Bivalirudin for cardiopulmonary bypass in a patient with heparin allergy.

BACKGROUND: Hypersensitivity reactions to heparin are uncommon conditions but pose a serious clinical problem for patients requiring cardiopulmonary bypass. Bivalirudin is a reversible direct thrombin inhibitor that can be used instead of heparin. CASE REPORT: A 49-year-old male patient was admitted to our hospital for coronary artery bypass graft operation with mitral insufficiency and tricuspid valve insufficiency. Heparin allergy was confirmed by skin biopsy and skin tests. Due to this allergy, we used bivalirudin (Bivacard VEM drug, Turkey) during the surgery. A loading dose of 1.0 mg/kg (100 mg) bivalirudin was administered through the central line and a continuous infusion of 2.5 mg/kg/h of the anticoagulant was initiated following the approved protocol. Serial ACTs were obtained at 15-minute intervals during the procedure and the measurements were 330s, 320s, 350s, 360s, and 340s consecutively. Additional boluses of 0.5 mg/kg (50 mg) were administered for each measurement. Left anterior descending, obtuse marginal arteries and the right coronary artery were grafted with the left internal mammary and saphenous veins. Also, mitral valve replacement with St Jude mechanical heart valve and tricuspid ring annuloplasty was performed with Medtronic Duran ring. After the surgery, the patient had an uneventful period in the postoperative intensive care unit with a total of 600ml and 300ml chest tube drainage for two days and was discharged on the 7th day. CONCLUSION: Alternative anticoagulation strategies are needed for cardiopulmonary bypass in patients unable to use heparin. Bivalirudin may be recommended as a viable alternative anticoagulant in patients with heparin allergy during cardiopulmonary bypass. However, each patient should be evaluated individually and it should not be forgotten that more than recommended doses may be needed.

David's procedure for pulmonary artery aneurysm.

Pulmonary artery aneurysm (PAA) is a rare entity with fatal complications. Its silent course contributes to large aneurysms with compression symptoms. We present a 39-year-old female idiopathic pulmonary arterial hypertension patient with a giant PAA causing severe pulmonary regurgitation (PR) and symptomatic left main coronary artery compression (LMCA). Since she had a failed LMCA stenting attempt, she underwent surgery. A valve-sparing David-like pulmonary trunk reconstruction and coronary artery bypass were performed. This case illustrates that David-like reconstruction procedure can be applied to the PAA with severe PR.

Application of LC-ESI-MS/MS Method for Analysis of Escitalopram Oxalate in Human Urine and Pharmaceutical Dosage Forms.

An effective and sensitive liquid chromatographic-electrospray ionization tandem mass-spectrometric (LC-ESI-MS/MS) method was developed and validated for quantification of escitalopram oxalate (ESC-OX), antidepressant drug in spiked human urine and pharmaceutical formulations. In this work, simple liquid-liquid extraction was optimized and used for extraction of cited drug from urine samples. The chromatographic separation was attained within 6 min including re-equilibration time by using gradient elution with 0.1% formic acid in acetonitrile and 0.1% formic acid in water as mobile phase, Zorbax Eclipse RP C18 (50 × 2.1 mm) column was used with a particle size of 1.8 µm; the flow-rate was 0.35 mL min-1. Ion signal m/z 262.0 and 109.0 for ESC-OX product ions were monitored at positive ESI mode. Validation of the method was carried out according to the ICH Q2 (R1) guidelines and EMEA criteria. The method was linear over 79-196,450 pg mL-1 with a regression of 0.9999 and 0.9993 for both standard and urine samples. The LOD was 3.88 and 10.66 pg mL-1 for standard and urine samples, respectively, while lower limit of quantification was 79 pg mL-1.

Surgical treatment of hydatid cyst infiltrating into myocardium and causing mitral valve regurgitation.

Hydatid cyst is a parasitic disease caused by Echinococcus granulosus. It is endemic in Asia, Africa, South America, and the Mediterranean region including Turkey. Cardiac involvement is rare. Surgery is the definitive treatment of cardiac hydatid cysts; however, to avoid recurrence after surgery, medical therapy should be also continued. Left ventricular free wall is the most common location, followed by the right ventricle and interventricular septum. Involvement of mitral valve is extremely rare. Herein, we present a case of hydatid cyst with myocardial involvement leading to severe mitral valve regurgitation which was successfully treated with surgery.

Humoral immune response and coated or uncoated oxygenators during cardiopulmonary bypass surgery.

AIM: To investigate and compare uncoated and phosphorylcholine-coated oxygenators in terms of induction of humoral immune response during coronary artery bypass surgery. METHODS: A total of 20 consecutive patients who underwent coronary artery bypass surgery were randomly distributed into two groups according to the type of oxygenator used during surgery. Group 1 consisted of 10 patients who were operated on using phosphorylcholine-coated oxygenators. Group 2 contained 10 patients who underwent surgery using uncoated oxygenators. Blood and oxygenator fibre samples were obtained and compared in terms of immunoglobulins (IgG, IgM), complements (C3c, C4), serum total protein and albumin levels using electron microscopy and flow cytometry. RESULTS: In group 1, levels of IgM, IgG, total protein and serum albumin were significantly increased at the end of cardiopulmonary bypass (CPB) compared to those at the beginning of CPB. In group 2, C3c and C4 levels at the beginning of CPB were found to be significantly higher than at the end. Electron microscopic examination of oxygenator fibres demonstrated that phosphorylcholine-coated fibres were less likely to be adsorbed by serum proteins and complements than the uncoated fibres. CONCLUSION: Our results indicate that phosphorylcholine-coated oxygenators seemed to induce humoral immune response to a lesser extent than uncoated oxygenators during coronary artery bypass procedures.

Modulation of Corpus Striatal Neurochemistry by Astrocytes and Vasoactive Intestinal Peptide (VIP) in Parkinsonian Rats.

The neurotoxin 6-hydroxydopamine (6-OHDA) is widely used in animal models of Parkinson's disease. In various neurodegenerative diseases, astrocytes play direct, active, and critical roles in mediating neuronal survival and functions. Vasoactive intestinal peptide (VIP) has neurotrophic actions and modulates a number of astrocytic activities. In this study, the effects of VIP on the striatal neurochemistry were investigated in parkinsonian rats. Adult Sprague-Dawley rats were divided into sham-operated, unilaterally 6-OHDA-lesioned, and lesioned + VIP-administered (25 ng/kg i.p.) groups. VIP was first injected 1 h after the intrastriatal 6-OHDA microinjection and then every 2 days throughout 15 days. Extracellular striatal concentration of glutathione (GSH), gamma-aminobutyric acid (GABA), glutamate (GLU), and lactate were measured in microdialysates by high-performance liquid chromatography (HPLC). Quantification of GABA and activity dependent neuroprotective protein (ADNP)-expressing cells were determined by glutamic acid decarboxylase (GAD)/ADNP + glial fibrillary acidic protein (GFAP) double immunohistochemistry. Our results demonstrated that a 6-OHDA lesion significantly increased the density of astrocytes in the striatum and VIP treatment slightly reduced the gliosis. Extracellular concentration of GABA, GLU, and lactate levels did not change, but GSH level significantly increased in the striatum of parkinsonian rats. VIP treatment reduced GSH level comparable to sham-operated groups, but enhanced GABA and GLU levels. Our double labeling results showed that VIP primarily acts on neurons to increase ADNP and GAD expression for protection. These results suggest that, in the 6-OHDA-induced neurodegeneration model, astrocytes were possibly activated for forefront defensiveness by modulating striatal neurochemistry.

Endovascular treatment for acute traumatic thoracic aortic transection.

BACKGROUND: This study aimed to present our experience in patients with acute traumatic thoracic aortic transection treated by endovascular stent-graft. METHODS: From October 2011 to October 2014, eleven patients were brought to our hospitals after suffering motor vehicle accident or fall from height. Computed tomography revealed acute traumatic transection of the thoracic aorta at the aortic isthmus just distal to the left subclavian artery in nine patients, at the middle or distal thoracic aorta in two, and both aortic isthmus and middle thoracic aorta in one. Endovascular technique was preferred as the treatment modality. All patients, except one, were treated within twelve hours of diagnosis. RESULTS: Deployment of stent-grafts was successful in all cases. The stent-grafts were oversized between 10% and 20%. The origin of left subclavian artery was covered with stent-graft in six patients to achieve adequate proximal landing zone. In two of them, carotico-subclavian bypass and periscope graft placement were applied to maintain subclavian artery blood flow. There were no procedure related deaths, paraplegia or ischemic complications. A patient with cardiac arrest, on whom cardiopulmonary resuscitation and transient aortic balloon occlusion within the aorta were applied in the angiography suit died at the postoperative twelve hours. Mean hospital stay after procedures was 14.8 days (range, 4-60 days). Mean follow-up time of ten patients was 16.6 months (range, 1-36 months). CONCLUSION: Our study supports that thoracic endovascular aortic stenting for acute transection is promising in terms of short- and mid-term results similar to other studies in the literature.

Patient-prosthesis mismatch increases the mean platelet volume in patients with aortic valve replacement.

PURPOSE: Patient-prosthesis mismatch (PPM) is defined when the ratio of the effective orifice area of the normally functioning prosthetic valve to the body surface area of the patient is <0.85 cm(2)/m(2). The aim of this study was to assess the measurements of the mean platelet volume (MPV) as an indicator of platelet activation in patients with PPM. METHODS: A total of 109 patients with isolated aortic valve replacement (AVR) procedures with a mechanical prosthesis and a control group from a normal population of 102 people compatible in terms of age and sex were chosen for the study. The AVR group was subdivided into a PPM group (n = 41) and non-PPM group (n = 68). All patients and control participants underwent echocardiographic examinations, with simultaneous measurements of the serum MPV values. RESULTS: The MPV measurements were significantly higher in the patients with AVR compared to the control group (8.97 ± 0.93 vs. 8.26 ± 0.14, p < 0.001). Higher results were also obtained in the patients with PPM compared to the non-PPM group (9.36 ± 0.61 vs. 8.73 ± 1.01, p < 0.001). The platelet counts were found to be similar in both groups (p > 0.05). CONCLUSIONS: We have herein shown that the PPM patients had a significantly higher MPV compared to the patients with AVR without PPM and healthy subjects.

Electron microscopic evaluation of internal thoracic artery endothelial morphology in diabetic coronary bypass patients.

BACKGROUND: Diabetes is a well- identified major risk factor for cardiovascular diseases. This study was performed to evaluate the effect of diabetes and impact of glycemic control on internal thoracic artery (ITA) morphology by electron microscopy. METHODS: Thirty patients scheduled for coronary artery bypass grafting were enrolled in this study. Samples of ITA were taken during the surgery for electron microscopic evaluation. Group I (n = 10) consisted of diabetics who have poor glycemic control (HbA1c > 7.5%), group II (n = 10) of well-regulated (HbA1c = 4.4% to 6.2%) diabetic patients, and group III (n = 10) of nondiabetic patients. Samples were prepared as ultrathin sections and an original semiquantitative method of scoring was applied to describe the morphologic changes of endothelium. Final scores were analyzed with analysis of variance and post hoc analysis. RESULTS: In group I large vacuoles, swollen mitochondria were seen in endothelial cells and subendothelial edema was prominent. Endothelia (2.5 ± 1.2), arterial wall (2.0 ± 0.0), and endothelial mitochondria (2.9 ± 1.3) scores of group I were significantly higher than the other 2 groups (p < 0.001). The samples of group II and group III did not show significant differences with each other. The correlation between HbA1c values and total endothelial scores statistically significant (r = 0.912; p < 0.001). CONCLUSIONS: There is a correlation between HbA1c values and morphologic changes of ITA graft. Uncontrolled diabetes is an important predictor of morphologic changes evidenced by the ultrastructural findings. These ultrastructural changes were not as prominent in the diabetes mellitus patients with well controlled metabolic statuses and patients without diabetes.

Single-centre experience with perioperative use of intraaortic balloon pump in cardiac surgery.

BACKGROUND: Intraaortic balloon pump (IABP) is frequently used in cardiac surgery in order to prevent or treat low cardiac output syndrome. Although being widely used and forming the first line therapy in these haemodynamically unstable patients despite maximal medication, optimal timing for IABP insertion is still discussed. This retrospective study evaluates hospital outcomes of patients receiving IABP at preoperative, intraoperative and postoperative periods during cardiac surgery. MATERIALS AND METHODS: Between 2006 and 2012, 2196 patients underwent open cardiac surgery in our centre. IABP was used in 121 (5.4%) patients. Nine patients had preoperative IABP insertion, 76 patients (62.8%) had intraoperative insertion to ease weaning from cardiopulmonary bypass, and 36 patients (29.8%) had postoperative insertion in the intensive care unit mainly due to refractory haemodynamic instability. Hospital outcomes of these 121 patients were analysed retrospectively. RESULTS: The majority of the patients were male (men 89, 73.6% and women 32, 26.4%; mean age was 65.9±11.5 years). Among the cohort 87 (71.9%) underwent isolated coronary artery bypass surgery (CABG) and the rest (34 patients, 28.1%) were operated for valve disease with/without CABG or for CABG with carotid endarterectomy, left ventricular aneurysm repair, post myocardial infarction ventricular septal defect or pathologies involving ascending aorta. The overall hospital mortality of the whole cohort was 27.3%. Mortality rates according to IABP timing were 33.3%, 19.7% and 41.7% for pre, intra and postoperative insertion, respectively. Logistic regression analysis identified female gender, low ejection fraction (<30%), complex surgery and postoperative insertion as risk factors for mortality. CONCLUSION: IABP insertion timing in cardiac surgery is crucial and many reports advocate early insertion since patient outcomes are poor for late insertions. This single centre study also confirms that the least favourable results are among patients with postoperative IABP insertion.

Comparison of original EuroSCORE, EuroSCORE II and STS risk models in a Turkish cardiac surgical cohort.

OBJECTIVES: The aim of this study was to compare additive and logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE), EuroSCORE II and the Society of Thoracic Surgeons (STS) models in calculating mortality risk in a Turkish cardiac surgical population. METHODS: The current patient population consisted of 428 patients who underwent isolated coronary artery bypass grafting (CABG) between 2004 and 2012, extracted from the TurkoSCORE database. Observed and predicted mortalities were compared for the additive/logistic EuroSCORE, EuroSCORE II and STS risk calculator. The area under the receiver operating characteristics curve (AUC) values were calculated for these models to compare predictive power. RESULTS: The mean patient age was 74.5 ± 3.9 years at the time of surgery, and 35.0% were female. For the entire cohort, actual hospital mortality was 7.9% (n = 34; 95% confidence interval [CI] 5.4-10.5). However, the additive EuroSCORE-predicted mortality was 6.4% (P = 0.23 vs observed; 95% CI 6.2-6.6), logistic EuroSCORE-predicted mortality was 7.9% (P = 0.98 vs observed; 95% CI 7.3-8.6), EuroSCORE II- predicted mortality was 1.7% (P = 0.00 vs observed; 95% CI 1.6-1.8) and STS predicted mortality was 5.8% (P = 0.10 vs observed; 95% CI 5.4-6.2). The mean predictive performance of the analysed models for the entire cohort was fair, with 0.7 (95% CI 0.60-0.79). AUC values for additive EuroSCORE, logistic EuroSCORE, EuroSCORE II and STS risk calculator were 0.70 (95% CI 0.60-0.79), 0.70 (95% CI 0.59-0.80), 0.72 (95% CI 0.62-0.81) and 0.62 (95% CI 0.51-0.73), respectively. CONCLUSIONS: EuroSCORE II significantly underestimated mortality risk for Turkish cardiac patients, whereas additive and logistic EuroSCORE and STS risk calculators were well calibrated.

Comparing S-100 beta protein levels and neurocognitive functions between patients undergoing on-pump and off-pump coronary artery bypass grafting.

BACKGROUND: In the present study, we aimed to investigate the effects of off-pump coronary artery bypass grafting and on-pump cardiopulmonary bypass on the serum S-100 beta (S-100B) protein levels and neurocognitive functions of the patients. MATERIALS AND METHODS: Sixty-four patients undergoing coronary artery bypass grafting (CABG) were enrolled in the study and were divided into two groups: off-pump (group I, n = 24) and on-pump CABG (group II, n = 40) group. Serum S-100B levels were measured before and 0, 6, and 24 h after the operation. Neurocognitive function tests were done preoperatively and were repeated in the postoperative period as well. RESULTS: Serum S-100B levels were similar between the two groups preoperatively. However, median S-100B levels at 0, 6, and 24 h after the surgery were found to be significantly lower in the off-pump CABG group than in the on-pump group. The preoperative neurocognitive functions of the patients were similar between the two groups, whereas neurocognitive function was found to be significantly impaired postoperatively in the on-pump group in comparison with the off-pump CABG group. CONCLUSION: We concluded that off-pump CABG is associated with decreased serum S100 protein levels and less impairment on neurocognitive functions compared with the on-pump group.

Sequential radial artery for coronary artery bypass grafting: five-year follow-up and evaluation with multi-detector row computed tomography.

This study was undertaken to compare early postoperative results, programmed multi-detector row computed tomography coronary angiographic patency and midterm results of revascularization by sequential radial artery grafting with those of single radial artery grafting during a five-year period. Patients were grouped as those with sequential radial artery grafts (Group A, n = 27) and single radial artery grafts (Group B, n = 26). Multi-detector row computed tomography coronary angiography was scheduled at 1 and 5 years postoperatively. Each distal anastomosis was accepted as nonfunctional if a radial artery graft was occluded proximally or there was a critical stenosis. One sequential radial artery graft and two single radial artery grafts failed in the 1-year period (p>0.05). In the 5-year period, three radial artery grafts failed in each group (p>0.05). In Group A, there was no mortality in the five-year period, but in Group B, one patient died four years after the operation due to cardiac problems (p>0.05). In addition to one death in Group B, there were three percutaneous interventions and two myocardial infarctions among the 26 patients during the five-year follow-up. In group A, among 27 patients, there were 4 percutaneous interventions and one myocardial infarction (p>0.05). Although the sample size is relatively small to be conclusive, these data suggest that sequential radial artery grafting may be considered as a method of choice for maximizing arterial graft survival and patency. Noninvasive control of sequential and single radial artery grafts with multi-detector row computed tomography is feasible with no discomfort for the patient and excellent visualization of grafts.

Impact of a large hemodialysis arteriovenous fistula: on myocardial protection during cardiopulmonary bypass.

Arteriovenous fistulae have a substantial impact on systemic hemodynamics, but their effect on cardiopulmonary bypass is not well understood. The left-to-right shunting of blood through an arteriovenous fistula can create flow problems during cardiopulmonary bypass. We present the case of a 59-year-old man with end-stage renal disease who underwent coronary artery bypass grafting. During surgery, a large brachiocephalic arteriovenous fistula provided excessive venous return to the heart, compromising the myocardial protection offered by cardiopulmonary bypass. We modified the venous cannulation from a 2-stage single cannula to a bicaval cannula and were then able to achieve cardioplegic arrest and myocardial protection with no further problems.

Antioxidant and anti-apoptotic activity of vasoactive intestinal peptide (VIP) against 6-hydroxy dopamine toxicity in the rat corpus striatum.

6-Hydroxydopamine (6-OHDA) is an oxidative stress neurotoxin, which is oxidized in neurons, causes respiratory inhibition, and induces free radical formation and oxidative stress. Therefore, a 6-OHDA-induced Parkinson's disease (PD) experimental model can be used to test a candidate molecule for use as an antioxidant that could be a promising therapeutic for treating Parkinson's disease. Recent studies have shown that vasoactive intestinal peptide (VIP) might be a good candidate agent for the treatment of PD. In this study, the anti-apoptotic and antioxidant actions of VIP were investigated using the 6-OHDA-lesioned rat model for PD. Twenty-four young adult Sprague-Dawley rats were used. The rats were separated into the following groups: group I (n = 8), sham operated; group II (n = 8), 6-OHDA lesioned; group III (n = 8), 6-OHDA lesioned + i.p. VIP-injected (25 ng/kg) every 2 days for 15 days. The first i.p. injection of VIP was made 1 h after the intrastriatal 6-OHDA microinjection. Antioxidant enzymatic activity [super oxide dismutase (SOD) and catalase (CAT)], lipid peroxidation, nitric oxide and DNA fragmentation were measured from homogenates isolated from the corpus striatum. SOD, CAT, malondialdehyde, and DNA fragmentation were measured using a spectrophotometer, and nitric oxide (NO) levels were measured by capillary electrophoresis. 6-OHDA significantly induced oxidative stress, lipid peroxidation, and DNA fragmentation in the corpus striatum of rats. VIP significantly protected neuronal tissue from oxidative stress and apoptosis by reducing lipid peroxidation and DNA fragmentation. 6-OHDA toxicity did not cause significant changes in NO production in the corpus striatum. However, VIP treatment significantly reduced NO levels in brain tissue.

A simple and sensitive LC-ESI-MS (ion trap) method for the determination of bupropion and its major metabolite, hydroxybupropion in rat plasma and brain microdialysates.

A specific and highly sensitive liquid chromatography-electrospray mass spectrometry (LC-ESI-MS) method for the direct determination of bupropion (BUP) and its main metabolite hydroxybupropion (HBUP) in rat plasma and brain microdialysate has been developed and validated. The analysis was performed on a Bonus RP C18 (100 mm × 2.1mm i.d., 3.5 µm particles) column using gradient elution with the mobile phase consisting of acetonitrile and ammonium formate buffer (10mM, pH 4). Plasma samples were analyzed after a simple, one-step protein precipitation clean-up with trichloroacetic acid (TCA), however clean-up for microdialysis samples was not necessary, enabling direct injection of the samples into the LC-ESI-MS system. Signals of the compounds were monitored under the multiple reaction monitoring (MRM) mode of the LC-ESI-MS (ion trap) for quantification. The precursor to product ion transitions of m/z 240-184 and m/z 256-238 were used to measure BUP and HBUP, respectively. The method was validated in both plasma and microdialysate samples, and the obtained lower limit of quantification (LLOQ) was 1.5 ng mL(-1) for BUP and HBUP in both matrices. The intra- and inter-day assay variability was less than 15% for both analytes. This LC-ESI-MS method provided simple sampling, rapid clean-up and short analysis time (<9 min), applicable to the routine therapeutic monitoring and pharmacokinetic studies of BUP and HBUP.

Validation of the EuroSCORE risk models in Turkish adult cardiac surgical population.

OBJECTIVE: The aim of this study was to validate additive and logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) models on Turkish adult cardiac surgical population. METHODS: TurkoSCORE project involves a reliable web-based database to build up Turkish risk stratification models. Current patient population consisted of 9443 adult patients who underwent cardiac surgery between 2005 and 2010. However, the additive and logistic EuroSCORE models were applied to only 8018 patients whose EuroSCORE determinants were complete. Observed and predicted mortalities were compared for low-, medium-, and high-risk groups. RESULTS: The mean patient age was 59.5 years (± 12.1 years) at the time of surgery, and 28.6% were female. There were significant differences (all p<0.001) in the prevalence of recent myocardial infarction (23.5% vs 9.7%), moderate left ventricular function (29.9% vs 25.6%), unstable angina (9.8% vs 8.0%), chronic pulmonary disease (13.4% vs 3.9%), active endocarditis (3.2% vs 1.1%), critical preoperative state (9.0% vs 4.1%), surgery on thoracic aorta (3.7% vs 2.4%), extracardiac arteriopathy (8.6% vs 11.3%), previous cardiac surgery (4.1% vs 7.3%), and other than isolated coronary artery bypass graft (CABG; 23.0% vs 36.4%) between Turkish and European cardiac surgical populations, respectively. For the entire cohort, actual hospital mortality was 1.96% (n=157; 95% confidence interval (CI), 1.70-2.32). However, additive predicted mortality was 2.98% (p<0.001 vs observed; 95%CI, 2.90-3.00), and logistic predicted mortality was 3.17% (p<0.001 vs observed; 95%CI, 3.03-3.21). The predictive performance of EuroSCORE models for the entire cohort was fair with 0.757 (95%CI, 0.717-0.797) AUC value (area under the receiver operating characteristic, AUC) for additive EuroSCORE, and 0.760 (95%CI, 0.721-0.800) AUC value for logistic EuroSCORE. Observed hospital mortality for isolated CABG was 1.23% (n=75; 95%CI, 0.95-1.51) while additive and logistic predicted mortalities were 2.87% (95%CI, 2.82-2.93) and 2.89% (95%CI, 2.80-2.98), respectively. AUC values for the isolated CABG subset were 0.768 (95%CI, 0.707-0.830) and 0.766 (95%CI, 0.705-0.828) for additive and logistic EuroSCORE models. CONCLUSION: The original EuroSCORE risk models overestimated mortality at all risk subgroups in Turkish population. Remodeling strategies for EuroSCORE or creation of a new model is warranted for future studies in Turkey.

Pituitary apoplexy after cardiac surgery.

Pituitary apoplexy after coronary bypass operations is a rare complication with very serious neurologic consequences. Anisocory, unilateral ptosis, and third cranial nerve palsy after coronary bypass surgery developed in a patient. The diagnosis was assured by computerized tomographic scan showing pituitary macro adenoma.