One-year results from cryopreserved mitral allograft transplantation into the tricuspid position in a sheep experimental model.

Mitral allografts are still used only exceptionally in the mitral or tricuspid position. The main indication remains infectious endocarditis of atrioventricular valves for its flexibility and low risk of infection. The aim of our study was to evaluate 1-year results of mitral allografts transplantation into the tricuspid position in a sheep model. Mitral allografts were processed, cryopreserved, and transplanted into the tricuspid position anatomically (Group I - 11 animals) or antianatomically (Group II - 8 animals). All survivors (4 from Group I, and 3 from Group II) were checked at 3, 6, and 12 months by echocardiography with the exception of one survivor from Group II (which was examinated only visually). Examination throughout follow-up included for mitral allograft regurgitation and annuli dilatation. At postmortem, the papillary muscles were healed and firmly anchored to the right ventricular wall in all subjects. Transventricular fixation of the papillary muscles with buttressed sutures was proven to be a stable, reproducible, and safe method for anchoring mitral allograft leaflets. There were no significant differences between the two implantation methods. Annulus support of mitral allografts might be very useful in this type of operation and could prevent annular dilatation.

[Left ventricular myxoma - an unexpected cause of dyspnoea and fever in a young patient]. / Myxom levé síne - necekaná prícina dusnosti a teplot mladého pacienta.

Primary cardiac tumours are rare. In 75% of cases, these are benign, mainly myxomas. The present case study describes a patient with an impressive epidemiological history, examined at a department of infectious diseases for progressing dyspnoea and subfebrile states. As part of differential diagnosis, the patient was sent for cardiological examination. Echocardiography unexpectedly revealed tumour of the left ventricle that explained patients symptomatology. The tumour was then quickly removed using right minithoracotomy and histology confirmed myxoma. The patient was, also due to the mini-invasive nature of the intervention, discharged from the hospital to home care on the 4th day of hospitalization with practically no complaints.

[Simultaneous carotid endarterectomy and coronary revascularization: indications and results]. / Simultánní karotická endarterektomie a koronární revaskularizace: indikace a výsledky.

AIM: Evaluation of operative results and complications in high-risk patients who underwent combined carotid and coronary revascularization. PATIENTS AND METHODS: Combined operation--carotid endarterectomy (CEA) and coronary artery bypass graft (CABG) was performed in the period 2000-2009 in 68 patients. Simultaneous operation was indicated in patients with unstable angina pectoris and 1. symtomatic internal carotid artery (ICA) stenosis > or = 50%, or 2. bilateral asymptomatic ICA stenosis > or = 60% or 3. asymptomatic ICA stenosis > or = 60% combined with contralateral ICA occlusion. Combined operations represented 5.8% of whole CEA series. Mean age was 69.9 (51-82) years, men were 46, women 22. Carotid angiography proved unilateral (always symptomatic) ICA stenosis in 25 patients, bilateral ICA stenosis in 35 patients and ICA stenosis combined with contralateral carotid occlusion in 8 patients. Neurological preoperative symptomatology: TIA was present in u 20 patients, minor stroke in 6 and major stroke in 5 patients. 37 patients were asymptomatic. One CABG was performed in 5 patients, 2 CABG in 20 patients, 3 CABG in 19 patients and 4 CABG in 6 patients. The rest of 18 patients had CABG operation combined with valve procedure. Comorbidity: hypertension 100%, diabetes mellitus 57.3%, hyperlipidemia 60.3%. Shunt was selectively used in 4.4%. The need for shunt was established using back stump pressure and near infrared spectroscopy. RESULTS: Mortality was 8.8% (6/68). The cause of death were multiorgan failure in two cases, ipsilateral stroke in two patients, respiratory insufficiency and cardiac failure due to graft occlusion both in one patient. Good recovery was recorded in 91.2%. CONCLUSION: Combined carotid and coronary revascularization has acceptable neurological morbidity/mortality in high risk patients. Strict requirement is thorough selection of patients.

Mechanical properties of mitral allografts are not reasonably influenced by cryopreservation in sheep model.

A mitral allograft is used exceptionally in the mitral, as well as in the tricuspid position, mostly as an experimental surgical procedure. The authors decided to evaluate the possibility of inserting a cryopreserved mitral allograft into the tricuspid position in a sheep experimental model. Within the framework of this experimental project the mechanical properties of the cryopreserved mitral allograft were tested. A novel methodology studying the functional unit composed of mitral annulus, leaflet, chordae tendinaea, and papillary muscle is presented. A five-parameter Maxwell model was applied to characterize the viscoelastic behavior of sheep mitral valves. A control group of 39 fresh mitral specimens and a test group of 13 cryopreserved mitral allografts from tissue bank were tested. The testing protocol consisted of six loading cycles with 1 mm elongation every 5 min. There was no significant difference in the mean values of the determined parameters (p>0.05) which confirms the main hypothesis that cryopreservation does not influence significantly material parameters characterizing the tissue mechanics. Slight discrepancy is observed in variances of viscous parameters suggesting that the values of the test group may be spread over larger interval due to the treatment.

[Midterm results aortic valve replacement with allograft]. / Strednedobé výsledky implantací aortálního alograftu.

INTRODUCTION: Aortic allograft implantation into the aortic position in adults is standard procedure with some controversary. The most popular indication is bacterial endocarditis. We would like to present our midterm results. RESULTS: We implanted 61 allografts in 60 patients (between 10/2002 and 04/2008). Men were 46 (76.8%) and average age was 57 +/- 10.76 year. 30 days mortality was 9 people (15.0%, all with bacterial endocarditis). Late mortality 1 man (1.6%). Follow up 1-66 months, average 39.18 SD +/- 14.3 months, median 42 months. CONCLUSION: Implantation of aortic allograft into the aortic position is standard procedure with good midterm results. Relative high early mortality is dependent on preoperative status in patiens with acute bacterial endocarditis--all early death people were people with acute bacterial endocarditis and minimally one vital organ severe dysfunction.

[Aortic valve sparing operations and reconstruction--from anatomy to the long-term results]. / Záchovné operate a plastiky aortální chlopne--od anatomie chlopne az k dlouhodobým výsledkum.

The implantation of an artificial heart valve (a mechanical valve or a xenograft valve) involves the risk of serious and life-threatening complications for the patient, such as hemorrhagic complications, thromboembolic complications, the risk of endocarditis, the risk of premature degeneration of the xenograft valve, etc. Preserving the patient's own aortic valve eliminates or at least significantly reduces the above complications. On the other hand, it brings about the disadvantage of a technically more demanding surgery and the possible risk of reoperation due to failure of the spared aortic valve. The authors present a comprehensive and up-to-date view ofthe issue of aortic valve sparing surgeries and plastic corrections, beginning with the basics of aortic root anatomy and ending with the indications and principles of cardiosurgical techniques, and long-term results.

[Endoscopic collection of v. saphena magna--early complication rates]. / Endoskopický odber v. saphena magna--výskyt ranných komplikací.

Endoscopic harvesting of v. saphena magna for CABG procedures represents a modern method, which in comparison to conventional methods reduces postoperative wound complications. We have analyzed 40 patients, who uderwent CABG procedure with endoscopic harvested venous graft.

[A female patient with heart fibrosarcoma. A case review]. / Pacientka s fibrosarkomem srdce. Kazuistika.

Authors are in their announcement describing a case of a patient with fibrosarcoma of a left atrium, who was treated on Cardiosurgery department in Hospital of Ceské Budejovice. Symptoms, clinical signs and development of this disease are described in the text. There are also information relating cardiac sarcomas, management of their diagnostics and treatment.

Cryopreserved semilunar heart valve allografts: leaflet surface damage in scanning electron microscopy.

OBJECTIVE: Allograft heart valves (AHV), biological valves of human origin, offer potential advantages over conventional xenografts in terms of superior hemodynamics and, perhaps, better durability. The most important factors for long-term AHV clinical performance are the processing and cryopreservation methods. The aim of this study was to evaluate the impact of current processing protocol on valve tissue morphology, mainly to address the effect of successive processing steps on the leaflet surface structure. For the detection of fine changes in endothelial covering and underlying layers, our own modification of the scanning electron microscopy (SEM) technique was utilized. MATERIAL AND METHODS: The study was based on an investigation of 20 AHV (40 specimens). Fourteen valves came from heart-beating donors (multiorgan harvesting) when the heart could not be transplanted for any reason (donor criteria, availability of recipient and/or logistics). Six were obtained at the time of routine postmortems--non heart-beating donors (NHBD). All specimens were initially fixed in Baker's solution. Tissue samples were dissected, dried with hexamethyldisilazane (HMDS), gold-coated, studied and photographed by SEM (Tesla BS 301). In order to define the integrity of the endothelium, subendothelial layers and the quality of the surface under SEM, a special six-level score system was introduced: 1-intact endothelium, 2-confluent endothelium with structural inhomogeneity, 3-disruption of intercellular contacts, 4-separation of endothelial cells, 5-complete loss of endothelium, 6-damage of subendothelial layers). AHV samples were divided into 4 groups for comparison. One aortic AHV "fresh" control sample obtained from a heart-beating donor was evaluated without any processing and was compared with (i) tissue from AHV obtained from NHBD with warm ischemia of 12 and 48 hours, (ii) samples stored at +4 degrees C in saline for 24 h, (iii) antibiotic-treated tissue for 24 h at 37 degrees C and finally with (iv) cryopreserved valves stored in liquid nitrogen (-196 degrees C) for 6-38 months. RESULTS: Our alternative for drying samples by the HMDS method proved to be suitable for thin membranes of human semilunar valves. We were able to detect early changes in the endothelium after harvesting and denudation of the endothelial covering during preservation with and without freezing. The surface of the AHV samples revealed the typical features and score system determined endothelial cell damage. Control "fresh" sample: score 2, (i) NHBD samples with warm ischemia of 12 h: score 3-4, with warm ischemia of 48 h: score 4-5, (ii) samples stored at +4 degrees C in saline for 48 h: score 5-6, (iii) antibiotic-treated tissue for 24 h at 37 degrees C: score 5, (iv) cryopreserved valves stored in liquid nitrogen for 6-38 months: score 5-6. CONCLUSION: SEM (using HMDS drying) together with other methods may be helpful for the morphological control of processing, cryopreservation and liquid nitrogen storage of AHV. Severe AHV leaflet endothelial destruction was proven on AHV grafts. These changes arose already in the initial steps of tissue processing, just after the donor heart harvesting and then at the time of antibiotic valve graft treatment. These results are considered as the starting point for the development of a better preservation protocol.

[A post-myocardial infarction interventricular septal defect. A case review]. / Poinfarktový defekt komorového septa. Kazuistika.

In this case review, the authors describe a case of a mechanical complication of acute myocardial infarction--an interventricular septal defect. The surgery could be postponed, to allow for a safer and technically simpler procedure a month after the onset of the heart attack and of the ventricular septal defect.

[Current applications of robotic heart surgery]. / Soucasné moznosti robotické kardiochirurgie.

OBJECTIVE: The objective of the article is to describe the history, development and current state of robotic heart surgery. INTRODUCTION: Robotic heart surgery is a new technology which has recorded dramatic growth in recent years. This is because of the effort to develop, in all fields of surgery, new and minimally invasive methods and to reduce surgical stress. METHOD: Overview of the relevant literature dealing with the history and development of robotic surgery, with a focus on heart surgery. RESULTS: The number of centres using a robot in clinical practice is growing fast. After a slow start, heart surgery is now the fastest growing field of robotic technology. It has been proven already that almost all heart surgeries can be performed with the use of a robot. Most of surgery fields have already introduced robots in current use. None of them, however, has yet advanced to a 100% robotic coverage of the whole range of interventions. Therefore it is a good strategy today to build multi-specialised operating theatres with robots that could be used for different fields of surgery. CONCLUSION: Even though robotic surgery is in its beginnings today, its great potential is quite apparent. Only the years to come will show the efficiency, safety, and the cost benefit of robotic technology as compared with traditional methods.

[Our first experience with rigid sternal fixation]. / Nase první zkusenost s rigidní fixací sterna.

The authors present their first experience with rigid osteosynthesis of the sternum using the SternaLock system, used in a 61-year old male patient with a complete sternal dehiscence, diagnosed eight years following his aortocoronary bypass. The authors give a brief overview of the methodology and technique of the system implantation, the discussion deals with pros of the rigid fixation procedures and the commonest risk factors resulting in postoperative sternal instability.

[Shot injury of the thorax associated with the left carotid trauma--a case review]. / Strelné poranenie hrudníka spojené s poranením l'avej karotídy--kazuistika.

The case review describes a shot injury of the thorax (without direct injury of the heart or lungs), with signs of advanced bleeding from the injured carotid artery. Employment of extracorporeal circulation facilitated safe extraction of the projectile and sound revisionining of all traumatized structures and their safe reconstruction.

[Aortic allograft (homograft) for the treatment of valvular disorders in adults with focus on treatment of infective aortic valve endocarditis]. / Aortální alograft (homograft) v lécbe chlopennich srdecních vad dospelých s durazem na lécbu infekiní endokarditidy aortální chlopne.

Still after 40 years of heart valve prostheses intensive development ideal valve substitute still does not exist. Aortic allograft represents one alternative which could be used for aortic and/or pulmonary valve replacement. This type of biological heart valve prosthesis is being currently discussed from the point of view of Tissue Banking, as well as from clinical aspects--e.g. surgical implantation technique and long term results. Live issue remains particularly the aortic allograft implantation into the aortic position. The authors discuss the aortic allograft role in the aortic valve infectious endocarditis treatment, which was widespread worldwide and accepted. Aortic allograft implantation is considered as a method of choice in that particular indication, especially in prosthetic aortic valve endocarditis and in left ventricle outlet tract destruction cases. The method is considered to be more technically demanding than routine heart valve surgery (heart valve replacement by means of mechanical or commercial biological prostheses), but literary and authors own experience in that particular group of patients looks encouraging. Aortic allografts permanent supply in our country is secured.

[Pulmonary embolism following aorto-coronary by-pass]. / Plicní embolie po aortokoronárním bypassu.

The authors present a case-review of a 65 year-old female patient, hospitalized for rest dyspnoea and collaps condition, 3 weeks following her completed aorto-coronary by-pass. The symptoms were caused by a massive lung embolism. Upon the echocardiographic examination, a massive thrombus in the right-sided cardiac spaces--a rare complication of cardiosurgical procedures--was detected. The patient was treated surgically. At the present time, 4 months following the procedure, the patient is completely recovered.

Implantation of cryopreserved mitral allograft into the tricuspid position in an experimental study in sheep: technical aspects of implantation and immediate results evaluated by epicardial echocardiography.

AIMS: Cryopreserved mitral allograft valve (MAV) offers theoretical advantages over conventional mechanical or biological prostheses in tricuspid position, especially in infectious endocarditis patients. MAV processing and tricuspid valve (TV) replacement in a sheep model is described. METHODS AND RESULTS: In 20 adult sheep, MAV were harvested, processed and cryopreserved. One month later, recipient's TV were excised and the MAVs were transplanted into the tricuspid position in 13 sheep, under general anaesthesia, via a right thoracotomy, with an extracorporeal circulation (ECC) and cardioplegic heart arrest. Both MAV papillary muscles were anchored into the right ventricular wall by transmural stitches and the MAV anulus was sewn into the recipient's tricuspid anulus. After weaning from ECC, the anatomy and function of the MAV in the tricuspid position was assessed by epicardial echocardiography. The average duration of the ECC was 58 minutes (42-88), the cardioplegic heart arrest was 36 minutes (28-45). Weaning from EEC was always uneventful. Right atrial & pulmonary artery pressure measurements and epicardial echocardiography documented good function of all MAVs. CONCLUSION: MAV remained mechanically strong enough for implantation into the tricuspid position. Reproducible technique of MAV transplantation into the tricuspid position with excellent early postoperative haemodynamic performance was developed.

[The radial artery in the myocardial revascularization, analysis of the patient subjects]. / Arteria radialis v revaskularizácii myokardu, analýza súboru pacientov.

INTRODUCTION: The use of arterial grafts in the myocardial revascularization procedures has grown more popular due to their long-term patency compared with that of the great saphenous vein. The aim of this retrospective study was to assess our experience and first results in the group of patients who had underwent revascularization procedures using their radial artery. MATERIAL AND METHODOLOGY: Between 7/2000-2/2004, 51 patients of acceptable age, aged 69.0 +/- 9.0 (42-82), underwent the revascularization procedure using the radial artery in combination with the left or right arteria mammaria interna. The angiographic examinations were conducted in 44 patients (86.3%), 5 patients refused to undergo their control angiographic examinations. Two patients exited a few months following their surgery, however there was no obvious connection with the use of the radial artery graft. RESULTS: Out of 44 patients (86.3%), who had their control angiographic examination completed, 9.4 +/- 9.8 months later, on average, (1-38 months), 5 patients (11.4%) suffered from the RA occlusion. In 4 patients, the occlusion was located at the branching site off the aorta, in 1 patient the occlusion was located at the site of the anastomosis with the left arteria mammaria interna. The total patency of the radial artery grafts reached 89%. CONCLUSION: The use of the radial artery in myocardial revascularization procedures has proven safe, associated with lower complication rates connected with its collection. Furthermore, the procedures result in a good short and mid-term graft patency confirmed also on the control angiographic examinations.

[Case description of the abnormally big pseudoaneurysm in a patient after myocardial infarction]. / Popis prípadu neobvykle velkého pseudoaneuryzmatu u pacientky po infarktu myokardu.

Authors present a case of a 72 years old woman with an abnormally big left ventricular pseudoaneurysm as a consequence of a rupture of the left ventricular wall during myocardial infarction. Pseudoaneurysm threatens its carrier with both sudden death as a result of the rupture and a progressing heart failure. The patient mentioned has undergone an infero-lateral myocardial infarction complicated with beginning cardiogenic shock in July 2001. Based on coronarography examination which proved only peripheral stenoses in coronary bed a conservative procedure was indicated. In June 2002 the patient was admitted to a hospital for progressive dyspnoea, nonspecific chest and epigastric pain, and dyspeptic complaints. Transtoracal echocardiography examination proved a large pseudoaneurysm coming from periapical bottom wall of the left ventricle. Diagnosis was further confirmed and specified by ventriculography and the patient was indicated for surgery. Authors present a range of clinical signs of pseudoaneurysm, an approach to an examination, differential diagnostics and treatment procedure in patients with this unusual complication.

[Is a bioprosthesis with a rigid stent a good choice for aortic valve replacement in elderly patients?]. / Je bioprotéza s rigidním stentem dobrou volbou pro náhradu aortální chlopne u starsích pacientu?

BACKGROUND: Either stented or stentless bioprostheses can be used for aortic valve replacement (AVR) in aged patients. However the choice of the valve type remains controversial. The implantation technique of the stentless valves is more complex but the haemodynamic performance supposed to be superficial to the stented ones. The aim of the study was to review our experience with stented bioprostheses implanted in the last year. MATERIAL AND METHODS: The study reviews retrospectively 35 patients who underwent AVR with Biocor fy St Jude Medical from May 2000 to May 2001. The mean age was 73 years (65-81). Associated procedures were CABG in 17, aortoplasty in 3 and Bentall procedure in 1. Thirty-two patients had aortic stenosis, the mean preoperative gradient was 44.2 mmHg. Nineteen implanted valves were 23 mm and smaller in diameter. All patients were examined by a cardiologist (including ECHO) one month after surgery. RESULTS: There was no early mortality (30 days) and no sign of structural valve deterioration or valve thrombosis. Mean hospital stay was 10.2 days (5-30). Mean postoperative gradient one month after surgery was 14.1 mmHg (6-24). CONCLUSIONS: The AVR with a stented bioprosthesis is a standard procedure with excellent results, the postoperative gradient is comparable to the gradient of the stentless valves.

[Traumatic rupture of the descending thoracic aorta. Is emergency surgery necessary?]. / Traumatická ruptura sestupné hrudní aorty. Je nezbytná urgentní operace?

The diagnosis of traumatic rupture of the descending thoracic aorta used to be an indication for urgent surgery. Recently, there has been a shift in the perspective regarding the need for an urgent procedure and increasing numbers of surgeons tend to suggest that it is safer to manage first other serious injuries and to perform reconstruction of the injured thoracic aorta in the second stage only. Provided conservative therapy is properly managed, the risk for bleeding from the injured aorta is minimal. In the present case report of a patient with descending thoracic aortae rupture, the authors demonstrate and discuss the strategy of optimal timing of surgery.