Morphine is a reasonable alternative to haloperidol in the treatment of postoperative hyperactive-type delirium after cardiac surgery.

OBJECTIVES: Patients who undergo cardiac surgery have an increased risk of delirium. Currently, there are few choices of treatment for postoperative hyperactive delirium in cardiac surgical patients. The aim of this study was to assess the effect of morphine compared with a haloperidol-based regimen in hyperactive-type delirium in patients after cardiac surgery. DESIGN: A prospective, randomized clinical study. SETTING: A single community hospital. PARTICIPANTS: Fifty-three consecutive, adult, delirious patients. INTERVENTIONS: Patients were randomized into 2 groups; in group 1, patients received 5mg of haloperidol intramuscularly and in group 2, patients received 5mg of morphine sulfate intramuscularly to control delirium symptoms. MEASUREMENTS AND MAIN RESULTS: During the second and third hour of the morphine treatment, statistically low Richmond Agitation and Sedation Scale scores were found and the target Richmond Agitation and Sedation Scale scores percentages were statistically higher than those of the haloperidol group (p = 0.042 and p = 0.028, respectively). The number of patients requiring additive sedatives was significantly more in the haloperidol group when compared with the morphine group (p = 0.011). CONCLUSION: During the treatment of patients, it was determined that the patients who were receiving morphine treatment responded more quickly compared with the patients receiving haloperidol treatment. Morphine was found to be a reasonable alternative to haloperidol in the treatment of postoperative hyperactive delirious patients after cardiac surgery.

Effect of body mass index on early morbidity and mortality after isolated coronary artery bypass graft surgery.

OBJECTIVES: Obesity is a risk factor for morbidity after isolated coronary artery bypass grafting. This study aimed to analyze the sole effect of body mass index (BMI) on early morbidity and mortality in patients after isolated coronary artery bypass grafting. DESIGN: This study was retrospective and used an electronic database of anesthesia information management. SETTING: A single community hospital. PARTICIPANTS: The data of 803 consecutive patients after isolated on-pump coronary artery bypass grafting were analyzed retrospectively; off-pump cases were excluded. INTERVENTION: According to measured BMI, patients were divided into 5 groups: underweight (BMI <20 kg/m(2)), normal weight (BMI 20.0-24.9 kg/m(2)), overweight (BMI 25.0-29.9 kg/m(2)), obese (BMI 30.0-34.9 kg/m(2)), and morbidly obese (BMI >34.9 kg/m(2)). Early postoperative morbidity and mortality were evaluated using logistic regression analysis. MEASUREMENTS AND MAIN RESULTS: Early cumulative postoperative mortality was 3.9% (32 of 803 patients). Mortality was recorded in 3 underweight (n = 15, 20%, odds ratio [OR] 6.54, p = 0.001), 9 normal-weight (n = 159, 5.7%, OR 1.62, p = 0.228), 12 overweight (n = 371, 3.2%, OR 0.68, p = 0.314), 6 obese (n = 199, 3.0%, OR 0.69, p = 0.421), and 2 morbidly obese (n = 59, 3.4%, OR 0.83, p = 0.808) patients. Prolonged intensive care unit stay (p < 0.001), prolonged hospital stay (p < 0.001), and mortality (p = 0.01) were significantly more common in patients in the underweight group than in the other groups. Univariate and multivariate logistic regression analyses showed that underweight, hypertension, and chronic renal failure were independent risk factors for mortality. CONCLUSIONS: Underweight patients with a BMI <20 kg/m(2) are at increased risk of postoperative complications and mortality compared with normal-weight or overweight subjects.

Cardiac tamponade from a giant thymoma: case report.

Thymoma, the most common neoplasm of the anterior mediastinum especially in adults, accounts for 20-25% of all mediastinal tumors and 50% of anterior mediastinal masses. These tumors are routinely asymptomatic for prolonged periods of time. Pericardial tamponade is a very rare initial manifestation of a thymoma. This report presents a patient who had hemorrhagic pericardial tamponade that likely resulted from the largest symptomatic mixed type (type AB) thymoma described in the literature.

Aortic root aneurysm after off-pump reduction aortoplasty.

We present a patient with aortic root aneurysm and severe aortic regurgitation who had a previous off-pump reduction ascending aortoplasty and external wrapping with concomitant coronary bypass grafting. Preliminary aortic dissection and erosion of the aortic intima were detected during the operation. This complication warrants the re-evaluation of the indications for reduction ascending aortoplasty and emphasizes the necessity for close follow-up.

Furosemide infusion prevents the requirement of renal replacement therapy after cardiac surgery.

OBJECTIVE: Acute kidney injury (AKI) is a devastating complication following cardiac surgery and the ideal management is controversial. This prospective, randomized, open-label and double-blinded study analyzed the renoprotective effects of furosemide infusion and intermittent bolus therapy administered with dopamine infusion in cardiac surgical patients. METHODS: Between August 1, 2007 and July 31, 2008, 100 adult patients undergoing elective coronary artery bypass surgery (CABG) surgery with normal renal function (creatinine <1.4 mg/dl) were enrolled in the study. The patients were randomized for the comparison of intermittent (Group 1, n=50, 1mg-3mg/kg) and continuous infusion of furosemide (Group 2, n=50, 10mg/ml). Continuous variables were expressed as mean+/- SD and compared by unpaired Student's t test or ANOVA for repeated measures. Statistical significance was assumed if p value was <0.05. RESULTS: Renal replacement therapy (RRT) was used in 5% of patients (all in group 1, p=0.028). The 30-day mortality was 5%. Only 2 patients became hemodialysis dependent in group 1. Group 2 patients showed a continuous and higher urine output postoperatively than group 1 (p<0.001). Both groups had significant increase in peak postoperative serum creatinine values (p<0.001), however peak postoperative creatinine-clearance was significantly lower in group 1 (p<0.001). CONCLUSION: Acute kidney injury necessitating RRT makes a small percentage of patients undergoing cardiac surgery and if RRT is not required the survival is excellent. Continuous infusion of furosemide seems to be effective in promoting diuresis and decreasing the need for RRT. However further multicenter studies with different doses of furosemide are required to confirm these results.

Results of adjunctive coronary endarterectomy in 548 patients.

Coronary endarterectomy is a controversial procedure that plays a particular role in the treatment of coronary artery disease. We retrospectively investigated the results for 548 patients who underwent coronary endarterectomy as an adjunctive therapy for coronary artery bypass graft surgery during the period between 1996 and 2004. We assessed short-term outcomes and identified risk factors for adverse outcomes. Mean patient age was 67.9 + 9.3 years and mean angina class was 2.7 + 0.3. The mean number of distal anastomoses was 3.8 + 1.1 patients (73.4%) had single and 151 (27.6%) multiple coronary artery endarterectomies. Of the 151 patients who underwent multiple endarterectomies, 97 (17.7%) had endarterectomies in 2 coronary arteries, 40 (7.2%) in 3 coronary arteries, 11 (2%) in 4 coronary arteries, 2 (0.36%) in 5 coronary arteries, and 1 (0.18%) in 6 coronary arteries. Postoperative mortality was 6.2% (34 patients). The predictors for early mortality were recent myocardial infarction and left ventricular dysfunction. Our results suggest that adjunctive coronary endarterectomy can be accomplished with acceptable results but with higher mortality rates than ordinary coronary artery bypass grafting. Adjunctive coronary endarterectomy should be considered as a last option for the surgical treatment of diffuse coronary disease.

Does intermittent aortic cross clamping decrease the incidence of atrial fibrillation after coronary bypass surgery?

Atrial fibrillation (AF) is the most common arrhythmia after coronary artery bypass grafting (CABG). AF is a vexing problem that causes morbidity, prolongs hospital stay, and increases costs. Numerous factors have been suggested to play a role in the development of AF. The aim of this study was to evaluate the effect of intermittent aortic cross clamping (IACC) compared with hypothermic cardioplegic solution (HCS) in the development of postoperative AF. We evaluated data obtained from 345 patients undergoing CABG with HCS (HCS group, n = 212) and IACC (IACC group, n = 173) between April 2004 and August 2005. Diabetes mellitus was observed more often in the HCS group (P < .05), otherwise both groups had similar preoperative characteristics including sex, age, the number of distal anastomoses, left ventricle ejection fraction, history of myocardial infarction, and use of beta-blocker medication. The only statistically significant difference between the groups was higher postoperative Ca-antagonist use in the HCS group. Rates of postoperative AF, however, were significantly lower in the IACC group (21.52%) than that in the HCS group (11.05%; P < .01). Postoperative Ca-antagonist use in the HCS group and smoking in the IACC group were independent predictors of AF after CABG. The incidence of postoperative AF after CABG with IACC was reduced compared with HCS. IACC with ventricular fibrillation may exert a counteractive effect against AF.

Determination of histopathologic risk factors for postoperative atrial fibrillation in cardiac surgery.

BACKGROUND: Postoperative atrial fibrillation is one of the most common complications after coronary artery bypass grafting. This study aimed to identify preoperative histopathologic risk factors for the development of postoperative atrial fibrillation. METHODS: One hundred elective coronary artery bypass grafting patients were enrolled into the study. Right atrial tissue from all patients was sampled before cardiopulmonary bypass. Patients were monitored for the occurrence of the postoperative atrial fibrillation. Right atrial tissue samples from the atrial fibrillation group were compared with samples belonging to the patients who remained in sinus rhythm postoperatively. Evaluation for atrial histopathology and myocyte apoptosis included light microscopic and immunohistochemical studies. RESULTS: Fourteen of 100 patients (14%) developed postoperative atrial fibrillation. On univariate analysis, the only predictor for the development of postoperative atrial fibrillation was chronic obstructive pulmonary disease (p = 0.014). Histologically, larger sized myolytic vacuoles were more common in patients who developed postoperative atrial fibrillation (p = 0.001). The percentage of apoptotic myocytes in each specimen was significantly higher in patients with atrial fibrillation (p = 0.000). Most of the specimens with positive apoptotic staining were also severely myolytic in patients with postoperative atrial fibrillation. CONCLUSIONS: Our results suggest that degree of myolysis and increased apoptotic pattern in right atrial myocardium are significant predictors for the development of postoperative atrial fibrillation. The improvement of preoperative metabolic status of the myocardial cells may reduce the incidence of this common complication.

Reduction aortoplasty and external wrapping for moderately sized tubular ascending aortic aneurysm with concomitant operations.

BACKGROUND: Replacement of the ascending aorta with a prosthetic graft is the preferred surgical procedure for an ascending aortic aneurysm. The choice of external wrapping of the aorta is a simple, fast, and effective method for moderately sized ascending aortic aneurysms with concomitant operations. In this study, we present the midterm results of 62 patients undergoing reduction aortoplasty with external wrapping and different cardiac procedures. METHODS: The study group consisted of 48 male and 14 female patients with a mean age of 59.3 +/- 6.0 years. Measurement of the ascending aorta diameters was obtained at three points: before surgery, during the early postoperative period, and during the follow-up. The mean preoperative aortic diameter was 52.7 +/- 0.5 mm. In all patients, the ascending aortic aneurysm was repaired by reduction aortoplasty with external wrapping. RESULTS: Mean follow-up time was 39.6 +/- 18.0 months. There was only one mortality (1.6%) as a result of septic multiple-organ failure and no major surgical complications in the 30-day postoperative period. Reduction aortoplasty of the ascending aorta with external wrapping resulted in a significant reduction of the ascending aorta in all patients (p = 0.000). There was an increase in the mean aortic diameter during the follow-up period (p = 0.000). Although this increase was statistically significant, all measurements of the follow-up period were still within normal range. CONCLUSIONS: External wrapping of the aorta offers excellent results with very low mortality and morbidity, and it can be regarded as a safe and effective method for the treatment of ascending aortic aneurysm in selected patients. However, the patients should be carefully monitored for redilatation after the procedure.

FK506 to prevent lung injury after hindlimb ischemia and reperfusion in a rat model: an electron microscopic study.

PURPOSE: Hindlimb ischemia and reperfusion leads to lung injury in various animal models. We investigated the effectiveness of FK506, an immunosuppressive agent, which also modulates neutrophilic infiltration, in preventing lung injury after hindlimb ischemia and reperfusion in a rat model. METHODS: Twenty-seven male Sprague-Dawley rats were randomized to received FK506 at doses of 0.3 mg/kg, 0.5 mg/kg, or 1 mg/kg body weight per day, or normal saline injections, as pretreatment, and there was also a sham group. On the 4th day, the animals were subjected to 2 h of ischemia induced by a tourniquet, followed by reperfusion of the extremities for 2 h. Lung tissue assays were performed for the lipid peroxidation product malondialdehyde (MDA) and total glutathione (GSH). Lung tissues were also examined histopathologically under light and electron microscopy. RESULTS: The MDA levels in the study groups were significantly lower than those in the control group ( P < 0.05), but the total GSH levels did not differ significantly among the groups. Histopathologically, there were no significant differences among the groups given different doses of FK506, but there was a significant difference between the control group and all the treatment groups. CONCLUSION: FK506 ameliorates the lung injury associated with ischemia and reperfusion of the lower limbs, and might have an inhibitory effect on the neutrophils that cause remote organ damage.

Delayed rupture of a postinfarction left ventricular true aneurysm.

Delayed rupture of a true left ventricular aneurysm is a rare clinical condition. We report a case of a 60-year-old woman who underwent emergency surgical repair of a ruptured true aneurysm of the left ventricular inferior wall 3 months after the myocardial infarction. The repair consisted of endoaneurysmorraphy patch technique. The patient made a satisfactory recovery.

A Mediastinal False Aneurysm with Aortocutaneous Fistula.

Abstract In this report, we present a case of the development of a false aneurysm of the ascending aorta with an aortocutaneous fistula in a 57-year-old patient 10 months following aortic valve replacement and concomitant coronary bypass surgery.

Neuroprotective effects of FK-506, L-carnitine and azathioprine on spinal cord ischemia-reperfusion injury.

OBJECTIVE: In our experimental study, we aimed to test the effect of FK506, azathioprine and L-carnitine on protection of spinal cord injury due to ischemia-reperfusion. METHODS: Twenty-seven Sprague-Dawley male rats were randomly divided into five groups. They were subjected to spinal cord ischemia by clamping the abdominal aorta for 45 min. Thirty minutes before the aortic clamping, group I received 0.5 mg/kg FK506, group II received 100 mg/kg L-carnitine, group III received 4 mg/kg azathioprine, the fourth group was the control group and received only normal saline injection intravenously and the last group was the sham group. Neurological status was scored by using the Tarlov scoring system. Sections of the lumbar cord were harvested for histopathological grades (1-4), having regard to percentage of the apoptotic cells. RESULTS: Hind-limb motor function had recovered normally 48 h after the operation in all rats which received FK506, azathioprine and L-carnitine prophylactically. In contrast, all rats in the control group had deteriorated to paraplegia by 48 h after the operation (P<0.05). Histopathologic sections in the involved spinal cord segment showed that a greater number of motor neuron cells were preserved and there were less apoptotic cells in the rats that received FK506, azathioprine and L-carnitine than those in control group. CONCLUSIONS: These results suggest that prophylactic use of FK506, azathioprine and L-carnitine protects motor neuron cells from ischemic spinal cord injury.

Coronary artery bypass surgery in patients with severe left ventricular dysfunction.

OBJECTIVE: The role of coronary artery bypass grafting (CABG) in patients with severe left ventricular dysfunction was evaluated. METHODS: Two hundred and twelve patients (152 men, 60 women; age 35 to 82, mean 55) with ejection fraction (EF) of less than 30% underwent CABG between January 1996 and February 2001 by a single surgeon (SA). They compromised of 12% of 1759 patients operated on in this period. EF ranged from 17% to 30% (mean 25%). Preoperatively 68% had congestive heart failure and 72% had severe angina (CCS 3 or 4). A left main lesion was found in 26% of the cases. The mean number of grafts was 3.18 per patient. The left internal mammary artery (LIMA) was used on 107 patients (50.4%). Preoperative intraaortic balloon pump (IABP) was used on 32 patients (15%). Endarterectomy was performed on 53 patients (25%). The patients were followed for up to 58 months (mean 28.7). RESULTS: Twelve patients died in hospital (5.6%). Survival was 94%, 87%, 80% and 73% at 1, 2, 3 and 4 years respectively. Among the preoperative variables survival was negatively affected by chronic renal failure, older age, congestive heart failure, elevated pulmonary artery pressure and recent myocardial infarction, by means of multivariate analysis. Preoperative IABP support improved the operative mortality significantly (P=0.002). Use of LIMA did not have any influence on survival. CONCLUSION: CABG on patients with poor left ventricular function: (1). Can be performed with an acceptable mortality. (2). Mid term results are encouraging. (3). Preoperative IABP support improves the chance of survival.

Missed diagnosis of unruptured, huge left ventricular pseudoaneurysm.

We report a case of a huge left ventricular pseudoaneurysm following myocardial infarction. Early after myocardial infarction, the pseudoaneurysm was missed during the cardiac examination. The patient underwent coronary bypass surgery with endoaneurysmorraphy of the pseudoaneurysm, and made a satisfactory recovery.

Ischemic preconditioning and nicotinamide in spinal cord protection in an experimental model of transient aortic occlusion.

OBJECTIVES: Spinal cord injury is a devastating complication after aortic surgery. The aim of the present study is to examine the effects of ischemic preconditioning (IPC) and nicotinamide containing perfusate in transient aortic occlusion in the rat. METHODS: Thirty-two male Spraque-Dawley rats under general anesthesia were randomly assigned to four groups (n=8 in each group). The infrarenal aortas were clamped for 45 min. Groups were as follows: Group 1, undergoing occlusion but receiving no treatment. Group 2, had 5 min of IPC before occlusion. Group 3, received nicotinamide (0.2 ml/l) during the transient occlusion. Group 4, received combined IPC (5 min) and nicotinamide infusion during the transient occlusion. The rats were then allowed for recovery and were tested for their neurological status. All animals were sacrificed at the end of the 48 h and spinal cords also examined histologically. Anti- poly (ADP-ribose) polymerase p85 fragment pAb was used as an immunohistochemical marker for detection of apoptosis. RESULTS: In 24 h paraplegia represented as grade 0 and 1 occurred in six animals in Group 1 and two animals in Groups 2 and 3 and one in Group 4. In 48 h six animals in Group 1 and only one animal in Groups 2 and 3 showed a paraplegia. The incidence of neurologic deficit was significantly reduced in animals who had IPC and nicotinamide infusion (P<0.05). At 48 h, combined IPC and nicotinamide showed a significant benefit compared to nicotinamide but not to the IPC alone. Histologic examination of the spinal cords revealed that a neuronal necrosis contributes to acute spinal cord degeneration after a period of aortic occlusion and both nicotinamide and IPC have protective effects against neuronal necrosis. No difference was found among the groups. CONCLUSIONS: Both IPC and nicotinamide are beneficial in protection against neurological damage in transient aortic occlusion. IPC alone as expected is significantly beneficial both at 24 and 48 h compared to controls. At 24 h combined nicotinamide and IPC show significant benefit compared to only nicotinamide, but this difference is not maintained at 48 h.