardiac Surgery. The patient underwent surgical removal of the tumour with extracorporeal circulation. The left atrium, mitral valve and the left ventricle were occupied by the infiltration. A radical resection appeared to be impossible. A valvular prosthesis was not implanted. The perioperative period was uncomplicated. On the 9th day a local recurrence was confirmed in the transthoracic echocardiography. Further oncological diagnostics revealed the spread of the malignant neoplasm to bones of the pelvis and spine. Chemotherapy was initiated. The authors discuss the most appropriate diagnostic and treatment procedures employed in the above case.