Commemorating 50 years since the first heart transplantation in Bratislava - Czechoslovakia.

The first human-to-human heart transplantation in Czechoslovakia, and the 25th transplantation in the world, was performed in Bratislava, the second largest city in Czechoslovakia on July 9, 1968. The operation was carried out by a team led by Professors Karol Siska and Ladislav Kuzela at the second Surgical Clinic at the Comenius University of the Medical Faculty in Bratislava, Partizanska Street-only seven months after the first heart transplantation performed by Dr. Christiaan Barnard in Cape Town. Other members of the team in Bratislava included surgery recipients Siska, Kuzela, Pivkova, Holoman; surgery donors Schnorrer, Kuzela, Holoman; an extracorporeal circulation team of Treger, Carsky, Podolay; anesthesiologists Sobesky and Neumanova; operating room nurses Machkova, Homerova, Kralova, and operating room laboratory technician Malinova. The donor was P.V., a 46-year-old man, who suffered from a deadly brain trauma. The recipient was S.H., a 54-year-old woman with a failing heart, heavily affected diseased lungs, kidneys and liver. Her heart began to work, but lasted only for five hours. (Additional members of the team, Prof. Simkovic and Drs. Silvay and Sujansky were in the USA at the moment of transplantation, in Houston and New York, subsequently) (Tab. 1, Fig. 2, Ref. 62). Keywords: first heart transplantation in Bratislava, 2nd Surgical Clinic at the Comenius University.

Characterization of surgical cardiac tumors.

OBJECTIVE: The primary tumors of the heart are extremely rare. There are divided to benign, malignant and metastatic. Metastatic cardiac tumors are more common. METHODS: The incidence in contemporary echocardiographic series is reported at a higher frequency of 0.15%. 75% of cardiac tumors are benign; approximately half of these are cardiac mommas. The malignant cardiac tumors are mostly histopathologically undifferentiated, followed by leiomyosarcomas and angio-sarcomas. RESULTS: Cardiac tumors have a wide range of unique clinical presentation. Even the most benign and smallest tumor can lead to significant morbidity and mortality. The clinical presentations of the primary cardiac tumors are due to: blood flow obstruction, tumor embolization and constitutional symptoms. Clinical presentations can be varied and may resemble coronary disease, pericarditis, cardiomyopathy or valve malfunction. The recent technological advances in non-invasive imaging modalities such as echocardiography and cardiac magnetic resonance imaging is rapidly increases the early diagnosis and management approach. CONCLUSION: In this review we aim to summarize the characterization of the most common cardiac tumors. Early recognition and treatment provided the best results (Tab. 2, Fig. 6, Ref. 66).

Major themes for 2013 in cardiothoracic and vascular anaesthesia and intensive care.

There has been significant progress throughout 2013 in cardiothoracic and vascular anaesthesia and intensive care. There has been a revolution in the medical and interventional management of atrial fibrillation. The medical advances include robust clinical risk scoring systems, novel oral anticoagulants, and growing clinical experience with a new antiarrhythmic agent. The interventional advances include left atrial appendage occlusion for stroke reduction, generalization of ablation techniques in cardiac surgery, thoracoscopic ablation techniques, and the emergence of the hybrid ablation procedure. Recent European guidelines have defined the organization and practice of two subspecialties, namely general thoracic surgery and grown-up congenital heart disease. The pivotal role of an effective multidisciplinary milieu is a central theme in both these clinical arenas. The anaesthesia team features prominently in each of these recent guidelines aimed at harmonizing delivery of perioperative care for these patient cohorts across Europe. Web-Enabled Democracy-Based Consensus is a system that allows physicians worldwide to agree or disagree with statements and expert consensus meetings and has the potential to increase the understanding of global practice and to help clinicians better define research priorities. This "Democratic based medicine", firstly used to assess the interventions that might reduce perioperative mortality has been applied in 2013 to the setting of critically ill patient with acute kidney injury. These advances in 2013 will likely further improve perioperative outcomes for our patients.

Practice variations in the conduct of hypothermic circulatory arrest for adult aortic arch repair: focus on an emerging European paradigm.

INTRODUCTION: Hypothermic circulatory arrest for adult aortic arch repair is still high-risk. Despite decades of clinical experience, significant practice variations exist around the world. These practice variations in hypothermic circulatory arrest may offer multiple opportunities to improve practice. The hypothesis of this study was that the current conduct of adult hypothermic circulatory arrest in Europe has significant variations that might suggest opportunities for risk reduction. METHODS: An adult hypothermic circulatory arrest questionnaire was developed and then administered at thoracic aortic sessions at international conferences during 2010 in Beijing and Milan. The data was collected, abstracted and analyzed. RESULTS: The majority of the 105 respondents were anesthesiologists based in Europe and China. The typical adult aortic arch repair in Europe was with hypothermic circulatory arrest at moderate hypothermia utilizing bilateral antegrade cerebral perfusion, typically monitored with radial arterial pressure and cerebral oximetry. Brain temperature was frequently measured at distal locations. The preferred neuroprotective agents were steroids, propofol and thiopental. CONCLUSIONS: The opportunities for outcome improvement in this emerging European paradigm of tepid adult aortic arch repair include nasal/tympanic temperature measurement and adoption of unilateral antegrade cerebral perfusion monitored with radial artery pressure and cerebral oximetry. The publication of an evidence-based consensus would enhance these practice-improvement opportunities.

Current conduct of deep hypothermic circulatory arrest in China.

INTRODUCTION: Deep hypothermic circulatory arrest for adult aortic arch repair is still associated with significant mortality and morbidity. Furthermore, there is still significant variation in the conduct of this complex perioperative technique. This variation in deep hypothermic circulatory arrest practice has not been adequately characterized and may offer multiple opportunities for outcome enhancement. The hypothesis of this study was that the current practice of adult deep hypothermic circulatory arrest in China has significant variations that might offer therapeutic opportunities for reduction of procedural risk. METHODS: An adult deep hypothermic circulatory arrest questionnaire was developed and then administered at a thoracic aortic session at the International Cardiothoracic and Vascular Anesthesia Congress convened in Beijing during 2010. The data was abstracted and analyzed. RESULTS: The majority of the 56 respondents were anesthesiologists based in China at low-volume deep hypothermic circulatory arrest centers. The typical aortic arch repair had a prolonged deep hypothermic circulatory arrest time at profound hypothermia. The target temperature for deep hypothermic circulatory arrest was frequently measured distal to the brain. The most common perfusion adjunct was antegrade cerebral perfusion, typically monitored with radial arterial pressure and cerebral venous oximetry. The preferred neuroprotective agents were steroids and propofol. CONCLUSIONS: The identified opportunities for outcome improvement in this delineated deep hypothermic circulatory arrest model include nasal/tympanic temperature measurement and routine cerebral perfusion, preferably with unilateral antegrade cerebral perfusion monitored with radial artery pressure and cerebral oximetry. Development and dissemination of an evidence-based consensus would enhance these practice-improvement opportunities.

John Heysham Gibbon and the 60th anniversary of the first successful heart-lung machine: brief notes about the development of cardiac surgery in Europe and Slovakia.

The development of the heart-lung machine and its first successful clinical application in 1953 was the culmination of Dr. Gibbon's lifetime research project. Despite many technical obstacles, financial problems, and discouragement from colleagues, his goal was achieved after twenty tedious years of tireless work. Posteriorly, his academic contribution established him as a leader and pioneer in the field of cardiac surgery. Parallel to his achievement and Dr. Kirklin's surgical experience, several authors around the world attempted open-heart surgery with the heart-lung machine, particularly in Europe. In Eastern Europe and particularly in the former Czechoslovakia, the lack of access to foreign medical literature forced a group of emerging young physicians from the Second Department of Surgery at Comenius University to furtively collect data on the topic. After building the Simkovic-Bolf heart-lung machine, the first successful open-heart surgery with the new device was performed only 5 years after Dr. Gibbons' experience (Tab. 1, Fig. 4, Ref. 22).

Mortality reduction in cardiac anesthesia and intensive care: results of the first International Consensus Conference.

There is no consensus on which drugs/techniques/strategies can affect mortality in the perioperative period of cardiac surgery. With the aim of identifying these measures, and suggesting measures for prioritized future investigation we performed the first International Consensus Conference on this topic. The consensus was a continuous international internet-based process with a final meeting on 28 June 2010 in Milan at the Vita-Salute University. Participants included 340 cardiac anesthesiologists, cardiac surgeons, and cardiologists from 65 countries all over the world. A comprehensive literature review was performed to identify topics that subsequently generated position statements for discussion, voting, and ranking. Of the 17 major topics with a documented mortality effect, seven were subsequently excluded after further evaluation due to concerns about clinical applicability and/or study methodology. The following topics are documented as reducing mortality: administration of insulin, levosimendan, volatile anesthetics, statins, chronic ß-blockade, early aspirin therapy, the use of pre-operative intra-aortic balloon counterpulsation, and referral to high-volume centers. The following are documented as increasing mortality: administration of aprotinin and aged red blood cell transfusion. These interventions were classified according to the level of evidence and effect on mortality and a position statement was generated. This International Consensus Conference has identified the non-surgical interventions that merit urgent study to achieve further reductions in mortality after cardiac surgery: insulin, intra-aortic balloon counterpulsation, levosimendan, volatile anesthetics, statins, chronic ß-blockade, early aspirin therapy, and referral to high-volume centers. The use of aprotinin and aged red blood cells may result in increased mortality.

Mortality reduction in cardiac anesthesia and intensive care: results of the first International Consensus Conference.

BACKGROUND: There is no consensus on which drugs/techniques/strategies can affect mortality in the perioperative period of cardiac surgery. With the aim of identifying these measures, and suggesting measures for prioritized future investigation we performed the first international consensus conference on this topic. METHODS: The consensus was a continuous international internet-based process with a final meeting on June 28th 2010 in Milan at the Vita-Salute University. Participants included 340 cardiac anesthesiologists, cardiac surgeons and cardiologists from 65 countries all over the world. A comprehensive literature review was performed to identify topics that subsequently generated position statements for discussion, voting and ranking. RESULTS: Of the 17 major topics with a documented mortality effect, seven were subsequently excluded after further evaluation due to concerns about clinical applicability and/or study methodology. The following topics are documented as reducing mortality: administration of insulin, levosimendan, volatile anesthetics, statins, chronic beta-blockade, early aspirin therapy, the use of preoperative intra-aortic balloon counterpulsation and referral to high-volume centers. The following are documented as increasing mortality: administration of aprotinin and aged red blood cell transfusion. These interventions were classified according to the level of evidence and effect on mortality and a position statement was generated. CONCLUSION: This international consensus conference has identified the non-surgical interventions that merit urgent study to achieve further reductions in mortality after cardiac surgery: insulin, intra-aortic balloon counterpulsation, levosimendan, volatile anesthetics, statins, chronic beta-blockade, early aspirin therapy, and referral to high-volume centers. The use of aprotinin and aged red blood cells may result in increased mortality.

Cerebral oximetry in cardiac and major vascular surgery.

We describe the development and current applications of cerebral oximetry (based on near-infrared reflectance spectroscopy) that can be used during cardiac and major vascular surgery to determined brain tissue oxygen saturation. There are presently three cerebral oximetry devices with FDA approval in the United States to measure and monitor cerebral tissue oxygen saturation. 1. INVOS (Somanetics Corporation, Troy, MI - recently COVIDIEN, Boulder, CO); FORE-SIGHT (CAS Medical Systems, Inc. Branford, CT); EQUANOX (Nonin Medical Inc.Minnesota, MN). All devices are portable, non-invasive and easy to use in operating room and intensive care unit. The data provided in these communication may provided information for improvement of perioperative neuromonitoring techniques, and may be crucial in the design of future clinical trials.

Day admission for thoracic aortic surgery.

Elective cardiac surgical patients can be admitted on the morning of the operation. The day admission surgery is safe with optimal care for patients and provides an economical benefit. In our institution if immediate surgery is not required, patients are entered into program for serial follow up. An elective aortic intervention for open surgical or endovascular surgery is recommended when the risk of aortic rupture outweighs the risk of surgery. Patients are seen 3 to 7 days prior of day admission surgery in preoperative clinic. On the morning of surgery, the patient undergoes a reassessment to ensure no interval changes have occurred. We hereby describe our three years experience with 350 patients were referred from the Aortic Aneurysm Surveillance Program. We believe that not only patients, but all medical personal benefit from a complete preoperative evaluation of these complicated patients and this creates harmony during the entire hospitalization!

Cardiac anesthesia and surgery in geriatric patients: epidemiology, current surgical outcomes, and future directions.

The mean life expectancy of the population of the United States is projected to increase from 78.3 years at present to over 81 years in 2025, with a concomitant increase in the percentage of the population over the age of 75 years. Elderly patients are more likely to present with valvular and coronary artery disease than younger patients, and as better perioperative management contributes to improving post-operative outcomes and lower referral thresholds, very elderly patients form an increasingly large proportion of the cardiac surgical population. This article summarizes the impact of age-related pathophysiologic changes on patients' response to cardiac surgery and anesthesia, outlines useful perioperative strategies in this age group, and reviews the literature on outcomes after valvular and coronary in elderly patients.

Descending thoracic and thoracoabdominal aneurysm.

The low incidence of permanent spinal cord injury in our most recent cohort (Group II) of patients suggests that serial sacrifice of intersegmental vessels, careful monitoring of spinal cord function are effective in preventing paraplegia after descending thoracic and thoracoabdominal aneurysm operations. Updated anesthetic and postoperative care minimized overall mortality risk. (Ref. 9.)

Factors that influence early extubation: bleeding.

Excessive bleeding after cardiac surgery is an important factor that can prevent early extubation. Hemostatic derangement is well recognized to be associated with cardiopulmonary bypass, with many possible contributing factors resulting in coagulation defects and fibrinolytic pathway activation. Measures to optimize hemostasis are critical when managing patients for whom early extubation and hospital discharge are goals. The intraoperative evaluation of the hemostatic system with tests like the thrombelastogram and the use of therapeutic agents such as aprotinin are simple, safe, and effective methods of achieving these goals.

Hemostasis in aortic and cardiothoracic surgery.

Hemostasis abnormalities in cardiovascular and aortic surgery remain a major source of morbidity and mortality in patients undergoing such complex procedures. The need for frequent transfusions of red cell and other blood products increases risks and costs to patients and institutions providing patient care. Specifically in cardiovascular and aortic surgery, the nature of the surgery is, at best, semi-elective, and careful preparation to preserve the hemostatic mechanisms of the body is essential. Contact of blood with the extracorporeal circuit induces a hemorrhagic diathesis through a variety of different mechanisms. Dilution of the patient's blood volume by the extracorporeal circuit prime causes depletion of platelets and coagulation factor levels. Aorto intimal disease initiates fibrinolysis by the release of tissue plasminogen activator. Due to the numerous etiologies of bleeding, a combination of blood conservation strategies is suggested. The ideal combination of interventions has yet to be determined and is currently dependent on patient variables, physician and institutional practices, and economic pressures.

Autologous platelet-rich plasmapheresis: risk versus benefit in repeat cardiac operations.

Preoperative platelet-rich plasmapheresis has been suggested as a means of reducing homologous blood transfusions in cardiac surgical patients. The current study evaluated this technique in patients undergoing repeat cardiac operations. Fifty-two patients undergoing repeat myocardial revascularization and/or valve replacement were evaluated in a prospective randomized controlled study design. Autologous platelet-rich plasma (PRP) was harvested after the induction of anesthesia in the experimental group. After reversal of heparin, each patient received his or her autologous plasma. Patients in the control group did not have plasmapheresis and received standard transfusion therapy if coagulation variables were abnormal and a coagulopathy was clinically evident. Routine coagulation tests, thromboelastography (TEG), perioperative bleeding, and transfusion requirements were compared in the two groups. Forty-four patients completed the study. A significantly larger volume of packed red blood cells (PRBCs) was transfused in the PRP group than in the control group (P = 0.03). Platelet and fresh frozen plasma (FFP) transfusions did not differ between the two groups. Mediastinal tube drainage did not differ between the two groups. During PRP infusion, 60% of the patients required treatment for moderate hypotension (mean arterial pressure [MAP] < 60 mm Hg). Only 16% of control patients required treatment for hypotension during the comparable time period (P < 0.05). No patient who completed the study returned to the operating room for postoperative bleeding. These data suggest that PRP did not reduce postbypass bleeding or transfusion requirements in repeat cardiac surgical patients. Moreover, the incidence of hypotension during PRP reinfusion introduces a potential risk to the procedure in the absence of any obvious benefit.