BNP, TnI and Lactic Acid variations in Warm Blood Cardioplegia vs Cold Crystalloid Cardioplegia in Coronary Artery Bypass Grafting (CABG)

Introduction: Myocardial protection is one of the key points during cardiac surgery. Inadequate myocardial protection in cross-clamping period is an issue of concern in cardiac surgery.  Cardioplegic solutions improve the tolerance of ischemia and reperfusion by preserving myocardial energy reserves, preventing osmotic, electrolyte imbalances and acidosis. Warm blood cardioplegia (WBC) has had a profound impact, especially in coronary artery bypass surgery and there have been many studies that compared it with Cold crystalloid cardioplegia (CCC). A good myocardial protection will be reflected especially on patients outcome, on postoperative ICU strategy, morbidity and mortality as well. Brain Natriuretic Peptide (BNP), Troponin I (TnI) and Lactic Acid LA) are very significant biomarkers that reflects an adequate myocardial and organ perfusion/protection. The purpose of this study is to determine if warm blood cardioplegia offers any advantages in comparison with CCC in Coronary Artery Bypass Grafting (CABG) based primary on variations of BNP, TnI and Lactic Acid. Patients and method: 60 patients with coronary artery disease (CAD) that will have Coronary Artery Bypass Surgery (CABG), were retrospectively randomized in two groups of 30 patients with different techniques of myocardial protection: group A had CCC, and group B had warm blood cardioplegia (WBC), according to Calafiore [1] protocols). Intraoperative and postoperative variables were used to assess primary outcomes. Results: This study found benefits of warm blood cardioplegia in clinical outcome after CABG Keywords:Myocardial protection, Cardiac surgery, Cardiopulmonary Bypass, Calafiore, Cardioplegia, Coronary Artery Bypass Grafting (CABG), Brain Natriuretic Peptide (BNP), Troponin I (TnI) and Lactic Acid LA) DOI: 10.7176/ALST/95-02 Publication date: November 30th 202

Idiopathic atrial flutter AFL in neonates (Case Report)

Atrial flutter AFL is a rare arrhythmia in the neonate and early infants. Here we report the case of a term female infant (A.K), with a birth weight of 3000 g, who was delivered by Cesarian section of a 26-year-old primiparous mother (I.K) in “Queen Geraldine” Maternity in Tirana. The APGAR scores were 9 and 10 at 1st and 5th minute, respectively. In prenatal history, no fetal arrhythmia was present. After waters breaks, a fetal arrhythmia was detected. Then the infant was delivered by an urgent C section. The infant was treated by medical treatment, which resulted unsuccessful. In the 16th day of life, the DC shock was applied and a sinus rhythm was detected immediately. Neonate: A.K Mother: I.K Keywords: infant, atrial flutter, antiarrhythmic, DC shock DOI: 10.7176/ALST/80-05 Publication date: July 30th 202

Patient with Wolff-Parkinson-White Syndrome undergoing Non-Cardiac Surgery. Perioperative Management

Background: Perioperative management of patients with preexcitation may become quite challenging, especially if there is no time for adequate preoperative investigation and clinical optimization, as in emergencies, or even worse, in undiagnosed cases. It is possible that the poorly controlled or unknown underlying electrophysiological abnormality will become unmasked during anesthesia and surgery, giving rise to potentially life-threatening arrhythmias. In the literature, pre-excitation syndromes have been mainly approached from the view of the disease (i.e., presentation, diagnosis, treatment), while anesthetic data are scarce. This case report aims to focus on the perioperative management of patients with WpW. Conclusion; Managing such cases provides an opportunity to revisit important considerations on Wolff-Parkinson-White syndrome avoiding neuromuscular blockers may make a difference in avoiding arrhythmias when laryngeal mask airway / general anesthesia is required in patients with Wolff-Parkinson-White syndrome. sympathetic stimulation should be avoided as it may shorten the refractory period of ap and alleviate life-threatening arrhythmias. Keywords: WpW, arrhythmias, bundle of Kent, anesthesia DOI: 10.7176/ALST/95-03 Publication date: November 30th 2022

Perioperative Evaluation of Heart Echinococcus Cyst in a 14-Year-Old Child

BACKGROUND: Echinococcosis of the heart has a rate 0.02–2% of all hydatid diseases. Clinical presentation is depending of the location of hydatid cyst in the heart. Patients can be an asymptomatic case or lethal stroke, arrhythmias, valvular dysfunction, pulmonary edema, cardiac tamponade, cardiac failure, shock, and even death. CASE REPORT: We present a case report, a 14-year-old child with 2 weeks of sore throat, whooping cough, subfebrile condition, sweating, fatigue and physical weakness, nausea, abdominal pain, and decreased appetite. He came to emergency room with cardiogenic shock and pulmonary edema. He was diagnosed with intramyocardial hydatid cyst. CONCLUSION: Echinococcus cyst lesion in the LV in lateral wall, not communicating with the LV cavity, has been removed successfully with on-pump technique in a 14-year-oldchild. Median sternotomy was preferred and cardiopulmonary bypass has been considered the safest method. Supplemental medical therapy with albendazole is recommended to reduce the risk of recurrence

Retrograde autologous priming RAP reduces deep hemodilution during cardiopulmonary bypass CPB

Immediate hemodilution and rapid decrease in osmotic pressure at the time of CBP onset are associated with the aforementioned organic dysfunctions. Decreased osmotic pressure increases effective filtration pressure and microvascular filtration. Consequently, an increase in pulmonary interstitial fluid and myocardial edema is observed after discontinuation of CBP. Retrograde autologous priming (RAP) is a means to effectively and safely restrict the hemodilution caused by the direct homologous blood transfusion and reduce the blood transfusion requirements during cardiac surgery.   Materials and Methods The study included 40 patients scheduled to undergo coronary surgical revascularization, divided into two groups: the RAP group and the non-RAP group. The average age in both groups is 55 years (SD 5).   Conclusion A significant benefit was observed between the two groups in the study regarding the amount of transfused blood (1.55 -SD 0.88) / (2.15 -SD 0.81). This is a very important fact in favor of using the RAP technique, taking into account the reduction of the risk for complications carried by heterologous transfusion. Also, a significant reduction in the use of donated blood at a time when the problems of blood insufficiency in the collection centers are known, is equally important. The hospitalization (days of staying) in the ICU is also significantly lower in the RAP group (2.6 -SD 0.68) / (3.1-SD 0.64). This should be related to the faster activation of RAP in patients as a result of faster return to normal weight (with less fluid load), better ventilator function, and faster decline of cerebral edema. Keywords: Retrograde autologous priming (RAP), hemodilution, cardiopulmonary bypassCPB)   DOI: 10.7176/ALST/81-04 Publication date: August 31st 202

A Novel Endosurgical Prosthesis to Treat Thoracoabdominal Aortic Aneurysm in Complex Anatomy or Emergency Settings

BACKGROUND: Despite improvements in operative techniques, open thoracoabdominal aortic aneurysm (TAAA) repair is complex and characterized by high mortality and morbidity rate. Less invasive techniques have been developed since 2005 for the treatment of TAAA. Unfortunately, many of these devices require custom fabrication, resulting in delay of many weeks until treatment can be delivered but crucial in critical emergency cases. We present a novel hybrid endovascular and surgical prosthesis, which was tested on five pigs, with the aim of reducing the barrier issues of endovascular therapy in such particular cases.METHODS: The principal characteristic of the proposed hybrid endovascular prosthesis is to combine a proximal and distal stented zones and, in between, a classical surgical blood tied Dacron prosthesis. The device was tested in five pigs where feasibility of implantation and acute postoperative outcomes were evaluated, including bleeding, bowel ischemia, renal function, and peripheral blood perfusion.RESULTS: In all cases, following laparotomy, the endoprosthesis was successfully implanted under fluoroscopy and the surgical prosthesis zone could be easily detected by the radio-opaque markers. No major bleeding or cardiac events occurred throughout preparation and implantation. One hour after prosthesis implantation and surgical anastomoses of all vessels were completed, normal urine output was registered, and no acidosis was detected.CONCLUSIONS: This novel graft has shown ease of endoprosthesis and visceral vessels implantation without the need of thoracotomy or extracorporeal circulation and may be useful in an emergency setting or high risk and complex anatomy TAAA unsuitable for traditional endovascular aneurysm repair, or to avoid an excess waiting time for a "custom made" prosthesis. The great adaptability of this "hybrid" prosthesis in complex anatomy for the majority of TAAA could be important in high-risk patients and in some difficult situations, such as a high risk of imminent rupture

Anesthesia in Patient with Left Ventricular Assist Device LVAD support. A Case Report

Background; Left ventricular assist device (LVAD) implantation is not only a bridge-to-transplantation option for patients awaiting a donor's heart, but is often used as bridge-to-destination therapy in patients unsuitable for transplantation for various reasons. Device infection remains a threatening complication, which may lead to prolonged hospitalization, need to devise exchange, urgent transplantation, and even death of the patient. Infections with multidrug-resistant (MDR) organisms pose major difficulties for eradication therapy. Especially patients who are subject to continuous hospital treatments risk contamination or change of resistances spectrum. Gold standard therapy of certain organisms often fails to eradicate surface-associated colonization of implanted devices such as cardiovascular implants, while failed eradication leads to numerous complications and an increased mortality rate among the affected patients. Device infections through multidrug-resistant bacteria, such as MRSA, are often resistant even to first-line antibiotics, due to extended resistance spectrum and reduce tissue penetration in scar tissue after multiple surgical procedures. In addition, a solid biofilm on devices is often impenetrable even for suitable antibiotics because of the isolating nature of biofilms

Unconjugated Hyperbilirubinemia after Open Heart Surgery

The occurrence of hyperbilirubinaemia after heart surgery using cardiopulmonary bypass or post-operative heart failure is fairly common. Mechanism of hyperbilirubinemiais still not completely clarified, and there are so few specific therapies available for acute hepatobiliary injury. Post-operative mortality well correlates with increasing total bilirubin values, particularly for bilirubin-associate acute kidney tubular necrosis. The difficulty to reduce mortality is partially a consequence of not completely understood physiopathology. It is obvious that long-lasting CPB plays an important role, in association with hemodilution, hypotension, ischemia-reperfusion, and increasing hematic level of endogenous catecholamine with reduction of hepatic blood flow. Case report. A 68 years old man with severe mitral valve regurgitation and pulmonary hypertension and low EF 30%. Mitral valve replacement and tricuspid anuloplastic was performed. Due to low cardiac output syndrome severe hyperbilirubiemeia was seen (24 mg/dl. and unconjugated fraction 16mg/dl) days after. Phenobarbital (luminal) was started 15 mg/kg daily. Two days later the level decreased until 8 mg/dl with normalization of conjugation/unconjugation ratio.Postoperative hyperbilirubinemia is a multifactorial process caused by both impaired liver function of bilirubin transport. In case of elevated level of unconjugated fraction we suggest to use Luminal as alternative for decreasing unconjugated fraction

Surgical Treatment of Abdominal Aortic Aneurysms. A Retrospective Study.

Introduction: Surgical treatment of abdominal aortic aneurysms poses a significant challenge in the field of vascular surgery, with numerous factors influencing operative technique and surgical outcome. This study aimed to assess the outcomes of open surgical treatment for patients with abdominal aortic aneurysms at the Vascular Surgery Service of University Hospital Centre “Mother Teresa” Tirana and provide recommendations for improving outcomes. Material and Methods: A single-center, non-randomized, retrospective study of the results of open surgical treatment of abdominal aortic aneurysms in 206 patients from January 2008 to December 2015 was performed at the Vascular Surgery Service of University Hospital Centre “Mother Teresa” Tirana. The study only included patients with a histologically confirmed diagnosis of abdominal aortic aneurysm, while patients with ruptured abdominal aortic aneurysm were excluded. The study evaluated the incidence of abdominal aortic aneurysms, clinical and imaging findings of the disease (ultrasound, tomographic, and arteriographic), frequency of involvement of the iliac artery in the pathological process, and postoperative complications. Transabdominal access was the most commonly utilized, while retroperitoneal access was deemed the safest. No significant differences in recurrence rates were noted between the two approaches. Results: During the study period, 206 patients underwent surgery for AAA and met the inclusion criteria. Of these, 188 (91.3%) were male and 18 (8.7%) were female. The mean age of the patients was 67.8±5.7 years, with 67.7±5.9 years for men and 69±3.1 years for women. There were no statistically significant differences in age between genders (p>0.05). Conclusion: In all other cases of abdominal aortic aneurysms, surgical treatment should be strongly recommended. Finally, given the clinical benefits of using surgical treatment of asymptomatic aneurysms to reduce mortality, it is necessary to conduct an economic assessment of the feasibility of abdominal aortic aneurysms screening in the population over 55 of the age of both sexes.

The Benefit of Open Rives-Stoppa Procedure in Complex Incisional Hernia.

Introduction: Ventral hernia is one of the most common general surgical pathologies. An incisional hernia will develop in 10–15% of patients with an abdominal incision, and the risk increases to up to 23% in those who develop surgical site infections. Ventral hernia repairs are mostly elective (90%) procedures, but the repair methods are highly variable. Popularized in Europe by Rives and Stoppa, the retromuscular technique has proven to be very effective, with a 94.2% probability of having the lowest odds for recurrence and a 77.3% probability of having the lowest odds for SSI. The study aimed to evaluate our experience at a secondary care center performing Rives-Stoppa repair for abdominal ventral and incisional hernias. Materials and Methods: Between April 2019 and August 2021, 46 patients in the practice at a secondary regional hospital, Teni Konomi, Korce, Albania, underwent a Rives-Stoppa incisional hernia repair. Results: There were 14 (31%) males and 32(69%) females (age range 31-75). Most incisional hernias were midline xiphoid-pubic incision and supraumbilical, with several subcostals (2 right and 1 left) hernias.At the time of repair, most incisional hernias were symptomatic and evident on physical exam. In four cases, the hernia sac was incarcerated at the presentation time. Conclusion: The Rives-Stoppa technique has excellent long-term results and low morbidity in patients with large primary or recurrent incisional hernias. It is the gold standard for most surgeons. Keywords: Incisional Hernia, mesh, polypropylene, abdominal wall surgery, rectus muscl