Hrvoje Gašparović

NT-pro-BNP, but not C-reactive protein, is predictive of atrial fibrillation in patients undergoing coronary artery bypass surgery

OBJECTIVE Atrial fibrillation (AF) remains the most commonly observed complication following myocardial revascularisation surgery. We aimed to evaluate the clinical utility of N-terminal fragment of the brain natriuretic peptide (NT-pro-BNP), troponin T, transcoronary lactate gradient (TCLG) and C-reactive protein (CRP) as predictors of AF in patients undergoing isolated coronary artery bypass surgery (CABG). METHODS This study included 215 consecutive patients in sinus rhythm (SR) undergoing elective CABG between May 2007 and May 2008. The patients were grouped according to their respective postoperative rhythm into SR and AF groups. The data are presented as mean values+/-standard deviation, or medians with quartiles. RESULTS Fifty-five patients developed AF (26%). The preoperative NT-pro-BNP values were 273+/-347 and 469+/-629 pg ml(-1) in the SR and AF groups, respectively (p<0.0001). The postoperative NT-pro-BNP values were 3110+/-3600 pg ml(-1) in the SR and 4625+/-5640 pg ml(-1) in the AF groups (p=0.027). The transcoronary lactate gradient rose from the pre-cardiopulmonary bypass values to those observed 5 min after revascularisation in both groups (-0.05+/-0.37 to 0.39+/-0.46 mmol l(-1) (p<0.0001) in the SR group and -0.01+/-0.27 to 0.43+/-0.46 mmol l(-1) (p<0.0001) in the AF group). The CRP values increased from 6+/-13 to 163+/-88 mg l(-1) (p<0.0001) in the SR group, and from 6+/-16 to 163+/-104 mg l(-1) (p<0.0001) in the AF group. The dynamics of TCLG and CRP did not differ between the groups (p=0.71, p=0.44, respectively). The troponin T values on postoperative day 1 were significantly higher in the AF than the SR group (0.86 (0.49-2.1) ng ml(-1) vs 0.67 (0.37-1.16) ng ml(-1), p=0.046). The duration of cardiopulmonary bypass (CPB) was 85+/-24 min in the SR and 93+/-30 min in the AF group (p=0.05). Patients who developed AF were older (66+/-7 years vs 60+/-9 years, p<0.0001) and had a higher EuroSCORE (3.9+/-2.7 vs 2.9+/-2.2, p=0.009). Multivariate analysis identified age (p=0.0043), preoperative NT-pro-BNP (p=0.019) and duration of CPB (p=0.035) as independent predictors of AF. CONCLUSIONS Preoperative and postoperative NT-pro-BNP as well as TnT values were significantly higher in patients who subsequently developed AF. TCLG and CRP were not useful in identifying patients at higher risk for AF. Multivariate analysis identified age, preoperative NT-pro-BNP and duration of CPB as independent correlates of AF.

Cardiac allograft vasculopathy: diagnosis, therapy, and prognosis.

Development of cardiac allograft vasculopathy represents the major determinant of long-term survival in patients after heart transplantation. Due to graft denervation, these patients seldom present with classic symptoms of angina pectoris, and the first clinical presentations are progressive heart failure or sudden cardiac death. Although coronary angiography remains the routine technique for coronary artery disease detection, it is not sensitive enough for screening purposes. This is especially the case in the first year after transplantation when diffuse and concentric vascular changes can be easily detected only by intravascular ultrasound. The treatment of the established vasculopathy is disappointing, so the primary effort should be directed toward early prevention and diagnosis. Due to diffuse vascular changes, revascularization procedures are restricted only to a relatively small proportion of patients with favorable coronary anatomy. Percutaneous coronary intervention is preferred over surgical revascularization since it leads to better acute results and patient survival. Although there is no proven long-term advantage of drug-eluting stents for the treatment of in-stent restenosis, they are preferred over bare-metal stents. Severe vasculopathy has a poor prognosis and the only definitive treatment is retransplantation. This article reviews the present knowledge on the pathogenesis, diagnosis, treatment, and prognosis of cardiac allograft vasculopathy.

Pretransplant and perioperative predictors of early heart transplantation outcomes

Aim To identify predictors of 3-month mortality after heart transplantation in a Croatian academic center. Methods A retrospective review of institutional database identified 117 heart transplantations from January 2008 to July 2014. Two children <14 years were excluded from the study. The remaining 115 patients were dichotomized into survivors and non-survivors adjudicated at 3-months postoperatively, and their demographic, clinical, and longitudinal hemodynamic data were analyzed. Results 3-month survival after heart transplantation was 86%. Non-survivors were older (59 ± 8 vs 50 ± 14 years, P = 0.009), more likely to have previous cardiac surgery (44% vs 19%; odds ratio [OR] 3.28, 95% confidence interval [CI] 1.08-9.90; P = 0.029), lower body mass index (BMI) (25 ± 4 vs 28 ± 2 kg/m2, P = 0.001), and be diabetics (44% vs 23%; OR 2.57, 95% CI 0.86-7.66; P = 0.083). Creatinine clearance was marginally superior among survivors (59 ± 19 vs 48 ± 20 mL/min, P = 0.059). Donor age and sex did not affect outcomes. Non-survivors were more likely to have had ischemic cardiomyopathy (69% vs 32%, P = 0.010). Postoperative utilization of epinephrine as a second line inotropic agent was a strong predictor of mortality (63% vs 7%; OR 21.91; 95% CI 6.15-78.06; P < 0.001). Serum lactate concentrations were consistently higher among non-survivors, with the difference being most pronounced 2 hours after cardiopulmonary bypass (9.8 ± 3.5 vs 5.2 ± 3.2 mmol/L, P < 0.001). The donor hearts exhibited inferior early hemodynamics in non-survivors (cardiac index 3.0 ± 1.0 vs 4.0 ± 1.1 L/min/m2, P = 0.001), stroke volume (49 ± 24 vs 59 ± 19 mL, P = 0.063), and left and right ventricular stroke work indices (18 ± 8 vs 30 ± 11 g/beat/m2, P < 0.001 and 5 ± 3 vs 7 ± 4 g/beat/m2, P = 0.060, respectively). Non-survivors were more likely to require postoperative re-sternotomy (50% vs 12%; OR 7.25, 95% CI 2.29-22.92; P < 0.001), renal replacement therapy (RRT) (69% vs 9%; OR 22.00, 95% CI 6.24-77.54; P < 0.001), and mechanical circulatory assistance (MCS) (44% vs 5%; OR 14.62, 95% CI 3.84-55.62; P < 0.001). Binary logistic regression revealed recipient age (P = 0.024), serum lactates 2 hours after CPB (P = 0.007), and epinephrine use on postoperative day 1 (P = 0.007) to be independently associated with 3-month mortality. Conclusion Pretransplant predictors of adverse outcome after heart transplantation were recipient age, lower BMI, ischemic cardiomyopathy, reoperation and diabetes. Postoperative predictors of mortality were inferior donor heart hemodynamics, epinephrine use, and serum lactate concentrations. Non-survivors were more likely to require re-sternotomy, MCS, and RRT.

Results of extracorporeal life support implementation in routine clinical practice: single center experience

Aim To describe our experience in the clinical application of extracorporeal life support (ECLS) and analyze whether ECLS leads to acceptable clinical outcomes in patients with cardiac failure. Methods Data from clinical database of University Hospital Center Zagreb, Croatia, on 75 patients undergoing ECLS support from 2009 to 2014 due to cardiac failure were retrospectively analyzed. Outcomes were defined as procedural and clinical outcomes. ECLS as a primary procedure and ECLS as a postcardiotomy procedure due to inability to wean from cardiopulmonary bypass were analyzed. Results ECLS was used in 75 adult patients, and in 24 (32%) of those procedural success was noted. ECLS was implemented as a primary procedure in 36 patients and as a postcardiotomy procedure in 39 patients. Nine out of 39 (23.08%) patients had postcardiotomy ECLS after heart transplantation. Bleeding complications occurred in 30 (40%) patients, both in primary (11/36 patients) and postcardiotomy group (19/39 patients). ECLS was established by peripheral approach in 46 patients and by central cannulation in 27 patients. In 2 patients, combined cannulation was performed, with an inflow cannula placed into the right atrium and an outflow cannula placed into the femoral artery. Eleven patients treated with peripheral approach had ischemic complications. Conclusion ECLS is a useful tool in the treatment of patients with refractory cardiac failure and its results are encouraging in patients who otherwise have an unfavorable prognosis.

Detecting volume responders prior to implantation of a cardiac resynchronization therapy device via minithoracotomy: the septal flash as a predictor of immediate left ventricular reverse remodeling

BACKGROUND Although cardiac resynchronization therapy (CRT) is well established as an adjunctive heart failure treatment, a 30% rate of nonresponders poses a challenge to improve the detection of potential responders prior to device implantation. A previously proposed mechanism-based approach to patient selection suggests in part that the septal flash is a sign of intraventricular dyssynchrony, which is predictive of CRT responsiveness. METHODS In this pilot study, data from 5 consecutive patients (2 women and 3 men; mean + or - SD age, 62 + or - 9 years) referred for CRT device implantation via a minithoracotomy were analyzed. Intraoperative transthoracic and/or transesophageal echocardiography data, as well as Doppler myocardial imaging data, were acquired before and after CRT device activation. The septal flash was defined as an early ventricular inward and outward septal motion within the isovolumic contraction period and was imaged with grayscale imaging or tissue Doppler color M-mode. Reverse remodeling was defined as a reduction in the left ventricular end-systolic volume (LVESV) of > or =10%. The right atrial and right ventricular leads were placed transvenously, and the LV screw-in lead was positioned epicardially on the lateral wall. RESULTS The septal flash was detected preoperatively in all patients and resolved immediately after the onset of biventricular pacing. Immediately following pacemaker activation, we measured a significant reduction in the LVESV (248 + or - 99 mL versus 190 + or - 100 mL, P = .01) and an increase in the ejection fraction (19% + or - 5% versus 28% + or - 5%, P = .01) in all patients. Likewise, a significant increase in the postactivation dP/dt (rate of LV pressure change) measured noninvasively from the mitral regurgitation trace was noted in all patients (298.6 + or - 58.0 mm Hg/s versus 601.7 + or - 111.2 mm Hg/s, P = .001). CONCLUSION The preoperative presence of the septal flash is a valid predictor of the response to CRT. Immediately after CRT device activation, the septal flash disappears, and LV reverse remodeling and an increase in contractility are observed.

Intracardiac shrapnel in a polytraumatized child

Penetrating cardiac trauma is a life-threatening condition and presents a therapeutic challenge for the surgeon. Additional multiple organ-system injuries, as are common in the setting of war, further complicate the management of such patients. We present the case of a 9-year-old girl who sustained multiple injuries from an unexploded artillery shell, resulting in a retained intracardiac shrapnel. Her cardiac pathology consisted of a shrapnel located in the interventricular septum accompanied by a pneumopericardium and a right-sided hemopneumothorax. The presentation and management of this patient are the subjects of this report.

Contemporary challenges in the management of advanced heart failure.

Heart failure (HF) is a public health concern with an immense effect on the utilization of precious and finite health care resources. More than 23 million people worldwide have been affected by symptoms of HF (1). The equivocal criteria for diagnosing HF have led to variable projections of its true incidence, but its impact and frequency grant it the status of a modern-day epidemic (1). Its prevalence continues to follow an upward trend, as it parallels the economic growth and progressive aging of a community. The syndrome of HF is multifaceted in origin, and encompasses a wide range of underlying clinical entities that all result in pronounced morbidity and mortality.

Combined surgical and angioplasty management of coronary artery aneurysms including the giant form.

Coronary artery aneurysms are a rare form of coronary artery disease. Due to the rarity of these aneurysms, particularly of the giant form, it is difficult to establish a standardized treatment. We report the case of a 65-year-old man who presented with symptoms of an acute coronary syndrome. A posterobasal myocardial infarction was diagnosed with a giant right coronary artery aneurysm as the underlying pathology. Two aneurysms of the left anterior descending artery were also revealed. The management strategy included ligation of the giant aneurysm coupled with distal coronary artery bypass grafting of the right coronary artery. This was complemented with a delayed percutaneous coronary intervention of the left anterior descending artery aneurysms.

The use of a femoral arterial cannula for effective dilation for percutaneous femoral venous cannulation.

Abstract  We present a technique for percutaneous femoral venous cannulation for initiation of cardiopulmonary bypass in the setting of previous femoral vessel exposure in which previous scarring prevents safe dilation of the subcutaneous tissues using standard techniques. The technique presented may be particularly helpful when redo sternotomy is deemed hazardous and cardiopulmonary bypass is judged mandatory prior to redo sternotomy. The patient presented in this paper had two previous cardiac operations with prior surgical exposure of femoral vessels in whom institution of cardiopulmonary bypass prior to sternotomy was of paramount importance due to a 7‐cm ascending aortic aneurysm.

Surgical excision of a hemangioendothelioma of the left ventricle

Primary intracardiac neoplasms are most commonly histologically benign with only 30% exhibiting signs of malignancy. Metastatic tumors of the heart are 30 times more common than primary cardiac tumors. Patients with intracardiac masses may present with dyspnea on exertion, thromboembolic events, pericarditis, arrhythmias, or congestive heart failure. In many, however, the diagnosis is made upon discovering a murmur in an otherwise asymptomatic patient. Hemangioendotheliomas are very rare tumors of the heart characterized by capillary-sized vessels lined by rounded and often multilayered endothelial cells. Cardiac muscle cells are found compressed between proliferating vascular channels. We present a patient with this unusual cardiac tumor with no previous cardiac history and a new systolic murmur.