The importance of inflammatory parameters in predicting deep sternal wound infections after open heart surgery.

OBJECTIVE: The aim of this study was to investigate the relationship between the development of deep sternal wound infection after open heart surgery and inflammatory parameters obtained from routine biochemical tests. METHODS: A total of 280 patients who underwent cardiac surgery with median sternotomy between January 2015 and January 2020 were examined retrospectively. Patients who developed deep sternal wound infection were identified as "Group 1," and those who did not develop deep sternal wound infection were identified as "Group 2." RESULTS: There were 70 patients with a mean age of 61.6±9.9 years in Group 1 and 210 patients with a mean age of 62.7±9.8 years in Group 2. As a result of the analysis, it was found that the presence of concomitant chronic obstructive pulmonary disease, concomitant diabetes mellitus, blood and blood product transfusion, postoperative 2nd day C-reactive protein, postoperative 1st day neutrophil-to-lymphocyte ratio, and delta neutrophil-to-lymphocyte ratio was found as independent predictive factors of postoperative deep sternal wound infection development (p=0.043, p=0.012, p=0.029, p=0.009, p=0.002, and p<0.001; respectively). As a predictor of deep sternal wound infections development, postoperative 1st day neutrophil-to-lymphocyte ratio cutoff value was 11.2 (area under the curve [AUC] 0.598; p=0.014; 60% sensitivity, and 65.2% specificity), and delta neutrophil-to-lymphocyte ratio cutoff value was 9.6 (AUC 0.716; p<0.001; 57.1% sensitivity, and 73.8% specificity). CONCLUSIONS: Deep sternal wound infection development can be predicted with inflammatory parameters such as neutrophil-to-lymphocyte ratio and C-reactive protein that are obtained from cheap and easily available routine biochemical tests.

The ımportance of ınflammatory parameters ın predıctıng deep sternal wound ınfectıons after open heart surgery

SUMMARY OBJECTIVE: The aim of this study was to investigate the relationship between the development of deep sternal wound infection after open heart surgery and inflammatory parameters obtained from routine biochemical tests. METHODS: A total of 280 patients who underwent cardiac surgery with median sternotomy between January 2015 and January 2020 were examined retrospectively. Patients who developed deep sternal wound infection were identified as "Group 1," and those who did not develop deep sternal wound infection were identified as "Group 2." RESULTS: There were 70 patients with a mean age of 61.6±9.9 years in Group 1 and 210 patients with a mean age of 62.7±9.8 years in Group 2. As a result of the analysis, it was found that the presence of concomitant chronic obstructive pulmonary disease, concomitant diabetes mellitus, blood and blood product transfusion, postoperative 2nd day C-reactive protein, postoperative 1st day neutrophil-to-lymphocyte ratio, and delta neutrophil-to-lymphocyte ratio was found as independent predictive factors of postoperative deep sternal wound infection development (p=0.043, p=0.012, p=0.029, p=0.009, p=0.002, and p<0.001; respectively). As a predictor of deep sternal wound infections development, postoperative 1st day neutrophil-to-lymphocyte ratio cutoff value was 11.2 (area under the curve [AUC] 0.598; p=0.014; 60% sensitivity, and 65.2% specificity), and delta neutrophil-to-lymphocyte ratio cutoff value was 9.6 (AUC 0.716; p<0.001; 57.1% sensitivity, and 73.8% specificity). CONCLUSIONS: Deep sternal wound infection development can be predicted with inflammatory parameters such as neutrophil-to-lymphocyte ratio and C-reactive protein that are obtained from cheap and easily available routine biochemical tests.

Early and late predictors of postoperative neurocognitive dysfunction in cardiac surgery.

Background and purpose: Postoperative cognitive dysfunction (POCD) is a multifactorial image characterized by insufficiency in features such as the ability to perform tasks requiring high brain functions. Cognitive dysfunction such as memory loss and decreased concentration, confusion, and delirium are common conditions in some patients in the early period after major surgical interventions such as cardiac surgery. POCD causes delays in postoperative recovery, long return-to-work times, and decreased quality of life. This study aims to demonstrate POCD in early and late stages in patients undergoing cardiac surgery through the Montreal Cognitive Assessment (MoCA) and the Mini Mental Test (MMT). In addition, we aim to determine predictive factors with these neurocognitive tests. Methods: MMT and MoCA tests were applied to the patients included in the study before cardiac surgery, on the sixth postoperative day and third month. Neuro-cognitive dysfunction detected on the sixth postoperative day was accepted as an early period, its detection in the postoperative third month was accepted as a late period. Results: 127 patients without neurocognitive dysfunction in the preoperative period were included in the study. For early neurocognitive impairment, age, mean platelet volume (MPV), New York Heart Association (NYHA) classification, x-clamp time, cardio-pulmonary bypass (CPB) time, postoperative intensive care and hospital stay duration, and an event of acute myocardial infarction (AMI) in the preoperative period were determined as predictive factors. In addition, in late-period of neurocognitive dysfunction age, MPV, NYHA classification, x-clamp duration, CPB time, postoperative intensive care and hospital stay duration were shown as predictors of neurocognitive dysfunction. Conclusion: The results of our study support the literature findings showing that delirium is associated with a decline in cognitive functions three months after cardiac surgery. As a result, the lack of agreed diagnostic tests in the definition of POCD makes it difficult to standardize and interpret the research in this area. Therefore, a consensus to be reached in the diagnosis of POCD will ensure the use and correct interpretation of neurophysiological tests. In our study, advanced age and long hospital and intensive care stays were shown as predictive factors for both early and late neurocognitive dysfunctions. Furthermore, smoking was shown as a predictive factor only for late neurocognitive dysfunction.

The value of atrial electromechanical delay in predicting atrial fibrillation development after coronary artery bypass surgery.

OBJECTIVE: Predicting postoperative atrial fibrillation (PoAF) in the preoperative period will provide a serious advantage in preventing the morbidity and mortality associated with this arrhythmia and in planning the treatment. In this study, we investigated the value of atrial electromechanical delay (AEMD) in predicting the development of PoAF. METHODS: A total of 93 patients who underwent isolated coronary artery bypass grafting (CABG) operation were included in this prospective study. Patients' demographic characteristics, laboratory parameters, echocardiographic data, and AEMD durations that could be measured by the co-use of electrocardiography and echocardiography were recorded. The patients at sinus rhythm during the postoperative period were identified as "Group 1", and those who developed PoAF were identified as "Group 2". RESULTS: PoAF incidence was 26.88% (n = 25). Left ventricle (LV) lateral AEMD, LV medial AEMD, right ventricle lateral AEMD, and left atrium (LA) lateral AEMD durations of Group 2 were significantly higher than Group 1 (p < 0.001, p = 0.004, p = 0.004, p < 0.001; respectively). In Univariate Logistic Regression Analysis, the age, hypertension, LA maximum volume, LA lateral AEMD and pulmonary artery pressure were significantly associated with PoAF development (p = 0.01, p = 0.004, p = 0.004, p = 0.001, p = 0.01; respectively). However, only LA lateral AEMD was found as an independent predictive factor for the development of PoAF in the Multivariate Logistic Regression Analysis (OR:1.03, 95% CI:1.001-1.06, p = 0.04). AUC was .741 for LA lateral AEMD in ROC Curve Analysis (95% CI: .633-.849, p < 0.001). CONCLUSIONS: The development of PoAF can be predicted by AEMD durations measured in the preoperative period in patients undergoing isolated CABG.

Comparison of Microplegia Solution and Del Nido Cardioplegia Solution in Coronary Artery Bypass Grafting Surgery: Which One is More Effective?

BACKGROUND: The aim of this study is to compare the efficacy of the microplegia solution and Del Nido cardioplegia solution in coronary artery bypass surgery with clinical, biochemical, and echocardiographic data. METHODS: Three hundred patients, who underwent coronary artery bypass surgery between January 2017 and January 2020, by the same surgical team were included in the study. Preoperative, operative and postoperative data (cardiac biomarker levels, cross-clamp and CPB times, echocardiographic measurements, etc.) of the patients were compared. RESULTS: In the study, cross-clamp time was significantly shorter in the DN cardioplegia group (55.60 ± 13.49 min/75.58 ± 12.43 min, P = 0.024). No significant difference was observed between the two groups in terms of intensive care stay, extubation time, hospital stay, and cardiopulmonary bypass time. In our study, it was shown that both the left and right ventricular ejection fraction was better protected in the Del Nido cardioplegia group (5.34±3.03 vs. 3.40±2.84, P = 0.017 and 3.82±1.19 vs. 2.28±1.87, P = 0.047, respectively), and the need for inotrope support was lower in this group (28% vs. 44%, P < 0.021). There was no significant difference between the groups, in terms of blood transfusion rates, IABP requirement. CONCLUSION: In light of short-term results, we can say that Del Nido cardioplegia provides better myocardial protection than microplegia. In addition, Del Nido cardioplegia can be given as a single dose for 90 minutes of cross-clamp time and therefore can be preferred to increase surgical comfort and reduce cross-clamp times.

Effects of Preoperative Statin on the Frequency of Ventricular Fibrillation and C-Reactive Protein Level in Patients Undergoing Isolated Coronary Artery Bypass Grafting.

OBJECTIVE: To investigate the effects of statin use in preoperative period on the development of ventricular fibrillation (VF) following the removal of aortic cross-clamp (ACC) and on the levels of inflammation biomarker C-reactive protein (CRP) in patients who undergo elective isolated coronary artery bypass grafting (CABG). STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Cardiovascular Surgery, Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey, between May 2019 and January 2020. METHODOLOGY: A total of 104 patients, who underwent elective isolated CABG with cardiopulmonary bypass, were included in this prospective study. Fifty patients, who received statin treatment for at least 16 weeks in preoperative period, were identified as Group S; and 54 patients, who did not receive statin treatment, were identified as Group N. The frequency of VF and defibrillation counter shock (DCS) requirement and postoperative CRP levels were compared in groups after ACC removal. RESULTS: VF development and related DCS counts were lower at significant levels in Group S compared to Group N (p <0.001 for both). Although no statistically significant differences were detected between the median preoperative CRP levels of the groups; median CRP levels, which were measured in postoperative 2nd and 7th days, were found to be significantly lower in Group S (p <0.001 for both). CONCLUSION: Preoperative statin use significantly reduced VF development after the removal of ACC, and decreased postoperative CRP levels. Key Words: Coronary artery bypass grafting, Statins, Pleiotropic effect, Ventricular fibrillation, C-reactive protein.

Predictiveness of different preoperative risk assessments for postoperative bleeding after coronary artery bypass grafting surgery.

AIM: Postoperative bleeding is a significant cause of morbidity and mortality in patients undergoing cardiac surgery. Studies have been conducted, and guidelines have been published regarding patient blood management and aiming to prevent blood loss in the perioperative period. Various bleeding risk assessments were developed for preoperative period. We aimed to examine the correlations of scoring systems in the literature with the amount of postoperative bleeding in patients undergoing first time coronary artery bypass graft surgery, and to show the most suitable preoperative bleeding risk assessment for coronary artery bypass graft patients. METHODS: The study included 550 consecutive patients who underwent coronary artery bypass graft operation. The inclusion criteria were considered as patients to be older than 18 years old and to undergo elective or emergent myocardial revascularization using cardiopulmonary bypass. All variables required for scoring systems were recorded. The initial results of the study were determined as the amount of chest tube drainage, the use of blood products, the change in hematocrit level, reoperation due to bleeding, duration of ventilation, duration of intensive care unit stay, and hospital stay. Mortality which occurred during first 30 days after operation was considered as operative mortality. Operative mortality was accepted as the primary endpoint. Secondary endpoints were massive bleeding and high amount of transfusion. RESULTS: Data were obtained from a series of 550 consecutive patients treated with isolated coronary artery bypass graft. It was seen that PAPWORTH and WILL-BLEED risk assessments responded better for E-CABG grade 2 and 3 bleeding compared to other risk assessments. TRACK, TRUST, and ACTA-PORT scales were found to have low ability to distinguish patients with E-CABG bleeding grade 2 and 3. CONCLUSION: Predicting postoperative bleeding and transfusion rates with preoperative risk scores in patients undergoing coronary artery bypass graft surgery will provide valuable information to physicians for establishing a proper patient blood management protocol and this will decrease excessive transfusions, unnecessary reoperations as well as improve postoperative outcomes.

Can Continuous Local Anesthetic Infusion After Median Sternotomy Reduce Opioid Use?

Introduction Effective treatment of postoperative pain due to median sternotomy speeds up hemodynamic healing of patients. For this purpose, opioids with a wide range of side effects are widely used at high doses. The aim of this study is to investigate the effect of continuous local anesthetic (bupivacaine) infusion on opioid use on cardiac surgery patients undergoing median sternotomy. Methods A total of 215 patients undergoing isolated coronary artery bypass grafting surgery were included in the study; and 105 patients who underwent parasternal continuous local anesthetic infusion (0.5% bupivacaine at 4 mL/h, for 48h) were determined as local anesthesia group and other patients were as control group. The primary outcomes evaluated between the groups in the postoperative period were pain scores (VAS: Visual Analogic Score, PHHPS: Prince Henry Hospital Pain Score) and the number of opioids used. Secondary outcomes were mechanical ventilation time, intensive care unit and hospital stay duration, development of atrial fibrillation and atelectasis. Results Postoperative pain was found to be significantly lower in the local anesthesia group compared to the control group (VAS: 3 ± 1.9 vs 6.4 ± 1.8, p < 0.001; PHHPS: 0.9 ± 0.8 vs 1.62 ± 0.82, p < 0.001). As a result of this, opioid drug use was significantly lower in the local anesthesia group compared to the control group (0 (0 - 4) vs 1 (0 - 8), p < 0.001). Mechanical ventilation time, intensive care unit and hospital stay duration, and development of atelectasis were significantly lower in the local anesthesia group. In terms of the development of atrial fibrillation, no significant difference was found between the groups. Conclusion Parasternal continuous local anesthetic infusion reduces postoperative opioid use and speeds up hemodynamic healing by preventing possible side effects of opioids. It is a simple and effective method in the treatment of postoperative pain due to median sternotomy.

Is the Mean Platelet Volume a Predictive Factor for Atrial Fibrillation Developing After Coronary Artery Bypass Grafting in Elderly Patients?

BACKGROUND: Postoperative atrial fibrillation (PoAF) is the most common arrhythmic complication detected after coronary artery bypass grafting (CABG). It is associated with increased morbidity and mortality, especially in elderly patients. Mean platelet volume (MPV) shows the activation of platelets effective in the inflammatory and thrombotic process. The purpose of the present study was to investigate the relations between the preoperative MPV levels and development of PoAF in isolated CABG in elderly patients. METHODS: A total of 103 elderly patients (aged ≥ 65 years), who underwent isolated CABG and were at preoperative sinus rhythm, were included in the study. Patients who did not have PoAF were identified as Group 1 (N = 74), and those with PoAF were identified as Group 2 (N = 29). RESULTS: PoAF incidence was 28.2%. Preoperative MPV level was 8.41 ± 1.13 fL in Group 1, and 9.28 ± 1.00 fL in Group 2. The difference was statistically significant (P < .001). Multivariate logistic regression analysis revealed that age, preoperative hemoglobin, and preoperative MPV were independent predictive factors for PoAF development (OR [odds ratio]: 1.149, 95% CI [confidence interval]: 1.043-1.265, P = .005; OR: 1.334, 95% CI: 1.013-1.758, P = .040; OR: 2.103, 95% CI: 1.324-3.339, P = .002, respectively). The cut-off value for MPV as the predictor of PoAF development was found to be 8.43 (sensitivity: 82.8% and specificity: 55.4%). CONCLUSION: This study showed that MPV levels are associated with PoAF development in elderly patients, and other independent predictive factors include age and preoperative hemoglobin levels for POAF development.

The Effect of Preoperative Hematocrit Level on Early Outcomes After Coronary Artery Bypass Surgery.

INTRODUCTION: Low hematocrit level is a hematological problem that is frequently encountered in the preoperative evaluation of patients undergoing coronary artery bypass grafting (CABG) surgery. The aim of this study was to investigate the effect of preoperative hematocrit level on the first 30-day outcomes in patients undergoing CABG surgery. METHODS: Ninety-four patients undergoing isolated CABG were included in the study. The patients were divided into two groups as patients with preoperative low hematocrit levels (<36%) in Group 1 and patients with preoperative normal hematocrit levels (≥36%) in Group 2. RESULTS: Forty-six patients in Group 1 (mean age: 63.6 ± 7.9 years) and 48 patients in Group 2 (mean age: 56.5 ± 8.8 years) were enrolled. European System for Cardiac Operative Risk Evaluation (EuroSCORE) scoring was statistically significantly higher in Group 1 (p = 0.011). In the postoperative period, the amount of drainage, transfusion of blood, and blood products were significantly higher in Group 1 (p < 0.001). The mortality rate of Group 1 was statistically higher in the first 30 days postoperatively (p = 0.020). CONCLUSION: Low preoperative hematocrit levels are associated with increased mortality after CABG surgery. We suggest that patients' preoperative hematocrit levels must be added to the risk scoring systems as an assessment parameter.

Approach to an unusual cardiac mass: mitral annulus caseoma

Abstract Caseous calcification of the mitral annulus (CCMA) is known to be a rare variant of mitral annulus calcification, a chronic and degenerative process of the mitral valve fibrous ring. It usually carries a benign prognosis. The following case demonstrates a huge mitral annulus caseoma that complicated with severe mitral regurgitation and was treated with a successful surgery. The common consensus on the optimal management of CCMA is conservative medical management and avoiding unnecessary surgery. Therewithal, the current indications for surgical intervention include mitral valve dysfunction, strokes and uncertain diagnosis. Aggressive debridement, risk of left ventricular perforation and exposure of caseous debris to the systemic blood flow may increase the risk of a standard mitral valve surgery. Mitral valve replacement should be preferred compared with mitral valve repair.

Approach to An Unusual Cardiac Mass: Mitral Annulus Caseoma.

Caseous calcification of the mitral annulus (CCMA) is known to be a rare variant of mitral annulus calcification, a chronic and degenerative process of the mitral valve fibrous ring. It usually carries a benign prognosis. The following case demonstrates a huge mitral annulus caseoma that complicated with severe mitral regurgitation and was treated with a successful surgery. The common consensus on the optimal management of CCMA is conservative medical management and avoiding unnecessary surgery. Therewithal, the current indications for surgical intervention include mitral valve dysfunction, strokes and uncertain diagnosis. Aggressive debridement, risk of left ventricular perforation and exposure of caseous debris to the systemic blood flow may increase the risk of a standard mitral valve surgery. Mitral valve replacement should be preferred compared with mitral valve repair.

Analysis of clinical outcomes of intra-aortic balloon pump use during coronary artery bypass surgery.

AIM: The mortality rate of coronary artery bypass surgery increases with advanced patient age. This intra-aortic balloon pump (IABP) study was conducted to compare older patients (above 65 years of age) with younger patients (below 65 years of age) who had undergone coronary artery bypass surgery and had had an IABP inserted, with regard to hospital stay, clinical features, intensive care unit stay, postoperative complications, and mortality and morbidity rates. METHODS: One hundred and ninety patients who had undergone coronary artery bypass surgery and had required IABP support were enrolled in this study. Patients younger than 65 years of age were considered younger, and the others were considered older. Ninety-two patients were in younger group and 98 patients were older group. The mortality rates, pre-operative clinical characteristics, postoperative complications, and duration of intensive care unit and hospital stay of the groups were compared. The risk factors for mortality and complications were analysed. RESULTS: One hundred and thirty-eight of the patients were male, and the mean age was 62.7 ± 9.9 years. The mortality rate was higher in the older patient group than the younger group [34 (37.7%) and 23 (23.4 %), respectively (p = 0.043) ]. The crossclamp time, mean ejection fraction, cardiopulmonary bypass time, and length of stay in the intensive care unit were similar between the two groups (p > 0.05). Cardiopulmonary bypass time was the unique independent risk factor for mortality in both groups. CONCLUSION: In this study, high mortality rates in the postoperative period were similar to those in prior studies regarding IABP support. The complication rates were higher in the older patient group. Prolonged cardiopulmonary bypass time and advanced age were determined to be significant risk factors for mortality.

Analysis of clinical outcomes of intra-aortic balloon pump during coronary artery bypass surgery.

AIM: The mortality rate in coronary artery bypass surgery increases with advancing patient age. This study was conducted to analyse and compare older (above 65 years of age) with younger patients (below 65 years of age) who had undergone coronary artery bypass surgery and had an intra-aortic balloon pump (IABP) inserted, comparing hospital stay, clinical features, intensive care unit stay, postoperative complications, and morbidity and mortality rates. METHODS: One hundred and ninety patients who had undergone coronary artery bypass surgery and required IABP support were enrolled in this study. Patients younger than 65 years of age were considered young, and the others were considered old. Ninety-two patients were young and 98 were old. The mortality rates, pre-operative clinical characteristics, postoperative complications, and duration of intensive care unit and hospital stays of the groups were compared. The risk factors for mortality and complications were analysed. RESULTS: One hundred and thirty-eight of the patients were male, and the mean patient age was 62.7 ± 9.9 years. The mortality rate was higher in the older patient group than the younger group [34 (37.7%) and 23 (23.4 %), respectively (p = 0.043)]. The cross-clamp time, mean ejection fraction, cardiopulmonary bypass time, and length of stay in the intensive care unit were similar among the groups (p > 0.05). Cardiopulmonary bypass time was the single independent risk factor for mortality in both groups. CONCLUSION: In this study, high mortality rates in the postoperative period were similar to prior studies regarding IABP support. The complication rates were higher in the older patient group. Prolonged cardiopulmonary bypass and advanced age were determined to be significant risk factors for mortality.