Aim To compare outcomes of two different surgical techniques of coronary artery bypass grafting (CABG) for treating isolated left anterior descending (LAD) coronary artery disease by full median sternotomy technique vs. minimally invasive approach via left anterior mini-thoracotomy. Methods This retrospective, observational study, which included 61 elective patients, was conducted at the Clinic for Cardiovascular Surgery of the Clinical Centre of the University of Sarajevo in the period from June 2019 to January 2022. Patients were divided in two groups according to the operative technique used, the sternotomy CABG group of 30 patients where the access considered full median sternotomy, and the minimally invasive CABG group where left anterior mini-thoracotomy was performed. The groups were compared by previously defined primary and secondary clinical postoperative outcomes. Results Out of 61 patients, the majority was males, 50 (82%). The analysis of the outcomes of the minimally invasive CABG surgery showed significantly shorter operative times (p=0.001), less postoperative drainage (p=0.001) and transfusion requirements, shorter mechanical ventilation duration (p=0.0001), low major adverse cardiac and cerebrovascular events rates, as well as shorter Intensive Care Unit stay days with mean of 3.3±1.442 days (p=0.025), but no total hospital stay days with mean of 6.7±1.832 days (p=0.075) compared to sternotomy CABG group. Conclusion Minimally invasive approach for CABG surgery in treating isolated single vessel LAD disease, together with the fasttrack protocol, offers a reasonable alternative to full median sternotomy, leading to faster patients' overall recovery and improving the quality of life.

Background: Coronary New blood in the vascular bed after Coronary Artery Bypass Grafting (CABG) may represent a turning point between ischemia and normal tissue nutrition. Its quantification can help to better understand coronary artery hemodynamics after revascularization. Objective: Quantification of coronary sinus blood flow changes over time after Coronary Artery Bypass Grafting (CABG) using Transthoracic Echocardiography (TTE). Methods: Prospective basic research, with repeated measurements on hospital sample of 61 patients whom CABG was conducted. We performed TTE recordings to measure CS flow before and two times after CABG (1 and 6 postoperative day). We measure CS diameter, Velocity Time Integral (VTI) and systemic hemodynamic data. Data needed for LV mass calculation were recorded once. During statistical analysis we define: α = 0,01, β = 0,01 (power = 1-β β= 0,99), Sample size = 60, Effect size= 0,68. We used ANOVA for Repeated Measures as main statistical test in SPSS. Results: Preoperatively we found low overall CS flow of 181 ±72 ml/min (0,68 ±0,30 ml/gram-LV/min). After surgery there was constant increase of CS flow from 276 ±79 ml/min (1,13 ±0,35 ml/gram-LV/min) first postoperative day, to 355 (±99) ml/min (1,30 ±0,46 ml/gram-LV/min) sixth postoperative day. Discussion: Amount of new blood was statistically significant after CABG with P<0,001. Same result was found after classifying patients per number of graft received, with the highest amount of new blood after four bypasses. Amount of new blood was not different if patient gets two or three bypasses. Conclusion: There was significantly new amount of blood in coronary bed after CABG, with constant increase over first 6 days.

Background: Despite many advances in the prevention, of sternal wound infection, especially deep ones, cardiac surgery with median sternotomy, still presents a significant postoperative complication. Numerous operative and non-operative procedures should be used in treatment, there is a prolonged hospital stay and increased hospital costs treating this postoperative complication. Objective: The present study was conducted aiming to determine the incidences, and risk factors, identify microbiology findings, and antibiotic therapy among patients with DSWI who underwent cardiac surgery with median sternotomy at our Clinic and VAC treatment. Methods: This retrospective observational study was conducted in Clinic for Cardiovascular Surgery at University Clinical Center Sarajevo from November 2015 to November 2020. The data were obtained from 15 patients with deep sternal wound infection (DSWI) following open-heart surgery. The inclusion criteria were DSWI after cardiac operation via median sternotomy, and complete results of microbiological findings obtained by sternal swab. The exclusion criteria were patients with incomplete clinical data. Results: We found that 9 (60%) patients were males and 6 (40%) were females. Coronary artery bypass grafting (CABG) operation had 11 (73,3%) patients, CABG with aortic valve replacement 2 (13,3%), valve replacement surgery operations (13,3%). The average age was 66 years. All patients were elective surgery patients. STS score in the Non-VAC group was 22.6, in the VAC group 16.6, and the average was 14.9. The number of patients with DSWI represents 1% of all sternotomy patients in the observed period. Two risk factors for DSWI had 37% of patients, 25% of them were diabetic, and 3 (9%) were overweight. Enterococcus faecalis was isolated predominantly in 6 (27%) patients, followed by Klebsiella pneumonia 3 (13%), Proteus mirabilis 2 (9%), and Serratia Maecenas 2 (9%). The mortality rate was 33.3% (5 of 15). Conclusion: The results of our study present our experience with DSWI treatment after open-heart surgery. What comes from our experience so far, is that is very important to determine patients who are at risk of developing DSWI after cardiac surgeries to lower its incidence.

BACKGROUND: Stenosis of the carotid arteries, as a consequence of atherosclerosis is the most common cause of cerebrovascular insult (CVI). Severe (>70%) contralateral stenosis or occlusion (SCSO) of the carotid artery may represent an additional pre-operative risk factor  for neurologic incidents.             AIM: The aim of this study was to confirm and compare early perioperative results (0-30 days) of carotid endarterectomy (CEA) in patients with and without SCSO.                 PATIENT AND METHODS: In our retrospective-prospective study, we analysed the results of 273 CEA, divided into two groups based on the presence of significant contralateral stenosis or occlusion (non-SCSO and SCSO groups)             RESULTS: 273 CEA’s were performed, divided into two groups: SCSO groups 40 (14.7%) and non-SCSO group 233 (85.3%). Between the two groups, a statistically significant difference between patients was found (54.1% compared to 87.5%; p<0.0005), CEA with patch angioplasty (25.3% compared to 52.5%; p=0.001),  and CEA with the use of a shunt (3.9% compared to 35%; p<0.0005) in favour of the SCSO group. There was no statistically significant difference (SCSO was not identified as a risk factor) for any type of stroke or mortality. Logistically regression confirmed SCSO to be an independent predictor of 30-day mortality (OR 21.58; 95% CI  1.27-36.3; p= 0.033) and any type of stroke or mortality (OR 9.27; 95% CI  1.61-53.22; p= 0.012). SCSO was not a predictor of any type of stroke within 30 days. Predictors of any type of stroke was dyslipidemia (OR 0.12, 95% CI  0.02-0.76; p= 0.024).             CONCLUSIONS: There was no statistically significant difference in the incidence of early (30 day) perioperative complications between the analysed groups. The percentage of perioperative complications remains within the accepted parameters, and thus, SCSO should not be qualified as a significant risk factor for CEA. We are of the opinion that CEA remains a safe and acceptable options for patients with SCSO, and SCSO should not be a reason for preferential use of carotid stenting.

Background: Sternotomy is a classical surgical procedure for approaching the heart and mediastinum. Sternotomy wound infections can be superficial or deep. Objective: The aim of this study is to retrospectively evaluate the results of two treatments for deep sternal wound infection (DSWI), closed treatment (debridement, refixation and retrosternal irrigation) and open treatment (debridement, VAC therapy and then pectoral flap). Methods: Retrospective analysis of two methods of treatment of DSWI in the period of six years. The first group (G1): surgical debridement, sternum fixation with, if necessary, retrosternal irrigation. The second group (G2): surgical debridement, open sternum with VAC therapy and subsequent pectoral flap with sternum refixation if necessary. Sternotomy wound infection will be classified according to the depth of the affected areas and the time of infection. Risk factors, outcome, local findings, number of revisions, number of hospital treatment days, types of isolates, etiology of sternotomy, time from onset of sternal instability to first surgical treatment will be observed.: Results: The number of patients with DSWI was 16, which represents 1% of all sternotomy in the observed period. Mortality in the DSWI group was 35%. Surgical myocardial revascularization was initially performed in 73% of patients with DSWI. Two risk factors for DSWI were in 32% of patients and 25% had diabetes mellitus. The average time for DSWI development in G1 was 10 days (min 0, max 30) and in G2 was 20 days (min 12, max 30). Number of revisions in G1 (min 1, max 2), G2 (min 1, max 3). Average number of hospital days were in G1 23.50 days (SD 13.15), and in G2 38.17 days (SD 28.65). The sternum was osteomyelitic and fragmented in 20% of patients. More than one revision occurred in 40% of patients. The main initial isolate was Enterococcus faecalis in 27% of all DSWI (dominantly in G1 2/3 of all): Conclusion: We found that there is no statistically significant difference in observed treatments, and that each treatment has its own indications. We suggested that studies with a larger sample are needed for a definite opinion on this issue.

Background: Acute left ventricular free wall rupture (LVFWR) is a life-threatening complication of myocardial infarction that requires urgent intervention. Surgical repair has continued to be the treatment of choice. Studies suggest a posterolateral or inferior infarction is more likely to result in free wall rupture than an anterior infarction. LVFWR generally results in death within minutes of the onset of recurrent chest pain, and on average was associated with a median survival time of 8 hours. Prompt diagnosis and management can lead to successful treatment for LVFWR. Objective: The aim of this article was to present an emergency case with an LVFWR in a COVID-19 patient who suffers from AMI and was treated with PCI stents in the ramus intermedius and circumflex coronary artery. Case report: We present an emergency case with an LVFWR in a COVID-19 patient who suffers from AMI and was treated with PCI stents in the ramus intermedius and circumflex coronary artery. Although dual antiplatelet therapy introduction and good outcome of PCI were achieved, soon after instant thrombosis of both stents appear to result in transmural necrosis and LVFWR. Urgent catheterization was performed and diagnosed in-stent thrombosis where the ventriculography confirmed LVFWR of the posteroinferior wall. Urgent surgery was performed. Transmural necrosis was noticed alongside the incision line. The incision is sawn with 4 U-stitches (Prolen 2.0 with Teflon buttressed stitches). Another layer of fixation was made by Prolen 2.0 running stitches reinforced with Teflon felts from both sides. A large PTFE patch was fixed to epicardium over the suture line by Prolen 6.0 running stitch and BioGlue was injected in-between patch and LV (Figures 8 and 9). After aortic cross-clamp removal, the sinus rhythm was restored. Conclusion: Despite the high mortality, the urgency and the complexity of surgical treatment the early diagnosis plays a key role in the management of postinfarction LVFWR patients presenting a case of preserved postoperative left ventricular function and accomplished good functional status, as presented in our case.

OBJECTIVE The aim of this study was to show perioperative complications of CABG procedure with and without cardiopulmonary bypass (CPB) in patients with combined coronary and carotid disease. PATIENTS AND METHODS This retrospective survey included patients with left main stenosis greater than 50% and carotid stenosis over 50%, who had undergone CABG without carotid endarterectomy at the BH Heart Centre, from May 2009 to May 2014. The patients were divided into two groups according to the surgical method used. Group A consisted of 50 patients who underwent surgery without CPB and the second group of 50 patients with CPB, conformed according to gender, ejection fraction values, EuroSCORE and the number of bypass grafts performed. RESULTS Analysis of the basic results indicates significant differences between the groups in the time spent on a respirator or time in the ICU, the amount of postoperative bleeding or compensated blood, as well as subsequent complications. The overall incidence of neurological complications showed a difference in the observed groups. CONCLUSION With ever easier technical performance, complete planned revascularization and the quality of performed grafts, the conditions have been created for a comparative analysis. According to the results we can say that CABG without CPB has a number of advantages over the other method, in patients with the combined disease.

Acute respiratory distress syndrome (ARDS) is a severe pulmonary disease first described in 1967 by Dr. Thomas L. Petty and colleagues as a syndrome of respiratory failure that presents with progressive arterial hypoxemia refractory to oxygen therapy, severe dyspnea caused by reduction of pulmonary compliance and diffuse bilateral pulmonary infiltrations. This clinical syndrome is characterised by acute, severe and life threatening respiratory insufficiency with high mortality rate [1-3]. The definition of ALI/ARDS was recommended by the American/ European Consensus Conference since 1994 (Table 1). The standard definition classifies the patients with bilateral pulmonary infiltrates and arterial hypoxemia, who have the ratio of PaO2 / FiO2 less than 300 mmHg. However, if the ratio is less than 200 mmHg, the diagnosis of ARDS can be made. In patients with left heart disease, the pulmonary wedge pressure less that 18 mmHg is a criterion to distinguish ARDS form cardiac failure. Recently, new Berlin classification of ARDS was accepted in 2013, where the term ALI was abandoned and ARDS was categorized [3,4].

Cardiac ischemia after coronary artery bypass grafting is often caused by graft occlusion. Short- and long-term graft patency is related to the quality of the surgical technique during harvesting and anastomosis. Transit time flow measurement is a recognized technique for the quality control of grafts but may not rule out structural abnormalities in the conduits, which can cause graft occlusion. This article reports on two cases of suspected intra-arterial dissection of the left internal mammary artery despite satisfactory flow measurements. Routine ultrasound scanning of arterial conduits is helpful in distinguishing dissection and hematoma in the graft conduits.