Pressure-controlled mechanical ventilation is more advantageous in the follow-up of patients with chronic obstructive pulmonary disease after open heart surgery.

OBJECTIVE: Cardiopulmonary bypass deteriorates pulmonary functions to a certain extent. Patients with chronic obstructive pulmonary disease (COPD) are associated with increased mortality and morbidity risks in the postoperative period of open-heart surgery. In this study we compared 2 different mechanical ventilation modes, pressure-controlled ventilation (PCV) and volume-controlled ventilation (VCV), in this particular patient population. PATIENTS AND METHODS: Forty patients with severe COPD were assigned to 1 of 2 groups and enrolled to receive PCV or VCV in the postoperative period. Arterial blood gases, respiratory parameters, and intensive care unit and hospital stays were compared between the 2 groups. RESULTS: Maximum airway pressure was higher in the VCV group. Pulmonary compliance was lower in the VCV group and minute ventilation was significantly lower in the group ventilated with PCV mode. The respiratory index was increased in the PCV group compared with the VCV group and with preoperative findings. Duration of mechanical ventilation was significantly shorter with PCV; however, intensive care unit and hospital stays did not differ. CONCLUSION: There is not a single widely accepted and established mode of ventilation for patients with COPD undergoing open-heart surgery. Our modest experience indicated promising results with PCV mode; however, further studies are warranted.

Coronary bypass surgery in a 105-year-old patient with cardiopulmonary bypass.

Coronary artery bypass grafting is one of the routine daily surgical procedures in the current era. Parallel to the increasing life expectancy, cardiac surgery is commonly performed in octogenarians. However, literature consists of only seldom reports of coronary artery bypass grafting in patients above 90 years of age. In this report, we present our management strategy in a 105-year-old patient who underwent coronary artery bypass grafting at our institution.

Mitral valve replacement and subaortic membrane resection following pneumonectomy.

The pulmonary status is a vital factor for patients undergoing open heart surgery. The cardiac surgery itself deteriorates the actual pulmonary functions. Today, patients are no longer living with a cardiac disease due to compromised respiratory functions secondary to various pathologies, patients with lung disorders more often seek solutions for their cardiac disease and they are commonly operated. However, the resection of a lobe or a whole lung is a major challenge for the patients planned for cardiac surgery. In this report, we present a 65-year-old patient, who had left pnemonectomy which had been performed 8 years ago and was admitted for mitral valve replacement and subaortic membrane resection.

Solitary coronary artery nourishing the entire heart.

Coronary artery anomalies are being more frequently diagnosed these days both because increasing numbers of patients are undergoing diagnostic studies and because advanced radiographic imaging methods are now commonly available. An isolated single coronary artery giving rise to the main coronary branches is a rare congenital anomaly. In this report we present a patient with a solitary coronary ostium, with both the left and right coronary artery systems arising from it, and then following their usual courses. This case was diagnosed incidentally during conventional angiography.

Magnesium sulphate and amiodarone prophylaxis for prevention of postoperative arrhythmia in coronary by-pass operations.

BACKGROUND: The aim of this study was to investigate the use of prophylactic magnesium sulphate and amiodarone in treating arrhythmias that may occur following coronary bypass grafting operations. METHODS: The study population consisted of 192 consecutive patients who were undergoing coronary artery bypass grafting (CABG). Sixty-four patients were given 3 g of magnesium sulphate (MgSO4) [20 ml = 24.32 mEq/L Mg(+2)] in 100 cc of isotonic 0.9% solution over 2 hours intravenously at the following times: 12 hours prior to the operation, immediately following the operation, and on postoperative days 1, 2, and 3 (Group 1). Another group of 64 patients was given a preoperative infusion of amiodarone (1200 mg) on first post-operative day (Group 2). After the operation amiodarone was administered orally at a dose of 600 mg/day. Sixty-four patients in group 3 (control group) had 100 cc. isotonic 0.9% as placebo, during the same time periods. RESULTS: In the postoperative period, the magnesium values were significantly higher in Group 1 than in Group 2 for all measurements. The use of amiodarone for total arrhythmia was significantly more effective than prophylactic treatment with magnesium sulphate (p = 0.015). There was no difference between the two drugs in preventing supraventricular arrhythmia, although amiodarone significantly delayed the revealing time of atrial fibrillation (p = 0.026). Ventricular arrhythmia, in the form of ventricular extra systole, was more common in the magnesium prophylaxis group. The two groups showed no significant differences in other operative or postoperative measurements. No side effects of the drugs were observed. CONCLUSION: Prophylactic use of magnesium sulphate and amiodarone are both effective at preventing arrhythmia that may occur following coronary by-pass operations. Magnesium sulphate should be used in prophylactic treatment since it may decrease arrhythmia at low doses. If arrhythmia should occur despite this treatment, intervention with amiodarone may be preferable.

Rhabdomyolysis following accidental intra-arterial injection of local anesthetic.

Drug-induced myopathy, also named Nicolau syndrome, is a well-known phenomenon following intramuscular injection of certain agents, most commonly reported with penicillin or diclofenac. The mechanism responsible for the pathology is proposed to be incidental administration of the drug into the small arterioles. In this report, we present a Nicolau syndrome-like case that developed following accidental injection of a local anesthetic agent into the femoral artery during coronary angiography.

Efficacy of remote ischaemic preconditioning for spinal cord protection against ischaemic injury: association with heat shock protein expression.

INTRODUCTION: We aimed to determine the efficacy of remote ischaemic preconditioning in the hind limb of rats for ischaemic damage of the spinal cord through neurological and histological investigation and examination of heat shock proteins (HSP). MATERIAL AND METHODS: Thirty male Sprague-Dawley rats were divided into three groups as Group 1 (control group, n=10), Group 2 (ischaemia control group, n=10), and Group 3 (remote ischaemia preconditioning group, n=10). The right lower limb of the rats in the study group was compressed with a tourniquet for three cycles of ten-minute ischaemia followed by ten-minute reperfusion. After a period of 8 hours, the peritoneal cavity was accessed through a midline vertical incision. The abdominal aorta was clamped between the origin of the renal arteries and the iliac arteries for 45 minutes and spinal cord ischaemia was induced. The same procedure of abdominal aorta clamping was performed in the control group without creating leg ischaemia. The rats were evaluated for neurological parameters at 24 and 48 hours. At the end of this time period, all rats were sacrificed and the spinal cords were stained for determination of HSP and histopathological classification. For immunohistochemical evaluation, the samples were analyzed according to the degree of staining with HSP70 rabbit antibody. RESULTS: After completing the neurological examinations and histological evaluations, we determined the spinal cords of the animals in the sham group to be completely normal. The post-operative neurological examination scores of Group 3 at 24 and 48 hours were significantly higher than scores measured in the other two groups. There were seven rats with HSP expression and this was detected in animals pretreated with remote ischaemic preconditioning. There were also two rats in Group 2 with HSP expression. CONCLUSION: Our results show that production of transient remote ischaemia preconditioning in the lower extremities reduces damage in the spinal cord secondary to ischaemia probably by the increase of HSP.

Papaverine solution improves preservation of saphenous vein grafts used during cardiac surgery.

The purpose of this study was to assess the viability and dilator response of the saphenous vein segments harvested during cardiac surgery. The saphenous veins were incubated with either normal saline (group A) or papaverine solutions (group B). The viability of saphenous vein endothelial cells was assessed by counting the number of total cells. Maximal endothelium-dependent vasodilator response to acetylcholine was also investigated. Cell viability of vein samples was decreased after 4 hours of incubation with normal saline (34 +/- 6.5%) as compared to solution containing papaverine (92 +/- 3.7%). By 24 hours, the viabilities of the endothelial cells incubated with saline and papaverine solutions were 22 +/- 4.5% and 87 +/- 5%, respectively.There was significant difference in vasodilatation responses to acetylcholine between saline-incubated and papaverine-incubated groups. By 4 hours of incubation, the relaxation response to acetylcholine significantly deteriorated in group A when compared to the initial value (P < 0.001). Furthermore, the decrease in this vasorelaxation response has also continued throughout the observation period and the values obtained by 24 hours were observed to be significantly lower than those obtained at the end of 4 hours (P < 0.01). In contrast, although a decrease was noticed in group B over time, this decrease was not statistically significant (P, not significant). We thus conclude that the use of papaverine solution improves endothelial cell viability and is associated with preservation of the maximal endothelial-dependent vasodilator response of a vein segment.

An interesting cause of chylopericardium after open heart surgery: a lymphatic channel.

Chylopericardium is a very rare complication after open heart surgery that is performed by median sternotomy. It is defined as uncontrollable chylous fluid loss, and may lead to hypoproteinemia, malnutrition, and immune deficiency; hence, overall increases postoperative morbidity. In this report, we present a case in which chylopericardium developed after coronary artery bypass grafting. The patient has been successfully treated; however, postoperative course was majorly complicated with the consequences of chylous fluid loss. Interestingly, the cause of the drainage was a lymphatic channel in the mediastinum. To the best of our knowledge, this is the first report in the literature in which a lymphatic channel has been demonstrated sporadically in the mediastinum as a cause of chylopericardium following open heart surgery in the adulthood.

Effects of intrapleural analgesia on pulmonary function and postoperative pain in patients with chronic obstructive pulmonary disease undergoing coronary artery bypass graft surgery.

OBJECTIVE: Pain after coronary artery bypass graft (CABG) surgery remains a significant problem and may cause serious complications because of restricted breathing and limited early mobilization. The aim of this study was to assess the effects of intrapleural analgesia on the relief of postoperative pain in patients undergoing CABG surgery. DESIGN: Postoperative pain, pulmonary function tests, and outcomes were compared with a placebo group after CABG surgery in a double-blind randomized clinical trial. SETTINGS: Cardiovascular surgery clinic. PARTICIPANTS: One hundred twenty-five patients with decreased lung function were studied. INTERVENTIONS: Group A (62 patients) received 20 mL of 0.5% bupivacaine bilaterally in the intrapleural spaces every 6 hours for 4 days, and group B (63 placebo patients) received sterile saline solution. MEASUREMENTS AND MAIN RESULTS: Group A had a significantly shorter extubation time than the placebo group (8 +/- 1 h v 10 +/- 4 hours, p < 0.001). Blood gas analysis showed higher PaO2 and lower PaCO2 levels in group A. The patients receiving bupivicaine had significantly higher FEV1, FCV, VC, MVV, PEF, and FEF 25-75% values postoperatively when compared with the placebo group. Postoperative analgesic requirements and visual analog pain scales were significantly lower in group A. The intensive care unit stay in group A was shorter (1.2 +/- 0.7 v 1.4 +/- 0.6 days, p = 0.04); however, the hospital stay did not differ between groups. CONCLUSIONS: Improvement in lung function parameters correlating with decreased postoperative pain with intrapleural bupivacaine was observed. Intrapleural analgesia provided a good level of analgesia, improved respiratory performance, and allowed rapid mobilization, which led to a reduction of postoperative respiratory complications.

A practical and effective approach for the prevention of ischemia-reperfusion injury after acute myocardial infarction: pressure-regulated tepid blood reperfusion.

BACKGROUND: The prevention of perioperative ischemia-reperfusion injury is of critical importance, and this issue becomes more important in patients undergoing an early emergent revascularization procedure after an acute myocardial infarction. In this study, we sought to test the hypothesis that our simplified pressure-controlled initial reperfusion technique would be protective against ischemia-reperfusion injury in this subgroup of patients. METHODS: The data of 20 patients (group I) who underwent an emergent coronary artery bypass grafting procedure were analyzed and compared with the results of 37 patients (group II) underwent an innovative reperfusion technique. In group I patients, the operation was carried out using standard techniques. In group II, after the completion of all anastomoses, reperfusion was initiated before rewarming with a pressure of 20 to 25 mmHg and continued for a 2-minute period. Systemic blood pressure was then gradually increased to 40 mmHg and the aortic root was perfused at this pressure for another 2-minute period. Following the completion of the second low-pressure reperfusion period, cardiopulmonary bypass flow was regulated to preoperatively calculated values until systemic temperature reached 37 degrees C. RESULTS: Both groups showed significant differences in terms of cardiac output, arrhythmia rates, and biochemical parameters. Spontaneous sinus rhythm recurred more frequently in group II (P < .01, 86% versus 45%). Atrial fibrillation attacks were observed in 5 and 3 patients in groups I and II, respectively. All patients were medically converted to sinus rhythm with amiadarone and/or beta-blockers. Persistent electrocardiographic changes indicating postoperative myocardial infarction occurred in 5 patients in group I and in 1 patient in group II (P = .003). Postoperative enzyme levels were found to be lower in group II patients and the differences became statistically significant at the end of 24 hours. CONCLUSION: These results indicate that our controlled initial reperfusion technique is effective in the prevention of ischemia-reperfusion injury. We advocate the use of this innovative technique as an alternative to complex controlled aortic root reperfusion with the guidance of the early promising results of this study.

Being an elderly woman: is it a risk factor for morbidity after coronary artery bypass surgery?

OBJECTIVE: Despite the refinements in surgical techniques and postoperative care, elderly women still have a higher prevalence of postoperative morbidity. METHODS: The outcomes of 112 elderly women (>80 years) who underwent an elective CABG procedure were compared with those of males operated during the same time interval (n, 164). RESULTS: Median age of female and male patients were 82 and 83 years, respectively. Mean number of grafts did not differ significantly (3.7+/-0.8 vs 3.9+/-0.3, p=0.4) between groups. Overall early operative mortality rate was 8.6% (24 of 276 patients); 8.9% (10 of 112 patients) for female and 8.5% (14 of 164 patients) for male patients (p=0.1). Postoperative complications including prolonged ventilation time (13.4% in females vs 8.5% in male, p<0.01), atrial fibrillation (40% in females vs 33% in males, p=0.01), sternal reclosure (8% in females vs 4.2% in males, p=0.01), pneumonia (5.3% in females vs 3% in males, p=0.03), leg wound infection (11.7% in females vs 2.4% in males, p<0.001), renal dysfunction (10.7% in females vs 7.3% in young patients, p=0.02) have been found to be significantly higher in elderly women. Mean intensive care unit (3.2+/-1.1 days in females vs 1.6+/-0.4 in males, p=0.03), and hospital stays (13.6+/-2.1 days in females vs 9.1+/-1.2 in males, p=0.02) were also longer in female patients. Five-year survivals including all deaths for female and male patients were 57% and 62%, respectively. CONCLUSIONS: In elderly women, revascularization procedures can be done with acceptable mortality rates; but these patients are still associated with a higher prevalence of postoperative morbidity when compared with the male counterparts. Therefore, these patients have to be very carefully evaluated preoperatively and their postoperative care should be more comprehensive to reduce the incidence of postoperative complications.

Long-term results of the left anterior descending coronary artery reconstruction with left internal thoracic artery.

BACKGROUND: Recent refinements in percutaneous techniques have resulted in an increase in the numbers of patients with diffuse coronary artery disease who are referred to cardiac surgeons. Long-segmental reconstruction of the diffusely diseased left anterior descending (LAD) coronary artery with the left internal thoracic artery (LITA) has been shown to be beneficial for patients with diffuse coronary artery disease. In this retrospective study, we analyzed the long-term outcomes obtained with this technique. METHODS: Between April 1997 and February 2006, 3736 coronary artery bypass grafting (CABG) operations were performed by our team. Of these cases, 524 patients (14%) with the diffusely diseased LAD underwent a long-segmental reconstruction procedure with a LITA graft. RESULTS: The cohort consisted of 372 men (71%) and 152 women (29%), and the mean age was 56.5 +/- 8.2 years. The mean length of the arteriotomy incision was 4.5 +/- 1.2 cm (range, 2 to 10 cm). Postoperative mortality was 1.9%, and the myocardial infarction rate was 6.9%. At 3, 5, and 7 years, overall survival was 93.8% +/- 0.5%, 89.6% +/- 1.5%, and 85.5% +/- 2.6%, and actuarial freedom from angina recurrence was 94.5% +/- 1%, 88.5% +/- 2%, and 82.9% +/- 3%, respectively. Among survivors, interim angiographic evaluation was performed in 128 patients at a mean follow-up of 52.4 +/- 13.5 months, and the patency rate of the LITA-LAD anastomosis was 91.4%. CONCLUSIONS: Patients with diffuse LAD disease present a major challenge for cardiovascular surgeons. The long-term results of long-segmental LAD reconstruction are very encouraging, and this approach may be used safely in this subgroup of patients.

Pericardial patch augmentation of both anterior and septal leaflets in Ebstein's anomaly.

In Ebstein's anomaly, the aim of surgical intervention is the restoration of tricuspid valve competence. In some circumstances, however, paucity of the leaflet tissue precludes successful repair and negatively influences the long-term durability of the valvuloplasty procedure. We report a modified technique that provides satisfactory results for right atrioventricular valve function.

An alternative technique of proximal anastomosis in patients with an atherosclerotic ascending aorta.

Coronary artery bypass grafting operations in patients with an atherosclerotic ascending aorta are still associated with an increased risk of cerebral embolism and mortality despite previously described techniques. Here we present an alternative technique for the construction of a proximal anastomosis avoiding aortic clamping and deep hypothermic circulatory arrest.

Simultaneous coronary artery bypass grafting and ascending aorta to bifemoral bypass for ischemic heart disease combined with critical leg ischemia: case reports.

Coronary artery disease may coexist with aortoiliac occlusive disease, and concomitant revascularization procedures may be required. The ascending aorta may be used as the source of inflow to both the femoral and coronary arteries in patients who present with coronary artery disease and critical leg ischemia. We present here 2 patients in whom coronary artery bypass grafting and ascending aorta-to-bifemoral bypass operations were performed simultaneously.

CABG without using heparin in a patient with heparin-induced thrombocytopenia.

BACKGROUND: Despite the low incidence of heparin-induced thrombocytopenia and thrombosis, these two syndromes are much disputed in life-threatening conditions especially in cardiovascular surgery where heparin is routinely used. Nowadays a pharmacological agent that can exactly replace heparin does not exist. Many of the drugs called "alternative drugs to heparin" are associated with a high risk of hemorrhagic complications and an increased need of blood transfusions. Neither the use of heparin nor "alternative drugs to heparin" may be the best way to revascularize a patient with heparin-induced thrombocytopenia. METHODS: Coronary artery bypass grafting without using heparin was performed in a 62-year-old male patient with heparin-induced thrombocytopenia. He received clopidogrel and acethyl salicylic acid for 2 days before operation. He was operated off-pump using special maneuvers. RESULTS: He was discharged on postoperative day 5 after an uneventful course and is doing well in the sixth month postoperatively. CONCLUSIONS: According to our investigations in English literature, this surgical technique and coronary artery bypass grafting without using heparin is firstly described in this article. Increasing the number of cases will show the reliability and safety of this method.