UVOD Neboleča aortna disekcija je dobro poznan, a redek in zato večkrat spregledan vzrok možgansk... more UVOD Neboleča aortna disekcija je dobro poznan, a redek in zato večkrat spregledan vzrok možganske kapi. Takojšna prepoznava je nujna, saj se zdravljenje teh bolnikov razlikuje od zdravljenja drugih bolnikov z ishemično možgansko kapjo. Vloge v prepoznavi tega življenje ogrožajočega stanja nimajo le klinične izkušnje urgentnega zdravnika, temveč tudi ustrezno izbrani diagnostični postopki pri obravnavi bolnikov z akutno možgansko kapjo. Kljub hitri prepoznavi in ustreznemu zdravljenju neboleče aortne disekcije je umrljivost bolnikov z akutno aortno disekcijo velika. Pogostost akutne aortne disekcije narašča s starostjo, in je najpogostejša po 60. letu starosti. Dvakrat pogostejša je pri moških. Skoraj tri četrtine bolnikov ima arterijsko hipertenzijo. Dodatna dejavnika, ki pospešujeta nastanek ateroskleroze in disekcije žilne stene sta kajenje in hiperlipidemija (1). Pri mladih bolnikih so glavni dejavniki tveganja za nastanek disekcije prirojene motnje veziva (Marfanov sindrom, Ehl...
Interactive cardiovascular and thoracic surgery, 2012
We present a case of a 62-year old man with a left main stenosis, left coronary artery dominance,... more We present a case of a 62-year old man with a left main stenosis, left coronary artery dominance, normal ejection fraction and no valvular pathology, and status post right carotid artery stenting, who was scheduled for elective coronary revascularization. We performed off-pump coronary revascularization, anastomosing the left internal thoracic artery to the left anterior descending artery, and three separate saphenous vein grafts to the intermediate artery and the first and second obtuse marginals, respectively. Proximally, the right internal thoracic artery was used as the inflow for all three venous grafts due to a heavily calcified ascending aorta. During the construction of the distal anastomoses to the obtuse marginals, the arterial pressure in the left radial artery suddenly dropped. The left hand was found to be pale and pulseless. A femoral artery catheter was placed for pressure monitoring and the anastomoses were completed as planned. Intraoperative transit-time graft flow...
Interactive CardioVascular and Thoracic Surgery, 2013
OBJECTIVES: Low mean bypass graft flow (Q) and high pulsatility index (PI) measured by the transi... more OBJECTIVES: Low mean bypass graft flow (Q) and high pulsatility index (PI) measured by the transit time flow measurement method are not specific for anastomotic stenosis, but occur with competitive flow and poor coronary run-off. We hypothesized that graft compliance is responsible for these changes and that flow measured at the proximal end of the coronary bypass can be viewed as a sum of the graft capacitive flow and flow that passes through the distal anastomosis.
Background-We investigated the effects of transendocardial CD34 + cell transplantation in patient... more Background-We investigated the effects of transendocardial CD34 + cell transplantation in patients with ischemic cardiomyopathy. Methods and Results-In a prospective crossover study, we enrolled 33 patients with ischemic cardiomyopathy with New York Heart Association class III and left ventricular ejection fraction <40%. In phase 1, patients were treated with medical therapy for 6 months. Thereafter, all patients underwent transendocardial CD34 + cell transplantation. Peripheral blood CD34 + cells were mobilized by granulocyte colony stimulating factor, collected via apheresis, and injected transendocardially in the areas of hibernating myocardium. Patients were followed up for 6 months after the procedure (phase 2). Two patients died during phase 1 and none during phase 2. The remaining 31 patients were 85% men, aged 57±6 years. In phase 1, we found no change in left ventricular ejection fraction (from 25.2±6.2% to 27.1±6.6%; P=0.23), N-terminal pro B-type natriuretic peptide (from 3322±3411 to 3672±5165 pg/mL; P=0.75) or 6-minute walk distance (from 373±68 to 411±116 m; P=0.17). In contrast, in phase 2 there was an improvement in left ventricular ejection fraction (from 27.1±6.6% to 34.9±10.9%; P=0.001), increase in 6-minute walk distance (from 411±116 to 496±113 m; P=0.001), and a decrease in N-terminal pro B-type natriuretic peptide (from 3672±5165 to 1488±1847 pg/mL; P=0.04). The average number of injected CD34 + cells was 90.6±7.5×10 6 . Higher doses of CD34 + cells and a more diffuse distribution of transendocardial cell injections were associated with better clinical response. Conclusions-Transendocardial CD34 + cell transplantation may be associated with improved left ventricular function, decreased N-terminal pro B-type natriuretic peptide levels, and better exercise capacity in patients with ischemic cardiomyopathy. These effects seem to be particularly pronounced in patients receiving diffusely distributed cell injections and high-dose cell therapy. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01350310. (Circ Cardiovasc Interv. 2014;7:552-559.)
We evaluated the effects of a levosimendan (LS)-based strategy compared with standard inotropic t... more We evaluated the effects of a levosimendan (LS)-based strategy compared with standard inotropic therapy on renal function in heart transplantation. Using a randomized study design, 94 patients were assigned to LS-based therapy or standard inotropic support. At the time of transplantation, the groups did not differ in age, gender, heart failure etiology, hemodynamic profile, LVEF, or comorbidities. While there were no differences in serum creatinine (sCr) or eGFR between groups at baseline, patients in the LS group had a greater increase in their relative eGFR (62% vs. 12%, p = 0.002) and a lower incidence of acute kidney injury (AKI) (28% vs. 6%, p = 0.01) during the first post-transplant week. On logistic regression analysis, correlates of AKI were randomization to LS therapy (OR = 0.21 [0.09-0.62], p = 0.01), baseline renal dysfunction (OR = 3.9 [1.1-13.6], p = 0.032), and diabetes mellitus (OR = 4.2 [1.1-16.5], p = 0.038). However, LS was associated with a greater need for additional norepinephrine therapy (40 [85%] vs. 15 [31%], p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001) and a trend toward longer intensive care unit stay (9.5 ± 9.0 d vs. 7.0 ± 6.0 d, p = 0.13). In patients undergoing heart transplantation, levosimendan-based strategy may be associated with better renal function when compared to standard therapy.
Brain injury manifested by subtle, transient neurologic and neuropsychologic dysfunctions occurs ... more Brain injury manifested by subtle, transient neurologic and neuropsychologic dysfunctions occurs in about a quarter of patients who are subjected to periods of deep hypothermia and circulatory arrest (DHCA). We describe a patient who sustained minimal neurologic damage despite prolonged DHCA. The patient was a previously healthy 62-year-old woman with acute type A aortic dissection that involved the ascending aorta. During surgery we established retrograde cerebral perfusion and DHCA to provide cerebral protection, and during the procedure the patient underwent 3 separate DHCA periods with a total circulatory arrest time of 91 minutes. Because of tubing damage, retrograde cerebral perfusion was not used during the final period (59 minutes). The patient&#39;s head was packed in ice to facilitate maintenance of brain hypothermia. Her average systemic temperature during the third period of circulatory arrest was 22.5 degrees C. Extensive neuropsychologic testing, which was performed to assess the patient&#39;s cognitive functions and abilities at 4-month follow-up, showed an absence of global cognitive decline and only a moderate impairment of attentional capacity. Overall cognitive functioning was within the normal range and did not interfere with everyday activities or quality of life. Although the total arrest time vastly exceeded the recommended safe period, our patient survived and sustained minimal neurologic damage. The combination of neuroprotective measures used may have contributed to this beneficial outcome.
The incidence of cardiac rupture complicating myocardial infarction has declined since the introd... more The incidence of cardiac rupture complicating myocardial infarction has declined since the introduction of thrombolytic therapy. Despite the advances in the management of myocardial infarction, cardiac rupture remains an important cause of death among infarction-related fatalities. We discuss a patient who presented to our hospital with myocardial infarction and who subsequently developed a complex ventricular septal rupture, for which surgical repair was not feasible. Implantation of a CardioWest Total Artificial Heart (SynCardia Systems) allowed for immediate hemodynamic stabilization and served as a bridge to transplantation.
We describe the technical details and the preliminary results of a new surgical approach for mult... more We describe the technical details and the preliminary results of a new surgical approach for multivessel disease that involves using a lower T sternotomy, grafting of the left internal mammary artery (LIMA) to the left anterior descending coronary artery (LAD) and use of the right internal mammary artery (RIMA) as inflow to the other vessels. The sternotomy was made from the xiphoid up to the fourth intercostal space and then was continued transversally (T incision). The LIMA was harvested for a length of approximately 8 cm, with preservation of the distal part. The vein was simultaneously taken from the leg. The RIMA was dissected for a length of approximately 5 cm, and the distal part was occluded. Then, 3 mg/kg heparin was given. The anastomosis between the vein and the RIMA was performed. The distal venous anastomoses were done either singly or sequentially. The anterior or posterior route was chosen according to the patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s anatomy. The LIMA was then anastomosed to the LAD. One drain was placed. The sternum was closed with 4 wires, 2 for the T incision and 2 for the sternum. Between September and December 2008, 9 patients underwent their operations with this technique. The mean age was 60 years (range, 55-68 years). The mean number of grafts was 2.8. The mean hospital stay was 5.2 days. Operative mortality was 0%. All patients were reevaluated with 16-slice multislice computed tomography, and all grafts were patent. At the 3-month follow-up, all patients were alive and free of symptoms. This minimally invasive technique is a useful alternative for complete revascularization. The sternal mammary supply and the upper part of the sternum are preserved.
A 66-year-old man with normal coronary arteries and left ventricular ejection fraction of 45% und... more A 66-year-old man with normal coronary arteries and left ventricular ejection fraction of 45% underwent elective aortic valve replacement (Model 23 St. Jude Medical Inc., St. Paul, MN, USA) with concomitant wrapping of ascending aorta (Vasutek 10-mm Geal Seal, Terumo Inc., Egham, Surrey, Scotland), mitral valve replacement (Model 31 MJ-501, St. Jude Medical Inc.), and tricuspid valve annuloplasty (De Vega). Initial anterograde cardioplegia was followed by repeat retrograde cardioplegia. Because of hemodynamic instability during weaning from extracorporeal circulation, dobutamine (5-10 μg/ kg/min) and norepinephrine (0.1-0.2 μg/kg/min) were started. An intraaortic balloon pump was inserted and set at 1:1. The patient was also given intravenous amiodarone to control complex ventricular arrhythmia. Immediately after admission to the postoperative intensive care unit, an emergency echocardiography was performed and revealed akinesis of basal and mid portion of intraventricular septum with hypokinesis of the apex. There were no abnormal findings related to the morphology and function of the new implanted valves. Decision was made to proceed with urgent coronary
The Journal of Heart and Lung Transplantation, 2013
ABSTRACT We evaluated the effects of perioperative levosimendan therapy on renal function in hear... more ABSTRACT We evaluated the effects of perioperative levosimendan therapy on renal function in heart failure patients undergoing heart transplantation.Methods and MaterialsOf 103 transplant recipients, 56 (53%) received perioperative infusion of levosimendan (0.1 microg/kg/min for 24 hours; LS Group), and 47 (47%) received no levosimendan (Controls). Renal function was assessed pre-transplantation and 1 week thereafter.ResultsAt the time of transplantation, the groups did not differ in age (53±11 years in the LS group vs. 49±14 years in Controls; P=0.07), gender (male: 77% vs. 79%; P=0.82), heart failure etiology (ischemic: 28% vs. 27%; P=0.73), or donor age (41±11 years vs. 38±12 years; P=0.2). Similarly, there was no difference in creatinine (134±126 μmol/L in LS Group vs. 115±72 μmol/L in Controls; P=0.53) and creatinine clearance (Ccr) (84±42 mL/min vs. 83±34 mL/min;P=0.91). At 1 week after transplantation, we found a decrease in creatinine and an increase in Ccr in LS Group, but not in Controls despite similar mean arterial pressure in both groups (76±10 mmHg in LS Group vs. 79±20 mmHg in Controls; P=0.39). This led to a significant intergroup difference in creatinine (79±37 μmol/L in LS Group vs. 107±50 μmol/L in Controls; P=0.02) and Ccr (110±48 mL/min vs. 83±40 mL/min; P=0.005). An improvement in creatinine ≥50 μmol/L occurred in 22 % of patients from LS Group; compared with 5 % of Controls (P=0.01).Conclusions In patients undergoing heart transplantation perioperative levosimendan therapy improves post-transplant renal function. Since impaired renal function is a predictor of adverse outcome, perioperative levosimendan use could improve prognosis of heart transplant recipients.
The Journal of Heart and Lung Transplantation, 2013
ABSTRACT We analyzed the value of ventricular repolarization dynamics for prediciton of sudden ca... more ABSTRACT We analyzed the value of ventricular repolarization dynamics for prediciton of sudden cardiac death (SCD) after heart transplantation.Methods and MaterialsIn a prospective study, we enrolled 54 cardiac transplant recipients who underwent yearly routine surveillance. Patients with recent (&lt;1 month) evidence of rejection or infection were excluded. At baseline we recorded a 5-minute high-resolution electrocardiogram and measured QT variability. Patients had an increased QT variability if above the 75th percentile (high QTV group). Follow-up lasted 5 years.ResultsHigh QT variability was present in 14 of 54 patients. Patients in the high QTV group and those in the control group did not differ with regard to age (52±10 years in high QTV group vs. 50±9 years in control group; P=0.42), sex (86% [men] vs. 73%; P=0.60), history of rejection (0.98±1.12 vs. 0.87±0.92; P=0.28), or heart rate variability (standard deviation of normal-to-normal [SDNN]: 11±3 ms vs. 13±5 ms, P=0.33; root mean square successive difference [rMSSD]: 37±7 ms vs. 35±3 ms, P=0.52). Cadriac allograft vasculopathy was more common in high QTV group (79%) than in control group (40%) (P=0.013). During follow-up, 7 patients (13%) died of SCD, and those patients had significantly higher QT variability compared to survivors (SDNN: 7.3±2.2 ms vs. 4.2±2.2 ms, P=0.001; rMSSD: 8.4±3.2 ms vs. 4.8±2.1, P=0.001; QTRR: 27±4 % vs. 20±6 %, P=0.002; QTVI: −0.65±0.37 vs. −1.31±0.41, P=0.002).Conclusions Increased ventricular repolarization dynamics is related to cardiac allograft vasculopathy and may be predictive of SCD in heart transplant recipients.
UVOD Neboleča aortna disekcija je dobro poznan, a redek in zato večkrat spregledan vzrok možgansk... more UVOD Neboleča aortna disekcija je dobro poznan, a redek in zato večkrat spregledan vzrok možganske kapi. Takojšna prepoznava je nujna, saj se zdravljenje teh bolnikov razlikuje od zdravljenja drugih bolnikov z ishemično možgansko kapjo. Vloge v prepoznavi tega življenje ogrožajočega stanja nimajo le klinične izkušnje urgentnega zdravnika, temveč tudi ustrezno izbrani diagnostični postopki pri obravnavi bolnikov z akutno možgansko kapjo. Kljub hitri prepoznavi in ustreznemu zdravljenju neboleče aortne disekcije je umrljivost bolnikov z akutno aortno disekcijo velika. Pogostost akutne aortne disekcije narašča s starostjo, in je najpogostejša po 60. letu starosti. Dvakrat pogostejša je pri moških. Skoraj tri četrtine bolnikov ima arterijsko hipertenzijo. Dodatna dejavnika, ki pospešujeta nastanek ateroskleroze in disekcije žilne stene sta kajenje in hiperlipidemija (1). Pri mladih bolnikih so glavni dejavniki tveganja za nastanek disekcije prirojene motnje veziva (Marfanov sindrom, Ehl...
Interactive cardiovascular and thoracic surgery, 2012
We present a case of a 62-year old man with a left main stenosis, left coronary artery dominance,... more We present a case of a 62-year old man with a left main stenosis, left coronary artery dominance, normal ejection fraction and no valvular pathology, and status post right carotid artery stenting, who was scheduled for elective coronary revascularization. We performed off-pump coronary revascularization, anastomosing the left internal thoracic artery to the left anterior descending artery, and three separate saphenous vein grafts to the intermediate artery and the first and second obtuse marginals, respectively. Proximally, the right internal thoracic artery was used as the inflow for all three venous grafts due to a heavily calcified ascending aorta. During the construction of the distal anastomoses to the obtuse marginals, the arterial pressure in the left radial artery suddenly dropped. The left hand was found to be pale and pulseless. A femoral artery catheter was placed for pressure monitoring and the anastomoses were completed as planned. Intraoperative transit-time graft flow...
Interactive CardioVascular and Thoracic Surgery, 2013
OBJECTIVES: Low mean bypass graft flow (Q) and high pulsatility index (PI) measured by the transi... more OBJECTIVES: Low mean bypass graft flow (Q) and high pulsatility index (PI) measured by the transit time flow measurement method are not specific for anastomotic stenosis, but occur with competitive flow and poor coronary run-off. We hypothesized that graft compliance is responsible for these changes and that flow measured at the proximal end of the coronary bypass can be viewed as a sum of the graft capacitive flow and flow that passes through the distal anastomosis.
Background-We investigated the effects of transendocardial CD34 + cell transplantation in patient... more Background-We investigated the effects of transendocardial CD34 + cell transplantation in patients with ischemic cardiomyopathy. Methods and Results-In a prospective crossover study, we enrolled 33 patients with ischemic cardiomyopathy with New York Heart Association class III and left ventricular ejection fraction <40%. In phase 1, patients were treated with medical therapy for 6 months. Thereafter, all patients underwent transendocardial CD34 + cell transplantation. Peripheral blood CD34 + cells were mobilized by granulocyte colony stimulating factor, collected via apheresis, and injected transendocardially in the areas of hibernating myocardium. Patients were followed up for 6 months after the procedure (phase 2). Two patients died during phase 1 and none during phase 2. The remaining 31 patients were 85% men, aged 57±6 years. In phase 1, we found no change in left ventricular ejection fraction (from 25.2±6.2% to 27.1±6.6%; P=0.23), N-terminal pro B-type natriuretic peptide (from 3322±3411 to 3672±5165 pg/mL; P=0.75) or 6-minute walk distance (from 373±68 to 411±116 m; P=0.17). In contrast, in phase 2 there was an improvement in left ventricular ejection fraction (from 27.1±6.6% to 34.9±10.9%; P=0.001), increase in 6-minute walk distance (from 411±116 to 496±113 m; P=0.001), and a decrease in N-terminal pro B-type natriuretic peptide (from 3672±5165 to 1488±1847 pg/mL; P=0.04). The average number of injected CD34 + cells was 90.6±7.5×10 6 . Higher doses of CD34 + cells and a more diffuse distribution of transendocardial cell injections were associated with better clinical response. Conclusions-Transendocardial CD34 + cell transplantation may be associated with improved left ventricular function, decreased N-terminal pro B-type natriuretic peptide levels, and better exercise capacity in patients with ischemic cardiomyopathy. These effects seem to be particularly pronounced in patients receiving diffusely distributed cell injections and high-dose cell therapy. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01350310. (Circ Cardiovasc Interv. 2014;7:552-559.)
We evaluated the effects of a levosimendan (LS)-based strategy compared with standard inotropic t... more We evaluated the effects of a levosimendan (LS)-based strategy compared with standard inotropic therapy on renal function in heart transplantation. Using a randomized study design, 94 patients were assigned to LS-based therapy or standard inotropic support. At the time of transplantation, the groups did not differ in age, gender, heart failure etiology, hemodynamic profile, LVEF, or comorbidities. While there were no differences in serum creatinine (sCr) or eGFR between groups at baseline, patients in the LS group had a greater increase in their relative eGFR (62% vs. 12%, p = 0.002) and a lower incidence of acute kidney injury (AKI) (28% vs. 6%, p = 0.01) during the first post-transplant week. On logistic regression analysis, correlates of AKI were randomization to LS therapy (OR = 0.21 [0.09-0.62], p = 0.01), baseline renal dysfunction (OR = 3.9 [1.1-13.6], p = 0.032), and diabetes mellitus (OR = 4.2 [1.1-16.5], p = 0.038). However, LS was associated with a greater need for additional norepinephrine therapy (40 [85%] vs. 15 [31%], p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001) and a trend toward longer intensive care unit stay (9.5 ± 9.0 d vs. 7.0 ± 6.0 d, p = 0.13). In patients undergoing heart transplantation, levosimendan-based strategy may be associated with better renal function when compared to standard therapy.
Brain injury manifested by subtle, transient neurologic and neuropsychologic dysfunctions occurs ... more Brain injury manifested by subtle, transient neurologic and neuropsychologic dysfunctions occurs in about a quarter of patients who are subjected to periods of deep hypothermia and circulatory arrest (DHCA). We describe a patient who sustained minimal neurologic damage despite prolonged DHCA. The patient was a previously healthy 62-year-old woman with acute type A aortic dissection that involved the ascending aorta. During surgery we established retrograde cerebral perfusion and DHCA to provide cerebral protection, and during the procedure the patient underwent 3 separate DHCA periods with a total circulatory arrest time of 91 minutes. Because of tubing damage, retrograde cerebral perfusion was not used during the final period (59 minutes). The patient&#39;s head was packed in ice to facilitate maintenance of brain hypothermia. Her average systemic temperature during the third period of circulatory arrest was 22.5 degrees C. Extensive neuropsychologic testing, which was performed to assess the patient&#39;s cognitive functions and abilities at 4-month follow-up, showed an absence of global cognitive decline and only a moderate impairment of attentional capacity. Overall cognitive functioning was within the normal range and did not interfere with everyday activities or quality of life. Although the total arrest time vastly exceeded the recommended safe period, our patient survived and sustained minimal neurologic damage. The combination of neuroprotective measures used may have contributed to this beneficial outcome.
The incidence of cardiac rupture complicating myocardial infarction has declined since the introd... more The incidence of cardiac rupture complicating myocardial infarction has declined since the introduction of thrombolytic therapy. Despite the advances in the management of myocardial infarction, cardiac rupture remains an important cause of death among infarction-related fatalities. We discuss a patient who presented to our hospital with myocardial infarction and who subsequently developed a complex ventricular septal rupture, for which surgical repair was not feasible. Implantation of a CardioWest Total Artificial Heart (SynCardia Systems) allowed for immediate hemodynamic stabilization and served as a bridge to transplantation.
We describe the technical details and the preliminary results of a new surgical approach for mult... more We describe the technical details and the preliminary results of a new surgical approach for multivessel disease that involves using a lower T sternotomy, grafting of the left internal mammary artery (LIMA) to the left anterior descending coronary artery (LAD) and use of the right internal mammary artery (RIMA) as inflow to the other vessels. The sternotomy was made from the xiphoid up to the fourth intercostal space and then was continued transversally (T incision). The LIMA was harvested for a length of approximately 8 cm, with preservation of the distal part. The vein was simultaneously taken from the leg. The RIMA was dissected for a length of approximately 5 cm, and the distal part was occluded. Then, 3 mg/kg heparin was given. The anastomosis between the vein and the RIMA was performed. The distal venous anastomoses were done either singly or sequentially. The anterior or posterior route was chosen according to the patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s anatomy. The LIMA was then anastomosed to the LAD. One drain was placed. The sternum was closed with 4 wires, 2 for the T incision and 2 for the sternum. Between September and December 2008, 9 patients underwent their operations with this technique. The mean age was 60 years (range, 55-68 years). The mean number of grafts was 2.8. The mean hospital stay was 5.2 days. Operative mortality was 0%. All patients were reevaluated with 16-slice multislice computed tomography, and all grafts were patent. At the 3-month follow-up, all patients were alive and free of symptoms. This minimally invasive technique is a useful alternative for complete revascularization. The sternal mammary supply and the upper part of the sternum are preserved.
A 66-year-old man with normal coronary arteries and left ventricular ejection fraction of 45% und... more A 66-year-old man with normal coronary arteries and left ventricular ejection fraction of 45% underwent elective aortic valve replacement (Model 23 St. Jude Medical Inc., St. Paul, MN, USA) with concomitant wrapping of ascending aorta (Vasutek 10-mm Geal Seal, Terumo Inc., Egham, Surrey, Scotland), mitral valve replacement (Model 31 MJ-501, St. Jude Medical Inc.), and tricuspid valve annuloplasty (De Vega). Initial anterograde cardioplegia was followed by repeat retrograde cardioplegia. Because of hemodynamic instability during weaning from extracorporeal circulation, dobutamine (5-10 μg/ kg/min) and norepinephrine (0.1-0.2 μg/kg/min) were started. An intraaortic balloon pump was inserted and set at 1:1. The patient was also given intravenous amiodarone to control complex ventricular arrhythmia. Immediately after admission to the postoperative intensive care unit, an emergency echocardiography was performed and revealed akinesis of basal and mid portion of intraventricular septum with hypokinesis of the apex. There were no abnormal findings related to the morphology and function of the new implanted valves. Decision was made to proceed with urgent coronary
The Journal of Heart and Lung Transplantation, 2013
ABSTRACT We evaluated the effects of perioperative levosimendan therapy on renal function in hear... more ABSTRACT We evaluated the effects of perioperative levosimendan therapy on renal function in heart failure patients undergoing heart transplantation.Methods and MaterialsOf 103 transplant recipients, 56 (53%) received perioperative infusion of levosimendan (0.1 microg/kg/min for 24 hours; LS Group), and 47 (47%) received no levosimendan (Controls). Renal function was assessed pre-transplantation and 1 week thereafter.ResultsAt the time of transplantation, the groups did not differ in age (53±11 years in the LS group vs. 49±14 years in Controls; P=0.07), gender (male: 77% vs. 79%; P=0.82), heart failure etiology (ischemic: 28% vs. 27%; P=0.73), or donor age (41±11 years vs. 38±12 years; P=0.2). Similarly, there was no difference in creatinine (134±126 μmol/L in LS Group vs. 115±72 μmol/L in Controls; P=0.53) and creatinine clearance (Ccr) (84±42 mL/min vs. 83±34 mL/min;P=0.91). At 1 week after transplantation, we found a decrease in creatinine and an increase in Ccr in LS Group, but not in Controls despite similar mean arterial pressure in both groups (76±10 mmHg in LS Group vs. 79±20 mmHg in Controls; P=0.39). This led to a significant intergroup difference in creatinine (79±37 μmol/L in LS Group vs. 107±50 μmol/L in Controls; P=0.02) and Ccr (110±48 mL/min vs. 83±40 mL/min; P=0.005). An improvement in creatinine ≥50 μmol/L occurred in 22 % of patients from LS Group; compared with 5 % of Controls (P=0.01).Conclusions In patients undergoing heart transplantation perioperative levosimendan therapy improves post-transplant renal function. Since impaired renal function is a predictor of adverse outcome, perioperative levosimendan use could improve prognosis of heart transplant recipients.
The Journal of Heart and Lung Transplantation, 2013
ABSTRACT We analyzed the value of ventricular repolarization dynamics for prediciton of sudden ca... more ABSTRACT We analyzed the value of ventricular repolarization dynamics for prediciton of sudden cardiac death (SCD) after heart transplantation.Methods and MaterialsIn a prospective study, we enrolled 54 cardiac transplant recipients who underwent yearly routine surveillance. Patients with recent (&lt;1 month) evidence of rejection or infection were excluded. At baseline we recorded a 5-minute high-resolution electrocardiogram and measured QT variability. Patients had an increased QT variability if above the 75th percentile (high QTV group). Follow-up lasted 5 years.ResultsHigh QT variability was present in 14 of 54 patients. Patients in the high QTV group and those in the control group did not differ with regard to age (52±10 years in high QTV group vs. 50±9 years in control group; P=0.42), sex (86% [men] vs. 73%; P=0.60), history of rejection (0.98±1.12 vs. 0.87±0.92; P=0.28), or heart rate variability (standard deviation of normal-to-normal [SDNN]: 11±3 ms vs. 13±5 ms, P=0.33; root mean square successive difference [rMSSD]: 37±7 ms vs. 35±3 ms, P=0.52). Cadriac allograft vasculopathy was more common in high QTV group (79%) than in control group (40%) (P=0.013). During follow-up, 7 patients (13%) died of SCD, and those patients had significantly higher QT variability compared to survivors (SDNN: 7.3±2.2 ms vs. 4.2±2.2 ms, P=0.001; rMSSD: 8.4±3.2 ms vs. 4.8±2.1, P=0.001; QTRR: 27±4 % vs. 20±6 %, P=0.002; QTVI: −0.65±0.37 vs. −1.31±0.41, P=0.002).Conclusions Increased ventricular repolarization dynamics is related to cardiac allograft vasculopathy and may be predictive of SCD in heart transplant recipients.
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Papers by Ivan Knezevic