Robertas Samalavicius

Incidence and precipitating factors of delirium after coronary artery bypass grafting

Objective. To analyze large contemporary patient population, undergoing on-pump coronary artery bypass grafting at our institution, and identify the prevalence and precipitating factors of delirium development. Design. Baseline demographics, operative data and postoperative outcomes of 1367 consecutive patients were recorded prospectively and analysed using multivariate logistic regression analysis, to determine independent predictors of postoperative delirium development. Results. Delirium was detected in 42 (3.07%) patients. Eight factors: age more than 65 years, peripheral vascular disease, Euroscore≥5, preoperative IABP support, postoperative blood product usage and postoperative low cardiac output syndrome were independently predicting delirium development after coronary artery bypass procedures. Postoperative delirium was associated with significantly higher mortality rate (16.6% vs. 3.9%, p=0.013), prolonged mechanical ventilation time (9.2±3.1 vs. 5.05±7.6, p=0.04) and increased length of intensive care unit stay (6.8±4.9 vs. 2.0±2.7 days, p=0.001). Conclusions. Delirium is a dangerous complication, prolonging intensive care unit stay and postoperative mortality. Factors associated with delirium development are advanced age, peripheral vascular disease, diminished cardiac function and blood product usage.

Pre-operative high sensitive C-reactive protein predicts cardiovascular events after coronary artery bypass grafting surgery: a prospective observational study.

C-reactive protein is a powerful independent predictor of cardiovascular events in patients with coronary artery disease. The relation between C-reactive protein (CRP) concentration and in-hospital outcome, after coronary artery bypass grafting (CABG), has not yet been established. The study aims to evaluate the predictive value of pre-operative CRP for in-hospital cardiovascular events after CABG surgery. High-sensitivity CRP (hs-CRP) levels were measured pre-operatively on the day of surgery in 66 patients scheduled for elective on pump CABG surgery. Post-operative cardiovascular events such as death from cardiovascular causes, ischemic stroke, myocardial damage, myocardial infarction and low output heart failure were recorded. During the first 30 days after surgery, 54 patients were free from observed events and 14 developed the following cardiovascular events: 10 (15%) had myocardial damage, four (6%) had low output heart failure and two (3%) suffered stroke. No patients died during the follow-up period. Serum concentration of hs-CRP > or = 3.3 mg/l (cut-off point obtained by ROC analysis) was related to higher risk of post-operative cardiovascular events (36% vs 6%, P = 0.01), myocardial damage (24% vs 6%, P = 0.04) and low output heart failure (12% vs 0%, P = 0.04). Multivariate logistic regression analysis showed that hs-CRP > or = 3.3 mg/l ( P = 0.002, O.R.: 19.3 (95% confidence interval (CI) 2.9-128.0)), intra-operative transfusion of red blood cells ( P = 0.04, O.R.: 9.9 (95% C.I. 1.1-85.5)) and absence of diuretics in daily antihypertensive treatment ( P = 0.02, O.R.: 15.1 (95% C.I. 1.4-160.6) were independent predictors of combined cardiovascular event. Patients having hs-CRP value greater or equal to 3.3 mg/l pre-operatively have an increased risk of post-operative cardiovascular events after on pump coronary artery bypass grafting surgery.

Durability of epicardial ventricular restoration without ventriculotomy

OBJECTIVES We previously presented early results employing a technique designed for beating heart, ventricular volume reduction (surgical ventricular restoration, SVR) without ventriculotomy for patients with antero-septal scar and dilated ischaemic cardiomyopathy. Significant volume reduction and clinical improvement were achieved. We now report durability in the first 11 patients available for assessment at 6 and 12 months after operation. METHODS After the Ethics Committee approval, 31 symptomatic patients with left ventricular (LV) dilatation and antero-septal scars underwent operation. The scarred lateral LV wall was apposed to the septal scar with serial paired anchors placed through epicardial transmural catheters, excluding non-viable portions of the chamber. Patients were followed at 1, 3, 6 and 12 months postoperatively with echocardiograms. Data are presented for the first 11 patients for whom core lab echocardiographic data were available at 12 months of follow-up. RESULTS LV end-systolic index (LVESVI), percent decreases from baseline at 6 and 12 months were 36.2 ± 18.3 (P < 0.001) and 39.6 ± 14.8 (P < 0.001). LV end-diastolic volume index (LVEDVI) percent decreases from baseline at 6 and 12 months were 28.6 ± 18.8 (P < 0.001) at 6 months and 32.2 ± 14.9 (P < 0.005) at 12 months. All comparisons were by one-tailed t-tests using paired data. CONCLUSIONS These results demonstrate the persistence of volume reduction employing a technique designed to be used on beating hearts without ventriculotomy or cardiopulmonary bypass. The extent of volume reduction was consistent with results of conventional SVR in experienced centres. These early data validate the further development of technical iterations leading to a clinical study employing a closed chest endovascular platform.

Asymptomatic carotid artery stenosis and cognitive outcomes after coronary artery bypass grafting.

Abstract Objective. Cognitive decline has a negative impact on early postoperative morbidity and affects subjective quality of life. The role of asymptomatic cerebrovascular disease in developing postoperative neurocognitive damage remains controversial. The aim of our study was to evaluate the impact of asymptomatic carotid artery stenosis on postoperative cognitive decline. Design. We investigated 127 patients undergoing coronary artery bypass grafting. The neuropsychological examination, including a cognitive battery of seven tests and two scales for evaluation of mood disorders, was conducted the day before surgery and before the discharge from hospital. Results. Early postoperative cognitive decline (POCD) was detected in 46% of patients. POCD was associated with longer duration of surgery (p = 0.02), low cardiac output syndrome perioperatively (p < 0.05), postoperative bleeding (p = 0.03), longer postoperative mechanical ventilation time and intensive care unit stay (p < 0.05). Carotid artery lesion was detected in 42 (68.8%) patients. Multivariate regression analysis showed that carotid artery stenosis of more than 50% was an independant predictor of POCD (OR 26.89, CI 6.44–112.34). Conclusions. Asymptomatic carotid artery stenosis is a risk factor for cognitive decline after coronary artery bypass grafting.

Successful treatment of a young woman with acute complicated myocardial infarction

Therapeutic hypothermia is method used to improve the neurological status of patients who are at risk of ischaemia after myocardial infarction. We report a case of a 28-year-old woman who suffered acute myocardial infarction complicated by ventricular fibrillation. The patient was successfully resuscitated. Invasive and non-invasive medical treatment was applied including therapeutic hypothermia. Success was achieved due to adequate public reaction, fast transportation, blood vessel revascularization and application of therapeutic hypothermia. The patient was successfully discharged after one week of treatment, and just minor changes in heart function were present.

Gender-Based Differences in Anxiety and Depression Following Acute Myocardial Infarction

Background Among patients with heart disease, depression and anxiety disorders are highly prevalent and persistent. Both depression and anxiety play a significant role in cardiovascular disease progression and are acknowledged to be independent risk factors. However, there is very little gender-related analysis concerning cardiovascular diseases and emotional disorders. Objective We aimed to evaluate depression and anxiety levels in patients suffering from myocardial infarction [MI] within the first month after the MI and to assess the association between cardiovascular disease risk factors, demographic indicators and emotional disorders, as well as to determine whether there are gender-based differences or similarities. Methods This survey included demographic questions, clinical characteristics, questions about cardiovascular disease risk factors and the use of the Hospital Anxiety and Depression Scale [HADS]. All statistical tests were two-sided, and p values < 0.05 were considered statistically significant. Results It was determined that 71.4% of female and 60.4% of male patients had concomitant anxiety and/or depression symptomatology (p = 0.006). Using men as the reference point, women had an elevated risk of having some type of psychiatric disorder (odds ratio, 2.86, p = 0.007). The HADS-D score was notably higher in women (8.66 ± 3.717) than men (6.87 ± 4.531, p = 0.004). It was determined that male patients who developed depression were on average younger than those without depression (p = 0.005). Conclusions Women demonstrated an elevated risk of having anxiety and/or depression disorder compared to men. Furthermore, depression severity increased with age in men, while anxiety severity decreased. In contrast, depression and anxiety severity was similar for women of all ages after the MI. A higher depression score was associated with diabetes and physical inactivity, whereas a higher anxiety score was associated with smoking in men. Hypercholesterolemia was associated with both higher anxiety and depression scores, and a higher depression score was associated with physical inactivity in women.

Retrospective analysis of single-center early and midterm results of transapical catheter‑based mitral paravalvular leak closure with a purpose-specific device

Introduction Due to the recent lack of definitions to establish the severity of paravalvular leak (PVL) and endpoints for its treatment, the effectiveness and safety of a new device for PVL closure have not been comprehensively analyzed. Aim To analyze a single center’s experience of mitral PVL closure in a surgical transapical catheter-based fashion with a purpose-specific device. Material and methods This is a retrospective cohort study of patients following transapical catheter-based mitral PVL closure with a purpose-specific device. Data were analyzed at baseline, perioperatively, at discharge, at six months and annually after the procedure. Results Nineteen patients underwent surgical transapical catheter-based mitral PVL closure with the Occlutech PLD Occluder. Mean follow-up time was 20 ±7 (range: 9–33) months. The patients’ mean age was 64 ±7 years, and 11 (58%) were male. Technical, device and individual patient success at follow-up was achieved in 18 (95%), 16 (84%) and 16 (84%) patients respectively. Median intensive therapy unit stay was one day (1–4) and mean hospital stay was 11 ±4 days. A reduction of paravalvular regurgitation to a mild or lesser degree was achieved in 18 (95%) patients. There were no strokes or myocardial infarctions at follow-up. There were no deaths at 30 days after the procedure. One (5%) patient expired due to progression of heart failure 12 months after surgery. None of the patients required immediate conversion to full sternotomy. Conclusions Surgical transapical catheter-based mitral PVL closure with the Occlutech PLD Occluder is a safe and clinically effective treatment.

Occlutech® Paravalvular Leak Device (PLD)

Since the first reported use of the double-umbrella Rashkind device [1] in 1992, transcatheter paravalvular leak (PVL) closure has been performed extensively by many centers around the world.

Acute pulmonary hemorrhage after dislocation of transcatheter aortic valve prosthesis

Transcatheter aortic valve implantation (TAVI) has been increasingly used as a preferred treatment for severe symptomatic aortic stenosis in inoperable and high surgical risk patients. The choice between the surgical or TAVI approach is made based on estimated surgical risk and comorbidities of the individual patient [1]. Contemporary imaging techniques and advances in valve technology resulted in a decrease of complications and improved overall outcomes. The role of TAVI is expanding – newer indications for its use are under research [2]. There is growing interest in the application of TAVI in lower surgical risk patients or in patients with anatomical difficulties [3]. Recent reports confirm the trend of transcatheter valve replacement in patients who are at low or intermediate risk [4]. The conventional surgical approach is not superior to TAVI in intermediate risk patients. Moreover, less invasive procedures result in lower risk of major postoperative complications and more rapid early recovery, which result in shorter durations of stay in the intensive care unit (ICU) and hospital. We present a case of unsuccessful TAVI complicated with acute severe bronchial bleeding in a patient with aortic coarctation. A 73-year-old woman with worsening shortness of breath (New York Heart Association class III) due to aortic valve lesions was referred for aortic valve replacement. Prior to admission she underwent interposition graft replacement for aortic coarctation in her childhood. Baseline transthoracic echocardiography reported a calcified aortic valve with an aortic valve area of 0.7 cm2, mean pressure gradient of 40.9 mm Hg alongside moderately impaired left ventricular ejection fraction of 30% and moderate pulmonary hypertension. Multislice computed tomography (MSCT) and cardiac catheterization angiography revealed normal coronary arteries; diameters of the aortic annulus and ascending aorta at the sinotubular junction were 25 and 33 mm, respectively. Images demonstrated postcoarctation repair appearance of the aortic arch with the diameter of 25 mm and evidence of re-coarctation narrowing and kinking in the proximal descending aorta up to 20 mm. Diameter of the descending aorta of was 26 mm with normal appearance of suprarenal and infrarenal segments. Patients’ logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE II) was 5.78% and Society of Thoracic Surgeons (STS)-predicted mortality was 2.3%. The patient refused to undergo conventional surgery. She was advised to undergo the surgical replacement of the aortic valve, but insisted on a non-invasive approach, or otherwise refused surgery at all. After multidisciplinary evaluation TAVI as an alternative strategy was suggested and the risks explained to the patient. The patient consented and accepted the risks of intervention. The TAVI procedure was performed under general anesthesia. The Medtronic Core Valve nitinolporcine prosthesis, with full expansion of 26 mm in diameter, corresponding to the aortic annulus diameter, was selected. The interventional cardiologist chose the right femoral artery approach for the procedure. Once the pre-implantation balloon valvuloplasty with a 20 × 40 mm Amplatzer (St Jude Medical, MN, USA) sizing balloon was successful, an 18 Fr (6 mm) sheath was used to introduce the valve prosthesis. Femoral vein access was used as well for HF pacing. After positioning the valve under fluoroscopic and TOE guidance, aortic insufficiency was detected. All attempts to reposition the valve were unsuccessful and ended up with a dislocated and stuck CoreValve in the descending aorta (Fig. 1). A pigtail catheter inserted through the brachial artery was used to verify that the valve was not occluding the carotid or subclavian arteries. Post-procedural TOE showed valve insufficiency of second degree. After approximately two hours from arrival at the ICU, while the patient was still intubated, sudden massive hemoptysis developed. Fiberoptic bronchoscopy with continuous suction and saline lavage were necessary to localize the source of bleeding, which appeared to be left main bronchus. Fluid replacement, inotropic agents, coagulation factors and hemotransfusion were used to stabilize the pa-

Prophylactic use of an intra-aortic balloon pump in a high-risk patient with peripartum cardiomyopathy requiring cesarean delivery

The use of intra-aortic balloon counter-pulsation for circulatory support in pregnant women with cardiac failure is limited to several case reports. Few publications have addressed the use of intra-aortic balloon counter-pulsation during delivery. We report a case using prophylactic intra-aortic balloon counter-pulsation during the management of a cesarean delivery in a patient with peripartum cardiomyopathy. A 28-year-old primigravid female at 37weeks of gestation was admitted with signs of worsening heart failure, and transthoracic echocardiography revealed a decreased left ventricular ejection fraction of 25%. A plan to proceed with cesarean delivery, using hemodynamic support with intra-aortic balloon counter-pulsation, was made during a multidisciplinary meeting. Shortly after initiation of intra-aortic balloon counter-pulsation, the patients hemodynamics improved, with a decrease in heart rate and an increase in mean arterial blood pressure. After uneventful cesarean delivery of a healthy 3.2kg infant, the patient was transferred to intensive care and was extubated three hours later. Due to hemodynamic instability, intra-aortic balloon counter-pulsation support and vasopressor infusion were maintained for four postoperative days. The patient was discharged from the hospital on diuretics and beta-blocker treatment after 20days. Heart failure persisted, requiring heart transplantation 25months later. This report highlights the role of a multidisciplinary team approach in the management of delivery in an obstetric patient with peripartum cardiomyopathy.