Hypertrophied myocardium protection in aortic valve surgery

Departamentul Chirurgie Cardiovasculară și Toracică, IMSP Spitalul Clinic Republican ”Timofei Moșneaga”, Chișinău, Republica Moldova, Al XIII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” și al III-lea Congres al Societății de Endoscopie, Chirurgie miniminvazivă și Ultrasonografie ”V.M.Guțu” din Republica MoldovaIntroducere: Protecția miocardului hipertrofiat în chirurgia valvulopatiilor aortale prezintă o provocare serioasă vis-a-vis de consecințele postoperatorii. Material și metode: S-au selectat 86 pacienți operați pentru protezarea valvei aortale, plastia valvei mitrale, cu sau fără intervenție la valva tricuspidă și perioada clampului aortal 100-170 min. 41 pacienţi aveau masa diastolică a VS > 150 g/m.p. (gr.1 ) şi 45 - < 150 g/m.p. (gr.2). Cardioplegia sangvină (Calafiore) în modificarea noastră prin suplimentarea permanentă cu Mg++ s-a aplicat repetat în ostiile arterelor coronare la fiecare 20-25 min. Temperatura cardioplegiei, identică cu cea a pacientului, era 30-33°C. Starea clinică a pacienţilor - fără deosebiri între loturi. Rezultate: După declamparea aortei gr.1 a demonstrat o capacitate de restabilire a ritmului similară celei din gr.2. Din 41 pacienţi ai gr.1, inima s-a restartat spontan la 29 (70,8%). Cardioversie au necesitat 12 (29,2%), numărul total de cardioversii fiind 15. În gr.2 din 45 pacienţi 13 (28,8%) au necesitat 16 cardioversii. Blocul AV a survenit identic. Necesitatea administrării cateholaminelor - fără diferențe semnificative între grupuri. În gr.1 au necesitat suport inotrop în doze mari 8 pacienţi (19,5%), iar în gr.2 - 9 pacienţi (20,0%). Durata aflării în TI a fost de 2,8±0,9 zile în gr.1, faţă de 2,6±0,8, gr.2. Concluzii: Cardioplegia intermitentă sanguină izotermică în regim de hipotermie ușoară sau moderată suplimentată în permanenţă cu Mg++ asigură protecţia miocardului hipertrofiat pe o perioadă standard (20-25 minute) de ischemie dintre reperfuzii şi are un efect pozitiv asupra capacității funcționale în perioada imediat postoperatorie.Background: Protection of hypertrophied myocardium represents a challenging situation in aortic valvular surgery. Material and methods: The study included 86 patients operated for prosthetic aortic valve repair, the mitral valve plasty with or without intervention on tricuspid valve and aortal cross-clamp 100-170 min. 41 patients had systolic LV mass index >150g/sq.m. (Gr.1); 45 - <150g/sq.m. (Gr.2). Blood cardioplegia (Calafiore) modified by us, supplemented constantly with Mg++, was applied in coronary ostia every 20-25 min. Cardioplegia temperature, identical to that of the patient, varied between 30°C and 33°C. The clinical condition of patients was with no significant differences between groups. Results: After aortic clamp release Gr.1 demonstrated a capacity to restore rhythm similar to that of gr.2. Out of 41 patients, the heart in Gr.1 restarted spontaneously in 29 (70.7%). Cardioversion required 12 patients (29.2%), total number of defibrillation being 15. In Gr.2 of 45 patients 13 (28.8%) required 16 defibrillations. AV block was expressed identical in both groups. The need in catecholamine was the same. In Gr.1 - 8 patients (19.5%) required high doses inotropic support and in group II - 9 patients (20.0%). Duration of stay in the ICU was 2,8±0,9 days for the Gr.1, versus 2,6±0,8, Gr.2. Conclusions: Isothermal intermittent blood cardioplegia under mild or moderate hypothermia constantly supplemented with Mg++ provides good protection of hypertrophied myocardium over a standard period (20-25 minutes) of ischemia between reperfusions and has a positive effect on functional capacity in the immediate postoperative period

Surgical treatment in acute aortic disection. Clinic experience

Secția Chirurgie Cardiacă a Viciilor Dobândite, Spitalul Clinic Republican ”Timofei Moșneaga”, Chișinău, Republica Moldova, Al XIII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” și al III-lea Congres al Societății de Endoscopie, Chirurgie miniminvazivă și Ultrasonografie ”V.M.Guțu” din Republica MoldovaIntroducere: Disecţia acută de aortă este o urgenţă cardiochirurgicală majoră, fiind cea mai frecventă complicație letală la pacienții cu dilatarea anevrismatică a rădăcinii de aortă în asociere sau nu cu sindromul Marfan. Înlocuirea aortei ascendente disecate este o intervenție chirugicală de urgență ”life saving”, asociată cu o morbiditate și mortalitate ridicată. Din cauza polimorfismului clinic extrem de variat şi a complicaţiilor severe care survin rapid, diagnosticul şi conduita pacientului prezintă dificultăţi. Material și metode: În cadrul clinicii au fost studiați 51 de pacienți operați, care s-au împărțit în 2 categorii: grupul A – 43 pacienți (84%) cu Disecție acută și grupul B – 8 pacienți (16%) cu Disecție acută în asociere cu sindrom Marfan. S-au analizat diferențele dintre cele două grupuri cu privire la caracteristicile preoperatorii, tehnicile chirurgicale, rezultatele postoperatorii imediate și la distanță. Rezultate: Pacienții din grupul B au fost semnificativ mai tineri (B:34,2±11ani) vs (A:58,3±9ani). Hipertensiune arteriala (HTA) a fost întîlnită preponderent în grupul A. Incidența complicațiilor postopertorii, precum și mortalitatea intraoperatorie și cea de la 30 de zile au fost similare. În urma rezultatelor postoperatorii la distanță mortalitatea din grupul B este mai mică. Concluzii: Mortalitatea postoperatorie este similară în disecția acută de aortă cu sau fără sindrom Marfan. Supraviețuirea la distanță este mai mare a pacienților cu sindrom Marfan operați. Diagnosticul precoce al anevrismelor de aortă cu sau fără sindrom Marfan, corijarea permanentă a HTA, intervențiile chirurgicle planice pot reduce semnificativ apariția disecției de aortă.Introduction: Acute aortic dissection is a major emergency in cardiac surgery, being the most common lethal complication in patients with aneurysmal dilatation of the aortic root in combination or not with Marfan syndrome. Replacement of the dissected ascending aorta is a ”life-saving” surgical intervention, associated with high morbidity and mortality. Due to the extremely varied clinical polymorphism and the severe complications that occur rapidly, the patient's diagnosis and conduct presents difficulties. Material and methods: In the clinic, 51 operating patients were studied, divided into 2 categories: group A - 43 patients (84%) with acute dissection and group B - 8 patients (16%) with acute dissection in association with Marfan syndrome. The differences between the two groups were analyzed for preoperative characteristics, surgical techniques, immediate and long-term postoperative outcomes. Results: Patients in group B were significantly younger (B:34.2 ± 11) vs (A:58.3 ± 9). High blood pressure (HBP) was predominantly found in group A. The incidence of postoperative complications as well as intraoperative mortality and the 30-day mortality were similar. After post-operative outcomes, the mortality in group B is lower. Conclusions: Postoperative mortality in acute aortic dissection is similar with or without Marfan syndrome. Remote survival is greater for operated patients with Marfan syndrome. Early diagnosis of aortic aneurysms with or without Marfan syndrome, permanent coronary care of HBP, planar surgeries can significantly reduce the occurrence of aortic dissection

Three embeddings of the Klein simple group into the Cremona group of rank three

We study the action of the Klein simple group G consisting of 168 elements on two rational threefolds: the three-dimensional projective space and a smooth Fano threefold X of anticanonical degree 22 and index 1. We show that the Cremona group of rank three has at least three non-conjugate subgroups isomorphic to G. As a by-product, we prove that X admits a Kahler-Einstein metric, and we construct a smooth polarized K3 surface of degree 22 with an action of the group G.Comment: 43 page

Trauma of the heart and the aorta. Case`s report

Secția Chirurgie Cardiacă a Viciilor Dobândite, IMSP Spitalul Clinic Republican ”Timofei Moșneaga”, Chișinău, Republica Moldova, Al XIII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” și al III-lea Congres al Societății de Endoscopie, Chirurgie miniminvazivă și Ultrasonografie ”V.M.Guțu” din Republica MoldovaIntroducere: Traumatismele cordului și aortei reprezintă 2,7-3,2% din urgențele cardiochirurgicale. Complexitatea cazurilor sunt extrem de variate. Indicația operatorie poate fi necesară atît în traumatisme penetrante cît și nepenetrante. Din trauma cordului penetrant doar 35% din pacienți supraviețuiesc pînă la unitatea de gardă. Material și metode: În cadrul clinicii s-au studiat 7 cazuri operate cu traumatismul cordului și aortei. În 2 cazuri intervenția fiind secundară, efectuată pe cord deschis cu by-pass cardiopulmonar, pentru rezolvarea defectelor restante postpenetrante. Trauma aortei în toate cazurile a fost nepenetrantă, ce a condus la declanșarea anevrismului de aortă. Rezultate: Pacienții operați au o supraviețuire de100%. În cazurile intervențiilor pe cord deschis s-a efectuat și corecție valvulară. La pacienții cu anevrism de aortă s-a efectuat protezarea segmentului aortic, în dependență de localizarea anevrismului operația s-a efectuat cu by-pass cardiopulmonar sau cu șunt de ocolire. Concluzii: Intervenția primară de urgență majoră pentru trauma cordului penetrant este vital necesară, dar în dependență de gravitatea leziunii unele defecte necesită reintervenție secundară pe cord deschis.Introduction: Heart and aortic trauma represents for 2.7-3.2% of cardiac surgery. The complexity of the cases is extremely varied. The operative indication may be required both in penetrating and non-penetrating traumas. From penetrating heart trauma, only 35% of patients survive to the on-call unit. Materials and methods: In the clinic, was studied 7 cases of heart and aortic trauma. In 2 cases, the intervention was secondary, performed on open heart with cardiopulmonary bypass, to solve post penetrating defects. The aortic trauma in all cases was nonpenetrating, which led to the onset of aortic aneurysm. Results: Operated patients have a survival of 100%. In cases of open heart surgery, valvular correction was also performed. In patients with aortic aneurysm, aortic segment prosthesis was performed, depending on the location of the aneurysm, the operation was performed by cardiopulmonary bypass or bypass shunt. Conclusions: The primary emergency intervention for penetrating heart trauma is vital, but depending on the severity, some defects require secondary open-heart re-insertion

Strategies of the treatment of cardiac prosthetic valve thrombosis

Department of Cardiac Surgery, Republican Hospital, Chisinau, the Republic of MoldovaBackground: The article deals with the analysis of principal causes of valve prosthesis thrombosis and “pannus” thrombosis. The diagnosis and contemporary treatment strategy of prosthesis dysfunction have been considered. Material and methods: In our department 1670 patients with extracorporeal circulation were operated on, among them 1260 had valve pathology that made up 74.2%. 1164 heart valves were replaced, 145 of them were biological prostheses and 1019 were mechanical ones of different types. Prosthesis thrombosis took place in 28 patients that represented 60% of the number of patients with prothesis disfunction and 2.2% of the total number of operated patients from which 21 patients, their age ranged from 35 to 63 years old. The surgical treatment was performed to 9 patients, thrombolysis – to 19 patients. Results: During last 6-7 years the thrombolysis treatment with ateplasum and reteplasse has been successfully implemented in the therapy of thrombosis valve prothesis. Thrombolysis was performed to 19 patients. The results are the following: in 17 cases good outcomes (a complete recovery of the prosthesis function with transprosthetic gradient and the normalization of systolic pressure in right ventricle) have been registered, one case has been complicated with transitory ischemic ictus. Out of 19 patients who underwent the thrombolysis treatment, there were 2 lethal cases. Conclusions: The patients that are in a critical state with prosthesis thrombosis (acute pulmonary edema, hypotension, heart insufficiency NYHA IV) should immediately receive EchoCG confirmation of the need of intravenous thrombolitic therapy. The thrombolysis efficacy in prosthesis thrombosis is high; the rate of embolic complications is low, which can be used as the first line treatment for all patients with prothesis thrombosis (in the absence of contraindications). In the case of partial response to the thrombolysis treatment, the patient can be operated on in good hemodynamic conditions and with low surgical risk

Original article title: "Comparison of therapeutic efficacy of topical corticosteroid and oral zinc sulfate-topical corticosteroid combination in the treatment of vitiligo patients: a clinical trial"

<p>Abstract</p> <p>Background</p> <p>Vitiligo is the most prevalent pigmentary disorder which occurs worldwide, with an incidence rate between 0.1-4 percent. It is anticipated that the discovery of biological pathways of vitiligo pathogenesis will provide novel therapeutic and prophylactic targets for future approaches to the treatment and prevention of vitiligo. The purposes of this study were evaluating the efficacy of supplemental zinc on the treatment of vitiligo.</p> <p>Methods</p> <p>This randomized clinical trial was conducted for a period of one year. Thirty five patients among 86 participants were eligible to entrance to the study. The patients in two equal randomized groups took topical corticosteroid and combination of oral zinc sulfate-topical corticosteroid.</p> <p>Results</p> <p>The mean of responses in the corticosteroid group and the zinc sulfate-corticosteroid combination group were 21.43% and 24.7%, respectively.</p> <p>Conclusion</p> <p>Although, the response to corticosteroid plus zinc sulfate was more than corticosteroid, there was no statistically significant difference between them. It appeared that more robust long-term randomized controlled trials on more patients, maybe with higher doses of zinc sulfate, are needed to fully establish the efficacy of oral zinc in management of vitiligo.</p> <p>Trial Registration</p> <p>chiCTRTRC10000930</p

Risks and pregnancy management in the patients with heart valves prostheses

Department of Cardiac Surgery, Republican Teaching Hospital, Chisinau, the Republic of MoldovaBackground: We have performed a systemic review of the literature to determine pooled estimates of maternal and fetal risks associated with 3 commonly used approaches: 1) the administration of oral anticoagulants throughout the pregnancy, 2) replacing oral anticoagulants with heparin in the first trimester of the pregnancy, and 3) the administration of heparin throughout the pregnancy. The prenatal care of women with artificial heart valves remains one of the most complex issues for cardiologists and obstetrician-gynecologists all over the world. Pregnancy and labor of women with artificial heart valves are usually associated with a high risk. During the pregnancy appears not only the risk of the cardiac pathology progression, but also of the manifestation of subclinical running hereditary thrombophilia and/ or antiphospholipid syndrome, in the above mentioned case the risk of thromboembolic episodes pathologies increases manifold. This overview presents the updated data on the ways of administration of anticoagulants that are most frequently used in the obstetric care. It outlines the principles of the rational anticoagulant therapy during the pregnancy and labor of women with artificial heart valves, as well as the laboratory monitoring of the performed treatment. The question of the management of pregnant women with mechanical valve prostheses is quite controversial and there is no universal consensus in this regard. Here there is an increased risk of complications for both mother and fetus: abortion and placental hemorrhage. Conclusions: Anticoagulation in pregnant women is individual. Therefore, the therapy strategy should be adequate to ensure a minimum level of anticoagulation and bleeding complications

TONAL AUDIOLOGICAL PERFORMANCE EVALUATION AFTER COCHLEAR IMPLANTATION IN CHILDREN WITH GJB2 GENE RELATED HEARING LOSS

Introduction: Audiological performance in cochlear implanted children may vary depending of the etiology of the deafness, one of which is GJB2 gene mutations. Aim: In this study we evaluated the auditory performance by pure tone audiogram testing after unilateral cochlear implantation for children with GJB2 related mutations and to compare the results with the ones from children that did not show any mutations in the GJB2 gene. Material and Methods: We have determined the auditory tonal thresholds in 28 patients and we calculated the average of these thresholds for the frequencies of 500, 1000, 2000 and 4000Hz. We have taken into consideration the first tonal thresholds that averaged at 35dB or better for the given frequencies. Results and Discussions: Comparison between the average tonal thresholds between the two groups show that even though children from the GJB2 mutation related deafness group need a slightly longer period of time to reach minimal conversational level thresholds, the dB value of these levels is lower than the ones in the second group. Conclusions: This can prove to be a useful tool for the clinician regarding cochlear implant counselling and for the patient in terms of better speech understanding skills and oral communication with parents and educational staff