Factors associated with early mortality in haemodialysis patients undergoing coronary artery bypass surgery.

INTRODUCTION: Coronary artery bypass grafting (CABG) results in higher morbidity and mortality rates in end-stage renal disease (ESRD) patient populations than in patients with normal renal function. This study aimed to identify the early results of CABG performed on ESRD patients, and the factors that affected the mortality rates of those patients. METHODS: A retrospective evaluation of our hospital database revealed 84 haemodialysis-receiving patients who underwent CABG during the years 2006 to 2012. Mortality was observed in 21 patients (group 1), and this group was compared with the remaining patients (group 2) for peri-operative parameters such as age, EuroSCORE, functional capacity, myocardial infarction, use of inotropes and completeness of revascularisation. RESULTS: The study included 60 male (71.4%) and 24 female patients (28.6%); the participants' mean age was 59.50 ± 9.93 years. The pre-operative additive EuroSCORE was 7.96 ± 2.88 (range: 2-18). Pre-operative functional capacity was impaired in 35.7% of the patients [New York Heart Association (NYHA) classes III-IV]. Mean age and preoperative EuroSCORE values of group 1 were significantly higher than those of group 2. Impaired functional capacity (NHYA classes III-IV) was also associated with mortality (OR: 3.333; 95% CI: 1.199-9.268). Fifty-four patients (64.3%) underwent on-pump CABG procedures, and 30 (35.7%) underwent off-pump CABG procedures. The study found no statistically significant difference in mortality rates between these two techniques. Mortality occurred in 12 patients (22.2%) in the on-pump group and in nine (30%) in the off-pump group. Complete revascularisation was performed on 46 patients (85.2%) in the on-pump group and seven (23.3%) in the off-pump group (p < 0.001). CONCLUSION: Advanced age, impaired NYHA functional capacity and pre-operative hypertension were determinative for early-term surgical mortality. An on-pump surgical technique is recommended to ensure completeness of revascularisation.

Comparison of Early Outcomes with Three Approaches for Combined Coronary Revascularization and Carotid Endarterectomy.

Objective: This study aims to compare three different surgical approaches for combined coronary and carotid artery stenosis as a single stage procedure and to assess effect of operative strategy on mortality and neurological complications. Methods: This retrospective study involves 136 patients who had synchronous coronary artery revascularization and carotid endarterectomy in our institution, between January 2002 and December 2012. Patients were divided into 3 groups according to the surgical technique used. Group I included 70 patients who had carotid endarterectomy, followed by coronary revascularization with on-pump technique, group II included 29 patients who had carotid endarterectomy, followed by coronary revascularization with off-pump technique, group III included 37 patients who had coronary revascularization with on-pump technique followed by carotid endarterectomy under aortic cross-clamp and systemic hypothermia (22-27ºC). Postoperative outcomes were evaluated. Results: Overall early mortality and stroke rate was 5.1% for both. There were 3 (4.3%) deaths in group I, 2 (6.9%) deaths in group II and 2 (5.4%) deaths in group III. Stroke was observed in 5 (7.1%) patients in group I and 2 (6.9%) in group II. Stroke was not observed in group III. No statistically significant difference was observed for mortality and stroke rates among the groups. Conclusion: We identified no significant difference in mortality or neurologic complications among three approaches for synchronous surgery for coronary and carotid disease. Therefore it is impossible to conclude that a single principle might be adapted into standard practice. Patient specific risk factors and clinical conditions might be important in determining the surgical tecnnique.

Comparison of early outcomes with three approaches for combined coronary revascularization and carotid endarterectomy

Abstract Objective: This study aims to compare three different surgical approaches for combined coronary and carotid artery stenosis as a single stage procedure and to assess effect of operative strategy on mortality and neurological complications. Methods: This retrospective study involves 136 patients who had synchronous coronary artery revascularization and carotid endarterectomy in our institution, between January 2002 and December 2012. Patients were divided into 3 groups according to the surgical technique used. Group I included 70 patients who had carotid endarterectomy, followed by coronary revascularization with on-pump technique, group II included 29 patients who had carotid endarterectomy, followed by coronary revascularization with off-pump technique, group III included 37 patients who had coronary revascularization with on-pump technique followed by carotid endarterectomy under aortic cross-clamp and systemic hypothermia (22-27ºC). Postoperative outcomes were evaluated. Results: Overall early mortality and stroke rate was 5.1% for both. There were 3 (4.3%) deaths in group I, 2 (6.9%) deaths in group II and 2 (5.4%) deaths in group III. Stroke was observed in 5 (7.1%) patients in group I and 2 (6.9%) in group II. Stroke was not observed in group III. No statistically significant difference was observed for mortality and stroke rates among the groups. Conclusion: We identified no significant difference in mortality or neurologic complications among three approaches for synchronous surgery for coronary and carotid disease. Therefore it is impossible to conclude that a single principle might be adapted into standard practice. Patient specific risk factors and clinical conditions might be important in determining the surgical tecnnique.

The use of posterior pericardiotomy technique to prevent postoperative pericardial effusion in cardiac surgery.

AIM: The goal was to determine the effectiveness of the posterior pericardiotomy technique in preventing the development of early and late pericardial effusions (PEs) and to determine the role of anxiety level for the detection of late pericardial tamponade (PT). MATERIALS AND METHODS: We divided 100 patients randomly into 2 groups, the posterior pericardiotomy group (n = 50) and the control group (n = 50). All patients undergoing coronary artery bypass grafting surgery (CABG), valvular heart surgery, or combined valvular and CABG surgeries were included. The posterior pericardiotomy technique was performed in the first group of 50 patients. Evaluations completed preoperatively, postoperatively on day 1, before discharge, and on postoperative days 5 and 30 included electrocardiographic study, chest radiography, echocardiographic study, and evaluation of the patient's anxiety level. Postoperative causes of morbidity and durations of intensive care unit and hospital stays were recorded. RESULTS: The 2 groups were not significantly different with respect to demographic and operative data (P > .05). Echocardiography evaluations revealed no significant differences between the groups preoperatively; however, before discharge the control group had a significantly higher number of patients with moderate, large, and very large PEs compared with the pericardiotomy group (P < .01). There were 6 cases of late PT in the control group, whereas there were none in the pericardiotomy group (P < .05). Before discharge and on postoperative day 15, the patients in the pericardiotomy group showed significant improvement in anxiety levels (P = .03 and .004, respectively). No differences in postoperative complications were observed between the 2 groups. CONCLUSION: Pericardiotomy is a simple, safe, and effective method for reducing the incidence of PE and late PT after cardiac surgery. It also has the potential to provide a better quality of life.

Does acute aortic dissection display seasonal variation?

BACKGROUND: The relation between cardiovascular diseases and the seasons is well known; however, only a few reports have addressed the seasonal aspects of acute aortic dissections. We investigated whether presentation of acute aortic dissection has monthly/seasonal variations. METHODS: From February 1985 to January 2006, 165 consecutive patients with aortic dissection admitted to our institution were reviewed. During this period, regional monthly atmospheric pressure data were supplied by the state's meteorological service. The mean and SD of atmospheric pressure data were analyzed statistically. RESULTS: The frequency of acute aortic dissection was found to be significantly higher during winter versus other seasons (P = .041). A relatively high positive correlation was found between the incidence of acute aortic dissection and the mean atmospheric pressure (P = .037). The study confirmed monthly variation with a peak in January. In winter, the frequency of acute aortic dissection was higher in male than in female patients. CONCLUSIONS: This study demonstrates that the occurrence of acute aortic dissection has significant seasonal/monthly variations. Thus, these observations may be a guide for prevention of acute aortic dissections by structuring treatment approaches with consideration given to the times of the year that patients are most vulnerable.

Association of prolidase activity, oxidative parameters, and presence of atrial fibrillation in patients with mitral stenosis.

BACKGROUND: Mitral stenosis (MS) is a common cause of atrial fibrillation (AF). Oxidative stress and inflammation factors were shown to be involved in atrial remodeling. The study aim was to compare the oxidative parameters and prolidase activity in severe MS patients with and without AF. METHODS: The study population was comprised of 33 patients with MS and sinus rhythm (group I), 27 patients with MS and AF (group II), and 25 healthy controls (group III). Plasma prolidase activity, total antioxidant capacity (TAC), total oxidative status (TOS), and oxidative stress index (OSI) were determined. Additionally, we measured tissue TOS and TAC in patients with mitral valve replacement. RESULTS: TAC and OSI were higher, but TOS and prolidase were lower in patients with MS than control (all p <0.001). These parameters were similar in group I and group II (ANOVA p >0.05). Tissue TAC was significantly lower in group II than group I (0.015 +/- 0.01 vs. 0.026 +/- 0.01 mmol Trolox equiv/L, p = 0.014), tissue TOS was similar between groups I and II (0.24 +/- 0.06 vs. 0.22 +/- 0.05 mmol Trolox equiv/L, p = 0.161). Presence of AF was correlated with systolic blood pressure, left atrial diameter, plasma TAC, tissue TAC, plasma TOS, plasma OSI, and plasma prolidase activity. Tissue TAC level (beta = -0.435, p = 0.006) and left atrial diameter (beta = 0.460, p = 0.003) were independently related with presence of AF in patients with MS. CONCLUSIONS: This study suggested that the presence of AF in patients with severe MS may be associated with the plasma prolidase activity, tissue and plasma oxidative parameters.

Surgical management of coronary malperfusion due to type a aortic dissection.

BACKGROUND: Acute aortic dissection coexisting with coronary malperfusion is a relatively rare but fatal condition. Surgical treatment of these patients is to perform early coronary revascularization concomitant with aortic repair. We review our surgical results of a selected group of 14 patients with type A acute aortic dissection and coronary artery dissection. METHODS: Between January 1993 and March 2005, 14 patients (10.2%) from a total of 136 consecutive patients with acute type A aortic dissection concomitant coronary dissection were treated by performing aortic repair and coronary artery bypass grafting. There were 11 men and 3 women (mean age, 56.7 +/- 8.4 years). The right coronary artery was involved in eight patients, the left in two patients, and both coronary arteries in four patients. At admission, nine patients had Q waves (64.2%), inferior in seven (50%) and anterior or lateral in two (14.2%). RESULTS: Hospital mortality rate was 21.4% (3 of 14 patients). Of these, two patients could not be weaned from cardiopulmonary bypass, and one patient died of multiorgan failure in the intensive care unit. CONCLUSIONS: Since acute type A aortic dissection with coronary involvement is associated with high mortality rate, immediate coronary artery bypass grafting and aortic repair is a safe and reliable approach to these challenging group of patients.

Simultaneous Carotid Endarterectomy and Coronary Revascularization is Safe Using Either On-Pump or Off-Pump Technique.

The appropriate surgical strategy for patients with combined carotid and coronary artery disease remains controversial. We retrospectively compared our surgical results for 2 types of approaches in this disorder. The records of 76 patients consecutively operated on for carotid and coronary artery disease between August 1993 and October 2004 were reviewed. There were 18 males (66.6%) and 9 females (33.3%) in group I. Group II consisted of 35 males (71.4%) and 14 females (28.5%). The patients were divided into two groups: patients with combined off-pump coronary artery bypass and carotid endarterectomy (group I, n = 27), and those with one-stage on-pump coronary artery bypass and carotid endarterectomy (group II, n = 49). Surgical mortality and morbidity and late outcome were compared among the two groups. The average number of grafts was 1.2 +/- 0.4, with the average operative time of 3.3 +/- 0.3 hours in group I, and 2.3 +/- 0.5 grafts with operative time of 4.6 +/- 0.4 hours in group II (P < 0.001 and P < 0.001, respectively). There was 1 death (3.7%) in group I and 2 deaths (4.8%) in group II (P = 0.937). No patient from either group I or group II had postoperative stroke. Mean hospital stay was 7.4 +/- 1.9 days in group I and 11.3 +/- 1.7 days in group II (P < 0.001). At a mean follow-up of 5.5 +/- 3.3 years in group I, 1 patient had contralateral carotid endarterectomy (3.7%). Group II had a mean follow-up of 5.2 +/- 3.0 years and contralateral carotid endarterectomy was performed in 1 patient (2.0%). There were no late strokes or deaths in either group. Combined coronary artery bypass grafting and carotid endarterectomy using 2 different types of technique is a safe and effective procedure in patients with significant concomitant monolateral carotid and coronary artery disease.

Aortic valve replacement for a patient with glucose-6-phosphate dehydrogenase deficiency and autoimmune hemolytic anemia.

Autoimmune hemolytic anemia and deficiency of glucose-6-phosphate deyhdrogenase (G6PD) result in severe hemolysis with different mechanisms. In patients with both pathologies, the effects of cardiopulmonary bypass on red blood cells and thrombocytes demand special care before and after open heart surgery. We evaluated the preoperative management and postoperative care of a patient with severe aortic insufficiency associated with G6PD deficiency and autoimmune hemolytic anemia who underwent aortic valve replacement.

Surgical management of cardiac myxoma.

OBJECTIVE: Between 1994 and December 2003, 55 patients were operated for cardiac myxoma in Kosuyolu Heart and Research Hospital in Istanbul. METHODS: We retrospectively analyzed our results according to the preoperative characteristics, operative procedures, and postoperative courses. RESULTS: Of 55 patients operated, 36 (65.4%) were female and 19 (34.6%) male. The average age of the patients was 48 +/- 15.5 years (range, 12-75). Thirteen patients (23.6%) previously had cerebrovascular accidents. Peripheral arterial emboli had occurred in 11 (20%) patients. The majority of the patients (44.4%) were in NYHA Class II preoperatively. One patient was presented with Carney's complex. Most frequent location was the left atrium (85.2%). Eight patients had concommitant surgery together with myxoma extirpation. Postoperative courses were uneventful. Three patients had a new onset atrial fibrillation, two had transient conduction disturbances. There were two (3.6%) in-hospital deaths. No recurrences have been noted during the 82.4 +/- 40.6 months (a total of 315.75 patient/years) follow-up. CONCLUSIONS: Surgical management of cardiac myxoma gives excellent results. In selected cases, a conservative approach may be adequate. Despite the scarcity of the neoplastic properties, careful follow-up is necessary.

Evolution of repaired and non-repaired tricuspid regurgitation in rheumatic mitral valve surgery without severe pulmonary hypertension.

The aim of this study was to evaluate the usefulness of repairing significant tricuspid regurgitation (> or = grade 2) without severe pulmonary hypertension (< or = 50 mm Hg). Between 1993 and June 2001, 88 consecutive patients were operated on for rheumatic mitral valve disease associated with significant tricuspid regurgitation and without severe pulmonary hypertension. The severity of the tricuspid valve disease was assessed by echocardiography. Sixty-three patients had severe (> or = grade 3) tricuspid regurgitation (Group I), and 25 patients had moderate (grade 2) tricuspid regurgitation (Group II). There was no hospital mortality. six patients died during follow-up. The overall actuarial survival rate for 8 years was 92.1% +/- 3.1%. Cox proportional hazard regression analysis showed that age ( p = 0.006) and pulmonary complication ( p = 0.01) were associated with increased late mortality. Freedom from death was similar in both groups at 8 years (93.1% +/- 3.3% versus 88% +/- 8%, p = 0.7). Severe postoperative tricuspid regurgitation (> or = grade 3), caused by the failure of tricuspid repair or leaving the valve untouched, impaired long-term survival after surgery, and actuarial survival was 96.1% +/- 2.7% and 83% +/- 7.8% at 7 years ( p = 0.048), respectively. Severe tricuspid regurgitation, functional or organic, should be corrected at the time of mitral valve surgery, whereas untouched functional moderate tricuspid regurgitation improves after mitral valve surgery.

[Traumatic vascular complications due to intraaortic balloon pump support]. / Intraaortik balon pompasi destegine bagli vasküler travmalar.

BACKGROUND: The use of an intraaortic balloon pump (IABP) catheter was retrospectively evaluated in terms of risk factors, insertion techniques, and complications in patients with low cardiac output. METHODS: A total of 1036 patients (804 males, 232 females; mean age 53.4 years; range 16 to 75 years) received IABP support from 1985 to March 2002. Of these, 789 patients (76.1%) underwent open heart surgery, 247 patients (23.8%) developed low cardiac output during medical treatment. Insertion of IABP was performed via the femoral artery either percutaneously by the Seldinger technique in 897 patients (86.6%), or by direct surgical exposure in 88 patients (8.5%). Open surgical IABP insertion was performed through an 8 mm Dacron graft placed with an end-to-side anastomosis to the common femoral artery (88 patients) or to the ascending aorta (23 patients). RESULTS: The overall mortality rate was 35.1% (364 patients). Vascular complications were associated with IABP in 104 patients (10%), of which 57 patients (5.5%) required surgical treatment. Major complications were aortic arch dissection in two patients and paraplegia in two patients. Vascular complications tended to increase with female gender, older age, diabetes, and peripheral vascular disease. The mean duration of IABP support in the presence of vascular complications was 7.8 days (range 5 hours to 77 days). CONCLUSION: Application of unsheathed IABP and proper evaluation of peripheral circulation seem to decrease the incidence of vascular complications.

Markers of myocardial ischemia in the evaluation of the effect of left anterior descending coronary artery lesion and collateral circulation on myocardial injury in 1-vessel off-pump coronary bypass surgery.

BACKGROUND: The purpose of this study was to use serum markers for myocardial tissue damage to evaluate the effect of the severity of left anterior descending artery (LAD) lesions after 1-vessel off-pump coronary artery bypass grafting. METHODS: A consecutive series of 20 patients with a totally occluded LAD and only retrograde filling (group T; n = 10) or critical stenosis (70%-99%) and only antegrade filling (group C; n = 10) were included in this study. One patient in group C who displayed no increases in the levels of markers for myocardial ischemia was excluded from the study because of the intraoperative repetition of the anastomosis. Creatine kinase activity (CK), CK-MB activity, and CK-MB mass, myoglobin, lactate, and cardiac troponin I (cTnI) concentrations were determined in venous blood samples taken immediately before and after the anastomosis and at 4, 8, 12, 24, and 48 hours postoperatively. RESULTS: There were no perioperative myocardial infarctions. One patient in group T developed low cardiac output syndrome 48 hours after the operation and died after 1 month. His enzyme levels did not increase in the first 2 days postoperatively. Anastomosis times were similar for the T and C groups (6.85 +/- 0.9 minutes versus 8.4 +/- 2.2 minutes, respectively; P =.069). The levels of all cardiac markers except cTnI increased significantly in the first 24 postoperative hours. CK-MB activity, CK-MB mass concentration, and cTnI concentration were not different between the 2 groups. Four patients in each group were evaluated for the patency of the anastomosis, and all control angiography and myocardial scanning tests showed patent anastomoses and no ischemia. CONCLUSIONS: One-vessel off-pump coronary artery bypass grafting can be performed safely in patients with serious LAD stenosis and borderline antegrade blood flow without the need for any coronary collateral circulation support. A short anastomosis time prevents myocardial injury during off-pump coronary surgery.

Effects of coronary artery bypass grafting on cellular immunity with or without cardiopulmonary bypass: changes in lymphocytes subsets.

Cell-mediated immunity responses decrease after all kinds of surgical procedures. Either anesthesia or surgical trauma plays an important role in this effect. Identification of functional lymphocyte subsets, by using appropriate monoclonal antibodies and analysis of flow cytometry data, appears to provide an accurate measurement of cellular immune competence. We found a significant decrease in the total number of T helper/inducer cells (p<0.035), B cells (p<0.043) and natural killer cells (NK) (p<0.018) but in contrast, increase in NK cell activity (p<0.012) in the peripheral arterial blood of ten patients undergoing coronary artery bypass grafting with cardiopulmonary bypass (group 1) immediately after surgery and postoperative day 1 (POD1). On the other hand, there was no significant change of these parameters occurred in the peripheral arterial blood of ten patients (group 2) who were undergoing coronary artery bypass grafting without cardiopulmonary bypass. Therefore, we conclude that coronary artery bypass grafting (CABG) with cardiopulmonary bypass induce a greater decrease in immunologic response than CABG without cardiopulmonary bypass (off pump) operations. Nevertheless, off pump CABG operations do not induce a greater decrease in immunologic response than other surgical operations.

Early- and long-term comparison of the on- and off-pump bypass surgery in patients with left ventricular dysfunction.

OBJECTIVE: The adverse effects of extracorporeal circulation increase the morbidity and mortality risk of coronary bypass surgery, especially in patients with left ventricular dysfunction. The purpose of this study was to provide a comparison of the early and long-term outcome between patient groups with left ventricular dysfunction (LVEF<40% or LVPS>or=15) operated with or without using cardiopulmonary bypass. METHODS: Fifty-one patients with left ventricular dysfunction, who were operated on between October 1992 and March 1994, were investigated retrospectively. They were divided into two groups: BH-group included 26 patients and cardiopulmonary bypass group had 25 patients. Mean age and risk factors were identical. All patients received one vessel bypass left internal mammary artery to left descending artery. RESULTS: There was no early mortality and perioperative myocardial infarction in either group. In the early postoperative period the need of cardiac support therapy was significantly higher in the cardiopulmonary-bypass group than in the beating heart-group: 32% versus 7.7% (p<0.05). The need for blood products (for fresh frozen plasma 3.63 +/- 2.15u versus 2.5 +/- 1.34u; p = 0.023; for packed red blood cells 1.8 +/- 0.75u versus 1.25 +/- 0.46u; p = 0.048), the extubation time (18.2 +/- 5.5 hours versus 15.3 +/- 3.8 hours; p = 0.03) and the hospital stay (10.64 +/- 3.2 days versus 7.92 +/- 2.25 days; p = 0.001) were higher in the cardiopulmonary bypass -group than in the beating heart-group. Actuarial survival for the beating heart-group was 92.3 +/- 5.2% at 6 years, and for the cardiopulmonary bypass group was 92 +/- 5.4% at 6 years (p = 0.67). CONCLUSIONS: In spite of more than four times as many patients in the cardiopulmonary bypass group requiring inotropic support after surgery, survival and cardiac death rates were similar for both groups. Off-pump bypass surgery conserves the blood constituents. The benefits of both techniques to improve the left ventricular performance score and ejection fraction were similar, but postoperative extubation time, length of intensive care unit and hospital stay were reduced significantly in the beating heart group. With these good results of the beating heart coronary bypass surgery and considering its cost effectiveness, we concluded that coronary bypass on a beating heart can be an alternative to cardiopulmonary bypass technique in selective patient groups.