Influence of methylprednisolone on levels of neuron-specific enolase in cardiac surgery: a corticosteroid derivative to decrease possible neuronal damage.

BACKGROUND: Cerebral injury is a well-known complication after cardiac surgery with cardiopulmonary bypass (CPB), especially in adult patients. Specific biochemical markers like neuron-specific enolase (NSE) and S-100beta protein were developed previously for early detecting neuronal damage after CPB. Corticosteroids are shown to reduce multisystemic deleterious effects of cardiopulmonary bypass due to their anti-inflammatory characteristics. The aim of this study is to demonstrate the decrease of serum neuron-specific enolase levels in patients who received corticosteroids before CPB. METHODS: Thirty patients scheduled for elective coronary bypass surgery were included in the study. Patients were divided randomly into two groups as the control group (n = 15) who underwent a standard coronary bypass surgery without any additional medication and the study group (n = 15) who received 1 gm of methylprednisolone before CPB. Blood samples for analysis of serum NSE, interleukin-6 (IL-6), and IL-10 were drawn before CPB, 4 and 24 hours after the end of extracorporeal circulation. RESULTS: Serum cytokine and NSE levels were significantly increased after CPB above their normal range in both groups. In the study group, IL-6 and NSE levels were significantly reduced while IL-10 levels were much higher after CPB. High NSE levels significantly correlated with IL-6 levels in the control group. CONCLUSION: The lower levels of NSE in patients who received methylprednisolone may suggest that corticosteroids might be useful in decreasing possible neuronal damage during heart surgery. However, we were not able to demonstrate an adverse neurological outcome.

Over 14 years of experience with cardiac myxomas.

Atrial myxomas are the most commonly encountered tumours of the heart and can present at different ages with different clinical symptoms. They are one of the curable tumours of the heart. Appropriate surgical treatment and surgery must be performed with great precautions in order to prevent fatal systemic embolizations. In this retrospective study we will present our experience of 14 years, between 1990 and 2004, in 27 patients who had been operated for cardiac myxomas. Diagnosis of the myxomas were made by echocardiography in all cases. Surgical approach to the tumour was biatrial in nine, left atrial in II, and transseptal in seven patients. Associated procedures included coronary artery bypass grafting in one, mitral valve repair with tricuspid annuloplasty in two patients, mitral valve replacement in one and bilateral femoral embolectomy in one patient. One hospital mortality occurred as a result of multiorgan failure in a patient with peripheral embolization. None of the patients required recurrent operation, however, mitral valve insufficiency was surgically corrected in one patient.

Endoluminal stenting of mycotic saccular aneurysm at the aortic arch.

Endovascular grafts have been widely used for the treatment of aneurysms since the early 1990s. They are preferred especially for use in patients in whom conventional surgical methods carry high risks of death and morbidity. Increasing operator experience and technical refinements in endovascular grafting have enabled these procedures to be performed even in critical segments of the aorta, such as the thoracic and arch levels. In this report, we present the case of a patient who was treated successfully with an endovascular graft for a mycotic saccular aneurysm located just below the left subclavian artery.

Childhood mediastinal masses in infants and children.

We reviewed all cases of primary pediatric mediastinal masses diagnosed and treated over a 24-year period. In this study, out of 187 primary mediastinal mass cases diagnosed between 1980 and 2004 in Istanbul University Istanbul Faculty of Medicine, Cardiovascular Surgery Department, 37 pediatric primary mediastinal mass cases were retrospectively evaluated according to age, sex, symptoms, diagnostic procedure, anatomical location, surgical treatment, histopathological evaluation and postoperative adjuvant therapy. The patients ranged in age from 2 months to 15 years at the time of diagnosis, with a mean age of 8 years. There were 24 benign (64.8%) and 13 malignant (35.2%) tumors. The cases were lymphoma (27%), neurogenic tumors (21.6%), cystic lesions (18.9%), germ cell tumors (13.5%), thymic lesions (10.8%) and cardiac tumors (8.1%). Complete and partial resections of the tumor were the surgical procedures performed in 24 patients (64.8%) and 3 patients (8.1%), respectively. The three patients with a malignant tumor, in whom the entire mass could not be removed, received chemotherapy and radiation after surgery. In 10 patients with lymphoma, surgery was not a part of treatment and they received medical and radiation therapy after the establishment of the definitive diagnosis. All patients survived and were discharged from the hospital. Except for the cases with lyphoma, all patients are now free of recurrent disease. Compared to adults, children had more lymphomas and neurogenic tumors. Primary pediatric mediastinal malignancies are relatively common in infants and children. Lymphoma, neurogenic tumors and cystic lesions predominated. These differences between the age groups should also be considered when dealing with a mediastinal mass.

Patency and venous pressure of arteriovenous fistulas for hemodialysis.

The early patency of arteriovenous fistulas created for hemodialysis is affected by various factors, including venous stenosis. We conducted a study to investigate the effect of venous stenosis on early patency by examining perioperative arterial and venous pressures of the fistula. Among the 15 patients selected for the study, 11 had snuff-box fistulas, 3 Brescia-Cimino, and 1 brachial. A thrill was palpable over the anastomosis in 10 patients and absent in 5 patients. In terms of venous pressure, the patients with a thrill had a mean systolic pressure of 35.8 mm Hg and systolic-diastolic pressure gradient of 3.4 mm Hg. In the patients without a thrill, the values were 102.6 mm Hg and 42.8 mm Hg, respectively. In conclusion, patients with venous obstruction in the fistula had a much higher venous pressure than those with a patent fistula. If venous stenosis is suspected, measurement of fistula pressures may be useful for determining the early patency of arteriovenous fistulas.

Role of transesophageal echocardiography in diagnosis and management of cardiac hydatid cyst: report of three cases and review of the literature.

Although diagnostic value of transthoracic echocardiography in cardiac echinococcus is well established, the role of transesophageal echocardiography in both the diagnosis and the management of this entity is not well known. We present 3 unusual cases of cardiac hydatid cyst in which transesophageal echocardiography was used. A review of the literature on the subject is also presented.

Peri-operative comparison of different transient external shunt techniques in bidirectional cavo-pulmonary shunt.

OBJECTIVE: In patients with functional single ventricular physiology, the avoidance of cardiopulmonary bypass offers many advantages including earlier extubation, decreased necessity of inotropic support, improved hemodynamical status and reduced likelihood of post-operative prolonged pleural effusion. We believe that the bidirectional cavopulmonary anastomosis operations may be performed with transient external shunt techniques. The purpose of this prospective study is the peri- and post-operative comparison of different transient external shunt methods used in bidirectional cavopulmonary shunt operations. METHODS: Between years 1997 and 2000, 30 patients have undergone bidirectional cavo-pulmonary shunt operation by using three different types of external shunt. The mean patient age was 13 months (range, 3 months-3 years). Previous operations had been performed in ten patients (33%). All patients were divided into three groups according to type of external shunt used. In group A (ten patients), the transient external shunt was constructed between superior vena cava and right atrium by uniting two standard venous cannulas with a Y-connector. In group B (ten patients), the external shunt was performed with a single short venous cannula constructed between superior vena cava and right atrium. In group C (ten patients), the external shunt was constructed between superior vena cava and left pulmonary artery by using a single short venous cannula. During operation, central venous pressure (CVP), arterial O(2) saturation and mean arterial blood pressure were recorded continuously. RESULTS: All operations are completed without the establishment of cardiopulmonary bypass. Hospital mortality was 3.3%. One patient in group A died because of low cardiac output at the end of postoperative day 2. All patients were extubated within 4h. In groups A-C mean superior vena caval pressures were measured 28, 24 and 21 mmHg, respectively during superior vena cava-right pulmonary artery anastomosis. In both groups A and B patients, arterial O(2) saturation decreased to a minimum 53+/-2 and 53+/-2%, respectively during the operation. In the group C, minimum arterial O(2) saturation was measured 82+/-2%. Although mean arterial pressure decreased in all groups during clampage; in group C patients, this drop is not significant. CONCLUSION: Based on the study presented here, bidirectional cavo-pulmonary anastomosis can be carried out by using different types of transient external shunt. The best hemodynamical condition and arterial O(2) levels were achieved with the shunt constructed between superior vena cava and left pulmonary artery.

Repair of ascending aortic aneurysm in a patient with fibrosarcoma over sternum.

The combination of an ascending aortic aneurysm and suprasternal soft tissue tumor is rarely reported in the literature. This case involves a 62-year-old man diagnosed with an ascending aortic aneurysm and a fibrosarcoma over the sternum that was successfully treated by surgery. The patient underwent an aortic replacement operation with a Dacron graft and a muscle flap transposition procedure to cover the defect over the sternum.

Aortic arch branches are occluded: which artery nourishes the brain?

Takayasu arteritis is an inflammatory vascular disease that primarily affects the aorta and its major branches. In this report, we present a 47-year-old woman whose aortic arch branches were totally occluded and the cerebral circulation is dependent on a dilated right vertebral artery.

Successful bleomycin pleurodesis in a patient with prolonged pleural effusion after extracardiac fontan procedure.

Pleural effusions after modified Fontan operations are unpredictable and contribute significantly to the morbidity and prolonged hospitalization. Chemical pleurodesis is widely performed in adults for malignant pleural effusions, but has found less chance of usage for benign cases or the cases with unidentified etiology. Although it is a safe and easily performed procedure, the use of bleomycin for the treatment of pleural effusions in the pediatric age population has been rarely reported in the literature. In this manuscript, we present a case with prolonged pleural effusion after extracardiac Fontan operation, which was successfully treated with bleomycin pleurodesis.

Common carotid trunk and right vertebral artery originating from the right common carotid artery in a patient with carotid stenosis.

Truncus bicaroticus is a very rare vascular malformation. In this report, we present a very rare anomaly in a patient with left internal carotid artery stenosis together with truncus bicaroticus and right vertebral artery originating from the right common carotid artery.

Complication of Behcet's disease: spontaneous aortic pseudoaneurysm.

Behcet's disease is an autoimmune multisystemic disorder based on vasculitis. In this disease, the most important predictor of morbidity and mortality is the vascular complications. Appropriate surgical interventions are critical and must be planned strategically. Here, we will describe a very rare complication of the disease; spontaneous aortic pseudoaneurysm in a 33-year-old patient.

Serum lactate level has prognostic significance after pediatric cardiac surgery.

OBJECTIVE: The determination of postoperative course after cardiac surgery has always been a challenging issue. It is more sophisticated in the pediatric age group. The aim of this investigation was to identify whether increased concentrations of lactate in arterial blood has a predictive value for postoperative morbidity and mortality after heart surgery. METHODS: From May 2002 to June 2003, 60 infants operated on at the authors' institution were included in this prospective study. The patients were divided into 2 groups according to their respective postoperative serum lactate values. After the stabilization period in the intensive care unit (first 3 hours postoperatively), samples for serum lactate were obtained from arterial blood at 3 (t1), 6 (t2), and 12 hours (t3) postoperatively. The patients were subdivided into 2 groups according to their respective mean serum lactate values. A value of 4.8 mmol/L (3 times the normal upper limit) was chosen as a threshold for serum lactate. The patients with a mean value of greater than 4.8 mmol/L (group 1) were compared with the remaining group of patients (group 2). The relationship between serum mean lactate level and intraoperative and postoperative clinical variables was evaluated. RESULTS: Among the patients in this study, 26 (43.3%) had a serum mean lactate level more than 4.8 mmol/L and 34 (56.7%) had a level of 4.8 mmol/L or less. Age, aortic cross-clamping time, cardiopulmonary bypass time, and the lowest hematocrit during cardiopulmonary bypass were significant variables that influenced the postoperative serum mean lactate level. Six patients died in the postoperative period and 54 infants survived. The hospital mortality was significantly higher in group 1 than in group 2 (19.0% v 2.9%; p = 0.037, kappa = 0.179). Multivariate analysis revealed that serum mean lactate level correlated significantly with inotrope score, intubation time, and intensive care unit stay. CONCLUSIONS: Blood lactate concentration of 4.8 mmol/L or higher during the early postoperative hours identifies a group of patients with increased risk of postoperative morbidity and mortality.

Idiopathic aneurysm of the inferior caval vein.

Idiopathic aneurysms of the inferior caval vein are uncommon in children and adults. We describe a 14 year old boy with a saccular aneurysm of the inferior caval vein, in whom no surgical intervention was required to repair the aneurysm. The patient is being followed-up periodically for the evaluation of any increase in the diameter of the inferior caval vein.

Epitheloid hemangioendothelioma of the heart in infancy.

We report a case of primary cardiac epithelioid hemangioendothelioma arising from the right atrium of a 2-month-old infant. The tumor was found incidentally during exploratory sternotomy for recurrent pericardial effusion. This case represents a very rare situation, because this is the youngest patient found in relevant literature, and because it involves extensive infiltration by the tumor without any development of intracardiac mass appearance.

Results of surgical treatment for infective endocarditis in children.

OBJECTIVE: Infective endocarditis is uncommon condition, with a high degree of morbidity and mortality. It is less common in children, albeit tending to be associated with congenital cardiac malformations. We describe our experience of the need for surgical treatment in children with infective endocarditis. PATIENTS AND METHODS: We analyzed retrospectively the records of 9 children aged below 16 years seen between May 2003 and March 2005 with infective endocarditis, reviewing the demographic details, clinical presentation, microbiological and echocardiographic data, operative findings, and outcome. RESULTS: Apart from pre-existing renal insufficiency in 1 patient, congenital cardiac malformations were the predisposing factors. Blood cultures were positive in 3, but remained negative in the other 6 patients. The indications for surgical treatment included uncontrolled sepsis, congestive heart failure, recurrent endocarditis, patch or graft dehiscence, and pseudoaneursymal formation. Death due to uncontrolled sepsis resulting in multiorgan failure occurred in 1 patient, who had tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries. Another patient died late postoperatively due to cardiac failure after relapse of the endocarditis in the setting of negative blood cultures. CONCLUSION: Despite advances in antimicrobial therapy, diagnosis, and measures of treatment for infective endocarditis, complications continue to be responsible for substantial morbidity and mortality. Since blood cultures are frequently negative, clinical and echocardiographic findings should be the major determinants of strategies used for treatment. We believe that our small series of patients seen over the past two years in which surgical treatment was performed will be helpful in guiding the clinical perspectives for children with infective endocarditis.

Aortic arch reconstruction with pulmonary autograft patch in coarctation and interruption of the aorta.

The surgical management of the aortic arch pathologies is still subject to discussion. Primary end-to-end anastomosis has some complications such as bronchial compression, tension in the suture lines, and probability of recurrence. On the other hand, patch aortoplasties combined with end-to-end anastomosis carry the risk of aneurysm formation and recurrence. Considering the growth potential, pulmonary autograft patch use in aortic arch reconstructions has recently been introduced into clinical practice. In this study, we present the early findings of combined end-to-end anastomosis and pulmonary autograft patchplasty procedure in six patients. According to our experience the technique applied in this report seems to be more advantageous than other conventional approaches.

Results of surgical treatment for nonthymomatous myasthenia gravis.

PURPOSE: To clarify the factors that influence improvement and remission after thymectomy for patients with nonthymomatous myasthenia gravis (MG). METHODS: We retrospectively reviewed 204 patients with nonthymomatous MG who underwent thymectomy and anterior mediastinal dissection through a partial median sternotomy, between 1980 and 2001, and examined whether age, sex, preoperative classification, and duration of symptoms influenced their prognosis. RESULTS: There was no perioperative or hospital mortality. The mean follow-up period was 7.2 +/- 1.2 years, with early and late postoperative remission rates of 44.6% and 73%, respectively. Seven patients died; two from pneumonia and five from causes unrelated to MG. Preoperative treatment and classification, duration of symptoms, age, and sex did not seem to have a significant influence on remission, but the response to thymectomy was greater in patients with thymic hyperplasia. Remission and improvement rates were significantly better at the end of the first year, with the same status found at the last follow-up. CONCLUSION: Thymectomy is an effective and highly curative method of treatment for patients. with MG. It provides excellent symptomatic improvement, which is enhanced over the long term.

The benefits of continuous ultrafiltration in pediatric cardiac surgery.

BACKGROUND: Systemic inflammatory response and capillary leak syndrome, caused by extracorporeal circulation, have negative effects on the function of vital organs during the postoperative period. Modified ultrafiltration (MUF) has been developed as an alternative method to reduce the detrimental effects of cardiopulmonary bypass. The aim of this prospective, randomized study is to analyze the effects of MUF in a pediatric population undergoing congenital cardiac surgery. METHODS: Twenty-seven patients who underwent open-heart surgery at our institution were included in this prospective study. They were randomized into two groups as follows: Group I (n=14) of conventional ultrafiltration during bypass and Group II (n=13) receiving both conventional and modified ultrafiltration during and after the cessation of the bypass, respectively. The amount of prime volume, postoperative chest drain loss, transfusion requirements, hemodynamical parameters, duration of mechanical ventilatory support, and length of intensive care unit stay were compared between the two groups. During the postoperative period, the concentrations of hematological, biochemical and inflammatory parameters were also compared by analyzing the blood samples obtained at various time points. RESULTS: MUF resulted in a significant increase in hemoglobin, hematocrit and platelet levels, and significantly reduced the amount of chest tube output and transfused blood and blood products. MUF also shortened the duration of postoperative mechanical ventilatory support, length of the intensive care unit stay and improved postoperative hemodynamical parameters. During the early postoperative hours, IL-8 is significantly reduced in patients undergoing MUF, however, the concentrations of IL-8 were similar in both groups at the end of 24 h. CONCLUSIONS: MUF decreases the duration of mechanical ventilatory support, the length of intensive care unit stay, the need for blood transfusion and improves postoperative hemodynamics. It is associated with increased levels of hemoglobin, hematocrit and platelets. We can conclude that MUF attenuates the inflammatory response by decreasing the levels of inflammatory mediators.