Comparison of early period results of blood use in open heart surgery.

BACKGROUND: Various adverse effects of homologous blood transfusion detected particularly in open heart surgery, in which it is frequently used, lead researchers to study on autologous blood use and to evaluate the patient's blood better. Due to the complications of homologous blood transfusion, development of techniques that utilize less transfusion has become inevitable. We aimed to evaluate the effects of acute normovolemic hemodilution (ANH) in patients undergoing open heart surgery. MATERIALS AND METHODS: In this study, 120 patients who underwent open heart surgery were included. Patients were grouped into three: Autologous transfusion group (Group 1), homologous transfusion group (Group 2), and those received autologous blood and homologous blood products (Group 3). Patient data regarding preoperative characteristics, biochemical parameters, drainage, extubation time, duration of stay at intensive care, atrial fibrillation (AF) development, and hospital stay were recorded. RESULTS: A statistically significant difference (P < 0.005) was found in favor of autologous group (Group 1) with respect to gender, body surface area, European System for Cardiac Operative Risk Evaluation, smoking, hematocrit levels, platelet counts, urea, C-reactive protein levels, protamine use, postoperative drainage, frequency of AF development, intubation period, stay at intensive care and hospital stay, and amount of used blood products. CONCLUSION: The use of autologous blood rather than homologous transfusion is not only attenuates side effects and complications of transfusion but also positively affects postoperative recovery process. Therefore, ANH can be considered as an easy, effective, and cheap technique during open heart surgery.

Vasodilation Responses to Non-Selective α-Adrenergic Blockage of Coronary Bypass Grafts in Diabetic and Non-Diabetic Patients: In Vitro Study.

BACKGROUND: Adrenergic tonus is increased in atherosclerotic coronary arteries. In this study, we aimed to demonstrate in vitro effects of phentolamine, a reversible nonselective alpha (α) adrenergic blocker, on coronary artery bypass grafts (CABG) and compare its effects in diabetic and nondiabetic patients. METHODS: A total number of 30 patients (15 diabetic and 15 nondiabetic) who were assigned to elective CABG surgery were enrolled into the study. For both groups of patients, 16 internal mammarian artery (IMA) samples, 16 saphenous vein (SV) samples and 16 radial artery (RA) samples were collected and studied in the tissue bath system. The vasodilatation responses to increasing doses of phentolamine were recorded. RESULTS: When grafts were compared in terms of amount of vasodilatation to phentolamine, IMA had the most prominent vasodilatation followed by RA and SV respectively. Although the vasodilatation responses in nondiabetic patients were numerically higher than diabetic patients, there was no statistically difference between the groups. CONCLUSION: Phentolamine, a nonselective α adrenergic blocker, is proven to have equal vasodilatory effects in diabetic and nondiabetic CABG grafts and can safely be used both intravenously and topically in the perioperative period.

In vitro effects of L-carnitine on coronary artery bypass grafts.

BACKGROUND: The gold standard treatment for multivessel coronary revascularization is coronary artery bypass grafting. The internal mammary artery and saphenous vein grafts are the conduits most frequently used for these operations. Spasm of arterial and venous grafts is a significant problem during the operation. OBJECTIVES: To evaluate the acute in vitro effects of L-carnitine on internal mammary artery and saphenous vein grafts using a tissue bath. METHODS: Ten consecutive patients who underwent elective coronary artery bypass grafting were enrolled in the present study (nine men, one woman; mean [± SD] age 62±9.1 years). Samples from left internal mammary artery and saphenous vein grafts were collected from each patient. Submaximal smooth muscle contraction was achieved by adding 1 µM phenylephrine, and L-carnitine was then added to the solution. The concentration-response curves of the vasodilation response were obtained. RESULTS: In the internal mammary graft samples, the vasodilation response to L-carnitine was 64.3±11.1% at a concentration of 5 mM. In the saphenous vein graft samples, the vasodilation response to L-carnitine was 41.5±11.4% at a concentration of 5 mM. There was a statistically significant difference (P<0.001) between the response of the internal mammary artery and saphenous vein grafts in the in vitro tissue bath system. CONCLUSIONS: These results indicate that L-carnitine is a potential vasodilatory drug for internal mammary artery and saphenous vein grafts.

Continuous renal replacement therapy after cardiac surgery in patients with acute renal failure.

AIM: Acute renal failure is an important adverse effect of cardiopulmonary bypass that can result in high mortality or morbidity rates. It can be treated with continuous renal replacement therapy after cardiac surgery. The purpose of this study was to determine the factors associated with the mortality and incidence of acute renal failure in patients of post cardiac surgery. METHODS: Patients (1564) who underwent cardiac surgery between January 2007 and January 2012 and treated with continuous renal replacement therapy were included (N=40). Patients with previous renal disorders were excluded. A retrospective analysis was carried out. RESULTS: Overall, continuous renal replacement therapy was used in 40 (2.6%) patients. The mean age was 62.7 ± 11 years. Mean duration of cardiopulmonary bypass was 166 ± 80 min, and aorta cross-clamping time was 97 ± 35 min. The patients' mean pretherapy creatinine level and mean creatinine level before hospital discharge were 3.3 ± 1.1 mg/dL and 1.1 ± 0.4 mg/dl, respectively. Thirty-day mortality was 35%. Only 6 patients required long-term renal replacement therapy. Conclusion Acute renal failure requiring hemodialysis after cardiac surgery is associated with higher mortality and morbidity and prolonged hospital stay. Early renal recovery with continuous renal replacement therapy seems to offer an evident survival benefit. CONTINUOUS: renal replacement therapy may represent an important therapy and reduce mortality rates. We believe that these rates might decrease even more with detailed preoperative evaluation and meticulous postoperative care with collaborative management.

An experimental model of aortic surgery and the effect of Iloprost on lung injury.

OBJECTIVES: Ischemia/reperfusion (I/R) damage of the lung is a frequently encountered complication following aortic surgery. The aim of the present study is to investigate the histopathological effects of Iloprost on pulmonary damage developed after I/R. DESIGN: Twenty-four Sprague-Dawley rats were randomly divided into 3 groups. In the control group, aortas were not clamped. In the I/R group, aortas were occluded, and after 1 h of ischemia, clamps were removed. After 2 h of reperfusion period, lungs of the rats were extracted. In the I/R + Iloprost group after 1 h of ischemia, Iloprost infusion was initiated, and maintained for the duration of 2 h reperfusion period. For histopathological scoring, density of polymorphonuclear leucocytes, congestion, interstitial edema, and bleeding were semiquantitatively evaluated, and histopathological changes were scored. RESULTS: In the I/R group, multifocal-marked histopathological changes in 5 (62.5%), and multifocal-moderate histopathological changes in 3 (37.5%) rats were detected. In the I/R + Iloprost group, multifocal-moderate histopathological changes in 4 (50%), and multifocal-mild changes in 4 (50%) rats were detected. CONCLUSIONS: In the experimental rat model, administration of Iloprost has been shown to have preventive effects for pulmonary damage occurring after I/R generated by infrarenal aortic occlusion.

Vascular complications of the intra-aortic balloon pump in patients undergoing open heart surgery: 10 years' experience.

BACKGROUND: The most encountered complications with intra-aortic balloon pump (IABP) use are seen within the vascular system. The purpose of our study is to evaluate vascular complications of the sheathless IABP in patients undergoing open heart surgery. METHODS: Between January 2002 and December 2011, a total of 148 patients undergoing open heart surgery and needed IABP support were included in the study. All vascular complications related with IABP were recorded. RESULTS: Mean age of the patients was 64.4 ± 9.4 years. Total 104 (70.2%) were male and 44 (29.8%) were female. Total number of patients who had ischemic complications of the extremity was 13 (8.7%). The most used surgical treatment was embolectomy in five patients. Only one patient required an iliofemoral bypass. Above the knee amputation was performed in one patient. No balloon-related mortality occurred. CONCLUSION: Incidence of vascular complications in IABP counterpulsation is still a problem despite improvements in catheter design and techniques. The presence of peripheral arterial disease and diabetes mellitus is important risk factors for ischemic complications.

Cardiac metastasis of hepatocellular carcinoma in a young non-cirrhotic patient, to the left ventricle.

Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver.(1,2) The most common extrahepatic metastatic sites are lung, abdominal lymph nodes and bone, while its cardiac metastasis is rare.(2,3) Metastasis of HCC into the cardiac cavity is mostly caused by direct tumor invasion of vena cava inferior with continuous extension into the right cardiac cavity.(4,5) Right heart metastasis without invasion of inferior vena cava, which may be caused by hematogenous spread of cancer cells, is rarely reported.(6,7) This paper announces an unusual case of isolated involvement of left ventricle (LV) together with myocardial invasion of HCC. Our patient is known to be the first case with isolated HCC metastasis to the left ventricle. Strikingly, the patient was young and non-cirrhotic with negative serum HBsAg, and anti-HCV results.

An interference study of the copper-induced plasma oxidizability test.

OBJECTIVES: The aim of this study is to investigate the effect of cristaloid cardioplegic fluid (CCF) and its contents on the susceptibility of plasma to copper-catalyzed lipid peroxidation test. DESIGN AND METHODS: The plasma pool was divided into eight groups. Equal volumes of CCF or one of its contents were added to each group of the plasma pool. The accumulation of conjugated diene (CD) by copper-induced oxidation was monitored for a period of 5 h. Thiobarbituric acid-reactive substances (TBARS) formed during the incubation of plasma with copper was also measured. RESULTS: It was found that, the production of CD and TBARS were inhibited and the lag time had increased, when the plasma was mixed with CCF or its contents. CONCLUSIONS: As a result, we conclude that that the susceptibility of plasma to copper-induced lipid peroxidation is interfered by CCF. The chloride ions, which major content of CCF, may play an important role on this effect.

Absence of infrarenal inferior vena cava is not a congenital abnormality.

The absence of inferior vena cava (IVC) is one among infrequent subtypes of IVC abnormalities that are rarely seen in general population. The absence of IVC involves either that of entire IVC or that of infrarenal segment. These two entities are relatively similar but their etiopathogeneses are still controversial. The absence of the entire IVC is thought to be a result of an embryologic disorder, whereas perinatal thrombosis is hypothesised to lead to the development of absent infrarenal IVC, thus the latter is a developmental disorder and the former occurs due to embryologic disorder. We report an adult man with renal-infrarenal absence of IVC, as well as missing common iliac veins. He clinically presented with extensive varicose collateral circulation on the thoracoabdominal wall, right varicocele and severe varices on lower limbs. Calcifications of adrenal glands indicate a hematologic disorder during perinatal period. The etiopathogenesis of this unusual abnormality is emphasized in this case report (Fig. 5, Ref. 10). Full Text (Free, PDF) www.bmj.sk.

Cardiac rhabdomyoma in an adult patient presenting with right ventricular outflow tract obstruction.

We present a 24 year old woman with cardiac rhabdomyoma. Cardiac rhabdomyoma is the most common benign cardiac tumor in infants, but in adults, cardiac rhabdomyoma is very rare. These tumors are often spontaneously reversible because they are associated to the right or left ventricular outflow tract obstruction, tachyarrhythmias and heart failure where surgery is necessary.

Analysis of C-reactive protein and biochemical parameters in pericardial fluid.

This study was designed to examine the relationship between pericardial fluid and plasma CRP levels, and to alterations in other biochemical parameters in patients undergoing Coronary Artery Bypass Grafting (CABG). The study group consisted of 96 Coronary Artery Disease (CAD) patients who were referred to our clinic for a CABG procedure and from whom sufficient amount of pericardial fluid could be collected. The patients were classified into 3 groups: Stable Angina Pectoris (SAP) (n=27), Unstable Angina Pectoris (USAP) (n=36), and Post-Myocardial Infarction (PMI) (n=33). Levels of CRP, glucose, albumin, total protein, Creatine Kinase (CK), Creatine Kinase-MB (CK-MB), and Lactate Dehydrogenase (LDH) were determined in pericardial fluid samples and in simultaneously collected blood samples from radial artery. The pericardial CRP and LDH levels in the PMI group were higher than in the SAP (p=0.015 and p=0.000, respectively) and USAP (p=0.011, p=0.047) groups. Serum CRP levels in USAP (p=0.014) and PMI (p= 0.000) groups were higher than those in the SAP group. Pericardial albumin levels in the PMI group were higher than in the USAP group (p=0.038). In all groups, the pericardial fluid/serum protein ratio was > 0.5, the LDL ratio was > 0.6, and pericardial fluid LDH concentrations were > 300 mg/dl. CRP level of pericardial fluid was significantly higher in the PMI group than in other groups. However, pericardial fluid LDH levels were higher than blood LDH levels in this group and were also higher than pericardial fluid LDH levels of other groups.

The importance of intrapericardial drain selection in cardiac surgery.

INTRODUCTION: To explore the impact of intrapericardial and infracardiac drains on pericardial effusions in cardiac surgery. MATERIALS AND METHODS: Patients undergoing coronary artery bypass grafting were randomized into two groups. At the end of the intervention, an intrapericardial and infracardiac Blake drain was placed in patients in group 1 (n = 97), and an intrapericardial and infracardiac semirigid drain was placed in patients in group 2 (n = 105). In addition, a semirigid drain was placed into mediastinum in all cases. The amount of drainage was calculated at six different time points postoperatively: postoperative 0 to 2 h, postoperative 2 to 4 h, postoperative 4 to 6 h, postoperative 6 to 12 h, postoperative 12 to 24 h, and postoperative 24 to 48 h. The amount of pericardial effusion was estimated by transthoracic echocardiography after the drains were removed. RESULTS: In all measurements, the amount of drainage from intrapericardial Blake drains was higher, the total amount of drainage being equal to 330.7 +/- 29.4 mL and 193.2 +/- 19.6 mL in the Blake drain and semirigid drain groups, respectively (p = 0.000) [mean +/- SD]. When the drains were removed, the volume of pericardial effusion was 3.86 +/- 0.76 mm in Blake drain group and 7.59 +/- 1.16 mm in semirigid drain group (p = 0.000). The incidence of postoperative atrial fibrillation was 11.3% in the group with Blake drains, and 23.8% in the group with semirigid drains (p = 0.016). CONCLUSION: The more effective drainage obtained with infracardiac Blake drains compared to semirigid drains helps to reduce the amount of postoperative pericardial effusion and the risk of atrial fibrillation.

Assessment of digital ischaemia and evaluation of response to therapy by 99mTc sestamibi limb scintigraphy after local cooling of the hands in patients with vasospastic Raynaud's syndrome.

AIM: Cold induced arteriolar constriction in patients with vasospastic Raynaud's syndrome (VRS) produces temporary digital ischaemia. The aim of this study was to ascertain whether 99mTc sestamibi scintigraphy is useful in the diagnosis and the monitoring of treatment in VRS. METHODS: Fifteen patients with VRS and 20 matched normal controls underwent examination. Twelve patients with VRS received therapy. For each patient, one hand was immersed in iced water for 30s while the other hand served as a control. Ten minutes after cooling, 99mTc sestamibi was injected and imaging was performed 60min later. The per cent decrease of the perfusion (%DP) was calculated by semiquantitative analysis to determine the severity of hypoperfusion. RESULTS: In all patients with VRS, moderate or marked hypoperfusion were seen in 99mTc sestamibi images after exposure to the iced water, while there was minimal or mild hypoperfusion in the control groups. Values for %DP were 46.86 +/- 19.04 and 7.85 +/- 4.53 for the VRS group and normal subjects, respectively. The difference between both groups was statistically significant (P = 0.0000). In 12 treated patients with VRS, pre-treatment and post-treatment %DP values were 51.16 +/- 18.42 and 33.58 +/- 17.83, respectively, and a significant difference was seen between both values (P = 0.001). However, there was still a statistically significant difference between control subjects and post-therapy values (7.85 +/- 4.53 vs. 33.58 +/- 17.83, P = 0.0000). The +/- 95% confidence interval of DP for control subjects was 5.7-10% (chi-squared, P = 0.000). When a DP of 10% was used as a cut-off point, sensitivity, specificity and diagnostic accuracy were 100%, 70% and 83%, respectively, for the 99mTc sestamibi scan. There was also a strong correlation between %DP and the duration of the disease (r = 0.80, P = 0.0003). CONCLUSION: The results of this study indicate that a 99mTc sestamibi scan is a valuable imaging method for the determination of digital ischaemia in vasospastic Raynaud's syndrome, and may play a role in evaluating the response to therapy.

Importance of pulmonary artery perfusion in cardiac surgery.

OBJECTIVE: To investigate the importance of pulmonary artery perfusion in cardiac surgery. DESIGN: Prospective randomized study. SETTING: University hospital. PARTICIPANTS: Patients undergoing cardiac surgery. INTERVENTIONS: Patients in whom the cross-clamp was applied only to the aorta were defined as group 1 (n = 11) and patients in whom the cross-clamp was applied to both the aorta and pulmonary artery were defined as group 2 (n = 11). MEASUREMENT AND RESULTS: Tissue samples obtained from the lower lobe of the left lung before CPB, 20 minutes after cross-clamping, and 20 minutes after declamping were examined under light and electron microscopes. Electron microscopic examination revealed changes in the blood-air barrier, epithelial cells, pneumocytes, and basal membrane were more prominent in group 2. Changes in the leukocyte, neutrophil, and lymphocyte counts of blood samples obtained from the right atrium and right superior pulmonary vein before CPB and 5, 30, 60, and 90 minutes after the removal of clamp were also investigated. The transpulmonary difference was statistically significant at 5 and 30 minutes after declamping in group 1. In group 2, transpulmonary differences continued to be significant at 5, 30, 60, and 90 minutes after declamping. There was no difference between groups in terms of PaO(2)/F(I)O(2) ratio before CPB (group 1: 342.0 +/- 80.0 mmHg, group 2: 349.0 +/- 67.0 mmHg); however, a statistically significant difference was found between the groups 2 hours after declamping (group 1: 418.0 +/- 87.0 mmHg and group 2: 290.0 +/- 110.0 mmHg; p = 0.007). CONCLUSION: Pulmonary artery perfusion was found to be important in cardiac surgery.

Electrophysiological evaluation of phrenic nerve injury during cardiac surgery--a prospective, controlled, clinical study.

BACKGROUND: According to some reports, left hemidiaphragmatic paralysis due to phrenic nerve injury may occur following cardiac surgery. The purpose of this study was to document the effects on phrenic nerve injury of whole body hypothermia, use of ice-slush around the heart and mammary artery harvesting. METHODS: Electrophysiology of phrenic nerves was studied bilaterally in 78 subjects before and three weeks after cardiac or peripheral vascular surgery. In 49 patients, coronary artery bypass grafting (CABG) and heart valve replacement with moderate hypothermic (mean 28 degrees C) cardiopulmonary bypass (CPB) were performed. In the other 29, CABG with beating heart was performed, or, in several cases, peripheral vascular surgery with normothermia. RESULTS: In all patients, measurements of bilateral phrenic nerve function were within normal limits before surgery. Three weeks after surgery, left phrenic nerve function was absent in five patients in the CPB and hypothermia group (3 in CABG and 2 in valve replacement). No phrenic nerve dysfunction was observed after surgery in the CABG with beating heart (no CPB) or the peripheral vascular groups. Except in the five patients with left phrenic nerve paralysis, mean phrenic nerve conduction latency time (ms) and amplitude (mV) did not differ statistically before and after surgery in either group (p > 0.05). CONCLUSIONS: Our results indicate that CPB with hypothermia and local ice-slush application around the heart play a role in phrenic nerve injury following cardiac surgery. Furthermore, phrenic nerve injury during cardiac surgery occurred in 10.2 % of our patients (CABG with CPB plus valve surgery).

Effect of pericardial fluid pro-inflammatory cytokines on hemodynamic parameters.

We investigated the effects of pro-inflammatory cytokines of pericardial fluid on hemodynamic parameters in patients undergoing coronary artery surgery. Seventy-eight patients were included in the study and they were allocated to three groups: group 1, stable angina pectoris (SAP, n = 15); group 2, unstable angina pectoris (USAP, n = 34); group 3, post-myocardial infarction (PMI, n = 29). Pericardial fluid and arterial blood samples were obtained from all patients and interleukin (IL)-1beta, IL-2 receptor, IL-6, IL-8 and tumor necrosis factor-alpha (TNF-alpha) levels were measured. Pericardial IL-1beta concentration (pg/mL) was significantly higher in the USAP group (26.6 +/- 10.9) compared to the SAP (5.0 +/- 0.1) and PMI (5.8 +/- 1.0) groups. IL-2R, IL-6, IL-8 and TNF-alpha concentrations of pericardial fluid were significantly higher than serum in all groups; difference was more prominent in the PMI group compared to the SAP and the USAP groups. Serum IL-1beta concentrations (pg/mL) were significantly higher in the USAP group (21.8 +/- 3.4) compared to the SAP group (5.0 +/- 0.1) and the PMI group (5.4 +/- 1.6). Cardiac index (CI) before opening the pericardial sac was found to be lower in the USAP group (1.6 +/- 0.3 L/min/m2) compared to the SAP (2.2 +/- 0.5 L/min/m2) and the PMI (2.1 +/- 0.5 L/min/m2) groups (p = 0.028 and p = 0.011, respectively). In the USAP group, there was a relationship between reduction of CI and increase of IL-1beta levels in serum and pericardial fluid.

Bilateral popliteal artery aneurysms with rupture and pseudoaneurysm formation on the left.

The rupture of a popliteal artery aneurysm is very rare, and can lead to serious complications if untreated. Any reports of a huge pseudoaneurysm, following rupture of the popliteal artery aneurysm could not be found in a review of the literature. A pulsatile huge mass leading to a deep venous thrombosis, was observed in a 74 years old male patient who for 2 months had had a progressively swollen and painful left leg. On angiographic evaluation, the mass was found to be a pseudoaneurysm originating from a ruptured true aneurysm of the popliteal artery. There was also a small true aneurysm in the contralateral extremity at the same localization. Both the false, and true aneurysms were resected surgically and arterial continuity was established with a synthetic polytetrafluoroethylene graft.