Karol Bartczak

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.

Short-term ECG recordings for heart rate assessment in patients with chronic atrial fibrillation

Introduction There is no consensus on the length of ECG tracing that should be recorded to represent adequate rate control in patients with atrial fibrillation (AFib). The purpose of the study was to examine whether heart rate measurements based on short-term ECGs recorded at different periods of the day may correspond to the mean heart rate and rate irregularity analyzed from standard 24-hour Holter monitoring. Material and methods The study enrolled 50 consecutive patients with chronic AFib who underwent 24-hour Holter monitoring. Mean heart rate (mHR) and the coefficient of irregularity (CI) were assessed from 5- and 60-minute intervals of Holter recordings in different periods of the day. Results The highest correlation in mean heart rate interval within 24 h was found during a 6-hour sample and in the periods 11.00 AM–12.00 PM, 12 PM–1.00 PM, and 1.00 PM–2.00 PM. With respect to irregularity, only the CI measurements based on a 6-hour interval (7.00 AM–1.00 AM) show a correlation > 0.08 compared to data from the 24-hour recording. Conclusions Only long-term (6-hour) recordings provide a high correlation within 24 h in mean heart rate interval and coefficient of irregularity. It seems that the mean heart rate interval in 1-hour periods between 11 AM and 2 PM might be predictive for 24-hour data. Short time recordings of the coefficient of irregularity of heart rate in AFib patients at this moment are not useful in clinical practice for long-term prognosis of ventricular irregularity.

A subcutaneous implantable cardioverter-defibrillator — the first implantation in Poland

We present the case of a 28-year-old patient successfully implanted with a subcutaneous implantable cardioverter-defibrillator (S-ICD) in secondary prevention of sudden cardiac death. The patient was resuscitated from out-of-hospital cardiac arrest due to ventricular fibrillation (VF). This was complicated by pneumothorax and respiratory failure that required mechanical ventilation for 5 days. After 2 weeks on the intensive care unit, the patient was transferred to the Cardiology Department. A subsequent medical evaluation revealed no structural heart abnormalities, nor other overt cardiovascular dysfunctions. However, during an invasive electrophysiological study, VF was induced with programmed right ventricular stimulation (Fig. 1). Therefore, the patient was implanted with an ICD. One week after this procedure, he presented symptoms of fever, shivers and chest pain. A fulminant endocarditis and right ventricle perforation was diagnosed. Subsequently, an adequate intravenous antibiotic treatment was introduced and the ICD system was explanted. Nevertheless, the important destruction of the tricuspid valve was revealed in echocardiography, and cardiothoracic surgery with artificial tricuspid valve replacement (Medtronic 29 mm) was performed. The surgery was complicated by intermittent complete atrio-ventricular block, thus the epicardial lead was implanted to the left ventricle and connected to the pacemaker placed in the right subclavian region. After 3 weeks of in-hospital recovery, the patient was consulted by an international board of arrhythmology specialists in order to establish the possibility of S-ICD implantation. The electrocardiography screening to check S-ICD arrhythmia discriminators matching with sensed cardiac signals was completed successfully, as well on the intrinsic rhythm as during pacing. Eventually, the patient was referred to S-ICD implantation. The procedure was performed on oral anticoagulation with acenocoumarol (INR on the day of procedure was 2.1), in volatile and maintenance anaesthesia by a joint team of cardiologist and cardiothoracic surgeon. The S-ICD was positioned in the left lateral region between the 5th and 7th intercostal spaces. The subcutaneous defibrillation lead was implanted atypically — in parasternal instead of medial line. The reason for atypical positioning of the lead was to avoid collision with the epicardial lead that had been previously implanted in the substernal region and to avert complications in case of future medial resternotomy. The position of the device and the lead is presented in Figure 2. Considering the high thromboembolic risk, testing of the defibrillator was successfully performed after transoesophageal echocardiography on the 4th day after the implantation. The post-procedure course was uneventful. We present the first Polish experience of implantation of a S-ICD system. This modern therapy is an option for those patients who cannot have a standard ICD implanted for any reason, e.g. vascular abnormalities or intravascular infection. This procedure, although it is still not routinely reimbursed by the public health system, has become a new treatment option for Polish patients.

Implantation of VVI epicardial pacemaker through mini-sternotomy in a patient with superior vena cava occlusion after radiotherapy

The paper presents a case report of a patient with a superior vena cava occlusion and post-operational (after the implantation of the aortic valve) atrioventricular block, which required constant stimulation. An epicardial VVI pacemaker was implanted through mini-sternotomy in the lower part of the previous operation field with very satisfactory stimulation parameters. Implantation of a screw-in epicardial lead is in some cases the method of choice, which provides efficient and constant heart stimulation.

Isolated coronary artery bypass grafting in extracorporeal circulation in patients over 65 years old - does age still matter?

Introduction Coronary artery bypass grafting (CABG) is conducted more and more commonly in patients in advanced age. Aim of the study To analyze the influence of age and concurrent risk factors on the complications and early mortality after CABG. Material and methods Medical records of 2194 patients were analyzed retrospectively. A group of 1303 patients who had undergone isolated CABG was selected. 106 (4.8%) patients were excluded due to missing data in their medical records. The remaining 1197 patients were divided into two subgroups by age: 1st group < 65 years (n = 662; 55.3%); 2nd group ≥ 65 years (n = 535; 44.7%). Results The total 30-day mortality was 3.93% and was six times higher in the older group (1.21 vs. 7.29%; p < 0.001). Complications were observed in 176 (14.70%) patients, more often in the older group (10.42% vs. 20.0%; p < 0.001). In this group all kinds of complications were noted more often and in particular: postoperative myocardial infarction (1.96% vs. 5.42%; p = 0.001), respiratory dysfunction (1.36% vs. 4.11%; p = 0.005), neurological complications (1.81% vs. 3.74%; p = 0.04) and multi-organ dysfunction syndrome (0.30% vs. 1.68%, p = 0.03). The older patients required longer time under mechanical ventilation (24.0 ± 27.9 vs. 37.0 ± 74.1 hours; p = 0.004) and stayed longer in the intensive care unit: 2.5 ± 3.0 vs. 4.1 ± 7.84 days; p < 0.001. Independent predictors of death were: female sex [OR (95% CI) = 2.4 (1.2-4.5)], age ≥ 65 years [OR = 4.9 (2.1-11.1)], eGFR < 60 mL/min/1.73 m2 [OR = 2.2 (1.0-4.7)], time at extracorporeal circulation > 72 minutes [OR = 5.5 (2.7-10.9)] and left main stem stenosis (> 50%) [OR = 2.4 (1.3-4.6)]. Conclusions Age still significantly influences postoperative complications and mortality after isolated CABG.

Influence of Atrioventricular Optimization on Hemodynamic Parameters and Quality of Life in Patients with Dual Chamber Pacemaker with Ventricular Lead in Right Ventricular Outflow Tract

The aim of this study was to ascertain whether individual atrioventricular delay (AVD) optimization using impedance cardiography (ICG) offers beneficial hemodynamic effects as well as improved exercise tolerance and quality of life in patients with requiring constant right ventricular pacing.

Fatal outcome of early postoperative myocardial infarction after implantation of aortic valve bioprosthesis and left internal thoracic artery anastomosis to left anterior descending coronary artery caused by closure of unchanged circumflex coronary artery

Acute perioperative myocardial infarction caused by coronary artery embolization after aortic valve implantation is a rare and often fatal postoperative complication. We present a case report of a 67-year-old patient operated on for aortic valve replacement (AVR) and myocardial revascularization (LITA-LAD anastomosis). Myocardial ischemia caused by occlusion of the previously intact circumflex coronary artery occurred in the early postoperative period. Despite a successful balloon angioplasty of the closed artery in the fifth hour after the procedure, the status of the patient did not improve significantly. A decrease in progressive arterial pressure, multiple organ failure, a significant rise of myocardial necrosis markers and the lack of external pacing led to death on the second day after the operation. Acute myocardial infarction after aortic valve replacement caused by occlusion of coronary vessels by calcium debris or thrombosis is a rare postoperative complication, which may be fatal even if the patency of the vessel is promptly restored.

Infective endocarditis complicated with left atrioventricular fistula in a 20-year-old patient. A case study.

Intracardiac fistulas are rare complications of infective endocarditis. We report an unusual case of successful surgical repair of intracardiac fistula between the left ventricle and the left atrium in the course of infective endocarditis in a 20-year-old patient. According to this we conclude that timely diagnosis, proper antibiotic treatment, and early surgical intervention should improve the outcomes of infective endocarditis complications.