Wojciech Kustrzycki

The role of depressive and anxiety symptoms in the evaluation of cardiac rehabilitation efficacy after coronary artery bypass grafting surgery.

OBJECTIVES The aim of this study was to evaluate the efficacy of early 3-week cardiac rehabilitation (CR) in terms of the reduction of negative psychological symptoms, and to determine which factors predispose patients to worse rehabilitation results in this regard. METHODS The study involved a random group of 50 patients (11 women and 39 men) who had undergone coronary artery bypass grafting, with a mean age of 63.3 (± 7.2) years. The following screening tests were used: Beck Depression Inventory, State-Trait Anxiety Inventory and Acceptance of Illness Scale. The pulse rate during the first session of physical training was recorded (t(1) P), and after training the patients assessed their level of exertion (t(1) E) on the Borg Scale (BS). The same procedure was repeated at the end of the rehabilitation (t(2) P, t(2) E). RESULTS Among the psychological parameters examined at t(1) (at baseline), the strongest relationship with poor acceptance of illness after 3 weeks of rehabilitation was indicated by the level of depression (P < 0.001), with a slightly lower correlation with the state anxiety and the trait anxiety results (P = 0.005 and 0.027, respectively). A relationship was also found between the severity of depression in t(1) and the level of exertion measured by the BS at the end of rehabilitation (P = 0.007). Before rehabilitation, depressed patients exhibited higher levels of both trait and state anxiety (P = 0.009 and 0.018, respectively). After rehabilitation in the depressed subgroup, there was no improvement in the subjective assessment of exertion or reduction of state anxiety. Sex and co-morbidities also had considerable importance in the context of CR efficacy. The women showed more severe depressive symptoms (P = 0.01), a higher personality tendency to anxiety (P = 0.036) and poorer results of rehabilitation (in relation to the level of exertion after physical training and the intensity of state anxiety symptoms). There was no reduction of state anxiety in patients who suffered from at least two co-morbidities. CONCLUSIONS The presence of severe anxiety-depressive symptoms before rehabilitation has an effect on its outcome. Psychiatric symptomatology should be diagnosed as early as possible and patients should receive additional therapeutic support.

Unchanged Plasma Levels of the Soluble Urokinase Plasminogen Activator Receptor in Elective Coronary Artery Bypass Graft Surgery Patients and Cardiopulmonary Bypass Use

Objective and Design The soluble urokinase plasminogen activator receptor (suPAR) has been recently recognized as a potential biological marker of various disease states, but the impact of a major surgical intervention on the suPAR level has not yet been established. The aim of our study was to investigate if the induction of a systemic inflammatory reaction in response to cardiopulmonary bypass would be accompanied by an increase in the plasma suPAR level. Methods and Subjects Patients undergoing coronary artery bypass grafting under cardiopulmonary bypass (CPB) were added. Based on the baseline suPAR level, patients were divided into group 1 (suPAR within normal range) or group 2 (suPAR above range). Blood was collected before the induction of anesthesia and 6 and 24 hours after surgery. Plasma suPAR, IL-6, IL-8, TNF-α, troponin I, NT-proBNP, and NGAL were quantified to assess the impact of surgical trauma on these markers. Results The baseline suPAR level was within the normal range in 31 patients (3.3 ng/mL), and elevated in 29 (5.1 ng/mL) (p<0.001). Baseline mediators of systemic inflammatory reaction concentrations (IL-6, TNF-α, and IL-8) and organ injury indices (troponin I, NT-proBNP, and NGAL) were low and increased after surgery in all patients (p<0.05). The surgery did not cause significant changes in the suPAR level either at 6 or 24 hours after, however the difference between groups observed at baseline remained substantial during the postoperative period. Conclusions There was no change in the suPAR level observed in patients subjected to elective cardiac coronary artery bypass surgery and CPB, despite activation of a systemic inflammatory reaction.

Risk factors of depressive and anxiety symptoms 8 years after coronary artery bypass grafting

OBJECTIVE The aim was to assess the severity and course of self-reported depressive and anxiety symptoms 8 years after coronary artery bypass grafting (CABG). METHODS Out of 53 CABG patients, 37 were examined 8 years later (68% men), mean age - 58.2 (SD 9.3) years. They completed the Spielberger State-Trait Anxiety Questionnaire and the Beck Depression Inventory (BDI). Out of the remaining 16 patients, seven died and nine did not respond. RESULTS The response group had the mean BDI scores of 13.3 (SD 8.0) before CABG and 11.5 (SD 9.5) at follow-up (p = 0.38). Over 37.8% remained depressed. Non-depressed patients before CABG remained free from depressive symptoms further on, whereas depressed patients continued suffering, even 8 years after the operation. Before the operation, the mean anxiety state score was 44.3 (SD 12.0). After CABG (3 months and 8 years), the significant reduction of anxiety symptoms was observed (respectively: p = 0.02, p = 0.01). Postoperative complications, lower physical and mental well-being, somatic symptoms and negative life attitude were related to bad prognosis several years after surgery. CONCLUSIONS Depressive and anxiety symptoms occurred in many cardiosurgical patients before and after CABG. Good results of the surgical procedure did not cause reduction of depressive symptoms. Anxiety symptoms were much more common perioperatively than depressive ones and decreased significantly after surgery. Preoperative assessment of depressive and anxiety symptoms can indicate the risk group and suggest care proceedings during the rehabilitation period to improve the effectiveness of surgical coronary revascularization.

Increased Content of Resistin in Epicardial Adipose Tissue of Patients with Advanced Coronary Atherosclerosis and History of Myocardial Infarction

OBJECTIVES The aim of the study was to assess whether the plasma level and content of adipokines, in adipose tissue, is associated with a medical history of myocardial infarction. PATIENTS AND METHODS The study group consisted of 33 consecutive patients (12 females, 21 males, aged 68.6 ± 6.8 years) who underwent cardiac bypass surgery. Patients were divided into groups; group 1 presented with a history of myocardial infarction and group 2 presented without a history of myocardial infarction. During cardiac surgery, samples of epicardial adipose tissue, adipose tissue located at internal mammary artery, subcutaneous adipose tissue, and blood samples were taken for further assessment.Significantly higher levels of resistin in adipose tissue from the epicardial tissue were found in group 1 than in group 2: median and interquartile range, respectively, 37.2 (8.9-121.5) ng/g versus 15.0 (7.1-24.1) ng/g; p < 0.049. Multivariate analysis found that previous myocardial infarction was associated with male gender, older age, and higher content of resistin in epicardial adipose tissue. CONCLUSION The resistin content in epicardial adipose tissue in patients with advanced coronary atherosclerosis seems higher in those with a history myocardial infarction. Increased resistin epicardial content seems related to the previous myocardial infarction independent of the other established risk factors such as age and male gender. The importance of paracrine function of adipose pericardial tissue in the occurrence of complications of atherosclerosis merits further investigations.

Porphyromonas gingivalis in periodontal pockets and heart valves

Background There is evidence that advanced infectious chronic periodontal inflammatory disease may have an impact on general health including cardiovascular diseases. The aim of this clinical study was to evaluate the ability of Porphyromonas gingivalis to colonize heart valves and, subsequently, to assess whether there is an association between the presence of the DNA of Porphyromonas gingivalis in periodontal pockets and in degenerated heart valves. Materials and Methods Thirty patients were enrolled in the study and 31 valve specimens harvested during cardiac surgery operations were examined. All patients underwent a periodontal examination. To evaluate the periodontal status of the patients the following clinical parameters were recorded: the pocket depth, bleeding on probing (BOP) and aproximal plaque index (API). The presence of P. gingivalis in heart valve specimens and samples from periodontal pockets was analyzed using a single–step PCR method. Results P. gingivalis DNA was detected in periodontal pockets of 15 patients (50%). However, the DNA of this periopathogen was found neither in the aortic nor in the mitral valve specimens. Conclusions This study suggests that P. gingivalis may not have an influence on the development of the degeneration of aortic and mitral valves.

Presence of Periodontopathic Bacteria DNA in Atheromatous Plaques from Coronary and Carotid Arteries

Objectives. Interest in periodontitis as a potential risk factor for atherosclerosis and its complications resulted from the fact that the global prevalence of periodontal diseases is significant and periodontitis may induce a chronic inflammatory response. Many studies have analyzed the potential impact of the Porphyromonas gingivalis, major pathogen of periodontitis, on general health. The purpose of this study was to find the presence of the Porphyromonas gingivalis DNA in the atherosclerotic plaques of coronary and carotid arteries and in the periodontal pockets in patients with chronic periodontitis, who underwent surgery because of vascular diseases. Methods and Results. The study population consisted of 91 patients with coronary artery disease or scheduled for carotid endarterectomy. The presence of Porphyromonas gingivalis DNA in atheromatous plaques and in subgingival samples was determined by PCR. Bacterial DNA was found in 21 of 91 (23%) samples taken from vessels and in 47 of 63 (74.6%) samples from periodontal pockets. Conclusions. Porphyromonas gingivalis DNA is frequently found in atheromatous plaques of patients with periodontitis. That is why more research should be conducted to prove if this periopathogen may have an impact on endothelium of patients at risk of atherosclerosis.

The use of minimally invasive videoscopic technique in large vessel and cardiac surgery. Does the potentially increased difficulty bring benefits to the patient

We present the clinical case of a 63-year-old patient who underwent in the Department of Cardiac Surgery implantation of an aorto-bifemoral graft prosthesis and coronary artery bypass revascularization with application of less invasive off-pump technique. Graft selection (arterial grafts, venous grafts) is very important during qualification for coronary artery bypass revascularization. Minimally invasive saphenous vein harvesting was performed during the presented case. The endoscopic technique of vein harvesting is a relatively rarely applied technique during myocardial revascularization surgery. The concept of minimally invasive videoscopic technique is presented. There is a discussion on why the team decided to prolong duration of the case consisting of two major operations performed simultaneously. Minimally invasive videoscopic technique may have a significant positive impact on postoperative outcome in a selected group of patients.

J. Mikulicz-Radecki, K. H. Bauer, and W. Bross. Three great surgeons, three different epochs, one clinic in Wroclaw.

The city of Wroclaw (Breslau) lies where the cultural and economic influences of the eastern, southern, and western Europe meet. Over a thousand years of history it changed the state affiliation several times. Since 1945, similarly as seven centuries ago, it lies within the borders of Poland. The historical complex of hospital buildings constructed at the end of the 19th century for the medical faculty remained almost untouched, despite catastrophic war destructions in the whole city. The building of surgical clinic witnessed epoch-making events in the discipline of surgery performed by the three great personalities. Jan Mikulicz-Radecki (1850-1905), the first head of the department, world famous physician and scientist, created in Wroclaw a modern surgical center. From among his numerous achievements the most important seems to be the performance of the worlds first safe thoracotomy in the low-pressure chamber (1904). Karl Heinrich Bauer (1890-1979) was the next great personality, who had been leading the surgical department since 1933. Genetics, transplantology, traumatology and oncology were the main points of his interest. Because of political reasons he had to leave Wroclaw. He continued his surgical and scientific career in Heidelberg. Wiktor Bross (1903-1994) came to the ruined city directly after the World War II. As an experienced general and thoracic surgeon he created a new surgical school. First in Poland open heart surgery (1958) and renal transplantation (1966) were performed by him and his team in the same building, where Mikulicz-Radecki and Bauer worked in the past. The memory of all three great surgeons has been honored by placing their sculptures among the prominent Wroclaw citizens in the city hall.

Long-term efficacy of surgical ablation of atrial fibrillation in a low-volume centre

Surgical ablation is a recommended procedure for patients with atrial fibrillation (AF) undergoing a cardiac surgery operation. However, the procedure is associated with significant risk of late recurrence of AF. The aim of the study was to assess the long-term efficacy of the procedure with respect to the comorbidities. The study group consisted of 22 patients: 9 women and 13 men, who underwent surgical AF ablation in the 2008-2013 period. The patients were interviewed by telephone and were asked to send their recently performed 12-lead electrocardiography (ECG). The semi-structured interview consisted of 25 items regarding the history of AF, concomitant comorbidities, lifelong syncopal history, smoking, family history of premature cardiovascular diseases, and current medical treatment. Furthermore, the Epworth test was performed to measure the daytime sleepiness, which in turn is related to the presence of obstructive sleep apnoea. On the basis of the obtained data, the CHADS2, and Epworth scale scores were calculated for each patient. As a result of the study six patients (27%) had sinus rhythm or paced dual chamber rhythm, and 16 patients had atrial fibrillation. The multivariate analysis revealed that Epworth scale scoring > 9, CHADS2 score > 0, and persistent type of AF were related to poor outcome of surgical ablation procedure. In conclusion, patients with AF treated with surgical ablation have similar prognosis of sinus rhythm maintenance to those treated with radiofrequency ablation. Moreover, the same predisposing factors play a significant role in AF recurrence both in surgical patients and in patients treated with radiofrequency ablation.

Does the Stage of Chronic Kidney Failure Influence the Outcome in Cardiac Surgery

BACKGROUND The number of patients with chronic kidney failure requiring cardiac surgery is continuously increasing. Additionally, significant worsening in the overall risk profile of this group of patients is noted. OBJECTIVES To investigate the effect of chronic renal dysfunction both in non-dialysis-dependent renal failure and end-stage renal failure patients, on early mortality--morbidity and late survival in a series of cardiac surgery patients at our institution. MATERIAL AND METHODS 1344 patients who had open heart surgery at our university hospital between 2010 and 2013 were retrospectively reviewed. Chronic renal dysfunction was defined according to preoperative glomerular filtration rate. Patients selection (n=80). Group 1 mild--(GRF 59-30 mL/min), Group 2 moderate--(GFR 29-15 mL/min), Group 3 end stage--(GFR<15 mL/min) renal failure. RESULTS Chronic renal dysfunction was present in 5.95% of all patients studied. Group 1--55 (68.75%), Group 2--16 (20%), Group 3--9 (11.25%). No difference between the groups in the need for heart inotropic support was noted; however the use of these medications was necessary in 60.6% of all studied patients. Forty nine percent in Group 1, 87.5% in Group 2 and 77% in Group 3, respectively. Renal replacement therapy in the early postoperative period was needed in 12 patients, with significance between the groups (p = 0.001). The overall hospital mortality was 2.5%. Follow-up was completed with a mean of 1.4 years (range 2 months to 4 years). There were 6 (7.5%) late deaths. CONCLUSIONS Our observations do not exhibit large variations in postoperative complications and deaths in patients with chronic renal failure, depending on the degree of preoperative renal function impairment. It seems that renal failure regardless of the degree of impairment is a factor aggravating the intra and post-operative course in cardiac surgery patients.