Persistent left superior vena cava: the anatomical and surgical importance.

OBJECTIVE: Persistence of the left superior vena cava (PLSVC) is a congenital anomaly resulting from failure of degeneration of the left cardinal vein. The prevalence of this anatomical variant is approximately 0.3% in the general population. The aim of this study was to determine the prevalence of the persistence of the left superior vena cava in order to avoid potential complications. SUBJECTS AND METHODS: The study was conducted during a five-year period in 152 patients (64 males, 88 females) aged 1-65 years who underwent cardiac surgery for congenital heart diseases. RESULTS: The persistence of the left superior vena cava was found in 5 of 152 patients (3.3%). All persistent left superior vena cavae opened into the coronary sinus. Furthermore, the coronary sinus was enlarged in all patients. The right superior vena cava was absent in one of the five cases (20%) in this study. CONCLUSION: This anatomical variant must be recognized to avoid the potential complications.

Laryngeal mask airway insertion with remifentanil.

INTRODUCTION: We conducted a study to find out the best conditions for LMA insertion with two different doses of remifentanil added to propofol and propofol administered alone. METHODS: Following hospital clinical research ethics committee approval, 60 ASA I-II patients were included in the randomized double-blind study. Following premedication, patients received i.v. 0.25 microg kg(-1) remifentanil (Group R1), 0.50 microg kg(-1) remifentanil (Group R2) or normal saline (Group P) in 60 sec. Then following 20 mg lidocaine, propofol 2 mg kg(-1) were administered in R1 and R2 groups and 2.5 mg kg(-1) in P group. Ease of insertion of LMA and airway quality at first attempt was assessed. Number of attempts of LMA insertion, apnea time, additional propofol requirement and hemodynamic changes were recorded. RESULTS: There were no significant differences in demographic data among the patients. Apnea time (mean +/- SEM) was significantly shorter in P group (34.09 +/- 5.5 sec) compared to R1 (82.5 +/- 12.7 sec) and R2 (87.2 +/- 6.6 sec) groups (p = 0.01 and p = 0.001). Ease of LMA insertion was assessed as grade 1 in 100% of patients in R2 group while 65% in R1 and 30% in P groups. Undesirable responses following LMA insertion were observed in 54% of patients in P group. CONCLUSION: Propofol given 2.5 mg kg(-1) alone is not a good agent for LMA insertion. Remifentanil used in both doses combined with propofol provides good and excellent conditions for insertion of LMA with minimal hemodynamic disturbances.

Long-term results of reconstructions of the left anterior descending coronary artery in diffuse atherosclerotic lesions.

UNLABELLED: One hundred twenty patients who had diffuse atherosclerotic lesions necessitating reconstruction of the left anterior descending artery with or without open endarterectomy and coronary artery bypass grafting were investigated retrospectively and compared with 130 patients who underwent conventional bypass grafting in the same time frame. METHODS: Sixty-one endarterectomies were performed with long arteriotomies (group I) and 59 patch reconstructions were placed over stenosing plaques without an endarterectomy (group II). Patients having only conventional coronary bypass constituted group III. RESULTS: Hospital mortalities were 6.5%, 5.1%, and 1.5% in group I, group II, and group III, respectively (p = not significant). Five patients in group I (8.1%), six in group II (10.1%), and two in group III (1.5%) had perioperative myocardial infarction (group II vs group III, p = 0.016). Angiographic restudy of grafts to the left anterior descending system revealed a patency rate of 81.5% in group I, 79.1% in group II, and 94.4% in group III patients after mean periods of 6.3, 5.7, and 6.1 years, respectively (p = not significant). Actuarial survivals at 7 years were 94% +/- 5.0%, 74.8% +/- 16%, and 90.9% +/- 7.4% in groups I, II, and III, respectively (group I vs group II, p = 0.007; group II vs group III, p = 0.008). Freedom from recurrent angina at 7 years was 42.7% +/- 15.6% in group I, 33.5% +/- 19% in group II, and 71.9% +/- 14.2% in group III (group I vs group III, p = 0.03; group II vs group III, p = 0.0001). Thirty-four percent of patients in group I, 24% in group II, and 60.4% in group III were working actively in the late postoperative period (p = 0.0001). CONCLUSION: Extended revascularizations of the left anterior descending coronary artery increase surgical risk, although not to a statistically significant degree, and should be performed only of necessity. However, once needed, revascularization is a lifesaving procedure with acceptable early and long-term results.

Preservation of myocardial metabolism in acute coronary artery occlusions with retrograde coronary sinus perfusion and iloprost.

A total of 12 healthy mongrel dogs were subjected to the study. The left anterior descending artery was occluded. The occlusion was done for 15 min. At the end of this period, without removing the occlusion, the heart was retroperfused for 3 h. Then, occlusion was removed and reperfusion was supplied. Animals were divided into two equal groups. Six animals received iloprost and the other six control did not receive any additional treatment. In the iloprost group, the drug was administered into the coronary sinus. After 15 min following occlusion, iloprost was infused at a rate of 50 microg/min continuously. Cardiac output (CO), mean arterial pressure (MAP), mean pulmonary arterial pressure (MPAP), heart rate (HR), pulmonary capillary wedge pressure (PCWP), right atrium pressure (RAP), myocardial oxygen extraction (MOE) and myocardial lactate extraction (MLE) parameters were examined in the two groups, before and during retroperfusion and during the reperfusion (1-4 h). Iloprost retroperfusion (50 microg/min) was started at the fifteenth minute of occlusion and continued till the end of the observation period (3 h). The measured hemodynamic data showed that the hearts treated with iloprost had satisfactory preservation of cardiac function. At the end of the reperfusion period cardiac output was 1.5 +/- 0.06 L/min in the control and 1.7 +/- 0.04 L/min in the iloprost group (P < 0.05). At the end of the reperfusion period, tumor necrosis factor level was raised significantly in the control group (P < 0.05). Myocardial lactate release was also high in the control group (P < 0.05). CPK-MB release was low in the iloprost group (P < 0.05). We conclude that retrogradely administered iloprost reduced the risk of myocardial injury and it is probable that this drug effectively distributes to the area of myocardium at risk.

Perinatal mitral valve interventions: a report of 10 cases.

BACKGROUND: Rheumatic mitral valve stenosis is still an endemic disease in some parts of the world and may complicate pregnancy and perinatal period. During the 10-year period between January 1988 and December 1997, 10 pregnant women with mitral stenosis were operated on. METHODS: Combined cesarean delivery and closed mitral valvulotomy (CMV) were performed on 6 patients, combined cesarean delivery and Mitral Valve Replacement (MVR) were performed on 1 patient, and 3 patients had CMV during their third trimester. RESULTS: There was 1 stillbirth. All other patients and delivered babies were healthy. MVR was necessary for mitral restenosis in one patient 5 years after her CMV. Three of the remaining patients had some degree of restenosis but did not require reoperation. CONCLUSION: CMV when indicated during pregnancy can be performed with low risk. For symptomatic patients responding to medical therapy, a combined approach of cesarean section and CMV will prevent possible complications that may arise on perinatal period due to hemodynamic fluctuation.

A clinical dilemma: cardiac and pericardiac echinococcosis.

BACKGROUND: Cardiac and pericardial echinococcosis as a life-threatening disease may present with a clear picture most of the time, however it may also become a clinical puzzle. METHODS: In the period between 1977 and 1998, 14 patients were operated on with the diagnosis of cardiac and pericardial echinococcosis. Nine patients were operated on with standard cardiopulmonary bypass (CPB) techniques, and the remaining 5 patients were operated on without CPB. Transesophageal echocardiography (TEE) or intraoperative surface echocardiography were used to plan and perform the operation for the late cases. RESULTS: One patient died during the postoperative period due to the rupture of interventricular septum. All other patients survived the perioperative period, received mebendazole treatment, and exhibited no recurrence during the follow-up. CONCLUSIONS: The definitive treatment is the surgical extraction of the cyst. Because the clinical picture may vary according to the number, size, and location of cysts, as well as complications, cardiac echinococcosis should be remembered and included in the differential diagnosis to achieve the treatment. Intraoperative surface echocardiography is of paramount value for diagnosis and planning the management of a successful surgery.

Iloprost added to the cardioplegic solutions improves myocardial performance.

A total of 12 mongrel dogs were divided into two equal groups. Six animals received IIoprost and the other 6 animals did not receive any additional treatment. In the Iloprost group, Iloprost was added to the cardioplegic solution (25 ng). Also, Iloprost was used (10 ng/kg/min.) 5 min. before and after cross-clamping. All cardiac output and biochemical measurements were evaluated before cross-clamp and 15 min., 1 h, and 4 h after cross-clamp. The measured dp/dt shows that the hearts treated with Iloprost preserved left ventricular function. Comparison of contractility indices between the groups revealed that contractile recovery was 59% in the control group and 71% in the Iloprost group (p < 0.05). Tumor necrosis factor (TNF) alpha level was significantly elevated in the control group (p < 0.001). Its level was 22.2 +/- 2.2 pg/mL in the control group and 13.8 +/- 1.0 pg/mL in the Iloprost group. E- and P-selectin levels were elevated in the control group (p < 0.001). ICAM-1 level was also elevated in the control group. ICAM-1 level was 17.7 +/- 1.8 ng/mL in the control group and 8.5 +/- 1.8 ng/mL in the Iloprost group. The Iloprost that was added to the cardioplegic solution and low dose administration during the pre- and post-ischemic period inhibits the toxic mediator release from endothelium-leukocyte interaction and reduces the severity of ischemia-reperfusion injury.

Low dose anticoagulation after St. Jude Medical prosthesis implantation in patients under 18 years of age.

Between September 1986 and January 1994, 129 St. Jude Medical prostheses were implanted in 113 patients who were 18-year-old or younger at the Cardiovascular Surgery Clinic of Turkiye Yuksek Ihtisas Hospital. Thirty-seven patients underwent aortic, 60 patients mitral and the remaining 16 patients double valve replacement. Overall hospital mortality was 7.9% (9/113). All patients received 2.5 mg/day warfarin from the first postoperative day, in addition 225 mg/day dipyridamole and 100 mg/day aspirin was given following the removal of mediastinal tubes. This regimen was continued indefinitely thereafter. Follow up period ranged between 2-94 months. Total follow up experience was 276.4 patient-years. There were five late deaths; the cause of death was prosthetic valve thrombosis in two patients, intracerebral hemorrhage in one, cardiomyopathy in one, and sudden death in one. Other late complications included one endocarditis, a further anticoagulant related bleeding and one paravalvular leak. There was no case of cerebral or peripheral embolism reported. Seven-year actuarial survival was 92.4 +/- 6.8% for the entire group, 84.6 +/- 13.8% after mitral and 100% after aortic or double valve replacement. In conclusion, low dose oral anticoagulation after heart valve replacement with St. Jude Medical prosthesis in this age group showed satisfactory clinical results.

Mitral valve replacement with St. Jude Medical prosthesis and low-dose anticoagulation in patients aged over 50 years.

BACKGROUND AND AIMS OF THE STUDY: These studies were designed to assess the effect of low-dose anticoagulation in elderly patients after mitral valve replacement. METHODS: Between 1986 and 1995, 250 patients aged > or = 50 years underwent isolated mitral valve replacement at the Cardiovascular Surgery Clinic of Turkiye Yuksek Ihtisas Hospital. The overall hospital mortality rate was 8%. Postoperatively, all patients received 2.5 mg/day warfarin, and 225 mg/day dypridamole and 250 mg/day aspirin following removal of mediastinal tubes. This regimen was continued indefinitely thereafter. RESULTS: Postoperatively, the mean International Normalized Ratio (INR) was 1.4 +/- 0.67 (range: 0.9 to 4.19) and mean prothrombin time 13.33 +/- 1.98 min (range: 11.7 to 21.3 min). Mean follow up was 1.42 +/- 1.2 years (range: 2 months to 8.3 years); total cumulative follow up was 322.75 patient-years (pt-yr). During follow up, six patients (1.85% per pt-yr) developed thromboembolic complications (including mechanical valve thrombosis), two (0.62% per pt-yr) developed oral anticoagulant-related bleeding, and two (0.62% per pt-yr) developed paravalvular leak. Five patients died during follow up (late mortality rate 1.2% per pt-yr). The nine-year actuarial survival rate was 93.9 +/- 4.8% for the entire group. CONCLUSIONS: Low-dose oral anticoagulation after mitral valve replacement with St. Jude Medical prosthesis in elderly patients provided satisfactory clinical results.

Low-dose oral anticoagulation and antiplatelet therapy with St. Jude Medical heart valve prosthesis.

BACKGROUND AND AIM OF THE STUDY: Since 1986, the St. Jude Medical (SJM) mechanical heart valve prosthesis has been implanted in patients at the authors' institution. We present our experience of low-dose oral anticoagulation and antiplatelet therapy following SJM valve implantation. METHODS: Among 2,585 patients (mean age 40.3 +/- 13.5 years) living in a rural environment, 865 underwent aortic valve replacement (AVR), 1,231 mitral valve replacement (MVR) and 489 double valve replacement (DVR). All patients received 2.5 mg/day warfarin and a combination of antiaggregation therapy (dypridamole 3 x 75 mg/day plus aspirin 100 mg/day), irrespective of their prothrombin time and cardiac rhythm. RESULTS: Postoperatively, 139 adverse events occurred (51 in AVR patients, 58 in MVR, 30 in DVR). Operative mortality rate was 5.9%, 4.7% and 6.1%, respectively, in the three groups (overall mortality rate 5.4%). The most frequent cause of operative mortality was low cardiac output. During follow up, there were 88 anticoagulant hemorrhages (1.2%/patient-year (pt-yr)), 11 paravalvular leaks (0.2%/pt-yr), 52 thromboembolisms (0.7%/pt-yr), 60 mechanical valve thromboses (0.8%/pt-yr) and 78 reoperations (1.1%/pt-yr). These complications occurred in 101 patients after AVR, in 125 after MVR, and in 63 after DVR (4.2%, 3.7% and 4.6% per pt-yr, respectively). Patient age (p = 0.0004), concomitant surgery (p = 0.0017) and late valve-related complications (p = 0.0159) were statistically significant mortality factors after AVR. Previous surgery was a significant risk factor for operative mortality after MVR (p <0.05). Female gender (p = 0.0059) and age (p = 0.017) were significant risk factors for operative mortality after DVR (p <0.01). CONCLUSIONS: Following implantation of the St. Jude Medical mechanical heart valve prosthesis, a fixed dose of 2.5 mg/day warfarin and combined dipyridamole/aspirin provided satisfactory results in terms of thrombosis, embolism and bleeding.

Long term results of mitral valve replacement with preservation of the posterior leaflet.

BACKGROUND AND AIMS OF THE STUDY: It is commonly held that preservation of the annulo-ventricular continuity during mitral valve replacement has a beneficial effect on postoperative ventricular function. This paper presents our eight-year experience with this technique. MATERIALS AND METHODS: From 1986 to December 1992, 120 patients with rheumatic valve disease underwent mitral valve replacement (MVR) combined with preservation of the posterior leaflet of the mitral valve. The mean age was 33.87 years (range 16 to 63). The preoperative New York Heart Association (NYHA) class was III in 64% of the patients and IV in 3%. The early (30 day) mortality rate was 2.5% (3/120). Follow up was 100% complete. The total cumulative follow up was 477 patient-years (pty) with a mean 3.94 years (range: 2-8 years). RESULTS: The actuarial survival rate (including hospital mortality) was 87.6% at eight years. Advanced age (p = 0.0457), increased preoperative functional capacity (p = 0.0251), increased preoperative end-systolic diameter (p = 0.0352) and combined tricuspid reconstruction (p = 0.0001) were found to be independent parameters for a lower actuarial survival rate. Six patients (1.25%/pty) developed thromboembolic complications. Two of these were cerebrovascular accidents (0.41%/pty) and four were caused by mechanical valve thrombosis (1.83%/pty). Freedom from thromboembolic complications (including mechanical valve thrombosis) was 89.8% +/- 7.9%. Fifteen patients (3.14%/pty) developed valve failure, four (0.83%/pty) mechanical valve thrombosis and nine (1.88%/pty) bioprosthetic valve failure. Freedom from reoperation was 60.7% +/- 16.1%. One patient with a St. Jude Medical valve (0.2%/pty) suffered from prosthetic valve endocarditis. Three patients (0.62%/pty) died during the follow up period, and, freedom from all valve related complications was 51.4% +/- 16.1% at eight years. CONCLUSION: Preservation of the posterior leaflet during mitral valve replacement reduces the risk of early mortality and did not cause additional complications to the patients. Despite the beneficial effects of this technique in the long term this technique did not increase the long term survival in patients with associated impaired valvular and/or ventricular function.

Treatment of functional tricuspid regurgitation by bicuspidalization annuloplasty during mitral valve surgery.

BACKGROUND AND AIMS OF THE STUDY: Surgical treatment of functional tricuspid regurgitation associated with advanced valvular disease remains controversial, mainly due to the difficulty in choosing between valve replacement or reconstructive surgery. Failure to correct tricuspid regurgitation during valvular surgery carries a poor prognosis, as reoperation may represent a significant risk to the patient. Thus correct tricuspid valve surgery is vital to achieve improved early and long-term clinical results. METHODS: A total of 142 patients underwent concomitant tricuspid annuloplasty with mitral valve replacement and their clinical outcome was assessed. RESULTS: Overall hospital mortality rate was 11.3%. Seven patients died during follow up. The overall actuarial survival rate for 10 years was 74.1 +/- 14.2%. Postoperatively, 75.8% of the patients had no residual tricuspid insufficiency, while 24.2% had first- or second-degree tricuspid insufficiency and were treated medically. All patients were in NHYA functional class I or II postoperatively. CONCLUSION: Clinically, it is important to assess the severity of functional tricuspid insufficiency before and/or during the operation. Bicuspidalization annuloplasty for functional tricuspid insufficiency has provided good results, with a low incidence of reoperation and significant clinical improvement. The technique could be used in most patients with functional tricuspid regurgitation.

Late results of mitral valve replacement with Carpentier-Edwards high profile bioprosthesis in young adults.

Carpentier-Edwards (C/E) high profile supra-annular porcine bioprostheses were implanted in 163 patients between September 1982-February 1987 in the mitral position due to rheumatic disease. The patients' ages ranged between 15 and 58 years (mean: 36.5 +/- 11.5). One hundred-two of the patients (62.5%) were female. The hospital mortality was 9.8% (16/163). The total cumulative follow-up period was 1093 patient-years (p-y) with a mean of 7.3 +/- 3.5 p-y (range 6 months-12 years). Linearised occurrence rates of the late complications were as follows: Thromboembolism 0.82%/p-v, anticoagulant-related bleeding 1.0%/p-y, prosthetic valve endocarditis 0.09%/p-y. Actuarial survival rates for 5 and 12 years were 87% +/- 6% and 76% +/- 9%, respectively, with 95% confidence limits. Freedom from structural deterioration was 92% +/- 5% for 5 years and 44% +/- 11% for 12 years. Freedom from all valve-related complications was 81% +/- 7 for 5 years and 26% +/- 9 for 12 years. In conclusion, this prosthesis provides satisfactory clinical performance in young population despite the high risk of degeneration with good prognosis and better tolerability of reoperation.

ATP-MgCl2 utilization for spinal cord protection during experimental thoracic aortic occlusion.

BACKGROUND: In this experimental study we investigate the effect of intravenous ATP-MgCl**2 administration for prevention of spinal cord injury occurring due to ischemia induced by aortic cross clamping. METHODS: Ten rabbits were studied. The abdominal aorta is ligated below the left renal artery. Five rabbits served as a control group and received no medication during 30 minutes of ischemic period. The other 5 rabbits received during 30 minutes of aortic occlusion ATP-MgCl2 solution (100 micromol/ml for each). Distal and proximal aortic pressures are measured during the procedure and incisions are closed. Rabbits are observed for 24 hours for their neurological status and scored accordingly. Specimens from the spinal cord are taken for electron microscopic investigations. RESULTS: All of the control group rabbits were paraplegic. One of the ATP-MgCl2 group rabbits was paraparesic and the others were normal Distal aortic pressure was 9+/-3 mmHg for the control group and was 17+/-4 mmHg for the ATP-MgCl2 group (p<0.05). Electron microscopic studies showed the preserved ultrastructure for ATP-MgCl2 group. CONCLUSIONS: ATP-MgCl2 administration during spinal cord ischemia reduces spinal cord injury. This may be an alternative modality for the protection of the spinal cord during aortic surgery.

Comparison of 21-23 size St. Jude medical valves to the 27-29 size mechanical valves in aortic position. Ten-year follow-up.

BACKGROUND: Between 1986 and 1996, 194 patients underwent isolated aortic valve replacement with 21-23 no. St. Jude Medical mechanical heart valves (small sized group) and 163 patients with 27-29 no. (large sized group). METHODS: The mean age at operation was 45.04+/-15.90 years (range: 12-76 years) for the small sized group and 38.05+/-13.41 years (range: 16-68 years) for the large sized group. Preoperatively, 39.7% of the patients from the small sized group and 42.9% from the large sized group had pure aortic stenosis, 31.9% and 27.6% had pure aortic insufficiency. Most of the patients had rheumatic valve disease. RESULTS: The overall hospital mortality rate was 12.4% and 3.07% respectively in the small sized and large sized groups (p<0.001). The overall actuarial survival rate for 10 years was 95.33+/-2.73% and 93.06+/-3.98% respectively in the small sized group and large sized group (p>0.05). In the small sized group male sex and all complications, in large sized group age and all complications were the statistically important hospital mortality predictors (p<0.05). CONCLUSIONS: Although, operative mortality and long term morbidity were higher in the small sized group, these changes did not reflect the actuarial survivals between the groups. Small sized valves carry some risk, but these risks do not affect long-term survival.

Coronary sinus retroperfusion during acute experimental coronary artery occlusion.

BACKGROUND: This study was planned to show the effect of retroperfusion and cardiopulmonary bypass on myocardial hemodynamic recovery. METHODS: Eighteen dogs entered this study. After, left anterior descending artery (LAD) was dissected and occluded, the animals were divided into three equal groups; Group I: retrograde coronary sinus perfusion, group II: cardiopulmonary bypass and retrograde coronary sinus perfusion, Group III: control group, left anterior descending artery occlusion only. RESULTS: In Group III, deterioration of the hemodynamic values progressed parallel with the degree of ischemic damage but in Group I, hemodynamic parameters were better because of the retrograde coronary sinus perfusion and minimally affected by the reperfusion. In Group II, at the end of the cardiopulmonary bypass minimal myocardial damage was observed. CONCLUSIONS: There is no statistical difference between Group I and II if we examine the data that was taken after reperfusion although myocardial performance was better in Group II.

Experimental evaluation of retrograde cerebral perfusion by single photon emission computed tomography technique (SPECT).

BACKGROUND: Protection of the brain is of vital importance during aortic arch aneurysms. In this study efficiency of retrograde cerebral perfusion was evaluated with the use of single photon emission computed tomography technique (SPECT) by using 99mTc hexamethylpropylene amine oxime (HMPAO). METHODS: Four animals were used. The internal maxillary vein was the site of retrograde cerebral perfusion. The animals were studied after the heart rate and respiration were stopped with the use of the high dose drug administration and the brain was perfused with cold Ringer's lactated solution. After this procedure, 99mTc HMPAO-SPECT study was performed. RESULTS: In one animal we did not get any cerebral image because of the competent venous valve in the internal maxillary vein. In the remaining animals, normal brain perfusion was achieved. CONCLUSIONS: 99mTc HMPAO-SPECT study documented that blood flow via the retrograde way meets the metabolic demand of the brain. Retrograde delivery of 99mTc HMPAO did not conclude any poorly perfused area in the brain when in given both sides and all parts of the brain can be effectively perfused by cerebral venous system in hypothermic conditions.

Experimental inhibition of protamine cardiotoxicity by prostacyclin.

Twelve animals (26+/-5 kg) were subjected to the study. In this experimental study, the authors used prostacyclin to inhibit the toxic metabolite release during protamine administration. Animals were divided into two equal groups. Six animals received prostacyclin (the prostacyclin group), and the other six animals did not receive any additional treatment (the control group). All cardiac output and biochemical measurements were evaluated at baseline; before cardiopulmonary bypass; and at 5, 30, and 60 minutes after protamine administration. The measured cardiac index showed that the hearts treated with prostacyclin had satisfactory preservation of left ventricular function. Metabolic and biochemical data showed that the tumor necrosis factor level was raised significantly in the control group (20.75+/-2.2 in the control group and 13.75+/-2.5 pg/mL in the prostacyclin group). Also, E and P selectin levels were elevated in the control group, but this change was less marked in the prostacyclin group. In addition, the intracellular adhesion molecule-1 (ICAM-1) level was significantly higher in the control group than in the prostacyclin group (9.26+/-2.13 in the control group and 5.13+/-1.66 ng/mL in the prostacyclin group). The authors observed that prostacyclin inhibited the toxic mediator release during heparin reversal with protamine. This inhibition is one way of protecting the myocardium reserves from protamine cardiotoxicity.

The association of lower extremity peripheral vascular disease in patients undergoing coronary bypass surgery.

The association of lower extremity peripheral vascular disease (PVD) in patients undergoing coronary artery bypass (CAB) has been studied in two groups of patients who have been operated upon between January and May 1987. Group 1 consists of 125 cases in which only resting ankle-arm pressure index (AAPI) were evaluated. Group 2 consists of 50 cases where both resting and after exercise AAPI were recorded. In total, 17 cases of one extremity and in 10 both lower extremity resting AAPI were below 0.9 (15.4%). In Group 2 comparison of resting and after exercise AAPI on both sides showed no statistically significant difference. However in Group 2, 13 cases (26%) had after exercise AAPI below 0.9 and in 26 (52%) cases after exercise AAPI were lower than the resting AAPI. This study showed that, although the coexistence of PVD in patients undergoing CAB is not as high as the coexistence of CAD in patients undergoing peripheral vascular procedures, this percentage can increase when the presence of PVD is evaluated with an exercise test whenever possible.