Atrial fibrillation after coronary artery bypass surgery: Possibilities of prevention

Atrial fibrillation occurs as a frequent complication after cardiac interventions. It can be found in 5% of all surgical patients, and it is far more common in cardiac (10% - 65% of patients) than in non-cardiac procedures. In a number of patients it remains asymptomatic, but may be accompanied by very severe symptoms of hypotension, heart failure, syncope, systemic or pulmonary embolism, perioperative myocardial infarction, cerebrovascular insult and increased operative mortality. Patients whose postoperative course is complicated by atrial fibrillation require longer hospitalization. Possible predisposing factors of this arrhythmia are numerous and are associated with surgery, extensive coronary heart disease and revascularization, and preoperative diseases. According to the recommendations of the European Society of Cardiology orally applied beta-blocker, amiodarone and sotalol can be used for prophylaxis of atrial fibrillation. Following the recommendations, treatment of postoperative atrial fibrillation should include beta-blockers, amiodarone, and in patients with heart failure and left ventricular dysfunction, digoxin. Due to the increased risk of stroke, an anticoagulant protection is necessary. Many studies have been conducted with results supporting the prophylactic use of amiodarone and beta-blockers, while the treatment with new agents such as magnesium, statins, omega-3 fatty acids and inhibitors of the renin-angiotensin-aldosterone system is still being investigated

Mitral valve endocarditis during brucellosis relapse

Introduction. Endocarditis is the most common cardiovascular manifestation of brucellosis with high mortality rate. Brucella is less accesable to antibiotic (but not for all) and relapse can occur after a various period of clinical latency. Case report. A 55-year-old farmer was diagnozed with acute systemic Brucella infection in May 2008 and treated with antibiotic therapy in regional hospital for two months and for three months after discharge. He began to feel myalgia, arthralgia, malaise, shortness of breath, abdominal pain, vomiting, diarrhoea and lost weight eight months after initial symptoms occured. Because symptoms progressed he was admitted to our hospital in February 2009. Based on a combination of epidemiological, clinical data (on admission he was catchetic, adynamic, dyspneic, hypotensive 80/50 mmHg, fever up to 39.50C), positive serological Wright test for brucellosis (1 : 5,120), and echocardiographic examination findings, the diagnosis of very severe relapse of brucellosis with mitral valve endocarditis, complicated with perforation of anterior mitral leaflet, severe mitral regurgitation and pulmonary hypertension was established. He was treated with a combined triple antibiotic therapy (vancomycin, ciprofloxacin and gentamicin, and swiched to regimen with doxycycline, gentamicin and imipenem, replacing gentamicin by rifampicin) for 4 weeks and for the next 2 weeks was receiving trimetoprime/sulfamethoxazole and rifampicin. The patients' condition was improved and he was operated. The diagnosis of infective endocarditis was confirmed intraoperatively. Mitral valve replacement was performed, and combined triple antibiotic treatment (amikacin + ciprofloxacin + cefazolin, for 2 weeks and cephazolin + doxycycline + rifampicin, for 2 weeks) was continued, following with two antibiotics (doxycycline + rifampicin) for 5 months. The patient completely recovered without any signs of infection 30 months postoperatively. Conclusion. A combined antibiotic therapy and surgery reduce complications and mortality associated with Brucella endocarditis and improve quality of patients' life

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

Surgical revascularisation of the heart in patients with chronic ischaemic cardiomyopathy and left ventricular ejection fraction of less than 30%

INTRODUCTION Patients suffering from chronic ischaemic cardiomyopathy and left ventricular ejection fraction (LVEF) lower than 30% represent a difficult and controversial population for surgical treatment. OBJECTIVE The aim of this study was to evaluate the effects of surgical treatment on the early and long-term outcome of these patients. METHOD The patient population comprised SO patients with LVEF< 30% (78% male, mean age: 583 years, range; 42-75 years) who underwent surgical myocardial revascuiarisation during the period 1995-2000. Patients with left ventricular aneurysms or mitral valve insufficiency were excluded from the study. The following echocardiography parameters were evaluated as possible prognostic indicators; LVEF, fraction of shortening (FS), left ventricular systolic and diastolic diameters (LVEDD, LVESD) and volumes (LVEDV, LVESV), as well as their indexed values (LVESVI). RESULTS Fifteen patients (30%) died during the follow-up, 2/50 intraoperatively (4%). The presence of diabetes mellitus, previous myocardial infarction, main left coronary artery disease, and three-vessel disease, correlated significantly with the surgical outcomes. The patient's age, family history, smoking habits, hypertension, hyperlipidaemia, history of stroke, peripheral vascular disease, and renal failure, did not correlate with the mortality rate. A comparison of preoperative echocardiography parameters between survivors and non-survivors revealed significantly divergent LVEF, LVEDD, LVESD, LVEDV, LVESV, and LVESVI values. Preoperative LVESVi offered the highest predictive value (R=0.595). CONCLUSION Diabetes mellitus, history of myocardial infarction, stenosis of the main branch, and three-vessel disease, significantly affected the peci opera five and long-term outcome of surgical revascuiarisation in patients with ischaemic cardiomyopathy and LVEF<30%. in survivors, LVEF, FS, and systolic and diastolic echocardiography parameters, as well as their indexed values, significantly improved after surgical revascuiarisation. LVESVI provided the highest predictive value for mortality

The degree of coronary atherosclerosis as a marker of insulin resistance in non-diabetics

Introduction. The metabolic syndrome and its influence on coronary artery disease development and progression remains in focus of international research debates, while insulin resistance, which represents its core, is the key component of hypertension, dyslipidaemias, glucose intolerance and obesity. Objective. The aim of this study was to establish relationship between basal glucose and insulin levels, insulin sensitivity and lipid panel and the degree of coronary atherosclerosis in nondiabetic patients. Methods. The coronary angiograms were evaluated for the presence of significant stenosis, insulin sensitivity was assessed using the intravenous glucose tolerance test with a minimal model according to Bergman, while baseline glucose (G0), insulin (I0) and lipid panel measurements (TC, HDL, LDL, TG) were taken after a 12-hour fasting. Results. The protocol encompassed 40 patients (19 men and 21 women) treated at the Institute for Cardiovascular Diseases of the Clinical Centre of Serbia, Belgrade. All were non-diabetics who were divided into 3 groups based on their angios: Group A (6 patients, 15%, with no significant stenosis), Group B (18 patients, 45%, with a single-vessel disease) and Group C (16 patients, 40%, with multi-vessel disease). Presence of lower insulin sensitivity, higher I0 and TC in the group of patients with a more severe degree of coronary atherosclerosis (insulin sensitivity: F=4.279, p=0.023, A vs. C p=0.012, B vs. C p=0.038; I0: F=3.461 p=0.042, A vs. B p=0.045, A vs. C p=0.013; TC: F=2.572, p=0.09), while no significant difference was found for G0, LDL, HDL and TG. Conclusion. Baseline insulinaemia, more precisely, fasting hyperinsulinaemia could be a good predictor of significant coronary atherosclerosis in non-diabetic patients, which enables a more elegant cardiometabolic risk assessment in the setting of everyday clinical practice