Lazar Velicki

Aortic Valve Endocarditis

Infective endocarditis (IE) is an endovascular infection of cardiovascular structures – usually valves – but also large intra-thoracic vessels and intra-cardiac foreign bodies. It is typically caused by bacteria or fungi. In contrast, sterile thrombotic lesions are termed non-bacterial thrombotic endocarditis (NBTE). IE is generally characterised by lesions of vegetations composed of platelets, fibrin, microorganisms, and inflammatory cells, as well as leaflet disruption to a various degree. Endocarditis may also produce a wide variety of systemic signs and symptoms due to sterile and infected emboli, as well as various immunological phenomena. IE is a fatal disease if left untreated (Horstkotte et al., 2004). Characterising aspects of IE were first described by Jean Francois Fernel in his book Medicini in 1554. Lazaire Riviere followed suit with gross autopsy findings of the disease in 1723 after which, in 1852, Kirkes described emboli arising from heart valves in cerebral, renal, splenic and other arteries. Although several reports of IE have been published since – some from well-known physicians like Morgagni and Virchow, it was not until 1885 that IE was comprehensively documented when Sir William Osler accumulated various works and presented them to the public in the form of the comprehensive analysis of this disease (Millar & Moore, 2004). Despite substantial improvements in diagnosis and treatment of native valve IE, disease incidence is on an increase currently averaging 3.3 new cases each year per 100,000 population in the United Kingdom, similar figures in the United States, and 1.4 to 4 new cases over the same population in European countries (Bashore et al., 2006). Native valve IE continues to be associated with high morbidity and mortality rate. Even though IE was previously associated with poor dentition and rheumatic heart disease, many factors have altered its epidemiology but have maintained its incidence: an aging population with degenerative valvular disease, injection drug use, increasing number of valve replacements, and medical interventions i.e. invasive vascular procedures (Wang & Bashore, 2009). Several variants to valve endocarditis have also been recognized: nosocomial IE, intravenous drug abuse IE, and prosthetic valve endocarditis (PVE). Nosocomial infective endocarditis is defined as acute IE, occurring 48 to 72 hours or more post-admission to hospital, or endocarditis directly related to a hospital-based procedure performed during a prior hospital visit within eight weeks of admission (Haddad et al., 2004). Intravenous drug abuse IE most commonly affects tricuspid valve and is associated with no previous structural damage of the valve. PVE accounts for 10-20% of cases. Incidence of PVE is reported to be most often between 0.2 and 0.8% for each year of life with an implanted valve (Dominik &

Predictors for Hospital Readmission After Cardiac Surgery

Unplanned hospital readmissions are responsible for increased health care costs and have direct influence on patient quality of life. The aim of the study was to determine the predictors for hospital readmission after open‐heart surgery.

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.

Left Ventricular Assist Device as a Bridge to Recovery for Patients With Advanced Heart Failure

Background Left ventricular assist devices (LVADs) have been used as an effective therapeutic option in patients with advanced heart failure, either as a bridge to transplantation, as destination therapy, or in some patients, as a bridge to recovery. Objectives This study evaluated whether patients undergoing an LVAD bridge-to-recovery protocol can achieve cardiac and physical functional capacities equivalent to those of healthy controls. Methods Fifty-eight male patients—18 implanted with a continuous-flow LVAD, 16 patients with LVAD explanted (recovered patients), and 24 heart transplant candidates (HTx)—and 97 healthy controls performed a maximal graded cardiopulmonary exercise test with continuous measurements of respiratory gas exchange and noninvasive (rebreathing) hemodynamic data. Cardiac function was represented by peak exercise cardiac power output (mean arterial blood pressure × cardiac output) and functional capacity by peak exercise O2 consumption. Results All patients demonstrated a significant exertional effort as demonstrated with the mean peak exercise respiratory exchange ratio >1.10. Peak exercise cardiac power output was significantly higher in healthy controls and explanted LVAD patients compared with other patients (healthy 5.35 ± 0.95 W; explanted 3.45 ± 0.72 W; LVAD implanted 2.37 ± 0.68 W; and HTx 1.31 ± 0.31 W; p < 0.05), as was peak O2 consumption (healthy 36.4 ± 10.3 ml/kg/min; explanted 29.8 ± 5.9 ml/kg/min; implanted 20.5 ± 4.3 ml/kg/min; and HTx 12.0 ± 2.2 ml/kg/min; p < 0.05). In the LVAD explanted group, 38% of the patients achieved peak cardiac power output and 69% achieved peak O2 consumption within the ranges of healthy controls. Conclusions The authors have shown that a substantial number of patients who recovered sufficiently to allow explantation of their LVAD can even achieve cardiac and physical functional capacities nearly equivalent to those of healthy controls.

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.

Surgical Treatment of Coronary Artery-Pulmonary Artery Fistula with Coronary Artery Disease

Abstract  Coronary arteriovenous fistulae present rare clinical finding with the incidence of about 0.002% in the general population. Usually they are asymptomatic, but sometimes they can mimic other cardiac diseases, most commonly heart failure, myocardial ischemia, and endocarditis. Coronary arteriovenous fistulae have been reported to arise more commonly from the right coronary artery. Most of these fistulae are congenital, and only a small fraction acquired. In this report we present successful surgical treatment of coronary artery to pulmonary artery fistula combined with myocardial revascularization.

CABG Mortality is Not Influenced by Prior PCI in Low Risk Patients

An increasing number of patients referred for coronary artery bypass grafting (CABG) have had prior percutaneous coronary intervention (PCI). We sought to determine whether a relationship exists between increased postoperative mortality and morbidity following CABG procedure in patients with prior PCI.

Impact of age on the association between cardiac high-energy phosphate metabolism and cardiac power in women

Objective Diminished cardiac high-energy phosphate metabolism (phosphocreatine-to-ATP (PCr:ATP) ratio) and cardiac power with age may play an important roles in development of cardiac dysfunction and heart failure. The study defines the impact of age on PCr:ATP ratio and cardiac power and their relationship. Methods Thirty-five healthy women (young≤50 years, n=20; and old≥60 years, n=15) underwent cardiac MRI with 31P spectroscopy to assess PCr:ATP ratio and performed maximal graded cardiopulmonary exercise testing with simultaneous gas-exchange and central haemodynamic measurements. Peak cardiac power output, as the best measure of pumping capability and performance of the heart, was calculated as the product of peak exercise cardiac output and mean arterial blood pressure. Results PCr:ATP ratio was significantly lower in old compared with young age group (1.92±0.48 vs 2.29±0.55, p=0.03), as were peak cardiac power output (3.35±0.73 vs 4.14±0.81W, p=0.01), diastolic function (ie, early-to-late diastolic filling ratio, 1.33±0.54 vs 3.07±1.84, p<0.01) and peak exercise oxygen consumption (1382.9±255.0 vs 1940.3±434.4 mL/min, p<0.01). Further analysis revealed that PCr:ATP ratio shows a significant positive relationship with early-to-late diastolic filling ratio (r=0.46, p=0.02), peak cardiac power output (r=0.44, p=0.02) and peak oxygen consumption (r=0.51, p=0.01). Conclusions High-energy phosphate metabolism and peak power of the heart decline with age. Significant positive relationship between PCr:ATP ratio, early-to-late diastolic filling ratio and peak cardiac power output suggests that cardiac high-energy phosphate metabolism may be an important determinant of cardiac function and performance.

Closure of an atrial septal defect with a one-way flap patch in a patient with severe pulmonary hypertension

An isolated atrial septal defect (ASD) can occasionally go unrecognized for decades and accounts for 25-30% of congenital heart disease cases diagnosed in adulthood. Pulmonary hypertension often develops as a result of a long-lasting, left-to-right shunt and may ultimately be associated with a fixed increase of pulmonary vascular resistance, sometimes rendering these patients inoperable. To reduce the risk of developing postoperative morbidity and possible mortality, we employed our technique of a unidirectional valved patch for the closure of ASD.