Surgical treatment of primary cardiac tumors: 20-year single center experience.

Introduction: Primary cardiac tumors are a rare condition presenting with a variety of symptoms. The outcomes of their surgical treatment in the modern era from central Europe have not been recently reported. Aim: To evaluate the short- and long-term outcomes of the cardiac tumor operations at our department throughout the last 20 years. Material and methods: This was a retrospective analysis of all primary cardiac tumor operations performed at our institution between 2000 and 2020. Perioperative data were extracted from patient records. Long-term data were provided by the National Registry of Cardiac Surgery. Results: Sixty procedures for primary cardiac tumor were performed throughout the study period. The most common type of tumor was myxoma (88%), followed by fibroelastoma (8%), lipoma (2%) and sarcoma (2%). There were 2 perioperative deaths (3%). The most common perioperative complication was atrial fibrillation (47%). One (2%) patient underwent reoperation 6 years later because of myxoma recurrence. We recorded 13 long-term deaths, but only 1 patient died as a consequence of cardiac tumor (sarcoma) 15 months after the surgery. Long-term survival of the cohort was comparable with the age- and sex-matched general population up to 15 years postoperatively (relative survival 0.91, CI 0.68-1.23). Rich histopathological illustrations are provided in the online supplementary material. Conclusions: Surgical resection is the standard treatment of primary cardiac tumors. The outcomes of benign tumors are excellent and the long-term postoperative survival is comparable with the general population. The prognosis of malignant tumors remains poor.

Solitary metastasis of clear cell renal cell carcinoma in sternum diagnosed unexpectedly during cardiac surgery - A rare but potentially fatal trap.

We present a very rare case of fatal complication during the cardiac surgery caused by unrecognized solitary metastasis of clear cell renal cell carcinoma in the sternum.

Lung Collapse during Mini-Thoracotomy Reduces Penetration of Cefuroxime to the Tissue: Interstitial Microdialysis Study in Animal Models.

Background: Single-lung ventilation facilitates surgical exposure during minimally invasive cardiac surgery. However, a deeper knowledge of antibiotic distribution within a collapsed lung is necessary for effective antibiotic prophylaxis of pneumonia. Patients and Methods: The pharmacokinetics/pharmacodynamics (PK/PD) of cefuroxime were compared between the plasma and interstitial fluid (ISF) of collapsed and ventilated lungs in 10 anesthetized pigs, which were ventilated through a double-lumen endotracheal cannula. Cefuroxime (20 mg/kg) was administered in single 30-minute intravenous infusion. Samples of blood and lung microdialysate were collected until six hours post-dose. Ultrafiltration, in vivo retrodialysis, and high-performance liquid chromatography-tandem mass spectrometry were used to determine plasma and ISF concentrations of free drug. The concentrations were examined with non-compartmental analysis and compartmental modeling. Results: The concentration of free cefuroxime in ISF was lower in the non-ventilated lung than the ventilated one, evidenced by a lung penetration factor of 47% versus 63% (p < 0.05), the ratio between maximum concentrations (65%, p < 0.05), and the ratio between the areas under the concentration-time curve (78%, p = 0.12). The time needed to reach a minimum inhibitory concentration (MIC) was 30%-40% longer for a collapsed lung than for a ventilated one. In addition, a delay of 10-40 minutes was observed for lung ISF compared with plasma. The mean residence time values (ISF collapsed lung > ISF ventilated lung > plasma) could explain the absence of practically important differences in the time interval with the concentration of cefuroxime exceeding the MICs of sensitive strains (≤4 mg/L). Conclusion: The concentration of cefuroxime in the ISF of a collapsed porcine lung is lower than in a ventilated one; furthermore, its equilibration with plasma is delayed. Administration of the first cefuroxime dose earlier or at a higher rate may be warranted, as well as dose intensification of the perioperative prophylaxis of pneumonia caused by pathogens with higher MICs.

Pentraxin 3 and other inflammatory biomarkers related to atrial fibrillation in cardiac surgery.

OBJECTIVES: The aim was to evaluate the association between perioperative inflammatory biomarkers and atrial fibrillation (AF) in cardiac surgical patients. METHODS: Forty-two patients undergoing cardiac surgery were divided into three groups according to the occurrence of AF: Group A (n = 22) - patients with no AF, Group B (n = 11) - patients with new onset AF postoperatively and Group C (n = 9) - patients with preoperative history of atrial fibrillation. The serum levels of PTX3, CRP, TLR2, IL-8, IL-18, sFas, MMP-7 and MMP-8 were measured at the following time points: before surgery, immediately and 6 h after surgery and on the 1st, 3rd and 7th postoperative days (POD). RESULTS: Serum levels of PTX3 showed a significant difference between Groups A and C on the 3rd POD (p<0.05) and on the 7th POD (p<0.0001). IL-8 levels were different between Groups A and C immediately after surgery (p<0.05), 6 hours after surgery (p<0.05) and on the 3rd POD (p<0.05). There was a difference between Groups B and C on the 1st POD in IL-8 levels (p<0.05). The sFas levels differed between Groups A and C on the 3rd POD (p<0.01) and the 7th POD (p<0.05). There was also a difference on the 7th POD (p<0.05) between the Groups B and C. No significant differences between the groups was seen for other biomarkers. CONCLUSION: This study demonstrates significantly different dynamics of PTX3, IL-8 and sFas levels after cardiac surgery in relation to AF.

Effects of conventional CPB and mini-CPB on neutrophils CD162, CD166 and CD195 expression.

OBJECTIVE: Cardiac surgery is known to trigger a systemic inflammatory response. While the use of conventional cardiopulmonary bypass (CPB) results in profound inflammation, modified mini-CPB is considered less harmful. We evaluated the impact of cardiac surgery on the expression of CD162, CD166, CD195 molecules and their association with the type of CPB used. METHODS AND RESULTS: Twenty-four patients were enrolled in our study. Twelve of them were operated using conventional CPB while the other twelve patients underwent surgery with mini-CPB. Blood samples were analysed by flow cytometry. We observed a significant increase in median fluorescence intensity of CD162 and CD195 that peaked instantly after surgery and normalized to the baseline value on the 1st day post surgery, whereas CD166 was initially down-regulated and its median fluorescence intensity (MFI) value increased to the baseline in the next few days. CONCLUSION: We observed immediate changes in the expression of CD162, CD166, and CD195 molecules on the neutrophils after surgery in both study groups of patients. The intensity of the observed changes was significantly greater in the group of patients who underwent conventional CPB compared to patients who underwent mini-CPB cardiac surgery.

Impact of cardiac surgery on the expression of CD40, CD80, CD86 and HLA-DR on B cells and monocytes.

OBJECTIVE: We measured and compared changes in the percentage of cells expressing CD80, CD86, CD40, HLA-DR and the expression of these molecules on B cells and monocytes of patients who underwent either on-pump, mini on-pump or off-pump cardiac surgery. METHODS: Blood samples from patients who underwent either on-pump, mini on-pump or off-pump cardiac surgery were collected before surgery, instantly after surgery and on the 1(st), 3(rd) and 7(th) days after surgery. Surface expression of CD80, CD86, CD40 and HLA-DR molecules was determined by flow cytometry. RESULTS: Our results show that all three surgical techniques altered the expression of these molecules, as well as the percentage relative number of specific cell populations. We identified statistically significant differences when comparing different surgical techniques. On-pump surgery revealed a more pronounced impact on the phenotype of immune system cells than the other techniques. Therefore, it is likely that the function of immune cells is changed the most by on-pump surgery. We found a lower decrease in the number of CD80(+) monocytes and a lower drop in the CD40 expression on monocytes in off-pump patients in comparison with on-pump patients. CONCLUSION: All the types of cardiac surgical techniques, off-pump, on-pump and modified mini-invasive on-pump, are associated with changes in CD80, CD86, CD40 and HLA-DR expression. We found several significant differences in the expression of the selected molecules when we compared all three groups of patients.

Effective and rapid sealing of coronary, aortic and atrial suture lines †.

OBJECTIVES: Cardiac surgical procedures carry a high risk of perioperative bleeding. Surgical sealants are often used to prevent suture line bleeding. PreveLeak™ is a surgical sealant composed of bovine serum albumin, a polyaldehyde cross-linker, and other components that forms a soft, flexible, water-tight, mechanical seal that is biocompatible and bioresorbable. METHODS: A prospective, multicentre study evaluated PreveLeak use in 44 subjects undergoing 63 cardiac procedures, primarily coronary artery bypass grafting (n = 23/63, 36.5%) and aortic valve replacement (n = 19/63, 30.2%). PreveLeak was applied to 127 suture lines and the time to sealing evaluated upon clamp release. The primary safety endpoint was the incidence of significant bleeding, infections, neurological deficits and immune/inflammatory allergic responses within 6 weeks post-treatment; subjects were followed for 3 months. RESULTS: Immediate sealing was achieved at all sites in 42 of 44 subjects (95.5%) and 125 of 127 treatment sites (98.4%). There were nine primary safety events: eight infections and one transient neurological deficit. Most adverse events were mild (n = 46/71, 64.8%) or moderate (n = 18/71, 25.4%) in severity. One adverse event (transient vasospasm) was considered possibly sealant-related. One death occurred due to a cardiac arrest. CONCLUSIONS: PreveLeak prevented bleeding at 98.4% of treated sites and was well tolerated; adverse events were consistent with those commonly observed in subjects undergoing surgical procedures. These results compared favourably with published studies of other sealants. The observed prevention of bleeding is clinically important in cardiac surgical patients. A randomized, comparative study is justified to further evaluate PreveLeak and confirm the findings from this study.

New biomarkers in the selection of patients for talcage of pleural cavity in the palliative therapy of malign pleural exudate.

BACKGROUND: Chemical pleurodesis using videothoracoscopically applied powdered talc under general anaesthesia and selective pulmonary ventilation is the most effective method of palliative therapy for malign pleural exudate. Talc produces an intense systemic inflammatory reaction with the development of aseptic pleurisy. The result is obliteration of the pleural cavity provided there is an intense inflammatory reaction in the pleural cavity and good contact of both pleural leaves. The course of the adherence of pleural leaves can be followed using skiascopy. In routine practice, the course of local inflammatory markers is difficult to evaluate. Selection of suitable patients who will respond to this procedure is another principal obstacle of this surgical method. AIM: To evaluate the course of local inflammatory changes in the pleural cavity following application of talc and to quantify their dynamics. Selection of specific biomarkers to predict the intensity of inflammation in the pleural exudate for targeted selection of patients suitable for talcage was the second aim of this study. MATERIALS AND METHODS: 114 patients were retrospectively divided into Group A (N1 = 98) or patients without relapse and Group B (N2 = 16), patients with relapse of exudate formation. The need for repeated thoracic punctures or drainage over the course of a 12-month monitoring period was a criterion of treatment failure. Quantification of the effusion was performed by ultrasonic examination over a one year observational period at 3-monthly intervals. The concentration of soluble CD163 scavenger receptor and soluble Apo/Fas molecule was determined in exudate by ELISA. RESULTS: Soluble receptors in the 2 groups differed significantly. Group B showed higher sCD163 levels before talcage (P0 = 0.00024), faster dynamic decline in 2 h (P2 = 0.0092) and in 24 h (P24 = 0.0087). During monitoring, decrease in group B was statistically significant at 2 h (P2 = 0.056) and at 24 hrs (P24 = 0.0066). CONCLUSION: This pilot study showed that high values of sCD163 and sApo/Fas in the pleural exudate can predict treatment failure. Unsuitable candidates for this type of therapy couldbe selected in this way.

Predictive value of systemic and local inflammation parameters in talc pleurodesis assessment.

BACKGROUND: One option for the palliative treatment of recurrent malignant pleural effusion is powdered talc using thoracoscopy. This paper presents the results of selected systemic and local manifestations of the talc-induced inflammatory reaction using a videothoracoscope. METHOD: A total of 114 patients with repeated malignant pleural effusion were treated at the Cardiac Surgery Clinic in Hradec Kralove from January 2010 to December 2012. Those with a life expectancy more than ≥ 3 months were eligible for talcage surgery. The group was retrospectively divided according to treatment results into Group A (N1 = 98 - successful) and Group B (N2 = 16 - relapsing). The pleural effusion was quantified using ultrasound over 1 year at 3-month intervals. Systemic changes due to the inflammatory reaction (body temperature, serum leukocyte and CRP levels) were evaluated. Local indicators of inflammation included changes in the leukocyte cell population in the effusion and changes in the pleural CRP levels. The dynamics of local expression of membrane receptors TLR-2 and CD-64 on granulocyte and monocyte cell populations in the pleural effusion were also evaluated. RESULTS: The reaction after talcage, included a significant increase in axillary temperature and leukocyte count, 12 h after the procedure. The dynamics were different in the two groups. The dynamics of local inflammatory changes were an early increase in the pleural CRP levels in both groups. The time interval of local inflammatory development and duration was related to the treatment efficacy and showed a significant rise 2 h after talcage in Group A. In Group B the local inflammatory reaction was slower and the rise was only observed 24 h after talc application. A decrease in lymphocyte count and an increase in granulocyte count 2 h after talcage were found. After an initial drop in monocyte level, a rise occurred within 24 h after talcage. Changes in the expression of TLR-2 and CD-64 receptors in relation to their cell carriers were observed depending on time after talcage. CONCLUSION: The differences in the serum and pleural effusion CRP levels suggest that the surgical stress manifests itself locally in the pleural space with a lower intensity and time delay. The TLR-2 and CD-64 receptors exhibit different behaviour depending on the type of cell membrane where they are found. The inverse relation between the granulocyte increase and TLR-2 receptor decrease in the membrane immediately after talcage is a new finding. The dynamics of TLR-2 expression on the monocytes demonstrates a direct proportion between the increasing expression of the TLR-2 receptor and increasing percent fraction of the cell carrier.

Could pentraxin 3 be a new diagnostic marker for excessive inflammatory response in cardiac surgery?

BACKGROUND: The aim of this study was to compare the dynamics of two inflammatory response biomarkers pentraxin 3 (PTX3) and C-reactive protein (CRP) after cardiac surgery with particular regard to different postoperative clinical manifestation of inflammatory response. PATIENTS AND METHODS: In this study, 42 patients undergoing open heart surgery with the use of cardiopulmonary bypass were included and divided in two groups according to the extent of clinical manifestation of inflammatory response: Group A (n=21)-patients with different severity of systemic inflammatory response syndrome (SIRS) and Group B (n=21)-patients with uneventful postoperative period (no SIRS). The serum levels of PTX3 and CRP were evaluated and compared at the following time points: before and at the end of surgery, 6 hours, 1st, 3rd, and 7th day after surgery. RESULTS: The dynamics of CRP levels were comparable between both groups and showed the classical characteristics after cardiac surgery with a peak on the 3rd postoperative day (113 vs. 132 mg/L). In contrast, the dynamics of PTX3 showed an earlier increase of serum levels with the peak on the 1st postoperative day in both groups (36.3 vs. 42.7 ng/mL). Importantly, a significant difference of PTX3 levels was found on the 3rd postoperative day (31.1 vs. 7.0 ng/mL; p<0.006) between the two groups showing significantly delayed decrease of PTX3 levels in patients with SIRS (Group A). CONCLUSION: This study demonstrates considerably different dynamics of PTX3 levels after cardiac surgery in patients with SIRS and patients without SIRS, thus it may be indicative to start the appropriate therapy.

Isolated thoracic aortitis.

Isolated thoracic aortitis is a new pathological entity. We review the histopathological features of this disease, the role of imaging, and diagnostic modalities necessary to make the diagnosis of aortitis and discuss the management of patients with an established diagnosis of isolated thoracic aortitis.

Broncho-pleural fistula following vacuum-assisted closure therapy.

We report a case of bronchopleural-cutaneous fistula following long-term vacuum-assisted closure therapy to manage a sternal dehiscence after coronary artery bypass surgery.

Peripheral tissue oxygenation during standard CPB and miniaturized CPB (direct oxymetric tissue perfusion monitoring study).

AIM: The aim of this study was to compare the impact of standard cardiopulmonary bypass (CPB) with mini CPB on peripheral tissue perfusion. METHODS: 24 patients with ischemic heart disease scheduled for CPB were randomised to two groups: Group A (12 patients, standard CPB) and Group B (12 patients, mini CPB). Oxygen tension was measured with an optical multiparametric sensor inserted into the patient's deltoid muscle. RESULTS: Lower priming in Group B (870 ± 221 mL) vs. Group A (1502 ± 48 mL) and significantly reduced hemodilution during mini CPB (Group B 25.3 ± 1.1% vs. Group A 30.1 ± 2.3%) were recorded. Higher and continuous blood flow during perfusion was analysed in Group A (4.58 ± 0.34 L.min(-1)) and lower than calculated blood flow was found in Group B (3.49 ± 0.51 L.min(-1) vs. 4.66 ± 0.38 L.min(-1)). There was a direct correlation between mean arterial pressure (MAP) and ptO2 in Group A during CPB and a direct correlation between pump blood flow and MAP during CPB in Group B. Higher levels of ptO2 during CPB and surgery after CPB in comparison with initial levels were found in Group B. Decreased ptO2 levels after surgery were found in both groups. CONCLUSION: Mini CPB enables perfusion with a relatively low flow. The results of this study suggest that a flow decrease in mini CPB is well tolerated by the organism.

The dynamics of selected local inflammatory markers to talc in the treatment of malignant pleural effusions.

BACKGROUND: Malignant pleural effusions accumulate in the space between the visceral (inner) layer covering the lungs and the parietal (outer) layer covering the chest wall. Larger effusions compress the pulmonary parenchyma resulting in increasing dyspnoea. Treatment is always local and palliative. Among others, chemical pleurodesis using talc can be performed in selected patients. Talc is hydrated magnesium silicate (chemically H2Mg3(SiO3)4) and has been used for pleurodesis since 1935. Videothoracoscopic talc powder insufflation (talc poudrage) is the most effective.However, markers of inflammatory reactions to extraneous substances like talc are not fully understood. The aim of this study was to assess the course of local inflammatory changes in the pleural cavity after talc insufflation. METHODS: The Department of Cardiac Surgery of the Faculty of Medicine and University Hospital in Hradec Kralove, treated 47 patients aged 65 on average; 29 males and 18 females with proven recurrent malignant pleural effusion of various aetiologies from January 2009 to December 2010. They were retrospectively divided into group A (40 patients) without recurring effusion, and group B (7 patients) with recurring effusion and the need for thoracentesis or chest drainage during the 9-month monitoring. RESULTS: Major findings were made in soluble forms of cell receptors. Group B showed statistically higher levels of the anti-inflammatory form of sCD-163 receptor in pleural fluid before the talc poudrage. This showed limited ability to create an adequate inflammatory response to external stimuli. This group also showed lower levels of the inflammatory form of sTLR-2 receptor immediately after the talc insufflation. This revealed low local reactivity to external stimuli. The effect of the treatment was not influenced by morphologic tumour type. No statistically significant differences in postoperative complications were found. This confirmed the safety of both videothoracoscopy and treatment. CONCLUSIONS: There was no correlation between the type of malignant affection and the outcome of the chemical pleurodesis. Patients with relapsing effusion have higher values of concentration of anti-inflammatory sCD-163 in pleural fluid even before the application of talc, and lower levels of concentration of inflammatory sTLR-2 immediately after application of talc.

Coronary subclavian steal syndrome causing acute myocardial infarction in a patient undergoing coronary-artery bypass grafting.

Coronary subclavian steal syndrome with retrograde blood flow in the left internal mammary-coronary bypass graft is a rare but severe complication of cardiac surgery. The authors present a case of a 68-year-old man after coronary-artery bypass grafting using an internal mammary artery. He had been suffering from angina pectoris for the last several years before surgery. The patient was resuscitated at home by emergency medical service because of primary ventricular fibrillation due to an acute myocardial infarction 5 years after surgery. An occlusion of the left subclavian artery with the retrograde blood flow in the left internal mammary coronary bypass was found. This could have been the cause of insufficiency in coronary blood flow and ischemia of the myocardial muscle. The subclavian artery occlusion was successfully treated with percutaneous transluminal angioplasty and implantation of 2 stents. The patient remained free of any symptoms 2 years after this procedure.

The effect of conventional and mini-invasive cardiopulmonary bypass on neutrophil activation in patients undergoing coronary artery bypass grafting.

Interleukin-10 (IL-10) is considered to be a cytokine with potent anti-inflammatory properties, which have been previously linked to increased incidence of sepsis. The level of IL-10 is elevated by cardiac surgery when cardiopulmonary bypass (CPB) and methylprednisolone are used. In our study, we compare the level of IL-10, IL-10 Receptor (IL-10R), and percentage of neutrophils between two groups of cardiac surgical patients undergoing Coronary Artery Bypass Grafting, both of which were not given methylprednisolone. The first group was operated with conventional CPB, while the second group was operated with minimally invasive CPB (mini-CPB). We detected enhanced level of IL-10 during surgery and at the end of surgery in both groups of patients. While no correlation between IL-10 and IL10R was found, IL-10 was positively correlated with increased percentage of neutrophils at the time points when the level of IL-10 peaked.

TLR2 in pleural fluid is modulated by talc particles during pleurodesis.

The aim of this study was to examine the role of TLR2 molecule in pleural space during thoracoscopic talc pleurodesis period in patients with malignant pleural effusion. We analyzed TLR2 molecule in soluble form as well as on membrane of granulocytes in pleural fluid. Pleural fluid examination was done at three intervals during pleurodesis procedure: 1st-before the thoracoscopic procedure, 2nd-2 hours after the terminating thoracoscopic procedure with talc insufflation, 3rd-24 hours after the thoracoscopic procedure. We reported significant increase of soluble TLR2 molecule in pleural fluid effusion during talc pleurodesis from preoperative value. This increase was approximately 8-fold in the interval of 24 hours. The changes on granulocyte population were quite different. The mean fluorescent intensity of membrane TLR2 molecule examined by flow cytometry on granulocyte population significantly decreased after talc exposure with comparison to prethoracoscopic density. To estimate the prognostic value of TLR2 expression in pleural fluid patients were retrospectively classified into either prognostically favourable or unfavourable groups. Our results proved that patients with favourable prognosis had more than 3-fold higher soluble TLR2 level in pleural fluid early, 2 hours after talc pleurodesis intervention.

Expression of urokinase plasminogen activator receptor on monocytes and granulocytes is modulated by cardiac surgery.

AIMS: Coronary artery bypass grafting (CABG) is linked to the induction of the blood coagulation/fibrinolysis cascade, which is an integral component of inflammation induced by cardiac surgery. We followed the modulation of urokinase plasminogen activator receptor uPAR (CD87) separately for monocytes and granulocytes in blood of cardiac surgery patients. METHODS: Expression of uPAR, analyzed as Median Fluorescence Intensity (MFI), on blood monocytes and granulocytes was determined by flow cytometry. Changes in uPAR expression in patients undergoing CABG using standard cardiopulmonary bypass ("on-pump") were compared to the changes in uPAR expression in patients undergoing CABG using mini-invasive cardiopulmonary bypass ("mini on-pump"). RESULTS: In "on-pump" patients, the median of uPAR expression on granulocytes before surgery was 18.1 (InterQuartile Range (IQR): 15.6-20.4). uPAR expression was significantly decreased after surgery (p<0.001), on the first postoperative day (p<0.001), and on the third postoperative day (p<0.05). In "mini on-pump" patients, the median of uPAR expression on granulocytes before surgery was 15.2 (IRQ: 13.8-19.4). The significantly decreased uPAR expression was found only at the end of surgery (p<0.05). The similar pattern of uPAR expression was also found for monocytes. The preoperative level in "on-pump" patients was 23.3 (IRQ: 18.9-30.2). There was significantly decreased uPAR expression at the end of surgery (p<0.01) and at the first postoperative day (p<0.05). In "mini on-pump" patients, the preoperative uPAR expression was 16.9 (IQR: 14.5-20.2). Expression of uPAR was significantly decreased only after surgery (p<0.05). When comparing "onpump" patients to "mini on-pump" patients, no significant differences in the expression of uPAR were found. CONCLUSION: uPAR expression on granulocytes and monocytes is significantly modulated by cardiac surgery.