Stavros Siminelakis

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.

Surgical management of cardiac implantable electronic device infections.

PURPOSE The infection of cardiac implantable electronic devices (CIED) is a serious and potentially lethal complication. The population at risk is growing, as the device implantation is increasing especially in older patients with associated comorbid conditions. Our purpose was to present the management of this complicated surgical condition and to extract the relevant conclusions. METHODS During a 3-year period 1,508 CIED were implanted in our hospital. We treated six cases of permanent pacemaker infection with localized pocket infection or endocarditis. In accordance to the recent AHA/ACC guidelines, complete device removal was decided in all cases. The devices were removed under general anaesthesia, with a midline sternotomy, under extracorporeal circulation on the beating heart. Epicardial permanent pacing electrodes were placed on the right atrium and ventricle before the end of the procedure. RESULTS The postoperative course of all patients was uncomplicated and after a follow up period of five years no relapse of infection occurred. CONCLUSIONS Management protocols that include complete device removal are the only effective measure for the eradication of CIED infections. Although newer technologies have emerged and specialized techniques of percutaneous device removal have been developed, the surgical alternative to these methods can be a safe solution in cases of infected devices.

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.

Effect of lornoxicam in lung inflammatory response syndrome after operations for cardiac surgery with cardiopulmonary bypass

BACKGROUND The establishment of Extracorporeal Circulation (EC) significantly contributed to improvement of cardiac surgery, but this is accompanied by harmful side-effects. The most important of them is systemic inflammatory response syndrome. Many efforts have been undertaken to minimize this problem but unfortunately without satisfied solution to date. MATERIALS AND METHODS Lornoxicam is a non steroid anti-inflammatory drug which temporally inhibits the cycloxygenase. In this clinical trial we study the effect of lornoxicam in lung inflammatory response after operations for cardiac surgery with cardiopulmonary bypass. In our study we conclude 14 volunteers patients with ischemic coronary disease undergoing coronary artery bypass grafting with EC. In seven of them 16 mg lornoxicam was administered iv before the anesthesia induction and before the connection in heart-lung machine. In control group (7 patients) we administered the same amount of normal saline. RESULTS Both groups are equal regarding pro-operative and intra-operative parameters. The inflammatory markers were calculated by Elisa method. We measured the levels of cytokines (IL-6, IL-8, TNF-a), adhesion molecules (ICAM-1, e-Selectin, p-Selectin) and matrix metaloproteinase-3 (MMP-3) just after anesthesia induction, before and after cardiopulmonary bypass, just after the patients administration in ICU and after 8 and 24 hrs. In all patients we estimated the lungs inflammatory reaction with lung biopsy taken at the begging and at the end of the operation. We calculated hemodynamics parameters: Cardiac Index (CI), Systemic Vascular Resistance Index (SVRI), Pulmonary Vascular Resistance Index (PVRI), Left Ventricular Stroke Work Index (LVSWI), Right Ventricular Stroke Work Index (RVSWI), and the Pulmonary arterial pressure, and respiratory parameters too: alveolo-arterial oxygen difference D (A-a), intrapulmonary shunt (Qs/Qt) and pulmonary Compliance. IL-6 levels of lornoxicam group were statistical significant lower at 1st postoperative day compared to them of control group (113±49 and 177±20 respectively, P=0.008). ICAM-1 levels were statistical significant lower at the patient admission in ICU, compared to them of control group (177±29 and 217±22 respectively, P=0.014), and the 1st postoperative day compared to them in control group (281±134 and 489±206 respectively, P=0.045). P-selectin levels were statistical significant lower, compared to them in control group in four measurements (97±23 and 119±7 respectively, P=0.030, 77±19 and 101±20 respectively, P=0.044, 86±4 and 105±13 respectively, P=0.06, 116±13 and 158±17 respectively, P=0.000). CONCLUSIONS Hemodynamics and respiratory parameters were improved compared to control group, but these differences was not statistical significant. Eosinofil adhesion and sequestration in intermediate tissue of lung parenchyma were significantly lower compared to control group. Also, alveolar edema was not noted in lornoxicams group. Lornoxicam reduce the inflammatory response in patients undergone coronary artery bypass grafting with extracorporeal circulation. This calculated from levels reduction of IL-6, ICAM-1 και p-Selectin, and from lung pathologoanatomic examination (absence of alveolar edema, reduce in eosinofil adhesion and sequestration in intermediate tissues). Despite the favorable effect of lornoxicam on the hemodinamics and respiratory parameters these improvement did not seem to be statistical significant.

Cerebral oximetry in cardiac anesthesia

Cerebral oximetry based on near-infrared spectroscopy (NIRS) is increasingly used during the perioperative period of cardiovascular operations. It is a noninvasive technology that can monitor the regional oxygen saturation of the frontal cortex. Current literature indicates that it can stratify patients preoperatively according their risk. Intraoperatively, it provides continuous information about brain oxygenation and allows the use of brain as sentinel organ indexing overall organ perfusion and injury. This review focuses on the clinical validity and applicability of this monitor for cardiac surgical patients.

Baseline cerebral oximetry values in cardiac and vascular surgery patients: a prospective observational study

AimThis study was conducted to evaluate baseline INVOS values and identify factors influencing preoperative baseline INVOS values in carotid endarterectomy and cardiac surgery patients.MethodsThis is a prospective observational study on 157 patients (100 cardiac surgery patients, 57 carotid endarterectomy patients). Data were collected on factors potentially related to baseline INVOS values. Data were analyzed with students t-test, Chi-square, Pearsons correlation or Linear Regression as appropriate.Results100 cardiac surgery patients and 57 carotid surgery patients enrolled. Compared to cardiac surgery, carotid endarterectomy patients were older (71.05 ± 8.69 vs. 65.72 ± 11.04, P < 0.001), with higher baseline INVOS (P < 0.007) and greater stroke frequency (P < 0.002). Diabetes and high cholesterol were more common in cardiac surgery patients. Right side INVOS values were strongly correlated with left-side values in carotid (r = 0.772, P < 0.0001) and cardiac surgery patients (r = 0.697, P < 0.0001). Diabetes and high cholesterol were associated with significantly (P < 0.001) lower INVOS and smoking was associated with higher INVOS values in carotid, but not in cardiac surgery patients. Age, sex, CVA history, Hypertension, CAD, Asthma, carotid stenosis side and surgery side were not related to INVOS. Multivariate analysis showed that diabetes is strongly associated with lower baseline INVOS values bilaterally (P < 0.001) and explained 36.4% of observed baseline INVOS variability in carotid (but not cardiac) surgery.ConclusionCompared to cardiac surgery, carotid endarterectomy patients are older, with higher baseline INVOS values and greater stroke frequency. Diabetes and high cholesterol are associated with lower baseline INVOS values in carotid surgery. Right and left side INVOS values are strongly correlated in both patient groups.

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.

Harvesting Radial Artery and Neurologic Complications

Abstract  Background: Determination of the incidence, mechanisms, and diagnosis of hand complications after radial artery (RA) harvesting in coronary surgery (CABG). Methods: The study group (RA group) includes 54 patients who underwent RA harvesting in CABG operation. The control group (noRA group) consists of 131 patients who underwent CABG without the use of RA graft. The average follow‐up time was 16.36 ± 5.13 months. The patients were examined clinically, (a) for motor function abnormalities associated with radial and median nerve damage and (b) for sensory abnormalities, and the function of radial nerve was determined by eliciting the brachioradialis reflex. They answered in a formal scripted questionnaire to elicit symptoms and clinical points attributable to nerve damage during RA harvest, such as hand weakness, thumb weakness, sensation abnormalities on the back and on the palm side of the forearm, hand numbness, hand‐reversible paresis or forearm infection postoperatively, and any other upper limb abnormality.Results: Of the patients in the RA group, 34.09% reported left‐hand abnormality after operation. On the other hand, in the noRA group left‐hand abnormality was reported in 18.68% of patients. In the RA group sensation abnormality was reported in 34.09% of patients and thumb weakness alone was reported in 6.82% of patients. There was a statistically significant difference between the two groups. Low EuroSCORE was the predicting factor for motor abnormalities. Conclusions: More knowledge has been added about the neurologic complications after RA harvesting lately. We demonstrated the rate of motor and sensory abnormality, the potential mechanisms of these complications caused by surgical trauma or devascularization, and any predictive factors of complications. Optimal surgical techniques to avoid the damage of the responsible nerves are recommended.

Endovascular Stent-Graft Repair as a Late Secondary Procedure After Previous Aortic Grafts

Thoracic and abdominal aortic endovascular procedures as alternatives to aortic reoperations were studied in three different cases. An anastomotic aneurysm after previous thoracic aortic graft for coarctation, a second-stage elephant trunk repair (descending thoracic aortic aneurysm), and a secondary aneurysm proximal to a previous abdominal aortic graft were successfully treated with endovascular stent-grafts. During the follow-up period no lethal events or major aortic or graft-related complications were observed, except a type II endoleak in the anastomotic aortic aneurysm case. An endovascular stent-graft can be safely deployed into a previously implanted vascular graft, avoiding repeat surgery.

Axillary Artery Cannulation for Cardiopulmonary Bypass during Surgery on the Ascending Aorta and Arch

Abstract  Background: Performing axillary artery cannulation, during cardiopulmonary bypass in patients with an atherosclerotic ascending aorta or acute dissection of the ascending aorta and arch, is of growing interest. Our aim is to present our experience, to describe the surgical technique, and to demonstrate the sufficient cerebral and total body perfusion through axillary artery cannulation. Patients and Methods: Twenty‐two patients (17 male, five female) underwent surgical treatment with the axillary technique. The log euro SCORE ranged from 6.77% to 70% (mean 28.28). Nine of these patients underwent elective procedure. Eight underwent aortic surgery for pathologies of the aorta and in one patient we performed combined aortic valve replacement and coronary artery bypass grafting. Thirteen patients underwent emergency operation because of acute dissection of the aorta. Twelve of these patients had a type A dissection (according to Stanford classification) and one patient had a type B aortic dissection. Results: The majority of complications were associated with ruptured dissection of the thoracoabdominal aorta and acute dissection of ascending aorta. Despite preoperative disease states that placed our patients at high risk of stroke and visceral end‐organ injury, no clinically demonstrable permanent postoperative deficits were observed. Our patients had no neurological dysfunction, stroke, or other complications. Conclusions: Antegrade cerebral perfusion is of paramount importance in cases of aortic atherosclerosis or aortic dissection. The axillary artery provides an excellent site for safe antegrade perfusion, which may play a role in preventing stroke.