Bedside surgery to treat patent ductus arteriosus in low-birth-weight premature infants.

BACKGROUND: Patent ductus arteriosus (PDA) is commonly seen in premature infants with low birth weights (LBW). It is a condition that has high mortality and morbidity rates. Early closure of the ductus arteriosus may require surgery or medical treatment. However, the decision of first medical approach for symptomatic PDA closure is still debated. In this study, we compared the surgical and medical treatments for the closure of PDA in premature LBW infants. METHODS: This study included 27 premature infants whose birth weights were lower than 1500 g, who were born in the period between 2011 and 2013 and had symptomatic PDA. Patients were separated into two groups: groups A and B. Group A included patients whose PDAs were closed with medical treatment (n = 16), and group B included patients who had undergone surgical operations for PDA closure (n = 11). RESULTS: There were no statistically significant differences between groups A and B when the groups were compared in terms of birth weight, gestational age, respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), sepsis, intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP), and pneumothorax. Although the mortality rate was determined to be lower in group B (2 out of 11, 18.1%) than in group A (7 out of 16, 43.7%), no statistically significant difference was found between the two groups. A statistically significant increase was determined in the incidence of kidney function loss in patient group that received Ibuprofen, a medical treatment, in comparison to the patients who had surgery. CONCLUSION: In conclusion, surgery is a safe method to repair PDA in premature LBW infants. Although there is no remarkable difference between surgery and medical treatment, we suggest that a surgical approach may be used as a first choice to repair PDA considering the lower rate of mortality and morbidity and higher rate of closure compared to medical treatment.

Advanced treatment of acute femoropopliteal bypass graft occlusion with Fogarty catheter guidance.

PURPOSE: The guiding role of the Fogarty catheter was investigated among patients suffering from limb ischemia due to acute femoropopliteal bypass graft occlusion. METHODS: A total of 27 patients with a history of femoropopliteal bypass operation who was admitted with acute limb ischemia were enrolled in this retrospective study. In cases in which the Fogarty catheter could not be passed through the popliteal anastomosis, the popliteal region was explored and a new bypass or patch plasty was performed for the distal anastomosis. The cases in which the blood circulation was observed in the graft, but in which the Fogarty catheter balloon was stuck in the native vessels on the proximal and distal side of the graft and the balloon could be withdrawn by deflation, were referred to conventional angiography. The stenosis observed in native vessels was managed by endovascular stent grafting and/or balloon dilatation. FINDINGS: Graft patency was achieved in all patients. In 11 patients, conventional angiography was implemented following embolectomy. In these patients, all the occlusions found as significant on angiography were removed by percutaneous transluminal angioplasty. CONCLUSION: Effective use of Fogarty catheter is safe in acute femoropopliteal bypass graft occlusions and in particular, in the planning of further treatment following thrombectomy.

Pulsatile versus non-pulsatile flow to reduce cognitive decline after coronary artery bypass surgery: A randomized prospective clinical trial.

BACKGROUND: In this prospective study, we aimed to compare the effect of pulsatile and non-pulsatile flow on the cognitive functions in patients undergoing coronary artery bypass surgery. METHODS: Patients scheduled for their first coronary artery bypass surgery (n = 148) were randomly assigned to the pulsatile flow group (Group A, n = 75) or non-pulsatil group (Group B, n = 73). Cognitive performance was assessed with (MoCA) montreal cognitive assessment test performed by psychologists before coronary artery bypass surgery and 1 month after the operation. RESULTS: Mild cognitive impairment was seen in 12 (16%) patients and serious cognitive impairment was seen in 1 (1.33%) patient in the pulsatile flow group. In the other group, mild cognitive impairment was detected in 23 (31.50%) patients and serious cognitive decline was found in 3 (4.10%) patients. Mean MoCA scores were 25.86 ± 2.62 in group A and 22.12 ± 2.20 in group B. The difference between two groups was statistically significant (P = 0.041). CONCLUSIONS: We suggest that pulsatile flow has beneficial effects to decrease cognitive dysfunction in patients undergoing on-pump coronary artery bypass surgery.

Preoperative mild cognitive dysfunction predicts pulmonary complications after coronary artery bypass graft surgery.

OBJECTIVES: In elderly patients with mild cognitive impairment, noncompliance with respiratory exercises, ineffective expectoration, reluctance in mobilization, and difficulty in learning the use of drugs such as inhalers were observed in the early postoperative period after coronary artery bypass graft surgery. It was hypothesized that respiratory complications may be more frequent in these patients, and so the postoperative respiratory complications in patients with preoperative mild cognitive impairment were compared with the postoperative respiratory complications of a control group. DESIGN: A prospective cohort control. SETTING: A university hospital. PARTICIPANTS: Patients undergoing elective coronary artery bypass graft surgery. INTERVENTIONS: Investigators separated 48 patients>70 years old who were scheduled for elective coronary artery bypass graft surgery into two groups: patients with preoperative mild cognitive impairment (group A, n = 25) and patients with no cognitive impairment (control group; group B, n = 23). The patients' cognitive status was evaluated preoperatively by the Montreal Cognitive Assessment test. MEASUREMENTS AND MAIN RESULTS: Pulmonary functions and respiratory complications were evaluated via chest x-rays and spirometry tests preoperatively and postoperatively. A significant difference was observed between the groups, particularly with regard to atelectasis and prolonged ventilation (p<0.001 and p<0.05). No significant impairment was observed in the spirometry tests of the control group. However, a significant deterioration was observed in the postoperative spirometry tests of patients with preoperative mild cognitive impairment. CONCLUSIONS: This study suggested that mild cognitive impairment was associated with pulmonary complications after coronary artery bypass graft surgery.

Effect of tadalafil on neointimal hyperplasia in a rabbit carotid artery anastomosis model.

PURPOSE: Intimal thickening, which results from the response to arterial damage caused by therapeutic interventions or other reasons, is usually called as neointima. Neointimal hyperplasia is a main step in the pathogenesis of late-term restenosis, which is developed after vascular interventions. Reduction in nitric oxide (NO)/cyclic guanosine monophosphate (cGMP) signaling plays a substantial role in the pathogenesis of neointima formation. Phosphodiesterase V is detected in the peripheral coronary and pulmonary vascular smooth muscle cells and in the cardiac tissue. Based on the effects of phosphodiesterase V inhibitors on vascular smooth muscle cells, in the present study, the effect of tadalafil, a new member of phosphodiesterase V inhibitors, on neointimal hyperplasia was investigated in the rabbit carotid artery anastomosis model. MATERIAL AND METHOD: Fourteen male New Zealand white rabbits weighing between 2.5-3 kg, were used. The rabbits were randomly divided into two equal groups; tadalafil group received oral tadalafil (2 mg/kg/day), and PBS group received sterile PBS solution (normal saline; 2 mg/kg/day) for 28 days after the surgery. The right carotid arteries of all rabbits were anastomosed in an end-to-end fashion using 8/0 polypropylene suture. The rabbits were sacrificed at the end of the postoperative period of 28 days. After sacrificing, firstly anastomosis segment on the right carotid artery and secondly a part of the left carotid artery (as control) of each rabbit were removed. Morphometric examination of tissue sections was performed under a light microscope connected to an image capture system. RESULTS: There was a significant difference between the right and left carotid arteries in terms of intimal area and intima/media ratio both in tadalafil and PBS groups (p <0.001 for each). Intimal area and intima/media ratio were increased in the right carotid arteries compared to the left carotid arteries (p <0.001 for each). Besides, when the right carotid arteries of both groups were compared using covariance analysis, it was observed that intimal area and intima/media ratio in the anastomosis site were significantly reduced with tadalafil treatment (p <0.001). CONCLUSION: The present study was promising in terms of tadalafil use as a new agent for the prevention of neointimal hyperplasia, which is the leading cause of late-term graft failure in vascular surgery.

The effects of PPAR-γ agonist pioglitazone on renal ischemia/reperfusion injury in rats.

BACKGROUND: Acute renal failure due to renal ischemia/reperfusion (IR) injury is a significant clinical problem in cardiovascular surgery. Reactive oxygen species and inflammation play essential roles in the pathophysiology of IR injury. Matrix metalloproteinases (MMPs) are enzymes that play important roles in inflammation and mediate extracellular matrix degradation. It is known that peroxisome proliferator-activated receptor-γ agonists have antiinflammatory and antioxidant effects. In the present study, we aimed to investigate the effects of pioglitazone, a synthetic peroxisome proliferator-activated receptor-γ agonist, on MMPs and oxidative stress in a renal IR injury model in rats. MATERIALS AND METHODS: Male Wistar albino rats were divided into three groups: control (n = 7), placebo (n = 7; saline/p.o.), and pioglitazone (n = 7; 5 mg/kg/day/p.o.). In the control group, a right nephrectomy was conducted without left renal IR injury. In the placebo and pioglitazone groups, pretreatments were started 3 d before operation. In both groups, left renal pedicles were clamped for 60 min and then reperfused for 60 min. Paraffinized renal sections were evaluated histopathologically. Furthermore, expressions of MMP-2, MMP-9, tissue inhibitor of metalloproteinase (TIMP)-2, superoxide dismutase 1 (SOD1), and p47-phox/p67-phox subunits of NADPH oxidase were determined by immunostaining and scoring. RESULTS: In the placebo group, renal IR injury induced diffuse tubular necrosis and intense acute inflammation, but pioglitazone inhibited these effects. MMP-2, MMP-9, and TIMP-2 expression increased in the placebo group. However, while MMP-2 and -9 expression decreased, TIMP-2 expression did not change in the pioglitazone group. p47-phox/p67-phox expression increased in the placebo group, but SOD1 expression did not change. Pioglitazone diminished p47-phox/p67-phox expression, whereas it enhanced SOD1 expression. CONCLUSION: Our results suggest that pioglitazone might be helpful to reduce renal IR injury because of its antiinflammatory and antioxidant effects.

The effects of PPARγ agonist rosiglitazone on neointimal hyperplasia in rabbit carotid anastomosis model.

BACKGROUND: Neointimal hyperplasia involving smooth muscle cell (SMC) proliferation, migration and extracellular matrix (ECM) degradation is an important component of atherosclerosis. It develops as a response to vascular injury after balloon angioplasty and vascular graft placement. Matrix metalloproteinases (MMPs) induce SMC proliferation, migration and contribute to intimal hyperplasia by degrading ECM. PPARγ agonists inhibit SMC proliferation, migration and lesion formation. In this study, we aimed to investigate the effects of PPARγ agonist rosiglitazone on neointimal hyperplasia and gelatinase (MMP-2 and MMP-9) expressions in rabbit carotid anastomosis model. METHODS: New Zealand white rabbits (n = 13, 2.7-3.2 kg) were divided into placebo and treatment groups. Right carotid artery (CA) was transected and both ends were anastomosed. Treatment group (n = 6) received rosiglitazone (3 mg/kg/day/p.o.) and placebo group (n = 7) received PBS (phosphate buffered saline, 2.5 ml/kg/day/p.o.) for 4 weeks postoperatively. After the sacrification, right and left CAs were isolated. Morphometric analyses and immunohistochemical examinations for gelatinases were performed. RESULTS: Intimal area (0.055 ± 0.005 control vs 0.291 ± 0.020 µm(2) anastomosed, p < 0,05) and index (0.117 ± 0.002 control vs 0.574 ± 0.013 anastomosed, p < 0,01) significantly increased in anastomosed arteries compared to control arteries from placebo group. However, in rosiglitazone-treated group, intimal area (0.291 ± 0.020 PBS vs 0.143 ± 0.027 rosiglitazone, p < 0,05) and index (0.574 ± 0.013 PBS vs 0.263 ± 0.0078 rosiglitazone, p < 0,01) significantly decreased. Furthermore, gelatinase immunopositivity was found to have significantly increased in anastomosed arteries from placebo group and decreased with rosiglitazone treatment. CONCLUSIONS: These results suggest that rosiglitazone may prevent neointimal hyperplasia, which is the most important factor involved in late graft failure, by inhibiting gelatinase enzyme expression.

The effects of zoledronic acid on neointimal hyperplasia: a rabbit carotid anastomosis model.

OBJECTIVE: The aim of the present study was to investigate the effect of zoledronic acid (ZA), as a matrix metalloproteinase inhibitor, on neointimal hyperplasia in rabbit carotid anastomosis model. METHODS: New Zealand male rabbits were divided into two groups as placebo and treatment groups in this experimental study. After anesthesia, the right carotid artery of each rabbit was end-to-end anastomosed with an 8/0 polypropylene suture. Left carotid artery was kept as control without any operation. Placebo group (n=6) received phosphate buffered saline (PBS) (0.5mL/kg/day/s.c.) for 28 days postoperatively, whereas ZA group (n=6) received ZA (100 µg/kg/day/s.c.) for the same period. After sacrification, the anastomosed and control arteries were isolated. Morphometric and immunohistochemical examinations were performed. Statistical analyses of morphometric and immunohistochemical data were performed using two-way ANOVA and Chi-square test respectively. RESULTS: In PBS group, vascular injury in the anastomosed artery significantly increased the intimal area (anastomosed: 112.51±61.18 µm(2)*1000 vs. control: 22.62±4.26 µm(2)*1000, p<0.01) and intima/media index (anastomosed: 0.347±0.29 vs. control: 0.075±0.01, p<0.05) compared to control artery. ZA significantly reduced the intimal area (39.29±18.21 µm(2)*1000 , p<0.01) and intima/media index (0.112±0.07, p<0.05) compared to PBS group. Additionally, α-smooth muscle actin immunopositivity was found significantly decreased in anastomosed arteries from ZA group (ZA: 2.33±0.52 vs. PBS: 3.50±0.5, p<0.05). Moreover, intensive gelatinase (MMP-2 and MMP-9) immunoreactivities were clearly seen in anastomosed arteries compared to control arteries from PBS group. ZA apparently decreased immunopositivities for gelatinases in anastomosed arteries. CONCLUSION: ZA might be a promising agent for prevention of neointimal hyperplasia, which is the most significant cause of graft failures in late postoperative period.

The beneficial effects of tadalafil on renal ischemia-reperfusion injury in rats.

Acute renal failure due to ischemia-reperfusion (I/R) injury is a common complication in cardiovascular surgery. We determined the influence of tadalafil on renal injury in a renal I/R model in rats. For this purpose, 21 male Wistar albino rats were separated into 3 groups: sham, placebo and tadalafil. A right nephrectomy was performed, and the left renal pedicles were occluded for 60 min and reperfused for 60 min in the placebo and tadalafil groups. A single dose of tadalafil (10 mg/kg) through an orogastric tube was administered to the tadalafil group. Tubular atrophy with acute inflammation in renal histology, total oxidant status (TOS) and total antioxidant status (TAS) were determined in tissue homogenates. Compared to the tadalafil group, tubular atrophy and acute inflammation was significant in the placebo group. TAS levels were significantly higher in the tadalafil group compared to the placebo (p = 0.01) and sham groups (p = 0.04). While TOS levels were significantly higher in the placebo group (p = 0.03), tadalafil did not significantly alter the TOS levels. The beneficial effects of tadalafil can be attributed to its protective effects on renal tubular cells and inhibition of leukocyte infiltration in renal tissue. We think that tadalafil treatment has an important role in reducing renal injury resulting from renal I/R.

Repair of isolated mitral papillary muscle rupture consequent to blunt trauma in a small child.

Blunt thoracoabdominal trauma is most often caused by high-velocity motor-vehicle accidents or by falls from a height. The clinical spectrum of cardiac injuries arising from this type of trauma varies from myocardial contusion to valvular rupture. Intracardiac valvular rupture is rarely observed, and few cases have been reported. The youngest of the patients in cases reported to date was 6 years of age. Here we report the case of a 2(1/2)year-old child, who sustained mitral valve insufficiency due to isolated rupture of the posterior mitral papillary muscle, which developed after a domestic accident.

Postcardiotomy extracorporeal life support.

The need for postcardiotomy mechanical support is uncommon and likely to decline. A mixture of options is necessary to meet the diverse indications for cardiac support in a comprehensive heart failure program. Between January 1997 and December 2000, 29 adult, neonate, and infant cardiac surgical patients were supported on an extracorporeal life support system. Indications for cardiac assist included post-cardiotomy low cardiac output syndrome, and hyperacute rejection after cardiac transplantation. Data for analysis were collected prospectively. Survival on the life support system was 20/29 (69%) and 12 patients (41%) survived to discharge. The mean time to starting extracorporeal life support was longer in survivors than non-survivors. The extracorporeal life support system provides effective cardiopulmonary and end-organ support.

Surgical resection for successful treatment of invasive pulmonary aspergillosis: report of 3 cases.

We present 3 patients, 2 with recent heart transplants, complicated with invasive pulmonary aspergillosis (IPA), treated successfully with surgical resection. These patients demonstrate the role of surgery in management of IPA, and 2 heart transplant patients are of particular interest as surgical treatment of IPA after solid organ transplantation is seldom reported.

Pleural flap for treating perigraft leak after a modified Blalock-Taussig shunt.

Plasa oozing through the graft after a modified Blalock-Taussig shunt is a troublesome complication. We encountered a massive leak following a modified Blalock-Taussig shunt in a 2 1/2 year-old-girl which required reexploration. The leak was treated by wrapping the polytetrafluoroethylene shunt with the parietal pleura flap harvested from the adjacent chest wall. The patient had an uneventful recovery. Covering of the polytetrafluoroethylene shunt with parietal pleura appears to stop plasma leak through the graft following a modified Blalock-Taussig shunt.