Successful Treatment of Acute Aortic Dissection uccessful Treatment of Acute Aortic Dissection Type Stanford A Presenting as Limb Ischemia, ype Stanford A Presenting as Limb Ischemia, Successfully Treated with Operative and uccessfully Treated with Operat

We report a successful treatment of unusual case of a 48 year old male patient with acute aortic dissection type Stanford A that expanded into left common and external iliac artery diagnosed by MSCT angiography, presenting as a single leg paresis, without symptoms of a chest or back pain. Patient was operated with conventional ascending aortic replacement. Patient had no known prior medical condition. He has been treated for acute thrombosis of the left popliteal artery developing one day after ascending aortic replacement surgery, embolectomy was performed. Critical limb ischemia developed due to preocclusive stenosis of the left common and left external iliac artery and was treated by endovascular procedure of iliac artery stenting performed on the fifth postoperative day. After 17 days patient was discharged form hospital, showing no neurological or vascular deficit. For successful treatment of acute aortic dissection type Stanford A complicated with limb ischemia, rapidandaccuratediagnosis is essential, together with close cooperation of cardio surgeons, vascularsurgeonsandinvasiveradiologists and individual approach to these demanding patients

Noninvasive technique of preventing thrombin escape into the systemic circulation during ultrasound-guided thrombin injection (UGTI) of the postcatheterization pseudoaneurysms

Introduction Iatrogenic, postcatheterization pseudoaneurysms (PSA) of the femoral artery are a common complication after diagnostic and interventional procedures, with up to 7.7% incidence. Treatment includes surgical repair, ultrasound-guided compression (USGC) repair of the tract of the PSA, or recently ultrasound-guided thrombin injection (UGTI). Large ([1.8 cm) PSA sac with short (\3 mm) and/or wide ([3 mm) tract has higher complication ratio such as thromboembolic events after UGTI. Those cases are considered for protective balloon inflation during thrombin injection. The aim of our study was to evaluate the success rate of preventing escape of the thrombin during UGTI with simultaneous manual compression on ipsilateral iliac artery. Methods and results We reported 46 patients, 17 males and 29 females, aged 53–74 years, with iatrogenic, postcatheterization femoral artery PSA. Out of 46 patients, 7 were successfully treated with USGC. The rest of the patients were treated with UGTI with simultaneous manual compression on ipsilateral iliac artery to stop the flow in PSA, and to avoid thrombin escape into the native circulation. Success rate of UGTI with manual compression of ipsilateral iliac artery was 97% with the complication rate of 2.6%. Conclusion Our study confirms that UGTI treatment of the PSA of the femoral artery combined with compression of the ipsilateral iliac artery could be a safe and reliable method of the thrombin escape prevention into the systemic circulation, as good as more invasive and demanding methods

Total Knee Replacement Surgery is Followed by Transitory Endothelial Dysfunction

Acute coronary syndrome (ACS) presents today the leading group of post-operative cardiovascular complications, while endothelial dysfunction (ED) is one of the key elements in its development. The chronic ED represents thus the basis for the gradual development of atherosclerotic changes, while its sudden aggravation leads to ACS. The persistent ED occurs due to the effects of chronic cardiovascular risk factors, while according to the available studies it can also develop or aggravate under the impact of different acute events. We have directed this study to the investigation of the dynamic of endothelial function before and after a major orthopaedic surgical intervention. This randomised prospective study included 19 patients that underwent the intervention of total knee replacement and 20 healthy examinees of the adequate age and gender. High-resolution ultrasound test based on the flow mediated dilatation of the brachial artery is what at we carried out at the beginning of the research, respectively 12, 24 48 and 72 hours, as well as 7 days after the surgical intervention. The starting values of the FMD test were within the normal range in both groups, although the ability of dilatation upon stimulus was significantly lower in the investigated group. The FMD percentage change in the total sample was negatively connected with the body weight, not having shown additional connections with other cardiovascular risk factors. During the early post-operative period, a significant transitory lowering of the FMD percentage change was recorded, having reached the lowest value 24 hours after the surgery. During the seven-day prospective surveillance, no significant cardiovascular complications were recorded. Further research is necessary in order to confirm these results as well as the testing of the possible connection of the described post-operative transitory endothelial dysfunction with the development of cardiovascular complications and the adverse event

INFLUENCE OF PREOPERATIVE PERORAL NUTRITION ON EARLY IMMUNE RESPONSE ON PATIENTS WITH CORONARY ARTERY DISEASE WHO UNDERWENT ON SURGICAL CORONARY REVASCULARIZATION

Cilj istraživanja Kirurška revaskularizacija miokarda značajno utječe na promjenu imunoloških parametara, osobito stanične imunosti, što može dovesti do slabljenja funkcije imunološkog sustava u cijelosti. Nepoznati su mehanizmi koji dovode do neravnoteže i slabljenja imunološkog sustava te utječe li i na koji način prijeoperacijsko hranjenje na imunološka zbivanja u bolesnika s koronarnom bolešću srca liječenih kirurškom revaskularizacijom miokarda. Cilj ovog rada bio je istražiti promjene udjela leukocitnih subpopulacija, izražaj citotoksične molekule perforina u pojedinim limfocitnim subpopulacijama, stupanj citotoksične aktivnosti stanica NK i izražavanje pojedinih citokina (interferona-gama: IFN, interleukin (IL)-15, IL-18) u krvi bolesnika s koronarnom bolešću srca liječenih kirurškom revaskularizacijom miokarda te istražiti kako prijeoperacijska peroralna prehrana utječe na navedene imunološke parametre. Ispitanici, materijal i metode Ovo prospektivno istraživanje je obuhvatilo bolesnike s koronarnom bolešću srca, koji su liječeni kirurškom revaskularizacijom miokarda. U studiji je ukupno sudjelovalo 80 bolesnika, podijeljenih u četiri grupe. Bolesnici iz Grupe 1 liječeni su kirurškom revaskularizacijom miokarda (CABG od eng. Coronary Artery Bypass Grafting) uz upotrebu stroja za vantjelesni krvotok (tzv."on-pump" CABG), a nisu bili hranjeni prijeoperacijski. U Grupi 2 bili su bolesnici liječeni s on-pump CABG koji su bili hranjeni prijeoperacijski. U Grupi 3 bili su bolesnici s CABG bez stroja za vantjelesni krvotok (off-pump CABG, OPCABG) a koji nisu bili hranjeni, dok su u Grupi 4 bili OPCABG bolesnici koji su uzimali hranu prijeoperacijski. Svakom bolesniku uključenom u studiju uzeto je 20 ml heparinizirane periferne venske krvi neposredno prije kirurškog zahvata (T1) te nakon 24 (T2) i 72 (T3) sata po završetku operacije. Uzorci su centrifugirani na gradijentu gustoće i iz njih su izolirane mononuklearne stanice kojima su istodobno označeni antigeni korištenjem florokromnih konjugiranih monoklonalnih antitijela. Tim postupkom detektirane su leukocitne populacije (limfocite T, stanice NK, stanice NKT) i njihove subpopulacije. Izdvojenim, označenim stanicama metodom direktne imunofluorescencije unutar stanice obilježavan je perforin i analiziran protočnom citometrijom. Za određivanje koncentracije IFNγ, IL-15 i IL-18 u plazmi bolesnika korišten je ELISA test (eng. enzyme linked immunosobrent assay). Pomoću pozitivne magnetske separacije izdvojene su iz periferne krvi stanice NK i potom je dvosatnim testom citotoksičnosti i protočnom citometrijom određivana njihova citotoksična aktivnost. Rezultati Dvadeset i četiri sata nakon kirurškog zahvatauočen je statistički značajnosmanjenje učestalosti CD3+ i CD3+CD4+ stanica te udjela perforin pozitivnih i perforin+CD3+CD8+ stanica u bolesnika liječenih s on-pump CABG operacijom u usporedbi s bolesnicima liječenih off-pump CABG operacijom. Udio T regulacijskih stanica je statistički značajno porastao u bolesnika liječenih on-pump CABG operacijom u usporedbi s bolesnicima liječenih off-pump CABG operacijom 24 sata nakon operacije. Udio IL-15+CD3+, IL-15+CD56+ te IL-15+CD3+CD56+ stanica bio je statistički značajno niži u bolesnika liječenih off-pump CABG operacijom u usporedbi s bolesnicima liječenih on-pump CABG operacijom 24 sata nakon oepracije. Istovremeno, nisu zabilježene značajne razlike u u udjelu IFNγ+ stanica unutar i između istraživanih grupa u svim istraživanim razdobljima. Nije uočena statistička značajnost u citotoksičnoj aktivnosti stanica NK između grupa u istraživanim vremenskim točkama. Koncentracije IL-15, IL-18 i IFN su bile statistički značajno više u bolesnika lječenih on-pump CABG operacijom u usporedbi s bolesnicima liječenih off-pump CABG operacijom 24 i 72 sata nakon operacije u odnosu na prijeoperacijske vrijednosti. Zaključak U bolesnika liječenih on-pump CABG operacijom značajno je smanjenudio CD3+ i CD3+CD4+ stanica, izražaj perforina u limfocitima periferne krvi te povećala koncentraciju pro-uplanih citokina (IL-15, IL-18 i IFN u odnosu na bolesnike liječene off-pump CABG operacijom. Ugljikohidratna prijeoperacijska prehrana nije imala statistički značajnog utjecajana promjeneudjela subpopulacijama limfocita i izražaja perforina u istraživanim skupinama bolesnika i istraživanim vremenskim točkama.Surgical myocardial revascularization significantly effects changes of immune parameters, especially cell immunity, leading to down-regulation of immune system. Mechanisms of regulation of and down-regulation the immune response and the effect of perioperative feeding on these changes in patients during and early after surgical revascularisation are still not fully understood. The aim of this study was analyse and compare the influence of peroral feeding on frequency different leukocyte subpopulation, their perforin expression and cytotoxic activity of NK cells as well as cytokine expression (interferon gamma; IFN, interleukin (IL)-15, IL-18) in the blood of patients underwent surgical myocardial revascularisation. Patients andMethods In this prospective clinical study 80 patients scheduled for CABG surgery was included in the study. The patients were randomly allocated into four groups (40 in each group): Group 1 underwent on-pump CABG and did not received perioperative nutrition support, patients in Group 2 underwent on-pump CABG and were preoperatively fed, patients in Group 3 underwent off-pump CABG and did not received perioperative nutrition support, while patients in Group 4 underwent off-pump CABG and received preoperative nutrition support. Blood samples (20 ml) were collected immediately before (T1), 24 (T2) and 72 (T3) hours after surgery. Peripheral blood mononuclear cells were isolated by gradient centrifugation and simultaneous labelled by antigens using fluorochrome conjugated monoclonal antibodies. Frequency of T lymphocytes, NK and NKT cells, their subsets as well as their perforin expression was detected and analysed by flow cytometry. Plama concentrationsofIL-4 and interferon gama (IFNγ) weredetected by ELISA (enzyme linked immunosobrent assay) according to the manufacturer instructions. For NK cells isolation from peripheral blood positive magnetic cell separation method was applied. The cytotoxic activity of NK cells was analysed by flow cytometry. Results The frequency of CD3+ and CD3+CD4+,allperforin+ and perforin+CD3+CD8+ cellssignificantly decreased in patients who underwent on-pump CABG when compared to patients who underwent off-pump CABG 24 h after surgery. Frequency of T regulatory cells significantly increased in patients who underwent on-pump CABG when compared to patients who underwent off-pump CABG 24 h after surgery. The frequency of IL-15+CD3+, IL-15+CD56+ and IL-15+CD3+CD56+ cells significantly increased in patients who underwent off-pump CABG when compared to patients who underwent on-pump CABG 24 h after surgery. The frequency of IFNγ+ cells and cytotoxic activity of NK cells did not differ significantly amnog groups at any time point. Concentrations of IL-15, IL-18 i IFN significanlty increaed in patients who underwent on-pump CABG surgery when compared to patients who underwent off-pump CABG surgery 24 and 72 h after surgery. Conclusion Significntly decreased frequency of CD3+ and CD3+CD4+ cells, perforin expression and increased concentration of proinflammatory cytokines (IL-15, IL-18 i IFNwas found in patients who underwent on-pump CABG surgery when compared to patients who underwent off-pump CABG surgery. Charbohydrate rich perioperative feeding did not significantly effect changes of frequency in different lymphocyte subpopulation and perforin expression among grups at different time points

INFLUENCE OF PREOPERATIVE PERORAL NUTRITION ON EARLY IMMUNE RESPONSE ON PATIENTS WITH CORONARY ARTERY DISEASE WHO UNDERWENT ON SURGICAL CORONARY REVASCULARIZATION

Cilj istraživanja Kirurška revaskularizacija miokarda značajno utječe na promjenu imunoloških parametara, osobito stanične imunosti, što može dovesti do slabljenja funkcije imunološkog sustava u cijelosti. Nepoznati su mehanizmi koji dovode do neravnoteže i slabljenja imunološkog sustava te utječe li i na koji način prijeoperacijsko hranjenje na imunološka zbivanja u bolesnika s koronarnom bolešću srca liječenih kirurškom revaskularizacijom miokarda. Cilj ovog rada bio je istražiti promjene udjela leukocitnih subpopulacija, izražaj citotoksične molekule perforina u pojedinim limfocitnim subpopulacijama, stupanj citotoksične aktivnosti stanica NK i izražavanje pojedinih citokina (interferona-gama: IFN, interleukin (IL)-15, IL-18) u krvi bolesnika s koronarnom bolešću srca liječenih kirurškom revaskularizacijom miokarda te istražiti kako prijeoperacijska peroralna prehrana utječe na navedene imunološke parametre. Ispitanici, materijal i metode Ovo prospektivno istraživanje je obuhvatilo bolesnike s koronarnom bolešću srca, koji su liječeni kirurškom revaskularizacijom miokarda. U studiji je ukupno sudjelovalo 80 bolesnika, podijeljenih u četiri grupe. Bolesnici iz Grupe 1 liječeni su kirurškom revaskularizacijom miokarda (CABG od eng. Coronary Artery Bypass Grafting) uz upotrebu stroja za vantjelesni krvotok (tzv."on-pump" CABG), a nisu bili hranjeni prijeoperacijski. U Grupi 2 bili su bolesnici liječeni s on-pump CABG koji su bili hranjeni prijeoperacijski. U Grupi 3 bili su bolesnici s CABG bez stroja za vantjelesni krvotok (off-pump CABG, OPCABG) a koji nisu bili hranjeni, dok su u Grupi 4 bili OPCABG bolesnici koji su uzimali hranu prijeoperacijski. Svakom bolesniku uključenom u studiju uzeto je 20 ml heparinizirane periferne venske krvi neposredno prije kirurškog zahvata (T1) te nakon 24 (T2) i 72 (T3) sata po završetku operacije. Uzorci su centrifugirani na gradijentu gustoće i iz njih su izolirane mononuklearne stanice kojima su istodobno označeni antigeni korištenjem florokromnih konjugiranih monoklonalnih antitijela. Tim postupkom detektirane su leukocitne populacije (limfocite T, stanice NK, stanice NKT) i njihove subpopulacije. Izdvojenim, označenim stanicama metodom direktne imunofluorescencije unutar stanice obilježavan je perforin i analiziran protočnom citometrijom. Za određivanje koncentracije IFNγ, IL-15 i IL-18 u plazmi bolesnika korišten je ELISA test (eng. enzyme linked immunosobrent assay). Pomoću pozitivne magnetske separacije izdvojene su iz periferne krvi stanice NK i potom je dvosatnim testom citotoksičnosti i protočnom citometrijom određivana njihova citotoksična aktivnost. Rezultati Dvadeset i četiri sata nakon kirurškog zahvatauočen je statistički značajnosmanjenje učestalosti CD3+ i CD3+CD4+ stanica te udjela perforin pozitivnih i perforin+CD3+CD8+ stanica u bolesnika liječenih s on-pump CABG operacijom u usporedbi s bolesnicima liječenih off-pump CABG operacijom. Udio T regulacijskih stanica je statistički značajno porastao u bolesnika liječenih on-pump CABG operacijom u usporedbi s bolesnicima liječenih off-pump CABG operacijom 24 sata nakon operacije. Udio IL-15+CD3+, IL-15+CD56+ te IL-15+CD3+CD56+ stanica bio je statistički značajno niži u bolesnika liječenih off-pump CABG operacijom u usporedbi s bolesnicima liječenih on-pump CABG operacijom 24 sata nakon oepracije. Istovremeno, nisu zabilježene značajne razlike u u udjelu IFNγ+ stanica unutar i između istraživanih grupa u svim istraživanim razdobljima. Nije uočena statistička značajnost u citotoksičnoj aktivnosti stanica NK između grupa u istraživanim vremenskim točkama. Koncentracije IL-15, IL-18 i IFN su bile statistički značajno više u bolesnika lječenih on-pump CABG operacijom u usporedbi s bolesnicima liječenih off-pump CABG operacijom 24 i 72 sata nakon operacije u odnosu na prijeoperacijske vrijednosti. Zaključak U bolesnika liječenih on-pump CABG operacijom značajno je smanjenudio CD3+ i CD3+CD4+ stanica, izražaj perforina u limfocitima periferne krvi te povećala koncentraciju pro-uplanih citokina (IL-15, IL-18 i IFN u odnosu na bolesnike liječene off-pump CABG operacijom. Ugljikohidratna prijeoperacijska prehrana nije imala statistički značajnog utjecajana promjeneudjela subpopulacijama limfocita i izražaja perforina u istraživanim skupinama bolesnika i istraživanim vremenskim točkama.Surgical myocardial revascularization significantly effects changes of immune parameters, especially cell immunity, leading to down-regulation of immune system. Mechanisms of regulation of and down-regulation the immune response and the effect of perioperative feeding on these changes in patients during and early after surgical revascularisation are still not fully understood. The aim of this study was analyse and compare the influence of peroral feeding on frequency different leukocyte subpopulation, their perforin expression and cytotoxic activity of NK cells as well as cytokine expression (interferon gamma; IFN, interleukin (IL)-15, IL-18) in the blood of patients underwent surgical myocardial revascularisation. Patients andMethods In this prospective clinical study 80 patients scheduled for CABG surgery was included in the study. The patients were randomly allocated into four groups (40 in each group): Group 1 underwent on-pump CABG and did not received perioperative nutrition support, patients in Group 2 underwent on-pump CABG and were preoperatively fed, patients in Group 3 underwent off-pump CABG and did not received perioperative nutrition support, while patients in Group 4 underwent off-pump CABG and received preoperative nutrition support. Blood samples (20 ml) were collected immediately before (T1), 24 (T2) and 72 (T3) hours after surgery. Peripheral blood mononuclear cells were isolated by gradient centrifugation and simultaneous labelled by antigens using fluorochrome conjugated monoclonal antibodies. Frequency of T lymphocytes, NK and NKT cells, their subsets as well as their perforin expression was detected and analysed by flow cytometry. Plama concentrationsofIL-4 and interferon gama (IFNγ) weredetected by ELISA (enzyme linked immunosobrent assay) according to the manufacturer instructions. For NK cells isolation from peripheral blood positive magnetic cell separation method was applied. The cytotoxic activity of NK cells was analysed by flow cytometry. Results The frequency of CD3+ and CD3+CD4+,allperforin+ and perforin+CD3+CD8+ cellssignificantly decreased in patients who underwent on-pump CABG when compared to patients who underwent off-pump CABG 24 h after surgery. Frequency of T regulatory cells significantly increased in patients who underwent on-pump CABG when compared to patients who underwent off-pump CABG 24 h after surgery. The frequency of IL-15+CD3+, IL-15+CD56+ and IL-15+CD3+CD56+ cells significantly increased in patients who underwent off-pump CABG when compared to patients who underwent on-pump CABG 24 h after surgery. The frequency of IFNγ+ cells and cytotoxic activity of NK cells did not differ significantly amnog groups at any time point. Concentrations of IL-15, IL-18 i IFN significanlty increaed in patients who underwent on-pump CABG surgery when compared to patients who underwent off-pump CABG surgery 24 and 72 h after surgery. Conclusion Significntly decreased frequency of CD3+ and CD3+CD4+ cells, perforin expression and increased concentration of proinflammatory cytokines (IL-15, IL-18 i IFNwas found in patients who underwent on-pump CABG surgery when compared to patients who underwent off-pump CABG surgery. Charbohydrate rich perioperative feeding did not significantly effect changes of frequency in different lymphocyte subpopulation and perforin expression among grups at different time points

INFLUENCE OF PREOPERATIVE PERORAL NUTRITION ON EARLY IMMUNE RESPONSE ON PATIENTS WITH CORONARY ARTERY DISEASE WHO UNDERWENT ON SURGICAL CORONARY REVASCULARIZATION

Cilj istraživanja Kirurška revaskularizacija miokarda značajno utječe na promjenu imunoloških parametara, osobito stanične imunosti, što može dovesti do slabljenja funkcije imunološkog sustava u cijelosti. Nepoznati su mehanizmi koji dovode do neravnoteže i slabljenja imunološkog sustava te utječe li i na koji način prijeoperacijsko hranjenje na imunološka zbivanja u bolesnika s koronarnom bolešću srca liječenih kirurškom revaskularizacijom miokarda. Cilj ovog rada bio je istražiti promjene udjela leukocitnih subpopulacija, izražaj citotoksične molekule perforina u pojedinim limfocitnim subpopulacijama, stupanj citotoksične aktivnosti stanica NK i izražavanje pojedinih citokina (interferona-gama: IFN, interleukin (IL)-15, IL-18) u krvi bolesnika s koronarnom bolešću srca liječenih kirurškom revaskularizacijom miokarda te istražiti kako prijeoperacijska peroralna prehrana utječe na navedene imunološke parametre. Ispitanici, materijal i metode Ovo prospektivno istraživanje je obuhvatilo bolesnike s koronarnom bolešću srca, koji su liječeni kirurškom revaskularizacijom miokarda. U studiji je ukupno sudjelovalo 80 bolesnika, podijeljenih u četiri grupe. Bolesnici iz Grupe 1 liječeni su kirurškom revaskularizacijom miokarda (CABG od eng. Coronary Artery Bypass Grafting) uz upotrebu stroja za vantjelesni krvotok (tzv."on-pump" CABG), a nisu bili hranjeni prijeoperacijski. U Grupi 2 bili su bolesnici liječeni s on-pump CABG koji su bili hranjeni prijeoperacijski. U Grupi 3 bili su bolesnici s CABG bez stroja za vantjelesni krvotok (off-pump CABG, OPCABG) a koji nisu bili hranjeni, dok su u Grupi 4 bili OPCABG bolesnici koji su uzimali hranu prijeoperacijski. Svakom bolesniku uključenom u studiju uzeto je 20 ml heparinizirane periferne venske krvi neposredno prije kirurškog zahvata (T1) te nakon 24 (T2) i 72 (T3) sata po završetku operacije. Uzorci su centrifugirani na gradijentu gustoće i iz njih su izolirane mononuklearne stanice kojima su istodobno označeni antigeni korištenjem florokromnih konjugiranih monoklonalnih antitijela. Tim postupkom detektirane su leukocitne populacije (limfocite T, stanice NK, stanice NKT) i njihove subpopulacije. Izdvojenim, označenim stanicama metodom direktne imunofluorescencije unutar stanice obilježavan je perforin i analiziran protočnom citometrijom. Za određivanje koncentracije IFNγ, IL-15 i IL-18 u plazmi bolesnika korišten je ELISA test (eng. enzyme linked immunosobrent assay). Pomoću pozitivne magnetske separacije izdvojene su iz periferne krvi stanice NK i potom je dvosatnim testom citotoksičnosti i protočnom citometrijom određivana njihova citotoksična aktivnost. Rezultati Dvadeset i četiri sata nakon kirurškog zahvatauočen je statistički značajnosmanjenje učestalosti CD3+ i CD3+CD4+ stanica te udjela perforin pozitivnih i perforin+CD3+CD8+ stanica u bolesnika liječenih s on-pump CABG operacijom u usporedbi s bolesnicima liječenih off-pump CABG operacijom. Udio T regulacijskih stanica je statistički značajno porastao u bolesnika liječenih on-pump CABG operacijom u usporedbi s bolesnicima liječenih off-pump CABG operacijom 24 sata nakon operacije. Udio IL-15+CD3+, IL-15+CD56+ te IL-15+CD3+CD56+ stanica bio je statistički značajno niži u bolesnika liječenih off-pump CABG operacijom u usporedbi s bolesnicima liječenih on-pump CABG operacijom 24 sata nakon oepracije. Istovremeno, nisu zabilježene značajne razlike u u udjelu IFNγ+ stanica unutar i između istraživanih grupa u svim istraživanim razdobljima. Nije uočena statistička značajnost u citotoksičnoj aktivnosti stanica NK između grupa u istraživanim vremenskim točkama. Koncentracije IL-15, IL-18 i IFN su bile statistički značajno više u bolesnika lječenih on-pump CABG operacijom u usporedbi s bolesnicima liječenih off-pump CABG operacijom 24 i 72 sata nakon operacije u odnosu na prijeoperacijske vrijednosti. Zaključak U bolesnika liječenih on-pump CABG operacijom značajno je smanjenudio CD3+ i CD3+CD4+ stanica, izražaj perforina u limfocitima periferne krvi te povećala koncentraciju pro-uplanih citokina (IL-15, IL-18 i IFN u odnosu na bolesnike liječene off-pump CABG operacijom. Ugljikohidratna prijeoperacijska prehrana nije imala statistički značajnog utjecajana promjeneudjela subpopulacijama limfocita i izražaja perforina u istraživanim skupinama bolesnika i istraživanim vremenskim točkama.Surgical myocardial revascularization significantly effects changes of immune parameters, especially cell immunity, leading to down-regulation of immune system. Mechanisms of regulation of and down-regulation the immune response and the effect of perioperative feeding on these changes in patients during and early after surgical revascularisation are still not fully understood. The aim of this study was analyse and compare the influence of peroral feeding on frequency different leukocyte subpopulation, their perforin expression and cytotoxic activity of NK cells as well as cytokine expression (interferon gamma; IFN, interleukin (IL)-15, IL-18) in the blood of patients underwent surgical myocardial revascularisation. Patients andMethods In this prospective clinical study 80 patients scheduled for CABG surgery was included in the study. The patients were randomly allocated into four groups (40 in each group): Group 1 underwent on-pump CABG and did not received perioperative nutrition support, patients in Group 2 underwent on-pump CABG and were preoperatively fed, patients in Group 3 underwent off-pump CABG and did not received perioperative nutrition support, while patients in Group 4 underwent off-pump CABG and received preoperative nutrition support. Blood samples (20 ml) were collected immediately before (T1), 24 (T2) and 72 (T3) hours after surgery. Peripheral blood mononuclear cells were isolated by gradient centrifugation and simultaneous labelled by antigens using fluorochrome conjugated monoclonal antibodies. Frequency of T lymphocytes, NK and NKT cells, their subsets as well as their perforin expression was detected and analysed by flow cytometry. Plama concentrationsofIL-4 and interferon gama (IFNγ) weredetected by ELISA (enzyme linked immunosobrent assay) according to the manufacturer instructions. For NK cells isolation from peripheral blood positive magnetic cell separation method was applied. The cytotoxic activity of NK cells was analysed by flow cytometry. Results The frequency of CD3+ and CD3+CD4+,allperforin+ and perforin+CD3+CD8+ cellssignificantly decreased in patients who underwent on-pump CABG when compared to patients who underwent off-pump CABG 24 h after surgery. Frequency of T regulatory cells significantly increased in patients who underwent on-pump CABG when compared to patients who underwent off-pump CABG 24 h after surgery. The frequency of IL-15+CD3+, IL-15+CD56+ and IL-15+CD3+CD56+ cells significantly increased in patients who underwent off-pump CABG when compared to patients who underwent on-pump CABG 24 h after surgery. The frequency of IFNγ+ cells and cytotoxic activity of NK cells did not differ significantly amnog groups at any time point. Concentrations of IL-15, IL-18 i IFN significanlty increaed in patients who underwent on-pump CABG surgery when compared to patients who underwent off-pump CABG surgery 24 and 72 h after surgery. Conclusion Significntly decreased frequency of CD3+ and CD3+CD4+ cells, perforin expression and increased concentration of proinflammatory cytokines (IL-15, IL-18 i IFNwas found in patients who underwent on-pump CABG surgery when compared to patients who underwent off-pump CABG surgery. Charbohydrate rich perioperative feeding did not significantly effect changes of frequency in different lymphocyte subpopulation and perforin expression among grups at different time points

Mitral Regurgitation and Coronary Artery Bypass Surgery: Comparison of Mitral Valve Repair and Replacement

Background : The aim of this retrospective study was to determine if there is a statistically significant difference (p ≤ 0.05) between mitral valve repair (MVRp) with concomitant surgical revascularization of the myocardium (CABG) and mitral valve replacement (MVR) with concomitant CABG, considering the duration of surgery, early postoperative morbidity, in-hospital mortality, length of stay in the Intensive Care Unit (ICU) and overall in-hospital stay. Methods : Between January 1st 2006 and December 31st 2008, 75 patients underwent surgery for mitral regurgitation and ischemic heart disease. Patients were divided in two groups determined by the procedure that was performed on the mitral valve (MVRp + CABG group had 34 patients, MVR + CABG group had 41 patients). All the patients were operated by the same surgical team and received the usual anaesthesia protocol. Results : Patients in the MVR + CABG group had statistically significant higher EuroSCORE risk levels, higher NYHA status and higher incidence of postoperative low cardiac output syndrome (LCOS). Neurological complications showed statistically significant higher incidence in the MVRp + CABG group. There was no statistically significant difference in regard to in-hospital mortality between these two groups. Patients in the MVR + CABG group had statistically significant longer in-hospital stay. Conclusions : Mitral valve repair and mitral valve replacement are complementary methods considering early postoperative morbidity and mortality. Higher incidence of LCOS and in-hospital stay in the MVR + CABG group was to be expected on behalf of poorer preoperative statu

Prognostic performance of the Simplified Acute Physiology Score II in major Croatian hospitals: a prospective multicenter study

AIM: To perform an external validation of the original Simplified Acute Physiology Score II (SAPS II) system and to assess its performance in a selected group of patients in major Croatian hospitals. ----- METHODS: A prospective, multicenter study was conducted in five university hospitals and one general hospital during a six-month period between November 1, 2007 and May 1, 2008. Standardized hospital mortality ratio (SMR) was calculated from the mean predicted mortality of all the 2756 patients and the actual mortality for the same group of patients. The validation of SAPS II was made using the area under receiver operating characteristic curve (AUC), 2×2 classification tables, and Hosmer-Lemeshow tests. ----- RESULTS: The predicted mortality was as low as 14.6% due to a small proportion of medical patients and the SMR being 0.89 (95% confidence interval [CI], 0.78-0.98). The SAPS II system demonstrated a good discriminatory power as measured by the AUC (0.85; standard error [SE]=0.012; 95% CI=0.840-0.866; P<0.001). This system significantly overestimated the actual mortality (Hosmer-Lemeshow goodness-of-fit H statistic: χ(2) =584.4; P<0.001 and C statistics: χ(2)(8) =313.0; P<0.001) in the group of patients included in the study. ----- CONCLUSION: The SAPS II had a good discrimination, but it significantly overestimated the observed mortality in comparison with the predicted mortality in this group of patients in Croatia. Therefore, caution is required when an evaluation is performed at the individual level

Decrease of Perforin Expressing Lymphocytes after On-Pump Coronary Artery Bypass Grafting Surgery Irrespective of Carbohydrate Preoperative Oral Feeding

Background: Coronary artery bypass grafting (CABG) surgery continues to be the gold standard for treating the patients with coronary artery disease. CABG surgery can be performed on or off cardiopulmonary bypass, termed as on- pump or off-pump CABG, respectively. It has been shown that CABG surgery, preferably on-pump CABG surgery, leads to the changes of cell immunity during perioperative and early postoperative period. The mechanisms of regulation of the immune response in patients during and early after surgical revascularization are not fully understood. The aim of this study was to investigate the influence of carbohydrate preoperative oral feeding on frequency and perforin expression in peripheral blood lymphocytes in patients after on- or off-pump CABG surgery in early postoperative period. Patients and methods: In this prospective clinical study, 80 patients scheduled for CABG surgery were included in the study. The patients were randomly allocated into four groups (20 in each group): patients in Group 1 underwent on- pump CABG and did not receive carbohydrate preoperative oral feeding ; patients in Group 2 underwent on-pump CABG and were preoperatively fed ; patients in Group 3 underwent off- pump CABG and did not receive carbohydrate preoperative oral feeding ; while patients in Group 4 underwent off-pump CABG and received carbohydrate preoperative oral feeding. Blood samples were collected immediately before (T1), 24 (T2) and 72 (T3) hours after the surgery. Peripheral blood mononuclear cells were isolated by gradient centrifugation and simultaneously labelled by antigens using fluorochrome- conjugated monoclonal antibodies. Frequency of T lymphocytes, NK and NKT cells, their subsets as well as their perforin expression were detected, and analyzed by flow cytometry. Results: There was significant decrease in frequency of CD3+ and CD3+CD4+ cells, as well as perforin expressing CD3+CD8+ cells in patients who underwent on-pump CABG in comparison to patients who underwent off- pump CABG 24 hours after the surgery. Carbohydrate preoperative oral feeding did not effect changes in lymphocytes subpopulations and perforin expression at any time point. Conclusion: Decreases of CD3+ cells on account of CD3+CD4+ subsets, and perforin expressing cells on account of CD3+CD8+ perforin+ cells were found in patients who had undergone on-pump CABG, but not in patients who had undergone off-pump CABG surgery, irrespectively of carbohydrate preoperative oral feeding