Successful use of fondaparinux in a patient with heparin-induced thrombocytopenia while on extracorporeal membrane oxygenation after mitral valve redo surgery

In patients with respiratory failure and impairment of the left ventricle, arteriovenous extracorporeal membrane oxygenation (ECMO) offers further therapeutic options. Systemic anticoagulation is mandatory and heparin is routinely administrated. However, repeated exposure to heparin may cause heparin-induced thrombocytopenia (HIT) and carries a risk of thrombotic mortality and morbidity. We present a patient who developed HIT during ECMO support and was treated successfully and safely by fondaparinux. Fondaparinux can be used for thromboembolic treatment or prophylaxis in a patient with HIT

Artykuł oryginalnyRozwarstwienie aorty jako powikłanie operacji kardiochirurgicznych

Background: Aortic dissection is associated with high mortality. Despite its rarity, it is often fatal. Aim: We have retrospectively analysed acute aortic dissections occurring intraoperatively (IAAD). Methods: Patients’ preoperative risk factors, and operative and postoperative courses were analysed from the hospital records retrospectively. Results: From 1985 to 2009, we performed 29 683 cardiac operations. Ten patients (0.43‰) (mean age 66.5 ± 7 years) were diagnosed with IAAD. There were type 2 dissections in 9 and one patient had it extending beyond the arcus. Four patients were operated on for coronary artery disease, 2 for mitral and 2 for aortic valve diseases. Two patients had concomitant valvular or valvular and coronary procedures. IAAD was identified after decannulation in 5, after creating the holes for proximal anastomoses in 3 and after declamping the aorta in 2 patients. Preoperatively, 6 (60%) patients had hypertension and 4 had hypercholesterolaemia (40%). No other significant risk factors could be identified. Hypothermic circulatory arrest was used in 6 operations. The dissected segment was replaced with a graft in 9 patients whereas the remaining patient had concomitant arcus aorta replacement and elephant trunk procedure. Aortoplasty with Dacron patch was used in one patient. All patients required inotropic and 4 patients IABP support postoperatively. Three (30%) patients died. Conclusions: The IAAD may occur in any patient at any phase of cardiac surgery. The surgeon should always be aware of the possibility of this complication. It is much better to prevent the IAAD than to treat it. When detected, abrupt change of the operation plan and reparative measures for the dissection should be undertaken.Wstęp: Śródoperacyjne rozwarstwienie aorty jest powikłaniem występującym sporadycznie, ale wiąże się z wysoką śmiertelnością. Cel: Retrospektywna ocena częstości i okoliczności występowania śródoperacyjnego rozwarstwienia aorty oraz jego wpływu na rokowanie. Metody: Analizie poddano dokumentację medyczną chorych, u których wystąpiło to powikłanie. Wyniki: W latach 1985–2009 wykonano w ośrodku kardiochirurgicznym 29 683 operacje serca. Śródoperacyjne rozwarstwienie aorty wystąpiło u 10 (0,43‰) chorych (średni wiek 66,5 ± 7,2 roku), u 9 był to typ 2 rozwarstwienia, a u jednego chorego dyssekcja wykraczała poza łuk aorty. U 4 chorych wykonywano zabieg rewaskularyzacji wieńcowej, u 2 – zabieg dotyczący zastawki mitralnej, a u 2 – zastawki aortalnej. Dwóch chorych miało jednocześnie zabieg rewaskularyzacji i wymiany zastawki. Rozwarstwienie aorty zostało wykryte po usunięciu kaniuli z aorty u 5 chorych, po wytworzeniu ujść proksymalnych dla pomostów wieńcowych u 3 chorych, a po uwolnieniu zacisku z aorty u pozostałych 2 chorych. Z obciążeń przedoperacyjnych u 6 (60%) pacjentów stwierdzono nadciśnienie, a u 4 (40%) – hipercholesterolemię. Operacje z zastosowaniem hipotermii i zatrzymaniem krążenia wykonano u 6 chorych. Rozwarstwiony fragment aorty został zastąpiony przez przeszczep u 9 chorych, a jeden chory miał równocześnie wykonaną wymianę łuku aorty. Plastykę aorty z użyciem łaty dakronowej wykonano u jednego chorego. Wszyscy chorzy wymagali leków inotropowo dodatnich, a czterech – kontrapulsacji wewnątrzaortalnej. Trzech (30%) chorych zmarło. Wnioski: Do rozwarstwienia aorty może dojść na każdym etapie zabiegu kardiochirurgicznego. Szybkie rozpoznanie umożliwia skuteczne leczenie tego sporadycznie występującego (0,43‰) powikłania

Surgical treatment of peripheral vascular injuries after cardiac catherization Kardiyak kateterizasyon sonrasi gelişen periferik vasküler yaralanmalarda cerrahi tedavi

Objective: Diagnostic and therapeutic cardiac interventions have being performed in expanding numbers during last years. Forty-two cases with peripheral vascular injuries requiring surgical therapy after 64.911 cardiac interventions in our center between 1985 and 2002 were evaluated retrospectively. Methods: Thirty-three of vascular injuries (78.6%) occurred after angiography/catheterization, and the remaining vascular injuries (21.4%) occurred after angioplasty/stent procedures. There were 12 female (28.6%) and 30 male (71.4%). The mean age was 51.3±4.1 years. The localization of the arterial injuries were femoral region in 37 cases (88.1%) and brachial region in 5 cases (11.9%). The complications were recorded as arterial thrombosis in 19 cases, pseudoaneurysm in 14 cases, hematoma in 5 cases, arteriovenous fistula in 2 cases, deformed stent stuck in 2 cases. Arterial injuries were treated by performing embolectomy in 16 cases, embolectomy and saphenous patch plasty in 3 cases, resection of pseudoaneurysm and PTFE patch plasty in 1 case, draining of hematoma and primary repair in 5 cases, primary repair of femoral arteriovenous fistula in 2 cases and removal of the deformed stent from femoral artery in 2 cases. Results: The incidence of vascular complications was significantly higher in brachial interventions when compaired with femoral interventions (p<0.0001). The postoperative morbidity was found as 14.3% in our cases. Conclusion: The early diagnosis and treatment are very important in peripheral vascular complications after cardiac interventions; otherwise, delay can cause loss of related extremity