Paraoxonase 1 low activity and SYNTAX score may predict postoperative complications after coronary artery surgery

OBJECTIVE: Coronary artery bypass grafting (CABG) seems to present a powerful trigger of oxidative stress (OS) and acute inflammatory response. This study aimed to estimate the effects of off-pump coronary artery bypass (OPCAB) grafting on the OS that is commonly observed in patients undergoing operation under cardiopulmonary bypass (CPB). Additionally, we aimed to examine the relationship between and paraoxonase 1 (PON1) activity and the degree of stenosis, severity and complexity of the atherosclerotic lesions, estimated by SYNTAX score (SS). PATIENTS AND METHODS: Study group of 107 patients scheduled for CABG were divided into CPB and OPCAB group. Blood samples for OS markers measurement were collected at six-time intervals: before skin incision (t1), immediately after surgery (t2), 6h (t3), 24h (t4), 48h (t5) and 96h after cessation of the operation and surgical trauma (t6). SS was calculated. RESULTS: A significant decrease in lipid hydroperoxides (LOOH) and advanced oxidation protein products (AOPP) levels after both types of surgeries were observed, whereas PON1 reduction was observed higher in the CPB than in the OPCAB group. A significant inverse correlation between SS values and PON1 activity, preoperatively and during the early postoperative hours after surgery [in t2, t3 time intervals (p<0.05 for all)] was found. ROC analysis showed that for CPB patients, Model with all OS parameters showed excellent accuracy (AUC=0.957, p<0.001) for prediction postoperative complications. CONCLUSIONS: Decrease in PON1 activity during the early post-operative phases was related to higher SS. This relationship was more convincing in CPB, compared with OPCAB patients. Moreover, integrated models of OS status parameters have the capability to predict the development of postoperative complications

Minithoracotomy as the primary alternative for left ventricular lead implantation during cardiac resynchronization therapy: Can the cardiac surgeon reduce the number of nonresponders

Introduction/Objective. Numerous anomalies of the cardiac venous system prevent the optimal endovascular implantation of the left ventricular (LV) lead in more than 15% of patients with indication for cardiac resynchronization therapy (CRT). The endovenous approach in these patients can be one of the potential reasons for the large number of nonresponders reported in the literature. The purpose of this study was to analyze the results of an alternative myoepicardial approach to the stimulation of the left ventricle in CRT. Methods. From June 2014 to December 2015 at the Department of Cardiac Surgery of the Clinical Centre of Serbia, 15 myoepicardial LV leads for CRT were implanted. Coronary sinus venography revealed thrombosis of the coronary sinus in nine patients, and unfavorable anatomy of the coronary venous system in six patients. In all patients, limited left thoracotomy was used as an approach to the lateral wall of the heart. Results. There were no major surgical complications and no lethal hospital outcomes. In a six-month follow-up period we registered a significant increase in the length of the six-minute walk test (for an average of 57.9 m), reduction of the QRS complex width (to 26.25 ms), increase in left ventricular ejection fraction (12.2%), and reduction of mitral regurgitation for 1+. Based on all the parameters, it was concluded that all patients responded favorably to the applied CRT. Conclusion. Closer cooperation between cardiologists and cardiac surgeons in identifying patients who would benefit the most from a myoepicardial approach for LV stimulation is necessary in order to attempt to reduce the nonresponder rate

Successful surgical treatment of terminal heart failure in an adolescent - left ventricular assist device implantation and subsequent heart transplantation

Introduction. Implantation of the new-generation left ventricular assist device (LVAD) is an efficient therapeutic option as a bridge to transplantation in adults, as well as in children and adolescents with small body surface. The aim of this work was to present a case of a successful surgical treatment of terminal heart failure in a male adolescent who had an LVAD implanted as a bridge to heart transplantation. Case outline. The patient, a 17-year-old male, was admitted with the end-stage heart failure due to the dilated cardiomyopathy and implanted LVAD. Fourteen months after LVAD implantation, a successful “second stage” surgical procedure was performed – orthotopic heart transplantation preceded by the LVAD explantation. Conclusion. Long-term mechanical circulatory support is an effective and safe method in treatment of the end-stage heart failure as a bridge to transplantation in the adolescent period

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

Correlation between atherosclerosis and periodontal putative pathogenic bacterial infections in coronary and internal mammary arteries

Chronic infections, such as periodontitis, have been associated with an increase for atherosclerosis and coronary artery disease. The aim of this study was to investigate biopsy samples of coronary and internal mammary arteries for the presence of putative pathogenic bacteria (Porphyromanas gingivalis, Actinobacillus actinomycetemcomitans, Prevotella intermedia, and Tannerella forsythensis), Chlamydia pneumoniae, and human cytomegalovirus (CMV). Methods: Patients with a diagnosis of coronary artery disease were included in the study. fifteen coronary arteries with atherosclerosis and 15 internal mammary arteries without clinically assessable atherosclerotic degeneration were investigated. Both groups of specimens were obtained during coronary artery bypass grafting surgery. In all cases, the coronary and mammary artery specimens were taken from the same patient. The detection of periodontal pathogens, C. pneumoniae, and CMV was done by polymerase chain reaction analysis. Results: Bacterial DNA was found in nine of 15 (60%) coronary artery biopsy samples: P. gingivalis in eight (53.33%), A. actinomycetemcomitans in four (26.67%), P. intermedia in five (33.33%), and T. forsythensis in two (13.33%) samples; CMV was detected in 10 (66.67%) samples, and c. pneumoniae was detected in five (33.33%) samples. Some of the samples contained more than one type of bacteria. Periodontal pathogens were not detected in internal mammary artery biopsies, whereas CMV was present in seven (46.67%) samples and C. pneumoniae was present in six (40%) samples. Conclusion: The absence of putative pathogenic bacteria in internal mammary arteries, which are known to be affected rarely by atherosclerotic changes, and their presence in a high percentage of atherosclerotic coronary arteries support the concept that periodontal organisms are associated with the development and progression of atherosclerosis