Dimitrios Konstantinou

Enhanced Recovery After Elective Coronary Revascularization Surgery With Minimal Versus Conventional Extracorporeal Circulation: A Prospective Randomized Study

OBJECTIVE A minimal extracorporeal circulation (MECC) circuit integrates the advances in cardiopulmonary bypass (CPB) technology into a single circuit and is associated with improved short-term outcome. The aim of this study was to prospectively evaluate MECC compared with conventional CPB in facilitating fast-track recovery after elective coronary revascularization procedures. DESIGN Prospective randomized study. SETTING All patients scheduled for elective coronary artery surgery were evaluated, excluding those considered particularly high risk for fast-track failure. The fast-track protocol included careful preoperative patient selection, a fast-track anesthetic technique based on minimal administration of fentanyl, surgery at normothermia, early postoperative extubation in the cardiac recovery unit, and admission to the cardiothoracic ward within the first 24 hours postoperatively. PARTICIPANTS One hundred twenty patients were assigned randomly into 2 groups (60 in each group). INTERVENTIONS Group A included patients who were operated on using the MECC circuit, whereas patients in Group B underwent surgery on conventional CPB. MEASUREMENTS AND MAIN RESULTS Incidence of fast-track recovery was significantly higher in patients undergoing MECC (25% v 6.7%, p = 0.006). MECC also was recognized as a strong independent predictor of early recovery, with an odds ratio of 3.8 (p = 0.011). Duration of mechanical ventilation and cardiac recovery unit stay were significantly lower in patients undergoing MECC together with the need for blood transfusion, duration of inotropic support, need for an intra-aortic balloon pump, and development of postoperative atrial fibrillation and renal failure. CONCLUSIONS MECC promotes successful early recovery after elective coronary revascularization procedures, even in a nondedicated cardiac intensive care unit setting.

Blurred vision due to choroidal metastasis as the first manifestation of lung cancer: A case report

BackgroundReduction in visual acuity combined with blurred vision is rarely the first sign of lung cancer and very few cases have been announced globally.Case presentationA case of a 46-year-old man who admitted with blurred vision is presented. His medical history, apart from a mild gastritis under treatment was negative. Ocular examination revealed a decrease in visual acuity due to a choroidal tumor. Further image body scans demonstrated a right lung lesion with dissemination to other organs. Diagnosis of a non-small cell lung cancer established after a VATS biopsy carried out.ConclusionBlurred vision due to choroidal metastasis as the primary symptom of lung cancer is very uncommon. A great index of suspicion is essential when a choroidal lesion appears.

Giant mediastinal teratoma presenting with paroxysmal atrial fibrillation

Mediastinum is a common site where benign tumors, like teratomas, can develop. Usually, these lesions do not cause any symptoms and the diagnosis is reached accidentally. As they enlarge they may cause symptoms by compressing the nearby structures of the thorax, mostly the trachea and the bronchi. Extrinsic compression of the heart or the great vessels appears to be a very rare occurrence. Atrial fibrillation as the first clinical presentation of left atrial compression by a giant mediastinal teratoma is extremely uncommon and very few cases have been described in the English literature.

Nine years experience in surgical approach of leiomyomatosis of esophagus

BackgroundLeiomyomas of esophagus, although rare, are the most frequent benign tumors of esophagus. Aim of this study is the presentation of 7 patients with esophageal leiomyomas who underwent surgical treatment during a 9-year period.MethodsEpidemiological data (sex, age), the presenting symptoms, diagnostic examinations, tumor location, histopathological findings and the safety and efficacy of surgical resection are analyzed and assessed.Results5 men and 2 women with mean age of 56.9 years were operated. In 3 cases the tumor was located at the lower esophagus, while in the other 4 cases, the leiomyoma was found at the median third of esophagus. 4 patients had severe symptoms related to the leiomyoma, such as dysphagia and epigastric pain. All patients underwent a right postolateral thoracotomy with enucleation of the lesion. None of them received resection of part of the esophagus. The mean diameter of the resected tumors was 4.3 cm. The dimensions of leiomyomas were immediately associated with the symptoms. In no case was detected malignancy or recurrence. All patients were relieved from their symptoms, while postoperative morbidity and mortality did not occur.ConclusionsEsophageal leiomyoma is a benign tumor, which causes symptoms only if its size becomes large. Surgical enucleation is considered to be safe and effective, without complications.

Non-diabetic hyperglycaemia correlates with angiographic coronary artery disease prevalence and severity.

AIM The role of glycaemia as a coronary artery disease (CAD) risk factor is controversial, and the optimal glucose level is still a matter of debate. For this reason, we assessed the prevalence and severity of angiographic CAD across hyperglycaemia categories and in relation to haemoglobin A(1c) (HbA(1c)) levels. METHODS We studied 273 consecutive patients without prior revascularization undergoing coronary angiography for suspected ischaemic pain. CAD severity was assessed using three angiographic scores: the Gensinis score; extent score; and arbitrary index. Patients were grouped, according to 2003 American Diabetes Association criteria, into those with normal fasting glucose (NFG), impaired fasting glucose (IFG) and diabetes mellitus (DM). RESULTS CAD prevalence was 2.5-fold higher in both the IFG and DM groups compared with the NFG group. Deterioration of glycaemic profile was a multivariate predictor of angiographic CAD severity (extent score: P=0.027; arbitrary index: P=0.007). HbA(1c) levels were significantly higher among CAD patients (P=0.016) and in those with two or more diseased vessels (P=0.023) compared with the non-CAD group. HbA(1c) levels remained predictive of CAD prevalence even after adjusting for conventional risk factors, including DM (adjusted OR: 1.853; 95% CI: 1.269-2.704). CONCLUSION Non-diabetic hyperglycaemia, assessed either categorically by fasting glucose categories or continuously by HbA(1c) levels, correlates with the poorest angiographic outcomes.

Minimal extracorporeal circulation reduces the incidence of postoperative major adverse events after elective coronary artery bypass grafting in high-risk patients. A single-institutional prospective randomized study

Coronary artery bypass grafting (CABG) using minimal extracorporeal circulation (MECC) has been associated with an improved short-term clinical outcome compared to conventional extracorporeal circulation (CECC). The aim of this study was to evaluate the impact of MECC compared to CECC on postoperative major adverse events in high-risk patients undergoing elective coronary revascularization procedures. Two hundred patients undergoing elective CABG were randomized into two groups. In Group A (n=100), MECC was used while Group B (n=100) included patients who were operated on CECC. The incidence of postoperative major adverse events (myocardial infarction, renal failure, stroke, death) was the primary end-point of the study. MECC was associated with a 77% relative risk reduction in the incidence of major adverse events compared to CECC (p=0.004). The rate of major adverse events occurring in the high-risk patient subgroup (preoperative left ventricular ejection fraction ≤40%, age >65 years, EuroSCORE II >5) operated on with MECC was significantly lower in comparison to their CECC counterparts. Based on our results, cardiac centres should be encouraged to use MECC as the standard circuit when performing elective coronary procedures, even in a high-risk population.

Spontaneous chylous cardiac tamponade: a case report

BackgroundChylous cardiac tamponade is a rare condition with little known cause.Case presentationA case of an otherwise healthy woman who admitted with dyspnea and palpitations is presented. She had a history of a painful flexion-hyperextension of the spine. Diagnostic evaluation proved a chylous pericardial effusion with a disruption of the anterior longitudinal spinal ligament. Video-assisted thoracic surgery with mass supradiaphragmatic ligation of the thoracic duct and pericardial window formation was carried out successfully and resulted in the complete cure of the patients condition.ConclusionChylous pericardial effusion and subsequent tamponade is a rare entity. Endoscopic surgery is offering a safe and effective treatment.

Implantable cardioverter defibrillators for primary prevention of sudden death in hypertrophic cardiomyopathy.

Aims Sudden cardiac death (SCD) may complicate hypertrophic cardiomyopathy (HCM) natural course. Patient selection for implantable cardioverter defibrillator (ICD) therapy in the primary prevention setting is still a challenge. Methods Thirty-seven HCM patients with a primary prevention ICD were included. All patients underwent preimplantation SCD risk assessment and semi-annual device interrogation during follow-up. Primary end point was the time to first appropriate ICD intervention including antitachycardia pacing or shock. Inappropriately delivered ICD therapies served as secondary end point. Results During a median follow-up of 3.1 years, 10 (27%) patients received one or more appropriate ICD therapies. First appropriate ICD intervention rate was 7.2%/year (95% CI: 3.4–13.2) with a 5-year cumulative probability of 29.2 ± 7.4%. No SCD risk marker was significantly associated with the primary end point, whereas event rates were comparable among patients with one, two or three or more SCD risk markers (log-rank P = 0.58). Patients with a history of SCD in first-degree relatives with HCM were at 3.8 times higher risk of experiencing an ICD intervention compared with those with no family history of SCD (HR: 3.8; 95% CI: 1.0–14.1, P = 0.05). Seven (18.9%) patients experienced one or more inappropriate ICD therapies; beta-blocker therapy was associated with 75% fewer inappropriate ICD interventions (HR: 0.15; 95% CI: 0.03–0.89). Conclusion Current criteria identify a subgroup of patients with HCM at increased risk of major arrhythmic events as indicated by high ICD intervention rates. However, no individual risk marker demonstrated superior predictive ability over the others, whereas simple arithmetic summing of risk markers was not associated with increased ICD intervention rates.

P wave analysis with wavelets identifies hypertensive patients at risk of recurrence of atrial fibrillation: A case-control study and 1 year follow-up

AIMS Hypertension is a major risk factor for atrial fibrillation (AF); however, reliable non-invasive tools to assess AF risk in hypertensive patients are lacking. We sought to evaluate the efficacy of P wave wavelet analysis in predicting AF risk recurrence in a hypertensive cohort. METHODS We studied 37 hypertensive patients who presented with an AF episode for the first time and 37 age- and sex-matched hypertensive controls without AF. P wave duration and energy variables were measured for each subject [i.e. mean and max P wave energy along horizontal (x), coronal (y) and sagittal (z) axes in low, intermediate and high frequency bands]. AF-free survival was assessed over a follow-up of 12.1±0.4months. RESULTS P wave duration (Pdurz) and mean P wave energy in the intermediate frequency band across sagittal axis (mean2z) were independently associated with baseline AF status (p=0.008 and p=0.001, respectively). Based on optimal cut-off points, four groups were formed: Pdurz<83.2ms/mean2z<6.2μV(2) (n=23), Pdurz<83.2ms/mean2z≥6.2μV(2) (n=10), Pdurz≥83.2ms/mean2z<6.2μV(2) (n=22) and Pdurz≥83.2ms/mean2z≥6.2μV(2) (n=19). AF-free survival decreased (Log Rank p<0.0001) from low risk (Pdurz<83.2ms/mean2z<6.2μV(2)) to high-risk group (Pdurz≥83.2ms/mean2z≥6.2μV(2)). Patients presenting with longer and higher energy P waves were at 18 times higher AF risk compared to those with neither (OR: 17.6, 95% CI: 3.7-84.3) even after adjustment for age, sex, hypertension duration, left atrial size, beta-blocker, ACEi/ARBs and statin therapy. CONCLUSIONS P wave temporal and energy characteristics extracted using wavelet analysis can potentially serve as screening tool to identify hypertensive patients at risk of AF recurrence.

Determinants of functional mitral regurgitation severity in patients with ischemic cardiomyopathy versus nonischemic dilated cardiomyopathy.

Functional mitral regurgitation (MR) is prevalent among patients with left ventricular (LV) dysfunction and is associated with a poorer prognosis. Our aim was to assess the primary determinants of MR severity in patients with ischemic cardiomyopathy (ICM) and nonischemic dilated cardiomyopathy (DCM).