Evaluation of positive inotropic drug effects on thyroid hormone levels after open heart surgery.

OBJECTIVE: The aim of this study was to examine the effects of positive inotropic drugs, including adrenaline, dopamine, and dobutamine on thyroid hormone levels following open heart surgery. METHODS: We analyzed free thyroid hormones (FT3 and FT4) and thyroid-stimulating hormones (TSH) in 200 consecutive patients undergoing open heart surgery. Patients were divided into 5 groups according to the inotropic drug administration as follows: Group A (n = 46) received dopamine alone; Group B (n = 40), dopamine and dobutamine; Group C (n = 36), dopamine, dobutamine, and adrenaline; Group D (n = 32), adrenaline alone; and Group E (n = 46), placebo. Procedural factors affecting thyroid hormones were recorded and included cardiopulmonary bypass (CPB) time, cross-clamping time, degree of hypothermia, and the duration and doses of positive inotropic drugs. Blood samples for hormone assays were collected before initiation of inotropic drug therapy (baseline) and postoperatively at 24, 72, and 120 hours after drug therapy. RESULTS: FT3, FT4, and TSH levels at baseline were similar in all groups. Although there was a trend showing very slight increases in thyroid hormone levels from baseline to the 24th, 72nd, and 120th postoperative hours after drug therapy, these changes were not significant, and there were also no significant differences between the groups. There was also no significant statistical difference in CPB time, cross-clamping time, degree of hypothermia, and duration and doses of positive inotropic drugs between groups. CONCLUSION: Although thyroid hormone levels were affected by positive inotropic drug usage after open heart surgery, this effect was not significant and thyroid hormone levels remained within normal ranges.

Comparison of the CoaguChek XS handheld coagulation analyzer and conventional laboratory methods measuring international normalised ratio (INR) values during the time to therapeutic range after mechanical valve surgery.

AIM: To compare the international normalised ratio (INR) value of patients evaluated using the CoaguChek XS versus conventional laboratory methods, in the period after open-heart surgery for mechanical valve replacement until a therapeutic range is achieved using vitamin K antagonists (VKA) together with low molecular weight heparin (LMWH). METHODS: One hundred and five patients undergoing open-heart surgery for mechanical valve replacement were enrolled. Blood samples were collected from patients before surgery, and on the second and fifth postoperative days, simultaneously for both the point of care device and conventional laboratory techniques. Patients were administered VKA together with LMWH at therapeutic doses (enoxaparin 100 IU/kg twice daily) subcutaneously, until an effective range was achieved on approximately the fifth day after surgery. RESULTS: The mean INR values using the CoaguChek XS preoperatively and on the second and fifth days postoperatively were 1.20 (SD ± 0.09), 1.82 (SD ± 0.45), and 2.55 (SD ± 0.55), respectively. Corresponding results obtained using conventional laboratory techniques were 1.18 (SD ± 0.1), 1.81 (SD ± 0.43), and 2.51 (SD ± 0.58). The correlation coefficient was r = 0.77 preoperatively, r = 0.981 on postoperative day 2, and r = 0.983 on postoperative day 5. DISCUSSION: Results using the CoaguChek XS Handheld Coagulation Analyzer correlated strongly with conventional laboratory methods, in the bridging period between open-heart surgery for mechanical valve replacement and the achievement of a therapeutic range on warfarin and LMWH.

Cardiac echinococcosis.

OBJECTIVE: Cardiac echinococcosis is an extremely rare disease, seen worldwide. Some clinical characteristics are unknown, and treatment modalities are unclear. METHODS: 41 patients diagnosed with cardiac or pericardial echinococcosis underwent surgery. We evaluated the patients echocardiographically in 8 different categories: cardiac echinococcosis lesions located within the heart, imaging appearance of each lesion, activity of the cysts, mode of cardiac echinococcosis, and number of cardiac lesions per patient. The surgical technique was reevaluated according to the intraoperative echocardiographic findings, especially according to the mode of the lesion. RESULTS: The hydatid cysts were located in the ventricular wall in 34 cases, the right atrium in 2, the noncoronary sinus Valsalva of the aorta in 1, between the aorta and the pulmonary bifurcation in 1, and in the pericardium alone in 4 cases. In 1 case, septal rupture occurred and the patient died. Relapse was seen in 1 patient who was operated on due to multiple ventricular and pericardial cysts; this patient underwent a second operation 6 years and 8 months after the initial surgery. CONCLUSION: Recent echocardiographic developments and application of intraoperative echocardiography enables a detailed classification for extirpation, and allows successful treatment.

Surgical removal of a knotted and entrapped subclavian hemodialysis catheter guidewire.

Many mechanical complications associated with insertion, maintenance, and removal of the hemodialysis catheters have been reported in the literature. A 47-year-old man was consulted to our hospital because of an entrapped hemodialysis catheter guidewire. Computed tomographic scan revealed that the right subclavian vein was perforated by the guidewire and the wire was knotted over itself, one loop inside the vein and two loops in the extravascular site. Guidewire is pulled out from a 3-cm incision over the wire loops lateral to the right sternocleidomastoid muscle. He was discharged home on postoperative day 2 without any complication. Our suggestion is that any abnormal resistance should be immediately evaluated for the presence of any potential knots using the most appropriate imaging technique.

Impact of genetic variations of the CYP1A1, GSTT1, and GSTM1 genes on the risk of coronary artery disease.

Carcinogenic and toxic molecules produce DNA adducts that contribute to the development of atherosclerosis. Genetic polymorphisms of xenobiotic-detoxified enzymes, which control the level of DNA adducts, may affect both enzymatic activity and individual susceptibility to coronary artery disease (CAD). In this study we investigated the effects of genetic polymorphisms of the CYP1A1*2C, GSTT1, and GSTM1 enzymes on CAD risk in a Turkish population. Genotypes were determined for 132 CAD patients and 151 healthy controls by the polymerase chain reaction/restriction fragment length polymorphism method. There were no significant differences between patients and controls in terms of CYP1A1, GSTT1, and GSTM1 genotypes. Analysis of the possible interactions between the genotypes, after adjustment for the risk factors, demonstrated that individuals carrying CYP1A1 variant GSTT1 null genotypes had an 8.907-fold increased CAD risk compared to their wild status (p<0.05). We suggest that genetic polymorphisms of xenobiotic-metabolizing enzymes could play an important role in CAD. Therefore, CYP1A1 and GSTM1 polymorphisms should be considered as important parameters for the prediction of CAD.

The effect of levonorgestrel-releasing intrauterine device on menorrhagia in women taking anticoagulant medication after cardiac valve replacement.

BACKGROUND: This study was conducted to evaluate the effect of levonorgestrel-releasing intrauterine devices (LNG-IUDs) on menorrhagia in patients receiving anticoagulant therapy after cardiac valve replacement. STUDY DESIGN: Forty women with menorrhagia who underwent cardiac valve replacement and were taking anticoagulant medication were enrolled in the study. The women were randomly divided into two groups: LNG-IUDs were inserted into 20 women in Group 1 over the first 3 days of menstrual bleeding, while the women in Group 2 were followed without any intervention. The activated partial thromboplastin time, prothrombin time, international normalized ratio, hematocrit level, hemoglobin level, ferritin level and pictorial bleeding assessments for the quantity of menstrual bleeding were recorded. RESULTS: Three months after insertion of LNG-IUDs, the women in Group 1 had a significant decrease in blood loss and higher hemoglobin, hematocrit and ferritin values. No difference was detected for these parameters in the control group at the third and sixth months of the study. Coagulation parameters did not differ between the two groups. CONCLUSION: LNG-IUDs can be considered as an effective non-surgical treatment for menorrhagia in women receiving anticoagulant therapy after cardiac valve replacement.

Giant cardiac lipoma: report of a case.

Cardiac lipomas are extremely rare benign tumors. We report a case of a 41-year-old man who was admitted because of cardiomegaly and a feeling of discomfort in his chest. Computed tomography and magnetic resonance imaging studies showed a large mass occupying the mediastinum and pericardial space. The patient underwent resection of a lipoma which weighed 1100 g and had a pedicle 6 cm in diameter, connected to the epicardial surface of right ventricle infundibulum.

Chronic total occlusion of the left main coronary artery.

Total chronic occlusion of the left main coronary artery is a rare angiographic finding in a catheterization laboratory and its treatment rarely is reported. We describe a patient with angiographic findings of chronic total occlusion of the left main coronary artery with left coronary circulation collateralized from the right coronary artery.

A case of intraventricular septum dissection presenting with aneurysmal dilatation through the outflow track of the left ventricle.

A dissecting aneurysm of the intraventricular septum is an extremely rare entity. Most of these aneurysms originate from the right sinus of Valsalva and are believed to result from rupture of a Valsalva sinus aneurysm. Such cases may present with aortic insufficiency, rhythm disorders, ventriculo-septal ischemia and infectious endocarditis. In this article, we present a patient who underwent surgical intervention with a diagnosis of intraventricular septal cyst (hydatid cyst) leading to both a flow gradient through the left ventricle outflow track and dysrhythmia, without any evident dilatation or aneurysm of the sinus of Valsalva.

Aortic arch aneurysm, pseudocoarctation, and coronary artery disease in a patient with Behçet's syndrome.

Aortic arch aneurysm, pseudocoarctation, and coronary artery stenosis are extremely rare in Behçet's syndrome. We present the case of a 25-year-old man with Behçet's syndrome who underwent coronary artery bypass grafting for severe stenosis in the proximal left anterior descending coronary artery and concomitant surgical correction of a saccular aneurysm that was causing pseudocoarctation of the aortic arch. The surgery was successful.

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.

Discharge to home rates are significantly lower for octogenarians undergoing coronary artery bypass graft surgery.

BACKGROUND: The incidence of coronary artery bypass graft surgery (CABG) performed in elderly patients has been increasing over recent years. We sought to evaluate clinical outcomes of octogenarians undergoing CABG using an audited state-wide mandatory database. METHODS: New York State Department of Health's Cardiac Reporting System was analyzed from 1998 to 2002. In all, 88,154 patients undergoing isolated CABG were identified. Patients were divided into four age groups: less than 50 years (group 1, n = 6,527), 50 to 64 years (group 2, n = 30,088), 65 to 79 years (group 3, n = 43,369), and 80 years and above (group 4, n = 8,170). RESULTS: Of all patients, 9.3% were octogenarians. In addition to marginally worse coronary artery disease, octogenarians generally manifested a higher incidence of preoperative risk factors such as cerebrovascular disease, peripheral vascular disease, and congestive heart failure compared with younger patients at baseline. Both length of hospital stay and in-hospital mortality rate were significantly higher among octogenarians. The incidence of postoperative complications was higher among octogenarians. Multivariate analysis demonstrated renal failure requiring dialysis (odds ratio [OR] = 4.4), myocardial infarction within 6 hours before surgery (OR = 3.6), chronic obstructive pulmonary disease (OR = 1.7), congestive heart failure at admission (OR = 1.7), emergent operation (OR = 1.6), Canadian Cardiovascular Society functional class IV (OR = 1.5), hypertension (OR = 1.4), and low ejection fraction (OR = 0.98) to be significant independent predictors of in-hospital mortality of octogenarians. Discharge to home rates were significantly lower for octogenarians. CONCLUSIONS: Although early outcomes in octogenarians are acceptable, these factors alone are not sufficient to reflect overall success of CABG in these patients, given the strikingly lower discharge to home rates. Attention to full functional recovery in octogenarians is essential.

Predictors and outcomes of continuous veno-venous hemodialysis use after implantation of a left ventricular assist device.

BACKGROUND: Post-operative renal failure is a common complication after left ventricular assist device (LVAD) implantation. This study was designed to evaluate predictors and outcomes of acute renal failure after LVAD insertion. METHODS: Two-hundred one patients undergoing LVAD implantation at a single institution from June 1996 through April 2004 were retrospectively analyzed. Patients were categorized into 2 groups: those who required post-operative continuous veno-venous hemodialysis (CVVHD) (Group 1, n = 65, 32.3%) and those who did not (Group 2, n = 136, 67.7%). Independent predictors of post-operative renal failure requiring CVVHD were determined using multivariate logistic regression techniques. RESULTS: Patients who had post-operative renal failure requiring CVVHD were older (53.7 +/- 12.9 vs 48.2 +/- 14.2 years, p = 0.009), had a higher incidence of intra-aortic balloon pump use (46.6% vs 26.2%, p = 0.006), and had a higher pre-operative mean LVAD score (5.8 +/- 3.5 vs 3.8 +/- 3.3, p = 0.001) than those without renal failure. LVAD score was the only independent predictor of post-operative renal failure requiring CVVHD (odds ratio = 1.226, p = 0.006). Sepsis rate was higher (33.3% vs 6.9%, p < 0.001) and bridge-to-transplantation rate was lower (52.4% vs 83.5%, p < 0.001) in Group 1 than in Group 2. Post-LVAD survival rates at 1, 3, 5 and 7 years for Group 1 and Group 2 were 43.2%, 39.1%, 34.7% and 34.7% vs 79.2%, 74.0%, 68.3% and 66.4%, respectively (log rank, p < 0.001). CONCLUSIONS: Acute renal failure necessitating CVVHD remains a serious complication after LVAD and confers significant morbidity and mortality. Pre-operative evaluation of patient risk factors and optimization of peri-operative hemodynamics are of utmost importance to prevent this major complication.

Increased levels of soluble adhesion molecules E-selectin and P-selectin in patients with cardiac syndrome X.

The role of endothelial dysfunction and platelet activation in patients with cardiac syndrome X is controversial. The aim of this study was to investigate the plasma levels of circulating E- and P-selectin molecules in patients with syndrome X. The study included 21 patients with cardiac syndrome X (11 men and 10 women, mean age = 56 +/- 5 years) and 20 patients with significant coronary artery disease who had stable angina pectoris (11 men and 9 women, mean age = 60 +/- 8 years). Twenty-two age- and sex-matched subjects (12 men and 10 women, mean age = 58 +/- 8 years) undergoing diagnosis of atypical chest pain in whom coronary arteries were found normal and exercise test had no signs of ischemia served as the control group. Syndrome X was defined as presence of typical chest pain on exertion or at rest with positive exercise test and angiographically normal epicardial coronary arteries with no evidence of coronary spasm after intracoronary infusion of ergonovine maleate. The mean plasma concentrations of P-selectin were significantly elevated both in patients with coronary artery disease and syndrome X as compared with control subjects (49.15 +/-7.47 and 42.80 +/- 8.93 vs 22.63 +/-6.47 ng/mL, p < 0.001). Similarly, both patients with coronary artery disease and syndrome X had higher plasma concentrations of E-selectin than the control group (78.85 +/- 16.69 and 68.38 +/- 15.30 vs 36.43 +/- 4.72 ng/mL, p < 0.001). In conclusion, patients with syndrome X had increased plasma concentrations of soluble adhesion molecules, E-selectin and P-selectin, reflecting an ongoing chronic inflammation involved with endothelial dysfunction and enhanced platelet activation/damage in this setting.

Off-pump technique for the treatment of ventricular myocardial echinococcosis.

BACKGROUND: This study was planned to investigate the off-pump operability of ventricular myocardial Echinococcosis, which has no close relation with the cardiac chambers. METHODS: Twenty patients with cardiac echinococcosis, and 2 patients with isolated pericardial echinococcosis were operated on. Hydatid cysts were located in the ventricular wall in 17 patients and 10 of these 17 patients were operated without cardiopulmonary bypass. We present these 10 patients in this report. We used transesophageal echocardiography (TEE) and peroperative surface echocardiography (PSE) to determine the relation of cysts with cardiac chambers. The cysts were aspirated for diagnosis and to facilitate the dissection. Cyst cavities were left open in all cases. RESULTS: We did not observe any early complication and in long-term follow-up only one patient underwent reoperation 68 months after her first operation due to reoccurrence. CONCLUSIONS: Ventricular myocardial echinococcosis without relation with the cardiac chambers can be operated without using cardiopulmonary bypass with the aid of TEE, PSE, and controlled cyst fluid aspiration.