Comparison of Custodiol® and modified St. Thomas cardioplegia for myocardial protection in coronary artery bypass grafting

Background/Aim. Custodiol® is a hyperpolarizing cardioplegic solution which has been used in our national cardiac surgical practice exclusively for the heart transplant surgery. Owing to its numerous advantages over the standard depolarizing solutions, Custodiol® became cardioplegic solution of choice for all other cardiac surgical procedures in many cardio-surgical centers. This study evaluated myocardial protection by Custodiol® compared to modified St. Thomas cardioplegic solution in coronary artery bypass surgery. Methods. In a prospective four-month study, 110 consecutive adult patients who underwent primary isolated elective on-pump coronary artery bypass grafting (CABG) were randomized into the Custodiol® group (n = 54) and the St. Thomas groupa (n = 50), based on the type of administered cardioplegia; six patients were excluded. Cardiac protection was achieved as antegrade cold crystalloid cardioplegia by one of the solutions. Myocardial preservation was assessed through following outcomes: spontaneous rhythm restoration post cross-clamp, and postpoperative cardiac specific enzymes level, ejection fraction (EF) change, inotropic support, myocardial infarction (MI), atrial fibrillation (AF), and death. Results. Preoperative and intraoperative characteristics of patients in both groups were similar except for a considerably longer cross-clamp time in the Custodiol® group (49.1 ± 19.0 vs. 41.0 ± 12.9 minutes; p = 0.022). The Custodiol® group exhibited a higher rate of return to spontaneous rhythm compared to the St. Thomas group (31.5% vs. 20.0%, respectively; p = 0.267), lower rates of AF (20.4% vs. 28%, respectively; p = 0.496), MI (1.8% vs. 10.0%, respectively; p = 0.075) and inotropic support (9.0% vs. 12.0%, respectively; p = 0.651), albeit not statistically significant. There was an insignificant difference in peak value of troponin I between the Custodiol® and Thee St. Thomas group (5.0 ± 3.92 μg/L vs. 4.5 ± 3.39 μg/L, respectively; p = 0.755) and creatine kinase-MB (26.9 ± 15.4 μg/L vs. 28.5 ± 24.2 μg/L, respectively; p = 0.646) 6 hours post-surgery. EF reduction was comparable (0.81% vs. 1.26%; p = 0.891). There were no deaths in both groups. Conclusions. Custodiol® and modified St.Thomas cardioplegic solution have comparable cardioprotective effects in CABG surgery. The trends of less frequent MI, AF and ino-tropic support, despite the longer cross-clamp time in the Custodiol® group may suggest that its benefits could be ascertained in a larger study

The Helical Ventricular Myocardial Band of Torrent-Guasp as the Basis for the Surgical Treatment of Post-infarction Remodeled Left Ventricle

Uvod: Veličina, oblik i raspored vlakana postinfarktno remodelovane leve komore (LV), uz prisustvo ishemije i funkcionalne mitralne regurgitacije (MR), značajno utiču na lošu prognozu pacijenata sa ishemijskom kardiomiopatijom (ICM). Koncept helikoidne ventrikularne miokardne trake (HVMT) Torrent-Guasp-a, omogućio je razvoj savremene, integrativne strategije (“3V” - eng. “vessel, valve, ventricle”) komorne restorativne hirurgije (SVR), za korekciju morfološko-funkcionalnih posledica postinfarktnog ventrikularnog remodelovanja (PVR). Cilj: Dokazati da integrativna strategija SVR dovodi do značajnog poboljšanja strukturnih i funkcionalnih ehokardiografskih (ECHO) parametara PVR-LV, u neposrednom, ranom i udaljenom periodu postoperativnog praćenja. Metode: U sklopu prospektivne kohortne studije, u Klinici za kardiohirurgiju KCS, (jul 2005. - februar 2010.), integrativna SVR strategija je primenjena kod 40 pacijenata, prosečne starosti 62.2 ± 8.2 godina (72.5% muškarci). Preoperativni klinički i elektrofiziološki status, medikamentozna terapija, morfološki i funkcionalni ECHO parametri LV, mitralnog valvularnog (MV) aparata i desne komore (RV), poređeni su sa odgovarajućim postoperativnim nalazima u neposrednom (˂ 6), ranom (6-12) i kasnom periodu (˃ 12 meseci) postoperativnog praćenja. Rezultati: Prosečno vreme praćenja: 22.2 ± 13.8 meseci. Ukupni mortalitet: 12.5% (operativni 0.0%; intrahospitalni 7.5%; rani 2.5% i kasni 2.5%). Količnici operativnog (0.0) i hospitalnog mortaliteta (0.4): ˂ 1. Ukupno aktuarijalno preživljavanje: 95.0% (hospitalno); 90.0% (prva i druga) i 77.1% (treća, četvrta i peta godina). Verovatnoća preživljavanja bez naknadnih hospitalizacija zbog srčanih razloga: 94.6% (hospitalno); 89.2% (prva i druga) i 74.3% (treća, četvrta i peta godina). Primenjena SVR strategija je dovela do statistički značajnog poboljšanja svih preoperativnih, kliničkih (NYHA III/IV: 100% vs. 23.4%; CCS III/IV: 100% vs. 0.0%), morfoloških i funkcionalnih ECHO parametara LV (LV-EF: 31.8% vs. 46.1% ; LV-EDD: 62.4 mm vs. 53.7 mm; LV-ESD: 47.7 mm vs. 40.3 mm; LV-EDV: 236.8 mL vs. 172.9 mL; LV-ESV: 138.7 mL vs. 90.3 mL; LV-EDVI: 123.6 mL/m2 vs. 90.6 mL/m2;, LV-ESVI: 72.5 mL/m2 vs. 47.1 mL/m2; i LV-SI: 0.59 vs. 0.49), MV (MR 3/4+: 22.5% vs. 0.0%) i RV (PAPs: 40.6 mmHg vs. 31.4 mmHg; TAPSE: 15.7 mm vs. 17.9 mm) - koje se održava u svim sukcesivnim periodima, tokom petogodišnjeg praćenja. Prosečna redukcija preoperativnog LV-ESVI=35%, prosečna rezidualna LV-ESVI=47 a prosečno poboljšanje LV-EF=15%. Atrijalna fibrilacija je bila češća (p=0.039) unutar 6 meseci nakon SVR (29.7%) nego preoperativno (10.8%). Pacijenti su medikamentozno tretirani u skladu sa preporukama za terapiju ICM. Nezavisni prediktori preživljavanja su bili: infarkt miokarda u ICU i dijaliza u ICU. ECHO kriterijumi efikasnosti SVR (LV-ESVI ≥ 30%, rezidualni LV-ESVI ≤ 60mL/m2) nisu uticali na preživljavanje. Analiza uz pomoć ROC krive ukazuje da je postizanje oba kriterijuma najvalidnije u smislu prognoze ishoda. Redukcija LV-ESVI ≥ 30% je senzitivniji i specifičniji kiterijum, od rezidualnog LV-ESVI ≤ 60mL/m2. Nijedan preoperativni parameter nije bio nezavisni prediktor postizanja kriterijuma efikasnosti SVR. Analiza uz pomoć ROC krive ukazuje da je LV-EDVI ≤ 115.7 mL/m2 najvalidniji u smislu prognoze postizanja oba kriterijuma efikasnosti SVR, a da su LV-EDD ≤ 66.0 mm; LV-EDV ≤ 227.0 mL i LVEDVI ≤ 148.3mL/m2 validni za prognozu postizanja rezidualnog LV-ESVI ≤ 60mL/m2. Zaključak: SVR je efikasna i bezbedna operacija za korekciju PVR-LV, koja predstavlja pouzdanu privremenu („bridge to transplant“) ili trajnu („destination therapy“) alternativu transplantacionoj hirurgiji. Integracija koncepta HVMT u savremene strategije geometrijske SVR, pruža bolji uvid u patoanatomiju i patofiziologiju PVR-LV, omogućuje adekvatnu selekciju i tumačenje relevantnih dijagnostičkih nalaza, bolju stratifikaciju rizikaBackground: Size, shape and fiber orientation of post-infarction remodeled left ventricle (LV), in a presence of ischemia and functional mitral regurgitation (MR), significantly affect prognosis in patients with ischemic cardiomyopathy (ICM). The helical ventricular myocardial band (HVMT) of Torrent-Guasp has enabled development of contemporary, integrative (“3V” - “vessel, valve, ventricle”) surgical ventricular restorative (SVR) strategy, aimed to correct morphological and functional consequences of the post-infarction ventricular remodeling (PVR). Objective: To prove that integrative SVR produces significant improvements of structural and functional echocardiography (ECHO) parameters of PVR-LV in the immediate, early and late postoperative follow-up period. Methods: As a part of prospective cohort study, conducted at Clinic for Cardiac Surgery CCS (July 2005. - February 2010.), integrative SVR strategy was applied in 40 patients, with mean age of 62.2 ± 8.2 years (72.5% male). Preoperative clinical and electrophysiological status, drug therapy, morphological and functional ECHO parameters of the LV, mitral valve (MV) and the right ventricle (RV), were compared to appropriate measures in immediate (˂ 6), early (6-12) and late (˃ 12 months) follow-up. Results: Mean follow-up time: 22.2 ± 13.8 months. Overall mortality: 12.5% (operative 0.0%; hospital 7.5%; early 2.5% and late 2.5%). Operative (0.0) and hospital mortality ratio (0.4): ˂ 1. Overall actuarial survival: 95.0% (hospital); 90.0% (1st and 2nd) and 77.1% (3rd, 4th and 5th year). Probability of survival without hospitalizations for cardiac reasons: 94.6% (hospital); 89.2% (1st and 2nd) i 74.3% (3rd, 4th and 5th year). Applied SVR strategy resulted in statistically significant improvements of all preoperative clinical (NYHA III/IV: 100% vs. 23.4%; CCS III/IV: 100% vs. 0.0%), morphological and functional ECHO parameters of the LV (LV-EF: 31.8% vs. 46.1% ; LV-EDD: 62.4 mm vs. 53.7 mm; LV-ESD: 47.7 mm vs. 40.3 mm; LV-EDV: 236.8 mL vs. 172.9 mL; LV-ESV: 138.7 mL vs. 90.3 mL; LV-EDVI: 123.6 mL/m2 vs. 90.6 mL/m2;, LV-ESVI: 72.5 mL/m2 vs. 47.1 mL/m2; i LV-SI: 0.59 vs. 0.49), MV (MR 3/4+: 22.5% vs. 0.0%) and the RV (PAPs: 40.6 mmHg vs. 31.4 mmHg; TAPSE: 15.7 mm vs. 17.9 mm) - which sustained in each successive time frame, during the 5-year follow-up. Mean reduction of preoperative LV-ESVI=35%, mean residual LV-ESVI=47 and mean improvement of LV-EF=15%. Atrial fibrillation was more frequent (p=0.039) within 6 months after SVR (29.7%) than preoperatively (10.8%). Patients received medical therapy in accordance with ICM treatment guidelines. Independent predictors of survival were: myocardial infarction in ICU dialysis in ICU. ECHO criteria of SVR efficiency (LV-ESVI ≥ 30%, residual LV-ESVI ≤ 60mL/m2) did not affect survival. ROC curve analysis revealed that the achievement of both criteria was the most valid for the outcome prognosis. Reduction of LV-ESVI ≥ 30% was more sensitive and specific than LV-ESVI ≤ 60mL/m2. None of the preoperative parameters was the independent predictor for attaining the SVR efficiency criteria. ROC curve analysis revealed LV-EDVI ≤ 115.7 mL/m2 to be the most valid for the prognosis of combined criteria, while LV-EDD ≤ 66.0 mm; LV-EDV ≤ 227.0 mL i LV-EDVI ≤ 148.3mL/m2 were valid for the prognosis of residual LV-ESVI ≤ 60mL/m2 attainment. Conclusions: SVR is safe and efficient procedure for the patients with PVR-LV, being a reliable temporary („bridge to transplant“) or even permanent („destination therapy“) alternative to the heart transplant surgery. Integrating the HVMT concept into contemporary strategies of geometric SVR, offers better insight in pathoanatomy and pathophysiology of PVR-LV, helping to select and interpret the most relevant diagnostic findings, stratify the risk and improve patient selection, all being the essential prerequisites for the success of this procedure

The Helical Ventricular Myocardial Band of Torrent-Guasp as the Basis for the Surgical Treatment of Post-infarction Remodeled Left Ventricle

Uvod: Veličina, oblik i raspored vlakana postinfarktno remodelovane leve komore (LV), uz prisustvo ishemije i funkcionalne mitralne regurgitacije (MR), značajno utiču na lošu prognozu pacijenata sa ishemijskom kardiomiopatijom (ICM). Koncept helikoidne ventrikularne miokardne trake (HVMT) Torrent-Guasp-a, omogućio je razvoj savremene, integrativne strategije (“3V” - eng. “vessel, valve, ventricle”) komorne restorativne hirurgije (SVR), za korekciju morfološko-funkcionalnih posledica postinfarktnog ventrikularnog remodelovanja (PVR). Cilj: Dokazati da integrativna strategija SVR dovodi do značajnog poboljšanja strukturnih i funkcionalnih ehokardiografskih (ECHO) parametara PVR-LV, u neposrednom, ranom i udaljenom periodu postoperativnog praćenja. Metode: U sklopu prospektivne kohortne studije, u Klinici za kardiohirurgiju KCS, (jul 2005. - februar 2010.), integrativna SVR strategija je primenjena kod 40 pacijenata, prosečne starosti 62.2 ± 8.2 godina (72.5% muškarci). Preoperativni klinički i elektrofiziološki status, medikamentozna terapija, morfološki i funkcionalni ECHO parametri LV, mitralnog valvularnog (MV) aparata i desne komore (RV), poređeni su sa odgovarajućim postoperativnim nalazima u neposrednom (˂ 6), ranom (6-12) i kasnom periodu (˃ 12 meseci) postoperativnog praćenja. Rezultati: Prosečno vreme praćenja: 22.2 ± 13.8 meseci. Ukupni mortalitet: 12.5% (operativni 0.0%; intrahospitalni 7.5%; rani 2.5% i kasni 2.5%). Količnici operativnog (0.0) i hospitalnog mortaliteta (0.4): ˂ 1. Ukupno aktuarijalno preživljavanje: 95.0% (hospitalno); 90.0% (prva i druga) i 77.1% (treća, četvrta i peta godina). Verovatnoća preživljavanja bez naknadnih hospitalizacija zbog srčanih razloga: 94.6% (hospitalno); 89.2% (prva i druga) i 74.3% (treća, četvrta i peta godina). Primenjena SVR strategija je dovela do statistički značajnog poboljšanja svih preoperativnih, kliničkih (NYHA III/IV: 100% vs. 23.4%; CCS III/IV: 100% vs. 0.0%), morfoloških i funkcionalnih ECHO parametara LV (LV-EF: 31.8% vs. 46.1% ; LV-EDD: 62.4 mm vs. 53.7 mm; LV-ESD: 47.7 mm vs. 40.3 mm; LV-EDV: 236.8 mL vs. 172.9 mL; LV-ESV: 138.7 mL vs. 90.3 mL; LV-EDVI: 123.6 mL/m2 vs. 90.6 mL/m2;, LV-ESVI: 72.5 mL/m2 vs. 47.1 mL/m2; i LV-SI: 0.59 vs. 0.49), MV (MR 3/4+: 22.5% vs. 0.0%) i RV (PAPs: 40.6 mmHg vs. 31.4 mmHg; TAPSE: 15.7 mm vs. 17.9 mm) - koje se održava u svim sukcesivnim periodima, tokom petogodišnjeg praćenja. Prosečna redukcija preoperativnog LV-ESVI=35%, prosečna rezidualna LV-ESVI=47 a prosečno poboljšanje LV-EF=15%. Atrijalna fibrilacija je bila češća (p=0.039) unutar 6 meseci nakon SVR (29.7%) nego preoperativno (10.8%). Pacijenti su medikamentozno tretirani u skladu sa preporukama za terapiju ICM. Nezavisni prediktori preživljavanja su bili: infarkt miokarda u ICU i dijaliza u ICU. ECHO kriterijumi efikasnosti SVR (LV-ESVI ≥ 30%, rezidualni LV-ESVI ≤ 60mL/m2) nisu uticali na preživljavanje. Analiza uz pomoć ROC krive ukazuje da je postizanje oba kriterijuma najvalidnije u smislu prognoze ishoda. Redukcija LV-ESVI ≥ 30% je senzitivniji i specifičniji kiterijum, od rezidualnog LV-ESVI ≤ 60mL/m2. Nijedan preoperativni parameter nije bio nezavisni prediktor postizanja kriterijuma efikasnosti SVR. Analiza uz pomoć ROC krive ukazuje da je LV-EDVI ≤ 115.7 mL/m2 najvalidniji u smislu prognoze postizanja oba kriterijuma efikasnosti SVR, a da su LV-EDD ≤ 66.0 mm; LV-EDV ≤ 227.0 mL i LVEDVI ≤ 148.3mL/m2 validni za prognozu postizanja rezidualnog LV-ESVI ≤ 60mL/m2. Zaključak: SVR je efikasna i bezbedna operacija za korekciju PVR-LV, koja predstavlja pouzdanu privremenu („bridge to transplant“) ili trajnu („destination therapy“) alternativu transplantacionoj hirurgiji. Integracija koncepta HVMT u savremene strategije geometrijske SVR, pruža bolji uvid u patoanatomiju i patofiziologiju PVR-LV, omogućuje adekvatnu selekciju i tumačenje relevantnih dijagnostičkih nalaza, bolju stratifikaciju rizikaBackground: Size, shape and fiber orientation of post-infarction remodeled left ventricle (LV), in a presence of ischemia and functional mitral regurgitation (MR), significantly affect prognosis in patients with ischemic cardiomyopathy (ICM). The helical ventricular myocardial band (HVMT) of Torrent-Guasp has enabled development of contemporary, integrative (“3V” - “vessel, valve, ventricle”) surgical ventricular restorative (SVR) strategy, aimed to correct morphological and functional consequences of the post-infarction ventricular remodeling (PVR). Objective: To prove that integrative SVR produces significant improvements of structural and functional echocardiography (ECHO) parameters of PVR-LV in the immediate, early and late postoperative follow-up period. Methods: As a part of prospective cohort study, conducted at Clinic for Cardiac Surgery CCS (July 2005. - February 2010.), integrative SVR strategy was applied in 40 patients, with mean age of 62.2 ± 8.2 years (72.5% male). Preoperative clinical and electrophysiological status, drug therapy, morphological and functional ECHO parameters of the LV, mitral valve (MV) and the right ventricle (RV), were compared to appropriate measures in immediate (˂ 6), early (6-12) and late (˃ 12 months) follow-up. Results: Mean follow-up time: 22.2 ± 13.8 months. Overall mortality: 12.5% (operative 0.0%; hospital 7.5%; early 2.5% and late 2.5%). Operative (0.0) and hospital mortality ratio (0.4): ˂ 1. Overall actuarial survival: 95.0% (hospital); 90.0% (1st and 2nd) and 77.1% (3rd, 4th and 5th year). Probability of survival without hospitalizations for cardiac reasons: 94.6% (hospital); 89.2% (1st and 2nd) i 74.3% (3rd, 4th and 5th year). Applied SVR strategy resulted in statistically significant improvements of all preoperative clinical (NYHA III/IV: 100% vs. 23.4%; CCS III/IV: 100% vs. 0.0%), morphological and functional ECHO parameters of the LV (LV-EF: 31.8% vs. 46.1% ; LV-EDD: 62.4 mm vs. 53.7 mm; LV-ESD: 47.7 mm vs. 40.3 mm; LV-EDV: 236.8 mL vs. 172.9 mL; LV-ESV: 138.7 mL vs. 90.3 mL; LV-EDVI: 123.6 mL/m2 vs. 90.6 mL/m2;, LV-ESVI: 72.5 mL/m2 vs. 47.1 mL/m2; i LV-SI: 0.59 vs. 0.49), MV (MR 3/4+: 22.5% vs. 0.0%) and the RV (PAPs: 40.6 mmHg vs. 31.4 mmHg; TAPSE: 15.7 mm vs. 17.9 mm) - which sustained in each successive time frame, during the 5-year follow-up. Mean reduction of preoperative LV-ESVI=35%, mean residual LV-ESVI=47 and mean improvement of LV-EF=15%. Atrial fibrillation was more frequent (p=0.039) within 6 months after SVR (29.7%) than preoperatively (10.8%). Patients received medical therapy in accordance with ICM treatment guidelines. Independent predictors of survival were: myocardial infarction in ICU dialysis in ICU. ECHO criteria of SVR efficiency (LV-ESVI ≥ 30%, residual LV-ESVI ≤ 60mL/m2) did not affect survival. ROC curve analysis revealed that the achievement of both criteria was the most valid for the outcome prognosis. Reduction of LV-ESVI ≥ 30% was more sensitive and specific than LV-ESVI ≤ 60mL/m2. None of the preoperative parameters was the independent predictor for attaining the SVR efficiency criteria. ROC curve analysis revealed LV-EDVI ≤ 115.7 mL/m2 to be the most valid for the prognosis of combined criteria, while LV-EDD ≤ 66.0 mm; LV-EDV ≤ 227.0 mL i LV-EDVI ≤ 148.3mL/m2 were valid for the prognosis of residual LV-ESVI ≤ 60mL/m2 attainment. Conclusions: SVR is safe and efficient procedure for the patients with PVR-LV, being a reliable temporary („bridge to transplant“) or even permanent („destination therapy“) alternative to the heart transplant surgery. Integrating the HVMT concept into contemporary strategies of geometric SVR, offers better insight in pathoanatomy and pathophysiology of PVR-LV, helping to select and interpret the most relevant diagnostic findings, stratify the risk and improve patient selection, all being the essential prerequisites for the success of this procedure

Giant left main coronary artery aneurysm

Introduction. Coronary artery aneurysms (CAAs) are rare disorders, especially the left main CAA. In the literature, there are several reported cases with CAAs, various localization, size, clinical presentation, and way of treatment. There is no unique consensus about the most adequate treatment for these patients; however, surgery is still preferable, although there are some new experiences of percutaneous treatment. The decision is made for each patient individually. We report a case of giant left main CAA, with acute coronary syndrome and heart failure presentation, surgically treated. Case report. A 66-year-old female patient was admitted to the emergency department of our clinic due to chest pain and dyspnea. Acute non-ST-elevation segment myocardial infarction (STEMI) of anterolateral localization was diagnosed (creatine kinase max 1,111 U/L, troponin T 3.754 ng/mL), complicated with acute heart failure. Heart catheterization and coronary angiography revealed a giant saccular, 3.5 × 3.5 mm left main CAA full with thrombi, compressing the proximal segments of the left anterior descending and circumflex artery. Conclusion. Giant left main CAAs are rare pathologic findings, and there are no established principles for treatment. Although the percutaneous way of treatment is now available in selected cases, the surgical approach is still preferred for these patients

Anomalous aortic origin of right and circumflex coronary arteries - procedural risks during combined aortic valve replacement and coronary artery bypass grafting

Introduction. Anomalous aortic origin of the right and the circumflex coronary arteries presents extremely rare and potentially dangerous combination in patients scheduled for combined coronary bypass grafting and aortic valve replacement surgery. We report this illustrative case to emphasize the importance of meticulous diagnostic setup enabling the surgeon to anticipate and avoid numerous possible pitfalls. Case outline. A 74-year-old woman, with anterior-wall myocardial infarction and aortic valve stenosis, underwent successful combined coronary artery bypass grafting and aortic valve replacement. Preoperative coronary angiography revealed unusually high take-off of the right main coronary trunk and anomalous origin and course of the circumflex coronary artery. Anatomy of both anomalous coronary arteries in the light of underlying surgical pathology necessitated a meticulous preparation and caution during successive phases of surgical treatment. Conclusion. Estimating potential procedural risk should be standard practice for each patient with known congenital coronary artery anomalies, regardless of the natural risk imposed by a particular anomaly. Preoperative evaluation of coronary circulation, with high surgical awareness and knowledge of different congenital coronary artery anomalies, should be a standard approach in cardiac surgical practice. This would add a predictive value for an actual procedural risk in cases of previously unrecognized anomalies

Surgical treatment of ishemic mitral regurgitation: Repair, replacement or revascularization alone?

Introduction. Treatment of ischemic mitral regurgitation in patients that require revascularization of myocardium is still debatable. Objective. The aim of this study was to compare three surgical approaches: valve repair and revascularization; valve replacement and revascularization, and revascularization alone. Methods. In 2006 and 2007 at the Institute for Cardiovascular Diseases, Clinical Centre of Serbia, Belgrade, 1,040 patients with coronary disease underwent surgery. Forty-three patients (4.3%) had also mitral insufficiency 3-4+. The patients were examined clinically, echocardiographically and haemodynamically. In group I there were 14 (32.3%) patients, in group II 16 (37.2%) patients and in group III 3 (30.5%) patients. Ninetythree per cent of patients were classified as New York Heart Association (NYHA) class III and IV, and three (7%) patients had congestive heart weakness with ejection fraction ≤30%. The decision as to surgical procedure was made by the surgeon. Postoperatively, patients were checked clinically and echocardiographically after 3, 6 and 12 months. The follow-up period was approximately 15 months (8-20). Results. Hospital mortality for the whole group was 6.9% (3 patients). In group I mortality was 14.2% (2 patients), in group II 6.25% and in group III there was no mortality. Long term results, up to 15 months, showed 100% survival in groups I and II, and in group III one patient died (7.7%). Conclusion. Short term results up to 30 days were best in group III, but longer term results were better in groups I and II

Ultrastructural analysis of small blood vessels in skin biopsies in CADASIL

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an inherited small- and medium-artery disease of the brain caused by mutation of the Notch3 gene. Very often, this disease is misdiagnosed. We examined skin biopsies in two members of the first discovered Serbian family affected by CADASIL. Electron microscopy showed that skin blood vessels of both patients contain numerous deposits of granular osmiophilic material (GOM) around vascular smooth muscle cells (VSMCs). We observed degeneration of VSMCs, reorganization of their cytoskeleton and dense bodies, disruption of myoendothelial contacts, and apoptosis. Our results suggest that the presence of GOM in small skin arteries represents a specific marker in diagnosis of CADASIL

Cardiac myxoma: The influence of preoperative clinical presentation and surgical technique on late outcome

Introduction Cardiac myxomas are the most frequent primary tumors of the heart in adults, and they can be found in each of four cardiac chambers. Although biologically benign, due to their unfavorable localization, myxomas are considered "functionally malignant" tumors. Diagnosis of cardiac myxoma necessitates surgical treatment. Objective To analyze: 1) the influence of localization, size and consistency of cardiac myxomas on preoperative symptomatology; 2) the influence of different surgical techniques (left, right, biatrial approach, tumor basis solving) on early, and late outcomes. Method From 1982 to 2000, at the Institute for Cardiovascular Diseases, Clinical Center of Serbia, there were 46 patients with cardiac myxomas operated on, 67.4% of them women, mean age 47.1±16.3 years. The diagnosis was made according to clinical presentation, electrocardiographic and echocardiographic examinations and cardiac catheterization. Follow-up period was 4-18 (mean 7.8) years. Results In 41 (89.1%) patients, myxoma was localized in the left, while in 5 (10.9%), it was found in the right atrium. Average size was 5.8×3.8 cm (range: 1×1 cm to 9×8 cm) and 6×4 cm (range: 3×2 cm to 9×5 cm) for the left and right atrial myxomas, respectively. A racemous form predominated in the left (82.6%) and globous in the right (80%) atrium. Fatigue was the most common general (84.8%) and dyspnoea the most common cardiologic symptom (73.9%). Preoperative embolic events were present in 8 patients (4 pulmonary, 4 systemic). In our series: 1) different localization, size and consistency had no influence on the preoperative symptomatology; 2) surgical treatment applied, regardless of different approaches and basis solving, resulted in excellent functional improvements (63.1% patients in NYHA III and IV class preoperatively vs. 6.7% patients postoperatively) and had no influence on new postoperative rhythm disturbances (8.7% patients preoperatively vs. 24.4% patients postoperatively); 3) early (97.8%), and late survival rates (91.3%) were excellent; 4) there were no relapses during the follow-up period. Conclusion Localization, size and consistency had no influence on the preoperative symptomatology. Excellent survival rate with significant functional improvement, rare postoperative complications and no recurrences, justify the applied strategies of surgical approach and tumor basis solving in our series

Saphenous vein graft true aneurysms: Report of nine cases and review of the literature

INTRODUCTION The true aneurysm formation of the autogenous saphenous vein graft (ASVG) is a very rare complication after bypass surgery [1 -5]. In 1969 Pillet [1] first described a true fusiform aneurysm formation of the ASVG which had been used as a replacement of the iwured superficial femoral artery in 26-year-old male patient. We present nine cases. CASE!. A 71-year-old man with previous history of arterial hypertension and higher serum lipid level, was admitted with an asymptomatic pulsating swelling of the medial portion on the thigh. Five years ago the bellow knee F-P bypass with ASVG due to occlusive disease has been performed. The transfemoral angiography (Figure 1) showed patent graft with fusiform true aneurysm formation at its mid portion. This aneurysm has been replaced with PTFE graft. The pathohistological examination showed an atherosclerotic origin of the aneurysm. This patient died four years after operation due to myocardial infarction with patent graft. CASE 2. A 57-year-old female with previous history of arterial hypertension and higher serum lipid level, had an elective resection and replacement of the superficial femoral artery aneurysm. For the reconstruction an ASVG was used. The saphenous vein showed postflebitic changes. Four years later she was admitted with asymptomatic pulsating mass of the mid portion of the thigh. The control transfemoral angiography showed patent graft with fusiform aneurysm formation of its mid portion. After aneurismal resection, an above knee F-P bypass with 8 mm PTFE graft was performed. A pathohistological examination showed a partially degenerated elastic membrane with fragmentation and disruption, without atherosclerosis (Figure 2). During the follow up period an elective resection of the subclavian artery aneurysm as well as abdominal aortic aneurysm, were performed. CASE3. A subclavian artery aneurysm caused by TOS has been repaired with sapehnous vein graft at 40-year-old female patient with regular arterial tension and normal serum lipid level. The pathohistologycal examination showed an intimai fibroelastosis associated with intimai and medial connective tissue proliferation of the aneurysm. The atherosclerotic changes were absent. Four years later this patient has been admitted urgently with ischemia of the left hand, absent distala arterial pulses and with asymptomatic pulsating mass over the supradavicular area. The Duplex ultrasonography and angiography, showed aneurysm of the ASVG, associated with occlusion (embolism) of the brachial artery (Figure 3). This aneurysm has been replaced with 6 mm PTFE graft Transbrachial thrombembolectomy has been performed too. The pathohistological examination showed a non atherosclerotic origin of the ASVG aneurysm (Figure 4). Three years after secondary operation the PTFE graft is patent. Echocardiography of the same patient showed mitral valve prolaps, probably caused by connective tissue disorder. CASE 4. A 56-year-old female patient was admitted urgently, due to hemorrhagic shock and giant pulsating swelling over the popliteal space. The Duplex ultrasonography and transfemoral angiography showed ruptured popliteal artery aneurysm. This patient had arterial hypertension and higher lipid level. During the urgent operation using dorsal approach, an aneurysm has been replaced with ASVG. A pathohistological examination showed an atherosclerotic origin of the aneurysm. Ten days postoperatively due to bleeding from the wound, a new urgent surgical procedure was performed. Intraoperatively 1 cm long graft laceration was found, while postoperative bacteriological examination showed an infection caused by Staphylococcus Aureus. The graft has been removed, and new extraanatomic, subcutaneous bypass from the superficial femoral to anterior tibial artery using ASVG was performed. Three years later this patient was admitted urgently with giant pulsating mass and skin necrosis at the knee region, associated with hemorrhagic shock. The control angiography showed a ruptured aneurysm of the ASVG (Figures 5 and 6). The aneurysm was replaced with 6mm PTFE graft. The pathohistological examination showed an atherosclerotic origin of the aneurysm. Two year postoperatively, the new graft is patent. CASE 5. A 65-year-old man with previous history of arterial hypertension and high serum lipid level, was admitted with pulsating swelling and skin necrosis at the portion on the thigh. Nine years ago the bellow knee F-P bypass with cephalic vein due to occlusive disease has been performed. Transfemoral angiography showed patent graft associated with ruptured fusiform aneurysm at its mid portion. This aneurysm has been replaced with 6mm tubular PTFE graft. The postoperative patohistological examination showed an atherosclerotic changes at the resected aneurysm. This patient was followed two years, and graft is patent., CASE 6. A 62-year-old male patient was admitted urgently, with giant pulsating swelling over the popliteal space and hemorrhagic shock. The Duplex ultrasonography and angiography showed ruptured popliteal artery aneurysm. The patients had previous history of arterial hypertension and higher serum lipid level. The aneurysm has been replaced with ASVG. Pathohistological examination showed an atherosclerotic origin of the aneurysmal sac. Seven days postoperatively, a massive bleeding from the wound due to graft infection, occurred. New urgent operation showed complete graft abrupption at the site of proximal anastomosis, while postoperative bacteriological examination showed a presence of Staphylococcus Aureus. The graft was removed and new extraantomic, subcutaneous bypass from the superficial femoral to the anterior tibial artery with contralateral ASVG, was performed. The patient recovered very well. Five years latter this patient was admitted urgently with large painful pulsating mass in the thigh. The angiography showed and ASVG fusiform aneurysm. The aneurysm has been replaced with 6 mm PTFE graft. The pathohistological examination showed an atherosclerotic origin of the resected aneurysm (Figure 7). Two years after the operation, a new graft is patent. CASE 7. A 78-year-old man with previous history of arterial hypertension and higher serum lipid level, has been admitted with an asymptomatic pulsating swelling of the medial portion on the thigh. Seven years ago the bellow knee F-P bypass with ASVG and exclusion of the poplietal artery aneurysm was performed. The Duplex ultrasonography and angiography showed a fusiform true aneurysm formation at the mid portion of the patent graft. The aneurysm has been replaced with femoro-anterior tibial artery bypass procedure using 6 mm PTFE graft. The pathohistological examination showed an atherosclerotic origin of the aneurysm. This patient died five days after the operation due to myocardial infarction with patent graft. CASE 8. A 65-year-old male with previous history of arterial hypertension and higher serum lipid level, had an elective replacement of the popliteal artery aneurysm. For the reconstruction a PTFE graft was used. Two years postoperativelly this graft occluded due to changes on the crural arteries. From these reasons a new bypass from the superficial femoral to anterior tibial artery with saphenous vein graft, was performed. Nine years later she was admitted with painful pulsating mass of the mid portion of the thigh. The Duplex ultrasonography and transfemoral angiography showed patent graft with fusiform aneurysm formation of its mid portion. The ASVG aneurysm was replaced with 8 mm Dacron graft. A pathohistological examination showed atherosclerotic origin of the ASVG aneurysm. One year latter this graft is patent. CASE 9. A 65-year-old male with previous history of arterial hypertension and higher serum lipid level, has been admitted due to disabling claudications discomfort caused by aorto-iliac occlusive disease. Nine years earlier a right sided aorto-renal bypass with ASVG was performed due to occlusive disease and renovascular hypertension. An translumbar aortography showed occlusion of the aortic bifurcation associated with fusiform aneurysm formation of ASVG (Figures 8, 9 and 10). During the same operation an aorto-bifemoral bypass and repairing of ASVG aneurysm with Dacron grafts, were performed. A pathohistological examination showed atherosclerotic origin of the ASVG aneurysm. One year latter both grafts are patent. DISCUSSION The table 1 shows 45 true aneurysmal formation at ASVG after F-P bypass surgery in cases with occlusive diseases [1-25]. In his famous paper Szilagyi [3] reported a study of the biologic fate of ASVG in 260 patients with F-P bypass procedures, and he found 10 (3.8%) aneurysms. In 1973 De Weese [5] found 4 (1.2%) ASVG aneurysms after 350 F-P reconstructions, while in 1975 Vanttinen [6] found 1 (0.9%) such case after these procedures. In 1987 Yuanagyia [26], and in 1989 Martin [27] described cases of ASVG aneurysmal formation after subclavian artery aneurysm replacement. Yanagyia's patient had a Behcet disease. We also had one case of ASVG aneurysm after subclavian artery aneurysm repair, manifested with hand ischemia due to distal embolization. Gemperle[12]in 1986 decribed ASVG aneurysm which developed 18 years after replacement of the injured brachial artery. Carrasaquilla [28] has in 1972 described a case of ASVG aneurysm formation after replacement of the common carotid artery, while in 1998 Tekeuchi et al [29] described a case of an ASVG aneurysm after subclavian to vertebral artery bypass due to stenotic lesions of the both vertebral arteries. Four years later a giant ASVG aneurysm was found, and successfully resected. In 1990 Peer et al [30] reported two ASVG aneurysms seven and eight years after popliteal artery aneurysm replacement. In 1991 Kogel et al [31] described one such case 10 years after primary operation. In 1997 Loftus [32] described 10 new cases of the ASVG aneurysms after popliteal artery aneurysm repair. We had two such cases developed three and five years after primary operation. In three of our cases ASVG aneurysm showed an atherosclerotic origin, while in 3 non atherosclerotic. The exact mechanism of aneurysm degeneration of the ASVG in arterial position is unknown. There is likely a combination of factors including: - mechanical trauma during vein harvesting and operation [9,30]; - weakness at branching sites in the vein [2,9]; - potential weakness in the vicinity of the venous valves due to absence of the circular muscle cuff in the media of the vessel wall [5]; - infection [16]; - trauma caused by bony structures near the graft [18,30]; - arteritis [13,14,26, 27, 30]; - atherosclerosis [2,3,5-11,18,19,21,24,25]; - hemodinamic factors from the arterial pressure [23]; - transmural ischemie injury of the vein wall due to disrupting of the vasa vasorum after removing of the vein segments [28,29,33]; Brody cold this fenomen „devascularization of the venous graft" [34]; - diffuse nature of this process in patients with multiple aneurysmal changes [20,32] (our cases 2,3,4,6 and 8); - using of the cephalic [9], or superficial femoral vein [1] (case 7); - changed veins (one of our cases). The use of in situ bypass technique for arterial reconstruction would theoretically, minimize endothelial trauma by reducing operative manipulation, preserving vasa vasorum, and eliminating the pressure induced endothelial desquamation that has been associated with mechanical destination of reversed vein graft during their harvest. However, Sassoust [15] in 1986 reported 5 cases of true aneuryms of the ASVG after in situ F-P bypass. After Sassoust's new cases of ASVG aneurysm following F-P in situ bypass surgery were reported [22-24]. CONCLUSION Early ASVG aneurysm formation occurring six months after surgery has been found to be the result of preexisting unrecognized vein wall weakness or injury at the time of harvest, while aneurysm discovered 5 or more years postoperatively, were atherosclerotic in nature. The aneurysms of the ASVG are frequent, at patients with multiple aneurysms of natural arteries. The ASVG aneurysms require active surgical treatment. Then autologous vein grafts are not „material of choice" for replacement of aneurysmally changed ASVG after peripheral vascular reconstructions

A comprehensive morphometric analysis of the internal thoracic artery with emphasis on age, gender and left-to-right specific differences

Aims of the study. The aim of this analysis was the morphometric description of the internal thoracic artery (ITA) with an emphasis on age, gender and left-to-right specific differences, as well as on age and atherosclerosis related changes of the elastic skeleton. Methods. Forty eight arteries were obtained during forensic autopsies from 32 persons who had died of non-vascular causes. The following morphometric parameters were analyzed: thickness of the intima, the medial layer and the wall, the intima-to-media ratio and the elastic skeleton parameters. Results. The intima thickness increases significantly with aging (ANOVA F=34.061, p<0.001), as does the intima-to-media ratio (ANOVA F=10.831, p<0.001). With aging, there is a significant increase in the thickness of the media (F=56.519; p<0.001) and of the wall (F=34.094; p<0,001). There is a significant increase in the media thickness during the development of atherosclerosis in the ITA (ANOVA F=11.848, p<0.001). No significant difference was found when these data were analyzed based on the left-to-right principle or depending on gender of the patients. However, the analysis of the elastic skeleton parameters indicated that the combined effects of aging, atherosclerosis and male gender lead to the degeneration of the elastic skeleton of the ITA. Conclusion. The grade of atherosclerosis gradually increases with aging as shown by morphometric analysis. The increase in the medial layer thickness suggests the potential for positive remodeling of the ITA during aging and atherosclerosis. The left/right position has no influence on morphometric parameters of the ITA, while male gender affects parameters of the elastic skeleton