Protective Effects of Betanin against Oxidative Stress in a Peripheral Artery Vasospasm Model in Rat.

Objective: The aim of this study is to determine protective/modulatory effects of betanin in a femoral artery vasospasm model in rats. Materials and Methods: Sprague-Dawley rats were divided into three groups. Group 1: sham (n = 7), group 2: vasospasm model only (n = 7), group 3: postoperative betanin treatment in the vasospasm model (n = 7). 100 mg/kg betanin was administered orally to group 3 for 7 days, postoperatively. Peripheral blood malondialdehyde (MDA) and nitric oxide (NO) levels were measured for the quantification of oxidative stress, lumen diameter and wall thickness of femoral artery segments were determined to assess vasodilator effects of betanin. Results: Femoral artery vasospasm formation significantly increased both MDA (13.54 ± 3.09 mmol/mL) and NO levels (0.61 ± 0.06 µmol/mL) relative to the sham (9.07 ± 1.09 and 0.48 ± 0.1, respectively). Upon betanin administration, both MDA and NO approached baseline levels (9.95 ± 0.92 and 0.5 ± 0.06, respectively). Pathological examination of lumen diameter and wall thickness of the femoral arteries also revealed that betanin administration resulted in significant increase in lumen diameter when compared to vasospasm group (614.15 ± 245.77 versus 117.40 ± 46.19 µm) and decrease in wall thickness (64.68 ± 14.13 versus 96.73 ± 9.20 µm). Conclusion: Betanin was shown to have protective effect against oxidative stress in a peripheral artery vasospasm model in rats. It may also have a role in mitigating maladaptive changes in arterial structure, as shown in pathological examination.

Visceral oxidative stress during antegrade cerebral perfusion and lower body circulatory arrest.

Background: Antegrade cerebral perfusion (ACP) is the standard neuroprotection method in aortic surgery. Visceral ischemia during this modality brings out some controversies. We aimed to investigate the level of oxidative stress at the lower part of body during ACP. Methods: Thirty consecutive patients underwent elective ascending aorta and hemiarch repair with ACP (without distal perfusion) were enrolled to study. The patients were enrolled into two groups which were based on 50th percentile of ACP duration (15 patients in each group). Blood samples from inferior vena cava at the end of ACP were collected to assess oxidative stress with biochemical parameters such as lactate, advanced oxidative protein products (AOPP) and thiol levels. Clinical follow-up parameters regarding to visceral and spinal cord ischemia were recorded. There were no clinical complications at both groups. Results: Mean ACP duration for the study group was found to be 15 min (10-28 min). Lactate, AOPP, and thiol levels were found to be similar between two groups. Furthermore, correlation analysis revealed only low level of correlation between ACP duration and lactate levels. Renal and liver function tests were found to be similar between groups. Conclusions: Immediate parameters (such as lactate, AOPP, and thiol) that show alterations in response to oxidative stress were not affected by the duration of ACP. Therefore, ACP without distal perfusion may not be harmful when conducted for short duration.

Tricuspid Valve Replacement Through Right Thoracotomy has Better Outcomes in Redo Cases.

BACKGROUND: The tricuspid valve is usually ignored and tricuspid interventions are mostly done in the context of other planned cardiac surgery. Isolated tricuspid reoperative procedure, especially tricuspid valve replacement (TVR) is very rare and carries a very high mortality rate. In this prospective study, clinical results of isolated TVR either through a median re-sternotomy or an antero-lateral thoracotomy with conventional cardiopulmonary bypass (CPB) have been evaluated. METHODS: Thirty patients with previous open heart surgery through median sternotomy had isolated TVR between 2004 and 2011. Operative approaches were through a median re-sternotomy in 13 patients and a right antero-lateral thoracotomy in 17 patients. RESULTS: Follow-up period is complete with a mean duration of 19.77±17.08 months. The hospital mortality rates were 46.2% (six patients) in the Median Re-sternotomy Group and 5.9% (one patient) in the Thoracotomy Group (p= 0.025). The surgical procedures lasted shorter and the postoperative drainage amounts were lower in the Thoracotomy Group (298.08±76.64min vs 246.76±47.40min, p= 0.032 and 1787.50±1399.53mL vs 903.33±692.43mL, p= 0.03 respectively). Presence of ascites in the preoperative period (p= 0.007), operative technique (median re-sternotomy) (p= 0.025), use of cross-clamp (p= 0.048), and need for inotropic support during the operation (p= 0.002) were statistically significant factors affecting the hospital mortality. The mean estimated life period was better for the Thoracotomy Group (16.7±5.03 versus 35.9±5.01 months, p= 0.044). Presence of ascites in the preoperative period was a significant risk factor for overall mortality according to Cox regression analysis. CONCLUSION: Thoracotomy for TVR in patients with previous median sternotomy is a practical and safe technique with lower mortality rates.

Glasgow aneurysm scores in patients undergoing open surgical procedure for aortic aneurysm.

BACKGROUND: To assess the applicability of the Glasgow aneurysm score (GAS) in patients with aortic aneurysm undergoing an elective open surgical procedure in our hospital. MATERIALS AND METHODS: A total of 105 patients undergoing elective open surgical procedure between January 2006 and June 2012 were evaluated retrospectively. Glasgow aneurysm score (GAS) was calculated as age+7 points for myocardial disease, +10 points for cerebrovascular disease, and +14 points for renal disease. The best cut-off value for GAS was determined using the ROC curve analysis. RESULTS: The hospital mortality rate was 3.8% (4 patients). GAS was significantly lower in patients who survived the operation (76.05 ± 14.71 vs. 92.0 ± 10.8 respectively, p = 0.031). The ICU stay was also significantly lower in patients who survived the operation (2.37 ± 5.23) compared to the nonsurvivors (25.67 ± 13.80, p = 0.001). No significant difference was observed regarding age, duration of hospital stay, and aortic diameter. The area under the ROC curve was 0.818 and for a 100% sensitivity rate, the cut-off value for GAS was 77.5 with a 58.4% specificity rate (p = 0.031). All patients with a GAS < 77.5 were alive after surgery. CONCLUSION: The GAS appears to be a reliable clinical predictor for in hospital mortality following elective repair of abdominal aortic aneurysm following open surgical procedure.

Glasgow aneurysm score in predicting outcome after ruptured abdominal aortic aneurysm.

OBJECTIVE: To assess the ability of Glasgow Aneurysm Score in predicting postoperative mortality for ruptured aortic aneurysm which may assist in decision making regarding the open surgical repair of an individual patient. METHODS: A total of 121 patients diagnosed of ruptured abdominal aortic aneurysm who underwent open surgery in our hospital between 1999 and 2013 were included. The Glasgow Aneurysm Score for each patient was graded according to the Glasgow Aneurysm Score (Glasgow Aneurysm Score = age in years + 17 for shock + 7 for myocardial disease + 10 for cerebrovascular disease + 14 for renal disease). The groups were divided as Group 1 (containing the patients who died) and Group 2 (the patients who were discharged). The Glasgow Aneurysm Scores amongst the groups were compared. RESULTS: Out of 121 patients, 108 (89.3%) were males and 13 (10.7%) were females. The in-hospital mortality was 48 patients (39.7%). The Glasgow Aneurysm Score was 84.15 ± 15.94 in Group 1 and 75.14 ± 14.67 in Group 2 which revealed significance (p = 0.002). The most appropriate cut-off value for Glasgow Aneurysm Score was determined as 78.5 (AUC = 0.669, p = 0.002, sensitivity: 64.6%, specificity: 60.3%). Glasgow Aneurysm Score value above 78.5 is associated with almost threefold increase in mortality (p = 0.007, OR:2.76, 95% CI 1.30-5.89). In further logistic regression models, Glasgow Aneurysm Score value and preoperative hematocrit values were found to be independent predictors for mortality (p = 0.023 and p = 0.007, respectively). CONCLUSION: Glasgow Aneurysm Score may have a predictive value for outcome of patients with ruptured abdominal aortic aneurysm undergoing open surgical procedure and it appears to be a useful tool in clinical decision-making of an individual patient when integrated with clinical experience.

Comparison of two different skin preparation strategies for open cardiac surgery.

INTRODUCTION: Surgical site infection (SSI) is a serious complication after cardiac surgery; skin preparation is an important step in the prevention of wound contamination with skin flora. In this study, two different skin preparation strategies (standard povidine iodine cleaning plus plain adhesive drape and microbial sealant (InteguSeal, Kimberly-Clark Health Care, Roswell, GA, USA) were compared in cardiac surgery patients. METHODOLOGY: This prospective study included 96 cardiac surgery patients randomized to either a standard plain adhesive drape (28 patients, control group) or a microbial sealant (68 patients, study group). Bacterial isolates were obtained from the wounds in the operating room before the skin incision and after the surgical procedure had ended. RESULTS: Microorganisms were isolated from 38 patients (39.6%) in the study population. Twenty-seven of these patients were from the microbial sealant group and 11 were from the plain adhesive drape group. No postoperative wound infection was encountered in either group. No statistically significant differences between the two groups regarding the number of patients with microorganism isolation (p = 0.974) or postoperative leukocyte counts and neutrophil granulocyte percentages were observed. CONCLUSIONS: Regarding SSI after cardiac surgery, microbial sealant is equivalent to the standard skin preparation strategy applied with povidine iodine cleaning and a plain adhesive drape.

Surgery for rheumatic valve disease in pregnancy: what about the newborn?

BACKGROUND: Valvular heart disease constitutes the majority of all causes of cardiac disease in pregnancy. The significant physiological haemodynamic changes of pregnancy may cause serious cardiac problems leading to severe maternal and foetal morbidity and mortality. In this study, we evaluate the effect of maternal rheumatic valvular disease requiring definitive operation concurrent with caesarian delivery on maternal and foetal outcome. METHODS: Between 2003 and 2010, a total of nine pregnant women and nine live births were examined. Immediately after caesarean section, the newborns were examined by the neonatologist and transferred to the neonatal intensive care unit. All the mothers were followed routinely with clinical and echocardiographic examinations. RESULTS: The age at the time of delivery ranged between 21 and 36 years (median 31 years). Postoperative period of mothers was uneventful and mean hospital stay was 7.56±3.97 days. Birth weight for the newborns was ranged between 1370 and 2900g. Six of the newborns were premature (≤37 weeks). Four newborns were small for gestational age (SGA). There was no mortality in newborns. Hospital stay for the newborns ranged between four and 54 days. CONCLUSIONS: Careful follow-up of pregnancies with valvular heart diseases and determining the optimal time of cardiac intervention are the essential issues. We suggest that careful follow-up of both mother and foetus until at least the 28th gestational week, following which combined caesarian section and cardiac surgery can be performed.

Post-traumatic tricuspid insufficiency: a case report.

Post-traumatic tricuspid insufficiency is a rare complication of chest trauma. An 18-year-old male patient was injured in a bicycle accident from his abdominal and anterior chest wall. The tear on the inferior diaphragmatic surface of the heart was repaired with primary sutures by the attending surgeon. Eighteen years later, he was admitted to the hospital with severe tricuspid regurgitation (3+/4+). During the operation, the valve was determined unsuitable for repair and was replaced with a bioprosthesis. The hemodynamic aberrations relevant to an isolated tricuspid valve injury are very often well-tolerated. Reconstructive surgery may be possible in the early period. In the late cases, repair is sometimes not feasible due to degeneration of the valvular apparatus. Replacement with a biological prosthesis may give the best long-term results in longstanding cases.

Primary cardiac myxomas: clinical experience and surgical results in 67 patients.

BACKGROUND: Primary cardiac tumors are rarely seen and have an incidence of 0.3% of all open-cardiac operations. Among those, myxoma is the most common cardiac tumor. There are only a few reports of such tumors from Turkey. METHODS AND RESULTS: We report our experience with 67 patients with primary cardiac myxoma operated on at our institute between December 1990 and October 2006. The study group comprised 22.38% males and 77.61% females with a mean age of 46.29 (+/-18.29) years. The predominant symptoms were dyspnea and palpitation. In addition, 3 patients presented with peripheral embolism with impending limb ischemia that necessitated emergency embolectomy. Echocardiography was generally enough for the demonstration of the myxomas. Two sporadic myxomas (%2.98) and one familial myxomas (1.49%) presented with recurrence. There were three (4.47%) hospital mortalities. Two patients (2.27%), with preoperative decompensation, died after tumor resection, from progressive low cardiac output. One patient, with preoperative massive pulmonary embolus, died two days after operation, from right ventricle insufficient. CONCLUSION: In conclusion, we herein summarized surgical results with primary cardiac myxomas. Surgical excision of primary cardiac myxomas tends to show excellent results after surgical excision.

On-pump beating heart mitral valve surgery without cross-clamping the aorta.

BACKGROUND AND AIM: Cardiac reperfusion injury is a well-described complication occurring after ischemia or following cardioplegic arrest. Various strategies have been developed to prevent ischemic reperfusion injury. The aim of this study was to assess the efficacy and applicability of the on-pump beating heart mitral valve surgery without cross-clamping the aorta in order to prevent reperfusion injury. METHODS: The prospective study (between April 2005 and December 2006) included 88 consecutive patients who underwent mitral valve surgery. The operations were carried out on a beating heart using normothermic cardiopulmonary bypass without cross-clamping the aorta, therefore perfusing the heart antegradely through the aortic root. Venting the heart from the aorta and the pulmonary vein provided adequate visualization of the operative field. RESULTS: Seventy-eight patients (88.6%) underwent mitral valve replacement and 10 patients (11.3%) underwent mitral valve repair with this technique. Concomitant surgery was required in 29 patients (32.9%). Twenty-five patients (28.4%) had also undergone previous open heart surgery. Mean cardiopulmonary bypass time was 57.4 +/- 18.4 minutes. Mean duration of ventilation was 12.2 +/- 3.5 hours, mean intensive care unit stay was 1.3 +/- 1.6 days, and mean hospital stay was 6.9 +/- 4.5 days. One-year survival was 96.6% for all causes of mortality. CONCLUSIONS: In this study, we showed that on-pump beating heart operations without cross-clamping is an acceptable surgical choice for mitral valve disease. Complication rates are low and perioperative mortality is lower than that generally reported with conventional technique.

On-pump beating heart versus hypothermic arrested heart valve replacement surgery.

BACKGROUND: Comparison of neurological parameters in patients undergoing prosthetic heart valve replacement with two operating techniques-either cardioplegic arrest of the heart under hypothermic cardiopulmonary bypass (CPB) or the heart beating on normothermic bypass, with or without cross-clamping the aorta, without cardioplegic arrest. methods: Fifty valvular surgery patients were randomly assigned into three groups. Sixteen patients underwent beating heart valve replacement with normothermic bypass without cross-clamping the aorta, 17 patients underwent the same procedure with cross-clamping the aorta and retrograde coronary sinus perfusion, and the remaining 17 patients had conventional surgery with hypothermic bypass and cardioplegic arrest. RESULTS: Two-channel electroencephalography (EEG) was recorded to assess changes in cerebral cortical synaptic activity and 95% spectral edge frequency values were recorded continuously. Bispectral monitoring was used to measure the depth of anesthesia. Blood flow rates in middle cerebral artery (MCA) were measured by transcranial Doppler (TCD). Reduction in spectral edge frequency (>50%) or bispectral index (BIS) (<20) or transcranial Doppler flow velocity (>50%) was detected in four patients in Group 1, five patients in Group 2, and three patients in Group 3. BIS or EEG values never reached zero, which indicates isoelectric silence during surgery. Gross neurological examinations were normal in all patients postoperatively. CONCLUSION: There is no difference regarding neurological monitoring results between on-pump beating heart and hypothermic arrested heart valve replacement surgery. Also no significant difference was encountered among the groups regarding the clinical outcomes.

Mitral valve replacement with the beating heart technique in a patient with previous bypass graft from ascending to descending aorta due to aortic coarctation.

BACKGROUND AND AIM: Conventional mitral valve replacement (MVR) is carried out under cardioplegic arrest with cross-clamping of the ascending aorta during cardiopulmonary bypass. In this case, MVR was performed with on-pump beating heart technique without cross-clamping the aorta because of the diffuse adhesion around the ascending aorta, and tube graft presence between ascending and descending aortas. METHODS: A 47-year-old female patient had aorto-aortic bypass graft from ascending aorta to descending aorta with median sternotomy and left thoracotomy in single stage because of aortic coarctation 2 years ago in our cardiac center. She was admitted to the hospital with palpitation and dyspnea on mild exertion. Transthoracic echocardiography revealed 4th degree mitral insufficiency. RESULTS: MVR was carried out through remedian sternotomy with on-pump beating heart technique without cross-clamping the aorta. CONCLUSIONS: MVR with on-pump beating heart technique offers a safe approach when excessive dissection is required to place cross-clamp on the ascending aorta.

Evaluation of hemodynamic changes in patients with mitral valve replacement using dobutamine stress echocardiography.

OBJECTIVE: The aim of this study was to investigate the response of heart to stress according to the size of the prosthetic valve in patients who had undergone mitral valve replacement by using dobutamine stress echocardiography (DSE) and to evaluate the relationship between the size of the prosthetic valve and cardiac recovery-remodeling process. METHODS: Thirty-nine patients, who had undergone mitral valve replacement were compared in terms of left ventricular diameters, systolic functions and cardiac mass indexes in order to investigate the effect of the mechanical valve size on postoperative cardiac remodeling in this longitudinal study. They were divided into three groups according to their valve size: Group 1 (valve size<29 mm, n=11), Group 2 (valve size=29 mm, n=11) and Group 3 (valve size>29 mm, n=17). Statistical analysis was performed using Chi-square and one-way ANOVA tests to determine the statistical differences between the groups. The repeated measurements of two-way ANOVA test was used to analyze effects during long-term follow-up. RESULTS: Only Group 1 patients achieved a significant decrease in terms of left ventricular mass index and end-diastolic diameter (138.3+/-29.7 g/m2 vs 86.6+/-15.6 g/m2 and 5.1+/-0.5 cm vs. 4.4+/-0.4 cm, p<0.05). Group 3 patients' left ventricular ejection fraction become worse after the operation (64.0+/-5.6% vs. 55.9+/-6.5%, p<0.05). Maximum and mean pressure gradients across the mitral prosthesis as well as pulmonary artery pressure were significantly increased in all groups during DSE. Maximum gradients increased from 14.2+/-4.6 to 20.7+/-7.5 mmHg in Group 1 (p<0.05), 11.6+/-4.7 to 16.2+/-6.8 mmHg in Group 2 (p<0.05), and 10.6+/-3.1 to 20.8+/-12.7 mmHg in Group 3 (p<0.05). Isovolumic relaxation time decreased in all groups following the dobutamine infusion, as expected, but this decline was not significant in Group 3. CONCLUSION: A worsening in left ventricular systolic function was observed in large- sized valve prosthesis group. Only the patients who had undergone MVR with small-sized valve prosthesis achieved a decrease in cardiac mass index and preservation of the systolic function. The echocardiographically determined differences and mass index that appeared after the operation may point out that, the effect of the operation on cardiac remodeling can be related with the ventricular size.

Penetrating cardiac injuries.

BACKGROUND: This study was planned to evaluate patients with penetrating cardiac injury. METHODS: Twenty-two patients had cardiac injury among twenty-five patients who had been referred to our hospital with a suspicion of this diagnosis. Data of the patients were retrospectively evaluated. RESULTS: Echocardiography could be performed in 11 patients with stable haemodynamics and pericardial effusion was established in all of them with one false positive result. The patient with false positive result had left internal thoracic artery and venous injury. Cardiac tamponade was seen in 17 (77%) patients. Injury sites were right ventricle 10 (45.5%), left ventricle 7 (31.8%), left ventricle consisting left anterior descending artery 2 (9.1%), right atrium 1 (4.5%) and pericardial injuries and hematoma 2 (9.1%). The mean physiologic index (PI) of the patients was 10.68+/-5.63, penetrating cardiac trauma index was (PCTI) 14.09+/-6.3, penetrating thoracic trauma index (PTTI) was 17+/-8.84 and organ injury scale according to the American Association for the Surgery of Trauma (AAST/OIS) was 3.86+/-1.25. Mortality rate was 27.3% with 6 out of 22 patients. PI, PCTI, PTTI and AAST/OIS scores of the non-survivors were significantly higher than those of the survivors (p<0.05). While there was no difference between survivors and non-survivors regarding the presence of tamponade and the frequency of the associated abdominal injury, left ventricular and left anterior descending artery injuries and associated lung injuries were more common in non-survivors (p<0.05). CONCLUSION: Non-survivors with penetrating cardiac injury have higher PI, PCTI, PTTI and AAST/OIS scores and they are more severely injured patients comparing to the survivors.

Aortic valve replacement with on-pump beating heart technique.

BACKGROUND: The aim of this study was to assess the efficacy and applicability of on-pump beating heart aortic valve replacement with retrograde coronary sinus (CS) warm blood perfusion. METHODS: The prospective study included 14 consecutive patients who underwent aortic valve replacement with mechanical prosthesis using retrograde CS perfusion. The operative variables and early outcome of this procedure are presented. RESULTS: Retrograde CS perfusion and venting the heart from the pulmonary vein provided good visualization of the operative field and performance of the operations without any difficulty. Partial oxygen pressures of CS perfusion blood and the returning blood from the coronary ostia were 288.5 +/- 34.4 and 39.6 +/- 4.6 mmHg, respectively. Postoperative peak creatine kinase-MB and troponin T values were mean 77.0 +/- 63.6 IU/L and mean 0.8 +/- 0.7 ng/mL, respectively. No mortality or major complication was observed and all the patients were discharged from the hospital in good condition. CONCLUSIONS: On-pump beating heart aortic valve replacement with retrograde CS warm blood perfusion is a good surgical option, and has the advantage of maintaining physiologic condition of the heart throughout the procedure.

Gene polymorphisms in patients below 35 years of age who underwent coronary artery bypass surgery.

OBJECTIVE: Genetic bases for novel prothrombotic, inflammatory risk factors may play a role in the early onset of coronary artery disease. METHODS: Twenty-one patients below 35 years of age who underwent coronary bypass grafting between 2002 and 2004 constituted the study group and were compared with 50 healthy, age and sex-matched controls. Gene analysis for genetic polymorphisms of angiotensin-converting enzyme, prothrombin G20210A, tumour necrosis factor-alpha G308A, factor V Leiden and interleukin-6 genes was carried out. RESULTS: The control group was 98% homozygous for the factor V Leiden GG allele and 2% heterozygous for the GA allele. On the other hand, the study group was 76.2% homozygous for the GG allele, and 23.8% heterozygous for the GA allele (P<0.05). Homozygosity for factor V Leiden mutation (AA) was not encountered in either group. With regard to interleukin-6, 70.0% of the control group demonstrated homozygosity for the GG allele and 30.0% showed heterozygosity (GC). The study group was 52.4% homozygous for the GG allele and heterogenicity was similar in this group (28.6% GC). On the other hand, 19.0% of this group demonstrated CC homogenicity (P<0.05). No difference was observed with regard to gene polymorphisms. CONCLUSIONS: Gene polymorphisms with regard to prothrombotic factor V Leiden mutation and inflammatory marker interleukin-6 may play a role in the pathogenesis of early-onset coronary artery stenosis in patients below 35 years of age.