Incidence and peri-operative risk factors for development of acute kidney injury in patients after cardiac surgery: A prospective observational study.

BACKGROUND: Patients admitted to intensive care unit (ICU) after cardiac surgery develop acute kidney injury (AKI) immediately post-operation. We hypothesized that AKI occurs mainly due to perioperative risk factors and may affect outcome. AIM: To assess peri-operative risk factors for AKI post cardiac surgery and its relationship with clinical outcome. METHODS: This was an observational single center, tertiary care setting study, which enrolled 206 consecutive patients, admitted to ICU after cardiac surgery. Patients were followed-up until ICU discharge or death, in order to determine the incidence of AKI, perioperative risk factors for AKI and its association with outcome. Univariate and multivariate logistic regression analysis was performed to assess predictor variables for AKI development. RESULTS: After ICU admission, 55 patients (26.7%) developed AKI within 48 h. From the logistic regression analysis performed, high EuroScore II (OR: 1.18; 95%CI: 1.06-1.31, P = 0.003), white blood cells (WBC) pre-operatively (OR: 1.0; 95%CI: 1.0-1.0, P = 0.002) and history of chronic kidney disease (OR: 2.82; 95%CI: 1.195-6.65, P = 0.018) emerged as independent predictors of AKI among univariate predictors. AKI that developed AKI had longer duration of mechanical ventilation [1113 (777-2195) vs 714 (511-1020) min, P = 0.0001] and ICU length of stay [70 (28-129) vs 26 (21-51) h, P = 0.0001], higher rate of ICU-acquired weakness (16.4% vs 5.3%, P = 0.015), reintubation (10.9% vs 1.3%, P = 0.005), dialysis (7% vs 0%, P = 0.005), delirium (36.4% vs 23.8%, P = 0.001) and mortality (3.6% vs 0.7%, P = 0.046). CONCLUSION: Patients present frequently with AKI after cardiac surgery. EuroScore II, WBC count and chronic kidney disease are independent predictors of AKI development. The occurrence of AKI is associated with poor outcome.

Prompt recovery after surgical treatment of pulmonary and aortic valve endocarditis in a patient with acute heart failure.

Infective endocarditis remains a medical challenge among urgent cases of cardiac disease. Multi-valvular endocarditis is uncommon and simultaneous right and left-sided valvular involvement, particularly affecting the pulmonary valve, is scarcely reported. A rare case of a patient with subacute myelodysplastic syndrome, who presented with endocarditis involving both aortic and pulmonary valves, complicated with new-onset heart failure, is described. The patient presented prompt recovery of both right and left ventricular function after combined aortic and pulmonary valve replacement.

Successful repair of a postcardiac surgery ascending aortic pseudoaneurysm.

We present the case of a 67-year-old asymptomatic man with a history of coronary artery bypass surgery and a pseudoaneurysm of the ascending aorta treated with a low-risk alternate procedure. At 1-year follow-up, the cardiac computed tomography was not detected residual aneurysm in ascending aorta.

Patient with unicuspid aortic valve and ascending aorta aneurysm treated with ozaki procedure and ascending aorta replacement

Abstract Although aortic valve replacement remains the gold standard treatment for aortic valve diseases like stenosis (AS) or insufficiency, new surgical methods have been developed with a focus in the reconstruction of the aortic valve rather than replacing it. The Ozaki procedure involves a tailored replacement of each individual valvular leaflet with glutaraldehyde-treated autologous pericardium and aims to reproduce the normal anatomy of the aortic valve. Cases of patients with unicuspid aortic valve treated with the Ozaki procedure are uncommon in the litrature and become even more rare when it comes to concomitant diseases like AS and ascending aorta aneurysm. We present the case of a 21-year-old, fit and asymptomatic male, with unicuspid aortic valve with severe stenosis and ascending aorta dilatation, surgically treated with tricuspidization of the aortic valve with glutaraldehyde-treated autologous pericardium and replacement of the ascending aorta with a straight synthetic graft. Postoperative studies showed a fully functional, neo-tailored tricuspid aortic valve with trivial regurgitation. The patient had an uncomplicated recovery, stayed in the intensive care unit for 2 days and was discharged on the 7th postoperative day.

Patient with Unicuspid Aortic Valve and Ascending Aorta Aneurysm Treated with Ozaki Procedure and Ascending Aorta Replacement.

Although aortic valve replacement remains the gold standard treatment for aortic valve diseases like stenosis (AS) or insufficiency, new surgical methods have been developed with a focus in the reconstruction of the aortic valve rather than replacing it. The Ozaki procedure involves a tailored replacement of each individual valvular leaflet with glutaraldehyde-treated autologous pericardium and aims to reproduce the normal anatomy of the aortic valve. Cases of patients with unicuspid aortic valve treated with the Ozaki procedure are uncommon in the litrature and become even more rare when it comes to concomitant diseases like AS and ascending aorta aneurysm. We present the case of a 21-year-old, fit and asymptomatic male, with unicuspid aortic valve with severe stenosis and ascending aorta dilatation, surgically treated with tricuspidization of the aortic valve with glutaraldehyde-treated autologous pericardium and replacement of the ascending aorta with a straight synthetic graft. Postoperative studies showed a fully functional, neo-tailored tricuspid aortic valve with trivial regurgitation. The patient had an uncomplicated recovery, stayed in the intensive care unit for 2 days and was discharged on the 7th postoperative day.

Outcomes and quality of life after aortic valve surgery in octogenarians.

BACKGROUND: The emergence of catheter-based techniques questioned existing treatment strategies for patients with aortic stenosis. The increasing effectiveness of transcatheter aortic valve implantation therapies justifies a renewed evaluation of the results in terms of survival rate as well as the quality of life (QoL) after surgical aortic valve replacement (SAVR) in the elderly. The aim of this study is the assessment of QoL in octogenarians undergoing isolated SAVR. METHODS: A retrospective observational and descriptive study between January 2015 and January 2018, was conducted. Eighty-four Caucasians patients over 80 years of age undergoing aortic valve replacement in a single unit were, finally, followed-up. The patients' medical records were reviewed and QoL after a median 22-month follow-up time was evaluated by administering the EQ-5D questionnaire on the telephone. RESULTS: Mean European System for Cardiac Operative Risk Evaluation II was 2.1%. The 30-day mortality was 0% and the 1-year mortality was 3.6%. On the assessment of QoL within mean follow-up time of 22 months, performed in 81 patients (survivors), a remarkable improvement was recorded in 76.5% of patients (62 patients), while 12.3% (10 patients) reported aggravation of their health status and 11.1% (9 patients) had no change. CONCLUSIONS: Mortality rates after SAVR can be kept at very low levels, especially in experienced high-volume centers, even in the elderly. Furthermore, it must be pointed out that the majority of these patients achieve a good functional status and a satisfactory QoL after the operation. Therefore, SAVR should not be withheld on the grounds of age alone.

Effectiveness of brain natriuretic peptide in predicting postoperative atrial fibrillation in patients undergoing non-cardiac thoracic surgery.

A best evidence topic was written according to a structured protocol. The question addressed was whether plasma brain natriuretic peptide (BNP) levels could effectively predict the occurrence of postoperative atrial fibrillation (AF) in patients undergoing non-cardiac thoracic surgery. A total of 14 papers were identified using the reported search, of which 5 represented the best evidence to answer the clinical question. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. All studies were prospective observational, and all reported a significant association between BNP and N-terminal (NT)-proBNP plasma levels measured in the immediate preoperative period and the incidence of postoperative AF in patients undergoing either anatomical lung resections or oesophagectomy. One study reported a cut-off value of 30 pg/ml above which significantly more patients suffered from postoperative AF (P < 0.0001), while another one reported that this value could predict postoperative AF with a sensitivity of 77% and a specificity of 93%. Another study reported that patients with NT-proBNP levels of 113 pg/ml or above had an 8-fold increased risk of developing postoperative AF. These findings support that BNP or NT-proBNP levels, especially when determined during the preoperative period, if increased, are able to identify patients at risk for the development of postoperative AF after anatomical major lung resection or oesophagectomy. The same does not seem to be true for lesser lung resections. These high-risk patients might have a particular benefit from the administration of prophylactic antiarrhythmic therapy.

Left ventricular post-infraction pseudoaneurysm mimicking mitral valve endocarditis.

In this report we present a patient who was initially diagnosed as suffering from mitral valve endocarditis. The proper use of diagnostic modalities revealed a pseudo aneurysm of the left ventricle which was mimicking mitral valve vegetations. This allowed better planning of the subsequent operation. The optimal preoperative diagnostic studies are discussed along with the proper surgical treatment.

Isolated sternal fractures treated on an outpatient basis.

AIM: The aim of this study is to investigate the need for admission of patients with isolated sternal fracture (ISF) by prospectively and randomly discharging or admitting them. METHODS: Patients with ISF after the completion of investigations were randomly discharged or admitted. Investigations performed included lateral chest x-ray; chest computed tomography; electrocardiogram; cardiac ultrasound; definition of C-reactive protein; and cardiac enzymes, such as creatine phosphokinase, myocardial branch of creatine phosphokinase, and troponin I (cardiac specific). These investigations were repeated after 6 hours in the admission and the next day in both groups. RESULTS: Forty-two patients were included in the study. Twenty-one were admitted, whereas 21 were discharged. Electrocardiogram and ultrasound were normal in both groups upon presentation and the next day. Creatine phosphokinase and myocardial branch of creatine phosphokinase, although elevated at presentation, were normal the next day and similar in both groups. There was no morbidity, need for surgery, or mortality in both groups during a 6-month follow-up. CONCLUSIONS: Patients with ISF can be discharged safely as soon as investigations are completed. Extensive myocardial assessment is not needed on the posttraumatic period. Myocardial involvement seems unlikely in patients with ISF, who can be treated with oral analgesics.

Extrathoracic chronic heamatoma presenting as a chest wall tumor 2 years after a blunt thoracic injury.

Chronic expanding heamatomas may present as masses mimicking chest wall tumors. We report the case of a patient who was presented with a giant posterior extrathoracic chest wall tumor. The mass was proven to be a chronic heamatoma possibly developed after a blunt thoracic injury which took place 2 years before presentation and was growing thereafter. Clinicians should have high suspicion of rare entities which mimic tumors and consider any information reported by the patient's history in their diagnostic process.

Unusual case of massive hemorrhage of a gastric duplication cyst in a very advanced age.

PURPOSE: The objective of this study was to report an unusual case of gastric duplication in an 82-year-old female patient. MATERIALS AND METHODS: The patient was treated immediately by Billroth I partial gastrectomy due to massive hematemesis. The surgical specimen was histopathologically examined. RESULTS: The histopathologic report confirmed the operative diagnosis of a gastric duplication cyst. Gastric duplication cysts are rare congenital abnormalities occurring mainly in the pediatric population and rarely in adults. They account for 2% to 7% of all gastrointestinal duplications, having a male to female ratio of 2:1 (Agha et al., AJR Am J Roentgenol 137:406-407, 1981; Macpherson, Radiographics 13:1063-1080, 1993). CONCLUSIONS: Gastric duplication cysts present with a variety of symptoms and complications including hematemesis. The massive upper gastrointestinal hemorrhage in our octogenarian patient indicates that there is no age limit in clinical manifestations of this rather common in the pediatric population, congenital malformation of the stomach.

Simultaneous off-pump coronary artery bypass graft and nephrectomy.

We report the one-stage surgical management of a 68-year-old patient with renal cell carcinoma and serious hematuria combined with coronary artery disease and unstable angina. After the accomplishment of coronary revascularization without cardiopulmonary bypass, we proceeded to nephrectomy and resection of the renal tumor at the same time. The patient's postoperative course was uneventful, and at 17 months of follow-up, the patient showed no signs of recurrence. To the best of our knowledge, such a case has never been reported before in the literature.

Left atrial giant thrombus infected by Escherichia Coli. Case report.

BACKGROUND: Left atrial thrombi are mostly related to mitral valve disease. The differential diagnosis of clots and myxomas in the left atrium is mostly based on echocardiography. Infection of intracardiac thrombi is extremely rare and mostly reported in ventricular clots or aneurysms following myocardial infarction. CASE PRESENTATION: We present the case of a 65 year old female with a history of mitral valve disease and chronic atrial fibrillation who suffered repeated embolic strokes and a giant infected clot in the left atrium. Although the patient underwent prompt surgery with removal of the clot and valve replacement the complication of septic emboli to the CNS led her to death. To the best of our knowledge this is the second report of an infected left atrial thrombus. CONCLUSION: The case is a representative example of a neglected and undertreated patient with catastrophic consequences. Anticoagulant therapy in patients with mitral valve disease and atrial fibrillation should be applied according the currently available guidelines and standards in order to avoid analogous paradigms in the future. Mitral valve substitution should be considered in patients with mitral valve disease presenting thromboembolic complications. Surgery should be considered as the treatment of choice in cases of organized left atrial thrombus and suspected tumor or infected mass.