Ryszard Jaszewski

Detection of infectious agents by polymerase chain reaction in human aortic wall

INTRODUCTION Several studies have been suggested that infectious agents may induce or progress the process of atherosclerosis in humans. In the present study, the samples of visually healthy human aortic wall were examined for the presence of Chlamydia pneumoniae, Mycoplasma pneumoniae, Helicobacter pylori, herpes simplex virus (HSV), and cytomegalovirus (CMV). METHODS Bacterial DNA of C. pneumoniae, M. pneumoniae, and H. pylori and viral DNA of HSV and CMV were analyzed by polymerase chain reaction. The specimens were obtained from 40 patients with atherosclerotic three-vessel stable coronary artery disease referred to surgical revascularization (coronary group) and 20 controls referred to aortic valve replacement (valve group). RESULTS C. pneumoniae was detected in 11 of 40 samples of aorta in coronary group (27.5%) and 5 of 20 in valve group (25%). M. pneumoniae was found in 6 of 40 (15%) and 5 of 20 (25%) samples, and CMV was found in 22 of 40 (55%) and 10 of 20 (50%) samples. The most frequent detected pathogens were H. pylori and HSV. H. pylori was found in 32 of 40 samples of aortic wall in coronary group (80%) and 17 of 20 samples in valve group (85%), whereas HSV was found in 27 of 40 (67.5%) and 17 of 20 (85%) aortic wall specimens. CONCLUSION Results demonstrate that C. pneumoniae, M. pneumoniae, H. pylori, CMV, and HSV can be detected in macroscopically healthy aortic wall of coronary and valve patients in similar frequency, which do not support hypothesis concerning the role of microorganisms in atherosclerosis etiology.

Clinical utility and use of DSM-IV and ICD-10 Criteria and The Memorial Delirium Assessment Scale in establishing a diagnosis of delirium after cardiac surgery.

Authors evaluated the sensitivity and specificity of DSM-IV and ICD-10 criteria and the cutoff value of the Memorial Delirium Assessment Scale (MDAS) in diagnosing postoperative delirium in 260 cardiac surgery patients. Incidence of delirium diagnosed on the basis of DSM-IV and ICD-10 criteria, and with the use of the MDAS was 11.5%, 9.2%, and 6.5%, respectively. The DSM-IV criteria for delirium were found to be more inclusive than those of ICD-10. The cutoff point of 10 of the MDAS was optimal in relation to the presence or absence of delirium after cardiac surgery.

Cortisol levels and neuropsychiatric diagnosis as markers of postoperative delirium:a prospective cohort study

IntroductionThe pathophysiology of delirium after cardiac surgery is largely unknown. Thepurpose of this study was to investigate whether increased concentration ofpreoperative and postoperative plasma cortisol predicts the development ofdelirium after coronary artery bypass graft surgery. A second aim was to assesswhether the association between cortisol and delirium is stress related ormediated by other pathologies, such as major depressive disorder (MDD) orcognitive impairment.MethodsThe patients were examined 1 day preoperatively with the Mini InternationalNeuropsychiatric Interview and the Montreal Cognitive Assessment and the TrailMaking Test to screen for depression and for cognitive impairment, respectively.Blood samples for cortisol levels were collected both preoperatively andpostoperatively. The Confusion Assessment Method for the Intensive Care Unit wasused within the first 5 days postoperatively to screen for a diagnosis ofdelirium.ResultsPostoperative delirium developed in 36% (41 of 113) of participants. Multivariatelogistic regression analysis revealed two groups independently associated with anincreased risk of developing delirium: those with preoperatively raised cortisollevels; and those with a preoperative diagnosis of MDD associated with raisedlevels of cortisol postoperatively. According to receiver operating characteristicanalysis, the most optimal cutoff values of the preoperative and postoperativecortisol concentration that predict the development of delirium were 353.55 nmol/land 994.10 nmol/l, respectively.ConclusionRaised perioperative plasma cortisol concentrations are associated with deliriumafter coronary artery bypass graft surgery. This may be an importantpathophysiological consideration in the increased risk of postoperative deliriumseen in patients with a preoperative diagnosis of MDD.

Raised IL-2 and TNF-α concentrations are associated with postoperative delirium in patients undergoing coronary-artery bypass graft surgery

BACKGROUND The knowledge base regarding the pathogenesis of postoperative delirium is limited. The primary aim of this study is to investigate whether increased levels of IL-2 and TNF-α are associated with delirium in patients who underwent coronary-artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB). The secondary aim is to establish whether any association between raised cytokine levels and delirium is related to surgical and anesthetic procedures or mediated by pre-existing conditions associated with raised cytokine levels, such as major depressive disorder (MDD), cognitive impairment, or aging. METHODS Patients were examined and screened for MDD and cognitive impairment one day preoperatively, using the Mini International Neuropsychiatric Interview and The Montreal Cognitive Assessment and Trail Making Test Part B. Blood samples were collected postoperatively for cytokine levels. RESULTS Postoperative delirium screening was found positive in 36% (41 of 113) of patients. A multivariate logistic regression revealed that an increased concentration of pro-inflammatory cytokines is associated with delirium, and related to advancing age, preoperative cognitive decline of participants, and duration of CPB. According to receiver operating characteristic analysis, the most optimal cut-off for IL-2 and TNF-α concentrations in predicting the development of delirium were 907.5 U/ml and 10.95 pg/ml, respectively. CONCLUSIONS The present study suggests that raised postoperative cytokine concentrations are associated with delirium after CABG surgery. Postoperative monitoring of pro-inflammatory markers combined with regular surveillance may be helpful in the early detection of postoperative delirium in this patient group.

Mild Cognitive Impairment with Associated Inflammatory and Cortisol Alterations as Independent Risk Factor for Postoperative Delirium

Aims: The present study aimed to determine the impact of mild cognitive impairment (MCI) on the development of postoperative delirium and, secondly, to assess the association between MCI and raised perioperative cortisol, cytokine, cobalamin and homocysteine levels. Methods: The study recruited 113 consecutive adult patients scheduled for cardiac surgery with cardiopulmonary bypass. The patients were examined preoperatively with the Montreal Cognitive Assessment and Trail Making Test. A diagnosis of MCI was established based upon the criteria of the National Institute on Aging and Alzheimers Association. Patients were screened for delirium within the first 5 days postoperatively. Results: MCI was diagnosed in 24.8% of the patients, whereas the frequency of delirium was 36%. A multivariate analysis demonstrated that individuals with MCI were at a significantly higher risk of postoperative delirium (OR = 6.33, p = 0.002). Preoperative cortisol, postoperative cortisol and IL-2 plasma levels were higher in the MCI group as compared to non-MCI subjects. Conclusion: MCI is associated with a higher risk of postoperative delirium. Perioperative cortisol and inflammatory alterations observed in MCI may provide a physiological explanation for this increased risk.

Sarcomas of the heart as a difficult interdisciplinary problem.

Cardiac tumors are assumed to be a rare entity. Metastases to the heart are more frequent than primary lesions. Sarcomas make up the majority of cardiac malignant neoplasms. Among them angiosarcoma is the most common and associated with the worst prognosis. Malignant fibrous histiocytoma comprises the minority of cardiac sarcomas and has uncertain etiology as well as pathogenesis. Transthoracic echocardiography remains the widely available screening examination for the initial diagnosis of a cardiac tumor. The clinical presentation is non-specific and the diagnosis is established usually at an advanced stage of the disease. Sarcomas spread preferentially through blood due to their immature vessels without endothelial lining. Surgery remains the method of choice for treatment. Radicalness of the excision is still the most valuable prognostic factor. Adjuvant therapy is unlikely to be effective. The management of cardiac sarcomas must be individualized due to their rarity and significant differences in the course of disease.

Redo surgery risk in patients with cardiac prosthetic valve dysfunction

Introduction The aim of the study was to analyse the risk factors of early and late mortality in patients undergoing the first reoperation for prosthetic valve dysfunction. Material and methods A retrospective observational study was performed in 194 consecutive patients (M = 75, F = 119; mean age 53.2 ±11 years) with a mechanical prosthetic valve (n = 103 cases; 53%) or bioprosthesis (91; 47%). Univariate and multivariate Cox statistical analysis was performed to determine risk factors of early and late mortality. Results The overall early mortality was 18.6%: 31.4% in patients with symptoms of NYHA functional class III-IV and 3.4% in pts in NYHA class I-II. Multivariate analysis identified symptoms of NYHA class III-IV and endocarditis as independent predictors of early mortality. The overall late mortality (> 30 days) was 8.2% (0.62% year/patient). Multivariate analysis identified age at the time of reoperation as a strong independent predictor of late mortality. Conclusions Reoperation in patients with prosthetic valves, performed urgently, especially in patients with symptoms of NYHA class III-IV or in the case of endocarditis, bears a high mortality rate. Risk of planned reoperation, mostly in patients with symptoms of NYHA class I-II, does not differ from the risk of the first operation.

Papillary fibroelastoma of the mitral valve as an unusual cause of myocardial infarction in a 20-year-old patient

The incidence of primary cardiac tumours is <0.1% and papillary fibroelastomas are relatively rare when compared with myxomas and lipomas. Papillary fibroelastoma is generally small and single, occurs most often on valvular surfaces, and may be mobile. Despite the embolic potential of primary cardiac tumours, they are extremely uncommon cause of ischaemic vascular accidents. Patients …

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.

Independent predictors of early mortality after coronary artery bypass grafting in a single centre experience — does gender matter?

BACKGROUND It is commonly believed that women undergoing isolated coronary artery bypass graft surgery (CABG) are subject to a higher risk of perioperative complications and death. AIM To evaluate the effect of sex as a risk factor on early complications and mortality after isolated CABG performed with cardiopulmonary bypass, and to evaluate the profile of the risk determined by the patients sex. METHODS Data derived from 2,194 surgical procedures performed in the Department of Cardiac Surgery at the Medical University of Lodz between January 2009 and March 2011 was analysed. The database was constructed on the basis of retrospective analysis of variables contained in a form of the National Registry of Cardiac Surgery. RESULTS Isolated CABG with cardiopulmonary bypass was carried out in 1,303 patients (59.4% of all procedures). Women constituted the minority of patients (24.2%), and were significantly older (mean age 67.3 vs. 62.8 years, p < 0.001). They more often suffered from concomitant diabetes (43.1% vs. 33.41%, p = 0.003), had impaired renal function (median eGFR 88.5 vs. 95.0 mL/min1/1.73 m2, p < 0.001), and had a history of smoking in fewer cases (54.1% vs. 83.0%, p < 0.001). Internal mammary artery was more rarely used as arterial graft in the group of women (84.8% vs. 95.0%, p < 0.001). Women were subject to a higher risk of recent postoperative myocardial infarction (5.5% vs. 2.9%, p = 0.03) and required reoperation more rarely than men (4.5% vs. 8.1%, p = 0.04). Higher 30-day mortality was observed among women (7.6% vs. 2.8%, p < 0.001) and female sex appeared to be an independent predictor of death in the multiple logistic regression analysis (OR = 1.8; 95% CI 1.2-2.7). CONCLUSIONS Women undergoing isolated CABG are subject to higher 30-day mortality. Female sex is an independent risk factor for death after isolated CABG. Further studies are necessary to identify causes of differences in prognoses among women.