The Treatment Strategy for the Atrial Septal Defect in the Presence of Severe Pulmonary Hypertension.

Atrial septal defect is one of the most common congenital heart diseases in adults. The defect often leads to volume overload in the right heart coupled with the potential risk of right heart failure and pulmonary arterial hypertension. These conditions lead to worsening in quality of life, decrease in physical capacity, and even to fatal outcomes. The main strategy for treatment of atrial septal defect is a transcatheter or surgical closure of the defect, but in patients with severe pulmonary arterial hypertension, it is recommended to manage pulmonary arterial hypertension and after that treat the defect invasively. This strategy is called "treat and repair" strategy. We present an illustrative case report of management and treatment of atrial septal defect, complicated with severe pulmonary arterial hypertension. In this case, surgical closure of the defect was contraindicated because of the high pulmonary vascular resistance. Therefore, the "treat and repair" strategy was approached. After specific medical treatment of pulmonary arterial hypertension, surgical closure of the defect was chosen and proven successful.

Multidisciplinary approach to rare primary cardiac sarcoma: a case report and review.

BACKGROUND: Undifferentiated pleomorphic sarcoma is a very rare and aggressive type of primary cardiac tumors. Most cardiac sarcomas result in rapid growth and quick death. According to different sources the median survival is typically 6 to 12 months. We are presenting a case of primary cardiac sarcoma with 26 months disease free survival following cytoreductive surgery and chemotherapy. CASE PRESENTATION: A 48-year-old woman with progressing symptoms of dyspnea and palpitations for over 2 months was referred to a cardiologist. With the help of echocardiography and cardiovascular magnetic resonance cardiac sarcoma was suspected. Open biopsy and cytoreductive surgery were performed, complete resection of the tumor was not possible. Histology revealed undifferentiated pleomorphic sarcoma. Seven cycles of chemotherapy with Doxorubicine and Ifosfamide were completed. Cardiovascular magnetic resonance revealed a complete response - only signs of fibrosis without any signs of tumor were visible. Follow ups with echocardiography, cardiovascular magnetic resonance and chest, abdomen and pelvic computed tomography is performed every 3 months. Twenty-six months from initial diagnosis the patient is still free of recurrence of tumor with no compromises of the quality of life. CONCLUSION: Standard chemotherapy together with cytoreductive surgery can have a complete response effect in undifferentiated pleomorphic sarcoma with unusual long-term survival.

Impact of Left Ventricular Diastolic Dysfunction and Biomarkers on Pulmonary Hypertension in Patients with Severe Aortic Stenosis.

Background: Severe aortic stenosis (AS) complicated by pulmonary hypertension (PH) is associated with poor outcomes after surgical aortic valve replacement (AVR). There is still scarce information about predictors of secondary PH in this group of patients. Objectives: The aim of this study was to investigate the prognostic impact of biomarkers together with conventional Doppler echocardiographic parameters of left ventricular diastolic function on elevated pulmonary systolic pressure (PSP) in severe AS patients before surgical AVR. Methods: Sixty patients with severe isolated AS (aortic valve area <1 cm²) underwent echocardiography, N-terminal pro B-type natriuretic peptide (NT-proBNP) and growth differentiation factor-15 (GDF-15) measurements before AVR. PSP, left ventricular ejection fraction (LV EF), parameters of LV diastolic function (E/E' ratio, mitral valve deceleration time (MV DT) and left atrial (LA) volume) were evaluated. PH was defined as an estimated PSP ≥ 45 mmHg. Results: Of the 60 patients, 21.7% with severe isolated AS had PH with PSP ≥ 45 mmHg (58.5 ± 11.2 mmHg). LV EF did not differ between groups and was not related to an elevated PSP (50 ± 8 vs. 49 ± 8%, p = 0.58). Parameters of LV diastolic dysfunction (E/E' ratio > 14 (OR 6.00; 95% CI, 1.41⁻25.48; p = 0.009), MV DT ≤ 177.5 ms (OR 9.31; 95% CI, 2.06⁻41.14; p = 0.001), LA volume > 100 mL (OR 9.70; 95% CI, 1.92⁻49.03; p = 0.002)) and biomarkers (NT-proBNP > 4060 ng/L (OR 12.54; 95% CI, 2.80⁻55.99; p < 0.001) and GDF-15 > 3393 pg/mL (OR 18.33; 95% CI, 2.39⁻140.39; p = 0.001)) were significantly associated with elevated PSP in severe AS. Conclusions: Left ventricular diastolic dysfunction and elevated biomarkers levels could predict the development of pulmonary hypertension in patients with severe aortic stenosis. Elevation of biomarkers paired with worsening of LV diastolic dysfunction could help to stratify patients for earlier surgical treatment before the development of pulmonary hypertension.

Successfully treated severe obstetric sepsis and acute respiratory distress syndrome with extracorporeal membrane oxygenation.

We report a unique clinical case about an 18-year-old woman, immediately post-partum after an urgent C-section, who survived severe sepsis, acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (DIC) and was successfully treated with 11 different antibiotics, massive blood transfusions and repetitive surgeries and was on extracorporeal membrane oxygenation (ECMO) support for 22 days. Although, ECMO is a time-limited procedure and most manufacturers do not advise more than 14 days of use, the situation for this patient was life-threatening and ECMO, despite the dangerous risks listed above, was the only way to win time for the lungs to recover and for treatment of the underlying disease, while maintaining adequate oxygenation and circulation. Fortunately, the condition of this woman was stabilized and she achieved complete physical recovery, despite minor neurological deficit in the fingers of her right hand.

The impact of myocardial revascularization after acute coronary syndromes on one-year cardiovascular mortality.

UNLABELLED: The aim of this observational study was to evaluate the impact of myocardial revascularization performed after acute coronary syndromes on one-year cardiovascular mortality. MATERIAL AND METHODS: The study population comprised 1226 consecutive patients who were admitted to the Clinic of Cardiology in 2005 because of acute coronary syndromes with significant (≥70%) coronary artery stenoses. The relationship between myocardial revascularization and one-year cardiovascular mortality was evaluated by applying multivariable logistic regression. Cardiovascular mortality was evaluated using the Kaplan-Meier method. RESULTS: Of all the patients included into the study, 540 had Q-wave myocardial infarction, 339 patients had non-Q-wave myocardial infarction, and 347 patients were treated for unstable angina pectoris. During hospitalization, 496 patients underwent percutaneous transluminal coronary angioplasty, 373 patients underwent coronary artery bypass grafting within 60 days following acute coronary syndromes, and 357 patients received pharmacological treatment alone. During one-year follow-up, 105 cases of cardiovascular death were registered. The one-year cardiovascular mortality was significantly lower in patients who underwent percutaneous transluminal coronary angioplasty or coronary artery bypass grafting comparing with those patients who received only pharmacotherapy (5.4% and 7.8% vs. 14.3%, P<0.05). Multivariate logistic regression analysis revealed that myocardial revascularization independently reduced one-year cardiovascular mortality (adjusted odds ratio for percutaneous transluminal coronary angioplasty, 0.304; 95% CI, 0.18 to 0.53; P<0.001, and coronary artery bypass grafting, 0.540; 95% CI, 0.32 to 0.90; P=0.018) in patients who were admitted because of acute coronary syndromes. CONCLUSIONS: Myocardial revascularization performed after acute coronary syndromes was significantly associated with the reduction of cardiovascular mortality within one-year period independently of clinical variables.

[Aortic root surgery: early postoperative results of different surgical techniques]. / Aortos saknies operacijos: skirtingu operaciniu metodiku ankstyvieji rezultatai.

UNLABELLED: The aim of the study was to evaluate early postoperative results of different surgical techniques of aortic root surgery. MATERIAL AND METHODS: Between January 2004 and November 2007, a cohort of 83 patients underwent aortic root surgery in the Heart Center, Hospital of Kaunas University of Medicine. Patients were divided into three groups: Group 1 (18 patients) - reimplantation of the aortic valve within a vascular graft (David operation), Group 2 (48 patients) - replacement of the ascending aorta and aortic valve using a valved conduit (Bentall de Bono operation), and Group 3 (17 patients) - biological aortic root replacement. Study protocol included clinical data, operative data, and postoperative major adverse effects: reoperations for bleeding, stroke and lethal outcomes. RESULTS: Patients undergoing biological aortic root replacement were older as compared with other groups. The mean age in the Group 1 was 50.3+/-3.5 years vs. 57+/-2.0 years in the Group 2 and 67.8+/-3.3 years in the Group 3 (P<0.05). The main indication for the aortic root surgery was the aneurysm of the aortic root and ascending aorta in the Group 1 and 2 patients (64.7% and 72%), while in the Group 3, the main indication was fibrocalcinosis of aortic valve, aortic annulus, and ascending aorta (61.1%). The 30-day hospital mortality rates were as follows: 5.8% (n=1), in the Group 1; 10.4% (n=5), in the Group 2; 5.5% (n=1), in the Group 3. In the early postoperative period, 11 reoperations were performed due to bleeding events: in the Group 1, after planned/emergency surgery (n=2/2), and in the Group 2 (n=1/6), respectively. The function of aortic valve improved significantly in all groups of patients early after surgery. In the Group 1, the degree of aortic regurgitation decreased from 2.5+/-0.8 to 1.1+/-0.6 (P<0.05); in the Groups 2 and 3, the mean gradient through the aortic valve decreased from 39.9+/-7.5 to 17.1+/-5.3 mm Hg and from 48.8+/-18.0 to 20.1+/-11.0 mm Hg, respectively (P<0.05). No reoperation for aortic valve failure before the discharge was required in all groups of patients, and neither thromboembolic complications nor stroke events were noted in any group. CONCLUSIONS: Different aortic root surgery techniques showed similar postoperative results. New aortic root surgery methods such as aortic root-preserving/sparing procedures and concurrent aortic valve leaflet repair or aortic root replacement with the bioprosthesis can be selected for a diverse class of aortic root pathology with low perioperative mortality rates and good early postoperative results.