Long-Term Follow-Up of Patients Needing Extracorporeal Membrane Oxygenation Following a Critical Course of COVID-19.

INTRODUCTION: Severe respiratory failure is one of the most serious complications of coronavirus disease 2019 (COVID-19). In a small proportion of patients, mechanical ventilation fails to provide adequate oxygenation and extracorporeal membrane oxygenation (ECMO) is needed. The surviving individuals need long-term follow-up as it is not clear what their prognosis is. AIM: To provide a complex clinical picture of patients during follow-up exceeding one year after the ECMO therapy due to severe COVID-19. METHODS: All subjects involved in the study required ECMO in the acute stage of COVID-19. The survivors were followed-up for over one year at a specialized respiratory medical center. RESULTS: Of the 41 patients indicated for ECMO, 17 patients (64.7% males) survived. The average age of survivors was 47.8 years, and the average BMI was 34.7 kg·m-2. The duration of ECMO support was 9.4 days. A mild decrease in vital capacity (VC) and transfer factor (DLCO) was observed on the initial follow-up visit (82.1% and 60%, respectively). VC improved by 6.2% and by an additional 7.5% after 6 months and 1 year, respectively. DLCO improved by 21.1% after 6 months and remained stable after 1 year. Post-intensive care consequences included psychological problems and neurological impairment in 29% of patients; 64.7% of the survivors got vaccinated against SARS-CoV-2 within 12 months of hospitalization and 17.6% experienced reinfection with a mild course. CONCLUSION: The COVID-19 pandemic has significantly increased the need for ECMO. Patients' quality of life after ECMO is temporarily significantly reduced but most patients do not experience permanent disability.

The use of extracorporeal membrane oxygenation in the treatment of critical course of pneumonia.

Extracorporeal membrane oxygenation is the highest form of resuscitation care in management of patients with respiratory failure. In the case of acute respiratory distress syndrome, the veno-venous setting is more often used. ECMO support enables, in case of lung function failure, to obtain the necessary time for the onset of the causal treatment effect or is used as a bridge to transplantation Mortality of the patients varies according to the underlying cause and presence of risk factors (e.g., age, complications or comorbid diseases). The onset of the COVID-19 pandemic has led to a significant increase in the need for ECMO. The quality of life of patients after ECMO is significantly reduced, but most patients do not experience permanent disability.

Expansive intracardiac leiomyosarcoma - a combined therapeutic approach resulting in survival with complete remission. A literature review and case report.

Primary cardiac sarcomas are extremely rare and often with dismal prognosis. Only a few case series and retrospective studies regarding its biological characteristics, diagnostics, and treatment were reported. The multi-modality therapeutic strategy has been discussed in the published literature, but often with contradictory results. There is thus, no consensus on the optimal therapeutic approach to date. We present the case report of the 66-year old female endangered by a large primary leiomyosarcoma expanding in the right-sided heart chambers with imminent risk of acute obstruction of blood flow. The patient was managed by urgent surgical resection. After the histological confirmation of incomplete R1 resection, the treatment was supplemented by adjuvant CT-targeted radiotherapy, resulting in extraordinary survival with complete remission over a 24-month follow-up period. Our case report aims to demonstrate a favorable result of an individually suited complex surgical and oncological treatment to support the multidisciplinary therapeutic approach to these patients. The article is supplemented by a detailed literature review providing a theoretical background and an overview of the acquired knowledge and possible strategies.

Thoracoscopic epicardial ablation of atrial fibrillation: Safety, efficacy, single center experience.

AIMS: Atrial fibrillation (AF) is associated with reduced quality of life and increased risk of ischaemic cerebrovascular events. The left atrial epicardial ablation procedures have evolved towards a successful and safe rhythm control strategy for patients with symptomatic drug-refractory paroxysmal, persistent or post-ablation AF or with a high risk of catheter ablation failure. The aim was to evaluate the efficacy and safety of thoracoscopic ablation at our instituiton. METHODS: We observed 81 patients undergoing thoracoscopic ablation from January 2015 to December 2019. RESULTS: The mean age was 61.3±8.5 years and the average duration of AF was 3.1±2.6 years. The cohort consisted of 16.5% of paroxysmal AF, 36.7% persistent, and 46.8% of long-standing AF. The procedure was completed in 79 patients; during follow-up, 15 patients (19%) received radiofrequency ablation. Freedom from atrial arrhythmia recurrence was 55.7% after a follow-up (FUP) period of 3.1±1.4 years. At the follow-up visit, sinus rhythm was present in 81% of patients. No relationships between arrhythmia recurrence and BMI, LVEF, left atrial dimension, gender, and AF duration were found. Major complications were noticed in 4 patients (5.0%); 2 had peripheral embolisation, 2 patients were converted to a sternotomy. At the time of the FUP visit, 25.3% of patients were using antiarrhythmic and 74.7% were still using anticoagulants. CONCLUSION: In the majority of patients, sinus rhythm remained despite a considerable atrial tachycardia recurrence rate, with a relatively low percentage of patients on antiarrythmic drugs.

COVID-19 and post-COVID - Jekyll and Hyde of modern medicine.

COVID-19 pandemic has massive impact on the whole world, lead to the death of milions of people and required excessive restrictions with large economical, psychological and other impacts. Post-COVID syndrome is defined according to the Czech pneumological and phtizeological society as a complex of symptoms persisting for more than 12 weeks from the acute stage of COVID-19 and which is not possible to explain by other causes. Exact pathopysiological mechanisms and its frequency are still not known, and the data from the literature are not consisent. We present case reports of 2 patients with very different disease and convalescence course. COVID-19 and post-COVID syndrome represent large space for the further research. The prediction of the persisting limitations and other consequencies of the diseases is still not possible. Even though there is usualy higher incidence of post-COVID symptoms in patients surviving severe COVID-19 course, the presented case reports show paradoxically exactly the oposite situation.

From open packing to negative wound pressure therapy: A critical overview of deep sternal wound infection treatment strategies after cardiac surgery.

Deep sternal wound infection is a challenging aspect of modern cardiac surgery. The considerable mortality rate, devastating morbidity and, negative impact on long-term survival has driven cardiac and plastic surgeons to seek a more advantageous treatment solution. This review summarizes progress in the field of deep sternal wound infection treatment after cardiac surgery. Emphasis is placed on outcomes analysis of contemporary treatment strategy based on negative pressure wound therapy followed by sternotomy wound reconstruction, and its comparison with conventional treatment modalities used afore. Furthermore, complications and drawbacks of treatment strategies are critically evaluated to outline current options for successfully managing this life-threatening complication following cardiac surgery.

Endoscopic radial artery harvesting for coronary artery bypass grafting. A single center evolving experience.

AIM: We sought to evaluate our experience with endoscopic radial artery harvesting for coronary artery bypass grafting (CABG). METHODS: From October 2005 to June 2010, 50 patients who underwent endoscopic radial artery harvesting for an elective CABG were prospectively assessed for harvesting characteristics, complications, postoperative and mid-term outcomes. RESULTS: There were 34 (68%) males and 16 (32%) females, average age 60.8 ± 9.2 years. All but two RA grafts (96%) were successfully harvested endoscopically. Mean harvesting time was 46.2 ± 9.3 min and mean length of harvested grafts was 23.4 ± 2.2 cm. In the post-operative period there were no wound-healing complications; residual forearm edema was recorded in 6 patients (12%) and peripheral neuropathy in 4 patients (8%). At 3 months after the surgery, peripheral neuropathy and residual edema persisted in 2 patients (4%). A significant drop of overall harvesting time (56.2 ± 18.6 vs. 38.6 ± 8.6 min, P<0.05) and forearm ischemia time (41.8 ± 12.7 vs. 24.2 ± 3.2 min, P<0.01) was found between first and last ten cases in the group. CONCLUSION: Endoscopic radial artery harvesting was associated with low risk of post-harvesting complications and most of these disappeared within a 3 months follow-up. However, there was a significant learning curve.

Pectoral muscle flap with V-Y skin paddle for covering sternal defects.

Deep sternal wound infection (DSWI) after a cardiac operation is a rare but serious complication associated with significant morbidity and mortality. It can lead to wound dehiscence with sternal osteomyelitis and both bony and soft tissue residual defects. When the infection is eradicated, reconstruction of the thoracic wall remains the main challenge. Tissue used for covering the defect must be well nourished and sutures must be tension free. We present our unique modification of the method using the pectoral muscle axial flap with a V-Y skin paddle.

Comparison of functional fibrinogen assessment using thromboelastography with the standard von Clauss method.

AIM: To compare assessment of fibrinogen by thromboelastography with the standard von Clauss method. METHODS: Observational prospective study. RESULTS: Thromboelastography provides direct and complex evaluation of the entire coagulation cascade based upon changes in blood viscosity. It affects both platelets and plasma components. New application of this method measures fibrinogen contribution to coagulation as opposed to fibrinogen antigen levels measured by immunoassay. Paired samples from 117 patients before cardiopulmonary bypass were compared. A moderate correlation was found between fibrinogen and functional fibrinogen with a Spearman correlation coefficient of 0.476. CONCLUSION: The functional fibrinogen test is a valid point-of-care method for fibrinogen assay with a moderate correlation to the standard method.

Accidental deep hypothermia with cardiac arrest. Prompt complete recovery after rewarming by extracorporeal circulation. Case report.

BACKGROUND: Deep accidental hypothermia (core temperature <28 degrees C) is an uncommon medical emergency requiring rapid active core rewarming. Extracorporeal circulation has become the treatment of choice for deep hypothermic patients with cardiac arrest. CASE REPORT: We report on a 30-year-old patient who suffered from deep accidental hypothermia (core temperature 24.8 degrees C) and cardiac arrest by prolonged exposure to a cold urban environment as a consequence of severe ethylalcohol intoxication. The rewarming with the aid of extracorporeal circulation was initiated shortly after his arrival at the hospital. External cardiac massage was maintained until full ECC fl ow was established. The patient was weaned from extracorporeal circulation after 157 min, awaked 4 hours later and consequently extubated within 16 hours after rewarming with no neurological impairment. At 3-week follow-up, the patient was fully re-integrated in his work and personal life. CONCLUSION: This case demonstrates the excellent prognosis of a young victim in the case of deep accidental hypothermia with cardiac arrest, provided that deep hypothermia precedes the cardiac arrest and rewarming by extracorporeal circulation is immediately applied. Simultaneous ethyl alcohol intoxication can be considered a protective factor improving the patient's outcome. Complete recovery was achieved within 24 hours after the accident.

Postoperative and mid-term wound disturbance outcomes of minimally invasive saphenous vein harvest using the VEGA system.

Great saphenous vein harvest is associated with a significant risk of impaired wound healing. The purpose of this study was to determine efficacy of one system designed for minimally invasive vein harvest (MIVH) and to assess postoperative and mid-term wound-healing disturbances. From February 2004 to June 2005, great saphenous harvest for coronary artery bypass grafting (CABG) was performed in a group of 120 consecutive patients employing the VEGA system (B/Braun-Aesculap, Tuttlingen, Germany). Patients were evaluated on 7th postoperative day, at the 3-month and 1-year follow-up for wound healing disturbances, residual leg edema, and saphenous neuropathy. The mean age was 67.3 years, male patients dominated (70%), and the leading procedure was CABG (83%). The mean number of harvested venous grafts was 1.9 +/- 1.2 and the mean number of skin incisions was 3.7 +/- 2.2. The mean total vein harvesting time was 40.2 +/- 16.8 minutes. Satisfactory healing was achieved in 98% patients on 7th postoperative day and at the 3-month follow-up all wounds were completely healed. Saphenous neuralgia remained a significant cause of morbidity, although its incidence decreased from 25% presented on 7th postoperative day to 8% presented at 1-year follow-up. Likewise, the incidence of leg edema decreased from 34% on the 7th postoperative day to 7% at 1-year follow-up. Minimally invasive vein harvest is a safe method associated with a significant reduction of wound disturbances. The VEGA system appears to be suitable and effective equipment for MIVH. Nevertheless, residual edema and mainly saphenous neuropathy represent a relatively frequent cause of patient morbidity at the postoperative and mid-term follow-up.

Simultaneous endoscopic radial artery and great saphenous vein harvesting for redo coronary artery bypass grafting. A report of two cases.

AIM: An ageing population and increase in patient co-morbidities are forcing cardiac surgeons to meticulously consider the benefits and risks of respective conduits and their harvesting techniques. CASE REPORTS: Two cases of simultaneous endoscopic radial artery and great saphenous vein harvesting, for redo coronary artery bypass grafting, are presented. A shortage of venous conduits after previous bypass grafting, as well as the presentation of several risk factors of wound-healing complications, favoured simultaneous utilisation of both endoscopic techniques. CONCLUSION: Endoscopic vessel harvesting together with the pre-harvesting duplex study is able to gain not only high-quality conduits but also minimize the risk of wound-healing and neurological disturbances associated the saphenous vein and radial artery harvesting.

Vacuum-assisted closure in the treatment of sternal wound infection after cardiac surgery.

AIM: Vacuum-assisted closure (VAC) was primarily designed for the treatment of pressure ulcers or chronic, debilitating wounds. Recently, VAC has become an encouraging treatment modality for sternal wound infection after cardiac surgery, providing superior results to conventional treatment strategies. METHODS: From November 2004 to September 2006, 34 patients, undergoing VAC therapy for sternal wound infection following cardiac surgery, were prospectively evaluated. Ten patients (29 %) were treated for superficial sternal wound infection and 24 (71 %) for deep sternal wound infection. The median age was 69.9 years (range 48 to 82) and the median BMI was 33.4 kg/m(2) (range 28 to 41). Twenty patients (59 %) were women and 19 patients (59 %) were diabetics. Owing to sternal wound infection complications, 16 patients (47 %) were readmitted to the department. VAC was used following the previous failure of the conventional treatment strategy in 7 patients (21 %). RESULTS: Thirty-three patients (97 %) were treated successfully. One patient (3 %) died of multiple organ failure. The overall length of hospitalization was 34.6 days (range 9 to 62). The median number of dressing changes was 4.6 (range 3 to 10). The median VAC treatment time until surgical closure was 9.2 days (range 6 to 21 days). VAC therapy was solely used as a bridge to definite wound closure. Three patients (9 %) with chronic fistula were re-admitted 1 to 6 months after VAC therapy. CONCLUSIONS: VAC therapy is a safe and reliable option in the treatment of sternal wound infection in cardiac surgery. VAC therapy should be considered an effective adjunct to conventional treatment modalities for the treatment of extensive and life-threatening wound infections following cardiac surgery, particularly in the presence of risk factors.

Sequential bypass grafting on the beating heart: blood flow characteristics.

BACKGROUND: The sequential bypass technique is a routine method of myocardial revascularization. The aim of this study was to determine flow characteristics of individual and sequential bypass grafts created on the beating heart. METHODS: Between January 2003 and February 2004, a consecutive series of 50 patients underwent off-pump coronary bypass surgery with at least one venous sequential coronary graft. During the procedure, flow values and pulsatility indexes were measured in both segments of the sequential graft using a CardioMed transit time flow meter (CM 4008; Medi-Stim, Oslo, Norway). The flow values were simultaneously compared with those of individual venous grafts sutured to the same coronary arteries. RESULTS: The mean flow through the distal anastomosis (individual bypass; D1) was 37.4 mL/min, and this was not significantly influenced by the creation of a proximal sequential anastomosis (D2, 39.0 mL/min). In 32% of the patients, the sequential bypass was unwittingly connected proximally to a larger coronary bed; despite this, the flow in its distal segment was not less than that in the individual bypass. CONCLUSIONS: The blood flow through an individual bypass is comparable with that through the distal segment (end-to-side anastomosis) of a sequential bypass. The grafting of a sequential bypass proximally to the larger artery (coronary bed) in sequence does not appear to have a significant effect on the blood flow in the distal segment of a sequential bypass.