The effects of Artemisia methanol extracts and ferulic acid, rutin, rosmarinic acid, and quercetin on micronucleus distribution on human lymphocytes.

Methanol extracts of A. absinthium, A. annua, A vulgaris, A. scoparia, and A. alba from Serbia at concentrations of 1.00; 2.00 and 4.00 µg/ml, and as pure compounds identified in examined extracts (ferulic acid, rutin, rosmarinic acid, and quercetin) were examined for their effects on micronucleus distribution in human lymphocytes in vitro. All extracts greatly reduced the number of micronuclei in the concentration of 2.00 µg/ml comparing to the control, whereby A. alba extract exhibited the most prominent effect on decreasing frequency of micronucleus (45.2%), followed by extracts of A. vulgaris, A. absinthium, A. scoparia and A. annua. The same declining trend was observed for the extracts at concentrations of 4.00 µg/ml, and 1.00 µg/ml, respectively. Among pure compounds (concentration 2.00 µg/ml), rutin showed the most pronounced effect on decreasing frequency of micronucleus (41.7%), higher than ferulic acid, quercetin, and rosmarinic acid comparing to the control.

The prevalence of polyvascular disease in patients with carotid artery disease and peripheral artery disease.

BACKGROUND: Cardiovascular disease remains the major cause of mortality in the Western World. AIMS: We aimed to assess the prevalence of polyvascular disease in patients with carotid artery disease and peripheral artery disease (PAD), and to determine the risk profile of patients with polyvascular disease. METHODS: The study included 1045 consecutive patients presenting to our department with carotid disease or PAD. Demographic characteristics, anthropometric parameters, and data on cardiovascular risk factors were collected in all patients. On the basis of medical history, patients were classified into those who had only symptomatic carotid disease or symptomatic PAD and those who had symptomatic polyvascular disease. RESULTS: Carotid disease alone was reported in 366 participants (35%), PAD alone, in 199 (19%), and polyvascular disease, in 480 (46%). Compared with carotid disease, PAD was more often a component of polyvascular disease (P = 0.002) and was combined with a higher number of other atherosclerotic diseases (P = 0.02). Compared with patients with symptomatic atherosclerotic disease in only 1 territory, patients with various types of polyvascular disease more often had hypertension (P from 0.03 to <0.001), dyslipidemia (P <0.001), high­sensitivity C­reactive protein levels of 3 mg/l or higher (P = 0.005), and more often were current smokers (P <0.001) or former smokers (P from 0.03 to 0.001). CONCLUSIONS: We showed a high prevalence of symptomatic polyvascular disease in patients with carotid disease or PAD. The risk profile was worse in patients with polyvascular disease than in those with a disease in a single vascular territory.

Role of recombinant factor VIIa in the treatment of intractable bleeding in vascular surgery.

BACKGROUND: Most recent publications have shown that the recombinant form of activated factor VII (rFVIIa; NovoSeven, Novo Nordisk A/S, Bagsværd, Denmark) induces excellent hemostasis in patients with severe intractable bleeding caused by trauma and major surgery. The purpose of this study was to determine the influence of rFVIIa on the treatment of intractable perioperative bleeding in vascular surgery when conventional hemostatic measures are inadequate. MATERIALS AND METHODS: There were two groups of patients: the NovoSeven group (group N), 10 patients with ruptured abdominal aortic aneurysms (RAAAs) and 14 patients operated on due to thoracoabdominal aortic aneurysms (TAAAs); the control group (group C), 14 patients with RAAAs and 17 patients with TAAAs. All patients suffered intractable hemorrhage refractory to conventional hemostatic measures, while patients from group N were additionally treated with rFVIIa. RESULTS: Postoperative blood loss was significantly lower in group N treated with rFVII (P < .0001). Postoperative administration of packed red blood cells, fresh frozen plasma, and platelets was lower in patients from group N, (P < .0001). Successful hemorrhage arrest was reported in 21 patients (87.5%) treated with rFVIIa, and in 9 patients (29.03%) in group C (P < .001). Thirty-day mortality in these two groups significantly differed. The mortality rate was 12.5% (3 patients) in group N and 80.65% (25 patients) in group C (P < .0001). CONCLUSION: Our findings suggest that rFVIIa may play a role in controlling the intractable perioperative and postoperative bleeding in surgical patients undergoing a repair of RAAAs and TAAAs. Certainly, prospective randomized trials are necessary to further confirm the efficacy and cost-effectiveness of rFVIIa in these patients.

[Recombinant activated factor VII in the treatment of intractable non-surgical bleeding following major vascular procedures].

INTRODUCTION: A recombinant form of activated factor VII (rFVIIa) is a haemostatic drug that is approved for use in haemophiliacs with antibodies to factor VIII or factor IX. Most recent studies and clinical experience have shown that rFVIIa (NovoSeven, Novo Nordisk A/S, Denmark) gives extreme haemostatic effect in patients with severe "non-haemophilic" bleeding produced after trauma and major surgery. OBJECTIVE: We present our preliminary experience of the use of rFVIIa in vascular surgery when conventional haemostatic measures are inadequate. METHOD: There were 32 patients divided into five groups: Group I--14 patients with ruptured abdominal aortic aneurysms; Group II--10 patients with thoracoabdominal aortic aneurysms; Group III--5 patients with retroperitoneal tumours involving great abdominal vessels; Group IV--2 patients with portal hypertension and Group V--one patient with iatrogenic injury of brachial artery and vein during fibrinolytic treatment, because of myocardial infarction. RESULTS: Clinical improvement was detected following treatment in 29 patients. Bleeding was successfully controlled as evidenced by improved haemodynamic parameters and decreased inotropic and transfusion requirements. CONCLUSION: In vascular patients more liberal use of rFVlla is limited, because no randomized controlled trial has proved its efficacy and safety in such patients; while also keeping in mind that the price of a 4.8 mg of rFVIIa is $4080. We recommend the use of rFVIIa in vascular surgery only during and after operative treatment of thoracoabdominal aortic aneurysms, ruptured abdominal aortic aneurysms, retroperitoneal tumours involving the aorta and/or inferior vena cava, as well as portal hypertension, when non-surgical massive uncontrolled bleeding are present.

[Surgical treatment of abdominal tumours closely related to major blood vessels].

INTRODUCTION: Radical operative treatment of abdominal tumours closely related to major blood vessels often demands complex vascular procedures. OBJECTIVE: The aim of this paper was to present elementary principles and results of the complex procedures, based on 46 patients operated on at the Institute for Cardiovascular Diseases, Clinical Centre of Serbia, Belgrade, from January 1999 to July 2006. METHOD: Primary localisation of the tumour was the kidney in 14 patients, the suprarenal gland in 2, the retroperitoneum in 23 and the testis in 7 patients. Histologically, the most frequent were the following: renal carcinoma in 14 patients, teratoma in 7, liposarcoma in 5, fibrosarcoma and lymphoma in 3 patients. The tumour compressed abdominal aorta occurred in 3 cases, vena cava inferior in 5 and both the abdominal aorta and vena cava inferior in 11 cases. In 4 cases the tumour infiltrated the abdominal aorta, in 11 the vena cava inferior and in 8 both of them. In two patients, the tumour compressed the vena cava inferior and infiltrated the aorta; in two patients the aorta was compressed and the vena cava was infiltrated. In three cases only the exploration was performed due to multiple abdominal organ infiltration. The ex tempore biopsy showed the type of tumour in which the radical surgical treatment did not improve the prognosis. In 20 cases of tumour compression, subadventitional excision was performed. In 23 cases of infiltration, the tumour excision and vascular reconstruction had to be performed. Intraoperative blood cell saving and autotransfusion were applied in 27 patients. RESULTS: The lethal outcome happened in 3 (6.5%) patients during hospitalization. In other patients all reconstructed blood vessels were patent during the postoperative hospitalization period. CONCLUSION: Treatment of the abdominal tumours closely related to major blood vessels must be interdisciplinary, considering diagnostics, operability estimation and additional measures. Tumour reduction cannot improve long term prognosis, and has no major impact on life quality. There have been not many papers that analyse the long term results after such complex operations proving their appropriateness.

[Effects of nitrous oxide on middle ear pressure].

INTRODUCTION: Recent literature data suggest that permanent or reversible hearing loss may occur after general anesthesia. The etiology varies, while hearing loss following middle ear surgery is attributed to exposure to nitrous oxide (N,0). The objective of our study was to measure, using tympanometry, the middle air pressure change caused by nitrous oxide during general anesthesia and to establish its emetogenic effects during the postoperative period. MATERIAL AND METHODS: This academic (non-commercial) prospective study included two groups of patients (a total of 58), with ASA status I, II and III. The study group (n 30) consisted of patients undergoing unilateral ear surgery. In this group, the intratympanic pressure was measured in the unoperated (healthy) ear before and during the surgery. The control group (n 28) patients underwent nose, throat or neck surgical interventions. This group underwent measurement of bilateral intratympanic pressure in healthy ears, before and during the surgery. Both groups were operated under general balanced anesthesia. Pain, nausea and antiemetics were monitored during the first 24 postoperative hours. Statistical analysis was performed using the Mann-Whitney-Wilcoxon test. RESULTS: This perioperative study confirmed the following: highly significant (p < 0.001) increase in intratympanic pressure in nonoperated ears in the study group and significant (p < 0.05) in controls. However, there was no statistical significance (p > 0.05) between groups. Pain was more freguent in controls, and nausea in the study group, but without significant difference (p > 0.05). CONCLUSIONS: Postoperative audiometry findings showed no conductive or sensorineural hearing loss after interventions. Nitrous oxide can be used in general balanced anesthesia with discontinuation 15 to 45 minutes before insertion of the tvmpanic membrane and completion of middle ear surgery.

Abdominal aortic surgery and horseshoe kidney.

Horseshoe kidney presents a special challenge during surgery of the abdominal aorta. The aim of this study was to evaluate the morbidity and define optimal management based on clinical histories of 15 patients with horseshoe kidney who underwent surgical procedures on the abdominal aorta over a 20-year period. There were 2 female and 13 male patients with an average age of 62.66 (50-75) years. The indications for surgery included aortic aneurysms in 10 patients and aortoiliac occlusive disease in 5. The horseshoe kidney was detected before surgery in 12 patients (80%) by ultrasonography, angiography, computed tomography (CT) or excretory urography. Angiography revealed multiple or anomalous renal arteries in 8 of 12 patients studied preoperatively. At surgery, 10 patients (66.6%) were found to have multiple or anomalous renal arteries. Five patients (33.41%) were without multiple or anomalous renal arteries. Ten required renal revascularization (reimplantation with a Carrel patch in 7 patients and aortorenal bypass in 3). Two patients, both with ruptured abdominal aortic aneurysms, died postoperatively. In the other 10 cases the average follow-up period was 5.3 years (6 months to 17 years). During this period there were no signs of graft occlusion, renovascular hypertension, or renal failure. From these results we conclude that aortic surgery can be performed safely in patients with horseshoe kidney without increased mortality. These patients require exact preoperative diagnosis (ultrasonography, CT scan, angiography), reimplantation of anomalous renal arteries, and preservation of the renal isthmus.

[Successful revascularization of the kidney--3 case reports]. / Revaskularizacija bubrega--prikaz tri bolesnika.

Three cases of successful kidney revascularization and recovery of renal function are presented in this study. In all three cases, renal failure and renovascular hypertension were caused by renal artery occlusion associated with aortic aneurysm (two abdominal and one thoracoabdominal). Prior to operation, one patient required dialysis 4 months, one 25 days and one 2 days. After kidney revascularization, renal function recovered immediately in the first case, in the second case after three months, and in the third case after 10 days. In one case, blood pressure restored to normal without medical therapy, while in two other cases blood pressure decreased nearly to normal with minimal medical therapy. In appropriately selected cases, revascularization of the occluded renal artery is recommended for treatment of both renal failure and renovascular hypertension. In such cases, collateral circulation is crucial to enable the preservation of dysfunctional kidney.

[Role of the Swan-Ganz pulmonary artery (PA) catheter in evaluation of hemodynamic changes during myocardial revascularization in patients with low left ventricular function]. / Uloga Swan-Ganz PA katetera u proceni hemodinams-kih promena tokom hirurske revaskularizacije miokarda u bolesnika sa oslabljenom funkcijom leve komore.

Coronary artery bypass surgery in patient with bad left ventricular function is a challenge for surgical time. Specially important is monitoring of haemodynamics. We performed this open, prospective, randomized study with the aim to assess haemodynamics and oxygen profile monitoring. 34 pts for coronary surgery (EF < 40%) were divided in two groups. Group A, 17 pts. Received glucose-insulin-potassium (GIK) solution. Group B, 127 pts. Received Ringer solution. Haemodynamic and oxygen metabolism parameters were measured in four time points. I after the induction in anesthesia; II after the operation; III 6 hours post op.; IV 24 hour post op. Data are expressed as mean +/- SD, Anova for repeated measures followed by Newman-Keuls testing were used. In both groups were evident deterioration of cardiac function during first 6 h as well as VO2 and DO2, more prominent in Group B. Significant recovery and improvement of cardiac function were evident in Group A after 24 h. CI during the time in Group A improves significantly (2.14 +/- 0.36 v. 3.05 +/- 0.55; p = 0.0002) and difference during the time between groups was p = 0.005. LVSWI improved significantly during the time him Group A (AIII vs. AIV) p = 0.007. Simultaneously. VO2 improves significantly in Group A (103 +/- 21 vs. 164 +/- 30, p = 0.00001) while difference between groups in DO was p = 0.037. Importance of oxygen metabolism monitoring for both, left ventricular function and haemodynamics assessment was evident in our study.

[Assisted circulation. I. Systems with short-term mechanical circulatory support]. / Asistirana cirkulacija I--sistemi za kratkotrajnu mehanicku potporu cirkulacije.

The concept of artificial circulatory support has been established almost 200 years ago. It has only been within the last four decades that physicians and engineers have developed mechanical assist devices that can temporarily support the circulation until the native heart recovers from a reversible injury. If the heart does not recover sufficient function to maintain adequate hemodynamics, long-term circulatory support or permanent replace (biologically--heart transplant or permanent mechanical circulatory support) is needed. In this paper we describe the devices (intraaortic balloon pump, roller, centrifugal and axial pumps), that are in current clinical use for temporary (short-term) mechanical circulatory support.

[Use of the internal thoracic artery in patients with stenosis of the left main branch of the coronary artery]. / Upotreba unutrasnje torakalne arterije kod bolesnika sa suenjem glavnog stabla leve koronarne arterije.

UNLABELLED: Internal thoracic artery (ITA) is the graft of choice in myocardial revascularization. However, superiority of the ITA graft in patients (pts) with left main coronary artery disease is still a matter of debate. PATIENTS: In the period from November 1986 through February 1999, ITA graft was used for myocardial revascularization in 2860 pts. Stenosis of the left main stem was present in 229 patients (8.0%); there were 39 women (17.0%) and 26 diabetics (11.4%). Severely depressed left ventricular function was present in 32 pts (14.0%), while the average age was 56.4 +/- 7.2 years. RESULTS: Operative mortality was 1.3% and postoperative morbidity was 5.2%. Average postoperative hospital stay was 7.9 days (6-29). There were no differences in analyzed parameters between patients who received ITA graft and similar group of 240 patients who received vein grafts only, during the same period of time. All 16 patients operated on in the period 1986-1992 (6-12 years follow-up) are alive. CONCLUSION: It is safe to use ITA graft for myocardial revascularization in patients with left main coronary artery stenosis. Early operative results are favorable and these patients should not be denied the benefit of the ITA graft, since long-term results are proved to be good as well.

[Perioperative myocardial failure and mechanical cardiac support --a five year experience]. / Perioperaciona slabost srca i mehanicka potpora radu srca--petogodnisnje iskustvo.

Inability to wean a patient from the cardiopulmonary bypass after open heart procedure is reality of the clinical practice. The only realistic chance for these patients is some form of mechanical circulatory support. Over the period from November 1988 to November 1993, in 17 patients the roller-pump mechanical assist device was inserted, i.e. 0.47% of 3589 patients were operated on during this period. Thirteen patients required mechanical circulatory support immediately after surgical procedure due to inability to wean them from cardiopulmonary bypass. In three patients the roller-pump was inserted preoperatively (percutaneous insertion), and in one patient mechanical circulatory support was started six hours after the procedure for sudden cardiac deterioration. Partial and temporary "bypass" of the damaged left ventricular function is achieved by insertion of inflow cannula into the left atrium, and outflow cannula into the ascending aorta. Depending on the inflow cannula size and volume load, we were able to achieve blood flow of 3.5 to 5 liters/minute. Using this system we were able to improve the left ventricular function in eight patients (47%), and five patients were discharged from hospital (29.4%). The roller-pump mechanical circulatory support proved to be efficient, reliable, easy to monitor and operate. Overall results are comparable to the published data as well as to other types of more versatile and costly devices for mechanical circulatory support.

[The importance of annulo-ventricular integrity in replacement of the mitral valve. Experience with the double-disc low profile Carbo Medics mechanical valve]. / Význam annuloventrikulárnej integrity pri náhradách mitrálnej chlopne. Skúsenosti s dvojdiskovou nízkoprofilovou mechanickou chlopnou Carbo Medics.

In the submitted paper the authors compare the results of the conventional replacement of the mitral valve with total excision of the subvalvular apparatus and the results of mitral replacement with a completely or partly preserved or reconstructed integrity of the annulopapillary structures. During the last five years the authors operated by the former method 115 patients (group A) and the second surgical method was used in 93 patients (group B). In both groups the authors compared 33 demographic, clinical, peroperative, postoperative and echocardiographic indicators. Group B comprised substantial more patients with severe myocardial disorders. In the latter group significantly more frequently a mechanical double-disc valve Carbo Medics was implanted than other types of synthetic valves which were used mostly in patients of group A. In patients of group B the operation took longer and after operation they needed more frequently intense inotropic support. Despite that their mortality on hospitalization was lower -3.2% than in group A where it was 6.9%. The late echocardiographic results were also in favour of group B where, contrary to group A, after operation the left ventricular function improved. The authors' experience support the view that preserving the integrity of the annulopapillary apparatus is nowadays one of the demands in surgical correlation of a mitral defect and is of decisive importance for the subsequent fate of the thus treated patients.

A technique of myocardial protection during aorto-coronary bypass in high-risk patients.

In the authors' opinion, profound myocardial hypothermia is imperative in myocardial protection while the aorta is cross-clamped. They based their own protection method, beside using a single dose of crystalloid cardioplegic solution, on very efficient topical cooling, by which myocardial temperature is reduced to below 15 degrees C. Very efficient topical cooling is achieved by a high flow (2 l/min) of continuously cooled fluid (0 degrees C- +2 degrees C). The great temperature-reducing capacity of the cooling system is due to 10-15 metres long metal coil tubing which is immersed in an ice-salt cold bath. The water pump placed in the bath makes heat exchange even more efficient. The described method of myocardial protection with stable profound myocardial hypothermia safely prolongs the ischaemic time during operation to more than two hours.