Is "Attenuation of Oxidative Stress" Helpful to Understand the Mechanism of Remote Ischemic Preconditioning in Cardiac Surgery?

OBJECTIVES: The aim of this study was to determine the effect of remote ischemic preconditioning (RIPC) on markers of cardiac ischemia and response to oxidative stress in patients undergoing coronary artery bypass grafting (CABG) surgery. DESIGN: A prospective, randomized, and blinded study. SETTING: A single-center university hospital. PARTICIPANTS: This study included patients who underwent isolated CABG surgery with cardiopulmonary bypass who were selected carefully to prevent confounding with factors known to affect markers of ischemia-reperfusion and response to oxidative stress. INTERVENTIONS: The authors randomly assigned patients to RIPC to the left lower extremity using a blood pressure cuff (study group) or a cuff that was applied but not inflated or deflated (control group). MEASUREMENTS AND MAIN RESULTS: At 6 hours after CABG surgery, high-sensitivity cardiac troponin T levels were significantly lower in the study group than in the control group. Levels of superoxide dismutase, an antioxidant enzyme, were significantly greater 15 minutes after release of the cross-clamp in the study group, whereas malondialdehyde levels were lower (not significantly) at 1 and 15 minutes after release of the cross-clamp. Hemodynamic parameters were not significantly different at any time point during the study. CONCLUSIONS: The authors' method of RIPC before CABG surgery resulted in less myocardial ischemia, as indicated by lower troponin levels. Changes in levels of endogenous antioxidant enzymes supported the hypothesis that this protection from ischemia-reperfusion injury was related to scavenging of free oxygen radicals. Future studies might include a more heterogeneous population and medications that lower the body's response to oxidative stress.

Does remote ischemic preconditioning affect the systemic inflammatory response by modulating presepsin levels?

OBJECTIVE: We investigated the effect of Remote Ischemic Preconditioning (RIPC) on the inflammatory response during CPB by means of serum presepsin levels at preoperative and postoperative 1st and 24th h. METHODS: In this prospective, randomized, cross-sectional study we included 81 patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass (CPB). Patients were randomized and RIPC was applied to 40 patients in the study group before anesthesia. The remaining 41 patients were determined as the control group. The relationships between RIPC and factors such as presepsin, C-reactive protein (CRP), and leukocyte levels were investigated. RESULTS: There was no significant difference between the groups in postoperative leukocyte and CRP values (p = 0.52, p = 0.13, respectively). When the preoperative and postoperative first hour presepsin values of the patients were compared, no significant difference was found in the control group (p = 0.17), but a significant difference was found in the study group (p < 0.05). When the presepsin values were compared between the groups, a significant difference was found only in the postoperative first hour value (p < 0.05). CONCLUSIONS: It was observed that RIPC application caused to increase the presepsin levels in the postoperative first hour significantly in the study group (p < 0.05).

Is genetic screening necessary for determining the possibility of venous thromboembolism in cancer patients?

OBJECTIVE: To determine the risk of an association with some genetic polymorphisms involved in venous thromboembolism (VTE) gene variations (FVL, FV H1299R, FII G20210A, MTHFR C677T, MTHFR A1298C, PAI-1 4G/5G, ß-fibrinogen -455 G → A, FXIII Val34Leu and GpIIIa HPA-1a) in cancer patients. SUBJECTS AND METHODS: Among 78 cancer patients, 28 who had proven first episode of VTE were selected as the patient group, with 50 control samples selected from age-, sex- and body mass index-matched healthy volunteers (healthy group). The differences in frequency of genetic polymorphisms were found to be statistically insignificant between these two groups. RESULTS: Logistic regression analysis after adjustment for age, sex, smoking and hypertension showed no difference. The screened mutations of these genes were not significantly associated with VTE risk. CONCLUSION: There is no possible benefit from genetic screening tests regarding VTE in cancer patients.

Left ventricle perforation and pseudoaneurysm with an unusual presentation of a patient with stomach ache. Case report.

A 49-year-old man admitted with a 3 weeks history of stomachache and without any cardiac symptoms and diagnosed as pseudoaneurysm of the left ventricle is reported. The repair was performed with the aid of cardiopulmonary bypass, defect was repaired with Gore-tex patch and myocardial tissues were approximated and closed by using two Teflon stripes. BioGlue was applied on the sutures and between the stripes. We report this unusual case because rarity and high clinical index of suspicion is needed to make correct diagnosis in such patients. Although there is a significantly high mortality of the pseudoaneurysm cases their repair can and should be performed as an urgent procedure.

Unusual location of hydatid cyst: the posterior leaflet of tricuspid valve.

Hydatid Cyst disease involves the heart in 0.02-2% of the cases. It can appear with symptoms very similar to coronary artery disease, cardiac valvular disease and pericarditis. We present a case of hydatid cyst that was located on the posterior tricuspid leaflet and that caused tricuspid regurgitation in 37 year old female patient who has gone through hydatid cyst excision from the bilateral lungs with median sternotomy 2 years ago. In addition to the right atrial and ventricular dilatation, second degree tricuspid regurgitation and significant pulmonary hypertension was found. The 2 x 2 cm smooth surfaced mass was resected from the posterior leaflet of the tricuspid valve and the defect was closed with suture with the aid of cardiopulmonary bypass. The patient followed with long term albendazole treatment. Cardiac echinococcosis should be kept in mind in some patients throughout their life with a history of previous hydatid cyst disease. Surgical excision without rupture is the treatment of choice for cardiac hydatid cyst, with following medical therapy in order to prevent recurrence.

Preoperative oral pentoxifylline for management of cytokine reactions in cardiac surgery.

BACKGROUND: Cardiopulmonary bypass may lead to many inflammatory responses that may cause myocardial dysfunction after open heart surgery. We aimed to investigate the effect of preoperative pentoxifylline treatment to reduce the occurrence of cardiopulmonary bypass-induced inflammatory response. METHODS: In a prospective, randomized study, 40 patients undergoing coronary artery bypass graft surgery received either pentoxifylline (study group, n = 21) or not (control group, n = 19). Pretreatment with pentoxifylline (800 mg/day orally) was started 5 days before the operation. Blood samples for measurements of tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-8 from the arterial line, and venous blood samples for creatine kinase (CK) and CK isoenzyme fraction MB (CK-MB) were taken in both groups at 5 different time points. Hemodynamic parameters were measured with the thermodilution technique. RESULTS: TNF-alpha, IL-6, and IL-8 plasma levels increased in both groups after cardiopulmonary bypass, with a greater increase in the control group (P < .05). There were no significant differences between the groups for the values of CK-MB and hemodynamic parameters. CONCLUSIONS: We conclude that pretreatment with oral pentoxifylline before cardiac surgery inhibits proinflammatory cytokine release caused by cardiopulmonary bypass and has some beneficial effects in protecting the myocardium during the cardioplegic arrest period in open-heart surgery, without affecting postoperative hemodynamics.

Sleep disturbances after cardiac surgery with or without elevated S100B levels.

OBJECTIVE: The aim of the study was to investigate sleep disturbances of cardiac surgery patients with or without elevated S100B levels. METHODS AND RESULTS: Twenty-two patients with serum S100B > 0.3 microg/l (study group) 12 hours after cardiac surgery with cardiopulmonary bypass and 23 patients with serum S100B < 0.3 (control group) were investigated in a prospective study. They were evaluated with the use of objective sleep tests. Cardiopulmonary bypass has negatively affected the sleep characteristics in the postoperative period for both groups. Maintenance wakefulness test, total sleep time, total activity score and sleep efficiency scores were significantly shorter in the study group in the postoperative period. Sleep latency, percentage of wakefulness after sleep onset, daytime napping episodes and total nap duration in the same period were significantly higher than in the control group. CONCLUSION: Cardiac surgery affects a patient's sleep characteristics. Patients with elevated S100B values have more sleep disturbances after cardiac surgery than patients with normal S100B values.

Trimetazidine may protect the myocardium during cardiac surgery.

BACKGROUND: Trimetazidine is an anti-ischemic agent with cardioprotective effects. The purpose of this double-blind, controlled, prospective randomized study was to investigate the possible effects of the preoperative use of trimetazidine on the biochemical markers of myocardial injury during open heart surgery and to determine if it has any myocardial protective effects. METHODS: Thirty patients undergoing coronary artery bypass grafting surgery, received either trimetazidine (study group, n = 15) or not (control group, n = 15). Pretreatment began 2 weeks before the operation with trimetazidine (60 mg/day orally), and the control group received no medication. We measured the levels of serum creatine kinase (CK), CK isoenzyme MB (CK-MB), myoglobin, and troponin T in venous blood samples obtained before and after the operation to evaluate the effect of this drug against myocardial damage. We also took serial blood samples from the radial artery and the coronary sinus before the institution of cardiopulmonary bypass (CPB) and at 2 and 15 minutes after the removal of the cross-clamp to measure lactate levels and calculate the lactate extraction of the myocardium. RESULTS: Postoperative levels of myoglobin, troponin T, CK, and CK-MB were significantly lower in the trimetazidine group than in the control group (P < .05). There was also a significant difference in the values for the lactate extraction calculation between the groups at minute 2 after the removal of the cross-clamp (P < .05). CONCLUSION: We conclude that pretreatment with trimetazidine has some beneficial effects in protecting the myocardium and decreasing myocardial injury during the cardioplegic arrest period in open heart surgery without affecting postoperative hemodynamics.

An uncommon cause of pulsation on the left side of the thorax. Case report.

A 70-year-old man affected by clinical findings of congestive heart failure eight months after aneurysmectomy of a true left ventricular aneurysm, presented with actual pseudoaneurysm of the left ventricle. There was a 5 x 5 cm soft tissue mass on the left side of the chest, synchronously pulsating with heart beating. The repair was performed with the aid of cardiopulmonary bypass. Myocardial tissues were approximated and closed by using two Teflon stripes. BioGlue was applied on the sutures and between the stripes. Although there is a significantly high mortality of the pseudoaneurysm cases their repair can and should be performed in an urgent procedure.

Objective and subjective characteristics of sleep after coronary artery bypass graft surgery in the early period: a prospective study with healthy subjects.

BACKGROUND: The purpose of this study was to investigate changes in sleep characteristics by examining both subjective tests and objective parameters such as actigraphic sleep analysis in patients who underwent coronary artery bypass graft surgery (CABG). PATIENTS AND METHODS: Forty-five patients who underwent CABG operations and did not have any sleep disturbance were examined. They were evaluated by subjective and objective sleep parameters at the beginning of the examination and on the fifth postoperative day. Forty healthy subjects who did not undergo the operation were also evaluated. RESULTS: The Pittsburgh Index and Epworth values in the postoperative group were significantly higher, but Maintenance of Wakefulness Test lengths were significantly shorter than in the preoperative and control groups. Sleep latency, napping episodes, total napping periods, and fragmentation index values of the postoperative group were significantly higher, but sleep efficiency values were significantly lower than in the preoperative and control groups. CONCLUSION: The cause of sleeplessness after CABG surgery may be the temporary deterioration of circulation in the centers of the brain stem and hypothalamus, which control sleep and awakening. It can be proposed that the improvement of the circulation in these centers a couple of months after the operation help to regain sleep control, and thus sleep disturbances disappear.

An alternative method of prosthetic mitral valve implantation in the presence of extensive calcification.

Annular calcifications carry some technical difficulties for success in conventional valve surgery. In this paper we present an easy alternative mitral valve replacement method applied for a patient with a heavily calcified mitral annulus. Excision of both leaflets and partial resection of the annular calcification with an ultrasonic dissector allowed the intra-atrial insertion of a 33-mm Omnicarbon monoleaflet prosthetic valve through a smaller opening of the left posterior atrium. The technical difficulties in inserting a prosthetic valve in a patient with a heavily calcified mitral annulus are discussed.

The effect of piroxicam on the prevention of postoperative retrosternal and pericardial adhesions.

BACKGROUND: The presence of adhesions after heart operations increases the risk of life-threatening damage to the heart and extracardiac grafts. Infections, tissue injury and inflammations are suspected aetiologic agents. The main purpose of our study is to evaluate the effect of an antiinflammatory agent piroxicam on the formation of retrosternal and pericardial adhesions in a rabbit model. MATERIAL AND METHODS: 23 of forty-two New Zealand white rabbits were labelled as group P (piroxicam group) and the others as group C (n = 19, control group). All animals were subjected to median sternotomy and abrasion was applied to the epicardium and pericardium. Piroxicam was given only to group P animals 10 mg/kg/day intramuscularly on the day of operation and twice daily for 2 days postoperatively. All animals were sacrificed on the 10th postoperative day. After cardiectomy, the pericardium was totally excised; retrosternal and pericardial adhesions were evaluated and scored. t-PA (tissue plasminogen activator), PAl-I (plasminogen activator inhibitor-I) levels and pericardial tissue myeloperoxidase activities were measured. RESULTS: More severe retrosternal and pericardial adhesions were observed in the control group (P < 0.05). Mean levels of t-PA were higher in the study group than in the control group (P < 0.05). Mean levels of PAI-I were lower in the study group (P < 0.05). Hence pericardial fibrinolytic capacity was significantly higher in the piroxicam group than in the control group. Myeloperoxidase activities in the pericardium were significantly lower in the study group than in the control group (P < 0.05). CONCLUSION: The use of piroxicam in the perioperative period prevents inflammation, preserves the fibrinolytic capacity of the pericardium and decreases the postoperative pericardial and retrosternal adhesions.

Opening the cardiac chambers does not make any difference in p300 measurement.

OBJECTIVE: Cognitive brain dysfunction after open heart surgery is a serious complication caused by cardiopulmonary bypass (CPB). The presence of gaseous and/or particulate emboli in the CPB circuit and cerebral hypoperfusion may be the causes of neurologic problems after cardiac operations. METHODS: In this prospective study we examined 42 consecutive cardiac surgery patients (24 mitral valve replacement [MVR] and 18 coronary artery bypass grafting [CABG] patients). In addition to determination of clinical measurements, cognitive brain function was measured objectively by P300 auditory-evoked potentials before operation, at day 7, and at 4-month follow-up. Electroencephalographic evaluations were also performed. RESULTS: In preoperative measures there was no difference between the groups (peak latencies in the MVR group were 324 +/- 8 milliseconds; CABG group, 318 +/- 6 milliseconds; P > .05). At day 7, cognitive P300 auditory-evoked potentials were significantly impaired (prolonged) in both groups compared to preoperative values (MVR group, 347 +/- 7 milliseconds; CABG group, 342 +/- 7 milliseconds; P < .05). P300 measurements almost returned to normal at 4-month follow-up (MVR group, 331 +/- 6 milliseconds; CABG group, 319 +/- 8 milliseconds; P > .05 compared to preoperative values). One week and 4 months after surgery no difference between the 2 groups could be found (P > .05). CONCLUSION: Postoperative patients had prolonged P300 values according to the preoperative measurements and we have not found any difference between the groups whether cardiac chambers were opened or not.

Cardioprotective effect of calcium dobesilate during open-heart surgery.

OBJECTIVE: The purpose of this double-blind, controlled, prospective randomized study was to investigate the possible effects of the preoperative use of calcium dobesilate (CLS2210) on the biochemical markers of myocardial injury during open-heart surgery, and to determine if it has any myocardial protective effects. METHODS: Twenty-four patients undergoing elective cardiac surgery were included in this study and randomized into two groups. CLS2210 was given orally to 12 patients for 14 days before the operation (CD group), but not to the other 12 patients (control group). Serum CK, CK-MB, myoglobin and troponin-T levels were measured from venous blood samples before and after the operation for evaluation of the effect of this drug against myocardial damage. Blood samples were also taken from the radial artery and the coronary sinus before the institution of cardiopulmonary bypass (CPB), and 2 and 15 minutes after the removal of the cross-clamp in order to measure the lactate levels and calculate the lactate extraction of the myocardium. RESULTS: First, CK-MB levels in patients of the CD group were significantly lower than those of the control group (p < 0.05) at the 2nd and 18th postoperative hour. Second, myoglobin and troponin-T levels in the CD group were significantly lower than those of the control group (p < 0.05) at the 2nd, 18th and 48th postoperative hour. Third, there was a significant difference in lactate extraction calculation values between the groups at the 2nd minute after removal of the cross-clamp (p < 0.05). CONCLUSIONS: We concluded that preoperative use of CLS2210 has some beneficial effects in protecting the myocardium and decreasing the myocardial injury during the cardioplegic arrest period in open-heart surgery.

Pentoxifylline affects cytokine reaction in cardiopulmonary bypass.

BACKGROUND: Cardiac surgery is associated with an inflammatory response that may cause myocardial dysfunction after cardiopulmonary bypass. We examined the efficacy of pentoxifylline to attenuate the cardiopulmonary bypass-induced inflammatory response during heart operations. METHODS: In a prospective, randomized study, 30 patients undergoing coronary artery bypass graft surgery received either pentoxifylline (group P, n = 15) (continuous infusion of 1.5 mg/kg per hour during operation) or not (group C [control], n = 15). Blood samples for measurements of tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-8, and IL-10 were taken from the arterial line in both groups at 5 different time points. RESULTS: TNF-alpha, IL-6, and IL-8 plasma levels increased in both groups after cardiopulmonary bypass, with a higher increase in the control group (P < .05). CONCLUSIONS: Our results indicate that pentoxifylline infusion during cardiac surgery inhibits the proinflammatory cytokine release caused by cardiopulmonary bypass.

Thromboelastogram reduces blood use by inspecting coagulation in heart surgery.

OBJECTIVE: Blood transfusion after coronary artery bypass surgery is carried out according to general coagulation tests and blood counts. Our aim was to determine the effects of rotational thromboelastography results on the amount of blood products used in the intraoperative and postoperative periods in coronary artery bypass patients. METHODS: Our study included 164 patients who underwent coronary artery bypass. A control group was formed from 82 patients picked from hospital records, who had elective coronary artery bypass before the introduction of rotational thromboelastography in our clinic. Blood transfusion was performed in this group according to conventional laboratory data. The study group comprised 82 patients who had elective coronary artery bypass after the introduction of rotational thromboelastography. Blood transfusion was performed in the study group according to rotational thromboelastogram results. The amounts of blood products used in the 2 groups were compared. RESULTS: There were statistically significant decreases in the intraoperative and postoperative amounts of packed red blood cells (p = 0.012 and p = 0.006) and postoperative whole blood (p = 0.013) used in the study group compared to the control group. Postoperative bleeding was also significantly reduced (p = 0.001) in the study group. CONCLUSION: Blood transfusion is an important issue after coronary artery bypass, and because of the decreased amount of blood products used, a rotational thromboelastography-based blood transfusion algorithm should be applied in patients undergoing coronary artery bypass.

Ischaemic preconditioning reduces spinal cord injury in transient ischaemia.

OBJECTIVE: Paraplegia remains a devastating complication after thoracic and thoracoabdominal aortic surgery for coarctations, dissections or aneurysms. Since the advent of ischaemic preconditioning of the myocardium, attention has been directed to the nervous system. This study was designed to evaluate the acute protective effect of ischaemic preconditioning on the spinal cord. MEDHODS AND RESULTS: Thirty-six New Zealand white rabbits were randomly assigned to one of three groups. The preconditioning group had 5 minutes of aortic occlusion, 25 minutes reperfusion and 20 minutes of ischaemia, whereas the controls had only 20 minutes of ischaemia. The sham group was anaesthetized and subjected to laparotomy without aortic occlusion. Physiological parameters and somatosensory evoked potentials were monitored during the experiment. Neurological outcome was clinically evaluated up to 48 hour after ischaemia and motor function was scored. Then the animals were sacrificed. Their spinal cord, abdominal aorta and its branches were removed and processed for histopathological examination. Histhopathological changes of the gray matter in the lumbosacral segments were scored from 0 to 6 according to a semi-quantitative scala. The changes in amplitudes of evoked potentials during ischaemia and recovery periods were similar in preconditioning and control groups. The average motor function score was significantly higher in the preconditioning group than the control group at 24 and 48 hours after the ischaemic event (p < 0.05). Histological observations were consistent with the neurological findings. The histopathological scores in the control group and the preconditioning group were 3.2 (1.4-5.2) and 2.4 (0.8-4.4), respectively (p < 0.05). CONCLUSIONS: The results suggest that ischaemic preconditioning reduces the spinal cord injury and improves neurological outcome in transient ischaemia in rabbits. This protective mechanism is rapidly invoked within only 25 minutes interval between the preconditioning stimulus and the ischaemic insult.

Superior mesenteric artery branch--jejunal artery aneurysm.

Visceral artery aneurysm (VAA) is a relatively uncommon disorder and it shows some vague symptoms. Therefore, the clinical diagnosis is difficult and these aneurysms are discovered and diagnosed only after rupture in many cases. This case report describes the history of a woman who had a superior mesenteric artery (SMA) branch aneurysm. A 62-year-old woman presented with fatigue and moderate to severe epigastric and mid-back pain. A computed tomography of the abdomen and pelvis demonstrated a partially thrombosed aneurysm (38×40 mm) rising from the jejunal branch of the SMA. The aneurysm which contains mural thrombus is resected, and a saphenous vein graft interposition is performed between the ends of the same jejuno-jejunal artery. The patient's recovery was unremarkable, and she was discharged on postoperative day 7. Rapid diagnosis, localization, and surgical or endovascular interventions are necessary to avoid devastating consequences in VAAs. Saphenous vein graft interposition is a good choice for surgical intervention for patients not suitable for endovascular treatment.