Intracardiac metastasis from germ cell testicular tumor.

Intracardiac metastases of germ cell testicular tumors are not commonly seen in clinical practice. The clinical presentation of right-sided heart metastases ranges widely. Depending upon its size and intracardiac location, it could be highly symptomatic, leading to a congestive heart failure, pulmonary embolism, and death, or completely asymptomatic. Improved imaging techniques and treatment strategies demonstrate that right-sided heart metastasis should be considered a potentially dangerous but treatable disease. Presented is the case of a 24-year-old man with a testicular nonseminomatous germ cell tumor, which after metastasizing in the right atrium differentiated into a teratoma and resulted in an inflow obstruction of the right ventricle.

Glyburide decreases myocardial oxygen pressure in dogs.

BACKGROUND: Reports show that glyburide, an adenosine triphosphate sensitive potassium (K+ATP) channel blocker, will reverse the myocardial protective effect of inhalational anesthesia. We evaluated the effect of glyburide on myocardial tissue oxygen pressure (PmO2) in dogs anesthetized with desflurane. METHODS: Twelve dogs were anesthetized with 8% end-tidal desflurane for baseline anesthesia. A flow probe was placed on the left anterior descending (LAD) artery. A probe that measured PmO2 was inserted into the middle myocardium in the LAD region. After baseline measures, six dogs received i.v. 1 mg kg(-1) of glyburide and six dogs received sham vehicle treatment. After the glyburide or sham treatment, each dog received an i.v. infusion of adenosine 0.1 microg kg(-1) x min(-1), sodium nitroprusside (SNP) 2-4 microg kg(-1) x min(-1) and 14% end-tidal desflurane in random order. RESULTS: Glyburide decreased LAD artery flow from 59 +/- 9 ml min(-1) to 30 +/- 6 ml min(-1) (P < 0.05) and PmO2 from 44 +/- 16 mmHg to 30 +/- 9 mmHg (P < 0.05). Adenosine infusion increased LAD artery blood flow 180% in the sham-treated dogs but produced no change in the glyburide-treated dogs. Sodium nitroprusside infusion increased LAD artery flow and decreased PmO2 in both the glyburide- and sham-treated dogs. Desflurane (14%) did not reverse the glyburide-induced vasoconstriction but increased PmO2 to 38 +/- 20 mmHg (P < 0.05). CONCLUSION: Glyburide produced myocardial tissue hypoxia, which was not changed by adenosine, worsened by SNP and improved by 14% desflurane. The improvement in PmO2 with desflurane occurred without a change in myocardial blood flow.

Myocardial tissue oxygen during coronary artery constriction and hypotension in dogs.

BACKGROUND: Sodium nitroprusside (SNP) may decrease myocardial tissue oxygenation in dogs with normal coronary arteries. We compared SNP- with desflurane-induced hypotension on myocardial tissue oxygen and pH in dogs with left anterior descending artery constriction. METHODS: Twenty-four dogs were anesthetized with 8% desflurane for baseline anesthesia. Catheters were inserted into the femoral artery and vein and the coronary sinus. A flow probe and flow restriction device was placed on the left anterior descending (LAD) artery. A probe that measured myocardial oxygen pressure was inserted into the middle myocardium in the LAD region. Baseline measures were made of LAD artery flow, arterial and coronary sinus blood gases, and myocardial tissue gases. A 30% decrease in blood pressure was induced with SNP with unrestricted LAD flow (n=6) or when LAD artery flow was restricted by 30% from baseline (n=6). In separate dogs, a 30% decrease in blood pressure was produced with 14 +/- 1% desflurane with unrestricted LAD flow (n=6) or with baseline LAD artery flow restricted by 30% (n=6). RESULTS: During SNP-induced hypotension with no LAD constriction, LAD artery flow and coronary sinus oxygen tension increased but myocardial tissue oxygen tension (PmO2) decreased by 40%. When baseline artery flow was decreased by 30% by LAD constriction, SNP-induced hypotension decreased tissue oxygen pressure by 80%, and ischemic acidosis was produced. During unrestricted LAD artery flow or with a 30% flow restriction, desflurane-induced hypotension produced no significant change from baseline myocardial tissue oxygen tension or pH. CONCLUSION: During coronary artery constriction, desflurane-induced hypotension maintained myocardial tissue oxygenation and pH better than did SNP-induced hypotension. The divergence between tissue and coronary sinus oxygen tension during SNP suggests that arteriovenous shunting may occur.

Brain compared to heart tissue oxygen pressure during changes in arterial carbon dioxide in the dog.

Myocardial tissue oxygen pressure (PmO2 ) and left anterior descending (LAD) artery blood flow were measured in dogs anesthetized with 1.5% isoflurane, and were then compared to brain tissue oxygen pressure (PbO2 ) and middle cerebral artery (MCA) blood flow during normocapnia, hypocapnia, and hypercapnia. A craniotomy was performed and a tissue probe (Codman, Inc.) that measures PO2, PCO2, and pH was inserted into the brain cortex in the MCA region (n = 8). Separately, after a thoracotomy, a probe was inserted into the middle myocardium of the left ventricle, within the distribution of the LAD, in eight dogs. Blood flow probes were placed on the LAD or MCA. Blood flow and tissue gases were measured during normocapnia (PaCO2 = 38 mm Hg), hypocapnia (PaCO2 = 26 mm Hg), and hypercapnia (PaCO2 = 53 mm Hg). Mean arterial pressure, heart rate, arterial gases, and pH were not different between brain and heart measurements. PbO2 was 21 +/- 9 mm Hg (mean +/- SD ), 40 +/- 16 mm Hg, and 47 +/- 11 mm Hg. PmO2 was 35 +/- 12 mm Hg, 40 +/- 14 mm Hg, and 48 +/- 15 mm Hg during hypocapnia, normocapnia, and hypercapnia respectively. During hypercapnia, LAD and MCA flow increased 50% and tissue oxygenation increased 20% ( P < .05). During hypocapnia, MCA flow and PbO2 decreased 50% ( P < .05), but LAD flow and PmO2 did not significantly change. These results indicated that LAD flow and myocardial PO2 were less responsive to hypocapnia than MCA flow and PbO2.

[Subcutaneous pseudoaneurysm of the left ventricle--a rare complication of ischemic dilated cardiomyopathy]. / Supkutana pseudoaneurizma leve komore--retka komplikacija ishemijske dilatativne kardiomiopatije.

INTRODUCTION: Pseudoaneurysm of the heart is extremely rare in cardiology and cardiac surgery. It can be presented as a complication of myocardial infarction, cardiac trauma or surgical intervention. CASE PRESENTATION: 9 years after by-pass surgery combined with left ventricle aneurysmectomy a 69-year-old patient was admitted in hospital after full cardiologic examination. On admission, during routine chest examination 9 years after by-pass surgery combined with left ventricle aneurysmectomy, a great pulsatile mass was found in the region of left mammilla++. A left ventricle aneurysm (aneurysm per magna) was confirmed by all noninvasive and invasive tests, and new surgical aneurysmectomy was indicated. The existence of pseudoaneurysm was suspected by intraoperative transesophageal echocardiography and during the operation a false aneurysm was finally confirmed. DISCUSSION: False aneurysm develops after acute rupture of an infarcted left ventricle area. It is usually fatal, but if the adhesion or pericardial fibrosis exists and is adherent to epicardium it can create a saccular cavity (hemopericardium). Persistent communication between the left ventricle and hemopericardium can create false aneurysm of different size and shape. In more than 50% of patients false aneurysm is found accidentally. In most cases the pseudoaneurysm is asymptomatic and the treatment is surgical. CONCLUSION: False aneurysms as case presentations are very rare. Sometimes they are difficult to confirm prior to surgery; even if full diagnostic screening was arranged (including 2-D transthoracic echocardiography, transesophageal echocardiography and complete hemodynamic investigation).

[Comparison of preoperative and postoperative hemodynamic parameters in replacement or reconstruction of the mitral valve in ischemic dilated cardiomyopathy]. / Uporedivanje preoperativnih i postoperativnih vrednosti hemodinamickih parametara kod zamene i rekonstrukcije mitralnog zaliska u ishemicnoj dilatativnoj kardiomiopatiji.

INTRODUCTION: Ischemic mitral insufficiency is a clinical syndrome described as a consequence of the coronary artery disease where the basic problem is blood regurgitation between the left ventricle and left atrium following mitral annulus dilatation. Mitral regurgitation occurs in different degrees during the natural evolution of the ischemic heart disease. The main reason for the existence of mitral regurgitation is global deterioration in the left ventricle geometry as a consequence of myocardial infarction or/and left ventricle dilatation. Surgical correction of this problem is possible by simultaneous correction of mitral insufficiency (repair or replacement) and complete myocardial revascularisation. MATERIAL AND METHODS: Complete hemodynamic monitoring was followed by Swan-Ganz catheter including: central venous pressure, mean pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac output, cardiac index and pulmonary vascular resistance. All surgical procedures were performed in extracorporeal circulation (ECC) with membrane oxygenator using moderate systemic hypothermia and transseptal surgical approach to mitral valve. Hemodynamic parameters were followed before and after ECC, immediately after surgery and during the first 48 hours after operation in the intensive care unit. In 88 patients posterior semicircular annuloplasty by N. Radovanovic was performed whereas in 13 patients mitral valve replacement was done. RESULTS: There is a great, statistically significant hemodynamic improvement after the surgical procedure and during the continuous 48 hours monitoring in the intensive care unit no matter if mitral repair or replacement was done. No statistically significant difference was recorded between these two groups considering that the hemodynamic improvement is very similar. DISCUSSION: Simultaneous surgical procedures, including myocardial revascularization, mitral and usually consecutive tricuspid insufficiency correction, are a very common surgical problem with higher operative risk than isolated coronary bypass procedures. In 88 cases where mitral reconstruction was possible, posterior semicircular reductive annuloplasty was performed. Thus mitral annulus area reduction is achieved preserving its physiologic shape and avoiding rigidity. Mitral valve replacement includes implantation of the latest generation of bileaflet valve prosthesis and operative technique that preserves subvalvular apparatus to maintain myocardial contractility as much as possible. This policy and also good immediate postoperative care, improve the hemodynamic status in both groups. CONCLUSION: All hemodynamic parameters followed by ECC and 48 hours in the intensive care unit were significantly improved no matter whether mitral reconstruction or replacement was done. There is no statistically significant difference in hemodynamic parameters and clinical improvement between these two groups. Carefully chosen operative tactic and techniques as well as good preoperative and postoperative care may explain these very good results.

Myocardial revascularization with skeletonized left mammary artery.

Graft selection has a direct influence on overall morbidity and mortality in patients selected for coronary artery bypass grafting (CABG) procedures. In the last decade internal mammary artery has been established as a conduit of choice for myocardial revascularization. However, there is still no official policy which operative technique has advantage in harvesting of the internal mammary artery (IMA). Current dilemma is whether pedicle or skeletonized grafts are better in immediate and long term results. Method of skeletonization of IMA increases surgeon's technical demands, but on the other hand has many advantages. Precise operative technique and selective preparation of IMA without concomitant elements reduces trauma to the chest wall, enables elongation and ideal graft positioning, and reduces graft compression by hyperinflated lungs. Complete graft visualization allows inspection of internal mammary artery in entire length, which excludes possibility to implant dissected or hypoplastic graft. From June 1996 we started using the method of skeletonization of IMA, and until February 1st 1999 skeletonized IMA was used as a conduit in 1001 patients. In our hands myocardial revascularization with IMA is a procedure with minimal morbidity and mortality. Precise operative technique during the harvesting of IMA is advantage especially in diabetics, old patients and patients with chronic obstructive pulmonary disease (COPD), that were considered as limiting factors for IMA use in the past. Our initial results with the quality of this conduit encourage us to extend the indication for using IMA as a dominant graft in multiple myocardial revascularization.

[Late results of myocardial revascularization in patients with coronary artery endarterectomy]. / Kasni rezultati revaskularizacije miokarda kod pacijenata kod kojih je radena endarteriektomija koronarnih arterija.

INTRODUCTION: The aim of this study was to evaluate long-term results after myocardial revascularization in patients with diffuse and distal coronary disease, and to compare this procedure with the classical approach--indirect myocardial revascularization (revascularization without endarterectomy). MATERIAL AND METHODS: This retrospective study was done in the period of three years, and includes patients operated between January 1, 1985 and December 31, 1990 at the University Clinic of Cardiovascular Surgery, Novi Sad. 500 patients were included and two groups were made. The investigated group consisted of 251 patients with endarterectomy and control group of 249 patients without endarterectomy. Other parameters (age, gender, preoperative hemodynamic parameters etc.) were practically the same. RESULTS: Postoperative mortality (PM) during immediate 30 postoperative days was 4.64% in the investigated group, and 1.97% in the control group (total PM = 2.66%). The main causes of death were cardiac (3.74%), and the rest of them were respiratory, renal and cerebral. The highest postoperative mortality according to the localization of endarterectomy was left artery descendent (LAD) in the position of the first septal artery (36.36%). The follow-up study included 500 operated patients. The mean follow-up period was 9 years (0-13 years). Cumulative survival curve and postoperative myocardial infarction curve made by Wilcocxon (Gehan) and Kaplan-Meier methods showed no statistically significant difference between groups after 13 years of follow up. Lower incident of new angina was found in the investigated group (p < 0.01). Most of patients show good physical condition, well toleration of the stress test (Bruce protocol) and no significant impairment of ejection fraction. DISCUSSION: Despite its long history and development, endarterectomy of coronary arteries is one of the most controversial methods in cardiac surgery. Application of this method was very restrictive mostly because its complexity and very controversial results from one institution to another. Endarterectomy of the first septal artery has the highest operative risk, but it is the method of choice in full revascularization of this region. Despite higher operative mortality, the immediate and long term results of this study show that endarterectomy of the coronary arteries is a method with very acceptable operative risk. CONCLUSION: Endarterectomy is a good and effective method for direct myocardial revascularization in cases with diffuse coronary disease. It is the best procedure for revascularization of the septum. The number of endarterectomies and low ejection fraction are independent predictors for early and long-term mortality. Endarterectomy is also a method of choice in patients with low ejection fraction and poor coronary bed. Frequent and repeated application of angioplasty, higher incidence of diffuse and distal coronary disease and no available donors for heart transplantation will increase the application of this method. In the future we expect further improvement and complete affirmation of endartrectomy of coronary arteries.