[Transplantation of allogeneic bone graft in the therapy of massive post-sternotomy defects - 6 years of experience with the method]. / Transplantace allogenního kostního stepu v lécbe rozsáhlých post-sternotomických defektu - 6 let zkuseností s metodou.

INTRODUCTION: Early complications due to deep sternal wound infection pose a serious problem in cardiac surgery, with an up to 40% risk of mortality. Massive loss of sternum bone tissue and adjacent ribs results in major chest wall instability difficult to resolve using classical AO osteosynthesis procedures, causing respiratory insufficiency making the disconnection from artificial pulmonary ventilation difficult, and additional defects of soft tissue healing. Based on orthopaedic experience with bone defect replacement, we used the allogeneic bone graft method to reconstruct the chest wall. METHODS: In the period of 20112015 we performed the transplantation of an allogeneic bone graft in 13 patients. In 10 cases, an allograft of the sternum was used, in one case an allograft of the calva bone and in two cases the crushed spongy bone was used. After primary cardiac surgery, a massive post-sternotomy defect of the chest wall developed in all the 13 patients due to deep sternal infection and osteomyelitis of the sternum and adjacent ribs. Vacuum wound drainage was applied in the treatment of all the patients. To stabilize the chest and the graft, transverse titanium plates were used, fixed using bicortical screws. The bone allograft was prepared by the official Tissue Centre. Crushed allogeneic spongy bone was applied to reinforce the line of contact of the graft and the edges of the residual skeleton. In 12 cases, the soft tissue was closed by direct suture of mobilized pectoral flaps. In one case, V-Y transposition of the pectoral flap was performed. RESULTS: In 8 cases, healing of the reconstructed chest wall occurred without further complications. In 4 cases, additional re-suture of soft tissues and skin in the lower pole of the wound was needed while the patients were still in the hospital. However, excellent chest wall stability along with adjustment of respiratory insufficiency and a very good cosmetic effect in the wound were achieved in all the 12 cases. In two cases, explantation of the plates was required. In one case, severe concomitant complications and no healing of the wound resulted in death within half a year after the reconstruction. The median follow-up period of all patients in the series was 21 months (136). In 5 cooperating patients, scintigraphy of the chest wall was performed repeatedly during the follow-up period showing a high healing activity of the graft and particularly of the crushed spongy bone. CONCLUSION: Our existing results show that allogeneic bone graft transplantation is a promising and easily applied method in the management of serious tissue loss in sternal dehiscence with favourable functional and cosmetic effects.Key words: sternotomy deep sternal wound infection massive post-sternotomy defect allogeneic bone graft.

Complex gunshot injury to the heart as a consequence of suicide attempt in a schizophrenic patient.

INTRODUCTION: Self-inflicted gunshot injury to the heart is uncommon in Western Europe countries. However it is considered to have a high mortality through cardiac tamponade or exsanguination and concomitant chest or abdominal cavity injury. CASE PRESENTATION: We present a 39-year-old schizophrenic woman who attempted suicide with the aid of a 6.35mm caliber handgun, after self-discontinuing of antipsychotic treatment. Lower third of sternum, right heart atrium and ventricle and inferior caval vein were hit by the bullet which consequently got lodged in the right paravertebral muscle mass at the lower thoracic vertebral level. As she was hemodynamically unstable due to hemopericardium and a huge right hemothorax, she underwent emergent surgery. Heart and inferior vena caval injuries were repaired on extracorporeal circulation. The postoperative course was uneventful and she was transferred to a psychiatric facility on the 7th postoperative day. One year after the surgery she is well, compliant to antipsychotic medications and on periodic follow-up by psychiatrists. CONCLUSION: This case represents management of complex self-inflicted gunshot cardiac injury in a schizophrenic patient who discontinued antipsychotic medication. Liaison between themedical rescue service and high level trauma center essentially reduced injury-to-surgery time. Complex heart injury was successfully repaired on extracorporeal circulation.

[Dissecting aortic aneurysm at Marfan syndrome--case report]. / Disekující aneuryzma aorty u Marfanova syndromu--kazuistika.

The authors present the case report of a Marfan syndrome patient with aneurysm of ascending, dissecting aneurysm of descending and abdominal aorta. Ascending aorta replacement with aortic valve sparing procedure was performed at first surgery. Later on descending and abdominal aorta were replaced. The patient was reoperated because of a chylus collection in retroperitoneal space. Three months following surgery the patient is completely recovered.

[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.