Tomasz Urbanowicz

Sustained Improvement of Clinical Status and Pulmonary Hypertension in Patients with Severe Heart Failure Treated with Sildenafil

BACKGROUND Sildenafil, a phosphodiesterase-5 inhibitor, has been shown to decrease pulmonary vascular resistance (PVR) in patients with heart failure. The purpose of the study was to evaluate the effect of sildenafil on clinical status and pulmonary vascular reactivity in patients with congestive heart failure. MATERIAL AND METHODS We enrolled 20 patients (18 men and 2 women, mean age 51 ± 12 years, diagnosed with congestive heart failure and pulmonary hypertension. This was a prospective, single-center study. Patients were treated with sildenafil 25 mg TDS for 12 months. Protocol included NYHA evaluation and repeated echocardiography, cardiac pulmonary stress tests, and right- sided catheterization. RESULTS Initially, there were 16 (80%) patients in III NYHA status and 4 (20%) patients in II NYHA. After 12 months, 8 patients were in NYHA III (40%) status and 12 patients in NYHA II (60%). Peak oxygen consumption increased from 12 ± 3 ml/kg/min to 19 ± 4 ml/kg/min after 1-year therapy (p<0.001). The cardiac index increased from 3.1 ± 0.6 L/min/m2 to 3.6 ± 0.4 L/min/m2 (p<0.05). Pulmonary vasculature resistance decreased after 1-year therapy (4.7 ± 1 vs. 1.6 ± 0.5 Woods units (p<0.005) comparing to initials. Mean pulmonary artery pressure decreased to 23 ± 6 mmHg from 42 ± 5 mmHg (p<0.001) after 1-year therapy. CONCLUSIONS One-year sildenafil therapy effectively improved clinical status and pulmonary vascular resistance in patients diagnosed with congestive heart failure.

Comparison of conventional tacrolimus versus prolong release formula as initial therapy in heart transplantation.

BACKGROUND A new formulation of tacrolimus that is characterized by prolonged release has been developed to facilitate treatment and patient compliance. Initial therapy with prolonged release formula in heart transplantation is not widely accepted. MATERIAL AND METHODS We enrolled 19 patients into a randomized analysis divided into 2 groups with different initial regimens. There were 8 patients with a mean age of 44 ± 13 years treated by Advagraf, and 11 patients with a mean age of 41 ± 9 years treated by Prograf. Serum concentration of immunosuppressive drug was followed by its oral dosage and endomyocardial biopsy results. Arterial hypertension, kidney function, and incidence of diabetes mellitus were recorded. RESULTS There were no perioperative deaths. The risk of acute rejection within 6 months following surgery was 1 (2%) in the Advagraf group and 1 (1.5%) in the Prograf group. Although the serum tacrolimus results were comparable between groups, the drugs daily dosages were different after 6 months of therapy (3 ± 1 mg in the Advagraf group and 6 ± 2 mg in the Prograf group (p<0.05). The low rate of adverse effects throughout the study was noted. CONCLUSIONS Prolonged-release tacrolimus formula is an efficient immunosuppressant in heart transplantation. Its initial application after surgery has low risk of adverse effects with similar results to conventional formula.

Customization of a patient simulator for ECMO training

Background: Poland is setting up its first regional ECMO program and relies heavily on the use of simulation in testing processes and training clinicians.1 As ECMO is a complex and expensive procedure, we developed an advanced ECMO simulator for high-fidelity medical simulation training.2–6 It can be used to modify any type of full-body patient simulator and allows for the creation of an unlimited number of scenarios. Methods: The system is equipped with an electronic core control unit (CCU) (Figure 1), a set of synthetic valves, pressure sensors, and hydraulic pumps. The major functions of the CCU are to stabilize the hydraulic system (flow of simulated blood, differential pressures in the arterial and venous lines), providing instant information about the system to the user via a display. Electric valves and sensors provide ‘on-the-fly’ information to the CCU about the actual systems status and it can be made to respond to specific instructions imitating the physiological circulatory system and simulating several scenarios (i.e. bleeding, low pressure, occlusion, reaction to proper and incorrect pharmacological treatment). It can be connected to an ECMO machine to act like the human body during ECMO run. Silicone tubes (modified polyethylene) that can be realistically cannulated using ultrasound imaging represent the artificial vessels. The CCU is made of electronic components that can be integrated to customize any mannequin as shown in Figure 1. The hardware includes both digital and analogue components that are controlled by a software run on a computer connected to the CCU via a serial port (RS232) (Figure 2). The software allows for the visualization of measurements obtained from the sensors and the control of the pumps and valves via electronic controllers. The controllers affect the ECMO circuit simulated blood flow, and hence the readings from the ECMO machine sensors, to recreate various clinical scenarios.Figure 1. The modified patient simulator with circulatory loop prepared for VA ECMO cannulation and CCU (core control unit) for high-fidelity simulations. Figure 2. The ECMO simulator architecture. Results: Every component used can be easily replaced. The total cost of the simulator modification, excluding the cost of the computer or future mobile device, is approximately 200 USD, and the consumable parts cost about 20 USD. It has been used to help simulate successfully a range of scenarios.1 Although the system is currently tethered, the next prototype will include a wireless controller so that the system can be controlled from a mobile application. Conclusions: This advanced simulator allows for unlimited possibilities with regard to creating clinical scenarios. Our ambition is to become a reference ECMO training center in Poland so that our high-fidelity ECMO simulator can be used to its full potential and for the benefit of more clinicians and their patients around Poland.

Induction therapy, tacrolimus plasma concentration, and duration if intensive care unit stay are risk factors for peripheral leucopenia following heart transplantation.

BACKGROUND Although survival among heart recipients has increased, a limiting factor is chronic adverse effects of immunosuppression therapy. MATERIAL AND METHODS We performed a retrospective analysis of 22 patients (19 men and 3 women) with a mean age of 48 ± 12 years who underwent orthotropic heart transplantation. There were 20 (91%) patients who received induction therapy (basiliximab, Simulect, Novartis Europharm Limited). All patients were treated with standard triple immunosuppressive regimen (tacrolimus, mycophenolate mofetil, and steroids). RESULTS Patients were divided into 2 groups according to postoperative peripheral cytopenia diagnosis. There were 16 (73%) in the cytopenic group and 6 (27%) in the non-cytopenic group. Mean time of peripheral leucopenia detection was 65 ± 13 days following surgery. The blood leucocyte count was 0.98 ± 0.2 × 10(3)/mm(3) vs. 5.85 ± 0.9 × 10(3)/mm(3) in patients with peripheral cytopenia compared to non-cytopenic patients (p<0.01). There was a statistically important difference in duration of intensive care unit stay between the 2 groups (p<0.01). A correlation between tacrolimus serum concentration and risk for leucopenia was also detected (p<0.05). CONCLUSIONS Basiliximab administration as induction therapy, tacrolimus serum concentration, and duration of intensive care unit stay are risk factors for leucopenia.

Seizures after Heart Transplantation – Two Cases of Non-Immunosuppressant Drug Interactions in Young Patients

BACKGROUND Neurological complications occur in 30-80% of patients following heart transplantation, and seizures account for 2-20% of these sequelae. The main risk factors are toxicity due to immunosuppression, infections, and brain lesions. We present 2 cases of grand mal type attacks that occurred on the 7th and 15th postoperative days. The origin of the attacks was an unusual interaction between 2 non-immunosuppressive drugs (metoclopramide and theophylline). CASE REPORT We present 2 cases of seizure episodes during the early postoperative period in young heart transplant recipients (a 26-year-old female and a 33-year-old man). Grand mal type attacks occurred on the 7th and 15th postoperative day, respectively. Both patients were treated with standard triple immunosuppressive therapy including tacrolimus, mycophenolate mofetil, and steroids. Therapy with metoclopramide was started because the patients reported gastrointestinal disturbances. Theophylline was administered due to postoperative bradycardia. Serum theophylline levels were 33 and 34 mcg/ml, respectively. There were no neurological deficits noticed thereafter. The magnetic resonance imaging (MRI) was negative for stroke and central nervous system infection in both cases. CONCLUSIONS We conclude that theophylline overdose combined with metoclopramide may provoke new-onset seizures, especially in young patients following heart transplantation.

CT-Guided Thrombin Injection to Control Rapid Expansion of Ascending Aortic False Aneurysm 15 Months After Bentall–Bono Operation

We report a case of 57-year-old man treated emergently with CT-guided local thrombin injection as the first, life-saving step for control rapid expansion of the aortic pseudoaneurysm. Fifteen months earlier, he was operated on for ascending aortic true aneurysm and coronary artery disease. Upon admission, he had an anterior thoracic wall pulsatile tumor. Due to critical status, definite surgery was postponed and thrombin was injected close to the origin of pseudoaneurysm. It controlled successfully, bleeding from the ascending aorta and enabled the patient to survive the acute phase.

Computer tomography guided transthoracic periaortic abscess needle biopsy in late mediastinitis after heart surgery

Mediastinitis is a well-known complication of open heart surgery. Abscess as late complication, presenting years after heart surgery, is adegnotical. Transthoracic needle biopsies of lung parenchyma guided by computer tomography are widely accepted. The puncture of periaortic masses is not routinely performed. We report the case of an encapsulated mediastinal abscess localized next to ascending vascular graft. The febrile 47-year-old white male patient with history of Bentall operation was admitted to Cardiac Surgery Department. He was transferred for urgent chest tomography after International Normalization Ratio was reversed by prothrombin complex concentrate. Tomography revealed 7 × 5 × 4 cm mass between the sternum and ascending aorta, that was punctured by the needle. After biopsy specimen was sent for microbiology, the patient was transferred for surgery. There was no vascular graft invasion by the mass. The surgery was limited to abscess removal with postoperative drainage of periaortic area. The 6-week antibiotic therapy was applied. Patient recovered uneventfully.

Acute coronary syndrome as a result of left main coronary artery stenosis after aortic valve replacement. A report of three cases.

Acute coronary syndrome (ACS) as a result of iatrogenic coronary ostial stenosis (ICOS) is a rare but potentially life-threatening complication of aortic valve replacement (AVR). We present three cases of patients with ACS shortly after AVR, in whom ICOS were revealed. They refused an operation and thus they were treated with percutaneous coronary intervention. The potential pathomechanisms of ICOS and treatment options are discussed.

The incidence of aspirin resistance in heart transplantation recipients

Introduction Coronary allograft vasculopathy can cause as many deaths as infections or rejection episodes within 3 years following heart transplantation. Aim To compare the aspirin resistance rate in an allograft heart transplantation population and in a control group by laboratory tests including the Aspirin-Resistant Patients Identification Test (ASPItest). Material and methods A total of 24 heart recipients (20 men and 4 women) at a mean age of 48 ±13 years who underwent routine clinical follow-up were consecutively enrolled in group 1. The control group consisted of 24 patients (19 men and 5 women) at a mean age of 64 ±7 years waiting for coronary artery bypass grafting in our department. All patients were treated with a standard dose of 75 mg aspirin (ASA) daily. Results Aspirin resistance was evaluated by the Multiplate platelet function test. The ASPItest revealed a mean value of 27 ±22 U in the transplant group. Results above 30 U were obtained in 8 (34%) patients, with a mean value of 50.3 ±20.6 U, indicating aspirin resistance. In the control group ASPItest results above 30 U were obtained in 5 (20%) patients, with a mean value of 43.3 ±6.4 U. Conclusions There is a high incidence (34% vs. 20%, NS) of ASA resistance in heart transplantation recipients and in the general population, respectively.

Post-traumatic acute thoracic aortic injury (TAI)—a single center experience

Background We assess the effectiveness and our experience in emergency thoracic endovascular aortic repair (TEVAR) in patients with post-traumatic acute thoracic aortic injury (TAI) and associated multiorgan trauma. TAI is a life-threatening condition. It usually results from a sudden deceleration caused by vehicle accident, a fall or some other misfortune. Techniques of endovascular aortic repair have become promising methods to treat emergent TAI. Methods Since 2007, 114 patients with thoracic aorta pathologies have been treated by TEVAR. Our study involved 15 (incl. 14 men) of them (13%) who underwent stent graft implantation for post-traumatic either aortic rupture or pseudoaneurysm. The procedural access was limited to small skin incision in one groin and percutaneous puncture of the contralateral femoral artery. We evaluated technical success, early and long-term mortality, complication rate of procedure and throughout clinical and instrumental follow-up. Results Technical success rate was 100%. All patients survived the endovascular interventions. No additional procedures or conversions to open surgery were necessary. After the operation, none of the patients had symptoms of stroke or spinal cord ischemia (SCI). No serious stent-graft-related adverse events such as endoleak, infection or migration were noted during follow-up period that ranged from 6 to 108 months. Conclusions In our department, techniques of TEVAR with stentgraft implantation have become methods of choice in treatment of traumatic TAIs since they have enabled to minimize operational risk, particularly in unstable multitrauma patients in severe clinical status. TEVAR for TAI performed in emergency settings provide favorable long-term results.