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A case of an intravascular hemolysis after multiple aortic and mitral valves replacement is described. Hemolysis was observed after second and third operation of mitral valve prosthesis due to prosthesis dysfunction -- paravalvular leak. We discuss the possibilities of treatment, difficulties in decision making in a patient who is in good condition but hemolysis is clinically significant, not amenable to conventional treatment and there is an increased risk of another operation.

Atrial fibrillation is the most common tachyarrhythmia after coronary artery bypass grafting. The etiology of this arrhythmia and factors responsible for its genesis are unclear. The aim of this study was to compare the frequency of AF in patients undergoing coronary artery bypass grafting without the use of cardiopulmonary bypass (CPB) with those undergoing CABG using standard CPB. The study population consisted of 325 patients who underwent coronary artery bypass grafting between June 2000 and December 2001 (mean age 60.02, range 38-83 years, 242 males). Each patient had continuous ECG monitoring since the operation to the third postoperative day. AF occurred in 100 of 325 patients (30.76%). Patients were divided into two groups according to the presence (group A-100 patients) or absence (group B-100 patients) of post-CABG AF. Patients in both groups were compared. Intraoperative variables were used to compare the two groups. Patients with AF were significantly older (66.04 +/- 7.88 vs. 60.49 +/- 9.74 p = 0.0001). There was no statistically significant difference in the incidence of atrial fibrillation between the patients after coronary artery bypass grafting procedures, performed with or without cardiopulmonary bypass.

Background: Gene therapy is a new, experimental method of treatment in patients with coronary artery disease (CAD)., Aim: To determine the safety and efficacy of gene encoding vascular endothelial growth factor (VEGF165) administered directly into the myocardium as the single treatment or combined with coronary artery by-pass grafting (CABG)., Methods: VEGF gene transfer was performed in 22 patients (20 male, 2 female, ages from 48 to 73 years old). A 200 micro g of the plasmid encoding VEGF165 was injected into the ischaemic myocardium which could not be surgically revascularised in patients undergoing CABG (n=14), and 400 micro g - in patients without CABG (n=8). The value of ejection fraction (EF), myocardial perfusion, angiogram, ventriculography, and nitroglycerine consumption as well as quality of life were evaluated pre- and postoperatively., Results: The majority of patients had no complications and no fatal outcome was observed. Two patients developed acute myocardial infarction. Left ventricular function values improved and the majority of patients were free from angina 6 months after surgery. Patients reported improved quality of life and a reduction in nitroglycerine usage. A reduction in the ischaemic defects detected by SPECT was also observed. In some patients angiography revealed improved collateral filling., Conclusions: Direct myocardial administration of genes encoding VEGF165 can be an effective method of treatment in patients with chronic and advanced CAD either as a supplementary treatment or as a single therapy.

Unlabelled: Orthotopic heart transplantation (OHT) is most effective method for treatment of irreversible heart failure. Patients after OHT considered for permanent pacing consist still present a challenge for the implanting physician due to distorted atrial geometry and specific electrophysiological conditions of atrium. The aim of our study was to analyse the effectiveness of permanent atrial pacing in these patients., Patients and Methods: We implanted atrial lead in 37 SND pts., 2 months--7 years after OHT, (3 pts with coexisting AV block received ventricular lead). Only straight BP screw-in leads and manually formed stylets were used; we found satisfactory pacing/sensing conditions in 25 pts in RA appendage or anterior/lateral wall, in 10 pts--in CS ostium region and in 2--in proximal part of CS., Results: All implantations were successful and no patient received VVI pacing system. One dislodged lead required revision (1/37, 3%) but this was not related to endomyocardial biopsy. In 2 pts, due to unacceptable low RA potential and/or high PTh values atrial lead was implanted to CS for sensing/pacing of left atrium. The average acute value of A wave were 2.4 mV and chronic 2.2 mV; values of pacing threshold were 0.9 V and 1.6 V respectively. Only in 13/37 pts native A waves were recorded but with amplitude < 0.6 mV. Wenckebach point was 120/min only in 2 pts., in borders 130-160 bpm in 15 pts. and exceeded 170 bpm. in remained 20 pts. Retrograde VA conduction was intact in 33/37 pts, but in 4 pts exceeded 260/min. During long term follow-up in no patient we observed AV conduction disturbances. In 6 pts. treadmill exercise (Bruce's protocol) was repeated three times during: sinus (spontaneous) rhythm, AAI pacing 70/min, AAI-R (DDD-R) pacing. AAI 70 bpm did not influence significantly attained workload, heart rate on peak exercise or duration of exercise. But atrial rate modulated pacing increased values of examined parameters significantly., Conclusions: 1. Atrial pacing (and atrial based pacing modes) are possible in majority of transplanted heart patients. 2. Frequency of atrial lead dislocation, appearance of atrial sensing problems and AV conduction disturbances (all in about 3%) are comparable to non-transplanted patients. 3. In most patients with SND after OHT AV conduction remains within normal limits; it indicates safety of rate responsive pacing modes in these patients. 4. Rate modulated atrial pacing improves exercise tolerance in heart transplanted patients with SND. 5. High ("supra-normal") values of Wenckebach's point observed in most of patients with transplanted (dennervated) heart may have clinical importance in cases of atrial arrhythmias in these patients.

Unlabelled: Lower-Shumway technique (atrioatrial anastomosis) is the most frequently used technique for orthotopic heart transplantation and such a patient has two right atria and two sinus nodes. Sinus node dysfunction (SND) is a frequent finding in pts. after OHT; taking advantage of the frequency of innervated sinus node of recipient's atrial remnant as a natural biosensor for triggered pacing of donor atrium is an interesting option for these pts. THE AIMS OF OUR STUDY: 1. the analysis of possibility of utility of recipient atrial sinus node as natural biosensor for triggered donor atrium permanent pacing in transplanted patients with SND. 2. the evaluation of pacing and sensing conditions of the recipient's atrium in the some pts.. 3. long-term observation of effectiveness A2A2T(/D) pacing mode., Methods: 10 out of 37 pts. received A2A2T (8 pts.) and A2A2T/D (2 pts) pacing systems. In pts. with NSR of recipients atrium, we evaluated acceleration of its frequency during slight exercise and atropine., Results: In recipient's atrium among 37 pts we recognized NSR only in 15/37 pts.; in the remaining 22 pts. we found: sinus bradycardia--in 3, atrial flutter--in 3, low voltage AF--in 12 and no electrical activity--in 4 pts. Positive response to isometric exercise and atropine was observed in 12/15 pts. and 8 of them received A2A2T or A2A2T/D pacing system. We found much better sensing and pacing conditions in donor (A wave 2.1 mV, p. threshold 0.8 V) than in recipient atrium (1.1 mV and 1.4 V respectively). We observed some problems with sensing of recipient atrium in 4 of 10 pts. and changes SST to AAI-R mode solved the problem without loss of atrial resynchronization. 9 out of 10 pts. preferred AAT to AAI-R pacing program. One dislodged lead required revision during postoperative period (1/44, 2%). There was no dislodgement related to endomyocardial biopsy. In one patient, atrial flutter in recipient atria was transmitted to atrium of transplanted heart by pacing system with 2:1 conduction; arrhythmia was interrupted with drugs and did not return., Conclusions: 1. Atrial resynchronization is possible only in about 1/4 patients with SND after OHT due to frequently noted electrophysiological changes in recipient atrium. 2. In transplanted heart patients sensing and pacing conditions are much more favorable in donor's than recipient's atrium. 3. Atrial resynchronization can be subjectively (positively) recognised by most of patient after OHT and it still remains a promising pacing mode for selected patients after OHT with SND.