Coronary artery bypass grafting in adolescent with myocardial infarction complicating undiagnosed Kawasaki disease.

Although Kawasaki disease is often self-limiting, significant cardiovascular sequelae may occur in the acute or late stage. The most common late complication is persistent coronary artery aneurysm, which can lead to myocardial ischaemia and even myocardial infarction. We report a case of coronary artery bypass grafting in a 16-year-old boy with a history of undiagnosed Kawasaki disease. Increased awareness of Kawasaki disease, especially among children between the ages of 6 months and 5 years, can increase early treatment and prevent serious complications that may occur in the future.

Aortic valve regurgitation and ventricular septal defect diagnosed 5 years after penetrating cardiac injury.

Despite high mortality rates for penetrating heart injuries, developments in transport, diagnosis, and surgical interventions have increased survival rates. In some cases, life-threatening complications may be misdiagnosed or remain asymptomatic and lead to loss of life. Herein, we report a patient with aortic valve regurgitation because of noncoronary cusp perforation and ventricular septal defect that remained asymptomatic and diagnosed 5 years after a penetrating heart injury.

[Subclavian-carotid transposition for subclavian artery stenosis causing recurrent brachial artery embolism: case report]. / Tekrarlayan brakiyal arter embolisi olusturan subklavyen arter stenozunda subklavyo-karotid transpozisyon: Olgu sunumu.

Subclavian artery stenosis represents a relatively lower rate for upper extremity emboli source. Subclavian artery stenosis with thrombus localized distal to the stenosis was diagnosed on the arteriography of a patient who had a history of three previous brachial artery embolectomies. In this report, a case with subclavian artery stenosis causing recurrent brachial artery embolism who was successfully treated using subclavian-carotid transposition is presented.

Comparison of the therapeutic efficacy of linezolid and vancomycin and correlation of serum and tissue malondialdehyde and myeloperoxidase in an experimental mediastinitis model.

BACKGROUND: We aimed to investigate the therapeutic efficacy of linezolid in an experimental mediastinitis model and to compare it with vancomycin, which is commonly used. The objective of this study was also to evaluate the role of the immune system in mediastinitis. MATERIALS AND METHODS: Fifty adult Wistar rats were randomly divided into five groups: an uncontaminated and contaminated untreated control groups; a group that received sefazolin prophylaxis; and two groups treated with vancomycin or linezolid. Median sternotomy without access to pleural spaces was performed on all rats. All groups, except the uncontaminated one, were inoculated with 0.5 mL 10(8) colony-forming units/mL methicillin-resistant Staphylococcus aureus in the mediastinal and sternal layers. Postoperatively, vancomycin and linezolid groups were given antibiotic treatment for 7 d, starting 24 h after the end of the procedure. After 7-d treatment tissue samples from the upper ends of the sternotomy line and mediastinum were obtained and evaluated microbiologically. Additionally, serum, heart, lung, liver, kidney, and mediastinal tissues samples were obtained to determine malondialdehyde (MDA) and myeloperoxidase (MPO). RESULTS: The study showed that either vancomycin or linezolid successfully reduced bacterial counts in mediastinum and sternotomy line. MDA and MPO levels were found to be decreased in the treated groups. There was a positive correlation between serum and tissues MDA and MPO in all of the groups. CONCLUSIONS: Our study showed that linezolid appears to be a promising option for treating mediastinitis due to methicillin-resistant S. aureus. Additionally, it was demonstrated that a wide inflammatory process occurred after mediastinitis.

Efficacy of linezolid in the treatment of mediastinitis due to methicillin-resistant Staphylococcus aureus: an experimental study.

INTRODUCTION: The treatment of postoperative mediastinitis is very important because of its high morbidity, mortality, and increased hospital stay and hospital costs. The aims of our research were to investigate whether linezolid alone can be an effective treatment agent for methicillin-resistant Staphylococcus aureus (MRSA) mediastinitis, and to determine whether linezolid can provide synergistic activity when given in combination with rifampin. METHODS: A partial upper median sternotomy was performed on 70 rats. The animals were divided into seven groups: an uncontaminated control group; an untreated contaminated group; three contaminated groups that received antibiotic therapy with either 25 or 50 mg/kg linezolid twice a day, or rifampin 5 mg/kg twice a day; and two contaminated groups that received a combination therapy consisting of 25 or 50 mg/kg linezolid and rifampin 5 mg/kg twice a day. The antibiotic treatment lasted 7 days. Tissue samples from the upper ends of the sternum and swab specimens of the upper mediastinum were obtained and evaluated microbiologically. RESULTS: The 25-mg/kg dose of linezolid, either alone or combined with rifampin, was not effective in reducing the bacterial counts in mediastinum and sternum. Quantitative bacterial cultures of mediastinum and sternum were significantly lower in the groups receiving 50 mg/kg linezolid alone or in combination with rifampin compared with the control. Adding of rifampin to linezolid therapy did not result in a significant change in bacterial counts versus linezolid alone. CONCLUSION: A high dose of linezolid should be considered as a possible therapeutic agent for the treatment of post-sternotomy infection caused by MRSA.

Linezolid compared with vancomycin for the prevention of methicillin-resistant Staphylococcus aureus or Staphylococcus epidermidis vascular graft infection in rats: A randomized, controlled, experimental study.

BACKGROUND: Graft infections are severe complications of vascular surgery that may result in amputation or mortality. Staphylococci are the most frequent cause of vascular graft infections. OBJECTIVE: In this study we assessed the prophylactic efficacy of linezolid in comparison with vancomycin in preventing prosthetic vascular graft infection due to methicillin-resistant Staphylococcus aureus (MRSA) or methicillin-resistant Staphylococcus epidermidis (MRSE). METHODS: This randomized, controlled, experimental study using healthy adult (aged >5 months) male Wistar rats was conducted in the research laboratory of the Pamukkale University, Denizli, Turkey. The study consisted of an uncontaminated control group and 3 groups for both staphylococcal strains: a contaminated group that did not receive any antibiotic prophylaxis; a contaminated group that received preoperative intraperitoneal (IP) prophylaxis with vancomycin; and a contaminated group that received preoperative IP prophylaxis with linezolid. All rats received a vascular Dacron graft placed inside a subcutaneous pocket created on the right side of the median line. Sterile saline solution (1 mL), to which MRSA or MRSE at a concentration of 2 × 10(7) colony-forming units per milliliter had been added, was inoculated onto the graft surface using a tuberculin syringe to fill the pocket. The grafts were explanted 7 days after implantation and assessed by quantitative culture. RESULTS: Seventy rats (mean [SD]weight, 323.7 [17.9]g; mean [SD]age, 5.98 [0.64] months) were evenly divided between the 7 groups. Statistical analysis of the quantitative graft culture suggested that both vancomycin and linezolid were effective in significantly inhibiting bacterial growth when compared with the untreated contaminated groups (all, P < 0.001). However, a statistically significant difference was not observed between the bacteria count in the vancomycin and linezolid prophylaxis groups. When a comparison was made between the bacterial growth in the contaminated control groups, MRSA had significantly greater affinity to the Dacron prostheses than MRSE (all, P < 0.001). CONCLUSION: Our study found that linezolid was as effective as vancomycin in suppressing colony counts in MRSA- or MRSE-infected vascular Dacron grafts in rats.

Preservation of pleural integrity in patients undergoing coronary artery bypass grafting: effect on postoperative bleeding and respiratory function.

OBJECTIVE: The purpose of this study was to evaluate the influence of preserved integrity of pleura on postoperative bleeding and respiratory function in patients undergoing coronary artery bypass grafting (CABG). METHODS AND RESULTS: Seventy-two CABG patients who received pedunculated IMA graft without opening the pleura (group of intact pleura, group IP) between July 2002 and September 2004 were matched to 72 CABG patients who received pedunculated IMA graft with opened pleura (group of opened pleura, group OP). To match the patients with IP and unique patients with OP, logistic regression was used to develop a propensity score. The C statistic for this model was 0.79. Patients with IP were matched to unique patients with OP with an identical 5-digit propensity score. If this could not be done, we proceeded to a 4-, 3-, 2-, or 1-digit match. Patients characteristics were well matched. There were no differences in preoperative and peroperative variables between the groups. The incidence of postoperative pleural effusion and thoracentesis were significantly lower in group IP than group OP (pleural effusion in 15.2 versus 30.5%; p = 0.029, thoracentesis in 5.5 versus 18.5%; p = 0.036). Other pulmonary complications such as prolonged ventilation, reintubation, pneumothorax, atelectasis, diaphragmatic paralysis were similar in both groups. Patients with IP had significantly lower blood loss (520 versus 870 ml; p < 0.001) and whole blood unit transfusion (26.3 versus 41.6%, p = 0.036). Also, intensive care unit and hospital stay were similar in both groups. CONCLUSIONS: Meticulous internal mammary artery harvesting and preservation of the pleural integrity significantly reduces postoperative bleeding and pleural effusion.

Comparison of simultaneous antegrade/vein graft cardioplegia with antegrade cardioplegia for myocardial protection.

Antegrade cardioplegic delivery via the aorta ensures distribution of cardioplegic solution through open arteries, but distribution may not be adequate beyond a stenotic coronary artery. This potential problem can be overcome by direct delivery of cardioplegia via a vein graft. The purpose of this study was to compare simultaneous antegrade/vein graft cardioplegia with antegrade cardioplegia during coronary artery bypass surgery. Twenty patients were divided into 2 groups. In group 1, intermittent antegrade cardioplegia was provided (n=10). In group 2, intermittent antegrade cardioplegia was supplemented by antegrade perfusion of vein grafts after distal anastomoses were completed (n=10). Data on enzyme release and hemodynamics were obtained preoperatively, before the induction of anesthesia, just before cross-clamping, immediately after aortic unclamping, and at 1, 6, 12, 24, and 48 h after unclamping. Enzyme release (creatinine phosphokinase-isoenzyme MB, cardiac troponin I, myoglobin) was similar in both groups (P>.05). Furthermore, no significant difference was noted in the incidence of postoperative low cardiac output syndrome, perioperative myocardial infarction, or ventricular arrhythmia (P>.05). In conclusion, both techniques permitted rapid postoperative recovery of myocardial function. Supplementation of antegrade perfusion of vein grafts with antegrade cold blood cardioplegia offered no advantage to study patients.However, hemostasis of a distal anastomosis may be controlled by this technique.

Neuraminidase decreases in vitro adherence of slime-forming coagulase-negative staphylococci to biosynthetic ovine collagen vascular graft.

Vascular prosthetic graft infection is a major complication of vascular surgery that starts with adhesion of the microorganism to the graft. Because slime-forming microorganisms are the major causative agents in graft infection, the goals of investigators in this study were (1) to investigate the bacterial adherence of slime-forming and non-slime-forming coagulase-negative staphylococci (CNS), and (2) to determine the role of neuraminidase (NANase) in bacterial adherence to the biosynthetic ovine collagen graft. Human plasma was instilled and incubated at 37 degrees C in preparation for fibrin deposition of grafts. After 48 hours, incubation grafts were drained and inoculated with slime-forming and non-slime-forming CNS in tryptic soy broth in the presence and in the absence of neuraminidase. After 24 hours of incubation at 36 degrees C, grafts were vortexed and cultured for colony count. Bacterial counts were expressed as total colony-forming units per longitudinal centimeter of the graft. Slime-forming CNS had greater affinity to the collagen graft compared with non-slime-forming CNS (P<.05). Adherence of slime-forming CNS was impaired by NANase treatment (P<.001). NANase treatment of patients with non-slime-forming CNS did not change adherence to the graft (P>.05). Results show that slime plays an important role in the pathogenesis of vascular graft infection. Adherence of slime-forming CNS can be decreased through the administration of NANase. This may have implications for the development of neuraminidase-embedded vascular grafts designed to reduce the occurrence of biomaterial-related infection.

Topical versus systemic vancomycin for deep sternal wound infection caused by methicillin-resistant Staphylococcus aureus in a rodent experimental model.

In 37 Wistar albino rats, we investigated the effects of topical vancomycin on deep sternal wound infection caused by methicillin-resistant Staphylococcus aureus. Partial median sternotomy was performed under sterile conditions. Group I (n=6) was the sham, and group II (n=7) was the control. Group III (n=8) received topical vancomycin, group IV (n=8) received systemic vancomycin, and group V (n=8) received topical and systemic vancomycin (combined). Rats in groups II through V were inoculated with 0.5 mL x 10(8) CFU/mL methicillin-resistant S. aureus in the mediastinum and sternum. No medication was given to groups I and II. Twenty-four hours after surgery, 40 mg/kg/day vancomycin was given topically in group III; systemically in group IV; and topically and systemically in group V After 7 days, smear samples from the mediastinum and tissue cultures from the sternum were obtained. We found 5.00 +/- 0 CFU/mL microorganisms in the mediastinum in group II, 1.90 +/- 1.70 in group III, 3.33 +/- 0.48 in group IV and 1.70 +/- 1.08 in group V. The quantity of microorganisms per gram of tissue in the sternum was 736 +/- 0.23 in group II, 6.01 +/- 0.33 in group III, 5.81 +/- 0.81 in group IV and 3.99 +/- 2.47 in group V The quantity of microorganisms was less in the 3 treatment groups than in the control group (P < 0.05). We conclude that topical plus systemic vancomycin treatment might be more effective in patients with deep sternal wound infections caused by methicillin-resistant S. aureus.

Iatrogenic cardiac herniation and torsion after surgery for a penetrating cardiac injury.

Cardiac herniation and torsion is a rare condition associated with a high mortality rate. We present an unusual case of sudden cardiogenic shock that was caused by torsion and herniation of the heart after an operation for a penetrating cardiac injury. The patient was successfully treated by urgent surgical intervention.

Effect of the type of cardiopulmonary bypass pump flow on postoperative cognitive function in patients undergoing isolated coronary artery surgery.

OBJECTIVE: Pulsatile flow, generated by a pump during cardiopulmonary bypass, has been accepted as more physiological in coronary artery bypass grafting surgery (CABG). Therefore, we aimed to investigate the effects of pulsatile and nonpulsatile flow on postoperative cognitive function and to review relationship with the biomarkers S100ß and neuron-specific enolase (NSE). METHODS: Patients who underwent isolated CABG were included this prospective, randomized, double-blind study, which was performed between March 2010 and December 2010. Patients were divided into two groups: pulsatile (Group I, n=20) and nonpulsatile (Group II, n=20) flow. Blood samples were collected 1 day before surgery and in the sixth postoperative hour for the analysis of S100ß and NSE. In addition, Mini-Mental State Examination (MMSE) was performed during preoperative period and on third postoperative day. Outcomes were determination of effects of pump flow type on cognitive function and relationships with concentrations of S100ß and NSE. RESULTS: Forty patients were included. No differences were observed between the groups with respect to complications, mortality, S100ß (Group I: 1.9±0.2 µ/L; Group II: 2.0±0.2 µ/L), NSE (Group I: 12.5±0.8 µ/L; Group II: 12.4±0.7 µ/L), MMSE scores [Group I: 25 (23-27); Group II: 25 (23-27)], and postoperative cognitive dysfunction (POCD) (p>0.05). No correlation was observed between MMSE scores and concentrations of S100ß (r=-0.032) and NSE (r=-0.423) (p>0.05). CONCLUSION: There was no difference between types of pump flow for POCD and no relationship between cognitive dysfunction and S100ß and NSE concentrations. Pump flow type does not affect NSE concentrations.

Anatomic variability in coronary arterial distribution with regard to the arterial switch procedure.

BACKGROUND: We investigated the coronary arterial origins and course and the position of the great arteries in hearts with discordant ventriculoarterial connections. At the same time, we sought to evaluate the practicality of alphanumeric classifications in accounting for surgically relevant features of the coronary arteries. METHODS AND RESULTS: We studied 200 postmortem hearts, noting the patterns of coronary arterial branching, the vertical and horizontal location of the arterial orifices within the aortic sinuses, the course of the proximal coronary arteries in relation to the aortic wall, and the relations of the great arteries and their respective commissures. All hearts examined had concordant atrioventricular and discordant ventriculoarterial connections. We found 7 of the 8 predicted patterns for sinusal origin of the 3 major coronary arteries and identified 5 different positions of the arterial trunks relative to each other. A correlation was found between less frequent relationships of the arterial trunks and unusual patterns of coronary arterial branching, as well as with mismatch between the valvar commissures. CONCLUSIONS: The surgically relevant features of the coronary arteries in hearts with discordant ventriculoarterial connections are best described rather than classified. Correlations exist between certain, less frequent relations of the great arteries and unusual patterns of branching of the coronary arteries. The presence of unusual great arterial positions should alert the surgeon to potentially complicated arrangements of the origin and distribution of the coronary arteries.

Systemic and local antibiotic prophylaxis in the prevention of Staphylococcus epidermidis graft infection.

BACKGROUND: The aim of the study was to investigate the in vivo efficacy of local and systemic antibiotic prophylaxis in the prevention of Staphylococcus (S.) epidermidis graft infection in a rat model and to evaluate the bacterial adherence to frequently used prosthetic graft materials. METHODS: Graft infections were established in the subcutaneous tissue of 120 male Wistar rats by implantation of Dacron/ePTFE grafts followed by topical inoculation with 2 x 10(7) CFUs of clinical isolate of methicillin-resistant S. epidermidis. Each of the graft series included a control group, one contaminated group that did not receive any antibiotic prophylaxis, two contaminated groups that received systemic prophylaxis with teicoplanin or levofloxacin and two contaminated groups that received teicoplanin-soaked or levofloxacin-soaked grafts. The grafts were removed 7 days after implantation and evaluated by quantitative culture. RESULTS: There was significant bacterial growth inhibition in the groups given systemic or local prophylaxis (P < 0.05). Methicillin-resistant S. epidermidis had greater affinity to Dacron graft when compared with ePTFE graft in the untreated contaminated groups (P < 0.05). CONCLUSION: The study demonstrated that the usage of systemic or local prophylaxis and preference of ePTFE graft can be useful in reducing the risk of vascular graft infections caused by staphylococcal strains with high levels of resistance.

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.

Bileaflet versus posterior-leaflet-only preservation in mitral valve replacement.

In the present study of mitral valve replacement, we investigated whether complete preservation of both leaflets (that is, the subvalvular apparatus) is superior to preservation of the posterior leaflet alone. Seventy patients who underwent mitral valve replacement in our clinic were divided into 2 groups: MVR-B (n=16), in whom both leaflets were preserved, and MVR-P (n=54), in whom only the posterior leaflet was preserved. The preoperative and postoperative clinical and echocardiographic findings were evaluated retrospectively. No signs of left ventricular outflow tract obstruction were observed in either group. In the MVR-B group, no decrease was observed in left ventricular ejection fraction during the postoperative period, whereas a significant reduction was observed in the MVR-P group (P=0.003). No differences were found between the 2 groups in their need for inotropic agents or intra-aortic balloon pump support, or in cross-clamp time, duration of intensive care unit or hospital stays, postoperative development of new atrial fibrillation, or mortality rates. Bileaflet preservation prevented the decrease in left ventricular ejection fraction that usually followed preservation of the posterior leaflet alone. However, posterior leaflet preservation alone yielded excellent results in terms of decreased left ventricular diameter. Bileaflet preservation should be the method of choice to prevent further decreases in ejection fraction and to avoid death in patients who present with substantially impaired left ventricular function.

Retroperitoneal approach via paramedian incision for aortoiliac occlusive disease.

Aortoiliac occlusive disease is a frequently encountered occlusive arterial disease. Different surgical approaches to the infrarenal abdominal aorta have been reported. We retrospectively studied the postoperative outcomes of patients who were treated for aortoiliac occlusive disease via a retroperitoneal versus a transperitoneal surgical approach.From January 2005 through May 2009, 47 patients underwent surgery at our hospital for the correction of aortoiliac occlusive disease: 30 via a paramedian incision and retroperitoneal approach, and 17 via a midline sternotomy and transperitoneal approach. In the retroperitoneal group, the surgical procedures involved iliofemoral bypass in 15 patients, aortofemoral bypass in 12, aortoiliac bypass in 2, and aortobifemoral bypass in 1. All 17 patients in the transperitoneal group underwent aortobifemoral bypass. The preoperative characteristics and perioperative data of the patients were analyzed. We believe that the retroperitoneal aortoiliac approach with a paramedian incision may be considered as a surgical option for aortoiliac revascularization.

Comparison of antimicrobial agents as therapy for experimental endocarditis: caused by methicillin-resistant Staphylococcus aureus.

We used an experimental rat model to compare the therapeutic efficacy of teicoplanin, linezolid, and quinupristin/dalfopristin with that of vancomycin as standard therapy for infective endocarditis.Aortic endocarditis was induced in rats by insertion of a polyethylene catheter into the left ventricle, followed by intravenous inoculation of 106 colony-forming units of methicillin-resistant Staphylococcus aureus 24 hours later. Forty-eight hours after bacterial challenge, intravenous antibiotic therapies were initiated. There were 6 groups of 8 rats each: uninfected control; infected, untreated control; vancomycin-treated (40 mg/kg twice daily); teicoplanin-treated (20 mg/kg twice daily after a loading dose of 40 mg/kg); linezolid-treated (75 mg/kg 3 times daily for 1 day, then 75 mg/kg twice daily); and quinupristin/dalfopristin-treated (30 mg/kg twice daily and an additional 10 mg/kg dalfopristin infusion over 6 to 12 hr daily). At the end of therapy, the aortic valve vegetations in the drug-treated rats were evaluated microbiologically.Compared with the infected, untreated group, all drug-treated groups had significantly reduced bacterial titers in the vegetations. Vancomycin, teicoplanin, and quinupristin/dalfopristin all effectively reduced the quantitative bacterial cultures of aortic valve vegetations. In addition, there was no significant difference in the comparative efficacy of teicoplanin, linezolid, and quinupristin/dalfopristin. Vancomycin significantly reduced bacterial counts in comparison with linezolid, which was nonetheless also effective.Our experimental model showed that each of the investigated antimicrobial agents was effective in the treatment of infective endocarditis.

Intracerebral hemorrhage treated with external ventricular drainage following coronary bypass surgery.

BACKGROUND: Intracerebral hemorrhagic brain injury after open heart surgery is a rare complication. We report a case of acute intraventricular hemorrhage after coronary bypass surgery. METHODS: The brain computed tomography revealed intraventricular bleeding in the patient and urgent external ventricular drainage was performed by neurosurgeons. RESULTS: The clinical findings disappeared after the drainage. CONCLUSION: Early diagnosis and treatment is important in preventing organic brain damage in this complication.