[The role of surgical embolectomy and extracorporeal membrane oxygen therapy in the treatment of massive pulmonary embolism - a review]. / Role chirurgické embolektomie arteria pulmonalis a membránové mimotelní oxygenoterapie v lécbe masivní plicní embolie - prehled.

Acute massive pulmonary embolism remains potentially lethal with mortality varying between 2553%. In the thrombolytic era, surgical pulmonary embolectomy is deemed as a rescue approach for patients with absolute contraindication of thrombolysis or its failure. However, close interdisciplinary cooperation, meticulous choice of optimal reperfusion strategy, standardization of surgical approach, and mainly the inclusion of mechanical circulatory support into the treatment algorithm have led to a drop in in-hospital mortality below 10% in the last 10 years. Nevertheless, cardiac arrest and refractory cardiogenic shock still remain independent risk factors of death with mortality exceeding 70%. Extracorporeal membrane oxygen therapy provides rapid circulatory support, end-organ perfusion and oxygenation which are essential for right-sided obstruction haemodynamic. Subsequently, optimal reperfusion strategy can be chosen or patients may be transported for it. The review highlights the contemporary role of surgical pulmonary embolectomy and extracorporeal membrane oxygen therapy in the treatment algorithm for acute massive pulmonary embolism, summarising current perspectives on the indications and contraindications for these treatment strategies and their results.Key words: massive pulmonary embolism - surgical pulmonary embolectomy - extracorporeal membrane oxygen therapy.

Superiority of topical negative pressure over closed irrigation therapy of deep sternal wound infection in cardiac surgery.

AIM: We sought to compare clinical outcomes, in-hospital mortality and 1-year survival of two different treatment modalities of deep sternal wound infection, topical negative pressure and the closed irrigation therapy. METHODS: Retrospective analysis of 66 consecutive patients treated for deep sternal infection at our institution. A total of 28 patients (February 2002 through September 2004) underwent primarily closed irrigation therapy, and 34 patients (November 2004 through December 2007) had the application of topical negative pressure. Four patients (July 2004 through December 2004) who underwent a combination of both strategies were excluded from the study. Clinical and wound care outcomes were compared, focusing on therapeutic failure rate, in-hospital stay and the 1-year mortality of both treatment strategies. RESULTS: Topical negative pressure was associated with a significantly lower failure rate of the primary therapy (P<0.05), shortening of the intensive care unit stay (P<0.001), a particular decrease in the in-hospital stay (P<0.05) and the 1-year mortality (P<0.05) in comparison with closed irrigation therapy. Comparable overall length of the therapy, in-hospital stay and the risk of wire-related fistulas after chest reconstruction were found. CONCLUSION: Topical negative pressure is a superior method of treatment for deep sternal wound infection, which is based on lower therapeutic failure rate, significant decrease in-hospital stay, and the decrease of the 1-year mortality rate, compared with primarily applied closed irrigation.

The effect of a cardiopulmonary bypass system with biocompatible coating on fibrinogen levels determined by the TEG--functional fibrinogen method: preliminary results.

When cardiopulmonary bypass (CPB) is used, the blood comes into contact with foreign surfaces. To diminish this impact, various types of biocompatibly coated surfaces have been developed. The study assessed the effects of heparin-coated CPB systems on the level and function of fibrinogen as measured by thromboelastography (TEG), as compared with non-coated systems. No statistically significant differences between both groups were revealed by comparing paired data. In our study, heparin-coated CPB circuits had no significant effect on either fibrinogen level or its function.

[Vacuum-assisted closure as a treatment modality for surgical site infection in cardiac surgery]. / Podtlaková terapie (vacuum-assisted closure) v lébe ranných infekcních komplikací po kardiochirurgických výkonech.

BACKGROUND: The vacuum-asssited closure has represented an encouraging treatment modality in treatment of surgical site infection in cardiac surgery, providing superior results compared with conventional treatment strategies, particularly in the treatment of deep sternal wound infection. METHODS: From November 2004 to January 2007, 40 patients, undergoing VAC therapy (VAC system, KCI, Austria, Hartmann-Rico Inc., Czech Republic) for surgical site infection following cardiac surgery, were prospectively evaluated. Four patients (10%) were treated for extensive leg-wound infection, 10 (25%) were treated for superficial sternal wound infection and 26 (65%) for deep sternal wound infection. The median age was 69.9 +/- 9.7 years and the median BMI was 33.2 +/- 5.0 kg/m2. Twenty-three patients (57%) were women and diabetes was present in 22 patients (55%). The VAC was employed after the previous failure of the conventional treatment strategy in 7 patients (18%). RESULTS: Thirty-eight patients (95%) were successfully healed. Two patients (5%) died, both of deep sternal infetion consequences. The overall length of hospitalization was 36.4 +/- 22.6 days. The median number of dressing changes was 4.6 +/- 1.8. The median VAC treatment time until surgical closure was 9.7 +/- 3.9 days. The VAC therapy was solely used as a bridge to the definite wound closure. Four patients (10%) with a chronic fistula were re-admitted with the range of 1 to 12 months after the VAC therapy. CONCLUSION: The VAC therapy is a safe and reliable option in the treatment of surgical site infection in the field of cardiac surgery. The VAC therapy can be considered as an effective adjunct to convetional treatment modalities for the therapy of extensive and life-threatening wound infection following cardiac surgery, particurlarly in the group of high-risk patients.

Postoperative and midterm outcomes of minimally invasive and endoscopic great saphenous vein harvesting for coronary artery bypass grafting - a prospective analysis.

BACKGROUND: We sought to determine whether the postoperative and midterm outcomes of minimally invasive and endoscopic great saphenous vein harvesting are comparable. METHODS: From February 2004 to September 2006, 120 patients underwent minimally invasive vein harvesting, and subsequently 150 patients had endoscopic vein harvesting for CABG. Patients were evaluated prospectively for wound-healing disturbances, residual leg oedema, pain intensity and saphenous neuropathy on the 7th postoperative day and after 3 months. RESULTS: Both harvesting techniques were associated with a low incidence of wound-healing disturbances; nevertheless, minimally invasive vein harvesting was associated with a significantly higher incidence of residual oedema (28 % vs. 13 %; P < 0.05), (19 % vs. 6 %; P < 0.001), pain (20 % vs. 9 %; P < 0.05), (10 % vs. 6 %; P < 0.05), and saphenous neuropathy (23 % vs. 7 %; P < 0.001) (14 % vs. 3 %; P < 0.001) during follow-up on the 7th postoperative day as well as 3 months after surgery, respectively. Mean harvesting time (40.6 +/- 15.5 vs. 43.9 +/- 10.2 min; P = 0.09), conversion rate (3 % vs. 2 %; P = 0.71), and injury per conduit (0.3 +/- 0.2 vs. 0.3 +/- 0.1; P = 0.91) were comparable for both groups. CONCLUSIONS: Endoscopic vein harvesting seems to be superior to minimally invasive vein harvesting in terms of a significant reduction of residual leg oedema, pain intensity and particularly saphenous neuropathy in the postoperative and midterm follow-up.

[Endoscopic saphenous vein harvesting for coronary artery bypass grafting]. / Endoskopický odber vena safena magna pro revaskularizaci myokardu.

BACKGROUND: Traditional great saphenous vein harvest for coronary artery bypass grafting is associated with a significant risk of impaired wound healing. Endoscopic saphenous vein harvesting (EVH) has been introduced in an effort to reduce the incidence of leg-wound complications, whereas the histological quality and long-term patency of harvested grafts are comparable with grafts harvested by means of traditional technique. METHODS: From July to December 2005, EVH was performed in a group of 60 patients employing the Vasoview 6 system (Guidant, Europe S.A., Belgium). Patients were evaluated on 7th postoperative day for wound healing disturbances, residual leg oedema and saphenous neuropathy. RESULTS: The mean age was 67.4 +/- 11.2 years, male patients dominated (68%). At least one independent risk factor of leg-wound disturbances such as obesity, diabetes, peripheral vascular disease and female gender, was presented in 39 patients (63%). The mean number of harvested venous grafts was 2.0 +/- 1.2 and the mean total vein harvesting time was 46.2 +/- 7.4. In one case (1.7%), EVH was converted to the traditional harvesting technique due to superficial course of the great saphenous vein. The presence of wound haematoma was noted in 31 patients (51%). No other wound disturbances such as wound infection, wound dehiscence, skin necrosis, lymphatic wound drainage, nor saphenous neuropathy were recorded in the group of patients. The leg oedema associated with EVH was presented in 7 patients (12%). CONCLUSIONS: EVH is a safe method associated with a significant reduction of leg-wound complications, residual leg oedema and saphenous neuropathy. EVH should become method of choice, particularly in the presence of independent risk factors of leg-wound disturbances. The quality and the harvesting time of harvested grafts were comparable to grafts harvested by means of the traditional harvesting technique.