Nikolaos G. Baikoussis

Antiphospholipid syndrome; its implication in cardiovascular diseases: a review

Antiphospholipid syndrome (APLS) is a rare syndrome mainly characterized by several hyper-coagulable complications and therefore, implicated in the operated cardiac surgery patient. APLS comprises clinical features such as arterial or venous thromboses, valve disease, coronary artery disease, intracardiac thrombus formation, pulmonary hypertension and dilated cardiomyopathy. The most commonly affected valve is the mitral, followed by the aortic and tricuspid valve. For APLS diagnosis essential is the detection of so-called antiphospholipid antibodies (aPL) as anticardiolipin antibodies (aCL) or lupus anticoagulant (LA). Minor alterations in the anticoagulation, infection, and surgical stress may trigger widespread thrombosis. The incidence of thrombosis is highest during the following perioperative periods: preoperatively during the withdrawal of warfarin, postoperatively during the period of hypercoagulability despite warfarin or heparin therapy, or postoperatively before adequate anticoagulation achievement. Cardiac valvular pathology includes irregular thickening of the valve leaflets due to deposition of immune complexes that may lead to vegetations and valve dysfunction; a significant risk factor for stroke. Patients with APLS are at increased risk for thrombosis and adequate anticoagulation is of vital importance during cardiopulmonary bypass (CPB). A successful outcome requires multidisciplinary management in order to prevent thrombotic or bleeding complications and to manage perioperative anticoagulation. More work and reporting on anticoagulation management and adjuvant therapy in patients with APLS during extracorporeal circulation are necessary.

Pharmacologic prophylaxis for atrial fibrillation following cardiac surgery: a systematic review

Atrial Fibrillation (AF) is the most common arrhythmia occurring after cardiac surgery. Its incidence varies depending on type of surgery. Postoperative AF may cause hemodynamic deterioration, predispose to stroke and increase mortality. Effective treatment for prophylaxis of postoperative AF is vital as reduces hospitalization and overall morbidity. Beta - blockers, have been proved to prevent effectively atrial fibrillation following cardiac surgery and should be routinely used if there are no contraindications. Sotalol may be more effective than standard b-blockers for the prevention of AF without causing an excess of side effects. Amiodarone is useful when beta-blocker therapy is not possible or as additional prophylaxis in high risk patients. Other agents such as magnesium, calcium channels blocker or non-antiarrhythmic drugs as glycose-insulin - potassium, non-steroidal anti-inflammatory drugs, corticosteroids, N-acetylcysteine and statins have been studied as alternative treatment for postoperative AF prophylaxis.

Intramural haematoma of the thoracic aorta: who's to be alerted the cardiologist or the cardiac surgeon?

This review article is written so as to present the pathophysiology, the symptomatology and the ways of diagnosis and treatment of a rather rare aortic disease called Intra-Mural Haematoma (IMH). Intramural haematoma is a quite uncommon but potentially lethal aortic disease that can strike as a primary occurrence in hypertensive and atherosclerotic patients to whom there is spontaneous bleeding from vasa vasorum into the aortic wall (media) or less frequently, as the evolution of a penetrating atherosclerotic ulcer (PAU). IMH displays a typical of dissection progress, and could be considered as a precursor of classic aortic dissection. IMH enfeebles the aortic wall and may progress to either outward rupture of the aorta or inward disruption of the intima layer, which ultimately results in aortic dissection. Chest and back acute penetrating pain is the most commonly noticed symptom at patients with IMH. Apart from a transesophageal echocardiography (TEE), a tomographic imaging such as a chest computed tomography (CT), a magnetic resonance (MRI) and most lately a multy detector computed tomography (MDCT) can ensure a quick and accurate diagnosis of IMH. Similar to type A and B aortic dissection, surgery is indicated at patients with type-A IMH, as well as at patients with a persistent and/or recurrent pain. For any other patient (with type-B IMH without an incessant pain and/or without complications), medical treatment is suggested, as applied in the case of aortic dissection. The outcome of IMH in ascending aorta (type A) appears favourable after immediate (emergent or urgent) surgical intervention, but according to international bibliography patients with IMH of the descending aorta (type B) show similar mortality rates to those being subjected to conservative medical or surgical treatment. Endovascular surgery and stent-graft placement is currently indicated in type B IMH.

Sex differentiation with regard to coronary artery disease

Coronary artery disease was considered a male disease for many years. However, nowadays, coronary artery disease constitutes the leading cause of death in women, although there are a lot of gender-related differences regarding the presentation of acute myocardial infarction, its diagnosis, its treatment, short- and long-term mortality rates, and post-acute myocardial infarction complications. Generally, women have smaller and stiffer hearts and cardiac vessels, suffering a greater extent of atherosclerosis and endothelial and smooth muscle dysfunction. They are usually older than men and they have more comorbidities such as hypertension, renal impairment, and diabetes mellitus. Moreover, female coronary artery disease, the diagnosis of which is more complicated due to more false negative results of some diagnostic methods in women, is more often presented with atypical symptoms and womens symptoms of typical or atypical angina are more severe. Furthermore, women delay significantly more in seeking care and they are more frequently undertreated. Finally, women are associated with generally poorer in-hospital and long-term prognosis having almost two-fold higher early mortality and they are more prone to complications such as bleeding complications, shock, and heart failure, as well as to post-myocardial infarction depression and poorer physical function and mental health. In this review, we discuss these sex-related differences according to current literature.

Left ventricular diastolic dysfunction of the cardiac surgery patient; a point of view for the cardiac surgeon and cardio-anesthesiologist

BackgroundLeft ventricular diastolic dysfunction (DD) is defined as the inability of the ventricle to fill to a normal end-diastolic volume, both during exercise as well as at rest, while left atrial pressure does not exceed 12 mm Hg. We examined the concept of left ventricular diastolic dysfunction in a cardiac surgery setting.Materials and methodsLiterature review was carried out in order to identify the overall experience of an important and highly underestimated issue: the unexpected adverse outcome due to ventricular stiffness, following cardiac surgery.ResultsAlthough diverse group of patients for cardiac surgery could potentially affected from diastolic dysfunction, there are only few studies looking in to the impact of DD on the postoperative outcome; Trans-thoracic echo-cardiography (TTE) is the main stay for the diagnosis of DD. Intraoperative trans-oesophageal (TOE) adds to the management. Subgroups of DD can be defined with prognostic significance.ConclusionDD with elevated left ventricular end-diastolic pressure can predispose to increased perioperative mortality and morbidity. Furthermore, DD is often associated with systolic dysfunction, left ventricular hypertrophy or indeed pulmonary hypertension. When the diagnosis of DD is made, peri-operative attention to this group of patients becomes mandatory.

The “benefits” of the mini-extracorporeal circulation in the minimal invasive cardiac surgery era

Mini-extracorporeal circulation (MECC) constitutes a novel miniaturized cardiopulmonary bypass (CPB) circuit, heparin-coated and primed with aprotinin. Its membrane oxygenation is similar to conventional cardio-pulmonary bypass (CCPB), but it is a completely closed-volume system due to the lack of the venous reservoir which has been removed. In a mini circuit, the reservoir is the patient himself. Consequently, air entering the venous cannula is avoided. Nevertheless, the capabilities of MECC have been expanded either by the inclusion of a suction device that is only activated on direct contact with liquid in some circuits or by postoperative autotransfusion of the wrecked erythrocytes by a separate suction device with a cell-saver. Although the tubing diameter is similar between the two systems, the tubing length of the MECC is around half that of the CCPB, resulting in the restriction of priming volume. As a consequence, a higher hematocrit thus a limited need for perioperative blood transfusion is achieved due to less hemodilution. In addition, the inflammatory response is also diminished as a result of less artificial surface area interacting with blood. Finally, a lower dose of heparin is required prior to MECC than prior to CCPB.

A successfully thrombolysed acute inferior myocardial infarction due to type A aortic dissection with lethal consequences: the importance of early cardiac echocardiography

Thrombolysis, a standard therapy for ST elevation myocardial infarction (STEMI) in non-PCI-capable hospitals, may be catastrophic for patients with aortic dissection leading to further expansion, rupture and uncontrolled bleeding. Stanford type A aortic dissection, rarely may mimic myocardial infarction. We report a case of a patient with an inferior STEMI thrombolysed with tenecteplase and followed by clinical and electrocardiographic evidence of successful reperfusion, which was found later to be a lethal acute aortic dissection. Prognostic implications of early diagnosis applying transthoracic echocardiography (TTE) are described.

Radial artery as graft for coronary artery bypass surgery: Advantages and disadvantages for its usage focused on structural and biological characteristics

Radial artery (RA) is the most popular arterial graft after the left internal thoracic artery in both low- and high-risk patients undergoing coronary artery bypass grafting. Various arterial grafts such as the right internal thoracic artery, the right gastroepiploic artery, and the inferior epigastric artery have also gained ground over the past 30 years because of the intimal hyperplasia and atherosclerosis of the saphenous vein leading to late graft occlusion. In this review article we would like to present the utility of the RA as a graft, focused mainly on its structural and biological characteristics.

Methods of estimation of mitral valve regurgitation for the cardiac surgeon

Mitral valve regurgitation is a relatively common and important heart valve lesion in clinical practice and adequate assessment is fundamental to decision on management, repair or replacement. Disease localised to the posterior mitral valve leaflet or focal involvement of the anterior mitral valve leaflet is most amenable to mitral valve repair, whereas patients with extensive involvement of the anterior leaflet or incomplete closure of the valve are more suitable for valve replacement. Echocardiography is the recognized investigation of choice for heart valve disease evaluation and assessment. However, the technique is depended on operator experience and on patients hemodynamic profile, and may not always give optimal diagnostic views of mitral valve dysfunction. Cardiac catheterization is related to common complications of an interventional procedure and needs a hemodynamic laboratory. Cardiac magnetic resonance (MRI) seems to be a useful tool which gives details about mitral valve anatomy, precise point of valve damage, as well as the quantity of regurgitation. Finally, despite of its higher cost, cardiac MRI using cine images with optimized spatial and temporal resolution can also resolve mitral valve leaflet structural motion, and can reliably estimate the grade of regurgitation.

Acute left main coronary artery thrombosis due to cocaine use

It is common knowledge that cocaine has been linked to the development of various acute and chronic cardiovascular complications including acute coronary syndromes. We present a young, male patient, drug abuser who underwent CABG due to anterolateral myocardial infarction. Our presentation is one of the very rare cases reported in literature regarding acute thrombosis of left main coronary artery related to cocaine use, in a patient with normal coronary arteries, successfully operated. Drug-abusers seem to have increased mortality and morbidity after surgery and high possibility for stent thrombosis after percoutaneous coronary interventions, because of their usually terrible medical compliance and coexistent several problems of general health. There are no specific guidelines about treatment of thrombus formation in coronary arteries, as a consequence of cocaine use. So, any decision making concerning the final treatment of these patient is a unique and individualized approach. We strongly recommend that all these patients should be treated surgically, especially patients with thrombus into the left main artery.