Ahmet Akgül

Acute renal failure following open heart surgery: risk factors and prognosis

Background: Acute renal failure (ARF) development after cardiac surgery carries high mortality and morbidity. Methods: Out of 14 437 consecutive patients undergoing open-heart surgery between January 1991 and May 2001, 168 (1.16%) developed postoperative ARF mandating hemodialysis. Possible perioperative risk factors, and the prognosis of this dreadful, often fatal complication were investigated. Results: The mortality rate in this group was 79.7% (134 patients). The risk factors associated with postoperative ARF were advanced age (p-0.000), diabetes mellitus (p-0.000), hypertension (p-0.000), high preoperative serum creatinine levels (p-0.004), impaired left ventricular function (p-0.002), urgent operation (p-0.000) or reoperation (p-0.007), prolonged cardiopulmonary bypass (CPB) (p-0.000) and aortic cross-clamp (ACC) (p-0.000) periods, level of hypothermia (p-0.000), concomitant procedures (p-0.000), low cardiac output state (p-0.000), re-exploration for bleeding or pericardial tamponade (p-0.000), and deep sternal or systemic infection (p-0.000). Of those who could be discharged from hospital, renal functions were restored in 21 patients (12.5%); however, eight patients (4.7%) became hemodialysis dependent. The mean follow-up period was 5.79/3.2 years (range: 4 months to 13 years; a total of 195 patient-years), and 10-year survival was 58.69/10.2% in the discharged patients. Conclusions: ARF development after cardiac surgery often results in high morbidity and mortality. Recognizing risk factors permits the timely institution of proper treatment, which is the key to reducing untoward outcomes.

Evidence of improved right ventricular structure after LVAD support in patients with end-stage cardiomyopathy.

BACKGROUND Although many reports demonstrate the hemodynamic benefits of left ventricular assist devices (LVAD) in right-sided circulation, it is not known whether the right ventricular myocardium goes through reverse remodeling after left ventricular mechanical circulatory support. Accordingly, the purposes of our studies were 1). to investigate the right ventricular changes that occur in fibrosis, in cellular hypertrophy, and in intra-myocardial tumor necrosis factor alpha (TNF-alpha) levels in patients receiving LVAD support; and 2). to determine whether the type of LVAD used influences right ventricular myocardial changes. METHODS AND RESULTS We measured myocyte size, total collagen content, and TNF-alpha levels using semi-quantitative immunohistochemical analysis of myocardial samples from the right and left ventricles of control and failing myocardia, either supported by 1 of 2 distinct forms of LVADs or without support. We found that when compared with control, although myocyte size was not increased in the right ventricle of failing myocardia (p = not significant), total collagen content and myocardial TNF-alpha levels were decreased in the right ventricle compared with controls (p < 0.01 and p < 0.001, respectively). CONCLUSION These data demonstrate that chronic left ventricular unloading with either pulsatile or continuous-flow devices decreases right ventricular total collagen and myocardial TNF-alpha content. We suggest that the decreased fibrosis and normalization of cytokine milieu observed may in part contribute to the recovery of right-sided cardiac function associated with chronic mechanical circulatory support.

Significance of serum interleukin-8 levels in patients with Behcet's disease: high levels may indicate vascular involvement.

Background  Interleukin‐8 (IL‐8) has been shown previously to associate with different individual clinical manifestations and activity of Behcets disease (BD), but its association with vascular involvement has not been established.

Homocysteine May Involve in the Pathogenesis of Behcet's Disease by Inducing Inflammation

Objective. Our aim was to evaluate the significance of homocysteine (Hcy) in Behcets disease (BD) and the association of elevated Hcy levels associated with the indices of inflammation in BD. Methods. Untreated 70 patients with BD and 33 healthy individuals were included into the study. Hcy, tumor necrosis alpha (TNF-α), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were evaluated with respect to activity and specific individual clinical manifestations of the disease. Results. Hcy levels were found significantly elevated in active BD when compared to inactive BD and healthy controls. Hcy levels were found to have high correlation with the number of active clinical manifestations increased. A significant positive correlation was found between serum Hcy and TNF-α levels, CRP, and ESR. Hcy was found to be the best predictor of TNF-α among other parameters. Conclusion. Hcy may involve in the pathogenesis of BD by inducing inflammation.

Quantitative changes in mast cell populations after left ventricular assist device implantation

Mast cells have been implicated as important in tissue remodeling and fibrosis. We investigated the effect of mechanical ventricular unloading upon myocardial fibrosis and cardiac mast cell density in patients undergoing left ventricular assist device (LVAD) implantation. Paired myocardial tissue samples were obtained from 30 patients with end-stage cardiomyopathy at the time of LVAD implantation and at the time of removal and were compared with samples taken from donor hearts. Tissue sections were stained and quantitated for mast cells and myocardial fibrosis. Mast cell density (tryptase positive cells) in cardiomyopathy was higher than that in donor hearts (33.5 ± 3.6 SEM cells/10 fields vs.15.2 ± 2.0 SEM cells/10 fields respectively, p = 0.04) and was lower than LVAD supported hearts (33.5 ± 3.6 SEM cells/10 fields vs. 49.8 ± 5.7 SEM cells/10 fields respectively, p = 0.01). Mast cells are primarily localized in areas of increased interstitial fibrosis adjacent to myocardial cells and not vessels. There was statistically significant correlation between mast cells and interstitial collagen (p = 0.03) in patients before LVAD implantation that did not persist after mechanical support (p = 0.18). These results suggest that mechanical support with left ventricular assist devices induces an increase in mast cell number in the myocardium and an associated decrease in myocardial fibrosis. We believe these data demonstrate a dual role for cardiac mast cells in the increase in fibrosis in heart failure and the decrease after LVAD and its associated cardiac improvement.

Hyperhomocysteinemia in patients with stasis dermatitis and ulcer: a novel finding with important therapeutic implications.

Background: Although homocysteine (Hcy) has profound effects concerning vascular lesions and thrombosis, it has not previously been investigated in patients with stasis dermatitis and ulcer. Objective: To evaluate plasma Hcy levels in patients with stasis dermatitis and ulcer. Methods: A total of 25 patients (17 male, eight female; mean age of 36 ± 5.97 years) with stasis dermatitis, 40 patients with stasis ulcer (27 male, 13 female; mean age of 38.5 ± 7.96 years) and 35 healthy control individuals (25 male, 10 female; mean age of 36.9 ± 6.49 years) were included in this study. Patients taking vitamin supplements or patients with folic acid or vitamin B12 deficiency, diabetes mellitus, chronic hepatitis, renal failure and chronic alcoholism which might affect Hcy levels were excluded from the study. Results: Hcy levels were found to be elevated in patients with stasis dermatitis (p = 0.00) and stasis ulcer (p = 0.00) compared to healthy controls with a median (range) of 19.1 µmol/l (15–28), 18.98 µmol/l (15–29), and 8.1 µmol/l (5–12.2), respectively. There was no statistically significant difference in Hcy level in patients with stasis dermatitis and ulcer (p = 0.877). Conclusion: As hyperhomocysteinemia can be treated by selected vitamin supplementation even in patients with normal serum vitamin concentrations, ulcer formation might be prevented by lowering Hcy in the clinical stage of stasis dermatitis.

Concomitant Transarterial and Transvenous Embolization of a Pelvic Arteriovenous Malformation Using a New Liquid Embolic Agent, Squid-12 and Detachable Coils

We describe a complex congenital pelvic AVM with multiple feeding arteries arising from the side branches of the right internal iliac artery and a single draining vein in a male patient. Concomitant transarterial and transvenous embolization with a new liquid embolic agent Squid-12 and metallic coils enabled a complete embolization at a single session. Squid-12 is composed of ethylene vinyl alcohol copolymers and its lower viscosity makes it a promising agent for the treatment of AVMs. The patient showed prompt resolution of the symptoms and complete devascularization of the AVM lesion was persisted on the 1-month control angiography. The patient was asymptomatic on the 6th month follow-up.

Repair of the aortic arch with left unilateral selective cerebral perfusion

A 67-year-old woman who presented with chest and back pain was diagnosed with an aneurysm of the ascending aorta. Coronary angiography and aortography were performed via the right brachial artery, which was complicated by axillary artery dissection. At surgery, despite our clinical experience of using the right upper brachial artery for arterial cannulation, right femoral artery cannulation was performed to establish cardio-pulmonary bypass (CPB) as the dissection was extending to the brachiocephalic artery. The aortic crossclamp was placed on the arch of the aorta just after the origin of the brachiocephalic artery so that cerebral perfusion was performed via the left common carotid and left vertebral and basilar arteries through the left subclavian artery. No neurologic event was observed during the intensive care unit stay and follow-up period. To the best of our knowledge, the literature contains no other report of the use of only the left carotid and subclavian arteries to perfuse cerebral structures during CPB.

[Comparison of standard Euroscore, logistic Euroscore and Euroscore II in prediction of early mortality following coronary artery bypass grafting].

OBJECTIVE EuroSCORE is the most widely used risk prediction system. Standard EuroSCORE, which had been published in 1999, was revised as a Logistic EuroSCORE in 2003. Further, it was reconsidered and published as EuroSCORE II in 2011. In this study we compared Standard, Logistic EuroSCORE and EuroSCORE II in prediction of early mortality following coronary artery bypass grafting. METHODS We retrospectively analyzed 406 patients who underwent coronary artery bypass grafting operation between 2011-1012. Standard, Logistic and new version were compared with ROC analysis. RESULTS In general population, mean standard EuroSCORE was 3.25±1.05, mean logistic EuroSCORE was found 2.48±0.58, mean EuroSCORE II was found 1.30 ± 0.09 and overall mortality was 10 (10/406 2.46%). Area under curve (AUC) was found 0.992 95% CI: 0.978-0.998 for standard EuroSCORE, 0.992 95% CI: 0.977-0.998 for logistic EuroSCORE and 0.990 95% CI: 0.975-0.997 for EuroSCORE II. In high risk patients (patients with standard EuroSCORE ≥ 6) AUC was found 0.870 95% CI 0.707-0.961 for standard EuroSCORE, 0.857 95% CI 0.691-0.954 for logistic EuroSCORE, and 0.961 95% CI: 0.829-0.998 for EuroSCORE II. CONCLUSION Standard, Logistic EuroSCORE and EuroSCORE II are similarly successful in mortality prediction. EuroSCORE II may be better in high-risk patients which needs confirmation in large prospective studies.

Prolidase Activity in Patients With Coronary Artery Aneurysm

Decreased collagen biosynthesis and increased collagenolysis may induce aneurysmal progress in arterial walls. Prolidase plays a role in collagen synthesis. In this study, we sought to evaluate whether there is a correlation between nonatherosclerotic coronary artery aneurysms (CAAs) and prolidase activity. A total of 174 CAAs were diagnosed in 144 (2.1%) patients among 6845 coronary angiographies performed between 2009 and 2012. In all, 23 (15.9%) patients had nonatherosclerotic aneurysms. Prolidase activity was compared to the results of 19 healthy volunteers with normal coronary arteries. Demographic parameters were similar between the groups. Mean prolidase activity was 241.6 ± 54.4 mU/mL in the coronary aneurysm group and 730.3 ± 243.1 mU/mL in the control group (P < .001). The incidence of CAAs ranges between 0.3% and 5.3% in the general population. Decreased prolidase activity may reduce collagen biosynthesis that may contribute to aneurysm formation.