An evaluation of factors affecting clinical outcomes in penetrating cardiac injuries: A single center experience.

BACKGROUND: Penetrating cardiac injury (PCI) has highly mortal outcome. Therefore, management of this emergency situation is extremely important. The present study is an investigation of main factors that can affect mortality and morbidity in PCI. METHODS: Records of 112 patients who were admitted to emergency department with PCI in the last decade were evaluated retrospectively. Demographic data, initial approach, transfer duration and conditions, vital status and findings, type of injury, localization, characteristics, and type of surgical application were recorded. RESULTS: Demographic findings (age, sex, cause of injury) were not found to be significant factors affecting mortality. Early mortality (1-week observation period) occurred in 14 (12.5%) patients. Method of transfer to hospital (under medical team supervision by ambulance, or without supervision), transfer duration, initial vital findings upon arrival (blood pressure, rhythm, breathing, consciousness), operation timing (elective or emergency), and injuries to additional organs were determined to be important predictors of survival. CONCLUSION: Cardiac injury is highly mortal emergency situation. Expert medical management is important for survival. However, basic first aid measures and immediate hospital transfer are as important as expert clinical management.

Evaluation of Pericardial Fluid C-Type Natriuretic Peptide Levels in Patients Undergoing Coronary Bypass Surgery.

Background Neurohumoral and hemodynamic mechanisms have an effect on cardiac activity. C-type natriuretic peptide (CNP) is accessible in the cardiovascular system. The aim of this study was to determine whether CNP concentrations in pericardial fluid and blood are related to cardiac dysfunction in patients undergoing coronary artery bypass graft surgery. Materials and Methods In this study, 40 patients undergoing coronary artery bypass grafting were enrolled. The patients were separated into two groups according to left ventricular (LV) ejection fraction (EF): group 1 contained 28 patients with normal LV systolic function (LVEF ≥ 50%) and group 2 contained 12 patients with impaired LV systolic function (LVEF < 45%). Plasma and pericardial fluid samples were acquired during surgery to measure CNP levels. Results In group 1, CNP levels were detected to be 0.46 ± 0.10 ng/mL in plasma and 0.66 ± 0.8 ng/mL in pericardial liquid. In group 2, these levels were 0.51 ± 0.09 and 0.79 ± 0.12 ng/mL, respectively. CNP levels were determined to be significantly higher in patients with low EF compared with those with normal EF in pericardial fluid concentrations (p = 0.013). Conclusions CNP level in pericardial fluid is a more sensitive and proper marker of LV dysfunction than CNP levels in plasma. To the best of our knowledge, this study is the first to examine pericardial fluid CNP levels in patients undergoing coronary artery bypass surgery. It may have a valuable role in organizing cardiac remodeling and hypertrophy.

Simple blood tests as predictive markers of disease severity and clinical condition in patients with venous insufficiency.

Chronic venous insufficiency (CVI) is a progressive inflammatory disease. Because of its inflammatory nature, several circulating markers were investigated for predicting disease progression. We aimed to investigate simple inflammatory blood markers as predictors of clinical class and disease severity in patients with CVI. Eighty patients with CVI were divided into three groups according to clinical class (grade 1, 2 and 3) and score of disease severity (mild, moderate and severe). The basic inflammatory blood markers [neutrophil, lymphocyte, mean platelet volume (MPV), white blood cell (WBC), platelet, albumin, D-dimer, fibrinogen, fibrinogen to albumin ratio, and neutrophil to lymphocyte ratio] were investigated in each group. Serum neutrophil, lymphocyte, MPV, platelet count, D-dimer and neutrophil to lymphocyte ratio levels were similar among the groups (P > 0.05). Although the serum WBC levels were significant in the clinical severity groups (P < 0.05), it was useless to separate each severity class. However, albumin, fibrinogen and the fibrinogen to albumin ratio were significant predictors of clinical class and disease severity. Especially, the fibrinogen to albumin ratio was detected as an independent indicator for a clinical class and disease severity with high sensitivity and specificity (75% sensitivity and 87.5% specificity for clinical class and 90% sensitivity and 88.3% specificity for disease severity). Serum fibrinogen and albumin levels can be useful parameters to determine clinical class and disease severity in patients with CVI. Moreover, the fibrinogen to albumin ratio is a more sensitive and specific predictor of the progression of CVI.

Pharmacomechanical thrombolysis with a rotator thrombolysis device in iliofemoral deep venous thrombosis.

OBJECTIVE: Deep venous thrombosis (DVT) is a life-threatening and morbid pathology. This study aimed to investigate the efficacy of an early thrombolysis procedure using a rotator thrombolysis device. METHODS: Sixty-seven patients with acute proximal DVT were enrolled in the study. Patients' data were recorded retrospectively. Initially, an infrarenal retrievable vena cava filter was placed through the femoral vein. Then, a rotator thrombolysis device and a thrombolytic agent injection were applied to the occluded segments of the deep veins by puncturing the popliteal vein. RESULTS: The identified reasons were trauma (43.3%), pregnancy (20.9%), undiagnosed (11.9%), major surgical operation (10.5%), immobilization (7.5%), and malignancy (5.9%). Immediate total recanalization was conducted in all patients, and the leg diameters returned to normal ranges in the early postoperative period. Hospital mortality or severe complications were not detected. CONCLUSION: New thrombolytic devices seem to reduce in-hospital mortality risks and may potentially decrease post-thrombotic morbidity.

Evaluation of the vasoplegic impact of papaverine in the rat aorta.

OBJECTIVE: To identify the degree of vasoplegic affinity of papaverine to rat thoracic aortas following constriction caused by adrenalin, serotonin and potassium chloride in an in-vitro model. METHODS: The in vitro vasoplegic efficacy of papaverine against adrenalin (10(-5) M), serotonin (5HT) (10(-4) M), and KCI (60 mM) was assessed, using a rat aortic vasospasm model in an organ bath. First, aortic rings were constricted with a submaximal dose of vasoconstrictor agents. The samples were then incubated with papaverine (3 x 10(-4) M) for 20 minutes, followed by readministration of the same vasoconstrictor agents. The first vasospastic response (before papaverine incubation) and the new vasoconstrictor responses (after papaverine incubation) of the vessels were then compared. RESULTS: The vasoplegic effect of vasoconstrictor agents in decreasing order was observed as adrenalin > KCl > 5HT. This different affinity for the vasoplegic effect is considered to be a temporary impact of the drugs and the maximal inhibition of vasoconstriction was detected for the adrenalin receptor. CONCLUSION: The relevance of the macromolecules is responsible for the permanent efficacy of the drugs. Different degrees of vasoconstriction were also obtained after papaverine administration, which suggests that different responses can occur as a result of different stimulation of receptor modulators.

Values of troponin T and myoglobin predictive of non-cardiac ischemia in rats.

OBJECTIVES: Biochemical markers are important for the timely diagnosis and follow-up of ischemic events. Most of the markers have been previously studied in the context of cardiac ischemia. However, research on markers of non-cardiac events has been insufficient. Therefore, we investigated the relationship between troponin and myoglobin which are commonly used markers of cardiac ischemia, in non-cardiac ischemia. MATERIALS AND METHODS: Forty-eight rats were equally divided into six groups. Group I was the control group. Group II was the sham group and received a simple laparotomy. The superior mesenteric artery was clamped in groups III and IV in order to create mesenteric ischemia. The left femoral artery was clamped in groups V and VI in order to create peripheral ischemia. Intracardiac blood samples were taken from all groups (during the 3(rd) hour of ischemia in groups III and V and the 6(th) hour of ischemia in group IV and VI) and troponin T and myoglobin levels were measured. RESULTS: Troponin and myoglobin levels were statistically similar in groups I and II. Moreover, increments were detected for troponin and myoglobin in ischemia groups according to group I and II. Furthermore, higher troponin Tlevels were detected after three hours of mesenteric ischemia and higher myoglobin values were observed after six hours of mesenteric ischemia (P<0.05). CONCLUSION: Troponin T and myoglobin are not specific for non-cardiac ischemia, and they may be useful for detecting other ischemic events.

The relationship between complete blood count parameters and Fontaine's Stages in patients with peripheral arterial disease.

OBJECTIVE: The aim of the present study is to evaluate whether blood count parameters differ according to the stages of Fontaine's classification and to investigate the relationship between hemogram parameters and the severity of the disease. METHOD: Eighty-two peripheral arterial disease patients were examined prospectively. Patients were classified according to the Fontaine classification system. Fifty newly diagnosed patients were included in the study. The neutrophil-to-lymphocyte ratio, mean platelet volume, and red blood cell distribution width values were recorded. RESULTS: Mean neutrophil-to-lymphocyte ratio values were found to be 3.31 ± 1.1% in Stage I, 3.11 ± 1.3% in Stage II, and 3.48 ± 1.1% in Stage III (p > 0.05). Mean platelet volume values were found to be 7.8 ± 0.6 fl (Stage I), 8.2 ± 1.0 fl (Stage II), and 9.0 ± 0.9 fl (Stage III) (p < 0.05). Red blood cell distribution width values were found to be 13.6 ± 1.0% in Stage I, 14.8 ± 1.7% in Stage II, and 15.4 ± 2.3% in Stage III, being significantly different among all three stages (p < 0.05). CONCLUSION: Both red blood cell distribution width and mean platelet volume are found to be associated with the severity of atherosclerotic disease in patients with peripheral arterial disease. This finding hypothesizes that complete blood counting parameters may serve as a beneficial and cost-effective method for monitoring atherosclerotic peripheral disease.

Investigation of the antiangiogenic behaviors of rivaroxaban and low molecular weight heparins.

Antithrombotic agents play important roles in the prophylactic and therapeutic management of many cardiovascular disorders. Therefore, many researchers have focused on developing new strategies for anticoagulation. New oral anticoagulants and factor Xa inhibitors are products of such research. Although they are identified as advantageous, there are limited data available about their multisystemic interactions. Thus, the antiangiogenic behaviors of oral factor Xa inhibitors and low molecular weight heparins (LMWHs) were investigated in this study. The chick chorioallantoic membrane (CAM) model was designed to investigate the antiangiogenic potential of new oral factor Xa inhibitors (rivaroxaban) and LMWHs (enoxaparin sodium and tinzaparin sodium). Four different molar concentrations (10, 10, 10, and 10 µmol/l) were studied for each drug. Each concentration was studied on 20 fertilized eggs. Vessel structures were evaluated under a stereoscopic microscope, and vessel formation was scaled according to previous literature. Both enoxaparin and tinzaparin sodium have increased antiangiogenic efficacy on CAM in a dose-dependent manner. However, this increased efficacy did not reach significant levels (average score < 0.5). On the contrary, while rivaroxaban showed dose-dependent antiangiogenic properties similar to enoxaparin and tinzaparin, a significant average antiangiogenic score (0.7) was detected at 10 µmol/l concentrations. New oral anticoagulants seem to be more favorable. However, their safety for the cardiovascular system needs to be clarified through microsystem studies on, for example, angiogenesis.

Factor-Xa inhibitors protect against systemic oxidant damage induced by peripheral-ischemia reperfusion.

Factor-Xa inhibitors are often used for prophylaxis and for the treatment of thrombotic vascular disorders. However, it is not known whether they are beneficial during the recanalization of the thrombotic vascular segment and during tissue reperfusion. Herein, we describe an animal study that was designed to investigate the possible protective effects and antioxidant properties of factor-Xa inhibitors. Forty rats were included in the study and were randomly divided into five equal groups. The first group served as a control group from which we obtained basal oxidant and antioxidant parameters. Peripheral ischemia was induced in the second group (sham group) for 6 h, and plasma levels of nitrogen oxide (NOx), prolidase and malondialdehyde (MDA) were obtained after 30 min of reperfusion. The sham group did not receive any drugs. Oral rivaroxaban (3 mg/kg) was administrated to Group III, intraperitoneal enoxaparin sodium (250 U/kg) was administrated to Group IV, and intraperitoneal bemiparine sodium (250 U/kg) was administrated to Group V 1 week prior to the induction of peripheral ischemia (for 6 h)-reperfusion. After 30 min of reperfusion, blood samples were obtained and NOx, prolidase and MDA levels in these groups were detected, and the rats were sacrificed. NOx levels were statistically similar (p > 0.05) between Groups I, II, III, IV, and V (20.7 ± 10.4, 17.4 ± 9.7, 25.9 ± 24.2, 27.0 ± 11.9, 23.3 ± 17.3 µmol/L, respectively). MDA levels were significantly lower (p < 0.05) in Groups III (rivaroxaban), IV (enoxaparin sodium), and V (bemiparine sodium) (24.9 ± 11.9, 25.9 ± 4.4, 25.4 ± 10.8 µmol/L, respectively) when compared with the sham group (Group II) (75.6 ± 24.3 µmol/L). Prolidase levels were higher (p > 0.05) in the ischemia reperfusion groups (659.2 ± 130.6 in II (sham), 1,741.0 ± 1,530.6 in III (rivaroxaban), 2,453.8 ± 1,590.4 in IV (enoxaparin sodium), and 889.2 ± 574.7 U/g in V (bemiparine sodium) than in the control group (144.6 ± 131.8 U/g). Ischemia-reperfusion events may occur in prothrombotic disorders. During these events, prophylactic or therapeutic factor-Xa inhibitors can protect against thrombosis and oxidative reperfusion injury. The new oral factor-Xa inhibitor, rivaroxaban, appears to provide the same antioxidant support as injectable low molecular weight heparins (LMWHs).

Can calcium dobesilate be used safely for peripheral microvasculopathies that require neoangiogenesis?

BACKGROUND: Calcium dobesilate (CaD) is a member of the synthetic veno-active drug family. Only a small number of reports are available that describe the micro-angiogenic effects of CaD in the current literature. MATERIAL AND METHODS: The antiangiogenic potential of CaD was compared with bevacizumab (Bb), which is a potent angiogenesis inhibitor, in a chick chorioallantoic membrane model. Four different concentrations (10-7, 10-6, 10-5, and 10-4 M) of drug pellet were prepared for each drug. Changes in vessel formation were scored and compared for each drug according to the previous literature. RESULTS: The antiangiogenic behavior of CaD was lower than Bb, despite the significant dose-dependent manner of escalation. The anti-angiogenic scores of CaD were determined as 0.20, 0.47, 0.66, 1.0 in 10-7, 10-6, 10-5, and 10-4 M concentrations, respectively (average score >0.5 was significant). CONCLUSIONS: According to the data obtained, this agent should be used carefully for cases in which angiogenesis plays an important role in healing.

Rosuvastatin may have neuroprotective effect on spinal cord ischemia reperfusion injury.

Ischemia reperfusion injuries can be threatening to end organ viability and can progress, with mortal and morbid outcomes. In particular, neural tissues are highly sensitive to hypoxia and reperfusion stress. This study aimed to determine the neuroprotective effects of rosuvastatin on spinal cord ischemia reperfusion injury. Forty male Sprague- Dawley rats were divided into four equal groups: group I (control), group II (sham with simple laparotomy), group III (ischemia-reperfusion), group IV (ischemia-reperfusion group with continuous rosuvastatin utilization), and group V (ischemia-reperfusion group with rosuvastatin-withdrawal after reperfusion). Spinal cord ischemia was induced by clamping the aorta below the left renal artery and above the aortic bifurcation. Reperfusion was provided after 72(nd) hours of ischemia. After reperfusion, blood samples and spinal cord tissue samples were taken from all the rats. Oxidative and antioxidant markers from both serum and tissue samples were evaluated, and tissues were examined histopathologically. There were no significant differences between the control and sham groups. A notable increase in oxidative markers was observed in group III compared to group I. In addition, a significant decrease in antioxidant markers was detected in group III. However, there was a marked preservation in the tissue and blood samples of groups IV and V compared to group III in terms of oxidative damage. Additionally, definitive prophylaxes were seen in the histopathological examination of the tissue samples in groups IV and V compared with group III. These significant findings show that rosuvastatin has a considerable protective effect on neural tissue against oxidative damage. Likewise, the early withdrawal of rosuvastatin has a clear neuroprotective effect similar to that of continuous therapy. Nevertheless, other systematic effects and beneficial neural effects of statins should be investigated in further clinical trials.

Reasons, procedures, and outcomes in ventriculoatrial shunts: A single-center experience.

BACKGROUND: Ventricular shunts are used to drain cerebrospinal fluid into extra-cranial spaces. Ventriculoatrial (VA) shunts are provided to transfer cerebrospinal fluid from the cerebral ventricle into the right atrium of the heart. A single center experience of indications, procedure, and clinical outcomes in VA shunt was presented in current study. METHODS: VA shunts were applied in 10 patients who had repeated previous shunt dysfunction or infection. The reasons, clinical findings, replacement methods, and postoperative clinical follow-ups and outcomes were recorded retrospectively. RESULTS: There were seven female (70%) and three (30%) male patients; their ages ranged from 5 to 13 years (mean ± SD; 8.5 ± 2.6 years). Shunt re-placement reasons were as follows: Shunt occlusion in five patients, intraperitoneal infection in four patients and a distal catheter was kinked and knotted in one patient. Postoperative early complications were seen in one patient as early catheter thrombosis and catheter revision were applied. Late complications were seen in two patients as follows: Catheter infection and infective endocarditis occurred in one patient and pulmonary thrombus occurred in one other patient. There was not any catheter-related mortality observed at the one year follow-up period. CONCLUSION: VA shunts may be an option for cerebrospinal fluid drainage at necessary conditions. However, sterilization and general training on asepsy and antisepsy are the most important determinants affecting the clinical outcome due to the cardio systemic relationship.

Serum nitric oxide level could be a predictive biomarker for detection of critical ischaemia duration.

OBJECTIVE: To investigate the predictive value of serum nitrate (nitrogen oxide: NOx) levels in the detection of peripheral and mesenteric ischaemia durations. METHODS: Rats were sacrificed for determining the basal serum values of NOx in Group I without any intervention. The superior mesenteric artery was clamped in Groups II and III and blood samples were taken at 120 minutes in Group II and at 360 minutes in Group III. The right common femoral artery was clamped in Groups IV and V and blood samples were taken at 120 minutes in Group IV and at 360 minutes in Group V. RESULTS: The peak values of NOx were obtained in Group II and Group IV. NOx levels were reduced in advanced periods of ischaemia. In the other words, the NOx levels were significantly higher at two hours of ischaemia (p < 0.05), and NOx levels were reduced to normal ranges at the sixth hour of ischaemia. CONCLUSION: Early diagnosis and rapid treatment are important for acute ischaemic disorders. Serum NOx levels can be a decisive biomarker for prediction of the critical ischaemia period.

An alternative therapy for recurrent stasis ulcers in chronic venous insufficiency: venocuff.

Chronic venous insufficiency may cause stasis ulcers that significantly impact on the quality of life. Many methods have been described for preventing or treating these ulcers. However, stasis ulcers often recur as a result of continuing venous insufficiency. Here we report a 30-year-old male patient with chronic venous insufficiency. He was admitted to the hospital owing to recurrent stasis ulcers. He had a history of various flavonoid drug usage and compression therapies over the previous six years. Venous Doppler sonography revealed combined saphenofemoral and deep femoral venous insufficiency. Venocuff was applied to the prejunctional and postjunctional parts of the femoral vein and the saphenofemoral junction. The patient was discharged on the postoperative second day, and a low-molecular-weight heparin dressing composed of calcium alginate was applied to the ulcer wound for one week after the operation. The stasis ulcer wound was totally healed after one month. The patient was followed up six months after the operation, and no postoperative complications or new ulceration was observed. Recurrent stasis ulcers are major reasons for hospitalization in patients with chronic venous insufficiency. Venocuff application for reducing venous insufficiency may be a good option for adjunctive ulcer therapy and for preventing recurrences of the problem.

Aortic coarctation in the presence of capillary hemangioma.

We report posterior mediastinal hemangioma in a 14-year-old girl patient with an extensive hemangioma encompassing the thoracic aorta, associated with complex coarctation. The masses were identified by contrast-enhanced computed tomography. An extra-anatomical bypass was made by grafting from the ascending to the distal descending aorta. Histological evaluation of the surgical specimens established the final diagnosis. Presence of mediastinal hemangiomas should be regarded as an important differential diagnosis of coarctation of aorta, although these are very rare tumors.

[Reexploration for bleeding and tamponade in intensive care unit following open heart surgery]. / Açik kalp ameliyatlari sonrasi kanama veya tamponad nedeniyle yogun bakimda yapilan reeksplorasyonlar.

OBJECTIVE: Following open-heart surgery some patients can need reexploration in the intensive care unit due to bleeding or pericardial tamponade. This study evaluates the impact of reexploration in the intensive care unit (ICU) on morbidity and mortality rates. METHODS: Between January 1990 and January 2002 overall 18,578 open heart surgery procedures were performed in our clinic and among them 570 (3%) patients required reexploration due to bleeding or pericardial tamponade. Reexplorations were done in the operating room (OR) in 385 (67.5%) patients and in the ICU in 185 (32.5%) patients. RESULTS: Among patients 383(67.2%) were male and 187(32.8%) were female. Mean age for reexploration in the OR group was 46.9+/-16.3 years, and in the ICU group was 48.2+/-15.7 years. The use of fresh frozen plasma and bank blood was significantly higher in the ICU group (p<0.0001). Fifty patients (27%) who were reexplored in ICU had intraaortic balloon pump (IABP) support (p<0.0001). Sixty-six patients (17.1%) died in OR group and 70 patients (37.8%) died in the ICU group (p<0.001). Following reexploration, 24 (6.2%) patients in the OR group and 17 (9.1%) patients in the ICU group had major infection (p>0.05). There was no statistically significant difference among groups in hospital stay time. CONCLUSION: Following open-heart surgery, especially among hemodynamically unstable patients, to avoid possible problems of transfer to the OR and time lost, explorations can be done in ICU. This practice does not increase morbidity and hospital stay.