Symptom progression following on-pump versus off-pump coronary artery bypass graft surgery in patients with peripheral arterial disease.

OBJECTIVE: This study aims to examine whether cardiac surgery leads to symptom progression in the early postoperative period in patients with the peripheral arterial disease (PAD) and evaluate the difference between on-pump (OPCAB) and off-pump (ONCAB) coronary artery bypass graft surgery with regard to the symptom progression. METHODS: This retrospective study included one hundred consecutive adult patients with PAD at Fontaine stage 2b (pain-free walking distance less than 100 m) undergoing ONCAB and one hundred consecutive adult patients with PAD at Fontaine stage 2b (pain-free walking distance less than 100 m) undergoing OPCAB. Symptom progression was defined as the development of ischemic rest pain (Fontaine stage 3). RESULTS: In the first week after surgery, 12 patients in the OPCAB group and 53 patients in the ONCAB group had postoperative symptom progression (p < 0.001). Rest pain resolved in most of these patients on the 15th postoperative day. At the end of the second month, rest pain resolved in all patients. Logistic regression analysis revealed that cardiac surgery with CPB, ABI < 0.5, postoperative nadir hct levels ≤ 25%, and intraoperative tissue hypoxia were independently associated with postoperative symptom progression. CONCLUSIONS: In summary, we found that cardiac surgery may lead to symptom progression in patients with severe claudication in the early postoperative period. Our results suggest that OPCAB may lead to lower rates of symptom progression compared to ONCAB.

Tepid Modified Del Nido Cardioplegia in Adults Undergoing Cardiac Surgery: A Propensity-Matched Analysis

Abstract Introduction: Del Nido cardioplegia was reported to provide adequate myocardial protection and clinical outcomes with improved surgical flow in adult cardiac surgical procedures. And many clinicians have already modified the traditional formula. This study aims to investigate the efficacy and safety of tepid modified del Nido cardioplegia compared to cold blood cardioplegia in adult patients undergoing cardiac surgery. Methods: This retrospective study included one hundred consecutive adult patients undergoing cardiac surgical procedures using tepid modified del Nido cardioplegia. One hundred consecutive adult patients undergoing cardiac surgical procedures with cold blood cardioplegia were the control group. Propensity score matching yielded 89 modified del Nido and 89 cold blood cardioplegia patients. Results: There were no significant differences when comparing the two matched groups regarding the requirement for intraoperative defibrillation (P=0.36), postoperative peak troponin T levels (0.18), perioperative inotropic support (P=0.26), intra-aortic balloon pump requirement (P=0.62), and postoperative left ventricular ejection fraction at discharge (P=0.4) and on the sixth postoperative month (P=0.37). Mean cross-clamping time (P=0.005), cardiopulmonary bypass time (P=0.03), and total operation time (P=0.03) were significantly shorter in the del Nido group. Conclusion: Tepid modified del Nido cardioplegia may be a safe alternative to cold blood cardioplegia in adult patients undergoing cardiac surgical procedures.

Propensity-Matched Analysis of Del Nido Cardioplegia in Adults Undergoing Cardiac Surgery with Prolonged Cross-Clamping Time

Abstract Introduction: There is not enough data in the literature regarding the safety and efficiency of del Nido cardioplegia in patients with prolonged cross-clamping time. This study aims to determine the efficacy and safety of del Nido cardioplegia compared to cold blood cardioplegia in patients with prolonged aortic cross-clamping time. Methods: In this retrospective study, patients with an aortic cross-clamping time ≥ 90 minutes were included. One hundred consecutive adult patients undergoing cardiac surgery using del Nido cardioplegia comprised the study group, and 100 consecutive adult patients undergoing cardiac surgical procedures using cold blood cardioplegia comprised the control group. Propensity score matching yielded 88 del Nido cardioplegia and 88 cold blood cardioplegia patients. Results: There were no significant differences when comparing the matched groups regarding the requirement for intraoperative defibrillation, postoperative peak troponin T levels, inotropic support, intra-aortic balloon pump requirement, and left ventricular ejection fraction at discharge and on the sixth postoperative month; also, there were no significant differences when comparing cardiopulmonary bypass time and total operation time. Mean cross-clamping time was significantly shorter in the del Nido group (P<0.001). Conclusion: Del Nido cardioplegia may be a safe alternative to cold blood cardioplegia in adults undergoing cardiac surgical procedures with prolonged aortic cross-clamping time.

Propensity-Matched Analysis of Del Nido Cardioplegia in Adults Undergoing Cardiac Surgery with Prolonged Cross-Clamping Time.

INTRODUCTION: There is not enough data in the literature regarding the safety and efficiency of del Nido cardioplegia in patients with prolonged cross-clamping time. This study aims to determine the efficacy and safety of del Nido cardioplegia compared to cold blood cardioplegia in patients with prolonged aortic cross-clamping time. METHODS: In this retrospective study, patients with an aortic cross-clamping time ≥ 90 minutes were included. One hundred consecutive adult patients undergoing cardiac surgery using del Nido cardioplegia comprised the study group, and 100 consecutive adult patients undergoing cardiac surgical procedures using cold blood cardioplegia comprised the control group. Propensity score matching yielded 88 del Nido cardioplegia and 88 cold blood cardioplegia patients. RESULTS: There were no significant differences when comparing the matched groups regarding the requirement for intraoperative defibrillation, postoperative peak troponin T levels, inotropic support, intra-aortic balloon pump requirement, and left ventricular ejection fraction at discharge and on the sixth postoperative month; also, there were no significant differences when comparing cardiopulmonary bypass time and total operation time. Mean cross-clamping time was significantly shorter in the del Nido group (P<0.001). CONCLUSION: Del Nido cardioplegia may be a safe alternative to cold blood cardioplegia in adults undergoing cardiac surgical procedures with prolonged aortic cross-clamping time.

Tepid Modified Del Nido Cardioplegia in Adults Undergoing Cardiac Surgery: A Propensity-Matched Analysis.

INTRODUCTION: Del Nido cardioplegia was reported to provide adequate myocardial protection and clinical outcomes with improved surgical flow in adult cardiac surgical procedures. And many clinicians have already modified the traditional formula. This study aims to investigate the efficacy and safety of tepid modified del Nido cardioplegia compared to cold blood cardioplegia in adult patients undergoing cardiac surgery. METHODS: This retrospective study included one hundred consecutive adult patients undergoing cardiac surgical procedures using tepid modified del Nido cardioplegia. One hundred consecutive adult patients undergoing cardiac surgical procedures with cold blood cardioplegia were the control group. Propensity score matching yielded 89 modified del Nido and 89 cold blood cardioplegia patients. RESULTS: There were no significant differences when comparing the two matched groups regarding the requirement for intraoperative defibrillation (P=0.36), postoperative peak troponin T levels (0.18), perioperative inotropic support (P=0.26), intra-aortic balloon pump requirement (P=0.62), and postoperative left ventricular ejection fraction at discharge (P=0.4) and on the sixth postoperative month (P=0.37). Mean cross-clamping time (P=0.005), cardiopulmonary bypass time (P=0.03), and total operation time (P=0.03) were significantly shorter in the del Nido group. CONCLUSION: Tepid modified del Nido cardioplegia may be a safe alternative to cold blood cardioplegia in adult patients undergoing cardiac surgical procedures.

Management of a Resistant Hypotension Developing After Reperfusion of a Living-Donor Kidney Transplant.

We present a case of hypotension developing after reperfusion of a living-donor kidney transplant and performing a graft nephrectomy and successful retransplant with the same kidney 12 hours later. Preemptive kidney transplant was performed on a 51-year-old woman who had a chronic kidney disease because of hypertension. Her 55-year-old husband was the living kidney donor. The patient was stable before reperfusion. After declamping, pink color of the transplanted kidney, thrill from the renal artery, and urinary output were seen. But shortly after reperfusion, the invasive arterial blood pressure of the patient abruptly decreased from 130/70 mm Hg to 70/40 mm Hg, her pulse was approximately 80 to 110 beats/minute. The thrill disappeared from the renal artery, but blood flow continued. A graft nephrectomy was performed 45 minutes after reperfusion. Invasive arterial blood pressure of the patient was stabilized at approximately 110/70 mm Hg in the intensive care unit, and the patient was retransplanted with the same kidney. The patient was well, with a serum creatinine level of 1.4 mg/dL, 12 months after the operation. Resistant hypotension that occurs after kidney transplant may cause a loss of the graft and the patient. To prevent graft loss, and to stabilize the patient, a graft nephrectomy and retransplant of the graft under suitable circumstances may be considered.

Rupture of a Subcapsular Hematoma After Kidney Transplant: Case Report.

Subcapsular hematoma after kidney transplant may result in kidney ischemia and graft loss. In this report, we present a patient who had a subcapsular hematoma that had no intraoperative enlargement but ruptured after surgery. A man who had chronic kidney disease secondary to hypertension had a preemptive living-donor kidney transplant from his wife. After declamping, appropriate renal perfusion and urinary output were observed. At perfusion, a subcapsular hematoma (diameter, 3 cm) was observed at the upper pole of the kidney. The hematoma did not enlarge during the surgery. Capsulotomy was not performed due to possible risks, and transplant surgery was completed with the plan for close postoperative ultrasonography and hemodynamic follow-up. Decreased urinary output was observed early after surgery. Renal Doppler ultrasonography showed decreased diastolic flow and a hematoma (width, 9 mm) that completely surrounded the transplanted kidney. The patient had emergency reoperation due to active hemorrhage from his surgical drain at 40 hours after surgery. Rupture of the capsule and hemorrhage from the surface of the kidney were observed. Extended capsulotomy and hemostasis of the kidney were performed. After surgery, urinary flow increased and renal Doppler ultrasonography findings improved. In summary, intervention for a subcapsular hematoma after kidney transplant is controversial. Capsulotomy should be considered for treatment of increased pressure to the graft, risk of permanent damage, and risk of graft loss.

Spontaneous coronary artery rupture without a pericardial effusion: a diagnostic challenge.

Spontaneous coronary artery rupture (CAR) is an extremely rare, life-threatening entity. It is a challenge to make a diagnosis of CAR in the absence of pericardial effusion. We describe a case of a spontaneous rupture of the right coronary artery (RCA) without pericardial effusion that emphasises the benefit of high clinical suspicion and early diagnosis. A 60-year-old man was admitted to the emergency department, with inferior myocardial infarction. Echocardiogram was negative for a pericardial effusion. Coronary angiography revealed complete occlusion of the RCA with intraluminal dissection and extravasation of contrast into the epicardium at the mid-portion of the RCA, which suggested rupture of the RCA. The patient underwent uneventful emergency coronary artery bypass grafting. CAR should be considered as a differential diagnosis in patients with acute chest pain, even in the absence of pericardial effusion, particularly in case of inferior wall involvement.

Delayed Presentation of Aortic Injury by a Thoracic Pedicle Screw.

Delayed presentation of a thoracic aortic injury is an extremely rare complication after spine surgery. We report a case of delayed presentation of a thoracic aortic injury with a vertebral pedicle screw after posterior spinal surgery without periaortic hematoma, hemorrhage or pseudoaneurysm formation and review the relevant literature.

The effects of hyperoxaemia on tissue oxygenation in patients with a nadir haematocrit lower than 20% during cardiopulmonary bypass.

UNLABELLED: Excessive haemodilution and the resulting anaemia during CPB is accompanied by a decrease in the total arterial oxygen content, which may impair tissue oxygen delivery. Hyperoxic ventilation has been proven to improve tissue oxygenation in different pathophysiological states of anaemic tissue hypoxia. The aim of this study was to examine the influence of arterial hyperoxaemia on tissue oxygenation during CPB. Records of patients undergoing isolated CABG with CPB were retrospectively reviewed. Patients with nadir haematocrit levels below 20% during CPB were included in the study. Tissue hypoxia was defined as hyperlactataemia (lactate >2.2 mmol/L) coupled with low ScVO2 (ScVO2 <70%) during CPB. One hundred patients with normoxaemia and 100 patients with hyperoxaemia were included in the study. Patients with hyperoxaemia had lower tissue hypoxia incidence than patients with normoxaemia (p<0.001). Compared with patients without tissue hypoxia, patients with tissue hypoxia had significantly lower PaO2 values (p<0.001) and nadir haematocrit levels (p<0.001). Nadir haematocrit levels <18% (OR: 5.3; 95% CI: 2.67-10.6; p<0.001) and hyperoxaemia (OR: 0.28; 95% CI: 0.14-0.56; p<0.001) were independently associated with tissue hypoxia. CONCLUSIONS: Hyperoxaemia during CPB may be protective against tissue hypoxia in patients with nadir haematocrit levels <20%.

Paraplegia Due to Spinal Cord Infarction After Coronary Artery Bypass Graft Surgery.

Paraplegia is an extremely rare complication after coronary artery bypass grafting (CABG) and the underlying mechanisms remain poorly understood. We report a patient who developed paraplegia after CABG and review the literature on spinal cord ischemia following CABG surgery.

Relationship between cobalamin deficiency and delirium in elderly patients undergoing cardiac surgery.

BACKGROUND: Delirium is common after cardiac surgery and is independently associated with increased morbidity, mortality, prolonged hospital stays, and higher costs. Cobalamin (vitamin B12) deficiency is a common cause of neuropsychiatric symptoms and affects up to 40% of elderly people. The relationship between cobalamin deficiency and the occurrence of delirium after cardiac surgery has not been examined in previous studies. We examined the relationship between cobalamin deficiency and delirium in elderly patients undergoing coronary artery bypass grafting (CABG) surgery. MATERIAL AND METHODS: A total of 100 patients with cobalamin deficiency undergoing CABG were enrolled in this retrospective study. Control group comprised 100 patients without cobalamin deficiency undergoing CABG. Patients aged 65 years or over were included. Diagnosis of delirium was made using Intensive Care Delirium Screening Checklist. Delirium severity was measured using the Delirium Rating Scale-revised-98. RESULTS: Patients with cobalamin deficiency had a significantly higher incidence of delirium (42% vs 26%; P=0.017) and higher delirium severity scores (16.5±2.9 vs 15.03±2.48; P=0.034) than patients without cobalamin deficiency. Cobalamin levels were significantly lower in patients with delirium than patients without delirium (P=0.004). Delirium severity score showed a moderate correlation with cobalamin levels (ρ=-0.27; P=0.024). Logistic regression analysis demonstrated that cobalamin deficiency was independently associated with postoperative delirium (OR 1.93, 95% CI 1.03-3.6, P=0.038). CONCLUSION: The results of our study suggest that cobalamin deficiency may be associated with increased risk of delirium in patients undergoing CABG. In addition, we found that preoperative cobalamin levels were associated with the severity of delirium. This report highlights the importance of investigation for cobalamin deficiency in patients undergoing cardiac surgery, especially in the elderly.

Role of diclofenac in the prevention of postpericardiotomy syndrome after cardiac surgery.

OBJECTIVE: Postpericardiotomy syndrome (PPS), which is thought to be related to autoimmune phenomena, represents a common postoperative complication in cardiac surgery. Late pericardial effusions after cardiac surgery are usually related to PPS and can progress to cardiac tamponade. Preventive measures can reduce postoperative morbidity and mortality related to PPS. In a previous study, diclofenac was suggested to ameliorate autoimmune diseases. The aim of this study was to determine whether postoperative use of diclofenac is effective in preventing early PPS after cardiac surgery. METHODS: A total of 100 patients who were administered oral diclofenac for postoperative analgesia after cardiac surgery and until hospital discharge were included in this retrospective study. As well, 100 patients undergoing cardiac surgery who were not administered nonsteroidal anti-inflammatory drugs were included as the control group. The existence and severity of pericardial effusion were determined by echocardiography. The existence and severity of pleural effusion were determined by chest X-ray. RESULTS: PPS incidence was significantly lower in patients who received diclofenac (20% vs. 43%) (P<0.001). Patients given diclofenac had a significantly lower incidence of pericardial effusion (15% vs. 30%) (P=0.01). Although not statistically significant, pericardial and pleural effusion was more severe in the control group than in the diclofenac group. The mean duration of diclofenac treatment was 5.11±0.47 days in patients with PPS and 5.27±0.61 days in patients who did not have PPS (P=0.07). Logistic regression analysis demonstrated that diclofenac administration (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.18-0.65, P=0.001) was independently associated with PPS occurrence. CONCLUSION: Postoperative administration of diclofenac may have a protective role against the development of PPS after cardiac surgery.

Factors affecting morbidity and mortality in traumatic colorectal injuries and reliability and validity of trauma scoring systems.

BACKGROUND AND AIM: This study aims to determine the factors that affect morbidity and mortality in colon and rectum injuries related with trauma, the use of trauma scoring systems in predicting mortality and morbidity. PATIENTS AND METHODS: Besides patient demographic characteristics, the mechanism of injury, the time between injury and surgery, accompanying body injuries, admittance Glasgow coma scale (GCS), findings at surgery and treatment methods were also recorded. With the obtained data, the abbreviated injury scale (AIS), injury severity score (ISS), revised trauma score (RTS) and trauma-ISS (TRISS) scores of each patient were calculated by using the 2008 revised AIS. RESULTS: Of the patients, 172 (88.7 %) were male, 22 (11.3 %) were female and the mean age was 29.15 ± 12.392 (15-89) years. The morbidity of our patients were 32 % and mortality were 12.4 %. ISS (p < 0.001), RTS (p < 0.001), and the TRISS (p < 0.001) on mortality were found to be significant. TRISS (p = 0.008), the ISS (p < 0.001), the RTS (p = 0.03), the trauma surgery interval (TSI, p < 0.001) were observed to have significant effects on morbidity. Regression analysis showed that the ISS (OR 1.1; CI 95 % 1.01-1.2; p = 0.02), the RTS (OR 0.37; CI 95 % 0.21-0.67; p = 0.001) had significant effects on mortality. While the effects of TSI (OR 5.3; CI 95 % 1.5-18.8; p = 0.01) on morbidity were found to be significant. CONCLUSION: Predicting mortality by using scoring systems and close postoperative follow up of patients in the risk group may ensure decreases in the rates of morbidity and mortality.

Relationship between nadir hematocrit during cardiopulmonary bypass and postoperative hyperglycemia in nondiabetic patients.

BACKGROUND: Hyperglycemia is common after cardiac surgery in both diabetic and nondiabetic patients and is associated with increased morbidity and mortality. Association between nadir hematocrit levels on cardiopulmonary bypass (CPB) and postoperative hyperglycemia is not clear. This study was carried out to determine the relationship between nadir hematocrit during CPB and postoperative hyperglycemia in nondiabetic patients. METHODS: Records of 200 nondiabetic patients undergoing coronary artery bypass grafting operation were retrospectively reviewed. In the first analysis, patients were divided into two subgroups according to the presence or absence of hyperglycemia. Further analysis was made after dividing the patients into 3 subgroups according to nadir hematocrit levels on CPB (less than 20%; 20% to 25%; greater than or equal to 25%). RESULTS: Compared to patients without hyperglycemia, patients with postoperative hyperglycemia had significantly lower preoperative hematocrit levels (p = 0.004) and were associated with lower nadir hematocrit levels during CPB (p= 0.002). Peak intensive care unit blood glucose levels and number of blood transfusions were significantly higher in patients with nadir hematocrit levels less than 20. (p<0.001 and p<0.001 respectively). Logistic regression analysis demonstrated that nadir hematocrit levels less than 20% (OR 2.9, p=0.009) and allogenic blood transfusion (OR 1.5, p=0.003) were independently associated with postoperative hyperglycemia. CONCLUSIONS: Nadir hematocrit levels on CPB less than 20% and allogenic blood transfusions were independently associated with postoperative hyperglycemia in nondiabetic patients. Patients with a nadir hematocrit levels less than 20 % during CPB should be closely monitored for hyperglycemia in the perioperative period.

Beating-heart mitral valve reoperation in a patient with a permanent pacemaker.

A 60-year-old man with a history of a prior double-valve replacement (DVR) and permanent pacemaker implantation underwent mitral valve reoperation due to a paravalvular leak. Reoperation was performed on a beating heart (BH) on cardiopulmonary bypass, by perfusing the heart continuously with oxygenated noncardioplegic normothermic blood via the coronary sinus. We report the case of a patient who underwent mitral valve reoperation on a beating heart, 10 years after his first double-valve replacement and permanent pacemaker implantation.