Bogoljub Mihajlovic

Reductive annuloplasty of double orifices in patients with primary dilated cardiomyopathy

BACKGROUND Patients with primary dilated cardiomyopathy exhibit extensive remodeling of the left ventricle, mitral and tricuspid annular dilation and both mitral and tricuspid regurgitation. These factors significantly contribute to heart failure, and are predictors of early lethal outcome. The aim of this study is to show hemodynamic and clinical improvement after reductive annuloplasty of both mitral and tricuspid orifices in primary dilated cardiomyopathy. METHODS There were 76 patients with primary dilated cardiomyopathy. Mitral annuloplasty using a Carpentier-Edwards sizer was performed on 9 patients, and posterior semicircular reductive annuloplasty was performed on 67 patients. Modified De Vegas tricuspid annuloplasty was performed on all patients. RESULTS Immediate and long-term results showed significant improvement in hemodynamic values and myocardial contractility after operation. CONCLUSIONS Reductive annuloplasty of both mitral and tricuspid orifices corrects remodeling of the left ventricle of the heart, changes sphericity and geometry of the left ventricle, improves hemodynamic action of the left and right ventricle, and slows down progression of heart failure. We recommend reductive annuloplasty of both mitral and tricuspid orifices before or soon after the first decompensation.

Clinical performance of the EuroSCORE II compared with the previous EuroSCORE iterations.

BACKGROUND The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II has been recently introduced as an update to the previous versions. We sought to evaluate the predictive performance of the EuroSCORE II model against the original additive and logistic EuroSCORE models. PATIENTS AND METHODS The study included 1,247 consecutive patients who underwent cardiac surgery procedures during a 14-month period starting from the beginning of 2012. The original additive and logistic EuroSCORE models were compared with the EuroSCORE II focusing on the accuracy of predicting hospital mortality. RESULTS The overall hospital mortality rate was 3.45%. The discriminative power of the EuroSCORE II was modest and similar to other algorithms (C-statistics 0.754 for additive EuroSCORE; 0.759 for logistic EuroSCORE; and 0.743 for EuroSCORE II). The EuroSCORE II significantly underestimated the all-patient hospital mortality (3.45% observed vs. 2.12% predicted), as well as in the valvular (3.74% observed vs. 2% predicted), and combined surgery cohorts (6.87% observed vs. 3.64% predicted). The predicted EuroSCORE mortality significantly differed from the observed mortality in the third and the fourth quartile of patients stratified according to the EuroSCORE II mortality risk (p < 0.05). The calibration of the EuroSCORE II was generally good for the entire patient population (Hosmer-Lemeshow [HL] p = 0.139), for the valvular surgery subset (HL p = 0.485), and for the combined surgery subset (HL p = 0.639). CONCLUSION The EuroSCORE II might be considered a solid predictive tool for hospital mortality. Although, the EuroSCORE II employs more sophisticated calculation methods regarding the number and definition of risk factors included, it does not seem to significantly improve the performance of previous iterations.

Trends of risk factors in coronary surgery

INTRODUCTION In current era of widespread use of percutaneous coronary interventions (PCI), it is debatable whether coronary artery by-pass graft (CABG) patients are at higher risk. OBJECTIVE The aim of the study was to evaluate trends in risk profile of isolated CABG patients. METHODS By analysing the EuroSCORE and its risk factors, we reviewed a consecutive group of 4675 isolated CABG patients, operated on during the last 8 years (2001-2008) at our Clinic. The number of PCI patients was compared to the number of CABG patients. For statistical analyses, Pearsons chi-square and ANOVA tests were used. RESULTS The number of PCI increased from 159 to 1595 (p < 0.001), and the number of CABG from 557 to 656 (p < 0.001). The mean EuroSCORE increased from 2.74 to 2.92 (p = 0.06). The frequency of the following risk factors did not change over years: female gender, previous cardiac surgery, serum creatinine > 200 micromol/l, left ventricular dysfunction and postinfarct ventricular septal rupture. Chronic pulmonary disease, neurological dysfunction, and unstable pectoral angina declined significantly (p < 0.001). Critical preoperative care declined from 3.1% in 2001 to 0.5% in 2005, than increased and during the last 3 years did not change (2.3%). The mean age increased from 56.8 to 60.7 (p < 0.001) and extracardiac arteriopathy increased from 9.2% to 22.9% (p < 0.001). Recent preoperative myocardial infarction increased from 11% to 15.1% (p = 0.021), while emergency operations increased from 0.9% to 4.0% (p = 0.001). CONCLUSION The number of CABG increases despite the enlargement of PCI. The risk for isolated CABG given by EuroSCORE increases over years. The risk factors, significantly contributing to higher EuroSCORE are: older age, extracardiac arteriopathy, recent myocardial infarction and emergency operation.

Evaluation of results in coronary surgery using EuroSCORE

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 analysing 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, Chi-square 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.

Changes in Left Ventricular Morphology and Function in End‐Stage Dilated Cardiomyopathy After Reductive Annuloplasty of Double Mitral and Tricuspid Orifices

Abstract Background and aim: The aim of this study is to show the changes in left ventricular morphology and function after reductive annuloplasty of double mitral and tricuspid orifices (RADO) in ischemic dilated cardiomyopathy (IDCM) and primary dilated cardiomyopathy (PDCM) analyzed by intraoperative transesophageal echocardiography (TEE). Methods: There were 274 patients, mean age 50.1 years, 188 operated due to IDCM with ejection fraction under 30%, and 86 patients due to PDCM. Mitral annuloplasty according to A. Carpentier and our own procedure was done in 49 and 225 patients, respectively. In 265 cases (97%) our modified De Vegas tricuspid annuloplasty was performed. Results: Conclusion: RADO significantly changes left ventricular morphology, reverses remodeling of the heart, decreases sphericity of the left heart, improves hemodynamic function of both ventricles, and slows down progression of cardiac failure. We recommend RADO in the early stage of PDCM, immediately after the first decompensation, and as an important associated procedure in IDCM.

3D epicardial fat registration optimization based on structural prior knowledge and subjective-objective correspondence

3D heart registration has become an important issue in cardio-vascular diagnosis and treatment. This is mainly due to more accessible medical imaging technologies that can nowadays provide high precision imaging data at relatively lower cost. One of the important features of the heart that has recently drawn attention is epicardial fat (surrounds the heart), which according to some preliminary studies can indicate risk level of various cardiovascular diseases. As such, 2D/3D registration of epicardial fat, through automatic or semi-automatic detection/segmentation, is considered as valuable task for medical doctors (MDs) to include as additional feature within the already existing software for medical imaging and visualization. Although MDs can visually detect regions of epicardial fat from the image slices manually, i.e., subjectively, it is usually time consuming and error prone task. Moreover, due to considerable amount of parameters used for image pre-processing, which can strongly influence visibility of certain features in the image by MD, it often happens that some important features are missed. Consequently, the most preferable solution is the one that combines objective and subjective (by MD) description of particular image feature (in this example epicardial fat) and then subsequently employs semi-automatic segmentation approach, where in execution stage MD would only roughly indicate particular region of interest (ROI), based on which designed algorithm would process the whole heart volume and compute the 3D volume of the heart and epicardial fat. In this paper, we aim at optimizing and enhancing previously developed algorithm for 2D fat segmentation based on (i) pre-knowledge about epicardial structure (provided by the MDs) and (ii) subjective and objective metric correspondence. Based on the 2D segmentation method we compute the 3D volume in order to perform 3D registration. This new optimized approach is shown to considerably improve the accuracy of the epicardial fat registration using CT images.

THE LEVEL OF GRAMMAR SCHOOL STUDENTS' KNOWLEDGE ON CARDIOVASCULAR DISEASE RISK FACTORS.

INTRODUCTION Cardiovascular diseases are one of the leading causes of mortality and morbidity worldwide. The atherosclerotic process in the aorta starts in childhood, while atheroclerotic changes of coronary heart vessels start in adolescence. The aim of the study was to evaluate the knowledge of the students attending all four grades of grammar school about the risk factors for cardiovascular disease, with special attention to the risk factors that can be influenced by modification of life-style. MATERIAL AND METHODS Data from the entrance and exit tests were collected from 197 students attending a grammar school in Novi Sad. Chi-square test and Student T-test or Mann-Whitney U test were used to examine the statistical difference between categorized variables and the continuous variables, respectively. RESULTS The difference between the number of correct answers for all the students on the entrance test and exit test was statistically significant (p<0.0005) and the overall knowledge level after lectures was increased by 29.4%. The lowest level of knowledge on the entrance tests was noted among the students of the third grade of grammar school and after the lectures, the students knowledge level was increased by 82.3% (p<0.0005). CONCLUSION Children and adolescents from Vojvodina and Serbia should be well informed about the cardiovascular disease risk factors and their prevention with special attention paid to the risk factors that can be influenced by changing lifestyle habits.

Relationship Between Prior PCI and Subsequent CABG

Dear Editor, With the number of percutaneous coronary interventions (PCIs) on the rise, it is expected that there will be a corresponding growth in population of patients with prior PCI referred to coronary artery bypass grafting (CABG) as a result of long-term PCI failure, incomplete revascularization, or coronary artery disease progression. The prevalent position of the interventional cardiologists of: ‘‘subsequent CABG may be successfully performed in any patient with a history of previous PCI’’ is now being seriously challenged. Furthermore, results of several studies that investigated the impact of previous PCI on subsequent CABG were found to be conflicting. For this reason, we read with great interest the article by Niclauss et al. regarding the influence of prior PCI on subsequent CABG. There are only a few studies reporting onmidor long-term results following surgical revascularization in patients with prior PCI, and from that point of view the article by Niclauss et al. is indeed a very fine contribution. This study produced another very important conclusion—there is no difference in terms of mortality depending on prior PCI status. However, a cautionary warning was identified in that particular study: the proportion of patients who underwent isolated percutaneous transluminal angioplasty (PTCA)—20% in PCI prior CABG group—looks to be far too big for contemporary clinical practice in our view. Having in mind different pathophysiological mechanisms responsible for PTCA and PCI failure, we believe that such a large number of patientsmight, in fact, skew the results of the study. We, therefore, think that excluding the subgroup of patients would yield results that would be more representative of a contemporary practice. In Table 1, it is indicated that a proportion of patients with prior myocardial infarction (MI) is very similar between the groups (40% vs. 44%, p1⁄4 0.07). Does this mean that the patients with MI were not treated with PCI in large number? The report did not appear to indicate the number of patients having previous MI treated with PCI that were subsequently referred to CABG. For the purpose of analysis, it would be useful to see in what percentage was the artery, already treated with stent, revascularized surgically. Another factor worthy of attention is the number of multiple PCIs and its influence on CABG. Based on our clinical practice, we know that cardiologists are likely to be very persistent in their attempts to percutaneously revascularize the artery. Table 2 of Niclauss et al. paper counts 22.3% (89) prior-PCI patients taking clopidogrel which seems quite low. We seek explanation about how long the patients took the drug following PCI. Again, 77.7% of patients with previous PCI were merged with those not submitted to PCI when the impact of active double anti-platelet therapy was investigated. We believe that conclusions would be more accurate (meaningful) if only the original groups were considered. Careful decision-making in the setting of multivessel disease is mandatory. Obviously, many risk factors (patient related, procedure related, drug related, coronary artery anatomy, and pathology) may influence the success or failure of specific procedures, thus emphasizing the need for adequate patient selection according to corresponding procedure type. In order to gain meaningful insight about the relation between PCI and subsequent CABG, more contemporary studies including a larger proportion of patients treated with drug eluting stents and/or biodegradable stents are highly warranted. Conflict of interest: The authors acknowledge no conflict of interest in the submission.

Postoperative nonlethal complications following open heart surgery

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 incapac ity 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.