Sławomir Jander

Laparoscopic cholecystectomy delayed by complicated myocardial infarction with papillary muscle rupture, and performed after unique complex mitral repair

A 65-year-old woman was admitted for laparoscopic cholecystectomy, a method of choice for gallbladder diseases. Symptoms of gallstones are similar to angina pectoris, especially in right coronary artery stenosis. In this case, masked by known symptomatic gallstones, unsuspected coronary artery disease manifested with complicated myocardial infarction and pulmonary edema. The patient survived the acute period, treated pharmacologically. Severe mitral insufficiency caused mainly by ruptured papillary muscle, with left ventricle and atrium enlargement, and right coronary artery stenosis were indications for heart surgery. Repair of this infrequent complication of myocardial infarction is rarely feasible. The complex repair, unique for this cause, is described. During the operation, the head of the ruptured posteromedial papillary muscle was re-implanted, and two neo-chords implanted for prolapsing the A2 mitral valve segment. Annuloplasty with a 29 mm elastic ring accomplished repair. Saphenous bypass graft was applied to the only feasible postero-lateral branch. Although intraoperative echocardiography revealed excellent results, inotropic support, and intra-aortic counterpulsation were necessary for weaning off cardio-pulmonary bypass and low cardiac output treatment. The patient was discharged home on postoperative day 12, with anticoagulant administered for 3 months. As soon as it was no longer required, she underwent laparoscopic cholecystectomy, with no complications. Durable results of both operations performed 5 years ago are confirmed by physical examination and ultrasonography. Complex mitral valve repair, rather than valve replacement, should be considered in similar cases. Possibility of coexistence of coronary artery disease should be considered before cholecystectomy. Good quality repair of cardiac disease allows for laparoscopic cholecystectomy.

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.

Infective endocarditis complicated with left atrioventricular fistula in a 20-year-old patient. A case study.

Intracardiac fistulas are rare complications of infective endocarditis. We report an unusual case of successful surgical repair of intracardiac fistula between the left ventricle and the left atrium in the course of infective endocarditis in a 20-year-old patient. According to this we conclude that timely diagnosis, proper antibiotic treatment, and early surgical intervention should improve the outcomes of infective endocarditis complications.