Does the additional usage of a local hemostatic patch reduce bleeding after aortic reimplantation?

INTRODUCTION: Our study aimed to assess the efficacy of a local hemostatic, consisting of human thrombin and fibrinogen, which was applied on the aortotomy suture line. MATERIAL AND METHODS: The study involved 93 patients undergoing elective aortic valve replacement. Patients were randomized to two groups. Group 1 comprised 41 patients, in whom a hemostatic patch (Tachosil) was used additionally. Group 2 comprised 52 patients in whom Tachosil was not applied. RESULTS: The postoperative drainage after 48 h was significantly lower in the group of patients where the local hemostatic patch (Tachosil) was additionally used, compared to the control group (p = 0.0335). The prevalence of rethoracotomies was twice as high in the control group compared to the Tachosil group (5% vs. 10%), but the statistical analysis did not show a significant difference. As a consequence, both measurements of hemoglobin concentration revealed significantly higher hemoglobin in Tachosil-treated patients than the control group (p < 0.001, p = 0.0002). Red blood cell count (RBC) was also significantly higher in the Tachosil group. The difference in perioperative blood loss between the two groups resulted in a difference in postoperative acute renal injury or renal failure. The rate of infection within the early postoperative period was also comparable between the groups, although it was slightly higher in the Tachosil group (23% vs. 18%). The perioperative mortality was higher in group 2 but the difference was not statistically significant (3% in the Tachosil group vs. 5% in the control group). CONCLUSIONS: Tachosil use reduced postoperative drainage considerably, which had an important influence on renal complications after aortic valve replacement.

Computed tomography angiography for imaging results of neochordal mitral valve repair.

INTRODUCTION: Degenerative mitral regurgitation is currently the most frequent indication for mitral valve repair. AIM: To visualize and assess the mid-term results of mitral valve repair with neochordae implantation, using computed tomography angiography (CTA) imaging. MATERIAL AND METHODS: The CTA with ECG gating and without modulation was applied in 10 patients to assess the results of a mitral valve sparing procedure. The results of 3 patients are presented. The patients were operated on for severe symptomatic degenerative mitral regurgitation, defined according to a modified Carpentier's functional classification. RESULTS: Neochordal repair, by placing expanded polytetrafluoroethylene sutures between the leading edge of the prolapsing segment and the corresponding papillary muscle, was conducted. From 1 to 3 double Gore-Tex loops were used. Leaflet clefts, if present, were sutured. All repairs included mitral valve ring annuloplasty. The CTA was performed at 20-24 months after the surgery. Long-axis views, reconstructed during mid-systole, seemed to be the most valuable. Good quality cardiac images, precisely presenting the mitral valve complex with its constituents, were obtained in the case of patients without obesity, with a relatively small anterior-posterior thorax dimension, with sinus, slow heart rhythm and quite good left ventricle contractility. The evaluation of the mitral valve included presence of calcifications, fibrosis or thickening, chordal insertion and coaptation points, and papillary muscle locations. Primary and secondary native chordae tendineae and artificial chordae were visualized. CONCLUSIONS: Contrast material-enhanced ECG-gated CTA applied after mitral valve repair with Gore-Tex neochordae allows one to obtain satisfactory mitral valve images, especially during mid-systole, and evaluate mid-term results of the surgery in chosen patients.

EuroSCORE II does not show better accuracy nor predictive power in comparison to original EuroSCORE: a single-centre study.

BACKGROUND: EuroSCORE is used to predict postoperative mortality in patients undergoing cardiac surgery. Its updated version was published in 2011. AIM: To assess whether EuroSCORE II (ESII) predicts more accurately postoperative mortality after cardiac surgery in comparison with additive (addES) and logistic EuroSCORE (logES). METHODS: A total of 461 patients (aged 21-88 years, 63.4% of men) who underwent cardiac surgery (December 2010 - June 2011) were included into the prospective research. For each patient ESII, addES and logES were calculated. Accuracy, calibration, and clinical performance of these models were assessed with receiver operating characteristics analyses using the area under the curve and the Hosmer-Lemeshow test. Out of this population, a group of 300 coronary artery bypass grafting (CABG) patients (aged 42-85 years, 73% of men) was selected and statistically analysed using the same methods. RESULTS: The mortality rate was 5.21%. Predicted mortality rates were as follows: addES 4.68%, logES 4.57%, and ESII 1.89%; the accuracy was: 0.589, 0.728, and 0.726, respectively. Only logES presented good predictive power (Hosmer-Lemeshow test: c2 = 12.79, p = 0.12). In the CABG patients, the postoperative mortality rate was 5.33%. Predicted mortality rates were as follows: addES 4.69%, logES 4.59%, and ESII 1.88%; the accuracy was: 0.512, 0.691, and 0.687, respectively. In the Hosmer-Lemeshow test also logES presented good predictive power (c2 = 10.72, p = 0.218). CONCLUSIONS: EuroSCORE II did not estimate mortality risk better in comparison to its previous versions, in the entire studied population or in the CABG patients. On the basis of the analysed data, it seems that the closest to the actual risk of death for the Polish population is the EuroSCORE logistic model.

Artificial aortic valve dysfunction due to pannus and thrombus - different methods of cardiac surgical management.

INTRODUCTION: Approximately 60 000 prosthetic valves are implanted annually in the USA. The risk of prosthesis dysfunction ranges from 0.1% to 4% per year. Prosthesis valve dysfunction is usually caused by a thrombus obstructing the prosthetic discs. However, 10% of prosthetic valves are dysfunctional due to pannus formation, and 12% of prostheses are damaged by both fibrinous and thrombotic components. The authors present two patients with dysfunctional aortic prostheses who were referred for cardiac surgery. Different surgical solutions were used in the treatment of each case. CASE STUDY 1: The first patient was a 71-year-old woman whose medical history included arterial hypertension, stable coronary artery disease, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and hypercholesterolemia; she had previously undergone left-sided mastectomy and radiotherapy. The patient was admitted to the Cardiac Surgery Department due to aortic prosthesis dysfunction. Transthoracic echocardiography revealed complete obstruction of one disc and a severe reduction in the mobility of the second. The mean transvalvular gradient was very high. During the operation, pannus covering the discs' surface was found. A biological aortic prosthesis was reimplanted without complications. CASE STUDY 2: The second patient was an 87-year-old woman with arterial hypertension, persistent atrial fibrillation, and COPD, whose past medical history included gastric ulcer disease and ischemic stroke. As in the case of the first patient, she was admitted due to valvular prosthesis dysfunction. Preoperative transthoracic echocardiography revealed an obstruction of the posterior prosthetic disc and significant aortic regurgitation. Transesophageal echocardiography and fluoroscopy confirmed the prosthetic dysfunction. During the operation, a thrombus growing around a minor pannus was found. The thrombus and pannus were removed, and normal functionality of the prosthetic valve was restored. CONCLUSIONS: Precise and modern diagnostic methods facilitated selection of the treatment method. However, the intraoperative view also seems to be crucial in individualizing the surgical approach.

Iatrogenic left main-stem dissection extending to the circumflex artery and retrogradely involving the left and non-coronary sinuses of Valsalva: iatrogenic aortocoronary dissection.

We present the case of a 57-year-old female who experienced iatrogenic left main-stem (LMS) dissection during elective coronary angiography. The dissection immediately affected the circumflex artery (Cx), causing its total distal occlusion, and the left anterior descending artery (LAD), in which a metal stent, implanted six months earlier, provided blood flow. The dissection spread retrogradely to the left and non-coronary sinuses of Valsalva (SV). Ventricular fibrillation (VF) occurred but the patient was successfully defibrillated. The subsequent introduction of a catheter resulted in recurrent VF, again successfully defibrillated. Total arterial myocardial revascularisation with double skeletonised internal thoracic arteries was performed without complications and SV repair was avoided. At the one-year follow up, a control multi-slice CT (MSCT) angiography was conducted, revealing complete healing of the SV and LMS dissections. It also showed native blood flow, the left internal thoracic artery (LITA) graft to the Cx occlusion, and a patent right internal thoracic artery (RITA) graft implanted to the LAD.

Independent predictors of early mortality after coronary artery bypass grafting in a single centre experience--does gender matter?

BACKGROUND: It is commonly believed that women undergoing isolated coronary artery bypass graft surgery (CABG) are subject to a higher risk of perioperative complications and death. AIM: To evaluate the effect of sex as a risk factor on early complications and mortality after isolated CABG performed with cardiopulmonary bypass, and to evaluate the profile of the risk determined by the patient's sex. METHODS: Data derived from 2,194 surgical procedures performed in the Department of Cardiac Surgery at the Medical University of Lodz between January 2009 and March 2011 was analysed. The database was constructed on the basis of retrospective analysis of variables contained in a form of the National Registry of Cardiac Surgery. RESULTS: Isolated CABG with cardiopulmonary bypass was carried out in 1,303 patients (59.4% of all procedures). Women constituted the minority of patients (24.2%), and were significantly older (mean age 67.3 vs. 62.8 years, p < 0.001). They more often suffered from concomitant diabetes (43.1% vs. 33.41%, p = 0.003), had impaired renal function (median eGFR 88.5 vs. 95.0 mL/min1/1.73 m2, p < 0.001), and had a history of smoking in fewer cases (54.1% vs. 83.0%, p < 0.001). Internal mammary artery was more rarely used as arterial graft in the group of women (84.8% vs. 95.0%, p < 0.001). Women were subject to a higher risk of recent postoperative myocardial infarction (5.5% vs. 2.9%, p = 0.03) and required reoperation more rarely than men (4.5% vs. 8.1%, p = 0.04). Higher 30-day mortality was observed among women (7.6% vs. 2.8%, p < 0.001) and female sex appeared to be an independent predictor of death in the multiple logistic regression analysis (OR = 1.8; 95% CI 1.2-2.7). CONCLUSIONS: Women undergoing isolated CABG are subject to higher 30-day mortality. Female sex is an independent risk factor for death after isolated CABG. Further studies are necessary to identify causes of differences in prognoses among women.

Free and bioavailable fractions of sex steroids may influence bones in young men, depending on age and oestradiol level.

INTRODUCTION: Longitudinal bone growth ceases by the end of puberty, and it is thought to be a result, in both sexes, of increased pubertal oestrogen serum concentrations. Since peak bone mass is achieved by the third decade of life or later, the aim of this study was to relate sex steroid hormones and sex hormone binding globulin (SHBG) levels to bone quality in men during their third and fourth decades of life. MATERIAL AND METHODS: Eighty men, healthy volunteers aged between 18 and 39 years, were subjected to an interviewer-administered questionnaire, body mass index (BMI) measurement, blood sample and calcaneal quantitative ultrasound (QUS) (Hologic-SAHARA). Blood was assessed for testosterone (T), oestradiol (E2), dehydroepiandrosterone sulfate (DHEAS), SHBG, luteinising hormone (LH) and follicle stimulating hormone (FSH). Free and bioavailable T and E2 levels were calculated knowing SHBG and albumin levels. RESULTS: While T, E2, DHEAS, LH and FSH levels were not related, free and bioavailable fractions of T and E2 were positively associated with QUS readings. SHBG level was associated negatively. After dichotomisation for age, the associations remained significant only for younger subjects (18-30 years, n = 47). After adjustment for other co-variants, only SHBG in younger subjects retained its negative association with QUS. Older subjects (31-39 years, n = 33) revealed higher BMI and lower serum concentrations of total (-17 %), free (-18.5%) and bioavailable (-22.5%) levels of E2 than younger subjects. CONCLUSION: Free and bioavailable fractions of sex steroids may influence bones in young men, depending on age and E2 level.

The assessment of the T102C polymorphism of the 5HT2a receptor gene, 3723G/A polymorphism of the NMDA receptor 3A subunit gene (GRIN3A) and 421C/A polymorphism of the NMDA receptor 2B subunit gene (GRIN2B) among cardiac surgery patients with and without delirium.

OBJECTIVE: The studies regarding the role of genes polymorphism in development of postoperative delirium are extremely rare. Therefore, we investigated the potential association of polymorphism in 5HT2a receptor gene and N-methyl-d-aspartate (NMDA) receptor 3A and 2B subunits genes with postoperative delirium. METHOD: We conducted a prospective, nested, case-control study. For analysis, 3723 G/A (rs3739722) polymorphism in the GRIN3A gene, 421 C/A (rs3764028) polymorphism in the GRIN2B gene and T102C (rs6313) polymorphism in the 5HT2A gene were selected. RESULTS: Genetic analysis confirmed that there were significant differences in genotype frequencies for 3723 G/A between delirium patients and controls. No other significant associations were observed. Moreover, according to the multivariate conditional logistic regression analysis the presence of AG haplotype of GRIN3A gene was independently associated with postoperative delirium. CONCLUSIONS: These findings suggest that the genetic variations of NR3A subunit of NMDA receptor may be a predisposing factor to delirium among the Polish population of cardiac surgery patients.

Cardiac tamponade and para-aortic hematoma post elective surgical myocardial revascularization on a beating heart - a possible complication of the Lima-stitch and sequential venous anastomosis.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) surgery can be associated with some intrinsic, but relatively rare complications. A pericardial effusion is a common finding after cardiac surgeries, but the prevalence of a cardiac tamponade does not exceed 2% and is less frequent after myocardial revascularization.Authors believe that in our patient an injury of a nutritional pericardial or descending aorta vessel caused by the Lima stitch resulted in oozing bleeding, which gradually leaded to cardiac tamponade. The bleeding increased after introduction of double antiplatelet therapy and caused life-threatening hemodynamic destabilization. According to our knowledge it is the first report of such a complication after OPCAB. CASE PRESENTATION: We present a case of a 61-year old man, who underwent elective surgical myocardial revascularization on a beating heart. On the 11th postoperative day the patient was readmitted emergently to the intensive care unit for severe chest pain, dyspnoea and hypotension. Coronary angiographic control showed a patency of the bypass grafts and significant narrowing of circumflex artery, treated with angioplasty and stenting. The symptoms and hemodynamic instability exacerbated. A suspicion of dissection of the ascending aorta and para-aortic hematoma was stated on 16-slice cardiac computed tomography. The patient was referred to the Cardiovascular Surgery Clinic. Transthoracic echocardiography revealed cardiac tamponade. On transesophageal echocardiography there were no signs of the ascending aorta dissection, but a possible lesion of the descending aorta with para-aortic hematoma was visualized. Emergent rethoracotomy and cardiac tamponade decompression were performed. 12 days after intervention the control 64-slice computed tomography showed no lesions of the ascending or descending aorta. On one-year follow-up patient is in a good condition, the left ventricular function is preserved and there is no pathology in thoracic aorta on echocardiography. CONCLUSIONS: Mechanical complications of surgical myocardial revascularization on a beating heart should be considered as a cause of the clinical and hemodynamic instability relatively early in the postoperative period. Echocardiographic examination must be the first step in diagnostics process in a patient after cardiac surgery.

Sarcomas of the heart as a difficult interdisciplinary problem.

Cardiac tumors are assumed to be a rare entity. Metastases to the heart are more frequent than primary lesions. Sarcomas make up the majority of cardiac malignant neoplasms. Among them angiosarcoma is the most common and associated with the worst prognosis. Malignant fibrous histiocytoma comprises the minority of cardiac sarcomas and has uncertain etiology as well as pathogenesis. Transthoracic echocardiography remains the widely available screening examination for the initial diagnosis of a cardiac tumor. The clinical presentation is non-specific and the diagnosis is established usually at an advanced stage of the disease. Sarcomas spread preferentially through blood due to their immature vessels without endothelial lining. Surgery remains the method of choice for treatment. Radicalness of the excision is still the most valuable prognostic factor. Adjuvant therapy is unlikely to be effective. The management of cardiac sarcomas must be individualized due to their rarity and significant differences in the course of disease.

Mild cognitive impairment with associated inflammatory and cortisol alterations as independent risk factor for postoperative delirium.

AIMS: The present study aimed to determine the impact of mild cognitive impairment (MCI) on the development of postoperative delirium and, secondly, to assess the association between MCI and raised perioperative cortisol, cytokine, cobalamin and homocysteine levels. METHODS: The study recruited 113 consecutive adult patients scheduled for cardiac surgery with cardiopulmonary bypass. The patients were examined preoperatively with the Montreal Cognitive Assessment and Trail Making Test. A diagnosis of MCI was established based upon the criteria of the National Institute on Aging and Alzheimer's Association. Patients were screened for delirium within the first 5 days postoperatively. RESULTS: MCI was diagnosed in 24.8% of the patients, whereas the frequency of delirium was 36%. A multivariate analysis demonstrated that individuals with MCI were at a significantly higher risk of postoperative delirium (OR = 6.33, p = 0.002). Preoperative cortisol, postoperative cortisol and IL-2 plasma levels were higher in the MCI group as compared to non-MCI subjects. CONCLUSION: MCI is associated with a higher risk of postoperative delirium. Perioperative cortisol and inflammatory alterations observed in MCI may provide a physiological explanation for this increased risk.

Implantation of VVI epicardial pacemaker through mini-sternotomy in a patient with superior vena cava occlusion after radiotherapy.

The paper presents a case report of a patient with a superior vena cava occlusion and post-operational (after the implantation of the aortic valve) atrioventricular block, which required constant stimulation. An epicardial VVI pacemaker was implanted through mini-sternotomy in the lower part of the previous operation field with very satisfactory stimulation parameters. Implantation of a screw-in epicardial lead is in some cases the method of choice, which provides efficient and constant heart stimulation.

Isolated coronary artery bypass grafting in extracorporeal circulation in patients over 65 years old - does age still matter?

INTRODUCTION: Coronary artery bypass grafting (CABG) is conducted more and more commonly in patients in advanced age. AIM OF THE STUDY: To analyze the influence of age and concurrent risk factors on the complications and early mortality after CABG. MATERIAL AND METHODS: Medical records of 2194 patients were analyzed retrospectively. A group of 1303 patients who had undergone isolated CABG was selected. 106 (4.8%) patients were excluded due to missing data in their medical records. The remaining 1197 patients were divided into two subgroups by age: 1(st) group < 65 years (n = 662; 55.3%); 2(nd) group ≥ 65 years (n = 535; 44.7%). RESULTS: The total 30-day mortality was 3.93% and was six times higher in the older group (1.21 vs. 7.29%; p < 0.001). Complications were observed in 176 (14.70%) patients, more often in the older group (10.42% vs. 20.0%; p < 0.001). In this group all kinds of complications were noted more often and in particular: postoperative myocardial infarction (1.96% vs. 5.42%; p = 0.001), respiratory dysfunction (1.36% vs. 4.11%; p = 0.005), neurological complications (1.81% vs. 3.74%; p = 0.04) and multi-organ dysfunction syndrome (0.30% vs. 1.68%, p = 0.03). The older patients required longer time under mechanical ventilation (24.0 ± 27.9 vs. 37.0 ± 74.1 hours; p = 0.004) and stayed longer in the intensive care unit: 2.5 ± 3.0 vs. 4.1 ± 7.84 days; p < 0.001. Independent predictors of death were: female sex [OR (95% CI) = 2.4 (1.2-4.5)], age ≥ 65 years [OR = 4.9 (2.1-11.1)], eGFR < 60 mL/min/1.73 m(2) [OR = 2.2 (1.0-4.7)], time at extracorporeal circulation > 72 minutes [OR = 5.5 (2.7-10.9)] and left main stem stenosis (> 50%) [OR = 2.4 (1.3-4.6)]. CONCLUSIONS: Age still significantly influences postoperative complications and mortality after isolated CABG.

Urgent splenectomy in the course of prosthetic valve endocarditis.

We present a case of a 51-year-old male patient hospitalized due to acute coronary syndrome requiring stent implantation to the left main stem. Double antiplatelet therapy was commenced. After 2-3 days, the patient presented with high fever, dyspnea on exertion, pain in the chest, myalgia, and general weakness. Transthoracic (TTE) and transesophageal (TEE) echocardiography revealed abnormal, turbulent flow across the aortic prosthesis, which was probably caused by the presence of a pathological smooth and mobile structure (10 × 9 × 5 mm) in front of the aortic annulus. Blood cultures were positive and staphylococcal prosthetic valve endocarditis (PVE) was diagnosed. Despite antibiotic treatment, the patient's condition deteriorated, and he was referred for prosthesis reimplantation. After being transferred to the Cardiac Surgery Clinic, he presented with nausea, vomiting, and abdominal pain. The results of imaging examinations suggested spleen hematoma. The patient underwent an urgent splenectomy. Histopathological examination revealed a spleen infarction consequent to an embolic event and subscapular hematoma. On the 10(th) day after the laparotomy, cardiac surgery was performed. No large vegetations were found on the aortic prosthesis. The mechanical valve, implanted 20 years earlier, was functioning properly; it was intact and well healed. Several fragments of a thrombus and fibrous tissue, resembling a pannus and covered with minor calcifications, were removed from the ventricular surface of the discs. A decision was reached to leave the aortic prosthesis in situ. The valvular material culture revealed the presence of Streptococcus anginosus, and the antibiotic scheme was modified. The postoperative period was uneventful.

Clinical outcome, echocardiographic assessment, neurohormonal and collagen turnover markers in low-fl ow severe aortic stenosis with high transvalvular gradient.

INTRODUCTION: Patients with severe aortic stenosis (AS), high mean gradient (HMG), and preserved left ventricular ejection fraction (LVEF) may present with paradoxical "low flow" (LF). OBJECTIVES: The aim of the study was to assess the potential effect of cardiac collagen metabolism on the HMG/LF phenomenon in patients with severe AS and to determine a clinical and echocardiographic pattern of these patients. PATIENTS AND METHODS: We assessed a clinical status of 89 patients, aged over 64 years, with severe AS, HMG, and preserved LVEF (≥50%). Cardiac structure and function as well as systemic arterial hemodynamics were assessed with echocardiography, conventional Doppler, and tissue Doppler imaging. Moreover, plasma levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP), procollagen III N-terminal propeptide (PIIINP), carboxyterminal telopeptide of collagen type I, matrix metallopeptidase 9, and inhibitor of matrix metalloproteinase type 1 were evaluated. We analyzed 2 groups of patients: with normal flow (stroke volume index [SVI], ≥35 ml/m²; n = 70) and with LF (SVI, <35 ml/m²; n = 19). RESULTS: Patients with LF were older, had a larger left atrium and left atrial volume index, smaller aortic valve area, lower energy loss index, stroke work, mitral flow E velocity, mitral annular E' and S' velocities and systemic arterial compliance, higher relative left ventricular wall thickness, E/E', systemic arterial resistance and valvulo-arterial impedance. We observed a correlation between SVI and NT-proBNP, PIIINP, and selected parameters of cardiac structure and function. CONCLUSIONS: In patients with severe AS, HMG and preserved LVEF, the LF is related to a more severe obstruction, altered aortic hemodynamics, cardiac dysfunction, and higher blood levels of NT-proBNP. An inverse association between PIIINP and SVI may indicate enhanced tissue fibrosis as an underlying pathology.

Raised IL-2 and TNF-α concentrations are associated with postoperative delirium in patients undergoing coronary-artery bypass graft surgery.

BACKGROUND: The knowledge base regarding the pathogenesis of postoperative delirium is limited. The primary aim of this study is to investigate whether increased levels of IL-2 and TNF-α are associated with delirium in patients who underwent coronary-artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB). The secondary aim is to establish whether any association between raised cytokine levels and delirium is related to surgical and anesthetic procedures or mediated by pre-existing conditions associated with raised cytokine levels, such as major depressive disorder (MDD), cognitive impairment, or aging. METHODS: Patients were examined and screened for MDD and cognitive impairment one day preoperatively, using the Mini International Neuropsychiatric Interview and The Montreal Cognitive Assessment and Trail Making Test Part B. Blood samples were collected postoperatively for cytokine levels. RESULTS: Postoperative delirium screening was found positive in 36% (41 of 113) of patients. A multivariate logistic regression revealed that an increased concentration of pro-inflammatory cytokines is associated with delirium, and related to advancing age, preoperative cognitive decline of participants, and duration of CPB. According to receiver operating characteristic analysis, the most optimal cut-off for IL-2 and TNF-α concentrations in predicting the development of delirium were 907.5 U/ml and 10.95 pg/ml, respectively. CONCLUSIONS: The present study suggests that raised postoperative cytokine concentrations are associated with delirium after CABG surgery. Postoperative monitoring of pro-inflammatory markers combined with regular surveillance may be helpful in the early detection of postoperative delirium in this patient group.

23-year experience on diagnosis and surgical treatment of benign and malignant cardiac tumors.

INTRODUCTION: Although myxoma is the most frequent cardiac tumor, other conditions should be taken into consideration in the differential diagnosis. Transthoracic echocardiography (TTE), followed by transesophageal echocardiography (TEE) remain the principal methods for cardiac tumor screening and visualizing. The aim of the study was to compare the diagnostics, surgical treatment and prognosis of malignant and benign cardiac tumors. MATERIAL AND METHODS: From 1986 to 2009 there were 121 patients with cardiac tumors operated on in the Cardiac Surgery Clinic of the Medical University in Lodz. Patients were referred to surgery mainly on the basis of the TTE and TEE image. In 4 cases valvular prosthesis implantation or valve repair were carried out. Patients remained under long-term observation in the Cardiac Surgery Outpatient Clinic. RESULTS: Myxoma was diagnosed in 114 cases. Malignancies were discovered in 7 cases. The left atrium was the most frequent localization. The echocardiographic image differed significantly in benign and malignant tumors. The postoperative period was complicated by embolic events or myocardial infarctions. Only malignant tumors were associated with mortality due to cardiovascular events. The survival for malignant tumors was significantly shorter. CONCLUSIONS: Short and long-term results of operative treatment are very good for benign tumors in contrast to cardiac malignancies. The TTE and TEE image can be very significant in the final diagnosis.

Laparoscopic cholecystectomy delayed by complicated myocardial infarction with papillary muscle rupture, and performed after unique complex mitral repair.

A 65-year-old woman was admitted for laparoscopic cholecystectomy, a method of choice for gallbladder diseases. Symptoms of gallstones are similar to angina pectoris, especially in right coronary artery stenosis. In this case, masked by known symptomatic gallstones, unsuspected coronary artery disease manifested with complicated myocardial infarction and pulmonary edema. The patient survived the acute period, treated pharmacologically. Severe mitral insufficiency caused mainly by ruptured papillary muscle, with left ventricle and atrium enlargement, and right coronary artery stenosis were indications for heart surgery. Repair of this infrequent complication of myocardial infarction is rarely feasible. The complex repair, unique for this cause, is described. During the operation, the head of the ruptured posteromedial papillary muscle was re-implanted, and two neo-chords implanted for prolapsing the A2 mitral valve segment. Annuloplasty with a 29 mm elastic ring accomplished repair. Saphenous bypass graft was applied to the only feasible postero-lateral branch. Although intraoperative echocardiography revealed excellent results, inotropic support, and intra-aortic counterpulsation were necessary for weaning off cardio-pulmonary bypass and low cardiac output treatment. The patient was discharged home on postoperative day 12, with anticoagulant administered for 3 months. As soon as it was no longer required, she underwent laparoscopic cholecystectomy, with no complications. Durable results of both operations performed 5 years ago are confirmed by physical examination and ultrasonography. Complex mitral valve repair, rather than valve replacement, should be considered in similar cases. Possibility of coexistence of coronary artery disease should be considered before cholecystectomy. Good quality repair of cardiac disease allows for laparoscopic cholecystectomy.