Prevalence of post-operative morbidity risk factors following cardiac surgery in patients with chronic viral hepatitis: a retrospective study.

OBJECTIVE: Current cardiac risk assessments such as EuroSCORE II and the STS-Score do not take liver dysfunction into account. The purpose of this study was to evaluate the prevalence and post-operative morbidity risk factors following cardiac surgery of patients with chronic viral hepatitis. PATIENTS AND METHODS: The study group consisted of 105 patients with documented chronic viral hepatitis who were subject to elective cardiac surgery from 2001 to 2012. Subjects were evaluated for pre-operative liver dysfunction according to the MELD score. RESULTS: The average MELD score of the study group was 10.00 ± 6.00. The average EuroSCORE ii of the study group was 2.07% ± 1.62%. The primary post-operative complication was cardiac complications (n=57, 54.3%). Analysis showed significant differences in meld score, bilirubin and smoking. Multivariate logistic regression analysis showed that the variables entering into the model included such risk factors with a significant or near significant (p < 0.2) influence on hospital morbidity and consisted in valve vs. coronary artery disease, valve/cad, aortic valve replacement vs. Coronary artery bypass graft, and bilirubin (mg/dl). CONCLUSIONS: it is vital that liver dysfunction is added to the risk models which are currently utilized to predict the post-operative morbidity of cardiac surgery patients.

[Etiology of ventilator-associated pneumonia at the Cardiovascular Surgery Clinic of Iasi]. / Etiologia pneumoniei asociata ventilatiei mecanice la clinica de chirurgie cardiovasculara din Iasi.

AIM: We want to assess the etiology of ventilator-associated pneumonia (VAP) and emergence of resistant phenotypes for greater efficiency of the first-line antimicrobial treatment post-cardiac surgery. The study focuses on patients with VAP post-cardiac surgery at the Institute of Cardiovascular Surgery between April 2nd 2002 and August 27th 2008, divided in two groups, before and after June 14th, 2005. MATERIAL AND METHODS: The tracheal aspirates were examined quantitatively (microscopy, culture). The isolates with clinical significance (> or = 106 CFU/mL) were identified by standard methods and tested by disk difussion or with the breakpoints method for susceptibility to antibiotics. RESULTS: Among the 1527 operated patients, 28 of them were diagnosed with VAP through the clinical pulmonary infection score > or = 6. The 9 most common pathogens in VAP etiology were Pseudomonas aeruginosa 23.81%, Acinetobacter baumannii 19.05%, Stenotrophomonas maltophilia 11.91%, Candida albicans 9.53%, while Klebsiella pneumoniae, Escherichia coli, Staphylococcus aureus, Corynebacterium striatum/amycolatum, Pneumocystis jirovecii amounted 4.76% each. Acinetobacter baumannii and S.maltophilia appear starting with June 15th, 2005. From that moment on we isolated with a higher frequency the gram-negative bacilli which produce extended-spectrum beta-lactamases 15.62%, with multidrug resistance (MDR) 46.86%. The MDR phenotype was more frequent at A.baumannii (15.62%), S. maltophilia (15.62%) and P. aeruginosa (12.50%) compared to K .pneumoniae (3.12%) or E. coli (0%). Methicillin-resistant S. aureus was isolated with a 6.25% frequency. CONCLUSIONS: The most common etiologic agents of ventilator-associated pneumonia post-cardiac surgery are Pseudomonas aeruginosa, Acinetobacter baumannii, Stenotrophomonas maltophilia and Candida albicans. The large use of antibiotics selects infectious agents with intrinsic resistance and multiresistant

A mediastinal germ cell tumor of yolk sac type--case report.

OBJECTIVE: We report an extremely rare case of germ-cell tumor localized at the level of the anterior mediastinum. CLINICAL PRESENTATION: A 36-year-old man who presented with left subclavial vein thrombosis was admitted to our hospital for specific cure. Computed tomographic scan of the chest showed a large anterior mediastinal mass. Surgical intervention revealed an infiltrative mediastinal tumor involving the left subclavial vein, which was biopsied for morphological examination. Histologically, the tumoral mass proved to be a carcinoma, with papillary and tubular growth patterns. Immunohistochemical stains for alpha-fetoprotein were positive in the tumor cells while stains for carcinoembryonic antigen and placental like alkaline phosphatase were negative. The serum level of alpha-fetoprotein of this patient was elevated, as well. This supported the diagnosis of Yolk sac tumor, a rare primary tumor within the mediastinum. Postsurgery, the patient received a combination chemotherapy consisting of cisplatin, vepesid and bleomycin every 3 weeks for a total of 4 cycles. During the treatment, the alpha-fetoprotein level, was decreasing. CONCLUSION: Primary mediastinal Yolk sac neoplasm is a rare tumor. The diagnosis should be made not only by morphological studies but also the patient's age and the elevation of serum alpha-fetoprotein. In spite of modern chemotherapy, the prognosis of mediastinal yolk sac tumor remains poor. The single most important prognostic indicator is whether the tumor mass can be completely excised before or after chemotherapy.

[Fungi as emergent etiologic agents in ventilator-associated pneumonia after cardiac surgery]. / Fungii ca agenti etiologici emergenti ai pneumoniei asociata ventilatiei mecanice post-chirurgie cardiaca.

UNLABELLED: Evaluation of the fungal involvement in the etiology of ventilator-associated pneumonia (VAP) after cardiac surgery. The study had as target the patients diagnosed with VAP after cardiac surgery at the Institute of Cardiovascular Diseases in Iasi, between April 2nd 2002 and December 31st 2009. MATERIAL AND METHOD: Our study included only cases with fungal etiology of VAP. We examined quantitatively the tracheal aspirates with cytology quality score Q = 2+: microscopy and cultivation. The isolates with clinical significance (= 10(6)UFC/mL significantly associated to inflammatory cells) were identified by standard methods or based on the API system (bioMérieux) and tested by the breakpoints method for susceptibility to antifungal agents. RESULTS: Among the 2167 operated patients, 35 of them were diagnosed with VAP through the clinical pulmonary infection score = 6. Fungi caused 15 of 44 VAP episodes. With a frequency of 30.19%, fungi are on 2nd place within the etiologic agents of VAP after non-fermenting Gram-negative bacilli (45.28%). The fungi involved in VAP were: Candida albicans (16.97%), Pneumocystis jirovecii (3.77%), while Candida glabrata, Candida sake, Candida krusei, Geotrichum capitatum and Cryptococcus humicola, amounted 1.89% each. The widespread use of broad spectrum antibiotics led to the emergence of fungi as a common cause of ventilator-associated pneumonia. The involvement in the VAP etiology of P. jirovecii, an un-cultivable fungus with special sensitivity to antibiotics, requires a careful microscopy of specimens.

[Postinfarction left ventricular saccular aneurysm]. / Anevrism sacular gigant al ventriculului stâng, postinfarct.

Postinfarction ventricular aneurysms may be either true or false, each with apparently definite diagnostic criteria on imaging techniques. We present the case of a 69 year-old male admitted to our hospital 6 weeks after an acute anterior myocardial infarction, for progressive exertional dyspnea. Transthoracic echocardiography demonstrated a large cystic cavity, 10 cm in diameter, communicating with the left ventricle's apex through an orifice of 5 cm diastolic diameter. The echocardiographic diagnosis was of a large, saccular aneurysm. Contrast ventriculography confirmed the existence of a large cavity connected to the apex of the left ventricle, 12 cm in diameter, with sluggish flow of contrast within it and features suggestive of pseudoaneurysm. The patient was referred for surgery because of continued symptoms and a preoperative diagnosis of either a large ventricular aneurysm or pseudoaneurysm. At the time of surgery a true aneurysm was found. We present this case because the rarity of a saccular configuration of a postinfarction left ventricular aneurysm, because of the unusual large size of it and to point on the possible disagreement between the conclusions of imaging modalities in differentiating a true from a false aneurysm.

[Adult onset Still's disease with normal level of serum ferritin]. / Boala Still a adultului cu manifestari aterosclerotice sistemice severe.

We present a case of an adult onset Still's disease: a 51 year old men presented with one month history of high spiking fever, asymmetric migratory polyarthritis and a previous history of pharyngitis. The diagnostic was based upon clinical criteria and laboratory findings, and necessitated the exclusion of infectious, neoplastic, and other "autoimmune" disease. The systemic involvement in our case induced us to comment therapy with corticosteroid. Patients with systemic disease have a favorable prognosis, with only rare serious complications from the disease (pericarditis, tamponade, diffuse intravascular coagulation, amyloidosis, hepatic disease, and respiratory failure) or the treatment (infections, gastrointestinal bleeding etc.).

[Post-cesarean acute aortic dissection in a Marfan syndrome patient]. / Disectie acuta de aorta postcezariana la o lehuza cu sindrom marfan. Prezentare de caz.

Marfan syndrome is an uncommon condition in pregnancy. We present the case of 37 years old gravida 1, para 1 with Marfan syndrome. She delivered at term by cesarean section, a healthy male infant weighing 3500 grams with Apgar's of 9. During the postoperative period she developed aortic dissection and was referred to the Cardiovascular Surgery Department. We described such a case and the difficult decisions that we faced.

[Five years of kidney transplantation in Iasi]. / Cinci ani de transplant renal în centrul universitar Iasi.

The activity of Renal Transplant Center Iasi started in November 2000, when we realized the first renal transplant from a live donor. Since then, 46 renal transplants were successfully realized in our center, to patients aged between 13-47 years (medium age = 30 +/- 5), M/F=27/19, 25 (56.8%) of them selected from HD, 17 (39.9%) from CAPD and 4 (8.7%) pre-emptive. Medium age of donors was 49.1 years (30-64), M/F=29/17. The donors were, in 78.3% of cases, first-degree relatives (parents, siblings). In 10 cases (21.7%) the grafts were donated by "emotionally related"donors (in most cases, spouses). An urologist-cardiovascular surgeon team, performed the transplant operations. There were no important complications during operation. We had one major vascular complication (graft artery thrombosis) in a 13 years recipient, successfully resolved after thrombectomy and stenting. Immunosuppressive therapy associated induction with monoclonal antibodies anti-Tac, cyclosporine, MMF and prednisone. Eight patients from 46 (17.39%) presented acute rejection episodes and all responded at corticosteroids. Medium values of serum creatinine were: 1.54 mg% at 1 month, 1.42 mg% at 6 months, 1.44 mg% at 1 year, 1.21 mg% at 2 years, 1.38 mg% at 3 years, 1.4 mg% at 4 years and 1.2 at 5 years. The survival of patients and donors is 100% and the survival of renal graft--97.1% (one case of chronic allograft nephropathy with lost of renal function). We also present the satisfactory evolution of the 51 renal transplanted patients addressed to our center from different other renal transplantation centers in Romania for management follow-up.

[Subacute bacterial endocarditis due to Pasteurella pneumotropica. Case Report]. / Endocardita bacteriana subacuta determinata de Pasteurella pneumotropica. Studiu de caz.

Endocarditis due to Pasteurella pneumotropica are very rarely described. We report a new case of bacterial endocarditis in a 43 years-old patient with mitral stenosis. The patient was admitted to the hospital for lethargy, malaise and hemiparesis. On physical examination, a new systolic murmur was found. Transthoracic echocardiography revealed a vegetation on the mitral valve. Three blood culture sets were drawn and after 24 hours of incubation, the last two sets yielded Pasteurella pneumotropica and cell wall deficient forms (L-forms). The patient was successfully treated with gentamicin and ceftriaxone and underwent mitral valve replacement.

Morphological evaluation of the surgically removed aortic and mitral valves.

In 2001, of the 114 valves surgically excised at the Iasi Center of Cardiology from 59 men and 54 women (mean age 51 years; age range: 25 to 78 years), half were aortic and the other half mitral valves. The 57 aortic valves, from 20 women and 37 men (mean age 51.1; age range 25 to 78 years), had been surgically replaced. Functionally, 57.63 percent (30) were stenotic, 21.05 percent (12) were incompetent, and 26.31 percent (15) were both stenotic and incompetent (aortic disease). Pure stenosis was related to calcification of degenerative (73.3 percent), bicuspid (3.33 percent), post-inflammatory (20 percent), and undetermined (3.33 percent) causes. Pure regurgitation was not related to calcification and causes included infective endocarditis (50 percent), bicuspid valve (16.66 percent), postinflammatory (16.66 percent), aortic root dilatation (8.33 percent), and undetermined (8.33 percent). Aortic disease was secondary to postinflammatory etiologies (40 percent), degenerative calcification (33.33 percent), bicuspid and undetermined (13.33 percent each) causes. The reminder of 57 mitral valves, from 35 women and 24 men (mean age 45.5 years; age range 28 to 71 years), were surgically replaced. Functionally, 40.35 percent (23) were purely stenotic, 19.29 percent (11) were purely regurgitant, and 40.35 percent (23) both stenotic and regurgitant (mitral disease). The causes of pure stenosis were postinflammatory (presumably rheumatic) disease in 91.3 percent (21 cases) and degenerative disease in 8.7 percent (3 cases). Pure regurgitation etiology involved floppy valves in 45.45 percent (5 cases), degenerative disease in 27.27 percent (3 cases), postinflammatory disease in 18.18 percent (2 cases) and infective endocarditis 9.1 percent (1 case).