Mitral regurgitation and coronary artery bypass surgery: comparison of mitral valve repair and replacement.

BACKGROUND: The aim of this retrospective study was to determine if there is a statistically significant difference (p < or = 0.05) between mitral valve repair (MVRp) with concomitant surgical revascularization of the myocardium (CABG) and mitral valve replacement (MVR) with concomitant CABG, considering the duration of surgery, early postoperative morbidity, in-hospital mortality, length of stay in the Intensive Care Unit (ICU) and overall in-hospital stay. METHODS: Between January 1st 2006 and December 31st 2008, 75 patients underwent surgery for mitral regurgitation and ischemic heart disease. Patients were divided in two groups determined by the procedure that was performed on the mitral valve (MVRp + CABG group had 34 patients, MVR + CABG group had 41 patients). All the patients were operated by the same surgical team and received the usual anaesthesia protocol. RESULTS: Patients in the MVR + CABG group had statistically significant higher EuroSCORE risk levels, higher NYHA status and higher incidence of postoperative low cardiac output syndrome (LCOS). Neurological complications showed statistically significant higher incidence in the MVRp + CABG group. There was no statistically significant difference in regard to in-hospital mortality between these two groups. Patients in the MVR + CABG group had statistically significant longer in-hospital stay. CONCLUSIONS: Mitral valve repair and mitral valve replacement are complementary methods considering early postoperative morbidity and mortality. Higher incidence of LCOS and in-hospital stay in the MVR + CABG group was to be expected on behalf of poorer preoperative status.

[Aortico-left ventricular tunnel]. / Aorto-lijevoventrikulski tunel.

The boy was first admitted to the Department of Pediatric Cardiology at the age of 4 1/2 because of cardiac murmur diagnosed on the third day of life. A diastolic murmur of a grade 4/6, left ventricular hypertrophy as well as left aortal and ventricular dilatation were discovered. The findings showed a tendency of increase with time, but the patient had no symptoms. X-ray in the long axis view revealed a defect within the upper part of the interventricular septum immediately below the aorta, and dilated right coronary sinus. An invasive diagnostic method was undertaken, as well. The operative procedure was done with a total cardio-pulmonary bypass and hypothermia (29 degrees C). A tunnel from the anterior aortal wall through the outflow tract of the right ventricle to the left side of the heart was established intraoperatively. The defect was solved by a "sandwich" technique (two patch technique). Postoperative period was uneventful. A Doppler echocardiogram demonstrated the normal hemodynamic status of the patient without the left-to-right or right-to-left shunt and aortal insufficiency.

[Direct communication of the pulmonary artery with the left atrium]. / Izravni spoj plucne arterije s lijevim atrijem.

A rare communication between the right pulmonary artery and the left atrium in a 3.5-year-old girl is described. Cyanosis of a central type and a continuous murmur over the heart were presenting symptoms. Echocardiography revealed only excessive pulsations of the pulmonary artery, while catheterization pointed to an abnormal aneurysmal communication between the right pulmonary artery and the left atrium. At this point the O2 saturation was at the level of the left atrium. The communication was clinically classified as a type IV according to Nelson. After an unsuccessful attempt through a right thoracotomy, the ligature of this fistula has been performed in the second attempt through a median sternotomy and under complete extracorporeal circulation. Clinical course and review of literature of this rare anomaly of the heart are being presented.

[Acute renal failure in heart transplantation]. / Akutno zatajenje bubrega u transplantaciji srca.

In this study the incidence and the development of acute renal failure (ARF) in heart transplant recipients is presented. Among the thirteen heart transplant recipients eight of them developed oliguric or nonoliguric ARF. Besides the known factors such as actual condition of the patient, kidney function, peri and post-operative compromised circulation, our results demonstrate the significance of postoperative cyclosporin concentration in combination with the use of other drugs. The results also show the importance of the way cyclosporin has been administrated. The parenteral route of appliance is connected with the greater risk of higher drug concentration in the plasma than the peroral one. In connection with this is the higher incidence of adverse reactions to cyclosporin given parenterally. In addition to ranitidine and captopril, which have been mentioned earlier, the findings of our study indicate that greater attention has to be paid to the treatment with ketoconazol given in combination with cyclosporin, since it results in decreased cyclosporin clearance. Other nephrotoxic drugs like amphotericin also increase the possibility of renal lesions. The incidence of acute renal failure in this group of patients is high. Our data suggest that the reasons for the development of ARF are multifactorial. These data further suggest that a reasonable way to solve nonoliguric form of acute renal failure is to maintain the "internal balance" and that it is not necessary to perform extracorporeal elimination of nitrogen substances, if there are no additional complications (i.e. gastrointestinal bleeding).(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical treatment of congenital obstruction of the left ventricular outflow tract]. / Kirursko lijecenje prirodene opstrukcije izlaznog dijela lijevog ventrikula.

This report presents the classification and all types of left ventricular outflow tract obstructions. The possibilities of operative therapies are surveyed as well. Results of surgical treatment in 34 patients with obstruction to left ventricular outflow are shown. The majority of patients underwent operation under extracorporeal circulation (84.4%), while the rest were operated by means of the inflow occlusion technique (14.7%). The obtained results were compared with those from the literature. The importance of echocardiographic evaluation of location of the left ventricular outflow tract obstruction and the appropriate choice of a surgical technique according to the patient's age are emphasized.

The patent ductus arteriosus as a source of recurrent peripheral embolisations.

A patient with a multiple peripheral embolisation of unknown origin is presented. Because of her extreme obesity, some diagnostic procedures could not be performed (CAT), and some were performed with great difficulty (conventional ECHO, DSA of the aorta). Transesophageal echocardiography was the key procedure in the diagnosis of the floating thrombotic mass in the descending aorta. A surgical operation was performed, and a thrombus was found in the aortic orifice of the hemodynamically insignificant patent ductus arteriosus. The patient has now been 18 months in good condition and free of thromboembolic events.

[War injuries of the thorax]. / Ratne ozljede prsnog kosa.

Chest injuries are very common in war circumstances. Chest injury is commonly associated with other injuries of intrathoracic organs and development of shock, which has to be treated immediately. Our patients with war chest injuries are presented, along with our approach to the treatment of these injuries. "The conservative treatment" is stressed, with particularly importance of proper chest drainage, as a corner stone of proper and successful therapy. Shock treatment and prevention of atelectasis does present an unavoidable procedure of this type of therapy.

Extrinsic erosion of the descending aorta by a vertebral fixator.

We report a rare case in which mechanical extrinsic erosion of the descending thoracic aorta resulted in perforation and periaortic hematoma formation in a 16-year-old girl. Five months before admission to our clinic, the patient had undergone surgical spondylosyndesis with inner vertebral fixation, for the correction of scoliosis. Subsequently, a screw on the fixator became loose, eroding and eventually perforating the wall of the descending aorta. The resultant lesion was at first misdiagnosed as a paravertebral abscess; extrinsic perforation of the descending aorta was suspected prior to operation, but was confirmed only upon surgical exploration. After evacuation of the hematoma, the 1.5-cm aortic perforation was closed directly with continuous sutures. Seven months later, the patient continues to do well.

[Non-occlusive mesenteric ischemia]. / Problem neokluzivne mezentericke ishemije.

Critical survey of functional anatomy of the upper mesenteric artery, patophysiology of the mesenteric ischemia, and the diagnostic procedures are assessed from the viewpoint of possibilities of operative correction and the author's hitherto experience in the upper mesenteric surgery. Comparison of diagnostic with operative management in two patients points to common causes of the disease, as well as to some of the preoperative misunderstandings. The indication for revascularization of the upper mesenteric artery and consequent amelioration of postoperative course in the patient with non-occlusive mesenteric ischemia is explained. Each of the described facts is of great importance for the postoperative course without fatal complications.

Interrenal coarctation of the abdominal aorta.

We report a case of congenital, segmental, hypoplastic interrenal abdominal aortic coarctation with inadequate collateral circulation. After preoperatively evaluating renal function and intraoperatively measuring vascular pressure, the coarctation was bridged with an aortico-aorta bypass; and an additional bypass graft was placed between the prosthesis and superior mesenteric artery. In this way, besides the successful surgical correction of coarctation, the inverse blood flow in the superior mesenteric artery was reversed to normal.

Surgical treatment of cardiac echinococcosis: report of nine cases.

We reviewed the results in eight patients followed from 10 months to 22 years after one-stage surgery for removal of primary and secondary myocardial and pericardial hydatid cysts. The results were satisfactory in eight patients who survived the operation. One patient, however, with recurrent myocardial echinococcosis, pulmonary embolization, and sepsis died at reoperation. The series was analyzed with reference to the surgical treatment and world-wide experience of complicated cardiac echinococcosis.

[Surgery of heart myxoma]. / Nasa iskustva u hirurgiji miksoma scra.

Myxomas are the most common benign tumors of the heart. It is important that an exact diagnosis be made and radical surgical treatment effected. The clinical interest in them increased particularly in 1950 when Goldberg first established a diagnosis of intracardial myxoma by means of angiocardiography, and Grafford (1954) performed a successful operation in extracorporal blood flow. Our first successful operation was carried out in the above Clinic in 1961, and since then in about 4500 open heart operations 10 myxomas were extirpated.

[Heart valve replacement]. / Zamena valvula srca.

From 1965 to 1980, the authors accumulated vast experience by operating on 2500 diseased heart valves. Some of these patients had one, two, or three valves replaced. Among the two/three patients, there was a monovalvular problem in III, and more than half the patients with multivalvular problems in IV functional group NYHA. In group II there were only one/three patients with stenosis of the aortic valve. Because of the advanced stage of the disease among the group II patients, the following conditions were often present: heart insufficiency, manifest lung hypertension, cardiomegaly, and pronounced arrhythmia with damage to the kidneys. The risk in such cases is significantly greater. In total, 2941 valves were built. 74% had a normal postoperative recovery, 9,2% died; and 14,2% suffered complications that were remedied. Among the complications were insufficiency of the heart, arrhythmia, hemorrhage, transitory cerebral damage, and tracheobronchial infections. Thus, it can be seen that valve replacement as a treatment for significant hemodynamic disturbances is an effective method of surgical treatment. Improved results, reduction of complications, and few fatalities signal the advancement in such treatment.