Ali Civelek

Mitral annuloplasty in patients with ischemic versus dilated cardiomyopathy

OBJECTIVE Mitral regurgitation is a frequent finding in patients with end-stage cardiomyopathy predicting poor survival. Conventional treatment consists medical treatment or cardiac transplantation. However, despite severely decreased left ventricular function, mitral annuloplasty may improve survival and reduce the need for allografts. METHODS From January 1996 to July 2002, 121 patients with severe end-stage dilated (DCM) or ischemic cardiomyopathy (ICM), mitral regurgitation > or =2, and left ventricular ejection fraction < or =30% underwent mitral valve annuloplasty using a flexible posterior ring. DCM was diagnosed in 30 patients (25%), whereas ICM was found in 91 patients (75%). Concomitant tricuspid valve repair was performed in 14 (46.6%) patients in the DCM, and in 11 (12%) in the ICM group (P=0.0001), coronary artery bypass grafting in three (10%) in the DCM, and in 78 patients (86%) in the ICM group (P<0.00001). The mean follow-up time was 567+/-74 days in the DCM and 793+/-63 days in the ICM group (ns). RESULTS Early mortality was 6.6% (8/121), and was equal for both groups. Improvement in NYHA class (DCM 3.3+0.1-1.8+/-0.16; ICM from 3.2+0.04 to 1.7+/-0.07) were equal between groups after 1 year. Seventeen (15%) late deaths occurred during the follow-up period. There was no difference in the 2-year actuarial survival between groups (DCM/ICM 0.93/0.85). Risk factors for mitral reconstruction failure, defined as regurgitation > or =2 after 1 year, were preoperative NYHA IV in the DCM group (P=0.03), a preoperative posterior infarction (P=0.025), decreased left ventricular function (P=0.043), larger ring size (P=0.026) and preoperative renal failure (P=0.05) in the ICM group. Risk factors for death were larger ring size (P=0.02) and an increased LVEDD (P=0.027) in the DCM group and the postoperative use of IABP (P=0.002), renal failure (P=0.001), and a larger preoperative LVESD (P=0.035) in the ICM group. CONCLUSION Mitral reconstruction with a posterior annuloplasty using a flexible ring is effective in patients with severely depressed left ventricle function and has an acceptable operative mortality. Mid-term results are superior to medical treatment alone and comparable to cardiac transplantation.

Genetic Polymorphisms Contribute to Acute Kidney Injury after Coronary Artery Bypass Grafting

BACKGROUND Acute kidney injury is one of the most serious complications after cardiac surgery. Genetic polymorphisms are reported to be associated with postoperative renal impairment. The aim of this study was to investigate the relationship between selected gene polymorphisms and acute kidney injury after cardiac surgery. METHODS Two hundred forty-eight elective coronary artery bypass grafting procedure patients were enrolled in the study. Angiotensin-converting enzyme (ACE) II, ID, and DD, apolipoprotein E (APO E), and angiotensin II type 1 receptor (AGTR1) A1166C genotypes were detected by polymerase chain reaction. Plasma levels of ACE were analyzed by enzyme-linked immunosorbent assay. Acute kidney injury after cardiac surgery was graded according to the RIFLE (risk, injury, failure, loss, and end-stage kidney disease) classification. RESULTS In our study, 21.8% of patients had acute renal impairment after cardiac surgery. Among the 54 patients with acute kidney injury, ACE D allele frequency was 0.620. The plasma levels of ACE were significantly higher in the D allele carriers (P = .018). Three of the 54 patients with acute kidney injury were APO E epsilon 4 allele carriers (P = .002). AGTR1 C allele carriers constituted 46% of all patients with postoperative acute kidney injury. There was no statistically significant difference between A allele homozygotes and C allele carriers with respect to postoperative renal dysfunction (P > .05). CONCLUSIONS The present findings support the hypothesis that ACE I/D and APO E gene polymorphisms may play a role in the development of acute kidney injury after cardiac surgery. However, AGTR1 does not have a unique association with postoperative renal impairment.

Clopidogrel-induced hypersensitivity syndrome associated with febrile pancytopenia

References 1 Fukuda E. In: Fukuda E, ed. Yakusinjyoho (Drug Eruption Information) , 10th edn. Fukuoka: Fukuda Clinic, 2003: 230 (in Japanese). 2 Iino S, Tango T, Matsushima T, et al. Therapeutic effects of stronger neo-minophagen C at different doses on chronic hepatitis and liver cirrhosis. Hepatol Res 2001; 19 : 31–40. 3 Sfar Z, Belkahia CH, Kamoun MR. Severe bullous forms of drug eruption. Tunis Med 1989; 67 : 805–808 (in French). 4 Velez A, Moreno J-C. Toxic epidermal necrolysis treated with N -acetylcysteine. J Am Acad Dermatol 2002; 46 : 469–470. 5 Popova O, Safronov BN. Action of cysteine hydrochloride in the body on the immune response and the formation of antigen–antibody complexes. Zh Mikrobiol Epidemiol Immunobiol 1984; 1 : 60–62.

The Use of Bonewax to Control Massive Presacral Bleeding

Abstract.Massive presacral bleeding during retroperitoneal resection is unusual, and can be difficult to control. We describe a technique for managing this complication whereby bonewax is pushed through the presacral fascia and periosteum directly into the bleeding point in the sacrum, followed by abdominal packing. This maneuver proved successful for achieving hemostasis when we recently encountered this intraoperative complication.

Neuroprotective effects of FK-506, l-carnitine and azathioprine on spinal cord ischemia-reperfusion injury

OBJECTIVE In our experimental study, we aimed to test the effect of FK506, azathioprine and L-carnitine on protection of spinal cord injury due to ischemia-reperfusion. METHODS Twenty-seven Sprague-Dawley male rats were randomly divided into five groups. They were subjected to spinal cord ischemia by clamping the abdominal aorta for 45 min. Thirty minutes before the aortic clamping, group I received 0.5 mg/kg FK506, group II received 100 mg/kg L-carnitine, group III received 4 mg/kg azathioprine, the fourth group was the control group and received only normal saline injection intravenously and the last group was the sham group. Neurological status was scored by using the Tarlov scoring system. Sections of the lumbar cord were harvested for histopathological grades (1-4), having regard to percentage of the apoptotic cells. RESULTS Hind-limb motor function had recovered normally 48 h after the operation in all rats which received FK506, azathioprine and L-carnitine prophylactically. In contrast, all rats in the control group had deteriorated to paraplegia by 48 h after the operation (P<0.05). Histopathologic sections in the involved spinal cord segment showed that a greater number of motor neuron cells were preserved and there were less apoptotic cells in the rats that received FK506, azathioprine and L-carnitine than those in control group. CONCLUSIONS These results suggest that prophylactic use of FK506, azathioprine and L-carnitine protects motor neuron cells from ischemic spinal cord injury.

Coronary artery bypass surgery in patients with severe left ventricular dysfunction

OBJECTIVE The role of coronary artery bypass grafting (CABG) in patients with severe left ventricular dysfunction was evaluated. METHODS Two hundred and twelve patients (152 men, 60 women; age 35 to 82, mean 55) with ejection fraction (EF) of less than 30% underwent CABG between January 1996 and February 2001 by a single surgeon (SA). They compromised of 12% of 1759 patients operated on in this period. EF ranged from 17% to 30% (mean 25%). Preoperatively 68% had congestive heart failure and 72% had severe angina (CCS 3 or 4). A left main lesion was found in 26% of the cases. The mean number of grafts was 3.18 per patient. The left internal mammary artery (LIMA) was used on 107 patients (50.4%). Preoperative intraaortic balloon pump (IABP) was used on 32 patients (15%). Endarterectomy was performed on 53 patients (25%). The patients were followed for up to 58 months (mean 28.7). RESULTS Twelve patients died in hospital (5.6%). Survival was 94%, 87%, 80% and 73% at 1, 2, 3 and 4 years respectively. Among the preoperative variables survival was negatively affected by chronic renal failure, older age, congestive heart failure, elevated pulmonary artery pressure and recent myocardial infarction, by means of multivariate analysis. Preoperative IABP support improved the operative mortality significantly (P=0.002). Use of LIMA did not have any influence on survival. CONCLUSION CABG on patients with poor left ventricular function: (1). Can be performed with an acceptable mortality. (2). Mid term results are encouraging. (3). Preoperative IABP support improves the chance of survival.

Post-mitral valve repair systolic anterior motion produced by non-obstructive septal bulge

OBJECTIVE Systolic anterior motion (SAM) may rarely occur after mitral valve reconstruction due to different anatomic factors. Several techniques have been described to reduce the incidence of post-repair SAM, e.g. leaflet sliding plasty. However, SAM can still occur after these special procedures. We reviewed data of patients developing SAM with significant mitral regurgitation due to non-obstructive septal bulge. METHODS During a 2-year period mitral valve repair was performed in 358 patients. Five of 358 (1.4%) patients with a mean age of 52+/-10.5 years developed post-repair SAM with severe mitral insufficiency due to non-obstructive septal bulge. Data of these patients were analyzed retrospectively and controlled after a mean follow-up of 18+/-2.7 months. RESULTS Preoperative echocardiography showed end-diastolic septum diameter of 7, 10, 10, 11 and 15 mm. The ratio between end-diastolic septum diameter and free wall diameter was 1 in four patients and 1.25 in one patient. There was no left ventricular outflow tract obstruction (LVOT). Intraoperative data revealed large myxomatous anterior (four patients) and posterior (three patients) leaflets. Quadrangular resection of posterior leaflet was carried out in four patients and sliding plasty in one patient. Cause for post-repair mitral regurgitation was a non-obstructive septal bulge. During a second pump run septal bulge was resected. Mean aortic cross-clamp time and cardiopulmonary bypass time for this procedure was 15+/-1.4 and 28+/-3.1 min, respectively. Mitral regurgitation disappeared in all patients immediately after this procedure. The grade of mitral regurgitation at follow-up was 0-1 in all patients. One patient had subaortic gradient of 36 mmHg. CONCLUSIONS If mitral regurgitation occurs after primary successful mitral repair, septum bulge should always be considered as the primary cause for SAM even there is no preoperative gradient in LVOT. Before performing time-consuming corrective operations to relieve SAM, a septum resection should be carried out during a short second pump run.

Effect of a Low Molecular Weight Heparin Molecule, Dalteparin, on Cellular Apoptosis and Inflammatory Process in an Incisional Wound-Healing Model

PurposeIn this study we aimed to test the effect of a low molecular weight heparin molecule, namely dalteparin, on the inflammation and cellular apoptosis in an incisional wound-healing model in rats.MethodsEighteen male Sprague–Dawley rats were randomly assigned to three groups (n = 6 for each group). Two full-thickness skin incisions were made over cervical and lumbar regions of all rats. Group 1 (sham group) received no treatment, group 2 (control group) received 0.01 ml/g saline subcutaneously 12 h two times daily from 0 to 10th postoperative day, and group 3 (dalteparin group): received 1 IU/g dalteparin subcutaneously two times daily from 0 to 10th postoperative day. A histological evaluation was done by light microscopy. Apoptosis was detected immunohistochemically by anti-poly (ADP-ribose) polymerase p85 fragment pAb.ResultsThe early inflammatory response and related tissue edema were depressed on day 3 in the dalteparin group when compared with those in the other groups (P < 0.05). Fibroblast proliferation was also depressed on day 10 in the dalteparin group compared to the others (P < 0.05). Furthermore, increased apoptosis was detected in the dalteparin group both on day 3 and day 10.ConclusionOur results showed that dalteparin may adversely affect the incisional wound healing by suppressing the early inflammatory process and increasing cellular apoptosis; however, further studies are warranted to confirm the results.

Recurrent cardiac metastasis of primary femoral osteosarcoma: a case report.

A 17-year-old female patient with a history of surgery for primary femoral and metastatic lung osteosarcoma was admitted to our clinic with palpitations. Upon evaluation, a metastatic osteosarcoma in the left ventricle was diagnosed. Based on the collaborative decision of the oncology and cardiovascular surgery clinics, surgery was performed and the patient was discharged without any problems. According to the recommendation of the oncology clinic, chemotherapy was postponed for 6 months after surgery. Five months postoperatively, however, she had a recurrence with 2 tumors. Based on the collaborative decision, chemotherapy was initiated and in 2 months the size of the recurrent tumors had diminished. The patient is still under the care of the oncology and cardiovascular surgery clinics and continuing her chemotherapy regimen. Osteosarcomas have a high mortality. Metastatic tumors of the heart are not common. The location of the metastasis and the characteristics of the primary tumor determine the treatment modality. In some previously published reports, various treatment choices have been described. In the present case report, we present a rare case with metastatic cardiac osteosarcoma.

FK506 to Prevent Lung Injury After Hindlimb Ischemia and Reperfusion in a Rat Model : An Electron Microscopic Study

PurposeHindlimb ischemia and reperfusion leads to lung injury in various animal models. We investigated the effectiveness of FK506, an immunosuppressive agent, which also modulates neutrophilic infiltration, in preventing lung injury after hindlimb ischemia and reperfusion in a rat model.MethodsTwenty-seven male Sprague-Dawley rats were randomized to received FK506 at doses of 0.3 mg/kg, 0.5 mg/kg, or 1 mg/kg body weight per day, or normal saline injections, as pretreatment, and there was also a sham group. On the 4th day, the animals were subjected to 2 h of ischemia induced by a tourniquet, followed by reperfusion of the extremities for 2 h. Lung tissue assays were performed for the lipid peroxidation product malondialdehyde (MDA) and total glutathione (GSH). Lung tissues were also examined histopathologically under light and electron microscopy.ResultsThe MDA levels in the study groups were significantly lower than those in the control group (P < 0.05), but the total GSH levels did not differ significantly among the groups. Histopathologically, there were no significant differences among the groups given different doses of FK506, but there was a significant difference between the control group and all the treatment groups.ConclusionFK506 ameliorates the lung injury associated with ischemia and reperfusion of the lower limbs, and might have an inhibitory effect on the neutrophils that cause remote organ damage.