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Background and Objectives : The combination of aortic valve stenosis (AS) and ischemic heart disease (IHD) is quite common and is associated with myocardial fibrosis (MF). The purpose of this study was to evaluate the association between the histologically verified left ventricular (LV) MF and its geometry and function in isolated AS and AS within IHD groups. Materials and Methods : In a single-center, prospective trial, 116 patients underwent aortic valve replacement (AVR) with/without concomitant surgery. The study population was divided into groups of isolated AS with/without IHD. Echocardiography was used, and LV measurements and aortic valve parameters were obtained from all patients. Myocardial tissue was procured from all study patients undergoing elective surgery. Results : There were no statistical differences between isolated AS and AS+IHD groups in LV parameters or systolic and diastolic functions during the study periods. The collagen volume fraction was significantly different between the isolated AS and AS+IHD groups and was 7.3 ± 5.6 and 8.3 ± 6.4, respectively. Correlations between MF and left ventricular end-diastolic diameter (LVEDD) ( r = 0.59, p = < 0.001), left ventricular mass (LVM) ( r = 0.42, p = 0.011), left ventricular ejection fraction (LVEF) ( r = -0.67, p < 0.001) and an efficient orifice area (EOA) ( r = 0.371, p = 0.028) were detected in isolated AS during the preoperative period; the same was observed for LVEDD ( r = 0.45, p = 0.002), LVM ( r = 0.36, p = 0.026), LVEF ( r = -0.35, p = 0.026) and aortic annulus ( r = 0.43, p = 0.018) in the early postoperative period; and LVEDD ( r = 0.35, p ≤ 0.05), LVM ( r = 0.43, p = 0.007) and EOA ( r = 0.496, p = 0.003) in the follow-up period. In the group of AS and IHD, correlations were found only with LV posterior wall thickness ( r = 0.322, p = 0.022) in the follow-up period. Conclusions : Histological MF in AS was correlated with LVM and LVEDD in all study periods. No correlations between MF and LV parameters were found in aortic stenosis in the ischemic heart disease group across all study periods.

Background and Objectives: To assess the correlation between the degree of target coronary artery stenosis measured by instantaneous wave-free ratio (iFR) and the intraoperative transit time flow measurement (TTFM) of attached grafts as well as evaluate flow competition between the native coronary artery and the attached graft according to the severity of stenosis. Materials and Methods: In total, 89 grafts were subjected to intraoperative transit time flow measurement after coronary artery bypass grafting (CABG) in 25 patients with multivessel coronary artery disease (CAD). The iFR was evaluated for all coronary arteries with grafts. The coronary artery stenoses were divided into three groups based on the iFR value: iFR < 0.86 (group 1); iFR 0.86-0.90 (group 2); and iFR > 0.90 (group 3). Results: The mean graft flow (MGF) was 46.9 ± 18.4 mL/min for group 1, 45.3 ± 20.9 mL/min for group 2, and 31.3 ± 18.5 mL/min for group 3. A statistically significant difference was confirmed between groups 1 and 3 ( p = 0.002) and between groups 2 and 3 ( p = 0.025). The pulsatility index (PI) was 2.49 ± 1.20 for group 1, 2.66 ± 2.13 for group 2, and 4.70 ± 3.66 for group 3. A statistically significant difference was found between groups 1 and 3 ( p = 0.006) and between groups 2 and 3 ( p = 0.032). Backward flow was detected in 7.5% of grafts for group 1, in 16.6% of grafts for group 2, and in 16% of grafts for group 3. A statistically significant difference was found between groups 1 and 2 ( p = 0.025) and between groups 1 and 3 ( p = 0.029). Conclusions: The iFR is a useful tool for predicting the impact of competitive flow observed between a native artery and an attached graft. The effect of competitive flow significantly increases when the graft is attached to a vessel with mild coronary stenosis. In a coronary artery where the iFR was not hemodynamically significant, the MGF was lower, the PI was higher, and a larger proportion of grafts with backward flow (BF) was detected compared to when there was significant stenosis (iFR < 0.86).

Background and objectives : The aims of this study were to investigate changes in the hemodynamics associated with different types of aortic prostheses and to evaluate patient-prosthesis mismatch (PPM) at rest and after exercise. Materials and Methods : We retrospectively analyzed 150 patients who presented with indications for aortic valve replacement (AVR) with/without concomitant surgery from March 2019 to January 2020. The study population included 90 (60%) men and 60 (40%) women (mean age, 67.33 ± 10.22 years; range, 37-88 years). Echocardiography data such as peak and mean transprosthetic pressure gradients (Gmax, Gmean), velocity (V), effective orifice area (EOA), and indexed EOA (iEOA) were derived at rest and after exercise at baseline and before discharge. The study patients performed the six-minute walk test (6MWT) on the 5th-7th postoperative day. Results : Stented tissue valves showed excellent performance at rest and after exercise in comparison with mechanical valves, which showed favorable hemodynamics at rest only. At the time of discharge, moderate PPM was observed in 7/74 patients (9.5%) at rest and 5/98 (3.3%) patients after exercise. None of the patients showed severe PPM. EOA and iEOA were not significantly different between the groups. However, the stented group showed more pronounced changes in EOA and iEOA after exercise, whereas the changes in the mechanical valve group did not reach significance. Conclusions: In the early postoperative period, mechanical valves and stented valves showed favorable resting hemodynamics. The PPM rate measured after exercise was lower than that at rest.

Optical mapping is recognized as a promising tool for the registration of electrical activity in the heart. Most cardiac optical mapping experiments are performed in ex vivo isolated heart models. However, the electrophysiological properties of the heart are highly influenced by the autonomic nervous system as well as humoral regulation; therefore, in vivo investigations of heart activity in large animals are definitely preferred. Furthermore, such investigations can be considered the last step before clinical application. Recently, two comprehensive studies have examined optical mapping approaches for pig hearts in situ (in vivo), likely advancing the methodological capacity to perform complex electrophysiological investigations of the heart. Both studies had the same aim, i.e., to develop high-spatiotemporal-resolution optical mapping suitable for registration of electrical activity of pig heart in situ, but the methods chosen were different. In this brief review, we analyse and compare the results of recent studies and discuss their translational potential for in situ cardiac optical mapping applications in large animals. We focus on the modes of blood circulation that are employed, the use of different voltage-sensitive dyes and their loading procedures, and ways of eliminating contraction artefacts. Finally, we evaluate the possible scenarios for optical mapping (OM) application in large animals in situ and infer which scenario is optimal.

Background and Objectives: The aim of this study is to identify risk factors for the development of delayed neurocognitive recovery (dNCR). Methods: 140 patients underwent neurocognitive evaluations (Adenbrooke, MoCa, trial making, and CAM test) and middle cerebral artery (MCA) blood flow velocity (BFV) measurements, one day before cardiac surgery. BFV was re-evaluated after anesthesia induction, before the beginning, middle, end, and after cardiopulmonary bypass (CPB) and postsurgery. To measure glial fibrillary acidic protein (GFAP) and neurofilament heavy chain (Nf-H), blood samples were collected after anesthesia induction, 24 and 48 h after the surgery. Neurocognitive evaluation was repeated 7-10 days after surgery. According to the results, patients were divided into two groups: with dNCR (dNCR group) and without dNCR (non-dNCR group). Results: 101 patients completed participation in this research. GFAP increased in both the non-dNCR group ( p < 0.01) and in the dNCR group ( p < 0.01), but there was no difference between the groups (after 24 h, p 0.342; after 48 h, p 0.273). Nf-H increased in both groups ( p < 0.01), but there was no difference between them (after 24 h, p = 0.240; after 48 h, p = 0.597). MCA BFV was significantly lower in the dNCR group during the bypass (37.13 cm/s SD 7.70 versus 43.40 cm/s SD 9.56; p = 0.001) and after surgery (40.54 cm/s SD 11.21 versus 47.6 cm/s SD 12.01; p = 0.003). Results of neurocognitive tests correlated with CO 2 concentration (Pearson's r 0.40, p < 0.01), hematocrit (r 0.42, p < 0.01), MCA BFV during bypass (r 0.41, p < 0.01), and age (r -0.533, p < 0.01). The probability of developing dNCR increases 1.21 times with every one year of increased age ( p < 0.01). The probability of developing dNCR increases 1.07 times with a decrease of BFV within 1 cm/s during bypass ( p = 0.02 ) . Conclusion : Risk factors contributing to dNCR among the tested patients were older age and middle cerebral artery blood flow velocity decrease during bypass., Competing Interests: The authors declare no conflict of interest

Enhanced recovery after surgery (ERAS) are specially designed multimodal perioperative care pathways which are intended to attain and improve rapid recovery after surgical interventions by supporting preoperative organ function and attenuating the stress response caused by surgical trauma, allowing patients to get back to normal activities as soon as possible. Evidence-based protocols are prepared and published to implement the conception of ERAS. Although they vary amongst health care institutions, the main three elements (preoperative, perioperative, and postoperative components) remain the cornerstones. Postoperative pain influences the quality and length of the postoperative recovery period, and later, the quality of life. Therefore, the optimal postoperative pain management (PPM) applying multimodal analgesia (MA) is one of the most important components of ERAS. The main purpose of this article is to discuss the concept of MA in PPM, particularly reviewing the use of opioid-sparing measures such as paracetamol, nonsteroid anti-inflammatory drugs (NSAIDs), other adjuvants, and regional techniques.

Background and Objective: Left atrium (LA) is an important biomarker of adverse cardiovascular outcomes and cerebrovascular events. This study aimed to evaluate LA myocardial deformation using cardiac magnetic resonance feature tracking (CMR-FT) in patients with acute ST-segment elevation myocardial infarction (STEMI) and secondary mitral regurgitation (MR). Additionally, to assess interobserver and intraobserver variability of the technique., Materials and Methods: Twenty patients with STEMI underwent CMR with a 1.5Tesla MRI scanner. According to the presence of MR patients were divided into two groups: MR(+) and MR(-). Total LA strain (ɛ s ), passive LA strain (ɛ e ), and active LA strain (ɛ a ) were obtained. Additionally, total, passive and active strain rates (SR s , SR e , and SR a ) were calculated. To assess interobserver agreement data analysis was performed by second independent observer., Results: LA volumetric and functional parameters were similar in both groups. All LA strain values were significantly higher in patients with MR: ɛ s (27.67±10.25 for MR(-) vs. 32.80±6.95 for MR(+); P=0.01), ɛ e (15.29±7.30 for MR(-) vs. 19.22±6.04 for MR(+); P=0.01) and ɛ a (12.38±4.23 for MR(-) vs. 14.44±5.19 for MR(+); P=0.03). Only SR e significantly increased in patients with MR (-0.57±0.24 for MR(-) vs. -0.70±0.20 for MR(+); P=0.01). All LA deformation parameters demonstrated high interobserver and intraobserver agreement., Conclusions: Conventional volumetric and functional LA parameters do not detect early changes in LA performance in patients with STEMI and secondary MR. In contrast, LA reservoir, passive and active strain are significantly higher in patients with MR. Only peak early negative strain rate substantially increases during secondary MR. LA deformation parameters derived from conventional cine images using CMR-FT technique are highly reproducible., (Copyright © 2017 The Lithuanian University of Health Sciences. Production and hosting by Elsevier Sp. z o.o. All rights reserved.)

Background and Objective: The purpose of our study was to evaluate 1- and 2-year results and the influence of risk factors on the outcome in the patients undergoing iliac artery stenting for TASC II type B, C, and D iliac lesions., Materials and Methods: In this prospective nonrandomized study conducted between April 15, 2011, and April 15, 2013, 316 patients underwent angiography with a diagnosis of aortoiliac atherosclerotic disease. Of these, 62 iliac endovascular procedures (87 stents) were performed in 54 patients., Results: The indications for revascularization were disabling claudication (Rutherford 2, 5.9%; Rutherford 3, 35.2%), rest pain (Rutherford 4, 22.2%), and gangrene (Rutherford 5, 16.7%). The overall complication rate was 9.2%. The cumulative primary stent patency at 1 and 2 years was 83.0%±5.2% and 79.9%±5.8%, respectively. Early stent thrombosis in ≤30 days was detected in two patients (3.7%). The primary patency rates for the stents ≤61mm at 12 and 24 months were 90.6%±4.5% and 86.6%±5.8%, respectively; those for the stents >61mm were 67.7%±10.9% and 60.2%±12.0%, respectively (P=0.016). The multivariate Cox regression analysis enabled the localization of a stent in both the CIA and the EIA (hazard ratio [HR], 3.3; 95% confidence interval [CI], 1.1-9.5; P=0.021) and poor runoff (HR, 3.2; 95%, CI 1.0-10.0; P=0.047) as independent predictors of decreased stent primary patency., Conclusions: The localization of a stent in both iliac (CIA and EIA) arteries and poor runoff significantly reduce the primary stent patency. Patients with stents >61mm have a higher risk of stent thrombosis or in-stent restenosis development., (Copyright © 2014 Lithuanian University of Health Sciences. Production and hosting by Elsevier Urban & Partner Sp. z o.o. All rights reserved.)

Successful heart-lung complex transplantation was performed in a 48-year-old man. During the postoperative period, M. tuberculosis infection was diagnosed, and the treatment subsequently started. One year after, the patient was urgently hospitalized due to myocardial infarction. However, despite the best efforts, the patient died. Antituberculosis treatment is recommended to all the patients with confirmed active tuberculosis. Treatment of tuberculosis in transplant recipients is similar to that of the general population, with the exclusion of rifamycins in the regimen and longer duration of treatment.

Ventricular septal defect after myocardial infarction is a rare but often life-threatening mechanical complication. The keys of management are a prompt diagnosis of ventricular septal defect and an aggressive approach to stabilize patient's hemodynamics. Invasive monitoring, judicious use of inotropes and vasodilators, and an intra-aortic balloon pump are recommended for the optimal support of patient's hemodynamics. The best results are achieved if optimally medically managed patients survive at least 4 weeks before elective surgery necessary for scar formation in a friable infarcted tissue. We report a case of acute myocardial infarction complicated by the rupture of ventricular septum. Instead of attempting an immediate surgical closure of ventricular septal defect, the postponed surgery was successfully performed 3 weeks after the occurrence of ventricular septal defect. Preoperatively, clinical and hemodynamic conditions of the patient were maintained stable with the support of an intra-aortic balloon pump and inotropes.

Objective: The aim of this study was to determine the prevalence of burnout among Lithuanian cardiac surgeons and cardiac anesthesiologists, and associations between burnout and the personal and professional characteristics of physicians., Material and Methods: A total of 29 cardiac surgeons and 30 cardiac anesthesiologists employed in Vilnius and Kaunas university hospitals as well as in Klaipėda Hospital were surveyed. Data on personal characteristics (age, gender, marital status, number of children, sleeping hours, and addictions), professional characteristics (years in practice, work character, work profile, and workload), career satisfaction, and symptoms of depression were collected by using an anonymous questionnaire. Burnout was measured by the Maslach Burnout Inventory-Human Services Survey (MBI-HSS)., Results: More than half (54.3%) of the physicians surveyed had been in practice for >15 years, 71.2% reported working more than 40 hours per week, and 62% reported of being burned out. As much as 19.3% of physicians reported high emotional exhaustion, 25.9% had high depersonalization, and 42.3% demonstrated low personal accomplishment at work. Nearly 95% of respondents would become a physician and 82.8% would choose to become a cardiac surgeon or a cardiac anesthesiologist again. Physicians who worked more than 40 hours per week, smokers, and those who were desperate were more likely to be burned out., Conclusions: Burnout was found to be prevalent among Lithuanian cardiac surgeons and cardiac anesthesiologists. Some personal and professional characteristics were significantly related to burnout. Burnout relief measures should be developed in order to prevent a further increase of burnout syndrome among Lithuanian cardiac surgeons and cardiac anesthesiologists.

Unlabelled: A clinical effect of warfarin depends on highly polymorphic drug-metabolizing (CYP2C9) and drug-target (VKORC1) enzymes. The objective of this study was to investigate the impact of CYP2C9*2, CYP2C9*3, and VKORC1 (G-1639A) polymorphisms on the variability of warfarin dosage requirements in Lithuanian patients after heart valve replacement., Materials and Methods: The study included 83 patients with a mean age of 65.2 years (SD, 13.31) after heart valve replacement with an achieved stable international normalized ratio of 2-3.5. The restriction fragment length polymorphism method was used to identify polymorphisms of VKORC1 and CYP2C9., Results: Daily warfarin dosage significantly correlated with weight (r=0.4087) and height (r=0.3883) of the patients. Patients younger than 60 years required significantly higher daily warfarin dosages than older patients. Two-thirds (66.3%) of the patients had the wild-type (WT) CYP2C9*1/*1 genotype; 38.6% and 54.2% of the patients had WT VKORC1 (G/G) and VKORC1 (G/A) genotypes, respectively. WT CYP2C9*1/*1 genotype was associated with a higher daily warfarin dosage (5.84 mg [SD, 2.84]) as compared to other CYP2C9 genotypes. Carriers of WT VKORC1 (G/G) required a higher warfarin dose as compared to (A/A) carriers (6.20±2.78 mg and 3.75±1.40 mg, respectively; P=0.04). Patients having CYP2C9*1/*1 or 1/*2 in combination with VKORC1 (G/G) or (G/A) genotypes required the highest daily warfarin dosage in comparison to other combinations of genotypes., Conclusions: The Lithuanian study sample is characterized by high a frequency (92.8%) of VKORC1 G/G and G/A genotypes that determines a higher warfarin-loading dose. Analysis of combined CYP2C9 and VKORC1 gene variants allows the prediction of warfarin dosage. These results can be used to individualize treatment with warfarin in the field of heart surgery in Lithuania.

Objective: Our study was designed to assess the incidence of atrial fibrillation, changes in serum electrolyte concentrations and urinary electrolyte excretion following coronary artery bypass grafting surgery., Material and Methods: A total of 165 patients who underwent elective coronary artery bypass grafting surgery at the Department of Cardiac Surgery (Heart Center) during the period of 2004-2005 were enrolled. Serum K(+), Na(+), Mg(2+), Ca(2+), Cl(-), and P(-) concentrations were measured before cardiopulmonary bypass (CPB), on the arrival to an intensive care unit, and 15-18 hours after the surgery. Urinary excretion of K(+), Na(+), Mg(2+), Ca(2+), Cl(-), and P(-) was estimated 24 hours before the surgery, during the surgery, and 24 hours after the surgery. Cardiac rhythm was monitored throughout the study. All patients randomly were divided into the group 1 (n=55), which received magnesium sulphate infusion, and group 2 (n=110), which did not receive magnesium sulphate., Results: The overall incidence of atrial fibrillation was 27.4%. The patients in the group 1 had significantly higher levels of serum magnesium before CPB and serum chloride after the surgery. Urinary magnesium and calcium excretion was significantly higher in the group 1 during and after the surgery. Before the surgery and 24 hours after the surgery, phosphate excretion was significantly higher in the group 1., Conclusions: The incidence of atrial fibrillation after myocardial revascularization surgery remains high (27.4%). Serum electrolyte concentrations after myocardial revascularization varied within normal ranges. Magnesium sulphate infusion did not decrease the rate of postoperative atrial fibrillation during the early postoperative period in normomagnesemic patients.

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.

Ischemic heart disease in European countries over decades causes up to 55% of all cases of sudden death and also has a high rate of mortality, morbidity, and hospital admission. Patients with such chronic diseases also require intensive home care facilities from community nurses. The aim was to establish international multilingual platform for transtelephonic ECG system as an alternative solution for home care and assess its performance. METHODS. During this pilot study, the international toll-free line between Lithuania and Germany was established, and practical applicability of the tele-ECG device was tested. Transtelephonic ECG system was implemented between Telemedicine Center in Bad Segeberg (Bad Segeberg Clinic, Germany), the Call Center in Kaunas at the Hospital of Kaunas University of Medicine, and a patient residence. RESULTS. Over a 6-month follow-up period, 34 patients were recruited. Following the ECG transmission, 86 teleconsultations were done. During the study, a total of 329 ECGs were sent by the patients; out of them, 14 ECGs were with clinical changes. Technical problems due to insufficient patient training, telecommunication systems, acoustic data transmission, and device itself were reported. Up to 23% of ECGs sent by patients were unreadable and not applicable for further clinical analysis. CONCLUSIONS. Our study showed the potential of telemedicine facilities to overcome the problems of access that makes the technique so potentially useful, but for telemonitoring application at patient homes in a wider population, it needs to be improved in terms of technical performance, transmission and analysis automatization.

Matrix metalloproteinase-3 (MMP-3) degrades extracellular matrix and may lead to development of dilatative pathology of ascending thoracic aorta. Expression of MMP-3 depends upon the 5A/6A polymorphism in the promoter region. An increased number of 5A alleles leads to high expression of MMP-3. Thus, objective of the study was to determine whether the 5A/6A polymorphism in the promoter region of MMP-3 gene is associated with the development of dilatative pathology of ascending thoracic aorta. We studied 76 patients (age ranged from 31 to 81 years; median age, 64 years) who underwent aortic reconstruction surgery due to dilatative pathology of ascending thoracic aorta and a random sample of the population (n=604) aged 25-64 years, all from Lithuania. DNA was analyzed by using real-time polymerase chain reaction to genotype polymorphism 5A/6A at a position -1171 of the MMP3 gene promoter. The prevalence of MMP-3 genotypes was similar in the group of dilatative pathology of ascending thoracic aorta and random sample of population. The frequency of 5A allele did not differ significantly between both groups and was 0.506 and 0.514, respectively. Male carriers of 5A/5A genotype were significantly younger compared with those with the 6A/6A genotype. In conclusion, the frequency of MMP-3 promoter 5A/6A genotypes did not differ between the group of patients with dilatative pathology of ascending thoracic aorta and the random sample of population, but the males with dilatative pathology of ascending thoracic aorta and 5A/5A genotype required aortic reconstruction surgery at the younger age than the males carrying 6A/6A genotype in the MMP-3 promoter region.

The high morbidity and mortality in patients with serious heart failure is a therapeutic challenge for current medicine. The leading cause of left ventricular dysfunction remains ischemic heart disease. Coronary artery bypass surgery is a treatment of choice in moderate-to-severe ischemic cardiomyopathy. The scarcity of completed prospective randomized clinical trials and high surgical risks create significant uncertainty concerning the optimal current treatment strategy. The role of imaging techniques of assessment for myocardial viability based on current guidelines may be very important in clinical decision-making. Present paper reviews some of the relevant literature concerning surgical treatment of ischemic cardiomyopathy and current evidence-based recommendations on this method of treatment. In advanced heart failure, coronary revascularization alone is an insufficient treatment modality. In the presence of moderate-to-severe ischemic mitral regurgitation, mitral valve repair or replacement should be considered at coronary artery bypass grafting surgery. One of the most common mechanisms of ischemic mitral regurgitation is Carpentier's type IIIb dysfunction, in which an undersized mitral anuloplasty might be helpful. Surgery of left ventricular shape and volume restoration leads to improvement of left ventricular function in patients with ischemic cardiomyopathy. When the results from three ongoing prospective randomized studies--the Surgical Treatment for Ischemic Heart Disease trial, Heart Failure Revascularization trial, the PET and Recovery Following Revascularization-2 trial--determining outcome of revascularization versus medical therapy are available, clinicians will have reliable data for making decisions concerning the optimum treatment strategy. At present, the choice of management still remains based on the data obtained from available retrospective trials or the state of art in the field.

Degenerative aortic stenosis and mitral annulus calcification are the most common valvular abnormalities in elderly population. The incidence of these abnormalities has increased due to increased life expectancy. In recent years, new diagnostic techniques have improved the accuracy of diagnosis of valvular heart disease, however, cases of advanced critical aortic stenosis with valvular cardiomyopathy and severe heart failure still occur. A clinical case of critical degenerative aortic stenosis and mitral annulus calcinosis, mitral stenosis and regurgitation, subsequently significantly decreased ejection fraction (15%) accompanied by valvular cardiomyopathy and severe congestive heart failure is described. Ischemic heart disease was excluded. Cardiosurgery including implantation of aortic and mitral bioprosthesis and tricuspid annuloplasty was performed after intensive medical treatment and improvement of heart failure symptoms. After follow-up of six months, a 76-year-old female patient has just symptoms of mild left-ventricular dysfunction corresponding to New York Heart Association functional class II.

The purpose of the present study was to determine whether extracellular osmotic pressure modulates beta2-adrenergic stimulation of the contraction force and L-type Ca2+ current in human atrial myocytes. Experiments were performed on human atrial trabeculae and myocytes isolated from the right atrium. We have studied the effect of salbutamol (SAL), a beta2-adrenoceptor agonist, on peak tension (P), time to half peak tension (tc), time to half relaxation (tr), resting tension (contracture) (C) and L-type calcium current (ICaL) under isosmotic (345 mOsm) and hyperosmotic (525 mOsm in experiments for P, and 405 mOsm for ICaL) conditions. Salbutamol (10(-8)/10(-5) M) added to the control solution increased P, with a half-stimulation constant EC50=(2.7+/-0.6)x10(-8) M (p<0.05) and the maximal stimulation of contraction force Pmax=180.6+/-45.8% (n=10). The time to half peak and time to half relaxation were reduced by salbutamol to 89.1+/-2.7% and 78.8+/-4.1% (n=8), respectively. Mannitol (180 mM) added to the Tyrode solution decreased Pmax to 34+/-5.5%; tc, tr and C were increased to 126.3+/-7.2%, 158.3+/-22.6% (n=4) and 0.54+/-0.22 (n=5) of the control level, respectively. Under these hyperosmotic conditions the same concentrations of SAL increased P with a half-stimulation constant EC50=(6.4+/-2.6)x10(-7) M and Pmax=57.2+/-12.6% (n=4). The tc and tr were reduced by 23.2+/-5.9% and 53.1+/-19.4% (n=4), respectively (as compared to mannitol). There was no significant effect of salbutamol on the resting tension induced by mannitol. Under isosmotic conditions salbutamol (10(-9)/10(-6) M) increased ICaL with an EC50 value of (2.9+/-0.9)x10(-9) M and Emax 182.3+/-19.8% (n=4). In hyperosmotic solutions the EC50 and Emax for ICaL were (1.2+/-0.5)x10(-8) M and 217.2+/-70.5%, respectively (n=5). These results indicated that hyperosmolarity reduced the effect of beta2-adrenergic stimulation on human atrial cells.

This article analyzes data obtained from the medical records of the patients with primary mitral valve prolapse. The study population was the patients admitted to Kaunas University of Medicine Heart Center (KUMHC) between 1999 and 2003. The objective of our study was to analyze the natural course of mitral valve prolapse, complications and their frequency, treatment strategy in KUMHC, as well as to review the results of surgical treatment. We gathered data from the medical records of 160 patients and analyzed their age, medical history, complications, comorbidities, functional status and echocardiographic parameters. Patients who underwent mitral valve surgery were followed 7.9+/-8.4 months after procedure. On average, 32+/-14 patients with primary mitral valve prolapse were treated at KUMHC annually. Their mean age was 48.4+/-16.5 years, 44.4% of them were male. The most frequent complications of mitral valve prolapse were > or =II degrees mitral regurgitation (78.4%), various cardiac arrhythmias (68.1%) and heart failure of > or =II NYHA class (79%). Surgical treatment was recommended for 64 (40%) KUMHC patients with primary mitral valve prolapse. Surgical treatment was applied in 44 (28.1%) of study patients. The patients, who were recommended surgical treatment, were older (mean age 53.2+/-11.9 years, p<0.05) and predominantly male (62.5%, p<0.05) as compared to medically managed patients. The heart failure (62.5% had NYHA class III or IV), severe mitral regurgitation (95.3% had mitral regurgitation of > or =III degrees ) and worse left ventricle function (15% had ejection fraction of <50%) were more frequent in this group as compared to medically managed patients (all p<0.05). During the last five years the number of hospitalized patients with primary mitral valve prolapse increased 3.2 times, the number of mitral valve surgical procedures among these patients increased 2.8 times, and the number of mitral valve repair increased 15.8 times. 56.8% of patients had uncomplicated postoperative course. The most frequent postoperative complication was new arrhythmias and/or conduction disturbances. 1 patient died in early postoperative period. There was significant decrease in left ventricle and left atrium size and the severity of mitral regurgitation 2 to 6 months after mitral valve surgery. These positive changes remained during all study period. Taking in the consideration the large number of mitral valve repair procedures and good outcomes, the low postoperative mortality of the surgical mitral valve prolapse treatment in KUMHC, we can strongly recommend surgical treatment for the patients with severe mitral regurgitation secondary to mitral valve prolapse.

The amount of patients with prosthetic valves is increasing and their follow up is an actual problem. The aim of this study was to estimate postoperative complications after valve replacement and to give the follow up schedule for family doctors and cardiologist. The article demonstrates late postoperative results of valve replacements performed in Heart Centre of Kaunas University of Medicine during five years (1999-2003). Hemodynamics, auscultation of patients with prosthetic valves, antithrombotic treatment, specificity of anticoagulants use before noncardiac surgery are described according to the last practical guidelines (1998). The follow up schedule after valve replacement is recommended for practical purposes. A total of 766 valves were replaced in this period: 82, 180, 167, 135 and 202, respectively per year. There were seen these late postoperative complications: thromboembolism (3.8%), valve thrombosis (2%), hypocoagulation (1.1%) and infective endocarditis (3.2%). CONCLUSION. Postoperative complications such as thromboembolism, valve thrombosis, hypocoagulation and infective endocarditis were detected more often than it is described in literature. The follow up schedule will help to identify near and late postoperative complications and to improve patients' life quality.

Objective: To evaluate the features of coronary artery bypass reoperations and to reduce the influence of the factors affecting postoperative morbidity and mortality., Material and Methods: The records of 53 consecutive patients (88.7% of men, 11.3% of women; mean age 67.1+/-7.5 years) who underwent coronary artery bypass reoperations were reviewed retrospectively. Coronary artery bypass reoperations comprised 2.98% of all coronary artery bypass grafting operations during that period. Coronary artery bypass reoperations performed within 4-week period after the last operation and complex procedures were excluded., Results: Postoperative mortality after 53 reoperations and 1775 primary coronary artery bypass grafting operations was 7.5 and 2.52%, respectively, and the results are comparable with the results from other clinics of cardiac surgery. Mean time interval between primary coronary artery bypass grafting and reoperation was 90.7+/-49.9 months. Angiography at that period showed patency of venous and arterial conduits--34.6 and 76.5%, respectively. Twenty-nine patients (54.7%) received only venous conduits during reoperation. There were 2.4+/-1.1 anastomoses constructed during reoperation comparing to 3.5+/-0.9 anastomoses per patient during primary coronary artery bypass grafting., Conclusions: According to our data mortality after coronary reoperations remains higher comparing to primary coronary artery bypass grafting, however, it does not differ significantly. We observed an increasing number of elderly patients in coronary reoperations. We think that it is related to the demographical changes within our country and increased use of arterial conduits during primary coronary artery bypass grafting operations. Arterial conduits are patent at least 10 years; it means that the time period until recurrent angina and reoperation is delayed. However, progression of arterial atherosclerosis remains the main reason for coronary artery bypass grafting reoperation.

Objective: The aim of the study was to estimate the differences in hemodynamic, metabolic and cardiovascular parameters in early postoperative period in hypertonic colloid solution and usual infusion therapy groups., Material and Methods: The study was blind placebo controlled. Thirty patients were randomly divided into two groups. The control group received usual Ringer solution for hypovolemia correction and the study group received 250 ml of 7.2% NaCl/6% Hydroxyethylstarch (HyperHaes, Frezenius) solution. The measurements were made before, immediately after the infusion, 60 min and 180 min after infusion. The parameters of central hemodynamics, oxygen transport, the temperature gradient, electrolyte concentration and fluid balance were evaluated., Results: After infusion of HyperHaes solution cardiac index increased from 2.8+/-0.2 to 3.8+/-0.3 L/min/m(2), pulmonary vascular resistance and systemic vascular resistance decreased. Serum Na(+)and Cl (-)increase in investigative group did not exceeded normal range and returned to initial level after an hour. The total fluid balance and fluid balance during surgery in investigative group was less than that in the control group., Conclusions: HyperHaes solution in early postoperative period after coronary artery bypass grafting surgery increased preload, had the tendency of decreasing afterload, increased cardiac index, decreased total fluid balance and did not cause hypernatremia and hyperchloremia.

Unlabelled: The aim of the study was to evaluate late changes of left ventricular geometry and function following non-ischemic mitral valve reconstructive surgery., Material and Methods: The study included 43 patients with non-ischemic mitral valve incompetence due to mitral valve fiber degeneration, Barlow disease, and endocarditis. Doppler echocardiography was performed prior, 10-14 days and 12 months following mitral valve anuloplasty., Results: Early after surgery preload reduction resulted in reduction of left ventricular end diastolic diameter index (from 31.7+/-2.8 to 27.9+/-2.4 mm/m(2), p<0.001), end diastolic volume index (from 81.1+/-15.8 to 55.7+/-12.2 ml/m(2), p<0.001). Due to increased afterload left ventricular systolic parameters remained unchanged with decrease in left ventricular ejection fraction (from 57.7+/-7.9 to 48.5+/-3.1%, p<0.001). Late after surgery left ventricular end systolic diameter index decreased from 20.2+/-2.4 to 17.4+/-2.8 mm/m(2) (p<0.001), wall stress - from 44.1+/-10.1 to 35.4+/-7.4 dyn/cm(2) (p<0.001), ejection fraction increased from 48.5+/-3.1 to 56.4+/-4.6% (p<0.001). Reduction of left atrium diameters and systolic pulmonary artery pressure from 46.4+/-13.2 to 37.8+/-4.6 mm Hg st. (p<0.001) were also noted., Conclusions: Surgical correction of non-ischemic mitral valve incompetence and reduction of preload result in positive left ventricular remodeling in early postoperative period. At the earliest reduction of left ventricular diastolic parameters is observed and following one year - reduction of left ventricular systolic parameters, left atrium, pulmonary artery pressure, and improvement in left ventricular systolic function.

Unlabelled: According to indications there is no difference in results of grafts patency and left ventricle function after minimal invasive myocardial revascularization in comparison to typical operation with cardiopulmonary bypass and cardioplegia. Only ranges of troponin T (TnT), CK and CK-MB are statistically significantly lower in the group of operations without cardiopulmonary bypass and cardioplegia., Material and Methods: According to possibilities different surgical technic of minimally invasive myocardial revascularization was used in 119 patients with chronic ischemic heart disease. Dynamic perioperative level of cardiospecific agents (TnT, CK, CK-MB) was determined in 30 cases; left ventricle function was echoscopically analyzed (ejection fraction, left ventricle wall motion index, left ventricle end diastolic diameter) for 70 patients and postoperative angiographic control was done for 46 patients., Results: All operations were done in the Clinic of Cardiosurgery of Kaunas University of Medicine until July 1, 2003. An analysis of operative data of 119 cases with ischemic heart disease is presented. All patients underwent thoracic coronary and aortocoronary bypass grafting using minimal invasive cardiosurgical technique on the beating heart without cardiopulmonary bypass ("off-pump"). In most cases median sternotomy was used. Left internal thoracic artery or saphenous vein were applied as a grafts. Perioperative investigation of TnT, CK and CK-MB for 30 patients in early postoperative period showed low level of signs of myocardial injury. Postoperative angiographic control of grafts in 46 patients was done until 30(th) postoperative day and showed excellent patency rate of arterial and vein bypasses. In cases of complete revascularization marked and statistically significant improvement of the left ventricle function was found., Conclusions: According to indications minimally invasive ("off-pump") operation is alternative method to traditional myocardial revascularization with cardiopulmonary bypass and cardioplegia. In these cases lower level of perioperative myocardial injury is observed; improvement of left ventricle function and high postoperative graft patency are similar to those after traditional operations.

Objective: Neuropsychological (cognitive) dysfunction has been described as an important complication, affecting up to 80% of patients early after cardiac surgery. Also it has been shown that cognitive abnormalities persist in a later postoperative follow up. The aim of our study was to determine incidence of cognitive complications early after isolated coronary artery bypass grafting using cardiopulmonary bypass, and to identify predictive factors, associated with perioperative cerebral dysfunction., Material and Methods: Eighty-six patients (63 men and 23 women; mean age 66.1+/-6.7 year) with identified isolated coronary artery disease were enrolled into prospective study using Case Report data collection document. Neuropsychological status was examined using Symbol Digit Modalities Test with additional Euro QOL test. All tests were performed at baseline (1 day before operation), at the 5(th) to 7(th) postoperative day and one month after operation., Results: Neuropsychological dysfunction (as compared with baseline) occurred in 59 patients (68.6%) at the 5(th)-7(th) postoperative day and persisted in 19 patients (22.1%) after one month. Patients who suffered postoperative cerebral dysfunction more often had history of prior cerebrovascular morbidity (p<0.05), poor left ventricular ejection fraction (

Unlabelled: The aim of our study was to evaluate the impact of stentless aortic bioprosthesis implantation on early and late postoperative results and hemodynamic changes., Material and Methods: Study group consisted of 66 patients, who received stentless aortic bioprosthesis in 1999-2003, and control group of 38 patients, randomly selected for data analysis out of 203 patients, who received mechanical aortic valve substitute during the same period at the Heart Center of Kaunas University of Medicine. Study protocol included clinical data, patients functional status and echocardiographic data pre and postoperatively up to 2 years., Results: Within a stentless bioprosthesis group clinically more severe forms of aortic valve disease were present (NYHA f. cl. 3.47 vs 3.0), with concomitant ischemic heart disease (51.5% vs 36.8%), and mitral valve insufficiency (51.5% vs 21.1%). Subsequently coronary artery bypass grafting was performed in 50% of patients within a stentless bioprosthesis group vs 28.9% in a mechanical valve group, and mitral valve repair in 30.49% vs 10.5%. Aortic cross clamp time in a stentless bioprosthesis group was 89.1+/-21.3 min, compared to 74.6+/-39.5 min in a "mechanical" group. Data analysis of valve/body surface area match was in favor of stentless valves: patients with the same body surface area received one size larger stentless valves. Mortality in a "stentless" group was 4.54 vs 7.3% in mechanical group. Mean transvalvular gradients after 2 years were statistically significantly lower in a "stentless" group: 9.4+/-3.1 mmHg vs 11.1+/-4.1 mmHg. Also there was significant decrease of left ventricular mass and mass index in both groups, however it was more pronounced in the "stentless" valve group., Conclusions: Despite more advanced patient age, stages of aortic valve disease, complexity of operations including more demanding stentless bioprosthesis implantation techniques, early and late postoperative results are in favor of stentless bioprosthesis. Low and acceptable postoperative mortality, lower transvalvular gradients, optimal matching of valve and body surface area, could be achieved, which warrants more pronounced positive postoperative left ventricular remodeling: reduction of left ventricle mass and left ventricle mass index with improved pts survival.

Unlabelled: The aim of the study was to compare late results of the minimally invasive operations of myocardial revascularization and conservative treatment in patients with acute ischemic syndrome., Material and Methods: Demographic, clinical and echocardiographic data was collected on patients with acute ischemic syndrome; data of 109 patients treated conservatively and data of 26 patients, who underwent minimal invasive operation of myocardial revascularization during acute phase of ischemic syndrome, were compared and ischemic consequences after one-year follow up period were determined in both groups., Results: The patients of both groups did not differ significantly according to the most clinical characteristics. One third of the patients in the surgery group had previous myocardial infarction, also they had higher rate of paroxysmal atrial fibrillation (26.9% vs 6.4%) and acute left ventricular failure (73.1% vs 44.0%) than the patients without operation. During one-year follow up period there were no cases of lethal events or myocardial infarction in the surgical group, however 37.5% of them had mild angina pectoris. At that time lethal outcome was observed in 6.1%, myocardial infarction in 3.5% and mild-severe angina pectoris in 68.8% of patients., Conclusion: The functional status of the patients significantly improved during one-year period after minimally invasive operation of myocardial revascularization compared to the patients treated conservatively.

Unlabelled: The aim of our study was to evaluate the influence of residual ischemic mitral insufficiency on patient's functional status and left ventricle remodeling after repair of ischemic mitral insufficiency., Material and Methods: The study group consisted of 95 out of 128 patients who underwent mitral valve repair for ischemic mitral insufficiency at the Department of Cardiac Surgery of the Heart Center of Kaunas University of Medicine in 1996-2002. The study protocol included general clinical data, patients NYHA functional class, pre, peri and postoperative echocardiographic data., Results: In patients with residual MI (MR>or=2 grade) late postoperative left ventricle morphometric parameters, left ventricle ejection fraction and mean pulmonary artery pressure did not change. Size of left ventricle was reduced (left ventricle end diastolic diameter index decreased from 28.9+/-0.4 to 27.7+/-0.4 mm/m(2), p<0.001; left ventricle end systolic diameter index - from 22.2+/-0.6 to 19.7+/-0.7 mm/m(2), p<0.001), left ventricle ejection fraction increased (33.3+/-1.0 and 40.1+/-1.2%, p<0.0001), mean pulmonary artery pressure, NYHA functional class significantly decreased with MR<2 grade late postoperatively., Conclusions: Residual MR is important factor for further worsening of patient's functional status and progressing of left ventricle remodeling after combined surgery.

Unlabelled: The aim of the study was to evaluate early complication rate and changes of left ventricular geometry and function after two types of left ventricular reconstruction surgery., Methods: The study included 54 patients with ischemic heart disease and left ventricular aneurysm, who underwent coronary artery bypass grafting and left ventricular reconstruction surgery: I group (31 patients) underwent modified Dor aneurysmectomy and II group (23 patients) underwent infarcted wall compression. The study protocol included operative data, early postoperative complications and evaluation of left ventricular function 10(th)-14(th) day after surgery., Results: Early complication rate had tendency to be higher in I group. Among patients with left ventricular ejection fraction <20%, in I group all 6 patients died, including 5 patients who underwent aneurysmectomy combined with mitral and tricuspid anuloplasty and 2 patients who underwent both apical aneurysmectomy and posterior wall compression, in II group - 1 of 3 patients died. Early changes of left ventricular geometry in I group included decrease in left ventricular diameter, volume, mass, as well as reduction of short axis of left atrium, in II group - decrease in left ventricular diameter, mass and both axis of left atrium. Left ventricular ejection fraction had tendency to increase in both groups: in 41.9% of patients in I group and in 56.5% in II group., Conclusions: Following different types of left ventricular reconstruction surgery early postoperative complications rate did not differ, except higher mortality rate in patients with left ventricular ejection fraction <20%, who underwent modified Dor aneurysmectomy combined with other surgical procedures. Early changes of left ventricular geometry and volume differed between patients who underwent different types of left ventricular reconstruction.

Objective: With the aim to check whether the atherogenic factors are involved in the mechanisms of valve fibrosis, we have studied the blood serum concentrations of apolipoproteins (apo) A-I and B concentration in patients suffering from rheumatic heart valve fibrosis., Method: The quantities of apoA-I and apoB in the blood serum were tested by the ELISA method. Concentration of apoA-I and B in the blood serum was determined in rheumatic females with replacement of the damaged valves: after aortic valve operation (n=11; mean age 43.3+/-3.6 years) and after mitral valve operation (n=29; 41.3+/-4.1). The results obtained for rheumatic patients were compared with the data on age-matched healthy females (n=43; 39.5+/-5.2 years)., Results: Significantly lower apoA-I level in the blood serum of all patients suffering from rheumatic heart valve disease was determined as compared with controls: in the pooled group of patients (1.02+/-0.22 vs 1.23+/-0.23 g/l, P<0.001), in women after aortic valve replacement (0.98+/-0.21 vs. 1.23+/-0.23 g/l, P<0.005), and in women after mitral valve surgery (1.03+/-0.23 g/l vs 1.23+/-0.23 g/l, P<0.005). The apoB level in patients suffering from rheumatic heart valve disease did not differ from that of controls. The apoB/apoA-I ratio for patients with valve fibrotic damage was significantly higher as compared to controls in all groups (P<0.02). The increase of apoB/apoA-I ratio in patients with rheumatic valve fibrosis was caused by lower apoA-I levels in blood serum., Conclusion: The obtained results indicate that decreased apoA-I levels in blood serum can be indicative of valve fibrosis in rheumatic heart valve disease patients.

The aim of the study was to determine the effect of pyruvate, a substrate of energetic metabolism, on the dependence of electromechanical activity on stimulation frequency in human myocardium. The experiments were performed on human ventricle myocardium from patients undergoing cardiac corrective open heart surgery at Clinic of Cardiac Surgery in Kaunas University of Medicine by using standard method of registration of myocardium electromechanical activity. The stimulation frequency of myocardial strips were 0.2, 0.5, 1.0, 1.5, 2.0, 2.5 and 3 Hz, duration of pulses -2-5 ms. In control, i.e. at perfusion of mycoardial strips by Tyrode solution and stimulation frequency 1 Hz, an average of contraction force (P) was 0.94+/-0.18 mN (n=12), half time of relaxation (t(a)) - 178.88+/-9.31 ms (n=12), and action potential duration measured at 50% repolarization level (VP(50)) - 294.75+/-27.95 ms (n=9). Pyruvate (10 mM) increased P to 159.9+/-13.4% (p<0.00), t(a)- 106.9+/-2.2% (n=12) (p<0.001), and VP(50)- 111.1+/-7.4% (n=5) (p<0.05), as compared to control. In the absence of pyruvate values of P, t(a) and VP(50) of myocardial strips were higher at 0.2 Hz and 0.5 Hz and lower at 3 Hz compared with those at 1 Hz of stimulation frequency. Although the dependence of these parameters on stimulation frequency in the presence of pyruvate (10 mM) was not altered but their values were persistently increased at all stimulation frequencies. The present data indicate that pyruvate is an effective inotropic agent, which can improve contractility function in wide-ranging diapason of stimulation frequency in failing human heart.

An impact of surgery for infective endocarditis on survival and heart failure has been analyzed. A total of 131 patients with IE have been observed during 1999-2001. Eighty seven of them were male and 44 female, mean age - 50+/-16 years. Sixty three (48.1%) patients underwent surgery, remaining 68 (51.9%) were treated conservatively. The surgical patients had signs of remarkably worse heart failure (p=0.0001), higher grade aortic (p=0.0001) and mitral (p=0.001) valve regurgitation. Surgery resulted in significant improvement of heart failure (p=0.01). Hospital mortality was 25.2% and did not differ between the groups. Elimination of the influence of complications revealed reduced hospital mortality of all patients by 9.9% and mortality of NYHA III-IV patients by 23.9% (p=0.02) as a result of surgery.

Technological development, implementation of new techniques and scientific knowledge into clinical practice, has a strong impact on development of surgical and anesthesiological professions. However, it creates new and unknown ethical issues within surgeons-anesthesiologist and their patient's relationship. Development of physiological-individualized anesthesia techniques focused on patient's outcome unquestionably is related to more general organizational ethical issues. Presented article analyzes factors influencing unavoidable, concomitant development of surgical and anesthesiological professions. It also addresses several ethical issues within the context of society development. There is a body of evidence ascribing identities of profession and different attitudes as well as interpretations of inter specialty relations. There is a need for constant discussion between the specialty representatives groups elaborating professional recommendations for further co-operation accepted by both sides.

Objective: The aim of this study was to review early postoperative results of the combined coronary artery bypass grafting and carotid endarterectomy (CABG/CEA) performed at the Clinic of Cardiac Surgery Heart Center of Kaunas University of Medicine., Material and Methods: A series of consecutive 19 patients (64.5+/-8.2 years old, 17 (89.5%) male patients) with coexisting severe ischemic cardiac and carotid artery disease were operated on during 8-year period ending December 2001. Seven (36.8%) patients with carotid artery stenosis were asymptomatic. Previous neurological events had occurred in 12 (63.2%) patients: five (26.4%) patients presented with a previous stroke, seven (36.8%) - with a transient ischemic attack. Demographics and perioperative variables of these patients were compared with variables of 42 patients, that underwent isolated CABG during this period (control group)., Results: After introducing of the routine preoperative screening carotid ultra-sonography in the year 2000, the rate of asymptomatic carotid artery stenosis among all diagnosed hemodynamically significant carotid stenoses has raised up to 43.8%. The in-hospital results were similar between the two groups with regard to 30-day perioperative mortality, stroke and major postoperative complications., Conclusions: Based on our results, combined interventions of CEA and CABG can be performed with an acceptable morbidity and mortality when severe carotid stenosis is associated with advanced, symptomatic ischemic heart disease. Patients with total occlusion of the carotid artery compose a high-risk subgroup for perioperative stroke. The introduction of routine preoperative carotid duplex scanning resulted in higher rate of asymptomatic carotid artery disease among the patients scheduled for combined CABG/CEA procedure.

Unlabelled: Earlier we have shown significantly more frequent B blood group and a significantly more rare O blood group of ABO blood group system in men aged under 45 years suffering from coronary atherosclerosis compared with these frequencies in the population of Lithuania. The aim of the study was to investigate the frequency of blood groups of ABO system in women with coronary atherosclerosis., Materials: The frequency of the ABO blood groups was examined in 441 women, suffering from coronary atherosclerosis, divided into two groups: I group - 109 women till 60 years old (mean age 55.1+/-4.8) and II group - 332 women aged over 60 years (mean age 68.1+/-5.0). For all patients coronary atherosclerosis was diagnosed by coronary angiography and confirmed during coronary bypass surgery. The frequency of the ABO blood group in the studied pts was compared with the frequency of the blood group in the control group of healthy blood donors (n=595). To evaluate the significance of data, we compared the frequency of ABO blood groups with the data in women long-livers (n=75, mean age 94.1+/-3.8). Earlier our studies showed that long-livers are an important antiatherosclerotic control group for evaluation of the genetic markers of atherosclerosis., Results: The O blood group was found significantly more rarely in the women group I as compared to that of healthy donors group (28.4% vs 38.2%, p<0.04). The B blood group was significantly more often in group II (22.9% vs 15.0%, p<0.04) compared with the frequency of the B blood group in the healthy donors' group. In the long-livers' group the frequency of the B group was significantly more rare than in healthy donors (6.7% vs 15%, p<0.01) as well as in the groups of tested pts (20.2% and 22.9% respectively, p<0.01). We did not find any significant changes in the frequency of AB blood group in women with coronary atherosclerosis., Conclusions: The B blood group can be related with coronary atherosclerosis in women. The O blood group can possibly serve as a protective antiatherogenic factor in women. The A blood group is not a risk factor for atherosclerosis in women in Lithuanian population. Long-livers are an important antiatherogenic control group for evaluation of atherogenetic markers of coronary atherosclerosis.

Objective: This retrospective study was undertaken to evaluate the accuracy of risk-adjusted EuroSCORE models in predicting mortality in individual patients who are undergoing coronary artery bypass grafting., Material and Methods: The study population is a consecutive series of 1698 isolated primary and repeat coronary artery bypass grafting patients, inclusive patients in cardiogenic shock or resuscitation, operated in Kaunas Heart Center from January 1997 to December 2001. The pre-operative risk of death was calculated with EuroSCORE models and then compared with the actual outcome. The accuracy score was used to evaluate the reliability of each score to predict the individual outcome. The studied event was in-hospital death, defined as mortality during hospital stay, which was unlimited in time and included a stay in a secondary hospital without discharge home., Results: Eighty deaths (4.7%) were observed. The age of this patients was 66.0+/-9.5 years, 73.7% were male and 3.7% were repeat procedures. In most patients who died the mean predictive scores were high. The EuroSCORE average was 11.0+/-4.3, with a range from 3 to 21., Conclusions: The EuroSCORE presurgical predictive models were highly accurate to predict overall mortality, but were inaccurate to predict mortality in individual patients.

Unlabelled: The aim of our study was to evaluate the initial results of left ventricular CABG and left ventricular remodelling operations. Study group consisted of 47 patients (pts) who underwent left ventricular geometry and volume restoration operations at the Kaunas University of Medicine Hospital during 1996 to 2002. Protocol included general clinical data, NYHA functional class, pre- and postoperative echocardiographic data, left ventricular aneurysm repair procedures. Pts mean age was 63.4+/-1.2 years. Men/women ratio 38/9. At admission NYHA functional class was 3.5+/-0.1. Mean left ventricular ejection fraction preoperatively was 24.2+/-0.9%, LV end diastolic diameter - 60.3+/-1.2 mm. Correction of left ventricular aneurysm consisted of: 1) direct aneurysmectomy - 11 pts, 2) endoventricular patch plasty - 7 pts, 3) circular suture - 19 pts, 4) aneurysmal reinforcement - 10 pts., Results: Early postoperative NYHA functional class decreased from 3.5+/-0.1 to 2.8+/-0.1 (p<0.0001) and late postoperative to 2.7+/-0.2 (p<0.0001). Within 2 weeks LV morphometric parameters, left ventricular ejection fraction, mean pulmonary artery pressure didn't change significantly. There was a significant reduction of mitral regurgitation in all survivals from grade 2.5+/-0.1 to 1.4+/-0.2 (p<0.0001). Hospital mortality - 25.5%, late mortality - 22.2%. Late postoperative LV end diastolic and systolic diameters had a tendency to increase. All of the patients showed late postoperative increase in deceleration time from 0.13+/-0.01 to 0.18+/-0.02 s (p<0.05), decrease in degree of MR from 2.6+/-0.1 to 1.8+/-0.3 (p<0.05). LV systolic function has a tendency to increase from 25.6+/-1.4 to 29.1+/-1.4. In conclusion, effective LV surgical remodelling combined with CABG improves pts functional status: NYHA functional class, LV diastolic function. But the results of these combined cardiac operations are not so excellent. The hospital mortality remains high, correction of LV morphometric parameters is not preferable.

Objective: The aim of this prospective study was to review incidence of neurological and cognitive complications after coronary artery bypass graft surgery and find out predictive factors, associated with perioperative cerebral dysfunction., Material and Methods: A prospective pilot study of 35 (27 men and 8 women, mean age 64.5+/-4.3 year) patients with identified coronary artery disease was conducted using Case Report data collection document. All patients underwent isolated elective CABG procedure at Cardiac center of Kaunas University of Medicine Hospital., Results: There were two cases (5.7%) of postoperative transient ischemic attack, two cases (5.7%) of restless agitation with delirium, characterised as an postoperative encephalopathy and eight patients (22.8%) with cognitive abnormalities., Conclusions: The Canadian Stroke Scale and The Confusion Assessment Scale are sensitive and objective methods for diagnostics of postoperative neurological dysfunction. To characterize the incidence and severity of neuropsychological dysfunction, a concise battery of neuropsychologic tests that provides reliable evidence of subtle brain trauma should be used.

Patients with coronary disease associated with abdominal aortic aneurysm or aortoiliac occlusive disease often raise problems of operative strategy. In particular, the order in which these lesions should be treated is a frequent source of controversy. Our approach for the past two years has been a combined myocardial revascularization with abdominal aortic reconstruction in patients with both lesions. From 1999 through 2001 seven patients underwent combined abdominal aortic reconstruction with coronary artery bypass grafting. We report here the fatal case of combined coronary artery bypass grafting and abdominal aortic aneurysm repair. Partial heparinization and operation without extracorporeal circulation caused acute thrombosis of abdominal aortic aneurysm and femoral arteries. Our first experience advocates using total heparinisation and cardiopulmonary bypass for combined cardiac-aortic procedures.

Objective: Patients with coronary artery disease associated with peripheral vascular disease often raise problems of operative strategy. Particularly the sequence of procedures in which lesions must be treated is a frequent source of controversy. The aim of this study was to research surgical strategy, early and late clinical outcomes for patients undergoing one-stage coronary and abdominal aortic or magistral artery surgical interventions., Material and Methods: From 1999 through 2002 twenty eight patients underwent combined major vascular reconstruction with coronary artery bypass grafting., Results: In group with abdominal aortic aneurysm 2 patients died. One patient died from intraoperative acute abdominal aortic aneurysm and bifemoral artery thrombosis with continuous bleeding from the vascular prosthesis in association with disseminated intravascular coagulation. Another patient died from bleeding from the sudden multiple gastroduodenal ulcers on post-operative day eight. In groups with peripheral vascular occlusive disease and carotid artery disease there were no deaths., Conclusions: The data show that combined coronary artery bypass grafting and vascular operations are feasible on patients with concomitant carotid artery or peripheral vascular occlusive disease. Management of CAD associated with abdominal aortic aneurysm remains controversial.

Unlabelled: The aim of our study was to evaluate the patients' (pts) survival, changes of functional status after repair of ischemic mitral insufficiency (IMI) and to determine their prognostic determinants. Study group consisted of 128 pts who underwent mitral valve (MV) repair for IMI at Kaunas University of Medicine hospital during 1996 to 2002. Study protocol included general clinical data, coronary artery involvement, patients NYHA functional class, pre, post and operative echocardiographic data, mitral valve repair procedures., Results: There was a significant reduction of MR in all survivals from grade 2.8+/-0.1 to 1.5+/-0.1 (p<0.0001). All of the patients showed late postoperative increase in LVEF from 32.2+/-1.0 to 37.1+/-1.1% (p<0.0001). Late postoperative NYHA functional class changed significantly from 3.3+/-0.1 to 2.3+/-0.1 (p<0,0001). Two-year years survival without heart failure was 51.6+/-7.9%. Prognostic markers of late postoperative heart failure (II-IV NYHA functional class): LVEF/=II grade late postoperatively. Two-year years survival without residual MR was 51.1+/-7.8%. Predictors of late residual MR are early residual MR>I grade (p<0.0001), LVEF<30% early postoperatively (p<0.0001) and LVEDDI late postoperatively >/=28 mm/m(2) (p<0,01). Hospital mortality - 17.2%, late mortality - 7.9%. Two and four-year years survival after combined heart surgery - 66.7%., Conclusions: Repair of IMI - effective method in treating ischemic heart disease complicated with MV regurgitation: late postoperatively patients functional status improves, LVEF increase. Prognostic markers of late postoperative heart failure (II-IV NYHA functional class) are: LVEF/=II grade late postoperatively.

Minimally invasive operations of myocardial revascularization (MIMR) are done using usual approaches, but without extracorporeal circulation and cardioplegia. Doing these operations according to indications, there is no difference in early results of these operations and the operations with extracorporeal circulation and extracorporeal circulation (1, 2). OBJECTIVE. To evaluate the late results of minimal invasive operations of myocardial revascularization 1 year after intervention, according to detection of patient's functional class, findings of echocardiography and stress test. Also to compare the results of operations in patient's groups of age up to 65 years old and over 65 years old. MATERIAL AND METHODS. From 88 patients, that underwent minimal invasive operations of myocardial revascularization, 34 patients were checked according to investigation protocol, evaluating functional class, myocardial contractility and stress test tolerance. The late results of two different groups of age were compared (each group includes 17 cases). RESULTS. All patients have survived 1 year after operation. Findings of stress test showed, that 60% of patients have reached 100 W and more strain tolerance. Pectoral angina was detected in 12% of cases. There was no difference, that was improved statistically in findings of myocardial contractility before and after operation. CONCLUSIONS. Evaluating the late results of minimally invasive operations of myocardial revascularization (1 year after operation), we can consider, that these operations, that were done according to indications, are improved, safe and suitable also to elderly patients.

Timing of surgery in infective endocarditis remains a challenge in the face of potential drug toxicity on one hand and recurrence of endocarditis on the other. The aim of the study was analysis of risk factors for hospital mortality and recurrent endocarditis. A total of 131 patients with infective endocarditis have been observed during 1999-2001. Eighty seven of them were male and 44 female with mean age of 50+/-16 years. Sixty three (48.1%) patients underwent surgery, remaining 68 (51.9%) were treated conservatively. Hospital mortality was 25.2%. Postoperative perivalvular leak was associated with culture negative endocarditis (p=0.09) as well as with positive valve culture (p=0.04). Recurrence was related to positive valve culture (p=0.08) and embolism (p=0.02). Increased risk of death was associated with neurologic, embolic, renal complications, myocardial abscess, NYHA IV f.cl. and extracardial surgery. According to the data obtained, optimal surgery time in the group appeared to be between 17 and 45 days after the diagnosis of infective endocarditis has been made (p=0.049).

Introduction: Surgical interventions because of mitral valve disease have been ascribed since 1951. Many changes within mitral valve replacement have passed including closed and open mitral commissurotomy, mitral valve repair operations implantation of mechanical, biological heart valve and finally use of mitral valve homograft. Despite changes in chirurgical tactics and medico-technical environment, mitral valve homograft implantation remains one of the most complex surgical interventions. Surgical and technical details of mitral valve homograft implantation are discussed., Objective: to estimate technical difficulties and anatomical positioning of mitral valve homograft considering a spectrum of indications of mitral valve replacement., Case Report: 62-year-old woman 26 years ago underwent mitral valve replacement with Starr-Edwards mitral valve prosthesis, because of rheumatic heart disease by homograft. Due to malfunction of the mitral valve prosthesis, and progressive left ventricular failure patient was reoperated on 26(th) of February 2002. Fresh antibiotic preserved mitral valve homograft was implanted. Surgical techniques were guided using left ventricle size measurement indicated by echocardiography., Results: The technique described by Acar/Carpentier was used except of mitral valve annuloplasty ring implantation. Peri- and early postoperative period was free of homograft related complications. The left ventricle function was improving and the heart size decreased dramatically during first postoperative week., Conclusion: The most important peculiarities for mitral valve homograft implantation are echocardiography data and intraoperative left ventricle measurements. Homograft implantation techniques are rather demanding therefore indications for mitral valve replacement have to be selected carefully and should be based on the presence of severe mitral valve dysfunction in order to achieve best hemodynamic results and prevent patient from anticoagulation therapy.