Radosław Zwoliński

Intrapericardial lipoma: diagnosed unexpectedly and resected during coronary artery bypass surgery

Cardiac lipomas are extremely rare tumors, they usually remain asymptomatic and are detected incidentally, mostly during autopsies. In symptomatic patients, the diagnosis can easily be made by echocardiography, computed tomography, or magnetic resonance imaging. We report a case of pericardial lipoma found unexpectedly during coronary artery bypass grafting (CABG) surgery. The patient underwent a successful resection of the tumor and CABG via a median sternotomy. The patient is currently asymptomatic and has not presented with evidence of recurrence at the 12-month follow-up.

Late diagnosis of congenital cardiovascular defect

Coarctation of the aorta (CoA) is a common congenital anomaly that is usually treated in infancy or childhood. Adult patients with coarctation have a high incidence of associated cardiac disorders, including valve diseases, atrial fibrillation and ischemic heart disease. Most patients with uncorrected CoA die before reaching the age of 50 from complications such as myocardial infarction, intracranial hemorrhage, congestive heart failure (HF), infective endocarditis or aortic dissection. We report the case of a 65 year-old woman admitted to hospital with symptoms of heart failure NYHA class IV. She had been treated for several years for refractory arterial hypertension and concomitant stenocardia (II CCS). The symptoms of HF had been increasing over several months. Outpatient echocardiography examination revealed significant, increasing mitral and tricuspid valve regurgitation with progressive left ventricular dysfunction. The patient was referred for surgical repair of the mitral and tricuspid valves. In-hospital echocardiography and angiography revealed descending aorta discontinuity at the level of the aortic isthmus. This congenital disease revealed during hospitalization was determined to be the underlying cause of all the symptoms the patient presented. Due to the clinical status of the patient, she was discharged from surgical procedures and put on medication.

Comparison of the clinical application of reactive oxygen species and inflammatory markers in patients with endocarditis.

Introduction Infective endocarditis (IE) is still connected with high operative mortality. Inflammatory markers are commonly used in monitoring patient clinical condition. Respiratory burst and reactive oxygen species (ROS) are the main way of pathogen elimination. Specificity of this process in the aspect of bacterial infection is the key for correlation assessment between ROS and inflammatory markers in patients with IE. In the study, assessment of ROS as a clinical indicator in IE was conducted. Material and methods During 2007/2008 in the Cardiosurgical Clinic of the Medical University in Lodz there were 20 patients operated on for IE. The examined population consisted of 13 men and 7 women, aged from 23 to 74 years. Inflammatory markers – leukocytosis (WBC), C-reactive protein (CRP), procalcitonin (PCT) and erythrocyte sedimentation rate (ESR) – were assessed preoperatively, on the 3rd, 7th, 12th and 21st day. Simultaneously, with the second venous blood sample chemiluminescence (luminal enhanced whole blood chemiluminescence) was carried out and used to assess ROS production. The results were analyzed statistically. Results Positive correlation between ESR, CRP and ROS in the preoperative period was confirmed. An increase in ROS and a statistically significant increase in inflammatory markers on the 3rd day were observed. The ROS normalized on the 12th day. Marked individual variability was specific for the inflammatory markers. Despite the significant decrease, not all of them achieved a normal level at the last control point. Conclusions Assessment of ROS seems to be a universal parameter with possible application in patients with IE.

Does the additional usage of a local hemostatic patch reduce bleeding after aortic reimplantation

Introduction: Our study aimed to assess the efficacy of a local hemostatic, consisting of human thrombin and fibrinogen, which was applied on the aortotomy suture line. Material and methods: The study involved 93 patients undergoing elective aortic valve replacement. Patients were randomized to two groups. Group 1 comprised 41 patients, in whom a hemostatic patch (Tachosil) was used additionally. Group 2 comprised 52 patients in whom Tachosil was not applied. Results: The postoperative drainage after 48 h was significantly lower in the group of patients where the local hemostatic patch (Tachosil) was additionally used, compared to the control group (p = 0.0335). The prevalence of rethoracotomies was twice as high in the control group compared to the Tachosil group (5% vs. 10%), but the statistical analysis did not show a significant difference. As a consequence, both measurements of hemoglobin concentration revealed significantly higher hemoglobin in Tachosil-treated patients than the control group (p < 0.001, p = 0.0002). Red blood cell count (RBC) was also significantly higher in the Tachosil group. The difference in perioperative blood loss between the two groups resulted in a difference in postoperative acute renal injury or renal failure. The rate of infection within the early postoperative period was also comparable between the groups, although it was slightly higher in the Tachosil group (23% vs. 18%). The perioperative mortality was higher in group 2 but the difference was not statistically significant (3% in the Tachosil group vs. 5% in the control group). Conclusions: Tachosil use reduced postoperative drainage considerably, which had an important influence on renal complications after aortic valve replacement.

Progression of coronary artery disease in a HIV-infected patient previously treated for ascending aorta aneurysm

The pathophysiology of increased cardiovascular risk in HIV infection is complex and multifactorial but chronic inflammation and immune activation seem to play a crucial role. Direct effects of HIV, leakage of bacteria from the gut, damage of lymphoid tissues as well as co-infections are responsible for the activation of the immune system [1], resulting in proinflammatory and pro-thrombotic status [2]. Pro-inflammatory high density lipoprotein (HDL) is dysfunctional with high redox activity and easy non-calcified coronary atherosclerotic plaque rupture [3]. Endothelial and macrophage cell function is significantly impaired. Some antiretroviral agents (either directly or via associated dyslipidemia and insulin resistance) may also contribute to the increased rate of cardiovascular disease in HIV and therefore require careful selection according to the underlying cardiovascular risk factors. A 35-year-old man was diagnosed (02.09.2009) with syphilis and HIV infection classified as stage A3. The patient was a cigarette smoker and had arterial hypertension and a family history of coronary artery disease (CAD). Combined antiretroviral therapy (cART) was composed of lamivudine, abacavir atazanavir and ritonavir. One year later atazanavir was replaced with darunavir due to potential drug-to-drug interaction with protein pump inhibitor (PPI). The patient remained asymptomatic and HIV RNA was undetectable. The CD4 T lymphocyte count was 386 cells/μl. Due to exercise capacity impairment control transthoracic echocardiography (TTE) was performed and revealed: aneurysm of the ascending aorta with maximal diameter 60 mm, aortic bulb 50 mm, aortic annulus 26 mm with good left ventricular ejection fraction (LVEF) – 66%. The aortic valve function was preserved. Preoperative coronarography revealed no significant atherosclerosis in coronary vessels. Initial lipid profile revealed hypertriglyceridemia (LDL 130 mg/dl, HDL 41 mg/dl, TG 240 mg/dl). Lipid-lowering therapy was initiated (atorvastatin 40 mg, fenofibrate 267 mg). Supracoronary ascending aorta replacement with a vascular prosthesis (Vascutek 28) and aortic commissure suspension were performed (25.03.2011) without complications. The patient was discharged on the 5th day after the surgery. The patient had outpatient check-ups regularly. Eighteen months later (22.08.2012) the patient had lateral ST elevation myocardial infarction (STEMI). Coronary angiography revealed narrowing of the circumflex artery (Cx), treated with bare metal stent (BMS) implantation. At that moment 50% de novo stenosis in the proximal segment of the left anterior descending artery (LAD) was also diagnosed (Fig. 1). Double antiplatelet therapy was introduced and continuation of antihypertensive and lipid-lowering medication was recommended. HIV RNA remained undetectable and the CD4 T lymphocyte count was 200– 300 cells/μl. Combined antiretroviral therapy was modified to tenofovir, emtricitabine, darunavir and ritonavir, due to the suspected adverse impact of abacavir on the cardiovascular risk. Six months later (1.03.2013) the patient was admitted again to the cardiology department with diagnosis of NSTEMI. Coronary angiography revealed de novo 95% narrowing in the 3rd segment of the right coronary artery (RCA) (without progression in the proximal LAD), treated with BMS implantation. The lipid profile showed a good response to cholesterol-lowering treatment (LDL 49 mg/dl, HDL 41 mg/dl). Due to hypertriglyceridemia (TG 249 mg/dl) lipid-lowering therapy was changed (rosuvastatin 40 mg and fenofibrate 267 mg, BioCardine Omega-3). Lifestyle modifications (cigarette and alcohol cessation) were once again recommended to the patient. At that time the CD4 T lymphocyte count increased to 660 cells/μl. In a 10-month follow-up the deterioration of angina pectoris (to CCS class III) was observed, and was confirmed with non-invasive tests. Coronary angiography revealed progression of proximal LAD stenosis (90%), and elec-

Computed tomography angiography for imaging results of neochordal mitral valve repair

Introduction Degenerative mitral regurgitation is currently the most frequent indication for mitral valve repair. Aim To visualize and assess the mid-term results of mitral valve repair with neochordae implantation, using computed tomography angiography (CTA) imaging. Material and methods The CTA with ECG gating and without modulation was applied in 10 patients to assess the results of a mitral valve sparing procedure. The results of 3 patients are presented. The patients were operated on for severe symptomatic degenerative mitral regurgitation, defined according to a modified Carpentier’s functional classification. Results Neochordal repair, by placing expanded polytetrafluoroethylene sutures between the leading edge of the prolapsing segment and the corresponding papillary muscle, was conducted. From 1 to 3 double Gore-Tex loops were used. Leaflet clefts, if present, were sutured. All repairs included mitral valve ring annuloplasty. The CTA was performed at 20–24 months after the surgery. Long-axis views, reconstructed during mid-systole, seemed to be the most valuable. Good quality cardiac images, precisely presenting the mitral valve complex with its constituents, were obtained in the case of patients without obesity, with a relatively small anterior-posterior thorax dimension, with sinus, slow heart rhythm and quite good left ventricle contractility. The evaluation of the mitral valve included presence of calcifications, fibrosis or thickening, chordal insertion and coaptation points, and papillary muscle locations. Primary and secondary native chordae tendineae and artificial chordae were visualized. Conclusions Contrast material-enhanced ECG-gated CTA applied after mitral valve repair with Gore-Tex neochordae allows one to obtain satisfactory mitral valve images, especially during mid-systole, and evaluate mid-term results of the surgery in chosen patients.

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.

Artificial aortic valve dysfunction due to pannus and thrombus – different methods of cardiac surgical management

Introduction Approximately 60 000 prosthetic valves are implanted annually in the USA. The risk of prosthesis dysfunction ranges from 0.1% to 4% per year. Prosthesis valve dysfunction is usually caused by a thrombus obstructing the prosthetic discs. However, 10% of prosthetic valves are dysfunctional due to pannus formation, and 12% of prostheses are damaged by both fibrinous and thrombotic components. The authors present two patients with dysfunctional aortic prostheses who were referred for cardiac surgery. Different surgical solutions were used in the treatment of each case. Case study 1 The first patient was a 71-year-old woman whose medical history included arterial hypertension, stable coronary artery disease, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and hypercholesterolemia; she had previously undergone left-sided mastectomy and radiotherapy. The patient was admitted to the Cardiac Surgery Department due to aortic prosthesis dysfunction. Transthoracic echocardiography revealed complete obstruction of one disc and a severe reduction in the mobility of the second. The mean transvalvular gradient was very high. During the operation, pannus covering the discs’ surface was found. A biological aortic prosthesis was reimplanted without complications. Case study 2 The second patient was an 87-year-old woman with arterial hypertension, persistent atrial fibrillation, and COPD, whose past medical history included gastric ulcer disease and ischemic stroke. As in the case of the first patient, she was admitted due to valvular prosthesis dysfunction. Preoperative transthoracic echocardiography revealed an obstruction of the posterior prosthetic disc and significant aortic regurgitation. Transesophageal echocardiography and fluoroscopy confirmed the prosthetic dysfunction. During the operation, a thrombus growing around a minor pannus was found. The thrombus and pannus were removed, and normal functionality of the prosthetic valve was restored. Conclusions Precise and modern diagnostic methods facilitated selection of the treatment method. However, the intraoperative view also seems to be crucial in individualizing the surgical approach.

Iatrogenic left main-stem dissection extending to the circumflex artery and retrogradely involving the left and non-coronary sinuses of Valsalva: iatrogenic aortocoronary dissection.

Abstract We present the case of a 57-year-old female who experienced iatrogenic left main-stem (LMS) dissection during elective coronary angiography. The dissection immediately affected the circumflex artery (Cx), causing its total distal occlusion, and the left anterior descending artery (LAD), in which a metal stent, implanted six months earlier, provided blood flow. The dissection spread retrogradely to the left and non-coronary sinuses of Valsalva (SV). Ventricular fibrillation (VF) occurred but the patient was successfully defibrillated. The subsequent introduction of a catheter resulted in recurrent VF, again successfully defibrillated. Total arterial myocardial revascularisation with double skeletonised internal thoracic arteries was performed without complications and SV repair was avoided. At the one-year follow up, a control multi-slice CT (MSCT) angiography was conducted, revealing complete healing of the SV and LMS dissections. It also showed native blood flow, the left internal thoracic artery (LITA) graft to the Cx occlusion, and a patent right internal thoracic artery (RITA) graft implanted to the LAD.

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.