Jarosław Stoliński

Preoperative platelet aggregation predicts perioperative blood loss and rethoracotomy for bleeding in patients receiving dual antiplatelet treatment prior to coronary surgery

INTRODUCTION Patients scheduled for coronary artery bypass graft surgery (CABG) are commonly treated with clopidogrel. We sought to assess the relation between preoperative platelet aggregation and bleeds in CABG patients on clopidogrel. MATERIAL AND METHODS In a case-control study, we compared 52 consecutive patients undergoing isolated CABG on aspirin and clopidogrel 75mg/d versus 50 controls on aspirin monotherapy. Platelet aggregation induced by 10μmol/l adenosine di-phosphate (ADP) in platelet-rich plasma was measured in subjects on clopidogrel within 5days prior to surgery. ADP-induced aggregation of ≥50% was used to define subjects with satisfactory inhibition of platelet reactivity. RESULTS In 29 patients with preoperative ADP-induced aggregation ≥50%, compared with 23 subjects with aggregation <50%, lower chest-tube drainage volumes (after 6h, p=0.002; and 12h, p=0.001) and fewer rethoracotomies were observed (p=0.03). The former group was characterized with lower transfusion rates of packed red blood cells (p=0.009), platelet concentrate (p=0.04) and fresh frozen plasma (p=0.001). Patients with ADP-induced aggregation ≥50% did not differ from untreated controls regarding the postoperative drainage, transfusions and rethoracotomy. The incidence of thromboembolic events and death during perioperative period were similar in all groups. Multivariate logistic regression identified ADP-induced aggregation <50% as the only independent predictor of rethoracotomy (OR=2.94 [1.12-7.75], p=0.029). CONCLUSIONS Patients on aspirin and clopidogrel <5days before CABG who had preoperative ADP-induced platelet aggregation ≥50% have bleeding risk similar to those receiving aspirin monotherapy. Reduced platelet reactivity to ADP can predict postoperative bleeding in CABG patients on dual antiplatelet therapy.

Preoperative values of inflammatory markers predict clinical outcomes in patients after CABG, regardless of the use of cardiopulmonary bypass

Objective The impact of systemic inflammation on clinical outcomes after CABG surgery is still controversial. In this study, we evaluated the impact of the markers of inflammation, endothelial damage and platelet activation on clinical outcomes after on- and off-pump CABG. Methods A group of 191 consecutive on- and off-pump CABG patients were prospectively studied. Blood samples were drawn before surgery, 18–36 h after the procedure and 5–7 days postoperatively and analyzed for 8-iso-prostaglandin F2α (8-iso-PGF2α), asymmetric dimethylarginine (ADMA) and β-thromboglobulin (β-TG). White blood count and C-reactive protein were measured twice, first before and then during the first 18–36 h after CABG. The primary clinical end-points were: low cardiac output syndrome (LCOS), postoperative myocardial infarction (PMI) and in-hospital cardiovascular death. Results Elevation of 8-iso-PGF2α, ADMA and β-TG before surgery was associated with an increased risk of morbidity and mortality after CABG. There were no differences in analyzed markers and clinical outcomes between the on- and off-pump groups. Even during the uncomplicated postoperative course the inflammatory response was enhanced and still remained higher than baseline 5–7 days after surgery. Conclusion Links between preoperative 8-iso-PGF2α, ADMA and β-TG and unfavorable early post-CABG outcomes suggest that these markers could be useful in identifying patients with increased risk of LCOS, PMI and in-hospital cardiovascular death following elective CABG.

Respiratory System Function in Patients after Aortic Valve Replacement through Right Anterior Minithoracotomy

Background The aim of the study was to analyze respiratory system function after minimally invasive aortic valve replacement through right anterior minithoracotomy (RAT‐AVR). Methods An observational study of 187 patients electively scheduled for RAT‐AVR between January 2010 and December 2013. Pulmonary complications were analyzed and spirometry examinations were performed preoperatively, 1 week, 1 month, and 3 months after surgery. Results Hospital mortality was 1.1%. A double‐lumen intratracheal tube was used in 88.2% and single‐lumen intratracheal tube was used in 11.8% of patients. Pulmonary complications occurred in 10.8% of the patients. Prolonged (>24 hours) mechanical ventilation time was present in five patients (2.7%). The reasons were stroke (n = 1), perioperative myocardial infarction (n = 2), and pneumothorax (n = 2). Right pleural effusion, which occurred in 7.7% (n = 14) of patients, was the most frequent respiratory system complication. One week after surgery, the spirometry parameters decreased in comparison to the preoperative period, then after 3 months statistically significant improvement occurred; however, the spirometry parameters still had not returned to preoperative values. Multivariable median regression analysis shows that the presence of chronic obstructive pulmonary disease and pulmonary complications were associated with lower values of forced expiratory volume in 1 second after surgery. There was no statistically significant difference regarding spirometry values or incidence of pulmonary complications after surgery between patients in whom single‐lung or double‐lung ventilation was applied. Conclusion Pulmonary functional status measured with spirometry parameters was diminished after RAT‐AVR surgery. Single‐lung ventilation did not result in a higher rate of respiratory complications after RAT‐AVR surgery.

Function of the Respiratory System in Elderly Patients After Aortic Valve Replacement

OBJECTIVE To compare the function of the respiratory system after aortic valve replacement through median sternotomy (AVR) or the minimally invasive right anterior minithoracotomy (RAT-AVR) approach among elderly (aged≥75 years) patients. DESIGN Observational cohort study. SETTINGS University hospital. PARTICIPANTS The study included 65 elderly patients scheduled for RAT-AVR and 82 for standard AVR. INTERVENTIONS Pulmonary function tests (PFT) were performed preoperatively, 1 week, 1 month, and 3 months after surgery. In addition, respiratory complications were analyzed. MEASUREMENTS AND MAIN RESULTS Respiratory complications occurred in 12.3% of patients in the RAT-AVR group and 18.3% of patients in the AVR group (p = 0.445). Mechanical ventilation time in the intensive care unit was 7.7±3.6 hours for RAT-AVR patients and 9.7±5.4 hours for AVR patients (p = 0.003). Most PFT were worse in the AVR group than in the RAT-AVR group when performed 1 week after surgery. After 1 month, forced expiratory volume in the first second, vital capacity, and total lung capacity differed significantly in favor of the RAT-AVR group (p = 0.002, p<0.001, and p = 0.001, respectively). After 3 months, the PFT parameters still had not returned to preoperative values, but the differences were no longer significant between the RAT-AVR and AVR groups. The multivariable median regression analysis demonstrated that RAT-AVR surgery was a key factor in a patients higher postoperative PFT parameter values. CONCLUSIONS RAT-AVR surgery resulted in shorter postoperative mechanical ventilation time and improved the recovery of pulmonary function in elderly patients, but it did not reduce the incidence of pulmonary complications when compared with surgery performed through a median sternotomy.

Veno-arterial extracorporeal membrane oxygenation as cardiogenic shock therapy support in adult patients after heart surgery

Introduction The authors present their personal experience in qualifying and treating adult patients using veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) in postcardiotomy cardiogenic shock. Aim The aim of this study was to analyze the results of VA ECMO in patients with postcardiotomy cardiogenic shock. An analysis of the risk factors of postoperative mortality was also performed. Material and methods We analyzed the perioperative results of survivors and non-survivors of treatment using VA ECMO. We compared the number of days on VA ECMO therapy, types of cardiac surgical procedures, and the frequency of VA ECMO complications such as coagulation disorders, lower limb ischemia, cardiac tamponade, and renal replacement therapy. Results There were 27 patients treated with VA ECMO during the study period. The mean patient age was 45 ±16 years. The hospital mortality rate of patients treated with VA ECMO therapy was 70% (19/27). There were no significant differences between the groups of survivors and non-survivors regarding age, gender, admission type and coexisting diseases. Type of cardiac surgical procedure had no influence on mortality or complications of therapy using VA ECMO. Conclusions The VA ECMO can be an effective form of therapy in some patients in postcardiotomy cardiogenic shock.

Acute-phase proteins and oxidative stress in patients undergoing coronary artery bypass graft: comparison of cardioplegia strategy

Introduction Several strategies are still being introduced to cardiac surgery techniques to reduce the signs of the inflammatory response and oxidative stress. Many efforts have been made to develop the best possible method for myocardial protection. Aim To assess the effect of the cardioplegia strategy on the systemic inflammatory response and oxidative stress. Material and methods A group of 238 consecutive, elective on-pump coronary artery bypass graft patients (CABG; 183 men, aged 64.6 ±8.1 years) were prospectively studied. Patients were enrolled in two groups: with warm blood cardioplegia (n = 124) and with cold crystalloid cardioplegia (n = 114). In each group, pre- and postoperative levels of plasma C-reactive protein, fibrinogen, interleukin 6 and 8-iso-prostaglandin F2α (8-iso-PGF2α) were measured. Results All studied markers significantly increased 18–36 h following CABG and then decreased in 5–7 postoperative days but remained above baseline levels. No differences in terms of studied markers and clinical outcomes were noted for the different types of cardioplegia. Regression analysis showed a significant correlation between preoperative level of oxidative stress measured by 8-iso-PGF2α and postoperative myocardial infarction as well as in-hospital cardiovascular death (p = 0.047 and p = 0.041 respectively). Conclusions This study extends previous reports by showing that the type of cardioplegia does not affect the systemic inflammatory response or oxidative stress, which are associated with the CABG procedure. It might be speculated that preoperative screening of oxidative stress could be helpful in identifying patients at increased risk of an unfavorable course after CABG.

Respiratory functional status after conventional and minimally invasive aortic valve replacement surgery – a propensity score analysis

Introduction Reports describing respiratory function of patients after conventional or minimally invasive cardiac surgery are infrequent. Aim To compare pulmonary functional status after conventional (AVR) and after minimally invasive, through right anterior minithoracotomy, aortic valve replacement (RT-AVR). Material and methods This was an observational analysis of 212 patients scheduled for RT-AVR and 212 for AVR between January 2011 and December 2014 selected using propensity score matching. Respiratory function based on spirometry examinations is presented. Results Hospital mortality was 1.4% in RT-AVR and 1.9% in AVR (p = 0.777). Predicted mortality (EuroSCORE II) was 3.2 ±1.1% in RT-AVR and 3.1 ±1.6% in AVR (p = 0.298). Mechanical ventilation time in intensive care unit (ICU) was 7.3 ±3.9 h for RT-AVR and 9.6 ±5.5 h for AVR patients (p < 0.001). Seven days and 1 month after surgery, the reduction of spirometry functional tests was greater in the AVR group than in the RT-AVR group (p < 0.001). Three months after surgery, all spirometry parameters were still reduced and had not returned to preoperative values in both RT-AVR and AVR groups. However, the difference in spirometry values was no longer statistically significant between RT-AVR and AVR groups. Presence of chronic obstructive pulmonary disease and conventional AVR surgical technique were associated with lower values of spirometry parameters after surgery in linear median regression. Conclusions Respiratory function based on spirometry examinations was less impaired after minimally invasive RT-AVR surgery in comparison to conventional AVR surgery through median sternotomy.

A huge primary pleomorphic liposarcoma of the left atrium

Address for correspondence: Dariusz Plicner MD, PhD, Department of Cardiosurgery, John Paul II Hospital, 80 Prądnicka St, 31-202 Krakow, Poland, phone: +48 12 614 30 75, e-mail: plicner@outlook.com Received: 30.10.2016, accepted: 20.01.2017. Primary cardiac tumors are exceptionally rare. Metastases of the heart occur 20–40 times more frequently than primary neoplasms [1]. Among primary cardiac tumors in adults, approximately 25% are malignant, and nearly all are sarcomas. Primary cardiac sarcomas are much more commonly reported than primary liposarcomas [2]. Primary liposarcomas of the heart are extremely rare neoplasms found in only about 1% of all primary malignant cardiac tumors. Only a few cases of primary cardiac liposarcoma have been reported [3–5]. We report a case of resection of left atrial primary liposarcoma. A 21-year-old woman (gravida 1, para 1, 0 Rh plus) was admitted with a presumptive diagnosis of acute endocarditis and mitral valve vegetations. On admission she presented an 8-week history of progressive dyspnea, malaise, fever, cough and sore throat. During this time she was treated with antibiotics without results. She was free of cardiovascular disease or other symptoms until fever developed. Auscultation revealed tachycardia, continuous murmur (Levine 4/6) over the apex and rales over all pulmonary fields. Electrocardiography showed tachycardia with normal 12-lead ECG. Chest roentgenogram showed a small tent-shaped adhesion over the left diaphragm dome. Other X-ray findings were within the normal range. The laboratory examination on admission revealed anemia (with Hb 9.1 g/dl and Hct 29.6%) and thrombocytopenia (with Plt 57.5 × 103/μl). Transthoracic two-dimensional echocardiography revealed a large mass extending from the left atrium through the mitral valve to the left ventricular outflow tract (Fig. 1). The patient underwent an emergency operation. Surgery was performed through a median sternotomy with cardiopulmonary bypass and mild hypothermia. The tumor originated from the wall of the left atrium, between the right superior and right inferior pulmonary veins. It extended to the left ventricle outflow tract and almost completely blocked the mitral valve orifice. En bloc resection was performed and the tumor pedicle was shaved from the atrial myocardium. The tumor was a 25 cm long, cone-shaped structure with a 4 cm diameter base and 0.5 cm diameter apex (Fig. 2). Aorta cross clamping time was 45 min and time of extracorporeal circulation was 70 min. Pathologic analysis of the resected specimen revealed neoplasma malignum anaplasticum mesenchymale–differentiated pleomorphic liposarcoma (Fig. 3). Bacteriological examinations of the tumor and patient’s blood were negative for both aerobic and anaerobic microorganisms.

Respiratory System Function in Patients After Minimally Invasive Aortic Valve Replacement Surgery: A Case Control Study

Objective The aim of the study was to comparatively analyze respiratory system function after minimally invasive, through right minithoracotomy aortic valve replacement (RT-AVR) to conventional AVR. Methods Analysis of 201 patients scheduled for RT-AVR and 316 for AVR between January 2010 and November 2013. Complications of the respiratory system and pulmonary functional status are presented. Results Complications of the respiratory system occurred in 16.8% of AVR and 11.0% of RT-AVR patients (P = 0.067). The rate of pleural effusions, thoracenteses, pneumonias, or phrenic nerve dysfunctions was not significantly different between groups. Perioperative mortality was 1.9% in AVR and 1.0% in RT-AVR (P = 0.417). Mechanical ventilation time after surgery was 9.7 ± 5.9 hours for AVR and 7.2 ±3.2 hours for RT-AVR patients (P < 0.001). Stroke (odds ratio [OR] = 13.4, P = 0.008), increased postoperative blood loss (OR = 9.6, P <0.001), and chronic obstructive pulmonary disease (OR = 7.7, P < 0.001) were risk factors of prolonged mechanical lung ventilation. A week after surgery, the results of most pulmonary function tests were lower in the AVR than in the RT-AVR group (P < 0.001 was seen for forced expiratory volume in the first second, vital capacity, total lung capacity, maximum inspiratory pressure and maximum expiratory pressure, P = 0.377 was seen for residual volume). Conclusions Right anterior aortic valve replacement minithoracotomy surgery with single-lung ventilation did not result in increased rate of respiratory system complications. Spirometry examinations revealed that pulmonary functional status was more impaired after AVR in comparison with RT-AVR surgery.

Perioperative Outcomes of Minimally Invasive Aortic Valve Replacement through Right Anterior Minithoracotomy

Background The aim of the study was to analyze perioperative outcomes after minimally invasive aortic valve replacement through right anterior minithoracotomy (RAT-AVR). Patient selection criteria, anesthesia protocol, and surgical technique are presented. Methods A retrospective analysis of 194 patients electively scheduled for RAT-AVR was performed between January 2009 and June 2013. For preoperative planning, computed tomography was performed. Results Among studied patients, there were 48.5% females and 51.5% males with a mean age of 69.9 ± 9.2 years. The predicted mortality calculated with EuroSCORE II was 3.2 ± 0.9%, and observed mortality of RAT-AVR patients was 1.5%. Finally, RAT-AVR surgery was performed on 97.9% of patients (n = 190). Reasons for conversions to median sternotomy were bleeding from aortotomy site (n = 4) and from the right ventricle after epicardial pacing wire placement (n = 1), pleural adhesions (n = 2), and ascending aorta hidden under the sternum (n = 2). The second intercostal space was chosen for surgical access in 97.9% of patients.There were 3.6% reoperations for bleeding: aortotomy place (n = 1), epicardial pacing wire placement (n = 3), right lung tear (n = 2), and intercostal vessels (n = 1). The intensive care unit and hospital length of stays were 1.3 ± 1.2 and 5.7 ± 1.4 days, respectively. Strokes were present in 1.5% of patients. The perioperative complications rate diminished with time, occurring in 44.9% of the patients between 2009 and 2010 and in 15.6% of patients in 2013. Conclusions RAT-AVR can be safely performed without increased morbidity and mortality. Reduced complication rates over time reflect a learning curve.