The effect of desflurane and propofol protocols on preconditioning.

BACKGROUND: Preconditioning is one of the most powerful mechanisms preventing the myocardial ischemic damage that occurs during coronary artery bypass grafting. OBJECTIVES: We aimed to investigate the effects of different propofol and/or desflurane administration protocols in terms of the prevention of ischaemia-reperfusion damage. MATERIAL AND METHODS: Ninety patients, aged > 18 years, American Society of Anesthesiologists (ASA) category III, scheduled to undergo primary elective coronary artery bypass grafting (CABG), were included in the study. During maintenance, the patients in group 1 (n = 30) received a propofol infusion (5-6 mg/kg/h) combined with a fentanyl infusion (3-5 mcg/kg/h); the patients in group 2 (n = 30) also received a propofol infusion (5-6 mg/kg/h) combined with a fentanyl infusion (3-5 mcg/kg/h), but they were also given 6% desflurane inhalation for 15 min both before cross-clamping of the aorta and after removal of the clamp; the patients in group 3 (n = 30) received a propofol infusion (2-3 mg/kg/h) combined with a fentanyl infusion (3-5 mcg/kg/h) and received the continuous 6% desflurane inhalation. Blood samples were drawn in the preoperative period (S1), during cardiopulmonary bypass, before cross-clamping the aorta (S2), after removal of the cross-clamp (S3) and 24 h after the operation (S4). RESULTS: All groups were similar in terms of age and BMI (p > 0.05). TNF-α levels were higher at S3 compared to S1, S2 and S4 (p > 0.001). The TNF-α levels at S4 were lower in group 3 than those in group 1 and group 2 (p < 0.05). In all groups, h-FABP levels showed an increase in S3 but were significantly lower at S4 (p < 0.05). In group 3, h-FABP levels at S2 and S3 were significantly lower than those in group 1 (p < 0.05). There was a moderate correlation between h-FABP and TNF-α levels (Spearman's rho = 0.472, p < 0.001). CONCLUSIONS: On the basis of the measurement of h-FABP and TNF-α, low-dose propofol and continuous desflurane inhalation provide more effective preconditioning than propofol alone or a short course of desflurane in patients undergoing CABG.

Management of Anesthesia during Lung Transplantations in a Single Turkish Center.

AIM: The aim of this study is to present our institutional experience during the management of anesthesia in lung transplantation (LT) surgeries as a definitive surgical treatment option in end-stage lung diseases. METHODS: From a total of 15 patients, lung transplantation was performed as single LT (SLT) in 4 patients (n = 4) and as sequential bilateral LT (BLT) in 11 patients (n = 11). The anesthetic management included; for induction; intravenous ketamine, midazolam at doses of 2 mg/kg, 0.05 mg/kg, respectively or propofol, fentanyl at doses of 1 mg/kg, 3 mcg/kg, respectively. For maintenance, all patients received; 100% O2 and total intravenous infusion of propofol and remifentanil at doses of 0.02 mcg/kg/min and 0.1-0.25 µg/kg/min, respectively. All patients received intravenous rocuronium bromide for induction and maintenance. Hemodynamic stability was maintained with appropriate and adequate administration of vasodilators (intravenous Prostaglandin (PGI2) (0.5-1 ng/kg/min), inhaled   nitric oxide  (10-40 ppm),  dopamine (2 mcg/kg/min) and vasopressors (intravenous dobutamine (5-15 mcg/kg/min), norepinephrine (0.05-1 mcg/kg/min),ephedrine (5 to 10 mg bolus doses ) to keep mean arterial blood pressure above 50 mmHg. RESULTS: Cardiopulmonary bypass (CPB) was performed in five patients who underwent sequential BLT and one SLT case. Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) was used in four cases of sequential BLT and in two cases of SLT. Neither ECMO nor CPB was performed in two BLT and in one SLT patient. One SLT patient who underwent CPB was admitted to the intensive care unit with support of intra-aortic balloon pump (IABP) and ECMO. Intraoperative death did not occur. CONCLUSION: During SLT or BLT, management of anesthesia with propofol and remifentanil provides a stable hemodynamic and medical support. Although our experience with VA ECMO was limited, our experience shows that this support system is a valuable tool to provide hemodynamic stability for patients undergoing LT.

The effect of melatonin on oxidative stress and apoptosis in experimental diabetes mellitus-related ovarian injury.

We aimed to evaluate the effect of melatonin on oxidative stress and ovarian injury in rats. Twenty-four Sprague-Dawley albino rats were divided into three groups: Group 1 as nondiabetic healthy controls (n = 8), group 2 as nontreated diabetic rats (n = 8) and group 3 as melatonin-treated diabetic rats (n = 8). After overt diabetes was produced by intraperitoneal injection of streptozosin, 20 mg/kg/day of melatonin was given intraperitoneally to group 3 for a week. NF-kB and caspase-3 immunoexpressions, lipid peroxidation, the activities of antioxidative enzymes, total oxidant capacity and total antioxidant capacity were assessed. Immunoexpressions of NF-kB and caspase-3 were significantly lower in group 3 than group 2. There was a significant decrease in superoxide dismutase activity in group 2 than group 1 and a significant increase in group 3 compared with group 2. We observed a nonsignificant decrease in catalase activity between group 1 and group 2 and a nonsignificant increase between group 2 and group 3. There was a nonsignificant increase in the plasma level of total oxidant status in group 2 than group 1, but a significant decrease was observed in group 3 compared to group 2. Total antioxidant status was significantly lower in group 2 compared with group 1 and group 3. In conclusion, melatonin ameliorates the negative effects of oxidative stress on DM-related ovarian injury.

The Effects of Diabetes Mellitus on Ovarian Injury and Reserve: An Experimental Study.

OBJECTIVE: The study aims to investigate the effects of diabetes mellitus (DM) on ovarian injury and reserve in a rat model. STUDY DESIGN: In this prospective experimental study, 16 female Sprague-Dawley albino rats (12 weeks, 220-240 g) were randomly divided into 2 groups. Group 1 included 8 normal healthy rats as controls. No drug was administered to the controls. Group 2 included the other 8 rats in which diabetes was induced by intraperitoneal injections of streptozotocin (STZ). After overt DM occurred (blood glucose >250 mg/dl), all the animals were euthanized and blood samples were collected by cardiac puncture for biochemical analysis. Bilateral oophorectomy was performed for histopathological examination. Immunoexpressions of nuclear factor-kappa B (NF-kB) and caspase-3 as well as anti-Müllerian hormone (AMH) levels were assessed. Values were analyzed by t test. RESULTS: Immunoexpressions of NF-kB and caspase-3 were significantly higher in non-treated diabetic rats than in the control group (p = 0.011 and p = 0.010, respectively). In healthy control group, AMH levels (3.22 ± 0.58 ng/ml) were significantly higher than in the non-treated diabetic group (1.41 ± 0.25 ng/dl; p = 0.024). CONCLUSION: Hyperglycemia causes severe ovarian injury via NF-kB pathway and caspase-3 apoptotic pathway, leading to the decrease in ovarian reserve in STZ-induced diabetic rats.

Surgical removal of guidewire entrapped within stent struts during percutaneous coronary angioplasty.

There has been a growing trend toward percutaneous coronary angioplasty for complex coronary artery lesions. Stent or guidewire break off or trapping within the coronary artery lumen is a rare complication, but it may have fatal consequences. In such cases, the entrapped device may be removed by either percutaneous route or surgical exploration. Here, we report a patient with guidewire entrapment within the struts of the intracoronary stent during primary percutaneous coronary angioplasty, which necessitated surgical removal and subsequent coronary artery bypass grafting (CABG).

Surgery for ruptured sinus of Valsalva aneurysm: 25-year experience with 55 patients.

OBJECTIVES: Different surgical strategies have been evolved for the surgical treatment of ruptured sinus of Valsalva aneurysm (RSVA) from simple primary closure to patching of the rupture site by a dual chamber approach. We reviewed our 25-year experience and current literature regarding the efficacy of different surgical approaches. METHODS: A retrospective review identified 55 patients who underwent RSVA repair between 1985 and 2011. The mean age was 30.9 ± 12.1 years. The RSVA originated from the right coronary sinus in 43 patients (78.2%), from the non-coronary sinus in 11 (20.0%) and from the left in 1. Rupture into the right ventricle was the most common result (n = 38). Dual-chamber exposure (the involved chamber and aorta) was used in 67.3% of the patients and isolated trans-aortic approach was used in 32.7%. RSVA was repaired with either a patch (n = 43) or direct sutures (n = 12), whereas the aortic valve was replaced in eight patients among the last group. RESULTS: The hospital mortality rate was 3.6%. The follow-up was available in 94.3% (50 patients) of survivors ranging from 1 month to 25 years (mean 15.3 ± 4.1 years). There were five late deaths. Recurrence of the fistula was seen in two primarily repaired (two of four patients) and none of the patched-closed patients. Actual survival was 93.4 ± 3.7% at 10 years and 87.1 ± 5.6% at 15 years. Freedom from reoperations was 81.6 ± 6.1% at 15 years. CONCLUSIONS: Surgical treatment for RSVA carries an acceptably low operative risk and long-term freedom from death and reoperation. Surgical approach must be chosen according to the ruptured chamber and associated lesions. Patch repair of RSVA must be preferred.

Should right coronary bypass grafts be anastomosed proximal or distal to the crux? A comparison of graft patencies.

AIM: Late occlusion of bypass grafts is one of the main issues associated with long-term survival after coronary artery bypass grafting (CABG) surgery. Left coronary system is generally revascularized using arterial conduits, whereas saphenous venous grafts are used for right coronary system. We investigated the prognostic factors that are related to the patency and risk of occlusion of saphenous venous grafts used for revascularization of diseased right coronary arteries. PATIENTS AND METHOD: 92 patients who underwent CABG operation including a right coronary artery (RCA) bypass using saphenous venous graft (SVG) between January 2003 and July 2010 were evaluated retrospectively. Mean time of follow up was 66.9 ± 27.2 months (range 104-13 months). Grafts patencies were investigated using coronary angiography, and associated risk factors for mortality and morbidity were determined during the mid-term and long-term follow up. During the data collection phase, a significant association was noticed between patency of right coronary bypass grafts and site of distal anastomoses on RCA. Thus, patients were divided into two groups, according to the site of anastomosis. Right coronary anastomoses were performed either proximal (Group A, n = 44) or distal (Group B, n = 46) to the crux of the RCA (PDA). RESULTS: Patency rates were similar in-group A (50% occluded and 50% patent) whereas patency rates were significantly higher in-group B (occluded 16.7%, patent 83.3%, p = 0.001). Mean age was significantly higher in-group A compared to Group B (p <0.05); however, there was no statistically significant difference between the two groups with regard to risk factors associated with cardiovascular disease (p >0.05). Also, mean diameter of the target vessel was significantly higher in-group A (p <0.01). CONCLUSION: Based on the results of our study we suggest that even though an appropriate segment for anastomosis is available proximal to the crux of the RCA, right posterior descending artery (PDA) should be preferred for revascularization when RCA is the target vessel in CABG.

Repair of left ventricular pseudoaneurysms.

The outcomes of 3 different methods of repair of left ventricular pseudoaneurysm after myocardial infarction were analyzed retrospectively. The operations were carried out in 22 patients between 1985 and 2008. Repair procedures included primary closure with Teflon-pledgeted sutures, and Dacron or pericardial patches. Overall hospital mortality was 27.3% (2 patients had primary closure, 3 had a Dacron patch, and 1 had a pericardial patch). Mean postoperative bleeding was 885 mL (range, 200-4,800 mL). Mean preoperative and postoperative ejection fractions were 40% (30%-47%) and 48% (30%-65%), respectively. The overall incidence of arrhythmia was 36.4% (8 patients). The incidence of arrhythmia was lowest in the pericardial patch group, but this was not statistically significant. No significant differences in postoperative ejection fraction or hemorrhage were found among the study groups. Mean survival was 61.9 + or - 41.4 months in the 16 hospital survivors. Although the 3 techniques gave similar results, repair with an autologous pericardial patch may offer an advantage in terms of less postoperative arrhythmias.