Our Experience in the Surgical Treatment of Chronic Constrictive Pericarditis

Introduction: We reviewed the cases of 21 consecutive patients who underwent surgery for chronic constrictive pericarditis between January 2004 and January 2016, to determine causes, surgical techniques, mortality and morbidity rates, and improvement of functional capacity. Patients and Methods: Eleven of our patients were men (52.3%) and ten were women (47.7%); their average age was 48.71±15.6 years. The pericarditis was tuberculous in 13 patients (61.9%), idiopathic in 4 patients (19%), rheumatic in two patients (9.5%), post surgical in one patient (4.75%) and neoplastic in one patient (4.75%).  Results: In all the cases, our approach was median sternotomy. All anterior pericardium was resected from left phrenic nerve to right phrenic nerve. No patient required cardiopulmonary bypass. We had no early postoperative mortality. In the 1st postoperative month, functional capacity improved dramatically: the number of patients in New York Heart Association functional class IV moved from 13 (preoperatively) to 4; in class III, from 7 to 3; in class II, from 1 to 6; and in class I, from 0 to 10.  Conclusions: We recommend the median sternotomy approach for chronic constrictive pericarditis. Tuberculosis still remains the main cause at our country. It can be treated with excellent results nowadays. Keywords: surgical treatment, chronic constrictive pericarditis DOI: 10.7176/JMPB/68-03 Publication date:September 30th 202

Idiopathic atrial flutter AFL in neonates (Case Report)

Atrial flutter AFL is a rare arrhythmia in the neonate and early infants. Here we report the case of a term female infant (A.K), with a birth weight of 3000 g, who was delivered by Cesarian section of a 26-year-old primiparous mother (I.K) in “Queen Geraldine” Maternity in Tirana. The APGAR scores were 9 and 10 at 1st and 5th minute, respectively. In prenatal history, no fetal arrhythmia was present. After waters breaks, a fetal arrhythmia was detected. Then the infant was delivered by an urgent C section. The infant was treated by medical treatment, which resulted unsuccessful. In the 16th day of life, the DC shock was applied and a sinus rhythm was detected immediately. Neonate: A.K Mother: I.K Keywords: infant, atrial flutter, antiarrhythmic, DC shock DOI: 10.7176/ALST/80-05 Publication date: July 30th 202

Patient with Wolff-Parkinson-White Syndrome undergoing Non-Cardiac Surgery. Perioperative Management

Background: Perioperative management of patients with preexcitation may become quite challenging, especially if there is no time for adequate preoperative investigation and clinical optimization, as in emergencies, or even worse, in undiagnosed cases. It is possible that the poorly controlled or unknown underlying electrophysiological abnormality will become unmasked during anesthesia and surgery, giving rise to potentially life-threatening arrhythmias. In the literature, pre-excitation syndromes have been mainly approached from the view of the disease (i.e., presentation, diagnosis, treatment), while anesthetic data are scarce. This case report aims to focus on the perioperative management of patients with WpW. Conclusion; Managing such cases provides an opportunity to revisit important considerations on Wolff-Parkinson-White syndrome avoiding neuromuscular blockers may make a difference in avoiding arrhythmias when laryngeal mask airway / general anesthesia is required in patients with Wolff-Parkinson-White syndrome. sympathetic stimulation should be avoided as it may shorten the refractory period of ap and alleviate life-threatening arrhythmias. Keywords: WpW, arrhythmias, bundle of Kent, anesthesia DOI: 10.7176/ALST/95-03 Publication date: November 30th 2022

Mitral Valve Replacement Surgery in Redo Patients with Mix Blood Cardioplegia (MBC) Protection

Aim of Study: Redo patient undergoing valve surgery are always a challenge for both cardiac surgeon and anesthesiologists. Mix blood cardioplegia has had a profound impact on cardiac surgery. but there have been few studies on its use in mitral valve replacement, especially in redo patient. The purpose of this study was to determine whether mix blood cardioplegia offers any advantages in redo patient undergoing mitral valve replacement.Patients and Methods:  20 patient, who have had a previous mitral valve surgery and were scheduled for mitral valve replacement with or without tricuspid repair, were randomized retrospectively to one of two groups of 10 with different technique of myocardial protection: group A (10 patients) had cold crystalloid cardioplegia, and group B(10 patients) had mix blood cardioplegia, a technique modified on our clinic condition (made by mixing  400-500ml oxygenated blood from oxygenator  and 10ml KCL 7.5%) . Systemic hypothermia was 28°C in Group A and between 32°C and 33°C in Group B. The results were primarily assessed on the basis of clinical outcome, such as hematocrit level intra and post CPB, maximum dose of inotropic support, spontaneous rhythm recovery after aortic cross clamping, length of intensive care unit stay and secondly on postoperative blood loss and blood requirements. Results: There were no preoperative or operative differences between the groups with regard to age, sex, diagnosis, rhythm, New York Heart Association functional class, left ventricular ejection fraction, estimated pulmonary artery systolic pressure, operation, or duration of the operation, CPB, or aortic cross clamping and the time when the patients underwent the first operation. There was one death in group A (10% mortality). The changes in hematocrit level differs significantly between the two groups on the post CPB period (p=0,02) There appeared to be a trend towards better spontaneous recovery of sinus rhythm after removal of the aortic cross clamp in group B compared with group A, the difference did reach statistical significance. (p=0.002). Patients on group A required more inotropic support than Group B (p=0.005). There were differences even on blood requirements postoperatively, more dominant these  requirement were in group A (p=0.02).Discussion: Mix Blood Cardioplegia had beneficial effects in clinical outcome in redo patients undergoing mitral valve replacement surgery. This may be due to its better preservation of high-energy phosphates and endogenous amino acids, less anerobic metabolic activity on reperfusion, reduced release of cardiac troponin T, and improved post-ischemic functional recovery. Keywords: Miocardial protection, cardiopulmonary bypass CPB, Mix Blood Cardioplegia (MBC) DOI: 10.7176/ALST/82-04 Publication date:October 31st 202

Perioperative Evaluation of Heart Echinococcus Cyst in a 14-Year-Old Child

BACKGROUND: Echinococcosis of the heart has a rate 0.02–2% of all hydatid diseases. Clinical presentation is depending of the location of hydatid cyst in the heart. Patients can be an asymptomatic case or lethal stroke, arrhythmias, valvular dysfunction, pulmonary edema, cardiac tamponade, cardiac failure, shock, and even death. CASE REPORT: We present a case report, a 14-year-old child with 2 weeks of sore throat, whooping cough, subfebrile condition, sweating, fatigue and physical weakness, nausea, abdominal pain, and decreased appetite. He came to emergency room with cardiogenic shock and pulmonary edema. He was diagnosed with intramyocardial hydatid cyst. CONCLUSION: Echinococcus cyst lesion in the LV in lateral wall, not communicating with the LV cavity, has been removed successfully with on-pump technique in a 14-year-oldchild. Median sternotomy was preferred and cardiopulmonary bypass has been considered the safest method. Supplemental medical therapy with albendazole is recommended to reduce the risk of recurrence

Retrograde autologous priming RAP reduces deep hemodilution during cardiopulmonary bypass CPB

Immediate hemodilution and rapid decrease in osmotic pressure at the time of CBP onset are associated with the aforementioned organic dysfunctions. Decreased osmotic pressure increases effective filtration pressure and microvascular filtration. Consequently, an increase in pulmonary interstitial fluid and myocardial edema is observed after discontinuation of CBP. Retrograde autologous priming (RAP) is a means to effectively and safely restrict the hemodilution caused by the direct homologous blood transfusion and reduce the blood transfusion requirements during cardiac surgery.   Materials and Methods The study included 40 patients scheduled to undergo coronary surgical revascularization, divided into two groups: the RAP group and the non-RAP group. The average age in both groups is 55 years (SD 5).   Conclusion A significant benefit was observed between the two groups in the study regarding the amount of transfused blood (1.55 -SD 0.88) / (2.15 -SD 0.81). This is a very important fact in favor of using the RAP technique, taking into account the reduction of the risk for complications carried by heterologous transfusion. Also, a significant reduction in the use of donated blood at a time when the problems of blood insufficiency in the collection centers are known, is equally important. The hospitalization (days of staying) in the ICU is also significantly lower in the RAP group (2.6 -SD 0.68) / (3.1-SD 0.64). This should be related to the faster activation of RAP in patients as a result of faster return to normal weight (with less fluid load), better ventilator function, and faster decline of cerebral edema. Keywords: Retrograde autologous priming (RAP), hemodilution, cardiopulmonary bypassCPB)   DOI: 10.7176/ALST/81-04 Publication date: August 31st 202

A Novel Endosurgical Prosthesis to Treat Thoracoabdominal Aortic Aneurysm in Complex Anatomy or Emergency Settings

BACKGROUND: Despite improvements in operative techniques, open thoracoabdominal aortic aneurysm (TAAA) repair is complex and characterized by high mortality and morbidity rate. Less invasive techniques have been developed since 2005 for the treatment of TAAA. Unfortunately, many of these devices require custom fabrication, resulting in delay of many weeks until treatment can be delivered but crucial in critical emergency cases. We present a novel hybrid endovascular and surgical prosthesis, which was tested on five pigs, with the aim of reducing the barrier issues of endovascular therapy in such particular cases.METHODS: The principal characteristic of the proposed hybrid endovascular prosthesis is to combine a proximal and distal stented zones and, in between, a classical surgical blood tied Dacron prosthesis. The device was tested in five pigs where feasibility of implantation and acute postoperative outcomes were evaluated, including bleeding, bowel ischemia, renal function, and peripheral blood perfusion.RESULTS: In all cases, following laparotomy, the endoprosthesis was successfully implanted under fluoroscopy and the surgical prosthesis zone could be easily detected by the radio-opaque markers. No major bleeding or cardiac events occurred throughout preparation and implantation. One hour after prosthesis implantation and surgical anastomoses of all vessels were completed, normal urine output was registered, and no acidosis was detected.CONCLUSIONS: This novel graft has shown ease of endoprosthesis and visceral vessels implantation without the need of thoracotomy or extracorporeal circulation and may be useful in an emergency setting or high risk and complex anatomy TAAA unsuitable for traditional endovascular aneurysm repair, or to avoid an excess waiting time for a "custom made" prosthesis. The great adaptability of this "hybrid" prosthesis in complex anatomy for the majority of TAAA could be important in high-risk patients and in some difficult situations, such as a high risk of imminent rupture

Re-Entry to the Mediastinum when the Ascending Aorta is Adherent to the Sternum: A Two Stage Sternotomy Approach

Re-entry to the mediastinum, when the ascending aorta aneurysm is adherent to the sternum is characterized by high risk of aneurysm rupture during sternum opening. In such cases, often cardiopulmonary bypass via peripheral vessels is institute and re-entry will be done in deep hypothermia and circulatory arrest. However, long CPB time and adhesion dissection when performed while the patient is heparinized, is demanding and notably time consuming. Also, post operative recovery might be complicated, including, prolonged intubation, kidney dysfunctionand numerous blood transfusions. In order to reduce both risks of aneurysm rupture during resternotomy and those related to prolonged CPB time, we present a surgical approach consisting of a two-stage sternotomy to avoid the risky zone, and extra-anatomic epiaortic vessels anastomoses. This technique presents several advantages: adhesion dissection and access to the heart before the heparin is administrated, simplifying surgical field preparation shorter CPB time, and circulatory arrest

Unconjugated Hyperbilirubinemia after Open Heart Surgery

The occurrence of hyperbilirubinaemia after heart surgery using cardiopulmonary bypass or post-operative heart failure is fairly common. Mechanism of hyperbilirubinemiais still not completely clarified, and there are so few specific therapies available for acute hepatobiliary injury. Post-operative mortality well correlates with increasing total bilirubin values, particularly for bilirubin-associate acute kidney tubular necrosis. The difficulty to reduce mortality is partially a consequence of not completely understood physiopathology. It is obvious that long-lasting CPB plays an important role, in association with hemodilution, hypotension, ischemia-reperfusion, and increasing hematic level of endogenous catecholamine with reduction of hepatic blood flow. Case report. A 68 years old man with severe mitral valve regurgitation and pulmonary hypertension and low EF 30%. Mitral valve replacement and tricuspid anuloplastic was performed. Due to low cardiac output syndrome severe hyperbilirubiemeia was seen (24 mg/dl. and unconjugated fraction 16mg/dl) days after. Phenobarbital (luminal) was started 15 mg/kg daily. Two days later the level decreased until 8 mg/dl with normalization of conjugation/unconjugation ratio.Postoperative hyperbilirubinemia is a multifactorial process caused by both impaired liver function of bilirubin transport. In case of elevated level of unconjugated fraction we suggest to use Luminal as alternative for decreasing unconjugated fraction

Surgical Treatment of Abdominal Aortic Aneurysms

ntroduction: Surgical treatment of abdominal aortic aneurysms poses a significant challenge in the field of vascular surgery, with numerous factors influencing operative technique and surgical outcome. Objective: This study aimed to assess the outcomes of open surgical treatment for patients with abdominal aortic aneurysms at the Vascular Surgery Service of Mother Teresa University Hospital Centre in Tirana, and provide recommendations for improving outcomes. Methods: A total of 206 patients who underwent transabdominal and retroperitoneal surgical access between January 2008 and December 2015 were included in the analysis